Health Care on the Ballot: Election Has Profound Implications for the Future of Emergency Care

Abstract

Though it won't be foremost on the minds of most voters as they walk into their polling station on Election Day, more than perhaps any election in history the future of the US health care system will be on the ballot. At the center of the coming changes stands the field of emergency medicine, viewed by some cost-cutting politicians as purveyors of expensive and unnecessary care, despite providing the only “universal care” for the past quarter century.“There is a lot at stake,” said Wesley Fields, MD, Chairman of the Emergency Medicine Action Fund and an assistant clinical professor in the Department of Emergency Medicine at the University of California–Irvine Medical Center.There are 3 principal areas of change in health care that directly involve emergency medicine and will be more or less on the ballot with President Barack Obama and would-be President Mitt Romney.First, there is the fate of the Patient Protection and Affordable Care Act (PPACA), informally referred to as Obamacare, the signature legislation of the president's first term that he signed into law in March 2010. The programs established by this law, which seeks to reduce costs in health care by holding health care organizations accountable for the quality of care they deliver and by moving away from a fee-for-service model, have drawn interest from the private health care sector and payers. These hundreds of contracts for these private accountable care models cannot be undone. But a new president could prevent new contracts with the federal government, and many health care analysts believe much of the law could be unwound.And that is just what presidential candidate Romney has promised to do.“What the Court did not do on its last day in session I will do on my first day if elected president of the United States,” Romney said in June, after the US Supreme Court upheld a challenge to the PPACA's individual mandate. “And that is I will act to repeal Obamacare … . Obamacare was bad policy yesterday. It's bad policy today. Obamacare was bad law yesterday. It's bad law today.”The second area of change is how the different campaigns treat Medicare. Both President Obama and Romney agree that the amount of money spent on the senior care program must be limited. But they differ significantly on how to make that happen and whether the federal government can find the solutions, or whether those decisions should be left to the private sector.The final area of concern for emergency physicians is the stated desire by all parties, from politicians to insurance companies, to create disincentives for patients to visit the emergency department (ED). This long-term trend could create barriers between patients and the ED.EDs Used to Universal CareAlthough much of America has only begun seriously grappling with health care reform during the last couple of years, EDs have been dealing with these issues for more than a quarter of a century. That's because in 1986, passage of the Emergency Medical Treatment and Labor Act, or EMTALA, made access to emergency care a right in the United States. In contrast to the bitterly partisan battle over the PPACA, passage of the EMTALA law, strongly supported by Democrats who sought universal health care, was bipartisan in nature.“We cannot stand idly by and watch those Americans who lack the resources be shunted away from immediate and appropriate emergency care,” said Sen. Dave Durenberger, a Republican from Minnesota who was the lead Senate sponsor of the mandate legislation at the time.A Republican president signed the EMTALA act into law and it hasn't undergone a serious attempt at repeal since then. In some ways, this law has allowed legislators to kick the health care reform can down the road because EDs ultimately provide a safety net of care for all, even those who lack insurance.The PPACA, which may have survived the Supreme Court but is nonetheless on trial during this election, seeks to remedy the problem of uninsured by extending coverage to at least half of the estimated 50 million Americans who do not have health insurance of any kind. This is the battle the Court fought over, and in upholding the law the Court provided some potential relief to the ED by ensuring that more patients are paying customers.The way to think about the PPACA is not as health care reform per se, but rather health insurance reform, says Kip Piper, a former senior advisor to the administrator of the Centers for Medicare & Medicaid Services and directors of the Wisconsin Medicaid program. The reform includes Medicaid expansion and changes in the marketplace likely to prompt small and midsize employers to drop coverage and move their workers into health insurance exchanges.