ACA: Where are we? And where should we go?

I am finished writing the book, as yet untitled, that I have been working on during my sabbatical, which accounts for the sparse number of blog posts. This is not to say that the book is anywhere near ready to be published; I am sure it will need more revisions.

However, it does mean that I am likely to be posting to the blog more frequently, as I find things that inspire me to write.

Thanks for your patience!
Josh

The Affordable Care Act (ACA) has been law since 2010, and was supposed to have been fully implemented this year in 2014, although as is clear many of its provisions have not yet been. The most important has been the failure of about half our states to implement the expansion of Medicaid, which was the mechanism through which the law intended to cover all those poor (incomes under 133% of the federal poverty level) who are currently ineligible for Medicaid (most of those now receiving it are poor children and their mothers, although the majority of dollars are spent on nursing home care). This is legal as a result of the Supreme Court decision that was important because it made the rest of the law legal; this is, I think, of faint solace to those poor people who live in my state of Kansas and the others who have failed to expand Medicaid despite the fact that the federal government would have paid 100% of the cost for 4 years, then 90%.

The newest court actions that affect ACA are two Court of Appeals decisions which say, basically, opposite things about the subsidies that support the premiums of people making above 133% of poverty but less than allows them to pay the full amount.[1] One court decided that people living in states that ran their own exchanges were eligible for the subsidies, but that those who were in federally-administered exchanges were not. The other appeals court decided that both were. Of course, those states that have federally-administered exchanges are those with governors and legislatures who oppose ACA completely; they include all those who did not expand Medicaid plus many more (about 36 altogether). This suggests some political agenda; the interpretation of Congressional intent rather than parsing the words, has historically been the basis for such court decisions. It also will mean that the cases will go to the Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL (Court of Citizens United and Hobby Lobby), where it will be amazing if a conscious, careful, legal approach supersedes politics. The decision to basically gut the Hobby Lobby decisions one remaining protection only a day after it was announced bodes ill. The Republicans in Congress have decided to sue President Obama for not implementing portions of the ACA, which, as Timothy Egan of the NY Times points out, “…they have tried to repeal more than 50 times.”[2]

What has the Republicans so flustered that they have taken to self-contradictory actions is, in fact, the success of the ACA at achieving many of its goals. These are summarized in another NY Times op-ed, by Paul Krugman, titled “Obamacare fails to fail”.[3] There has been a huge surge in enrollment, and while indeed some people are paying more (largely healthy young people who are low risk for high-cost illness, thus previously had lower premiums), most people (including 74% of Republicans) are happy with their current premiums. In addition to the early wins (preventing insurance companies from not covering those with pre-existing conditions, allowing young people to stay on their parents’ insurance until they are 26), we now add over 6 million people who are newly covered, and can access health care. Despite decisions such as Hobby Lobby, most women will now get contraceptive coverage without a copayment. It is a good thing. This is why opponents (mainly ideological) are trying any trick that they can to limit its effectiveness, including the two biggest addressed above—not expanding Medicare and trying to block subsidies for those on the federal exchanges. That is to say, trying to limit health insurance coverage to our less-affluent citizens.

But ACA, even if it came through all the court decisions unscathed, is not a solution. It doesn’t cover those who are not citizens, even though they live here. It is a gift to insurance companies, who still get to charge high rates and make enormous profits, but now have the federal government paying the premiums. Therefore, it will not really save cost. Don’t get me wrong – I am not advocating that we provide less of the health care people need to save money (although I do advocating not providing “health care” that will not help or even harm people just because someone can make money on it). I am saying that the huge profits guaranteed for insurers, and other components of our system who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes, than do the healthcare systems of other developed countries. The latest edition of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11 overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre performance by spending (2011) $8508 per capita, while the other 10 countries spent from $3182 (New Zealand) to $5669 (Norway).[4]

The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.

But that is unacceptable. We need a health system designed to maximize the health of our people. All our people. And we need it yesterday.

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[1] Goodnough A, Ruling on Health Care Subsidies Puts Coverage at Risk, NY Times 7/23/14, http://www.nytimes.com/2014/07/24/us/politics/court-ruling-on-health-care-subsidies-risks-loss-of-coverage.html

[2] Egan, T, “Ambulance Chaser in the House”, NY Times, 7/26/14, http://www.nytimes.com/2014/07/26/opinion/timothy-egan-Congresss-Next-Big-Idea-Sue-Obama.html

[3][3] Krugman P, “Obamacare fails to fail”, NY Times, 7/13/14. http://www.nytimes.com/2014/07/14/opinion/paul-krugman-obamacare-fails-to-fail.html

[4] Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update, The Commonwealth Fund, June 2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror