The Moral Case for Romneycare 2.0

Since 2010, when the Affordability Care Act was signed into law, the American mainstream media has insisted that President Obama’s bill provides the most at-risk Americans, low income families and seniors, with better health care. And that must mean, by any logic, better access to doctors, more access to the modern tools of diagnosis and treatment, and ultimately better health outcomes. That poor Americans benefit greatly from the ACA, and that seniors will be more secure under the president’s law, has seemed so obvious to the left-leaning news outlets that this fact has yet to be critically examined by them.

President Obama’s ACA law purports to provide new health coverage to upwards of 16 million low income Americans by way of Medicaid. We already see in the wake of the Supreme Court decision that many, if not most, states simply cannot be burdened with massive increases in their Medicaid outlays, regardless of the promise of financial support from the federal government (itself a financially unsustainable funding source).

But President Obama’s assertion about new insurance for the poor and all it brings is, in fact, a grand deception. We know that 55 percent of primary care physicians and obstetricians already refuse all or most new Medicaid patients (about four times the percentage that refuse new private insurance patients), and only half of specialist doctors accept most new Medicaid patients. Clearly, granting poor people Medicaid is not equivalent to providing access to doctors.

Another sham, one less well understood by voters, is the implication that pushing millions more patients into Medicaid offers good quality health care. Owing to Medicaid’s restrictive guidelines for diagnosis and treatment, Medicaid patients experience more deaths, longer hospitalizations, and more serious complications from major surgery, cancers, heart disease, interventional procedures, transplants, and AIDS than patients with the same illnesses and health status but with private insurance—objective conclusions proven by medical scientists in the world’s top peer-reviewed medical journals like Annals of Surgery, Cancer, Journal of Heart and Lung Transplantation, and the American Journal of Cardiology. These are outcomes so shamefully poor that, when comparing patients with the same risk factors and status, Medicaid patients at times fared worse than those with no insurance at all.

Health reform should be founded on the understanding that low income Americans and Americans at risk are no different from the rich. These most vulnerable Americans want choices and autonomy, not government paternalism, when they and their families need medical care.

An Alternative Vision

Americans must realize that there is an alternative vision at hand, a plan for health-care reform that provides new freedom and opportunity for all Americans, especially the poor. According to this alternate vision, reforms would expand access and accelerate the excellence of America’s health care, rather than restrict its access and punish innovation. Solutions would directly address its exploding cost, rather than double down on the ineffective policies of more price fixing, higher taxes, and ever increasing bureaucracies, strategies modeled on systems of other countries beleaguered by unconscionable waiting lists for care and worse health outcomes.

An alternative plan, guided by honesty, would be committed to personal empowerment, based on a steady confidence in free market innovation and a certainty that individual Americans understand what’s best for themselves, rather than relying on unaccountable government panels and appointed bureaucrats.

What should guide leadership in health-care reform? That all Americans deserve the opportunity to exercise freedom and personal choice in pursuit of health. This is the cornerstone of Governor Romney’s vision of health-care reform.

Governor Romney understands that the high cost of American health-care excellence, not the quality of care, is the true crisis at hand. And despite the media’s silence about the truth on this issue—that the ACA fails, by all estimates, to reduce the costs of America’s health care—it is our most vulnerable, the poor and seniors, who will ultimately suffer the most from the failure of our leaders to address this situation. As the Obama administration celebrates the constitutionality of its law, the fact is that the costs of the ACA represent an unsustainable burden to the taxpayer, to employers, and to the American economy, threatening in particular low income Americans and those employed by small businesses now incentivized to drop coverage.

Rather than ignoring fiscal realities and serving up false promises, Governor Romney will leverage the power of competition and information transparency in reducing price. The Romney reforms will focus federal regulation of health care to benefit individual Americans. He will tear down government barriers to competition and choice, like the archaic rules that protect state insurance monopolies and prevent families from seeking better insurance value across state borders. He will cut unnecessary regulation, so consumers can buy cheaper coverage they actually want, rather than what they are forced to buy.

