Virtues of the ACA Translated Into GOP-Speak

The GOP has been gleefully beating the drum and quick-step marching the nation towards the purported promised land free of “Obamacare” aka the Affordable Care Act aka ACA (yes, they are one and the same) with the advent of the 115th Congress and new administration. Over the past weeks I’ve been pondering both the better-known and the unsung elements of the ACA – the provisions people either don’t know, see, or truly appreciate – and why Republicans are so resolute in their mission to destroy this landmark legislation. I work in healthcare and have witnessed firsthand how the ACA has improved not only patient care, but positively impacted the economics of organizations involved in delivering that care. And this knowledge doesn’t take into account the benefits I’ve seen it provide to those I personally know and have experienced myself.

Republicans attest they worship at the altar of fiscal conservatism, so the ACA supporters’ ability to explain its benefits in economic terms is critical. It may not be the warm, touchy-feely conversation progressives like to hear, but if speaking in the cold, hard language of the GOP helps make the case for its value we need to do so. Even though the primary objective of the ACA is to provide healthcare coverage to every American, it is just as much about grappling with the financial strains placed upon individuals, corporations, and the government by the healthcare delivery system in this country. In that spirit, allow me to co-opt a line from a very vocal – and powerful, if not presidential – Obamacare opponent: “what have [we] got to lose?”

First: the Affordable Care Act is the healthcare policy known as “Obamacare”. Just as the missile defense shield Ronald Reagan proposed in the 1980s was nicknamed “Star Wars” but officially called the Strategic Defense Initiative, so too is “Obamacare” a nickname for the Affordable Care Act. It’s branding…marketing…a tag line…an easily digestible sound bite provoking emotional responses in those both against and for it. But indeed the two – the ACA and Obamacare – are one and the same. Sorry to burst your bubble.

Second: no matter how one refers to it, discussing the ACA often focuses on four of many provisions the legislation contains:  1) an individual’s pre-existing condition no longer is a reason for insurance companies to deny them coverage; 2) children may stay on their parents’ insurance plans until the age of 26; 3) everyone is mandated to have coverage – whether through an employer plan, a plan purchased through public-private health insurance exchanges, or a government program like Medicare, Medicaid, or the VA; and 4) the success of the exchanges has run the gamut from “home run” to “complete disaster”.

Third: the visceral reaction on the political right associated with my first point has contaminated the ability to rationally discuss & evaluate the merits of the legislation I listed above. So while a majority of people like many (or all) of the components of the ACA, those on the right also claim they want to get rid of “Obamacare”. Yet despite the 50+ votes the House GOP has held to repeal the ACA, they still have not put forth a truly viable alternative to the legislation already in place containing everything people like about it but eliminating everything they say is wrong with it. “Repeal & replace” yielded to “repeal & delay” and then “repeal & repair” – all inventions allowing the GOP to claim the moral victory of keeping their campaign promise to dismantle Obamacare.

The ramshackle, cut-and-paste, frankensteined bill Paul Ryan & friends hastily chucked at us this past week is like a term paper the GOP’s had 8 years to write and only started working on 5 days before it was due. One might have thought they’d be more prepared until the President accidentally told the truth he said nobody knew healthcare was so complicated. This enterprise’s hail-Mary flavor is especially curious since gutting Obamacare is merely the appetizer in Ryan’s orgiastic multi-course meal leading us to the entitlement-free dystopia of his dreams. All the while it’s becoming more clear many of those who voted Republican this cycle thought that repealing the ACA was a promise that wouldn’t actually be kept and that the healthcare they’ve come to rely on was safe.

So while factions of the GOP continue arguing over various – and destructive – plans to repeal, replace, and/or repair the Affordable Care Act and the President blanks on his promise of a “tremendous” plan that willcover everyone “beautifully”, here is what I know…

The healthcare organization I work for focuses mainly on providing primary care. With the advent of the ACA and its emphasis on delivering coordinated, proactive & preventive care I have seen tangible positive impacts for not just our patients, but for our providers and the company’s bottom line. We receive cost-savings reimbursements by utilizing practices proven to prevent and/or reduce the severity of potentially serious conditions at levels meeting or exceeding prescribed quality care standards. For example, by ensuring 90% of our patient population over age 65 has had a colon cancer screening in the past 5 years, we might be reimbursed $250K at the end of the year, while if only 85% of that population had screenings the reimbursement would be only $125K. The rationale is simple: performing regular screenings significantly increases the chances of catching, diagnosing, & treating a disease before it reaches a stage requiring more extensive – and therefore more costly – treatments. If this sounds like a merit-based system incentivizing providers to ensure all their patients receive the highest quality of care, that’s because it is.

