Opinion: Healthcare reform turns 1, no party planned


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First anniversaries are traditionally celebrated with gifts of paper, and so it is with the first anniversary of the passage of the Patient Protection and Affordable Care Act, a.k.a. Obamacare. Supporters and opponents alike are observing the occasion by cranking out press releases and opinion pieces. My favorite is the nearly hysterical op-ed by Sen. Ron Johnson (R-Wis.) in Wednesday’s Wall Street Journal, who calls the passage of the law ‘the greatest single assault on our freedom in my lifetime.’

Johnson will be 56 soon, so he wasn’t alive when a real assault on freedom -- the Japanese attack on Pearl Harbor -- took place. Nor was he alive when one of his predecessors, Sen. Joseph McCarthy (R-Wis.), ran roughshod over civil liberties in pursuit of imaginary communists. But I digress. Johnson puts a personal spin on an argument commonly heard from the law’s opponents, suggesting that his daughter wouldn’t have survived her neonatal heart defect had the healthcare reform law been in place back then.


I respect how traumatic that incident must have been for the Johnson family. But the new law is not, as Johnson argues, an inexorable march toward a government takeover of healthcare. It’s an expensive, complex and uncertain attempt to move the healthcare system off the road to ruin which it is now on. It does not replace private insurers, doctors and hospitals with government bureaucrats, or even force them to compete with government-run programs. Instead, it tries to slow the rise in costs by bringing as many Americans as possible into a more efficient system that rewards quality, not quantity.

Whether it will work as intended is impossible to say at this point. The most important elements of the law are still being phased in, and the most dramatic changes it imposes -- the mandate to buy insurance, the ban on insurers denying coverage to people with preexisting conditions, the new marketplaces for individuals to shop for policies and the restrictions on price discrimination by insurers -- won’t take effect until 2014.

Supporters tout a laundry list of smaller changes that have gone into effect. Insurers can no longer impose a lifetime cap on the benefits they pay, deny coverage to children based on preexisting conditions or impose co-pays in new policies for preventative care. Small businesses can obtain tax credits for offering coverage to employees. Parents can keep children up to age 26 on their own insurance policies. Insurers must spend at least 80 cents out of every premium dollar on healthcare and related expenses. People who are denied policies can obtain coverage from state-run high-risk insurance pools, although the high premiums have led far fewer people to sign up than anticipated.

Insurers say that these changes raise their costs, but not by much -- the vast majority of the premium increases they’re seeking still stem from the rising cost of medical care. Those increases are one reason the public remains skeptical about the value of the new law.

Work is moving ahead on cost containment. The administration and the healthcare industry are gradually implementing provisions of the law and the 2009 economic stimulus package that are designed to increase coordination among caregivers, reduce medical errors and preventable hospital admissions, improve the quality of medical records and promote innovation in the delivery of care. But realigning the incentives of the healthcare industry so that it profits from health, not disease, is a tough slog that will take years to accomplish.

A more profound and troubling question is the one at the heart of Johnson’s op-ed: How can we rein in spending on healthcare without denying treatment to someone who could benefit from it? To many opponents, the law’s efforts to promote more effective, higher-quality care carry a troubling whiff of cost-effectiveness analysis. Will expensive drugs and procedures be denied to Medicare and Medicaid recipients, or blocked by the Food and Drug Administration, because they only help a few people?


The law wouldn’t impose that kind of rationing, but it does impose a cap on Medicare spending tied to inflation and the size of the economy. An expanded advisory board is tasked with recommending ways to keep spending within that cap, but the law forbids it from recommending steps that would raise costs for beneficiaries or ration care. How exactly that’s going to work isn’t clear.

Although the division of power in Washington means that no meaningful changes in the law are likely to happen until after the 2012 elections (or the Supreme Court rules on the law’s constitutionality), Republicans are waging a seemingly relentless assault on its funding and implementation. That tension makes for a less-than-happy anniversary for the Affordable Care Act. For those of us who believe the act is an important step toward saving the healthcare system, though, it’s better than no anniversary at all.


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-- Jon Healey