Beyond Obamacare: 5 opinions on health care reform

Health care reform remains a contentious issue in the United States. The Supreme Court upheld the constitutionality of President Obama's health-care law, the Affordable Care Act, known as Obamacare. But some Republicans, like presidential candidate Mitt Romney, hope to repeal the law under the next Congress. Meanwhile, Americans spend a higher percentage of GDP on health care than other advanced nations, for care that many argue isn't as good.

Here, we've excerpted some of the most compelling opinions about US health care that have run on our pages – from the debate over Obamacare, to cost, to health literacy, to finding common ground. Writers explore five key aspects of health-care reform.

1.Medicare, Obamacare future? Snip, snip, snip

Dr. Sonia Nagda puts on a pin supporting the health-care reform law known as Obamacare as she and other health-care professionals gather in front of the Supreme Court in Washington on March 26, where the court began hearings on the health-care law. (Charles Dharapak/AP)

Former Monitor economics reporter and columnist David R. Francis urges: 

Congress is going to have to tackle rising health-care costs in Medicare and “Obamacare.” House Republicans can try to repeal Obamacare or starve it for funds. Democrats can beat back such attempts. But the laws of economics still rule.

Francis notes that health-care spending in the United States is “more than twice as costly as what other advanced nations spend as a share of GDP. Yet America’s average life expectancy is lower and it’s advancing more slowly.” He says that the high cost “weakens America’s international competitiveness.” He wants lawmakers to address cost controls, but says “The issue is how.”

The health-care law passed last year was billed as a cost-cutter.... The one reform Congress considered that really could have begun to change the cost equation – a so-called “public option” where government insurance would compete with the private sector – was dropped.

For those who equate the new health-care law with a “government takeover,” Francis explains: 

The fact is that the health-care industry – physicians, nurses, hospitals, drug companies, clinics, insurance companies, etc. – remains in private hands though the government pays some of the bills. But competition for clients has “not worked” to cut costs, [Wendell Potter, a former public relations manager for major health insurance company CIGNA] says....

Potter charges that the health-care industry has deliberately tried to frighten Americans away from government efforts to cut costs.... The reform law includes pilot projects aimed at shrinking medical costs, he notes. 

Francis says Potter admits cutting costs is “easier said than done,” but offers some suggestions:

Trimming costs in any substantive way would include cutting incomes of medical professionals (who are paid significantly more than their counterparts in other nations), drug-company executives (who charge US patients more for drugs than patients in other countries), and health-insurance executives.

David R. Francis is a former Monitor economics reporter and columnist. 

ObamaCare and the Constitution: What would Jefferson and Madison think?

Attorney Nathan Tucker writes: 

While the thought that the Constitution actually limits the power of Congress to enact legislation may be foreign to some Democrats, the framers of the Constitution intended for the federal government to be limited to the powers that are specifically enumerated, or listed, in the text of the document.

He continues:

Out of the 17 named powers given to Congress in Section 8 of Article 1, however, none mentions anything about heath care, insurance, doctors, medical treatment, or anything approaching an enumerated power that would allow Congress to legislate our health.

Tucker says that Democrats “point to two constitutional provisions as their grant of authority to enact health-care legislation”: the “general welfare” clause and the Commerce Clause.

Tucker disputes this first claim:

The term “general welfare” appears twice in the Constitution, once in the Preamble and another time in the “tax and spend” clause. The Preamble to the Constitution, however, has never been considered a grant of power to the federal government.... The tax and spend clause, however, is an enumerated power given to Congress in the Constitution.... [But] [t]o read the term “general welfare” in the clause to be a broad grant of authority to Congress to tax for whatever purposes it deems are in the general welfare of the country would be to make a mockery of the Constitution.

He also takes issue with the second:

The [Commerce] clause...was simply meant to prevent trade wars between the states, a common occurrence under the Articles of Confederation..... As originally understood, the Commerce Clause was intended to create a “free trade zone” throughout America, only giving Congress the power to strike down state laws that discriminated against the buying, selling, and transportation of out-of-state goods.

Tucker warns:

But the health-care legislation goes even further than the court has previously upheld by requiring an individual person to engage in economic transaction with a private company (i.e., buy health insurance) or face a fine. That is an unprecedented and unconstitutional power grab by Congress that, if upheld, would leave no check on Congress’s power.

He urges: 

It is time for the Supreme Court to once again hold that the Constitution imposes restrictions on Congress and to close the general welfare clause and Commerce Clause expressways by which the federal government has become one of infinite powers rather than finite authority.

Nathan W. Tucker is an attorney in Davenport, Iowa, and the author of “We The People: The Only Cure to Judicial Activism.”

Next big obstacle for Obama’s Affordable Care Act? It’s not just the Supreme Court.

RAND health policy researcher Laurie T. Martin and Emory professor Ruth M. Parker point out another obstacle for the successful implementation of the health-care law:

Over the next three years, as the Patient Protection and Affordable Care Act (ACA) goes into effect, America’s state and local officials will be responsible for reaching out to more than 30 million individuals and enrolling them in publicly funded or subsidized health plans offered through state insurance exchanges. The majority of those individuals have low health literacy and will have difficulty finding, understanding, and using insurance information critical to getting them properly enrolled.

