Stevenson C

I was interested to read Dr. JP Tasto’s remarks on the Affordable Care Act (ACA) and his characterization of providing health coverage for the uninsured as “idealistic”.¹ It is an ideal that most of the developed world has achieved. Are its 2000 pages too many? Considering that it attempts to reform a $2.8 trillion-dollar segment of our economy, roughly equal to the gross domestic product of France, one should expect it to be long. Campbell’s Operative Orthopaedics is longer.

Tasto’s second paragraph on Medicaid fails to note the important point that reimbursement for family practice, internal medicine, and pediatrics will be increased to 100% of Medicare. It seems unlikely that these newly insured individuals would flood the emergency rooms (ERs) because it is more likely that their insurance companies would be directing them to primary care providers to keep them out of the expensive ERs. In regards to the comments on the uninsured, if the uninsured have money, they have plenty of access to medical care. The uninsured who have little money don’t have access to health care because they cannot afford it and now end up in the ER when their illnesses become intolerable or the paramedics bring them in with their injuries.

On the subject of health exchanges, who would Dr. Tasto have run the health exchanges? The federal government runs Medicare, and 80% of seniors are happy with their Medicare program. No one has to buy insurance on the exchange, but if you cannot get it elsewhere or you are looking for a subsidy, then the exchange is where you will need to go. If the
taxpayer is going to pay your subsidy, it seems reasonable that your financial information be required and the government be involved.

I am at a total loss to find data to support Dr. Tasto’s fourth paragraph comments on the relation of small business health coverage and providers. The Congressional Budget Office has made estimates that some small business employees could lose coverage because their employer would rather pay the penalties. But that has not been the case in Massachusetts, where employer coverage has actually increased. In regards to finding primary care providers and specialists, again it is likely that the insurance companies will be arranging this as they have in the past with their state regulators spurring them on.

Few people with individual income over $40,000 or family income over $90,000 do not have insurance. The typical uninsured is a young person with a low paying job. If he is a male, I would speculate that his entrance into the healthcare system would be by arriving in the ER with a broken femur. If he has waited until this moment to buy coverage, he will find there is no mandate on how quickly the company company he chooses will pick him up and his uncovered bills would likely be considerable. It is like buying fire insurance after the house has burned down.

Finally, and again, who would Dr. Tasto have regulate one of the “largest and most complex industries in the world”? Remember the 2000 pages; maybe it is reasonable. His examples of 3 poorly run government programs are Medicare, which our seniors like, Medicaid—I bet if they increased their reimbursement to orthopedists, Dr. Tasto would like it—and The Department of Veteran’s Affairs—but nothing remotely like the United States Department of Veteran Affairs is in the ACA.

So is the ACA unaffordable? What we have now is certainly not affordable. The cost of rising insurance premiums is being passed on at even higher levels to employees from their employers. The total health care costs are taking a bigger share of our country’s gross domestic product each year, with no evidence of improved health for the population for that extra cost. A median family income in the United States, stagnant at about $55,000, makes it hard to afford the average insurance premium for that family of about $13,000, which is increasing yearly. In the insurance exchanges, subsidies would reduce that family’s costs to around $4000 per year. The ACA was probably not anyone’s first choice for health reform in this country, but it is the one, after 100 years of trying, our political system finally passed.

Craig Stevenson, MD 

1. Tasto JP. The Affordable Care Act: politics over policy. Am J Orthop. 2013;42(4):158. 

Commentary

James P. Tasto, MD

I would like to thank Dr. Stevenson for his thoughtful rebuttal to my recent editorial. Our views are quite different. My comments are based on over 48 years in the practice of medicine, including 40 years in private practice. I have dealt with, and continue to deal with MediCal, Medicare, TriCare, Medicaid Health Maintenance Organizations, Accountable Care Organizations, academia, and the United States Department of Veterans Affairs Hospital.

Dr. Stevenson is currently employed by the Kaiser health-care system, and his views are driven, I suspect, by ideology, but certainly not by practical experience. I have the utmost respect for Kaiser Permanente and their physicians, but they are not exposed to the weakness of many of these government systems. The medical healthcare delivery system is indeed broken, but the Affordable Care Act (ACA) does little to address the real issues.

