President Obama just signed into law the Patient Protection and Affordable Care Act -- one of the most significant health reform measures since enactment of Medicare and Medicaid.
This Act attempts to build on our existing health care system by significantly expanding Medicaid, giving Medicare beneficiaries better prescription drug coverage, and increasing consumers' access to affordable, quality health insurance. Among the most important provisions in the bill are legal rules that remove existing barriers to health insurance. Plans will no longer be able to deny people insurance on the basis of preexisting conditions, terminate coverage when an insured turns out to be high risk, or set annual or lifetime limits on benefits. Children can stay on their parents' insurance until age 26, and government regulators will have more authority to review and regulate insurance rates to prevent unreasonable rate hikes, like the recent one by Anthem Blue Cross in California (the one that reinvigorated the health reform bill everyone thought was dead). And there are many other consumer protections, as well as promises of government subsidies to help some people pay for insurance.
Immediately after the law's enactment, state lawmakers opposed to it began mounting local political challenges and filed a law suit challenging the law's constitutionality. In later posts, I will address the details of these challenges and why I think they will probably fail. But for now I want to address the most common fear given for opposing the law -- a fear of "goverment takeover" of health care - the concern that government is getting too big and doing too much in ways that will jeopardize quality and access in the private health care market.
This fear is very confusing for a number of reasons. First, the federal and state governments have been intensely involved in the design and financing of health care for quite some time. Much of this may not be visible to patients, but this is certainly clear to the state lawmakers and health care providers (including managed care plans) that depend on this help. States and health care providers, especially hospitals, get massive amounts of federal funding - directly and indirectly. Surely, the federal government not only has a right, but a duty on behalf of citizens, to ensure that recipients of these funds try to expand health care access. Fears of "big government" seem surface when the federal government increases consumer protections and accountability with respect to the amount and quality of care being provided; yet such fears do not seem to inhibit demands for federal funding or support.
Second, many of the protections we have now - things we now take as a given - only came about because of government intervention. Racial minorities, women, and people with disabilities were routinely denied health care and insurance before federal antidiscrimination laws were enacted. For decades, many people were also refused care by some hospital emergency rooms, resulting in death or permanent injury. States did not do a good job of protecting consumers, so Congress passed EMTALA, which requires hospitals receiving Medicare (essentially all hospitals) to screen and stabilize every patient who comes to the emergency room, regardless of ability to pay. This is why everyone is entitled to care for emergency treatment. Finally, the federal government has enacted important, though limited, protections in the private insurance market. Most people are able to afford insurance through employment because of federal tax incentives and antidiscrimination protections for people buying group policies. And people can change jobs freely, without fear of losing coverage or having a condition excluded, because of the COBRA subsidies and portability protections Congress enacted in 1996.
The reality is that legal protection and government regulators play a critical role in helping people access the health care they need. And despite heated rhetoric by the opponents of reform, there is a growing recognition of the importance of legal protections and legal help in improving health care access and outcomes. In fact, the LA Times and NY Times recently published articles highlighting this trend, and describing the evolution of partnerships between medical professionals, lawyers, and communities who use legal tools to improve health.
Doctors understand that medicine alone cannot improve some patients' health. Socioeconomic factors, such as unhealthy living conditions, homelessness, discrimination by employers and insurers, and lack of resources, impede patients' ability to get care and stay healthy. Increasingly we see medical-legal partnerships popping up around the country to address these barriers: attorneys are embedded in community clinics and medical centers, and they work with doctors and patients to identify health-related problems that require legal solutions.
Sometimes, the legal help is pretty straightforward. For example, a patient may not have the money to pay for treatment, but the patient either had trouble getting public benefits or didn't realize he was entitled to them. An attorney can help that patient get the insurance he needs in order to get regular medical care. Other times, the need may be more complex. For example, the LA Times article profiled a doctor who became frustrated when medical treatment did not prevent the asthma and respiratory problems that plagued one of his patients. Her problems were caused by infestation and mold in her apartment. The doctor sent her down the hall to talk to an attorney who was on-site to help patients facing precisely these kinds of problems. The attorney, knowledgeable about housing law and health regulations, contacted both the landlord and the LA Housing Department; this improved the patient's living conditions, which ultimately improved her health.
The Patient Protection and Affordable Care Act is an important step toward expanding access to care by creating more robust legal protections for consumers in the private health care market, and attacking the inequality and other barriers that can impede health care access and good health outcomes. But enactment is only a first step. As the recent articles on medical-legal partnerships show, lawyers and other patient advocates also have a critical role to play in ensuring that these goals are realized. Rather than worrying about too much government, patients' advocates will be watching to make sure that government is doing enough to live up to its promises. They will monitor federal and state regulatory agencies responsible for implementing these new protections to make sure that they are effectively protecting consumers, they will educate patients and insureds about their new rights, and they will use legal tools to help protect these rights when necessary.
As the LA Times noted in its recent article, "sometimes good legal help is the best medicine." Only time will tell how effective this latest dose of legal medicine will be.
