Congressional Republicans, emboldened by their recent midterm election victories, have lost no time assuring the public that they plan to repeal the Affordable Care Act (aka 'health care reform.'). They have not, however, been specific or transparent about the considerable consequences of repeal. As physicians who care for patients, we remain concerned about this approach.
Repealing ACA would mean millions of children and adults with pre-existing conditions would find their health insurance in jeopardy. Thousands of young adults who can now get coverage on their parent's insurance plan would lose their coverage. Seniors would no longer get prescription drug rebates and would continue to face the Medicare "donut hole." Small businesses would have to give up tax credits for providing health insurance to their employees.
But the real nightmare is in the alternative that Congressional Republicans have proposed: expanding high risk insurance pools, expanding tax-deductible health savings accounts, and allowing insurers to sell poorly-regulated policies across state lines.
Expand high risk insurance pools. 35 states already have such government-run insurance plans for high risk individuals whom private companies won't cover. As Harold Pollack and others have described, these arrangements don't work well. Ordinarily, insurance pools together sick and healthy people to spread the enormous cost of illness over time and across the population. Most of us pay insurance premiums even though we're healthy because we know that we may get sick at some point - and we can't predict when.
A high risk pool turns this model on its head by pooling only high risk individuals who have already lost coverage--the sick or those who are likely to be sick. The predictable results to date: such programs charge prohibitively high premiums in many states (thereby not serving most of the people who need help) and state governments still have to cover 40% of their cost. Despite some valuable recent improvements in these programs, it's unrealistic to presume that high risk-pools can provide anything more than modest, temporary help.
Expanding health savings accounts (HSAs.) HSAs are tax-advantaged savings accounts usually offered to people with high-deductible health insurance plans. The idea: if you consume less health care, you keep more money and incur less cost. HSAs are an attempt to address a genuine problem, whereby patients are shielded from the actual cost of health care decisions and hence consume more.
Unfortunately, this approach has enormous problems. First, the biggest savings in health care aren't in reducing discretionary care--the big money is in managing chronic disease and end-of-life care. Especially in such cases, health care choices are complex, and often arise in difficult circumstances which make it hard for many people to make these choices well. The available data indicate that patients cannot reliably distinguish between necessary and unnecessary services. So, while HSAs may lower utilization, patients will end up forgoing both necessary and unnecessary care. Third, the economic benefits of HSAs are largest for healthy, affluent people who enjoy significant tax benefits and who (for a while) bear the lowest risks.
If we want to reduce unneeded or harmful care, we should create a rational payment system that rewards quality, not quantity, of care. We should fund research that helps doctors understand which treatments help patients and which do not. And we should invest in building models of care that use team-based approaches and modern technology to improve quality and safety. The ACA makes advances in each of these areas.
Allow firms to sell insurance across state lines with little accompanying oversight. Without proper regulation, the likely effect of Republican proposals would be a race to the bottom. Insurers would relocate to states with low regulatory standards and provide low cost but also low quality care plans with inadequate benefits. We've seen this before, as when credit card companies attracted consumers with easy credit only to impose debilitating fees and other unethical practices. For many patients, the full costs of bad insurance would only become apparent once they become sick and discover that their insurer will not cover reasonable care.
Insurers have had many decades to impose high standards for transparency and quality on themselves. They have not done so. A better approach is to protect patients through regulation and to promote interstate transactions. The new health law actually does this through strong regulatory provisions and enabling the creation of health insurance compacts between states. Through these compacts, consumers can buy insurance with greater confidence that there is meaningful coverage behind their insurer's glossy brochures.
For all its flaws, the ACA is the most significant step our nation has taken toward providing health security to all Americans and controlling health care costs. Congressional Budget Office estimates of Republican proposals have consistently indicated they would only cover a few million of the 32 million people covered by the ACA - and they would worsen the deficit. As physicians who see seriously ill uninsured or under-insured patients suffering under the staggering weight of medical bills, this is not acceptable from a humanitarian or policy perspective.
There is undoubtedly more work to be done. If Congressional Republicans want to get serious about helping ordinary Americans, they can start by building on the Affordable Care Act, rather than trying to score political points by tearing it down.
Vivek Murthy, MD, MBA is an attending physician and instructor at Brigham and Women's Hospital and Harvard Medical School. He is the co-founder and president of Doctors for America, a national grassroots organization of 15,000 physicians and medical students in 50 states whose goal is a high quality, affordable health care system for all Americans. [Note to readers: I am an advisor to this group.]
Rahul Rajkumar, MD, JD is an attending physician at Brigham and Women's Hospital and Harvard Medical School. He was a health care advisor to the Obama campaign and Presidential Transition Team.