Affordable Care Act puts U.S. at health-care crossroads
By Melissa Grau
Feeling his chest constrict, heart race and eyes widen, 26-year-old Jacob tells his long-time girlfriend, “I think we’re ready for that next step. I think we should enter into a domestic partnership.”
“Really?” asks Rachel, a UW-Madison graduate student.
“Yes,” replies Jacob, an out-of-work engineer. “I need your health insurance.”
There’s no romancing America’s health care crisis today.
No longer a problem politicians can sweet talk and kiss goodbye for another four years, America’s health care system is broken and economically unsustainable. It’s time to commit.
A vast majority of physicians agree immediate reform is necessary, and the continued implementation of President Barack Obama’s Affordable Care Act (ACA), though not perfect, is critical. Many of those physicians say repeal, which is the goal of Republican presidential candidate Mitt Romney, is not an option.
Andrew O’Brien, a 25-year-old UW-Madison graduate, says that even though his friend Jacob has his master’s degree in environmental engineering, the current economic recession renders him unemployed.
“He’s here in Wisconsin while his girlfriend is going through grad school, and he’s suffering from anxiety attacks at age 26,” said O’Brien, referencing the age young adults can no longer stay on their parents’ health insurance policies.
“He didn’t have health care coverage because he’s not currently fully employed. He’s doing a lot of odd time jobs, helping out babysitting, coaching at a local high school. In order for him to get the care he needed, he would either have had his girlfriend lie and claim she was having anxiety, or they had to enter into some sort of domestic partnership so that he could get the care that he needs.”
Most Americans understand how cost, quality and access to health care affect their personal lives and personal finances. About 60% of personal bankruptcy occurs because of health care issues, making health care the biggest financial strain on individuals.
Political speeches lamenting sad stories about Americans without health care are enticing and easy to grasp for the general public. However, health care is also the largest economic issue for the nation’s pocketbook.
Dr. Richard Roberts, president of the World Organization of Family Doctors (WONCA), said, “Healthcare is the single largest sector in the economy, with 18% of our GDP supporting it.”
That means the United States spends $2.8 trillion annually on health care. Experts estimate that 25% -- or $700 billion -- of that is spent on administrative waste caused by a broken insurance system.
Dr. Richard Rieselbach, chair of the Wisconsin Health and Public Policy Committee of the American College of Physicians, said:
“We spend twice as much on health care in this country as many of the western European countries who have results that are every bit as good as ours, if not better, in terms of morbidity and mortality.”
For example, the 2000 World Health Report estimated that Switzerland spent 11% of its GDP on health care and ranked 20th in overall health system performances; the US was 37th.
Roberts, who has analyzed health care systems in more than 50 countries, said, “What people find so frustrating, both in the financing and the delivery of health care in our country, is that it feels chaotic…When you go to systems where it’s much better organized and have much simpler funding mechanisms, you don’t see that.
“From a finance point of view, [the ACA] boosts the system toward a more equitable and rational approach.”
Dr. Sarah Van Orman, executive director of the UW-Madison’s University Health Services (UHS), called the nation's health care system "just a wreck."
"There’s no way around it, in terms of the quality of what we get for what we pay. The equation doesn’t add up," Van Orman added. "I view health care reform as a national economic issue, and I don’t think that’s talked about enough.”
A century in the making, American's health care economic crisis is enormously complex and multifaceted. President Theodore Roosevelt was the first of 10 presidents to recommend some form of universal health care reform.
In 2009, the World Health Assembly adopted a resolution recommending that all member states “accelerate action towards universal access to care,” citing the equitable and financial benefits of such systems.
ACA passed one year later in 2010, and was upheld by the U.S. Supreme Court two years later. It was a major attempt to balance political realities and effective policy.
The American Medical Association, the National Physicians Alliance, the American Academy of Pediatrics, and the Association of American Medical Colleges have touted their support for the policy, while conceding that it will have to be tweaked in the future.
“People complain that the ACA is unreadable and large, and it is about 1,000 pages of fine print," said Rieselbach. "But then what most people in this country don’t realize is that health care in this country is extremely complex and complicated.
"The only way you can deal with this complex and complicated animal is with a piece of legislation like the ACA," he said, adding:
"The interesting thing is that, when you look at polls, 50% of the country is opposed to the ACA. But when you look at individual components of the ACA, the enthusiasm about many of the individual components is rampant.... It doesn’t make sense.”
Roberts, who has worked with conservative and liberal politicians, said, “ACA needs to move forward because it takes us a step closer. It’s not Nirvana, it’s not the panacea. It won’t fix everything for us, but it gets a step closer towards universal coverage, towards rearranging the priorities and deliveries of the health care system, and towards preventive and primary care.”
Health care is one clearly contested topic in Tuesday's presidential election, with Obama supporting the continued implementation of the ACA and Romney promising to immediately repeal it - a move that worries some health-care professionals, who say repeal would be costly and leave no clear alternative.
The non-partisan Congressional Budget Office revised their accounting in July 2012 to estimate that repealing ACA would cost a net of $109 billion in the next decade.
Many aspects of the ACA have already been implemented, and insurance companies and medical centers already made adjustments in anticipation of the new federal requirements.
