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Ideas and Opinions |

Universal Health Care Coverage in the United States: Is It “Slip Slidin' Away”? FREE

Robert B. Doherty, BA
[+] Article and Author Information

From the American College of Physicians, Philadelphia, Pennsylvania.


Acknowledgment: The author thanks Michelle Kline for her important contributions to the manuscript, including background research, citations, and fact-checking.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2741.

Requests for Single Reprints: Robert B. Doherty, BA, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.

Author Contributions: Conception and design: R.B. Doherty.

Analysis and interpretation of the data: R.B. Doherty.

Drafting of the article: R.B. Doherty.

Critical revision of the article for important intellectual content: R.B. Doherty.

Final approval of the article: R.B. Doherty.

Collection and assembly of data: R.B. Doherty.


Ann Intern Med. 2011;154(2):118-120. doi:10.7326/0003-4819-154-2-201101180-00302
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With passage of the Affordable Care Act, affordable health insurance for all Americans is in sight, yet politics could cause it to slip away. A resurgent Republican Party will mount a sustained challenge at the federal and state levels, but the new Congress will not bring about the Affordable Care Act's repeal. More likely, the law's effectiveness could be undermined by congressional restrictions on its implementation, underfunding of programs to improve public health and train more primary care physicians, and resistance by many states to its mandates. Congress could instead seek a bipartisan accord on improving the law, such as by giving the states more options, but this is unlikely in the current polarized environment.

This debate is occurring even as the United States faces an unprecedented crisis in access to health insurance coverage, affecting nearly every demographic group, yet the uninsured have largely become an afterthought. Medical professionalism requires a commitment to improving access to care, and physicians could play a crucial role in informing lawmakers that providing all Americans with affordable health care coverage is a moral and medical imperative to prevent needless suffering and death, and must not be allowed to slip away.

Slip slidin' away

Slip slidin' away

You know the nearer your destination

The more you're slip slidin' away.

—Paul Simon

Paul Simon's refrain seems an apt description of universal health care coverage in the United States today. With passage of the Affordable Care Act (ACA)—the provision of affordable health care insurance to all Americans—a goal long supported by the American College of Physicians (13) and many physicians (4), is in sight. Unfortunately, politics could cause it to slip away.

A resurgent Republican Party (GOP) has pledged to repeal and replace the ACA (5). With majority control of the House of Representatives and most state governments, the GOP can mount a sustained challenge. Much of the public believes the ACA will not make care more affordable (6), and voters are split between wanting to repeal or keep and expand it (7).

Strangely, the political fight is divorced from 2 stubborn realities. First, the 112th Congress will not repeal the law, although underfunding and state resistance could make it less effective. Second, the United States is experiencing an unprecedented crisis in access to affordable coverage, making the case for the ACA's reforms stronger than ever.

Repeal might pass the House of Representatives but die in the Senate. If a House vote for repeal is sent to the Democratic-controlled Senate, it would be blocked by the majority and if necessary, filibustered, requiring the votes of 60 to bring it to the floor. Then, a majority of senators would have to vote for repeal. If it passed, President Obama would veto, requiring a two-thirds vote in both chambers to override.

More plausibly, the GOP could force votes on less popular provisions, daring Democrats to vote against rolling back payroll tax increases for high-wage earners, cuts in hospital and Medicare Advantage payments, and the individual insurance mandate. Some Democrats, particularly those facing 2012 elections in conservative states, might go along. However, such votes would still be subject to filibusters and the President's veto. An additional reality here is that repeal of the reductions in Medicare payments to hospitals and plans would add $400 billion to the federal deficit unless offset by other spending cuts or tax increases (8).

Many of the programs that the ACA creates are subject to annual legislative appropriations, which mean no guaranteed funding. Because appropriations bills originate in the House, the GOP has leverage to deny or limit funding for many of them. The ACA's most controversial requirements, though—taxes, changes in Medicare and Medicaid, and the individual mandate—are not funded through appropriations and can be changed only by repealing or amending the ACA itself. Instead, the ACA's most vulnerable programs could be the ones that relate to expanding the primary care workforce, improving clinical outcomes, reducing health care disparities, and promoting wellness and prevention.

