The Affordable Care Act--Should I try to hate it?

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 HbA_1C'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?

See also:

Supreme ambivalence . . . with a sliver of optimism

Your comments

	The Affordable Care Act--Should I try to hate it?
	# 1 of 18	July 1, 2012 04:40 (EDT)
	Georgiana	Here, this should help fill the gaps in your knowledge.    http://www.reddit.com/tb/vbkfm?fwcc=1&fwcl=1&fwl
	# 2 of 18	July 1, 2012 10:00 (EDT)
	Melissa	Thanks Georgiana but unfortunately, it's still opinion and conjecture, though heartening that it's being discussed, for the most part with civility and thoughtful dilogue. Melissa
	# 3 of 18	July 3, 2012 08:16 (EDT)
	C M Morris, MPAS, PA-C	Unfortunately, we do NOT take care of those needing even basic care in the US. As a PA in rural Family Medicine/ER for over 32 years, I have seen SO many examples of people losing any savings and security over one devastaing illness-- or occurrence with themselves or family members. I saw an uninsured man with his own yardcare business who presented with an acute MI. Appropriately, I sent him on to the hospital, where he received life-saving surgery. Later, I saw him in our community and he sighed, saying "Thank you. Yes, I am alive, but I will spend the rest of my life paying off hospital bills".  WHY is the US the only industrialized nation that does not provide basic healthcare to its working citizens? Answer that very basic query and we can proceed from there on developing a solution.
	# 4 of 18	July 6, 2012 10:34 (EDT)
	Ken	Once the government is permitted to abrogate personal choice and require a "tax" to sign up for healthcare, then the government can also tell us how to "behave" (diet, exercise, adherence, etc) - a series of choices that should be left to the patient and her/his physician, not an impersonal bureaucratic board of czars who know nothing about the patient, or healthcare.   If we want people to exercise after a diagnosis of diabetes, the VERY FIRST consult should be with a PHYSICAL THERAPIST to determine what activities the patient can and cannot do within the parameters of her/his existing condition.  Then coaching to change and remediate that condition.  If diet and exercise works, then wouldn't we expect that all of Hippocrates' patients would still be alive....?  Thus, we need to protect innovation in healthcare for the sake of our patients, and the people who earn a living creating those innovations.  The current ACA act is toxic to innovation. Under the new ACA, we would still be using rauwolfia alkaloids for hypertension.  Stuffy nose, anyone?
	# 5 of 18	July 6, 2012 11:15 (EDT)
	OhioMD	The worries that Medicaid won't be able to cover the influx of patients may be mitigated by the fact that there will be dedicated revenue stream to help pay for some of them now that the ACA can proceed (the new "tax"). Also, the hope is that there will be fewer patients with HgA1C's in the double digits because they will now be able to afford to see a doctor and their medicines. The need to choose between rent, food, and medicines will be reduced to some degree. Perhaps these "hateful, sick" patients will be less hateful and sick because they will have more reliable access to medical care without having to live under a bridge.
	# 6 of 18	July 6, 2012 11:42 (EDT)
	Alan Gadsby	Wonderfully thoughtful, written piece, thank you.  Alan
	# 7 of 18	July 6, 2012 12:11 (EDT)
	Molly.RN	The ACA is a first start. We need universal healthcare for all. Every citizen should get the same healthcare as congress and the senate gets period. After all they work for us so why should we get less healthcare. We need to join the rest of the civilized world and recognize that healthcare is a right of citizenship. Without health our citizens can not be productive, good tax payers. This is common sense people and also compassionalte. What would the Christian Jesus do? As an atheist, I think caring for all of our people is right and just.
	# 8 of 18	July 6, 2012 02:51 (EDT)
	Daniel	Thankfully, libertarians are a distinct minority among MDs and nurses. The broken, supply-side driven system we "enjoyed" up to this point was the product of libertarian principles applied to an oligopolistic insurance marketplace.
	# 9 of 18	July 6, 2012 03:07 (EDT)
	Al	Since 1966 everyone buys health insurance for age over 65 (Medicare). Why buying health coverage for younger individuals should be unconstitutional? And yes, the government can make you remove your shoes and belt at the airport and probably would make you eat broccoli and okra as well.
	# 10 of 18	July 6, 2012 06:05 (EDT)
	Ream, MD	The ACA or Obamacare was a poorly crafted bill that did not have bi-partisan support. The incomprehensible bill is an ever growing metastasized Trojan horse of taxes and unintended consequences. America being comprised of Libertarians, Democrats, Republicans, Conservatives, and Liberals, would be better served by identifying the problem or problems with our current healthcare system, (Uninsured citizens, healthcare costs, accountability, and access, HCP compensation) and bring everyone together who has a part in it and working out the details in an easy, yet comprehensive manner. That didn't happen.Frivolous litigation wasn't dealt with. Insurance companies still operate in a state controlled silo. Healthcare savings accounts are taxed and demonized yet they put patient's skin in the game and portability would keep insurance rates competitive by being able to shop across state lines. Holding insurance companies to a high standard of customer service would also be an end result because if a policy is portable, the policy