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U.S. Health Care: A Conundrum and a Challenge

Ivan S. Ciric

-BACKGROUND: This report was conceived as a contri-bution to the national debate regarding U.S. health care(HC) and as a means of explaining the challenges facingU.S. HC to the international readers of WORLDNEUROSURGERY.

-METHODS: The basic economic concepts pertinent tohealth care, including fundamentals of economic theories,gross domestic product (GDP), U.S. revenues and expen-ditures and the U.S. federal deficit and national debt, arediscussed at the outset of this study. This is followed bya review of the U.S. health insurance paradigms anda detailed analysis of the escalating cost of U.S. healthcare. Finally, the efforts designed to reverse the paradigmof escalating health care costs will be discussed.

-RESULTS: This study reveals that should the U.S. HC costcontinue to escalate at the same rate, HCwould consume theentire gross domestic product by 2070. The root causes forthis trend are overutilization of HC, inappropriate allocationof HC costs at the end of life, defensive medicine, high-endtechnology and prescription drugs, failure of competitivemarket forces, and administrative costs, inefficiency, andwaste. The proposed means of reversing this paradigm,including the Patient Protection and Affordable Care Act, arediscussed in light of their economic and social impact.

-CONCLUSIONS: The reversal of the current paradigm ofescalating cost of U.S. HC will require extraordinary leader-ship across the entire spectrum of HC delivery. It is concludedthat neither the Affordable Care Act nor the Path to Prosperitywill succeed unless the escalating cost of U.S. HC is reversed.It is hoped that this report contributes to that end.

Key words- Affordable Care Act- Escalating cost- Health care- Opposing views- Root causes- United States

Abbreviations and AcronymsACA: Patient Protection and Affordable Care ActGDP: Gross domestic productMRI: Magnetic resonance imagingU.S.: United States of America

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INTRODUCTION

ccording to the Central Intelligence Agency FactBookU.S., infant mortality in 2011 was 5.98 per thousand live

Abirths, or 48th in the world, behind members of the

European Union and behind countries such as Cuba (4.83), FrenchPolynesia (4.88), and Taiwan (5.10). Similarly, according to thesame source, U.S. life expectancy (78.49) is 50th in the world,again trailing the European Union and countries such as Bosniaand Herzegovina, Jordan, and Cayman Islands (4). While lifeexpectancy and infant mortality are influenced by a multitude ofextraneous factors, these less than salutary facts neverthelessstand in sharp contrast with the accomplishments of U.S. medi-cine in terms of its power to prevent disease and its therapeuticwonders, and they are also remarkably incongruous with the ever-escalating cost of U.S. health care (22).In this report, the root causes of the progressively increasing

cost of U.S. health care and the efforts designed to reverse thistrend will be reviewed in detail.

BACKGROUND

This report was conceived as a contribution to the ongoingnational debate regarding U.S. health care and as a means ofintroducing the challenges facing U.S. health care to the inter-national readers of WORLD NEUROSURGERY.

MATERIALS AND METHODS

The basic concepts of elements of the U.S. economy pertinent tohealth care, including the gross domestic product (GDP), the U.S.revenues and expenditures and the U.S. national debt, are discussedat the outset of this study. This is followed by a brief discourse on theprinciples of economic theories as they relate to health care, a reviewof U.S. health insurance paradigms, and a detailed analysis ofvarious aspects of the escalating cost of U.S. health care.

Department of Neurosurgery, NorthShore University HealthSystem,Evanston, Illinois, USA

To whom correspondence should be addressed: Ivan S. Ciric, M.D.[E-mail: iciric@northshore.org]

Citation: World Neurosurg. (2013) 80, 6:691-698.http://dx.doi.org/10.1016/j.wneu.2012.10.021

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.

