With the ACA, put politics aside and focus on the facts

On the day the U.S. Supreme Court delivered its historic decision on the Affordable Care Act (ACA), aka Obamacare, I was rounding on my hospital patients: a man on the ventilator with pneumonia who had private insurance, one elderly woman with abdominal pain going for gall bladder surgery on Medicare, and one middle aged obese woman with a skin infection without any health insurance.

On my patients’ TV screens I watched our nation’s reaction to the decision. Some called for “repeal and replace,” while others felt vindicated.

Placing a stethoscope over my patient’s heart, I wondered how the court’s decision will affect us, as patients and doctors, and our health care system, which brings us together and includes the insurance companies and hospitals.

Undoubtedly, our opinions on the ACA are in large part aligned with our political affiliations. However, what if we put politics aside for a moment, and tried to understand the law. Over the past two years, I have referred to the nonpartisan Kaiser Family Foundation website, kff.org, which has simple-to-understand summaries.

Nearly 65 percent of us, like my patient on the ventilator with pneumonia, have private insurance through our employers or individual policies such as Blue Cross Blue Shield. What concerns us most are increases in our premiums, which have nearly doubled over the past decade.

I wanted to know, how would the ACA affect premiums? “It’s hard to tell,” said Cyril Chang, a health economics professor from the University of Memphis. “There are too many moving parts to the cost equation for an accurate prediction.”

My elderly patient going for surgery is nearly the age of my father, who is a cancer survivor and also has heart disease. And like 15 percent of Americans on Medicare, he is pleased that the ACA is closing in the “doughnut hole,” and that he does not have to make co-payment for preventive services such as colonoscopies or vaccines.

Yet, the cost will be offset by taxes such as an additional Medicare payroll tax of 0.9% on earnings over $200,000 for individuals and an investment-income tax for high earners.

The uninsured will benefit the most and will be angered the most by the Supreme Court decision. For my patient with the skin infection, health insurance at $15,000 per year for her and her family was unaffordable. Such working poor — 30 million of them — will benefit from ACA.

Yet, my landscaper will likely be angered because he will have to pay a penalty tax, which ranges from about $100 to $2,000 each year for being uninsured.

How will doctors and hospitals be affected by the decision?

In ways, providing insurance to millions through the ACA is like distributing discount movie tickets. However, the problem is that there are not enough seats in the theaters for everyone. Doctors, especially, primary care doctors, will face the greatest burden, and many may stop taking Medicaid, Medicare and possibly the insurances from the newly formed state-run Health Insurance Exchanges.

It will add to the frustration and chaos for patients unless our health care system quickly finds new ways to deliver quality health care.

While the ACA does not provide a single new way to deliver health care, it does provide the general guidelines: pilot projects with accountable care organizations and medical homes, which are innovative approaches to deliver quality care at lower cost.

What will happen to insurance companies?

I believe, this is where the ACA will have its greatest impact. Currently, if an uninsured pregnant woman in labor or a man with cancer came to the hospital in distress, the ER and ER physician cannot legally turn them away, however, insurance companies can, due to pre-existing conditions. Insurance companies can “cherry pick” healthy patients even if it is immoral and uncompassionate. The ACA changes this. After 2014, insurance companies will be mandated to accept all patients regardless of pre-existing conditions, gender, or age. In part, this is a trade-off for mandating all Americans to purchase insurance.

Insurance companies play another critical role. They are middlemen doctors, patients and employers. Under the ACA, they will be controlled under stricter regulation. A large chunk, 80 to 85 percent of premiums we pay to them, must go toward clinical services or else the money will be refunded back to us.

Many are fearful: Will ACA bankrupt America? The Congressional Budget Office, CBO, estimates the cost will be on average $94 billion dollars each year for a decade, which is 3.6% of the annual health expenditure.

The cost will be partially offset by fees to insurance companies, pharmaceuticals and taxes on high-income individuals and those who do not purchase insurance.

According to the CBO, the revenues and the cost will reach close to break-even.

