Mental Health Matters: What lies ahead of the Affordable Care Act? (opinion)
January 19, 2017
Prior to passage of the 2010 Affordable Care Act (ACA), a first step toward universal health care, I met with a group of Incline Village locals to discuss the bill.
To my surprise, some 80% of those in attendance believed that if you don't have insurance, you should not be provided uncompensated care, which is to say that health care is a commodity, something you purchase, not a fundamental American birthright.
Now, as a physician who worked in both the public and private health care sectors, I am personally acquainted with the devastating life impacts caused by the lack of health insurance and health care.
The Urban Institute, reflecting my experience, concludes that the absence of health insurance correlates with lower quality of life, an increase in health problems, and an increase in death rates. Before passage of the ACA, the absence of health insurance was killing Americans at the rate of one every twenty-four minutes.
Fast forward from passage of the ACA to the present and some 30 million Americans have health care coverage now who would not have it otherwise.
So, what happens when the new Congress "repeals" it?
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Young and healthy adults will pocket money because they won't be required to purchase health insurance they don't need. Wealthy folks will still be able to buy the health care they want. Employers will still provide coverage for full-time employees, though deductibles will likely increase. Medicare for seniors will still be available, at least for now.
What else? The Congressional Budget Office estimates that full repeal of the ACA will increase the federal budget deficit by $137 billion through 2025. A 2016 study estimates that 58 million would be uninsured with full repeal. Moreover, 52 million under 65 with preexisting conditions would be uninsurable.
The ACA requires, at least in theory, parity of mental health and physical health coverage. The mental health component might be gone under full repeal.
It's estimated that under repeal, 4,148,000 Californians would lose health coverage, as would 340,000 Nevadans. Also, that 5,805,000 Californians would have a disqualifying preexisting condition as would 439,000 Nevadans.
And the cost of "uncompensated coverage" would increase by $9.4 billion in California and $985 million in Nevada.
These are daunting numbers.
Why, you ask, would the federal budget deficit increase if the ACA goes away? After all, if the government isn't paying for health care insurance they should save money.
Not so, because federal and state law require paying some hospitals for "uncompensated care," namely care provided to individuals who can't pay for it, and because providing care to the uninsured and underinsured costs more.
Here's an example illustrative of the larger problem. Diabetes afflicts 20% of those over 60. Poor diabetic disease control is associated with lack of primary care and poor adherence to treatment, problems exacerbated by poverty and lack of insurance. This in turn leads to more diabetic complications and more costly emergency and hospital inpatient care.
The same principles apply to all health problems including mental health and substance abuse. Preventive care, early intervention, and coordinated care as an outpatient are most efficient over time. The absence of care early on increases its overall cost over time.
Also, with mental health and substance abuse problems, the absence of care creates additional costs for the criminal justice system, another financial burden on government.
There is one sure way to "repeal" the ACA and save money, and a recent experience suggests how we might do it:
"I visited a dentist for a root canal. I have no dental insurance. I signed a document agreeing to pay the full cost of care immediately following the treatment. Turned out I didn't need a root canal, it was already too late for that, so, still reclining in the dentist's lounger, I signed another document agreeing to pay the full cost of a tooth extraction immediately after that treatment was rendered."
Get the picture? No money, no treatment.
Just imagine the billions of dollars our government would save by ending the requirement that hospitals provide uncompensated care. If you don't have health insurance or bundles of cash with you, forget about hospital care for that heart attack, stroke, or gun wound.
It won't be pretty to refuse care to a person who might die without it, but in reality, it happened with some frequency before passage of the ACA, to a lesser extent after its passage, and will surely continue to happen until health care is a fundamental American right.
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at firstname.lastname@example.org.