This article first appeared in the St. Louis Beacon, Oct. 1, 2012 - Arthur Visor was just over age 30 when Medicare began in 1965. He never expected to benefit from the program because he had assumed, sadly, that his life would be cut short by high blood pressure, diabetes or kidney disease.
Visor, who lives in Florissant, is now an energetic 78, feeling so fit that he devotes plenty of his free time to volunteer work. He's thankful that a combination of Medicare and private health insurance has given him resources to fight his ailments.
He says his diabetes and blood pressure are under control, and a transplant in 1998 freed him from being tethered three times a week to a kidney dialysis machine.
In between handing out brochures and advice to out-of-towners at the downtown Visitor Information Center last week, Visor talked about the importance of Medicare and the Affordable Care Act. The programs are widely debated, praised and condemned, in this election year.
Many share Visor’s feelings that the two health laws should be preserved, and studies show that ACA will help ease the federal deficit. But critics argue that spending on Medicare is out of control and needs to be cut and that ACA is a budget buster that should be repealed.
Visor is alarmed by such talk, as is Patsy Hecker, 81, of Affton, a paid staffer at the visitor center. “Medicare has been very helpful for me,” she says. “I think people need to think about how changing it would hurt a lot of people on fixed incomes.”
Around the corner from the visitor center, at 8th and Locust streets, Dave Snyder, a downtown accountant, expressed a different view. He spoke during his lunch break in a tree-shaded plaza, where he had been reclining on a concrete bench and listening to music by Billy Ocean.
“I’m pretty fortunate right now,” says Snyder, 32, after removing his earplugs. “But if I were out of work and got sick, I think I could get myself in trouble pretty quickly with some bills.” Even so, he’s not confident about the future of health care, particularly Medicare, for his generation.
“I think there should be something else. I don’t count on Medicare being around for me because of the way it’s stretched right now. I don’t know the answer, but I hope someone does. Maybe the alternative is a health savings account or something like that. And I don’t think I can count on Social Security, either.”
At a Starbucks in the Loop last week, Bill Lakin pointed across the table to his daughter, Katie, 21, when asked about the health reforms.
“The law is very important to me,” says Lakin, a Jefferson County resident and a a real estate agent with LaMar International Realtors in Pacific. Without ACA, he says his daughter wouldn’t have been allowed to remain on a parent’s health insurance, whether or not she's a student, until she turns 26.
“The health-care system is broken badly,” he says, adding that the changes made by President Barack Obama so far represent “the best he could get done from what I could see. It’s a good first step.”
Katie Lakin is among an estimated 55,000 young people able to retain health insurance coverage through parents. In addition, federal officials say the law already has offered lots of other relief to Missouri residents, including 50 percent discounts on brand-name prescription drugs to seniors as a step toward eliminating the so-called doughnut hole; free preventive services to thousands of Missouri residents; and insurance rebates to Missouri consumers or their employers from insurers who spent less than 80 percent of premiums on benefits.
In spite of such benefits, ACA hasn’t been popular in Missouri. On August of 2010, voters across the state gave strong support to Proposition C, in effect repudiating a federal mandate that people buy health insurance or be fined. That measure was approved by 70 percent of those who went to the polls. The Missouri action was regarded by some as the first victory by Republicans nationwide to overturn the law that created ACA. Since that time Republicans in the U.S. House, including those from Missouri, have voted to overturn the law.
Two sessions ago, a bill to set up an affordable insurance exchange won bipartisan approval in the Missouri House. But the measure never came up for a vote in the Senate.
In November, voters will have a chance to have their say once again on the exchange issue. On the ballot is Proposition E, which asks voters whether the Nixon administration should be forbidden to set up or operate an exchange unless it is authorized by voters or by the state Legislature. That measure might also win strong approval.
The health reform law provided tax breaks to make it easier for some small business owners to cover the cost of health benefits for workers. While some small merchants say the provision hasn’t been of much help, others embrace it.
“Last year we got a check, basically a tax credit, that amounted to about 20 percent of what we laid out” for employee health premiums, says Lew Prince, co-owner of Vintage Vinyl. The company covers the full cost of health insurance for its 16 full-time employees.
