Writing Overly Ambitious Laws Without Assessing Results, i.e., The ACA
Congress creates large costly programs as a finished product with no follow-up for unintended consequences, cost, or effectiveness. The Patient Protection and Affordable Care Act (ACA) is a classic example. The law was created in a byzantine manner because of a surprise Massachusetts Senate loss (1). It encompasses many thousands of pages with its added regulations. A famous phrase by Speaker Pelosi was, “If you want to know what’s in it you will have to pass it” (Ref.2). Provisions included, “Expand Access to Insurance Coverage, Increase Consumer Insurance Protections, Emphasize Prevention and Wellness, Improve Health Quality and System Performance, Promote Health Workforce Development, Curb Rising Health Costs, State Roles in Implementation”, a collection of objectives anyone of which would need careful follow-up and adjustment to meet the stated goal (Ref.3).
So far only one component of the ACA has been repealed by the opposite political party, the fine for not having insurance. This fine was intended to encourage healthy uninsured Americans, within a certain range of income, to join this insurance market to prevent only the expensive sick to be insured, grossly driving up costs relative to revenue. The fine was made $0 in the 2017 tax reform bill (Ref.4).
The ACA was contentious when signed into law, with results far from what was its stated goals (Ref.5).
- Lowering health insurance costs has NOT happened, rather they have significantly increased; from 2013 to 2017 premiums doubled.
- The ACA has caused a far greater than expected increase in entitlement spending. The subsidies for the exchanges and the costs of Medicaid expansion from 2018-2027 are projected to cost $4.8 trillion.
- The supposed decrease in overall healthcare costs has NOT materialized. Projected costs in 2025 is expected to reach almost 20% of GDP from 17.2% before ACA inception.
- Health insurance is less of a value, higher premiums with yet higher deductibles.
- Fewer insurance companies since the law’s origin are participating in the ACA exchanges.
- Millions of Americans via the ACA obtained Medicaid coverage, which many hospitals and physicians refuse to accept because of below cost payments.
- The numbers of uninsured remains in the multiple millions.
- The law has prevented experimentation with alternatives that could deliver better care at far less cost, while still retaining protections for pre-conditions and providing care for ALL Americans (Ref.6).
Despite these many unresolved ACA issues, legislation to help Americans with the pandemic (the Covid Relief Bill) added an additional $20 billion paid to insurance companies to expand coverage and decrease individuals’ payments. These increases in support will run through 2022 costing $8,500/ person, an increase of 40% versus 2020. This is $1,500 more than the yearly expenditure/person for Medicaid, that has no co-pays or deductibles, causing cost shifting by hospitals onto private insurance. Thus, working Americans are subsidizing Medicaid by their employers paying significantly higher health insurance premiums (Ref.7,8).
The practice that billions of dollars spent by the federal government each year on inefficient, overly ambitious, untested and poorly performing programs is a concept that our huge national debt makes no longer viable. As an example, ALL Americans need access to good healthcare, but it must be done in a much more efficient manner. Thus, bills should be relatively simple, focused and initially passed as a work in progress, then reviewed for effectiveness and cost.
- Ewen MacAskill, Republicans take Ted Kennedy’s seat in dramatic upset: Democrats lose Senate seat in Massachusetts, throwing Obama’s health reform plan into doubt, The Guardian, January 20, 2010, available at: https://www.theguardian.com/world/2010/jan/20/republicans-massachusetts-scott-brown-obama-health (accessed November 5, 2021)
- Nancy Pelosi, You Tube, available at: https://www.youtube.com/watch?v=9uC4bXmcUvw (accessed November 4, 2021)
- Martha King, The Affordable Care Act: A Brief Summary, National Conference of State Legislatures, March 2011, available at: https://www.ncsl.org/portals/1/documents/health/HRACA.pdf (accessed October 27, 2021)
- Louise Norris, Is There Still a Penalty for Being Uninsured in 2021?: Penalties Still Exist in D.C. and Four States, verywell health, August 29,2021, available at: https://www.verywellhealth.com/obamacare-penalty-for-being-uninsured-4132434#:~:text=The%20ACA%27s%20individual%20mandate%20penalty%2C%20which%20used%20to,will%20continue%20to%20be%20the%20case%20for%202021. (accessed November 4, 2021)
- Stephen Moore, 8 Reasons to Still Hate Obamacare, The Heritage Foundation, June 5, 2018, available at: https://www.heritage.org/health-care-reform/commentary/8-reasons-still-hate-obamacare (accessed October 27, 2021)
- Ken Fisher, M.D., Medicare and Medicaid Have Obvious Structural Flaws Politicians Will Not Address, Authentic Medicine, September 27, 2021, available at: https://authenticmedicine.com/2021/09/medicare-and-medicaid-have-obvious-structural-flaws-politicians-will-not-address/ (accessed November 4, 2021)
- Noam N. Levy, The Covid Relief Bill Expands The Affordable Care Act. It Doesn’t Come Cheap, npr, Shots, March 23, 2021, available at: https://www.npr.org/sections/health-shots/2021/03/23/980364322/the-covid-relief-bill-expands-the-affordable-care-act-it-doesnt-come-cheap (accessed October 27, 2021)
- Jack A. Meyer and William R. Johnson, Cost Shifting in Health Care: An Economic Analysis, Health Affairs, 1983, available at: https://www.healthaffairs.org/doi/10.1377/hlthaff.2.2.20 (accessed November 4, 2021) Note – Some authors since this publication have denied “cost-shifting” that supports federal programs. But the present drive for hospital consolidation giving them more pricing power against private insurers is confirmatory.
