This morning the Secretary of Health and Human Services, Kathleen Sebelius, was testifying before a committee of the United States House of Representatives. Nominally, the subject of the hearing was the mess that is the healthcare.gov Website, about which we've been hearing so much since people started trying to use it on October 1. To say the Website crashed and burned would be very charitable.
But of course the give-and-take at the hearing ranged much more widely, and there was much discourse on the Affordable Care Act that went far beyond the fact that people haven't been able to sign up for new health insurance coverage through the Website. That is as it should be, because the hearing should have been very short if it were about nothing else:
Rep. Gerrymander: "The Website is a disaster."
Sebelius: "Yes, it is. President Obama said to me, 'You didn't build that,' and he's right, I didn't. If I had, I should be fired. But it's a mess, and I'll see to it that it gets straightened out. It's a temporary problem, and it won't keep anyone from signing up long before the deadline. Oh, and by the way, a Website that seems to have been designed by incompetent fools doesn't have anything to do with the merits of the law or the wisdom of imposing an individual mandate."
Rep. Gerrymander: "Thank you, Madame Secretary. Mr. Chairman, I yield the balance of my time to the American people, so the 24-hour news channels can go back to their special coverage on twerking."
But members of the committee had a lot to say about the Affordable Care Act. Occasionally they actually asked Secretary Sebelius a question instead of just prattling on, and every so often they even allowed her as much time to answer a question as they spent asking it.
The dividing line between Democrats, who like the ACA, and Republicans, who don't, was not subtle. One Democrat representative said the ACA would achieve universal coverage, putting an end to the problem of having 50 million uninsured Americans. That is so obviously delusional that I'm sure the only reason she wasn't immediately removed to a psychiatric institution is that she is a Member of Congress. Even the most ardent proponents of the ACA know it will not do that.
Some people who will be newly eligible for Medicaid won't sign up. Some who are not, and who will face a penalty if they don't sign up for health insurance and pay for it, will choose to pay the penalty, because even with whatever subsidy they might qualify for, they still would have to pay more than they think they can afford in premiums, and the penalty is a lot cheaper. Some who will be newly eligible for Medicaid live in states where Medicaid is not being expanded. The Supreme Court told Congress it doesn't have the power to force the states to expand Medicaid, and some won't. Those people are out in the cold, and they'll stay there. Some people will actually go from having some sort of coverage to having none. Their small-business employers will drop coverage, or their employment status will be changed so they don't qualify, and they'll be forced into the exchanges, where they will discover the penalty is cheap compared with the premiums (see above). Others have individual coverage that doesn't meet the requirements of the law. Those policies will be cancelled, and the new policies they could get instead, through the exchanges, will be more expensive, and they will pay the much cheaper penalty and go without insurance.
So the Congresswoman who made that claim for the ACA was either indulging in hyperbole (to put it mildly), or she cannot do arithmetic and thinks reducing the number of uninsured by about 60% (from 50 million to 20 million) is the same as reducing it to zero.
[Oh, by the way, if you're wondering about the 10-12 million undocumented immigrants, they're not counted in the 50 million, so if you want to count them, make it 60 million uninsured, and the total left uninsured after the ACA is fully implemented will be 30 million.]
So the glass is half full. Not full. I hope the Congresswoman isn't too thirsty.
Much of the rest of what I heard was also untrue, and I gave a little thought - but only a little, because it may not really matter - to whether the people saying these things really believed them and were just mistaken, or whether they are liars. The fact that all this was taking place on Capitol Hill strongly favors both, because these are people highly skilled in saying false things and say them so often that they begin to believe them.
Sebelius, for example, said that the newly insured will be able to see primary care doctors and stop going to emergency departments, where the care they receive is very expensive and ineffective. Multiple lies in one statement. Wow! An artist!
