We gratefully acknowledge the sponsorship of Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference
The following transcription is of the first plenary session of the 26th National Conference on Primary Health Care Access, held April 13, 2015 at the Hyatt Regency Orange County.
John Boltri, MD, Northeast Ohio Medical University, Rootstown, Ohio [Doctor Boltri is a Senior Fellow of the National Conferences on Primary Health Care Access]: Good morning. It’s a great pleasure to be here. I’m John Boltri, the Chair of the Department of Family and Community Medicine at Northeast Ohio Medical University.
I have the distinct honor of introducing the great debate: “Coast” versus “Heartland”. The question being debated is whether of not The Patient Protection and Affordable Act [PPACA, or ACA, or Obamacare] is a huge success.
Before introducing our debaters today, I will mention that we’ve been working on this for some time. After some heated email exchanges and meetings, we’ve agreed on a format: 20 minutes for each debater.
I will be sitting in the front row and I will hold up the time cards at five minutes and two minutes, and one minute. And if they go over you will see me stand up. (I use this same format in our department meetings. And then I will begin inching toward them and then if they go over too much. I will put my hand on their shoulder. In an extreme circumstance I might have to invoke the Dr. Gary LeRoy’s approach to ending the presentation of a speaker who has exceeded his time limit, applying a “wedgie”.
But both speakers have promised me that they will not go over 20 minutes, so I doubt I’ll even have to get up out of my seat.
Our first debater; will be Doctor Mike Prislin. He is a professor of family medicine and an associate dean at the University of California, Irvine. He will start off with one perspective. Then Doctor Charles North, who is a professor at University of New Mexico, Albuquerque for an alternate perspective.
Then each person will have an opportunity to ask the other a question; for which they will be given four minutes to respond. If they don’t use their entire amount of time they will be given more time to respond and provide additional back up material if they so choose. So without further ado, here’s Mike.
The Great Debate – For the Affirmative:
Michael D. Prislin, MD, University of California, Irvine. [Doctor Prislin is a Fellow of the National Conferences on Primary Health Care Access]: My fellow Americans – on behalf of the Left Coast, it’s my pleasure to welcome you to the great debate this morning.
My charge is to convince you that the healthcare overhaul that we’re all experiencing now is a resounding success. And I will do that I’m sure. Wait, wait a second, I’m getting a phone call. Yes Mr. President. Yes Mr. President. Yes Mr. President, yes sir. OK, thanks.
Let’s move on. First of all I’d like to provide you with this disclaimer, I have not injured any politicians in preparing this. Most of what I have to say will be somewhere near the truth. But I do reserve the right, I will shamelessly advocate my perspective at any opportunity that I have; so without further ado.
I think it’s important that we frame this debate in the appropriate context. I’d like to point out during the recent presidential election that President Obama did indeed let the candidate Mitt Romney know that we’re really not dealing with Obama’s healthcare act; we’re dealing with Romney’s healthcare act. So Mitt, could this really be true?
Well let’s examine it. We’ve got state-based health insurance exchanges, We’ve got subsidies for lower income households, We’ve got individual and business mandates, We’ve got cost sharing for preventive services. Loosely defined, we have expansion of government-supported healthcare: Romneycare.
So let’s really change what we’re going to talk about, we’re no longer going to talk about Obamacare. We’re going to spend the rest of this discussion talking about Romneycare. Now we’ll get back to PPACA. I don’t know where the Patient Protection part of it came from, so I’m just going to focus on the Affordable Care Act.
And this is a quote from a weekly Saturday radio address; I don’t know whether Barack still does these. I seem to be missing them on my Saturday morning radio station. But he said “This week I conveyed to Congress my belief that any healthcare reform must be built around fundamental reforms that lower costs, improve quality and coverage, we know that is the triple aim. And also protect consumer choice.” And so let’s frame that. I want to no longer think of this as the triple aim, but I want to think about it as the quadruple aim; because we’re also protecting consumer choice in this act.
Let’s take a look at it. As we know from our colleagues in the Republican Party, the Affordable Care Act is incredibly complex. In fact it goes on to thousands of pages. Somebody told me last week that the language in the act is intentionally designed to obfuscate what really is mentioned. Now I’m not really going to get into that, but I would say that we’re going to talk about three key pieces; expansion of coverage, improvement in quality of care, and reduction in cost.
Expansion of Coverage
So let’s look at expansion of coverage. What does the Act do? Well, we created a health insurance marketplace, we’ve expanded Medicaid coverage eligibility, we’ve extended dependent coverage for young adults, we’ve eliminated pre-existing conditions, exclusions from coverage, and annual and lifetime coverage limitations, and we’ve expanded the Medicare and Medicaid scope of coverage; particularly in the areas of preventive services and pharmacy coverage.
