The Supreme Court on health reform: Everybody wins!

The Supreme Court on health reform: Everybody wins!The Supreme Court upheld the Affordable Care Act.

I’ll leave the detailed legal analysis  to other commentators that you’ll no doubt find elsewhere.

Although some may not feel this way, this is an outcome everybody should be happy with.

Most important, patients should be happy.  As I wrote in the New York Times Room for Debate recently, the ACA has already provided benefits not to only the uninsured, but one of the most vulnerable segments of the population — seniors:

One of the unsung benefits of the Affordable Care Act is Medicare’s Annual Well Visit exam, which has been offered since 2011. Thanks to these visits, which I perform everyday in my primary care clinic, I have the opportunity to evaluate seniors for their risk of falling, screen for depression and ensure preventive services like vaccines and cancer screening are adhered to.

Furthermore, health reform has already helped seniors save money. In 2011 alone, nearly 3.6 million Medicare beneficiaries saved $2.1 billion in prescription drug costs.

Primary care doctors should be happy as well. As the ACP’s Bob Doherty has written, they had much to lose, including billions of dollars in higher Medicare and Medicaid reimbursements.

Of course, progressives will be happy with the outcome. The President’s signature accomplishment is allowed to stand. 32 million previously uninsured Americans will have access to affordable health insurance in 2014, which will certainly help the scores of millions who live everyday without that safety net. Those with pre-existing conditions will have access to insurance at reasonable prices. And although not optimal, various cost control initiatives, like bundling care and the formation of Accountable Care Orgnaizations, will proceed.

Conventional wisdom dictates that it would be those on the political right who would be most disappointed with this outcome. Although they may be stinging now, here’s why they should be happy as well. It will prevent, or significantly delay, the prospect of a single payer system.

The Affordable Care Act entrenches the current system of private insurers. In fact, they should expect tens of millions of new patients because of Obamacare. And concerning the individual mandate, remember it’s actually a conservative idea born from the Heritage Foundation, and implemented by Republican presidential candidate Mitt Romney in Massachusetts.

Had the ACA been struck down, we would have been back to the drawing board. No one would touch health care again for years, while costs continue to spiral out of control, and the number of uninsured continue to rise. Progressives would have introduced a Constitutionally compliant way to expand coverage that could be passed via budget reconciliation, bypassing the need for a Senate supermajority. That solution would have been a gradual expansion of Medicare: effectively, steps to a single payer system.

In fact, had the Supreme Court ruled the other way, some states couldn’t wait to go the single payer route.

And that is a true government takeover of health care.

Now, I’m aware that scenario may happen whether the ACA was held up or not. If the ACA’s cost control measures fail, for instance.  But at least this gives the private insurance system a chance to fix our system before resorting to a draconian single payer route.

Obamacare is far from perfect. It doesn’t do anything to fix our broken medical malpractice system, its most glaring flaw. It doesn’t provide enough incentive for medical students to choose primary care. It doesn’t address the crushing burden of medical school education.

But it’s a start.

The Supreme Court’s ruling is an obvious victory for primary care doctors, patients, and progressives. Considering what the alternative could have been, those on the political right should take comfort in the decision as well.

The Supreme Court on health reform: Everybody wins!Kevin Pho is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • JM

    “But at least this gives the private insurance system a chance to fix
    our system before resorting to a draconian single payer route.”

    I suggest you might want to look up the definition of “draconian” before using it in this context. You may not like the idea of single-payer but calling what would just be an expanded medi-care program draconian seems excessive and out of place with the rest of this post that is mostly free of over-heated rhetoric.

  • sFord48

    RE: Of course, progressives will be happy with the outcome.
    and
    RE: And concerning the individual mandate, remember it’s actually a conservative idea born from the Heritage Foundation, and implemented by Republican presidential candidate Mitt Romney in Massachusetts.

