AMA Promotes Obama’s Healthcare Agenda


This week’s health policy news roundup curated by Jane M. Orient, M.D.

Barack Obama, JD, is the first sitting President to publish an article in JAMA. Accompanying it are four generally supportive editorials. Obama applauds his own work; the frequent use of “I” and “my” is likely also unprecedented in a JAMA article.

Obama attributes any positive trends to the Affordable Care Act (ACA). James Capretta writes: “On cost growth, the president engages in the usual post hoc fallacy. He says that recently costs have been growing less rapidly than in the past and that therefore the cause must be the enactment of the ACA in 2010…. Most of the slowdown of recent years was due to the deep recession of 2007–09 and the slow recovery that followed.”

Any problems confronting ACA are the result of “hyperpartisanship,” Obama writes.

Obama ignores the increasing instability of ACA exchanges, Capretta notes.

Obama’s main suggestion for the future is adding a “public option.” “It is telling that President Obama is once again calling for the public option as he ends his time in office. He has spent the past several years denouncing opponents of the ACA for using the overheated rhetoric of a ‘government takeover,’” Capretta states. “But a public option would bring millions of Americans into a Medicare-type insurance plan and make it very difficult for private insurers to compete for customers. The president knows this, which is why he supports the idea. He believes in government-run health care and has been pushing to bring it about throughout his time in office, even if he won’t admit it.”

JAMA editor-in-chief Howard Bauchner writes that “it would be unfair to expect that the ACA, in a matter of only a few years, would improve true health outcomes of individuals, much less that of the nation.” He expects those big gains to be in the future.

However, AMA Morning Rounds for Aug 9 is headlined “Medicaid expansion linked to better health outcomes, study shows.” The outcomes were: a decrease of 11.6 percentage points in patients skipping prescription medications and 14 percentage points in trouble paying medical bills. The was an increase of 16.1 percentage points in annual checkups and 12 percentage points in patients receiving regular care for chronic conditions. People’s health should improve—ultimately.

Details not noted in JAMA:

ObamaCare hides $104 billion in federal spending by labeling its direct outlays to insurance companies “tax credits” (not outlays)—even though they don’t actually cut anyone’s taxes. This could set a notorious precedent, writes Jeffrey H. Anderson.

Not-yet-implemented provisions will limit what private citizens are allowed to spend on their own care.

Insurers are suing the federal government in an attempt to recoup their losses.

ACA’s risk-adjustment methods are hammering small insurers.

ACA’s risk-adjustment program presents a fundamental trap, a sort of “damned if you do, damned if you don’t” scenario, explains Brian Blase. To the degree that risk adjustment works, insurers individually lack the incentive to enroll the young and healthy people needed for the ACA’s complicated structure to survive. To the degree that risk adjustment doesn’t work, large arbitrary transfers between insurers occur that produce significant uncertainty in the market.”

The way that ACA’s Accountable Care Organizations (ACOs) reduce costs is to encourage doctors and hospitals to deny services to seniors and disabled Medicare beneficiaries. “The system encourages hospitals, physicians and potentially other providers to merge, to make it easier to ‘make sure’ that patients don’t get ‘extra’ healthcare from unaffiliated providers,” writes Robert Book.

Newly insured persons under ACA are largely on Medicaid. And the average cost per enrollee of the Medicaid expansion was 50% higher than estimated. Moreover, new Medicaid enrollees only receive about 20 to 40 cents of benefit for each dollar of spending on their behalf, writes Brian Blase (Forbes 7/20/16).

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