There is a great deal written on President Obama’s health care – actually mostly insurance – reform, the Affordable Care Act (ACA), much of it driven by the ideology of the writer and / or the organization for whom the writer scribes.  I have contributed to this – in some small measure – myself; I am not sure that this is something of which I should be proud.

Asking why health reform didn’t go further, why we don’t have a single payor option, a socialized option, why so much emphasis is placed upon the private insurance companies, and so forth are all good and important questions.  But at this point, they are not entirely relevant. We have the ACA, it is law.  We now have to determine how we will make it work for our people.  Hence the title of this missive.

In the Past:

From 1979 through 1983 I was a member of the internal medicine house-staff at The Cook County Hospital (CCH), in Chicago.  (Chicago is where I learned that the winter does not end after December !  Great city as long as you are there only from May through November.)  During one of my rotations in the Emergency Department, the section nurse brought me the ED work sheet of a man who had presented with a complaint of “bloody urine”.  Doctor Layon, she said, here is your next patient.  So I go into the cubicle, introduce myself and ask this man what was happening.  He said, indeed, that he was having bloody urine.  After asking a few more questions, I requested permission to examine the man’s genitalia; he agreed and I pulled back the sheet and lifted up his hospital gown.

Imagine my surprise when I noted – astute clinician that I was at the time – that there was NO genitalia present.  The man’s penis and scrotum were gone, replaced by a fungating mass that represented, penile cancer.  Bloody urine indeed.  I admitted the man and soon lost track of him.  The nature of safety-net hospitals often results in that kind of care.  My suspicion is that he did not live long after he was diagnosed.

What has this to do with the ACA ?

The Answer Revolves Around the Number “50 Million”:

Former President GW Bush famously noted that there was no access problem in the American Health Care System.  That anyone could walk into any ED and be cared for (1).  And of course, as my example case above notes, this is sort of correct.  Yes, this man walked into the CCH ED.  Yes, we cared for him.  Yes, I am pretty sure he died rapidly.  Is this what we want from a health system ?

First of all, the number of ED beds is decreasing (see Reference # 1).  Secondly, as the Division Chief of Emergency Medicine at the University of Florida – Shands Hospital from 1995 through 1999 (how I became this is a story best told with a glass – actually several glasses – of good red wine) I have seen the way this system doesn’t work.

Anyone can walk into any ED and be seen.  If they have a life-threatening emergency, they will be cared for.  When they are sent out they may be given a number to call for follow-up care.

So the man with the penile cancer might have come to see us earlier in Chicago. We might have noted that there was a problem and given him a number to call for an appointment with one of our Urology colleagues.  He might or might not have gotten the appointment, depending upon whether or not he had funding (likely did not) and whether or not the funding was Medicaid (likely would have been).  This matters today because much of the expansion in access to health care called for in the ACA revolves around the issue of Medicaid funding.  Question is: Will this work ?

The answer is “Perhaps”

The ACA-driven expansion in Medicaid will indeed provide better access.  But is we add 45 to 50 million people to our health care system, and manage it the way we always have – that is procedural based with very little consideration given to quality – we will sink.

Hospitals are looking forward to the Medicaid expansion as there will be less un-reimbursed care; but the key is that quality must also increase or the increased funding will not cover the additional care (2).  The mantra of some governors that increasing Medicaid will break their budgets is most likely an exaggeration (3).

This is the / a key to expansion.  We provide a great deal of care, not all of which is needed or high quality.

Access and better quality care would likely have saved my patient’s life back the The County.  At least there is a chance of a better outcome.  Admittedly the ACA has many imperfections, but with the status quo, we are doomed.

The issue of quality and what it might actually mean will be the topic on my next piece.

References:

1. http://www.dailykos.com/story/2011/05/18/977178/-Disappearing-Emergency-Rooms-Expose-GOP-Health-Care-Farce accessed 17 March, 2013

2. http://www.washingtonpost.com/blogs/wonkblog/wp/2012/07/03/why-hospitals-heart-the-medicaid-expansion-in-one-chart/ accessed 17 March, 2013

3. http://www.washingtonpost.com/blogs/wonkblog/wp/2012/07/03/the-truth-about-medicaids-cost-to-states-in-three-charts/ accessed 17 March, 2013

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