The Patient Protection and Affordable Care Act

They got it done, but at what cost. There is no doubt that things could not stay the way they were. Something had to give. US health care by public health standards trails most of the developed world. Emergency rooms bear the burden of our uninsured who seek help only when forced to do so by an illness they cannot afford. The cost shifts to those who can pay, and the government regulations designed to contain cost actually drive costs higher in an unending spiral. It is a paper chase wherein the dollar has become the goal rather than patient care. Most doctors agree. Many have quit.

The fix is complicated. There will be some good and some bad with the new law. The backlash comes as somewhat of a surprise to me. I assumed the vast majority of the population was as cynical about the system that we have as I was as a clinical doctor. This was not the case. Demonstrations spawned by radio talk shows grew ugly. President Obama tried public education then public campaigning with limited results. I think the problem is with youth who have good health and little financial responsibility and with the marginally employed or gainfully unemployed who would rather continue to live outside of the system – both for pragmatic and financial reasons.

My grand daughter, commenting on her lack of automobile liability insurance said, “It is cheaper to pay the fine if and when they catch me, rather than pay for the insurance.” I think the same thing will play out with mandatory health insurance. It will be a question of what percentage of people will opt out on that basis. State’s attorney generals are already filing lawsuits, claiming that mandates on individuals and on the states are unconstitutional. Is the Supreme Court political?

The new public law, 111-148 is as complex as the problem. I tried to download the 406,887-word document, and my computer locked up. I was able to order an official copy from the Government Printing Office bookstore, however, for $29 with free shipping, all 906 pages of it, delivered by May 5. I actually intend to read it.

I am hopping that there is a mechanism to fix what does not work and leave room for innovation. I am concerned that a law, this inclusive, may be inflexible. If so, it is a shame. I am also fearful that the solution may lack sufficient provision for rapid scientific medical advances and challenges. There needs to be a provision for provider education. Our entire Public Health System needs strengthening. The authority for `criteria of diagnosis,` provision for `differential diagnosis` and `evidence-based` recommendations for treatment should be distributed to regional research and teaching centers. It is no exaggeration to say that any published guidelines are obsoletes the day they are published. The science is moving that fast. The authority should go to the scientific leadership of regional teaching institutions not to a central medical bureaucracy.

Perhaps it will become opportune for the Administration to play the Republican `States-Rights` Card and move the Health Care authority from Washington to centers of medical science, distributed among the states. Time will tell. It is a certainty that this law is a first step, hopefully the first constructive step of many to follow.

Our teaching institutions are indeed the best in the world; however, we have a way to go in regaining our once renowned leadership in public health and a healthy public. More after the long read. I will look for all of the above considerations.