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RESULTS

U.S. GDP, Revenues and Expenditures, and the U.S. National DebtGDP is the composite value of goods and services produced bya country within a given period of time. The U.S. GDP in 2011 was$15.09 trillion, the largest in the world, constituting 23% of theworld GDP and approximating the U.S. debt to date (34).According to the U.S. Office of Management and Budget, U.S.

government revenues in 2011 were $2.3 trillion, 83% of which wasdivided fairly equally between individual income on one hand andSocial Security/Medicare taxes on the other. Interestingly enough,tax revenues on corporate income constituted only 8% of totalrevenues (34).In contrast and based on the same source, the U.S. Budget for

2011 identifies $3.5 trillion in expenditures, of which nearly half(43%) was allocated for Social Security and public health care(Medicare and Medicaid) payments and close to 20% for nationaldefense. After paying interest on the national debt (8% of thebudget) and meeting other by law mandatory expenditures, only17% of the budget remained for discretionary expenditures thatinclude, among others, infrastructure and the environment,education, the judiciary, foreign aid, and the space program (34).It is clear from this brief review that U.S. revenues cover only 60%

of U.S. budgetary needs. The difference between the revenues andexpenditures constitutes the U.S. federal deficit. To meet itsbudgetary obligations, the difference between U.S. governmentrevenues and expenditures is financed through U.S. debt, themechanism of which is U.S. treasury notes. The cumulative U.S. debtas of February 2012was a remarkable $15.5 trillion (37). Since the U.S.constitution was enacted in March of 1789, the U.S. debt ceiling hasusually risen during wars and economic downturns. The two mostrecent data in this regard show that the debt ceiling of $5.7 trillion inJanuary of 2001 nearly doubled by December of 2008, with another$5.2 trillion, however, added to the debt ceiling in the past 4 years (36,37). The distribution of outstanding U.S. treasury notes as of the endof the fiscal 2011 year included U.S. individuals and institutions(30%), Social Security Trust Fund (17%), U.S. Federal Reserve (12%),China (9%), Japan (6%), and other foreign holders (38).

Economic Theories Pertinent to Health CareClassical Economics. Classical Economics, first promoted by AdamSmith in 1776 (29), states that macroeconomics of a country equalthe aggregate of microeconomics of individuals, families, andcorporations, including service providers, and that it is thus subjectto the same economic principles as those guiding microeconomics.It is not surprising, therefore, that Classical Economics favorsa balanced national budget and, according to the same tenet,a balanced health care budget. It is conceivable that one of theinsidious reasons behind the escalating cost of U.S. health care isthat historically the United States has not had a budget that hasencompassed both the public and private sectors of health care.Another postulate of Classical Economics is that supply creates itsown demand (28). Applied to health care, this economic paradigmcan explain how proliferation of high-end health care, frequentlytechnology driven, can lead to an increased demand on health care,resulting in health care cost escalation. In a somewhat counterin-tuitive way, however, Classical Economics also asserts that free

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markets, including health care, when not interfered with, willregulate themselves and will thus remain in equilibrium (7).

Keynesian Economics. In stark contrast, Keynesian Economics,introduced by Maynard Keynes in 1936 (18), is based on the tenetthat aggregate microeconomic actions and behavior of individuals,families, and corporations are inadequate to explain or justifythe macroeconomic demands and responsibilities of a nation. Aspecific example in this regard would be employment. Conse-quently, Keynesian Economics advocates government interven-tion, mainly lowering of interest rates and deficit spendingstimulus programs, during economic downturns on a temporarybasis and as a bridge toward private enterprise prosperity. Thereare numerous historic examples of successful governmentalinvolvement during periods of recession or when significanteconomic kindling was necessary: notably, the public worksprojects of Franklin Delano Roosevelt in the 1930s, the World WarII U.S. economy, and the Europe-saving U.S. government inter-vention of the Marshall Plan. According to this economic theory,albeit in reverse, government intervention may also be necessarywhen the economy at large or a sector of it, such as health care,overheats and there is an increasing demand on assets. Sucha scenario may require either raising interest rates to preventinflationary pressures or rationing in the case of health care.

