The American Heart Hospital Journal


keratomileusis (LASIK) surgery to obviate the need for eyeglasses or contact lenses. And with more and more of everyday life subject to medical intervention, the desire for healthcare becomes insatiable and ultimately unaffordable.


Ideal Healthcare from Reform The ideal healthcare reform goal for this country would be, first and foremost, to lower the inexorable rise of costs, increases that are unsustainable and are having negative consequences for all of us and for future generations. ‘Bending the cost curve’ is the often-heard mantra. The key to this would be to somehow limit the adoption of new medical technology to those technologies whose effectiveness and safety are based on good scientific evidence, and whose benefits are in some reasonable proportion to cost. This would require sound TA, the introduction of cost-effectiveness analysis, and the adoption of a culture in which medical practice is firmly based on scientific evidence. Such a culture is difficult, because Americans love technology, especially new medical technology (‘newer is better’) and when the costs are perceived to be free, i.e. when true costs are obscured by private or government insurance (moral hazard).


Victor Fuchs put it well when he said: “The role of new medical technology deserves special attention in thinking about future healthcare spending because biomedical innovations as a whole have been the primary source of both improvements in health and increasing expenditures. On the one hand, it is fiscally irresponsible to continue to accept innovations regardless of cost, even if they pass tests of safety and efficacy—and it is particularly irresponsible when the interventions are provided at public expense. On the other hand, we must avoid an innovation policy that cuts off new interventions prematurely. Some interventions that are not cost-effective at first may prove to be so over time and with greater experience in implementing them.”8


Under ideal healthcare reform, access to at least a basic set of essential medical services would be extended to all Americans. If accomplished in the context of a private insurance system, all would be compelled to participate so the system would be actuarially sound. Universal access via a private health insurance system must include subsidies for the poor and compulsion to participate for the young and healthy. The alternative to universal access to health insurance provided by the private sector is a public plan, a ‘single-payer’ healthcare system financed and run by the government.


Under ideal healthcare reform, incentives would be in place for continuous quality improvement, including new


Winter 2010


Special Report


payment systems that reward performance, i.e. improved, patient-centered clinical outcomes, rather than conventional reimbursement for services rendered.


To What Extent Does the Patient Protection and Affordable Care Act 2010 Conform to Ideal Reform? Any analysis of the PPACA is difficult because of its complexity (the bill is more than 2,000 pages). It is to be phased in over four years (2010–14), and many provisions are couched in vague terms such as “… the Secretary of the Department of Health and Human Services (HHS) shall …,” leaving much to the discretion of Secretary Kathleen Sebelius and her successors. Parts are of the bill are already being litigated over their constitutionality, especially the ‘individual mandate,’ which compels individuals to purchase health insurance under the power granted to the congress under the Commerce Clause. The Commerce Clause is an enumerated power listed in the United States Constitution (Article I, Section 8, Clause 3). The clause states that the US Congress shall have power “to regulate commerce with foreign nations, and among the several States, and with the Indian Tribes.” The purchase of health insurance in this bill falls under the power of Congress to regulate commerce among the several states. The Accountable Care Act is fundamentally an access bill and secondarily an insurance reform bill.


Patient Protection and Affordable Care Act 2010 Access The PPACA promises to make available or compel health insurance coverage for an additional 32 million American citizens beginning in 2014. One half of the increased access to health insurance coverage will result from Medicaid eligibility expansion affecting an estimated 16 million US citizens and legal residents. Medicaid coverage is expanded to cover individuals and families up to 133% of the federal poverty level (FPL). Those not currently insured and not eligible for Medicaid coverage will be required, as of 2014, to purchase health insurance in compliance with the ‘individual mandate,’ a mandate facilitated by subsidies and penalties. State-based insurance exchanges will be created where insurance policies are offered for purchase, and subsidies are available for individuals and families whose incomes are between 133 and 400% of FPL. The penalties for not purchasing (individuals) or not providing (businesses) health insurance will be administered by the Internal Revenue Service (IRS) as punitive taxes. If and when this expansion of coverage takes place, serious healthcare workforce issues will be raised as the industry seeks to care for these additional insureds, especially around providing the large numbers of additional primary care physicians that


Healthcare Reform 2010—A Surgeon’s Perspective 83


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68