What Are the Real Consequences of ObamaCare?

Leonard Zwelling, MD,Question: What Are the Real Consequences of ObamaCare?

Answer: Intended or Unintended, They Are Far Less Than You Have Been Told Except By Jonathan Gruber

The Affordable Care Act (ACA or ObamaCare) is many things. After all, how can a health care reform bill of over 2000 pages in length not include a whole lot of stipulations? It also spawned many additional pages of federal regulations so this bill must really be affecting the American health care system in a big way, right? Not really.

Let’s start with a definition of health care reform.

My favorite is that of American Enterprise Institute resident scholar Norman Ornstein. Dr. Ornstein was on a panel in late 2008 and was asked his definition of health care reform. He said, “Everyone’s definition of health care reform is the same. I pay less!”

This drew a chuckle from the gathered press and politicos, but it was the truth for health care reform is largely about money not medicine. But before I illustrate how the ACA was more a deal than a bill, let me go a little further on the definition of health care reform.

The generally accepted components of health care reform are Access, Cost and Quality. Who can get health care, usually by dint of having insurance and can this be expanded; Who pays for health care and how much is the country paying collectively and can this cost be decreased; and How good is the health care the system actually delivers and can this be improved?

Working backwards, quantifying quality in health care is an ethereal endeavor as no one has a handle on an agreed upon metric. Is it doing the right things or is it having the best outcomes? Doing the right things can be enforced through systems of box checking and checklists linked to reimbursement. But outcomes are far more critical to most patients who really don’t care whether all the boxes got checked as long as they benefit from their interaction with the health care system.

Furthermore, most people know far more about the features and reliability of their cell phones than about the quality of the care delivered by their doctors. That is why results from surveys of patient satisfaction are not real measures of health care quality, but more reflections of the affability and availability of the doctors and staff, not to mention the convenience of parking, the currency of the issues of People magazine in the waiting room and the presence or absence of a near-by Starbucks.

Remember, the person who came in last in his or her medical school class or made a barely passing grade on his or her licensure exam is still called “doctor” and he or she could be your doctor and you would never know. So while improving quality is a worthy goal, I am not at all clear how we would know we got there.

Cost on the other hand is easy to measure. The unit of measure is dollars and we spend way too many of them in this country on health care, about $2.7 trillion per year, over $8000 per capita. This is at least twice what any other Westernized democracy spends and most of them have some form of guaranteed universal health care, something the US does not have as we still have about 50 million uninsured (see below). There’s a lot of finger pointing when it comes to barriers to health care cost reduction. The usual suspects are the insurance companies, the pharmaceutical and biotechnology companies, the large hospital chains, the greedy doctors, the overuse of technology and the aging population. And, of course the answer is all of the above.

Everyone is guilty of feeding at the trough of the health care-industrial complex. The problem is that to reduce health care costs someone has to make less money and no one is volunteering to do that. On the contrary, the lobbyists for all the factions on that list were working overtime as the ACA was being formulated to make sure their constituents’ financial interests were protected in the bill. Every little and big piggy wanted to protect his or her revenue stream.

As an example, let’s address how the ACA protects the on-going interests of big health insurance companies. Health insurance is a nutty idea. Why? Most insurance works by pooling the premium dollars of a large group of people on the supposition that only some of these people will need the resources (e.g., automobile or home owners’ insurance). Most people pay premiums and never use the services for which they willingly pay.  In fact, they hope they don’t have to. How many other products do we pay for hoping to never use? Few. Maybe a automobile jack and spare tire, hurricane lamps, gas generators and bandages.

Insurance is a rather communitarian product in which everyone chips in to support the unfortunate few at their time of need. The problem with this model in health care is that sooner or later, everyone needs the money. As life expectancy has increased, more people need more money. As technology advances, doctors can do more. And, since they don’t want to be sued and really don’t know half the time whether or not a given service or test is needed, and the more they order the more they make, they order a few million MRIs. This costs a lot of money. How did we ever get along without these machines being used for every imaginable ailment?