Supply Side Economics. Supply Side Economics (“trickle downeconomics”) was more recently introduced in its present form byPresident Nixon’s economic advisor Herb Stein and his cotem-porary, journalist Jude Wanniski (39). The theoretical basis ofSupply Side Economics was provided by President Regan’seconomic advisor Arthur Laffer (20, 39). Although also focusingon the supply side of economy, Supply Side Economics differsfrom the hands-off attitude of Classical Economics by advocatingproactive stimulation of economic growth through lowering ofindividual and corporate taxes across the board, irrespective ofthe level of affluence, and by eliminating cumbersome regula-tions. According to Supply Side Economics, these measureswould leave more monetary resources in the hands of citizensand corporations, resulting in either a greater consumption ofgoods and services or in the jumpstarting of new businesses andexpansion of existing businesses. Both would lead to a greateremployment and thus to a greater pool of taxpaying individualsand corporations.

U.S. Health Insurance Paradigms Before the Patient Protectionand the Affordable Care ActHealth Insurance for Those Younger than 65 Years of Age. The para-digm of health care coverage for U.S. individuals younger than65 years of age differs from that of individuals 65 years or older.A recent study by the U.S. Bureau of Census in 2007 showed that16% of U.S. individuals younger than 65 years had no healthinsurance, whereas 13%, with an income under the federal povertyline ($15,000 for an individual and $31,000 for a family of four),were insured through the Medicaid program (33). This program isfinanced on an equal basis between the states and the federalgovernment and administered by the states. Because of the fiscaldifficulties that most states have encountered since the economicdownturn began in 2008, the hospital and physician Medicaid

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reimbursements have been low and therefore inadequate tosustain the operation of institutions or medical practices that arecompletely dependent, or largely so, on Medicaid patients. Thesame report also identified 59% of individuals younger than age65 years who had employment-dependent insurance coverage.A similar report by the U.S. Bureau of Census in 2010 showed thatthe breakdown between insured, noninsured, and Medicaidpatients had remained essentially unchanged (32).The employment-dependent insurance varies from the straight-

forward indemnity insurance (premium buys coverage) to a varietyof managed care programs such as the health maintenance orga-nizations, preferred provider organizations, and the independentpractice organizations (32). All managed care programs have astheir common denominator, to a greater (health maintenanceorganizations) or lesser (preferred provider organizations) degree,cheaper premiums, albeit in conjunction with regulated and oftentime-restricted coverage options. These include preselected accessto the institutions or physicians from which the patient can seekhealth care and a restriction on the available treatments andprescription drugs. The steadily decreasing indemnity insurancelandscape and the burgeoning number ofmanaged care programs isnot surprising when one considers that in the decade between 1999and 2009 the indemnity insurance premiums rose by 131% whereasthe average U.S. salary rose by only 38%, a fact most certainlyreflected in the budgetary decisions of U.S. families (13).

Health Insurance for Those Older than 65 Years of Age. Healthcoverage for individuals aged 65 years or older is guaranteed by theMedicare program that was enacted into law by President LyndonJohnson in 1965 (35). Medicare also covers the health care of peoplewith disabilities, end-stage renal disease, and amyotrophic lateralsclerosis. Medicare reimbursements for hospitals are based ondiagnostic-related groups, which means that the institutions receivea predetermined sum from the Medicare program for a given diag-nostic group. It is in the interest of the institution to spend less thanthe allotted sum (less testing, no complications, and early dischargeamong other means of staying within the budget). The reimburse-ment for physicians is based on relative value units that rewardsquantity of work performed and is based on 80% of the federalgovernment predetermined fee schedule, with private coinsuranceplans offering to cover the remaining 20% of the fixed fee schedule.As of 2015, the Medicare reimbursement for physicians will berestructured to reflect quality rather than quantity of care with thelikelihood that the relative value units will be phased out (23).The economic downturn has brought into question the long-

term solvency of the Medicare program. A total of 48 million U.S.citizens were covered by Medicare in 2010. It is estimated that thisnumber may increase to 80 million by 2030. The total cost of theMedicare program in 2010 was $560 billion. It is estimated that by2022 the annual cost of Medicare will rise to close to $1 trillion(8, 15e17). In 2011, the Social Security Administration (16) and,more recently, the Congressional Budget Office (6) projected thatthe Medicare Fund will become insolvent by 2024. Presently, theMedicare Program is financed through a 2.9% tax on individualincome that is shared equally between the employer and theemployee. In 2013, this tax will increase to 3.8% on earned as wellas unearned (e.g., dividends, sales) income for those with anannual family income of more than $250,000 (23).