Governor Romney will expand consumer-driven health insurance with health savings accounts for all Americans, less expensive coverage that makes sense for tens of millions, improves health with wellness programs, and saves hundreds of millions of dollars overall, the very coverage that is now under siege by President Obama’s new limits on contributions, actuarial requirements, and bloated coverage mandates.

Governor Romney is committed to saving assistance programs critical for the most vulnerable Americans. Instead of pretending that Medicaid coverage actually means access to doctors and good quality health outcomes, Governor Romney wants to undo the federal restrictions to states on how to use that money, so low income beneficiaries will have the same choices, flexibility, and access to the medical advances that privately insured Americans enjoy.

And for seniors, those Americans who need health care far more than any other segment of society, Governor Romney will not hide from the fact that Medicare is financially unsustainable, by all estimates, spiraling into bankruptcy, with an unfunded liability of almost $38 trillion and a hospital insurance trust fund that will become insolvent in 2024, according to the 2012 Medicare Trustees Report. Governor Romney understands what will happen with Medicare under the ACA—namely, that it will be cut until it provides no coverage whatsoever—given that two-thirds of hospitals already lose money on Medicare.

An increasing proportion of doctors are already not accepting Medicare patients, as demonstrated in the 2008 HSC national tracking survey, which reported that more than 20 percent of primary care doctors were not accepting new Medicare patients (compared to their not accepting 4.5 percent of privately insured patients) and about 40 percent of primary care doctors and 20 percent of specialists refused most new Medicare patients. By 2019, Medicare cuts under the Obama law will be so draconian that payments will become even lower than Medicaid, a system by which doctors already lose money and most refuse to accept patients.

“Saving” Medicare?

Yet, despite these well-documented facts, our president and his supporters maintain that the way to “save” Medicare is to markedly reduce payments to doctors and hospitals and empower a new panel of bureaucrats charged with cutting payments even further. Beyond overtly cutting payments for care, the Obama law creates a wholly unaccountable, government-appointed 15-member Independent Payment Advisory Board, which has the unprecedented power to further reduce payments to doctors, policies that the Secretary of Health and Human Services is required to implement.

And while the president’s supporters defensively point to language that prohibits specific and overt “rationing,” this is implausible deniability, since all evidence points to the de facto rationing that will result from the IPAB’s mission of cutting payments to doctors and hospitals.

Instead of falsely promising an illusion of security and undeliverable health-care access by virtue of government-defined insurance, Governor Romney’s plan will instead save Medicare and improve coverage by allowing recipients, particularly low income seniors, to use the government support for private insurance. Instead of being restricted to the federal government’s insurance coverage, seniors under the Romney-Ryan plan would have the option to use the government’s fixed-dollar contribution and choose from private insurance plans.

A fixed-dollar contribution means that an individual has the opportunity to save money by choosing a less expensive plan, one tailored to their own needs. Their plan would present American seniors with the option of private insurance, instead of traditional Medicare. But giving seniors the choice is an idea that President Obama and his supporters find unacceptable and threatening. Rather than allowing government panels to limit medical options, Governor Romney’s commitment is that seniors deserve the right to decide, with their doctors, how and when to pursue advanced medical care.

As opposed to President Obama’s preference for government centralization, Governor Romney trusts capitalism, the choices of individual Americans, private ownership, and individual empowerment. Governor Romney’s plan would introduce fiscally sound tax reforms to end tax discrimination against individuals whose employers don’t offer insurance. He will promote portability and increase coverage options through deregulation, rather than empowering the government via the ACA’s massive government-defined essential benefits. With Governor Romney’s reforms, individuals—low income Americans as well as higher income citizens—will be able to choose coverage they value and then own it independently of their employer.

Unless it is repealed, the ACA will proceed to destroy the unsurpassed choice, access, and proven excellence of U.S. health care, rolling back the clock on specialty care and medical technology and giving the government overwhelming authority over health-care decisions. While President Obama considers the bill a great achievement, his plan fails to address the single most important problem with America’s health care and the biggest threat to the future of our people—cost.

Beyond its detrimental fiscal consequences, the plan is seriously flawed on the most basic moral grounds. While the president’s supporters do their best to control the message, it becomes even more urgent that all Americans, especially America’s most vulnerable, realize that an alternative choice is at hand.

