Health care: Let’s get on with the Affordable Care Act


As we get closer to the start of 2014, the emphasis on educating people about decisions and responsibilities under the Affordable Care Act seems to be cranking up.

There is a general reality to the fact that ACA is going to be implemented. The administrative actions are getting clarified and many of the necessary systems to put it in place are being created or implemented. Unfortunately, there are still some politicians once again trying to reverse the law instead of using their leverage to fix what is wrong with certain aspects of it.

That discussion is an old issue. What really needs our attention and effort is addressing those related matters that are undermining the U.S. health care system.

The ACA takes on a number of important issues — coverage, minimizing discriminatory practices, wellness emphasis, costs — indirectly. Early treatment improves health, utilizes lower cost solutions, as well as spreading the risks to reduce premium impact on individuals and families. However, it doesn’t address other critical matters: how health care is priced and the quality of the care.

Four recent publications again emphasize our health care system is broken. As examples, pricing practices are being spotlighted in an extensive report by the Federal Centers for Medicare and Medicaid Services; a National Research Center/ Institute of Medicine report shows a comparison of the U.S. health care system to other rich countries utilizing multiple critical assessment factors; a ProPublica/Washington Post analysis digs into abuses in the Medicare drug plan program; and a quality satisfaction assessment survey by Consumer Reports addresses health care from the end-user perspective. 

It seems there is almost no aspect of the system that is achieving what we expect. The frequency with which reports surface on negative aspects of the health care system is amazing, although I did see an AARP article recently about specific hospital programs taking aim at improving procedures to correct flawed systems. Three hospital systems in Michigan (including Spectrum from West Michigan) were cited. 

The Federal Centers report shows how out of control the pricing structure is among hospitals, and it doesn’t even deal with all the variations with list prices and actual payment practices. The detailed study by the NRC/IM shows, in an analysis of 16 developed/rich countries, that we are near the bottom in all outcome measures. It also notes that we spend substantially more per person on health care than any of the other countries. This is the most disturbing, as people in this country believe we are the best when it comes to health care, so we don’t look at alternatives.

The ProPublica report cites numerous examples of physicians prescribing incredible amounts of drugs that are not only costly but often dangerous for senior citizens covered by Medicare Part D. The CR report sort of sums up the system when it provides a scorecard of how people are quite unhappy with the delivery processes.

Frequently, news commentators state the ACA legislation is over 2,000 pages, which must mean it is poor legislation. The length is not surprising when you consider how complex the health care business is. And, as I mentioned above, ACA only covers a limited aspect of the health care system and related problems. It seems to me that in health care we have a similar dynamic to what has been known as the Military/Industrial Complex, in which the two main elements scratch each other’s back, including politicians, and everybody wins except the individual taxpayer.

In the case of health care, it might be called the “Health Provider/Insurance Juggernaut.” In this equation, finances once again motivate the main players (again, including politicians) with individuals and employee organizations footing the bill with limited control. In fact this “alliance” has some aspects that are even more disturbing than the MIC arrangement, which at least produces high-quality equipment and personnel and can generally prove superior results. Although its budget is very large, it is not increasing as an ever-larger percent of GNP. It also is an alliance that can be controlled by Congress and Executive branches of government, should they choose to step up to the issue.

The juggernaut mentioned above, on the other hand, has enormous options to utilize when they are applying their vast resources. Even the government has difficulty controlling this vast machine. For example, when the government sets price reimbursements (as with Medicare and Medicaid), the Juggernaut just price shifts the unpaid fees to the private sector, either in higher premiums or charges to the uninsured, and they get very aggressive in leverage practices.

Many people believe the insurance industry is control. All you have to do is look at the profits generated from health care related premiums or claims processing fees and you can see they are doing well and it is not in their interest to reduce charges. They too have the ability to pass on the costs to companies, institutions and individuals with higher premiums. There is almost no relationship between the true expense of providing service and charges. There is one aspect of ACA which may help in this matter. Insurance carriers have to show that their premiums have at least 80-85 percent going toward health care charges and quality improvement. Keep in mind, we’re talking charges, not actual care costs.

There are some pretty basic things we need to do to start to fix the system:

1) Decide we are not going to accept business as usual. We need to get angry with the politicians. Those who are rewarded by the system won’t fix it.

2) Establish measurable national goals on health care matters. (Maybe start with the NCR/IM measures, if we can’t come up with our own.)

3) Demand transparency. All aspects of the system must be reported and analyzed and the problem players rooted out of the system. (If you want nonprofit status, maybe you should have to meet some rules for the public interest.)

4) Tie costs to outcomes, recognize those who address more complicated matters, reward the higher performers and provide meaningful research and improved options. (Just like with Congress, if we expect self-regulation to work, the only fool in the discussion is us.)

It’s not complicated; it just takes the will to control the Juggernaut.

Ardon L. Schambers is president and principal P3HR Consulting & Services,

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