Should US doctors mourn for Obamacare?BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1441 (Published 24 March 2017) Cite this as: BMJ 2017;356:j1441
- Adam Gaffney, instructor1 2,
- Zackary D Berger, associate professor3 4,
- Saurabh Jha, associate professor of radiology5
- 1Harvard Medical School, Boston, MA, USA
- 2Cambridge Health Alliance, Cambridge, MA, USA
- 3Johns Hopkins University School of Medicine, Baltimore, MD, USA
- 4Johns Hopkins Berman Institute of Bioethics, Baltimore
- 5Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Correspondence to Z D Berger , S Jha
Yes—Adam Gaffney, Zackary D Berger
The Affordable Care Act (ACA), otherwise known as Obamacare, is in the crosshairs of Donald Trump’s rightwing government. The president and congressional Republicans have made clear that they want to repeal the law. And on 6 March the House Republicans released a bill (the American Health Care Act) designed to do so, but it doesn’t have the party’s full support. Trump has threatened lawmakers that he will abandon healthcare reform altogether if they fail to pass the bill, but surely Obamacare cannot escape unscathed for long.
The Republican agenda should be resisted. This is not because the ACA is perfect: in truth, it leaves much to be desired, a fact that contributed to many voters’ dissatisfaction with the healthcare status quo. Yet the Republicans’ proposals would only make things worse, risking the ACA’s most useful—and lifesaving—provisions, to the detriment of healthcare in the United States. They would, however, benefit the rich through generous tax cuts.
Millions more people insured
The ACA reduced the ranks of America’s uninsured by 20 million people.1 It also banned insurers from discriminating against people with pre-existing conditions, from charging women higher premiums, and from setting lifetime or annual insurance caps on coverage, among other provisions. These are all long overdue reforms that the Republican plan would keep.
The ACA’s funding also included a new progressive tax on high income investors, which the Republican plan eliminates (together with various taxes on the healthcare industry).
Nevertheless, the new bill could result in an estimated 24 million more people being uninsured by the year 2026, according to the nonpartisan Congressional Budget Office (CBO).2 Such a reduction in health insurance coverage would be a moral catastrophe.
Estimates of the resultant mortality are admittedly wide ranging, though still essential. Whether we assume that the “number needed to insure” to save one life a year3 is as few as 455,34 or as many as 1094,35 the estimated rise in the number of uninsured people could result in tens of thousands of unnecessary deaths annually.
The precise adverse effects of Republican reform will depend on the final form of the legislation, but if it resembles the bill released on 6 March67 much harm could be done. Although the bill would, like the ACA, continue to provide subsidies for the purchase of private insurance plans, the subsidies are more regressive than those in the ACA. Tax credits would depend only on age, not on healthcare costs and income of the recipient (they would start to fall only once individual income exceeded $75 000 (£60 000; €70 000) or family income $150 000).
Tax cut for the rich
The bill would also end the ACA’s cost sharing subsidies, which help reduce out-of-pocket spending for some low income Americans (albeit inadequately), hurting those with greater medical needs. And it would reduce federal funding for the ACA’s Medicaid expansion while moving federal funding of state Medicaid programs to a “per capita” system that could lag behind growth in healthcare needs, driving people from Medicaid. Therefore, the law effectively provides a tax cut for the rich—so that the poor may suffer.
In fairness, the ACA left much unaccomplished. The CBO estimates that 26 million people are uninsured in 2017 even with the ACA in place,8 while increasing out-of-pocket costs in recent years (in particular, rising deductibles) have strained finances and limited access for millions of families.9
But rather than moving backward—as the Republicans seem to intend—we should move forward, to real universal healthcare with single payer financing. Single payer healthcare could provide coverage to the whole nation while effectively controlling costs.10 The perilous rightwing healthcare agenda—which would do neither—should be vigorously opposed.