The newly insured may have Medicaid, though expanded Medicaid coverage. Try calling a primary care doctor's office to become a new patient and wait for the response when you say your insurance coverage is Medicaid. Dr. Smith is not taking new patients. (Translation: Your kind ain't welcome 'round here.) Maybe your new insurance is not Medicaid. Dr. Smith may very well still not be taking new patients, because there is a serious shortage of primary care doctors. My internist, who has a strictly office-based practice, providing adult primary care, hasn't been taking new patients for years. When I started seeing him as a new patient, the answer I got when I first called for an appointment was that he wasn't taking new patients. Then I made the case, to the receptionist, for being an exception to his not taking new patients: (1) my mother-in-law had been his patient; (2) my wife was his patient; (3) I was a resident when he was junior faculty, and we'd known each other for 30 years. If you think those things made it a slam dunk, think again. I wouldn't have been surprised if she'd still said no.
So you have insurance now, but you still can't find a primary care doctor, or when you do find one, getting a timely appointment is no mean feat. So, you call the office when you're sick, and you are offered an appointment the second Thursday of next week. By then, you figure, you'll be over whatever it is that ails you, or you'll be dead, and it doesn't seem prudent to take the "watchful waiting" approach to see which it is. "Really?" you ask. "Nothing sooner than that?" "If you think you need to be seen right away, go to the ER," says the receptionist, trying to be helpful but condemning you to a two-hour wait on a Monday afternoon, when every emergency department in the galaxy is swamped.
Secretary Sebelius doesn't really believe the ACA will reduce ED visits by people who can be seen in a primary care doctor's office instead. She knows better. She was governor of a state, and she's a cabinet secretary, and it's not possible to have that resume and be stupid. Well, maybe it is, but I've listened to her, and I'm pretty sure she's not stupid. She cannot possibly believe what she said. And that makes her a liar. Surprise!
Then there is the part about emergency departments being terribly expensive and ineffective. Is that so? Well, let's look at those claims. If you go to the emergency department because you have a fever and a cough and are worried you have pneumonia, does it cost more to provide the care than it would if you go to your doctor's office? Well, you see a doctor and are examined. Then you have a chest x-ray. The doctor looks at the x-ray, and tells you that you do have pneumonia. Discussion ensues about whether you are sick enough to be treated in hospital. You and the doctor agree that you are not. You leave with a prescription for an antibiotic suitable for pneumonia. The cost of providing that care is no higher than if you'd gone to the doctor's office. But there is no way for you to know that. You don't get a bill showing the cost. You get a bill showing the price. And the price will be high compared to what you'd pay if you went to the doctor's office. That's partly because the ED has higher overhead, but mostly because the ED has to provide care to people who cannot pay, and everyone else must pay more to make up for that. Your doctor's office has no such obligation.
How about the "ineffective" part? At the emergency department you didn't need an appointment, although you may have had to wait. The ED never closes. You saw a doctor, and a chest x-ray was ordered. Where did you go for that? Down the hall. Some primary care doctors' offices can do basic x-rays and lab tests. Many cannot. Your doctor read the x-ray himself. He does that all the time, and he's really good at it. No waiting for a radiologist to read it, although one may have read it right after it was done, depending on how busy she was. Oh, and by the way, while your regular doctor may be pretty good with illnesses, how about injuries? Emergency physicians see all comers, all the time. They have to be knowledgeable about everything, and what they are best at is figuring out if what you have is going to cause you serious harm or kill you.
Does that sound "ineffective" to you? When I heard that word, I didn't take it personally. I know Secretary Sebelius is just saying something that many folks inside the beltway say all the time, even the ones who know better. And I know if she ever needs to see a doctor right away for something that's really worrying her, and she goes to an ED for that purpose, "ineffective" will be the word farthest from her mind.
There is no question that the ACA, when fully implemented, will reduce the number of uninsured in this country by 50-60%. And that is a good thing. But having insurance is not the same thing as having timely access to high-quality medical care. That is what people want.
There is one place where people have timely access to high-quality medical care 24-7-365. You know where that is. It's where I work. Can we take care of everyone's health care needs in the emergency department? Of course not. But in a health care system that serves so many so poorly, providing care in a way that is highly fragmented and often chaotic, in the ED we do our best - which is pretty darned good - to pull it all together and provide excellent care to everyone who shows up.
If Secretary Sebelius, or anyone else inside the beltway, thinks we are too expensive, or ineffective, or that the ACA means people won't need us except for true emergencies, they are seriously misinformed or just being careless with the truth. I'd like to give them the benefit of the doubt, assume they are seriously misinformed, and keep striving to correct that. It might help if this blog were required reading for them.
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