Affordable Care Act: Reforming the Reform

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With a historical and heated Presidential Election on the horizon, one of the more decisive campaign issues playing on voter's sympathies (besides the economy of course) is health care reform in the United States. The passage of President Obama's Affordable Care Act (Informally called "Obamacare"), one of the most controversial hunks of legislation in recent history, has many outspoken members of the medical sector fearing the stability and function of their own professions, as a move into socialized health care becomes a reality.

As a quick recap, the Affordable Care Act angles to shrink the population of uninsured Americans and to reduce the overall expenses of health care. The novel legislation offers numerous incentives (including subsidies and tax credits) to employers and individuals as means to enlarge the overall insurance coverage swath. The law also encompasses other reforms aimed at improving the healthcare machine by streamlining the health care delivery method, and by requiring that all insurance companies cover all applicants and offer the same deductible rates regardless of their pre-existing conditions or gender. Furthermore, the Affordable Care Act's budget strives to lower future deficits and extraneous spending.

To some members of the general public, the law reform may be a godsend. It extends the insurance coverage of numerous Americans and builds on the societal expectation that indeed, everyone has the right to be insured. However, the legislation comes under heavy criticism. In Alyene Senger's Side Effects: Doctors Fear Obamacare, she cites a Michigan surgeon who describes the move from fee-for-service healthcare to socialized healthcare as a step away from "humanity based patient healthcare to commodity based healthcare." Physicians must also consider the shrinking reimbursements, higher wait times for patients and a prolongation of their own retirement timeline. Many highlight these very points as evidence of the law reform's deteriorating effects on the medical profession.

ACA's "Opposition"
"Day One, Job One: Repeal Obamacare" sings a widely distributed ad campaign paid for by the Romney administration. In fact, according to Kivon Yoo's Romneycare vs. Obamacare: A Comparison the Affordable Care Act has come under much condemnation from the Presidential hopeful as "inappropriate for the Nation" and has become a significant crux in the campaign. Indeed, repealing the act was a unanimous battle cry from all seven Republican Presidential candidates.

However, despite the outspoken opposition to the law, critics aren't ready to sink all their hope into Romney as the profession's saving grace or white-coated prince. Why not? A piece of Massachusetts reform legislation that then Governor Romney signed into law in 2006.

The Massachusetts Health Care Insurance Law Reform (cleverly nicknamed "Romneycare") mandates that nearly every Massachusetts resident procure some type of state government-regulated minimum level of healthcare insurance. Additionally, the law provides free health care insurance for residents earning less than 150 percent of the federal poverty level, and was conceived to cover roughly 95 percent of the states uninsured population (500,000) over a three year period. Though the reform has undergone some amendments since its introduction (including a major revision related to health care industry price controls) many, including Kivon Yoo, regard it as a spiritual forerunner to the federal reform enacted by President Obama.

Same Difference?
Ultimately, the three major tenets of Romneycare, chalk up to the same ones of the Affordable Care Act. Both reforms aim to expand the Medicaid program for those without financial access to sufficient insurance coverage. Both reforms open up the Health Insurance Market via subsidies for low-to-moderate income individual's families and both reforms outline "tiers" of coverage, as well as individual requirements and pre-requisites for parties to purchase insurance.

However, the reforms have some differences, one standout being that the Massachusetts Health Care Insurance Law Reform provides more monetary assistance for small business owners looking to insure their employees. Still, the most notable difference between the two comes in the form of vitriol and opposition towards the Federal law, a phenomenon that doesn't entirely register with Massachusetts state reform.

To better understand the healthcare climate that could result in the wake of the Affordable Care Act's from the passage and integration of the Affordable Care Act, we can actually look to the Republican opponent's reform ("The Massachusetts Experiment") for ideas. Since the reform was enacted, roughly 98 percent of Massachusetts' population has become insured. Higher insured populations are generally ones more health conscious and more likely to keep close contact with their physicians and clinicians. Certainly, the expansion of Medicare/Medicaid programs contributes to a more insured populace and a paper by the Massachusetts Institute of Technology and the Harvard School of Public Health reports on the impacts of these expansions. The study finds that with higher insured populations, particularly those covered by Medicare, Hospital utilization increases by 30 percent and the number of health procedures increases by 45 percent. Insured populations proved more likely to seek preventative care (For example, Women are 60 percent more likely to have mammograms and recipients are 20 percent more likely to get their cholesterol checked). Furthermore, these populations showcased an increased propensity to report one's health as "good" or "Excellent" (25 percent higher than the National average) and those insured were roughly 10 percent less likely to be diagnosed with depression.

Generally, the Massachusetts reform was well received by doctors and patients. A Physicians News article titled A Peek into Obamacare's Future via Romneycare cites surveys by Harvard and the Boston Globe in declaring 63 percent of them in open support of the legislation. The fact that the reform actually encourages patients to seek preventative care is described as a "brilliant concept" in the article and the close communication shared between doctors and government agencies creates an open dialogue for them to be heard. Health care providers, physicians and clinicians have a clear voice in the discussion and can enact policy and change for better or for worse.