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U.S. Health Care CostTotal cost of U.S. health care in 2011 was a remarkable $2.6 tril-lion, or 17% of the GDP, a sum that is more than the $2.3 trillionthe United States collected in tax revenues that year (34). One thirdof this cost (31%) was spent on acute and chronic hospital care,including rehabilitative institutional care, one fifth (20%) wasspent on physicians, 13% was spent on drug prescriptions andother retail health purchases, and the rest was spent on outpatienthealth care and other health care needs, such as nursing homesand home health care.Until the early 1980s, U.S. health care cost was progressing along

amildly increasing curve parallel to western European countries andother industrialized nations such as Australia, Canada, and Japan(31, 40). The health care cost of industrialized nations, including theUnited States, in 1960 ranged from 2% to 6%, and in 1980, between4% and 8% of the countries’ GDPs, with the United Kingdomspending the least (2% in 1980). Since the 1980s, U.S. health carecost has taken off along a steeply inclined curve that is out ofproportion to other industrialized nations. In 2008, U.S. health carecost increased to 16% of the GDP, whereas other industrializednations spent anywhere between 5% and 11%of their correspondingGDP on health care. These data also show that should U.S. healthcare cost continue to escalate at the same rate, i.e., an average of 6%per year with the GDP rising at 3% per year, U.S. health care wouldconsume 100% of the GDP by 2075 (9, 10, 19). Clearly, should theannual increase in GDP decline due to economic downturns, as isthe case at present, health care cost and the GDP curves wouldintersect at an earlier date. Theoretically, at that point, no resourceswould be left for the Social Security pension plan, national defense,infrastructure, education, or the judiciary system, to name but a fewof the programs essential to the existence of a country. The gravity ofsuch a scenario is self-evident.The disproportionate escalation of U.S. health care cost

compared to other industrialized nations is probably best illus-trated when one reviews the per capita spending on health care. In1970, health care cost in the United States per capita was $1600. In2010, it was close to five times higher, at $8400. It is anticipatedthat by 2019, the per capita health expenditure in the United Stateswill reach $13,000. This unrelenting increase in the United States’per capita health care cost appears even more significant whenone considers that the second most expensive country in the worldin terms of health care cost, Norway, spent only $5352 and Canada(6th most expensive country in terms of health care cost) $4478 onhealth care per capita, respectively, in 2010 (14, 31).

DISCUSSION

Root Causes of the Escalating Health Care Cost in the UnitedStatesThis discourse invites the question, why is U.S. health care costescalating at such an unsustainable, rapid rate? We have identifiedseveral factors that, if left to their own devices, without correction,would surely result in a steady erosion of U.S. resources to anunsustainable level.

OverutilizationAmong the possible causes contributing to the ever-escalating costof U.S. health care, overutilization stands out as potentially the

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greatest culprit. A significant segment of U.S. health care iscurrently influenced by a vicious cycle that beginswith the consumer(patients) driven demand on immediate and complete health careservices under any and all circumstances, in part due to a lack ofpersonal financial responsibility (“insurance will pay”). The result isa proliferation and duplication of health care services (more testing,more expensive technology, more expensive prescription drug use),which in turn seeks more consumers to justify the proliferated andduplicated health care services. Although there are numerousexamples of health care proliferation, one that is most frequentlyquoted (though not necessarily the most expensive) is the dispro-portionately large number of magnetic resonance imaging (MRI)units in the United States compared to other industrialized nationsandwestern Europe. For example, in 1994, therewere 11.2MRI unitsper million population in the United States compared to 1.1 inCanada and 3.7 in Germany (26). By 2008, this difference was evenmore glaring, with the number ofMRImachines in theUnited Statesincreasing to 27 per million population, whereas other nationslagged behind (31). The same reports indicate a similar discrepancyin the availability of other high-end technology, including cardiaccatheterization, lithotripsy, and organ transplantation, between theUnited States and other industrial nations.Duplication of health care also contributes to health care cost

