USC Gehr Family Center for Implementation Science
August 26, 2016
Slow Medicine: Assessing the ACA in the Political Fog
First in a new series on healthcare delivery reform
By Steffie Woolhandler, MD, MPH, Adam Gaffney, MD, David U. Himmelstein MD
The Gehr Center/Slow Medicine series "Disruption or Distraction: A Critical Look at Healthcare Delivery Reform" unpacks the data behind healthcare delivery system interventions, highlighting well-intended reforms that have yet to achieve the impact many have assumed. The series is edited by Slow Medicine columnists Pieter Cohen, MD, Michael Hochman, MD, MPH, and Rachael Bedard, MD. This first article in the series is written by three prominent experts in healthcare financing and offers a counterpoint to President Barack Obama's recent article describing the benefits of the Affordable Care Act.
In the current overheated political climate, the Affordable Care Act (ACA) has garnered harsh criticism from some quarters and extravagant praise from others. Both miss the mark.
Critics from the political right seem to ignore the fact that the law has substantially reduced the number of uninsured, and propose alternatives that would sharply increase uninsurance, underinsurance, and healthcare inequality.
On the other hand, President Obama's recent defense of the ACA in the Journal of the American Medical Association papered over its flaws -- notably the fact that 29 million remain uninsured, a figure that the Congressional Budget Office predicts will not change much in the years ahead, even if all states were to accept the ACA's Medicaid expansion.
While persistent uninsurance is the ACA's most glaring deficiency, it has other shortcomings: failure to slow the hollowing out of already inadequate coverage; further stimulation of the already overgrown healthcare bureaucracy; lack of effective cost controls; and Medicare payment reforms that tilt the playing field towards giant corporate organizations and have triggered a surge of mergers and acquisitions.
(Twelve paragraphs discuss the specific deficiencies of the Affordable Care Act - link below)
In sum, the ACA was a useful but inadequate step forward for American healthcare. Tens of millions remain uninsured, and at least as many others have grossly inadequate coverage. Costs are again rising rapidly, and the corporate takeover of care proceeds apace. By any reasonable measure we remain in last place among wealthy nations for coverage, and an outlier for our high costs. The need for more fundamental reform is clear.
Steffie Woolhandler, MD, MPH, is a primary care physician at the CUNY School of Public Health at Hunter College. Adam Gaffney, MD, is a research fellow at Massachusetts General Hospital. David Himmelstein, MD, is a professor at the CUNY School of Public Health at Hunter College. Woolhandler and Himmelstein are co-founders of Physicians for a National Health Program.
Comment by Don McCanne
As the first in a series on healthcare delivery reform, this article sets the stage by describing the profound deficiencies that remain after implementation of the Affordable Care Act. Although ACA did improve coverage and access, the authors note, "The need for more fundamental reform is clear."
This article was merely to assess ACA in the "political fog" and not to suggest solutions. But the problems presented are not amenable to mere teaks and patches. Since the authors are the nation's leading experts on single payer reform, we can assume that the fundamental reform they would call for would be single payer. And they would be right since anything less, such as adopting a public option, would leave in place most of the deficiencies.