(HealthNewsDigest.com) – With the convening of the 115th Congress and the inauguration of Donald Trump as the 45th president on January 20, 2017, medicine and health care in the United States are in flux. The future of the Affordable Care Act (ACA) and payment reform are uncertain, as are the standards of the US Food and Drug Administration (FDA) for approving drugs and clearing medical devices and women’s access to reproductive health care.
We remember daily why we entered the medical profession and the principles we continue to hold dear. We went to medical school because we wanted to help people improve their health, to feel better, and to live longer. We believe that health care is a right, not a privilege, and all Americans should have access to high-quality health care, regardless of their income or personal circumstances. The United States has the most advanced health care system in the world by many criteria, but access to the system is uneven. Even with the ACA, 29 million people were without health insurance coverage for the entire 2015 calendar year.1
There is widespread agreement from all sides of the political spectrum and among health care experts that our current system is very expensive for the outcomes it produces. In 2015, health care spending was $3.2 trillion, or $9990 per person and accounted for 17.8% of gross domestic product (GDP).2 To provide perspective on $9990 per person, the 2015 federal poverty level for a household of 4 persons was $24 250. Spending on prescription drugs alone was about $1000 per person. As a percentage of GDP, our health care spending is off the chart compared with the rest of the world. In 2013, the United States (17.1% of GDP) spent almost 50% more than France (11.6%) and nearly double the United Kingdom (8.8%).3 Yet the United States ranked 31st among nations in life expectancy, much lower than many countries that spend a fraction of what we do on health care.4
Fee-for-service medicine, as still frequently practiced in the United States, leads to an expensive, high-volume system, but not a system that places the emphasis on high-quality and appropriate health care. Physicians and hospitals are well paid for procedures and operations, regardless of whether they are good for patients. Compared with most nations, we are top consumers of magnetic resonance imaging machines, computed tomographic scanners, and positron emission tomographic scanners, as well as of prescription drugs, and we pay higher prices.3We have a relative abundance of specialists but a relative shortage of primary care physicians. The net benefit to patients of all this additional expense is unclear.
Since the ACA became law in 2010, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, which is a major accomplishment.1,5 Yet the overall statistics obscure the fact that wide disparities in health insurance and medical care related to income persist; in 2015, 95.5% of people with annual household income of $100 000 or more had health insurance, compared with only 85.2% of people with household income of less than $25 000.1 In 2015, the percentage of adults ages 18 to 64 years who did not obtain needed medical care owing to cost at some time during the past 12 months was 3.8% for those who were not poor but 12.4% for those who were poor.6
If Congress were to modify or repeal the ACA, the adults most likely to lose health insurance are more likely to be minorities, poor, and unemployed than those with private health insurance through their employers, as Karaca-Mandic and colleagues7 highlight in a Research Letter in this issue of JAMA Internal Medicine. Their findings point to the many consequences Congress should anticipate and address before—not after—changes to the ACA.
Shifting costs from one payer to another, as occurs when a hospital cares for an uninsured or underinsured patient, or to patients, as occurs when insured patients have large out-of-pocket expenses for emergency hospitalization, are symptoms of the problem, not solutions. Another important symptom is the fact that 85% of people who obtain health insurance through the ACA’s marketplaces cannot afford to pay their premiums without the help of government subsidies (there was an average monthly advance premium tax credit of $290 in 2016, which represented 73% of the average monthly premium) and still have high out-of-pocket costs.8The central questions remain of how to attain a health care system that is accessible to all Americans, that provides needed care while avoiding unnecessary care, and that delivers care at an affordable and sustainable price. The next steps are to build on the progress that has been made, which will require further improvements in health insurance coverage, the ability of people to obtain needed medical care regardless of income, and a continued shift away from fee-for-service medicine. The future is about universal health care coverage and access, improved quality, and payment reforms that will have a meaningful impact on the costs of health care and prescription drugs.
The 21st Century Cures Act, which President Obama signed into law in December 2016, introduced more uncertainty.9 The act allows for the increased use of “real-world evidence,” instead of the current standard of randomized clinical trials (RCTs), to guide regulatory decisions. Amid the clamor for speedier access to new drugs and medical devices, which is a goal of the new legislation, we should remember that first and foremost physicians should be recommending treatments that are safe, that benefit patients, and that are better than the established treatment or doing nothing. Otherwise, physicians expose patients to unneeded harms as all treatments have risks. We rely on the FDA to ensure the safety and effectiveness of the drugs and devices on the market, which most reliably is based on the findings of RCTs. Surrogate end points, observational data, and other real-world evidence can add to what is learned from high-quality RCTs with clinical outcomes but cannot replace them. Instead of deemphasizing clinical trials, the groups of patients who are included should be expanded so the findings apply more directly to patients who are seen in clinical practice. Although the clinical effectiveness of treatments should be clearly established before widespread use, this is often not the case at present. With the new legislation, it may be even less likely.
Uncertainty also extends to the potential for changes in women’s access to reproductive health care. Under the ACA, plans in the health insurance marketplace must cover FDA-approved contraceptive methods and counseling for all women. Admittedly, the provision of birth control benefits is controversial for some people and some employers. But changing the federal requirement for insurance coverage for contraception, an essential part of preventive health services for women, or prohibiting federal funding of specific organizations that provide reproductive health care, such as Planned Parenthood, would make no medical sense, intrude on women’s self-agency, and increase the chance that mothers living in poverty will stay in poverty.10
In 2017, more than ever, we remember why we became physicians, and that with the privilege of caring for the sick comes the responsibility to lead the medical profession and the health care system forward for the benefit of our patients. Facts matter. At JAMA Internal Medicine, we will continue to seek research and opinion articles that better inform the national discussion about how to advance the interests of patients, clinical practice, and the delivery of health care. We welcome your thoughts and contributions.
Published Online: January 20, 2017. doi:10.1001/jamainternmed.2016.9542
Conflict of Interest Disclosures: None reported.