Articles by Dr. Phillip Caper re Healthcare in America


ACA’s bungled rollout aside, government health insurance works

By Dr. Philip Caper, Special to the BDN

Posted Oct. 17, 2013, at 5:59 a.m.

The lead story in the Oct. 13 New York Times details the ongoing problems of the Affordable Care Act’s websites intended to facilitate access by individuals to the law’s hallmark online health insurance marketplaces. Those problems continue.

To summarize, many of the state-run and all of the 36 federally run websites are currently experiencing significant problems providing access to the exchanges, and nobody seems willing or able to predict when they will be fixed. This failure to launch President Barack Obama’s signature domestic achievement is hugely embarrassing for the administration, and will undoubtedly provide a great deal of fodder for late-night comedians. It will also provide an almost unlimited source of talking points for tea partiers and other government-haters, who will cite this unfolding fiasco as more evidence that “government can’t get anything right.”

That would be incorrect.

In 1965 and the years following, I witnessed the implementation of Medicare, which enrolled 19 million beneficiaries almost seamlessly in less than a year, despite the formidable opposition of Southern hospitals wary of its requirements that they desegregate their wards. As I wrote last month, the problem with the ACA is not that the federal government is involved, but that literally thousands of private insurers have their fingers in the cookie jar, resulting in a law that is much too complicated for what it needs to accomplish, and too complex for anybody to administer efficiently and effectively.

Together, Medicare and Social Security — both run by the federal government — have been successfully providing access to private health care and income security for millions of seniors and the disabled for almost 50 years. They have been a major factor in keeping seniors in our country out of poverty.

Both programs are overwhelmingly popular with doctors, patients, the general public and most politicians. Medicare is also much more successful than private, for-profit insurance in holding down the prices paid for medical services and products and overhead costs — 6 percent compared with 20 percent or more. But Medicare is still not doing nearly enough to control costs.

It is estimated that there is at least $750 billion worth of waste in the U.S. health care system.

Politics is the only credible reason for retaining the complex and confusing web of private insurance plans in a health care system that aspires to cover everybody. In order to gain congressional approval, the ACA had to first accommodate the interests of the corporate medical-industrial complex, putting the interests of the American people in a distant second place. Congress’ approval rating now hovers around five percent.

We can do better. It took over 50 years from the time President Theodore Roosevelt first proposed national health insurance until Medicare and Medicaid were enacted. It took almost another 50 years for the ACA to be enacted, expanding insurance coverage and enacting some protections against some of the insurance industry’s predatory practices.

We have had to endure almost 100 years of acrimonious political debate, name-calling, disinformation and outright lies — much of it designed to protect and defend some doctors’ incomes and corporate health care companies’ windfall profits — to even approach what all other wealthy countries take for granted: health care as a human right.

We need expanded and improved Medicare-for-All. And we need to vote any politician who won’t advance us toward that goal out of office. We’re moving in the right direction. But we can’t afford to take another 100 years to get there.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at works/ printed on October 17, 2013



The high costs of complexity in health care reform

By Dr. Philip Caper, Special to the BDN

Posted Sept. 19, 2013, at 10:45 a.m.

I have great admiration for the political courage of President Barack Obama and the congressional leaders who were willing to take on health care reform, justifiably called the “third rail” of American politics. Our system cries out for reform. But they made a fatal mistake in allowing the law to be drafted by Congress, which is composed of 535 members with vastly varying values, goals and interests.

Consequently, the resulting law is a conglomeration of ideas from across the political spectrum, thrown together and lacking any coherent conceptual framework. (Congress is usually a better editor than author.) This lack of coherence has resulted in a law that is far too complicated and therefore too expensive to manage, full of holes, will be applied unevenly and unfairly, be full of unintended consequences, and be easily exploited by those looking to make a quick buck.

It has been credibly estimated that administrative costs make up more than 30 percent of our national health care bill, most of it unnecessary. The waste in this area alone is equivalent to around $400 billion annually. That is more than enough to provide health care to every uninsured person living in our country. Some of these costs result from the slicing and dicing of Americans into ever-tinier and more confusing categories, the inevitable result of applying the principles of insurance to health care.

But the costs go beyond dollars to a lack of basic fairness, and of public understanding and support.

A plurality of the public still views the law negatively. Even many experts are confused by it. The law tries to deal with this confusion by providing a host of federally funded “navigators” to help people find their way through the maze it creates. While this provision will provide many well-paying jobs, it uses health care funds but does not pay for any health care — an example of your health care dollars not at work.

The ways in which the costs and benefits of the law are distributed are patently unfair. Even if it is perfectly implemented, it will leave around 30 million Americans without health care coverage. Some of this was intentional, but some wasn’t. The Affordable Care Act’s architects intended the federal government to expand the Medicaid program and make it more uniform to cover the poorest among us on a fairer basis.

But the Supreme Court found that requiring the states to expand their Medicaid programs would be unconstitutional, thereby gutting that provision. About half the states, including Maine, have declined the Medicaid expansion. They have decided to forgo the 100 percent federal funding (dropping to 90 percent after three years). That has created the anomalous situation where some of the poorest Mainers will receive no help, while those who are slightly wealthier will receive federal subsidies to buy insurance.

Similarly, some people who make too much money to qualify for any federal assistance but cannot afford increasingly expensive health insurance on their own will continue to pay state and federal taxes to finance Medicare, Medicaid, the VA and other programs for others. They will also pay higher federal taxes to compensate for the fact that private insurance for union members, corporate executives, and others with employment-based coverage, some of it quite comprehensive, is tax exempt.

