Opinion: Affordable Care Act comes with side effects

With the Affordable Care Act (ACA) passing constitutional muster in a surprising 5-4 Supreme Court decision, all eyes now turn toward the law’s implementation. Some states’ governors have put their plans on hold pending the results of the November election; others are moving ahead with the insurance exchanges . And while most of the major provisions have yet to kick in, there are already some troubling signs on the horizon.

A story in The New York Times reported that by 2015, the country will have roughly 62,000 fewer doctors than needed, according the estimates from the Association of American Medical Colleges. That shortfall could hit 100,000 by 2025, as aging baby boomers and the insurance mandate drive up demand. More ominous is the fact that fewer doctors are accepting Medicaid, a massive expansion of which is at the very heart of the law. Even supporters of the ACA admit there is nothing that can be done to address the shortage, certainly in the near term, as it takes about 10 years to train a new doctor. The Times’ article echoed the results of a survey by the Doctor Patient Medical Association, which said that 83 percent of American physicians had considered leaving their practices because of the law.

On the employer front, the trends are equally discouraging. A study by Deloitte Consulting, which surveyed 560 U.S. companies, found one in 10 businesses plans to end its insurance plans as the ACA measures begin to come online. Smaller firms, those with fewer than 100 workers, were more likely to drop coverage.

Sadly, it was all too predictable.

One of the most maddening aspects of the health care debate in 2009 and 2010 was that the focus was entirely on the demand side — the millions of uninsured who, according to the narrative at the time, would now have access to “quality, affordable health care.” Few people, certainly those in favor of the law, ever mentioned the supply side: the doctors, nurses, hospitals and diagnostic equipment that would be necessary to meet the new demand. Rather than being treated as a limited resource, health care was implicitly lumped in the same category as sunshine or fresh air — a commodity that could be dispensed in equal measure to anyone who wanted it, whenever they needed it, without any impact on quality.

It didn’t make sense then and it still doesn’t today. If you belong to a fitness club and 100 new members suddenly sign up one weekend, it’s safe to assume that finding a free treadmill or weight bench would be much more difficult. All members have equal access to the club, of course, but they would quickly find that “access” is not the same as actually getting in a workout. The club’s owners, to continue the analogy, would have to come up with a way to control the lines, perhaps using a reservation system for each machine or giving priority to the more overweight members. But someone with authority would have to decide who gets dibs.

With the ACA, this is where the Independent Payment Advisory Board (IPAB) comes into the picture. The IPAB’s mandate states that it cannot make any recommendations that “ration” care, but it remains to be seen how this can be done, or whether “rationing” is a malleable term. (Several states, for example, are limiting the number of prescription drugs they will cover for Medicaid patients — it may not be “rationing” in the strictest sense if everyone faces the same, limited options.) Indeed, looking at health-care models around the globe, in every case where government bureaucrats are charged with reducing costs, the best tool in the kit is to control demand by limiting either access or the number of choices.

For those who were appalled at how the ACA was ground through the legislative meat grinder, the sobering concern was that such a mammoth and far-reaching law, conceived and passed in the crudest and most partisan of manners , would have reams of unintended consequences buried in its 2,700 pages. It’s what made President Obama’s assurances at the time — that we could keep our doctors, keep our insurance plans, period — ring so hollow. How could he possibly have known what the impact would be on millions of businesses, doctors and patients?

As it turns out, he didn’t. With big ideas come big consequences, yet the ACA was pitched as the magical exception to the rule: It wouldn’t “add a dime to the deficit,” we could keep our doctors and insurance plans, and, according to a curious claim by former Speaker Nancy Pelosi, it would add 400,000 jobs “almost immediately.” None of this, we’re quickly finding, was true.

In writing the majority decision, Chief Justice John Roberts noted that it was not “[the court’s] job to protect the people from the consequences of their political choices.” As the ACA slowly comes to life, the relevance of that observation is becoming painfully clear.