“On one hand, some of the services now being provided to the uninsured would become covered and reimbursable, either by Medicaid or a qualified health plan,” Piper said. “Uncompensated care and that gap would go down. The not-so-good news is that a fairly sizable proportion of those who are currently privately insured would move to public programs, Medicaid and participating health plans, and they would pay lower rates.”But the PPACA, most of which went unchallenged in the court system and has been moving forward during the last couple of years, entails much more than an expansion of coverage. With a primary goal of containing costs, the law has several payment reform programs: patient-centered medical homes, accountable care organizations, payment bundling, and value-based purchasing. Although there is no definitive count, more than 200 programs have begun, according to America's Health Insurance Plans, a trade association representing the health insurance industry.An example of these programs is the patient-centered medical home developed by Humana in conjunction with WellStar Health System. With care organized around well-insured patients, this plan has resulted in 12% lower inpatient costs, with shorter hospital stays, and 17% lower ED costs. It is clear that a primary goal in many of these programs is to reduce money spent in the ED by patients and their insurers. It is not clear how well these programs would work organized around patients funded at Medicaid levels. These are the kinds of results the government would like to continue to see as these programs move from the experimental to well-established stage.The fundamental difference between the president's approach and the health care plans advocated by Romney and his choice for vice president, Paul Ryan, is philosophy.It is not possible to compare and contrast the plans in detail because the Republican plan is not spelled out. Indeed, even for the PPACA it is not possible to speak to the granular level of, say, emergency physician payments. Nevertheless, the Republicans believe the private sector, rather than the government, should best determine how to control costs.“Philosophically, the Ryan approach is 179 degrees from the Democratic approach,” said Len Nichols, a professor of health policy and director of the Center for Health Policy Research and Ethics at George Mason University. “The goal is to slow the federal cost growth rate, and instead of having the feds and Medicare in the middle of these incentive mechanisms, let's give the private plans a budget and let them work it out. That's in a nutshell what this whole debate is about.”As the presidential campaign has reached a fever pitch this fall, Medicare has become a primary issue on the trail. And it's an issue that's intertwined with the fate of the PPACA and the future of health care.Again, as with health care reform, the goals of the 2 campaigns with respect to Medicare are not dissimilar. Both parties want to limit the amount Medicare pays for seniors; they just differ in how to accomplish the goal.To pay for expanded insurance coverage under the PPACA, President Obama would “cut” Medicare spending by $716 billion, and as part of the health care law those cuts to providers are slowly being phased in. Ryan's plan, which also calls for spending less on Medicare, wouldn't go into full effect until 2023.The nonpartisan Congressional Budget Office performed some long-range calculations to compare Medicare spending by the 2 plans. Today the average spending for a 67-year-old enrolled in Medicare is about $6,000 a year. The budget office found that under the PPACA and its Medicare reforms, the annual expenses for a 67-year-old senior would increase to $14,300 by 2040. Under Ryan's plan, that spending would average $9,500. In subsequent decades, the divide in spending under the PPACA and Ryan's plan would only increase.“It is those out years that people get the horror stories out of the Ryan budget,” Nichols said. “A third of what Medicare pays for now would not be paid for under Ryan's trajectories. So if you make those assumptions, then 15 to 20 years out they get kind of ugly. That's what the nasty part of the debate is about.”But it's not entirely accurate to say Ryan's plan would cut Medicare more than the president's plan. That's because under the Ryan plan, a fixed insurance payment would be made to retirees, somewhat like changing the health care model from a defined pension benefit to a 401(k) plan for seniors. Ryan envisions more cost-conscious decisions by hospital and insurance officials, as well as patients, under his plan.The bottom line is that no one knows for sure what model might work best to contain costs, said Charles Begley, PhD, a professor of management, policy, and community health at the University of Texas School of Public Health.The best comparison to the Ryan plan is probably in the Netherlands, Begley said, where there is a health insurance mandate that allows for-profit companies to offer competitive minimum insurance plans. There the cost of health care is lower than in the United States but higher than the European average where most countries have a health care system more like that envisioned by the PPACA.“At the end of the day, no one has really figured out how to do cost containment in health care,” Begley said.Because of the complexity of the debate and the centrality of emergency medicine in health care, the American College of Emergency Physicians and other emergency medicine groups banded together in 2011 to create the Emergency Medicine Action Fund, which Fields chairs.The Cloud and the Silver Lining?He said there's another factor, critical for emergency medicine, underlying the debate. In seeking to control costs, both parties would like to give consumers more control and more risk in their health care choices. For the ED, that translates into higher copayments and disincentives from employers sponsoring insurance plans, he said. This may drive privately insured patients to other locations for all but the most life-threatening situations, leaving more Medicare, Medicaid, and uninsured patients using the ED for more routine care.