Note:  This item has been modified since the original posting on December 10 in response to reader comments.

Beating out his opponent by a narrow lead in the popular vote, Barack Obama secured his re-election on November 6.  The question still remains – should his re-election be viewed as an endorsement of our President’s first term performance and policies, or should it more correctly be viewed as a clear rejection of an archaic platform favoring the wealthy elite that the GOP’s power center attempted to cram down our throats?

To be sure, both candidates made their share of gaffes during this particularly mean spirited campaign.  While Barack Obama managed to get re-elected, his first term performance has fallen short of his lavish promises to the American people.  As he prepares for his re-inauguration in January the burning question on my mind, and the minds of millions of fellow Americans, is – can he take a cold hard look at both his successes and his mistakes over the past four years, and take to heart the lessons he needs to learn in order to remake his presidency and effectively lead our nation during these extremely troubled times?  That pivotal question forms the focus of this two-part series.

Why this critique?

When I voted for Obama the first time I was buoyed by hope and enthusiasm.  Like millions of voters, I was sick and tired of eight years of unfunded wars and welfare for the rich, and hungry for change.  I was particularly inspired by Obama’s book “The Audacity of Hope: Thoughts on Reclaiming the American Dream” and was convinced that he was our man!

To our President’s credit he has done much to move our country forward during his first term, despite being hamstrung by an obstructionist GOP-dominated Congress over the past two years.  Landmark accomplishments include his signature Affordable Care Act, repeal of “Don’t Ask, Don’t Tell”, badly needed banking regulation reform, and student loan and credit reform.  I also credit him with averting a possible depression by bailing out the auto industry early in his term.  By the same token I have, along with many others, been disturbed by many aspects of both his style and demeanor that I believe have seriously detracted from his effectiveness over the past four years.  The purpose of this two-installment series is to provide a (hopefully) constructive critique of his performance, highlighting salient items that I hope our President and his advisers may take to heart as his second term approaches.

This year I once again voted for Obama.  Extremely disillusioned with his first four years in office, this time I cast my ballot with considerable reluctance.  As a public health professional and social commentator, the main reason I voted for Obama this time was my firm conviction that his signature first term accomplishment, the Affordable Care Act, provides a workable starting point for badly needed health care reform.

Even on that score I initially flirted with voting for Romney: After all, he had demonstrated impressive bipartisan leadership as Governor of our nation’s most liberal state, and had implemented a universal health coverage program in Massachusetts that served as the prototype for Obamacare.  As it became evident, however, that Romney had been forced to sell his soul to appease his party’s arch conservative power base, I chose to cast my lot with Obama once again.

Almost from his first day in office, I harbored a disconcerting sense of incongruity between the lofty ideals that Obama set forth so eloquently in his campaign rhetoric and the shocking realities of his first term performance.

Earlier this year I read Edward Klein’s book: “The Amateur: Barack Obama in the White House”.  Klein is, to be sure, a staunch detractor of our President who goes overboard in zealously embracing the “socialist conspiracy” diatribe in reference to Obama’s so-called “hidden agenda”.  Nonetheless, “The Amateur” is a well-documented piece of work based on painstaking interviews with hundreds of members of Obama’s inner and outer circles.  As I read this book, many of the pieces began to come together concerning my own discomfort with the chasm between our President’s campaign promises and the realities of his first term.

While Obama garnered an overwhelming victory in terms of electoral votes, his lead in the popular vote was nothing to write home about.  My biggest fear is that our newly re-elected President and his team will view the election results as a mandate for “four more years of the same”.  Nothing could be further from the truth.  Indeed, if Obama aspires to emerge as a true leader during these extremely challenging times and leave behind a truly presidential legacy, he must take to heart some very serious lessons he needs to learn based on his first term in office.

Walk the walk

In a nutshell, Obama must whole-heartedly focus on getting beyond the rhetoric and truly walk the walk in terms of translating his lofty promises into reality.  Being a charismatic campaigner is one thing – serving as a truly effective president requires a very disparate set of attributes and skills, including the qualities of accessibility, candor and focused determination.  On many occasions these qualities have been sorely lacking in Obama’s performance over the first four years.  In particular, our President needs to take the reins in his hands and assume a truly presidential stature.  In this regard, a healthy dose of humility would be most helpful.

To be blunt, the public persona that he projects is too slick and overly cerebral, and too often he comes across as believing that the day-to-day political maneuvering that goes with the territory is beneath him.  He has failed to win the trust of the American people.  To do so he must get out of his head and into his heart.

The words of an eminent Chicago based physician, Dr. David Schneider, as related to author Edward Klein are instructive here.  According to Dr. Schneider, who served as Obama’s personal physician for 22 years, “…he is a great speaker and a lousy communicator…He isn’t getting his message across to the people.  He isn’t showing that he really cares.  To this day he hasn’t communicated with members of Congress!” (emphasis added)  Dr. Schneider goes on to state that Obama simply has “too much of the University of Chicago in him” – that he is overly aloof and academic, lacks passion and feeling, and doesn’t have the sense of humanity that one would expect to see in a president.