Scott W. Atlas, MD is the David and Joan Traitel Senior Fellow at the Hoover Institution, and senior fellow by courtesy at the Freeman Spogli Institute for International Studies at Stanford. This essay originally appeared in Defining Ideas, an online journal of the Hoover Institution.

18 replies »

  1. Wow. What a colossal load of tripe you’ve managed to collate into one article. Kudos for ignoring basic market forces and human nature!

  2. “Random chance is 1 out of 20.”


    I’ve been a working statistical analyst since 1986. How did that escape me?

  3. Random chance is 1 out of 20, but with politicians more like 1 out of 200, hence what I read senate candidate Bob Kerrey said about the sorry state of his party, democraps, but politicians as a whole of late:

    “If I were there, I would say that our biggest budget problem — the growing cost of federal retirement programs — was not caused by the Republicans. It wasn’t caused by the Democrats either, for that matter. It was caused by politicians of both parties promising more and more generous benefits to voters over the age of 65 in an effort to win their support at election time,” he said.”.

    Again, the older population really is setting that bar of entitlement for society, eh? Can ya pole vault 50 feet up, ’cause that is what social security and Medicare have set the distance with all the debt incurred.

    Oh, sorry, didn’t realize most of you still are sucking sand down there!

  4. Ok, who ya gonna believe, democrat rhetoric or facts from providers and patients? Hey, marvolous Governor Martin O’Malley from Maryland was caught today telling us on CBS ‘s morning show that things aren’t better now than they were 4 years ago, and We are still to believe this is George Jr’s fault still in 2012. So, I guess WHEN PPACA shows its massive failings in 2014 should OBummer is still in office, that’ll be Bush’s fault too? No, your crafty blamer in chief will put it on Nancy Fullofitosi’s lap, cause hey, she wanted it passed before the bill was read.

    Fact 1: Medicare is NOT paying better than most insurers because FACT 2: more than a little number of provider are at least not taking new Medicare patients because FACT 3: doctors are aware that having a large percentage of Medicare patients will not lead to autonomy and opportunity to practice as trained, but just micromanaged and WILL be punished WHEN outcomes don’t meet unrealistic expectations of bean counters from DC.

    Believe the Mahars of the world all you want. Their deeds will not match their words. Oh yeah, and most of these writers extolling the wonders of PPACA aren’t even providers in the first place.

    Happy Labor Day colleagues, you’ll be laboring more if this garbage stays in place as is!!!!

  5. Thanks to Maggie for another fine post.

    The issue for office visits, I think, is not just that Medicaid pays so little.
    (as of few years ago, Medicaid paid $7 for teeth cleaning.)

    The issue I suspect is that doctors and dentists cannot do balance biling.

    This may not be the end of the world.

    The American food stamp program is kind of tragic, when you think about it,
    but operationallly it seems rather fantastic.

    Every day 40 million+ people buy food at prices where grocery stores and farmers appear to make money.

    That is nothing to sneeze at.

    Why not give Medicaid recipients their debit card of $1500 a year and turn them loose with any provider of health care?

    • And very day millions of dollars of food stamps are spent buying things other than food. In the mid-south ( and I am sure other places too)there seems to be a market where people trade these things ( eavesdropping and hearing stories first hand) such as car parts, clothes in high end retail stores, and of course very expensive pre- made food in grocery stores. I don’t allow at my house because it breeds laziness. But I guess we should not worry that it is going to waste. It is getting used for something. If you really wanted to make it equal, we would just tell grocery stores that now when those “low income ” people need food, you just give it to them for what ever the government decides to pay you, regardless of the actual cost. And we will see how that goes over with the grocery stores. Maybe the grocery store owners are just not the “right” kind of owners we need.

  6. I’m afraid Matthew & Steve are right. This post is nearly fact-free, and Dr.
    Atlas’ assertions “destroy his credibility.”

    But let’s consdier one true statement in the post: , today, many doctors refuse to take Medicaid patients.

    As we expand Medicaid who will care for these patients?