    So progressive are happy with the implementation of a conservative idea?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      No. I can’t speak foe all “progressives”, but I am happy that although upholding the law, the Court chose to not create precedent for future transgressions under the nebulous Commerce Clause. So I am grateful for that little clarification which I think is (was) looming larger than the entire health insurance debate, which is most likely going to be largely theoretical, since neither the newly insured nor the previously insured will be able to afford medical care for much longer.
      Kevin’s “draconian” vision has been postponed, not eliminated.

    • anomalouserudite

      Making this a political argument is much of the problem. It doesn’t matter if it was a democrat or republican idea. It is still plain awful. A conservative justice was the swing vote in favor of it. A liberal justice voted against it.

      It’s the political players making proposals for political gain that are screwing everyone. I cannot think of a single reason any physician would favor the ACA in its current, and proposed form. Bureaucrats are taking over medicine and essentially telling docs how to practice, and patients what to expect.

  • AuthenticBioethics

    Lots of ways of looking at the situation, Doctor. “Should be happy” is only one, and one that in my book does not really think things through. By the way, it is somewhat elitist if you don’t mind me saying so with regard to those who disagree with you.

  • Jonathan Rouse

    So, I’m $350,000 in debt from medical school and still have to finish my last 10 months. If reimbursements are going to be decreased, how the hell am I ever going to pay off my loans and have a decent living?!?!!

    • CATEEP

      There may be options, such as programs to go to underserved areas, work for VA, some hospital employers may help with debt if they are hoping to attract staff (typically not major urbanized areas). Just listing some alternatives to going into lucrative specialties like Derm, Plastic/Cosmetics.

  • CATEEP

    I’m glad that it wasn’t struck down, but we still have a lot of problems to solve. A patient of mine came in late this morning and was glum. He had been seen the night before in the ER after a 3 hour wait. He’s glum because he expects the next time he will have an even longer wait because of all the new Medi-Cal patients now coming to the ER. This may be true, I said, but isn’t it better that people are getting care they need? “But I’m paying for my care, they’re not. I’m not saying they don’t deserve as good care as I get, but I feel I should get better service and customer experience than they do.” Well, that may start happening, I told him. We are considering not answering after hours calls for the Medicaid patients, no urgent appointments, limiting length of appointment and limiting slots, the Medi-Cal volume is the fastest growing segment of our volume. Parsed out between office salary, office rent, work the biller has to do for a 15 minute Medi-Cal visit, and it is a negative balance. It is closer to break even if it is a 5-6 minute appointment. On the other hand, patients with nice insurance we will continue to offer phone calls returned even after hours, answering service, urgent appointments, e-mail support, 15-20 minutes for new patient appointments, etc. I predict we will see increasingly multiple tiers of service, most likely, with concierge at the top and the no-pay/Medicaid at the bottom.

    • Kimberly Spering

      Wait…did I just read this correctly? You will not answer after-hour calls if they have Medicaid? I can see the lawyers jumping all over this now…How about the people WORKING multiple jobs, yet who have no insurance due to their employer(s) not being able to afford to offer it? Are they more “undeserving” of care than others?

      • CATEEP

        No non-emergency calls, that’s right. Blood pressure is 132/80 is not an emergency. My sugar is 160 and should I take 2 units like my instructions say I’m supposed to is not an emergency. They do have the option to go to the Emergency Room. I know of many primary care practices in my community that don’t take after hours calls at all or only from the emergency room/inpatient hospitalists. After 8, for example, my kid’s pediatrician’s office is closed, and if we think we have an urgent issue, we can go to an urgent care clinic up till midnight (here is the number) or to the emergency room. If we don’t think it’s an emergency, please call in the morning. This is pretty common and we have Blue Shield. Our office used to answer all calls no matter the urgency and it’s wearing us down. We did an analysis and found 45%+ of our calls were from Medicaid patients. When you’re being constantly woken and have to work a full day the next day, this is miserable, especially when we found 94% of calls were non-emergent. Asking for a pain medication refill at 2AM is not an emergency, there should be some responsibility to have the foresight to see you are running low. This often is not ‘care’ but customer service. People who are paying our bills get that service, people who are actually costing us money don’t. The reduction in stress and burnout look very attractive when these factors are covered. Good luck trying to come after us with a lawyer. There are requirements and there are boundaries, the requirements are likely not what you think (we have researched this extensively) and the boundaries are often violated by patients abusing our answering service. Also, the VA system, for example, when I worked there, had no after hours services by telephone, only their emergency room.

