Oct. 26, 2012
-- The Patient Protection and Affordability Care Act (ACA) was passed by Congress and signed into law by President Obama in March of 2010. All Americans, physicians and patients alike, remember the political turmoil and popular upheaval over its passage. Media attention to its implementation and ongoing legal challenges has taken a backseat to other important issues such as Osama bin Laden, deficit spending, uprising in the Middle East, the 2012 presidential election, earthquake in Japan, and tornadoes in Midwest. Paul Simon’s refrain, “slip slidin away, the nearer your destination, the more your slip slidin away”, seems an appropriate description for for universal health care coverage in the United States today. Most would agree that the health of America is dependent on the health of its individual citizens, so it seems that physicians and citizens should stand up and and help prevent universal access to quality healthcare for all Americans from slip slidin away. Most physicians believe that access to affordable high-quality health care for all Americans is a moral and medical imparative to prevent needless suffering and death.
Some of the provisions of the affordable care act have already been implemented and others will be implemented over the next few years. Most all Americans support the positive elements of the bill such as elimination of pre-existing health problems as a condition for acquiring insurance, or the ability of dependent children to have insurance on their parent’s policy until age 26, or the ability to insure nearly 50,000,000 Americans who are currently uninsured. That is the easy part, however there are number of difficult areas that we must overcome to have successful implementation of the bill, such as how will we pay for it, is it constitutional to force all of us to buy health insurance, how will it impact the funding of Medicare, and who will have to pay additional taxes. Additionally , from a physician perspective, a major concern is the ability of current physician manpower and hospital infrastructure to manage the influx of nearly 50,000,000 new patients superimposed on the increased healthcare needs of an aging population. An added concern for physicians is the absence of any reasonable medical malpractice lawsuit reform in this bill, thus preventing the elimination of 7 % of the cost of healthcare due to “preventative medicine” and fear of a lawsuit. Clearly there’s still a lot of work that is required before full implementation can achieve its goal of high quality affordable health care to all Americans.
It seems that the most important challenge to full implementation of the ACA law is the issue of its constitutionality. Is it constitutional for United States government to force all Americans to purchase insurance, referred to as the individual mandate? There are a growing number of states that have filed lawsuits to challenge the constitutionality of the ACA’s requirement that individuals buy health insurance or pay a penalty starting in 2014. We must understand that insurance works as a result of the rule of large numbers, therefore it must have healthy people and sick people in the insurance pool, otherwise it does not work. Furthermore, if we were allowed to buy health insurance only when we get sick, the cost of the insurance would be unaffordable because there are no healthy people premiums to balance the cost. An example would be an ability to buy fire insurance after the house has burned down. Certainly there are precedents such as the requirement that drivers have automobile insurance. In our current system, there are some 50 million uninsured Americans who use the emergency room or urgent healthcare facilities and this is at taxpayers expense. It is this requirement that is getting the majority of the court’s attention and it is the vehicle that is most likely to take healthcare reform“slidin”
if the Supreme Court were to declare it unconstitutional. I predict that this will not happen.
Another major challenge is the fear of the government interfering with our personal medical care. Can the government decide when healthcare should be discontinued (the death squad issue)? During the debate about the health care Reform Act, there was much discussion and many rumors about a provision in the bill that allows Medicare and health insurance companies to discontinue payment for healthcare to terminally ill and elderly patients. There is a section in the bill that describes reimbursement to physicians for discussing with patients and families, prior to their becoming terminally ill or elderly or demented, the question of a living will, durable power of attorney, and the patient’s wishes if a terminal illness were to occur and they are not able to make such decisionsons for themselves. Good physicians have always had such discussions with their patients even when there was no reimbursement for it. There is, however, some uncertainty about the power of the 15 member, nonelected, Board of Overseerers and the decisions that this group could make with regard to rationing of care, particularly to elderly and terminally ill patients.
The financial issues are a major concern. Who will we pay for universal access, how will it add to the deficit, who will be financially disadvantaged, and when will reasonable malpractice lawsuit reform be added? Is it a liberal political ploy to redistribute wealth? The reform act does not satisfactorily deal with the issue of the source of the money to provide healthcare to 50 milion new patients. There’s been a lot of movement of dollars from one bucket to the other at the federal level as well as at the state level. It seems that the more important issue is one of controlling the escalating cost of healthcare in the future. In 2010, 17% of our gross national product was used to pay for healthcare. This far exceeds the amount of money spent on healthcare in other developed countries, many of whom have better healthcare outcomes than we do in the United States. That begs the question as to whether more spending means better healthcare and better healthcare value. Perhaps we should be focusing on the payment system for medical services and how to reduce the escalating payment requirement rather than focusing on putting new dollars into the healthcare pot. Currently, each time a hospital or a physician or a pharmacy provides a service, the health insurance companies, Medicare, Medicaid, or individual patients pay a certain amount of dollars for that service. This type of reimbursement incents overutilization, added testing, added services, and sometimes these added services do not improve the health outcome of the patient. There are mechanisms on the horizon that will alter the reimbursement process. This would include capitated reimbursement to integrated delivery systems for the care of a given population of patients for a given period of time. This may or may not involve an insurance company as the internmediary. Most integrated delivery systems will evolve into an “Acountable Care Systems” (ACS) and will be reimbursed based on the quality of their service and not the quantity, or said another way “value not volume”. This means that doctors and hospitals will join together both clinically and financially into integrated systems of care connected by an electronic medical record system. The Elctronic record system of the future will be designed primarily for good patient care rather than its current design which focuses on billing and collecting for services. This technology will reduce medical malpractice lawsuits as healthcare decisions are standardized, thus increasing quality. These integrted systems will compete with one another based on cost and quality. In the view of the writer, such systems of care with appropriate reimbursement will improve the qualtiy of care delivery and will stablilize the cost such that ACA can ultimately work for all Americans. The Greater Cincinnati market is ahead of most metropolitan areas with regard to integration and will in the end prevent desired health care reformr from “slip slidin away”.