I oppose Obamacare; I support the Affordable Care Act

Tomorrow, more than three years after being signed into law, and more than a year after surviving a Supreme Court challenge, the Affordable Care Act, more commonly known as Obamacare, finally begins to fulfill its promise. Most of this country has long since taken sides, despite appalling gaps in popular understanding of what the law means, what it does, and what it doesn't do.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy is a mess. The trillions in debt that the U.S. has run up over the past 5 years will hurt my generation and future generations, and if Republicans can be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. He is a perpetual campaigner, preferring theatrical gestures to the backstage grunt work of governing. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that includes morally repugnant death panels staffed by faceless bureaucrats who will decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that says that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that will regulate the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieves the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discourages irresponsible health care "free riders" and provides support for people of modest means to purchase private health insurance in regulated open marketplaces. It tells insurers that in exchange for new customers, they can no longer discriminate against the old and sick and make their profits off the young and healthy. Finally, the ACA rewards physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may or may not improve health.

The ACA has flaws. Since it doesn't do much to narrow the income discrepancy between different types of physicians, it may overwhelm the capacity of primary care as millions of uninsured patients look for family doctors for the first time. The ACA's provisions to discourage overuse of unnecessary medical services are limited and probably inadequate to the scope of the problem. But it's worth noting that these problems all predated the law. We don't have enough family physicians and other primary care clinicians, specialists make too much money in comparison, and overdiagnosis and overtreatment are already rampant today. That the ACA takes on these issues at all is a small victory of sorts.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, who was the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for people of all political persuasions to set aside the overheated rhetoric about Obama and Obamacare and focus on making the ACA work, starting tomorrow.

Guest Post: Why clinical questions are only a starting point

Dr. Robert Bowman is a Professor of Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. He blogs at Basic Health Access and Clinician Specific Medical Education.

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People come to family physicians with some indication or faith that we can help them. As the learned “high priests” of medicine, we can answer their questions in various ways. The following 5 ways that Christians perceive that God answers prayers also provide a framework for how we address clinical questions.

"No, I love you too much."

Daily we see patients who already have answers to their questions. They come to us for many reasons. One reason is so that we can confirm their impression. If we do so wrongly, we contribute to their problem. We also know that what some people are asking is wrong. For this and for other presentations, we have to say “No, I love you too much.” This can be difficult for physicians who want to please all of their patients or improve their “patient satisfaction” scores.

"Yes, but you will have to wait."

We gather information and then do exams, tests or sometimes treatments. Haste can help answer a clinical question, but a hasty answer can be wrong. Hundreds of hasty diagnoses or treatments have been proven wrong in later years. For 20 years we were pushing an unproven test for prostate cancer screening when we should have been saying: “You will have to wait.”

Those on the front lines of care recognize that some diseases and conditions go away. Patience is needed. When people come in with fever, chills, and headache within 24 to 48 hours, chances are that this will resolve with little consequence. Deciding who can wait or not is a clinical decision, but one that does not necessarily lead to a diagnosis. We fail to measure much of clinical decision making. Those who measure immediately will find many clinical questions unanswered. This is about the patient, physician, interaction, the state of the science, and limitations in each of these areas. Immediate diagnosis and treatment can be wrong and harmful – but sometimes delays can be harmful. Outside players (legal, payers, practice pressures, daily situations) exert influences that can impede optimal decisions and care.

"Yes, but not what you expected."

This is always a tough situation as people have already moved their minds down one path. It takes time and effort on our part to erase this path so that they can move down another. Our treatments often do not work and some are harmful. Even with correct diagnosis and treatment, some patients find that our treatments are too inconvenient or expensive to continue and may or may not tell us.

"Yes, and here’s more."

Family physicians have more to offer than just diagnosis and treatment. Because of our tens of thousands of patient care experiences, we have experienced the impacts upon others and how they responded and what helped. The context of neighborhood, family, and individual past experiences is a rich database. Teaching of medical students and residents adds to the reflection, discussion, learning, and management. Ideally we have experienced the disease and condition and can speak with regard to practical matters, with evidence as a foundation. It helps to have access to pharmacists, behavioral professionals, and nurse educators who can step in and connect patients to needed care. But adding more can be difficult with financial margins so thin, with penalties for serving patients in settings where margins are thin, with fast rising costs of delivery, and with stagnant reimbursement. 

"Yes, and I thought you would never ask."

This is what we tend to focus on too much. People come in and we make the diagnosis and treatment together and have great agreement and all are pleased about expectation, diagnosis, treatment, and outcome. We like to measure this outcome since it is easy to measure. Much of what we do in family medicine, though, is in the first four answers rather than this last one. Saying no, getting people to wait patiently, or redirecting wrong impressions is often more important to individual outcomes than is the clinical question. Unfortunately, current designs for training and practice support make responding "Yes, and here is more" difficult unless we personally sacrifice to provide more care.

Family physicians generally do not experience the immediate rewards of diagnosing an inflamed appendix with confirmation during removal at surgery. But we do see the negative consequences of focusing on short-term outcomes at the expense of long term approaches to health, where the "clinical question" may only be a convenient starting point.

Conservative Medicine: Who needs to read it?

"Don't just do something, stand there." This deliberate rephrasing of "don't just stand there, do something" reminds me that the typical impulse of a physician to take immediate action in the face of clinical uncertainty can sometimes lead to a worse outcome than exercising patience, collecting more information, and waiting for any harmful conditions (if present) to declare themselves in time.

However, as I explained in this week's MD Global Health podcast, powerful monetary and psychological incentives present throughout the health care industry push physicians, advocacy groups, and medical institutions to aggressively seek out and treat persons with "underdiagnosed" diseases, expand the definitions of existing diseases (e.g., pre-osteoporosis, or low bone density), and sometimes, create new diseases (e.g., restless legs syndrome) out of whole cloth. Recognizing that these issues are often exacerbated by expert consensus recommendations of dubious quality, a distinguished international working group recently proposed a short list of questions that, if properly implemented, could permit clinicians and patients to evaluate financial conflicts of interest in clinical guidelines.

Conservative Medicine will not only outline a list of problems that result from overtesting and overtreatment, but offer a set of solutions in the areas of medical education, public policy, regulation, and patient advocacy. Who needs to read it? I believe that my book will appeal to a broad audience of health professionals, journalists, policymakers, and ordinary people with and without defined health problems who wonder if they actually need "preventive health care," and if so, how much.

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This is the sixth and final entry in a series of brainstorming posts about a book that I am writing titled Conservative Medicine.