From our neighbors to the north.
https://www.theglobeandmail.com/opinion/article-quebec-wants-to-force-family-doctors-to-see-more-patients-is-that-the
Quebec wants to force family doctors to see more patients. Is that the way to fix primary care?
Toronto Globe and Mail
ANDRÉ PICARD PUBLISHED NOVEMBER 2, 2021
Quebec Premier François Legault is exasperated with the province’s family doctors.
Back in 2018, when his Coalition Avenir Québec was running for office, they promised that every citizen would have a family doctor by the end of their mandate. The “chicken in every pot” promise was a popular one, helping propel the CAQ to victory.
Back then, there were 400,000 Quebeckers without a family doc. Today the number is 857,000. (The province has a centralized Guichet d’accès à un médecin de famille, or GAMF, where residents can register and be assigned a doctor, at least theoretically.)
So Mr. Legault is on the warpath.
At a news conference last week, he thundered “my patience has run out” and threatened legislation if the province’s 10,000 family physicians don’t put a big dent in the waiting list by accepting more patients.
The Premier even brandished a blacklist of physicians he said were not pulling their weight – a binder full of laggards, if you will. He said they could expect big pay cuts if they don’t pull up their socks.
The CAQ government wants every family doctor to have a roster of at least 1,000 patients. According to provincial data, 52 per cent have fewer than that magic (read: random) number and 14 per cent have fewer than 500 patients, and/or work less than 150 days a year.
To prevent another pandemic catastrophe, long-term care needs a long-term fix
Mr. Legault has had this bee in his bonnet for a long time. Two decades ago, when he was health minister in a Parti Québécois government, he introduced legislation that would cut the pay of physicians by 30 per cent if they did not meet productivity standards. The Liberal government eventually passed similar legislation but it was never enforced.
A lot of what the Premier says on this issue is complete nonsense and his ham-fisted solution is ridiculous.
The vast majority of family physicians work full-time hours, and then some.
But 70 per cent of family docs are women, many of them of child-bearing age, and they choose family medicine and part-time work specifically to have a better family life. Punishing them for doing so – which is what the threatened legislation would do – is preposterous and counter-productive.
Quebec, unlike most provinces, forces family physicians to work at least 12 hours a week proffering care in “priority areas” such as emergency rooms, hospitals or long-term care homes. This law takes them away from their clinics one to two days a week and forces them to have fewer patients.
The province also severely restricts where physicians can practise, a rule that is supposed to ensure care in rural and remote areas but whose unintended consequence is that it is virtually impossible to get a family doctor if you live in a big city such as Montreal.
Access to primary care is a serious issue in Quebec and all of Canada. That millions of Canadians do not have a primary care practitioner (a family doc, nurse practitioner or multidisciplinary care team) is a travesty.
The system is completely dysfunctional from the way we train family doctors through to the way we pay them.
Mr. Legault, in a back-handed manner, has drawn attention to this reality. But the solution is not to bash doctors, it’s to fix the system so doctors can work more efficiently, and we can get more bang for our health care bucks.
Quebec’s Premier is right when he says that doctors have little or no accountability within our public system. Most doctors are independent contractors with only the vaguest of contracts.
We pay family physicians on a fee-for-service basis, for treating one thing at a time, when we should pay them to treat people with complex chronic conditions, not specific ailments.
The big unspoken question in this political drama is: What are the metrics for measuring the performance of family physicians?
Having 1,000 patients on a roster is one potential metric, but a crude one, especially since “having a doctor” does not guarantee getting an appointment. (Only 43 per cent of Canadians can get a same-day appointment with their doctor.)
We actually have very little idea what doctors do, and almost no data on outcomes. As the adage goes, you can’t manage what you don’t measure.
We need to fundamentally rethink how primary care is delivered and paid for. That’s going to take collaboration, co-operation and political risk-taking.
Mr. Legault is right about one thing: We need a profound change in health care culture. But waving around blacklists and issuing threats is not going to improve access to care, or quality of care, for anyone.
Legislators love to find problems that were solved in the Days of the Dinosaurs. (Our State proposes allowing generic substitution for Brand Names all the time in committee. That’s as relevant as golf on Wednesday afternoon.) They never check their work. They don’t understand why surgeons do, postoperatively. Legislatures leave towels in and cut off the wrong leg all the time. I was bawled out by a legislator for promoting waste – if anaesthesiologists are needed at 3-5% of routine colonoscopies, that’s a lot of money down the drain, right, doctor? They think they are hired for innovative new ideas. Instead, they paper over old rules with new rules. And so on…