Repeal Obamacare; sustain the Affordable Care Act

On the Election Day that made Donald Trump the next President of the United States, I traveled to Lancaster, Pennsylvania to give a lecture. Long a conservative political stronghold, Lancaster County was dotted with "Make America Great Again" campaign signs, forecasting Trump's comfortable 47,000 vote margin there, which ended up being more than two-thirds of his 68,000 victory margin in Pennsylvania, one of the states that effectively decided the election. Ironically, Lancaster is where I trained to become a family physician from 2001 through 2004, and it is the place where I first recognized that the health care system our country had then was not up to the task of caring for all the people. Lancaster, which started me on my path toward advocating for reforms that ended up in the Affordable Care Act, voted overwhelmingly for a candidate who has promised to repeal it.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy has been a mess. The trillions of dollars in debt that the U.S. has run up over his term will hurt my generation and future generations, and if Republicans should be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that included morally repugnant death panels staffed by faceless bureaucrats who decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that said that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that regulates the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar politically conservative law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieved the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discouraged irresponsible health care "free riders" and provided support for people of modest means to purchase private health insurance in regulated open marketplaces. It told insurers that in exchange for millions of new customers, they could no longer discriminate against the old and sick. Finally, the ACA rewarded physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may not improve health.

The ACA has flaws. It didn't narrow the income disparity between different types of physicians or encourage more medical students to choose careers in primary care. It didn't prevent pharmaceutical companies from arbitrarily jacking up prices on old but essential drugs. Its provisions to discourage overuse of unnecessary medical services were limited and inadequate to the scope of the problem. But it's worth noting that all of these problems all predated the law. We don't have enough family physicians and other primary care clinicians, drugs in the U.S. cost more than anywhere else in the world, and overdiagnosis and overtreatment have been rampant for years. That the ACA took on these issues at all was a small victory.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for thoughtful Republicans to look past their leaders' overheated rhetoric about repealing Obamacare and focus on strengthening and sustaining the ACA, starting now.

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A slightly different version of this post first appeared on Common Sense Family Doctor on September 30, 2013.