Yet, I believe the estimated costs will likely exceed the projected costs. By how much is hard to tell. Without any health reform changes, health care costs have risen to about $2.6 trillion each year or 17 percent of our GDP.

As a doctor, the biggest question I have is, “How will the ACA impact the doctor-patient relationship?”

Will it make me spend less time with my patients? Will it make me order more or fewer tests? Will it make me limit my treatment options?

Hopefully not. In fact, pilot programs are encouraging providers to improve coordinated care and patient-centered care. Yet again, the ACA will fail in providing sufficient doctors for the large number of insured patients seeking health care. Finding a doctor will become difficult.

So when patients and friends ask me. “Is the Supreme Court decision good or bad?” I reply “It depends on your insurance and your political affiliation.” And then I come back to what Cyril Chang said. Our health system has too many moving parts, “implementing and improving” the present law may be as good or bad as “repealing and replacing” it.

Yet, all the details about the ACA only matter once we sidestep the political rhetoric, which neither political party is willing to do in an election year.

As patients and doctors we need to do this, because lives are on the line. The man on the ventilator is dying, the elderly woman had successful gall bladder surgery and the woman with the skin infection is going home.

Manoj Jain is an infectious disease physician and contributor to the Washington Post and The Commercial Appeal, where this post originally appeared.  He can be reached at his self-titled site, Dr. Manoj Jain.

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

    Perhaps instead of worrying about the premiums and the shortage of physicians, both of which are very important, we should also worry about usage of the term “insurance”.
    What exactly is this “insurance” that will be provided to many more poor people and does the “insurance” you think you have is really the same “insurance” you actually have?
    We have become quite adept at using meaningless (or worse) terminology in health care (e.g. patient-centered, consumer-driven, value, quality, etc.)

    • kjindal

      absolutely right. I remember once, when i did some housecall medicine, I had a potential patient call and ask to be seen. He lived in a bad area of the Bronx, which I really don’t mind except for the thieves (by that I mean the parking ticket guys). When I inquired about his “insurance” he proudly stated “I am fully covered – I have medicare and medicaid”. I politely declined and advised him to be seen at Montefiore Hospital’s primary care clinic.
      If we have an expansion of medicaid & medicare into the uninsured population, “covering” everyone, and we insist that costs need to be cut, and the easiest way is to cut fees a la medicare & medicaid, then isn’t the obvious outcome that there’ll be lots of people with an “insurance” card but nobody who will accept it? In NY that has resulted in lots of private offices not taking medicaid, with recipients using, for primary care, either ERs or bloated clinics subsidized by the state getting obscene taxpayer-funded rates, going mostly to their MBA executives rather than the MDs seeing patients.
      so when Obama says “it’s simple – if you like your doctor, you can keep him”, that is just a lie.

  • Bradley Evans
    • FCinNH

      Excellent. This explains clearly the economic problem with Obamacare. It does ignore that rates of insurance and payment will be set by an appointed group in Washington, as will what treatment modalities will be allowed for various conditions. I don’t think many doctors realize how much more constrained their treatment choices will be. Doctors already covertly ration care because they know what they and the hospitals can afford to do (under current payment schemes) and they know what insurances won’t cover at all, so they don’t “bother” to discuss those options with patients. See Richard Fogoros’ website at http://www.covertrationingblog.com for a more thorough explanation. Obamacare ratchets this behavior up to new levels.

  • AuthenticBioethics

    I’m not sure I understand what the “facts” are that need to be focused on. If you mean that people still need medical care irrespective of whatever coverage they might happen to have, and that’s the reality — sick people needing care — then, I’m with you. But you raise bigger questions and defer answers to further discussion, which is ok.

    I am not sure, however, that deciding whether it is better to repeal and replace the ACA or to tinker with and refine it can ever be separated from heated political rhetoric. As a country, we need to come to some semblance of consensus about what exactly we are trying to do (and “fix the healthcare system” is not specific enough), so that we can set about deliberating over whether this or that means is suitable to achieve the goal. “Universal insurance coverage” seems to be the goal of the ACA, and that is not something that everyone can agree on. It could be argued that the involvement of third-party payers in the system is what is making it complex, costly, and increasingly depersonalized for both patients and physicians; and the involvement of federal bureaucracies only threatens to make it worse.