escalation. For example, high end, expensive cardiac surgery isperformed in 6 and neurosurgery in 8 community hospitals allwithin a radius of 15 miles in a suburban Chicago setting.

Inappropriate Allocation of Health Care Resources at the End ofLifeOne may be justified to ask the question whether the increasingpopulation of older and thus disease-prone patients may be anotherpossible cause of escalating U.S. health care costs. To some extent,yes, but themere fact that there is an increasingly aging population initself should not be the cause for disproportionately escalating healthcare cost compared to other industrialized nations (4). The healthcare cost problem related to aging is that, in theUnited States, there isan inappropriate allocation of health care resources at the end of life,especially in the last 6 to 12 months of life (3, 11, 25). In a study byHoover et al. (12) on Medicare beneficiaries from 1992 to 1996, themeanmedical expenditures for persons agedmore than 65 years were$37,581 during the last year of life versus $7365 for nonterminal years.In a more recent study by Chastek et al. (5) on 28,530 cancerpatients, the mean health care cost grew exponentially from $7835 inthe sixth month before death to $25,260 in the last month of life.

High-End Technology and Branded Prescription DrugsInstead of favoring prevention and wellness programs, since the1980s, the United States has embraced high-end technology andbranded prescription drugs and has trained more specialists,resulting in high-end, expensive treatments, and the U.S. is there-fore paying more for it (13, 26, 31).

Medical Liability SystemThe medical liability system in the United States can be charac-terized by lawsuits that are often unjustified at best and frivolousat worst. The lawsuits are brought by the legal profession ona contingency basis, with no punitive damages to the plaintiff orthe attorney in case the lawsuit is adjudicated in favor of the

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defendant, which is, incidentally, true for the majority of thesecivil litigations. To avoid lawsuits, physicians and surgeons tend topractice defensive medicine (13). One of the consequences of suchdefensive medical practice is that physicians often focus onproving what the patient is not suffering from or afflicted withrather than following the clues given by history and examinationand targeting laboratory and imaging evaluation accordingly. Theoverall result, therefore, is superfluous, extensive, and expensivetesting for the sake of physician protection. In a study by Melloet al. (21), the defensive medicine posture of physicians accountedfor more than 80% of the estimated $55.6 billion annual cost ofmedical malpractice in 2008, a sum by far greater than the actualdamages paid to patients and the legal costs of the litigations.

Failure of Competitive Market ForcesThe everyday observations reveal that competitive market forcesapplicable to industry at large do not seem to have the same hold onhealth care. For example, the ever-increasing number of MRI unitsin a community does not substantially lower the price of an MRIstudy (and in some instances does not lower the price at all). Thesame can be said for laboratory testing, specialists’ services, and thelike. The failure of competitivemarket forces to keep health care costdown may be in part influenced by the absence of personalresponsibility on the part of the health care consumers to defray thecost of services rendered.

Increasing Administrative Costs, Waste, and InefficiencyFinally, there has been a steady increase in health care relatedadministrative costs, both public and private, and waste and inef-ficiency in administering of the burgeoning governmental healthcare programs (13).

Proposed Means and Methods Designed to Reverse the Paradigmof the Escalating Cost of U.S. Health CareThis discourse illustrates that the United States is faced with thedilemma and challenge of how to reverse the unsustainableescalating cost of health care. Ideally, the solution should respectand not disrupt the superb medical care currently enjoyed by themajority of U.S. citizens yet recognize the financial constraintswithin the context of U.S. national debt that presently stands closeto $16 trillion (37); certainly, a tall order.After a lengthy national debate, different plans have emerged, all

with the intent to reconcile the health care dilemma. These plans arerooted in different viewpoints as to entitlements, including healthcare in particular, and the need for a social safety net in general, andthey are supported by different economic models (22).

