Is Obamacare working?

Well, Is It?

The answer, as one might imagine, depends completely on whom you ask. The recent, end of March deadline had most members of the Obama administration very happy, showing over 8 million people signed for insurance through state and federal exchanges, which exceeded their goals.¹ Overall, 31 states exceeded their targets for enrolment, including a number of heavily Republican states in the South.² So the answer from the administration would be ‘yes’.

The Republicans would say, of course, ‘no’, because that is what they say about anything that might extend financial support for people on a low-income, especially anything proposed by President Obama. The Republican House has voted 54 times now to repeal or alter the Affordable Care Act (ACA). It gives them something to do while they are not passing any legislation of importance on, let’s say, climate change or immigration.

STATE GOVERNORS

States could either design the exchange process themselves or punt it to the federal exchange, which has had well-publicised start-up problems and website crashes. The states that chose to do it themselves were often surprising. Kentucky is a poor state whose economy relies on tobacco and coal (not the best products on which to build a future). Yet Kentucky, led by a practically minded Democratic governor and despite having two of the more reactionary senators in Congress, used federal dollars to help dramatically increase the number of people on Medicaid and begin to enrol people in private programmes.

Georgia and Florida were two other states with large enrolments through the federal exchange. Both states are seeing a large demographic shift with increases in African-American and Latino populations that are changing the voting profile to potentially be more Democratic. The governor of Florida, a former champion of industry in the country’s largest for-profit healthcare system, which paid $2 billion in fines for fraudulent Medicare billing, was elected with Tea Party credentials. He, however, like so many other Republican governors up for re-election, is finding he has absolutely no answer to ‘so what do you offer instead?’ when asked by his constituents. He recently went on a ‘listening session’ with Florida seniors to air faults with the ACA and instead got an earful of overwhelming support for it.

The closer legislators are to the lives of real people, the more likely they are to hear that having insurance is better than not having insurance. So, when asked about Obamacare, the governors might reply with a guarded ‘probably’. Except Texas of course.

Tea-party-against-Obamacare. (Image courtesy of FRONTPAGEMAG.COM)

DOCTORS

Doctors might answer the question of whether Obamacare is working with ‘we think so’, which is a good hedge. Resistance is not coming from younger doctors. The ACA is the reality that they will work with and so they are more interested in adapting and learning.

Each year 29 000 graduates of US residency training programmes join the physician workforce and, for them, there will never have been a pre-ACA environment. Within a decade, over a third of practising doctors will have started practice in the world of Obamacare and will be diligently working, out of self-interest as well as patients’ needs, to improve the law, not to repeal it.

FAMILY DOCTORS

The response from family doctors is a more enthusiastic ‘we certainly hope so’ since they see hundreds of examples of patients, for whom they have cut corners, finally being able to get the care they need and deserve. We hear daily attestations from patients who relate that their chronic anxiety about being financially wiped out by a health problem is relieved by now having insurance.³ All the system changes mandated by the ACA put primary care front and centre. But all one has to do is re-read the discussions that took place about health maintenance organisations in the 80s and 90s to see what happened to payment systems that emphasised preventive care, population management, and decreasing unnecessary testing and hospitalisations. The managed-care debacle ended up with a well-orchestrated campaign against primary care that resulted in decreasing the number of US medical students who entered residency programmes in family medicine.

Even such specialty-dominated markets as New York, Washington, DC, and Los Angeles, are writing about the shortage of generalists being the rate limiting factor in managing care. Recent distressing scandals about long waiting lists for care in the Veterans Affairs (VA) System are being blamed on the VA’s inability to attract and pay sufficient numbers of generalists for the growing population of veterans and their families. Large integrated health systems like Kaiser or Mayo Clinic or Group Health in Seattle have known and acted on primary care as being essential to both cost and quality. Family doctors in those systems are financially supported to increase new models of population care that include teams of nurses, educators, pharmacists, and outreach staff.