provider will work to keep the patient happy. Medicaid and Medicare oriented plans have horrific reimbursement rates if you are actually treating a patient and trying to thwart morbidity or mortality. Those pay rates are scheduled to be cut and get more questionable. To police the new laws in the future, more IRS agents and bureaucracies will be created. Ask yourself, “when has a good or service got better when the government got involved or worse yet, controlled it?"So while the sprinkles on the cupcake are getting the attention like "Children" of up to 26 years old being able to be on the parent's policy, and the removal of pre-existing conditions from new policies, I have looked further down the road and this law is bad and will get worse. I am asking everyone to support the repeal and replacement of this atrocity with a better plan that includes everyone being involved in making it and accepting it.
	# 11 of 18	July 6, 2012 09:05 (EDT)
	Dr RBSingh	Affordable Care Act (ACA) of the United States  appears to be a practical approach to deliver health education on prevention. The ACA plans by major private insurers aim to test innovative payment and service delivery models to reduce expenditure growth and improve quality, including the examination of primary care models through pilot programs. The ACA also authorizes fee increases of 10% over 5 years (2011–2016) for primary care providers (including physicians, nurse practitioners, clinical nurse specialists, and physician assistants) and equalization of Medicaid and Medicare fees for primary care services in 2013 and 2014. This approach is also a capitalist approach via insurers to provide jobs to more people and more money to capitalists, but it is good to provide funds for technological therapies as well as health education on physical activity, cessation of tobacco use, and alcoholism, but does not treat the cause of the lack of health education and provide affordable prudent foods for prevention. It is possible that unless affordable and cost-effective multi-sectoral and health-system interventions are available, socioeconomic determinants of health such as poverty, inequality, unemployment, social instability, unfair trade, and global imbalances will continue to be the root causes of the NCDs. There is a need to collaborate the Ministries of Health with Agriculture and Food for development of policies to produce healthy nutrient rich foods. Health education, sports, yoga, and meditation should be a major agenda in schools by making changes in the curricula. More incentives should be provided to private  as well as government schools for educating the children along these lines in an attempt to prevent risk factors of NCDs from childhood.
	# 12 of 18	July 6, 2012 09:34 (EDT)
	Colenso	Americans eat too much, drink too much, and exercise too little. It's impossible to get Americans to exercise more. Studies show that in the longer-term neither trying to educate nor counsel fat American adults or children works, at least not on the limited one-to-one sessions that can be afforded. The only faint possibility is that Americans can be made to drink and eat less through fiscal measures. Small, lab-based studies suggest that the price elasticity of food in the USA in the field might be about 1%. That is, increase the average price of foodstuffs by 1% and the average US consumption will decrease by about 1%.  Further, a federal Value Added Tax (or Goods and Services Tax) of 20% (I know, I know) levied on all goods and services, including on all food and beverages, would solve almost all the USA's deeply entrenched budgetary problems, force the super rich and the ne'er-do-wells to contribute to a better society, and pay for the best universal health care in the world along with better schools, public-housing and policing. VAT or GST is much easier, cheaper and more efficient to administer than income tax.  The opportunities for evasion or avoidance are less than for income tax.  Most importantly, VAT on all food and drink would reduce the nation's waistlines. The only way to find out the actual effect on consumption is to suck it and see.  Start with a federal VAT of 5% on all goods and services, including on all food and drink, to replace all equivalent state taxes.  Measure the outcomes for the next decade on consumption.  Then take it from there.  Of course, even a federal VAT of 5% ain't going to happen because the one thing that unites almost Americans of all political persuasions in a screaming frenzy is their fear and loathing of a federal VAT or GST.  It attacks the rich!  It attacks the poor!  In fact, it does neither because the poor get back what they pay in improved services such as health care, schooling and housing. The rich get to pay less income tax - legally - and live in a fairer, healthier, safer, better society.  If Americans want the USA to return to being an exceptional country, then American exceptionalism needs to end.  The USA needs to adopt the modern health care systems and fiscal measures of the rest of the civilised world.
	# 13 of 18	July 7, 2012 03:07 (EDT)
	Bruce	Just a couple of points: 1.  The only auto insurance required is that which in effect insures OTHERS from loss from my errors (liability.)  I am not required to insure against my losses. 2.  As much of the ACA that I've read leads me to believe that it is an insurance regulatory bill and has nothing to do with medical care cost.  The notion that someone else (insurance company, government, employer etc.) is responsible for my care does not go away.  The ONLY way that costs will be controlled will be through personal responsibility.  Office visit for a head cold?  I would wager that if the individual had to pony up $50 for that visit they would evaluate the situation a little more closely before making the appointment. 3.  If all medical service providers were required to post the price of their services we would see a drop in overall costs.  I believe a large portion of the population would do a quick cost/benefit analysis when they saw posted prices.  At the very least questions would be asked and that alone would exert downward pressure on costs.
