Can We Afford the Affordable Care Act (ACA)?

This is a complex topic that has been a very political and emotional issue in the news. Understanding the complexity of universal healthcare requires a knowledge of history of access to health care for those of lower socioeconomic status, the financial aspects of universal healthcare, and the performance of the ACA (Obamacare) thus far.

Prior to 1986, hospitals could turn patients away from emergency departments because they did not have insurance or could not pay for services. If you “accidentally slipped” and fell on a bottle of shampoo in the shower, an emergency department could turn you away for inability to pay and you would have to waddle to a county hospital. This was also a problem for life threatening emergencies and women in labor.

In 1986, Congress passed the Emergency Medical Treatment and Labor Act (EMTALA), a federal mandate that people arriving at an emergency department must be stabilized and treated, regardless of their status or ability to pay. This treatment was mandated but not funded by the federal government and hospitals currently still accept the financial burden. Providing free care is offset by patients with insurance and given the tight margins for most hospitals, that means that the insured are paying for those who do not have insurance.

Although Neighborhood Health Centers emerged during Lyndon Johnson’s War on Poverty in 1965, our current system funding Federally Qualified Health Centers began in 1991. This created a safety net providing primary care and preventive care to millions of Americans regardless of their ability to pay. As we all know, the ACA was passed in 2010 in an effort to expand universal access to health care. In other words, we have been providing access to health care for the uninsured or underinsured for a lot longer than you thought.

Now let’s make it even more boring and throw out some statistics. Mark Twain is quoted as saying, “There are three kinds of lies: lies, damned lies, and statistics.” These statistics are from the federal government and we all know the government doesn’t lie. In 2015, the total percentage of the gross domestic product (GDP, the total goods and services provided in a country) spent on health care in the United States was 17.9%. In 2009, the year before the ACA implementation, it was 17.3%. If you go back another 6 years, to compare the same period of time, the amount of GDP that went toward healthcare in 2003 was 15.4%. In other words, our health care spending has been growing much more than our GDP long before the ACA and that growth has actually decreased.

We’ve been paying for health care for the uninsured all along and the ACA doesn’t appear to be increasing that burden. Don’t tell that to Paul Ryan.

For many years and far before the ACA, we’ve seen our health insurance premiums go up at the same time that we pay more out of pocket. The ACA did not change that trajectory, it just provided better access to health care for the underserved. Damn you, Obama! We have been told by politicians that we should repeal the ACA because the ACA is increasing our insurance premiums. That doesn’t seem to make any sense because we are requiring healthy people to get insurance. With more healthy people with insurance, insurance companies have to pay out less per person and insurance should cost less per person. Those same people without insurance are still guaranteed health care while uninsured and cannot pay for catastrophic illness or accident, passing the cost of the uninsured to the rest of us. It seems like the ACA is actually affordable to us.

Finally, how is the ACA doing? First of all, it certainly has its flaws. Because of the required covered services, the plans offered in exchanges are significantly more expensive than more bare bones, higher deductible plans that may work fine for some. In other words, requiring insurance companies to cover more services makes us all pay more. We are adding expense to a flawed health care delivery system where the proportion of GDP spent on health care continues to increase. Changes in coverage often results in patients having to change their health care providers. Who would have guessed that a 2000+ page document didn’t get it all right?

I will speak to my experience with the ACA in California. I have worked with patients with MediCal before and after the ACA. Partnership Health Plan (PHP) manages care for MediCal patients in our county currently. PHP has a robust program to reduce harm from prescription opioids, a strong and active Quality Assurance program, and provides preventive healthcare to many more residents of Shasta County with the cost savings of preventing disease instead of treating it. Patients who I see in the emergency department have far better access to primary care and specialty services than they did ten years ago.

The bottom line is that health care is a right in the United States, as it should be. Congress has repeatedly provided mandates for care and access to that care. We have had access to health care regardless of socioeconomic status for well over two decades. This access was expanded by the ACA while the growth of the proportion of our GDP devoted to health care slowed down. On top of that, we are delivering health care with improved preventive medicine, investing in our future.

Looking back, the ACA was inevitable. It is a way to deliver better health care to ALL Americans. Repealing the ACA would be a step back and it doesn’t appear that it would save us money. Instead of an endless debate about repealing the ACA, our efforts would be best invested in improving it. Despite its many faults, it has been successful. Let’s stop debating if we should have universal healthcare and start discussing how we can make it better and more cost efficient.

