Thursday, August 10, 2017

The Affordable Care Act was not repealed. What next?

In light of the vote against repeal of the Affordable Care Act (aka Obamacare) two weeks ago in the Senate, it’s a good time to continue the dialogue about the successes of the Affordable Care Act, its problems, as well as reflect on what the future may hold.

While I won’t go into the politics of healthcare, I believe it is important that the public remain educated and informed on how we arrived at this major crossroads in the American healthcare system.

The Two Main Components of the Affordable Care Act
First, did you know that there are actually two major bodies of work within the Affordable Care Act? The first has to do with health insurance. By far, covering Americans with health insurance was the biggest draw of this healthcare bill. Before the ACA was enacted, roughly 50 million citizens were uninsured. Since the ACA was passed, that number has been cut roughly in half.

The other component of the ACA focuses on the actual health care delivery system. As you know, even though we don’t cover all of our citizens with health insurance, we still spend 40 percent more per capita on healthcare than every other advanced nation and we don’t have outcomes for chronic disease that are as good as those other countries. So the ACA began changing incentives to meet the triple aim of improved health outcomes, better care delivery, and lower cost. This part of the ACA has been successful. We’ve seen annual Medicare cost increases lower than ever before and new programs set in motion that incentivize hospitals, physicians, and nurses to drive better health care value that has also kept employer-based health insurance cost increases relatively low. We’ve been experiencing the success of the ACA and the incentive programs at GBMC.

Of course, no bill, no matter how well designed, is without its problems. Yes, the ACA significantly increased the number of low-income individuals and families who qualified for Medicaid coverage to the tune of about 20 million Americans. It also made it easier for middle-class Americans to buy individual policies when they did not receive employer sponsored insurance, accounting for about 15 million more Americans who could purchase and choose their own plans on the newly created healthcare exchanges.

Why was this a big deal? Because prior to the ACA, people could buy individual policies from insurance brokers – if they were healthy. Because only healthy people could qualify, the rates for these policies were relatively low. People who were sick or had a pre-existing condition (such as epilepsy, diabetes, or even cancer), however, were deemed uninsurable. The pre-existing condition clause in the ACA opened up health insurance to a whole new pool of individuals who were no longer discriminated against by the insurers. This was a great win for millions of people.

But, once you create a market for sick people to buy insurance, the healthy people must also be required to buy insurance to balance out the costs.

This is the part of the ACA that is not working.
The incentives for healthy people to buy coverage were just not enough for many. Every time a healthy person decides to forgo health insurance pays the penalty, and takes their chances that they won’t wind up with a major illness or accident, the cost of insurance goes up…and up, and up.  And every time the cost of healthcare insurance goes up, more and more young and healthy people decide to roll the dice, take the risk, and not buy insurance, leaving a yet higher percentage of sick individuals in the insurance pool which drives costs up further. In some states across the country, this is causing insurance companies to stop selling policies to individuals. In these states, the exchanges are at risk of failing.

Going forward, we need to figure out how to make these exchanges work. We need a bipartisan effort to fix this part of the ACA, whether that means steeper penalties for healthy people who don’t buy health insurance, or more significant incentives for the healthy to enroll in coverage to keep costs lower for everyone. I am hopeful that the bipartisan work that started in Congress last week will come up with some good ideas to help fix this. Remember, the goal is better health outcomes with better care experience at lower cost. I don’t know anyone…Republican, Democrat or Independent…who is against this. 

As a result of this turmoil, many people are now considering a single payer system for the first time in our healthcare history. This would eliminate the problem of pre-existing conditions and differing policy costs because every citizen would be covered in the same huge pool of people.

This doesn’t mean socialized medicine or total government control of our healthcare system. This is the misperception that is hindering our efforts to even discuss this as an option.

Think about this: There is a single payer system in Canada. In Canada, it’s like Medicare for all, where Canada (like Medicare), is just paying all the bills, not providing the care. Actually, it is the U.S. government that provides more care than the Canadian government. The Veterans’ Administration is government-delivered care (is the VA socialized medicine?). Because of the single payer system, Canada spends about five cents on the dollar on insurance administration. In the U.S., we spend about  18 cents on the dollar on administrative costs and profit (which is actually lower than the previous 22 cents on the dollar the U.S. spent before the ACA). The difference between that 18 percent and five percent is billions of dollars! Many Americans believe this is pure waste.

A single payer system does not mean government provided healthcare. In all of the debates and discussions about the future of our healthcare system, Americans need to stay calm and listen to the dialogue about what single payer actually means.

There are pros and cons of all of the healthcare systems in the world. There is no perfect system…our goal as a nation should be to make our system better. We can make great progress even without a single payer system but we must come together to truly explore the evidence and our options.

We have a long road ahead of us to get to where we need to be with our healthcare system in this country. Staying educated and informed is vital to keeping a smart dialogue moving forward.


  1. I appreciate you explaining how the ACA affects us all in terms that are easy to understand. There's a lot of misconception out there & it helps me to have a better discussion when that topic comes up.


Thank you for taking time to read "A Healthy Dialogue" and for commenting on the blog. Comments are an important part of the public dialogue and help facilitate conversation. All comments are reviewed before posting to ensure posts are not off-topic, do not violate patient confidentiality, and are civil. Differing opinions are welcome as long as the tone is respectful.