The Arc of Justice in Healthcare


We all fear that phone call.  A medical report turns out the wrong way and life may never be the same.  When that call arrives we all have the same needs:  A doctor who cares, a place to go for treatment and the finances to afford what’s needed.  Starting on January 20th, some of my patients will join the 20 million whose lifeline to those fundamental needs becomes jeopardized.  

One of my patients facing this threat lost his job and health insurance during the 2008 recession.   Because he’s a diabetic and has a special needs son, no insurance company would sell his family a policy.   Why would they?   Diabetics and others with serious illnesses pose high risks for future health expenses.  Insurance companies make money by avoiding such risk.   After exhausting all the options, he sweated out 18 months with no coverage.   Finally, the roll-out of the California Exchange, funded by the Affordable Care Act (ACA), allowed him to buy an Anthem Blue Cross policy for his family.  

Do we really want millions of our fellow Americans to relive those nightmares?  We all benefit from the ACA’s fundamental commitment: That everyone deserves access to healthcare regardless of their ability to pay.  The policies guided by this principle moved us toward the achievement of universal coverage without changing the existing care of the majority of working families with employer based plans nor those with self-funded coverage.   

Two key features of the ACA make the difference for patients like mine.  The first, subsidized insurance exchanges, allows them to get coverage at prices negotiated for all.  This provides economies of scale in pricing and spreads the risks over a larger group, reducing the costs for higher risk individuals. The insurance premiums are subsidized by income to keep them affordable. 

The second key feature of the ACA, and the most controversial, is the individual mandate.  This provision requires individuals to purchase insurance or pay a fine.  Opponents consider the mandate an infringement on individuals’ freedom to decline coverage.  Despite the superficial appeal of the argument, no one in the United States actually declines coverage.  When uninsured individuals arrive in an emergency room with a severe illness or injury they receive treatment and the costs get passed on to the insured and to taxpayers.  Such “uninsured” individuals are free riders.  They enjoy catastrophic coverage paid for by others.  

Additionally, many free riders are young and healthy.  Their departure from the system, if allowed by a repeal of the mandate, would leave a sicker, costly population that would likely face unsustainable increases in premium costs.  We don’t allow individuals to opt out of auto insurance because it affects the public welfare.  Similarly, we should not allow free riders to opt out of health insurance and undermine the financial stability of the health system. 

The ACA isn’t perfect but almost everyone gets a fair chance at coverage.  Under the ACA the percentage of non-elderly uninsured fell from 18% to 10.5% as 20 million gained coverage.  Vice-President Elect Pence recently called for “an orderly transition…to a market based healthcare economy.”  The ACA includes market mechanisms, such as the markets for health plans on the exchanges and the markets for providers once insurance is purchased.  A purely free market approach, as the Vice-President seems to support, could never reach the level of coverage achieved by the ACA.  If markets are completely free, they price out individuals who lack sufficient resources.   Healthcare costs are so high that cutting off help from the ACA would deprive millions of needed coverage.   

As President-Elect Trump considers healthcare, he may want to consider the words of Martin Luther King, whose holiday precedes the inauguration by just four days.  “The arc of the moral universe is long, but it bends toward justice.”  Part of that arc includes our social justice system and the safety net that protects patients like mine.  Americans never have made a commitment to public welfare and then reneged on it.  Despite their party’s opposition to the creation of Social Security and Medicare, incoming Republican administrations never threatened to withdraw existing commitments.  Instead, they supported bipartisan efforts to improve the programs.   The Trump administration should do no less.  

Members of the Trump administration and their congressional allies also should consider that most of them and their family members will someday also receive that call.   They should not threaten to deprive fellow Americans of the healthcare security they would want for themselves. 

The arc of justice in healthcare has been long indeed.  We will soon learn whether the Trump administration will choose to defer the progress of the arc of justice under the ACA.  In the long run they cannot stop it. 