The House will try to deny federal agencies the funds needed to implement the ACA, but the Senate would have to go along, and President Obama could veto an appropriations bill that includes such restrictions or underfunds key programs. Some speculate that a confrontation about appropriations could lead to a government shutdown if the GOP House refuses to pass an appropriations bill without restrictions on the ACA and President Obama refuses to sign a bill that includes such restrictions (9).

The GOP may face public resistance if it tries to undo or block ACA initiatives that are or will soon be in effect. These include several initiatives that went into effect in 2010: coverage of children with preexisting conditions, tax credits for small businesses, allowing young adults to stay on their parents' insurance, and more National Health Services Corps' scholarships and loan repayment options. In 2011, more generous Medicare benefits for preventive services, including an annual wellness examination, requiring insurers to spend more on patient care and less on administration, and increasing Medicare payments to primary care physicians, begin with the last rolling out through 2015. However, the largest expansion of coverage does not take effect until 2014, and the future of the ACA may remain unresolved until after the 2012 presidential election.

The biggest challenge to the ACA may come from the states. In the November 2010 elections, Republicans gained control of governorships and state legislatures in most states. The ACA gives states “considerable flexibility in central tasks like structuring a new insurance exchange, pressuring insurers to suppress premium increases and expanding enrollment in Medicaid” (10). Instead of expanding Medicaid to all persons with incomes below 133% of the federal poverty level, as called for by the ACA, some states are considering withdrawing from the program (11), which by law is permissible as long the state forgoes all federal Medicaid dollars.

Some will not accept federal dollars to create the exchanges, although the ACA gives the federal government the authority to set up and run an exchange if a state does not comply. Can a federally run exchange be successful if it is imposed over the objections of a state's elected legislators and governor?

A growing number of states have filed lawsuits to challenge the constitutionality of the ACA's requirement that persons buy health insurance or pay a penalty (the “individual mandate”) starting in 2014. The Congressional Research Service says it is unclear how federal courts will rule on the challenges, with different district courts issuing conflicting initial rulings on the plaintiff's claims and the question of whether the individual mandate is a “constitutional exercise” of Congress's authority to regulate interstate commerce (12). The issue will probably not be resolved until it ends up in the U.S. Supreme Court years from now.

For at least the next couple of years, no one will win the battle over health care reform. Repeal and replacement of the ACA almost assuredly will not occur, but funding limits and state resistance to its mandates could undermine its effectiveness, and the fight over repeal will create great and undesirable uncertainty in the $2.3 trillion health care industry.

By insisting on repeal, the GOP may be giving up its best chance to positively influence implementation. Former Senator Majority Leader, Bill Frist, a Tennessee Republican and heart surgeon, notes that “the reality is that the law will remain largely intact. … That being the case, it is important that it be made to work as effectively as possible … there are lots of things that can be fixed or modified by working together” (13).

Senators Ron Wyden (D-OR), Scott Brown (R-MA), and Bernie Sanders (I-VT) have introduced a bill that would allow states to develop their own plans to provide comprehensive coverage to as many persons as required by the ACA, provided that the cost is no higher and does not add to the federal deficit. In return, the states would be free from most of the ACA's other mandates (including the individual insurance requirement) and would get the same amount of federal funds as they would have received under the ACA (14). This “Empowering States to Innovate Act” could in theory provide the basis for a bipartisan accord. However, accord would require that the GOP move away from “repeal and replace” and aspire to universal coverage and that Democrats yield more discretion to the states. Regrettably, in today's hyperpolarized world, it is unlikely that either political party will take the steps needed to reach bipartisan agreement. Confrontation, not compromise, is king.

Unfortunately, the continued political confrontation about the ACA comes at a time when the Census Bureau reports that a record 50.7 million residents from nearly every demographic and geographic group had no health insurance in 2009 (15). The percentage of Americans with private, employer-based coverage decreased for the ninth consecutive year (16). The Centers for Disease Control and Prevention reports that 59 million persons lacked coverage for at least part of the year, many of them had chronic illnesses, and more of the uninsured were from middle-class families than in previous years (17).