How have we done? The percent of uninsured Americans has dropped from 20.3% to 13.2%. That includes nearly two and a half million under age 26 who have gained insurance as dependents in their parents’ coverage. We have 14.1 million who have gained access through Medicaid expansion and increased access to private insurance. We have 36 states that have chosen not to create healthcare exchanges. We all know the decision regarding the federal marketplace is currently pending. We have 22 states who have elected not to participate in Medicaid coverage. That number seems to be declining. As resources get tight more states are signing up.
So if these policies were fully implemented we would probably have an additional 12 million more who could be covered. And I’d like to point out since we are on the coast in California, if we thought about our undocumented residents, and we provided access to coverage there, we could cover another 12 million.
We have a presidential election coming and I’d like to put forward that we do have a candidate who has spoken strongly in terms of immigration reform. It will sort of perpetuate a great American dynasty. And I present to you this morning Jeb Bush, the immigration president. Perhaps he will expand the Affordable Care Act to cover undocumented aliens.
Let’s talk a little bit about quality improvement. This is what the act proposes: expansion of preventive services primarily though Medicare, to a lesser degree through Medicaid. Those of us who are doing our annual well visits now know what the Medicare expansion is all about.
The act supports the creation of accountable care organizations. It established the Center for Medicare and Medicaid improvement. It established the Prevention and Public Health Fund. It established the Patient-Centered Outcomes Research Institute. It established the community care transitions program, increased support for community health centers, and it’s rebuilding the primary care workforce.
The vote is: The ACA innovation center has been established. There is a hospital injury program that has demonstrated improvement in outcomes and cost savings. We have 32 pioneer ACOs, 13 of which have saved money. We have a community based transitions program. We have the Patient Centered outcomes Research Institute, which I think you’ll all agree is a wonderful idea. Community health centers have received $11 billion to fund the support of improvement expansion over the next five years. This has increased the patients served in community health centers from 19 to 24 million since the implementation of the Affordable Care Act.
I think you’ll all agree that rebuilding the primary care workforce is another wonderful idea.
Reductions in Healthcare Costs
Let’s talk about reduction in cost. What does the Act do there? We’ve established the Accountable Care Organizations. We’re cracking down on healthcare fraud. We’ve addressed overpayments to large insurance companies and we’re reducing healthcare premiums. We’re linking payment to quality. We’ve reduced paperwork and administrative cost through the implementation of electronic health records. We’re improving individual and employer responsibility with the employer and individual mandates. And we’re paying physicians based on value, not volume.
So here’s the vote. Now admittedly you can’t really reduce healthcare costs. I mean nobody really thought that was going to happen, right? We can only hope to reduce the rate of increase in healthcare costs.
As you can see here – having a depression, or a recession – or whatever you want to call it, is fairly effective in reducing the rate in increase in healthcare cost. But we’ve also done pretty well.
You have to define when the recession ended, but if you assume that the recession ended in about 2010 or 2011, in the post-recession Affordable Care Act era we’ve also been fairly successful in reducing the rate of increase of healthcare costs.
Nobody really knows how much fraud is occurring in healthcare, there’s really no methodology to figure out how much fraud there might be. So it’s difficult to figure out exactly what’s happening there. But in terms of overpayment to insurance companies the estimate is, is that they’ve decreased by about $17 billion since the initiation of the act. Interestingly, health insurance premiums in the insurance marketplace are 16% lower than they would have been predicted by our own Congressional Budget Office.
Preservation of Choice
I want to get back to the fourth point of the quadruple aim because remember that was that we were going to preserve choice – which meant that we were going to continue to have private insurance cover the bulk of the expansion and access to care. I think that was – you have to be fair – an intention of the act.
It’s no surprise the insurance companies are doing well. Profits are up 10-17% for the Big Five, and the price per share has increased to twice the average for the Standard and Poors 500 index since the implementation of the act. If we’re talking about that as part of the quadruple aim, we clearly have had a success there.
Then there’s another winner, and that is our friends in the do nothing Congress. Most of the publications you’ll say that they’ve only voted, had motions to repeal 54 times, but I would point out to you that they voted again in February of this year so that makes it the 55th time. The number of times that the House has voted on a specific time to modify or replace Obamacare is zero.
I think I can stop here and turn the podium over to my most worthy adversary.
John Boltri, MD, Debate Moderator: Thank you very much. You’ve only used eleven minutes, so you’ve reserved nine minutes for future rebuttals. While we’re queuing up the next presentation I’ll let you know that we’ve debated previously about how to resolve the debate if there’s a tie. And we talked about using either height, or age, or another form to help decide and at the end I decided I would reserve the right as the moderator to make the final decision.