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.