Heartfelt with Dr Melissa Walton-ShirleyView all posts »
The Affordable Care Act--Should I try to hate it?Jun 30, 2012 18:23 EDT
I've called a lot of people over the past few days. I've read newspaper articles, listened to Monday-morning quarterbacks, back-seat drivers, politicians, physicians, patients, office managers, and presidential candidates. When asked to expound on the Supreme Court's ruling on the Affordable Care Act (ACA), I replied that the prevailing opinion reminded me of what girls in popular high school cliques say when the new kid walks by. "She's so nice," says Susie. "No, she isn't," says Alexis, the alpha female. "We hate her, remember?" "Oh yeah, right . . . we forgot. We hate her," replies Susie, as the rest of the girls shake their heads in agreement, with ponytails bobbing. They hate her without knowing anything about her, which is how the average American has arrived at their opinion of the current legislation. A recent ABC news/Washington Post poll indicated that only 34% of those surveyed support it. I'd be willing to bet of those polled, less than 1% could even explain it. So instead of just following a popular Republican stance on the issue (to clarify—I'm a Clinton Democrat, although I've voted Republican more often), I decided to spend the past few days trying to figure out why I should hate the ACA before I actually do. The following is a synopsis of my stepwise process in search of my opinion.
What's not to love about ending denials due to a preexisting condition? Ending lifetime caps? Covering my kids on my plan until they are age 26? Access to screening, prevention, and well care? "Even" rates for insurance coverage despite my medical history? Guaranteed coverage for the duration of my illness and the reining in of the insurance companies? My niece has cystic fibrosis, and although she is healthier than most other CF kids I've seen, an average CF patient can tap out their $1 million lifetime expenditure allotment at a very young age. What about doctor's offices? Our office has a modest share of the local noninsured. We never deny care and simply place the noninsured on payment plans they can afford. It sure would be nice to slide all of those folks onto a Medicaid program so we can be paid for our office visits, echocardiogram, and stress tests. I decided after I examined those pros that I very much "like" the ACA.
But Dr Shawn Jones, an ENT surgeon and president of the Kentucky Medical Association, isn't a proponent. He understands the extent to which state Medicaid programs are already overextended. "When we expanded our Medicaid coverage by adding three other Medicaid programs, we modeled this after other state programs, but what we later realized is that those programs had made money from delays in reimbursement and denial of care. Some of our state's pediatricians have not been paid since November 2011." He is concerned that "businesses will rather pay the penalty for not insuring their employees because it will be cheaper to dump them into the public pool." He then said that "everyone will have a [medical] card, but there will be no one willing to provide care" under those programs due to the inability of our infrastructure to support that wonderful notion of national coverage. Prior to the Supreme Court's ruling, Dr J Scott Littleton Jr of the Physicians Practice blog, said, "This low reimbursement schedule already forces private practices like mine to be very mindful of the percentage of Medicaid patients enrolled, so that the overall percentage is not so large that it affects the vitality of our practice. I am concerned that this new provision will make it more difficult now for Medicaid patients to receive the medical care that they need."
Then there are concerns about tying reimbursement fees to patient outcomes, compliance, etc. Most of us already scrutinize our own outcomes every time a patient comes back through the door for their follow-up visit. I already discuss dietary compliance, exercise, and smoking cessation ad nauseam. I maybe under the false impression that I'm not often surprised with a poor outcome because of it. Perhaps I'm in denial, but I think this sort of thing will take care of itself. I will not change my practices with regard to difficult or noncompliant patients. I only fire patients if they are belligerent or threatening. At the end of the day, hateful sick people need doctors, too. I think these concerns with regard to how outliers such as HbA1C's of 10 will affect reimbursement will have a way of working themselves out. Surely they will be balanced by the majority of patients who will try to do the right thing for themselves. Perhaps the greatest change to my practice will be the need to document more often the extent of noncompliance with dietary measures, medications, and weight loss. It will become necessary to "toot our own horns" on our daily office visit notes so we get good marks for good measures.
The one thing I'm certain I loathe about this entire Affordable Care Act business is all the political grandstanding. I would like to ask the Tea Partying libertarians, "Why do you sanctimoniously protest the very notion of an insurance mandate, since car insurance has been mandated for decades?" A friend of our family and lawyer John Rogers of Glasgow, KY explained that "the state mandate to require folks to have car insurance is based on the police power of the state. This state power comes from the 10th Amendment to the Constitution, which reserves to the states the power to regulate behavior and enforce order within their boundaries. The Obama administration, on the other hand, argued that the requirement to have health insurance or pay a penalty or tax is based on the Constitution's Commerce clause. The administration also alternatively argued that the requirement to have health insurance was permissible because of the federal governments' ability to levy a tax," he added. "So, in summation, the state government's police power is legally different from the federal government's power to levy taxes." I appreciated this patient explanation to my remedial question, one I'm certain has caused significant wincing in embarrassment on behalf of my friends in politics and law. I still insist that to act as if we as Americans have never heard of a mandate for the purchase of insurance, albeit previously for our automobiles, is a bit much.
