Our Editorial in the New York Times: “We Stand For Access”

As a member of the American Society of Law, Medicine & Ethics, I’m proud to add my name to this letter to the editor in the New York Times:

To the Editor:

We, many of the nation’s health law and health policy professors from law, medical, public health and graduate schools across the United States, write to address one of the most fundamental issues impacting our country: the potential repeal and replacement of the “Affordable Care Act” (“Obamacare”). It is clear that the House-passed “American Health Care Act,” as well as the legislation likely to be considered by the Senate, will cause severe, lasting harm to all of us, especially our society’s most vulnerable and middle class.

Today we raise our voices to oppose these proposals. While the Affordable Care Act has its shortcomings that should be fixed, the current proposals are merely “repeal,” with no effective “replace.” These proposals are wrong, and must be rejected. At a time when we are seeing significant declines in the number of uninsured and inadequately insured in our country, the House and Senate proposals represent a giant step backward. By cutting Medicaid funding, eliminating federal assistance for families securing private coverage, and encouraging individuals to either not purchase insurance or to buy barebones coverage, these proposals will result in a less equitable, less accessible system of health care. Ultimately, the public’s health will decline as needed care is forestalled or not sought, and costs will rise as a shrinking pool of Americans with “good” insurance pay more to subsidize those without.

Given the many health care challenges that we face— an aging population needing an increasing amount of health care services; a young and middle age population facing growing rates of obesity, heart disease, and other chronic conditions; a rapidly expanding “gig” economy of independent contractors needing to secure insurance without employer subsidies; and a rising number of individuals addicted to new and more prevalent illegal drugs— reducing access to health care services simply cannot be an acceptable policy option.

We also are deeply concerned about what this new legislation portends for women and children. Currently, the United States leads the developed world in maternal mortality. More women die during childbirth in the United States than in any other Western nation. Despite the urgency to protect women’s health and strive for better outcomes, lawmakers have specifically targeted maternal health coverage for cuts.

The same is true for infants in the U.S, whose health care is also at risk with these proposals. Our nation ranks 50th in the world on infant mortality. By shifting more families off of Medicaid, and creating a larger uninsured and under-insured population, children’s access to health care services will decline.

The Affordable Care Act protects all Americans from discrimination based on preexisting conditions, expands coverage for mental health treatment and drug addiction, and fosters preventive care. Millions of Americans have health insurance for the first time, and we are at an all-time low in the percentage of citizens who lack coverage. The reform legislation under development proposes to wipe away these essential gains, returning Americans to the pre-Affordable Care Act era of coverage limitations and exclusions thwarting the provision of essential health care services.

In 1966, Dr. Martin Luther King explained to a group of health providers, “Of all the forms of inequality, injustice in health is the most shocking and inhumane.” We agree.

Letter to a Trump Supporter #1: Undocumented Immigration

We will all remember this election. Our children and grandchildren will read about it. They will ask us what it was like to live through it. They will want to know what we did, where we stood, how we voted.

This is the record I will leave behind.

Throughout this election season, I have been corresponding with a family friend who supports Donald Trump. I have explained, point by point, why I oppose Mr. Trump and why I see the country so differently than he does. In this final month leading up to Election Day, I will publish these “Letters to a Trump Supporter” on this blog.

I will begin with the issue that started it all: undocumented immigration.

He sent me this video as an argument in favor of Mr. Trump’s rhetoric on this issue. Below is my response.

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Dear Mr. ——,

Thank you for sending this video. It’s interesting to see the fears that people have about undocumented immigration.

Hopefully, it’ll comfort you to learn that most of those fears are unwarranted.

First and most importantly, the undocumented immigrant population is shrinking. It peaked in 2007 at 12.2 million people. Now, there are only 11.1 million. So, contrary to all the accusations in this video, undocumented immigrants have been leaving more than they’ve been coming here during the Obama administration.

Contrast that with the Bush administration, during which the population grew from 8 to 12 million…a 50 percent increase!

Second, President Obama never said that he welcomed undocumented immigrants to cross the border. Notice that they never show him saying such a thing. That’s because such a video doesn’t exist. He never said it.

