Editorial: U.S. health reform in the context of entelechy

Abstract

ARTHUR W. SCHLESINGER, JR., who served as "court historian" and Special Assistant to President John F. Kennedy, was asked not long after the chief executive was assassinated on November 22, 1963 to assess the Administration's impact. He responded by indicating that a quasi-categorical demurral best characterized the situation, by which he meant it still was much too early to be able to provide a full assessment of the achievements of the Kennedy presidency. Currently, self-appointed pundits on both sides of the political divide do not lack opinions on the value or lack thereof of the Patient Protection and Affordability Act (ACA), which became the law of the land on March 23, 2010. Yet, to invoke Schlesinger's point of view, it remains somewhat premature to issue a fully informed judgment on the value of this legislation because many of its main provisions have not been fully implemented as of mid-summer 2013. A useful term that underlies this essay is entelechy, which in one sense of the word means that there always are new forms of knowledge destined to emerge, but which despite that inevitability, observers of the health scene may be taken utterly by surprise. A good example is that an announcement on July 2, 2013 from the Department of Health and Human Services (HHS) indicated that the implementation date of a mandate aimed at companies with 50 or more full-time workers (i.e., employed 30 or more hours per week) to provide health insurance coverage would be postponed from January 1, 2014 to the beginning of the following year. One consequence is that there will be $12 billion in lost tax revenue and additional costs, according to the Congressional Budget Office [1]. The result of this decision was akin to tossing a banana to starving denizens of a zoo monkey cage. Opponents of the law, primarily Republicans, scrambled to seize on the announcement to proclaim that it provided just one more justification for scuttling an unworkable law. Accompanying this assertion was a demand that the imposition of the individual mandate, another key component of the ACA, also be deferred until 2015. Despite President Obama's veto threats, House lawmakers on July 17 approved two separate bills amending portions of the Affordable Care Act, the latest moves by Republicans to repeal the health law. A measure was approved 264 to 161, with 35 Democrats in favor, to codify President Obama's decision to suspend the employer mandate. A second bill was passed 251 to 174, with 22 Democrats joining the majority, to delay the individual mandate to purchase insurance for the same 1-year period. Both efforts are consistent with approximately 40 different attempts since the law was enacted to repeal it either in whole or in part. Meanwhile, Senator Mark Begich (D-AK) introduced S. 1330 on July 18 to delay the implementation of the employer mandate until 2016. Congress already has been instrumental in (1) achieving a repeal of the Form 1099 mandate that would require companies to track and report to the Internal Revenue Service all business-to-business transactions over $600, and (2) terminating the Community Living Assistance Services and Supports Act (CLASS), a long-term care insurance provision. Also, in March 2013, 79 Senators voted to repeal the 2.3% tax on medical-device company revenues that is in effect as of January of this year. © 2013, Baywood Publishing Co., Inc.