	# 14 of 18	July 8, 2012 05:51 (EDT)
	Melissa	Bruce, Just to use your insurance illustration: So many patients who wait too long to seek medical attention from lack of coverage wind up costing more because they can literally put it off no longer. THey wind up utilizing more resources.   Additionally, because it may well drive the first wave of preventative medicine our country has ever backed, it could be thought of as "collision" insurance because if we take care of ourselves, we will not take away from others who become ill  for other causes.  The smokers, the obese, the capable sedentary,  the wreckless, alcoholics, drug abusers....all cost more Maybe the new era of health care can help shrink that costly sector of our population. Melissa
	# 15 of 18	July 16, 2012 12:28 (EDT)
	Alan Gadsby	You are an incredibly good and thoughtful writer.  Thank you for this work. AG
	# 16 of 18	July 16, 2012 06:08 (EDT)
	Melissa	Thanks for reading Alan! Melissa
	# 17 of 18	July 17, 2012 01:02 (EDT)
	Becky C	I am one of "those" who was deeply shocked and saddened by the Court's decision.  Why did it take 1200+ pages to "reform" healthcare?  Why did "healthcare" need reforming?  This started out as "healthcare INSURANCE reform", but just like HIPAA morphed from providing insurance PORTABILITY to this idea that all medical records, while belonging to the patient, still (just as it did before) requires permission from just about everyone to be able to share the patients info EXCEPT to the government, who has the authority to take all things private now. If you recall, 5 years ago on this very site, we all debated and discussed and came up with an absolutely wonderful healthcare INSURANCE reform list.  I got permission from you all, copied it off, and sent it to the 2 candidates.  Neither one acknowledged it.  We addressed tort reform, preventive health, Medicaid reimbursement, disability requirements, and a host of things there.  We had "bipartisan" agreement on just about all of it!  We did this on our own, with open minds, looking FIRST at what was needed for our patients, THEN how to pay for it. The ACA is nothing more than 1200+ pages of draconian and contradictory regulations, built to make the government even more powerful and intrusive into our personal and professional lives.  It will only create more jobs for government workers (now just WHAT does the IRS need to look at my medical records or see if I have medical insurance???) There was put in place over 6 years ago an auditing arm of CMS called RAC--Recovery Audit Contractors.  They go around the nation looking for over- or under-payments, and the hospital gets fined if either are found.  Then the hospital gets to go through an appeal process (involving Risk Management and of course lawyers--big bucks there) in the hopes they can get back some or all of the fine.  Talk about waste, fraud, and abuse---coming directly from CMS!!!!  Local news reporters come up with "physicians" and staff that regularly commit fraud......and CMS doesn't pay them a dime for their work!  Those reporters find more fraud than the RAC's do!!!!! I am deathly afraid of this entire law---what it is going to do to ALL the subspecialties and general physicians, what it is going to do to our patients, and in the end what it will do to our country.  I truly think we need to resurrect that whole thread from 5 years ago and send it again to both sides of both the representatives and the senate, and to the candidates again.  WE thought of the veggie gardens in the community BEFORE Michelle did!  WE thought of ways to get healthcare education into the patients.  WE didn't ask to be penalized for what we chose to be for all our adult lives, only to be told that WE are the ones who are wasteful and fraudulent. Thanks for letting me do my ranting as always!
	# 18 of 18	August 16, 2012 01:07 (EDT)
	smg	"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" We "sanctimoniously" protest the individual mandate to purchase health insurance and not car insurance because you are only required to purchase car insurance if you drive a car. If a person chooses not to drive a car, not to own a car, he is not forced to purchase insurance. The individual mandate, government forcing a person to buy a product just because he is alive, is unconstitutional. Justice Roberts wrongly saved the mandate by re-defining it as a tax.     You write about the need for personal responsibility, however Obamacare (I refuse to call it the ACA, as it is not affordable) negates personal repsonsibility.  Insurers must take all regardless of health status, insurers cannot drop your coverage, insurers cannot set a cap on benefits. There will be no incentive to live a healthy lifestyle --  why bother. I will receive subsidies to purchase the insurance if I cannot afford it, I can stay on my parents plan even if I am married, I can get free birth control, free abortions, free sterilizations, free pre-natal care, free free free free... Obamacare is all about the heavy hand of bloated government controlling our lives. The sad part is that a large number of people in this country actually want that.

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