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Should the Affordable Care Act of 2010 Be Repealed?

       Most Republicans in the 112th Congress pledged to repeal the Affordable Care Act of 2010. When Speaker of the House John Boehner was asked why the Republicans want to repeal the Affordable Care Act, he replied: “because ‘Obamacare’ would destroy the best health care delivery system in the world” (NBC News, January 6, 2011).

      Does the US Have the Best Health Care Delivery System in the World? Do All Americans Have Access to It?

      There are many reasons why one would expect the US to have the best health care delivery system in the world. We have a well-educated population with a high standard of living. We have well-trained health professionals and well-equipped hospitals and clinics. And most of all, we spend far more on health care than any country in the world!
      Organisation for Economic Co-operation and Development (OECD)
      OECD Health Data, 2010.
      If we have the world's best health care system, it follows that we would have the world's best health care outcomes. We don't! We lag behind other industrial nations in life expectancy, infant mortality, maternal mortality, and immunization rates.
      Organisation for Economic Co-operation and Development (OECD)
      OECD Health Data, 2010.
      In 2000, the World Health Organization ranked our health care system as the 37th best among 119 nations. We ranked #17 of 17 industrial nations.
      • Blendon R.J.
      • Kim M.
      • Benson J.M.
      The public versus the World Health Organization on health system performance.

      Why We Don't Have the World's Best Health Care System: The Uninsured

      The reason that we do not fare well in these health outcomes is that many of our citizens do not have access to ongoing primary and preventive care. To have access to ongoing preventive care, one must have adequate health insurance. In our country, up to 22% of our citizens were uninsured or had inadequate health insurance in 2007.
      • Schoen C.
      • Collins S.R.
      • Kriss J.L.
      • Doty M.M.
      How many are underinsured? Trends among U.S. adults, 2003 and 2007.
      Those without adequate insurance can seek help for emergencies in our hospitals' overcrowded emergency rooms—but where do they go for ongoing preventive care?
      The uninsured at greatest risk are those with chronic conditions. Nearly 40% of our population have a chronic condition such as diabetes, hypertension, asthma, or heart disease.
      • Hoffman C.
      • Schwartz K.
      Eroding access among nonelderly U.S. adults with chronic conditions: ten years of change.
      These conditions require ongoing physician care and nearly always require prescription drugs.
      Multiple studies document that patients with chronic conditions who are uninsured are less likely to have a usual source of health care, do not see a physician at least once a year, and have an unmet need for prescription drugs for their condition.
      • Hoffman C.
      • Schwartz K.
      Eroding access among nonelderly U.S. adults with chronic conditions: ten years of change.
      • Wilper A.P.
      • Woolhandler S.
      • Lasser K.E.
      • et al.
      A national study of chronic disease prevalence and access to care in uninsured U.S. adults.
      • Lasser K.E.
      • Himmelstein D.U.
      • Woolhandler S.
      Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
      Lasser et al
      • Lasser K.E.
      • Himmelstein D.U.
      • Woolhandler S.
      Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
      compared access to health care in Canada, where all are insured, with Americans who were or were not insured (Table 1). Access to care was almost identical between Canadians and Americans who had health insurance. Uninsured Americans were far less likely to receive regular care than Canadians or Americans with health insurance.
      Table 1Access to Health Care: Canada and the US
      • Lasser K.E.
      • Himmelstein D.U.
      • Woolhandler S.
      Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
      CanadaUS InsuredUninsured in the US
      Have regular physician85%85%40%
      Seen MD within year83%86%56%
      Unmet health needs?11%10%36%
      Can't afford medications5%8%28%
      The end result is more visits to emergency rooms, more hospitalizations, and increased mortality. In 2002, the Institute of Medicine reported that the mortality for uninsured Americans is 25% higher than for the insured.
      Institute of Medicine
      Care Without Coverage, Too Little, Too Late.
      In 2009, Wilper et al reported a 40% increased mortality in the uninsured.
      • Wilper A.P.
      • Woolhandler S.
      • Lasser K.E.
      • et al.
      Health insurance and mortality in U.S. adults.

      The Affordable Care Act and the Uninsured

      The major goal of the Affordable Care Act was to increase the number of Americans with adequate health insurance. Each of the methods to increase the number of insured was met with protest by the affected party. Many Americans objected to the individual mandate that they could face a modest fine if they did not purchase health insurance. Businesses objected to the mandate that they must provide health insurance. State governments objected to the expansion of Medicaid. Some insurance companies objected to the state-based insurance exchanges for individuals and small businesses. All these protests must be weighed against the fact that 95% of legal US residents could be insured by 2014 if this Act is not repealed. The US would finally join its fellow Western nations in ensuring that nearly all of its citizens have access to health care.
      • Dalen J.E.
      • Alpert J.S.
      National Health insurance: could it work in the US?.
      If all Americans had health insurance and received ongoing primary and preventive care, unnecessary hospitalizations could be prevented with a resultant decrease in our health care expenses.

