Affordable Care Act Deeply Flawed in Face of Reality
Color me skeptical. I’m a bit of a non-believer when it comes to the Affordable Care Act (ACA).
Since the beginning, I’ve lacked the faith required to accept the notion that the federal government—the same people who brought you the managerial efficiency of the United States Postal Service—have the understanding required to effectively reshape the American healthcare system. I’m not alone. A recent USA Today poll shows that 4 in 10 Americans still believe that the ACA will make things worse, compared to only 3 in 10 believing it will make the system better.
I routinely present on this topic to audiences ranging from senior citizen’s groups to professional societies and college classrooms. Their responses to my skepticism range from outright anger to absolute elation.
In my presentation I discuss the many problems presented by the design of the ACA, most poignantly the gross underestimation of the cost of the legislation, as well as the innumerable challenges presented by the law’s implementation. I’m often labeled a cynic for my opinion.
But it’s hard to not be cynical of a piece of legislation passed on a party-line vote, by elected officials who voted in favor of the law without actually reading it—and of those who claim to have read it, few of them understand the depth and complexity of the issue. Comprehending the nearly 2,500 pages of the law itself would be near impossible; understanding the tens of thousands of pages of references in the law would be an otherworldly challenge.
Beyond that, there are thousands of pages of not-yet written rules, regulations, and additional legislation. Not only did they not understand what they were passing, but we’re expected to believe that the members of the state and federal legislative branches and the political appointees of the administrations of the President and various governors have what it takes to successfully implement the law.
To put this into perspective, I offer the following example regarding Medicaid (aka Medi-Cal in California), the joint federal-state health insurance program serving low-income families, seniors, persons with disabilities, children in foster care, as well as pregnant women, and certain low-income adults. The problems with Medicaid are well documented, including the fact that the program under reimburses healthcare providers, which reduces patient access, while simultaneously driving up the cost of private insurance through cost shifting. Medicaid is underinsurance. Despite Medicaid’s paltry reimbursement, it’s still bankrupting the state. To top it off, research has shown that some Medicaid patients actually have worse health outcomes than people who are uninsured.
Yet despite this reality, the political supporters of the ACA saw Medicaid as such the model for high-quality healthcare services that the majority of the so-called “coverage” expansion under the ACA is accomplished through an expansion of this welfare program. According to a Kaiser Family Foundation study, if all states participated in the Medicaid expansion as envisioned under the ACA, the number of new Medicaid recipients would increase by 17.9 million people by 2016, compared to 5.9 million under pre-ACA criteria. Surprisingly, none of the new Medicaid recipients will be our elected officials.
But my family and I are privately insured, so what do I know?
Well, in addition to working in healthcare for nearly two decades, I was a Medi-Cal recipient for the better part of my young life.
I learned firsthand at a very young age that the politicians’ prescription for health is often based on idealistic intentions, rather than a pragmatic understanding of the reality on the ground. The care that my siblings and I received under Medi-Cal was sorely lacking, to put it mildly. My congenital heart disorder was not found when I was a child, despite the fact that I was clearly symptomatic. It wasn’t until I had private insurance as an adult that the problem was diagnosed, and fixed. My sister stills lives with the challenge of being a Medi-Cal patient.
But this is a reality that few of our politicians have ever experienced.
I believe that it is imperative for elected officials to see the outcome of their decisions and to shape policy accordingly. They must be insightful—and agile—to help fix the many problems of the ACA and in our health system in general. Unfortunately, in our current political climate, this is unlikely to happen.
The Republicans will never admit that there are any positive attributes to the ACA. I actually believe there are a number of helpful initiatives related to outcomes based reimbursement and innovation, for example. If they recognized this, Republicans would have to admit that the Democrats got it partially right.
The Democrats, conversely, can never admit that there is anything wrong with the ACA. It was their signature domestic policy achievement from 2008-2010—and they went all-in for the President.
For a bipartisan legislative body that is supposed to find common ground for the betterment of the country, this is not a good starting point. Regardless, I challenge them to try.
I recently presented about the challenges of the ACA at a medical society dinner in Imperial County. During the question and answer session, a physician asked if I had any ideas for fixing the system. I replied:
“The first thing I would do is reform Medicaid, and the best first step there would be to limit all federal elected officials and their families to Medicaid for their healthcare coverage. I guarantee it will be fixed in a matter of weeks.” This suggestion was very popular with the physicians present.
Perhaps the benefit of some perspective would change the nature of this debate, and help shape a brighter healthcare future for all Americans. As elected officials and their families came face-to-face with the realities of Medicaid, we might finally see some real reform for the most vulnerable among us. Given the scope of the looming Medicaid expansion, this might be a good first step toward reforming the reform.
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Byzak specializes in healthcare government affairs and is board certified in healthcare management by the American College of Healthcare Executives. He was recently recognized by San Diego Magazine as one of the 50 People to Watch in 2013.
This opinion piece represents Mr. Byzak’s personal views of is not intended as a policy or position statement of any institution.