For these reasons, Van Orman predicts the insurance lobby will fight against repeal.
“If Romney repeals the ACA, we will have chaos in this country for a period of several months in terms of our health care system,” said Rieselbach.
That fear is attributed to the fact that Romney has not proposed a specific option to ACA. Republican leaders repeatedly say the answer is giving health-care consumer more choice.
But, Roberts said, “In my experience, people don’t want choice. They just want a good plan. The connection between choice and empowerment is an illusion.”
Essentially, many health care professionals equate Romney’s promises to putting a band-aid over a wound that needs stitches.
Romney has promised to keep popular provisions of the ACA, such as young adults staying on their parents’ insurance until they are 26 and not allowing insurance companies to discriminate against someone with a pre-existing condition.
Repealing ACA and reinstating provisions like those would take time -- and a Congress that agrees with a President Romney.
“I think what we’re seeing is some rather illogical opposition based on political rhetoric and propaganda and that type of thing,” said Rieselbach. “And that is tragic. This legislation is classic legislation that is probably even more important or equally important as with Medicare.”
Most physicians agree three factors must be addressed by any health care reform to truly fix the system: cost, access and quality.
While the ACA’s individual insurance mandate is most often debated, it is the most essential component of the legislation to control costs.
“The individual mandate is the heart of it," Van Orman said. "The only way that you’re going to make [health care] affordable to everyone is if everyone pays in something. I know that was certainly politically problematic. But it just doesn’t work otherwise.”
The current system is a revolving door of cost increases:
The uninsured wait until their health becomes critical to seek medical attention. The emergency room, bound by law to not refuse care to anyone, becomes the only access point and provides the most expensive care. Because hospitals must pay for these emergency room costs somehow, they are forced to charge insurance companies more money. Insurance companies absorb the increase by raising premiums for those already insured, driving up health insurance costs. More people cannot afford health insurance.
Dr. Steve Pearson, governor of the Wisconsin Chapter of the American College of Physicians, described the options this way:
“We’ve got to somehow take care of those uninsured, or they’re going to go broke. And then that forces all of us to go broke, because someone is going to have to pay for their health care when they show up in the emergency room with no insurance. Somebody pays. That’s kind of a forgotten piece.”
Opponents of the individual mandate most often cite the right to make personal choices.
Said Roberts: “I’m all for choice. What the people…are saying, ‘Well America should be able to choose.’ Yeah, but if I’m poor, I have no choice.
“And even if I’m well off, I’m not willing to spend hours and hours and hours trying to understand my insurance coverage and negotiating this service and that service…We have this extraordinarily complicated system.”
One number that documents how complex the system is comes from Roberts:
“We have over 3,000 health insurance companies out there, and even that’s not sufficiently descriptive of how complex it is. One company can have upwards of 15,000 diverse contracts...We spend up to a quarter of all our health care spending on administrative stuff. It’s shuffling paper.”
Rieselbach and Roberts have some differences of opinion on solutions that are part of the ACA. Rieselbach stresses the importance community health centers, a kind of federally funded primary care outpatient clinic, while Roberts underlines the need for an increase in primary care doctors.
Community health centers are most often located in areas with primary care shortages, and are hailed for their affordability. Medical bills on are assessed on a sliding pay scale, so patients pay only what they can realistically afford. These centers dramatically decrease the ER revolving door by increasing access and decreasing overall cost.
“An ounce of prevention is worth a pound of cure,” Roberts said.
Despite where people get their health care, studies show the importance of primary care doctors for people of all socio-economic statuses. Rieselbach, who has studied health-care delivery systems in Brazil and the United Kingdom, insists that the health of a country is directly correlated with the number of primary care doctors.
For example, increasing the number of primary care doctors in the United States by one doctor per 10,000 people decreases the preventable death rate by 5%. If the number of family doctors specifically is increased by the same amount, the death rate decreases by 9%. The opposite is true of specialty doctors; increasing the number of specialists increases the death rate by 2%.
“We have a serious shortage of primary care physicians in this country,” said Rieselbach.
Roberts said, “What we’ve learned all around the world is universal coverage is necessary, and you can’t get universal coverage without everybody having a primary care doctor. It gets way too expensive when people are bouncing around from specialist to specialist, and their outcomes actually get worse.”
One underrated health care reform issue, despite who wins the election, is the expansion of Medicaid, which provides health care to the poor, elderly and disabled.
The Supreme Court did not uphold this section of the ACA, ruling that states can decide whether to expand their Medicaid programs. Basically, it would expand coverage to individuals from age 19 to 65 with incomes up to 138% of the poverty level.
“If Wisconsin accepts expansion of Medicaid, the federal government will pay for all the cost of Medicaid for three years -- from 2014-2017,” said Rieselbach, adding:
“And then after that, they will pay 90% of the cost indefinitely. There is really no fiscal sense for states to be opposed to be accepting the expansion of Medicaid under the ACA, except to make a political statement.”
Recently, Wisconsin’s version of Medicaid, BadgerCare, is reported to be in financial trouble, with at least three of the four managed care organizations threatening to drop out. With inadequate rates to cover rising costs, the Medicaid program, as well as the health care system in general, is in a dire situation.
It’s a bad romance. Put a ring on it.
Affordable Care Act: At A Glance