From Today’s Christian Doctor – Fall 2012

For months, it seemed like the country was holding its breath. With baited breath, some waited in anticipation and others waited in dread. Experts and analysts outlined countless “what if” scenarios, examining and scrutinizing various sides of the argument. On Thursday, June 28, 2012, the U.S. Supreme Court announced its decision to uphold the constitutionality of the Affordable Care Act. And just like that, the country exhaled, some with a sigh of relief and others with a groan of disappointment. As we move ahead under its umbrella, this polarizing law will continue to have a profound effect on our country, especially on us as healthcare professionals. Non-scientific spot surveys of our members show that the majority of our members oppose the ACA. I haven’t met any CMDA members who think it is a perfect law. Everyone disagrees with certain aspects of the law or wishes other features were included. That is the nature of almost every law. ACA has several popular components like keeping your children on your insurance policy until the age of 26, no lifetime caps, no exclusions for pre-existing conditions and no co-pays for preventative services. The ACA hopes to provide insurance for more than half of the uninsured and significant aid to federally qualified healthcare clinics where some CMDA members sacrificially serve the poor. It also provides funds for studying better healthcare delivery models and intends to increase the number of primary care physicians. Many of these features are positive goals to attain. It’s important to note that CMDA does not have an official position on the ACA as a whole. In other forums, CMDA has addressed how some parts of the law do clash with principles supported in CMDA’s biblically-based ethical statements, including right of conscience and abortion. Speaking against these concerns about ACA does not mean we are against reform. Here I will simply share my point of view on other aspects of the law, which is no more important than your perspective. As we prepare for the law to take full effect in 2014, and as it is likely to face new legislative review, I propose the following questions to guide our analysis. Does the problem need to be addressed? Is the solution wise? Is it practical? Can we afford it? Will this lead to undesirable consequences? The answers to such questions are matters of judgment, influenced by our experiences, training, available information, opinions and preferences. The apostle Paul might label these as “disputable matters” (Romans 14:1). Our various opinions should not be grounds for disunity.

Do we need healthcare reform?

Let me loudly shout that I think we need healthcare reform! Of the many aspects of healthcare needing change, better care for the poor is a top motivator for me. But I am not willing to accept reforms that are not economically viable. That serves no one. In 1980, we spent just 9 percent of the gross domestic product on healthcare, a cost of $1,091 per person per year. The next highest country was Switzerland spending $1,013, about 8 percent less than the U.S. In 2008, we spent $7,538 per capita (16 percent of the GDP), compared to the next highest country, Norway, at $5,003.¹ In just 18 years, costs escalated so much we were spending 50 percent more than any other country in the world. By June 2011, that amount grew to 18.2 percent of the GDP in the midst of a recession when many people lost their job-related health insurance.² Some think this increase is okay since you are paying for quality healthcare, but that’s apparently not the case since the U.S. is ranked 50th on the list of countries by life expectancy.³ If we continue down this same road, the signs are starkly clear. The bridge is out ahead and the raging river below is cost. We cannot sustain this inflationary curve. The main reason many people don’t have insurance is because they simply can’t afford it.

How can we afford it?

Unfortunately, ACA doesn’t address the cost issue; instead, its main focus is on increasing access by providing subsidized insurance. When it passed in 2009, the bill was estimated to increase healthcare cost nearly $1 trillion over a 10-year period. Though many of its costly provisions have not yet kicked in, the Congressional Budget Office now estimates the increased cost for the same period at $1.76 trillion, almost double the original estimate.⁴ More than half of that total is unfunded, thereby increasing the federal deficit by more than $1 trillion. The “funded” part is questionable. While we need to have a safety net for those in need, it must be sustainable or we are just fooling ourselves. I also have concerns about “exchanges,” the government-operated health insurance market. Insurance is so expensive that the exchanges are expected to supplement the cost of policies for everyone earning up to $92,000 a year (400 percent of the poverty rate).⁵ ACA rules are written in such a way that most people will be forced into an exchange. If employers significantly change benefits, co-pays or deductibles, they are no longer allowed to keep their old insurance plan and must go through the exchanges. When threatened with a 50 percent increase in healthcare premiums for 2012, CMDA was forced to increase the deductibles on our health plan. The consequence of this change is that we will have to enter our state exchange when it is operational. We will join many other employers in looking at the economical impact of our options. If employers with more than 50 employees completely drop insurance coverage, the government fines them $2,000 per employee.⁶ Considering what CMDA already pays for a family plan, we could pay the penalty, give each employee an $8,000 raise and still come out ahead by dropping our insurance coverage, thus requiring our individual employees to go on the exchanges. It is likely employer-based insurance will become a historic footnote. How can we significantly decrease healthcare costs? We need tort reform that could decrease cost by $54 billion or more over a decade by decreasing defensive medicine.⁷ We need to reduce wasteful spending on tests and treatments that offer little value. A recent article in the New England Journal of Medicine estimated this alone could save up to 30 percent of healthcare costs annually.⁸ We need to better coordinate and manage care of patients with chronic diseases that consume up to 75 percent of healthcare dollars.⁹ We need to decrease unnecessary bureaucracy, which decreases time with patients. And we need to eliminate fraud.

What about government control?