  • http://www.7POH.com/ Natasha Deonarain, MD, MBA

    As long as profit is imbedded in a health-care system, this mandate will be even worse for Americans. Now, all Americans will be supporting the uninsured as well as trying to pay for their own policies. Employers will struggle to offer coverage. Health insurance companies continue to cherry-pick the healthiest and youngest among us to pay for shareholder earnings. The shrinking middle-class will keep paying for all this mess.
    Instead of being responsible for the uninsured like THEY should be mandated to do, health insurance companies will do everything in their power to post $4 + billion dollars a quarter, including false-promises that “they are no longer in the business of disease but will cover prevention and health.”
    Soothing words? Absolutely not!
    Health is a gift! Meditation, yoga practice and personal health practices are free! Behavioral coaching, life coaching, nutrition classes are negligible in cost. This is what will correct today’s degenerating diseases. Not drugs, not screening, not lap-band surgery! And health practice does NOT cost 17,000 dollars in “health” insurance premiums per person. What we are paying for with this amount is the fear of disease. And disease will continue to cost more and more and more from our pockets….as long as profit is imbedded in the system.

    • http://www.facebook.com/people/Su-Camarrari/100000583910954 Su Camarrari

      Yeah, good health is a “gift” tell that to my sister who died from uterine Leiomyosarcoma at age 40 after fighting it for 3 years. She was a young, healthy 37 year old woman with a 2 year old child when she contracted this horrible illness. She was not overweight, didn’t smoke or drink excessively, got plenty of exercise, was a stay at home mom married to a fairly well off man…..She lost the health lottery. Despite traveling around the country to Dana Farber and Sloan Kettering and receiving the finest care from doctors who were experts in the treatment of sarcoma as well as participating in clinical trials this disease killed her in three years. She died in 2002. May she RIP. Let’s stop blaming the victims.

      • http://twitter.com/JamesFPMD James Biggerstaff

        Su,
        It is patients such as your Mom that doctors opposing the ACA are fighting for. She could very well be ruled “incurable” under the ACA and not even offered treatment. This is what has happened in CA and in other countries. Why waste money on people when all we’re giving them is 3 years to raise their children, see children and grandchildren get married, graduate, etc. This is how the bean counters think I fear the consequences. We should not blame victims for their disease, nor should we practice “vengeance is mine” medicine where we punish those that may have brought on their own illness. We should practice with empathy and compassion.

        BTW, It’s never too expensive to do the right thing!

        • BetsyQRoss

          “She could very well be ruled “incurable” under the ACA and not even
          offered treatment. This is what has happened in CA and in other
          countries.”

          Baloney. Please offer up some proof this is true.

          The standard treatment for uterine sarcomas in Canada is the same as it is in the U.S. Most often surgery, followed by chemo and/or radiation.

          If, however, one doesn’t have the means to pay, one won’t be offered treatment. A singular and unique privilege among OECD nations afforded to U.S. citizens. Frankly, it’s embarrassing that a wealthy nation such as ours would be so barbaric as to allow people to die for lack of ability to pay. Fifty million without the ACA. And for the remainder to run the risk of bankruptcy, medical expenses being the cause in over 50%, and of which the majority of those bankruptcies, the debtors had health insurance. With healthcare expenses, irregardless of payor, eating up more and more of GDP, how long do you think our current system, ACA or not, is sustainable? We have many working models of universal health care at half the cost or less we could choose from. Instead we insist on trying to fix an unfixable system, to protect the almighty profit. Free market wins. Industry negotiates windfalls into health care reform. Health stocks up on SCOTUS decision.

          Empathy and compassion are not strong suits of the American citizenry, and evidence points to it being on the decline. The new (cleaned-up version) meme is: “I got mine. Nothing else matters.”

