The Affordable Care Act: Spinning reform without real reform

It’s been three years since the Patient Protection and Accountable Care Act (PPACA) became law.  There have been widely divergent opinions published by journalists on the impact of the law for Americans: from a rose-colored account from the New York Times, to a not-so-peachy account published at Reason.com.  Few doctors have ventured into this discussion.

The need for health care cost reform

I should start by saying that I am biased.  I grew up in the days of an idealized image of the physician –where doctors were still held in relatively high esteem by our society.  I had to think this way for I was joining the system.  Back then, like now for the younger doctors, medicine was a still considered a calling, not just a job.  The unspoken code was that it was the patient above all else: screw the establishment, screw hospital loyalty, screw the drug company – if they couldn’t help your patient, you’d take them elsewhere.  So hospitals courted doctors.  Drug companies courted doctors.  Insurance companies courted doctors.  But the truth be known, doctors weren’t the apple in everyone’s eye, patients were.  And doctors enjoyed the limelight – so much so, that a few in our ranks succumbed to the greed, too.  After all, like now, patients paid everyone’s bills.

But health care costs for patients became increasingly hard to cloak.  Insurance companies, in the business of making the expensive seem cheap, needed an exit strategy.  The new hospital buildings, multi-million dollar corporate earnings, drug innovations costing tens of thousands of dollars, and the aging population that was growing too quickly weighed heavily on the entire system’s sustainability.  Something had to be done.

The first steps

So without belaboring the obvious: we created health care reform as we know it.  Health care reform wasn’t just the PPACA, though, but rather a carefully orchestrated series of legislative achievements that laid the groundwork for payers to offload the costs of health care on to the only other entity that could pay these high costs: our government.

The process (as we have seen) first involved an expensive, multibillion computer roll-out that was part of the American Recovery and Reinvestment Act.  These computer systems promised “cost savings” by “improving efficiencies” of care.  Information systems were sold as our salvation from cost excesses like $15 Tylenols.  Corporate America (and their political lobbyists) bought it and so did the government.  To keep doctors quiet, doctors were promised $44,000 a piece to install computers in their offices.  Little did they realize their payments from government to private offices were to be slashed forty percent in the same legislation and computers would be required to bill the government.  So, the $44,000 actually went to doctors’ new employers.  Doctors were thanked for their services with a new $700-dollar iPad and a treasure trove of Meaningful use regulatory benchmarks that slowed patient care rather than sped it.

Our new “reform”

Next came the PPACA, our signature health care law.  The law was spun as a way to save health care costs while adding 34 million more uninsured patients to the system.  Pulling heart strings was much more palatable politically than the much needed reality of fiscal restraint.

But we should admit that our health care system has flaws when it comes to the uninsured.  To prove the health care reform’s benefits, the easy-to-sell low-risk coverage for young adults was given as a loss leader to the new health care law’s health care happy meal.  This benefit was universally welcomed by all because it was needed.  Yeah, it cost a bit more to provide this insurance, but in the scheme of things, the cost of this health care was relatively cheap to provide.  It was (and remains) a win-win. But our attachment to this part of the law may be a clever way to buy us off.

Preventative services, provided for free, were also included in the PPACA.  But this is a problem because nothing is free in health care.  Proving preventative services for free perpetuates an expectation that everything will be free in health care and have no consequences.  After all, preventative services take time and time for care providers overloaded with more and more patients entering the system is our most precious commodity.   Others argue that catching problems early will save money but the proof that this makes a difference to health care costs is really just a delightful narrative.  In fact, even the annual physical’s benefit to our health care has been called into question – especially when we recognize its value to the system compared to the benefits derived for the patient.

And people have argued that the PPACA has already reduced costs.  While I am not an economist, I really can’t speak to this.  I am just a worker and observer.  These days I see four or five administrators where, just a few short years ago, we had one.  I see fewer nurses with less experience caring for more patients now.  I see bigger buildings but fewer patient beds as wards are consolidated.  I see hospital-system employers with hiring freezes that are laying off workers in anticipation of upcoming costs imposed by the new law.