His Finest Hour

One January 12, 2011, while I was putting together my most recent book “The Tucson Tragedy: Lessons from the Senseless Shooting of Gabrielle Giffords”, I was one of 26,000 people who attended President Obama’s memorial speech at the University of Arizona just four days after the shooting.  Speaking from the depths of his being, he brought tears to the eyes of many attendees including myself.  In this heartwarming talk he reminded us of the decency of the vast majority of Americans and underscored the need “to listen to each other more carefully, to sharpen our instincts for empathy and remind ourselves of all the ways that our hopes and dreams are bound together”.  He delivered compassionate eulogies for each of the six victims slain that day and in closing, challenged us to live up to the expectations of the youngest victim, nine-year-old Christina-Taylor Green, whose tragic death serves as a poignant reminder to all Americans that we can – and must – do better.

To be sure, our President’s healing message delivered just four days after the tragic shooting of our beloved Congresswoman and eighteen others, was a definite turning point in our heart-broken community’s ability to move forward from tragedy to healing.  It was, in my opinion, his finest hour.  Unfortunately, the dignity and compassion pouring from our leader’s heart that evening has often been lacking in his day to day interaction with government representatives on both sides of the aisle and with the American people.

Failure to Take the High Road

Shortly after Obama’s inauguration I became profoundly disenchanted with his inability to take the high road in regard to critical junctures confronting him early in his term.  I was equally disappointed with the relative lack of criticism from the press concerning these disturbing incidents.

The first incident took the form of Obama’s blatant opportunism concerning the appointment of Roland Burris, by discredited Governor Rod Blagojevich, to fill the Illinois election seat about to be vacated by Obama’s inauguration as President.    Blagojevich’s appointment of Burris on December 30, 2008 was extremely controversial, as the Governor was already under investigation for allegedly seeking bribes in a pay-to-play scheme for the empty Senate seat.  While Illinois Secretary of State Jesse White registered the appointment in the official state records on December 31, White declined to sign the Senate’s certification form.

On January 5, 2009, Secretary of the U.S. Senate Nancy Erickson rejected Burris’ certificate of appointment as invalid, and Senate Majority Leader Harry Reid and Illinois senior Senator Dick Durbin agreed with Erickson that Senate rules required the Illinois Secretary of State’s signature on the certification form.

On January 9 the Illinois Supreme Court ruled that the Senate appointment only required the signature of the Governor to make the appointment valid.  Informed sources allege that behind-the-scenes maneuvering on the part of President-Elect Obama and his cronies most likely played an instrumental role in the Illinois Supreme Court decision.  Furthermore, Senate Majority Leader Harry Reid was pressured by Obama to retract his initial statement that the Senate would not seat Burris.  Thus Roland Burris was sworn into the Senate “under a cloud” on January 15, and Governor Blagojevich was subsequently removed from office and sent to prison.

While it is understandable that Obama and his advisers were chafing at the bit to ensure a filibuster-proof super majority in the Senate as he entered office, his behind-the-scenes maneuvering to ensure that Burris would gain “back-door entry” to the Senate via appointment by a highly discredited Governor was both highly controversial and simply the wrong thing to do.

Indeed, Obama’s credibility in terms of bringing truly presidential qualities to the office would have been infinitely better served if he had stood the moral high ground in this matter.  Specifically, he should have come forth publicly and urged Burris to demonstrate that he was, indeed, the best candidate for the job by running for the seat in a special election.  The highly questionable appointment of Burris by the ousted Governor should have been set aside, and Obama could have then returned to Illinois to vigorously campaign on his behalf.  Had this been the case, I believe there is an excellent chance that Burris would have won the election.  And most importantly, Obama would have begun his term in office as a trusted friend of the people who elected him.

In addition to his failure to take the high road on numerous occasions over the course of his first term, Barack Obama has repeatedly let down both his ardent supporters and the American people over the past four years.  Read on for details in the next installment.

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John Newport (Dr. John) is a centrist Democrat and an author, speaker and social commentator who lives in Tucson and loves the city and its people.  He writes from the heart and has four books under his belt, together with over 200 articles focusing on personal and societal wellness, self-help and spirituality.  His most recent book “The Tucson Tragedy: Lessons from the Senseless Shooting of Gabrielle Giffords”, was featured on Tucson channels 4 and 13 and in the FOX 11 forum, as well as on “Good Morning Arizona”.  (For further information on this book visit www.healingtucson.net)  He frequently contributes letters and opinion pieces to the Arizona Daily Star, Los Angeles Times, Seattle Times, The Therapist and other publications.

In the first two installments in this series, which were posted concurrently on October 22, I compared and contrasted basic features of the Affordable Care Act, generally referred to as Obamacare, and the Romney/Ryan alternative for health care reform.

