Presented by: Marci Krop Cook, M.D.
As physicians, you have a rare role in society. Not only are you doctors, but you are also U.S. citizens, business men/women, and eventually patients. The newly passed Affordable Care Act (ACA) affects all four of your societal roles making it extremely influential in your lives. You can no longer afford to think that you don’t need a voice in political matters. The voice you thought you had from your current medical societies may not be truly representing your needs. Physicians have respect from the public, but in order to command this respect you need knowledge about the issue and a voice.
Originally, the Senate and the House of Representatives were drafting separate healthcare reform bills and were going to combine them to make an approved law. However, when Senator Kennedy left the Senate, they lost their voting majority. To get the bill passed into law they bypassed the normal legislative process of meshing the house and senate bills and instead used the reconciliation process to get just the senate bill into law. What was left after the dust settled was the ACA. This enormous 2,000 page document was never intended to be the final law and was passed without many Congressmen actually reading it. Constituents can either read the law or rely on a biased media to inform them of what it entails.
The law is intended to provide easier access to insurance for everyone, higher quality healthcare and lower costs for healthcare. Upon reviewing the 10 titles that encompass the ACA, it begs the question of whether it actually achieves any of these goals.
1) Insurance reforms/mandate: This title stipulates that insurance companies must accept everyone, their deductibles will be limited, they are forced to renew coverage and many other regulations. Their premiums will be strictly regulated and cannot be based on the health status of the enrollee. In order to participate in the exchanges, insurance companies will also be required to provide a Qualified Health Plan (QHP) which is a plan that provides essential benefits which are determined by the secretary of Health and Human Services. Essential benefits include ER/hospital visits, maternity, pediatric care and others. Each state will make its own exchange. This exchange is where individuals and small businesses will be able to go to buy a QHP from individual insurance companies. They will be able to pick from a variety of plans from insurance companies. Citizens will be eligible for subsidized health insurance from the exchange if they have income of 133-400% of the federal poverty level. There is also an individual mandate in this title that requires you to purchase a qualified health plan or to pay a penalty.
- Concerns: With insurance companies’ expenses increasing and premiums decreasing, many of them will leave the medical field. This may lead to only government insurance plans available for consumers. This will reduce patient choice.
2) Medicaid: The ACA forces the states to accept anyone with a 133% income in relation to the federal poverty level into Medicaid. State governments have always been allowed to decide an appropriate level for acceptance into Medicaid. The ACA takes away this right and gives it to the federal government.
- Concerns: This is a constitutional issue. States need to be able to govern without extensive federal interference. This significantly weakens the states power when it comes to healthcare. Also, 50% of the new people who will be added to Medicaid already have insurance or have chosen to be self insured.
3) Healthcare Delivery Models: The newest healthcare delivery system created by the ACA will be an Accountable Care Organization (ACO). Basically this is a number of different practices (i.e. primary care, hospitals, specialists etc.) that come together as one to provide high quality and low cost health care.
- Concerns: This all sounds great but seems unrealistic. Consumers prefer to go to their own primary care, their own hospital and their own specialists. ACOs take away this option and force patients stay within the ACO. Some patients may even be automatically funneled into an ACO.
4) Public Health: The most applicable aspect of this title is that all of your medical equipment must be handicap accessible. That means every waiting room, every medical table, and every doctor’s office must be handicap accessible.
- Concerns: If you office is not fully handicap accessible, you will have to spend money doing so or will be subject to a penalty.
5) Workforce: The ACA will establish the National Healthcare Workforce Commission which will be responsible for training a workforce, such as nurses, to provide more accessible healthcare.
- Concerns: This title creates the training of a workforce to replace doctors. Already, there are Federally Qualified Health Centers operated by medical practitioners who did not go to medical school. These will only expand with the enactment of the ACA and will make it easier for people to practice medicine without attaining the proper education.
6) Oversight and Penalties: “Whoever pays holds the power.” The ACA will create the Patient Centered Outcome Research Institute. This institute will create the research justification for establishing protocols for diagnosis and treatment that doctors must adhere to. In addition, standards of performance are established in the ACA to evaluate doctors. The standards are health outcomes, efficiency of care (adherence to protocols via number of resources used), patient satisfaction and meaningful use of electronic health records. This data will then be analyzed and results will be posted on a website where patients can go to see specific ratings of each doctor.
- Concerns: Because doctor’s reimbursement will be tied to performance ratings, there will be no choice but to adhere to government standard protocols. Having these standards set by a centralized bureaucratic agency prevents your ability to use your medical knowledge and experience to treat patients as individuals. This is what destroys the doctor patient relationship.
7) Drugs: Whenever you are given samples, the pharmaceutical company must report it to the government.
8) CLASS Act: CLASS stands for Community Living Assistance Services and Supports. The CLASS Act is intended to help functionally disabled or impaired adults by providing long term care insurance.
- Concerns: to receive any benefits you must pay monthly premiums for at least 5 years. Unless participation is mandatory, it is highly likely that CLASS will be insolvent in the near future. The upfront premiums provide additional funding to the ACA.
9) Raising Money: To keep the ACA running, the government must create 163 new federal agencies. In addition, the ACA dramatically expands entitlements in Medicaid and in the exchanges. This all, of course, requires money. The CLASS Act is intended to be one form of funding. $500 million is being taken Medicare trust fund to provide money for other parts of the ACA. There is an assortment of taxes on health care practices. There will be new taxes on medical supplies companies, drug companies, plastic surgeries (5% of amount paid for the procedure), indoor tanning and many other medical related taxes.
- Concerns: In addition, your FICA, income tax and Medicare tax are all going to increase. This limits your funds and makes it even harder for you to run your business. It also taxes companies that you buy supplies from which will in turn raise prices.
10) Amendments to Preceding Titles: This title simply alters the previous nine titles.
The ACA gives vast power to these new government agencies and their decisions require no judicial or administrative review. It also challenges state and individual rights by forcing states to relinquish Medicaid decisions and forcing citizens to purchase a QHP. The government has never been able to tell its citizens that they must buy something. The ACA significantly increases government control over the business of medicine. Additionally, enacting each title of the bill will cost billions of dollars as well as “sums as necessary.” The ACA takes money out of the already dwindling Medicare trust fund and pushes the country further into debt. With all the changes ACA attempts to make, it did not address two very important issues for doctors: medical liability and tort reform. In the end, the original goals of improving accessibility, quality and cost of medical care have actually been exacerbated rather than solved.
As physicians, you must come together with organizations like HCBA and Dr. Cook’s organization, Docs 4 Patient Care, to have your voice heard by Congress. You need to regain control over your profession. Visit docs4patientcare.org and get involved with an organization that has your best interest in mind.