National health care advocates quantity, undermines quality

When Lyndon B. Johnson signed Medicare into law July 30, 1965, skepticism was immediately omnipresent among the American public. Simply put, the bill was just too complicated for many people to comprehend.

As a result, the public naturally clung to the talking points and rhetoric spewing from the media at the time in order to formulate their opinions on the bill. For instance, the American Medical Association called it “the beginning of socialized medicine,” and politicians warned of the inevitable army of eligible senior citizens busting down hospital doors as a consequence of the expansive program. An apprehensive, polarized Congress and their constituents braced in apocalyptic-like fashion for the day these benefits would become available for seniors. The start of the rollout was coined “M-day” by the New York Times in 1966. Many of the same tactics have been employed in the rhetorical war over the Affordable Care Act.

The Affordable Care Act, or Obamacare, is an inherently different story, but there are parallels such as the comparable rhetoric, which includes a similarly polarizing effect, and the almost identical worries e.g.,  the long lines and Uncle Sam prying into our doctor’s office. 

Unlike Medicare, however, the Affordable Care Act’s rollout has been anything but smooth. 

With many having trouble gaining their promised benefits on a severely broken website alongside others losing their coverage, the program has already been marred soon after its commencement. But if anything, the rollout of Medicare should provide some historical context. 

When M-day came it was rather anticlimactic. Of the 19 million seniors eligible for health care, 93 percent enrolled in the summer of 1966. But the long lines never came, and hospitals braced for the worst, only to find their pessimism met with a surprisingly smooth rollout. There were some bumps in the road, for instance, some hospitals in the South refused to hand out the benefits to eligible blacks. Nonetheless, today Medicare is an extremely popular program. Most Americans expect to reap the benefits, and no politician would ever dream of cutting it — so eventually, the program was deemed worth the cost. 

Although Medicare’s smooth rollout set it on a path toward success, the initial quantitative problems with the Affordable Care Act can be easily overcome, at least in comparison to the troubles the rollout poses in terms of quality of care. 

On the aforementioned issues the rollout has already faced, President Barack Obama assured in his end-of-the-year press conference that “a couple million people, maybe more, are going to have health care on Jan. 1.” This claim is backed by rising enrollment numbers on Healthcare.gov and by widespread registration found in the new State Health Exchanges. For example, New York state has had more than 100,000 people sign up for coverage, with about one-third signing up for Medicaid, and the remaining two-thirds selecting private insurance. So while many other state legislatures are still squabbling over expansion, New York state officials say they are on track in reaching their goal of having 1.1 million state residents insured by the end of 2016. 

Furthermore, the Obama administration has acted on the fact that many lost their insurance at the beginning of the rollout by temporarily canceling the individual mandate for those whose plans were rescinded. Thus, giving the government the chance to smooth out the threshold of the mandate. 

The numbers are improving, and “that is a big deal,” as Obama said. Some hospitals across the nation might agree that it is a “big deal,” but not nearly with the same level of optimism. 

There still exists a very dramatic concern — similar to the one that existed during Medicare’s inception — that the rollout will cause an influx of patients who will overwhelm hospital staffs across the country. Doctors such as Jeannette South-Paul of UPMC’s Matilda Theiss Health Center in Oakland have voiced such concerns.

“We’re going to be inundated with patients,” she said. With more than 200,000 uninsured people living in Western Pennsylvania, South-Pal claimed there simply “aren’t enough of [doctors]” for UPMC to be fully prepared for the rollout. Other doctors believe these worries are exaggerated.

Dr. C. Richard Schott, a Philadelphia-area cardiologist and president of the Pennsylvania Medical Society, said, “It’s very unlikely that 30 million people are going to instantly appear on the doorsteps of physicians across the country as of Jan. 1.” He went on to clarify this, nothing that “Historically, people in this country and in this state have had access to care.”

Sick patients have always come to hospitals with or without insurance, and hospitals will not house patients with minor injuries or illnesses for longer than necessary.

Even UPMC’s executive vice president and chief medical and scientific officer Dr. Steven Shapiro agreed.

“We’re not expecting too much of a difference in admissions,” Shapiro said. 

The expected quality of care, however, poses a different story. 

I spoke with longtime pediatrician Dr. Giuseppe Lancellotti on the subject. Lancellotti runs a private clinic in the rural town of Ephrata, Pa., and makes rounds in the pediatric wing in the local hospital there.

When asked about the rollout, he predicted that “overall, the quality of care is going to go down due to the weakening of accessibility between doctors and patients.” He blamed this on the large medical bureaucracy he sees growing from the rollout. 

“Nonprofit hospitals are merging with for-profit hospitals, creating bigger and bigger health systems,” he said.

Consequently, this means that hospital administrations will have control over a greater number of doctors. 

“What’s happening is that you have some decisions leaving from the doctor [and transferring] to the administrator,” Lancellotti said.

He cited the “Bundled Payments” aspect of the Affordable Care Act as an example. Bundled payments are federal payments that care providers receive based on certain diagnoses of patients.

“The administrators of hospitals decide how to divide these payments, and a lot of it is just going right back into ‘administration fees.’ The doctors aren’t seeing a lot of it,” he said. 

Administrative fees could include the mandatory shift toward electronic health records in hospitals, which is pretty big investment for many hospitals despite federal incentives.

As a result, according to Lancellotti, “Productivity will go down because doctor incomes are going down […] as is the time spent between the patient and the doctor due to these electronic medical records.” 

The Affordable Care Act seems to cast a dehumanizing effect upon doctor-patient relations, and even if millions obtain health insurance, this possibility could undermine its value.

If future Americans are to look at the Affordable Care Act in the same way that we look at Medicare now, the rollout will have to seriously overcome the problems facing quality of care as well as quantity. At this point, however, time will prove to be more telling than the rhetoric.  

Write Nick at njv10@pitt.edu.