I believe that the Affordable Care Act offers many positive benefits to our nation’s people and moves us in the right direction for fixing our broken health care system.  At the same time I am aware that the act in its present form presents significant problems that must be resolved in implementation.  This installment addresses two of the most daunting issues – fears of overwhelming our system through extending coverage to an estimated 30 million additional Americans, and fears concerning adverse repercussions to seniors that may result from alleged cutbacks in Medicare outlays over the next 10 years.

Fear of overwhelming the system

Many doctors and health care administrators fear that our health care system will be overwhelmed with extension of insurance coverage to an estimated 30 million additional citizens, beginning in 2014.  As a public health professional I believe our nation has a moral responsibility to provide coverage for all Americans; this is particularly true as we are the only developed country that does not provide universal health care coverage.  At the same time I am keenly aware that the newly covered persons must be brought on board in a manner that does not unduly burden doctors, hospitals and other providers, and does not impose an inordinate disruption of care to the over 255 million Americans who  are currently insured

Obviously this will require careful planning involving all stakeholders, working in concert to ensure a smooth transition in the most effective and efficient manner.  As discussed below, this will require unprecedented levels of cooperation among widely disparate factions, together with implementation of boldly innovative approaches to improve health care access while focusing on skillful provision of that care which is truly needed.  Effective implementation of the Affordable Care Act will also require dramatically increased use of preventive services while both enabling and encouraging doctors, nurses and other providers to empower their patients to take charge of their health.

To gain a perspective on the problem, let’s look at the composition of the 30 million new health insurance enrollees to be brought on board beginning in 2014.  Over the past several decades our country has undergone a serious erosion in provision of health coverage by employers.  As a result, we now have large numbers of working people, self-employed people and their dependents who are uninsured, together with historically high ranks of unemployed Americans who in most cases are uninsured.

Many of the projected 30 million new enrollees are currently in the system, while lacking any form of coverage.  Instead, they tend to defer care until it is absolutely necessary and then either pay for services out of pocket, until their resources become exhausted, or use hospital emergency rooms, public clinics and public or charitable hospitals as their primary source of care.  Of course when these people can no longer pay for care the government steps in, in one form or another and we all pick up the tab as taxpayers.

These Americans are either wholly or partially medically disenfranchised, and are often forced to either forego early treatment of their conditions, or utilize highly expensive portals of care, particularly hospital emergency services.  This forced use of emergency services as a primary care resource poses a considerable cost burden on our nation’s hospitals, privately insured patients and taxpayers, as hospitals are forced to engage in “cost-shifting” in an effort to cover costs of uncompensated care that they are legally obligated to provide.

This non-system of providing care for uninsured patients is impractical, highly inefficient and inhumane.  Our de facto policy of forcing millions of Americans to repeatedly visit hospital emergency rooms for primary care is highly inefficient, and the resultant fractionated care results in both duplication of services and astronomical increases in overall costs of care.  It also imposes a heavy burden of economic and human costs in the form of unnecessary suffering, avoidable disability and premature death.

In reality, making affordable health care coverage available to 30 million additional Americans offers unprecedented potential for cost containment and cost reduction by granting these people access to appropriate care, provided in the right place at reasonable costs.  Furthermore, by requiring presently uninsured Americans to purchase health insurance at affordable prices, the Act will reduce out-of-pocket costs for the majority of Americans.  This will be accomplished by reducing cost-shifting through spreading the overall cost burden of providing care on a more equitable basis.

It is imperative that policy makers be fully aware that minimizing the disruption of service that may result from extending coverage to 30 million more Americans will require diligent cooperative efforts and decisive action on the part of all parties.

On the plus side, the Affordable Care Act contains positive incentives to increase the supply of primary care providers and to incentivize more doctors to provide primary care for both Medicare and Medicaid patients through providing more equitable reimbursement for these essential services.

As a nation, we must waste no time in eliminating our shortage of primary care resources.  We need to dramatically increase our supply of primary care providers, particularly nurse practitioners and physicians assistants.

As a stopgap measure, serious consideration should be given to establishing an entry level category for nurse practitioners who would be able to provide a wide range of primary care services, provided that they concurrently adhered to pre-established requirements for completing their training and certification as full-fledged nurse practitioners within a designated time frame.  Likewise, we must give serious consideration to fast-tracking certification of former military medical corps-men and corps-women as primary care providers.  Given our pressing shortage of these front line providers, requiring these veterans to go back to square one in completing training for advanced health care occupations is both wasteful and counterproductive.

Problems in ensuring access for Medicare patients

Theoretically, traditional Medicare assures that patients are given free choice in accessing qualified physicians and other providers.  In actuality millions of seniors, my wife and myself included, experience serious difficulty in finding a doctor they want to see who will accept Medicare patients.  This is especially true in retirement meccas such as Tucson where Medicare enrollees make up a large part of the population.  In Tucson trying to find a well qualified primary care doctor who accepts Medicare can be extremely frustrating.  The same holds true for many medical specialties.