          • http://twitter.com/JamesFPMD James Biggerstaff

            Wow, you’ve shown your ignorance so many times in this one post that it’s hard to decide where to start.
            I know personally a physician who worked for Kaiser in CA whose mother had multiple myeloma. She was deemed “incurable” and the oncologists wouldn’t even see her, much less offer her treatment! I have seen people cured with bone marrow transplant but, that would be too expensive.

            This happens routine basis in the UK where patients are denied dialysis or kidney transplant based on age with no consideration on mental state, productivity. As the husband of a patient of mine said “the medical system(in the UK) killed her first husband”. He was on the waiting list for renal transplant for years but when his beeper finally chimed a “panel” ruled that he was too old to get it.
            Within recent memory a young woman was approved for bone marrow transplant in CA but the process killed her liver. Then they denied her the liver transplant she needed to survive. It was only after this decision received publicity (the insurance companies hate people publicizing it when they kill people, OTOH the gov’t doesn’t care) that they relented and approved the transplant. Unfortunately it was too late and she died before she could get it. Did I mention that she already had a compatible liver available when they refused to approve the procedure?
            The cooked up statistic you site about medical expenses being responsible for more than 50% of bankruptcies has been discredited so many times that it is laughable that anyone would even cite it anymore. Even if it were true (which it is not) the fact that these patients are still alive to declare bankruptcy bears witness to the fact that people are rarely denied care on the basis of ability to pay. I assume you feel that this is evidence of a vast conspiracy to keep them alive so that they can pay their bills.
            Finally, your statement that empathy and compassion are rare in American citizenry would certainly seem to be true if everyone had your point of view but I refuse to believe that most folks are like you.
            Physicians are the only patient advocate in the system and when we are owned by that system, who will then advocate for you?

          • http://profiles.google.com/andeevb Andee Bateman

            HD in the UK starts at 3 tx per week, and is INCREASED based on lab values if needed. Here, you get three turns per week in the chair, whether your values are mediocre or not. 3. So, as you blather on about the horrors of the NHS and its ‘panels’ I can assure you that transplantation requirements here and there both require compliance with the treatment plan. So if one insists on heading down the pub for a pint or two, you can rest assured that one will NOT be getting that liver after all. Same with dietary non-compliance, or smoking or marijuana use. The fact that the NHS is transparent in their determinations may be off putting to those that observe it from here, but no doubt, the OPO of any state does the same thing here. And, no we DON’t have anyone filing bankruptcy for medical charges, so if its 50% or 10%, its still more than if you had a plan that allowed US citizens to hold on to their familiy wealth in the face of catastrophic illness or injury. Ta mate.

          • http://twitter.com/JamesFPMD James Biggerstaff

            Andee, Your knowledge is very limited on this subject. We don’t have anyone declaring bankruptcy because of medical bills either. I know many people getting HD 5 x /wk so apparently your wrong there. Who said anything about non compliant patients? Of course, they have to stick to the plan, but in the UK they still run the risk of being denied transplants based on some arbitrary number. So, do you know a bunch of patients who have stem cell transplants to CURE their multiple myeloma? I just saw another one yesterday but this is still “experimental” in the UK. So, if you want to say you favor sacrificing life to save a few bucks, just say it but your view may change if you ever need these life saving services. I will continue to advocate for my patients and all patients to receive the best care available for their medical problems and unlike you I will not support laws like the ACA whose intention is to pull us all down to the lowest common denominator.

      • Sarah

        I appreciate you saying this. I’m all for healthy living, positive attitudes, good nutrition, moderate exercise, accountability, etc., but I’m tired of those who love to preach “health is a choice”. It’s ignorant. It implies those who get sick did something wrong. Just because these “health promoters” aren’t sick, doesn’t mean it’s attributable to their behaviors. Also, “the power of positive thinking” is lovely and all and while it may make you happier, when studies have been reviewed objectively, it’s noted that there’s no proof the positive thinking prevents illness or cures it. Sort of like when we all used to think stomach ulcers are caused by stress, when in fact they’re caused by bacteria. I guess it seems right if enough people believe it.

