The National Right to Life Committee on Thursday released a new report, “The Affordable Care Act and Health Care Access in the United States.” Burke Balch, director of the Robert Powell Center for Medical Ethics there talked with National Review Online about it.
KATHRYN JEAN LOPEZ: What is the National Right to Life Committee doing opposing Obamacare? That’s got to be a question on people’s minds who do not quite see the law as you do. Shouldn’t NRLC be pro-health-care reform?
BURKE BALCH: There are, of course, many ways to reform health care — some better than others. The wrong way, embodied in Obamacare, is to limit the health care Americans can receive. Since its inception, the National Right to Life Committee has been as committed to protecting the vulnerable born from euthanasia as to protecting the unborn from abortion, and we have recognized that when the government denies people life-saving medical treatment against their wishes, that is a form of involuntary euthanasia. That is why, while consistently advocating positive measures to protect access to life-preserving medical treatment, as well as to assisted feeding and hydration, the National Right to Life Committee fought the rationing in the Clinton Healthcare Plan in the 1990s and why it is fighting the rationing in Obamacare now.
LOPEZ: You put out a press release that says: “Obamacare is bad medicine for America.” If I’m an American fatigued by all this opposition to the president’s law, why should I read on?
BALCH: Ask yourself three questions:
1. Should the federal government limit what private citizens are allowed to spend on health care to save the lives of their family members?
2. Should the federal government limit how much life-saving medical treatment doctors are allowed to give their patients?
3. Finally, despite all the talk about Obamacare, did you know it does both of these? If not, read on!
LOPEZ: How does the “Excess Benefits” tax work and why is it of concern to the National Right to Life Committee?
BALCH: If your employer pays for your health insurance, any amount above a government-set limit will be taxed at 40 percent; the intent is to deter employers from offering pricey insurance. Remember the problem with the alternative-minimum income tax? Originally designed to target a few wealthy individuals who used tax deductions to avoid paying any tax, because of “bracket creep” it snared more and more middle-class Americans as inflation brought their nominal incomes above the trigger point for it. Only in 2012 was that trigger point permanently indexed to inflation.
The “Excess Benefits” tax will have a similar effect. The trigger point for it is indexed to the Consumer Price Index, but not to medical inflation, which since 1990 on average has annually exceeded the CPI by 3.3 percent, as documented on our website. Because that difference “compounds” like interest in the bank, by 2011 the medical inflation index stood at almost 1800, compared to a bit over 200 for the CPI index.
That means that over time, the value of employer-paid health insurance, adjusted for medical inflation, will shrink drastically, placing ever-greater downward pressure on the diagnostic tests and medical treatment that will be covered for life-threatening illness and injury.
LOPEZ: But the “excess benefits” business doesn’t come into effect until 2018. Why is this a priority for you now?
BALCH: As Politico has reported, “[The consulting firm] Towers Watson found that more than six out of ten employers said the fear of triggering [it] would influence their health-care benefit strategies in 2014 and 2015 . . . [E]mployers are . . . concerned that they’ll get busted for offering fairly standard plans.”
LOPEZ: What’s your beef with the exchanges and what people have access to there?
BALCH: It’s been widely reported that in many exchanges most or all of the available health-insurance plans have very narrow panels of health-care providers you can use, excluding top specialists and highly rated health-care centers, and in some cases forcing beneficiaries to go many miles away to get hospitals or doctors that will take their plans. But there’s been little attention to a key reason for this: A little-noticed provision in the law excludes from the exchanges plans offered by insurers who allow consumers to pay what the government deems an “excessive or unjustified amount” to save the lives and preserve the health of their family. It is as though the government set up marketplaces for automobiles, and only allowed people to buy subcompacts — “protecting” them from paying “too much” and buying a mid-sized car or minivan.
LOPEZ: Isn’t it only practical that a federal plan would place limits on what doctors can do?
BALCH: Not necessarily. To assist those who genuinely need help paying for health insurance, sliding scale subsidies could be provided to be used toward the cost of health insurance, and then we could rely on free-market competition to strike a balance between the costs and benefits of health care, without the government putting artificial constraints on what people are allowed to pay and doctors and insurers are allowed to provide.
LOPEZ: What do you say to those who claim that some rationing is inevitable no matter the health-care system?
BALCH: Too often we hear the claim that because no one can afford to spend unlimited amounts on health care, health-care “rationing” is inevitable and the only issue is how best to “ration” justly and efficiently. But most of us can’t afford to eat every meal, every day at a top-of-the-line expensive restaurant and spend 365 days a year on vacation. Yet we don’t commonly speak of food and vacations as being “rationed.” That’s because rationing means government allocation of scarce goods and services. During World War II, for example, food was rationed — you couldn’t just get whatever you could afford, you also needed a ration coupon.
In cases of war or national disaster, sometimes rationing may be necessary. But when government routinely rations health care — as opposed to helping those genuinely in need to obtain the wherewithal to take part in the market economy for it — inefficiency and unfairness are inevitable. That is because allocation of resources by central planners, no matter how brilliant and well-intentioned, both cannot possibly adequately take into account ever-changing shifts in supply and demand or keep pace with medical innovation, and must ultimately rely on a high degree of arbitrary decision-making.
From the pro-life standpoint that insists on the equal dignity of all human beings, regardless of age, disability, or condition of dependency, the arbitrary nature of rationing is especially troubling because of the tendency of its practitioners to allocate health care based on assumptions about various individuals’ so-called “quality of life” — which usually amounts to discrimination based on age and degree of disability.
LOPEZ: What are your concerns about the Independent Payment Advisory Board?
