Saturday, July 26, 2014

ObamaCare Issue: Private Choice Versus Government Coercion

Debate on public issues should be uninhibited, robust, and wide open.

William Joseph Brennan, Jr (1906- 1997), Supreme Court Justice, New York Times v. Sullivan (1964)

Issues raised by ObamaCare boil down to private choice versus public coercion. There are unsettling issues on both side of the political divide that do not lend themselves to easy solutions.

Some issues come down to volume-based care (i.e. paying for care without question while trusting doctors and hospitals ) and to value-based care (paying for results and outcomes based on data).

It’s not that simple. Psychological , philosophical, and ideological issues, e.g. trust in government versus trust in markets, government control and coercion versus individual freedoms and free enterprise loom.

An example of coercion is ObamaCare with its individual and employer mandates with penalties if one does obey these mandates. Exemplifying choice is free market medicine allowing physicians and hospitals to charge fee-for-service with market competition allowing consumers to choose providers.

Phil Gramm, former House of Representative member (R-Texas). believes choice and freedom will be winning issues for Republicans in the upcoming midterms.

“There is one unifying principle that Republicans can and should rally around now; the right of American families to choose their own health-care coverage…Americans should have the right to buy insurance that meets their own needs…in the end they debate is not about money or efficiency, it is about freedom.( “ 2014 Health-Care Strategy: Freedom, WSJ, July 25, 2014).

Aligned against the freedom concept are ObamaCare supporters who insist the central issue is affordability for the uninsured, the poor, and the sick. This strategy requires subsidies , redistribution of resources , and coercion in the form of mandates, penalties, and higher taxes.

Both solutions require tradeoffs, compromises, and tectonic shifts in thinking (Rene Letourneau, “ Four Tectonic Shifts Shaking Up Health Care”, Health Leaders Media, July 24, 2014). According to Andrew Croshaw, president of Leavitt Partners Consultants, four of these tectonic shifts are:

1. Risk-based reimbursement - Accountable Care Organizations, bundled services, shared savings for Medicare patients. These approaches tend to be coercive. They require government oversight and losses of freedoms and choice for patients and physicians, particularly specialists.

2. Health insurance exchanges - Implementing these exchanges is coercive . Making them work demands federal-state cooperation, federal subsidies of $4200 per patient, an efficient computer system, narrowing of physician networks, and significant increases in premiums for the young and the healthy. Coercion is needed to generate enough revenue in penalties to support the system. Patients lose freedom of choice through narrowed networks.

3. High deductible plans with health savings accounts. These plans stress freedom of choice of action for consumers. Liberals and Obama advocates in general oppose HSAs with high deductible plans because they leave choice in the hands of consumers, who may exercise their own judgments rather than following federal guidelines.

4. Economic dispassion - Coercive. ObamaCare is based on premise market dispassion trumps emotions surrounding keeping your doctor and health plan. Tends be coercive. Under ObamaCare, patients will be directed to low cost hospitals an and doctors (sometimes called “race to bottom’) who will be paid on basis of adherence of guidelines and value (outcomes /dollar spent), rather than volume ( paying and trusting doctors to do the right thing). The notion is: use data to control and judge performance and improve quality: sacrifice choice and freedom of patients and doctors if necessary.

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