Greg Greenberg
Greg Greenberg grew up in Santa Monica, California. After undergraduate training at UCLA he attended medical school at Ohio State University and completed a residency in family medicine in Columbus, Ohio. He moved to Redding after residency in 2004 and has served the Redding community as a family physician, hospitalist, emergency physician, and, most recently, in addiction medicine. When he’s not enjoying the calm atmosphere of the emergency department he enjoys the chaos of being a full-time parent as well.
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33 Responses

  1. cheyenne says:

    Actually the ACA repeal is dead.  Sure my Wyoming legislators, who don’t have to worry about being reelected, toe the GOP party line but I only have to look ten miles south and see the turmoil in Colorado as the GOP is backing away from the repeal.  Also, in Arizona where my grandkids live, not only is the GOP repeal dead but so is the border wall and I would say Trump is on his way out as he is backing a chem-trail politician over the GOP main stream Flake.  The GOP has already started ads condemning Kelli Ward as they say if she is the GOP candidate the Democrats will win the seat easily and they can’t allow that to happen.

    John McCain was right in voting against the skinny plan that would only do away with the healthcare mandate.  I have my own paid fully by me Blue Cross so the mandate requirement means nothing to me.  The problem lies in the under funded subsidies which is driving insurance companies to go bankrupt, like Win Health here in Wyoming, and causing the remaining ACA carrier, Anthem, to raise ACA fees 50% next year.

    • Greg Greenberg Greg Greenberg says:

      I agree and I applaud McCain.  I’m sure sticking it to Trump felt good in the process.  I don’t think the ACA will be repealed because the same politicians who rail against “Obamacare” also know that it’s working.  I don’t think Trump’s attempts to repeal the ACA are over which is why we need to remind our politicians of the value to us.

      • cheyenne says:

        The biggest problem I see with the ACA is the risk reimbursement part where the losses incurred by insurance companies for insuring the unhealthy would be paid.  The school district where I worked in Redding had a health carrier that, in exchange for insuring the healthy and unhealthy, required all employees to join the health plan.  Some employees did not like this universal plan but the district never had to refund losses to the insurer.

  2. conservative says:

    The ACA should have given hospitals and doctors incentives to control cost.  The Mercy project on the Sac river shows how hospitals are flush with cash and waste money.  Hospitals advertise surgical robotic machines which drive up costs.  Two hospitals could share one. Practice management consultants tell specialty groups how to maintain their income when they are losing money on medicaid patients.  For example, America has the highest rate of mammograms reported as “suspicious” leading to more expensive procedures.  Pathologists can do unnecessary immunostains to add to their reimbursement.

    We have a horrible obesity epidemic with prediabetes and type 2 diabetes rising sharply, but doctors and hospitals are not effectively teaching patients to lose weight.  70,000 amputations are done every year because of diabetes.  The quality of life is awful for an 80+ year old with an above knee amputation trying to use a prosthesis when they are prone to fall under the best of circumstances.

    U.S. medicine spends something like a quarter of the costs in the last few months of life.  There are incentives to put patients dying of widely metastatic cancer on ventilators, do hemodialysis, etc.  In every hospital, there are patients who are “no code” who get coded and put on the ventilator anyway, driving up costs and fruitlessly adding to the suffering of dying patients and families.

    Healthcare reform should give the states flexibility to experiment with approaches to change the incentives for doctors and hospitals to lower cost.

    • Greg Greenberg Greg Greenberg says:

      I skirt over some of my opinions in this article for the sake of presenting facts.  I feel strongly that we must ration health care.  That’s a dirty word in our entitled society and then people start talking about death panels and try to scare people.  We have way too many lobbyists from pharmaceutical companies and device companies in the ears of our politicians. As health care gets more expensive, we have to recognize our finite resources and determine the value of treatment options.

      The obesity issue is much more complex. As a family practitioner I have been counseling people on diet and exercise for over a decade.  Unfortunately I need to work on that myself.  Education doesn’t seem to do much and people struggle against a sedentary lifestyle with too many calorie dense foods at our disposal. Carbs are evil.  Yummy but evil.

      • Tim says:

        The only thing scarier than a government healthcare plan with a “death panel” deciding how to allocate scarce funds, is a government healthcare plan without a panel deciding how to allocate scarce funds.

  3. R.V. Scheide says:

    Nice backgrounder Doc. Another thing to mention: Repeal of the ACA essentially amounts to a tax cut for the rich that would leave millions uninsured.

  4. Beverly Stafford says:

    During the 1992 election campaign, the two main planks in Ross Perot’s platform were health care costs and the national debt.  Here we are 25 years later still not addressing the debt while the Republican Congress ignores its constituents and continues to attempt to repeal the ACA.  POTUS swept into office declaring that he would repeal Obamacare, build a wall, and get out of Afghanistan, and we’re now three for three it seems.