      The Affordable Care Act and the For-profit Insurance Companies

      A second major goal of the Affordable Care Act is to prohibit many of the predatory business practices of health insurance companies. Some of the predatory acts that will be prohibited are shown in Table 2. Is there anyone other than health insurance executives who believes that these acts should not be prohibited?
      Table 2Predatory Business Practices by Insurance Companies that Are Prohibited by the Affordable Health Care Act
      Denial of coverage to children under 18 with pre-existing conditions (2010)
      Lifetime caps on benefits (2010)
      Retroactive rescission of insurance when expensive illness occurs (2010)
      Some restrictions on annual limits (2010)
      Some controls on premium increases (2010)
      “Medical Loss” <85% for large employers and <80% for small employers (2011)
      Annual limits on coverage (2014)
      Denial of coverage for prior conditions (2014)

      Who Are the Winners of the Affordable Care Act?

      Table 3 lists the net winners of the Affordable Care Act. All uninsured Americans will certainly benefit by receiving coverage. Patients with private insurance will be spared many of the most predatory acts of their insurance companies. Seniors on Medicare will be able to receive preventive measures such as mammograms and colonoscopy without co-pays or deductibles. In addition, by 2020, the “donut hole”
      • Dalen J.E.
      It's time to bail out seniors trapped in the Medicare donut hole!.
      that restricts coverage of prescription drugs will be eliminated.
      Table 3The Affordable Care Act: Who Are The Winners?
      200+ million Americans with private insurance
      50+ million uninsured Americans
      46+ million seniors on Medicare
      Health insurance companies
      Pharmaceutical companies
      Hospitals and clinics
      Physicians
      Health insurance companies will have additional patients. Pharmaceuticals will profit by the extension of insurance benefits that cover prescription drugs. Hospitals and clinics will have fewer nonpaying patients. Physicians will have fewer nonpaying patients and will receive increased compensation for primary care from Medicare (2011) and Medicaid (2013).
      The potential losers are shown in Table 4. The most vocal losers are those states that have difficulty funding their share of the cost of Medicaid for their citizens.
      Table 4The Affordable Care Act: Who Are the Losers?
      Health insurers with predatory business practices
      Individuals who do not want to pay for health insurance
      Employers with >50 employees
      State Medicaid budgets (2014)
      Patients with “Cadillac” health insurance (2018)
      Wealthy who will pay higher Medicare taxes (2018)

      Why do so Many Citizens Oppose the Affordable Health Care Act?

      The myriad lobbyists convinced many Americans that the government was “taking over health care.” This was a step toward “socialized medicine!” This fear of big government spawned the “Tea Party” movement, which led to the election of many congressmen who pledged to repeal the Affordable Care Act. Many Americans were convinced that a “public option” would mean government control, and the possibility of government “death panels” denying health care.
      The opponents of a government role in health care overlooked the fact that, as of 2010, nearly half of all US health care expenses are paid by local, state, and the federal government.
      • Hartman M.
      • Martin A.
      • McDonnell P.
      • et al.
      National health spending in 2007: slower drug spending contributes to lowest rate of overall growth since 1998.
      Those seniors who protested against a government role in health care seemed to forget that their insurance—Medicare—is administered by the federal government. Worst of all, the congressmen who railed against a public option had very generous health insurance administered by, and paid by, the federal government.
      Let's not repeal the Affordable Care Act of 2010!

      References

        • NBC News
        Brian Williams interview with John Boehner.
        (Accessed February 27, 2011)
        • Organisation for Economic Co-operation and Development (OECD)
        OECD Health Data, 2010.
        OECD Publishing, Paris2010
        • Blendon R.J.
        • Kim M.
        • Benson J.M.
        The public versus the World Health Organization on health system performance.
        Health Aff (Millwood). 2001; 20: 10-20
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        • Collins S.R.
        • Kriss J.L.
        • Doty M.M.
        How many are underinsured?.
        Health Aff (Millwood). 2008; 27: w298-w309
        • Hoffman C.
        • Schwartz K.
        Eroding access among nonelderly U.S. adults with chronic conditions: ten years of change.
        Health Aff (Millwood). 2008; 27: w340-w348
        • Wilper A.P.
        • Woolhandler S.
        • Lasser K.E.
        • et al.
        A national study of chronic disease prevalence and access to care in uninsured U.S. adults.
        Ann Intern Med. 2008; 149: 170-176
        • Lasser K.E.
        • Himmelstein D.U.
        • Woolhandler S.
        Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
        Am J Public Health. 2006; 96: 1300-1307
        • Institute of Medicine
        Care Without Coverage, Too Little, Too Late.
        The National Academies Press, Washington, DC2002
        • Wilper A.P.
        • Woolhandler S.
        • Lasser K.E.
        • et al.
        Health insurance and mortality in U.S. adults.
        Am J Public Health. 2009; 99: 2289-2295
        • Dalen J.E.
        • Alpert J.S.
        National Health insurance: could it work in the US?.
        Am J Med. 2008; 121: 553-554
        • Dalen J.E.
        It's time to bail out seniors trapped in the Medicare donut hole!.
        Am J Med. 2009; 122: 595-596
        • Hartman M.
        • Martin A.
        • McDonnell P.
        • et al.
        National health spending in 2007: slower drug spending contributes to lowest rate of overall growth since 1998.
        Health Aff (Millwood). 2009; 28: 246-261