The New York Times recently noted that approximately one-half of the “poorest of the poor” with yearly incomes below $15,000 per year will not be eligible for subsidized healthcare because their states have refused to expand Medicaid.¹ The Supreme Court has upheld this decision of State rights. Yes, the 2000 or more pages of legislation are quite lengthy to say the least, and certainly can be equated to an orthopedics textbook. My bigger issue than the number of pages is the fact that there is an estimated 22,000 pages of supportive regulation that has yet to be defined. Medicare patients are indeed generally happy with their insurance today, but benefits are beginning to unravel.

One needs to spend some time analyzing the explanation of benefits on services rendered, and he/she will be shocked by the discounted value of the physician’s care. I am sure everyone that is familiar with ACA has heard that 14,000 to 16,000 new Internal Revenue Service agents will be employed to enforce the mandates of this law. How comfortable is everyone with this little publicized element of the law in light of the recent scandal at the Internal Revenue Service? This agency that has access to our financial records will now have access to our health records, as well as taxing potential for those that do not comply.

Admittedly, our healthcare system is broken, but the administration missed a golden opportunity to fashion meaningful bipartisan legislation to solve many of these problems.

1. Pear R. States’ policies on health care exclude poorest. The New York Times. May 25, 2013: A1.

Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.

I was interested to read Dr. JP Tasto’s remarks on the Affordable Care Act (ACA) and his characterization of providing health coverage for the uninsured as “idealistic”.¹ It is an ideal that most of the developed world has achieved. Are its 2000 pages too many? Considering that it attempts to reform a $2.8 trillion-dollar segment of our economy, roughly equal to the gross domestic product of France, one should expect it to be long. Campbell’s Operative Orthopaedics is longer.

Tasto’s second paragraph on Medicaid fails to note the important point that reimbursement for family practice, internal medicine, and pediatrics will be increased to 100% of Medicare. It seems unlikely that these newly insured individuals would flood the emergency rooms (ERs) because it is more likely that their insurance companies would be directing them to primary care providers to keep them out of the expensive ERs. In regards to the comments on the uninsured, if the uninsured have money, they have plenty of access to medical care. The uninsured who have little money don’t have access to health care because they cannot afford it and now end up in the ER when their illnesses become intolerable or the paramedics bring them in with their injuries.

On the subject of health exchanges, who would Dr. Tasto have run the health exchanges? The federal government runs Medicare, and 80% of seniors are happy with their Medicare program. No one has to buy insurance on the exchange, but if you cannot get it elsewhere or you are looking for a subsidy, then the exchange is where you will need to go. If the
taxpayer is going to pay your subsidy, it seems reasonable that your financial information be required and the government be involved.

I am at a total loss to find data to support Dr. Tasto’s fourth paragraph comments on the relation of small business health coverage and providers. The Congressional Budget Office has made estimates that some small business employees could lose coverage because their employer would rather pay the penalties. But that has not been the case in Massachusetts, where employer coverage has actually increased. In regards to finding primary care providers and specialists, again it is likely that the insurance companies will be arranging this as they have in the past with their state regulators spurring them on.

Few people with individual income over $40,000 or family income over $90,000 do not have insurance. The typical uninsured is a young person with a low paying job. If he is a male, I would speculate that his entrance into the healthcare system would be by arriving in the ER with a broken femur. If he has waited until this moment to buy coverage, he will find there is no mandate on how quickly the company company he chooses will pick him up and his uncovered bills would likely be considerable. It is like buying fire insurance after the house has burned down.

Finally, and again, who would Dr. Tasto have regulate one of the “largest and most complex industries in the world”? Remember the 2000 pages; maybe it is reasonable. His examples of 3 poorly run government programs are Medicare, which our seniors like, Medicaid—I bet if they increased their reimbursement to orthopedists, Dr. Tasto would like it—and The Department of Veteran’s Affairs—but nothing remotely like the United States Department of Veteran Affairs is in the ACA.

