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Stand and Deliver or Repeal and Replace?
BY JOHN F. BREHANY
Less than one year after President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), the largest health-care legislation passed in the last 45 years, the House of Representatives has voted to repeal the law (and is pledging to hold hearings into its many provisions), more than half of the states have filed lawsuits to have the PPACA overturned, a key provision of the law was ruled unconstitutional by a federal judge on Jan. 31, and the majority of the public continues to voice opposition.
What should faithful Catholics be thinking and doing at this time?
I think Catholics should welcome this opportunity to review, and perhaps substantially revise, the PPACA as the law raises issues of prudence and principle requiring honest debate and timely action.
For example, there are key economic fault lines in the law that should be matters of serious prudential concern, particularly as the effects of governmental borrowing and spending are coming home to roost. Creative accounting was used during passage to make the apparent cost of the law seem acceptable, such as paying only six years’ worth of benefits with 10 years of revenue.
The “doc fix” in Medicare — which will cost at least $200 billion over a decade — was left off the table and the budgeting. Even apart from these two issues, the chief actuary of Medicare and Medicaid estimates that PPACA will add a minimum of $250 billion to the deficit. Health-insurance premiums are rising, and promise to go higher, and for good reasons. To name only one, PPACA will require health insurers to cover a range of preventive services at no up-front cost. This may seem convenient at the point of service, but the costs of the treatment must be paid at some point, and will result in higher premiums.
Furthermore, the new law will cause upheaval in people’s health-insurance coverage, notwithstanding Obama’s promise that people could keep their insurance if they liked it (and more than 80% of people are satisfied with their health insurance). Last fall, a respected health-insurance analyst estimated that 80 million-100 million people may well be forced to change their health-insurance arrangements between 2014 and 2016.
In a 2010 survey, only 55% of employers say they are likely to continue offering health insurance. The reason is that PPACA will raise the costs to employers of providing coverage, but level only a minimal fine if they decline to do so (and allow their employees to buy insurance in the new exchanges). The chief actuary of Medicare and Medicaid has estimated that at least 14 million employees will lose employer-provided coverage, while 7 million seniors will lose their Medicare Advantage plans. More than 18 million people receiving health-insurance coverage will be put on Medicaid, a system already failing to provide ready access to quality care.
Higher costs and disruptions in coverage will not be the only deleterious effects of the new law. While the government plans to cut costs in health care, most of these revolve around reducing payments to physicians and other health-care providers. Several national surveys of physicians show they understand this dynamic and fear for the future. A national survey conducted by Thomson Reuters recently reported that 65% of physicians think the quality of care will deteriorate in the next five years; 57% think the new system will be worse for patients, and 78% think it will be worse for physicians. Already burdened by regulations and battles over reimbursement with third-party providers (governmental and private), many physicians are contemplating early retirement.
Abortion Funding Beyond Dispute
As serious as these prudential issues are, they pale in comparison to the issues of principle at stake in the new law. For example, it is now beyond dispute that PPACA provides an avenue for federal subsidies of abortion. Whatever doubts existed evaporated when states began using federal funding for high-risk pools to pay for abortions. The nonpartisan Congressional Research Service found that neither PPACA itself nor the executive order precludes federal funds from subsidizing abortions. And former presidential chief of staff Rahm Emanuel admitted in a recent interview that he worked successfully to keep abortion advocates satisfied while convincing former Rep. Bart Stupak, D-Mich., to drop his amendment. Finally, PPACA forces people to subsidize the abortion coverage of others, even if they are opposed to abortion.
The PPACA also contains inexcusably flawed language regarding conscience protections. The law requires state and federal governmental bodies to respect rights of conscience with regard to assisted suicide and euthanasia, but not with regard to abortion and other medical procedures. (Only insurance plans are barred from discrimination based on refusal to participate in abortion.) Finally, language in the PPACA is vague regarding whether state-law protections of conscience will be respected in the new regime.
Vast New Federal Powers
Perhaps the core Catholic teaching least respected in the new legislation is the principle of subsidiarity. Essentially, this teaching holds that a larger (and more remote) entity should not usurp the authority and functions of a smaller, local entity. This principle has been repeatedly taught in encyclicals, most recently by Pope Benedict XVI in Deus Caritas Est (God Is Love): “We do not need a state that regulates and controls everything, but a state which, in accordance with the principles of subsidiarity, generously acknowledges and supports initiatives arising from the different social forces and combines spontaneity with closeness to those in need.”
Yet the PPACA vests vast and unprecedented powers in the federal government, and within the government, in unelected bureaucrats and advisors. According to the Center for Health Transformation, the secretary of Health and Human Services was given 1,968 new or expanded powers, including the power to determine the type of insurance Americans must purchase, which hospitals can participate in certain programs, what health-care services are considered “essential,” etc. And a new Independent Payment Advisory Board (IPAB) will have the power to set the level of reimbursements in health care. Since it will take a supermajority vote in Congress to overturn its recommendations, the IPAB will largely determine which services will be provided and which will not. Taken together, the federal government will dictate to an unprecedented degree how much people must spend on health-care services, what services can be offered and what services will be denied, either explicitly or implicitly.
What is the proper response to the significant principled and policy flaws in the PPACA?
Given the issues at stake, Catholics should welcome the chance to review and revise the new law. While some problems — even those related to abortion funding and conscience rights — may be correctable by amending the current law, others, particularly those provisions violating the principle of subsidiarity, may well require substantial change.
There are a variety of political tools and options at hand. Catholics should make use of these judiciously. What Catholics should not do is either rest content with the status quo or become intimidated by the sheer scale of the challenge at hand. Catholics can bring many resources — from venerable teachings to hands-on experience in providing health care. Catholics should draw on the full spectrum of the Church’s teaching and provide a united witness on the principles of authentic health-care reform.
John F. Brehany, Ph.D., S.T.L., is executive director and ethicist at the Catholic Medical Association.
More information about the CMA can be found at CathMed.org.