Avik Roy, an adviser to the Romney campaign on health care issues, correctly points out that the problem boils down to doctors’ frustration with Medicare reimbursement levels.  This issue has been festering for decades, as Medicare has repeatedly cut back on reimbursement to physicians and other providers.  This is a key reason why reform is necessary!

According to the Congressional Budget Office, the Affordable Care Act will cut $716 billion from Medicare over the next 10 years.  It is reported that the largest chunk – $415 billion – will come from slashing reimbursement rates to hospitals, doctors and nursing homes.

In actuality, as I have previously discussed, the act increases Medicare reimbursement for primary care doctors in recognition of their vital role as both a point of entry and a coordinating hub for the health care system.  This provision will definitely alleviate the accessibility problem for Medicare patients.

Getting back to the projected $716 billion dollar reduction in Medicare outlays, will this deter our nation’s seniors from accessing their doctors of choice and the care they need?  The answer depends on who you’re talking to.  The Romney campaign adamantly asserts that the Affordable Care Act will saddle Medicare patients with enormous barriers to accessing care.  On the other hand Kathleen Sebelius, Secretary of Health and Human Services, states that the near term reduction in Medicare outlays will serve to strengthen Medicare by extending the Trust Fund’s solvency for eight more years.

In attempting to ascertain the impact of the near term reduction in Medicare outlays, we must pursue two specific lines of questioning:

• Will the projected reduction result in substantially reduced reimbursement to specialists and other providers?  If that turns out to be the case, then these reductions would do a gross disservice to Medicare patients by further exacerbating their difficulty in accessing their doctors of choice.  Ensuring that this does not happen will require both earnest dialoging and concerted action on the part of government officials, working in concert with power brokers representing physicians, hospitals and other health care providers.  As I will discuss below, I am confident that this highly undesirable outcome can be avoided.  I must emphatically add, however,  that earnest bipartisan dialoging and concerted action by all stakeholders must begin NOW to ensure that Medicare patients will not penalized by the near term cost reduction.

• The corollary question – Is there excessive fat in the system that can be eliminated without compromising quality of care or access to providers?  Given the estimated 2011 spending of slightly over $11,640 per Medicare enrollee – a rather hefty amount – there are indeed a number of viable options that would collectively achieve the necessary cost reductions without penalizing either Medicare patients or providers.  Again, I must emphasize that resolving this issue will require immediate good faith dialoging and action on the part of all stakeholders.  We cannot afford the luxury of partisan bickering in resolving this issue!  As a bonus, if we are able to reach agreement on responsible cost-cutting measures, then we will be well on the way toward accomplishing HHS Secretary Kathleen Sebelius’ stated objective of extending Medicare’s solvency for eight more years!

The following are some of the options that need to be actively explored in achieving the necessary cost reductions to extend the solvency of the Medicare trust fund for eight more years:

• Follow recommendadtions of the Institute of Medicine:  On September 6 the prestigious Institute of Medicine released a consensus report titled “Best Care at Lower Cost”.  This blockbuster report attests that the American medical system squanders 30 cents of every dollar spent on health care!  The report, developed by a panel of 18 world class clinicians, policy experts and business leaders, details how our health care system wastes an estimated $750 billion a year while failing to deliver reliable top-notch care.  Some 210 billion dollars are wasted on repeated tests and unnecessary services, $130 billion are spent on inefficiently delivered services, $75 billion is eaten up by fraud, $55 is lost on missed prevention opportunities, and an astronomical $190 is spent of unnecessary paperwork and administrative costs.  By way of reference, the projected reduction in Medicare outlays over the next 10 years under the Affordable Care Act totals $716 billion.  Quoting from the report’s authors, the bottom line is that “Money should not be spent on unnecessary administrative costs, inefficiencies and care that does not improve health (and may actually harm the patient)”.   Highlights of the Institute of Medicine report include:

• Doctors need to partner with patients – Less than half of patients surveyed receive clear information on benefits and trade-offs associated with treatment for their conditions – and less than half of patients are satisfied with their level of participation and control in medical decision making.

• Hospital care is alarmingly unsafe – An estimated one-third of patients are harmed during their hospital stay, and 30 percent of Medicare patients are rehospitalized within 30 days of discharge.  Underlying these frightening statistics are untold suffering and thousands of unnecessary deaths among patients, accompanied by the generation of billions of dollars in unnecessary costs as a result of these avoidable errors and inefficient practices.

• Inefficient transfer of medical records and duplication of tests is rampant throughout the system – Twenty percent of patients report that their test results and records are not transferred from one place to another in time for their appointment.  Twenty five percent report that their doctors have had to reorder tests and procedures to obtain needed diagnostic information.

• Improved transparency of information is needed – Patients and clinicians should have easy access to prices of tests and procedures, and to reliable information concerning outcomes and quality of care from one provider to another.

• Improved teamwork, communication and coordination of care must be aggressively promoted – Fifty percent of adults report serious problems with coordination of their care, notification of test results and communication with their doctors.

