What an exciting week with the SCOTUS decision regarding the personal mandate! To summarize for those not glued to the coverage of this event, the Supreme Court decided that the Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. The penalty that an individual who chooses to go uninsured must pay is considered to be a kind of tax that Congress can impose because of its taxing power. Because the mandate survived, the Court did not need to decide what other parts of the statute were constitutional, except a provision that required states to comply with new eligibility requirements for Medicaid (covering everyone that is below 133% of the poverty level) or risk losing their funding. On that question, the Court held that the provision was constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.
I personally believe that since all citizens will utilize healthcare at some point in their lives, all citizens should have to contribute to the healthcare spending pool. It’s no wonder our system can’t pay for services when so many healthy people are choosing to not buy insurance out of the misguided hope that they will not need to utilize healthcare at some point. The analogy I always make is how long would a home owner’s insurance company stay in business if only people planning on burning their homes down this year buy a policy?!? We need those NOT immediately cashing in on the system to be paying in so that there is money to pay for those who are using it. When these same “investors” ultimately need healthcare, those who are healthy will in turn fund their care. It is the ultimate “pay it forward” philosophy.
But obviously NOTHING is ever this simple. In addition to providing access to care, we need to make sure we are training an adequate number of qualified physicians to meet this need. We need to make sure these doctors are coming out trained to manage a complex healthcare delivery ecosystem where understanding the needs and expectations of the consumer (aka “patient”) is as important as knowing how to treat the disease process. As Atul Gawande says, physicians can no longer operate as cowboys, they need to function in the health care arena as an efficeint pit crew, which requires understanding their roles and responsibilities as part of a team, not as a savior. In the words of healthcare cousultant Paulo Machado (@pjmachado), doctors now need to function as health care sherpas – badass mountain climbers with backs like armadillos that can use their knowledge of the healthcare system to lug the patient and their family up the mountain towards maximal health and wellbeing. Like the sherpas in Nepal, this is not a glamorous job. Nepalese sherpas are rarely on the camera in National Geographic films and do not get to stay in comped hotel rooms like the researchers they are serving. But lugging all that gear is one of the most critical jobs!
Physicians are used to the limelight. Historically, we’ve made an excellent living and have enjoyed our position on the pedastal society has placed us on as the Kings and Queens of the healthcare world. So it’s no wonder that the shift to a team based mentality could be hard for those with particualarly big egos to swallow. It’s a paradigm shift to understand that we have to engage our patients to achieve the best outomes. It is the sum of these individual outcomes that leads to overall improved population health.
Of course, in addition to an insured population and well trained physicians we also need tort reform, system delivery reform, and outcomes research to ensure that our limited health care dollars are spent most effectively. Two weeks ago I was asked to summarize some of the problems the healthcare system is facing and how the ACA is starting to address these issues to a group at UIC. Below I have provided the slides from my talk. I hope this is helpful to those of you doing your best to understand the complicated health care landscape. After reviewing the slides, please post any additional questions you have below, and I will do my best to answer. My ultimate stance, which is also shared by the American College of Physicians, is that the ACA is NOT perfect and still needs to be improved, but repeal at this point would have devastating consequences that many citizens are not even aware of. I do not agree with every philosophy the democratic party espouses, but when it comes to healthcare, they’re miles ahead of the republican party when it comes to addressing pressing healthcare issues. If these important issues are not addressed, our country will surely go bankrupt as a result of runaway health care costs. When it comes to the ACA, we cannot afford to throw the baby out with the bathwater.