This post was originally published on Rob Tenery, MD’s blog
When the Affordable Care Act (Obamacare) was first introduced, the public was told that they could keep the doctor of their choice and their premiums would not escalate. Quickly, it became obvious that was not possible. Many doctors failed to become participants and the costs for coverage in 2017 ranged anywhere from 20 to 60 percent higher since the ACA’s inception. Additionally, not every uninsured individual chose to participate. Thus, almost 20 million remained without coverage.
“If you have a law that makes it explicit healthy people pay in and sick people get the money, it wouldn’t have passed,” said the often-called architect of the ACA, MIT Professor Jonathan Gruber. “Lack of transparency is a huge political advantage, and basically call it the stupidity of the American voter or whatever, but basically that was really critical to getting the thing to pass.”
There are several social and economic realities that doomed the ACA from the start:
1.) The patient was taken out of the decision-making process, with no incentive or effective disincentive for financial responsibility.
2.) There was a failure to develop an affordable basic benefits package of health care services that would be available to all, through expansion of the state-run Medicaid programs, medical savings accounts, vouchers, and allowing the private health insurance carriers to compete for patients across state lines.
3.) Similar to automobile liability insurance, the ACA is mandated personal coverage with punitive penalties that weren’t persuasive enough to force compliance under an individual mandate regulation.
To make the ACA work, the more healthy individuals would have to sign up or face a fine if they didn’t. The fine would be levied under the Individual Mandate (IM) stipulation dictated under the ACA. The problem with the IM was that the penalty was relatively minimal and only recoverable by a withholding part of any tax rebate for which they might be eligible.
When Justice Roberts joined the other liberal justices on the Supreme Court in ruling the ACA constitutional, he ruled on the basis that the ACA was not a mandate, but a tax, which the Congress could lawfully create. The other part of his ruling was that Congress could not lawfully issue mandates.
The Republicans were not able to pass their version to repeal and replace the ACA. When President Trump issued an Executive Order to do away with the very unpopular IM, a George W. Bush appointee Federal District Judge Reed O'Connor in Ft. Worth ruled that without the IM, the ACA was no longer constitutional, since that was the only tax in the original ACA.
This ruling, once again, brings up options: Reinstate the IM, but make it more punitive, so as to force more of the uncovered into obtaining coverage. Another, create a mandatory catastrophic coverage plan that would be a variant of the IM. A third, 'Medicare for All', as proposed by Bernie Sanders and reportedly to be introduced as a bill in the US House of Representatives. Unfortunately, this option will lead to a single payer system and would cost added trillions of dollars in additional costs.
To say that Medicare works well, denies the fact that in many patients are no longer able to go to the doctor of their choice. In fact, even finding a doctor is difficult. Additionally, many doctors no longer participate in the Medicare program.
This program is only one step away from a single payer health care system, which was once referred to as socialized medicine. Under this system, the government, controlled by federal dictates and paid for by taxes or raising the federal debt, provides all medical and hospital services, and determines all reimbursement levels.
Under a single payer, all people are guaranteed health care services, but that care is dependent on the availability of the services and the providers who would render that care. One just has to look at the Canadian system where examinations, tests and procedures are often put off for weeks to months, while patients’ morbidities drag on.
The complexities of reimbursement may be reduced under a single payer system. But added billing and coding time requirements, often take doctors away from direct patient care. Although escalation of overall costs of care is easier to control, the reimbursement levels usually decrease to the doctors and institutions, resulting in potential compromise of the time that is devoted to that care.
The questions for any new plan or revision of what is left are two: What to do with pre-existing conditions as pointed out in the recent New York Times article and how to bring money back into health care to offset the losses from including pre-existing conditions. The latter is most easily resolved by going back to the healthy individuals who are not eligible for a government program and have decided to go ‘bare’. Reintroducing the Individual Mandate again, but make it much more punitive than before if they don’t choose that option. Or create a catastrophic coverage plan that is mandated to protect the patients that have unexpected, catastrophic medical or surgical events, the public from bearing those added costs through taxes or accepting these losses by the health care providers and hospital systems.
Community rating alone makes others’ premiums too high. Continuing high-risk pools, as we have, is another option. The current Democratic answer seems to be 'Medicare for All', which is much more expensive in the long run. Then there is the ’single payer’ option. This should be the LAST choice, because then the government makes all the choices, which is close to what we already have now.
Is moving into a single payer the answer? Just because the coverage questions are addressed, the skyrocketing costs and access for these added patients are not. Simply put, this country’s delivery system is second to none. Why would we want to give that up?
Robert Tenery Jr., MD, is an ophthalmologist in Dallas. He is a TMA past president and Distinguished Service Award winner.