I was at a conference of Alabama Family Physicians in Birmingham this weekend and attended a lecture entitled “Health Care Reform Update.” I know a lot about health care reform but am always interested in what others have to say. It turned out it was a completely different kind of talk. Richard Sanders  gave the talk. He is a health care attorney who according to the firm’s web site specializes in health industry defense (such as negotiating settlements between health care entities and the federal government). He gave a very different talk than I would give.

First he pointed out, as I do, that repeal is unlikely in the next two years. This is because the Republicans gained control of the House, only, and it takes the Senate and the President as well (or else a veto proof majority in both houses) to pass legislation. His implied message, though, was that repeal could happen in two years so resistance might be a consideration.

Secondly, he focused on the tax increases passed to fund the expansion. He pointed out that high earners were on the hook an increase in Medicare Part A taxes and for an a 3.8% tax for investment income. This elicited a moan of concern from the physician audience.

Thirdly, he focused on increases in cost of coverage for those who own expensive policies under the current system. Health Savings Accounts contributions are limited as are distributions. Itemized medical expense deductions are limited. “Cadillac plans” (those worth over $10,200 for the individual) that are not a consequence of a negotiated union contract are taxed as income.

Fourthly, he focused on the health sector taxes. The law contains taxes on pharmaceutical manufacturing firms, health insurance, and medical device manufacturers in addition to the infamous tanning booth tax.

Fifthly, he focused on the mandate and the likely implications of the mandate. There is a lot of information that can be found here but the Spark Notes version is as follows:

  • Everyone is mandated to have insurance
  • Under 50 employees, mandates do not apply and employees can seek coverage on the exchanges if the employer does not supply coverage. The subsidy will be in the form of a tax credit
  • Over 50 employees must offer coverage. If the workplace does not offer coverage and an employee applies for the credit then the employer will have to pay about $2000 per employee
  • Employers can offer a voucher for coverage through the exchange if they elect not to offer coverage

I must admit I was disappointed in the talk. This is the single greatest opportunity to transform the care delivery system in our lifetime (a fact acknowledged by Mr Sanders as well). I would have hoped that the talk would have focussed on the opportunities to deliver care more effectively (and in a potentially more lucrative manner) given the limited educational time available. Instead, my colleagues heard a lecture on the importance of how to shelter their income and why to keep their office staff numbers below 50 so they could avoid paying for employee health insurance (until recently seen as a civic responsibility).

As I discussed before here and here, what it all comes down to is philosophy. To me, as an underlying philosophy, it is important that all Americans have access to healthcare. Therefore, how it is paid for is unimportant except as it is sustainable. To others, access is not to be offered as a benefit of citizenship so much as a commodity to be purchased. Because of my life philosophy I don’t see anything wrong with figuring out a politically tenable way to pay for preventive care and chronic illness care (acute care has been mandated in an unfunded fashion through EMTALA). Richard Sanders, in contrast, expressed a concern that by having to create artificial methods to fund access meant that Americans do not support such access. He expressed support for exclusively using income-based funding of government services. The converse is that if Americans will not willingly raise taxes on income we shouldn’t provide the services.

In addition, as an attorney specializing in negotiating the health care regulatory maze, he sees opportunities where I see potential landmines. We elected to keep employer based health insurance because Americans didn’t want to “lose their current insurance.” It frightens me when I hear consultants describing how to game the system. I would hate to have the name of the Affordable Care Act changed to the Health Care Consultant and Lobbying Relief Act of 2010.

 While Americans have been taught to hate ObamaCare because of the death panels and provision of health care to undeserving obese folks, they seem to be accepting of the VA and Medicare. Can we get Congressman Boehner to “repeal and replace” ObamaCare with a single payor system? It would keep me from having to sit through any more of these lectures.

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