Blog Commentary
In the July 2011 issue, The American Journal of Medicine published Should the Affordable Care Act of 2010 Be Repealed? by James E. Dalen, MD, MPH, AJM associate editor and Dean Emeritus of the University of Arizona College of Medicine, in the Journal and on this blog. AJM has received several e-mails and a few phone calls (pro and con) related to this article. Here is one commentary that takes issue with Dalen’s commentary supporting the Affordable Care Act.
Should the Affordable Care Act of 2010 Be Repealed? A Fuller Picture
Dr. Dalen’s commentary in the July 2011(1) issue simply repeats the longstanding arguments supporting the Patient Protection and Affordable Care Act (PPACA), without shedding any new light on it since its passage in March of 2010. I take issue with his one-sided view of the law and its subsequent impact, and supply responses to contentions while describing some underpinnings of the opposition.
The Politics of Passage
Table 1 (below) delineates the votes of the health care bill, beginning with the initial version crafted from three House committees and passed on November 7, 2009.(2) Then, on December 24, 2009, the Senate passed its version on a party-line vote.(3) Because the Senate bill differed from that of the House, it needed to return there for ultimate approval. After much politicking, and the inability to alter anything, it was ultimately brought to the floor late Sunday evening on March 21, 2010, and narrowly saved the President from scathing defeat.(4) Table 1 also shows Medicare’s passage for comparison.(5)
After claiming that Americans would watch the health care debate occur on C-SPAN, in the most transparent government, President Obama failed to deliver on either. Most Americans did not envision back-room deals tantamount to bribery to secure votes, or accounting gimmicks to seemingly keep the price tag below the $1 trillion ceiling. They did not expect to hear Nancy Pelosi (D-CA) tell them that they needed to pass it to find out what was in it 6 or have no time to actually digest the monstrosity before rendering a well-read opinion. And they certainly did not expect a vote on an issue that consumes nearly 20% of our GDP to occur in such a clearly partisan fashion on Christmas Eve or late one Sunday night. The ends do not justify the means.
The World’s Best Health Care System
The commentary resurrects the issue of health outcomes by solely touting those statistics that satisfy the author’s premise. Some noteworthy others – according to the WHO’s 2010 World Health Statistics, the USA ranks as the 3rd lowest (best) country in those under age 5 who are underweight. To immunization rates, the Americas have the lowest incidence of measles and mumps in the world, a significantly higher percentage of neonates protected at birth against neonatal tetanus compared to our European colleagues, and the highest rates of hepatitis B vaccination among 1-year olds in the world. Further, according to the Organization for Economic Co-operation and Development (OECD) Health Care Quality Indicators Project, the US has the highest five-year relative survival rates in the world for breast cancer, and the third highest rate for colorectal cancer.(7)
The Americas have 23 physicians and 55 nursing and midwifery personnel per 10,000 population compared to 33 and 68, respectively, for the European region. Perhaps some statistics touted by others as better are simply a result of a larger healthcare workforce, thereby increasing access to care.(8)
The Uninsured
Dr. Dalen writes “22% of our citizens were uninsured or had inadequate health insurance in 2007,” and then lists “50+ million uninsured Americans” in table 3. Not all uninsured people in this country are in-fact American, or even legal residents. According to 2005 census data, 45.8 million people were uninsured. While non-citizens represented 7% of the population, they accounted for 21% of this group, or more than 9.5M individuals. Further, 20% (9.16M) were uninsured for less than 3 months. And, 28% (12.8M) were above 300% of the federal poverty line (FPL). [Federal Poverty Level chart] At that level, single coverage premiums would account for 2% of annual income and premiums for a family of four would amount to 4.7%. This leaves a legitimate number of 14.2M US citizens making less than 300% of the FPL who were uninsured for more than 3 months – 5% of all US inhabitants.(9)
In the description of table 3, it states that “all uninsured Americans will certainly benefit by receiving coverage.” Yet under the section on ACA and the uninsured, the figure is “95% of legal US residents…” Based on a population of 300 million, this 5% disparity accounts for some 15 million people and does not satisfy the claim of insuring everyone, as originally billed in the run-up to the bill’s final passage.
Does Coverage Equal Access?