Optimism too Simplistic?
Is it all rosey? Unfortunately not and optimism may be a bit too simplistic. Many Massachusetts physicians remain wary of the administrative burden created by the reform. In RomneyCare 2.0 and Chances for a Reformed System Jeffery Singer, M.D. FACS describes his experience with the reform as witnessing "the death of the medical profession as doctors become bureaucratic clerks." Additionally, many physicians find that with the government presence in their work, a growing amount of time-consuming paper work gets introduced. Some, like Dr. Joseph W. Ganel Jr, President of the Massachusetts Academy of Family Physicians, have found that they've had to employ people to their practice just to handle the paper work alone. (In Massachusetts, Physicians Bearing Brunt of Reform Effort). This increased emphasis on red tape and bureaucracy limits the effectiveness and efficiency of physicians and takes their minds off the more important aspects of their job.

Though already well verbalized by opposition to President Obama's Federal reform, state reform comes under fire because the increased coverage swath "disincentives" doctors from seeing patients because reimbursements are so poor. In extreme cases, Medicaid directly results in a decrease in reimbursements for health care. Take for example, Dr. Wertsch. In 2011 he had to stop admitting new Medicare patients to his Wildwood practice (one he opened in the 70's) because of shrinking government reimbursements. "The reimbursement is so low with Medicare, in some cases $60-80, it costs you more to get a plumber at your house than to get a rheumatologist at your hospital" (How Obamacare's $716 Billion In Cuts Will Drive Doctors Out Of Medicare).

Perhaps the most troubling component of the Massachusetts reform comes in the form of cost containment...or lack thereof. Essentially, the administrative plan was to get everyone covered, and then to start working on the logistics. Councils were established in 2008 to try and curb spending, and a 2011 proposal by Governor Deval Patrick (D) pleaded for a changeover from fee-for-service work to global payment for state employees, Medicaid recipients and newly enrolled recipients of the commonwealth health reform (roughly 25 percent of the state's populace). These gargantuan expenditures that accompany such reforms and expansions (approx $67 million) have many in the profession shaking their heads and postponing their retirements.

Objectively speaking, problems with Medicare's costs predate the Massachusetts' Health Insurance reform, and even that of the Affordable Care Act. Since the '60s, politicians have struggled to reduce runaway expenses, but quick fixes (like bumping up the retirement age, raising premiums or reducing benefits) were considered politically dangerous and so Doctors and Governors grind to the same halt: paying healthcare providers less to provide the same level of service.

The Future for Small Practice Physicians
Looking to "The Massachusetts Experiment" gives us some insight into the road ahead if the Affordable Care Act becomes fully implemented. Harvard professor of Economics, Greg Mankiw, cites American economist Arthur Okun's "tradeoff" principle to illustrate a point. Where Okun declares that the tradeoff between economics as a continual compromise between "quality and efficiency," Mankiw uses the same structure to illustrate healthcare reform as a tradeoff between "community and liberty." While the bill offers more community in that all Americans get more insurance regulated by a centralized authority, they are also offered less liberty in the form of insurance mandates and higher taxes.

Furthermore, he believes that the bill will add to the fiscal burden as it raises taxes substantially. Though 80% of healthcare premium charges are to be spent on benefits and quality improvement (something that was conceived to drive the cost of health insurance down), premiums have increased by another 4-6%. It's true there are some credits and tax breaks to working physicians, but they're clearly not enough to offset mounting expenses. While talk of the bill's "deficit neutrality" may calm some frazzled nerves, it's an erroneous proposition as the legislation makes solving the problem of the fiscal imbalance even more difficult. It raises taxes and heavily impacts the GDP.

Indeed, under the new legislation CBO experts predict that Medicare spending will increase significantly more slowly and that payment rates for physicians will continue to decrease, as Medicare payments have already been reduced by 21% in 2010.

Ultimately, how to pay for health care, and the way in which it is delivered are two crucially important, but significantly divergent aspects of the healthcare equation. Both should be treated as such for the best result, and equal consideration must be given to each separately. Regardless of the best intentions put forth into covering Americans, the economic outlook for physicians isn't a good one.

The Massachusetts experiment, as well as the National reform, may satisfy the humanist aspect of the healthcare puzzle in that everyone has access to insurance, the populace is healthier and we live longer. Unfortunately, the fiscal and political side has yet to be curbed, and voters and small practice physicians should take note for an overhaul or a repeal.


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Doulgeris, James. "How a Romney-Ryan Administration Could Affect Physicians.
"Physicians Practice. UBM Medica, 16 Aug. 2012. Web. 12 Sept. 2012.

Mankiw, Greg. "Healthcare, Tradeoffs, and the Road Ahead." N.p., 22 Mar. 2010. Web. 17 Oct. 2012.

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Roy, Avik. "How Obamacare's $716 Billion in Cuts Will Drive Doctors Out of Medicare."
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Senger, Alyene. "Side Effects: Doctors Fear Obamacare."
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