“I would contend that emergency medicine is ideally placed and practices at the hub of communities and higher technologies available in hospitals,” he said. “We're already engaged in patient-centered care for 134 million people a year. We know more about uniform access and patient-centered care because we've been doing it since 1986. Regardless of the details of health care reform, it's inevitable that emergency physicians will continue to provide leadership and care throughout the health care continuum.” Though it won't be foremost on the minds of most voters as they walk into their polling station on Election Day, more than perhaps any election in history the future of the US health care system will be on the ballot. At the center of the coming changes stands the field of emergency medicine, viewed by some cost-cutting politicians as purveyors of expensive and unnecessary care, despite providing the only “universal care” for the past quarter century. “There is a lot at stake,” said Wesley Fields, MD, Chairman of the Emergency Medicine Action Fund and an assistant clinical professor in the Department of Emergency Medicine at the University of California–Irvine Medical Center. There are 3 principal areas of change in health care that directly involve emergency medicine and will be more or less on the ballot with President Barack Obama and would-be President Mitt Romney. First, there is the fate of the Patient Protection and Affordable Care Act (PPACA), informally referred to as Obamacare, the signature legislation of the president's first term that he signed into law in March 2010. The programs established by this law, which seeks to reduce costs in health care by holding health care organizations accountable for the quality of care they deliver and by moving away from a fee-for-service model, have drawn interest from the private health care sector and payers. These hundreds of contracts for these private accountable care models cannot be undone. But a new president could prevent new contracts with the federal government, and many health care analysts believe much of the law could be unwound. And that is just what presidential candidate Romney has promised to do. “What the Court did not do on its last day in session I will do on my first day if elected president of the United States,” Romney said in June, after the US Supreme Court upheld a challenge to the PPACA's individual mandate. “And that is I will act to repeal Obamacare … . Obamacare was bad policy yesterday. It's bad policy today. Obamacare was bad law yesterday. It's bad law today.” The second area of change is how the different campaigns treat Medicare. Both President Obama and Romney agree that the amount of money spent on the senior care program must be limited. But they differ significantly on how to make that happen and whether the federal government can find the solutions, or whether those decisions should be left to the private sector. The final area of concern for emergency physicians is the stated desire by all parties, from politicians to insurance companies, to create disincentives for patients to visit the emergency department (ED). This long-term trend could create barriers between patients and the ED. EDs Used to Universal CareAlthough much of America has only begun seriously grappling with health care reform during the last couple of years, EDs have been dealing with these issues for more than a quarter of a century. That's because in 1986, passage of the Emergency Medical Treatment and Labor Act, or EMTALA, made access to emergency care a right in the United States. In contrast to the bitterly partisan battle over the PPACA, passage of the EMTALA law, strongly supported by Democrats who sought universal health care, was bipartisan in nature.“We cannot stand idly by and watch those Americans who lack the resources be shunted away from immediate and appropriate emergency care,” said Sen. Dave Durenberger, a Republican from Minnesota who was the lead Senate sponsor of the mandate legislation at the time.A Republican president signed the EMTALA act into law and it hasn't undergone a serious attempt at repeal since then. In some ways, this law has allowed legislators to kick the health care reform can down the road because EDs ultimately provide a safety net of care for all, even those who lack insurance.The PPACA, which may have survived the Supreme Court but is nonetheless on trial during this election, seeks to remedy the problem of uninsured by extending coverage to at least half of the estimated 50 million Americans who do not have health insurance of any kind. This is the battle the Court fought over, and in upholding the law the Court provided some potential relief to the ED by ensuring that more patients are paying customers.The way to think about the PPACA is not as health care reform per se, but rather health insurance reform, says Kip Piper, a former senior advisor to the administrator of the Centers for Medicare & Medicaid Services and directors of the Wisconsin Medicaid program. The reform includes Medicaid expansion and changes in the marketplace likely to prompt small and midsize employers to drop coverage and move their workers into health insurance exchanges.