This unprecedented crisis in access should be of concern to everyone, yet the uninsured have largely become an afterthought. A bill offered by the House GOP leadership last fall would have covered only 3 million persons by 2019, leaving the percentage of Americans without health insurance unchanged (18). Democrats have been advised to talk more about how the ACA will help persons with insurance than about what it will do for the uninsured (19).

Because physicians directly see the health consequences on patients who do not have health insurance, they could play a crucial role in refocusing the debate on the uninsured. Physicians could explain that the uninsured are less likely to see a physician for a medical problem, receive follow-up care, get a prescription filled, or see a specialist when recommended by their physician (20). The Centers for Disease Control and Prevention reports that “among persons aged 18 to 64 years with diabetes mellitus, those who had no health insurance during the preceding year were 6 times as likely (47.5% vs. 7.7%) to forgo needed medical care as those who were continuously insured” (17). Physicians could remind policymakers and the public that lack of health insurance leads to tens of thousands of premature deaths annually and unnecessary suffering (21).

The problem is that physicians themselves are deeply divided about the ACA. Although such differences should be acknowledged and respected, medical professionalism requires a “commitment to improving access to care … [and] demands that the objective of all health care systems be the availability of a uniform and adequate standard of care” (22).

Individual physicians and their professional associations appropriately will differ on how best to achieve “availability of a uniform and adequate standard of care” and on the ACA itself, yet physicians who believe in the law's promise of reform should reach out to legislators, Republicans, and Democrats alike. Physicians should discuss specific elements of the law that should be priorities, including funding for programs to train more primary care physicians and research on comparative effectiveness to allow physicians and patients to make better decisions on the basis of better evidence. They can encourage them to improve the ACA, such as by enacting more meaningful liability reforms and repealing the Medicare Sustainable Growth Rate payment reductions. Such priorities have the potential of attracting bipartisan support, even from some Republicans who otherwise oppose the law.

The most urgent priority is for physicians to tell lawmakers that providing all Americans with affordable health care coverage is a moral and medical imperative to prevent needless suffering and death, and must not be allowed to go “slip slidin' away.”

American College of Physicians.  Access to health care. Ann Intern Med. 1990; 112:641-61.
PubMed
 
Ginsburg JA, Doherty RB, Ralston JF Jr, Senkeeto N, Cooke M, Cutler C, et al. Public Policy Committee of the American College of Physicians.  Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med. 2008; 148:55-75.
PubMed
 
Senkeeto N; American College of Physicians.  Achieving Affordable Health Insurance Coverage for all Within Seven Years: A Proposal from America's Internists, Updated 2008. Position Paper. Philadelphia: American Coll Physicians; 2008. Accessed atwww.acponline.org/advocacy/where_we_stand/access/7yrplan_update08.pdfon 18 November 2010.
 
Carroll AE, Ackerman RT.  Support for National Health Insurance among U.S. Physicians: 5 years later [Letter]. Ann Intern Med. 2008; 148:566-7.
PubMed
 
House Republicans Congress.  A pledge to America: a new governing agenda built on the priorities of our nation, the principles we stand for & America's founding values. Accessed athttp://pledge.gop.gov/resources/library/documents/solutions/a-pledge-to-america.pdfon 18 November 2010.
 
Blendon RJ, Benson JM.  Health care in the 2010 congressional election. N Engl J Med. 2010; 363:30.
PubMed
CrossRef
 
Cass C.  Exit poll: bad economy eclipses all for voters. Washington Post. 3 November 2010. Accessed atwww.washingtonpost.com/wp-dyn/content/article/2010/11/02/AR2010110204971.htmlon 18 November 2010.
 
Congressional Budget Office.  A letter to Senator Crapo on the budget impact of enacted health legislation in March 2010. 24 August 2010. Accessed atwww.cbo.gov/ftpdocs/118xx/doc11820/CrapoLtr.pdfon 18 November 2010.
 
Volsky I.  Former Obama health policy advisor: Republicans will shut down the government over health reform. The Wonk Room. Posted 5 November 2010. Accessed athttp://wonkroom.thinkprogress.org/2010/11/05/shut-down-gop/on 18 November 2010.
 
Sack K.  Republicans rise to power, with enmity for health law. New York Times. 18 November 2010. Accessed atwww.nytimes.com/2010/11/19/us/politics/19wisconsin.html?_r=1&emc=tnt&tntemail0=yon 19 November 2010.
 