• Implement and effectively administer Affordable Care Organizations – In previous postings in this series I have referred to provisions of the Affordable Care Act that incentivize providers to band together to create Affordable Care Organizations (ACOs) to promote better coordination of care for Medicare patients across care settings.  The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while putting patients first and meeting performance standards on quality of care.

• Drastically reduce medical malpractice costs – Medical malpractice litigation makes a substantial contribution to unnecessary medical costs by forcing doctors to practice defensive medicine.  By definition, defensive medicine is a deviation from sound medical practice to avoid the threat of malpractice litigation.  The American Medical Association reports that over 90 percent of physicians admit to practicing defensive medicine.  This ranges from “positive” defensive medicine, like ordering unnecessary tests, performing unnecessary procedures and making unnecessary referrals to consultants; to “negative” defensive medicine in which doctors avoid treating high risk patients or performing high risk procedures out of fear of being sued.  A post by a physician addressing this topic claims that defensive medicine is expensive, has no basis in evidence-based research, and exposes patients to risks of complications.  Costs of defensive medicine are difficult to quantity as for obvious reasons doctors to not keep their records on this basis.  One study which attempted to arrive at a “ballpark” estimate was conducted by Kessler and McClellan, who analyzed the effects of malpractice liability reforms using data on Medicare patients who were treated for serious heart disease.  The researchers concluded that liability reforms could reduce defensive medicine practices, leading to a five to nine percent reduction in medical expenditures without any adverse effect on mortality or medical complications.  If one were to extrapolate these findings to total U.S. health care spending in 2005, the year on which the study focused, one could surmise that total defensive medical costs ranged between $100 billion and $178 billion for that one year.  One physician writing on this topic advocates that standard clinical evidence-based guidelines be globally applied to malpractice cases, thus lessening the impact of “hired gun” experts whose testimony can be used to support whatever standard of care is convenient to the lawyers.  At any rate, concerted efforts to curb unnecessary malpractice litigation and exorbitant settlements need to be applied in achieving responsible cost reduction under the Affordable Care Act.

• Negotiate discounts for pharmaceutical products – The pharmaceutical industry in this country is highly profitable.  Despite the economic downturn, many pharmaceutical companies rack up profits in the neighborhood of 20 percent per year, and stock prices are riding high, with price to earnings ratios often running twice the average for the S&P 500.  When the Bush administration initiated the Medicare drug benefits a number of years back, to my knowledge no attempt was made to apply the government’s purchasing power to negotiate discounts with the drug companies.  It is also technically illegal for U.S. citizens to purchase prescription drugs by mail from Canada and other off-shore sources, which are often available at a fraction of the cost of domestic pharmaceuticals.  If the government is serious about reducing Medicare costs while preserving full benefits for Medicare enrollees, then it needs to exercise its muscle in negotiating discounts with big pharma.  In addition, while I am generally a staunch supporter of “buy American”, if our pharmaceutical companies refuse to make their products available to consumers at a reasonable price, then I believe that Americans should be able to order prescription drugs from Canada and other off-shore suppliers without fear of being penalized.

• Making the system work smarter -  To its credit, the Affordable Care Act requires insurance to plans cover a number of preventive benefits at no out-of-pocket costs to patients.  It also provides entitles Medicare enrollees, for the first time, to schedule annual wellness visits with their doctors.  While these represent impressive breakthroughs, they barely scratch the surface in terms of realizing the cost saving potential inherent in incentivizing physicians and other health care providers to place a major emphasis on wellness and prevention – empowering patients to take charge of their health!  I am confident that this shift in emphasis would be welcomed by the vast majority of patients as well as by many health professionals – particularly members of the nursing profession and primary care physicians.  This topic will be the focus of the final installment in this series, “A New Paradigm for Health Care Reform”.

Concluding Remarks

While I firmly believe that the Affordable Care Act provides a sound basis for beginning to reform our broken health care system, I am also aware that the Act as it presently stands poses some significant problems that need to be resolved in implementation.  This installment has addressed two key issues – fear of overwhelming the system by bringing on board 30 million insured patients, and the need to ensure that Medicare patients have timely access to care provided by their doctors of choice.  While I strongly believe that the projected $716 billion in cutbacks to Medicare outlays can be dealt with in a manner that will ensure timely access to needed services while actually effecting significant improvements in overall quality of care, I also believe that achieving this outcome will require immediate good faith dialoging and decisive action on the part of all stakeholders.  I also believe that, if our nation’s leaders set their minds to it, that we can use the Affordable Care Act as a springboard for effecting truly positive and revolutionary changes in the manner in which health care is delivered in this country.  This will be the topic of my final installment in this series, “A New Paradigm for Health Care Reform”.  Stay tuned!