“On one hand, some of the services now being provided to the uninsured would become covered and reimbursable, either by Medicaid or a qualified health plan,” Piper said. “Uncompensated care and that gap would go down. The not-so-good news is that a fairly sizable proportion of those who are currently privately insured would move to public programs, Medicaid and participating health plans, and they would pay lower rates.”But the PPACA, most of which went unchallenged in the court system and has been moving forward during the last couple of years, entails much more than an expansion of coverage. With a primary goal of containing costs, the law has several payment reform programs: patient-centered medical homes, accountable care organizations, payment bundling, and value-based purchasing. Although there is no definitive count, more than 200 programs have begun, according to America's Health Insurance Plans, a trade association representing the health insurance industry.An example of these programs is the patient-centered medical home developed by Humana in conjunction with WellStar Health System. With care organized around well-insured patients, this plan has resulted in 12% lower inpatient costs, with shorter hospital stays, and 17% lower ED costs. It is clear that a primary goal in many of these programs is to reduce money spent in the ED by patients and their insurers. It is not clear how well these programs would work organized around patients funded at Medicaid levels. These are the kinds of results the government would like to continue to see as these programs move from the experimental to well-established stage.The fundamental difference between the president's approach and the health care plans advocated by Romney and his choice for vice president, Paul Ryan, is philosophy.It is not possible to compare and contrast the plans in detail because the Republican plan is not spelled out. Indeed, even for the PPACA it is not possible to speak to the granular level of, say, emergency physician payments. Nevertheless, the Republicans believe the private sector, rather than the government, should best determine how to control costs.“Philosophically, the Ryan approach is 179 degrees from the Democratic approach,” said Len Nichols, a professor of health policy and director of the Center for Health Policy Research and Ethics at George Mason University. “The goal is to slow the federal cost growth rate, and instead of having the feds and Medicare in the middle of these incentive mechanisms, let's give the private plans a budget and let them work it out. That's in a nutshell what this whole debate is about.”As the presidential campaign has reached a fever pitch this fall, Medicare has become a primary issue on the trail. And it's an issue that's intertwined with the fate of the PPACA and the future of health care.Again, as with health care reform, the goals of the 2 campaigns with respect to Medicare are not dissimilar. Both parties want to limit the amount Medicare pays for seniors; they just differ in how to accomplish the goal.To pay for expanded insurance coverage under the PPACA, President Obama would “cut” Medicare spending by $716 billion, and as part of the health care law those cuts to providers are slowly being phased in. Ryan's plan, which also calls for spending less on Medicare, wouldn't go into full effect until 2023.The nonpartisan Congressional Budget Office performed some long-range calculations to compare Medicare spending by the 2 plans. Today the average spending for a 67-year-old enrolled in Medicare is about $6,000 a year. The budget office found that under the PPACA and its Medicare reforms, the annual expenses for a 67-year-old senior would increase to $14,300 by 2040. Under Ryan's plan, that spending would average $9,500. In subsequent decades, the divide in spending under the PPACA and Ryan's plan would only increase.“It is those out years that people get the horror stories out of the Ryan budget,” Nichols said. “A third of what Medicare pays for now would not be paid for under Ryan's trajectories. So if you make those assumptions, then 15 to 20 years out they get kind of ugly. That's what the nasty part of the debate is about.”But it's not entirely accurate to say Ryan's plan would cut Medicare more than the president's plan. That's because under the Ryan plan, a fixed insurance payment would be made to retirees, somewhat like changing the health care model from a defined pension benefit to a 401(k) plan for seniors. Ryan envisions more cost-conscious decisions by hospital and insurance officials, as well as patients, under his plan.The bottom line is that no one knows for sure what model might work best to contain costs, said Charles Begley, PhD, a professor of management, policy, and community health at the University of Texas School of Public Health.The best comparison to the Ryan plan is probably in the Netherlands, Begley said, where there is a health insurance mandate that allows for-profit companies to offer competitive minimum insurance plans. There the cost of health care is lower than in the United States but higher than the European average where most countries have a health care system more like that envisioned by the PPACA.