The Medical Profession View Point and RecommendationsAlthough the medical profession may not have necessarilya unified message regarding the solution to the U.S. health carecost crisis, as different organizations may have disparate view-points, there are several facts that are embraced by the professionas a whole. These facts are probably best summarized in a reportby the Institute of Medicine, a respected and independent memberof the U.S. Academies, titled The Healthcare Imperative (13). In thisreport, the Institute of Medicine has identified $765 billion inunnecessary costs out of a total health care cost in 2009 of$2.5 trillion. These include unnecessary services ($210 billion);

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inefficient services ($130 billion); lack of preventive measures($55 billion); excessive administrative costs ($190 billion); too-high prices ($105 billion); and fraud ($75 billion). Commensu-rately, the Institute of Medicine has also identified $463 billionthat could have been saved in 2009 through decreasing adminis-trative costs ($181 billion); increasing efficiency in delivery of careand preventing medical errors and fraud ($100 billion); preventingavoidable admissions ($68 billion); targeting expensive services($20 billion); and, last but not least, through reforming themedical malpractice system ($30 billion). This centrist viewpointis surrounded on either side by the more liberal and less pro-physician viewpoints on the left and by an array of more conser-vative and more pro-physician viewpoints on the right (1).

The Democratic Party ViewpointThe Democratic Party viewpoint is that the governmental socialnetwork, such as the entitlement programs, including universalhealth care coverage, is essential to the fabric of U.S. society and ishere to stay, even if temporarily under deficit spending (18), and thatfairness requires shared sacrifice with an increase in taxes on theaffluent (both earned income and dividends). This should offset thedeficit and thus make the entitlements solvent. This fundamentalpremise led to the formulation of the Patient Protection andAffordable Care Act (ACA) (23), consisting of 10 sections and 450provisions that were signed into law by President Barak Obama in2010, to be phased in over 4 years. Because of constitutional chal-lenges, including the individual mandate that all U.S. citizens mustacquire health coverage, the ACA was contested in courts by itsdeterrents. TheU.S. SupremeCourt upheld the law as constitutionalin June of 2012, thus allowing for implementation of the ACA aswritten, albeit with some restrictions. Specifically, theU.S. SupremeCourt struck down as unconstitutional the provision that individualstates could be penalized if they opted not to implement extensionof the existing Medicaid program that would cover all citizens ofa state who are under the federal poverty line.The U.S. Office of Management and Budget initial projection for

the total cost of the ACA was less than a $1 trillion over 10 years.This number has since been gradually revised upward to approx-imately $1.5 trillion (34). According to the ACA, it will be financedby an increase in Medicare taxes (2.9% to 3.8%) on the affluent,i.e., those with a family income of more than $250,000, andthrough excise taxes on pharmaceutical and health insurancecompanies in accordance with their market share: a 2.3% excisetax on the production and sale of medical devices and a 40%excise tax on the purchase of costly (“Cadillac”) health insurancepolicies, as well as additional excise taxes on purchase of luxurygoods and services. The projected annual revenues from thesemeasures, as estimated by the U.S. Office of Management andBudget, should be $400 to $500 billion (23).What does the ACA offer? Here are some of the most important

provisions.

1. It makes health services available to the 32 million who arecurrently uninsured.

2. It mandates that each person has insurance; it penalizes, withtaxes, those who fail to obtain insurance (up to 1% of income).Patients can keep existing insurances.

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3. Children can remain covered by parental insurance until age26 years.

4. It eliminates denying coverage for preexisting conditions ordropping from coverage due to illness.

5. It mandates coverage for preventive care. It also establishesa National Prevention Council.

6. It regulates drug prescription payments for the elderly.

7. It regulates insurance companies by:

a) eliminating annual and lifetime “caps” and;

b) limiting out-of-pocket expenses. It also mandates insurancecompanies to rebate a portion of the premium if less than80% of the premium was spent on health care.