    Thank you, Dr. Greenberg, for stating right out loud what so many of us realize:  the ACA is flawed but can and should be revised into a workable act.

  5. Tim says:

    1)  Is healthcare a right?  It is an almost entirely ignored possibility that the US healthcare system does more harm than good.  250,000+ Americans die each year from medical mistakes (many many more are disabled); 500,000 Americans are addicted to opioids; the average American lifespan actually declined during Obamacare.  Where is the evidence-based justification for US healthcare, especially now that patients are spending less and less time with doctors before being prescribed drugs, scheduled for surgery, or kicked down a chain of specialists who will rinse & repeat?

    2) Insurance is meant to cover large and infrequent expenditures.  You don’t get a homeowner’s policy that covers mowing the lawn or painting the walls.  And you can’t buy that policy after a tree has already fallen into your house.  Medical insurance used to be the same way, with patients covering the small routine stuff and insurance covering the rare catastrophic events.  This meant that the consumer shopped around and obtained good values — buying paint on sale or paying the neighbor to mow the lawn.  Under Obamacare, the consumer pays a small fixed cost no matter which option they choose, so why not get the best?  Or why not just defer to your housepainter, who may pick the gold-infused hue sold by that sexy sales rep who gives away all the cool paint brushes?  Who cares what it costs, you’re not paying for it?  Enter Martin Shkreli…

    3)  If healthcare is a right, why must an employer be the one primarily saddled with the costs?  Would you stop paying that neighbor boy to mow your lawn if it meant you had to buy his braces?  Why do you think the calculus is any different for employers, big and small?  Isn’t it hard enough for American businesses and the workers to compete with low cost labor and slack environmental regulations overseas?  Why ship more jobs to India and China?

     

    If healthcare is a right, it should be easily able to prove its own worth.  As of yet, it doesn’t.  And if healthcare is a right, it shouldn’t be set up as an insurance system.  Rights are protected by the government, so a government healthcare system makes sense (single payer).

    And if that were to occur, the costs of the program should be shouldered by society as a whole through property and/or consumption taxes — not taxes on productive behavior (employment).  But again, prove it; prove we aren’t just incrementally better than the days of blood letting, mercury treatments, and lobotomies.  Explain why, as recently as 1991, doctors prescribed tonsillectomies in ~50% of the children they saw, even when those children were the 50% judged healthy by someone else (meaning a healthy child has a ~3% chance of being deemed healthy after being screened for tonsillitis by 5 doctors).  Anyone care to get a heart screening by Redding Medical?

    • Greg Greenberg Greg Greenberg says:

      Tim, you have some valid points.  I often say that our patients live despite us, not because of us.  As I’m sure you know, the largest contributor to increasing lifespan is modern sanitary practices, not medicine.  However vaccines and preventive medicine have some evidence that they also contribute to the increase in life span that we have seen.  Those advances are being counteracted by changes in modern society that lead to decreasing exercise and increasing obesity.

      I strongly believe that healthcare is a right and I also believe that it should be delivered through a single payer healthcare system.  I kept those opinions out of my article so I didn’t dilute the message about what the ACA has done.  We have a very flawed delivery of healthcare that rewards procedures (even if potentially their necessity is unproven), rewards more care which is not always better.  We need a focus on outcomes and proven therapies — a discussion that Obama had before his election and was widely criticized.  Paying for discussions about end of life care became fear of “death panels”.

      We need a radical overhaul of how we deliver healthcare.  I don’t see that happening anytime soon.  In the meantime, the ACA, although flawed, is a step forward.

      • George T. Parker says:

        Well said. Bravo.

      • Tim says:

        If you were advocating every American have free access to the type of health clinic one might find in Haiti, I’d be all for it.  But the American health care system is so perverted (ACA included) that I see it more as a step way, way afield than a step ahead — especially when the system that pays for it costs Americans good, full-time jobs (and meaningful employment has a large effect on longevity).

        Only the American health care system can review a chronic migraine study in which a (free) placebo is 40% effective and (expensive) botox is 45% effective and determine we should start prescribing botox.  No!  We should be prescribing placebos!

  6. Gary Ault says:

    Not that I’m a fan of the ACA. but once a program is created that gives something for nothing to many people, it is near impossible to take it away!  Therefore what we have left is fixing parts of the program that are not working and to find more ways, including charging lower income families a small percentage to help with the cost!  The welfare mentality has created such a divide between the poor and the working families that struggle to get by, everyone who benefits from this program needs to pony up to the bar and pay their portion of the tab!  Knowing that you have to pay something will also cut down on the wasted ER visits for the common cold……just check Mercy November thru March….crazy!

