We have our answer regard­ing the Patient Pro­tec­tion and Afford­able Care Act (PPACA, or Oba­macare). The indi­vid­ual man­date stands. But, as I have often pointed out, Oba­macare doesn’t appear to have done much regard­ing “Afford­able”. And yet, afford­abil­ity is one of the key desires of Amer­i­cans, and with good rea­son. We spend twice as much per-​​capita on health­care as the next most spendy nation, yet we are not get­ting results that are twice as good. Clearly, we are get­ting less bang for the buck than are other countries.

But does that mean that the only path to afford­abil­ity is single-​​payer? Or, if there are many paths, is that the best one? Some of my own recent expe­ri­ences sug­gest that a move to single-​​payer may not lead to afford­abil­ity at all, but Oba­macare (plus a pre­ceed­ing bill) may get us there — albeit not overnight — even if no new leg­is­la­tion is passed.

For most of my career, I have had med­ical insur­ance through my employer, and I chose a pre­ferred provider orga­ni­za­tion (PPO) pol­icy. As long as I selected a doc­tor from a pretty exten­sive direc­tory, my med­ical expenses were essen­tially entirely cov­ered. This gave me a great deal of power over my med­ical care — or, at least, the sense of a great deal of power. After all, it’s long been nearly impos­si­ble to deter­mine which doc­tors are really great, and which ones are not. Recently, the power of crowd sourc­ing on the Inter­net has made the choices eas­ier to make, but it’s still extra­or­di­nar­ily dif­fi­cult to com­par­i­son shop for health­care providers.

Nonethe­less, I’m an Amer­i­can, and Amer­i­cans love hav­ing the free­dom to choose, even when we can’t be suf­fi­ciently informed to make the choice. I enjoyed hav­ing that free­dom, too, and really appre­ci­ated it when I needed to have surgery. I was able to use Inter­net crowd sourc­ing to choose my sur­geon, and I’m glad I did.

But life goes on, and I changed employ­ers. My new employer didn’t offer a PPO, and I was instead cov­ered by Kaiser Per­ma­nente. I remem­bered hear­ing all of the hor­ror sto­ries about Kaiser, and so I was not look­ing for­ward to the kind of care I had heard one received from them. But I dis­cov­ered that the Kaiser of today bears lit­tle resem­blance to the Kaiser of the 1980s. And along the way I came to appre­ci­ate some aspects of the way they man­age healthcare.

My biggest sur­prise came when I went to see a spe­cial­ist. In my PPO days, I would spend a good twenty min­utes at the begin­ning of the appoint­ment talk­ing with the spe­cial­ist about my symp­toms, med­ical his­tory, and what steps I had already taken with regards to the issue behind the appoint­ment. I always hoped I didn’t for­get to men­tion any­thing impor­tant, but I could never be cer­tain that I cov­ered every­thing rel­e­vant. And the spe­cial­ist would often request med­ical tests that had already been per­formed, because he didn’t have the results and I either didn’t know they were needed or never got them myself. This didn’t usu­ally increase my out-​​of-​​pocket expenses (because of the plan I was on), but it did increase the amount of time I spent in var­i­ous med­ical facil­i­ties, and increased the num­ber of times I had nee­dles poked into my arms. And, of course, it also increased the amount of money spent by my med­ical insurer, which ulti­mately trans­lated to more dol­lars spent by my employer.

With the Kaiser model, since all med­ical records are stored elec­tron­i­cally in a sin­gle shared sys­tem, the spe­cial­ist had already read my med­ical his­tory, includ­ing the notes from my gen­eral prac­ti­tioner, who had rec­om­mended that I see a spe­cial­ist. The spe­cial­ist had a cou­ple of more detailed ques­tions, but we spent far less time on the med­ical his­tory, and more time on get­ting to the heart of the mat­ter. I didn’t need to get redun­dant tests. And I didn’t have to worry about acci­den­tally omit­ting impor­tant infor­ma­tion. I fin­ished my appoint­ment more quickly than I had with PPOs, and I was less likely to have a course of treat­ment that would be con­traindi­cated by some other med­ical con­di­tion for which I was being treated.