    • Tanya Smith

      Wow. What does one say to your final comments? I was recently diagnosed at age 36 with rheumatoid arthritis. Have always taken care of myself, so I’m pretty devastated to now be sick with a chronic illness that has radically changed my life, and most certainly not for the better. Meditation, yoga, and my sensible health practices didn’t help me before, and they won’t help much now. I’m surprised you didn’t tell me I should also believe in purple unicorns.

      There are a lot of problems with the ACA that need to be worked out, but stop blaming everyone who might benefit from it as though they are responsible for their own illnesses. Not all of us who are sick and who might benefit from some aspects of the legislation are Big Mac and french fry-eating couch potatoes.
      Good grief, Doctor.

    • BetsyQRoss

      I believe the “health is a gift” comment was misinterpreted. Good health IS a gift, as in blessing, that one should be thankful for. It doesn’t imply that poor health is due to some sort of moral shortcoming or failure.

      In general, Natasha makes good points. We shouldn’t have to pay for an overpriced, inferior product in a system that isn’t addressing exploding costs. Chronic, preventable disease is the largest single culprit, 80% spending has been quoted as being attributed to diseases that fit this category. Compared to other nations, and even to our own country of 30 years ago, Americans are obese and sedentary. Lifestyle changes would dramatically reduce costs. The public needs to be non-judgmentally educated, not finger-pointed or blamed, about choices and consequences. There are profits to be made in pills and treatments, while exercise and eating better aren’t reimbursed and will see better results. Not that most docs don’t make attempts to encourage these healthy habits, but fee-for-service encourages increased, and yes, sometimes, unnecessary utilization of care. Sometimes it may be defensive medicine at work, sometimes it’s to boost that bottom line. Everybody who practices in the field knows this whether they will admit it or not. How else can one pay off $350,000 in student loans as one person has posted?

  • southerndoc1

    Primary care docs should be happy because we will lose slightly less money each time we treat a Medicare or Medicaid patient? Sorry, doesn’t work for me.

    There are lots of good things in the ACA but none of them are for primary care physicians, and it’s delusional to think so.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Someone high up the food chain on the “dark side” of the industry told me today that primary care docs are the Davids to health care’s Goliaths, but don’t realize that they have very powerful slingshots in their hands. Hopefully, this is going to change, and then, and only then, good things will happen for primary care physicians and for patients in general, with or without the ACA.

      • David Huss

        The “power” that the PCP wields is that they are the gateway to all of the aspects of healthcare that are cash cows (outpatient procedures/surgeries, etc.). Sadly this is of no benefit to the PCP in private practice; which is why more and more PCP physicians are becoming salaried employees of healthcare systems. In such an arrangement the hospital system can afford to pay their PCP’s more money than they bill (ie use the PCP as a “loss leader”) in order to pump more patients (through intra-system referrals) into their more profitable services. The two hospital systems in my area are currently feuding and one is actually using this exact tactic (they built several new state of the art family practice clinics and then poached PCP’s from the competing hospital network by giving them salary increases/signing bonuses). So yes, PCP’s do have some “power”, but not the sort of power they’d really like.

  • http://www.facebook.com/khensel3 Karl Hensel

    Everyone wins. Dr.,Insurance companies,investors. Another mandatory payment. Car insurance, medicare,federal,state,local tax, sales tax, Yeah right minimum wage. Bull. Everyone gets paid except the workers. What will we now payout 50% in mandatory junk. Yes $10.00he. $3.75 gas. Electric,rent,food,water. All on the $5.00 an hour I get to keep. Slavery in increments.

  • NewMexicoRam

    Sorry, you have the short-sided view.
    This decision just ran over the US Constitution.
    It will never be looked at as the guidepost for our nation’s laws ever again.
    The 9 (or should I say 5) opinions from the elitist court will rule from now on, with no regard for restraint and will decide based on their own interpretation of words rather than the evidence placed before them.
    Even a GOP landslide in Nov won’t be able to stop the Court’s future progressiveness.

  • http://www.drjshousecalls.blogspot.com/ Dr. Mary Johnson

    I haven’t commented on this blog in ages – pretty much because it’s pointless.