Ramshaw E.  States' woes spur medicaid drop-out talk. Kaiser Health News. 12 November 2010. Accessed atwww.kaiserhealthnews.org/Stories/2010/November/12/medicaid-drop-out.aspxon 18 November 2010.
 
Congressional Research Service.  Requiring individuals to obtain health insurance: a constitutional analysis. 15 October 2010. Accessed atwww.cnsnews.com/sites/default/files/documents/Requiring%20Individuals%20to%20Obtain%20Health%20Insurance%20-%20A%20Constitutional%20Analysis.pdfon 23 November 2010.
 
Levey N.  Republicans are spoiling for a healthcare fight. The Los Angeles Times. 15 November 2010. Accessed atwww.latimes.com/health/healthcare/la-na-health-congress-20101115,0,6971170,print.storyon 18 November 2010.
 
Klein E.  Have Scott Brown and Ron Wyden figured out the way forward on health care? Washington Post. 18 November 2010. Accessed athttp://voices.washingtonpost.com/ezra-klein/2010/11/have_scott_brown_and_ron_wyden.htmlon 18 November 2010.
 
DeNavas-Walt C, Proctor BD, Smith JC.  Income, poverty, and health insurance coverage in the United States: 2009. U.S. Census Bureau. Accessed atwww.census.gov/prod/2010pubs/p60-238.pdfon 18 November 2010.
 
Gould E.  Decline in employer-sponsored health coverage accelerated three times as fast in 2009. Economic Policy Institute. 16 September 2010. Accessed atwww.epi.org/publications/entry/decline_in_employer-sponsored_health_coverage_acceleratedon 18 November 2010.
 
Centers for Disease Control and Prevention.  Vital signs: health insurance coverage and health care utilization—United States, 2006–2009 and January–March 2010. MMWR Morb Mortal Wkly Rep. 2010; 59:1448-54.
PubMed
 
Congressional Budget Office.  Letter to John Boehner, estimate of a substitute for H.R. 3962, the Affordable Health Care for America Act. 4 November 2009. Accessed athttp://cbo.gov/ftpdocs/107xx/doc10705/hr3962amendmentBoehner.pdfon 18 November 2010.
 
Herndon Alliance.  Presentation: August 2010 research. Accessed athttp://herndonalliance.org/resources/what-s-new/august-2010-lrp-and-gqr-research.htmlon 18 November 2010.
 
Commonwealth Fund.  Unmet needs for medical care: working-age adults. Accessed atwww.commonwealthfund.org/Content/Performance-Snapshots/Unmet-Needs-for-Health-Care/Unmet-Needs-for-Medical-Care–Working-Age-Adults.aspxon 19 November 2010.
 
Institute of Medicine.  America's Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: National Academies Pr; 2009. Accessed atwww.iom.edu/Reports/2009/Americas-Uninsured-Crisis-Consequences-for-Health-and-Health-Care.aspxon 18 November 2010.
 
ABIM Foundation.  American Board of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002; 136:243-6.
PubMed
 

Figures

Tables

References

American College of Physicians.  Access to health care. Ann Intern Med. 1990; 112:641-61.
PubMed
 
Ginsburg JA, Doherty RB, Ralston JF Jr, Senkeeto N, Cooke M, Cutler C, et al. Public Policy Committee of the American College of Physicians.  Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med. 2008; 148:55-75.
PubMed
 
Senkeeto N; American College of Physicians.  Achieving Affordable Health Insurance Coverage for all Within Seven Years: A Proposal from America's Internists, Updated 2008. Position Paper. Philadelphia: American Coll Physicians; 2008. Accessed atwww.acponline.org/advocacy/where_we_stand/access/7yrplan_update08.pdfon 18 November 2010.
 
Carroll AE, Ackerman RT.  Support for National Health Insurance among U.S. Physicians: 5 years later [Letter]. Ann Intern Med. 2008; 148:566-7.
PubMed
 
House Republicans Congress.  A pledge to America: a new governing agenda built on the priorities of our nation, the principles we stand for & America's founding values. Accessed athttp://pledge.gop.gov/resources/library/documents/solutions/a-pledge-to-america.pdfon 18 November 2010.
 