How’s the quality?

And then there’s the overall quality of care.  I can’t say I really see a difference from five years ago.  Sure, I see things being done faster by fewer.  I see computers moving information around like never before.  But is the care to our patients really better?  I see reams and reams of documentation made not for the patient’s benefit, but for bureaucrats and bean-counters more interested in our use of computers than our patients.  I see better communication between doctors improved with the EMR, but has this translated to better care delivery? Not always. And when it comes to quality, the New York Times editors cited the example that health care in America is cheaper because Medicare patients have fewer re-admissions since the PPACA was enacted.  But they also failed to note that hospitals receive financial incentives to reward this behavior.  They claim this is “better coordination of care” while ignoring the fact that patients are labeled with scarlet A’s and shunted to health care facilities that don’t “count” as re-admissions.  They also failed to mention the effects of the higher costs that patients see from their higher insurance premiums.  Cha-ching.

What’s ahead

In the end, health care reform is still about the money for the system rather than the real needs of most patients.  We are cutting costs to corporations by inflating our health care Hindenburg with cheaper hydrogen.  We have spun a narrative of providing more care for more people with less cost while ignoring the shear forces and telltale weather patterns of cost concerns that blow our way and threaten our ship’s buoyancy.

Some doctors have leapt from the ship.  More will certainly follow.  Others remain silent yet quietly discontented; they do their job as just job now, marking time with little incentive for doing more.  They have become the common workforce drone  increasingly asked to do more by those who go home at 5pm and have no liability for the care they provide.  More risk with less reward has been the mantra for care providers in health care reform.  The stress is growing for everyone.   Unfortunately, the doctors that leave will soon be back-filled by well-meaning young physicians with fewer hands-on hours of training that have been sculpted by an educational system dependent on tenured med-school professors complicit with our new progressive mindset.

Health care reform is here, alright, doing what it’s always done: spinning reform without real reform for three years (so far) and counting.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • Dave

    Like other tirades against the ACA, this article tries to lay the ills of American medicine at the feet of Obamacare. You could probably find articles from 2005 with 70% of the same content — shoot, you can find articles with 90% of the same content from 1965, just change ‘ACA’ to ‘Medicare’ and ‘computers’ to ‘desegregation.’

    That doesn’t mean there aren’t problems today — there are — but ACA is not the culprit behind all of them. I don’t understand why doctors would attempt to paint things this way. Politicians, yes — decrying ACA equals dollars and votes in many districts — but physicians? Is it easier to cope with the problems in medicine by fixing the blame to one entity, to indulge in the pipe dream that all was well until Obamacare was thrust upon us? I ask that half rhetorically and half sincerely.

    At its heart, ACA is about insurance reform more than healthcare reform. It dabbles in healthcare and has a strange mix of kickbacks, pet projects, good ideas, and enough creative accounting to allow the bill to pass the Senate via reconciliation, but it’s heart is in making insurance affordable and it does that mainly via subsidies for people to purchase their own plans.

    You can cherry pick a few points: yes, meaningful use was a PITA; yes, premiums are going to rise as more things must be covered; yes, some hospitals are finding ways to circumvent the new rules; yes, many of the mandated services may have negligible effects on health. Sure some doctors are peeved and probably going to quit, but those guys weren’t all rainbows and lollipops prior to 2010.

    The truth is that we had plenty of problems before ACA and will continue to have problems afterward. Only now, maybe one of those problems won’t be 49,000 people dying each year because they lack health insurance. The older generation can go ahead and jump ship just like many southern docs did in the 1960s. We young ones are a smart, innovative, and determined lot, and we’re going to be okay.

    • Mike L.

      “…‘desegregation.’ [...] The older generation can go ahead and jump ship just like many southern docs did in the 1960s.”

