In the news this week is an upcoming vote about possible repeal of the Affordable Care Act. The NY Times reported on Tuesday, “Doctors are telling Congress to proceed with caution, insisting that no one should lose coverage. The American College of Physicians, representing 148,000 specialists in internal medicine, has sent letters to senators urging them to “vote no” this week on the budget resolution.”
Healthcare has been a hot topic for years, and most of us know just enough about it to be dangerous! I hear a lot about it because I’m married to a physician, Dr. Stephen Dahlstedt of Alliance Urology Specialists, and he keeps me abreast of the changing landscape. His main concern with a possible repeal of the ACA is for the millions of people who now have insurance who previously did not. What will happen to them? He worries that if we go back to our previous fee-for-service system, sick people without insurance will over-utilize the emergency rooms unable to pay for conditions that were preventable. Of course, healthcare is different from, say, buying groceries; if you can’t pay for what’s in your basket at checkout, you don’t get to leave with the groceries. But when sick people arrive at the hospital, or at my husband’s practice, they are not turned away, which means the hospital loses out, and physicians give away their services for free. (And the reimbursements not only pay their salaries, but also those of their nurses, staff, equipment, etc.)
Even with a direct line to my husband, I myself only know enough about the ACA to be dangerous, as I don’t work in the healthcare industry; so I wanted to better understand and explain what the Affordable Care Act is, how it has benefitted our country, and how it has fallen short of expectations. I reached out and engaged some professionals who know much more than I do about this topic. They were all very willing to answer my questions.
I called John Wrenn, MD, President of Alliance Urology Specialists in Greensboro, a large private practice; David Grapey, MD, a physician at Alliance Urology Specialists and one of the Medical Directors of Triad Healthcare Network, a small, local ACO (Accountable Care Organization); and Stephen Parsons, a Senior Program Director at United Healthcare, the largest provider of healthcare insurance in the United States.
A few themes repeatedly came up with everyone I spoke to:
- 20 million additional people now have insurance coverage
- Patient’s rights have improved
- The ACA had fundamental flaws with funding from the start
Dr. Grapey explained that funding of the Affordable Care Act depended on young, healthy people buying insurance, which would have paid for the newly insured sick people who previously didn’t qualify for insurance, a redistribution of funds. But not enough young, healthy people entered the risk pool. Many actuaries say that in order for a system to be financially stable at least 40% of the people in the risk pool should be healthy. But the ACA risk pool contains only about 25% healthy people.
“What about the mandate?” I asked Dr. Grapey, referring to the penalty for not purchasing coverage.
It was unenforceable, he told me. The penalty for not purchasing health insurance was much lower than the cost of insurance, so many healthy people just didn’t buy it, meaning the money to fund ACA didn’t come in.
Initially, the very poorest citizens were to qualify for Medicaid under an expansion. Then, those citizens who didn’t quite qualify for Medicaid would be able to go onto exchanges and purchase insurance subsidized by the federal government on a sliding scale, depending on their income. But the states sued the federal government, because many of them didn’t want to expand Medicaid, and that’s when the Supreme Court ruled in favor of the states, resulting in some of them, including North Carolina, choosing not to expand Medicaid. “The way that worked was that the government said, if you expand Medicaid, we’ll pay 90% of it, but you have to pay 10% of it. And some, mostly Republican governors, including [Governor] McCrory in our state, decided that they did not want to expand Medicaid,” said Dr. Grapey. This resulted in many North Carolinians, who didn’t quite qualify for Medicaid, falling into a gap where they also didn’t qualify for insurance on the ACA exchanges. So states like North Carolina, Florida, and Texas didn’t see as much of an improvement in their uninsured rates as other states that did expand Medicaid, like Kentucky. Overall, our country made it to around 10% uninsured lives, though there are great discrepancies in that number from state to state.
Those 20 million additional covered adults resulted from:
- Medicaid expansion
- The change in the law that allows young adults to remain on their parent’s insurance until age 26
- Insurance purchased on the ACA exchanges.
If the Republicans vote for a budgetary reconciliation, they can strip away the funding for those who obtained insurance through Medicaid expansion, and they can decide to stop subsidizing the insurance policies purchased on the ACA exchanges. Those insured people will be threatened with loss of their coverage.
“But think about it from an insurance standpoint,” added Dr. Grapey. “If anybody can sign up for insurance that already has cancer, that already has diabetes, that already has had three heart attacks, and none of the young healthy people are signing up for your insurance, well that’s not a business model that’s very sustainable, and that’s why all these insurance companies have lost a tremendous amount of money.”
So are the insurance companies in favor of repealing the ACA altogether? Mr. Parsons suggests that insurance companies have a real expertise to offer in healthcare management, including their networks of physicians who have been rated by insurance companies as excellent providers. A public/private partnership could help rein in costs and make shopping for a doctor more straightforward. He says that United Healthcare, for one, was on board with some of the changes brought about by the ACA, such as eliminating pre-existing conditions as a barrier to buying coverage. United Healthcare also went to great lengths and costs to support the Affordable Care Act, and would likely favor a redesign over a complete repeal.
“Government has a strong role to play,” says Dr. Wrenn, referring to how hospitals, insurance companies, physicians, and drug companies tend to look out for their own interests. Discriminating based on age and gender, exclusions for pre-existing conditions, prescription overcharges, were abuses of the prior system. “The Democrats and President Obama got the ball rolling as best they could,” he said.
The United States is the only advanced country without a universal healthcare, says Dr. Wrenn. And Dr. Grapey agrees, adding that if nothing else, the Affordable Care Act has put a spotlight on our wealth as a country and how many uninsured citizens we have.
Dr. Grapey thinks there is an opportunity here for the Republicans. Obamacare wasn’t
bipartisan, he says. The Democrats own it. Instead of an outright repeal, the Republicans can fix the flaws. “If you slowly made it better, then you would own that better product. And if you just repeal it, put nothing in there or put something even worse in place, then you own that, so I don’t understand the strategy there at all.” He described the worst-case scenario, “If they just repeal Obamacare through all these mechanisms and just dismantle it and don’t have something in to help these people and to provide these safety nets and help hospitals, it’s just going to be a huge mess.”
Dr. Dahlstedt summed it up, “You have to start with something. Think about the first Model T. The one that came ten years later was nothing like the original; the first was much like a prototype.”