Blendon RJ, Benson JM.  Health care in the 2010 congressional election. N Engl J Med. 2010; 363:30.
PubMed
CrossRef
 
Cass C.  Exit poll: bad economy eclipses all for voters. Washington Post. 3 November 2010. Accessed atwww.washingtonpost.com/wp-dyn/content/article/2010/11/02/AR2010110204971.htmlon 18 November 2010.
 
Congressional Budget Office.  A letter to Senator Crapo on the budget impact of enacted health legislation in March 2010. 24 August 2010. Accessed atwww.cbo.gov/ftpdocs/118xx/doc11820/CrapoLtr.pdfon 18 November 2010.
 
Volsky I.  Former Obama health policy advisor: Republicans will shut down the government over health reform. The Wonk Room. Posted 5 November 2010. Accessed athttp://wonkroom.thinkprogress.org/2010/11/05/shut-down-gop/on 18 November 2010.
 
Sack K.  Republicans rise to power, with enmity for health law. New York Times. 18 November 2010. Accessed atwww.nytimes.com/2010/11/19/us/politics/19wisconsin.html?_r=1&emc=tnt&tntemail0=yon 19 November 2010.
 
Ramshaw E.  States' woes spur medicaid drop-out talk. Kaiser Health News. 12 November 2010. Accessed atwww.kaiserhealthnews.org/Stories/2010/November/12/medicaid-drop-out.aspxon 18 November 2010.
 
Congressional Research Service.  Requiring individuals to obtain health insurance: a constitutional analysis. 15 October 2010. Accessed atwww.cnsnews.com/sites/default/files/documents/Requiring%20Individuals%20to%20Obtain%20Health%20Insurance%20-%20A%20Constitutional%20Analysis.pdfon 23 November 2010.
 
Levey N.  Republicans are spoiling for a healthcare fight. The Los Angeles Times. 15 November 2010. Accessed atwww.latimes.com/health/healthcare/la-na-health-congress-20101115,0,6971170,print.storyon 18 November 2010.
 
Klein E.  Have Scott Brown and Ron Wyden figured out the way forward on health care? Washington Post. 18 November 2010. Accessed athttp://voices.washingtonpost.com/ezra-klein/2010/11/have_scott_brown_and_ron_wyden.htmlon 18 November 2010.
 
DeNavas-Walt C, Proctor BD, Smith JC.  Income, poverty, and health insurance coverage in the United States: 2009. U.S. Census Bureau. Accessed atwww.census.gov/prod/2010pubs/p60-238.pdfon 18 November 2010.
 
Gould E.  Decline in employer-sponsored health coverage accelerated three times as fast in 2009. Economic Policy Institute. 16 September 2010. Accessed atwww.epi.org/publications/entry/decline_in_employer-sponsored_health_coverage_acceleratedon 18 November 2010.
 
Centers for Disease Control and Prevention.  Vital signs: health insurance coverage and health care utilization—United States, 2006–2009 and January–March 2010. MMWR Morb Mortal Wkly Rep. 2010; 59:1448-54.
PubMed
 
Congressional Budget Office.  Letter to John Boehner, estimate of a substitute for H.R. 3962, the Affordable Health Care for America Act. 4 November 2009. Accessed athttp://cbo.gov/ftpdocs/107xx/doc10705/hr3962amendmentBoehner.pdfon 18 November 2010.
 
Herndon Alliance.  Presentation: August 2010 research. Accessed athttp://herndonalliance.org/resources/what-s-new/august-2010-lrp-and-gqr-research.htmlon 18 November 2010.
 
Commonwealth Fund.  Unmet needs for medical care: working-age adults. Accessed atwww.commonwealthfund.org/Content/Performance-Snapshots/Unmet-Needs-for-Health-Care/Unmet-Needs-for-Medical-Care–Working-Age-Adults.aspxon 19 November 2010.
 
Institute of Medicine.  America's Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: National Academies Pr; 2009. Accessed atwww.iom.edu/Reports/2009/Americas-Uninsured-Crisis-Consequences-for-Health-and-Health-Care.aspxon 18 November 2010.
 
ABIM Foundation.  American Board of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002; 136:243-6.
PubMed
 

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