But family doctors in small unaffiliated groups, which are the dominant form of delivery of care, are quite anxious about the expected increased demand for care that the ACA is already producing and being overwhelmed by it. They don’t have the capital that big systems do to create clinical care teams to manage populations. They hope they don’t crash from too much demand, like the Obamacare website. Family medicine may be like the spring floods that are a perpetual problem in the Midwest; we spend dry years bemoaning our fate and contemplating perdition, and then spend the rainy and snowy years, like the most recent winter and spring, worrying about drowning in floods. The first 5 years of the ACA is a thousand-year flood for family medicine.

ACADEMIC HEALTH CENTRES

Academic health centres would answer the question of whether Obamacare is working with ‘we are engaging in studies that are, thus far, inconclusive and so we will wait and do more studies.’ Medical schools are full of very bright people who intellectually understand the likelihood of dramatic change in a short period of time but are paralysed by culture, bureaucracy, and a lack of urgency, as well as not a little arrogance.⁴–⁵ Medical schools may not just have first-class tickets on the Titanic but actually ARE the Titanic, and the evacuation will not be pretty. The failure of academic health centres to assure an adequate workforce to care for the people of the US is a scandal and one that they have never seriously addressed.

Deans have much on their minds and any inclination they might have to advocate principles of social accountability, like those outlined by Health Canada,⁶ gets quickly drowned in the clamour for more technology, decreasing funds from the National Institutes for Health (NIH), and clinical investigators who feel under-appreciated. The intractable nature of workforce issues quickly becomes someone else’s problem, perhaps the next dean’s.

THE PUBLIC

And, oh yes, the public! What would they say? They are confused. One of the funniest and most telling YouTube posts of the year was a man/woman-on-the-street interview by comedian Jimmy Kimmel asking Americans whether they favoured Obamacare or the Affordable Care Act (most favoured the ACA not knowing, of course, that it was the same thing).⁷ The ACA requires standards for different policies rather than allowing infinite amounts of fine print with variation that lets insurance companies off the hook. That has brought Americans into direct contact with costs of care: the different ‘standards’ have different coverage and different co-pays and deductibles. But what you get and what it costs is clear, for once, rather than the muddle of obfuscation that health insurance has always been — except Medicare, of course, which is clear, simple, and standard for everyone over 65. We seniors just love our Medicare. We even get our information in large print.

Americans also feel like things are too expensive but insist on getting what they want when they want it, whether it is an unproven test at great expense, like serum testosterone, or a phone call reassuring them that their bad cold is really a bad cold and nothing more. Being front-line physicians for the ACA requires family doctors to be negotiators with patients, be available so to decrease the urge patients have to go to emergency departments unnecessarily, and to use clinical guidelines to keep costs down. Specialists and hospital-based physicians feel no such compunctions and, in fact, to do so may affect their incomes. Until there are clear and consistently adhered-to processes for care by all clinicians, the public will always see ‘man with brain tumour denied CT scan’ headlines instead of ‘9000 patients receive unnecessary CT scans for headache’. The latter doesn’t have much traction. An important initiative of the American Board of Internal Medicine, co-sponsored by 60 additional specialty societies, is starting to make headway in advising doctors and patients what doesn’t work.⁸

The answer from the public about whether Obamacare is working or not is ‘absolutely’ for the 8 million people who have received care and ‘maybe’ from most of the rest. The Kaiser Family Foundation tracking poll on the ACA shows most people want it fixed rather than repealed.⁹ A recent New York Times editorial reinforced that trend.¹⁰ Even my more conservative friends, who actually had some increased premiums for care, admit that they understand better what they are getting than with their previous convoluted insurance plans. This is bad news for Republicans whose whole raison d’être since 2010 has been ‘repealing Obamacare’. Every new recipient of health care who was denied in the past can be reminded by Democrats that their care came about in spite of Republicans. That might change a few minds, even in places like Kentucky.