    Under the Affordable Care Act, those who provide primary care will see their
    fees rise to Medicare levels (today Medicare pays roughly 30% more than
    Medicaid) . This will help.

    What will help even more is the expansion of community health centers.
    Today, they treat many Medicaid patients. The ACA provides for funding to
    expand their capacity by 50%.

    There, both doctors and nurse practioners will care for patients.

    Nuse practioners are becoming a larger and larger part of primary care, not
    just in community health centers,but in university heath centers, hospitals
    and other places.

    Some Ob-Gyns may well refuse Medicaid patients. (I have a hard time imagining an Ob-Gyn turning away a pregnant woman who needs pre-natal care because she is on Medicaid, but I’m sure it happens.)

    By contrast, certified nurse midwives take Medicaid patients. They provide excellent pre-natal care and as the word spreads, they are delivering more and more babies.

    (In Europe, they deliver the majority of babies and outcomes –in terms of maternal mortaity as well as infant mortality– are better than they are here. There also are many fewer unnecessary C-sections.

    Nurse midwives spend more time with patients.
    Nurse midwives are far less likely to urge a patient to have a C-section These are reasons why my daughter, who recently had a baby, chose a nurse-midwife group over the Ob-Gyn group they work with when she had a baby last summer.

    Nurse practioners provide primary care to patients in many areas where
    physicians will not go. (Rural areas in southern states, inner cities in certain cities…

    This brings us to the fact that what we need is a different mix of physicians,
    including many more who will go “where no one else will go.”
    Our problem is not so much that we have too few physicians but that they are poorly distributed.

    The Affordable Care Act greatly increases funding for the National Health Corp, which provides scholarships for med students who go where primary
    doctors are most needed–and where ‘no one else will go.”
    . Reserach shows that often these are
    students who grew up in low-income families in inner cities and rural areas.
    They are returning home And very often, they stay and continue to practice in
    the area where the Corp. sent them.

    Med schools are beginnning to realize that they need to recruit many more students from low-income families to increase the diversity of the
    medical profession. This may mean lowering the required test scores for
    admission in med school. Experience shows that students from low-income
    backgrounds don’t test as well , but when it comes to clinical practice, they are
    as good, or better.

    Medicaid can be a much better program than it is today. Down the road, I
    expect that it will become a national program (rather than federal/state) that pays all caregivers the same fees that Medicare pays.

    • The Medicaid fee increase Maggie talks about conveniently expires before the 2014 Medicaid expansion takes effect. THere is only one direction for physician access under this program post expansion and it is down.

      The alternative is buried in Maggie’s post: we have an extensive and high quality safety net in place already. Why not simply give people under 138% of poverty free care (maybe a dollar or two copay) in those safety net institutions and dispense with the claims payment circus: the VA could provide care to veterans AND their families, FQHC’s to the present Medicaid and uninsured’s who are not veterans, and where there are none of these facilities, critical access facilities (most of whom already employ their communities’ docs on salary).

      The duals should go to Medicare in any case. Financing a separate conversation.

    • Seriously! Did you just say that low-income med students need lowered requirements for med school? I was low income and I made better grades than many of my high income friends. You speak like a true English teacher on this one. I never trust “they”, or as you call them “experience”. Some people don’t test well. Let’s see what scientific data you have to show that a larger bank account improves test scores. Better education maybe, so of course these students have to work harder while in college if they start out with poorer educational backgrounds. It has NOTHING to do with their income.
      “This brings us to the fact that what we need is a different mix of physicians,
      including many more who will go “where no one else will go.”
      Our problem is not so much that we have too few physicians but that they are poorly distributed. ”
      So now you know how to recruit the “right” physicians. Excellence is usually driven by compensation. It doesn’t have to be millionaire compensation, but it does need to justify one’s time, training, time away from family, etc… I don’t know much about Massachusetts plan, but I would be willing to learn more before I run off saying it is not going to work. I think having each state do what works for them is not a bad idea myself. I don’t like the republicans or the democrats, but sometimes the lesser of two evils is better. More control by the individual sounds much better than more government control.

