Getting to the Health System We Need

Vol. 3 • Issue 9 • Page 12


In the wake of the Supreme Court’s recent decision to uphold the Patient Protection and Affordable Care Act (PPACA), it seems an appropriate time to reflect on the state of the U.S. health system. The PPACA aims to improve the dysfunctional and inefficient American health system, one that in most key respects (cost, quality and access) is failing to meet the needs of the population.

Two Primary Points

One aspect of the PPACA seems clear: There is a great deal of misunderstanding about the content of the bill on the part of the public and a considerable amount of exaggeration on both sides of the political spectrum about what it does.

Another point is also clear: With the affirmation of the constitutionality of the PPACA, the result will be health insurance reform and the extension of insurance coverage to approximately 32 million additional citizens.

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The Decision

In their decision, the Supreme Court justices voiced considerable differences of opinion about the law and its insurance provisions – particularly the individual mandate to purchase insurance. Justice Ruth Bader Ginsberg wrote the following for the majority: “By requiring those who do not carry insurance to pay a toll, the minimum coverage provision gives individuals a strong incentive to insure.” She added that the reduced number of uninsured would mitigate the adverse impact the uninsured have on the healthcare market.

The minority opinion differed sharply, stating that the PPACA “creates a debilitated, inoperable version of healthcare regulation that Congress did not enact and the public does not expect … And it leaves the public and the States to expend vast sums of money on requirements that may or may not survive the necessary congressional revision.”

A Widening Split

The obvious split among the justices appears to be reflective of the divide that exists among the American people. The issue at hand is how the nation can improve its healthcare system so that it better meets the needs of the public.

From the point of view of NPs and PAs, it is highly likely that the extension of health insurance coverage will increase the demand for healthcare services. It is a well-known tendency (which economists refer to as moral hazard) for people who have insurance to use increased amounts of services. This will lead to a greater demand for healthcare services, which in turn will lead to increased requirements for healthcare providers. The need will be particularly acute for primary care providers, and this will almost certainly mean more jobs for NPs and PAs.

Can We Deliver?

Given that most physicians are in specialties and subspecialties and that two-thirds of PAs and probably half of NPs work for specialty and subspecialty practices, is either profession in a position to supply a large number of primary care providers?

It is a fair and challenging question. There is a tendency for newly trained physicians, PAs and to some degree NPs, to seek positions in specialties and subspecialties and to avoid primary care for lack of incentive. The medical care system is a specialty-dominated system, with primary care and its physicians given less status and emphasis. If NPs and PAs are to respond to the increase in demand for primary care services, a change in the medical culture toward one of a more welcoming environment for primary care – including increases in salary and reimbursement – will be necessary.

The challenge for us as citizens is to recognize and accept that the PPACA is the law of the land and in truth it does have a number of provisions that by any standard provide a public good. The challenge for the NP and PA professions is to recognize that even though the prospect of increased demand will be present, there are issues inherent in successfully meeting that demand. Providing the amount of services that the additional millions of covered citizens will need is a task that will be faced by providers of all sorts. Our duty, both as providers and citizens, seems clear.

James F. Cawley is a professor in the Department of Prevention and Community Health in the School of Public Health and Health Services at George Washington University in Washington, where he also is the interim chairperson for the department. He is the 2011 recipient of the American Academy of Physician Assistants Eugene A. Stead Jr. Award of Achievement.


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