Patient Protection and Affordable Care Act (ACA)

Doctors
Since I have been studying health care intensely for more than three years, I feel compelled to make some comments about what is going on currently with the Patient Protection and Affordable Care Act (ACA). There is no political agenda to what I have to say. My comments relate to healthcare, not the positions or arguments of political parties. There are many aspects of healthcare that I plan to write about, but for today, just two topics,  both with regard to the ACA. Do we need it? Should it be repealed?
Do We Need the ACA?
The United States is the only developed country in the world that does not have universal healthcare, meaning that all citizens have healthcare insurance. I am not referring here to “single payer” — that is a different subject. Germany has universal healthcare coverage and 200+ payers. Canada has universal health operated by 13 provinces. More on that subject later. What I am posing here is a moral question: Do all citizens have the right to healthcare? Some say it is a privilege, not a right, but the developed countries of the world, other than the United States, believe healthcare is a right. All American citizens have a right to vote, a right to free public education, a right to be defended by the military, and a right to be protected by local police. All these rights apply whether you make $20 million per year or $20,000. In countries other than the United States, you would add healthcare to the list of rights. This is a moral question and I have not heard any politicians from either party talk about the subject. One reason for the unending debates about healthcare is that, as a country, we have not come to grips with the basic question of whether citizens have a right to healthcare.  
Many citizens and politicians believe that people who lack healthcare insurance get the care they need through emergency departments (ER) of community hospitals. The Committee on the Consequences of Uninsurance at the  Institute of Medicine  studied the consequences for adults who lack health insurance and  released a report called Care Without Coverage: Too Little, Too Late. The committee looked at the consequences of being uninsured for people suffering from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks. The study focused on roughly 30 million – one in seven – working-age Americans without health insurance. (The number today is at least 50% greater).  This study excluded those over 65 who are covered by Medicare and 10 million uninsured children. The main findings, extrapolated to today, show that 25-50,000 people die each year because they do not have healthcare insurance. A person with a serious cancer that was not diagnosed until the pain was significant can go to the ER and then go home with pain killers ultimately to die. Our great nation has a history of unleashing unlimited resources when a number of our citizens are killed by attackers, but we have not been able to establish universal healthcare coverage to prevent tens of thousands from dying every year because of lack of healthcare insurance.
Should We Repeal the ACA?
The ACA became law in March 2010. In ACA Implementation: How’s It Going?, John McDonough explained the 10 titles of the ACA that make up the law:
I. Reform of private health insurance, the­­ individual mandate (upheld by the June 2012 U.S. Supreme Court decision that upheld the ACA)., subsidies, guaranteed issue, and employer responsibility
II. Expansion of Medicaid to all low­-income Americans­ made a state option (also upheld by Supreme Court).
III. Reform of the U.S. medical care delivery system and changes to Medicare
IV. Prevention, wellness, and public health initiatives
V. Health workforce initiatives
VI. Fraud and abuse prevention, transparency, and comparative effectiveness research
VII. Creation of a regulatory pathway for marketing and sale of biosimilar drugs
VIII. Community Living Assistance Services and Support (CLASS) -­­ repealed by Congress on January 1, 2013
IX. Revenue measures to pay for about one half the cost of the ACA
X. Amendments to Medicaid and the Indian Health Care Improvement Act
McDonough said that each title description could have ended with the words “and a lot more”.  No matter how you look at it, the ACA is the most significant law ever passed that seeks to provide comprehensive health system reform, dwarfing the 1965 law that created Medicare and Medicaid. I am not suggesting that all of these titles are free of error or mischief. No doubt, all of them can and should be improved, but when a politician says we should repeal “it”, I am not sure they know what the “it” is.
While there is plenty of room for improvement, there are some excellent programs in the ACA that are well underway and that are improving patient safety and quality and reducing the cost of healthcare. Do we want to repeal them? In addition to not having made the moral decision to make healthcare a right, there are major issues about how to pay for universal healthcare. One way is through cost savings. If there are 50 million people without healthcare insurance and if the cost of healthcare is $10,000 per person, that would represent $500 billion. That is less than 25% of what the United States spends for healthcare. We spend far more per person for healthcare than the other developed countries who get better health outcomes than we do. I won’t go into it now, but most healthcare economists believe that the waste, redundancy, fraud, and inefficiency of American healthcare is much more than $500 billion. Repealing “it” may be throwing out the baby with the bath water.

References
Institute of Medicine. (2002). Care without coverage: Too little, too late. Retrieved from http://www.iom.edu/Reports/2002/Care-Without-Coverage-Too-Little-Too-Late.aspx
McDonough, J. E. (2013). ACA implementation: How’s it going? Medscape Family Medicine. Retrieved from http://www.medscape.com/viewarticle/811334
Reid, T. R. (2009). The healing of america : A global quest for better, cheaper, and fairer health care. New York: Penguin Press.

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