  7. Yeah, you guys are right. Let’s do nothing and watch the whole thing blow up. As a Physician, I can tell you that reimbursements are going down and I am bring home less than I did 20 years ago. (this is not adjusted for inflation, I’m speaking actual dollars). My colleagues across the country are struggling. There are too few patients well-read enough, or invested enough, to take charge of their own healthcare. For most people taking charge means spending the least amount of money on healthcare because they are spending their declining incomes on increased housing costs, utility cost, auto and gasoline cost and the escalating price of groceries. And don’t forget the the government, local, state and federal, who are also reaching into their pockets with greater fervor. What we are doing isn’t working. We have a healthcare financing crisis pure and simple. Prevention sounds great until it is recommended and the consumer has to pay something. Yes, go ahead and support a bill that was presented and voted upon without the masses reading it. Don’t try any ideas supported and proposed by someone who is your political polar opposite. You’re doing well.

  8. Who the heck is Dr. Atlas? I thought this was supposed to be a serious health care blog? Notice how this hack uses no numbers to support his assertions. Useless.


  9. This a mendacious piece of work. If Dr. Atlas were capable of feeling shame he should be ashamed of himself. I doubt he’s capable of that.

  10. “Unless it is repealed, the ACA will proceed to destroy the unsurpassed choice, access, and proven excellence of U.S. health care”


    Yes Medicaid is a dogmeat program and its terrible that it’s the best we can do for poor Americans. But with that one sentence the Hoover dude has destroyed any credibility he might ever have had.

  11. Is anyone who reads and comments here tired of the sheer hypocrisy of these two presidential candidates? Romney wants to repeal the crap that is PPACA that is somewhat based on what he created in Massachusetts years earlier, and Obama continues to tell us what this legislation will do to help people , save money, and improve care by professionals.

    I don’t speak for anyone else but myself, but I genuinely know this: George Carlin was right on the mark in his comments about politics, politicians, and the public who continues this process every 2 to 4 painful years: it is about garbage in, garbage out, politicians come from the public process that is so pathetic it is to now, and, there is no hope. You expect politicians to make health care more efficient and effective, you are doomed.

    And no one will look you in the eye and admit it starts with not promoting the false hope people will live longer and with good quality of life over 70+ years old. Sure, reality is really about working 40 some years and then getting reimbursed for it another 20 or more years. Yeah, Barnum was right, believing that is bought by one every couple of minutes!!!

    • “Governor Romney will leverage the power of competition and information transparency in reducing price.”

      Whose price – doctors? I guess Doctor Atlas can’t wait to advertise lower prices.

      “Governor Romney will expand consumer-driven health insurance with health savings accounts for all Americans”

      I know that Medicaid eligible Americans have been waiting for a place to put their disposable income – and can’t wait for those high deductible plans.

      “An increasing proportion of doctors are already not accepting Medicare patients,”

      Why is competition to lower price a “solution” when we all know that docs don’t accept Medicare/Medicaid patients because they feel their “price” is too low?

      “Yet, despite these well-documented facts, our president and his supporters maintain that the way to “save” Medicare is to markedly reduce payments to doctors and hospitals and empower a new panel of bureaucrats charged with cutting payments even further.”

      But Doctor Atlas says prices are too high and want them lowered through competition. Tell us what prices you want lowered doctor so that docs won’t refuse treatment to low income Americans.

      “A fixed-dollar contribution means that an individual has the opportunity to save money by choosing a less expensive plan, one tailored to their own needs.”

      What would that plan look like doctor? Would a “less expensive” plan give full coverage? What would you cut from plans to make them “less expensive”?

      “Governor Romney’s plan would introduce fiscally sound tax reforms to end tax discrimination against individuals whose employers don’t offer insurance.”

      Would individuals be able to deduct their health insurance from their taxes, or would he end tax preferred status of employees with employer plans?

      Nothing this doc says makes any sense, but look where it’s coming from, an institution named for a president who supported the free market to solve the Great Depression – and failed.

      • Hoover actually was known for advocating public-private cooperation and rejected Mellon’s advice of “leave it alone” with respect to governent intervention. And, since he was not reelected, he really didn’t fail. Rather, his economic plans were simply “incomplete”.

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