JAMA Forum: 3 Congressmen’s Views on ACA’s Flaws, Alternatives for Health System Reform

By Rep Phil Roe, MD; Rep Tom Price, MD; and Rep John Fleming, MD

We represent the House GOP Doctors Caucus, a group of 18 clinicians in Congress who use our medical expertise to shape health care policy. As clinicians and legislators, we believe we have a unique perspective to bring to the health care debate.

We agree that the US health care system needed reform before the Affordable Care Act (ACA) was enacted. Before the ACA, health care cost too much, care was difficult to access for too many people, and quality care was not always incentivized.

But we strongly believe the ACA was not the best way to reform health care delivery in this country. While the administration claims that the ACA has helped tens of millions of Americans gain coverage, simply adding millions more into a Medicaid system that is woefully inadequate at providing actual access to quality care is not health care reform. We believe the federal government has no right to force Americans to purchase anything, and the ACA even goes a step further to also dictate what kind of health coverage patients must purchase. The administration also fails to mention that there are roughly 5 million Americans who had coverage that was deemed inadequate through the ACA and were forced into a government-approved plan. Unfortunately, it’s clear to us that this law has made health care more complicated for physicians and patients alike and exacerbated a cost crisis in health care for millions of Americans.

Ostensibly, the ACA’s primary intent was to expand access to underserved populations, but simply having an insurance card does not ensure that a patient has access to quality, affordable health care. Unfortunately, the all-out push to ensure access to health insurance is having 2 serious adverse effects: it’s making premiums unaffordable for middle-class individuals who are ineligible for subsidies and it’s increasing out-of-pocket costs, deductibles, and co-payments. This is partially why more and more providers and hospital systems are amassing the majority of their uncollectible debt from people with insurance.

Our fellow physicians are making great efforts to navigate a set of constantly shifting metrics—some of which are directly attributable to the ACA. It’s frustrating to hear from so many of our physician colleagues about how much more difficult it is to practice medicine and the troubles they have navigating the changing health care landscape. These are troubles we predicted when Democrats cut Republicans out of the legislative process during the health care debate. As physicians, we believe it’s important to explore the ACA’s implementation not as Republicans or Democrats, but as physicians whose main concern is caring for patients.

Increased Costs

The ACA’s mandatory coverage requirements use a one-size-fits-all approach, and that’s one of the reasons costs continue to rise. To make insurance more affordable, we need to reduce the number of required essential health benefits and let patients decide what coverage they need and can afford. Furthermore, because the ACA reduced the ratios, or “bands,” by which age-based rates for adults can differ, to 3:1 (so the cost of a premium for an adult aged 64 years is no more than 3 times the cost of the same policy for a 21-year-old), the ACA is making health insurance cost-prohibitive for many young adults who are being forced to subsidize older, sicker patients.

Additionally, under the ACA, many preventive services are required to be covered for free, but if a more serious health issue is discovered, many patients now must pay for follow-up tests out of pocket instead of only having to pay a co-payment, as was the case in many plans before ACA.

Finally, while many of the plans on the exchange started with unrealistically low premiums, premiums have now skyrocketed, with some policy holders facing 20% hikes. Further, most of the lower-premium plans have high deductibles, making it difficult for middle-class patients to seek care. Because of how much uncollectible debt is now coming from people who have insurance, many providers are being forced to request payment up front because they simply can’t afford to provide the care and not be reimbursed for their services.

Rewriting a Failing Law Through Rule Making

There are other areas of the law that are almost certainly assured to wreak havoc on the employer-sponsored health insurance system, which covers nearly 150 million Americans. Rather than work with Congress to address those areas of bipartisan concern, such as the employer mandate, the Independent Payment Advisory Board, and the individual mandate, the Obama Administration has instead used questionable rule-making authority to rewrite major provisions within the ACA. For instance, the administration delayed the employer mandate multiple times, extended the enrollment deadlines, and unilaterally reduced out-of-pocket caps—just to name a few changes made to the law without Congressional approval.

We believe the statute is clear on what the law requires the administration to do. There’s no clause in the Constitution about changing laws you championed just because they aren’t working.

Moving Forward

We are invested in what the next era of health care should look like, and we believe it should be patient centered with a focus on innovation and research. We believe we can and should repeal the ACA and replace it with commonsense, patient-centered reforms, which is why several of our members have written comprehensive proposals to do just that. Simply put, we believe the reforms we are advancing would make it so every American would have the financial wherewithal and incentive to purchase the coverage that they want for themselves, not the high-cost coverage mandated by the ACA that patients have been forced to purchase under threat of a tax penalty.

Additionally, we support reforms like the ones recommended in House Speaker Paul Ryan’s Better Way agenda, such as expanding health savings accounts, providing portable financial assistance for health insurance, and making it easier for individuals and small businesses to pool together to purchase health insurance. We believe in providing preexisting condition protections and bringing fairness to insurance premiums by addressing the cost drivers in health care, including medical malpractice improvements to address the practice of defensive medicine and changing the age-rating ratio. As we mentioned above, the ACA-mandated age-based ratio of 3:1 leaves younger, healthier individuals paying more for their care. These are just a few of the things we can do to expand coverage and lower costs.

Let us be clear: no one is talking about returning to the pre-ACA status quo, but there is a better way to achieve health system reform in this country.


About the authors:

Rep Phil Roe, MD (R, Tennessee) (Image: US House of Representatives Photography)

Rep Phil Roe, MD (R, Tennessee) (Image: US House of Representatives Photography)

Rep Phil Roe, MD (R, Tennessee), represents Tennessee’s First Congressional District and serves as cochairman of the House GOP Doctors Caucus. He is the chairman of the Health, Employment, Labor, and Pensions Subcommittee of the House Education and Workforce Committee and also sits on the House Committee on Veterans Affairs. Prior to serving in Congress, Roe practiced medicine as an obstetrician-gynecologist for more than 30 years, delivering nearly 5000 babies.






Rep Tom Price, MD (R, Georgia) (Image: US House of Representatives Photography)

Rep Tom Price, MD (R, Georgia) (Image: US House of Representatives Photography)

Rep Tom Price, MD (R, Georgia), was first elected to represent Georgia’s Sixth Congressional District in November 2004. He serves on the House Committee on Ways and Means. In the 114th Congress, Price was named chairman of the House Committee on the Budget. For nearly 20 years, Rep Price worked in private practice as an orthopedic surgeon.







Rep John Fleming, MD (R, Louisiana) (Image: US House of Representatives Photography)

Rep John Fleming, MD (R, Louisiana) (Image: US House of Representatives Photography)

Rep John Fleming, MD (R, Louisiana), has represented Louisiana’s Fourth Congressional District since 2009. He is currently chairman of the Natural Resources Subcommittee on Water, Power and Oceans and is a member of the House Armed Services Committee. He is also a physician, small-business owner, cochairman of the House GOP Doctors Caucus, and cofounder of the House Freedom Caucus.







Financial disclosures for Reps Roe, Price, and Fleming are available online at the Office of the Clerk of the US House of Representatives by searching by name and year.

About the JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

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