My cousin is a trauma nurse at a hospital in New York City and sees the benefits from another perspective. Since the ACA had rolled out, she encounters fewer people in the emergency room seeking treatment for symptoms related to untreated chronic conditions like diabetes. She also has observed a decrease in “frequent flyer” patients – the ones who end up in the ER every few weeks for the same (manageable) issue because they lack insurance and do not receive appropriate follow-up care for their condition. When you can’t afford to go to the doctor – even for an “easy” visit with a price tag far lower than a trip to the ER – you don’t go. So instead, these patients wait until the situation is critical enough they end up in the ER yet again.

Access to primary care allows these people to better manage their condition in a far more healthy and cost-effective way. For a $30 co-pay, Mr. Jones can visit his primary care physician to check up on how his current diabetes management plan is working, they make any necessary changes, and the provider bills out perhaps $150-200 for the visit and routine blood tests. For the same patient with unmanaged diabetes, a trip to the ER might be billed at $1500+. Depending on the coverage in a patient’s insurance plan (if they even have insurance), that ER visit could cost anywhere from a $125 ER co-pay to 20% of the total ER services or more. When the patient can’t pay, the hospital eats the costs and then passes them along to everyone in the system by billing higher rates in the future to compensate for the loss they incurred. In the meantime, you may very well have a patient who does not receive follow up care, comes back to the ER for the exact same treatable issue, and the cycle continues.

This situation doesn’t happen because hospitals are out to screw people over. They have the capacity to provide specialized care for serious conditions requiring immediate attention in an appropriately-equipped facility at all times. Quite simply put, that costs a lot of money. You wouldn’t expect your local family practice doctor’s clinic to handle the type of mass-casualty situation you see on “ER” or “Grey’s Anatomy,” nor would you go there for open-heart surgery or an organ transplant. Hospitals have the infrastructure and staffing to handle those things…and much more. But their overhead costs don’t magically disappear when the patient in the ER needs to be seen for unmanaged high blood pressure or diabetes and a hospital is their only option for care.

The full range of benefits provided by the Affordable Care Act were never going to be felt instantaneously. It will take time for the cost savings to make their way through the entire system and be seen & felt not just by patients, but healthcare providers and insurance companies as well. Data indicates healthcare costs are increasing at a slower rate since the implementation of the ACA, and although there are outliers to this trend they are primarily in states with the most opposition to it. In a world where a key indicator of success is the ability to deliver instant gratification, playing the long game and implementing a plan whose full impact will take years to materialize is an enormous risk. However, you’d think all this would make sense to supporters of trickle-down economics who call for increased quality & efficiency and oppose “rationing” healthcare with (so-called) “death panels”. Apparently not.

Cynical as it may be, when those making policy decisions are (literally) taken care of when it comes to healthcare, it’s difficult to put much hope in people who don’t comprehend the real-life impact of their actions dismantling the Affordable Care Act. Let’s be honest:  while politicians claim their focus is on passing legislation to best suit their constituents’ needs, most of them care first and foremost about satisfying their own. In order to secure re-election, ambition, ego, and adherence to core ideologies far too often supersedes a politician’s responsibility to do the right thing as an elected representative. But public response to elected officials’ actions cannot be minimized or ignored, and speaking up about the actual effects the ACA is having on people’s lives can make a bigger impact than dealing in hypotheticals.

While the new president claims to have a secret healthcare plan almost ready to go, the whole repeal/replace/repair situation seems highly suspect considering the Republicans in Congress have had 6+ years to come up with a plan yet are still mulling “ideas”. The resistance may still have an opening to sway the proverbial hearts and minds of the majority party’s more moderate members with a full-on assault combining logic & reason with heartfelt warm-fuzzies. After all, for a party that so emphatically touts their embrace of Christian values the GOP doesn’t walk the walk when it comes to demonstrating compassion, empathy, and generosity. And if they truly believe we are all entitled to the unalienable rights of life, liberty, and the pursuit of happiness, they’d do well to consider one must be in good health to fully & truly enjoy them.

So instead of talking past each other, let’s do something radical:  meet the Republicans on the battlefield over healthcare and argue our position in language that they will understand.

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