The Affordable Care Act: Politics Over Policy

ACA (The Affordable Care Act) is now law, and it is clear that it is not only unaffordable, but also will not have a positive impact on care. Over 2,000 pages of regulations are overwhelming in their detail, and contain over 20 new taxes. The concept of insuring the non-insured is idealistic, but on close examination of the details, it will only render them underinsured and underserved. Implementation of this bureaucratic monstrosity will be a nightmare.

The Medicaid population today is victimized by lack of access to care because of remunerations to hospitals and physicians that are so far below standard that medical practices and institutions continue to limit the amount of access. Because of the limited availability of all healthcare providers, most of the uninsured seek medical care through the hospital emergency room departments. Those that have Medicaid coverage will occasionally have some access to primary care, but specialty care is extremely difficult to obtain. Those who have acquired these new benefits will then have to flood the emergency department to seek primary and specialty care and drive up the cost even further. Medicaid expansion is no longer compulsory, but is being implemented by 14 states. Hospital lobbying efforts are promoting either Federal or State expansion to guarantee additional funding sources for themselves. Medicaid expansion is also favored by the liberal press.

Health insurance exchanges are another mandate of the ACA. They may be controlled either on the State or Federal level. Many states are not attempting to set these up because of the complexity of the regulations. Some states, such as California, have been working on the structure and function for over two years. These exchanges are thought by many to be the largest regulatory undertaking in healthcare history. The information needed on each individual's financial history, as well as his/her family will be a virtually impossible task. There are multiple levels of income calculated on the Federal Poverty Level that will determine all of the benefits, as well as the premium. California is mandating reasonably modest premiums from the insurers, as well as generous benefits for patients. The squeeze comes from the providers. When that scenario is present, you have the same problem that exists today, access. Dr. Robert Hertzka and Dr. James Hay of the California Medical Association refer to this as MediCal-lite.

Insurer's participating in the health insurance exchange have already begun contracting providers with their proposed fee schedule. In most cases, it is at MediCal levels. Physician participation will undoubtedly be poor. This poses a significant problem for small to moderate size businesses. They no longer can afford the cost of providing healthcare for their employees. They will refer them to an HIC provider, and not until they are in need of care will they discover that they have limited access because of a paucity of physician participation. One of the most treacherous segments of the ACA affects the individual earning just over $40,000 per year or families of four over $90,000 per year. There are no subsidies, premiums are high, and there is little incentive to purchase insurance, so most will not. With the considerable number of patients that will pay the penalty and only purchase insurance if they are facing a medical problem, funding of the program is in further jeopardy and will continue to be supported by additional taxes and premiums on those that purchase private insurance.

We are also intrusting our Federal and State governments to regulate and control one of the largest and most complex industries in the world. We only need to see how successful they have been in Medicare, MediCal, and the United States Department of Verterans Affairs system. Our returning veterans are subject to the inefficiencies of the system, have long waiting times, and have inexcusably long delays in recovering disability payments for the injuries they sustained in defending our country. We are about to embark on an irreversible and expensive trip that will not be pleasant for anyone.

In the years to come, the deficiencies of this program will become more apparent and, unfortunately, not easily reversed. If you look at the goals of the ACA, they have failed to deliver and at a cost that will further threaten our fragile economy. We have again witnessed a victory of politics over policy.

Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.

Author's Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.

Acknowledgement: A special thank you to Dr. Robert Hertzka, past president of the California Medical Association, for his insight into this issue.

Am J Orthop. 2013;42(4):158. Copyright Frontline Medical Communications Inc. 2013. All rights reserved.