BALCH: Almost all discussion of the Independent Payment Advisory Board has focused on its authority to cut Medicare spending. Little attention has been paid to the “Lieberman Amendment” under which the Board is required, every two years starting in 2015, to recommend measures to limit private health-care spending to grow below the rate of medical inflation. (Even if Board members are not nominated — or confirmed by the Senate — as a fallback the law empowers the federal Department of Health and Human Services to assume its functions.)
How is private health-care spending to be forced below the rate of medical inflation? The law says that the recommended measures are to include ones that can be implemented “administratively” and, in turn, authorizes HHS to impose so-called “quality” and “efficiency” measures on health-care providers. Essentially, doctors, hospitals, and other health-care providers can be told by Washington just what diagnostic tests and medical care are considered to meet these “quality and efficiency” standards. Treatment that a doctor and patient deem needed or advisable to save the patient’s life or to preserve or improve the patient’s health, but which runs afoul of the imposed standards, must be denied, even if the patient is willing and able to pay for it. Any doctor who dares to give a patient more or better treatment than the measures allow is made ineligible to contract with any qualified health-insurance plan.
LOPEZ: Does the fine print on Obamacare hurt senior citizens the most?
BALCH: Indeed. Buried in the arcane text of the law is a provision that enables Washington bureaucrats to limit — or even eliminate — the ability of senior citizens who choose to do so to make up for part of the impending cuts in government support for Medicare. Under the prior law, they could do so by adding their own money on top of the Medicare payment to purchase health insurance that would be less likely to constrict the availability of treatment and choice of health-care providers. (This pre-Obamacare option, solidified in 2003 by a Medicare amendment backed by National Right to Life, somewhat resembled the “premium support” Medicare proposal recommended in 1999 by a majority of the bipartisan Medicare Commission whose executive director was the current governor of Louisiana, Bobby Jindal.) Obamacare effectively gives HHS the ability to exclude from the alternatives annually available to senior citizens any Medicare Advantage insurance plans HHS contends allow them to allocate too much of their own money to their health care.
LOPEZ: What is the Powell Center for Medical Ethics?
BALCH: The Robert Powell Center for Medical Ethics is the arm of the National Right to Life Committee that focuses on euthanasia-related issues, including involuntary denial of medical treatment and rationing. It is named in honor of Robert Powell, National Right to Life’s deceased vice president who was a long-time fighter for disability rights as well as the right to life, and who, because of his disability, personally experienced threatened denial of life-saving medical treatment.
LOPEZ: What would a more pro-life health-care law look like? Is anything like it being proposed?
BALCH: One alternative, which we have been promoting since well before the debate on enacting Obamacare, involves a twist on what economists call “cost-shifting.” For many years, budgetary restraints have kept Medicare and Medicaid reimbursement rates for health-care providers significantly below the cost of actually treating beneficiaries of those programs. Hospitals and other health-care providers attempt to make up for this shortfall by charging more for services to privately insured patients, although there is scholarly dispute about the degree and prevalence of this practice.
This sort of “cost-shifting” was the prevalent mode of providing health care to the destitute in the years before Medicare and Medicaid. While it has many problems, one of its advantages is that the amount of money available to subsidize health care for those who are poor is directly linked to the level of private health-care spending by those who can afford it (directly or through their employers). As more money is spent on health care by employers and individuals who purchase health insurance, cost-shifting keeps pace in making available health care for those who cannot themselves afford to pay its full cost.
Moreover, as private purchasers of health insurance balance the benefits and the costs of available health-insurance plans, they unconsciously take into account not just the costs of health care for themselves and their employees, but effectively also their “fair share” of the cost of subsidizing others. This means both that, collectively, we will not spend more on health care than we can afford and that we will spend as much as we can afford (and collectively choose to spend). In contrast, government programs financed out of general tax revenue have no such link, and over time fall farther and farther behind comparable private health-care spending.
Our twist on this is to propose moving cost-shifting from the level of the provider to the level of the insurer. Government subsidies based on general tax revenues could be effectively frozen, provided in the form of vouchers to low-income individuals and families. Much as with automobile insurance high-risk pools, health-insurance companies (in proportion to their market share) would be required to absorb the difference between the voucher amount and the cost of, say, a set percentage of the average amount paid for health-insurance plans in the previous calendar year. Those otherwise unable to afford health insurance would thus be able to obtain plans whose value would remain below that of the average plan but would regularly rise in tandem with overall private health-care spending. As the economy grew, health care for all would grow with it (not suppressed by arbitrary governmental limits), but not beyond the capacity of the economy to absorb that cost. At the same time, with general revenue funds devoted to health-care subsidies essentially capped at the nominal level of a base year, as the economy grew and government revenues grew with it, governmental spending on health care would take up a shrinking rather than a growing share of the budget, with positive effects on the projected deficit. Our website provides details.
LOPEZ: Where is Obamacare on the beginning-of-life front at this point?
BALCH: In a sharp departure from the long-standing principles embodied in the Hyde Amendment, the Obamacare law provides massive tax subsidies that pay for elective abortion. Indeed, even the statutory provisions that supposedly would require that abortion coverage be paid for by a separate check are not being implemented by the Obama administration. (Read more here.)
LOPEZ: What is your advice to lawmakers as it pertains to this law and moving forward towards health care that protects the most vulnerable?
BALCH: Most important, it is wrong to suppose that in order to provide health care to those with low incomes the government must limit health care for others, or that the government must “protect” ordinary Americans from using too many of their resources to save the lives of their family members by imposing arbitrary limits on what they are allowed to spend for health insurance and health care. Contrary to conventional wisdom, in the aggregate and over the long term Americans can afford to devote an ever growing proportion of our income to saving our lives and promoting our health, because increasing productivity in producing other goods and services frees up resources that enable us to do so. Indeed, in the seven decades since 1940, our increased spending on health care has been entirely financed by reductions in the proportion of our income we have had to spend for food, clothing, and shelter, as documented on our website.