“At the end of the day, no one has really figured out how to do cost containment in health care,” Begley said.Because of the complexity of the debate and the centrality of emergency medicine in health care, the American College of Emergency Physicians and other emergency medicine groups banded together in 2011 to create the Emergency Medicine Action Fund, which Fields chairs. Although much of America has only begun seriously grappling with health care reform during the last couple of years, EDs have been dealing with these issues for more than a quarter of a century. That's because in 1986, passage of the Emergency Medical Treatment and Labor Act, or EMTALA, made access to emergency care a right in the United States. In contrast to the bitterly partisan battle over the PPACA, passage of the EMTALA law, strongly supported by Democrats who sought universal health care, was bipartisan in nature. “We cannot stand idly by and watch those Americans who lack the resources be shunted away from immediate and appropriate emergency care,” said Sen. Dave Durenberger, a Republican from Minnesota who was the lead Senate sponsor of the mandate legislation at the time. A Republican president signed the EMTALA act into law and it hasn't undergone a serious attempt at repeal since then. In some ways, this law has allowed legislators to kick the health care reform can down the road because EDs ultimately provide a safety net of care for all, even those who lack insurance. The PPACA, which may have survived the Supreme Court but is nonetheless on trial during this election, seeks to remedy the problem of uninsured by extending coverage to at least half of the estimated 50 million Americans who do not have health insurance of any kind. This is the battle the Court fought over, and in upholding the law the Court provided some potential relief to the ED by ensuring that more patients are paying customers. The way to think about the PPACA is not as health care reform per se, but rather health insurance reform, says Kip Piper, a former senior advisor to the administrator of the Centers for Medicare & Medicaid Services and directors of the Wisconsin Medicaid program. The reform includes Medicaid expansion and changes in the marketplace likely to prompt small and midsize employers to drop coverage and move their workers into health insurance exchanges. “On one hand, some of the services now being provided to the uninsured would become covered and reimbursable, either by Medicaid or a qualified health plan,” Piper said. “Uncompensated care and that gap would go down. The not-so-good news is that a fairly sizable proportion of those who are currently privately insured would move to public programs, Medicaid and participating health plans, and they would pay lower rates.” But the PPACA, most of which went unchallenged in the court system and has been moving forward during the last couple of years, entails much more than an expansion of coverage. With a primary goal of containing costs, the law has several payment reform programs: patient-centered medical homes, accountable care organizations, payment bundling, and value-based purchasing. Although there is no definitive count, more than 200 programs have begun, according to America's Health Insurance Plans, a trade association representing the health insurance industry. An example of these programs is the patient-centered medical home developed by Humana in conjunction with WellStar Health System. With care organized around well-insured patients, this plan has resulted in 12% lower inpatient costs, with shorter hospital stays, and 17% lower ED costs. It is clear that a primary goal in many of these programs is to reduce money spent in the ED by patients and their insurers. It is not clear how well these programs would work organized around patients funded at Medicaid levels. These are the kinds of results the government would like to continue to see as these programs move from the experimental to well-established stage. The fundamental difference between the president's approach and the health care plans advocated by Romney and his choice for vice president, Paul Ryan, is philosophy. It is not possible to compare and contrast the plans in detail because the Republican plan is not spelled out. Indeed, even for the PPACA it is not possible to speak to the granular level of, say, emergency physician payments. Nevertheless, the Republicans believe the private sector, rather than the government, should best determine how to control costs. “Philosophically, the Ryan approach is 179 degrees from the Democratic approach,” said Len Nichols, a professor of health policy and director of the Center for Health Policy Research and Ethics at George Mason University. “The goal is to slow the federal cost growth rate, and instead of having the feds and Medicare in the middle