Affordable Care Act… the Real Problem


We have estimated 40 to 60 million uninsured Americans for the last several decades.  The last available estimate in 2012 was 47.0 million.  It is commonly believed this group has not received routine health care, and has swarmed hospital emergency rooms and overwhelmed the system with acute health care needs.  This is all true… to a very small degree, and most importantly this main objective of the ACA remains unresolved.


The numbers coming in for the ACA enrollment clearly reflect a shift of previously insured parties to new insurance plans in the ACA.  This shift does nothing to resolve the uninsured problem; and won’t in the near or far term unless the plan is dramatically altered.


The almost accidental positives of ACA include no limit health care, removing pre-existing conditions, offering guaranteed issue to all, and extending coverage for aging dependent children.  The guaranteed issue comes with the cost of the myriad of extremely confusing state and federal plans.  There were far easier ways of accomplishing these offerings, none of which were used because of the administrations unilateral approach to the legislation.


The vast majority of participants in the new plans come from previous individual policy insured’s who were forced to change because their policy was canceled; or from Medicaid eligible individuals.  It is now clear the previous multi-millions of uninsured have not flocked to the new plans and probably will not do so.  Yes, the 47 million uninsured will be reduced, but probably only by a small percentage.  We will be left with some 30+ million uninsured and a revised health care financing system that will take years to sort out and modify in order to get it to run smoothly.


And, one of the dirty little truths is this large and hardly changed uninsured group will continue to visit ER’s but for an entirely different reason than once believed.


If you are sick and need to see a doctor and you don’t have a primary care physician, I would challenge you to A)  Fine one, and more importantly B) Find one that will see you right now to treat your acute medical issue, not in four or six weeks.  Studies are reflecting the fact that sick people seek medical care in the ER because they cannot see a doctor without waiting days or often times weeks…far too long for someone who is sick and hurting.

And, Medicaid is simply not the answer.  In fact, the Annals of Emergency Medicine published a survey that reflects this startling fact…61% of Medicaid patients visited the ER in the previous year.


Even those Medicaid patients who have primary care physicians — and that is less likely than for people with private insurance — report significant barriers to seeing their doctor.” senior study author Dr. Adit Ginde, of the University of Colorado School of Medicine, said in a journal news release.


“Medicaid patients tend to visit the ER more, partly because they tend to be in poorer health overall,” Ginde added. “But they also visit the ER more because they can’t see their primary care provider in a timely fashion or at all.”


“The efforts by some states to keep Medicaid patients out of the ER do not take this lack of access to primary care into account,” Dr. David Seaberg, president of the American College of Emergency Physicians, said in the news release. “It puts both patients and providers into an impossible position that will only get worse as more people enroll in Medicaid.”


The real problem with healthcare in the U.S. is a drastic lack of primary care health providers and the ACA does absolutely nothing to help resolve this issue.  Further, it does almost nothing to reduce costs in this fee for service industry.


We can offer many suggestions on how the ACA should have been structured, but that won’t be constructive.  But, here are a few suggestions for reforming the ACA and making it more viable:


  • Immediately launch new educational programs outside the purview of the AMA for educating and training new primary care physicians.  Federally fund it by expanding the National Health Service Corps program to include urban areas.
  • Pass federal legislation empowering Physician Assistants and Nurse Practitioners to provide the basic functions of the primary care physician unfettered from the overly protective AMA guidelines and various state legislatures.  This will free up many primary care doctors to handle the more complex levels of treatment needed.
  • Federalize Medicaid and simply make it a part of Medicare…which would remove the hurdles to care and the stigma of being poor or unemployed.
  • Fund the Medicare system so healthcare providers at all levels will accept it and earn a well-deserved living for their many years of education and training they have invested;
  • Accomplish what has been threatened by every Congress since LBJ. REALLY get rid of fraud and waste without the accompanying silliness that drives providers crazy, wastes their time and doesn’t reduce costs or improve the system.
  • And yes, pass tort reform to protect both the patient and the system;


The problem of reform is extremely difficult if not impossible in the current political environment.  The unilateral approach to passing the initial legislation has led to the most cantankerous atmosphere not seen before in politics.  There is virtually no hope of cleaning up the ACA at the moment.  Perhaps our “best shot” is a one party takeover of the congress and their best effort to “save” health care by making some the much needed and obvious changes.   I honestly believe if either party had complete power, they would make the necessary changes, but the current split will simply not allow it.


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