Surgeon On Health Care Bill: The Stakes Are 'Extremely High' For Patients

Mar 13, 2017
Originally published on March 22, 2017 11:46 am

On Monday, as GOP leaders tried to rally Republican lawmakers to support their health care proposal, the non-partisan Congressional Budget Office released a report showing that the plan would lead to an estimated 14 million fewer people with health insurance by next year.

The CBO also found the proposed plan would reduce the federal deficit by $337 billion.

Atul Gawande is a cancer surgeon at Brigham and Women's Hospital in Boston, Mass., and a staff writer at The New Yorker magazine. He has spoken out against the GOP bill, expressing concern that it would cause poor and sick people to lose health coverage.

The stakes for patients, he argues, are "extremely high," and he says the bill is at the "center of the debate [about] what our responsibilities are for covering people over the course of their lives."

Gawande discusses the Republican plan with NPR's Robert Siegel, including how his experience as a surgeon changed after the first universal health care bill was passed in his state, the ways in which the Affordable Care Act could be improved and the problem of high medical costs. The interview has been edited for length and clarity.


Interview Highlights

On the potential effects for his patients of repealing parts of the Affordable Care Act

"Well, I'm a cancer surgeon, and in many ways it will affect the patients widely. [President] Trump has said his aim is better coverage than the [Affordable Care Act] at lower cost, and if that were where it was going, it would likely protect the people that unexpectedly come in to see me. But that is in conflict with this other goal that Republicans have, which is actually to dismantle the ACA and its funding, and it's that pull that lies in the middle of this."

On how people who use the Medicaid program could be affected by the bill

"Before Romneycare, [which is] a version of the ACA passed here in Massachusetts where I practice, about 10 to 15 percent of my cancer patients were people who didn't have coverage. They gained coverage in two ways. One way was that they gained coverage by Medicaid. Second, they gained coverage, if they didn't have an employer who covered them, on the online exchanges.

"I haven't taken care of an uninsured patient in years."

On how the Affordable Care Act could improve

"There are some obvious things to do. We have the group of people who don't have coverage under Medicare, don't have coverage under Medicaid, and their employer is not providing coverage or they don't have an employer. They are in the online exchanges, going to Healthcare.gov, and with some tweaks we would get more young and healthy [people] in to go along with the sicker, older population and that would help flatten the premiums and keep that system [grow].

"One thing that has people really angry is ... where you have multi-thousand-dollar deductibles and copayments, so you still have some major barriers in your care. We've made huge progress [on that] and should be making more."

On the goals of the Republican health bill

"What is the human goal of this bill? What's it aiming to solve? If the aim is to solve the problems they criticize, they've not put forward solutions that actually do that. There are directions to get there. And there's a moment when [President] Trump talked about [the fact] that he could get a bipartisan group around this goal of insurance for everybody.

"But what we have right now is a bill that doesn't ... [address those] problems that have been singled out. Now we just are waiting to see how much worse the costs will be for individual people."

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ROBERT SIEGEL, HOST:

And for a doctor's perspective on the Republican health care proposal, I spoke earlier in the day with Atul Gawande. He is both a surgeon at Brigham and Women's Hospital in Boston and a staff writer for The New Yorker.

ATUL GAWANDE: I'm a cancer surgeon. And in many ways, it will affect the patients widely. Trump has said his aim is better coverage than the ACA at lower cost. And if that were where it was going then it would likely protect the people that unexpectedly come in to see me. But that is in conflict with this other goal that Republicans have, which is to actually dismantle the ACA and its funding. And that's that pull that lies in the middle of this.

SIEGEL: As you say, you're a cancer surgeon. Much of the plan has to do with changes to Medicaid. Do you have Medicaid patients? And do you figure they would be affected by this?

GAWANDE: Absolutely. Before Romneycare, a version of the ACA passed here in Massachusetts where I practice, about 10 to 15 percent of my cancer patients were people who didn't have coverage. And that group of people disappeared. I haven't taken care of an uninsured patient in years.

SIEGEL: I asked Atul Gawande about a criticism that the new health and human services secretary, Tom Price, has made of Obamacare. Price, who is an orthopedic surgeon, says some people who now have insurance have such big deductibles to pay that they still can't afford recommended procedures. Well, Gawande pointed out that the ACA does away with deductibles for primary care. But as for Price's criticism...

GAWANDE: He's not wrong. If you just take the people who picked up coverage on healthcare.gov and the other exchanges around the country, over 40 percent have health plans with deductibles of $2,500 dollars or more. And for most of them that means that catastrophic expenses are still very difficult for them to meet. There are people really stuck in the middle. Medicaid, if you're at or near poverty, it has first dollar coverage. You have good benefits. Whereas if you are on the exchanges, you have a high likelihood, if you want one of the lower-cost plans, that you are with a very high deductible and set of co-pays.

SIEGEL: But when people say that - when defenders of the ACA say you should repair it, you shouldn't repeal it or replace it, is it evident to you what a few repairs are that have to be done? Or are we looking forward to decades of routinely repairing something because it's a very complex part of our economy?

GAWANDE: It's going to be, in answer, a little bit of both. There are some obvious things to do. We have the group of people who don't have coverage under Medicare, don't have coverage under Medicaid and their employer is not providing coverage or they don't have an employer. They are in the online exchanges, going to healthcare.gov. And with some basically tweaks at this point, we would get more young and healthy people in to go along with the sicker, older population. And that would help flatten the premiums and keep that system growing. Insurance only works when you have young and healthy people joining the old and sick people in the insurance plans.

You have a couple of options then to get people there. One is to enforce the mandate, though that's unpopular. There are ways that also you encourage marketing to bring young people in. One of the - one of the concerns that I have about some of the executive orders are that they shorten the open enrollment period, and longer open enrollment periods get more young people in.

SIEGEL: And I'm curious, your having been a surgeon in Massachusetts, practicing medicine from before Romneycare, through Romneycare, through the Affordable Care Act, now with this new Republican replacement on the horizon - do these changes change the way you make decisions as a surgeon?

GAWANDE: I've seen the biggest change from when we went from a system that had large numbers of people who didn't really have coverage to one where it just was something you didn't have to think about. And so the kinds of things that I used to have to think about were right from the screening phone call of who could come in. Now, that hasn't completely disappeared. Now I'm in the realms of does your network actually cover you to see me?

And they end up having to go see someone who doesn't have a lot of experience because they can't afford the required thousand-dollar extra deductible that gets applied if they come to see me. Those kinds of problems are still there, but it's a radically different problem from the one where we were. We've made huge progress. We should be making more.

SIEGEL: Surgeon Atul Gawande of Brigham and Women's Hospital in Boston and the Harvard Chan School of Public Health. Thanks for talking with us today.

GAWANDE: Delighted. Thank you. Transcript provided by NPR, Copyright NPR.