A
Start
By
Leonard
Zwelling
I am uncertain that any bill ever passed
by the US Congress and signed into law by the President can compare with the
Affordable Care Act (ACA) for the controversy generated (huge) compared with
the actual consequences of the bill (small).
Supporters of the legislation ascribe all
sorts of good to the bill. Seven and half million people now have insurance.
People with pre-existing conditions cannot be discriminated against. Children
under 26 can be carried on their parents’ policies. Medicaid has been expanded
in some, mostly blue, states. All true.
The bill’s detractors note the pending
collapse of the insurance market. They cite rising health insurance premiums to
defray the costs of the newly insured ill as a consequence of ObamaCare. They
bemoan the additional financial burden on medium-sized businesses to either
insure more workers or pay a penalty. Of course, the fact that the President
has the goal posts on wheels and keeps changing the dates of implementation and
oversaw what has got to be the worst IS rollout in history doesn’t help. Most
of this is true, too.
The real problem is misunderstanding what
the bill intended to do, what it actually does and where it stands in a
continuum of change in the American health care system.
The bill was intended to lock in the
current system of paying for health care, the competitive private/non-competitive
public insurance industry. It had nothing to do with health care delivery, its
cost or its quality. It basically said the current fee-for-service model
remains and now the government will assist in giving more people access to it
through insurance exchanges and subsidies for the poor plus the expansion of Medicaid
and the mandate to buy insurance forcing everyone in, especially the healthy
young.
What it actually does is even less thanks to the
Supreme Court. The Court threw a monkey wrench in much of that when it declared
Medicaid expansion optional on a state-by-state basis and most of the Republican
states rejected expansion beyond existing levels of coverage and population
covered. This was despite the fact that the federal government would have
covered 100% of the cost of expansion until 2017 and 90% thereafter (Medicaid
is paid for by both the federal government and the states). The Congressionally
imposed penalty for not expanding Medicaid, loss of a state’s current level of federal
Medicaid funding, was struck down by the Supremes. Thus, there were no
consequences of doing nothing to help the poor, especially children and
pregnant women, and many states opted not to expand Medicaid. Texas was one of
these.
Increasing access is all this bill intended to do.
That has resulted in a modest increase in coverage because it is yet unclear
how many of the 7.5 million who have signed up for new health insurance already
had coverage or cancelled it or lost it due to aspects of the law’s
stipulations of what a plan had to cover. The question of how many previously
uninsured gained coverage has yet to be quantified.
To summarize, this bill, much like the
Massachusetts plan of 2006, was only a start. It was never meant to be
comprehensive. It does not really lower costs and has virtually no effect on
quality. It was supposed to be a first step.
The furor that followed its passage stems
from many things. First, some people genuinely do not like any government
intervention into health care. Of course, when you combine those serviced by
Medicare, Medicaid, CHIP, the military, the VA and the Indian Health Service,
that is almost half of all Americans. The government has been deeply imbedded
in health care for over 50 years.
Second, Republicans don’t like to lose.
Neither do Democrats. The legislative tricks played on the Rs by the Ds to get
this passed would leave a sour taste in the mouth of any opponent.
Third, the Republicans really do not like
President Obama. This is humorous because this bill was generally a product of
the Congress not the White House and based on Republican ideas from the
Heritage Foundation. It should have been labeled PelosiCare for it was Speaker
Pelosi who rammed the Senate version of the bill through the House once the
Dems lost their veto proof majority in the Senate with the death of Ted Kennedy
and the election of Scott Brown (R-MA). Had the bill gone to conference
committee to reconcile the House and Senate versions which were not identical,
the Senate Rs would have filibustered it to death.
Fourth, and most critically, the Obama Administration
never told the truth about this bill. The President kept saying that ”if you
like what you have you can keep it” which was either naïve, duplicitous or a
lie or all three. He knew better or should have. Who was advising this guy?
Put it all together and you get a bill that aimed
low, missed and then resulted in a firestorm of controversy blown way out of
proportion for political purposes.
Cancer Genomics. Here too the promise has
outstripped the deliverable. There can be no question that the sequencing of the
human genome was a major scientific (technical really) accomplishment that will
undoubtedly lead to many important discoveries beyond those already unearthed
in the 14 years since the announcement of success under President Clinton. But
it too was a start.
To sell genomics as the only path to a cancer CURE
(yes, many have used this word) is preposterous. Genomics is a tool. It will be
useful. Whether the identification of any therapeutically actionable signature
of a patient’s cancer will lead to individualized therapy for all that does not
cost a small fortune to administer and thus beyond the reach of many even if
they just have to fork up the co-pay is not a cure.
To sell the novelty of the concept of personalized
medicine is a bit of a scam anyway. Most good doctors have been delivering
personalized care for 5000 years, one patient at a time. All the latest
discoveries have done is start us on a path to developing new tools for the
toolbox. For if the goal of medicine is the alteration of the natural history
of disease states in humans and mostly to alleviate suffering, as I believe it
ought to be, when it comes to cancer, we still have a way to go. And by the
way, if we cured all cancer tomorrow, how much would the national average life
expectancy shift? It’s a disease of adults over 50. By definition, everything
we do in medicine is personalized care. And everything we do in medicine
eventually and ineluctably fails. As Greg House said in the final episode:
“Everybody dies.”
So just like the ACA, genomic medicine is a start.
It will take a while to figure out how to best employ it to alter the natural
history of fatal malignancies.
Perhaps we can learn from President Obama’s
mistakes surrounding the promise of the ACA. It was always clear that no one
was guaranteed the retention of their current insurance if the ACA passed,
except Mr. Obama and those on Medicare. Genomics may lead to therapies or
prevention and screening strategies that extend the lives of patients. May.
It’s a start and we should be honest about that. If we aren’t, medicine,
particularly, academic medicine, will suffer the same fate in the public’s
esteem as Mr. Obama has.
In his case, all that is at stake is his legacy of
8 years in office.
In the case of academic medicine, there is a
5000-year old trust of “above all, do no harm” between patients and their
doctors. We physicians who have been passed the torch of the tradition of all
those who have come before us who had far fewer tools in their black bags than
we have today, need to respect that they gave us a good start and we have an
even better one. But it all starts at the bedside, one human to another.
Personalized medicine starts with a relationship not a gene sequence.
