A Dissenting Viewpoint on the ACA

To the Editor: With great interest I read the perspective piece written by Miriam Reisman, “The Affordable Care Act, Five Years Later: Policies, Progress, and Politics,” published in the September 2015 issue of P&T.1 I suggest that it is not possible to separate politics from the Affordable Care Act (ACA). If not for the questionable nature through which it was advocated, bordering on overt illegality at times, the vote itself demonstrates the highly partisan nature of its passage, as not a single Republican in either chamber voted in support and several Democrats voted against it. The law is compared to the passage of Medicare at times, yet even that vote had Republican support and Democratic opposition. Almost immediately, it was clear that this was to be a slanted view of the most controversial health care reform this country has passed, as Reisman ends her introductory section with, “But politics aside, is the law working as intended and meeting its primary goals?” A worthwhile query, one that should have offered the reader a litany of successes, failures, and opportunities for improvement. Yet, Reisman took the opportunity to paint a one-sided picture of selective and, at times, questionable achievements. In fact, her next section claims that the law has not only increased access to quality health care but has surpassed expectations. The statement demonstrates a lack of understanding or appreciation of three separate tenets of the provision of health care, namely, coverage, access, and quality. Each is mutually exclusive; obtaining one in no way is equal to the others. Safety-net hospitals across the country provide world-class health care to all, regardless of their coverage status. The ACA was enacted to affect coverage first and foremost. So, while I will submit that more citizens are covered under the ACA, I challenge claims about access or quality. These are indeed curious as they demonstrate an obvious failure to recall that the ACA was intended to completely address uninsured citizens of this country. According to the Kaiser Family Foundation, the uninsured rate among nonelderly individuals in 2013 was 16.7%, a level comparable to prerecession uninsured rates. In fact, a review of their data shows that rate to be consistent since 2000.2 Thus the first myth about the ACA is that all of our country’s uninsured would be covered. The data definitely do not surpass the expectation that the number of uninsured should be zero. With respect to the disparity of coverage in the Hispanic population, the Centers for Disease Control and Prevention (CDC) website indicates the percent of people under the age of 65 without health insurance coverage as 30.4%,3 not a figure with which one would associate success. The section “ACA Myths Versus Facts” reads as if it had been written by the White House administration. The first section deals with the minimum essential coverage (MEC) provision and the infamous statement by President Obama, “If you like your health care plan, you can keep it.” Repeated dozens of times, this was coined the 2013 Lie of the Year by the Tampa Bay Times Politifact.com.4 The article goes on to describe why some 4 million Americans were sent health insurance cancellation letters. And, to add fuel to the fire, some college student health plans were deemed not to have been in compliance with the MEC requirements and thus had to stop being offered. The next claim attempts to assuage critics of the ACA who warned that employers would drop health benefits. Reisman writes that “just 1% of employers reported that they had decided to stop offering health coverage …” A Washington Post article related similar information, but went on to describe a separate survey conducted by the Mercer consulting firm. Other notable findings: “4% of large employers are likely to drop coverage within the next five years, compared with 16% of employers with fewer than 199 workers.”5 Not sure that I would minimize the effects just yet as time will be the ultimate determiner of truth. Additionally, according to the CDC, “The percentage with private [health insurance] coverage generally decreased among persons under age 65 between 1997 and 2014 but remained stable from 2010 to 2013. Among adults aged 18–64, private coverage was more than 5 percentage points lower in 2014 (67.3%) than in 1997 (72.8%). Among children, private coverage decreased between 1997 (66.2%) and 2014 (53.7%).”6 This data demonstrates a clear shift away from private coverage to those public means, and stands in direct opposition to the claims made by the author. Her attention next turns to access to care for the millions of newly insured. Reisman dismisses the claim about a lack of access as “largely unsubstantiated.” Attempts are made to spin this point to focus on the number of patients seeing a physician, yet a number of articles have detailed an increase in wait times for patients to be seen.7–11 A Forbes article cites results from a study done by the Merritt Hawkins consulting firm.12 The purported magical fix of insuring everyone, which did not occur, also did not improve access, so patients are not being seen in a timely fashion. To add to the burden, organized medicine has claimed an impending physician workforce shortage for some time, yet Reisman’s hypothesis is that “… the current supply of hospitals, doctors, and other providers should be sufficient to meet these needs.” An impossibility for those facilities that, and health care personnel who, are already working at their peak; an irrational and baseless claim that they are not, hence the arithmetic impossibility that the country’s health system is well staffed to assume care for millions of additional, newly insured patients. With respect to the claim that “… newly covered patients do not appear to be sicker …”, articles from The New York Times,13 CNN Money,14 Kaiser Health News,15 Bloomberg View,16 and CBS MoneyWatch17 over the last four months have all reported that health insurance companies are seeking big rate increases for precisely this reason. Make no mistake, the ACA does not increase access to care; it was intended to expand coverage opportunities, and that it did. It was erroneous of the law’s architects to think coverage begets access, which in turn leads to quality health care. Seemingly logical, this fails to account for how health care is delivered in the United States. Access is based on the delivery of health care by highly trained professionals. Aside from advocating scope-of-practice expansions for physician assistants, nurse practitioners, and other mid-level providers, it did little to address the physician deficit the country faces presently and will continue to in the near future. Reisman touches on the pay-for-performance measures enacted as part of the ACA, specifically, hospital readmissions and hospital-acquired conditions. She rightly states that both carry financial disincentives. What is absent is the data showing a disproportionate affect to the nation’s safety-net facilities, institutions that have realized factors external to health affect one’s care. Socioeconomic status, highest level of education attained, transportation and employment, the presence of grocery stores with healthy food, or even the ability to walk in one’s neighborhood for exercise, all play a role in whether or not patients will accept the personal responsibility necessary to manage their own health. Penalizing institutions that provide quality care for the sickest and poorest patients will not help those whom they serve. In fact, quite the opposite, when faced with tremendous losses, services need to be cut, disadvantaging the same population they are there to help. One thing about which Reisman and I agree is that there will continue to be an incredible divide between those who advocate for, and those who rail against, the ACA.