Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address for correspondence:
Spencer B. King III, MD, MACC, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
“Unprecedented” is a term often used to describe the incoming Administration, but uncertainty is undeniable. The new Administration and Congress face a daunting task in balancing campaign rhetoric with future reality. Health care financing is going to be at the forefront, and the providers of health care are nervous. Those who should be most nervous are the consumers of health care, also known as patients. The Affordable Care Act (ACA), commonly known as “ObamaCare,” is under fire, and Congress has pledged to repeal it. The incoming Administration demonized it in the campaign, and now just preaching against it will not be an effective policy. The citizens are waiting for answers.
There is no doubt that the United States has the infrastructure to provide health care to all its citizens. We spend 50% to 100% per capita more than any other modern country, so the money is there. The discussion is about how to finance it. Admittedly, the ACA is a bit of a camel (also known as a horse put together by a committee) because all of the players had to be in on the action. Compromises had to be made for insurance companies, pharmaceutical and device industries, hospitals, physicians, and so on to agree to the plan. Because it involves insurance, it needed to have almost everybody participating. Now there are exceptions. A “mandate” has become the main feature for attack. Why do we not call the requirement to have auto insurance a “mandate?” It is popular to talk about individual responsibility for health care, but is that possible? Are we individually responsible for national defense? Fire or police protection? I pay a water bill each month whether or not I use any water, so that we can have a municipal water system. The interstate highways are possible because we have agreed that our society wants to be able to drive anywhere. Accessibility to health care for all citizens is an issue that our society must consider. Individual responsibility to purchase health care is, for many, a flawed concept. How many healthy people would purchase health insurance if it was not subsidized by their employer? If they are self-employed or unemployed, they likely will buy groceries or a car before insurance. Who pays when the uninsured do get sick or injured? We all do—the struggling hospital, the medical practice, and the taxpayer. Many things have been decided to be in the common interest. Is health care one of them? In most developed countries, it is. Despite its problems, the ACA is more popular than ever, with record numbers signing up for coverage. Nonetheless, repeal of it seems to be the first order of business for Congress now that they failed to abolish the ethics panel.
In considering what to replace the ACA with, there might be room to consider what is actually beautiful about this “camel.” The expansion of insurance, including Medicaid to millions, should not be jeopardized, but expanded. The move toward health care financing for all Americans has started with the ACA. Now the opportunity to improve it has arrived. Many constituents of Congress undoubtedly have accepted the assertion that the ACA is responsible for their increased premiums. In part, it is because it has not yet been implemented as broadly as originally conceived, but also because health care costs have not been contained and nobody wants to give up their piece of the pie. Containment of medical costs will require efficiencies that will be painful to some who have been eating the pie. Effective improvement in patient care and accessibility needs to be rewarded (ineffective activities that do not influence patient care should not provide opportunities for saving). Should savings be put back on the patients by making them pay more and therefore avoid seeking medical care? How about reducing the incessant direct-to-patient marketing of drugs and devices? It must work by driving up utilization and therefore costs, or why else would it be done? Americans are the only people in the world who have to be constantly reminded of how Viagra works.
Individual initiative and entrepreneurship are hallmarks of successful American business, but health care is not a commodity to be marketed like hamburgers for profit. Our “pursuit of happiness” does not always just favor the individual. Schemes enabling low-cost coverage only for those young and healthy without pre-existing conditions while not providing comprehensive coverage for people who are more likely to need it will not approach reasonable universal health care. Changes in health care financing are necessary and complex, but should not be placed on the back of the patients. The first principle should be that appropriate and necessary health care is the responsibility of our society, not just “accessible” to those who choose to buy it. During this highly polarized time, it is no longer adequate to just attack ObamaCare. Those who have attacked it and those who have defended it now have to fix it. Much that is broken is due to this polarization. Many who like the benefits hate the name. Change the name if you must, but do not incur the shame that will come with shorting the citizens who deserve (in the 21st century) a health care financing system for all. Do that and you will help keep America great!
- American College of Cardiology Foundation