    I am a dues-paying member of the American Academy of Pediatrics and I do NOT support Obamacare, but yesterday I got a gem in my Inbox from the AAP praising the Supremes’ decision. And after fifteen years of CRIMINAL NEGLECT AND INDIFFERENCE – courtesy of a government program that kept NONE of its promises to me (as someone who actually went into public service TO SERVE the under-served), it was just too much. Nothing I ever envisioned for my life as a doctor has come true.

    Of course, I could just tell the rest of the country, “Welcome to the club. You got what you voted for.”

    The AAP, the AMA, and most of the rest of the professional organizations supposedly “representing” physicians in the political realm have totally thrown primary care physicians under the bus. It’s nothing new. But it remains disappointing/so discouraging.

    As unhappy I am with this decision, at least the Supremes correctly called the individual mandate what it is (even though supporters would not own up to the truth as they rammed it down the country’s throat) – A TAX.

    The biggest unenforceable tax in history. Upon the middle class. As for the “draconian single-payer” bit? We’re well on our way there.

    Obamacare is a partisan/vote-buying MESS of new rules and regulations – exponentially expanding entitlement (and ergo COSTS) – casting those who provide medical care as “the enemy” – that did not fix ANY of the “third rails” in medicine – from real malpractice reform to whistle-blower protection to non-profit corruption – to fraud and abuse – to putting personal responsibility and limits for Medicaid participants into the equation.

    Our only hope now is the electorate. There is NOTHING WRONG with going back to the drawing board, when the drawing needs to be re-drawn.

    Happy, Kevin? Not. Energized and determined. You betcha.

    • BetsyQRoss

      “The AAP, the AMA, and most of the rest of the professional organizations
      supposedly “representing” physicians in the political realm have
      totally thrown primary care physicians under the bus.”

      Yep. They certainly have. Docs such as yourself are subsidizing the profits of specialists.

      C’mon, Mary. You do want their kids to get a new Lexus for their 16th birthdays, dontcha? (And how many Medicaid patients do you think your friends in private practice see? Allow me to share. In my city of 200,000, we have less than a handful of primary care (adult) docs in private practice who will see Medicaid patients, the list ever changing, as its mostly young docs in first year or two of practice……. but quality of care is less of a crapshoot than going to one of the clinics.)

      Betsy Ross
      RN for 35 years, community health, and ready to redraw

  • anomalouserudite

    Personally, I am flabbergasted by the upheld mandate. I also happen to be appalled. Do not the physicians commenting here in favor of the mandate understand that written into the PPACA is that nationalized accreditation and quality monitoring groups will be in charge of implementing sweeping standardized measures to judge the competency of physicians, and will, in fact, decide their reimbursement level based upon how he or she scores on these measures?

    This is NCLB for the medical field (no patient left behind)! For example, Dr. Jones will be monitored as he treats patient X to see if Dr. Jones is keeping X’s HbA1C below 7% (or if he is keeping X’s LDL less than 100). Surgeons are going to be paid based upon how long a surgery is thought to take based upon a “national average.”

    Judgments such as these will be imposed on the physicians to determine our pay! There is no consideration for how awfully the patient manages his diabetes. It’s up to us to ensure the patient, at his own house, is not drinking that 2-liter of Mountain Dew and eating half-pound cheese burgers. Where is the care for patients here? Sounds like overwhelming bureaucracy, and politicians taking over medicine.

    So…lawyers, NOT doctors are going to be deciding what is best for patients, and how medical treatment should look and feel and work. Excellent!

    Sources: http://www.jointcommission.org/standards_information/npsgs.aspx; http://www.qualitycheck.org/qualityreport.aspx?hcoid=10095#comparative; http://www.cms.gov/

  • http://www.facebook.com/george.m.mitchell1 George M. Mitchell

    In Spain the healthcare system is nationalist but there´s many problems coming up like the co-payment when you get your medicine. Plus when you go see the doctor too. Spain and Italy are having these problems since the late 1970´s when the national healthcare system started. Don´t forget that in Europeans people pay more taxes for the ” free healthcare system”. Nothing is free. This is like Medicare in the states but the Doctors have the right to help you out right when you go to the hospital. No questions asked!!

