Interview conducted by Jaime Ortega.
Scott L. Greer, Ph.D., a political scientist, does research on the consequences for health policy and the welfare state of federalism, decentralization, and European integration.
1) Without Obama Care, how does the U.S. healthcare compare with other wealthy westernized countries?
1. Without Obamacare- the ACA- the United States stood out for generally middle-of-the-pack results, a bit better on some things, a bit better on some others. But it also stood out for astronomical costs and, of course, the uninsured. So we paid twice as much as comparable countries for the same quality, distributed worse. We also, contrary to myth, show no sign of offering the world’s best health care; even very rich people often go to Switzerland or Singapore rather than the US. Neither quality measures nor indirect measures such as technology intensiveness put us clearly first. And if you spend twice as much as somebody else and aren’t getting something at least a little bit better, you are being ripped off.
2) For many conservatives from the Tea Party and GOP, the Obama care health care program sounds to much like socialism. But is it fair to call Obama care, a socialist program?
2. Not remotely. We know what socialist-desgined health systems look like. They involve, typically, fully tax-financed and often publicly provided health care, and generally do well on access and efficiency if not customer satisfaction. The ACA is hardly socialist; it is rather a classically American construction in which we make sure that every interest group with Washington lobbies, even highly unpopular groups like health insurers, is afforded a role in policy. Otherwise, it would not have passed.
I’d also add that while the definition of socialism is pretty fuzzy, stretching as it does from some pretty right wing people in Eastern Europe to some people who are basically Communists, it basically never gets an intelligent definition in American politics. Socialism is basically just an insult in American political discourse, and should be regarded as such.
3) How will the FDA, Pharma, Medicare and Medicaid be affected by the new health-care reform?
3. Complex question. Short answers: the FDA is unaffected. Other legislation has given it enough to do. PhrMA (the lobby for big branded firms such as Pfizer) gets the terms of its basic deal in which the industry gives back a certain sum in taxes and in return is shielded from the kinds of price controls other countries use to control drug prices. Medicaid is expanded in states that agree to do so (under some quite radical Roberts Court jurispridence). Medicare is made slightly more efficient, notably by ceasing to subsidize the failed experiment called Medicare Advantage- though that is under counterattack by insurers who receive the subsidies and people who benefit from the subsidized policies. The ACA also closes the “donut hole” in Medicare Part D, which was a weird legacy of Bush-era budgeting. Each of these answers obscures a bunch of details.
4) Its seems fair to say that those who can afford private health care, that Obama Care is a disaster because it will result into a “waiting list”. But is it fair for those who cannot afford private Insurance premiums? Is Obama Care really more beneficial for some and not for others?
4. There is nothing directly in Obamacare to produce waiting lists. Expanding health insurance coverage without expanding the medical workforce suggests that there will be more difficulty getting an appointment, but that is likely confined to primary care. There is no reason to expect that the bulk of Americans- those with employer-provided insurance or Medicare- will experience a loss of access to care. They will continue to be the most lucrative patients for health care systems, and be treated as such.
5) Many mention the waiting list as something negative. Is this “waiting list” really that problematic, considering those who are sicker should be attended first, before those who are not? Is the waiting list a better option than paying private elevated premiums to get great health care?
5. Are waiting lists problematic? This is the kind of debate that people in other countries have all the time. Americans generally recoil from it (or, better, American politics rules it out- the survey evidence is ambiguous) and have no instruments through which to express our decisions anyway. We are no more capable of having a debate about rationing and priorities after the ACA than we were before. The reason is that we quite deliberately, as a polity, have chosen to avoid having the tools that would permit rationing on grounds other than finances- so tools like tough health technology assessment, price controls, and priority-setting for expensive treatments, which are common worldwide, are ruled out in the US context. The US, even post-ACA, generally rations health care by ability to pay rather than need.
6) How will Obama Care play with doctors pay rate? Will it possibly lower it?
6. There are two big ways doctors are paid that the federal government can affect. One is Medicare payment rates, which are separate from the ACA (and a mess in their own right). The other is efforts to reform the structure of payment by rewarding care rather than procedures thorough innovations such as Accountable Care Organizations. The effects of the latter are yet to be seen. Outside the ACA and Medicare law, the US health care system is also undergoing huge changes which we can crudely summarize as consolidation of providers into big systems and an increasing transformation of doctors from small businesses to employed shift workers accountable to managers for what they do. That is only partially because of federal policy- every sensible business wants to be a monopolist.
7) Will Obama Care improve or lower the health care system?
7. The ACA delivers one win: increased access, especially in states that expanded Medicaid. Right now there is a spirited effort to argue that health care doesn’t improve health, but it never seems to end in people giving up health insurance. It remains to be seen whether it will improve quality or efficiency, given that the price of passing legislation in the US system was removal of most of the policies that international experience shows to control costs.
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Right now, there is a particular effect at work in which existing dysfunctions of the health care system are being blamed on Obamacare- whether by people who basically oppose it as too left-wing, or people who view it as too right-wing (around 15-18%). So, when prices go up, or it is difficult to get an appointment, or the local health system becomes a near-monopoly of a badly run “system” it is natural to blame it on the ACA. Establishing an actual link is harder, though; medical cost inflation, access problems and a trend towards monopoly existed before the ACA but the politics, and blame, were different. That is why we saw decreasing employer insurance coverage, decreasing richness of benefits, and longer wait times every year for decades but only now have them as major political issues. The ACA changed the politics and the profile of who is happy and who is not happy.
