EDITOR'S NOTE: The series is a joint project between the Denton Record-Chronicle staff, a graduate class from the Mayborn School of Journalism at the University of North Texas and Professor George Getschow, writer-in-residence and Pulitzer Prize finalist.
America’s health care system has been called the envy of the world.
But rising costs, attributed to a number of factors, fueled calls for reform.
The problems are many: inefficient and defensive health care practices, irrational pricing systems, and increasing numbers of people without insurance getting care the only place they can — a hospital emergency room, the most expensive place in the system.
Before national health care reform, U.S. health care costs were expected to rise from $2.5 trillion in 2009 to $4.6 trillion in 2020, a phenomenal and unsustainable growth, experts say.
Irwin Segal shakes his head over what happened to his practice since the 1970s and ’80s, which he calls the “golden years” of family doctoring. He moved to North Texas from Canada in 1978, weary of that country’s socialized medicine.
“Now, from a business standpoint, we basically work for the insurance companies,” Segal said. “Problem is, because fees are set by insurance companies, fees are going down and overhead is going up.”
For about half the system, the government pays through Medicare or Medicaid, said Jonathan Scholl, chief strategy officer for Texas Health Resources. Commercial insurance makes up for the gap that Medicare doesn’t pay.
Those trillion-dollar numbers boil down simply when you consider a visit to a doctor’s office, Scholl said. Americans spend $86 for a visit to the family doctor; Canadians spend $36.
The gap is even more pronounced for a day in the hospital, he said. Americans spend, on average, $3,612 per day, compared to $1,183 in Australia or $544 in Germany.
When considering the full range a day in the hospital can cost, it’s far wider in America than in other countries, he said, going as high as $14,306 per day.
The Patient Protection and Affordable Care Act of 2010 aimed to reform the system by reining in costs, improving the delivery of care and expanding insurance coverage to nearly all Americans. Instead of creating a state-run or “single-payer” health insurance system, the law builds on the current system of employer-based health insurance.
Some provisions are already in effect, including a tax credit for small businesses that offer health insurance and a change allowing young adults to stay on their parents’ health plans until their 26th birthday. But many of the law’s major changes are still to come.
At its heart are mandates that most Americans buy insurance — and most businesses offer it — by 2014, or face a penalty. The law also expands access to insurance by allowing more people to be covered under Medicaid, a health insurance program for the poor; creating new state-based insurance exchanges for people who lack adequate insurance from their jobs; and offering government subsidies to offset the cost of coverage.
The law is supposed to expand coverage to 32 million people who now lack health insurance, meaning about 94 percent of Americans would be insured, according to government estimates.
For some Americans, the law was a landmark social achievement. For others, it was an alarming overreach by the federal government that opens the door to all kinds of mandates.
The intense political debate that surrounded the law turned into a legal fight as soon as President Barack Obama signed it.
Twenty-six states, including Texas, have joined lawsuits challenging the law, arguing the individual mandate exceeded Congress’ constitutional power to regulate interstate commerce. Last year, the U.S. Supreme Court agreed to hear the case after lower courts issued conflicting opinions.
Three days of oral arguments on the individual mandate and other aspects of the law are planned over six hours starting March 26. A decision is expected before the court’s term ends in June.
“In modern times this is a historic length for an oral argument, and that underscores the magnitude of the issue before the court,” said Texas Attorney General Greg Abbott, who believes the mandate is unconstitutional. “This case does not involve health care or health care insurance. What the case really comes down to is whether or not there are any limits on congressional power.”
Never before has the government forced people to buy something as a condition of citizenship, said U.S. Rep. Michael Burgess, R-Lewisville, who strongly opposed the law.
“My opinion is because the potential for excess by the federal government is so vast that it’s something that I think the court should look at quite seriously,” Burgess said. “And I hope they would overturn that.”
Burgess said he is working on legislation that would be necessary if the court strikes down the entire law.
