There are a lot of things not to like about the Affordable Health Care Act, including the fact that it isn’t actually affordable, but I feel certain that the great majority of people, those who favor the law and those who do not, would agree that two of its purported benefits are good things. Those would be near-universal coverage and improved access to medical care. The problem is that the law does not provide either.
To achieve near-universal coverage the law seeks a huge expansion of the Medicaid program. Some twenty million people or so will be added to the various state-run programs, which in my state is known as MediCal (i.e., Medicaid). Proponents of the law call this providing health insurance to those currently without it. But MediCal isn’t insurance. It’s welfare. There’s a difference.
Insurance is something you buy. You pay premiums, deductibles, and co-pays for a product that, in theory, indemnifies you against large financial losses in the case of illness or injury, helps with the cost of medications, and avails you of the services of a wide range of physician specialists. Because it is expensive, you use it judiciously.
Medicaid is something provided to the medically indigent as a safety net. There are no premiums, deductibles, or co-pays. It is paid for by tax dollars. As a practicing emergency room physician for over thirty years I can attest to the benefits it provides those who must rely on it for their healthcare needs. I also understand its limitations.
Reimbursement rates under the Medicaid program are absurdly low. As a result most specialists, especially surgical specialists like orthopedists and ENT’s, don’t take it. Increasing numbers of primary care doctors don’t take it, either. Which leads to the AHCA ‘s second false promise, that of improved access to health care.
Simply having a Medicaid card does not guarantee you will get to see a doctor. Unless that doctor is working in an emergency room. We who work in the specialty of Emergency Medicine have always provided care to all comers, insured or not, and the EMTALA law codified that practice when it was passed in 1986. Under the new health law we will continue to see and treat all who come seeking care, but it will become even more difficult to do.
In the face of twenty million more patients with nowhere else to go our ER’s are going to become more crowded than they already are and waiting times will increase. Compounding the problem will be patients needing a specialist with no specialist on-call. This is already the case in many hospitals where trying to find an orthopedist, neurosurgeon, plastic surgeon or otolaryngologist is nearly impossible because these physicians have taken themselves off the ER back-up panels as a means of protecting themselves from having to provide high-risk, uncompensated care. The Medicaid patient needing a fracture reduced or repaired surgically will be splinted, treated for pain, and parked in an ER bed until a transfer can be made to a County hospital. That ER bed remains unavailable to another patient until the transfer can be made, and the overcrowding and wait times get worse.
To pay for the new health care law over half a trillion dollars will be taken from the MediCare program. MediCare is still accepted by most primary care physicians and a sufficient number of specialists and sub-specialists to make the treatment of those covered by it reasonably easy. Once the MediCare budget is cut, that will change and then seniors and the disabled will find themselves in the ER waiting room alongside the Medicaid patients.
Although there is speculation that the Supreme Court’s decision about the law’s constitutionality might render this entire discussion moot it is nevertheless an important discussion to have. One way or another our system of healthcare delivery and the way we pay for it is going to be revamped. If the Court gives us a do-over we must use that opportunity to construct a system that can actually do what the current law only pretends to do, namely make quality healthcare available to all Americans at a reasonable cost.
As I said at the top of this piece there are many reasons not to like the Affordable Health Care Act. If the Court allows the law to stand I will likely be writing about some of them between now and the November elections, which will then be our only chance to avert this impending disaster.
James V. Pagano, M.D., FACEP