Prince said the credit “does give me some wiggle. ACA takes some of this worry out by giving me this little pool of money to hold back” against the next premium hike. “But I didn’t do that. I used the money to give out some raises.”
Another small business owner who praises ACA benefits is Lily Seymour, owner of several area Subway restaurants. The company has about 50 workers. It provides health benefits to some of them. Like Prince, Seymour says health benefits have the advantage of giving their businesses a more stable workforce.
Health benefits are “part of the cost of doing business,” she says. “We are in an industry that’s well-known for heavy turnover. But we’ve managed to retain our managers for a long time. I think the benefits make us more productive. It’s saving us money by not having this heavy turnover” among managers.
She adds that “health care is something that every human being should have. It should be available to everybody from every socioeconomic class.”
Part of the debate in this election year focuses on whether the presidential candidates should focus on health care or the economy. But in many ways the two issues are closely connected. Consider this finding by the Census Bureau: Health expenses not covered by insurance are the reason 10 million additional people fell under the poverty line in 2010.
That finding came from a new Census Bureau tool called the Supplemental Poverty Measure. Pointing to that finding, the National Research Council says more attention needs to be paid to the way medical costs are increasingly competing for income in both middle- and lower-income households.
The two presidential candidates have not been clear about all the steps they would take to rein in health costs. Obama has discussed cost containment in the context of ACA, notes an analysis by the Medicare NewsGroup, which includes members with broad knowledge of the federal program. It notes that cost-cutting Medicare provisions in ACA include closing the doughnut hole on prescription drugs and recovering $10 billion from Medicare scams.
Since GOP Presidential candidate Mitt Romney has talked of appealing ACA if he wins in November, those savings presumably would be lost.
NewsGroup points to other Obama administration cost-reduction plans, including some that could adversely affect beneficiaries. One proposal would impose a premium surcharge for those buying supplemental insurance to cover expenses not paid directly by Medicare. By coincidence, NewsGroup notes, all these suggestions would take effect, if they take effect at all, in 2017, a year after the end of what would be Obama's second term.
Many local scholars have praises the health-reform law, while others regard some provisions as federal overreach. Scholars who have consistently espoused broad health reforms and support for ACA include Sidney Watson, law professor at Saint Louis University, and Timothy McBride, a professor at Washington University. Both say the law offers more benefits than drawbacks.
At the other end of the spectrum are scholars such as Susan Feigenbaum, an economics professor at the University of Missouri at St. Louis.
“I don’t want to portray this legislation as being 100 percent bad,” Feigenbaum says. “I would simply argue that there is a lot in it that will have unintended consequences that people have not thought through.”
An example, she says, is the controversy over expanding Medicaid. She says the federal government should have given more attention to the issue and made a commitment to fund it rather than mandating that states eventually cover the full cost several years after the expansion takes effect. That proposed mandate was shot down in the Supreme Court ruling on ACA. At the same time, Feigenbaum says those reaping the benefits of Medicaid expansion should have been required to be responsible for more of its cost.
She also raises concerns about other new programs, such as the creation of Accountable Care Organizations. She says that idea is behind the trend here and nationwide of local hospital groups buying up medical practices on what she regards as a dubious assumption that putting all doctors under one roof will improve care and help cut expenses.
Cutting expenses can be achieved in other ways, she says. “There are innovative things you can do. You could say to patients that if you don’t engage in a certain amount of testing each year, we will lower your premiums. That would make people utilize health care more effectively.”
But others say that more collaboration among health providers isn’t a bad idea.
“One thing that I think is going to become a lot bigger is patient-centered medical homes,” says Dr. Kate Lichtenberg, a family physician and president of the Missouri Academy of Family Physicians. A medical home is supposed to help reduce costly duplication and improve care because it allows for more coordination. All providers would have electronic access to up-to-date patient records and would be able to communicate with one another about treatment.
“I think we’re going to see more practices headed in that direction. That may be one way we may be able to alleviate some of the stress to the system.”
She adds that doctors are about as divided as the general public about the nation’s health system and changes made since the last presidential election.
“Some are very much supportive, some are negative, but whether or not you agree, those are the rules we’re playing under now. I think family doctors are gearing up to take care of the patients who are going to be needing care and have been putting things off because they couldn’t afford it.”
