Affordable Care: Back to the Future?

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In the days before this issue of Emergency Medicine (EM) went to press, the United States Senate tried unsuccessfully, first to repeal and replace the Affordable Care Act (ACA), then to repeal key provisions of ACA without a replacement bill. Despite having a majority in both the Senate and House of Representatives as well as a Republican President, after 7 years of vowing to repeal “Obama Care,” Republicans have still not been able to fulfill that vow.

When ACA was signed into law in March 2010 (See “Springing Forward,” April 2010 EM), we wrote “though the new law will undoubtedly be challenged, tested, modified, refined, used—and probably abused—it will not be repealed. As was the case with Medicare and Medicaid previously, this will change everything in subtle and not-so-subtle ways.” (For a discussion of how the healthcare industry has managed to co-opt and abuse ACA, see the recently published book An American Sickness by Elisabeth Rosenthal, who was an emergency physician [EP] in our department before becoming a senior science and healthcare reporter for the New York Times.)

But the failure of ACA to deliver on many of its promises, its uncertain financial future, and the lack of improvements to ACA since 2010, directly or indirectly affects every American. Predictably, for those in need of care who cannot find a physician to accept their insurance or schedule a timely appointment, the ED remains the safety net for obtaining care.

After the constitutionality of ACA was upheld by the Supreme Court in June 2012 (See “Our National Pastime,” July 2012 EM), we noted that “ACA contains no provisions for increasing the number of healthcare providers [and] if 24 million more Americans now have access to affordable health insurance, but there are no new providers, who will they go to for care?” Seven years after passage of ACA, the answer to this question has been provided by published studies confirming that even more insured Americans are now seeking care in EDs than before “affordable care” became available. At the same time, urgent care centers, freestanding EDs, and “convenient care” centers, have sprung up and proliferated throughout the country, while in many states, nurse practitioners, physician assistants, and now emergency medical technicians and paramedics have sought and received authorization to evaluate and treat patients independent of physician supervision and oversight. Telemedicine or “telehealth” is the latest attempt to stretch the available supply of physicians to manage patients remotely, in the hope of obviating the need for an ED visit.

But none of these measures completely addresses a basic weakness of ACA: There are not enough physicians, including EPs, in this country to care for everyone entitled to healthcare; at the same time, there is a generation of highly qualified, highly motivated young men and women seeking entrance to medical school who will never get the opportunity to become fine physicians because there are not enough places for them. The solution to these problems seems obvious and the funds needed to finance it would be well spent, though the benefits of increasing the number of medical school places would not be realized for 4 to 8 years after they are made available.

In the meantime, we leave you with the solution President George W. Bush offered to a Cleveland audience on July 10, 2007 (See “Dream On,” March 2008 EM): “people have access to healthcare in America. After all, you just go to an emergency room.”

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