The government already pays more than 50 percent of healthcare costs.¹⁰ The ACA will elevate that percentage and markedly increase government control over healthcare as a whole. While government is now needed to address our problem, it should be as limited as possible or it brings other risks. Government intrusion introduces a great risk of further deprofessionalization of medicine. As we already know, those paying the bills call the shots. If government control continues to increase, healthcare professionals essentially become employees of the state and have little recourse other than unionizing and striking to handle grievances, as is common in other countries.¹¹ This breaks the covenant between doctor and patient, erodes trust and further turns medicine into a trade rather than a profession. Under ACA rules, exchanges must also offer policies with government-subsidized abortion coverage. The ACA mandates that insurance companies offering these policies are not allowed to communicate in advance to individuals that their plans include an “abortion premium” of $1 or more that will be deducted directly from their paycheck into an abortion on demand fund.¹² If only 50 percent of the companies on exchanges pay this $1 monthly premium per individual, it will fund 2 million abortions a year, a figure much higher than the 1.2 million annual abortion rate.¹³

What about the contraceptive mandate?

The ACA gives unprecedented powers to the Secretary of Health & Human Services. We already see an example of this in the contraceptive mandate. The Secretary was given power to determine what constituted the “preventative services” to be fully funded without copays. She asked the Institute of Medicine, the healthcare arm of the Academy of Science, to provide political coverage for her actions. Claiming to be “unbiased and authoritative,”¹⁴ they convened a committee without any known pro-life representation but a number of members with close ties to Planned Parenthood and other groups in the abortion industry. They recommended that all FDA-approved contraceptives, sterilization and counseling be required by all insurance policies without co-pay or deductibles. This included Ella, a known abortifacient.^15,16 The Secretary then imposed the most limited right of conscience exemption ever articulated in federal law. In order to meet this exemption, an organization must: (1) be a church, religious order or integrated auxiliary; (2) exist to inculcate its religious values; (3) primarily employ people sharing its religious tenets; and (4) primarily serve persons sharing its religious beliefs.¹⁷ This means religious nonprofits, church-affiliated hospitals and colleges cannot follow their convictions. Even Mother Teresa’s Missionaries of Mercy would not qualify! Employers not providing insurance plans compliant with the mandate will be fined $100 per employee per day.¹⁸ For CMDA, the penalty would be more than $3.5 million each year and we could be sued by the Department of Labor for further damages. Children will be automatically and mandatorily enrolled in HHS-mandated coverage and receive free contraception including early-abortion pills, counseling and education. Healthcare professionals will not be required to inform parents, who won’t receive any bills to notify them since these services will be fully funded without co-pays or deductibles. The contraceptive mandate and the abortion premium’s biggest benefactors are not women, but Planned Parenthood and its allies. Their industry will be funded nationwide without personal cost to their patients. I firmly believe the contraceptive mandate is unconstitutional based on the First Amendment’s “free exercise of religion” clause. (This was not considered in the recent ruling.) If not overturned, it constricts religious freedom to just freedom of worship. We would have no religious freedom outside the doors of a church, synagogue or mosque. Under this new definition, Christian organizations could be forced to hire employees not sharing their religious beliefs or practices. It could require Christian healthcare professionals to participate in abortions or other practices violating their beliefs and more. This myopic view of right of conscience must be rescinded. CMDA is pouring itself into that battle.

How do we move forward?

Whether you support the ACA or are opposed to it, there’s no question that we face enormous challenges in healthcare. We certainly can’t afford to be silent. CMDA members continue to have influence in our culture, often more than we know. We can elect men and women who represent our views. And then we can share our concerns with them. My experience is that our representatives welcome thoughtful input from the doctors they represent. There is no better time for Christian healthcare professionals to revisit their calling to this profession, remind themselves that God is still in control and grasp the great opportunities to be salt and light during difficult times. God’s work is often best demonstrated in crises. Bibliography ¹ Organisation for Economic Co-operation and Development (2010), “OECD Health Data”, OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011). ² http://nchc.org/node/1171 ³ https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html ⁴ http://cbo.gov/publication/43080 ⁵ Reconciliation Act Pg. 3. ⁶ 26 U.S.C. 4980H Pg.1; Affordable Care Act Sec. 1562(f), Pg. 152) ⁷ http://www.washingtonpost.com/wp-dyn/content/article/2009/10/09/AR2009100904271.html ⁸ From an Ethics of Rationing to an Ethics of Waste Avoidance, Howard Brody, M.D., Ph.D., N Engl J Med 2012; 366:1949-1951. ⁹ Centers for Disease Control and Prevention. Rising Health Care Costs Are Unsustainable. April 2011. ¹⁰ http://american.com/archive/2011/august/the-government-share-of-health-care-is-bigger-than-advertised-health-fact-of-theweek ¹¹ http://www.guardian.co.uk/society/blog/2012/jun/21/doctors-strike-pensions-live-coverage; http://www.kevinmd.com/blog/2010/05/german-doctors-strike-american-physicians-follow.html; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1349694/ ¹² Affordable Care Act Sec. 1303(b)(1) & (2), Pg. 779-780) ¹³ Guttmacher Abortion Statistics and Cost ¹⁴ http://www.iom.edu/About-IOM.aspx/ ¹⁵ CHMP Assessment Report for Ellaone, European Medicines Agency (2009). This report can be found online at http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_- _Public_assessment_report/human/001027/WC500023673.pdf ¹⁶ Background Document for Meeting of Advisory Committee for Reproductive Health Drugs (June 17, 2010). Prepared by the Division of Reproductive and Urologic Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/ReproductiveHealthDrugsAdvisoryCommittee/UCM215425.pdf ¹⁷ HHS Mandate, Pg. 2

¹⁸ 26 USC 4980D Pg. 1; ACA Sec. 1562(e)-(f), Pg. 152: 42 USC 300gg-13