01:51 - Source: CNN
Trump's HHS pick hates Obamacare

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Ford Vox: For future HHS Secretary Tom Price, your pre-existing condition isn't a priority

"Empowering Patients" begins to look a lot more like "Empowering Insurance Companies," writes Vox.

Editor’s Note: Ford Vox is a physician specializing in rehabilitation medicine and a journalist. He is a medical analyst for NPR station WABE-FM 90.1 in Atlanta. He writes frequently for CNN Opinion. Follow him on Twitter @FordVox. The opinions expressed in this commentary are his.

CNN —  

You might remember President-elect Donald Trump telling us that he’d like to keep some parts of Obamacare. That was two weeks ago. With his announcement Tuesday that Rep. Tom Price, R-Georgia, will be his pick for Health and Human Services secretary, any type of preservation is highly unlikely. Price is one of the law’s archenemies.

Ford Vox
Ford Vox

Seven years ago, during the heat of committee debates over the ACA, Price delivered a blistering speech condemning Democrats for an unwillingness to negotiate with him and other Republicans amid their harried push to get the Affordable Care Act through Congress.

Price didn’t have a fully articulated alternative back then, but he knew what he didn’t like about Obamacare. “What you all are planning is to increase drastically the intrusion of the federal government into the practice of medicine and the care of patients,” he said.

Of course Price was right. But we needed that “intrusion” of the federal government due to the crisis precipitated by the failures of medical professionals, the health care industry and the insurance industry to get the job done for tens of millions of Americans who had no access to care. Individual clinicians and hospitals may not be public utilities, but the system as a whole requires oversight to make sure it serves that function.

Obamacare and its Medicaid expansion are by no means elegant solutions, but they get the job done for tens of millions of Americans who didn’t have coverage before, and offer important new protections for everyone else.

Price didn’t just sit and fester over the years. He’s got a plan now

But it’s not written with the uninsured and the poor at the forefront. No, the driving concept behind Price’s Empowering Patients First Act is protecting the choices of patients who have money. If you have the money to shop around, you’ll be able to choose from a broad national market of insurance plans. There’s no mandate to buy insurance at all, unlike Obamacare, and if you do buy insurance, you can pick from a threadbare plan that’s cheaper because it excludes large categories of care – like maternity care, reproductive care, or rehabilitation, for example. Obamacare required holistic health insurance covering all the major categories of events that we know can happen to anyone.

Price is also looking out for any well-to-do patients on Medicare who would like to be able to use Medicare dollars to offset more expensive fees from doctors and clinics who don’t participate in Medicare. This rule change alone would rock health care by encouraging an exodus of providers out of Medicare’s core cost-containment bargain: to treat Medicare patients, providers have always had to agree to take whatever reimbursement Medicare offers for the privilege of serving its beneficiaries.

What about coverage for pre-existing conditions? Trump told “60 Minutes” and the Wall Street Journal he really liked that aspect of Obamacare, but for Price, your pre-existing condition isn’t a priority. Price’s plan will allow sick patients to stay in the regular market so long as they can keep paying their premiums.

If a patient gets so sick she can’t work to pay her premiums, insurers can jack up her rates 150%. If she becomes too poor to afford that, then she is relegated to high risk pools that will vary in quality state by state. These are small markets that need federal subsidies to work, and those subsidies are capped. If the high risk pools fill up, using up all its funds, then new patients simply can’t enroll.

Suddenly, “Empowering Patients” begins to look a lot more like “Empowering Insurance Companies.” Indeed, insurers can charge what they like for the one pre-existing condition we all may be so fortunate to develop: old age. As you get into the age brackets where you’re more likely to need health care, you’ll pay whatever insurers think the market can bear. Price wants our health care access to depend on how much competition we can foster between insurance companies to get new customers. In other highly regulated markets, like the airline industry, that concept isn’t working out too well. Your only protection against those extra costs will be a capped tax deduction.

In contrast to Price’s efforts to empower insurance executives, I think Obamacare erred in large part by not regulating insurance companies even more tightly (the law could have forced them to participate in the exchanges to stay in business at all, for example). Price’s law even acknowledges some insurance plans will have to come with an asterisk and a warning. “This policy may be less expensive than others because it is not subject to all of the insurance laws and regulations” of your home state, shoppers are told, and “this policy is not subject to all of the consumer protection laws or restrictions on rate changes” of your home state.

But all the skimpy plans Price could potentially offer would still be better than the void we had before Obamacare. It’s my sincere hope that we won’t see a repetition of the errors Democrats made while crafting the Affordable Care Act. Having experienced the other side of a legislative fiat, I hope that an HHS Secretary Price will bring Democrats to the table as he participates in crafting legislation behind the scenes with congressional Republicans. And everyone in Congress needs to keep in mind that the health care industry, particularly clinicians and hospitals, can only endure so much radical change within a short period.

It certainly does no good if Republicans implement a whole new health care reform that will only be wiped away in a few years if the other party takes charge. To that end, the ideal course of action is revising Obamacare to inject more of the freedom and choice Republicans prioritize, both for patients and providers, while preserving and strengthening the law’s requirements that insurance companies offer holistic coverage to everyone. But our toxic politics won’t allow for such sensible, professional legislating.

The best we can hope for from Price and his cohort are policies that manage to achieve the same ends in markedly different ways. I live in Price’s district of northern Atlanta suburbs. The value of these suburbs as places to live comes not from their being 70% white. The value of Atlanta’s suburbs comes entirely from their proximity to a more cosmopolitan urban center. We have to think of health care the same way, it can’t work just for the rich.

Indeed if anyone in Price’s district has a serious enough injury, they’ll go to a publicly funded hospital on the south side of downtown Atlanta, where the demographics are quite different. Price knows it well. Besides founding a private orthopedic practice that is now the largest in the state, he also spent time training orthopedic residents at Grady Memorial Hospital, the region’s safety net. Hospitals like Grady do the work the private hospitals up north don’t want to do. Grady would be a stronger institution if Georgia had expanded Medicaid as Obamacare intended, but Price even calls for taking that option away from other states who want to continue using the expansion.

I don’t know what Price experienced in his 25 years of medical practice that ever convinced him the average patient knows their future health care risks so well that saving money by shopping for skimpy plans is an important social good. I don’t know why Price doesn’t recognize the patients he once treated at Grady have enough struggles without worrying about how they’re going to pay for health care. And I will never understand a fellow physician who’s ever treated a gay or lesbian patient in distress who doesn’t think everyone deserves to have a spouse by their side.

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    Price is a smart man, and he’s put something on the table that’s better than nothing, but we need far more. So, I hope he’ll heed his own cries from seven years ago and negotiate with the other side.

    The United States is bumbling its way toward the bitter end of the death penalty. As the numbers of executions fall every year, the state-ordered deaths that we do commit become that much more unusual, freakish and unfair applications of the law. As states scramble to implement arbitrary new lethal injection protocols, the cruelty of the procedure only worsens. The way Alabama killed the convicted murderer Ronald B. Smith on Thursday is only the latest example.