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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