Lakeside Medical Musings

Obamacare–The Why Nots

My next few blogs are going to discuss the Affordable Care Act, also known as ObamaCare. I have become a much greater fan of it as I have gotten to know it better.  I recently completed a thirty-hour course that qualified me as a Navigator, and I will be using that information to assist people in signing up for health insurance for 2015. I feel like I finally have serious and significant facts – not just left- or right-wing blather – about what the ACA is and what its scope entails.

Is Affordable Healthcare a Right?

First of all, do we, as a country, believe that affordable healthcare is a right that the residents of this great nation are entitled to, according to the social contract under which we live? As a physician, I see patients whose lives have been shortened, the quality of their lives affected, or their financial well-being ruined because they did not have health insurance. As a hospitalist, I see patients who can’t afford ongoing maintenance medical care after they are discharged from the hospital, and I see many admissions — and subsequent readmissions —  to the hospital because patients can’t afford to see a primary care physician.

“Bankruptcies due to medical bills increased by nearly 50 percent in a six-year period, from 46 percent in 2001 to 62 percent in 2007, and most of those who filed for bankruptcy were middle-class, well-educated homeowners, according to a report that will be published in the August issue of The American Journal of Medicine.”

“Unless you’re a Warren Buffett or Bill Gates, you’re one illness away from financial ruin in this country,” says lead author Steffie Woolhandler, M.D., of the Harvard Medical School, in Cambridge, Mass. “If an illness is long enough and expensive enough, private insurance offers very little protection against medical bankruptcy, and that’s the major finding in our study.” Reference is here.

I don’t believe that healthcare – or medical insurance — is a right that we as Americans are necessarily born with, an inalienable right such as the right to “… life, liberty, and the pursuit of happiness,” as stated by Thomas Jefferson.  However – and this is a BIG however —  I do believe that, as the wealthiest nation in the world, we as a country have an obligation to provide quality, comprehensive healthcare to all of our citizens, and the cost of that healthcare must be affordable for all. No one in this country should have to pass on seeing a physician to treat their diabetes, hypertension, or cancer because they need to buy food for their family. That’s just wrong.

Is ObamaCare the answer or the problem? 

In 1985, President Ronald Reagan signed the COBRA law, (see my post D.O.A.) that, among other provisions, required physicians and hospitals to evaluate and stabilize all patients who present at an emergency room regardless of the patients’ ability to pay for this care.  It never made any sense to me that the government mandated that everyone, regardless of their financial ability to pay, should receive hospital care, yet there was no such mandate in place for continued coverage once a patient left the hospital in order to prevent continual re-admission! Let me make sure you understand my point by using an example. Under the law, a patient who shows up at the ED with symptoms of stroke because of uncontrolled hypertension is admitted to the hospital; he is stabilized and treated, his life saved. Then the patient is discharged from the hospital with prescriptions for medications —  that the patient cannot afford — to control the hypertension that put him into the hospital in the first place. The patient also does not have the money to see the primary care physician that the hospitalist scheduled him to see. So no medications and no follow up doctor’s visit, and the whole cycle theoretically — and often actually — starts all over again. Wow! ObamaCare is an attempt to redress this expensive, circular, systemic malfunction.  And it is a reasonable start to addressing this problem.

There are many objections to ObamaCare, a few of which I will present here and attempt to discuss.

Big Government

Many people do not believe that our government should be involved with healthcare at all. Many people believe in a strictly limited Federal government holding the primary roles of national defense, border defense, and internal security, and little to no involvement in social initiatives. This is a typical libertarian point of view of the appropriate role of government. This is not my political leaning, but I can respect this intellectual viewpoint. If this is truly your view, you must also be against both Medicare and Medicaid, for the same reasons. Are you? I find that many people who voice this exact objection to ObamaCare have no intellectual objection to saying, “Just don’t touch my Medicare benefits!” There is no real argument against a libertarian political mindset, I just don’t agree with it. I believe that the Federal government exists to provide a nationwide safety net to ALL of its citizens, regardless of how conservative individual states might be with their benefits or their rights.

