By Samuel Metz, M.D.
Gastroenterology & Endoscopy News, Oct. 29, 2014
Is the Affordable Care Act a failure? For some of us, the answer is simple: If you voted for President Obama, it must be a success. If you voted against the president, it must be a failure.
But if you think the legacy of Barack Obama is irrelevant to health care reform, the answer gets more complex.
Will the Affordable Care Act (ACA) achieve anything at all? Maybe. More Americans will own health insurance policies, especially if they are young and employed. Government spending on health care will decrease, despite the added cost of new computer programs and 17 different state insurance exchanges. Also, the financial burden of Medicare patients who have excessively costly diseases will move from the payer (the U.S. government) to the providers (us).
But these changes hardly qualify as reform. For patients, physicians and employers, none of these potential achievements has the slightest bearing on health care reform.
Patient Expectations
What do patients want from reform? Simple: access, lower costs and better health outcomes. The ACA misses all three.
Access? According to the Congressional Budget Office (CBO), despite the new law, the ACA will leave 10 million to 30 million Americans under-insured, putting them at risk for bankruptcy or death if they get the wrong disease at the wrong time. Another 30 million will be left with no insurance at all. In other words, when their incomes end, so does their health care — and maybe their lives. And that’s if the ACA works perfectly.
Lower costs? Although the CBO anticipates a $100 billion annual decrease in government health care spending, it also predicts a net increase of $100 billion in total health care spending. That means patients and employers will pay $200 billion more annually than they pay now. And that’s if the ACA works perfectly.
Improved outcomes? The Massachusetts experience says no. Six years after implementing its version of the ACA (Jonathan Gruber, the Massachusetts Institute of Technology economist who worked on both the Massachusetts program and the ACA, called them “the same [expletive deleted] bill”), 95% of state residents own insurance policies. Yet outcomes are unchanged, medical bankruptcies are 30% higher, and costs are increasing faster than anywhere else in the country.
(This is not entirely true. Those Massachusetts residents newly covered by Medicaid expansion now enjoy better health and lower medical debt. The same can’t be said, however, for those with private insurance.)
If you’re a patient, the ACA is a failure.
Physician Expectations
What do physicians want from reform?
First, payment. Given the amount of pro bono work that physicians provide, sometimes unwillingly, payment is not a slam dunk. It’s one thing to voluntarily perform charity care in Third World countries to prevent patients from dying of easily treatable diseases. But it’s a real tragedy to realize that without our charity work, many Americans similarly will die of easily treatable diseases.
In no other industrialized country do the poor and sick get charity care — physicians caring for them get paid the same amount as the physicians would if they cared for the rich and the famous. Only in the United States do physicians go unreimbursed if they care for the wrong patients.
Second, our payment should reflect the value of our services, not the value of the insurance policies of our patients. If we are paid more for patients with pearls than we are for those with tattoos, then financial motive favors care for the pearls.
Lastly, physicians want easy billing and prompt payment. Most of us haven’t seen that for decades. The ACA makes no pretense of simplifying either.
Physician-Employer Expectations
What should health care reform provide to employers?
First, employers want healthy employees. When office staff call in sick, it doesn’t matter if they are full-time or part-time — it’s lost productivity.
Next, employers want out of the health benefit management business. Just to manage the complexities of employee benefits costs employers an extra 2% of payroll. Can we rid ourselves of this added cost of doing business? Employers want health care benefits removed from labor–management negotiations.
To remain competitive, employers want costs for employee health care to be no more than what our competitors pay. Similarly, our employee benefits should be no worse than what our competitors offer.
Lastly, employers want health care costs to be predictable and consistent.
The ACA addresses none of these needs.
Health Care Basics
Whatever else the ACA may achieve, it completely fails to address the basic health care needs of patients, physicians and employers. Whether we voted for or against our current president, whether we register to vote as Republicans or Democrats, whether we are in private practice or academics, the ACA leaves our health care landscape in the same shape as before: a complete shambles.
It’s disappointing that this massive opus strives so valiantly to make a difference, yet falls so short of achieving what we really need. Is the ACA a well-intended piece of legislation? Yes. Is it reform? Sadly, no.
Maybe Congress will have better luck next time, if there is a next time. Let’s hope so.
Dr. Metz is a private practice anesthesiologist who lives and works in Portland, Oregon. He can be reached at s@samuelmetz.com.
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