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John Newport holds doctorates in public health and psychology and has spent the past 40 years working in various capacities in health services policy analysis, health care administration and wellness promotion.  He is a former commissioned officer with the U.S. Public Health Service, and has served as a senior level research associate in health policy analysis at the UCLA School of Public Health and as a senior planning associate with a major metropolitan hospital/health services planning agency.  He is author of “The Wellness-Recovery Connection”, published by Health Communications, Inc. and has published well over 200 articles focusing on health care issues, wellness promotion and the role of wellness in recovery from addictive disorders.

This is the first installment in a four-part series dealing with the good, the bad and the ugly of the Obama and Romney/Ryan plans for health care reform.  This first post provides a detailed analysis of Obamacare, the next installment will focus on the Romney/Ryan alternative.

With election day rapidly approaching the future of the Affordable Care Act, popularly known as Obamacare, is a key factor influencing voter’s choices.  This is especially true in this year’s extremely close and heated presidential race.

Virtually everyone agrees that our current health care system is unsustainable.  Actually the term health care system is a misnomer, as we are really dealing with an overwhelmingly profit driven sickness care system.

Health care costs, which now consume 18 percent of our GDP, have risen 172 percent since 1999, compared with a 38 percent general rise in inflation.  Yet our nation fares abysmally poor in comparison with other developed countries in terms of average life expectancy, infant and maternal mortality and other key indices of health care outcomes.  Sky-rocketing health care costs threaten the ability of American employers to remain competitive in a global economy.  As a result employers are increasingly being forced to shift the cost of premiums for employer-provided health insurance onto their employees.

Our nation’s health care bill for 2010 exceeded $ 2.6 trillion, which equates to a whopping $ 33,600 for a family of four!  Uncovered costs associated with catastrophic illness are driving millions of families into bankruptcy, and an estimated 50 million Americans lack health care coverage of any form, including Medicaid.  It is abundantly clear that our current mode of financing and delivering health care is totally unsustainable.

The Affordable Care Act (Obamacare)

While the Affordable Care Act cleared Congress without a single Republican vote, the act’s provisions embody major concessions to the pharmaceutical industry, insurance companies and other proprietary interests.  Admittedly the act as it presently stands is far from perfect: in future installments I will elaborate on key problems that remain to be resolved.

Despite my reservations, I believe that the Affordable Care Act provides a very workable starting point for achieving truly meaningful health care reform.  Yet polls consistently show that prospective voters who disapprove of the act significantly outnumber those in favor of it.

Coming from a public health background I am baffled by these statistics.  To date the Obama administration has failed to drive home to Americans the truly impressive breakthroughs that this legislation sets forth to accomplish in terms of providing dramatically improved access to the right kind of health care, together with the act’s potential to foster responsible cost containment.

I will now highlight some of the positive features of the Affordable Care Act.  Most of these features are covered by the “Patient’s Bill of Rights” which forms the cornerstone of this legislation.

1. Improved accessibility to coverage – The law ushers in a series of landmark reforms designed to dramatically increase access to health insurance coverage.  Provisions already in place allow young adults lacking employer-based health coverage to stay on their parents’ health plans until they reach age 26, and bar insurers from denying coverage to children on the basis of pre-existing conditions.  Adults who have been uninsured for six months or longer because of a pre-existing condition now have access to new coverage options.  Furthermore, when the law kicks into full gear in 2014 insurance companies will no longer be able to deny coverage to any American due to pre-existing conditions.  And finally, the law’s stated intent is to extend health coverage to 30 million uninsured Americans.
2. Eliminating coverage ceilings – Under provisions already in force, insurers can no longer impose lifetime limits on essential benefits, such as hospital stays.  Annual coverage limits must be  eliminated by 2014.
3. Promoting increased access to primary care – To incentivize more doctors to serve as primary care physicians, the law provides for increased reimbursement to primary care doctors treating Medicare and Medicaid patients.  In recognition of our nation’s shortage of primary care physicians (PCPs), nurse practitioners (NPs) and physicians’ assistants (PAs), the law allocates substantial funding to create new residency slots for training PCPs and also includes provision for forgiving student loan payments for PCPs, NPs and PAs who choose to practice in medically underserved areas.
4. Increased access to preventive services – Under provisions currently in force, insurers are required to provide a wide variety of preventive services at no out-of-pocket cost to patients.  Mandated preventive benefits for women include well-woman visits, support for breastfeeding equipment, domestic violence screening and counseling, and contraception.  Additional mandated preventive benefits include blood pressure and cholesterol tests, mammograms, colonoscopies, screening for osteoporosis, and vaccines.
5. Enhanced prevention and wellness benefits for seniors – These provisions of the law represent an important milestone for Medicare beneficiaries and providers treating these patients, as previous Medicare restrictions discouraged patients from visiting doctors for preventive services and also discouraged doctors from actively assisting seniors in taking charge of their health.  With the exception of a one-time “Welcome to Medicare” evaluation visit, periodic health evaluations were previously not covered by Medicare unless the doctor could link the evaluation to a medical diagnosis.  Fortunately the new law has changed the rules of the game.  Medicare beneficiaries are now covered for a comprehensive range of preventive services, including an annual wellness visit, tobacco cessation counseling, and an array of no-cost screenings for cancer, diabetes and other chronic conditions.
6. Additional benefits – These include the creation of health insurance exchanges to enable both individuals and small businesses in purchasing coverage at affordable rates, a variety of mechanisms to assist financially challenged uninsured persons, tax credits to assist small businesses in providing employee health insurance, and incentives to encourage doctors offices, hospitals, long term care facilities and other providers to band together to effectively coordinate care for Medicare patients with multiple chronic conditions.  This coordination of care will be provided by accountable care organizations (ACOs), which will bring providers together to better serve Medicare beneficiaries, eliminate duplicative services and reduce risk of medical errors.