The Affordable Care Act (ACA) inspires ideologically driven love and hate. It is neither utopia nor hell but an experiment with delivery and payment methods, a provisional assumption. According it permanence is conceding that healthcare cannot be improved.
Though logical, a single payer system is improbable: even the most liberal state, Vermont, deemed giving everyone access to the highest end medical care too costly. Reform should therefore focus on costs, which, ironically, the ACA barely addressed despite its name.
The ACA’s creators were reluctant to cap payments because of memories of the public backlash to health maintenance organizations. Instead, they believed that incentivizing doctors for value and quality, not volume, of services, could improve quality and reduce costs. These evidence-free aspirations, yielding clever soundbites such as “healthcare, not sick care,” were premature, however, because the science of measuring quality is rudimentary and prevention is a blunt tool.
Encouraging physicians to deliver the “right care” sounds simple, but in a complex clinical encounter knowing when the wrong care is being delivered isn’t easy. The electronic health record, the crux of payment reform, became so clunky that physicians became disillusioned with it. The quest for value found neither value nor thrift. Instead, it frustrated physicians with an epidemic of metrics, mindless compliance with which led to ennui in many.
Difficulties in individual market
The ACA reformed the individual market for insurance, which covers 10% of the population, but left alone consequential employer sponsored insurance, the way that half the population gets its healthcare paid for.
The individual market is the Achilles’ heel of health insurance because of low participation, high administrative costs, and a battle of attrition between regulators and insurers. The ACA raised premiums for healthy people by forbidding insurers from rating people by risk and mandating the medical services that compliant plans must cover. To reduce premiums, insurers limited the physicians in their networks. Thus, some people are paying 14-49% more but for fewer options.
Because of the losses they incurred, a few insurers abandoned the individual market. But this market is the last refuge of small businesses, the engines of the economy, and must be nurtured with care, not dictatorial supervision. To reduce premiums for healthy people, insurers should be allowed to rate by risk. People at high risk should have their insurance subsidized by general taxation.
The safety of employer sponsored insurance relative to the individual market created “job lock,” because people feared losing coverage if they changed jobs. Guaranteed renewability, whereby premiums are unaltered when people at low risk become ill, should be extended to employer sponsored insurance so that people can carry their premiums to the individual market. Premiums in the individual market and health savings accounts should be tax deductible, or this status should be abolished for employer sponsored insurance.
ACA’s good features
The Republicans must overcome ideology and support the ACA’s good features, such as mandated health insurance and insurance subsidies, and be cautious of market fundamentalism. Although there is scant evidence that markets entice consumers to choose wisely, they can encourage direct pay medicine. This predated the ACA and will become more popular with high deductible insurance and health savings accounts. Direct pay, by saving on the costs of complying with insurers’ regulations, can make primary care cheaper for middle class people.
Hospitals should be forbidden from charging people who are uninsured or have high deductibles more than Medicare rates. Costs can be reduced. Many regulations of the Food and Drug Administration are necessary but barriers to bringing generic drugs to market, which allow distributors to price gouge, should be reduced. Importation of generics should be allowed. And Medicare should negotiate prices with drug companies.
Trade-offs in healthcare
Trade-offs in healthcare must be discussed publicly. Reverse moral hazard, or demand pooling, has imposed the costly medical care preferred by affluent people, such as advanced imaging for screening, on the less affluent, who may want bread not cake. Market segmentation should be allowed because healthcare is not “one size fits all.” The goal should be universal basic healthcare and universal protection from bankruptcy, not universal access to the highest end care.
Competing interests: All authors have read and understood BMJ policy on conflicts of interest and declare the following: AG is a board member and officer in Physicians for a National Health Program, an organization that advocates for single payer healthcare in the United States. ZDB is active in National Physicians Alliance, a physicians’ group advocating for the Affordable Care Act, and is the treasurer of Clinicians for Progressive Care, a political action committee advocating for access to quality healthcare.
Provenance and peer review: Commissioned; not externally peer reviewed.