Republican members of the U.S. House approved the American Health Care Act after amending it to allow states to eliminate the pre-existing conditions protections of the Affordable Care Act. Apparently they took comfort that people with pre-existing conditions already have guaranteed access to health care in America. Congress created that right back when Ronald Reagan was president, but did so in the most expensive and least effective way possible. If the AHCA becomes law, we will exacerbate that mistake.
As the political fervor suggests, the pre-existing condition protections are a big deal. More than 50 million people under age 65 have pre-existing conditions. Jimmy Kimmel’s newborn son has one as a result of a congenital heart anomaly. Far more common are the conditions mostly affecting adults: heart and lung diseases, diabetes and joint problems.
These chronic, often lifelong conditions drive more than 85 percent of U.S. health care spending. Many conditions can be reversed with early, relatively inexpensive, care that helps patients change lifestyles and adhere to medication programs. But when care is delayed or done poorly, patients’ health declines. Those people become frequent, expensive visitors to hospitals.
Although the intent of Congress was clearly not to create universal access to health care, it did so when it passed the Emergency Medical Treatment and Labor Act in 1986. That law guarantees every person emergency care at virtually every hospital. Congress passed the law to prevent the dumping of uninsured patients onto publicly funded safety net hospitals, such as Chicago’s Cook County, but its universal coverage effect remains, as House Speaker Paul Ryan said, the law of the land.
The emergency care limitation of the 1986 law is its fundamental flaw, and the House’s willingness to deny coverage for people with pre-existing conditions repeats the blunder. Instead of quickly bringing people with a health condition into the health care system, the AHCA pushes them out. There’s no magic wand; very few medical conditions simply disappear over time. If people with pre-existing conditions lose insurance coverage and can’t access health care, they will get worse.
When they get ill enough, they’ll go to an emergency room where they will receive less effective care that is vastly more expensive than if they had been treated before the illness became an emergency. Instead of maintaining health with lower-cost medication and treatment, patients get crisis treatment in a rushed emergency room setting where the overhead costs dwarf those of any primary care practice.
For example, insulin to control diabetes costs in the tens of dollars; a single hospital stay can run to tens of thousands of dollars. In the midst of the mayhem, busy clinicians often lack bandwidth for the time-consuming counseling that chronic disease patients need. Necessary follow-up rarely happens. Late and rushed is a one-two punch that almost guarantees patients stay in poor health and their care remains expensive. While it’s clearly absurd to wait for a person’s condition to degrade, these delayed emergencies happen daily.
One might think that any imminent threat to health constitutes an emergency. Chest pain would correctly be viewed this way. But slightly less imminent threats don’t count as emergencies. For example, coverage is not assured for refilling a prescription drug. However, when the lack of medication triggers an emergency, say for a person with diabetes, hospitals must provide care.
The AHCA repeats this fundamental mistake of the 1986 emergency care law, the Republicans’ last, albeit unintentional, universal health insurance plan. By eliminating basic insurance coverage, the AHCA precludes millions from access to primary care. But primary care is how people effectively manage chronic conditions that drive health spending.
The AHCA throws people back into the warped world of having to wait for care until an emergency. If the goal is fiscal responsibility, ensure basic insurance for primary care. It’s the decent thing to do and it saves lives. It also saves money.
This op-ed previously appeared in the Dallas Morning News. Scott Wallace, JD, MBA, is an associate professor and managing director of the Value Institute for Health and Care at the Dell Medical School at The University of Texas at Austin.