Guest post from Kimon Bekelis, MD
Neurosurgical Resident, Dartmouth-Hitchcock Medical Center
The passage of the Affordable Care Act (ACA) has led to sweeping changes in the United States healthcare system, yet many questions about its implementation remain. Fortunately for neurosurgeons, during the 83rd AANS Annual Scientific Meeting held in May 2015, James C. Capretta, a senior fellow at the Ethics and Public Policy Center and a visiting fellow at the American Enterprise Institute, was one of the featured speakers who delivered an impassioned speech expressing his current view of the status of the ACA. He covered three areas in his talk:
- Drawbacks of the ACA;
- A current legal case against the ACA (King v. Burwell); and
- The potential for viable replacement of the ACA (Burr-Coburn-Hatch proposal).
Drawbacks of the ACA
Mr. Capretta suggested that the ACA is unpopular with the public for the following reasons:
- Millions have seen increased health insurance premiums;
- Millions have been forced out of their insurance plans;
- Many have had to leave doctors that they liked (which they were told they could keep);
- Medicare payments have been reduced; and
- Taxes have been raised to pay for a massive new entitlement program.
Mr. Capretta further contended that healthcare reform has largely ignored the poor. He noted that the healthcare safety net has far too many holes because the ACA was built on a flawed system of health insurance. Lower income families, especially those enrolled in Medicaid, have a difficult time finding doctors who will accept their coverage. About one-third of physicians refuse to see new Medicaid patients, and referrals to specialists are especially difficult. In Washington State, for example, primary care physicians had 75 percent more problems obtaining a specialty referral for Medicaid patients than for those with commercial coverage.
Lastly, Mr. Capretta pointed out the ongoing dysfunction and inaccuracies of the ACA website, which he claims continues to cost U.S. taxpayers a significant amount of money. In his analysis, despite the claims and costs, the ACA has increased insurance coverage for Americans by a mere five percent.
The outstanding legal case against the ACA (King v. Burwell)
King v. Burwell is the case, now on the Supreme Court’s docket, contesting the legality of the federal government subsidizing insurance premiums for individuals in states that chose to utilize the federal insurance exchanges, rather than opting to build their own state-based exchange. A decision against the government’s provision of the subsidies would undermine the law in the 37 affected states and, in the process, disrupt insurance for millions of people who signed up for coverage on the assumption that the subsidies would be available.
Mr. Capretta speculated that there is a high possibility the Supreme Court will rule against these federal subsidies. He believes if the administration loses the case, President Obama will denounce the ruling as ideological and demand that Congress fix it, with no strings attached. He also estimated that the administration would develop a workaround for the states, allowing them to designate and use the federal exchange as if it had been built by the states. This would give administration officials a justification to continue paying federal subsidies in the states agreeing to the workaround, even if it were legally questionable. However, Mr. Capretta sees this case as one of the last opportunities for re-directing healthcare policy and replacing the ACA.
The potential for viable replacement of the ACA (Burr-Coburn-Hatch proposal)
Mr. Capretta was careful to point out that America’s healthcare system has significant strengths that must not be overlooked. Most notable is an openness to medical innovation, less centrally planned systems, and a network of clinics and hospitals capable of offering the most advanced care found anywhere in the world. The vast majority of Americans (almost 80 percent) have ready access to this high level of care through third-party insurance arrangements through coverage from their employers or federal programs like Medicare and Medicaid. Another 10 percent have individually purchased coverage. However, in his opinion the rising cost of healthcare necessitates a new system to replace the ACA.
Mr. Capretta claimed that significant progress has been made in developing a practical and workable alternative to ACA. For example, in January 2014, Sens. Richard Burr (R-N.C.); Tom Coburn, MD (R-Okla.); and Orrin Hatch (R-Utah) introduced a plan called the, “Patient Choice, Affordability, Responsibility, and Empowerment Act,” to replace the ACA. Listed below are key features in the proposal which were deemed as a credible alternative to the ACA:
- A commitment to market-driven healthcare;
- Retention of employer-based coverage;
- Continuous coverage protection; and
- Better healthcare for the poor.
Although, it’s unlikely that this plan will be passed into law, Mr. Capretta believes that it’s a good basis for discussion and future attempts to replace the ACA.
Within a days, the Supreme Court will announce a decision in the King v. Burwell case. Regardless of what the court ultimately decides, it will be interesting to watch how the next chapter of the ACA will unfold.