ALBUQUERQUE, N.M. — The Affordable Care Act, also known as Obamacare, is 906 pages long and contains provisions on everything from medical schools to record keeping. Its destiny at the Supreme Court likely will turn entirely on whether Congress has the constitutional authority to require people to buy health insurance.
While observers view this as one of the most important constitutional questions in years, the health of America isn’t going to change very much regardless of how the court rules.
Even if the mandate is eliminated, there are some major ACA provisions that could have a real and positive effect on health — things like identifying treatments that deliver the best results and rewarding medical practices that improve patient health rather than merely treating their ailments. These provisions should survive a court decision to eliminate the mandate.
Mandated coverage makes a certain amount of business sense, but mostly it would force millions more people into an inefficient, wasteful, sometimes dangerous, always crowded, understaffed cottage industry of uncoordinated providers of care who are compensated by a mechanism of payment that encourages them to provide as many services as possible without regard to how healthy their efforts might make a patient.
ACA is largely an attempt to pay for the health care of 40 million people who don’t have private insurance, vast personal wealth or publicly funded coverage. In other words, it is designed to get everybody using the financing and health delivery mechanisms that 80 percent of us use as a matter of course.
This is a world in which almost half of tests ordered are unnecessary, where almost 100,000 people a year are killed by accident in hospitals, where adults receive the care that is recommended for their ailments only about 55 percent of the time, and where 30 percent of the $2 trillion spent annually does nothing to improve people’s health.
Since our society is not in the habit of letting people die in the street, clearly people without coverage are getting some sort of health care now. For most of them, it is sporadic, inefficient and inadequate, heavy on intervention during disasters and light on prevention or maintenance of chronic conditions like diabetes.
More to the point of ACA, it is paid for by taxpayers and people who already have insurance. The cost of care is shifted from people who don’t have coverage to those who do.
Depending on the year, between 20 percent and 25 percent of New Mexicans have no health coverage. There are a substantial number of New Mexicans who simply don’t want to buy insurance. There are several thousand children who are eligible for publicly funded coverage through Medicaid whose parents never enroll them. There are businesses that choose not to offer insurance because they can compete for the labor they need without it.
More often, people don’t have health insurance because they can’t afford it. They are seasonal, temporary or part-time workers. Some work for small companies that can’t afford to offer insurance. These problems are worse in bad economic times, so the number of uninsured people increased during our latest recession.
Occasionally, before ACA became law, people lost coverage when insurance companies canceled their insurance because treatment costs would get too high. Sometimes, before ACA, companies would deny coverage to people who had conditions insurers didn’t want to pay to treat.
Insurers were willing to stop those practices and support ACA because the law was designed to guarantee them tens of millions of new customers. Absent mandated coverage, insurance companies will almost without question argue they can no longer afford to guarantee they will issue and continue coverage to anyone, regardless of condition.
If mandates are unconstitutional, there are options.
Millions of Americans receive Medicare and veterans benefits. Such benefits could be extended to everyone. That’s called the single-payer option. Alternatively, government could provide tax incentives to encourage uninsured Americans to purchase coverage from private companies. The Swiss operate a system something like that.
Two realities will still be in the way of improved health. The first is that only about 30 percent of your health depends on medical care. Your health depends a great deal on your lifestyle, your personal financial situation, the neighborhood you live in, your educational attainment, the adequacy of your housing and your genetic code.
The second is that our nation’s health care problem isn’t who pays the bill. The problem is how health care is manufactured.
My March 20 column requires some clarification. The state’s Health Department is leading efforts to control costs of services for developmentally disabled people funded by a waiver obtained from the federal government. The state Human Services Department is the agency responsible for obtaining the waiver from the feds.
UpFront is a daily front-page news and opinion column. Comment directly to Winthrop Quigley at 823-3896 or email@example.com. Go to www.abqjournal.com/letters/new to submit a letter to the editor.
— This article appeared on page A1 of the Albuquerque Journal