I have no idea, but my late, great Chief Resident Dr. Bruce Dixon said the most common test that would have been ordered at Duke Hospital in 1975 was the BD 2700. BD stood for Bruce Dixon and the 2700 was the cost of the ordered test which was every single lab test available then. His joke was that if he didn’t put a stop to it, every Duke intern (including me) would have ordered a BD 2700 on every patient every day.

But the insurance companies who reimburse BD 2700s (which would cost about $10,000 or more today) don’t take care of anyone. They are a made-up necessity and an historical aberrancy, a leftover relic from World War II wage and price controls when companies only had “benefits” to attract needed workers and health insurance was the newest, shiniest penny on the benefits beach. After the government jumped in with Medicare and Medicaid, what was once a “benefit” became an “entitlement” and away we go. Now almost 18% of the gross domestic product is expended on health care. And what do we get for all this spending? Very little as our infant mortality rates and life expectancy are nowhere near the best in class among first-world nations. We are surely not the healthiest country on Earth, nor the best educated, nor the longest living. (We are also not the fattest. The US is 8th. Kuwait wins. http://www.therichest.com/rich-list/poorest-list/the-10-fattest-countries-in-2014/4/)

Given that the ACA’s stated goal is to increase access of more Americans to health insurance, it seems unlikely that costs will drop any time soon.

That brings us to Access. While in the initial phases of the discussion about health care reform when I served on the staff of the US Senate Committee on Health, Education, Labor and Pension, access was to be access to health care, but it rapidly transformed to being about access to health insurance. Why? Because many physicians, especially, but not only, primary care doctors, won’t accept new Medicaid patients and the mechanism in ObamaCare to insure the most needy uninsured Americans was via Medicaid. Medicaid is the joint federal-state program to insure the needy, especially pregnant women, children and the disabled. It usually constitutes the largest single item on any state’s budget, so the states were reluctant to comply with any Medicaid expansion. Unlike the federal government, states cannot borrow money from China.

But no worries. The ACA stipulated that states that refused to increase Medicaid insurance to all of those citizens with incomes up to 138% of the federal poverty line would lose all of their federal component of Medicaid. But in June of 2012 the Supreme Court deemed this overly punitive, most states, especially the Red ones, did not expand Medicaid and the poorest uninsured Americans pretty much stayed that way—poor and uninsured. Thus the ACA didn’t even expand access to insurance as originally intended. Let alone access to actual care.

There are one million of these uninsured people in my hometown of Houston. Houston is also the home to the largest medical center in the world, the Texas Medical Center or TMC. Needless to say most of the one million uninsured of Harris County could not gain access to the world-class TMC BECAUSE they have no insurance and would not pass the so-called “green screen” that takes place at the entrance of every hospital of the TMC.

What’s more, even if the Supreme Court had not dropped a dime on ObamaCare, it was never clear there were sufficient doctors to care for the newly Medicaid insured any way.

Other stipulations of the bill did get some people health insurance who did not have it before. Some acquired it through the health insurance exchanges once healthcare.gov became functional. Some people under 26 became insurance eligible under their parents’ policies. Many with pre-existing conditions who were shut out of the previous market were now allowed in. But the President’s promise that “if you liked the insurance you had you could keep it” was never true and many people have lost insurance for a variety of reasons including employers who could just walk away from the whole mess. Even if the employer mandate kicks in and they get penalized, at least that penalty is a fixed and predictable cost not one like insurance premiums that rise every year. Furthermore all the insurance paperwork is now gone saving the employers thousands in overhead administrative costs.

The net gain of ObamaCare is positive, but meager. Nowhere near the 30 to 34 million Americans as promised in the initial phases of the implementation of ObamaCare will gain access to health insurance, let alone health care.

So in summary, ObamaCare has probably had no effect on medical quality and surely only minimal if any effect on medical costs. It has had a small effect on making insurance available to some previously uninsured Americans, but whether the number who actually acquire care increases or that the general health of the country gets better remains a mystery.