<em>Daniel Stone, MD is the director of a multi-specialty group in Los Angeles.</em>

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  1. Regarding the numbers of citizens with ACA mediated health insurance, I am moderately unsure that the reported total number of citizens with continuing ACA health insurance is accurate. This comment is NOT intended to represent undue scepticism. The folks at ACA may be not be schooled on the origins of their data, and thus, the reporting of data is based on variously defined origins for their data. Historically, the INITIAL homelessness reporting of statistics by the VA and HUD were difficult to analyze since the origins of their data was based on alternate definitions of homelessness. Those issues were resolved by a structured and collaborative effort by the staff within both HUD and the VA.

  2. I think this is a very good defense of the ACA/ObamaCare. Unfortunately, it didn’t work. Frankenstein level deductibles, forcing everyone to pay for a hugely expanded list of services for all (not allowing folks to buy policies that fit their needs), and trying to coerce the young into paying for much of this. Good intentions notwithstanding, the ACA has run amuck. It will be challenging, but I think the new HHS head and the policy wonk Republicans (Ryan) will be able to come up with a replacement that works much better.

    • “Frankenstein level deductibles, forcing everyone to pay for a hugely expanded list of services for all (not allowing folks to buy policies that fit their needs), and trying to coerce the young into paying for much of this.”

      Paul Ryan says he wants to replace it with something better. I’m sure now we’ll get lower premiums with better coverage, smaller co-pays and deductibles, and still no caps and pre-exist inclusion.

      Don’t you think this would be great Paul?

      And what do you mean by “hugely expanded list of services”? Tell us what services should be optional?

      • Peter,
        Of course there are the 10 “Essential Health Benefits” now federally mandated….except for grandfathered plans. That is why my wife’s grandfathered plan monthly premium is still about 1/2 of those of our similarly aged friends….and we are very happy about the services we have and the lower premium. Yes, I do think people should have the right to choose what is covered in their plans.
        re mandates in general “Then there’s the fact that the act of mandating benefits alone will bring advocacy groups out of the woodworks to lobby for particular items and services, leading to arbitrary and unnecessary inclusion of certain benefits. Benefit mandates at the state level have shown this effect. In its annual report, the Council for Affordable Health Insurance observed, “Mandating benefits is like saying to someone in the market for a new car, if you can’t afford a Cadillac loaded with options, you have to walk.” Existing state-mandated benefits include things like acupuncture, hair prosthesis, massage therapy, and other services that are unnecessary for most patients. Nevertheless, once mandated, all covered individuals must pay for these.
        Defining what kind of coverage Americans must have is just one way the Administration will have unchecked power to determine the direction of health care reform under Obamacare. ” Quote from Kathryn Nix. My psychologist colleagues who practice clinical psychology are great at lobbying for expansion of mandated services in all states driving up insurance premiums. In NC the autism lobby successfully got unproven behavioral therapy services mandated….I think the annual cap is $18,000. I am now hearing radio ads for behavior therapy services….and with the expansion of “autism spectrum disorders” the number of autism diagnoses has risen tremendously. All service groups play the game.

        • Paul, there is a good reason mandates are legislated into policies, they provide essential benefits whose cost is spread across the broader group. The risk is shared so that those who really need it can afford the coverage.

          What is wrong in America with lobby groups – I bet you support a few yourself? This whole country lobby’s for something. It’s up to political leaders to determine if the mandate is frivolous or not and they will be accountable to the voters.

          Tell me which of the “10 essential” benefits you would want not mandated. I can’t comment on your wife’s plan and cost since I don’t know the details or the coverage. But it interesting to note that she was grandfathered in, a provision of the ACA that you dislike. Not sure how you get your health insurance?

          In the end having a buffet method of coverage choices means people will choose what’s they can afford not what they need.

        • Maybe instead of mandating specific benefits, all subject 5o lobbying, we could mandate a minimum actuarial value like, say, 50% as opposed to the 60% minimum (Bronze level) in the ACA. There has to be some definition of minimum creditable coverage either to satisfy a mandate to purchase insurance or establish subsidy criteria for people who can’t afford even minimum coverage.

    • Hi, Paul.

      Thanks for commenting, but, as you might suspect, I can’t agree.

      In regard to “a hugely expanded list of services for all,” I think it’s worthwhile considering that no one ever knows the services that they’ll need in advance. Before the ACA, employers could buy bare bones insurance for their employees and, unless someone was a benefits expert, they had no idea what they were getting. I once had a patient find out that his insurance didn’t cover transfusions! Having a standard benefits plan allows consumers to compare apples to apples. They also have the piece of mind knowing that they don’t have insurance in name only.

      Let’s remember that with the ACA, all preventive services and an annual Wellness Exam are not subject to cost sharing. This feature has huge impact by preventing cost concerns from producing delays in diagnosis lead to morbidity, mortality and high deferred costs.

      The perennial Republican proposals to allow health insurance to be sold across state lines tie in here. If there’s no standard insurance, an insurance company in Alabama can sell a bare bones policy to companies in California. If Federal law prevents states from setting their own standards, employees will end up having these “insurance in name only” plans. The only other reason that health insurance would be cheaper in Alabama than in California is that the covered services are cheaper. Alabama insurance companies would have to pay the same costs here that others do. So, this proposal is either meaningless or its stealth benefit reduction.

      I find the “Frankenstein level deductibles” comment ironic. First, no Republican administration since Nixon put forth any proposal to increase access for the uninsured. So, after showing general indifference to the healthcare access of these individuals, it seems odd that there is suddenly so much concern for their finances. The other irony is that the deductibles and copayments is an area of the ACA that is market based. One can choose one’s level of deductible. At least in California, there is a lot of competition among the groups taking insurance under the ACA and a lot of pressure to keep costs down. The value proposition for plans in the ACA is at least as good as it is for plans elsewhere. I know this personally, as our health system struggles constantly to keep our costs down to remain competitive and in the Exchange plans.

      The real underlying issue for both high premiums and high deductibles is that healthcare is just expensive in the U.S. The insurance is expensive because the care is expensive. Despite Republican claims, no sleight of hand can escape this quandary. You can’t reduce the cost of the insurance if the care costs the same, unless you shift the costs or reduce access to the care. The administration may realize that it’s an impossible nut to crack. If you don’t subsidize the care of low income individuals, that care won’t happen.


      • DS,
        Thanks for the thoughtful reply. A few thoughts in response:
        1. Agreed, an exclusion of transfusion coverage sounds kind of nuts. I don’t disagree with some sort of standards of coverage. My beef is that these are subject to lobbying and often include low value…or even harmful when overused….procedures/services. This is especially bad with state insurance mandates which require everyone buy coverage for things that have little or no evidence of efficacy.
        2. You and many others have faith in the usefulness of annual exams as a good practice that saves money and aides health….an example you cite. My main source for this being useless or even harmful is Nortin Hadler M.D (see his books The Last Well Person, Citizen Patient and others). Annual exams are only the tip of the iceberg re expensive and on balance useless practices (see #4 below).
        3. Cross state line competition. It hasn’t worked so far…I think because of the hodge podge of state insurance regulations. Our balkanized insurance markets have resulted in bloated insurance mark ups….probably around 14% over the cost of service. This is far too high. More competition could well save us all up to 7% of our annual health care expenditures. But to do this I think we will need to allow patients to choose plans that avoid the fore mentioned state mandates. But note, I don’t object to some kind of minimum coverage standard.
        4. Re cost of medical care is just expensive. I rely on Hadler here too….he estimates wasteful/unnecessary/harmful care is above 30%. As I think this is right, the answer isn’t to squeeze providers….the right answer is to incent patients to be prudent users/shoppers (gasp!…what a term!) of health care…..by allowing them to keep some of the funds saved by passing on an mri they think might not be really necessary….and then they will start asking docs/hospitals “what is the charge for that?” and “do I really need that”).

