DOCTORS’ LOUNGE
MEASURE TWICE, CUT ONCE
Gordon R. Tobin, MD
T
he time-honored aphorism of car-
penters, “measure twice, cut once,”
serves armorsmiths, tailors and
surgeons as well. That principle is also
sound guidance for health policy change,
as health care provides vital protective ar-
mor and garments of security needed by
all. With major health policy remaking
now underway through various Affordable
Care Act (ACA) repeal proposals (repeal
and replace, repeal without replacement,
or repeal of major components), thought-
ful comparative analysis is in order. In the
February Louisville Medicine President’s
Essay, “Saying Goodbye to Obamacare
and Hello to … What?” Dr. John Roberts’
SWOT analysis is a good example of ex-
amining and measuring proposed chang-
es.
In replacement plans, or changes, the
most critical factors to measure and to
compare with ACA successes and short-
comings, are the numbers of citizens
left uninsured and underinsured, while
knowing the full consequences and costs
of both. Key parameters inclu de prevent-
able death tallies, uncovered care costs
and medical bankruptcies, together with
productivity losses and other secondary
effects. These vital data are often ignored,
while only costs to the federal budget, to
state budgets or to employers are counted.
This is like accounting one’s investment
expenses, without compiling the gains or
losses returned.
Essential data on losses from the unin-
sured were generated in the first decade
of the 21 st century, when the number of
uninsured persons reached 45-50 million
nationally, and consequences were mea-
sured. Annual, preventable deaths among
uninsured ranged between 26,000 (Fam-
ilies, USA data) and 45,000 (Wilper et
al, Am J Pub Health, 2009). These deaths
largely resulted from advanced diseases
that were not prevented by early detec-
tion, together with the ravages of poorly
managed chronic diseases, such as diabe-
tes and hypertension. The cost of care for
these uninsured sick people totaled $111
billion annually. $85 billion of this was un-
compensated and thus transferred to oth-
ers, while $26 billion of this was self-pay
(Kaiser Family Foundation data for 2013).
Unpaid hospital bills and Emergency De-
partment overuse bills are cost-shifted to
taxpayers by Federal and State hospital
subsidies, and to premiums of the insured,
adding about $1,000 per policy annually
(American College of Physicians data).
Also, hospitals must accept all who present
for care (EMTALA, 1985), and uninsured
patients are charged for that care, often at
rates above those negotiated with insurers.
As a result, annual individual bankrupt-
cies from medical expenses affect nearly
one million persons in bankrupted house-
holds, as medical expense bankruptcies
are 62 percent of 1.5 million total individ-
ual bankruptcies (Himmelstein, et al, Am
J Med, 2009). In summary, for an annual,
per million person basis, the uninsured
population generates 500 - 1,000 prevent-
able deaths, 4.4 billion dollars of shifted
care costs, and 20,000 affected by medical
bankruptcies: an enormous, unnecessary
loss to our society and economy.
These data can readily be applied to
analysis of any new proposal or any pri-
or system. For example, the ACA brought
coverage to 25 million nationally, or one-
half of the previously uninsured, and can
be credited for reducing the prior harm
and losses by one-half. However, the ACA
can be simultaneously faulted for failing to
cover and benefit the other one-half. These
data can also be applied to any specific re-
gion or group. For example, Kentucky had
500,000 to 600,000 uninsured before the
ACA (just under one percent of the na-
tional total), with 80 percent gaining ACA
coverage and benefits, largely through
Medicaid expansion. This brought 80 per-
cent associated savings to Kentucky citi-
zens, and it becomes a standard for com-
parison to proposed changes here.
A second critical consideration to mea-
sure is the heavy cost of not providing
high-quality, full coverage insurance to
all. Those who are underinsured by weak
coverage or high deductibles have been
shown to avoid or delay preventive care
and chronic disease management, just like
the completely uninsured. Thus, they suf-
fer the same consequences and generate
the same losses when needing advanced
disease care, which again are shifted to
others. The ACA eliminated sales of the
weakest policies, but it allowed far too
many with high deductibles. Now, all
should be wary of schemes to re-intro-
duce poor-coverage policies by allowing
their sales across state lines. Quality in-
surance can already be sold across state
lines. However, this is repeatedly mis-
represented so that out-of-state sellers of
weak policies can capture the profits, while
citizens of the buyer’s state are left to cover
(continued on page 32)
MAY 2017
31