Repeal and Replace the ACA?

I have been reading a lot lately about the challenges the 115th United States Congress is having with a “Repeal and Replace” strategy for the Patient Protection and Affordable Care Act (the PPACA, commonly referred to as the ACA or “Obamacare”) law. Given the new administration’s struggle to even grasp the scope of the ACA, I can only imagine that it’s like climbing Everest or rowing across a small ocean.

Partisanship is the tendency for representatives and senators to vote on legislative measures as dictated by the letter that designates them as (R) or (D). However, I don’t think that party affiliation is the true nature of Congressional difficulties with the ACA, regardless how much their members may protest it. The lines are well-drawn between the aisle on many fundamental issues, and despite the fact that the ACA was the darling of the former President and his party, there can be no denying that it has proven disastrous for middle-class Americans.

I also don’t believe the complexity of the law itself (its rules and regulations written by the Secretary of Health & Human Services with virtual carte blanche control over its content) is the cause of the difficulties – despite containing over 2,000 original bill-signed-into-law pages and its thousands of subsequent pages of regulations. It is very easy to say, “This thing is far more complex than a simple repeal and replace”, and place the blame on the self-imposed vastness of the law.

I have only a few acquaintances who have benefited from the passage of the ACA, based on the fact that they now have “affordable” health insurance. However, most of the people with whom I have come in contact have experienced negative effects, including;

  • Loss of their working policies, as employers were forced to cut coverage
  • Prices that escalated quickly to unaffordable levels, and/or
  • Penalty taxes imposed for being unable to afford an “acceptable” (i.e., federally-approved) policy.

There is very little that is Affordable about the Affordable Care Act. I must also point out that in addition to not being affordable, the ACA is not (as no law could ever be) Care. Care is provided by medical personnel, not by insurance and not by laws. So the only true-to-its-nature aspect of the law’s name is Act. And I believe that therein is where the difficulty arises.

In March of 2015, I traveled to Washington DC to be a part of a Healthcare Coalition composed of practicing physicians of all specialties from across the nation. We came together to design and present to Congress a one-page proposal of “How practicing physicians would ‘fix’ the healthcare system in this country.” It only took us less than one morning to compose the proposal – three hours, tops. Since it is near-impossible to get even two or three physicians to agree on much of anything, that mere three hours it took to gain consensus between the 30 of us in the room is nothing less than miraculous. But the point is this: were able to do in one morning what Congress has failed to do during numerous sessions, across multiple years.

We printed our one-page proposal and set out that same day, to present our historic proposal to Congress via their legislative assistants. Across our two days of meetings, these staffers were – for the most part – kind and silently attentive, offering very few questions. Feeling great and patting ourselves on the backs, we left with high hopes for progress.

Little did we know that – at the same exact moments we gathered around conference tables and in hallways (and even getting kicked out of South Carolina congressman Trey Gowdy’s office) – those same elected representatives were quietly and quickly passing MACRA, the Medicare Access and CHIP Reauthorization Act.

Touted by the major physician organizations as the “Doc Fix,” MACRA is the completion of the ACA. It is the How the ACA will complete the Single Payer System that the architects of the ACA envisioned. It is also a tool to force independent physicians and other healthcare providers into the big systems, while driving private insurance companies into oblivion. It’s no wonder the legislative assistants were being so polite and listening so intently. “Let’s keep these doofus physicians who think their opinions matter busy so they don’t find out what our bosses are doing.” Their courtesy was just a smokescsreen.

I came back from our nation’s capital with a single message to my friends, colleagues, patients and family: Washington, DC is not about to give up any control. While they handed over responsibility to the Secretary of HHS to define the language of the ACA and MACRA, the control still lies in Federal hands, and they are NOT going to relinquish willingly that power over their constituents. They are NOT going to put control back in the hands of the individual sovereign States, nor into the hands of the People themselves. They may not even fully understand their own reasoning, but control – once locked in federal hands – is hard to wrench away.

Keep this truth in your mind when you hear of the difficulties they are having on Capitol Hill. If they so willfully disregard an educated recommendation from practicing American physicians to pragmatically shift responsibility and control of patient decisions to the patients themselves, just imagine the derision and contention if they were asked to repeal control of those decisions altogether. Our leaders clearly feel that you and I are not equipped to govern ourselves, much less make big decisions about our own health, safety and wellbeing.