        • DJ writes, “You can’t reduce the cost of the insurance if the care costs the same, ”

          Your response is right on target. We need a complete shift in thinking, “incent patients to be prudent users/shoppers”. That is not what government has been doing and that is why every time government creates new programs to reduce spending the spending actually goes up.

  3. “Americans never have made a commitment to public welfare and then reneged on it.”

    1)Americans never had an entitlement without some bipartisan support that the ACA totally lacked.
    2)Americans were never given the time promised by the President to review a bill of this nature.
    3)The President lied to the American people about his transparency and what the ACA would do.

    Any thoughts of bipartisanship regarding improvements in the ACA should have been considered when the bill was passed. Unfortunately, those considerations seem only to occurring now when the other party is in power forgetting how the bill was rammed through in the first place.

    In any event, the ACA was a total failure and going down in flames. It needed to be put out of its misery. Democrats should thank the Republicans for killing the bill that was killing them.

    • “1)Americans never had an entitlement without some bipartisan support that the ACA totally lacked.
      2)Americans were never given the time promised by the President to review a bill of this nature.
      3)The President lied to the American people about his transparency and what the ACA would do.”

      Repugs never wanted to participate, their political strategy throughout the Obama term. They never wanted him to get credit for anything. They had full opportunity to contribute.

      As usual you are wrong.

      • “Repugs never wanted to participate”

        Such foolishness The facts are against you. Obama and the Democrats wanted to act in a dictatorial manner. They got what they wanted and they passed the ACA unfinished. Most of the major comments made explaining why Obamacare would fail have now been proven correct, but neither Obama nor the Democrats wanted to listen to anything constructive. Nancy Pelosi’s own words told us that the bill was not understood. “We have to pass the bill so you can find out what is in it.” That tells us more about the stupidity of the passage of the bill than most things.

        You just don’t get it and apparently will never get it. In the past, it was the Republicans that pushed MSA’s and then HSA’s. They actually work, but that doesn’t seem to be what the Democrats or the President was interested in. I am not really a Republican, but I give Obama a lot of credit for passing a lousy healthcare bill, inflaming the middle east, permitting Russia and China to become more aggressive and for nearly destroying our economy. I give him credit for a lot of other things including his use of the race card to stir up racial problems, but I am sure you knee-jerk reaction is to say none of this is true..

        • Okay, Allan, I’ll take the bait.

          Your comments don’t square with the facts. How has the ACA been a failure? When it passed, the Republicans called it the “job killing care act” and years later we’re under 5% unemployment with the 20 million more individuals covered. And, healthcare inflation in the last five years is a third less than it was in the previous five years and two thirds less than the five years before that.
          (Source: Kaiser Healthcare Foundation: http://kff.org/health-costs/press-release/average-annual-workplace-family-health-premiums-rise-modest-3-to-18142-in-2016-more-workers-enroll-in-high-deductible-plans-with-savings-option-over-past-two-years/)

          If this is failure, I’ll take some more of it, thank you…


          • DJ, For the most part ObamaCare’s big success was in increasing the numbers on Medicaid. Private insurance may have just returned to what it was a deade earlier. Premiums and deductibles have increased dramatically while networks have narrowed. More of the same is on the horizon and will get worse. The ACA is unsustainable. We don’t have true figures of how many are insured today because it appears gaming is occurring and people have been known to drop insurance after signing up.

            We can’t keep our doctors and we aren’t saving the $2,500 promised.

            As far as employment you should look at the U6 rather than just the U3 and look at the type of jobs available and its compensation. When you are done with that look at the number of people that are not working. That number has risen.

  4. I think Republicans will ultimately pay a high political price if too many of the 20 million or so people who got health insurance coverage as a result of the ACA via either subsidized exchange plans or expanded Medicaid lose it as part of legislation that repeals and replaces the ACA.

