I started responding to specific comments from readers on two of my recent blogs, but have decided that they raise issues important enough to make up today’s entire post.
On “What happens if universal coverage is allowed to slip away” commenter ryanjo writes that there “is rapidly evaporating support for the ACA.” I think we pay too much attention to polls, but I took a look at recent survey data to see if she is right. Instead, I found that polls taken since the November elections do not show declining support; rather, public opinion remains pretty well split in half between those favoring repeal and those who want to keep or expand the Affordable Care Act; as it has been for months. A McClatchy-Marist of all registered voters found that 16% want to “let it stand” and 35% want to “change it so it does more” compared with 11% who said “change it so does less’ and 33% who said “repeal it completely. CNN/Opinion Research poll found that 24% want to leave the new law as is, 24% want to expand it, 49% want to “repeal and replace” and 4% were unsure. A Quinnipiac University poll found that 30% want to expand it, 18% want to leave it as is, 47% want to repeal it, and 6% were unsure. While it is true that a lot of Americans don’t like the ACA, there are as many or more who want to keep or expand it.
Her observation that the ACA will leave [more than] 20 million without health insurance is correct but doesn’t tell the whole story, because a big portion of them would be people who are not legal residents. The Congressional Budget Office estimates that the ACA will “reduce the number of nonelderly people who are uninsured by about 32 million, leaving about 23 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under the legislation, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 94 percent”-- a huge and historic step toward universal coverage.
I’ve addressed the issue of Medicare “cuts” in past blogs, but the bottom-line is that the reductions in payments to hospitals and Medicare Advantage plans extends the long-term solvency of the program (because the Trust fund will spend less, and therefore the funds will last longer).
I share the concern that ryanjo expresses about Medicaid’s “shaky” finances. But if the ACA was repealed, the continued decline of employer-sponsored health insurance would result in millions more Americans ending up on Medicaid anyway, but without an influx of federal dollars to help states afford it. (Last year, almost 4 million people ended up on Medicaid, the biggest increase since the program was created.) A new report by the Urban Institute think tank finds that the ACA will put Medicaid on a much more solid funding foundation with “potential savings for state Medicaid budgets which, even in a worse-case scenario, would outweigh costs associated with the health reform law.” The analysis shows that “savings could range between $40.6 billion to as high as $131.6 billion during 2014-2019.” The ACA also increases Medicaid payments to primary care physicians in 2013 and 2014 so they are no less than the Medicare rate, at no cost to the states.
As far as the link between employment and coverage is concerned, once the ACA is fully implemented in 2014, people who lose their jobs or can’t get coverage from an employer will have access to subsidized coverage through the state health exchanges or from Medicaid if eligible. In the short-term, employers like McDonald’s that offer so called “mini-med” plans are seeking waivers from the ACA’s requirements, but such plans have been criticized as providing bare-bones, inadequate coverage to low-wage employees. Once 2014 comes around, these companies and their employees will have more options to choose from but they won’t be able to stick their employees in plans that don’t cover the medical care they need.
The above improvements will happen, of course, only if Congress doesn’t pull back from the ACA’s promise of providing affordable coverage to (nearly) all Americans.
In response to my post “Looking out for internists . . . and patients”, ryanjo thanked ACP for its efforts but she rightly pointed out that many ACP members called their own legislators. I agree that any successes that ACP has in its advocacy efforts is directly related to the willingness of its members to engage in the political process, so my hats-off to ryanjo and the many others who took the time to call Congress.
PCP and Arvind posted comments suggesting that “not losing” or “playing defense” isn’t the same as winning, but any successful football coach, battlefield general, or political strategist would tell you that defense and offense are equally important in achieving victory. Jay Larson is right that the 10% Medicare increase and relief from the SGR cut is “welcome” but not enough to “stop war weary general internists from leaving practice or infuse internal medicine” but it’s a start.
The members of ACP’s Council of Subspecialty Societies who wrote ACP’s “medical home neighbor” position paper would likely disagree with Arvind that ACP has left subspecialists out to dry. Also, the Medicare and Medicaid payment increases to general internists and other primary care physicians that are mandated by the ACA do not come from reducing payments to other specialists, but are completely paid for by the federal government.
I appreciate the comments made by ryanjo, Arvind, PCP, Jay Larson and the many others who take the time to read my commentary and add their own. We clearly don’t agree on some of the issues, and I don’t expect to change many minds. But this blog is all about providing a forum for respectful dialogue. and although I can’t respond directly to every comment, I read them all and am genuinely interested in your views.
Today’s question: Are there other issues that have been raised here, or elsewhere, that you would like to see addressed in future ACP Advocate blogs?