Marya Zilberberg, MD, MPH is an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. I recently reviewed her excellent book on evidence-based medicine, Between the Lines. The following post was first published on her blog, Healthcare, etc.
This was a big day for President Obama's signature legislation, the Affordable Care Act. The Supreme Court upheld its constitutionality, and the punditdom thinks that further challenges are unlikely. On the other hand, if Romney takes the White House in the next election... Well, you can guess what will happen then.
It has been interesting to watch the run-up to this decision. Most recently I have been amused by surveys finding that on the one hand, many American people are in favor of the pre-existing condition inclusion (this part of the bill forbids insurance companies to discriminate against people with prior health conditions), as well as the provision that allows young adults to stay on their parents' insurance policies through a certain age. On the other hand, the majority of Americans are against the healthcare law itself, and most also oppose the individual mandate provision (this is the part where everyone has to buy insurance or pay a tax). Given this imbalance in the public opinion, a more pertinent survey should have assessed how well people understand these provisions in the first place. And this would have had to establish how well the public gets our whole healthcare "system."
To start from the beginning, any healthcare system can be judged on three criteria:
1. How accessible is it?
2. Is it of adequate quality?
3. How expensive is it?
The answer to the first question provides one of the rationales for the individual mandate. Currently there are about 50 million people without health insurance in the US, and, hence, without adequate access to the system. Many of these people are the young and the healthy who gamble on staying young and healthy. And many are consigned to relying on expensive emergency care when this gamble fails. Some of them go bankrupt trying to pay for it, while others become "safety net" cases, where the institution that cares for them swallows the costs. These institutions do get some public dollars for providing safety net care, but not nearly enough to break even. Since many of the 50 million don't buy health insurance because they cannot afford it, the healthcare bill provides a way to create more affordable insurance products.
The answer to the second question is not related directly to the individual mandate. Since much of this blog is devoted to the issues of healthcare-associated harm, I do not wish to belabor this point here. Suffice it to say that the bill does try to address this catastrophic situation, though it remains to be seen if it will succeed.
The third question is the crux of the story. Many have said that the escalation of healthcare costs is unsustainable, and I subscribe to this notion: I am not sure how much more than $2.6 trillion/year we want to pay for this insatiable beast. Yet judging by the near-revolt that "death panels" rhetoric caused, the citizenry is not interested in being thoughtful about what services make sense. The vehement knee-jerk to the "R" word shuts down the discussion before it even starts. So, OK, how do we pay this ever-increasing bill? Moreover, since we are all happy with the government mandate for all insurance to pay for pre-existing conditions, how do we propose to pay for this additional coverage? Short of printing money (not generally a good idea) or creating a single-party payer system that regulates these expenditures, the only way is to broaden the pool of revenue. The way the ACA has proposed to broaden this pool is through the very individual mandate that is anathema to our American way of life. But without it, there is no broadening of coverage, and there is no paying for every intervention that we seem to feel entitled to.
I doubt very much that the ACA will substantively contain healthcare costs. I even doubt that it will solve the quality problems, but I am willing to wait and see on that. This bill is but a band-aid on an arterial bleed. However, I do believe that upholding this legislation allows us to take the first steps toward a reasonable national dialog about the kind of healthcare system we need. This dialog will not be helped by stupid surveys that reinforce our willful ignorance. We have the opportunity to move this conversation to a higher level, where people begin to understand the issues we are up against more deeply. Let's take it.