Family Physicians and "ObamneyCare"

Who wrote this in a USA Today editorial in 2009?: 

Obama could learn a thing or two about health care reform from Massachusetts … No other state has made as much progress in covering their uninsured as Massachusetts.

Obviously, this was written by former Massachusetts governor, Mitt Romney. The editorial—in the form of an open letter to President Obama—offered advice on rekindling the stalled congressional debate on health care reform during the summer of 2009. The former governor proposed a list of recommendations for forging a bipartisan bill based on the 2006 Massachusetts health insurance reform law. 

Unlike the government-sponsored “public option” plan endorsed by the president at that time, Mr. Romney proposed that we build upon the existing private insurance market. His plan would establish “incentives for those who were uninsured to buy insurance”—an incentive enforced by “tax penalties.” Under this mechanism, "free riders" would “take responsibility for themselves rather than pass their medical costs on to others.” For people who can’t afford insurance, Mr. Romney recommended that the federal government use systemic cost savings “to help the poor buy private insurance.”

Mr. Romney goes on to identify the federal government as the only entity with the power to “stop or slow medical inflation”:

At the core of our health cost problem is an incentive problem. Patients don't care what treatments cost once they pass the deductible. And providers are paid more when they do more; they are paid for quantity, not quality. We will tame runaway costs only when we change incentives. We might do what some countries have done: Require patients to pay a portion of their bill, except for certain conditions. And providers could be paid an annual fixed fee for the primary care of an individual and a separate fixed fee for the treatment of a specific condition.

In a remarkable turn of events, Mr. Obama abandoned his platform of government-sponsored insurance, and adopted every one of the recommendations in Mr. Romney’s editorial. The final result was the Patient Protection and Affordable Care Act, a conservative plan that is essentially identical to Mr. Romney's Massachusetts health plan. We might as well call it “ObamneyCare.”

The PPACA relies on the private insurance market. It broadens participation in the market by charging a tax penalty on persons who refuse to obtain insurance. It provides subsidies for the poor to purchase private policies through state-based insurance exchanges. And it begins the process of reforming the Medicare program through an enhanced primary care payment system and greater emphasis on the comparative effectiveness of medical interventions. Savings derived from Medicare reform will be used to subsidize the purchase of private policies, and to expand state-run Medicaid programs. All of these components are clearly spelled out in Mr. Romney’s editorial.

The similarities between the PPACA and Mr. Romney’s plan (and the Republican Health Equity and Access Reform Today Act of 1993) are remarkable, making it difficult to comprehend the current vehement political opposition to the PPACA. Even more perplexing is the opposition coming from physicians.

The South Carolina Medical Association has been strident in its criticism of the PPACA, expressing its extreme disappointment with the Supreme Court’s ruling upholding the law, and vowing to oppose healthcare reform on the federal level. An editorial in the Spring issue of this journal noted that the next election is the most import of our life time because it may be our last opportunity to stop the Obama administration from turning our country into a “socialist state.” These hyperbolic statements are counterfactual, and family physician should know better.

Family physicians should know better, because we have first-hand knowledge of the dysfunctional nature of our pre-PPACA health care system. We see patients struggling to pay their medical bills and hear about the resulting bankruptcies. We see how being uninsured leads to costly delays in treatment and adverse outcomes. We see the waste of money and resources that results from accessing routine care through the emergency room. And we hear the tragic stories of the working poor who must rely on the meager assistance we can provide through our community free clinics.

Family physicians should know better, because we have the knowledge and expertise to understand the evidence that supports a high performing health care system. We know the facts about our country’s poor performance on health care outcomes compared to other developed countries. We have seen the dreadful statistic on health care disparities, and the charts projecting unsustainable growth in the Medicare program over the next decade. We understand how cost-shifting and adverse selection make private insurance unaffordable. We should know better because we can see how reliance on a private employer-financed system and an underfunded public Medicaid system leaves us with the worst of both worlds.

Family physicians should know better, because the current system is destroying our profession. Primary care medicine is in peril because of the present fee-for-service reimbursement system. The PPACA includes several reforms aimed at strengthening the primary care workforce, and compensating physicians for the work involved in care management. Without these reforms, family medicine will eventually find itself in an untenable financial position.

Now that the Supreme Court sideshow is over, it is time to move on and fully implement the PPACA. There is much more work ahead, including fixing the Sustainable Growth Formula, and achieving meaningful liability reform. As a professional society, we should be willing to work with policymakers of all political stripes to enhance the quality of health care, improve access and affordability, and promote a health care system based on primary care. Health care reform is a complex issue that requires dispassionate debate and fact-based reasoning. For the sake of our patients, our country, and our profession, we should refrain from making exaggerated and inaccurate claims about the nature of of the PPACA. 

Perhaps this year’s election really is the most important one in our lifetime. Regardless of who wins, we will have a president who understands—and has supported—the reforms embodied in the PPACA. If Mr. Obama wins, his administration is likely to continue these reforms. If Mr. Romney wins, we can hope that his recent statements are simply election year rhetoric, and that the thoughtful positions he eloquently expressed prior to the campaign season, will prevail after November.

This article was published in South Carolina Family Physician.