While the U.S. Supreme Court mulled the constitutionality of the Patient Protection and Affordable Care Act, a major physicians association was declaring it a success and an American Medical Association journal was detailing a need for broader health insurance coverage - with a caveat.
An element of the issue was made clear by editors of Scientific American when they pointed out the Affordable Care Act reforms health insurance - not health care systems ("Physician heal the system," July 2011, www.scientificamerican.com).
"It will change how we pay for health care, but not how much we pay - and that is a problem," the Scientific American editorial board said.
Provisions of the law attempt to affect how much medical care will cost. Requiring more people to have insurance may encourage preventive health care, if patients get checkups rather than hold off seeing a physician until they have severe symptoms. Treating a disease at an early stage is less expensive.
An examination by a primary-care physician is also less expensive than one in an emergency room - if a patient has one.
This week, an editorial in the Archives of Internal Medicine warned that demand on overloaded hospital emergency rooms by patients without a primary-care physician affect quality of care as well as costs ("Emergency Department Care: When needed -- not when better choices are unavailable," March 26, 2011).
Dr. Mitchell H. Katz cited federal law requiring hospitals that receive Medicare patients to admit all patients regardless of ability to pay as a reason for the load on emergency departments (ED).
"Indeed, one reason why the uninsured now use the ED is that under the federal Emergency Medical Treatment and Active Labor Act, patients who go to a hospital ED cannot be denied care because of inability to pay. No such obligation exists in physician offices or other outpatient settings, in which patients who cannot pay are routinely turned away," Katz said. "The ED should not be the default option because other places are not open or are open only to those with the right billfold."
Katz's commentary aligns with a review of emergency room usage in the Archives, including a finding that Medicaid patients were just as likely as uninsured patients to use emergency rooms for primary care ("Health Insurance Status Change and Emergency Department Use Among U.S. Adults," March 26, 2011; Adit N. Ginde M.D., Robert A. Lowe M.D., Jennifer L. Wiler M.D.).
"Adults with new Medicaid coverage were disproportionately likely to use EDs, suggesting that their reduced out-of-pocket cost for care was not associated with increased access to primary care services," according to Dr. Adit Ginde, an author of the study.
While the study reviewed emergency room usage only through 2009, not over the two years since the Affordable Care Act was approved, it suggests that patients who lost their medical insurance "had greater ED use because these newly uninsured individuals may experience a sudden decrease in their access to care."
That contrasts with an evaluation by the American College of Physicians finding the Affordable Care Act "has resulted in major improvements in access and coverage for tens of millions of Americans seen by internal medicine physicians" ("The Present and Future of the Affordable Care Act," March 26, 2011, www.acponline.org/pressroom/aca).
ACP President Virginia L. Hood said the requirement that individuals purchase insurance is needed to implement the mandate that insurance companies provide insurance without discrimination.
"Without an individual insurance requirement, some people may wait to obtain insurance until they are sick, aware that insurers will not turn them down or charge them higher premiums. . . . This will drive up premiums for everyone else, causing more persons to drop coverage, and potentially resulting in millions more uninsured persons," she said.
* Edwin Tanji is a former city editor of The Maui News. He can be reached at hakumoolelo@earthlink.net. "Haku Mo'olelo," "writing stories," is about stories that are being written or have been written. It appears every Friday. More on this issue will be posted in the blog section of The Maui News website, www.mauinews.com.
