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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Voting With the Weight of 32 Million

Next Tuesday, each of us has a chance to make our vote count 32 million times. What I mean by that is a vote for reelecting President Obama will ensure that 32 million uninsured people gain coverage as promised under the Affordable Care Act (ACA). A vote for the challenger, Governor Mitt Romney, endorses his commitment to overturn the coverage expansion, insurance regulations, reforms in the health care delivery system, and public health strategies that are the foundation of the law.

Andrew Bindman, MD

You know these 32 million people, but maybe not as well as you might were they to have health coverage. Because of the gaps between private insurance markets and public programs, they are primarily low-income adults between the ages of 19 and 64 years who do not have dependent children. The majority of them work, but they do so for employers who do not provide health insurance benefits. The 32 million are more likely to live in southern and southwestern states that have the most restrictive Medicaid policies and in states that have experienced higher rates of unemployment.

The 32 million get sick, just like the rest of us, but in many cases they put off seeking care because of major financial barriers to obtaining it. Although uninsured individuals seek health care, evidence shows that when they obtain coverage that helps protect them against the financial burden of care, they increase their use of health care services by about one-third. The 32 million are less likely than those who are insured to have a regular source of care, and because the only part of our health care system that has a legal requirement to see them is an emergency department, they are more likely than those who are insured to use these high-cost sites of care for health problems.

Governor Romney has suggested that emergency departments provide an adequate safety net for these 32 million uninsured people when they need care. Without question, emergency departments can provide lifesaving remedies for many in dire need, but they are not equipped to provide preventive care or to manage the chronic suffering of those who face financial barriers to care. An emergency department is better prepared to respond to an uninsured person with an acute hip fracture than to someone who needs an elective procedure to address chronic agonizing hip pain from arthritis. An emergency department does not have the capacity to provide annual immunizations, to perform cancer screening, or to monitor hypertension. The lack of these services for the uninsured can have a profound effect on their future disease burden and costs of care when they inevitably present in a state of emergency.

Compared with some physicians, I may know a few more of the 32 million because I practice at a public hospital. It is fairly routine in my safety-net setting to see the health consequences for persons who have a chronic lack of insurance, who lose their eligibility for public coverage when their life circumstances change, or who experience a disruption in health insurance coverage because of a change in employment. Some of the most obvious examples of these consequences are unnecessary hospitalizations for chronic illnesses such as asthma, diabetes, or heart failure that result from inadequate access to a primary care physician who can educate patients about self-managing their disease with behavioral changes and medications. The most painful cases are those of patients who have irreversibly advanced diseases, such as cancers that are no longer treatable, because the opportunity to diagnose and address the condition at an earlier stage was missed. Even when conditions are detected in time, it can be difficult for a primary care physician or an emergency room physician to find another physician or a hospital willing to accept a referral to evaluate and treat on an elective basis an uninsured patient with a potentially reversible condition.

The ACA offers the country a once-in-a-lifetime opportunity to change all of this for 32 million uninsured Americans and for every physician who has ever participated in their care. Approximately half of the expansion will be through Medicaid and half through private insurance purchased primarily through an exchange. Perhaps some physicians hoped that when coverage expansion occurred, it would be entirely through commercial insurance that would offer higher rates than are typically available through the Medicaid program. Others might have wished that coverage expansion would eliminate health insurance companies altogether and take the form of a public plan, such as “Medicare for all.” There is no doubt that the ACA reflects some political compromise, but there should also be no question that it offers a dramatic improvement over the status quo for 32 million uninsured individuals and those who care for them.

The ACA will not only enable physicians to practice in a more equitable system than exists today, but it will also provide substantial new resources for delivering that care—more than $100 billion dollars a year in new federal funding to provide coverage for the 32 million uninsured. Assuming the same 20% of all health care expenditures that go to physicians today will continue to flow to physicians through the expansion of coverage under the ACA, physicians can expect a major financial windfall, perhaps as much as $20 billion per year. Some states may attempt to blunt this effect by refusing to expand their Medicaid programs or by designing their state insurance exchange in ways that do not incorporate an outreach campaign that can maximize the opportunity for those newly eligible to become enrolled. However, if the history of Medicaid is a lesson, the full expansion will occur with time, even in those states that currently appear most resistant.

After a remarkable legislative process and a constitutional challenge in the Supreme Court, the ACA is on the verge of full implementation. The presidential election on November 6 is the final hurdle, the outcome of which could derail 32 million uninsured people from gaining coverage as intended by the health care law. Elections are rarely about a single issue, but physicians have a compelling reason in this year’s election to express their combined support for the ACA. Next Tuesday, each one of us in the physician community has an opportunity to have our vote count not only for the 32 million but also for ourselves, giving us, through implementation of this law, a greater ability to do our job of providing care and comfort to the sick.

About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.
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