There are many aspects of the health-care law that are not getting the attention they deserve and make the Affordable Care Act (Obamacare) more complex than the media is focusing on.

First, there has been a lot of complaining about the ability to keep your health care and provider, as well as the president’s claims that if you liked your policy you could keep it. People have been upset that policies are being canceled, as they might not meet the requirements of the new law. The larger story here is that insurance companies have always lowered their risk by canceling polices. Someone who was using the medical system a lot or was too old with medical problems often had to deal with higher premiums (I was paying about $2,035 per month), or they were getting canceled. If people want to keep their policies, there most likely will be no way that it will be affordable or that insurance companies will even operate in some of those states.

Then there are the issues of liability, malpractice claims and being sued. I have had countless discussions with people about the issues of reducing liability. One option is to put a cap on liability awards so there can be a reduction of the costs of tests ordered for “defensive” medicine. The legal professions lobbyists have essentially made sure that would not happen. The other is a self-report system, similar to what exists in aviation, where there is an incentive to self-report and data can be compiled with aggregate data pointing to needed changes in the system. It works like this: Unless there is outright negligence, there is no restriction on the pilot’s license but a positive effect for aviation as patterns can be identified and dealt with as they come up. This kind of creative solution was not written into the law and should be part of the fix.

Much has been written about the coming doctor shortage due to the additional number of people seeking basic medical care because there will now be insurance. However, little has been taken into account about how services will be delivered. Just a few years ago, if you wanted a flu shot, you had to make an appointment with your physician or nurse practioner. Now, you can get the flu shot from the local CVS. More and more health care is available in walk in clinics that may not be staffed with doctors. This past week, at the Washington Ideas Forum, Dr. Ezekiel Emanuel discussed how much of medicine and medical care will be decided by algorithms decided by computers. Doctors will be taking care of the most complicated patient cases, and basic medical care will be provided by nurses and other health care professionals as the care becomes automated.

Another innovation in health care, according to robotics expert Andrew McAfee from the Sloan School at MIT, is that pills we swallow will be able to report back to the doctor about what is taking place in the body. We are not there yet. Smart pills do not exist, but they will. That will completely change medicine because this will change what physicians know and understand about their patients.

The sheer knowledge base has changed medical education for doctors as well as nurses and even X-ray and ultrasound technicians. The ACA, either because of politics or the complexity of health care, did not build in the rapid changes in technology that we will continue to see in health-care research and delivery. It did not take into account how health-care students will learn and access information. Although the Internet was addressed in terms of privacy, education and technology changes were not.

There needs to be the equivalent of a base-closure commission and legislation to address these rapid changes. With the military base closures, there were up and down votes in Congress. They had to vote to close all on the recommended list or close none of them. Which bases were to close were decided by an independent committee then taken to Congress. The same needs to take place in changes to the Affordable Care Act. Learned and expert professionals should make suggestions to Congress, which should have an up or down vote on these so that politics can be kept to a minimum.

Keeping our insurance policies is the least of the problems with the ACA. The most important is the massive changes in delivery of health care that are on the horizon. Little of how to deal with these changes is in the law and somewhere between one-sixth and one-seventh of our total economy is health and wellness. We need to address this or the issues around keeping a current policy will look minor in comparison to the tsunami of new procedures and delivery system that is just over the horizon.


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