      DOCTOR WES!!! IF YOU’RE NOT FOR OBAMACARE, YOU’RE A SEGREGATIONIST WHO WOULD QUIT RATHER THAN TREAT BLACK PEOPLE!!!111 RAAAACIST!!11!

      Seriously? This narrative that anyone who doesn’t sing Obamacare’s praises is akin to a bedsheet-wearing white supremacist racist who hates black people is both insulting and ridiculous.

      No-one who draws this kind of analogy is interested in a serious discussion. Waving the race card around like that just signals, “I am not a serious person; I have no cogent arguments.” Stop it.

    • http://twitter.com/AventuraCardio Dr. Alan Ackermann

      I don’t know if the 49000 that die per year figure is true or not. I am going to stipulate that it is, but I would argue that the assumption that it may not be realistic to assume that 100% of the population will be insured 5 years from now. Keep in mind that ACA does not gift away coverage and the 35-40 million that are supposed to “benefit”, will likely be underinsured. It may be cheaper for a good percentage to pay the fine than get coverage. How many will still die under this premise?

    • ninguem

      Opposition to Obamacare is like Jim Crow segregation?

      Who is this jackass?

  • M.K. Caloundra

    Dave writes: “…one of those problems won’t be 49,000 people dying each year because they lack health insurance.”

    I ask: Did these 49,000 people die for lack of health *insurance* or for lack of health *care*?

    (and out of curiosity, where does that figure even come from? could you please provide a link or citation?)

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

    Speaking from the rather far left of the “progressive” spectrum, I mostly agree with Dr. Wes. The stated goals of Obamacare are noble, but the mechanics are neither noble nor likely to be effective.
    Since desegregation was brought up and Medicare too, it may be useful to remember that neither one of those landmark legislations was formulated to protect corporate profits from the adverse effects of doing the right thing for the people.

    Obamacare is more like the unfortunate Medicaid provision, but this time for the majority of Americans who are not independently wealthy. We are creating a different health care system that looks like it provides health care, and does provide some services, but nothing even close to what is available to those who can pay extra. That’s why you see retail clinics, non-physician providers, peep-show medicine on computer screens and all sorts of do-it-yourself machines, and all sorts of rich people doing TV shows where they sing the praise of medicine without doctors.

    Just like Medicaid deteriorated over the years, this new system for the masses will also deteriorate, and is meant to deteriorate, into third world health care, which is increasingly being given as an example of how “we” can be more frugal with health care services.

    And the doctor role is visibly shifting from independent patient’s advocate to that of “steward of scarce resources”.

  • M.K. Caloundra

    Thank you very much for sharing that article, Ninguem. What a fascinating development! I hope that in the coming week one or more of the knowledgeable bloggers featured on this site will be writing about the Oregon Health Insurance Experiment and its implications for healthcare and health insurance policy in the States.

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

    They may have died from the lack of health care and insurance is the instrument by which health care is being obtained in this country.

    Medicaid was a cheap knockoff of such instrument from day one, so nobody should be surprised that it’s broken.

    • ninguem

      The countries that are always argued to be our “betters” with respect to healthcare, have their own outcome inequalities based on race and socioeconomic status.

      In their lands, the inequalities are felt to be due to certain realities of being poor. Cultural and educational inequalities. Perhaps personal choices (substance abuse) which rendered them impoverished.

      Of course those same people in the USA have worse healthcare outcomes because of our evil capitalistic healthcare system.

      It just might maybe have more to do with certain things that come along with the poverty and minority status, and less to do with the healthcare system.

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

        Yes, poverty is the root cause, but it has little to do with personal choices, unless choosing one’s parents is considered a personal choice.
        http://www.nytimes.com/2012/01/05/us/harder-for-americans-to-rise-from-lower-rungs.html?pagewanted=all&_r=0

        • ninguem

          Did you happen to notice that I put “personal choices” at the bottom of that list with a “perhaps” qualifier?

          N>0

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

            I did not. My apologies…
            Either way, I think we agree that this has little or nothing to do with the health care system per se.