“The likelihood of that happening is probably less than 50 percent, but it doesn’t mean we shouldn’t be ready for it,” Burgess said.
Burgess, who worked as a physician for three decades before his election to Congress in 2002, wrote a book last year outlining his ideas for improving the health care system.
He said his bill would preserve some needed insurance reforms, such as the one allowing children to stay on their parents’ insurance longer. The bill also would end inequities in the tax code that penalize people who buy insurance individually or in small markets; encourage states to form high-risk insurance pools for people with pre-existing conditions; and include medical liability reform to combat a rise in malpractice insurance premiums — an issue Burgess said the 2010 law all but ignored.
Given that the law is pending in court, Gov. Rick Perry has no plans to implement a health care exchange, spokeswoman Lucy Nashed said.
“The governor thinks it’s unconstitutional, misguided and overreaching,” Nashed said.
The Texas Department of Insurance spent just $96,100 of a $1 million federal grant to explore the process. The department gave the rest of the money back, according to spokesman John Greeley.
Some states are working to establish exchanges to avoid having the federal government do it for them. Should the law be upheld, Perry isn’t concerned that Texans will be shopping for insurance through a federal exchange, Nashed said.
“It’s still kind of hypothetical that that would even happen,” she said.
Many legal experts say that even if the individual mandate falls, the court is unlikely to strike down the entire law. Those challenging the law disagree, arguing in court filings that without the mandate, the law won’t work as Congress intended.
Supporters say the mandate is needed to ensure that younger, healthier people enter the insurance market and hold down rates when, starting in 2014, insurers can no longer deny coverage to people with pre-existing conditions.
The state insurance department also received a $2.7 million grant to help Texans understand their rights under the new law. Since the reform became law, Texans have filed 116 complaints about health insurance companies, 14 of which the department deemed justified, Greeley said.
Most of the complaints since the reform became law are about excessive rates, rate increases, denial of coverage and pre-existing conditions.
On Monday, the Public Health Committee of the Texas House will hold a joint hearing with the Committee on Insurance to take testimony on how the law is being implemented.
Scholl said reform isn’t just about money. It’s also about making health care systems accountable — providers and payers.
“To get better, we have to lower costs of health care, regardless of where the law is headed,” Scholl said. “We’ve made a commitment to get better, regardless of what happens in Washington, D.C. There is that much momentum in the system.”
Eric Nishimoto contributed to this report.
PEGGY HEINKEL-WOLFE can be reached at 940-566-6881. Her e-mail address is email@example.com.
LOWELL BROWN can be reached at 940-566-6882. His e-mail address is firstname.lastname@example.org.
THE SERIES AT A GLANCE
This six-part series on health care reform is a joint effort of the Denton Record-Chronicle and graduate students from the University of North Texas Mayborn School of Journalism, along with professor George Getschow, formerly with The Wall Street Journal and a Pulitzer finalist. The series ends Friday.
Today: An overview of health care as it stands today. A look back shows reform isn’t a new concept. Results of Massachusetts reforms show unexpected results.
Monday: Small businesses react to new law. Reform spotlights need for faster results from research.
Tuesday: Prevention is key to curing cost concerns. Workers with no insurance take health into their own hands.
Wednesday: Physicians struggle to maintain their business model. Patients try “accountable care.”
Thursday: Texas lags behind other states in setting up insurance exchange, while reform banks on student loans.
Friday: Mental health treatment remains fragmented, affecting physical health care. Texas county jails are primary provider of mental health services.
IF YOU GO
What: “Healthcare 101,” a nonpartisan, apolitical seminar on the new health care law
Who: A panel of speakers will explain the health care reform law in a free event sponsored by the Denton Black and Hispanic chambers of commerce.
When: 6 to 8 p.m. Tuesday, with a mixer preceding the seminar from 5 to 6 p.m.
Where: Emily Fowler Central Library, 502 Oakland St., Denton