Third, immigrants actually commit fewer crimes than native-born American citizens. This shouldn’t be surprising, when you consider the fact that violent crime rates have plummeted nationally over the past couple decades when undocumented immigration has been rising. What this video is doing is pure racism, assuming that foreigners are more “dangerous” when the facts say the exact opposite.

They’re trying to scare you. Don’t be fooled.

Fourth, there are very, very few undocumented immigrants who are granted asylum on the border. In 2013, for example, only 155 Mexican immigrants were granted “defensive asylum.” The numbers from other Central American countries are even lower.

That shouldn’t be surprising, since it’s not nearly as easy as this video alleges. The Border Patrol has no control over it, and neither does the President. The asylum-seeker has to prove their case before an immigration judge.

Fifth, it is not true that immigrants run to the Border Patrol. On the contrary, the Border Patrol is regularly accused of using excessive force, to the point that it “has normalized policing practices that would be considered patently unconstitutional if carried out by local police.”

Sixth, undocumented immigrants cannot receive “free heart surgery.” The Affordable Care Act (a.k.a. Obamacare) explicitly prohibited undocumented immigrants from receiving subsidized health insurance. Some community clinics provide charity care, but they do not do expensive operations. Even those options are few, however, and too underfunded to serve most of the undocumented population.

Finally, I want to point out how this is a classic case of biased, unprofessional journalism. Notice that he only presents one side of the case: He only interviews Border Patrol workers. He never interviews a single undocumented immigrant!

This presentation would fail even the most basic journalism class. It’s not news. It’s propaganda.

Best regards,
Anthony

Republicans Want to Replace Obamacare with…Obamacare-Lite?

Americans Trust Democrats Over Republicans on Health CareEver since Barack Obama signed the Affordable Care Act on March 23, 2010, the Republicans in Congress have tried to repeal it. This week’s vote was their 50th attempt.

And yet, despite their unyielding opposition, their earnestness rings hollow to most Americans for the simple reason that they have not offered an alternative path to health care reform. Even the party’s own strategists have chastised it for its negative approach, for failing to offer a plan of their own, for obstructing rather than leading.

Finally, their pleas have been answered — in the form of the Patient Choice, Affordability, Responsibility, and Empowerment Act, or “PCEREA,” sponsored by Republican Senators Orrin Hatch, Tom Coburn, and Richard Burr.

At long last, we can answer the simple question that Democrats have been asking Republicans since March 23, 2010: You got a better idea?

Unfortunately, the answer is a disappointing “no.”

The ACA, better known as “Obamacare,” has four major provisions: (1) a ban on price discrimination against sick people, (2) an “individual mandate” requiring everyone to purchase health insurance or pay a fine to the IRS, (3) tax credits for Americans who cannot afford to purchase insurance, and (4) a Medicaid expansion for the poorest Americans who don’t pay enough taxes to qualify for the tax credits.

The PCEREA does away with the first provision right off the bat. The most popular feature of Obamacare, the one that appeals to our basic sense of fairness, is the rule prohibiting insurers from charging different prices to different consumers based on health status. The Republicans would erase this rule, once again making insurance least affordable for the people who need it the most.

With the first provision gone, there isn’t much need for the second one. This is what most people have trouble grasping about the individual mandate: As unpopular as it is, it’s necessary in order to sustain the most popular part of the law. Without an individual mandate, a ban on price discrimination will simply result in insurers charging high rates to everyone, driving all but the sickest consumers out of the market. Insurers can only afford to charge reasonable rates across the board if healthy people are required to buy in.

The PCEREA replaces these two provisions with two new provisions called “continuous coverage” and “auto-enrollment.”

Under “continuous coverage,” Americans would be given a one-time opportunity to buy insurance at prices that aren’t based on health status. So long as they keep this insurance plan for the rest of their lives, they’ll never be discriminated against. If they miss this opportunity — say, by being born after the window passes — they can be discriminated against. If they lose their plan — say, because they change jobs — they can be discriminated against. Basically, “continuous coverage” is a con, a “first come, first serve” lottery that doles out the right to fairness like it’s a privilege, a prize in some twisted game, and then snatches it out from your hands if you fall on hard times or dare to exercise your freedom of choice.

Under “auto-enrollment,” states can sign you up for insurance without your consent, but you can opt out. Basically, the Republicans are assuming that the problem with the insurance market is that Americans are so stupid that they aren’t signing up for insurance that they need and can afford.

