I confess I was a strong proponent of the Affordable Care Act. My reasoning was subtler than the hallowed pantheons of its staunch supporters and the apocalyptic predictions of its detractors. Forty years after graduating medical school I concluded, after many stutter steps, the American healthcare delivery system was economically unsustainable and the citizenry was neither living longer, nor better, despite medical expenditures that dwarf any other developed nation. My career also allowed me to personally interact with cardiac surgeons from all continents and see that their clinical results and research efforts were laudatory by any standards.
It pained me to see the counterproductive hurling of inaccurate, invective, and promulgating fear and misinformation based on political ideology with no regard for attempting to confront the problems of the status quo. Obamacare is not, in fact, a revolutionary change in healthcare delivery; it is health insurance reform with a mandate for universal coverage that on the fringes promotes new reimbursement models, but mostly preserves, at present, a fee-for-service system.
What was potentially the most beneficial aspect was that a political third rail had been breached-- the medical-industrial complex was confronted and legislation was passed and judicially approved. Obviously the law was tainted, imperfect and inexpertly introduced. I was naive and felt it was a start; the first step had been taken and now we could start the process of actually improving healthcare delivery to everyone because it was now a premise that all were entitled to.
As Cicero so aptly lamented during his first Catalonian Oration, “O Tempora, O Mores;” what difficult times, how unethical the political climate. I still do not get my facts from viewing the Republican Presidential Debates, nor sound bites from right-wing talk radio. To the chagrin of my GOP friends, I subscribe to and read daily the New York Times. Two recent articles from the fountain of liberal mantras suggest that the Affordable Care Act is not working and this attempt at reform maybe significantly flawed. Our present administration may be more interested in painting rosy pictures than facing uncomfortable economic reality.
On January 6, 2016, the front page headline was “Medical Debt Often Crushing Even for the Insured”. Despite coverage by Obamacare, 20% of people too young for Medicare eligibility had having trouble paying their medical bills last year. They are still vulnerable because of the rising cost of coverage and covering 15,000,000 more Americans has accelerated the burden of copays and deductibles. That take-home message was reiterated and anecdoted over the rest of the 1/2-page article and a week later the headline was about costs climbing as more people enroll past the health act set deadline.
The administration is focused on the metric of increasing the number of enrollees; therefore, it has allowed large numbers of people to sign up past the deadline by creating “special categories” or “new onset circumstances” as a humanitarian response. However, once the medical emergency is over, these folks drop out after a temporary subsidization. These temporary riders, so to speak, are, according to insurers, harming and destabilizing the exchange markets. The Feds set up these post-deadline circumstances for eligibility, but provided no support, nor guidance, to verify that this cohort actually qualified.
Behind the ideological sniping, there is accumulating more and more evidence that the economic premise of universal coverage, i.e. large pools of insured made up of multitudes of the young and healthy to offset the older and sicker, and efforts to eliminate waste and fraud, may not be attainable as this bill is implemented. Where is the political will and expertise to be found to fix it?
By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton