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Closing Arguments II: Obama Health

Posted by John McDonough  November 2, 2012 08:50 AM

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Let's start with the proposition that the Affordable Care Act (ACA, ObamaCare) is far from perfect. So were the 1935 Social Security Act and 1965 Medicare and Medicaid Act. Given the chance, the ACA will be revisited repeatedly to be improved, fixed, expanded, and trimmed. Given the chance -- and that's what next Tuesday's election is about. 

Like no time I can remember, Tuesday's election is a national referendum on the ACA. Most American voters will not cast their ballots for or against the ACA -- yet the impact of their votes will determine the fate of U.S. health reform more than anything else. Mitt Romney's election will guarantee dismantling the ACA in whole or substantial part, and Barack Obama's re-election means implementation of the law he signed on March 23 2010.

What's at stake? Of the 25 most advanced nations on our planet, the United States is the only one without some form of national health insurance, public or private, the only one that permits its citizens to suffer financial ruin because they get sick. If this is what is meant by "American exceptionalism," you can have it. When nations such as Mexico, Taiwan, South Korea, and Thailand can do it, what's our excuse?

No more excuses, America.

It's forward or backwards. Forward to refashion our health care system to better meet the changing and dynamic needs of American society or backwards to a pre-reform place where our health system careens like a driverless bus in a parking lot, destroying lives and wrecking havoc not only on our economy but on our society. Everything else we care about -- education, environmental protection, infrastructure, everything -- is diminished because our health care system is so out of kilter and out of balance.

In parts of our nation today, life expectancy is dropping for lower income folks, really. When it comes to life expectancy and infant mortality, two of the most fundamental measures of a nations health, the U.S. is worse than mediocre.

ObamaCare is not the final solution.  There is no final solution because the struggle to keep any health system in balance is never over. ObamaCare is the beginning of the path to system improvement, to real financial security for those who get sick, and to better quality care for everyone. My approach to explaining the ACA has been to explain the key titles of the law.

One more time:

Title I, if fully implemented in 2014, will fundamentally change the nature and regulation of private health insurance that badly needs radical change. It's already well underway as insurance companies can no longer impose lifetime or annual benefit caps, must spend 80-85 cents or every premium dollar on pure medical costs (or rebate the difference to consumers), and much more. In 2014, there will be affordable available coverage for just about every U.S. citizen or legal resident.

Title II, if implemented and accepted by states, will offer Medicaid to every low income citizen or legal resident in America. Medicaid will finally become what most Americans believe it already is: the essential insurance guarantee for lower income Americans.

Title III, already being implemented, sets in motion new initiatives to improve the quality, efficiency and effectiveness of medical care delivery in the U.S. Already, hospitals with excessively high rates of readmissions and hospital infections are facing financial penalties for this poor performance, and the penalties will get tougher if they don't change. Though many complain the law did not do enough to control rising costs, the ACA does more than any law ever passed in the U.S. to advance cost control. And improvements to Medicare because of the ACA are already in operation, including closing the prescription drug donut hole, new preventive services, and other benefits. And because of Title III, the financial solvency of the Medicare Trust Fund has been extended from 2016 to 2024.

Title IV, already being implemented, puts the U.S. health system on a path to keep people healthier through prevention, wellness, and public health. All proven clinical preventive services now are covered under private health insurance and Medicare with zero cost sharing because of the ACA. A National Prevention Strategy provides a blueprint for the nation, states, and communities. Very soon, all chain restaurants will start posting the calorie content of their menu items.

Title V, some parts being implemented and some parts being stalled, advances an agenda to make sure we have a health care workforce to meet our nation's needs. Already, community health centers and the National Health Service Corps have seen major expansions because of the ACA. The centerpiece of this title, a National Health Care Workforce Commission, was named in the fall of 2010 and has yet to hold its first meeting because House Republicans refuse to provide the insignificant amount of funding needs to launch the group.

Title VI, the grab-bag, has triggered the most aggressive effort in U.S. history to fight and prevent fraud and abuse in Medicare, Medicaid, and private insurance -- an effort already achieving major advances.

Title VII, directing the Food & Drug Administration to approve generic-like versions of bio-pharmaceutical drugs called "biosimilars" will provide new and more affordable versions of life-saving therapies and is already spurring broad innovation in this market.

Title VIII, a new, voluntary national program to provide cash support to persons with disabilities, called CLASS (or Community Living Assistance Services and Supports) was put on ice by the Obama Administration in the fall of 2011 because there is no way to get the current Congress to address easily-remedied flaws in the language of the ACA. Republicans just want repeal and offer nothing in addressing the needs of America's disabled.

People ask, what's Obama's health agenda for a second term? This is it: implementing the most significant set of comprehensive health system reforms ever. It's more than a ton of work, and it will be tough, because change is always tough.

Next Tuesday's choice does indeed come down to two words: forward or backwards.

I vote "forward."

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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