Astonishingly, the Republicans have simply taken the provisions of Obamacare and made them temporary — and called it “reform”! We’ll give you fair prices, but only for a little while. We’ll require you to sign up for insurance, but only until you back out.

The third provision confirms this ploy. Just like the ACA, the PCEREA offers tax credits to Americans who purchase insurance on the individual market. The only difference is that the Republicans’ tax credits are far less generous, helping far fewer people.

Finally, the PCEREA addresses Medicaid by restricting its availability to only certain types of Americans, apparently the ones whom the Republicans deem worthy: pregnant women, children, the disabled — but not, for example, working parents. It would also change Medicaid into a block grant program, where it would get a chunk of money every year regardless of how much it needs, leaving most states with tremendous shortfalls during recessions and leaving patients out in the cold when they need help the most.

This last provision is just cruel, but the Republicans can slip it into the bill because the rest of the proposal looks so thoughtful and measured that they’re hoping you won’t notice that it will do almost nothing to address the serious problems ailing our health care system. It is little better than the status quo that existed before Obamacare — and in that sense, they haven’t really offered an alternative after all.

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This op-ed was published in the Huffington Post, and an abbreviated version was published in the South Florida Sun-Sentinel.

Yes, Obamacare Critics, Health Insurance Does Make You Healthier

Michael Barone and Charles Krauthammer have some medical advice for you: Don’t get health insurance, they say. It won’t make you healthier. It’s a waste of money.

Obamacare Enrollment SurgeThey must be desperate. They don’t want to admit that they’ve run out of criticisms of Obamacare. The website is working, enrollments are surging, and millions of Americans are getting affordablehigh-quality health insurance. They couldn’t deny these facts, so they needed a new argument to discredit the law — and they found it tucked away in the New England Journal of Medicine.

In 2008, Oregon conducted an experiment. They held a random lottery. They picked 20,745 names out of a waiting list of 90,000 low-income adults who wanted to sign up for Medicaid. Of the winners, half received Medicaid, and half did not. After two years, they compared the two groups to see if the ones who had Medicaid were any better off.

Barone and Krauthammer claim that the Medicaid group did not have better health than the uninsured group, proving the futility of health insurance, but their conclusion is based on a very narrow, selective reading of the evidence.

It’s true that the individuals on Medicaid did not fare any better than their uninsured counterparts on blood tests for cholesterol, blood sugar, and blood pressure. But it’s also true that the Medicaid patients scored higher on the mental quality-of-life test, experienced significantly lower rates of depression, and reported that they felt healthier.

The Medicaid patients also experienced significantly less financial strain. They were 25 percent less likely to have an unpaid medical bill sent to a collection agency.

In other words, health insurance has significant mental and financial benefits.

In this study, the physical benefits are less clear, but that’s not surprising, given that it only lasted two years and it only measured three simple blood levels. Fortunately, other researchers have measured more than just cholesterol.

A 2008 study in the prestigious medical journal The Lancet, for example, revealed that uninsured patients were significantly more likely to develop advanced-stage cancer because they didn’t receive early screening to detect it.

A year later, Harvard researchers published a study in the Annals of Surgery showing that uninsured patients who arrived at the emergency room with traumatic injuries were almost twice as likely to die in the hospital as patients with insurance, even if they had the same race, gender, age, and severity of injury. Later that year, a similar study was conducted at the Boston Children’s Hospital and published in the Journal of Pediatric Surgery. It found that uninsured children were more than three times as likely to die from traumatic injuries as children with commercial insurance.

And if all that wasn’t enough to convince you, the American Journal of Public Health published a study that same year comparing the death rates of the insured and the uninsured when they had the same education, income, weight, rates of smoking and drinking, etc. They concluded that 44,789 Americans die every year simply because they don’t have health insurance.

That is the bottom line we should be talking about.

If the Oregon experiment were carried out beyond two years, the differences between the insured and the uninsured would accumulate. They found that the Medicaid patients were 70 percent more likely to visit the doctor, 20 percent more likely to have their cholesterol monitored, and for the women, 60 percent more likely to get a mammogram. Those kinds of preventive measures don’t make a huge impact in two years, but in the long run, they can mean the difference between life and death.