8. It establishes state-based insurance exchanges that are market-places for consumers to shop for health coverage that meetsminimum government standards. The federal government willoffer graduated premium subsidies for households from above135% up to 400% of the federal poverty line. In this state/federalpartnership, states may have to forfeit the right to select theinsurance plans offered. Buying insurance across state lines is notpart of theACA, as thiswould allegedly lead to a race to the bottom(buying insurance in states with the least consumer protection).

9. It extends Medicaid coverage for millions of Americans whoseincome is below 135% of the federal poverty line by extendingstate-based Medicaid programs. The federal government hasallocated $1 trillion over the next decade and will pay 100% forthis program until 2020 when the federal contribution will dropto 90%.What the Supreme Court did not uphold is the penalty tothe states if they opt out of this program, asmanyRepublican-ledstates intend to do in spite of the promise of easy money up frontand fearing uncontrollable budgetary deficits in the long run.This will create a significant inequality among states withuniversal coverage in some but not all states, clearly an unin-tended goal of ACA. Nevertheless, according to a recent studypublished in the New England Journal of Medicine, there has beena statistically significant decrease in mortality in states that havealready extended their Medicaid programs (30).

10. For seniors, Medicare is here to stay, with a projected $750billion in savings over a decade by eliminating unnecessaryadmissions, inefficiency and fraud, and overpayments, and byreplacing physician reimbursement based on quantity of workdone with quality benchmarks, to be determined by the newlyformed Independent Payment Advisory Board (23).

The ACA leaves a number of questions unanswered or inade-quately so.What will happen to the burgeoning group of poor people in states

that opt out of the extendedMedicaidprogram?Would sucha scenarioadd to the national debt if the federal government takes upon itselfthe full obligation of financing such states’ Medicaid programs?What will happen if employers decide not to employ new

workers or outsource jobs to avoid an increase in health carecosts? What if employers decide that the penalty option is cheaper

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($2000 per employee in businesses with more than 50 employees)compared to escalating insurance costs, leaving thereby theiremployees uninsured?What will happen to the medical profession’s ability to

provide health care to the influx of new patients in light of theshrinking pool of physicians and clinics accepting governmentinsurance?What will happen to Medicare eligible seniors considering that

the decrease in Medicare reimbursement to providers of healthcare will affect Medicare recipients as fewer physicians will acceptMedicare patients and hospitals may limit the scope of theirservices?What will happen to the insurance landscape? Will insurance

companies opt out of the business, opening doors to ACA-sanc-tioned state waivers that allow the states to opt out of the ACA ifthey enact a state-sponsored single payer system? The state ofVermont already has, and Oregon has requested such a waiver.

The Republican Party ViewpointIn contrast to the Democratic Party, the Republican Party viewpointis that entitlements as structured presently under a governmentbureaucracy are too expensive and that they would be less expensiveif partially “restructured,” thus givingU.S. citizens an opportunity tochoose how to save for retirement and where to seek health insur-ance (2, 6, 24, 27). Also, according to this viewpoint, decreasingtaxes across the board and deregulation (6, 7, 20, 39) would stim-ulate the economy and thus boost economic growth, leading to anincrease in employment, with more individuals therefore partici-pating in the tax revenue pool.Consequently, the Republican Party recommendation is to

replace the current defined (guaranteed) benefit Medicare modelwith a defined contribution model based on an income adjustedsystem of stipends (vouchers) that would be provided to futureseniors (individuals presently 55 years of age or younger) who wouldthus be free to seek the health insurance of their choosing on thefree market. The Republican plan also calls for increasing theMedicare eligibility age from 65 to 67 years, shifting of Medicaidcosts to the individual states, and opening interstate barriers forthose seeking the most competitive insurance coverage. Since theNovember 2012 elections, however, the Republican plan is nolonger on the table as a unit, although some of its components mayresurface in the debate on the reduction of the U.S. national debt.

