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LeonardZwellingLeonard Zwelling, M.D. is a medical oncologist and molecular pharmacologist. He writes and speaks frequently about health care reform.

During my residency in Washington, D.C., I served as a Robert Wood Johnson Foundation health policy fellow and had the opportunity to be a staff member of the U.S. Senate Committee on Health, Education, Labor, and Pensions during the initial phases of the health care reform debate. Long after I left the Hill, the Affordable Care Act (ACA) was passed and signed by the president. Now its many complex tenets are being implemented throughout the country.

We were taught early in the orientation period for the fellowship that Congress’ main job was to prevent the passing of bad legislation. Republicans and Democrats strongly disagreed on the effectiveness of the bill. Whether or not the ACA could lower health care costs or improve its quality was not really addressed, though—this was not a bill about health care. It was a bill about how to pay for health insurance, primarily for the 15% of the population who had no coverage.

The bill’s final form was driven by a simple principle elucidated to me in November of 2008 by the American Enterprise Institute’s Norman Ornstein when he said:

“Everyone’s idea of health care reform is the same. I pay less!”

Health care reform legislation was never about health care. It is about money and how the major players in the health care industrial complex—insurers, pharma, hospitals, and providers—divided up the profits from the health care industry.

Why did the insurance industry like the bill? Why not, if it passed it would have gained them a predicted 30 to 32 million new customers.

Why did pharma and biotech back the bill? In that part of the Medicare Part D coverage known as the donut hole, where beneficiaries must cover their own drug costs, generics rule. After the ACA is fully in effect, this hole of non-reimbursement shrinks for both the brand name and the generic drugs functionally closing the donut hole but also functionally increasing the business for the brand name drugs for these previously generic-favoring patients. This opened previously closed markets to the brand name drug makers.

For now, it appears that hospitals will not be worse off .. This will be particularly true in states where people who used to be without insurance and cared for by major centers will now have some coverage with Medicaid expansion. This will work only if these patients do not crowd out the full paying or well-insured.

The providers didn’t do so well. The recurrent passage of sustainable growth rate (SGR) legislation appears to be with us. The SGR is not fixed. The mandate of using electronic medical records did cost practices some money, and it is as yet unclear whether they will save any money other than to avoid errors, which is in and of itself a good thing. On the whole, the doctors made out the worst, probably because rather than presenting a uniform lobbying front to the members of Congress, they ascended Capitol Hill in phalanxes of like-minded specialists competing with their colleagues for some sort of financial advantage such as additional Medicare coverage for whatever they do. Where insurers, pharma, biotech, and hospitals tended to speak with discipline and uniform voices, the doctors did not.

It as yet remains to be seen if the ACA will be good or bad for American medicine. It was never going to be more than an intermediate step to identifying and adopting a truly American health care system so that we need not stand as the only Westernized democracy without a guarantee of some minimal universal coverage for all of our citizens. The resistance to the ACA makes any additional bills, including much better ones, very unlikely to see the light of day. Not having a national discussion about whether or not access to affordable, quality health care is an American right like access to the police and fire departments is impeding our progress as a nation by driving up the price of our goods without benefitting our people.

Congress might consider trying again, but this time focus on health care, not money.