Mitt Romney gave a speech about health care last week. We all know he is in favor of repealing the Affordable Care Act (ACA). This speech, which laid out his ideas for its replacement, didn’t get a lot of attention. That may be good news for Romney, for the truth of the matter is that his plan for replacing the ACA is degrading to doctors and patients. For physicians, it would mean a loss of professional esteem. For patients, it would mean losing the consumer protections provided by the ACA and replacing them by passing a law that already exists. It’s snake oil dressed up as policy, and it’s scary.
Start with Romney’s vision of health care. He said:
I want to get health care to act more like a consumer market, meaning like the things we deal with everyday in our lives: The purchases of tires, of automobiles, of air filters, of all sorts of products. Consumer markets tend to work very well—keep the costs down and the quality up.
Focusing on the consumer market is where Romney’s heart is. In an entire speech about health care, Romney never mentioned the words “doctor,” “physician,” or “nurse.” The “consumer market” comes up 4 times.
This shift in focus is profound. Physicians believe that what they do is unique; Mitt Romney disagrees. Doctors think they have a special obligation to patients; Mitt Romney doesn’t.
For those interested in the economics, medicine and car sales are very different. Medicine has always been special because health is so fundamental to a good life, because doctors have such immense influence over our health, and because medicine is more technically complex than nonspecialists can handle. For these reasons, medicine has always been viewed as a noble profession. In contrast, Mitt Romney views it as just another day job—like selling cars or tires.
Implications for Physicians
When you view doctors as auto salesmen, the obvious inclination is to pay them less. Romney follows through on this. Repealing the ACA will add 30 million people to the ranks of the uninsured. What does Romney propose to do about this burden on providers? He wants to dump the problem on the states, letting them “care for their own people in the way they think best.”
Actually, there’s some interesting math here. Romney wants to add 30 million people to state Medicaid roles (a 40% increase) and give states 30% less federal money to pay for them. Bear in mind that when Romney was governor of Massachusetts, he showed no such ability to cut Medicaid by 30%.
How will states cope? Medicaid programs starved of cash will cut physicians’ and hospitals’ fees and leave more people uninsured. Those health care professionals compelled by law or moral integrity to see low-income patients will do so; others will opt out. Romney did not mention how physicians are supposed to function when 1 in 5 Americans is without insurance and an equal number have coverage that reimburses physicians at such low rates that seeing those patients does not cover costs.
A free market in health care has certain undesirable properties for patients as well—like the fact that insurers may deny them coverage when they get sick. Since the consumer protections in the ACA are very popular, Romney needed to address this. Here is what he said:
I also want to make sure that people can’t get dropped if they have a preexisting condition. What I mean by that—so let’s say someone has been continuously insured and they develop a serious condition, and let’s say they lose their job or they change jobs, they move and they go to a new place. I don’t want them to be denied insurance because they’ve got some preexisting condition. So, we’re going to have to make sure that the law we replace Obamacare with assures that people who have a preexisting condition—who’ve been insured in the past are able to get insurance in the future—don’t have to worry about that condition keeping them from getting the kind of health care they deserve.
This sounds like a great idea, right? Indeed, it is such a great idea that it was passed into law in 1996. That’s right—Romney has proposed to replace the ACA with a law that was enacted 16 years ago. Does that mean Congress gets to vote on it again? Would President Romney sign next to President Clinton? No word on that yet.
When asked after the speech about protections for people moving from uncovered to covered (this is the group that will lose protections if the ACA is repealed), Romney’s spokesperson said: “And for those purchasing insurance for the first time, he supports reforms that empower states to make high risk pools more accessible by using cost reducing methods like risk adjustment and reinsurance.”
Ah, the magic risk pool, a staple of every Republican who wants to finesse the fact that he has no real plan to cover people (George W. Bush and John McCain proposed them as well). Alas, high-risk pools have been tried in 34 states going back to 1976. They have had only modest success, because the people they insure are very expensive, and no one can afford to cover them without a big subsidy. What kind of businessman thinks that a product that hasn’t sold well in 35 years is a good one to advertize widely?
So there you have it. Make medicine more like selling cars or tires and let it go. If that degrades doctors, hurts patients, and removes the uniqueness of medical care, well, who needs those things? Who knew that when Romney said he liked being able to fire people who provide bad service, he meant the entire medical profession?
There is another part of the speech that summed up well Romney’s view about health care. It came when he described a rally he attended for US Senator Marco Rubio (R, Fla) in Orlando:
I heard Marco Rubio the other day. He said, you know, when we came to America and we had our home—very modest home, apparently—he said he looked around and saw some very fancy homes. Big cars. People lived extremely well. He said “I never once heard my parents say, ‘I wish we could have some of what they have. I wish they’d give it to us.’ Instead they said, ‘Aren’t we lucky to live in a country where if we work hard and have a little good luck and get a great education, we might be able to achieve that for ourselves.’ That is the nature of America.
That is Romney’s real message to doctors and patients. “Yes, what you have won’t be good. But you should feel fortunate you have something. Maybe one day you will be able to afford decent health care. Until then, don’t complain.” Sorry, Mr Romney. That may be your vision of America, but it’s not the country’s.
About the author: David M. Cutler, PhD, is the Otto Eckstein Professor of Applied Economics in the Department of Economics and Kennedy School of Government at Harvard University and a member of the Institute of Medicine. He served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and was senior health care advisor to Barack Obama’s presidential campaign.
About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.
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