I have been paying attention to the national political scene for the last several weeks as you might imagine. I watched the last debate and, though it was entertaining, I was left with the odd feeling that the President of the United States probably is given too much credit for the price of gasoline. Health care, being 21% of the national budget, is something the President ought to try to get a handle on. Federal and state government, accounting for 40% of the total health care dollars spent, ought to demand value and accountability for its money. The Affordable Care Act attempts to do just that. As it is one of the signature (and most controversial) pieces of legislation enacted by this administration, it was odd that it was only mentioned indirectly during the debate:

The issue first arose, in fact, from a question about how the candidates would rectify the women’s pay inequality problem.

“You know a major difference in this campaign is that Governor Romney feels comfortable having politicians in Washington decide the healthcare choices that women are making,” Obama said. “I think that’s a mistake. In my healthcare bill, I said insurance companies need to provide contraceptive coverage to everybody who is insured. Because this is not just a health issue, it’s an economic issue for women.”

Obama continued that “Governor Romney not only opposed it, he suggested that in fact employers should be able to make the decision as to whether or not a woman gets contraception through her insurance coverage.”

Continuing his attack on the broader matter of healthcare, Obama said that when Republicans wanted to repeal Obamacare, Romney indicated it was the first thing he would do, “Despite the fact that it’s the same healthcare plan that he passed in Massachusetts and is working well.”

Governor Romney countered when asked to compare and contrast himself to George W Bush:

“The thing I find the most troubling about Obamacare – well, it’s a long list, but one of the things I find most troubling is that when you go out and talk to small businesses and ask them what they think about it, they tell you it keeps them from hiring more people,” Romney said. “My priority is jobs. I know how to make that happen.”

As the law closely resembles the Massachusetts health care law enacted while a Republican Governor (Mitt Romney) was in office, is based on principals first put forth by the conservative Heritage Foundation, and incorporates many elements related to consumer choice, I am convinced it is as close to universal coverage as we will get in my practice lifetime. I am also convinced, like the President, that reliable access to healthcare is more than just emergency treatment but must include access for preventive and chronic illness care. I am disappointed that none of the eighty-two undecided voters at the second debate wanted to make it an issue.

As we now have a law, should I be worried about the election? In a discussion orchestrated by the Kaiser Foundation between Tom Daschle (taking the Democratic side) and Avik Roy (taking the Republican side), Daschle pointed out how the act could be undone with a change in President and 50 Republicans in the Senate:

I would say that the bulk of it can be dismantled.  If a president is determined to do it, he can do three things.  First of all, he can pass legislation.  As you say, he can use reconciliation for certain amounts affecting the budget of the federal government.  And that’s calculated to be somewhere in the 40 to 60 percent range, depending on how parliamentarians ultimately rule on some of these budgetary questions.  So that’s number one.  Number two: through rule making.  He can really do a lot to change the course of the legislation because – especially with the Affordable Care Act – the secretary and the president were given wide latitude.  And third, he can defund it.  He can just simply not dedicate resources within the budget.  That will be his prerogative as he sets his own budget.  So he could have a profound effect on the outcome of the ACA in a very short period of time.

Should the election bring a change in the Senate and Presidency, would we restart the conversation under a President Romney? Or once again would the Emergency Department represent sufficient access for poor people before they succumb to death inconveniently in their apartment?