UPDATE: Thank you to the Community Spotlight people. As pointed out in the comments, if you like this, please re-share on Facebook et al. so that non-dKos people can see it. The newspapers (Globe, NYT, Christian Science Monitor) have so far passed on it.
UPDATE 2: Doctors for America site is excellent. http://www.drsforamerica.org/
My work is anxiety. As a psychiatrist, people come to me with their fears. Not surprisingly, that often includes anxieties over affording their healthcare. In Massachusetts, where the 2006 healthcare reform assures coverage, such anxieties relate to the fine print of premiums and co-pays rather than having a policy. However, I also hear worries about the Affordable Care Act (ACA) and whether it will change care for the worse. The national debate, unfortunately, has not advanced the conversation.
We sorely need a factual explanation of the ACA. So, I’m going to take a pause from my usual neutral stance as a psychiatrist, and give some direct answers. As a member of Doctors for America from its inception in 2009, I have advocated for a national healthcare framework modeled after our system in Massachusetts. The result of this advocacy is the ACA. It does not strip people of their current coverage, any more than the framework established by Governor Romney. It connects people to informational and financial resources to find and keep private insurance coverage. Insurance companies compete to attract empowered patients.
(More below the squiggle-fold)
This is all good news. In Massachusetts, we are nearing 100% coverage of our friends and neighbors. In much the same way, 32 million Americans who lacked insurance in January of 2010 will have access by January of 2014, unless the ACA’s opponents weaken it. The current health insurance exchange here in Massachusetts is unchanged in this process. Instead, the other forty-nine states will catch up to us. Lower income and middle-class families throughout America soon will be able to afford private coverage sold on their state’s exchange. When employees have coverage, they can keep it. When they don’t, their employers will have financial incentives to provide it. The ACA preserves choice and ensures access.
The ACA is not a liberal boondoggle; it is good practice. The conservative Heritage think-tank developed the blueprint, incorporating ideas from Richard Nixon. Bob Dole proposed it in 1996 as an alternative to “Clintoncare.” It relies on the private market as the primary engine of coverage, establishing “rules of the road” and “safeguards” to ensure that we can all participate in that market. Government is not the health-care provider or the payer.
Its provisions are already working. It is currently protecting young adults. Young people can stay on their parents’ coverage until age 26. This provides a buffer period to get started in life without getting set back by health care expenses. My patients are mainly between ages 18 and 35. I have personally seen the positive effect of those extra 5-8 years of coverage. The repercussions of a flare of illness end with the remission of symptoms. There are fewer prolonged “financial symptoms.” In a tough economy, inhospitable for entry-level workers, that grace period is a welcome boon to even the healthiest young American. National scope brings mobility vital to establishing a career path. Repeal will instantly unravel these gains.
The ACA also protects seniors. Those in the Medicare Part D “donut hole” receive significant medication discounts; the hole closes completely in eight years. Medicare will further shift focus to prevention. It is phasing out co-pays and deductibles for proven preventative services. It is increasing payments to primary care providers who mainly bill for such services. In this way, the ACA backs the thinking of physicians: our society too often waits for disease to advance to treat it. Particularly with our senior citizens, we should focus on health promotion and quality of life. Intervening primarily at the point of catastrophe has not worked, fiscally or medically. To further strengthen the Medicare fund without sacrificing coverage, the ACA has stopped bonus payments that were going directly to private corporations for co-insuring Medicare patients. This had been an unnecessary manipulation of the free market by government. These changes will work on behalf of seniors. Reversing them will not.
The ACA protects “middle-aged” citizens too. For two years, it has banned lifetime limits on cost coverage. Over the next two years, it will phase out rejection of coverage due to pre-existing conditions. As state-regulated private insurance exchanges appear, it will provide tax credits to more than 50% of Americans to help buy coverage from those exchanges. A family of four making $88,000 will be eligible. And, to provide basic fairness through free market incentives, forestalling coverage after 2014 will incur a “free rider” penalty. This will relieve taxpayers of the catastrophic care cost for uninsured patients brought to emergency departments. The penalty is not regressively punitive: it caps at $695 per individual, 2.5% of household income, or $2085 per family in 2017. People are free to forego coverage but they cannot hand their neighbor the bill.
Massachusetts should be proud of this law. There is much in it that we can eagerly anticipate. The focus on prevention extends from Medicare to private insurance plans. It lasts from pediatric to geriatric care. Co-pays will be eliminated so as to promote wellness. They will disappear from routine checkups for children and seniors, and from major screening tests at all ages. Women will no longer pay out of pocket for hormonal medication, halting the worsening of endometriosis, polycystic ovary disease, and premenstrual mood disorder, among other conditions. Currently, more invasive and expensive alternatives are still used too often because these pills are not used in time . Communities will now be able to fund prevention programs through block grants. Outbreaks of contagious disease will decline. Shared costs of chronic disease will decrease. The public square will be safer. The physical and financial health of our country will be greater.
This law is not anti-business. On the contrary, it is structured to favor business development. It makes small business more competitive via a slow unrolling of a 50% tax credit for insurance premiums. This is much needed assistance with a historic burden on our engines of innovation and growth. Already, firms with fewer than 50 workers are eligible for as much as a 35% tax credit, ensuring a healthy workforce by insuring workers. In so doing, the ACA places small businesses on a more equal footing with multinational corporations that reduce their insurance costs through economies of scale or foreign universal coverage systems. When American small business is competitive, it creates jobs that are unlikely to be outsourced. In addition, the law has a “free rider” penalty for larger companies, similar to the one for individuals: it is incurred when large firms withhold coverage from workers and thereby divert them to state-regulated insurance exchanges. The penalty helps underwrite the tax credits to smaller businesses and the private insurance exchanges themselves. Taxpayers do not foot the bill for corporations that can well afford to provide coverage. Repeal of the ACA thereby favors the well-connected over the working person.
Finally, the ACA is about increased healthcare accountability. Insurers must spend at least 80% of their intake on healthcare. They must rebate the difference to plan holders if they spend less. No longer can they divert this money to executive bonuses or corporate profits. When they increase premiums, they must publically explain why on their website. By the same token, the government must display the ACA’s provisions on HealthCare.gov. The law also establishes a new website for the CMS Innovation Center that will display its findings as they conduct comparison studies of different care strategies. Patients and professionals alike can see if there are more efficient methods to promote health. The ACA ensures transparency and empowers the individual to make informed choices.
These facts have been left out of the public debate. Instead, we have frequently debated feared phantoms. There are no death panels, no tribunals of federal health commissars, just a research center that will publish findings from head-to-head trials of different modes of care. There is no central governmental take-over of healthcare, any more than we have had in Massachusetts. No one is forced to receive care against their wishes. These phantoms are born and perpetuated from the anxiety that we all have about our health. We keep thinking there must be some reason that we feel nervous, that the solution cannot be so simple. It isn’t, but the ACA is the result of over 100 years of debate on healthcare. Balancing liberal and conservative ideas, and factoring in existing biomedical knowledge about prevention, it’s a pretty good system that many doctors have been backing for years. The alternatives proposed thus far will not cut it. Total repeal of patient protections? Giving employers the power to cherry-pick which procedures they want to cover? Some nebulous plan called “YouCare,” in which “you” get the care “you” can pay for out of your savings? These are radical ideas completely at odds with American notions of liberty, democracy and responsibility. More importantly, they disempower the physician-patient alliance in favor of corporations and insurers. I prefer a system that helps my patients find the care they choose. That is the ACA.