Health insurance is so beneficial to your health, in fact, that its effects spillover and benefit those of us around you. Studies have shown, for instance, that companies that offer health insurance are more productive because insured workers take 52 percent fewer “sick days” than their uninsured co-workers.

I have to wonder if Barone and Krauthammer have ever even met anyone on Medicaid. I wonder if they know the terrible fear that uninsured Americans feel when they get sick and they’re forced to choose between astronomical medical bills and untreated illness.

I think they should find out. If they’re so confident that health insurance doesn’t affect your health, then I would like to issue this challenge to them: Give up your own health insurance. Don’t waste another penny on it. Join the ranks of the uninsured.

If not, if they’re unwilling to follow their own advice, then they should stop giving it. They should stop spreading misinformation that can hurt millions of Americans who read their op-ed columns and who depend on the access to lifesaving medical care that only health insurance can provide.

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This op-ed was published in today’s Huffington Post. An abbreviated version was published in the South Florida Sun-Sentinel.

Does Obamacare Infringe on Our Liberty? Or Does It Give Us Even More Freedom?

What right does the government have to make you buy health insurance?

That’s the question that riles Obamacare critics the most. It’s not the premiums or the website or the dropped coverage. It’s the infringement on their liberty.

Does Government Threaten Our Freedom?You hear it all the time: “This is a free country!” That’s what everybody says. But what do they really mean? Do they know what freedom is?

It seems obvious at first. Freedom is lack of coercion. Therefore, anything the government makes you do infringes on your freedom.

But there are different types of coercion, and the government isn’t the only one doing the coercing.

Let’s say that you want your daughter to attend the best school in America. But you can’t afford the tuition. Do you really have freedom of choice? If you choose the school you want, they won’t let you through the front door. If you force your way in, they’ll arrest you.

So you “choose” a more affordable school. You wanted a better school, but they forced you to settle for a different one. Sounds like coercion to me.

Let’s consider another example. You want to retire at the age of 65. You’ve worked hard throughout your entire adult life. Unfortunately, wages haven’t risen, and the bills kept piling up. You saved as much as you could, but it’s only enough to live off for a couple years. Oh, and one more thing: Social Security and Medicare don’t exist.

If you “choose” to retire, you’ll go broke. You’ll go without preventive health care. Your chances of dying early will increase significantly.

So you have a choice: Keep working or die young.

In this case, you actually have less freedom because the government is less involved. Without Social Security and Medicare, you do not have the freedom to choose a long, healthy retirement.

Freedom requires more than the absence of laws and taxes. True freedom of choice requires the capability to make that choice — and the free market doesn’t always give us that capability.

Jobs are scarce. Most of us don’t have the freedom to work anywhere we want. We take what we can get. For many of us, that means working at a company that doesn’t pay for our health insurance. So we “choose” to buy insurance on the individual market.

Before Obamacare, the individual market charged really low rates to healthy people and really high rates to sick people. So the people who needed insurance the most couldn’t afford it. They didn’t have the capability — and therefore the freedom — to buy it.

Obamacare outlaws that kind of discrimination. It requires insurers to charge the same rates to healthy and sick people alike, and that means that healthy people will have to pay higher rates. Some of them won’t want to, so they’ll stop buying insurance. When they drop out, they leave behind the sicker people who are most costly to insure, forcing insurers to raise rates even more. It’s a vicious cycle, a “death spiral,” that results in almost everyone being priced out of the market.

Virtually no one will have the freedom to buy health insurance on the individual market.

And that’s why we have an individual mandate. If the healthy people don’t drop out, there’s no death spiral, and the insurance remains affordable for the people who need it the most.

The government gives them a freedom that the free market cannot. It gives them the capability to purchase health insurance.

If we choose not to buy insurance, we pay a penalty. As Supreme Court Chief Justice John Roberts has written, “it makes going without insurance just another thing the Government taxes, like buying gasoline or earning income.” Those taxes pay for our roads and Army and Navy and Social Security and Medicare — and those things give us the freedom to live a life that we often take for granted. Without those taxes, without those government-funded investments, we could not call ourselves a free country.

In the same way, without Obamacare, without the government making us buy health insurance, we would be condemning millions of Americans to lives without health care. We would be restricting their freedom. And what right do we have to do that?

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This op-ed was published in today’s South Florida Sun-Sentinel and Huffington Post.