The Road Ahead for the Affordable Care Act

John E. McDonough, Dr.P.H.

July 2, 2012 (10.1056/NEJMp1206845)

COMMENT: 

This is a nice discussion of the future of the ACA following the Supreme Court’s decision. Basically the Act’s future lies in the hands of the electorate.   While there are many issues that deeply divide the country, the ACA will be one of the most divisive.  What may be underappreciated by our non-US reader and many in the US is the comprehensive nature of the Act.  If implemented, it will change the face of American medicine remarkably

Unappreciated in this chaotic political environment is that the ACA is the first U.S. law to attempt comprehensive reform touching nearly every aspect of our health system. Even President Lyndon Johnson's achievement in establishing Medicare and Medicaid in 1965 was more narrowly focused. The law addresses far more than coverage, including health system quality and efficiency, prevention and wellness, the health care workforce, fraud and abuse, long-term care, biopharmaceuticals, elder abuse and neglect, the Indian Health Service, and other matters.3 In a less hostile political environment, congressional Democrats and Republicans would collaborate in assessing, modifying, and reconstructing many ACA elements, large and small — typical activities after the launch of any major law. And perhaps we will still get there, as the Supreme Court ruling begins to recede in the rearview mirror and the dust from the November elections settles.

For now, there are still many obstacles ahead.”

Thank you for your interest.  You are correct that I generally favor the changes contained in the ACA.  The reasons are not easy to articulate because there is so much to consider.  As a primary care practitioner, albeit with a practice limited in the past to persons with diabetes, I have been constantly disillusioned with the shortsightedness of the US system that will pay for everyone’s dialysis or kidney transplant, but not for the medications needed to prevent ESRD.  Over half of all bankruptcies in the United States are the result of the inability to pay for medical treatments.  As we implement the ACA a number of changes will be occur to lessen these problems.  For those with health insurance their coverage will now include their children up to age 25 and insurance companies will no longer be able to deny children’s coverage because of preexisting conditions.  This will be extended to adults in 2014.  An average family pays $1,000 /year in insurance premiums to cover the costs of uncompensated care.  The mandate will require persons who can afford health insurance to purchase it or pay a fine (tax?) enlarging the pool of insured persons and potentially lowering that $1,000 remarkably.  For individuals whose employer does not offer health insurance (the most common mechanism to obtain health insurance in the US) or who are self-employed there will be statewide standardized insurance pools.   For those who cannot afford health insurance the ACA offers states incentives to expand the health insurance for the poor, Medicaid. 

For physicians there are a number of changes that will encourage the development and evaluation of new models of primary care under the federal Medicaid and Medicare programs.  These and other aspects of the ADA are discussed in detail at the web site:

file://localhost/Users/chclark/Library/Caches/TemporaryItems/Outlook%20Temp/Affordable%20Care%20Act%20Brochures%20&%20Educational%20Presentations%20%20%20HHS.gov%5B1%5D.htm