The more we learn about the Patient Protection and Affordable Care Act (Obamacare, PPACA, ACA), the more it appears our seniors and the providers of heath care services (physicians, etc.) have become the ‘fall guys’ to pay for it. With the hundreds of billions of dollars that are projected to be diverted out of the Medicare program over the next 10 years, the Centers for Medicare and Medicaid Services (CMS) imposed reimbursement penalties for Medicare and Medicaid patients who are readmitted to the hospital within the first 30 days of a prior admission (1) and proposals to provide only palliative care for some of the most serious maladies after patients reach a certain age as enumerated by Betsy McCaughey PhD, a constitutional scholar from Columbia University (2), it seems the elderly and the physicians who care for them are being asked to take on a disproportionate share of the sacrifices under the dictates of this new and controversial legislation. (3)
Why then have the American Association of Retired Persons (AARP), the American Medical Association (AMA), and the American College of Physicians (ACP) all supported passage and continue to support this potentially harmful legislation to the senior population?
For the Board of Directors of AARP, it has always been about the money. It was a payoff to the President. Through its subsidiary company, AARP was one of the main suppliers of Medi-gap insurance, a privately purchased coverage that picked up where Medicare benefits left off. The George W. Bush administration passed the Medicare Advantage program that was a lower-cost alternative to the Medi-gap coverage. More than 11 million seniors took advantage of the program that significantly cut into the AARP Medi-gap revenues. President Obama eliminated subsidies for the Medicare Advantage program that made the more-expensive Medi-gap coverage more competitive.
Even though over $700 billion flagged for the Medicare program would be shifted out to cover the new enrollees under Obamacare and although seniors would end up paying more money for their coverage, the leadership at AARP threw its support behind proposed legislation. Appearing to be more concerned with corporate revenues than abandoning the seniors who comprised its membership, the leadership of AARP donated millions of dollars toward the advertising campaign and lobbying efforts in support of the proposed legislation. Referred to as ‘corporate cronyism’ much of their membership has openly rebelled against AARP’s leadership. (4)
The leadership of the AMA backed the President’s plan early on when he promised to support a permanent fix to broken Sustainable Growth Rate (SGR). In 1997, Congress passed the Balanced Budget Act (BBA). In an attempt to control the growth rate of expenditures to doctors, the sustainable growth rate (SGR) was established. Using a fee schedule determined by relative value units (RVUs), the intended goal was to limit the total pay for doctors to not exceed the growth rate of the rest of the country. Unfortunately, the formula to calculate the SGR was flawed from the beginning.
When the 1997 law first went into effect in 2002, the SGR formula called for a cut in doctors’ fees of 4.8 percent for over 7000 physician services. Congress overrode the enactment of the BBA, but claimed it was too costly to eliminate the SGR on a permanent basis. Every year since, Congress has blocked the reductions called for under the SGR. They have accomplished this by using two methods: The ‘clawback’ legislation that temporarily prevents the proposed SGR reductions, but allows for this additional funding to be taken out in future years. The other is labeled ‘cliff’ legislation that prevents the scheduled SGR fee reductions, but overrides the law that says that rate reduction cannot be more than seven percent in any year. Although the draconian cuts in reimbursements were put off for another year, President Obama was not able to deliver on his assurances of a permanent fix.
Why then has the AMA leadership continued to support this harmful legislation that will cut reimbursements to many of their membership and most of the elderly patients they claim to support? The same should be asked of the ACP.
One overriding question that seems to be at the heart of any health care delivery system with limited resources is balancing the obligations between helping young people to become older verses helping older people to become older indefinitely. (5)
Prioritization of health care services has been around since the beginning of time. In earlier times, battlefield victims were left to die when their wounds were judged too severe to sustain life. Triaging mass casualties when delivery systems are overwhelmed. Organ transplant allocation that leaves many in need of a second chance at life. Rationing of health care services is a less palatable term but, means the same—- costs, urgency, likelihood of outcome and availability are all a part of making therapeutic decisions.
The federal programs, Medicare and Social Security, are similar to long term care insurance— they are based on a promise. When individuals are younger, part of their wages are set aside or taxed to fund benefits for later in their life. Although all carry obligations to fulfill promises, none can completely insure their participants against less coverage due to inflationary costs and more expensive advances in technology.
A century ago the limiting factors were access to and availability of any needed therapy. Today, it is affordability. Advances in technology have allowed patients to live longer, more productive lives. By necessity, as the costs of care rise, cost/benefit ratios become a delineating factor. Consider the example of contrasting the costs generated by giving an 1800-gram neonate a chance at a long, productive life versus an eighty-five year old senior with multiple system organ failure who is clinging to life in an ICU. Multiply that by a thousand times a day in hospitals across the country. Both have priorities. But what happens when the resources are limited? Which gets cut first? Just as we don’t have the right to take a life, we don’t have the obligation to automatically prolong life.
There are four disadvantaged populations in this country: the extremely young, the extremely old, the uninsured and those that are in this country illegally. Each creates significant costs to our already-strained delivery system. Instead of broad, sweeping dictums that give support to one group over another, maybe the answers lie in the individual encounter—- what is the most humane decision. After all isn’t that the way medicine was practiced until the third parties became involved?
Call it by any name: Obamacare, the Patient Protection and Affordable Care Act (PPACA) or the Affordable Care Act (ACA), they are one and the same. It is interesting that lately this controversial legislation is most often referred to as the Affordable Care Act. We can only presume that once the powers in Washington found out more of what was in the legislation that they voted for without first reading it, the Patient Protection part was left out. At least it would seem that way for the elderly.
The outcome of the election that is almost upon us, possibly the most important this country has faced in recent times, maybe ever. As physicians, citizens, potential patients and, if we are fortunate, seniors, we should cast our vote only after very careful consideration. The future of health care delivery for the elderly depends on it!
- President Obama 1, President Clinton 0, Echoes for the Future, July 23, 2012.