Personal ViewpointThe personal viewpoint, reflecting the credo of the medical profes-sion that is rooted in the Hippocratic ethos and steeped in science, isthat health care is a right and not a privilege and that medicine isbased on humanism and not business or politics. This idealisticviewpoint aside, however, neither the ACA nor the Republican planfor restructuring of the social network and health care will workunless the escalating health care costs are reigned in. With this inmind, the starting point in halting escalation of health care costsshould be the following:

1. Reversing the paradigm of proliferation and duplication ofhealth care services, especially high-end, expensive services,albeit always in accordance with evidence-based medicine.

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2. Reforming the medical malpractice system that rewards thepatient for suffering from true medical negligence, but at thesame time holds the plaintiff’s attorney legally responsible forunjustifiable lawsuits that are adjudicated in favor of thedefendant physician.

3. Rationing end-of-life treatment and expenditures rationally andin accordance with evidence-based medicine.

4. Curbing of administrative costs by eliminating cumbersomeregulations.

Themedical profession in the United States should recognize thatthe ACA acknowledges that runaway overutilization of health careis unsustainable. Accordingly, the ACA has established a nonprofitPatient-Centered Outcomes Research Institute charged withestablishing “relative health outcomes, clinical effectiveness, andappropriateness of medical treatments” based on the existingstudies and by conducting its own (23). Such a scenario of govern-ment-sponsored studies that adjudicate the validity of certain testingand treatments have, on occasion in the past, resulted in erroneousconclusions. Consequently, considering that level I evidence-basedstudies (double-blinded randomized controlled trials) are expensiveand time-consuming propositions, it is advisable that each specialtyconducts scientifically less rigorous but nevertheless valid level II-2outcome studies, such as multicenter, cohort, or case-controlanalytic studies, that also address cost effectiveness.The ACA has unintentionally brought along on the horizon one

more possible future health care scenario that has its harbinger inthe presently increasingly popular concierge medicine (patientspaying the primary care physician a lump sum annually forthe privilege of being cared for). Similarly, it is conceivable thata two-tier health care system may emerge as the result of the ACA.Specifically, patients who do not want to “wait in line” and canafford to do so could and should take some of the responsibility fordefraying the increased cost of their preferentially serviced care.Such service-oriented class difference is not without precedent in anotherwise egalitarian society (airlines, first and coach class, butsame pilot and safety). At the same time, if enacted, the vouchersystem (6) itself could also become conducive to a two-tier healthcare. The reason behind this possibility is that the vouchers alonemay be inadequate for the purchase of meaningful and superior-to-Medicare coverage. Consequently, seniors with lesser means andweightier medical history that may preclude them from obtaininghealth coverage on the free market to begin with may be, bynecessity, compelled to seek health coverage under the Medicareprogram. It is essential, however, that physicians and health careinstitutions recognize the imperative that preferentially servicedcaremust not become synonymouswith better care or greater safety.

CONCLUSIONS

Whatever plan is finally arrived at, it will be a daunting task,requiring extraordinary leadership, to gradually change the attitudeof purpose by consumers (patients), who will be asked to recognizethe economic limitations of the health care delivery system unlessthey agree to participate with personal resources in defraying thecost of their health care; by institutions providing health care, whichwill be asked to share rather than duplicate certain resources; and by

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physicians, who should be encouraged to resist practicing defensivemedicine, a quest that must be coupled with lawmakers enactinga meaningful reform of the medicolegal system. Such sweepingchanges in attitude can only be successful if implemented nation-wide. Isolated, such efforts would be counterproductive, as those

WORLD NEUROSURGERY 80 [6]: 691-698, DECEMBER 2013

willing to implement themwould be swept away by thosewho preferthe status quo. Clearly, each participant in this noble task of healthcare delivery should and must be willing to relinquish some of thepresent self-oriented gestalt, so that the United States can remainboth healthy and fiscally sound.

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Received 17 August 2012; accepted 22 October 2012

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