Congressional Representative Tom Price (R-GA) illustrates that having an M.D. after your name is no guarantee that you can understand or honestly represent the complexities of healthcare reform.
The Affordable Care Act is not perfect. Parts of it annoy the hell out of me (as a provider). But there is no question that it has given tens of millions of Americans access to healthcare who didn't have it before and made the policies everyone else has more robust (no lifetime caps, no pre-existing condition exclusions, copayment-free access to a list of essential medications, for starters).
But Price is simply not being honest (or hasn't done his homework) when he repeats the rightwing talking point that "Many Americans lost ... health coverage."
Many Americans beg to differ. The rate of uninsured has been roughly halved by the law:
So why the hell are Republicans so intent on aborting it? And why did Trump just put the GOP's chief abortionist in charge of overseeing it?
Price is an outlier since most physicians support healthcare reform. Although they are either some surveys show a physician split along party lines on the Affordable Care Act others show as many as 59% in favor, as a 2015 survey of California physicians across different specialties indicated.
A begged question that the California researchers tried to answer was whether physicians knew what they were criticizing. The ACA is a large, complex laws with many parts, so should we really assume that busy physicians are much more familiar with it than their patients, or that they see the entire elephant beyond the trunk, tail, leg, or other body part in front of their faces?
Not really. The more specialized the physician, the less likely she is to be able to answer 8 questions about the ACA such as where it covers undocumented immigrants (it doesn't) where it affects Medicare coverage (it doesn't) and whether it increases Medicare payroll taxes (it does). Another interesting finding: the more one knew about the law, the more one was to support it (confirmed by other studies), and the more conservative politically physicians rated themselves, the lower their knowledge of the law they were criticizing:
Support various inversely with income - those physicians in specialties making the most support the ACA the least. Orthopedic surgeons ($443,000 per year in 2016) such as Price top the list of specialties ranked by income. Primary care physicians whose responsibilities are broader and more continuous make far less. Pediatricians ($204,000) and family medicine doctors ($207,000) earn less than half of the average orthopedic surgeon.
Income after expenses but before income taxes, 2016 Medscape Physician Compensation Survey.
Why might this be?
Political affiliation drives Affordable Care Act support among physicians as much as among everyone else, and a high-earning physician ceteris paribus is more likely to gravitate to the party promising a reduction of income taxes. They may come for the $100,000 tax bill reduction but stay for the ObamaCare-bashing.
Also, specialists earning income many multiples of other physicians and 1,000% of the median family income are unlikely to see those deviantly high incomes continue in any sort of rational health care system. Primary care physicians might earn more, although they would arguably have far less to lose, income-wise, and many aspects of the law, such as the expansion of the insured population base, make providing care to a diverse community less stressful (the uninsured not only cannot pay but often only present when a treatable or preventable condition has worsened to a crisis point, increasing the acuity of care that must be provided).
Specialists, especially surgeons, only see patients after a "wallet biopsy" has been done by someone else. Their concern about the uninsured might be lower since they rarely if ever deal face-to-face with the uninsured or marginally insured, whereas any primary care physician with a busy practice is reminded every day of the depth and breadth of the uninsured in America.
Indeed, surveys of physicians do indicate that support for the law is correlated with whether the provider believes the law will help his practice, and primary care physicians are far more likely to believe this.
Absent from Price's resume is any public health experience. I don't know if he ever took a course in healthcare economics or studied solutions to healthcare allocation developed overseas or in Canada for their pros and cons.
Yet the man feels confident enough in his abilities to offer his personal overhaul of our healthcare system.
In 250 pages.
The plan, which he introduced as a 2015 bill called the "Empowering Patients First Act of 2015" starts and ends with the idea that funneling as many dollars through the massively profitable giant American for profit health insurance companies is the way to go.
It's unclear why Dr. Price believes this group needs such a boost. They have thrived under the Affordable Care Act which the GOP said was socialism, a dastardly government takeover of the health care industry. Yet last year (2015), UnitedHealth Group reported a profit of $11 billion (on revenues of more than $157 billion) up from $10.3 billion (on revenues of $131 billion) the year before. And the CEO's of these companies certainly don't feel times are lean enough to cut back on their compensation - UnitedHealth’s CEO Stephen Hemsley made more than $66 million in 2014. (In case you're wondering, since all UnitedHealth does is collect premiums and pay them out in claims, his salary represented $66 million of unpaid mammograms, cancer chemotherapy, and denied hospital days.)
Back in March 2009 when President Obama was surely going to destroy the private health insurance industry (according to any Republican that wasn't too busy explaining why healthcare reform was going to ruin the overall economy), had you bet against those GOP Cassandra's, you would be very, very rich today. You could have bought a basket of health insurance stocks for bargain basement prices. Had you held them for exactly 7 years (through March 2016), you would have achieved returns that Peter Lynch or George Soros would envy:
Humana: up 1,010 percent (a ten-bagger);
Cigna: up 1,113 percent, over 400% the return of the Dow Jones Industrial Average;
Anthem: up 469 percent;
Aetna: up 628 percent;
UnitedHealth
Group: up 814 percent;
WellCare: up 1,410 percent.
Had you taken out a mortgage on your house, backed up the truck and bought $100,000 worth of each of these companies, you would have over $5.4 million right now, excluding dividends.
Here's a fun fact about WellCare - every penny they made is thanks to us, the US taxpayer. Their revenue comes entirely from federal and state government customers (ain't free enterprise grand?).
Another fun fact about WellCare: they keep committing fraud, the sort of thing that would put you or me behind bars or certainly bar us from future government contracts. But they just pay their fines and keep on making money. Wouldn't you if you could?
