Emanuel & Gudbranson v. Puzder
POLICIES FOR THE NEXT ADMINISTRATION. PART 4: HEALTH
Response to Andy Puzder
By Ezekiel Emanuel and Emily Gudbranson
No legislation works perfectly from the start. We must remember that the ACA is still in its infancy and, as such, is liable to experience “growing pains.” Mr. Puzder has woefully proclaimed that the ACA is nearing “its final death throes,” that insurance co-ops are “on the brink of collapse,” and that, as a result, health care has become a “scary story.” Certainly, Mr. Puzder’s ominous-sounding narrative makes for quite a tale. Yet while his claims are premature, if you strip away some of his rhetoric, we think Mr. Puzder could actually agree with us on several bipartisan reforms. Neither of us want a single-payer system. We both believe that competition in the health care sector must be increased. And we both favor deinstitutionalization of care.
The ACA is much more than just exchanges and premiums — it is a law that has expanded Medicaid, prevented discrimination against people with pre-existing conditions, and ensured that nine out of 10 Americans now have health insurance. Republicans like Mr. Puzder would do well to acknowledge both these successes and the existence of very feasible reforms to the ACA that both major political parties can support.
(For the opposing view, see Andy Puzder, "The Health-Care Reform We Need.")
Response to Ezekiel Emanuel and Emily Gudbranson
By Andy Puzder
“No matter the metric — access, quality, or cost — the ACA has undeniably been a success.” Such a claim reminds me of the American leftist intellectuals who claimed that Russian communism was thriving mere months before its collapse.
As demonstrated by finalized premium rate increases in the 30 to 50 percent range, the desertion of major insurers, and recent high-profile Democratic denunciations, the ACA reality is much different.
In an effort to back up their claim, Dr. Emanuel and Ms. Gudbranson point to the 20 million Americans who gained health-insurance coverage under the ACA between October 2013 and early 2016. At first glance that seems like a reasonable, if modest, access improvement in a nation of 322 million. But the devil is in the details.
The vast majority of increased coverage under the ACA is a result of the ACA’s Medicaid expansion. According to the Department of Health and Human Services, enrollment in Medicaid/CHIP has grown by 14.5 million since October 2013. According to the Kaiser Family Foundation, total monthly Medicaid/CHIP enrollment has increased by 16.4 million compared to the pre-ACA average monthly enrollment.
In other words, between 72 and 82 percent of the people who received expanded coverage under the ACA got it from taxpayer-funded free or nearly free insurance. Jeffery Anderson of the Hudson Institute examined the increase of Medicaid coverage and concluded that Obamacare is little more than “a massive Medicaid expansion.”
Expanding Medicaid could have been accomplished without the ACA’s labyrinth of incentive-destroying mandates, regulations, and exchanges. In addition, Medicaid, itself, is very flawed. Doctor reimbursement rates for Medicaid have been driven so low that roughly half of U.S. doctors are not even accepting new Medicaid patients. In practice, Medicaid’s rationed care often means no care at all — hardly an improvement in “access.” Several studies have also found that Medicaid recipients have no better health outcomes than those who go without health insurance.
Dr. Emanuel and Ms. Gudbranson do recognize the need to improve the ACA. But the fixes they propose fail to address the ACA’s diseased heart: the big government regulations, taxes, subsidies, and cronyism that dramatically drive up costs, limit choice, and demean quality.
They’re right that more insurers are needed, but wrong to say that more regulatory compulsion is the way to achieve this. They’re right that insurers should cover larger geographic areas and risk bands, but wrong to say they should “be forced” to do this. Rather than enacting malpractice reform to reduce insurance costs, they would even use government coercion to have physicians “assume more financial risk for their clinical judgments.” This would increase the costs of both malpractice insurance and health care in general. But more government intervention cannot fix a problem that government intervention caused in the first place.
We do agree that the business tax credit for health-care costs should be expanded to insurance bought on exchanges — a reform that would increase competition and choice as well as strengthen exchanges. Generous and refundable tax credits should be part of any reform so that health care can become truly universal.
But the only way to truly fix the ACA is by striking at its root. That means repealing it and replacing it with a market-based health-care system that eliminates the existing web of regulations, mandates, taxes, and cronyism that distort the market and destroy the incentives necessary to bring down costs and improve the quality of care.
(For the opposing view, see Ezekiel Emanuel and Emily Gudbranson, "Our Next Administration's Health-Care Agenda.")
Ezekiel J. Emanuel, M.D., Ph.D., is the Vice Provost for Global Initiatives and Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Emily Gudbranson is a senior research assistant to Dr. Emanuel.
Andy Puzder is CEO of CKE Restaurants, Inc., a member of the Job Creators Network, and an economic advisor to the Trump campaign.