The Affordable Care Act: A Not-So-Little Train That Must0

This article was first published in the Los Angeles Daily Journal on February 25, 2013.

“Things do not change. We change.”  – Henry David Thoreau

Finally free from the uncertainty of looming elections or Supreme Court decisions questioning constitutionality, modern American health care can now be compared to a speeding train serving infinite destinations, with conductors and passengers alike learning the routes along the way. Public transportation is usually forgiving, as the tardy or confused passenger always has the opportunity to catch the next train, but such is not always true in matters of public health.  Whether fan or foe of the Affordable Care Act (the ACA), this epic codification of health care reform is something that America cannot afford to miss.

At the time the ACA was passed in March 2010, by a margin of seven of the collective 431 Congressional votes, few of those involved had any real working knowledge of the 10,909 sections contained within the Patient Protection and Affordable Care Act, which were quickly adjusted and finalized by congressional changes the following week in the form of the Health Care and Education Reconciliation Act. Weighing in at over 900 pages, hindsight makes it clear that the ACA was only the beginning of the federal government’s plan to restructure the nation’s health care system, a fact that has been compounded by an estimated 70,000 pages of further regulations in the three years since President Barack Obama signed the ACA into law.

Since its inception, the ACA’s path to 2014 had been fraught with peril, yet it has somehow managed to survive both the Supreme Court and Electoral College. With less than 10 months remaining before the more salient and highly publicized provisions take effect, it appears that health care reform is here to stay. For those still looking for their ticket to ride the health care train, the following is a basic overview of this not-so-simple law:

Patients: Eventually this category may include everyone in America. Under the ACA, Congress hopes to insure 30 million of the nation’s estimated 50 million uninsured. For those under the age of 26 who have a parent with health coverage, those previously excluded due to a preexisting condition, or those simply unable to afford, let alone understand exactly how to obtain health insurance, the ACA will certainly come in handy. Sponsored in part by the World Wide Web as well as each state choosing to participate in Medicaid Expansion, the ACA is determined to eliminate all obstacles that may stand between patients and coverage.

Payers: While it may appear on the surface that the days of payers are numbered, the fact remains that the ACA will fail without their participation. Armed with nothing more than an individual mandate and a seemingly insignificant obligation for employers, payers are leading the charge to 2014 with a zeal unfazed by such factors as medical loss ratio requirements, the end of lifetime limitations, heightened scrutiny over future premium increases in excess of ten percent, the establishment of accountable care organizations that do not need their support, and the overwhelming obligation to peddle their products from a fishbowl on an internet site that resembles

Providers: If nothing else, the ACA may force providers to serve their public with a smile as focus shifts dramatically from a formerly cost-based system toward one that gauges success or failure based on patient experience. This new era of performance is marked by a Value-Based Purchasing Program for hospitals and physicians, additional penalties for patient readmissions and enhanced pecuniary punishment whenever expectations fall short or something goes wrong. Add to this an unprecedented federal focus on the elimination of fraud and waste, and one can only hope that these changes will not further compromise the already tenuous financial position of the providers, whose presence is the very cornerstone of our modern health care system.

The Gamble: As patients, payers and providers jockey for position under these new regulations, it remains unclear exactly how the ACA will reduce patient health care expenditures that result in nearly twenty percent of the nation’s gross national product without putting payers and providers out of business at the same time. The literal solution, which in some ways will prove to be an incredibly large gamble, is innovation. At the heart of the ACA lie tens of billions of dollars to be directed at finding new ways to improve upon the delivery of health care in the United States. In doing so, its primary goal is to transform a super-sized, over-utilizing society into one that focuses instead on health and fitness, and as such its structure is supported by an army of preventative measures designed to ensure that we the people for whom it provides stay the course. Regardless of whether the nation can afford the inherent risks associated with this type of psychological restructuring in today’s troubled economy, this is the founding principle upon which the ACA has built its new designs.

Three years and 70,000 pages later, in many ways the ACA did not create a dramatic shift in America’s health care system. However, the fact remains that for health care reform to work, the change must be made not by providers, regulators or administrators, but by the patients themselves. If the current health care structure is to survive and flourish, those who benefit must evolve. Make no mistake, the ACA train has left the station. With a little luck and a bit more fortitude, we can all find a comfortable place from which to enjoy the ride.

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