Now health insurance is a complex solution to what is at its core a simple problem: how do we pay for healthcare?
Most sane societies (meaning every developed country except for the United States for some reason) decided to create an enormous risk pool of all of their citizens, most of whom would not need all that much health care, if any, if a given year. A few would need a lot. Since it's impossible to know for sure who will be in which group, everybody puts a small or modest amount of money (what are called premiums) into a big hat, understanding that most of those contributing in any given year will lose their premiums (that's a good thing). The core idea of insurance that Republicans cannot seem to understand is that it involves an exchange of a low probability but catastrophic loss (getting cancer, struck by a car, having a stroke) for a small, high probability (guaranteed) loss (premiums paid as well as deductibles and copayments and other out of pocket expenses). By definition, healthcare spending is other people's money since that is how insurance works! If my house burns down but a thousand homeowners' homes don't, then it's the money of all those homeowners I never met that pays for me to rebuild mine.
I cannot understand how otherwise bright people - people who tell us what business geniuses they are - fail to understand this basic concept.
Health insurance is a zero sum game, at least in the short term. That means that every claim paid by an insurer must come out of premiums paid (plus returns on invested premiums collected but not paid out). All an insurance company does is collects premiums and pays claims. They don't provide health care, they don't contribute anything directly to your health. They are a go-between. In fact, they are a drag on the system, since their overhead reduces the amount available of your premiums paid to be paid for claims one day (imagine the guy in charge of the hat reaching in from time to time to take out a bill or some coins to pay himself for the trouble of collecting the money).
The real art of insurance is setting the premium right. Too low and claims will swamp premiums collected and the company will either go bankrupt or have to turn to a reinsurer (or both). Too high and no one will want to participate (or a competitor's premiums will seem more attractive if there is a transparent, competitive market).
And the premiums, in turn, are driven by fiduciary responsibilities of for profit companies whose primary responsibility is not to you, dear policyholder, but to investors who are expecting to be enriched (and over the last half decade most certainly were).
So let's say that actuarials hired by the insurance company tell the CEO that absolute lowest price they could charge and still keep the lights on is $10,000 a year for a family of 4. The CEO might then calculate the mortgage on his fifth house, work out the minimum salary he can live on (the nearest $10 million), multiply by a fudge factor to take into account his buddies in top management, then add a healthy return he would like to be able to report to shareholders, so instead turns around and sets premiums at $12,000.
When policyholders complain, he can just blame ObamaCare.
For the trouble of handling all your money (invested and generating a stream of income the actuarial works into his calculations, but always conservatively), your typical private company just added 20% overhead.
Many countries reason that this system is too expensive and take over the business of collecting premiums and paying claims themselves. In fact, our government already does this through Medicare, Medicaid, and a number of other federally-administered plans, except instead of premiums, the government collects a (much smaller) tax from a much larger risk pool (everyone). And because their administrative overhead is 1.8%, because they don't have to advertise, and because the person administering the plan earn a few hundred thousand dollars rather than $100 million, right off the bat, hundreds of millions are available for healthcare claims.
Private health insurance is an experiment that seems to have mostly failed. It's unclear why we need to subsidize or make work for a group of smart people that no doubt would have no trouble finding real jobs.
Price's plan would take the elements of the Affordable Care Act that helped the private health insurance industry grow so dramatically and add their own version of Miracle Grow. They would make sure it's called something completely different to make sure they get the point across about how mad! mad! mad! they are that a black Democratic president did something that Nixon and Clinton failed to do: systematically overhaul our healthcare system. How about TrumpTraumaTriage or something?
But it's based on the same model of propping up a private health insurance industry. Again: why?
The United States spends more on healthcare as a percentage of GDP (17.1%) or in per capita spending but we're the only developed country that doesn't cover all of our citizens - even after the massive improvements of Affordable Care Act, 10% of our citizens remain uninsured.
But American taxpayers wouldn't subsidize this industry directly the way we must subsidize private defense contractors or agribusiness. No, those subsidies would be sprinkled among Americans who could then use them to buy private policies which, once again, could suck. Oh, but they would be affordable - low premiums in exchange for a deductible of as high as $20,000.
Everything is up in the air right now, which is no way to run a healthcare system. Anyone who bought coverage through the exchanges or thanks to Medicaid expansion or because of the law's allowance of continuing on a parental policy through age 26 has no idea if she can get health care next year. Or ever. If the pre-existing conditions exclusions return, then anyone who left a group policy for a better policy on the exchange and actually used the insurance to get health care now has a pre-existing condition.
Price is an extremist who does not represent the views of most physicians. It's fair to say he doesn't represent the views of most Americans whose health care access he is threatening. But Price, like so many in his party, never lets facts or lack of personal experience get in the way of personal opinion.
He claimed back in 2010 when joining the tea people that he was trying to beat back a "vile liberal agenda." (Vile? Really?)
He wants to prohibit abortion, making pregnancy termination clandestine and dangerous. Planned Parenthood rates him as zero. He has voted to defund Planned Parenthood and helped pass on later debunked claims that the organization was operating a black market in "baby parts" [sic].
He is a homophobe, bemoaning the recent SCOTUS marriage equality ruling as a "a sad day for marriage" and a "further judicial destruction of our entire system of checks and balances."
Trump is clearly removing any hope that some of his apologists had that he really didn't mean all those nasty things he said on the campaign trail and would never carry them out.
Trump is clearly removing any hope that some of his apologists had that he really didn't mean all those nasty things he said on the campaign trail and would never carry them out.
If the people he is picking are any indication, he did and he will.
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