I still don’t like hav­ing a gen­eral prac­ti­tioner who may veto my desire to see a spe­cial­ist (that whole free­dom to choose thing). And I wish I weren’t restricted to Kaiser’s doc­tors. But wouldn’t it be great to be able to get the ben­e­fit of the Kaiser med­ical record model with­out those HMO restrictions?

This was the goal of the Health Infor­ma­tion Tech­nol­ogy for Eco­nomic and Clin­i­cal Health (HITECH) Act, part of the Amer­i­can Recov­ery and Rein­vest­ment Act (ARRA) passed in 2009. HITECH pro­vides incen­tives for physi­cians to keep their med­ical records in a stan­dard elec­tronic for­mat as elec­tronic health records (EHRs). Oba­macare extended HITECH by pro­vid­ing addi­tional incen­tives beyond those stip­u­lated in HITECH.

There were some teething issues with the early imple­men­ta­tions of EHRs, but in the past cou­ple of years the field of EHR providers has sta­bi­lized and matured. Physi­cians are now begin­ning to reap the ben­e­fits of going elec­tronic — and so are their patients. As the net­work effect begins to take hold, the same shared-​​record ben­e­fits avail­able at Kaiser become avail­able out­side the HMO world. Physi­cians glean more infor­ma­tion about their patients before ever walk­ing into the exam­i­na­tion room, and are able to diag­nose more quickly and accu­rately with fewer tests.

In short, almost every­body wins. Physi­cians have fewer lia­bil­ity con­cerns, since they are less depen­dent upon the reli­a­bil­ity of infor­ma­tion sup­plied by the patients from mem­ory or rudi­men­tary notes. Both doc­tors and patients have less wasted time. Patients retain the abil­ity to choose physi­cians, and to choose when to see spe­cial­ists. Patients’ out­comes are improved, reduc­ing the like­li­hood of return vis­its to address pre­ventable com­pli­ca­tions, which fur­ther reduces the amount of wasted physi­cian and patient time. Insur­ance com­pa­nies spend less per capita, yet those cov­ered by their poli­cies have bet­ter results.

None of this should be expected to address the under­ly­ing expo­nen­tial health­care cost increases, which are occur­ring glob­ally, and for rea­sons entirely sep­a­rate from those that cause Amer­i­cans to spend more than any­one else on their health­care. Nor are EHRs a sin­gle magic bul­let that will fix every­thing that makes health­care in the United States so much more expen­sive than in other nations. It should, how­ever, do a great deal to bring per-​​capita health­care costs in line with the rest of the indus­tri­al­ized world.

Imag­ine for a moment that national imple­men­ta­tion of EHRs would reduce health­care costs by 30 per­cent. It’s not hard to believe that it could; the Con­gres­sional Bud­get Office esti­mates that 30 per­cent of our med­ical costs arise from unnec­es­sary tests and pro­ce­dures. While I doubt that we’d elim­i­nate all of those, the improved time effi­ciency and patient out­comes could eas­ily cover the gap in remain­ing unnec­es­sary test and pro­ce­dure costs.

If we could reduce our health­care costs by 30 per­cent, Amer­i­cans would col­lec­tively save one tril­lion dol­lars per year — over six per­cent of our gross domes­tic prod­uct. About $800 bil­lion of our health­care costs are cov­ered today by the fed­eral gov­ern­ment, so that would trans­late to a reduc­tion of $240 bil­lion per year from the fed­eral bud­get. That’s 10 per­cent of the bud­get (exclud­ing Social Secu­rity, which adds all sorts of com­pli­ca­tions), or 21 per­cent of the deficit. All with­out a decrease in the qual­ity of healthcare.

So, while it’s true that Oba­macare did lit­tle itself to cut the costs of health­care, it still looks like it has helped lay the foun­da­tion. Our future will have greater effi­ciency and bet­ter out­comes, which will reduce our costs com­pared to the sta­tus quo. I, for one, look for­ward to that future.

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