    • Tim says:

      Hospitals encourage this behavior.  Drive around the country and you’ll see hundreds of hospital billboards advertising their current ER wait time.

      • cheyenne says:

        In Cheyenne, CMS CU Health with wait times of no more than 15 minutes, hired 5 PA’s to cover emergency care that doesn’t require an ER visit.  Healthcare Specialties, who are open seven days a week, has the same wait time.  What is actually happening in the nation are clinics are opening to serve those who used to go to the ER.  Banner Health in Phoenix has opened 3 clinics in Safeways, get your health care between the fresh produce and meat aisles.  What has driven this is the ACA.  Colorado was the first to note that ER visits went up when the ACA was passed so other health clinics have opened.  A common misconception was that there were many that were uninsured when actually Medicaid was always available.  The difference now is these health providers are assured of some payment which is better than nothing.

        I know there is disagreement when I say I had better health care and shorter wait times in a small Nebraska town, 12,000, than I had in Redding, but it is the truth.  And that better healthcare has been in Wyoming and Colorado too.  I also know I had better healthcare and shorter wait times than Redding when I lived in Walnut Creek, Kaiser.

    • Greg Greenberg Greg Greenberg says:

      You’re preaching to choir on that one, Gary.  A vast majority of the patients I see in the emergency department are there for convenience.  However multiple studies have demonstrated that occurs with those who are insured in addition to uninsured/Medicaid.  It’s more of a change of our mentality as a country.  When you see hospitals advertising wait times it’s because they have stopped fighting this change and have embraced it.

      As far as the cost of health insurance, our inefficient delivery of healthcare has made it unaffordable for many.  My health insurance for my family and myself is over $1300 per month.  That’s about the same as it cost me prior to the ACA.  The average income family cannot afford this which is why we put the burden on the employers and the government.  To me, it still doesn’t make sense not to just have a government paid, single payer healthcare system.

      This is my way of responding to several different comments.

      • Tim says:

        Hospitals are embracing the hospital-as-primary-care model because it now pays to do so.  If unnecessary ER visits were only reimbursed at urgent-care rates, all those fancy new real-time wait billboards would go down in a hurry…

        Lobbyists are a problem only because we allow a regulatory system that protects entrenched institutions.  It says “no you cannot start specialized medical training at age 16” and “no you cannot buy that benign drug over the counter” and “no, without a doctor you cannot see the results of your own blood test to see if your maintenance dose is still optimal.”  Sure, there can be risks of customers screwing up without professional supervision, but when those risks don’t seem to be causing problems elsewhere (e.g. Mexico) you have to wonder if your laws are doing more to protect an established industry than the consumer.  I can pump my own gas too, thank you very much…

  7. Duke K. says:

    There is a need to reduce health care costs, among other governmental expenditures,  if we want to have a sustainable financial future (i.e. reducing the national debt).

    The eight hundred pound gorilla would lose weight if we had a single payer system as was originally the case with Medicare, and if everybody was incentivized to control costs, which seems impossible with for profit insurance companies managing health care.

    The two ton elephant, however, is military expenditures.  Clinton was fortunate  to have a “peace dividend” (no wars) which enabled the country to balance its books for the first time since Truman and Eisenhower.

    Trump’s take on that is to declare the war is over and say that we’ll kill the terrorists where ever they are. Lotsa luck with that…

    • Tim says:

      You could eliminate the entire military budget and still run a slight deficit: the federal government spent $3.8 trillion (of which $598 billion is military) and took in only $3.2 trillion in revenue.  And those numbers do jot account for the growing unfunded medicare & social security liabilities (which currently total over $100 trillion — 5x the stated national debt).

      P.S. Bill Clinton’s budget surplus was due to an accounting sleight of hand involving intergovernmental debt; the total US debt still went up $18 billion during this supposed 268 billion surplus.

  8. hollynchase says:

    Thank you Dr. Greenberg for a clear and concise article. It’s true what they say about opinions and certain body parts, but the opinion of an experienced ER doctor is worth my time.

     

  9. Michael Xywz says:

    Reality Time. 29 million people have opt-ed out of ACA, likely to grow to 45 million in a couple of years. ACA has tripled premiums for unsubsidized low-users in the individual market. For most self-employed, it makes no sense to purchase an ACA policy for $26,000 a year, with a $13,000 deductible. We have never participated in ACA, as we have exercised our right to opt-out.

    • Gary Tull says:

      That’s your prerogative, Mr. Xywz. However, IMO, It’s a better idea to shore up the ACA (which is already standing) rather than to totally squash it before having a plan to rebuild and move forward.

