Mission Not Accomplished

Three recent public announcements have convinced some to claim victory in the healthcare wars. Such a declaration is just as timely as the Iraq "Mission Accomplished" banner behind President Bush on the aircraft carrier USS Abraham Lincoln in May of 2003. Rather than being a roaring success, the mission of reforming our healthcare system is increasingly showing itself to be a failure.

Claim #1: Affordable health insurance rates

The ACA mandates the creation of Health Insurance Exchanges (HIX) that are supposed to provide low-cost health insurance for small business owners as well as individuals, especially the poor and those with chronic conditions. State HIXs in Vermont and California have recently published health insurance rates that they claim are lower than were available pre-ACA in the private market. Quite a feat, if true.

Vermont may be cheaper. As yet there is no objective comparison analysis to validate their claim. California is a different story.

Peter Lee, Executive Director of Covered California -- the name for their State HIX--proudly (and disingenuously) announced that they had reduced health insurance rates to levels lower than before ACA. California's "home run" (Lee's phrase, not mine) prompted some Kool-aid drinkers to ask if they might borrow President Bush's banner.

The California home run is, in fact, a strike-out. Lee's analysis was like comparing apples and hand grenades: after all, they are both round.

When Avik Roy and other reporters actually compared apples to apples, they found that Covered California health insurance rates were 64% to 146% higher than what was available before Obamacare. ACA is turning borderline affordable insurance into the truly unaffordable for all but the poorest citizens. For the middle class of America, this is the antithesis of "mission accomplished." 

It makes a mockery of the promises attached to ACA. After all, affordable or not, insurance is really only a door key. The door leads to the doctor's office and to health care. If the key does not open the door, what good is having insurance?

Even before ACA, many U.S. doctors could not afford to accept government insurance payment schedules: 30% refuse Medicaid and close to 50% could not accept Medicare patients.

What is ACA's solution? It reduces payments to providers by an additional 21-27%. As Robert Moffit of the Heritage Foundation testified before Congress, "You cannot get more of something by paying less for it." As a direct result of ACA, there will be even fewer doctors.

Now do the arithmetic (Congress didn't): more insured people + fewer doctors = less available medical care. The healthcare mission was never health insurance, not really. It was health care. That mission is being subverted.

Claim #2: ACA improves health care quality

Consumer advocate groups have been hailing the fact that ACA is starting to measure healthcare quality. But what we should be measuring is health, not health care. What they are calling "quality," what they are measuring, is: deaths, hospital readmissions, complications, lawsuits, and costs.

Management experts and experienced businesspersons know that, you get what you measure. Healthcare measures all the things we don't want? Is anyone surprised that what we "get" deaths, complications, readmissions, lawsuits and out-of-control spending?

What we want from healthcare is (a) long life; (b) good health; (c) prompt and complete restoration of health when we are sick; and (d) having money. We should measure those outcomes. ACA does not.

Not dying (low mortality) is not the same thing as living a long life. Staying out of the hospital after your back surgery is hardly the same as being able to walk without pain. Not spending money is very, very different from having money in your hand.

The trouble with what ACA calls quality is that it bears no close relationship to what we want. Further, what ACA measures can be "gamed," and most important, the government has the wrong time horizon. They look only at immediate results, when what we want is decades in the future. How can you tell if the mission is accomplished when you do not measure mission objectives?

Claim #3: ACA reduces healthcare costs

The third claim for mission success is the most egregious. Kathleen Sebelius, U.S. Secretary of Health and Human Services, recently released a statement (03/12/13) titled, "Affordable Care Act is Working to Bring Down Health Care Costs." If true, this would be a start to "mission accomplished." It isn't. It is the same sleight-of-hand, smoke-and-mirrors political spin as we have come to know and love. (Okay, no one outside the Beltway loves it.)

Secretary Sebelius writes "costs" but she is talking about spending. They are very, very different, as anyone knows who has ever balanced a checkbook.

The average estimate for the projected spending on ACA is $1.76 trillion. That is new spending. I fail to understand how anyone can then claim that ACA has lowered (!) our spending on healthcare.

Next, there is Sebelius' assertion that the Congressional Budget Office (CBO) says, "the law is [already] fully paid for." How can a Law be already paid off that is scheduled to spend well over $1 trillion over the next ten years??

For example, our own New Mexico HIX has not yet spent a dime of the federally promised hundreds of millions it will cost to implement our Exchange and then provide ongoing care. The same is true for all the other states. Hundreds of billions, probably trillions, have not yet been spent on Exchanges and Medicaid expansion, but they will be spent, in the future!

ACA is force-feeding an already overbloated national deficit, and handing the bill for all this spending (not costs) to our children. Do you think they will be happy about their inheritance?

Instead of rehanging President Bush's banner "Mission Accomplished," we need to make a new one. This one should read: What should we do NOW?

Deane Waldman MD MBA is a member of the newly constituted New Mexico Health Insurance Exchange Board; Adjunct Scholar for the Rio Grande Foundation; Emeritus Professor of Pediatrics, Pathology and Decision Science; and author of "Uproot US Healthcare" as well as "The Cancer in Healthcare" (September 2013).

