david pate

Dr. David Pate

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COVID has brought many issues to the forefront — the inadequacy of our public health system, our lack of preparedness for the inevitable next pandemic, the strained lines between politics and science, the impact of socioeconomic disparities, etc. — but an even greater risk to the American health care system lies in wait like an incubating virus. In less than two months, the U.S. Supreme Court will hear the challenge to the Affordable Care Act (ACA) brought by about 20 Republican states seeking to have the law struck down. A decision is expected before next summer.

In 2009 and 2010 when this law was being debated, I came out against the ACA, not because it did not have desirable elements, but because I did not believe President Obama’s claims that the ACA would lower health care costs and the average family’s premiums as was being touted. To me, it was inconceivable that we could add tens of millions of Americans insurance coverage in a broken, disjointed health care system that still rewarded fee-for-service and believe that somehow health care costs would decrease.

But, the ACA is the law of the land and has been for the past decade. The American health care delivery system has gone through tremendous change since then. I do not have the space here to explain all the dramatic changes that would occur if the ACA were now struck down. But let me explain what that decision might mean for you.

The most significant change would be the loss of guaranteed issue. That means a return to the days when an insurance company could decline to offer you a health insurance policy because of preexisting conditions. Along with this would be the loss of community rating. Today, an insurance company offering ACA-complaint health plans can only vary the premium based on age, whether or not the insured is a smoker or not and the location where the insured lives for each level of plan offering. In other words, if you have high blood pressure or any other preexisting condition, the insurance company cannot charge you a higher premium for that.

Now, imagine that you have been infected with COVID or may be in the future. Under the ACA, insurance companies cannot refuse you coverage or charge you more because of that diagnosis, but if the ACA is struck down, they can. As we learn more about the long-term effects of COVID, insurance companies must rightly be concerned about the increase in future health care costs for people who were infected with COVID, even if they have recovered.

Further, in a time when many have lost their jobs, and along with that their insurance coverage, this is an especially vulnerable time for many to face the prospect of the ACA being struck down, because that would also mean no more public health exchanges where people could purchase insurance and receive the benefit of advance premium tax credits and subsidies to help pay for their insurance. It would also mean the end of Medicaid expansion.

So, I say to President Trump and Republicans in Congress, show us your plan. I certainly don’t argue that the ACA cannot be improved upon. But, we are coming up on an election. Health care is one of the most important issues for voters. You ran on repealing Obamacare. You have had four years to come up with a plan. If you prevail in court and the ACA is struck down, we deserve to know what the ACA will be replaced with in order for you to deserve our vote.

Dr. David Pate is a physician and the recently retired CEO of St. Luke’s Heath System. He writes a blog at drpatesblog.com.

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