The passage of the Patient Protection and Affordable Care Act of 2010 (PPACA), our new health care legislation, in March was hailed by its supporters as an historic event of the magnitude of Social Security and Medicare. But four months later, it remains controversial, with repeated polls showing three large groups of divisive opinion, including those who would work to repeal it and others who believe that it will make no difference. The Democrats have launched a $125 million PR campaign to defend the new law amidst growing signs that many Democrats facing re-election are failing to get political traction on the issue. (1)
We are being advised by many to "wait and see" how this complex new bill plays out over the next five to ten years, but we can already know what its outcomes will be. More than 30 years of health policy science, including documentation of the repeated failures of incremental changes built into the new law, together with well-entrenched trends in our market-based system, allow us to project its outcomes with confidence. For this legislation has been molded and crafted by the political power and money of corporate stakeholders in the medical-industrial complex.
Five previous posts in 2009 described the uneasy "alliance" of the five biggest players -- the insurance industry, the drug industry, the hospital industry, business and organized medicine. They will do just fine with the new law at the expense of patients, families and Main Street.
Health care "reform" this time around was intended to address these four basic system problems: (1) containing health care costs, (2) making health care more affordable, (3) increasing access to care, and (4) improving the quality of care. This post introduces a series of five that will examine how well the PPACA will do on each of these four goals, followed by an overall assessment of the law. These posts will draw in part from my new book Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform, soon to be released by Common Courage Press in both print and eBook format.
Continued Unrestrained Drivers of Health Care Costs
These are some of the many reasons that we can already conclude that health care costs will continue to run out of control at rates far exceeding the costs of living and median household incomes.
• No price controls. Wall Street has already factored in rapid expansion of markets for drugs, medical devices and other services in a system of expanded access. There is also a long line forming of providers of information technology and administrative services that will exploit the complex implementation of this law.
• No bulk purchasing. The PPACA has prohibited the government from negotiating the prices of prescription drugs and retains a ban on importation of drugs from Canada and other countries.
• Lack of control over perverse incentives that drive increased volume of services. These in turn are driven by retention of fee-for-service (FFS) reimbursement that encourages physicians and other providers to offer more services than are medically appropriate or necessary.
• No effective mechanism to rein in marginal or ineffective technologies. Coverage policies for new drugs and medical devices are still lax and not subject to rigorous evidence-based criteria for either efficacy or cost-effectiveness.
Although the PPACA does call for a Patient-Centered Outcomes Research Institute, its role is already neutered by not having the power to mandate or even endorse coverage or reimbursement rules for any particular treatment. (2)
• The dominant business model of health care prevails, with many facilities and services remaining for-profit and investor-owned and with an ongoing trend for increasing consolidation within industries.
• The PPACA has grandfathered-in specialty hospitals, typically physician-owned facilities that focus on well-reimbursed procedures in such areas as cardiology and orthopedics, whereby physicians can "triple dip," earning high incomes as providers, owners and investors.
• More preventive services will further fuel health care inflation. While the PPACA does provide new coverage for many preventive services, this will lead to increased costs due to additional diagnostic and treatment services engendered. (3)
• Private insurers can't contain health care costs, even where they have dominant market power. A 2009 report by the Congressional Research Service, "The Market Structure of the Health Insurance Industry," concludes that:
The exercise of market power by firms in concentrated markets generally leads to higher prices and reduced output -- high premiums and limited access to health insurance -- combined with high profits. (4)
• There are no controls over premium rate increases by insurers. Despite the outcry by government officials, annual premium rates are escalating at rates up to 56 percent (5), and there is no end in sight for continued exorbitant rate increases. Insurers will continue to game the system by extracting maximal profits and offering reduced coverage with actuarial values (the amounts insurers actually pay in coverage) as low as 60 or 70 percent.
• National health care spending will grow unabated despite the passage of PPACA. The Centers for Medicare and Medicaid Services (CMS) projects that overall national health expenditures (NHE) will increase from its present 17 percent of GDP to 21 percent in 2019, a total of $4.470 trillion. (6) (Foster, RS. Office of the Actuary. Estimated financial effects of the "Patient Protection and Affordable Care Act," as Amended. Centers for Medicare and Medicaid Services, April 22, 2010)
These well-documented trends leave no room to think that health care "reform" will have any chance to contain health care costs. Instead, health care inflation will be exacerbated by all the new incentives and inefficiencies in the new "system." In our next post we will examine the impact of these trends on affordability of health care.
(1) Allen, M. Dems launch $125 M health campaign. Politico, June 7, 2010
(2) Kaiser Health News staff. True or false: Seven concerns about the new health law, March 31, 2010
(3) Russell, L. Preventing chronic disease: An important investment, but don't count on cost savings. Health Affairs 28 (1): 42-5, 2009
(4) Austin, DA, Hungerford, TL. The Market Structure of the Health Insurance Industry. Washington, D.C. Congressional Research Service, November 17, 2009
(5) Johnson, A. Fight over health-care premiums heats up. Wall Street Journal, February 19, 2010: A6
(6) Foster, RS. Office of the Actuary. Estimated financial effects of the "Patient Protection and
Affordable Care Act," as Amended. Centers for Medicare and Medicaid Services, April 22, 2010
Dr. John Geyman is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, a past president of Physicians for a National Health Program and author of "Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It." Buy John Geyman's Books at: http://www.commoncouragepress.com