In other words, I am arguing that ObamaCare is not as wonderful as the Democrats would have you believe or as Apocalyptic as the Republicans say it is. In fact, it hasn’t changed the fee-for-service system or medical education. It has not created a stimulus for more doctors entering careers in primary care, reduced costs or made comparative effectiveness research aimed at determining what really works in health care a more prevalent determinative of care. It has not stimulated a serious discussion of end-of-life care costs or addressed the crippling college and medical school debt incurred by many future physicians that precludes them entering careers in primary care because they need to repay these debts and must make far more in income to try to crawl out from the debt. Thus, there is a plethora of cardiologists instead of primary care docs because the former make far more money than the latter. An American health care system? I don’t think so!

If America has anything, it’s a disease care system that focuses on episodic interventions by health care professionals trying to salvage a patient from the ravages of chronic diseases, many of which are self-induced. It’s a system that does not focus on health maintenance, something that really would alter the nature of the country’s well-being. I would argue that using the same money we are spending on this ObamaCare nonsense to teach kids in elementary school how to eat, shop, cook, exercise, not use drugs or tobacco and to have safe sex would probably improve health in the country far more than this bill ever did or will. It is also more useful than trigonometry, as would be probability so people could really understand risks and benefits of health interventions like mammography.

Amazingly not only our kids would gain from such a health maintenance system that originated in elementary schools. My household did not start to recycle until my oldest child (now 34) came home from school and made us do it. I suspect a similar approach to tobacco use, vaccination, and a proper diet with exercise would improve the health of our children AND their parents. It would also tend to shrink the size of the wallets of the insurance companies and their brethren at the trough of the health care-industrial complex and that might include the doctors as well.

ObamaCare is less than. It improves quality less than anyone could hope. It cuts costs minimally, far less than is necessary to really positively impact the competitiveness of American products whose prices have the premiums for employer-supplied health insurance built into every price tag. Its increase in access is far less than was originally planned and that’s to an insurance card not to true health care.

This leaves the country with three choices. We can leave ObamaCare in place and forget it really happened. Those who benefitted, good for you. We can modify it so that its goals are clear and they are not, “I pay less!” Or we can replace it. I really don’t care which we do because until we have the national discussion about what access to quality, affordable health care is, a right or privilege, (is it like the police or Gucci loafers?), we will never arrive at a truly American solution to universal care as the rest of the civilized world has.

Just remember this, we do have a single payer system in America. It is in place for those over 65 and it is called Medicare. And in case you wish to bad mouth Medicare, I suggest you go to a senior citizen assisted living community in Florida and ask for the votes of those residents (and they vote) with the elimination of Medicare as your major platform point. You will be lucky to leave alive.

We know what to do for we did it 50 years ago for the elderly. Let’s just do it for everyone else, but do it the way David Goldhill suggests in his book Catastrophic Care. The government pays for the system through taxes but contracts for the care with organizations that bid for the privilege of providing it. Turn health care into jets for that is how we buy fighter planes. The Pentagon makes none. We pay and the Pentagon buys them. Why can’t we do that for health care? Oh wait. We already do. As long as you are old enough.

Dr. Gruber was right about the ACA. It was a bill passed with no transparency that tried to dupe Americans into feeling good about a bill that really would affect the system very little. It was an attempt to preserve the revenue streams of the major financial players in the health care-industrial complex. It no more addressed the real issue of health care in America than the Clinton bill of 20 years before that never made it to a congressional committee for mark-up.

The best solution is to leave ObamaCare in place for the benefit of the few who got something and then have a meaningful national discussion about whether health care is a right or a privilege (I am fine with a national referendum on the subject) and then devise a system to meet the needs of implementing the system we have chosen. Anything else just perpetuates the broken non-system of disease care with its origins in businesses coping with labor shortages at a time of war while ignoring the 50 years of testing for a single payer system for the elderly. It works.

If that means our elders have shown us the way once again, that’s fine with me. I am one of them now.