Thursday August 23, 2012

The rising cost of health insurance premiums. The successes and failures of the Affordable Care Act. The shortage of primary care doctors in the Berkshires.

Today, the three Democrats vying to represent the 1st Massachusetts District in Congress tackle health care in America.

The topic, chosen by readers as part of The Eagle's Citizens Agenda series, is one of the major issues facing citizens in the district.

In the exchange that follows, incumbent U.S. Rep. Richard Neal, Middle Berkshire Register of Deeds Andrea F. Nuciforo Jr., and writer and activist Bill Shein share their positions. The three will face off during the Sept. 6 Democratic primary, which in the absence of any Republican candidates will likely decide the November general election.

 

Q: What action would you support to combat the rising cost of health insurance?

Neal: I think that some of the things that have been done on a state basis, for example the way that the governor and the Leg islature have approached some of these cost containment measures is important. The states have really been great crucibles of experimenting. I think there are realties that have to be acknowledged, and one of the realties is that it's technology that drives the cost of health care. In a hospital where you're being treated for colon cancer, you want to know that there is a linear accelerator available, and those are very expensive pieces of equipment when you consider the changes that are impacting health care, there's nothing that drives the cost more than the cost of technology. That's a challenge, how we keep advancing technology and containing costs. I think where the government can assist in helping with the cost of technology, including the National Institutes of Health, is a key consideration.

Nuciforo: I think we have to move in the direction of a universal, single-payer system. Let me relay a story to you. My first term in the state Senate, the Greater Boston Chamber of Commerce was absolutely opposed to any movement in the direction of the single-payer system. And the Greater Boston Chamber of Commerce is the big employers in the Boston area. As I was leaving the Statehouse, the big employers in the city of Boston were no longer as rigidly opposed, and the reason they weren't was because they saw inflation going up by an annualized rate of 3 percent, but they saw their insurance premiums going up by 7, 8, 9, 10 and 11 percent per year. I think as the business community starts to come around to the notion of the single-payer system -- with reduced administrative cost [and] most insurance dollars going toward actual care -- I think in that case you're going to start to see the business community in general embrace the idea of single-payer and I want to be one of the people in Washington that helps them get there.

Shein: I'm going to keep coming back to single-payer. We built this reform on top of a system that is not going to be able to contain costs the way that we need to and also provide quality care to everyone. Keep in mind that [the Affordable Care Act] does not provide health care for everyone. We're still going to have tens of millions of people who don't have health care. We pushed a lot of people in this reform into Medicaid, and remarkably, one out of six Americans gets their health care from Medicaid. We need a better program than Medicaid. That's, I believe, a weakness in this reform. The problem with health care costs right now, among others, is that people are finding they can't even afford to use the health care that they're going to have to pay for because of rising co-pays and rising deductibles. I meet people almost every day and it's remarkable how often that precise example comes up. They'd like to go to the doctor, but they can't afford the deductible. ... The winners are the insurance companies, because that means they're receiving premium dollars and they're not providing health care.

 

Q: What action do you think Congress and the federal government can take to address the shortage of primary care doctors in rural areas like the Berkshires?

Nuciforo: I think the federal government could play a role in two respects. No. 1, supporting programs in medical schools that will encourage young physicians to go into primary care, some of this can be done with loan accommodation and loan forgiveness programs. No. 2, with respect to reimbursements, health care is an industry built around payment schedules. So the payment schedules have to be attractive enough so that those physicians that go into that particular practice can do so and know that they'll be fairly compensated for their work.

Shein: We need to change the economics; we need to make sure the primary care physicians are paid better. The system right now is set up to incentives doctors who specialize and we need to increase what we're paying for services provided by the primary care doctors and particularly preventative care services. ... I think we can look to loan forgiveness for doctors who become primary care physicians. That's important. ... One of the advantages of a single-payer system is we can address that.

Neal: I think that Congress has a role in expanding the slots at medical schools, particularly those that are government-funded medical schools. It's more complicated than that, but I think it would certainly be a step in the right direction. And I think a more significant subsidy in terms of helping a primary care physician, to write off the costs of their educations, as long as they become a primary care physician for up to five or 10 years would be very helpful.

 

Q: Where would you like to see further reform to the country's health care system?

Shein: One of the things the Affordable Care Act does nothing on is dental care. I also don't support the language, the idea of the Stupak amendment, which is important because Congressman Neal supported it. It was an effort by pro-life Republicans and a handful of Democrats who blocked any health care subsidies for plans that include reproductive health services, including abortions. It just about derailed the entire process. And Congressman Neal supported that. I don't believe women should be denied legal reproductive health services just because they are poor. ... The problem is that reforms [are] built on top of the broken, expensive, private health insurance system. That's why over the long-term I don't think it will achieve everything that is necessary. So that's why I support enhanced Medicare for all. Single-payer health care would save us an estimated $400 billion a year in money that we now spent on insurance company overhead and profit. ... We did not have single-payer Medicare for all as part of the conversation, despite broad support across the country and particularly in Western Massachusetts. Every time there's been a nonbinding ballot question across the region on single-payer health care, it gets overwhelming support. That speaks to one of the central arguments of my campaign, which is that campaign money from insurance companies, pharmaceutical companies drown out the best ideas.

Nuciforo: I will tell you that I don't think that it went nearly far enough. During my service in the state Senate, on several occasions I offered and co-sponsored the Health Care For All measure with respect to a universal single-payer health plan. And while I think that arch of health care in this country is in the direction of a Medicare-for-all style universal, single-payer system, and I regret that that did not occur back in 2009 and 2010. ... I would love to see a greater range of services offered and paid for through Medicare and the various Medicaid programs that are provided in the home. Institutional settings such as nursing homes, skilled nursing facilities, hospitals -- institutional settings tend to be the most expensive way to provide care, and with advances in technology, medical devices, drugs, many health care services can now be provided in non-institutional settings, at home, for example. ... The issue of women's health was raised in a major way in connection with President Obama's Affordable Care Act. As you know, Congressman Neal joined with House Republicans in an attempt to undermine that act in supporting the Stupak Amendment ... restricting access to reproductive care and contraception for millions of women. So when the chips were down ... Cong ressman Neal helped House Re publicans in voting for it. Ultimately the president had to include an executive order that contained that same language in order to assure passage of the Affordable Care Act by both the House and the Senate. I would not have voted for it and I think any responsible Democrat would not have taken that vote.

Neal: I think you're going to continue to see changes as you move along based on a component [already in] the health care bill, known as opportunities for geographic experiments. So there's going to be an opportunity here for certain regions -- they're called technically regional demonstration projects -- and they'll be able to do some experimenting. And there will be financial incentives for the purposes of the experiment. ... There's some really good stuff in here when you drill down on it. Not only has [the act] not played out, but remember that a lot of the really good parts have gone into effect right now, including the women's health care. Osteoporosis [and] mammography screening are the two good examples, but the regional demonstration projects will give us an opportunity to figure out where we want to go in the future. I mean, I think the approach that we've learned since Medicare, to Clinton, to Obama, has really been to experiment and to offer incremental advances.