    Most likely Mr. Obama will take Medicare and Medicaid out to put it in another name just like in Europe. Just don´t forget the a Doctor and Nurse in USA make way more money than in Europe.

  • Sarah

    I’m confused. You seem to have changed your attitude. What about the piece you wrote almost a year ago about the Boston Medical Center getting “screwed”. Your opinion seemed to be that Massachusetts’ insurance mandate was harming community medical centers and low income patients and that the same would happen to the rest of the country with the ACA. Do you think this is a good thing just because it’s “something” rather than “nothing”?

  • Amber Habig

    Healthcare is more expensive than ever. This sets a precedent that will chip away every vestige of freedom left. It is not constitutional. I’d rather pay high prices for healthcare than with my freedom. Being taxed for not buying something is atrocious.

  • FCinNH

    Having read through much of the bill (and it wasn’t easy) all I can say is any physician who thinks that the ACA is a good thing must not have read it. It has given small pesidentially-appointed committees the power to dictate not only what you will get paid for your services from every payer, but also what treatments you will be allowed to use. Patients will be able to get second opinions but there are treatments they will not be eligible for no matter where they go or who they see in this country. I expect “medical tourism” will increase for those who can afford it. Privately paying for services in this country that Medicare covers but has denied is already illegal, and I believe (from what I read in the bill) that that policy will be extended to all payers.
    I believe that this bill was specifically designed to make it advantageous for employers to abandon providing health insurance. The penalties they must pay are a pittance compared to what they have to pay now for that insurance. They will abandon providing insurance in droves, the requirement that insurance companies must cover pre-existing conditions will undermine the individual health insurance policy market, and insurers will end up abandoning the market altogether, because I expect rates to be set so low by the fedreal governemnt (who will now have teh absolute power to do that as well as dictate what services must be covered) that it will be impossible to stay in the market. In three years time or so there will be a great clamor for the government to step in and provide a “public option.” Game, set and match. Single payer will have become a reality.
    I also believe that the era of “personalized medicine” is now stillborn because it is impossible to standardize treatment regimens in the face of the incredible varibility of the human genome, and standardized treatment pathways are the ACA’s biggest tool in controllng costs. Since the greatest driver of the increase in healthcare costs over the last five decades has been the advent of new treatments and technologies, the only way to hold down costs, and stabilize the cost of healthcare, will be to make medical innovation incredibly difficult. So this is as good as it will ever be, so long as this Act is in force.

  • Dorothygreen

    I agree mostly with Dr. Pho that while the ACA it is not perfect, and needs lots of tweaking, it is on a better path than a single payer system. If we could get closer to the model the Swiss
    have, along with addressing two other major cost drivers besides the ones already being addressed, the US would have the best system in the world.
    The Swiss system is insurance based -non profit for basic care; for profit for supplemental services – more choice, dental, private hospital rooms etc. Employers are not bound to provide
    insurance. Basic care costs are set – subsidies are provided– no one is denied. Average administration costs are 6 %.

    We can’t come to terms with end-of-life issues – a huge cost. Perhaps we will do better with the ACA but beliefs and money continue to be major drivers.
    We have to use the tobacco model to address other legal addictive substances. It works. Sugar, bad fats and sodium are addictive substances. Call it a RISK model as thousands of studies show these substances are the root cause (risk factor) of chronic PREVENTIBLE disease. Note: Switzerland has a 9% obesity rate and the gov’t is concerned about escalating health costs compared to ours of 34%. The push back in the US to maintain the status quo will overshadow all the good that health care reform is doing. This is the biggest driver in health care costs.
    All pre-existing diseases are considered the same. Only tobacco smoking along with age (which I feel is discriminatory) can rates be raised. Care will continue to favor those with PREVENTABLE chronic diseases because they are profitable. Consequently, everyone’s rate will go up,regardless of how well individuals take care of themselves..

    This will also be PCPs Albatrossbecause they are wrongly being judged on biometrics they have little control over.