The Colorado Health Symposium’s Debate Over Repealing and Replacing the ACA

Resolved: The Affordable Care Act should be repealed and new approaches to health care reform explored.

Three of the four presenters debating the resolution before a capacity audience of health professionals agreed that the Affordable Care Act of 2010 (ACA) should be repealed and replaced.

And yet the lone debater who argued that the law should be preserved won the debate in a landslide. The audience, voting in real time on keypads, disagreed with the resolution by a margin of 79 percent to 21 percent. The debate, held on July 27, was part of the thirtieth annual Colorado Health Symposium, which was held in Keystone, Colorado.

Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University, won the debate with his argument that, while the ACA is imperfect, “If this law fails, no other Democratic president in our lifetimes will ever tackle health reform again.” He added, “This is our one chance to do this.”

T.R. Reid, former Washington Post correspondent and author of The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, forcefully argued that the ACA falls far short of its goal of achieving universal coverage, leaving at least twenty million people uncovered. As a result, these “free-riders” will continue to get health care that the rest of us pay for and will continue to drive up the cost of care. “If France can achieve universal coverage, certainly we can do it!” he emphasized.

Following the debate, Lynn Parry, past president of the Colorado Medical Society, said, “Most of the people here tonight already support the health reform law. The real debate, then, for us was between Len Nichols and T.R. Reid,” Parry said. “They both agree that we need universal coverage, but we wanted to hear their views about whether the health reform law is the best way to get there. We all know we have to figure out how to spend a lot less money and cover a lot more people.”

Jon Caldara, president of the Colorado-based Independence Institute, asked the members of the audience to raise their hand if they have homeowner’s insurance, then car insurance, and then life insurance. Virtually all in the audience raised their hand each time. Then he asked how many of them expect to file a claim on those policies this year. No hands went up.

He used the example to show that health insurance is indeed different, because people expect to use this insurance regularly. Yet, he argued, the cost of the policy is generally hidden from the insured, so people expect to cycle bills for even the most routine health care services through health insurance, driving up the cost of insurance dramatically.

Caldara said what people need in a health crisis is real insurance. His family’s personal experience with his one-year old daughter’s fatal brain tumor ten years ago and his seven-year-old son’s Down’s syndrome have given him enormous respect for the quality of health care delivered in this country. “In no other country would my children have been able to get the extraordinary care they received.” But he said he fears that we are putting this high-quality care at great risk with the health reform law’s centralized government control.

I told the audience at the symposium that I am particularly concerned about the law’s impact on vulnerable Americans, described in more detail in a book I co-authored titled Why ObamaCare Is Wrong for America. Current Medicaid recipients, most of whom have few, if any, other options for coverage, will soon be forced to compete for care from a limited number of Medicaid providers with the sixteen to twenty-five million people added to the program under the reform law. The ACA could shred the safety net because it does not increase capacity or make desperately needed structural reforms to Medicaid—it simply drives more people into the program. I agree with Edward Miller of Johns Hopkins Medicine who argued in a 2009 Wall Street Journal article, in its Opinion section, entitled “Health Reform Could Harm Medicaid Patients” that our system simply doesn’t have the capacity to absorb so many more patients so quickly. The most vulnerable will be harmed the most. I said that we absolutely do need health reform but argued that the ACA builds on dysfunctional systems in both the private and public sectors, and it will cause a cascade of negative consequences:

* Employers are looking for the exits and could send tens of millions of people who have job-based coverage now to the exchanges for subsidized insurance, causing the cost of the law to soar in a time of severe governmental budgetary crisis.

* While states have major responsibilities to implement the ACA, the majority are rebelling, with twenty-eight states challenging the law in the courts. States face at least $118 billion in new mandated costs during the first decade of full implementation of the ACA.

* The ACA, with its 159 new boards and commissions and programs, moves power over decisions away from doctors and patients and toward technocrats in Washington who will try to regulate our health sector into functionality. A true patient-centered system would recognize the reality that medicine is moving toward personalized care, not centralization, and health care financing must support rather than fight that trend.

I argued that the focus instead should be on solutions that concentrate energy and resources on the uninsured and the most vulnerable in society. I said that we could get much closer to universal coverage with properly structured subsidies that don’t disrupt the coverage that tens of millions of people have today.

T.R. Reid, while an admirer of government health systems in other countries, concluded that we must respect the culture of the United States and work toward reform that includes both private- and public-sector programs but which gets to universal coverage. Only then, he said, would we be able to eliminate the problem of free-riders who drive up the cost of care for everyone.

I pointed out that the cost of uncompensated care is estimated at $43 billion a year, representing 1.7 percent of our $2.6 trillion in health spending—in my opinion, hardly a reason for such dramatic centralization of our health sector.

Len Nichols said that the ACA provides tremendous opportunities to experiment with new care delivery and financing models. He suggested that if providers don’t like the regulations that have come out for Accountable Care Organizations, for example, they could just ignore them and design their own. He implored, “We have to make the incentives work.”

Jan Kief, speaker of the house of the Colorado Medical Society, said afterward, “The debate was fascinating and challenged the views of many people in the room, forcing us to think outside the box. It’s clear that putting extra pressure on a dysfunctional system could create real chaos.”

Kavita Patel, fellow at the Brookings Institution, commented, “The debaters went beyond the political rhetoric of ‘repeal and replace’ with a substantive dialogue about the important subtleties of health reform.”

There was not a single point of difference in the number of people who agreed and disagreed with the debate resolution when votes were tabulated before and after the debate. But there was movement inside the numbers, and I swayed the most votes—from 3 percent who originally agreed with me to 9 percent who agreed at the end of the debate. (And I won the coveted box of Colorado peaches, as a result.)

The 2011 Colorado Health Symposium, entitled “State of Health: Seizing Opportunities, Achieving Results,” attracted 450 attendees. Many more people were turned away. Colorado Health Foundation President and CEO Anne Warhover moderated the debate and chaired the conference. Chris Adam, president of Engaged Public, facilitated the interactivity.

Posted on the Health Affairs GrantWatch blog, August 3, 2011.