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The House vote to repeal what critics call "Obamacare" (the Patient Protection and Affordable Care Act - ACA -- signed by President Obama on March 23, 2010) was a key part of the GOP campaign to win back the House of Representatives in the November elections. It worked as an effective mobilizing call to arms.
HR2 (Repeal of the Job-Killing Health Care Act) passed the House by a vote of 245 to 189 on January 19, 2011. The Senate, however, killed the bill February 2, and the issue receded to a background murmur. Republicans and Democrats have drawn their swords over the President's budget, instead.
Still, repealing the health care act is likely to return to the political agenda. House Speaker John Boehner (R-Ohio) states that "The Congress can do better in terms of replacing Obamacare with common sense reforms that will bring down the cost of health insurance and expand access for Americans."
To assess such a proposition, one would have to know more details about his party's solutions. But proposals so far are conspicuously absent.
After Congress passed the ACA, Boehner called it a "dangerous experiment." Texas Gov. Rick Perry called it "socialism on American soil." Many of their Republican colleagues have reread the script used by the American Medical Association (AMA) in opposing extensions of health insurance coverage propounded by President Franklin Roosevelt, Harry Truman, Lyndon Johnson and Bill Clinton. They suggest that the ACA will result in a "government take-over" of American medicine, at worst, and "government-run" health care, at best.
But such attacks are dangerously misleading because they distort present realities and generate ill-founded fears.
We already have a massive government role in American health care; and for good reasons. We have socialized expenditures for our highest-risk populations - the elderly and severely handicapped (Medicare) and for the very poor (Medicaid) -- and we have a system of socialized medicine for our military veterans, which delivers health care of higher quality than what is received by the average American.
At the same time, most health care in the U.S. is provided by private non-profit hospitals and private doctors reimbursed on a fee-for-service basis. Clinical decisions remain largely in the hands of our physicians and to the extent that there has been increasing intervention and regulation of these decisions, it has come most forcefully from private insurance companies. Meanwhile, we have more government expenditure of biomedical research (NIH) and public health (CDC) than any nation in the world. And the system produces staggering rates of innovation in pharmaceutical research, medical devices and medicine.
The ACA is largely a bipartisan, half-way reform strategy inspired more by former Republican Governor Mitt Romney of Massachusetts than by left-leaning advocates of single-payer health insurance reform. It does not nationalize the health insurance industry. It does not increase the share of public hospitals. It does not set uniform prices for hospital and physician payment across all payers. And it does not assure universal coverage.
At best, the ACA, if implemented in 2014, will begin to increase coverage to 32 million of the more than 50 million Americans who are currently uninsured. It will achieve this objective through Medicaid expansion and the creation of health insurance exchanges that will strengthen federal regulation of the private health insurance industry through the prohibition of risk selection by insurance companies (the ban on refusals to cover pre-existing conditions and to set annual and life-time limits on coverage).
Finally, the ACA, passed before the extension of the Bush tax cuts for the wealthiest Americans, begins to reverse the post-Reagan policies of increasing income inequalities. It does so by increasing the existing Medicare payroll tax on all those earning over $200,000 ($250,000 for couples).
These are significant, but modest, steps toward what political scientist Jo White calls the "international standard" among health systems in wealthy capitalist democracies - Japan, Germany, France, United Kingdom, Canada, Switzerland, Australia, Netherlands, and many more.
This standard, met by all governments in such nations, either imposes taxes on its citizens or enforces a health insurance mandate to provide access to a minimum level of health care services. Without taxes or a mandate, there can be no universal health insurance coverage. Without universal health insurance coverage, we cannot meet the international standard.
New York City Health Commissioner Thomas Farley was the keynoter at the "Speeding Summit" held at NYU Wagner on November 19, 2010 -- and he pledged a major new public health emphasis on urban design.
"After quitting smoking, there's probably no behavior that promotes health more than regular physical activity," said Dr. Farley. "Okay, that's great. So what are we going to do about that? To me, the answer to that is thoughtful urban design and transportation infrastructure. "
The event, sponsored by the nonprofit group Transportation Alternatives, examined a proposal by cycling and other traffic safety advocates to reduce the side-street speed limit from 30 mph to 20 mph, and was hosted by the Rudin Center for Transportation Policy and Management at NYU Wagner.
Mayor Michael Bloomberg has long made it a paramount goal to rid New York City of unhealthful foods, and he recently asked the Federal government for permission to prohibit Food Stamp recipients from using stamps to buy soda and other sugared beverages in the city.
Supporters are cheering Bloomberg’s stance, saying he’s striking a blow for better dietary habits and ultimately lower public health costs and consequences such as obesity. But critics question the move, seeing it as an example of big government, even patronizing toward the poor.
Research can be a valuable guidepost for public officials. In 2009, after Mayor Bloomberg required restaurant franchises to put calories counts on their menus, NYU Wagner professors Rogan Kersh and Brian Elbel sought to measure the impact of the calorie labeling initiative on consumer habits at fast-food restaurants in low-income neighborhoods. Their survey of 1,156 adult found little direct evidence to support the Mayor’s view that the posting of calorie counts causes fast-food patrons to buy items containing fewer calories. Elbel’s and Kersh’s widely discussed study, published in the journal Health Affairs, emphasized that follow-up studies are needed to determine the value and effectiveness of menu labeling and other obesity-related policies.
Professor Elbel describes the Mayor’s current proposal to prohibit the use of food stamps for the purchase of soda and sugary drinks as “an extremely innovative policy approach to tackle the complicated and multifaceted problem of obesity. It deserves a rigorous assessment, to evaluate its overall impact on healthy food choice and obesity,” says Professor Elbel, assistant professor of medicine and health policy. “The rest of the nation can then learn from the New York City experience as these and other policies to fight obesity are considered across the country.”
What’s your opinion of the Mayor’s food stamp initiative? Is it good public policy? Or should it just be allowed to fizzle out? Visit Wagner’s Public Service Today blog to post your comment today.