As the country’s electorate prepares to cast ballots for the U.S. President, some health care advocates may still be weighing which political party would best serve their needs. Health spending accounted for nearly a fifth of the U.S. gross domestic product (GDP) in 2010 and costs have been rising faster than inflation for years, yet 48.6 million Americans lack health insurance.
Endocrinologists and other health care practitioners are concerned about how to balance rising costs while providing quality health care, but a political path based on such issues is “not clear cut,” according to William Applegate, consultant to The Endocrine Society and director of Health Care Government Relations Practice at Bryan Cave law firm in Washington, D.C.
“We tend to have friends on both sides of the aisle,” he says, acknowledging that his firm “cultivates bipartisan support.” This election is complicated by the fact that the Mitt Romney camp has not put forth a “comprehensive clear plan,” Applegate says, and President’s Barack Obama’s landmark Affordable Care Act (ACA), passed in 2010, “simultaneously has support and opposition depending on the various provisions and pieces of the law.” Much of the ACA has yet to be implemented and people “are waiting to see how it all gels.”
Although the full extent of ACA’s impact on the health care system can’t be known yet, health care coverage has slowly ticked upward in the last year due to young adults gaining health insurance under their parents’ plans. Cover age is expected to increase in 2014, with the end of health insurance discrimination for pre-existing conditions and gender, the implementation of state health insurance exchanges, and the expansion of Medicaid, the federal plan for low-income families.
The American College of Physicians, the largest medicalspecialty organization in the country and a longtime advocate of universal health care, supports the initiatives of the Affordable Care Act. Team-based care and preventive provisions of the ACA are particularly attractive, says endocrinologist Dennis Cope, a member of the ACP’s Board of Regents and Chair of Internal Medicine at UCLA Medical Center. Access to screening and preventive care can reduce and alleviate chronic diseases such as thyroid disorders and diabetes, he says.
“Right now we’re having an epidemic of obesity, which can lead to type 2 diabetes. Early treatment would be beneficial,” he says. “But currently, there is not much reimbursement if you don’t do procedures, and endos typically don’t do procedures. The Affordable Care Act pays for integrative care. If we start paying more for cognitive information and integration of material, we can save a lot on procedures and have a better outcome.”
William F. Young, Jr., president of The Endocrine Society and chair of the Division of Endocrinology, Metabolism, and Nutrition at the Mayo Clinic College of Medicine in Rochester, Minnesota, agrees: “The Affordable Care Act encourages integration of health services.” But Young has reservations. “In an ideal world it would result in more effective hand-offs between primary care physicians and endocrinologists. However, it has also encouraged the newly integrated systems to limit provider choice as a means of coordinating care. These closed systems, or narrow networks, may discourage the referral of patients for subspecialist consultations in a timely fashion,” he adds.
Under the ACA, the Centers for Medicare & Medicaid Services created the Medicare Shared Savings Program and established 33 quality measures for patient care coordination and safety; six of the measures directly relate to diabetes care.
“That positions endocrinologists to play a very important role in working with primary care physicians and patient-centered medical homes and accountable care organizations to help achieve those targeted metrics,” says David Longworth, chairman of the Medicine Institute at Cleveland Clinic.
Usha Srinivasan, who has practiced endocrinology in Bel Air, Maryland, for 30 years, says she likes some features of the ACA, mainly the contraception provision for women, coverage for young people on their parents policy until age 26, acceptance of patients with pre-existing conditions and removal of the lifetime cap for coverage, but “we don’t have the infrastructure for it,” she says. “As an endocrinologist, I am already overworked. You need time with your patients. ACA is going to increase the number of patients, but it will decrease the quality of care.”
Relying on the premium contributions of healthy young people to pay for the expansion of coverage is not realistic, she says. “Type 2 diabetes and other endocrine diseases are occurring in young people, so they can’t bear the [financial] burden for others.”
Another questionable aspect of the ACA is the documentation required by “the gatekeepers,” Srinivasan adds. “It’s extensive and the electronic recording-keeping is already subject to fraud.” She, however, dismisses Romney on the issue of health care: “He doesn’t have a health care plan.”
Like Srinivasan, other health care experts have expressed concerns about the far-reaching impact of the ACA. The Supreme Court decision that upheld the legislation allows states to opt out of the expansion of Medicaid. If states choose not to participate—and most Republican governors have said they will not expand their Medicaid programs — hospital funding will be decreased and benefits to millions of low-income people will be reduced. “The cuts could have devastating effects on hospitals,” says Dave Dillon, a Missouri Hospital Association spokesman. “We’re very worried about the viability of Medicaid.”
Other health care watchers have raised concerns about cuts in Medicare funding to private insurers. “The Affordable Care Act will significantly decrease Medicare reimbursements to all physicians,” contends Richard Dolinar, a clinical oncologist in Phoenix and a senior fellow on health care policy for the Heartland Institute, a conservative think tank. “Medicare rates will eventually be less than Medicaid rates. More than 40 percent of Medicare providers will go out of business or stop seeing Medicare patients.
Mitt Romney promises to work with Congress to repeal the ACA. “I’m replacing it with my own plan,” the candidate said on “Meet the Press” in September. Though the details of Romney’s replacement plan have yet to be released, he is known to favor a free-market approach he says would create competition that in turn improves efficiency and effectiveness in health care.
Romney has also promised major changes to Medicare and Medicaid that he claims would cut costs while keeping physician payments at current levels. Individuals already in retirement or near retirement age would see no change to their Medicare, but the system would be repackaged for younger people, who would be given a fixed-amount benefit to purchase insurance. In addition, Medicaid would be transformed into a block grant program for states, which would receive a lump sum amount that would grow by inflation plus one percent each year, controlling spending on the program.
A recent analysis from the Kaiser Family Foundation, a non-partisan health policy organization, however, concluded that repeal of the ACA could result in increases in Medicare premiums and prescription drug payments for current retirees. A 2011 Kaiser analysis found that repealing the ACA and converting Medicaid into a block grant program would save the federal government $1.4 trillion over a 10-year period but also result in tens of millions of people losing their health insurance.
Whoever wins the White House will have to contend with costly and critical health care issues, notes Longworth. “The trend of escalating health care costs, despite the relatively poor quality outcomes that we get when compared to other developed countries, is an unsustainable combination of events.”