How will President Romney and the Republican-led 113th Congress move the nation's health care system to the right of the Affordable Care Act (a.k.a., "Obamacare")?
We all understand, as we've been over it ad nauseam, that the ACA is essentially the same as any and all Republican/conservative health care reform proposals dating back to the late 1980's. We know that Republican politicians and media enablers are lying through their teeth when they describe the law, and particularly its individual mandate, as a far-left-wing super-ultra-liberal socialist-commie Democrat-party policy, because it is in fact about as far to the right as one can go if one's goal is to make basic and emergency medical care accessible and affordable to the largest possible number of people.
It's important to begin any discussion of health care reform with an understanding of the problem that the ACA, or any other reform plan, purports to solve: the existence of tens of millions of uninsured people who cannot afford basic or emergency medical care, and the tens of billions of dollars per year of uninsured medical risk that the system has to subsidize as a result, which drives up the cost for those who can afford it and makes it unaffordable for more and more people. Regardless of one's political orientation, we have to start from here in crafting a solution.
The Affordable Care Act and its individual mandate represents a conservative, market-based solution to this problem: mandatory participation in a competitive marketplace of well-regulated private insurers. To the left of the ACA are any and all forms of public/social insurance, including single-payer (i.e., a single tax-funded public insurer with minimal overhead, no profit motive, and the largest possible risk pool), a "public option" (voluntary rather than mandatory participation in said public insurer), and a true socialized system owned, operated, and funded publicly. But what kind of system may be found to the right of the ACA?
It is practically impossible to get to the right of the ACA without abandoning its core goal of making health care accessible to more people, and focusing instead on reducing costs to patients who can pay while preserving the profit-making potential for insurers and providers. No matter how hard they try, conservatives cannot wish away the existence of people who can't afford medical care or insurance, and the cost of all the uninsured risk that they carry. So any "solution" to the right of the ACA has to take this into account.
Mandate or no mandate, there are really only two things we can do about the uninsured: treat them anyway and subsidize the cost if they can't pay in full, or don't treat them and make them suffer the consequences of their choice to go without insurance or their inability to afford it. The former is what we've been doing; the latter appears to be the broad stroke of what conservatives and Republicans want. To put it another way, we can avoid the cost of treating the uninsured either by getting them insured, or by not treating them.
A commenter over on HuffPo recently expressed the conservative approach as clearly and directly as I've ever heard or read:
[H]ow about this. Pay for Service. If you can afford it you get it. If you can't, then you have to find someone to treat you for free, or eggs, or a goat, or whatever. If you got nothing then find a nice soft place to lay down and wing off.
Of course I asked him to take this idea a step further and explain how to go about actually making it happen, but of course he couldn't and instead flew into a rage of insults and anti-Obamacare talking points. This is a recurring pattern among GOP fans I've debated who hate Obamacare but cannot articulate the practical, working details of a more conservative alternative. It's one thing to
say that people who have no insurance and can't afford treatment should not get treated. It's quite another to make sure that that actually happens.
So how do we make sure that people who are uninsured and cannot afford to pay for medical care, don't get treated? Any Republican health care plan that is to the right of the ACA would have to, at a minimum, include the following provisions and features:
- Repeal both the Affordable Care Act and EMTALA (Emergency Medical Treatment and Active Labor Act of 1986), alleviating the requirement that ERs and EMS treat all patients regardless of insurance, payment and/or citizenship.
- Allow (or require) 911 operators and ER desk clerks to demand proof of insurance, and/or payment in full up front, before dispatching EMS or administering treatment in an emergency.
- Make it illegal for any 911 operator or hospital personnel to dispatch or administer any medical treatment or services of any kind, including emergency, to any person they have reason to believe is uninsured and cannot afford to pay in full.
- Limit the liability of 911 operators, EMTs, hospital staff, &c. for negative medical outcomes caused by delays and errors in ascertaining insurance/payment prior to treatment.
- Eliminate all liability for medical malpractice in cases involving uninsured patients and/or unpaid-for medical services.
- Provide civil and/or criminal penalties for calling 911 or showing up at an ER without insurance and without paying in full up front (i.e., for trying to free-ride off the system).
Of course, more details would need to be ironed out. For example, the Republicans might want to consider finding a way to prevent doctors and providers from extorting money from patients in distress (since they would now be allowed to insist on being paid
before administering treatment and would have limited liability if, e.g., the patient dies before his check clears). They might also consider amending the Bankruptcy Code to deal with medical bankruptcies in a way that is more advantageous to providers. I expect they would also need to find a way to address the externalities and costs of living, and trying to do business, in a country filled with sick and disabled people whose sickness and disability we have consciously chosen
not to ameliorate.
But those details can be worked out by President Romney, Speaker Boehner, and Majority Leader McConnell, next year. This nevertheless is the outline of the Republican health care plan, in more detail than any Republican politician or media enabler has thus far been able to articulate it. I call it the Pay Or Suffer Act of 2013. Or, POS for short.