Please note that the above summary is not intended to provide a comprehensive overview of new benefits available under the law: for further information visit www.healthcare.gov/law.

To be sure, the Affordable Care Act as it presently stands is not without problems.  I do believe, however, that the law affords many positive benefits to our nation’s people and moves us in the direction of fixing our broken health care system.  The next installment focuses on the Romney/Ryan alternative for health care reform.  This will be followed by an examination of key problems inherent in the current law, together with suggestion for remedying these problems.

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The Romney/Ryan reform strategy

While Governor of Massachusetts, Romney orchestrated a comprehensive health coverage program that in many respects has served as a model for the Affordable Care Act.  In fact, when Romney secured the GOP presidential nomination I initially intended to vote for him, as I felt that his backlog of experience might uniquely qualify to propose and implement creative solutions to “bugs that need to be worked out” regarding the Affordable Care Act.  Given my initial stance, I was shocked when he unequivocally stated that if elected, on his first day in office he would set forth to repeal this “terrible law”.

This 180-degree turnaround completely threw me for a loop – causing me to scratch my head and scream out “Will the real Mitt Romney please stand up?”  As will described below, the Romney/Ryan stance regarding health care reform is almost totally out of step with the progressive universal health coverage legislation that he designed and implemented in the state of Massachusetts.  So much so, in fact, that I am left wondering whether he found himself forced to abandon his own core beliefs in regard to health care reform, in order secure the nomination by appeasing his party’s controlling ultra-conservative faction.

While more recently Romney has somewhat softened his stance concerning the Affordable Care Act by alluding to his intention to retain popular provisions of this new law, I am unaware of his committing to any specifics.

In brief, the Romney/Ryan health care reform strategy can be summarized as:

1. Relying on the free market to solve our nation’s daunting health care problems via “creative innovation”

2. Leaving any planning and implementation relating to health care reform to the individual states, and

3. Voucherizing Medicare

Let us address these points one by one.

• Reliance on free market to effect health care reform:

Unquestionably, the American ingenuity and entrepreneurial spirit has been the driving force behind many innovations that have improved our lives.  Witness Steve Jobs’ phenomenal success in building the Apple empire starting from a modest beginning in a garage in Palo Alto.

Likewise, in the health care field private enterprise has also been the engine driving many life-saving pharmaceutical breakthroughs, together with superb technological advances in medical devices and medical imaging, to name a few.

Unquestionably the private sector has pioneered innovative health system prototypes that have forged creative linkages between doctors, hospitals and other providers with the mission of providing high quality, truly patient centered care, while simultaneously holding down costs.  Examples include the Mayo Clinic, Cleveland Clinic, Kaiser-Permanente and the Puget Sound Health Cooperative.  Significantly, each of these leading edge models operates as a non-profit organization.

Patient centered innovations in the private sector are by no means limited to the non-profit sphere.  About a year ago my next door neighbor was diagnosed with adult onset diabetes.  His health care provider, CIGNA Healthplans, a for-profit HMO, expeditiously employed their case management system to cajole and empower my neighbor to take charge of his health.  Working hand in hand with his case managers, my friend converted to a very health conscious diet, lost over 50 pounds, and joined a local gym and became an “exercise junky”.  Needless to say, these health conducive lifestyle changes that were actively facilitated by my neighbor’s health care provider have had a very positive impact on his overall state of health.

Despite the shining examples cited above, it is undeniably true that domination of our nation’s health care by aggressively profit-oriented financial interests has been, to put it mildly, a double edged sword.

In truth, these heavy proprietary interests have produced a highly profitable sickness care system that is bankrupting our nation!  In accordance with the manner in which our health care system is structured, there is very little profit to be realized through empowering our citizens to stay well and actually improve their state of health.  From a strictly financial perspective, the real money to be made is generated by letting patients become very sick, and then overwhelming their bodies with highly technological, highly expensive end stage interventions.

Indeed, a very disproportionate share of our health care resources is concentrated on highly technological treatment of end-stage illness: treatments that often produce questionable results in terms of both life extension and quality of life.  While this is highly profitable for our nation’s hospitals, medical specialists, pharmaceutical companies and manufacturers of advanced imaging devices and other high-tech equipment, I submit that this state of affairs results in an incredible waste of resources that would, in my opinion, be better employed in the prevention and wellness arenas.  I would add that the latter approach would end up saving tons of money for the government, employers, and private citizens.