of these incentive mechanisms, let's give the private plans a budget and let them work it out. That's in a nutshell what this whole debate is about.” As the presidential campaign has reached a fever pitch this fall, Medicare has become a primary issue on the trail. And it's an issue that's intertwined with the fate of the PPACA and the future of health care. Again, as with health care reform, the goals of the 2 campaigns with respect to Medicare are not dissimilar. Both parties want to limit the amount Medicare pays for seniors; they just differ in how to accomplish the goal. To pay for expanded insurance coverage under the PPACA, President Obama would “cut” Medicare spending by $716 billion, and as part of the health care law those cuts to providers are slowly being phased in. Ryan's plan, which also calls for spending less on Medicare, wouldn't go into full effect until 2023. The nonpartisan Congressional Budget Office performed some long-range calculations to compare Medicare spending by the 2 plans. Today the average spending for a 67-year-old enrolled in Medicare is about $6,000 a year. The budget office found that under the PPACA and its Medicare reforms, the annual expenses for a 67-year-old senior would increase to $14,300 by 2040. Under Ryan's plan, that spending would average $9,500. In subsequent decades, the divide in spending under the PPACA and Ryan's plan would only increase. “It is those out years that people get the horror stories out of the Ryan budget,” Nichols said. “A third of what Medicare pays for now would not be paid for under Ryan's trajectories. So if you make those assumptions, then 15 to 20 years out they get kind of ugly. That's what the nasty part of the debate is about.” But it's not entirely accurate to say Ryan's plan would cut Medicare more than the president's plan. That's because under the Ryan plan, a fixed insurance payment would be made to retirees, somewhat like changing the health care model from a defined pension benefit to a 401(k) plan for seniors. Ryan envisions more cost-conscious decisions by hospital and insurance officials, as well as patients, under his plan. The bottom line is that no one knows for sure what model might work best to contain costs, said Charles Begley, PhD, a professor of management, policy, and community health at the University of Texas School of Public Health. The best comparison to the Ryan plan is probably in the Netherlands, Begley said, where there is a health insurance mandate that allows for-profit companies to offer competitive minimum insurance plans. There the cost of health care is lower than in the United States but higher than the European average where most countries have a health care system more like that envisioned by the PPACA. “At the end of the day, no one has really figured out how to do cost containment in health care,” Begley said. Because of the complexity of the debate and the centrality of emergency medicine in health care, the American College of Emergency Physicians and other emergency medicine groups banded together in 2011 to create the Emergency Medicine Action Fund, which Fields chairs. The Cloud and the Silver Lining?He said there's another factor, critical for emergency medicine, underlying the debate. In seeking to control costs, both parties would like to give consumers more control and more risk in their health care choices. For the ED, that translates into higher copayments and disincentives from employers sponsoring insurance plans, he said. This may drive privately insured patients to other locations for all but the most life-threatening situations, leaving more Medicare, Medicaid, and uninsured patients using the ED for more routine care.“I would contend that emergency medicine is ideally placed and practices at the hub of communities and higher technologies available in hospitals,” he said. “We're already engaged in patient-centered care for 134 million people a year. We know more about uniform access and patient-centered care because we've been doing it since 1986. Regardless of the details of health care reform, it's inevitable that emergency physicians will continue to provide leadership and care throughout the health care continuum.” He said there's another factor, critical for emergency medicine, underlying the debate. In seeking to control costs, both parties would like to give consumers more control and more risk in their health care choices. For the ED, that translates into higher copayments and disincentives from employers sponsoring insurance plans, he said. This may drive privately insured patients to other locations for all but the most life-threatening situations, leaving more Medicare, Medicaid, and uninsured patients using the ED for more routine care. “I would contend that emergency medicine is ideally placed and practices at the hub of communities and higher technologies available in hospitals,” he said. “We're already engaged in patient-centered care for 134 million people a year. We know more about uniform access and patient-centered care because we've been doing it since 1986. Regardless of the details of health care reform, it's inevitable that emergency physicians will continue to provide leadership and care throughout the health care continuum.”