COMMENTARY

The American Health Care Act: What Can We Check Off on the Primary Care Wish List?

Kenneth W. Lin, MD, MPH

Disclosures

March 20, 2017

Editorial Collaboration

Medscape &

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

In February, toward the end of a medical school course about health systems and policy, I asked my students to propose the outline of an Affordable Care Act (ACA) replacement plan that would improve healthcare quality, equity, and outcomes; contain costs; and enhance the patient experience for all Americans. As one might expect, their proposals ranged across the political spectrum, from a single-payer "Medicare for all" plan to a loosely regulated free-market system that restricted the use of health insurance to truly catastrophic events.

A physician is as likely as anyone else to view the ACA through the lens of his or her own political affiliation, and recent surveys have found that physicians are as politically polarized as the general population.[1,2] Although primary care physicians are more likely to support the ACA than are surgeons and procedural specialists,[3,4] there is a pluralism of views within each specialty. Compared with the days when the American Medical Association was the only important medical lobbying group on Capitol Hill, the house of organized medicine now rarely, if ever, speaks with one voice.

In this context, it is noteworthy that so many medical organizations are speaking out against the American Health Care Act (AHCA), the House Republican proposal to "repeal and replace" the ACA. Prior to the release of the proposed legislation, five major organizations that collectively represent virtually all primary care physicians in the United States set forth a set of principles to guide health reform,[5] centered on maintaining insurance coverage gains, protecting patient-centered insurance reforms, and optimizing the system for physicians and patients.

The AHCA does maintain the ACA's guarantee that children can stay on their parents' insurance policies until age 26, insurance underwriting protections for persons with preexisting health conditions, and prohibitions on annual or lifetime limits on coverage. However, the nonpartisan Congressional Budget Office (CBO) projects that its passage would lead to 24 million more uninsured persons by 2026, and eliminating the Prevention and Public Health Fund would damage the ability of the Centers for Disease Control and Prevention and state and local health departments to respond to public health threats such as lead-contaminated water and the Zika virus.

After every health reform, there are winners and losers. In my practice, I see patients who were able to start receiving regular primary care as a result of the ACA as well as patients whose insurance premiums and deductibles rose substantially after the law was passed. It would not have been reasonable to expect that any ACA replacement bill would remedy every shortcoming of our poorly organized, inequitable, and expensive healthcare system.

Here is my personal primary care wish list for health reform:

  • I want to spend more time with patients and less time completing paper or electronic documentation that doesn't make them any healthier.

  • I want my patients to be able to see me when they need to without being punished financially.

  • I am satisfied with my income, but I recognize that the future of my specialty depends on making family physician payment more equitable relative to that of other medical specialties. I think it's critical to stay up-to-date on evidence-based medicine and practice high-quality, high-value care, but measurement needs to be less intrusive and based on patient-oriented outcomes that matter.

  • Finally, I want to be protected against malpractice lawsuits and bureaucratic obstacles to maintaining a scope of practice consistent with my education and training.

I read both versions of the bill that passed the House Ways and Means and Energy and Commerce Committees, as well as a summary of the CBO report, and I have concluded that the AHCA doesn't fulfill any of my wishes. Instead, it changes the structure of premium tax credits to lower the insurance cost burden on younger and wealthier patients at the expense of those who are older and poorer. (The CBO projects that overall premium costs will fall by 10% because up to 30% of people age 50-64 will be unable to afford insurance, leaving a younger and healthier insured population.) The AHCA drops the requirement for health insurers to spend a minimum percentage of premiums on healthcare, rather than administration and profits. It provides additional funds for community health centers and state "safety net" programs in exchange for capping federal support for Medicaid, which paid for healthcare for 74 million people at the end of 2016.[6] And, bizarrely, it makes a point of clarifying that Medicaid recipients who win the lottery will no longer be eligible for benefits.

As health systems in countries around the world have demonstrated, and as my students showed me recently, there are many different paths to a better health system than the one we have now. A better health system would value the contributions of family physicians to maintaining and improving the health of our patients. Based on this standard, the AHCA is a path best not taken.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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