So is the ACA unaffordable? What we have now is certainly not affordable. The cost of rising insurance premiums is being passed on at even higher levels to employees from their employers. The total health care costs are taking a bigger share of our country’s gross domestic product each year, with no evidence of improved health for the population for that extra cost. A median family income in the United States, stagnant at about $55,000, makes it hard to afford the average insurance premium for that family of about $13,000, which is increasing yearly. In the insurance exchanges, subsidies would reduce that family’s costs to around $4000 per year. The ACA was probably not anyone’s first choice for health reform in this country, but it is the one, after 100 years of trying, our political system finally passed.

Craig Stevenson, MD 

1. Tasto JP. The Affordable Care Act: politics over policy. Am J Orthop. 2013;42(4):158. 

Commentary

James P. Tasto, MD

I would like to thank Dr. Stevenson for his thoughtful rebuttal to my recent editorial. Our views are quite different. My comments are based on over 48 years in the practice of medicine, including 40 years in private practice. I have dealt with, and continue to deal with MediCal, Medicare, TriCare, Medicaid Health Maintenance Organizations, Accountable Care Organizations, academia, and the United States Department of Veterans Affairs Hospital.

Dr. Stevenson is currently employed by the Kaiser health-care system, and his views are driven, I suspect, by ideology, but certainly not by practical experience. I have the utmost respect for Kaiser Permanente and their physicians, but they are not exposed to the weakness of many of these government systems. The medical healthcare delivery system is indeed broken, but the Affordable Care Act (ACA) does little to address the real issues.

The New York Times recently noted that approximately one-half of the “poorest of the poor” with yearly incomes below $15,000 per year will not be eligible for subsidized healthcare because their states have refused to expand Medicaid.¹ The Supreme Court has upheld this decision of State rights. Yes, the 2000 or more pages of legislation are quite lengthy to say the least, and certainly can be equated to an orthopedics textbook. My bigger issue than the number of pages is the fact that there is an estimated 22,000 pages of supportive regulation that has yet to be defined. Medicare patients are indeed generally happy with their insurance today, but benefits are beginning to unravel.

One needs to spend some time analyzing the explanation of benefits on services rendered, and he/she will be shocked by the discounted value of the physician’s care. I am sure everyone that is familiar with ACA has heard that 14,000 to 16,000 new Internal Revenue Service agents will be employed to enforce the mandates of this law. How comfortable is everyone with this little publicized element of the law in light of the recent scandal at the Internal Revenue Service? This agency that has access to our financial records will now have access to our health records, as well as taxing potential for those that do not comply.

Admittedly, our healthcare system is broken, but the administration missed a golden opportunity to fashion meaningful bipartisan legislation to solve many of these problems.

1. Pear R. States’ policies on health care exclude poorest. The New York Times. May 25, 2013: A1.

Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.

I was interested to read Dr. JP Tasto’s remarks on the Affordable Care Act (ACA) and his characterization of providing health coverage for the uninsured as “idealistic”.¹ It is an ideal that most of the developed world has achieved. Are its 2000 pages too many? Considering that it attempts to reform a $2.8 trillion-dollar segment of our economy, roughly equal to the gross domestic product of France, one should expect it to be long. Campbell’s Operative Orthopaedics is longer.

Tasto’s second paragraph on Medicaid fails to note the important point that reimbursement for family practice, internal medicine, and pediatrics will be increased to 100% of Medicare. It seems unlikely that these newly insured individuals would flood the emergency rooms (ERs) because it is more likely that their insurance companies would be directing them to primary care providers to keep them out of the expensive ERs. In regards to the comments on the uninsured, if the uninsured have money, they have plenty of access to medical care. The uninsured who have little money don’t have access to health care because they cannot afford it and now end up in the ER when their illnesses become intolerable or the paramedics bring them in with their injuries.

On the subject of health exchanges, who would Dr. Tasto have run the health exchanges? The federal government runs Medicare, and 80% of seniors are happy with their Medicare program. No one has to buy insurance on the exchange, but if you cannot get it elsewhere or you are looking for a subsidy, then the exchange is where you will need to go. If the
taxpayer is going to pay your subsidy, it seems reasonable that your financial information be required and the government be involved.