The ACA does not go nearly far enough in restraining ballooning health care costs or reforming the way we pay those providing health care products and services. These abuses have been brilliantly and persuasively

documented in Steven Brill’s Time Magazine cover story “ Bitter Pill.” Health care prices are completely out of control and the uninsured, many of them the least able to pay, are often the only ones charged full sticker price.

The only persuasive reason that has been given for our failure to address these glaring problems is that the power of the health care industry (that spends three times as much on lobbying as the defense industry) is too great. Pretty pathetic, and yet another example of your health care dollars at work — this time against you.

It doesn’t have to be this way. It is now well-documented that Medicare, a far simpler program than the ACA, spends much less on administration and is much more effective in controlling prices than private insurance. Apologists for the existing system of private insurance claim that it preserves “choice” of insurers, and that Americans want that choice.

But the choice people really want is a choice of health care providers, not insurance. Medicare beneficiaries can already choose any participating provider they wish. I have never heard a single Medicare patient complain about not having more choice of insurance companies.

Even Sen. Harry Reid, one of the ACA’s architects, now admits that it must be a way-station to a Medicare-like, single-payer plan. He has said he thinks the country has to “work our way past” insurance-based health care.

Fortunately, in Maine we have a couple of ways to do that. Next year, hearings will be held on L.D. 1345, co- sponsored by Rep. Charlie Priest and Sen. Geoff Gratwick. That bill would start us on a path toward a statewide nonprofit, unified and universal health care system, similar to the route recently taken by our neighbors in Vermont.

Failing approval of that measure, Maine (unlike Vermont) has a referendum process, a direct vote of the people for sanity in health care. If we were to follow either path, Maine would once again have the right to say “Dirigo” — I lead — and set a historic example for other states to follow.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at printed on September 19, 2013



Obamacare: Good intentions won’t make health care affordable

By Philip Caper, Special to the BDN

Posted Nov. 15, 2012, at 4:20 p.m.

Mercifully, the election is over. Obamacare is here to stay. A strong role for the federal government in moving toward the goal of health care as a right of everybody in the United States is now firmly and, in my opinion, irreversibly established.

Obamacare was a monumental political achievement in that it established an aspiration to health-care coverage for all Americans in federal law for the first time. President Barack Obama and former House speaker Nancy Pelosi deserve great personal credit for taking on this politically radioactive task.

But as a mechanism for providing access to health care for everybody at a reasonable cost, Obamacare has a number of serious shortcomings. Even if it works entirely as intended, it will still leave 25 million to 30 million people without any coverage at all. It lacks any persuasive mechanism for controlling the costs of public or private programs, meaning that insurance, even with federal subsidies, will likely become increasingly unaffordable.

It is way too complicated, and complications are expensive. To make it work will require thousands of federal regulations.

Deficit hawks will resist the expansion of Medicaid, the subsidies for the purchase of private insurance, the boost to community health centers, and funding for the exchanges that must be set up to create a more functional health insurance “marketplace.” The new law even includes funding for “navigators” to help people sort through the maze of insurance plans it creates.

Our fractured and fragmented health-care system will become even more so as Americans are further divided by income, employment status, and the type of insurance they choose in the exchanges. Despite the modest tax penalties, many will choose to remain uninsured, shifting the cost of care they may need to everybody else.

In previous columns, I have argued for a right to health care on moral grounds and on economic grounds. It’s actually cheaper to cover everybody than to figure out how not to cover some.

I would now like to make a case for less complexity in our health-care system. Much of the complexity of our existing system is defended as a way to preserve choice. But the virtues of choice are being vastly oversold, especially when it comes to how it’s paid for.

Most people care little about how their health care is financed. They do care about how it’s delivered. Medicare, financed largely by taxes, is far more popular with the public than private insurance.

The ability of individuals to make intelligent choices among insurance plans is an illusion. A recent column written by a Harvard-trained health-care economist drives this point home. Despite her extensive education and experience with health insurance, she was unable to choose the most appropriate coverage for herself when she really needed to. With deteriorating health and rising anxiety about her illness, worries about incurring a huge bill to get the potentially life-saving treatment for her brain tumor added to her stress.

Although some groups are more vulnerable than others to some diseases or injuries, when it comes to individuals, it’s nearly impossible to predict where and when illness or injury will strike or what its nature will be. Unless one has a pretty good crystal ball, the basic information needed to make an informed choice about a health insurance or prescription drug plan simply doesn’t exist.

The dilemma the health-care economist faced was not because of a lack of expertise, but rather a lack of necessary information.

Choice can be a good thing. But as anyone who has tried to navigate the Medicare prescription drug program can testify, there is such a thing as too much choice.

Rather than making our already byzantine health-care system more complicated, we need to make it simpler. We need to move away from health insurance and put everybody in the same tax-supported system.

As in Medicare, we could still give everybody a reasonable choice of doctors and other providers under an acceptable and enforceable budget. If every other wealthy country can do it, so can we.

Since everyone would benefit equally, it would be far more popular than what we have now. In other words, simplify our health-care system by enacting “Improved Medicare for All.”

It’s unlikely that could be done anytime soon at a national level, but I believe it could be done in Maine under the existing waiver provisions of the Affordable Care Act. Compared to our current system, it would be simpler, fairer, far more efficient and would allow us to join all other wealthy countries in making health care a right.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at affordable/ printed on November 15, 2012