    This is not necessarily political rhetoric or reflective of party affiliation. In fact, if I object to the ACA, it may very well be on grounds that have nothing to do with my political affiliations. Or, if there is an association, it might not be causal.

  • chris

    Back to basics:
    Do we believe that universal healthcare is a right? Or even a good idea? Or do we believe that a person has to earn the right to healthcare? Analogy: We DO believe that we have a right to public education . . . Is there a basic difference in our right to healthcare v public education? The answer to this question tells us if we will have the political will to make ACA or some version of it work.

    Are we all in this together? In some ways this 2nd basic question is related to the first question above. But it is also somewhat different. Do we believe in sharing the wealth? Do we believe in supporting the poor or less-advantaged people within our society? If the answer is YES, then we may be willing to subsidize or pay taxes towards universal healthcare. If the answer is NO, then we won’t want to pay taxes or subsidies. We will want the less-advantaged to fend for themselves.

    The irony is that we do now pay for the trips to the ER by people who have no other option via our taxes. Or via our insurance programs.

    Medicare (in my state) pays about $0.35 on the dollar for medical care. Medicaid (in my state) pays about $0.13 on the dollar. Is that sustainable?

    WHY is the cost of medical care so high? Why is that cost escalating so quickly/drastically?
    Medicine, as practiced in the USA needs to be scrutinized carefully, compared to the cost of medical care in countries that have stable universal healthcare arrangements. We need to learn from those other countries. If we find out that taxes are involved, then we need to go back to paragraph #2 above, Are We All in This Together?

    Set up a “think tank” with members from every state and every community–not just with experts. These think tanks will examine the costs of medical care locally. Some think tank thinkers will research healthcare in other countries that provide universal healthcare. Some will visit those countries to examine universal healthcare at close range. Oh, yes, transparency in the costs of health care will be necessary.

    Transparency in insurance companies may give us answers. If there are any fat cats in insurance companies or in pharmaceutical companies, red flags will be raised, and their ability to profiteer will be audited/scrutinized. There cannot be any fat cats in a system that operates close to the bone. There should be frugality for all.

  • MarcGarfield_DPM

    Do those that expect health care to be deemed a right believe that every component of health care should be included in this right? I don’t understand why those pushing for universal health care are not starting with cancer, injury, infection, and vital organ systems. Should we really be covering every whimsical visit to any doctor? Does anyone ever consider how much you pay for insurance because of people going to the doctor because their coccyx hurts from excessive upright sedentary activity and other variations on this theme covered under the guise of “preventative health care”?–just a thought
    To those of you asking why health care is so expensive the answer is easy–not complicated. We demand too much. We want no cost liability on patients, no interference with our doctors decisions and no limit to the legal lottery if your doctor is wrong. At the same time we want no risk- latest advancements in surgery and medicine and limitless authority of the FDA to restrict medical products from coming to the market without paying off our government to be apart of the game. We also seem to have less of a problem with our insurance companies paying 10s of thousands of dollars to perform routine procedures and diagnostics in a hospital rather than paying paying doctors a few hundred dollars for the same service in their offices. Fix that and we might approach European health care costs (about 1/2 of what we pay).

  • Molly_Rn

    I just want the same healthcare as congressmen and senators, nothing more or less. It seems unreasonable and laughable that these people who we hire (elect) to work for us have given us the short end of the stick. They take very good care of themselves and their families and couldn’t care less about us. Personally they should not get any benefits as they were expected to just serve a term or two and then return to their normal life. I don’t think our founding fathers expected life time politicians! So until we get the exact same healthcare that they do, we should keep after the bastards until we do.

  • Moises Tuckler

    Amazingly unbiased and insightful article. Thank you

  • doc99

    Good or Bad also depends on whether you are an Employed-Physician or in Private Practice.