Dr. Dalen claims that by expanding coverage to the uninsured, “the US would finally…[ensure] that nearly all of its citizens have access to health care.” He makes the colossal mistake of equating coverage to access. The nation’s current physician shortage already results in delays to access. Add to this some 30 million newly-insured patients, and the delay simply becomes longer. Coverage does not equal access. Just look at Massachusetts.(10, 11)
The Devil is in the Details
The paper purports that nearly everyone stands to benefit from the government’s attempt at healthcare overhaul. It conveniently neglects to highlight what needs to be replaced, or simply repealed. (1) The 1099 tax reporting requirement under PPACA for all vendors receiving more the $600 was repealed earlier this year. (2) CMS recently disseminated its proposed rule regarding accountable care organizations (ACOs). When most of the institutions it touted as successful examples publicly stated their resistance, CMS promulgated new rules to entice participation. Still far from making any significant impact on the nation’s healthcare expenditures, ACOs will not likely meet their January 1, 2012 implementation target date because of inherent design flaws. (3) The independent payment advisory board (IPAB) is being attacked at present with bills in both houses of Congress calling for repeal. In bipartisan fashion, it appears likely that this will be eliminated. (4) Above all else is the individual mandate, currently under legal attack. The Supreme Court will rule on its constitutionality.
There appear to be aspects of the law that may benefit patients, namely insurance industry reforms. But these come at a cost, one that will certainly be borne by those insured in the nature of higher premiums.
While obvious is the massive expansion of entitlement programs (read government takeover), glaringly missing from PPACA is meaningful tort reform and a fix to the sustainable growth rate (SGR). Physicians who care for Medicare beneficiaries continue to be shackled to this failed reimbursement calculation. Faced with a nearly 30% cut in reimbursement rates on January 1, 2012, some physicians have stopped accepting Medicare patients, while others have opted to retire early or leave medicine altogether because they cannot run their business under the constant threat of disastrous cuts. Combine the increased number of newly-insured patients clamoring for access, the growth of the baby boomer population, and a decreasing supply of physicians, and a perfect storm is brewing leading to an incredible gap between supply and demand.
The PPACA should be repealed and replaced with a real attempt at addressing our nation’s issues, without exceptions for unions, bribes for lawmakers, or back-room deals in the middle of the night in a strictly partisan fashion. The Democrats had a golden opportunity to put everything on the table, but squandered it to save face for the President. This came at a price, one that was only partially paid in November of 2010, but whose debt will be fulfilled next November.
— Joshua D. Lenchus, DO, RPh
University of Miami Miller School of Medicine
References
1. Dalen JE. Should the affordable care act of 2010 be repealed? Am J Med. 2011;124(7):575-577.
2. H.R.3962 – Affordable Health Care for America Act. Available at: http://www.opencongress.org/bill/111-h3962/show. Accessed June 21, 2011.
3. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396#position. Accessed June 21, 2011.
4. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://clerk.house.gov/evs/2010/roll165.xml. Accessed June 21, 2011.
5. H.R.6675 – The Social Security Amendments of 1965. Available at: http://www.ssa.gov/history/tally65.html. Accessed June 21, 2011.
6. Roff P. Pelosi: Pass Health Reform So You Can Find Out What’s In It. US News and World Report, March 9, 2010. Available at: http://www.usnews.com/opinion/blogs/peter-roff/2010/03/09/pelosi-pass-health-reform-so-you-can-find-out-whats-in-it. Accessed June 23, 2011.
7. Organisation for Economic Co-operation and Development (OECD). Health care quality indicators. Available at: http://www.oecd.org/document/34/0,3746,en_2649_37407_37088930_1_1_1_37407,00.html. Accessed June 22, 2011.
8. World Health Organization (WHO). World health statistics 2010. Available at: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf. Accessed June 21, 2011.
9. U.S. Department of Health and Human Services. Overview of the uninsured in the United States: An analysis of the 2007 current population survey. Available at: http://aspe.hhs.gov/health/reports/07/uninsured/report.pdf. Accessed June 22, 2011.
10. Access to Massachusetts health care still tight. GazetteNet.com, Daily Hampshire Gazette. 2010 Nov 16. Available at: http://www.gazettenet.com/2010/11/16/report-health-access-still-tight. Accessed June 22, 2011.
11. Massachusetts Medical Society. 2011 Patient access to health care study: A survey of Massachusetts physicians’ offices. Available at: http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&CONTENTID=54336&TEMPLATE=/CM/ContentDisplay.cfm. Accessed June 22, 2011.