      • Michael Xywz says:

        Better for whom?  Not for the 29 million who have chosen to opt-out.  There is no fixing ACA, other than pouring more and more money into it.  ACA will push out funding for education, housing, science, infrastructure, welfare, art, etc.  A massive waste of money. For now, our best hope is that millions more of us will opt-out until this immoral and irresponsible money-sucking-mess is destroyed.

  10. Wes says:

    I don’t understand why no one addresses healthcare costs.  Why can you fly to some other country and get an operation and a month off for less than an outpatient surgery in the US?  What specifically makes US healthcare so expensive?  Malpractice insurance?  Profits? Doctor’s salaries? Unnecessary tests?  Is US healthcare just that good compared to the rest of the world?

    I’d like more information on costs of healthcare vs. access and premiums.  Can something be done to control/lower costs?

    • Greg Greenberg Greg Greenberg says:

      Wes, I addressed this in other comments but simply our healthcare delivery is inefficient and there are incentives to deliver unnecessary care.  We have a massive number of lobbyists that protect this crazy system, not just the pharmaceutical companies.  We should be looking at rewarding quality and outcomes, not just doing something.  Our system needs a radical overhaul and the ACA didn’t go nearly far enough.

      • Wes says:

        Greg,  So if we compare someone fighting breast cancer in the US vs. another country (a specific case may be hard to compare- perhaps country-wide averages) what are the cost differences?  How many more tests do we do here?  Are our outcomes better?  I feel like “our healthcare delivery is inefficient…we should be looking at rewarding quality and outcomes…” is correct, but it’s a sound bite.  What does efficient delivery of healthcare look like specifically?  What country is doing it correctly (or better that us)?  It seems to me ACA addressed access and to lesser extent premiums (by way of government handouts) but didn’t do anything about costs.

        • Tim says:

          5 year survival rate:

          US: 89%  China: 81%

          Average total cost of treatment:

          US: $100,000 (3.4 × average annual salary)  China: $24,000 (3.2 × average annual salary)

          Average age at diagnosis:

          US: 65  China: 53

          The prevalence of breast cancer in China is lower than the US, but rising rapidly as they adopt a more western lifestyle.  The use of birth control alone increases the risk of breast cancer by 30%.  Each childbirth reduces the risk of breast cancer by 14%.  Western diet & exercise also increase incidence of cancer.

          As for the difference in treatment costs, few Chinese hospitals have the latest imaging technology and almost all drugs are generic.  Additionally, medical schooling is shorter in China and doctors are salaried (no incentive to perform extra treatment).  Offsetting this, corruption is higher and bribery is not uncommon.

  11. Daniel Philpott says:

    As Einstein said, “The solution to the problem does not lie in the paradigm that created the problem.” We need to move away from disease management and toward health…..

  12. Denise says:

    Thank you! This is in line with my key sources of information. Margaret Beck is another wise word in this circle.

    Preventative care is where it’s at. Family planning actually hits several key areas: if mom has good guidance on her and the children’s obesity/other health concerns, she’ll build on seeking, cooking better food for her family, even planing physical activities. Yes, daddies can do it too but statistically young men don’t see health care professionals as often as women do.

    On a related note, I’m increasingly worried about Women’s health access in our rural area. Oddly several poverty level women in my circle are hitting brick walls when they try get care (tubal ligation, ablation, etc) from MediCal. Does anyone know if there’s been a funding hiccup in this area?

     

     

     

  13. Greg Greenberg Greg Greenberg says:

    Denise I agree with you on both levels — Margaret Becknis awesome and preventive health care is vital.  As the focus on quality increases, I hope that we get better at preventive maintenance and preventing illnesss instead of treating it.

    Im not sure that there are any funding changes for family planning.  Family planning is available through many clinics in our area.  The procedures you mentioned (tubal ligation, uterine ablation) require a gynecologist and that’s a limited resource with possible delays.

  14. Common Sense says:

    Good info and much appreciated Dr. G!

    The reason health care costs keep going up is the RX companies and Insurance companies have some pretty influential Lobbyists! Not to mention the Political donations are pretty decent!

    We need to get back to a Prevention approach and compensate Dr’s for their “Healthy” patients…not for hitting 68% on their patient counts that are immunized for the bonus!

    The Middle Man….the Insurance company is a for profit entity…they contribute to the overall expense of health care….

    The Repeal and Replace was just an attempt to cut taxes on the rich and for spite….yes ACA needs some tweaks…no doubt….but without something better in place or proposed that helps All Americans it was just another Political move with Zero Compassion.

    As the old saying goes…an ounce of prevention….

     

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