I am at a total loss to find data to support Dr. Tasto’s fourth paragraph comments on the relation of small business health coverage and providers. The Congressional Budget Office has made estimates that some small business employees could lose coverage because their employer would rather pay the penalties. But that has not been the case in Massachusetts, where employer coverage has actually increased. In regards to finding primary care providers and specialists, again it is likely that the insurance companies will be arranging this as they have in the past with their state regulators spurring them on.

Few people with individual income over $40,000 or family income over $90,000 do not have insurance. The typical uninsured is a young person with a low paying job. If he is a male, I would speculate that his entrance into the healthcare system would be by arriving in the ER with a broken femur. If he has waited until this moment to buy coverage, he will find there is no mandate on how quickly the company company he chooses will pick him up and his uncovered bills would likely be considerable. It is like buying fire insurance after the house has burned down.

Finally, and again, who would Dr. Tasto have regulate one of the “largest and most complex industries in the world”? Remember the 2000 pages; maybe it is reasonable. His examples of 3 poorly run government programs are Medicare, which our seniors like, Medicaid—I bet if they increased their reimbursement to orthopedists, Dr. Tasto would like it—and The Department of Veteran’s Affairs—but nothing remotely like the United States Department of Veteran Affairs is in the ACA.

So is the ACA unaffordable? What we have now is certainly not affordable. The cost of rising insurance premiums is being passed on at even higher levels to employees from their employers. The total health care costs are taking a bigger share of our country’s gross domestic product each year, with no evidence of improved health for the population for that extra cost. A median family income in the United States, stagnant at about $55,000, makes it hard to afford the average insurance premium for that family of about $13,000, which is increasing yearly. In the insurance exchanges, subsidies would reduce that family’s costs to around $4000 per year. The ACA was probably not anyone’s first choice for health reform in this country, but it is the one, after 100 years of trying, our political system finally passed.

Craig Stevenson, MD 

1. Tasto JP. The Affordable Care Act: politics over policy. Am J Orthop. 2013;42(4):158. 

Commentary

James P. Tasto, MD

I would like to thank Dr. Stevenson for his thoughtful rebuttal to my recent editorial. Our views are quite different. My comments are based on over 48 years in the practice of medicine, including 40 years in private practice. I have dealt with, and continue to deal with MediCal, Medicare, TriCare, Medicaid Health Maintenance Organizations, Accountable Care Organizations, academia, and the United States Department of Veterans Affairs Hospital.

Dr. Stevenson is currently employed by the Kaiser health-care system, and his views are driven, I suspect, by ideology, but certainly not by practical experience. I have the utmost respect for Kaiser Permanente and their physicians, but they are not exposed to the weakness of many of these government systems. The medical healthcare delivery system is indeed broken, but the Affordable Care Act (ACA) does little to address the real issues.

The New York Times recently noted that approximately one-half of the “poorest of the poor” with yearly incomes below $15,000 per year will not be eligible for subsidized healthcare because their states have refused to expand Medicaid.¹ The Supreme Court has upheld this decision of State rights. Yes, the 2000 or more pages of legislation are quite lengthy to say the least, and certainly can be equated to an orthopedics textbook. My bigger issue than the number of pages is the fact that there is an estimated 22,000 pages of supportive regulation that has yet to be defined. Medicare patients are indeed generally happy with their insurance today, but benefits are beginning to unravel.

One needs to spend some time analyzing the explanation of benefits on services rendered, and he/she will be shocked by the discounted value of the physician’s care. I am sure everyone that is familiar with ACA has heard that 14,000 to 16,000 new Internal Revenue Service agents will be employed to enforce the mandates of this law. How comfortable is everyone with this little publicized element of the law in light of the recent scandal at the Internal Revenue Service? This agency that has access to our financial records will now have access to our health records, as well as taxing potential for those that do not comply.

Admittedly, our healthcare system is broken, but the administration missed a golden opportunity to fashion meaningful bipartisan legislation to solve many of these problems.

1. Pear R. States’ policies on health care exclude poorest. The New York Times. May 25, 2013: A1.

Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.