Unquestionably, the ingenuity of America enterprise needs to be effectively harnessed in reforming our health care system.  However, to place the daunting task of health care reform in primarily the hands of unfettered free enterprise, as Romney and Ryan appear to be suggesting, is in this author’s opinion highly questionable.

• Delegating health care reform to the individual states:

This is another basic cornerstone of the Romney/Ryan strategy.  Essentially, they want to repeal the Affordable Care Act and leave it up to each state to craft and implement its own health care reform program.

To be sure, individual states and localities must be granted considerable latitude in customizing solutions that best respond to their own unique sets of circumstances.  Indeed, state-directed health care reform has worked well in Romney’s home state of Massachusetts, and would very likely yield effective results in other progressive states such as New York and California.

I shudder to think, however, of what might happen in my own state of Arizona if responsibility for health care reform were placed in the hands of Jan Brewer and her “wing-nut” cronies in Phoenix!  Remember, back in the sixties we were the last of the 50 states to implement Medicaid, and our state has recently undergone draconian cut-backs in health services for indigent patients.

• Voucherizing Medicare:

Playing on the fears of older Americans concerning possible adverse consequences of the Affordable Care Act affecting Medicare beneficiaries (a topic that I will address in detail in the second installment in this series), Romney and Ryan have repeatedly stated that they do not intend to implement any changes in regard to Medicare that will effect Americans who are currently age 55 or older.

While at first glance this may sound appealing if you fall within that age bracket (as I have for the past 16 years), we need to look beyond the sound bites to the foreseeable consequences of what they are proposing.  For what I have seen to date, it appears to me that they want to duck the issue by kicking the can 10 years down the road in terms of effecting any meaningful reform impacting the segment of the health care economy that consumes the largest portion of our nation’s health care expenditures.

Even more frightening to my way of thinking are their plans to effectively destroy Medicare as we know it by “voucherizing” the system.  Under this scheme, they intend to privatize Medicare by shifting over from the comprehensive system of defined benefits that currently exists to a defined contribution system, whereby Medicare beneficiaries will receive a voucher to apply toward purchasing coverage from private insurers.

While it is true that Romney has modified his initial stance to include the option of remaining with traditional Medicare in his reform strategy, what he fails to share with us is that his agenda will undermine the ability of traditional Medicare to effectively control costs.  Given the option to purchase health coverage on their own via a voucher, many healthy seniors will understandably opt to purchase low cost coverage providing reduced benefits, and pocket the savings.  This, predictably, will burden the traditional Medicare program with an inordinate proportion of very sick patients who will run up expensive health care tabs.  Under these circumstances it will be virtually impossible for administrators of the traditional Medicare component to implement effective cost containment measures.

Analysts who have studied the voucherization proposal have overwhelmingly concluded that it is fraught with problems.  There is consensus that the government will in all likelihood choose to hold down its defined contribution to purchasing health coverage as a “cost-cutting” measure.  Thus, seniors will be faced with a growing gap between what they are allotted to purchase health care coverage in the private market and the actual cost of that coverage.

The GOP’s proposed reform provisions for Medicare essentially flow from a document titled “The Path to Prosperity” that Ryan released on April 5, 2011 in his capacity as chairman of the Congressional Budget Committee.  In addition to plans for voucherizing Medicare, Ryan proposed to turn Medicaid into a block grant program, to operate under the assumption that the amount allocated to each state for Medicaid increase each year at a slower rate than the projected increase in health care costs.

When the Congressional Budget Office (CBO) analyzed Ryan’s proposal, they concluded that 10 years into the Ryan program the share of total out of pocket costs paid by seniors enrolled in Medicare would increase from 25 percent to a whopping 68 percent!

All in all, I have a hard time in attempting to conclude that the Romney/Ryan health care reform strategy represents a good deal for Medicare and Medicaid recipients, and the rest of our nation’s citizens.

While I favor building upon the Affordable Care Act as the most viable pathway to health care reform, I am aware that the act in its present form presents significant problems that must be resolved in implementation.  In the next installment I will address two of the most serious issues – fear that we may overwhelm the system by extending coverage to 30 million “new” patients, and charges that Medicare beneficiaries will suffer devastating consequences as a result of alleged  cutbacks that will occur in Medicare outlays over the nest 10 years.  Stay tuned!

John Newport holds doctorates in public health and psychology and has spent the past 40 years working in various capacities in health services policy analysis, health care administration and wellness promotion. He is a former commissioned officer with the U.S. Public Health Service, and has served as a senior level research associate in health policy analysis at the UCLA School of Public Health and as a senior planning associate with a major metropolitan hospital/health services planning agency. He is author of “The Wellness-Recovery Connection”, published by Health Communications, Inc. and has published well over 200 articles focusing on health care issues, wellness promotion and the role of wellness in recovery from addictive disorders.