Affordable Care Act (ACA), are there any benefits?

Posted by Stephen Weinberg, MD FACC FACP
The most frequent question I am asked, aside from medical issues, is what is my opinion of Obamacare. To borrow a cliche, there is the good, the bad, and the ugly.

The GOOD:  No denial of insurance coverage for pre-existing illnesses, insurance cannot be dropped for developing a costly illness, no lifetime insurance benefit payment cap, children up to 26 years of age are covered by parents insurance, premium subsidies for low income people, promote quality of care, insurance companies must spend at least 85% of premium dollars on actual health care limiting profits.
The BAD: More than 2000 pages of little understood regulation, uncertainty about long term global savings (it may become very expensive), does not complete universal health care.
The UGLY: Complex proposed system reforms of payments that have not been shown to improve quality of care or reduce the costs (recent program studies by Medicare have shown no benefits), programs that put hospitals and physicians at financial risk if costs exceed budgets, complex formulas that promote electronic medical records use and e-prescribing, and "Medical Homes" (defined here) which is an unsubstantiated plan to promote quality of care without really knowing what metrics are important and what are the best ways to measure them.

I think the GOOD and the BAD are fairly self-evident. I would like to amplify the UGLY.

Obamacare has set in motion a series of changes to healthcare delivery in an effort to reduce costs and improve quality. One major change is the advent of Accountable Care Organizations (ACO's). These entities are large hospital systems, physician collaboratives, and insurance companies that agree to accept a lump sum payment for the total care of patients. Could this be a reincarnation of the HMO system that was not felt acceptable to the US population? The groups make money if the expenditures are less than the amounts they receive and they lose money if the costs exceed those amounts. So what? That's how it has always been. Well, the problem is that physicians will also be at financial risk, meaning their incomes will be inversely impacted by the amount of money they spend on your healthcare. My concern with this is that physicians should have as their primary concern the health and well-being of their patients. They should be the ones to fight for the needs of the patients. Once they are salaried by the parent group and their income is dependent upon the bottom line of the insurer or hospital, the need to conform and not advocate for the patient is too overwhelming. As a patient, I do not want my doctors to have that intense conflict. I want to know that my physician will do whatever is necessary to fight for my needs, whether it is a CAT scan, stress test, chemotherapy, surgery, rehab, or any other element of care I may need. I do not want to feel that I must second-guess my doctors decisions as to whether they are made with my best interests as the primary concern or the interests of the ACO or himself. As a physician, multiple times a week I argue with insurance companies on behalf of my patients so they can obtain needed tests or procedures. How confident are we that this will continue under the new system? Do we really want to worry about who is looking out for our welfare? Currently, it is the physician, but likely, no longer. This is the beginning of rationing of healthcare.

Another UGLY is the development of "Medical Homes" (defined here again) which are designed to promote coordination of care, save money, and improve quality. Though the concept of coordinating care with these objectives in mind is laudable and makes sense, there is little or no evidence that it actually works. A recent study demonstrated no benefit of these collaboratives. What seems to make sense does not always stand up to scientific testing. An accompanying editorial by the Dean of the Nevada School of Medicine cautioned against adoption of new healthcare systems until they are proven to be effective. He stated, "It is time to replace enthusiasm and promotion with scientific rigor and prudence ..." In other words, before we scrap a system that is responsible for superb healthcare that is the envy of the world, we should know the changes will create better quality and lower costs. Obamacare is moving ahead with sweeping, drastic changes that have never been proven to be effective.

Of note is a Congressional Budget Office, CBO review of 10 large integrated medical practices that demonstrated no significant cost savings despite monetary incentives in a 5 year demonstration project. Another 6 year project involving 278 hospitals demonstrated no savings either. These studies were designed to determine whether financial incentives could result in overall cost savings. They did not, but that does not seem to have stopped the initiation of these programs by the government.

More about electronic medical records and e-prescribing later.

Bottom line: There are many good things about Obamacare and several things that are not. However, it is the UGLY that concerns me the most. These aspects of the law are going to create significant changes in the manner in which healthcare is delivered without any evidence they are effective. What is more disturbing is the fact that these changes will place your physician at financial risk in terms of the amount of money spent on your behalf. If your care and others cost more than the budget, your physician's salary will be decreased. This conflict of interest is disturbing and dangerous. As a patient, I think this is intolerable.

Call Congress and the President.