Three recent public announcements have convinced some to claim victory in the healthcare wars. Such a declaration is just as timely as the Iraq "Mission Accomplished" banner behind President Bush on the aircraft carrier USS Abraham Lincoln in May of 2003. Rather than being a roaring success, the mission of reforming our healthcare system is increasingly showing itself to be a failure.

Claim #1: Affordable health insurance rates

The ACA mandates the creation of Health Insurance Exchanges (HIX) that are supposed to provide low-cost health insurance for small business owners as well as individuals, especially the poor and those with chronic conditions. State HIXs in Vermont and California have recently published health insurance rates that they claim are lower than were available pre-ACA in the private market. Quite a feat, if true.

Vermont may be cheaper. As yet there is no objective comparison analysis to validate their claim. California is a different story.

Peter Lee, Executive Director of Covered California -- the name for their State HIX--proudly (and disingenuously) announced that they had reduced health insurance rates to levels lower than before ACA. California's "home run" (Lee's phrase, not mine) prompted some Kool-aid drinkers to ask if they might borrow President Bush's banner.

The California home run is, in fact, a strike-out. Lee's analysis was like comparing apples and hand grenades: after all, they are both round.

When Avik Roy and other reporters actually compared apples to apples, they found that Covered California health insurance rates were 64% to 146% higher than what was available before Obamacare. ACA is turning borderline affordable insurance into the truly unaffordable for all but the poorest citizens. For the middle class of America, this is the antithesis of "mission accomplished." 

It makes a mockery of the promises attached to ACA. After all, affordable or not, insurance is really only a door key. The door leads to the doctor's office and to health care. If the key does not open the door, what good is having insurance?

Even before ACA, many U.S. doctors could not afford to accept government insurance payment schedules: 30% refuse Medicaid and close to 50% could not accept Medicare patients.

What is ACA's solution? It reduces payments to providers by an additional 21-27%. As Robert Moffit of the Heritage Foundation testified before Congress, "You cannot get more of something by paying less for it." As a direct result of ACA, there will be even fewer doctors.

Now do the arithmetic (Congress didn't): more insured people + fewer doctors = less available medical care. The healthcare mission was never health insurance, not really. It was health care. That mission is being subverted.

Claim #2: ACA improves health care quality

Consumer advocate groups have been hailing the fact that ACA is starting to measure healthcare quality. But what we should be measuring is health, not health care. What they are calling "quality," what they are measuring, is: deaths, hospital readmissions, complications, lawsuits, and costs.

Management experts and experienced businesspersons know that, you get what you measure. Healthcare measures all the things we don't want? Is anyone surprised that what we "get" deaths, complications, readmissions, lawsuits and out-of-control spending?

What we want from healthcare is (a) long life; (b) good health; (c) prompt and complete restoration of health when we are sick; and (d) having money. We should measure those outcomes. ACA does not.

Not dying (low mortality) is not the same thing as living a long life. Staying out of the hospital after your back surgery is hardly the same as being able to walk without pain. Not spending money is very, very different from having money in your hand.

The trouble with what ACA calls quality is that it bears no close relationship to what we want. Further, what ACA measures can be "gamed," and most important, the government has the wrong time horizon. They look only at immediate results, when what we want is decades in the future. How can you tell if the mission is accomplished when you do not measure mission objectives?

Claim #3: ACA reduces healthcare costs

The third claim for mission success is the most egregious. Kathleen Sebelius, U.S. Secretary of Health and Human Services, recently released a statement (03/12/13) titled, "Affordable Care Act is Working to Bring Down Health Care Costs." If true, this would be a start to "mission accomplished." It isn't. It is the same sleight-of-hand, smoke-and-mirrors political spin as we have come to know and love. (Okay, no one outside the Beltway loves it.)

Secretary Sebelius writes "costs" but she is talking about spending. They are very, very different, as anyone knows who has ever balanced a checkbook.

The average estimate for the projected spending on ACA is $1.76 trillion. That is new spending. I fail to understand how anyone can then claim that ACA has lowered (!) our spending on healthcare.

Next, there is Sebelius' assertion that the Congressional Budget Office (CBO) says, "the law is [already] fully paid for." How can a Law be already paid off that is scheduled to spend well over $1 trillion over the next ten years??

For example, our own New Mexico HIX has not yet spent a dime of the federally promised hundreds of millions it will cost to implement our Exchange and then provide ongoing care. The same is true for all the other states. Hundreds of billions, probably trillions, have not yet been spent on Exchanges and Medicaid expansion, but they will be spent, in the future!

ACA is force-feeding an already overbloated national deficit, and handing the bill for all this spending (not costs) to our children. Do you think they will be happy about their inheritance?

Instead of rehanging President Bush's banner "Mission Accomplished," we need to make a new one. This one should read: What should we do NOW?

Deane Waldman MD MBA is a member of the newly constituted New Mexico Health Insurance Exchange Board; Adjunct Scholar for the Rio Grande Foundation; Emeritus Professor of Pediatrics, Pathology and Decision Science; and author of "Uproot US Healthcare" as well as "The Cancer in Healthcare" (September 2013).

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