    If it were up to me, I would let the insurers return to medical underwriting and allow the young and healthy to buy low cost plans that reflect their low health risk. For those who can’t pass underwriting, either create adequately funded high risk pools or let insurers quote astronomical premiums for people who may need hundreds of thousands of dollars of care. To ensure affordability, provide subsidies on a sliding scale so that people pay anywhere from zero percent to a maximum of 10% of modified adjusted gross income for their insurance plan. If I have a disease like, say, cystic fibrosis and the insurer quotes a premium of $300,000, I would be OK with it if my out-of-pocket premium contribution were capped at 10% of income. I don’t like tax credits because they would be more than adequate for some people and grossly inadequate for others. To relate the premium to income, though, the income verification process would have to be pretty robust.

    To save money, focus on attacking the cost of actual medical care instead of health insurance which merely reflects the cost of medical care. Strategies could include streamlining the FDA’s drug approval process for both new drugs and new competitors who want to manufacture generic drugs. We could push for sensible tort reform to reduce defensive medicine. We could make some additional investments in analytics to reduce fraud in the Medicare and Medicaid programs. We could encourage more people, especially seniors, to execute a living will or advance directive that outlines the care they want and don’t want in an end of life situation. We could experiment with bundled pricing and reference pricing, especially for surgical procedures and imaging tests that lend themselves well to the concept. We could have price transparency so both patients and referring doctors can identify the most cost-effective high quality providers in real time and direct their business to them. While there is no silver bullet here, there are lots of silver pebbles. Let’s pursue as many of those as possible.

    • Great suggestions and thoughts Barry. As always, I like the way you think. Price transparency is a huge part of primary care in the future!

    • “If it were up to me, I would let the insurers return to medical underwriting and allow the young and healthy to buy low cost plans that reflect their low health risk.”

      A very healthy change of opinion.

    • Good, Barry. I agree with you (on most points) and Allan, below.
      Figuring our how to subsidize the poor and needy is a tremendous and interesting intellectual problem. There is not much to go on either…. when you think of the tools we have on hand to do this: tax returns, property records, past medical utilization, present medical diagnoses.

      You have to realize also, that we do not have to run health care as an insurance program. It can be run simply as an entitlement. Forget about how to make the insurers whole. Do the thing from taxes. I do not favor this on a national basis, but it might work if hospital districts or counties or states ran the show.

    • Barry, their plans are already low cost. The young don’t have to buy ACA policies, all they need is to be covered. How come they have not purchased insurance? Is it because of price or because they are invincible? How come most young people don’t invest in retirement? How come the ACA had a mandate? If young peoples income is low they get a subsidy – how much below that will people buy insurance?

    • I think Republicans will ultimately pay a high political price if too many of the 20 million or so people who got health insurance coverage as a result of the ACA via either subsidized exchange plans or expanded Medicaid lose it as part of legislation that repeals and replaces the ACA.”

      I wonder how many with subsidized ACA coverage voted for Trump and Repugs? According to Jeff’s article A LOT? How stupid can they be – voting against their best interests.

  5. Daniel, the copayments and deductibles are too high and it’s going to self destruct anyway, unless it is fixed. The Pubs are only keeping this runaway train from crashing, nothing else. You can’t have 70% actuarial values and expect people to go for these silver plans. The “value” of the plans is too low. This is what you want to improve in every service in health care….charge for value. Let us do this for the whole package synoptically.

    There has been plenty of time to fix the ACA. It’s time for another set of hands to do the job.

    • “…the copayments and deductibles are too high and it’s going to self destruct anyway, unless it is fixed.”

      Yes, let’s go to the deductibles and co-pays of non-ACA insurance that was available before ACA. I’m sure that will be refreshing.

  6. The law of unintended results will likely apply, driven inexorably and incessantly by is companion, Parkinson’s Law. However the transition is configured, the twosome will still apply, and our healthcare industry will still produce 60% of our nation’s annual Federal deficit. Unless….Oh, never mind!

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