And what about the Ted Kennedy RIP references? I agree there has been no one in the history of human kind, living or dead, who would have been more pleased with the upholding of this legislation than Sen Kennedy. However to suggest that heaven is a political realm where great debates occur on the topic of healthcare or to suggest that God himself would have to have been convinced by Sen Kennedy that poor sick people need care was really not my idea of what heaven or for that matter what God really is. Then there was the Mitt Romney statement generated from a perch high above the Capitol, in which he said, "Obamacare does not violate the constitution," (cue the "Star Spangled Banner") but then spewed sour grapes about a program that is strikingly similar to the one passed under his governorship in Massachusetts, one he's now made an orphan for political gain. President Obama, obviously proud of his accomplishment, sweated bullets all the way to a victory. The president, even as a law professor, required it be explained to him that he had triumphed because major news outlets wrongly thought (heck, almost everyone wrongly thought) that the rambling gazillion-page dissent had cast the Affordable Care Act into outer darkness, where there is weeping and gnashing of teeth. I did gain a new respect for the letter of the law and Lady Liberty when the appropriately and admirably "blind" Justice Roberts crossed the conservative line to reach out to the poor and the helpless, despite his very disappointed Republican parents who stood aghast in the political realm that bore him.
The need for insurance reform in our country is undeniable, but there is no denying that in our current state we cannot afford it. Of our population, 16%, approximately 50 million Americans, until this week were hopelessly uninsured. The $2.6-trillion bill for our nation's healthcare, accounting for roughly 18% of our country's economy, was just never going to be enough, no matter how it was sliced, and we have no more to slice to give away. Our stubborn refusal to engage in tort reform, an obvious omission in the current legislation, continues to run up the tab for testing and medications. Insurance companies have become fat as their CEOs deny coverage for necessary testing from their yachts, making our medical secretaries and schedulers sweat, beg, and plead for approval. In addition, Americans are living longer, stretching our resources enormously. "Care" is a guaranteed need, a direct consequence of the longer lifetime we insist upon. Adding to our bill is a goodly portion of our tax dollars that must support the portion of our society who are fat and lazy, abusers of illicit drugs and alcohol, risk takers, careless drivers, etc. Most of those in this sector of society insist the government owes them healthcare, affordable or not, regardless of how many poor choices they make. Never in our history have we provided more support for the ne'er-do-wells of our nation, but no longer is it just those who are at risk. The population toward whom most feel sympathetic, those who cannot help themselves and working middle-class America, step-up-to-bat, honest folks, are now the ones who are just beginning to endure the suffering. Maybe a welcome relief is in sight for them.
The ACA is a bookie's dream. There isn't one single person, including the author of the ACA, who knows for certain how it will affect any sector of the US population. Whether or not anyone can afford it is a crapshoot, but there is one certainty. The ACA must herd us toward the ever-elusive doorway of personal responsibility if it's ever going to work, and we'd better find that door, because 2014 is coming! The year 2014 is when all US citizens must be covered by private or government insurance. I am afraid. I'm very afraid, because I don't think we are making adequate preparation for what's coming. Governors must get busy passing smoke free legislation so we can afford the burden of 2014. Decreasing cancer, heart attack, stroke, and emphysema expenditures are all that will save states like Kentucky. Hospitals had been get busy implementing programs that promote compliance, decrease 30-day readmit rates, and improve discharge planning. Patients better starting eating the Mediterranean diet, exercising, and avoiding sodium, so that stroke rates, heart attack rates, and the incidence of diabetes plummet. Communities should help each other by promoting legislation that allows for easy sharing of unused medications by making pharmaceutical repositories not only legal, but desirable. Small towns should find ways to get blood-pressure cuffs into places where their citizens congregate weekly to affect heart-failure and stroke rates. Small clubs in conjunction with their local healthcare providers should offer more screening programs. Emergency departments should develop programs that decrease unnecessary office visits by allowing competent nurses to screen calls, make appointments, and facilitate communication between covering physicians and office physicians who will see the patient next day. Elementary schools and high schools should design programs that teach children how to eat, how to exercise, and how to recognize disease states. The cost to enter and complete med school had better be subsidized, or doctors will become extinct. The list of opportunities could go on for much more than the 187 pages of dissent written regarding the constitutionality of the ACA. A broad plan of wellness planning would have been a far better use of paper.
Ultimately, our success will depend upon whether we get busy taking care of ourselves and each other. If we had already done that, we wouldn't have needed the ACA to begin with. Being personally and socially responsible is the only philosophy that can make healthcare reform affordable for everyone. When it comes down to it, why should anyone hate that?