Failure to meet the enrollment goals of new health care law, however, will not only undermine the success of the new health law, but more importantly, will do little to expand health insurance coverage. Unless steps are taken to clarify the language and procedures surrounding the enrollment process, individuals are not likely to enroll, resulting in a significant waste of time, energy, and taxpayer dollars.

They explain that “[p]roperly enrolling in a health insurance plan, particularly a government funded or subsidized plan (such as Medicare or Meicaid), is a complex task.” It requires individuals to “navigate the system” and requires them to understand complex terms and requirements, complete forms, and provide documentation.

Martin's and Parker’s recent estimates suggest that “over half of currently uninsured adults – those who will become newly insured under the ACA – have difficulty finding, understanding, and using even the most basic health information.”

They urge:

The success of the Affordable Care Act to enroll those newly eligible in an appropriate insurance plan therefore depends on clear communication to individuals who have limited health literacy. It is not realistic to expect that a website and assistance from insurance exchange navigators (counselors) can do this.... Provisions in the Affordable Care Act require health plans seeking certification in state exchanges to provide information in plain language.... Yet policymakers continue to take action that undermines clear communication.

 Martin and Parker suggest some solutions:

Trusted community-based organizations and health providers can help consumers navigate the enrollment process and fill out applications, as was shown to be effective in Massachusetts. And performance standards for exchange counselors can include an understanding of and sensitivity to challenges related to low health literacy.

Laurie T. Martin is a health policy researcher at the nonprofit RAND Corporation and Ruth M. Parker is a professor at the Emory University schools of medicine and public health. This piece is based on an article published by the authors in August in the “Journal of the American Medical Association.”

Barrier to better health care: Republican definition of freedom

Anthony L. Schlaff, director of the Master in Public Health Program at Tufts University School of Medicine, claims: “If traffic lights were invented today, the Republican Party would be against them.” He continues: 

After all, aren’t traffic lights a perfect symbol for government imposition on individual freedom? The government takes our money to build and maintain them, and then uses them to tell us when we can stop and when we can go. But anyone who drives in a city knows how necessary traffic lights are.

Schlaff explains how this “thought experiment” applies to Republicans’ objection to the individual mandate in the new health-care law:

Freedom is about rights, choices, and opportunities. As with traffic lights, [government action] can enhance freedom, and we need to be thoughtful, not reflexive, in how we view what we ask of government.

Schlaff asks:

How many of us want the freedom to face medical bankruptcy, or the freedom to be denied coverage (and care) because of a preexisting condition? And how many of us see dying, due to lack of insurance, from a treatable or curable disease as an acceptable cost of individual liberty?

As with traffic lights, there is a trade-off; we cannot get something for nothing. The only way to have a system that guarantees necessary care for those in need – to give us the freedom to live our lives without that fear – is to make sure everyone is included in the system.

He argues: “We need to take back the meaning of freedom from those who cheapen it with simplistic bromides.”

According to the simplified notion of personal responsibility, people should take it upon themselves to get educated, keep their water clean, and properly dispose of household waste. It sounds good in theory, but would you live in a town that had no schools, and no water or sewer treatment, but gave every household the “freedom” to manage these concerns on their own? Probably not.

Schlaff concludes:

Thankfully, citizens across America have the freedom – through government – to manage these problems collectively. A century ago, that is what they did, and we are all the freer for having school, water, and sewer systems run by our cities and towns. 

Anthony L. Schlaff, MD, MPH, is director of the Master in Public Health Program at Tufts University School of Medicine. The views expressed here are his own.

A health-care plan Ryan, Obama, and Romney should all get behind

Brookings Institution budget expert Isabel Sawhill is concerned: “Health-care spending in the United States is on an unsustainable path.” She explains that “we face a fork in the road”:

One path leads to a privatized system. The other path leads to a public system. The path we take will have enormous consequences for our society.

Sawhill says there’s good news, though:

A sensible compromise is not only possible but may be the best outcome. In a hybrid system, everyone – whether young or old – would have access to both private insurance and a public plan.

Sawhill notes the differences, advantages, and disadvantages of public and private systems, and concludes:

Medicare for all is not a viable solution in a country that doesn’t like big government or much higher taxes..... A privatized system has some advantages; however, the benefits of choice and competition are often exaggerated.... Fortunately, we don’t have to choose one system over the other.

Sawhill argues for a grand compromise – a hybrid system:

Democrats would have to accept some form of premium support for the elderly in return for Republicans accepting a public option for the non-elderly. Over time, individuals would then vote via their enrollment decisions on which option they liked better. The government would be forced to compete with the private sector on an equal footing. And the private sector would not be able to raise premiums without limit. Best of all, seniors and working-age Americans would be in the same system, leading to more fairness and greater efficiency for the system as a whole.

Isabel Sawhill is a nationally known budget expert who focuses on domestic poverty and federal fiscal policy. She directs the Budgeting for National Priorities project at The Brookings Institution. She also served as an associate director of the Office of Management and Budget from 1993 to 1995 during the Clinton administration.