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From the Heart

If you have read some of my previous blog posts, you might think I add WAY too many links to my source material.  I am not going to include any links in this piece.

The truth is, I have invested almost 5 years of blood, sweat and tears into ensuring that the Patient Protection and Affordable Care Act was written, passed by both houses of Congress, signed by the President of the United States and survived a Supreme Court Challenge.  Now I am spending my time doing my best to see that the law is implemented.  As much as anyone, I am terribly frustrated with the deficiencies of the website healthcare.gov.  I am more frustrated that a few million Americans may see their health insurance premiums rise as their old policies are cancelled by insurers while making just too much income to qualify for offsetting tax subsidies.  These folks, especially if they are healthy, may not feel that there is any benefit to them to purchase a more comprehensive health insurance policy that they rarely use. 

But here’s the deal: we are all going to be better off.  By expanding the individual health insurance marketplace, we will see health insurance premiums stabilize.  This has not been the case for the past 30 years.  We have seen double digit premium rate increases, year after year, through many presidential administrations, without any legislation passed to protect consumers.  The Affordable Care Act finally protects consumers.  The law mandates that insurance companies spend at least 80% of all premium dollars collected on your health care, a needed provision when all of the major insurers’ CEOs get paid tens of millions of dollars every year.  The law forbids insurers from continuing the horrible practice of rescission, where policy holders are suddenly dropped once an illness is discovered.  The law ensures that your policy is renewable even if you get sick.  The law provides consumers access to an affordable policy, one that does not turn them away for having a pre-existing condition as trivial as heartburn or allergies.  The law prevents an insurer from cutting off support for medical bills since annual and lifetime benefit caps are no longer. 

The law has baked into it pilot projects attempting to revolutionize health care delivery systems.  Currently, we have a fragmented system – hospitals, doctors’ offices, pharmacies, and other providers administered care without much coordination.  The right hand of the health care system often was not aware of what its left hand was doing.  But coordinated care is now the hottest topic in health care thanks to the dialog begun by the Affordable Care Act.  The law has allocated funds for these pilot projects, although many coordinated care initiatives are being led by private hospitals, insurers and communities because of its transformative potential.  This would not have been so without the national debate begun with the Affordable Care Act.

I must admit, the single greatest driving source inspiring me to advocate for the Affordable Care Act are the innumerable uninsured patients I have cared for in Emergency Rooms, Hospitals, Free Clinics, and my office – beginning in medical school over 17 years ago.  I do not ever want to say to a patient, who is desperately asking me “how am I going to afford this,” that I am not sure how we will obtain a test, procedure or life saving medicine.  I want to be able to say, “You’re covered.” 

The Affordable Care Act has standardized – across Medicare, Medicaid, Tricare and private insurers – that preventive care is to be provided without out of pocket costs (co pay or deductible).  My practice experience has made it crystal clear that out of pocket costs shape the decisions of patients.  If it is unaffordable, they will delay needed care.  Without out of pocket costs for preventive care, it’s not quite as much of a challenge to help patients participate in recommended disease screenings.  

Underappreciated by all, The Affordable Care Act is going to encourage providers to focus much more on the costliest element of our health care system: those individuals who require complicated, ongoing, disease management.  When chronic care is executed poorly, preventable complications occur in patients with skyrocketing downstream costs.  Our sickest patients with the greatest need represent 84% of total health care expenditures – 99% of all Medicare spending.  The Affordable Care Act is going to encourage providers to screen for chronic diseases and intervene early while those conditions are still easily manageable using effective and efficient coordinated care. This will allow us to reduce health care spending for all of us – everyone who pays taxes and everyone who pays health insurance premiums.

The mantra of the Affordable Care Act among “insiders” mirrors the mission of the Institute of Healthcare Improvement – better individual care, better population health, at a lower cost for all.  This is the so-called “triple aim” drilled into us by Dr. Don Berwick.  I strive for this, as I know the 16,000 members of Doctors for America do every day.

You cannot communicate all of this in a sound bite.  Even harder is communicating all of the provisions in the law in a discrete period of time (think cable news).  I can speak ad nauseum about our $2.3 Trillion dollar health care system – we spend more on health care than the size of the entire national economy of all but 6 other countries. It is remarkable, and discouraging, to know how complex our health care system is and just how complex this law is, meant to attempt to improve just about every aspect of it. 

The Affordable Care Act will improve our health care system so long as it is allowed to work and provided some help in properly achieving implementation.  I am privileged in my career to have been witness to the most affluent and high tech care in the Duke Medical Center Intensive Care Units and the most impoverished care on the trauma surgery service at the District of Columbia’s General Hospital.  After taking care of thousands of patients in my lifetime, and immersing myself in health policy in the last 5 years, I want to see the Affordable Care Act succeed. 

Success will depend on advocates like Doctors for America sticking with this effort – learning about loopholes and problems and applying the proper fixes to the law.  This has a long tradition in our great nation.  After Medicare’s passage in 1965, there have been both major and minor changes to the program every year to make it better.  The Affordable Care Act has the same potential to improve year-after-year. 

The Affordable Care Act is here to stay, but without better public education and understanding, the effectiveness of the law is in jeopardy.  It would be foolish to abandon this critical law simply because a website is temporarily not functioning.  A website can be fixed. 

We need to meet the Americans who are losing their previous insurance policy and make too much to qualify for a subsidy.  These folks are angry, and understandably so.  I hope with good information, they will see that they will benefit in the long run.  I hope they never have to learn of the protections of their new policies due to a devastating illness, but I am glad if they get sick they will avoid bankruptcy. 

Every victory for this law brings new challenges, and that’s OK by me.  The law was never going to be perfect and fix everything.  It’s a start.  I have a feeling that I and my colleagues at Doctors for America will need to continue to work to improve our healthcare system for quite some time to come.  We plan to see this through.