Individual Mandate

Certainly the most unpopular aspect of ObamaCare is the individual mandate. The individual mandate requires almost all documented residents to have health insurance or pay a fine.  Mandates are a part of life under the US legal code:  I am required to have auto insurance to register my car; I am required to wear a helmet to ride a motorcycle; and I am required to pay income taxes every year on the money I earn.  “Live Free or Die” might make a good bumper sticker, but it is a thing of the past, like muskets and outhouses.  There are some individual freedoms that I believe must be forfeited in order to have a functioning, fair, and modern society.  Medical care is something that everyone will one day require and, whether insured or not, will receive.  Medical care is expensive, and almost no one is able to pay the bills without help from health insurance, whether private, employer-supplemented, or government-provided. Today when you go into a hospital, your bill is inflated to pay for the cost of services not paid by the uninsured — the COBRA laws mandate that this care be given. The individual mandate is a fairness issue, just like the requirement to have auto insurance.  If you are in an auto accident with someone who doesn’t have auto insurance, you will have to pay for the damages to your property, regardless of fault.  Additionally, it is not financially realistic to allow people to be uninsured until they actually develop a medical problem.  Insurance is something that protects you financially, proactively, when an untoward event happens.  Imagine if you only needed to buy auto insurance after you had a car accident? How would that work? I remember listening to talk radio one day and laughing, as I listened to an earnest young man go on and on about how the government was impeding his freedom by requiring him to wear a motorcycle helmet AND now he has to buy health insurance, too. The next caller was a woman whose son had been in a terrible motorcycle accident, not wearing a helmet, and had been in a vegetative state in a nursing home for the past four years. He, too, did not have insurance and his mother was grateful that his nursing home stay was being paid for by Medicaid, after everything the young man had was lost to pay his medical bills. I wasn’t laughing by the end of that conversation.

Do you remember that the individual mandate was actually a conservative Republican concept that was first brought forth by New Gingrich’s Heritage Foundation?

Back when HillaryCare was being discussed, the Clintons were pushing for an employer mandate and the conservatives were pushing back with an individual mandate.  I think they were right. I am not sure what changed, when it changed, or why they don’t feel this way now, but Republicans today, as much as can be generalized, believe the individual mandate is the root of all evil regarding the ACA.

Obamacare is Just Too Expensive

The reasoning goes that we, as a country, just can’t afford ObamaCare.  This actually is absolutely correct.  We cannot afford for everyone to have health insurance in today’s medical economic environment. We also can’t afford the healthcare system that we have had for generations, pre-ObamaCare. Healthcare inflation and insurance premium inflation have been out of control since long before the advent of ObamaCare.  Here is a chart illustrating the rate of increase in insurance premiums for each year between 2000 and 2011.  As you can see, the rate decreased in the years that the US economy faltered, as did the rate of growth of healthcare consumption, but as the economy improved, medical inflation accelerated.  ObamaCare will add an increased cost of medical insurance for some — and a decrease for many others — but most of the medical inflation going forward will be the result of the increased cost of medical care, entirely independent of ObamaCare.  Look at the significant increases in medical insurance costs in the chart below.  These are unsustainable numbers, and remember that there was no ObamaCare at all during this period.

We must make some fundamental changes in our healthcare system independent of ObamaCare.  Let’s not make ObamaCare the villain when, in fact, it is not the real problem.

Government is Incompetent to Run Insurance

Another argument states that the government cannot run something this big.  Irrelevant!  There is no such thing as an ObamaCare policy; you cannot go to your insurance agency and purchase an ObamaCare policy. These are policies offered by companies, such as Blue Cross, Aetna, Cigna, United HealthCare, and many others, not the government, that now must comply with certain ObamaCare requirements. There is no new government program except a state-optional expansion of existing Medicaid enrollment.  In the past, individual state governments have been responsible for setting rules, regulations, and criteria for all the insurance sold in your state.  Now these rules, regulations and criteria for health insurance are being set – and monitored — at the Federal level.  This should make it much easier for insurance companies to abide by rules and regulations as they will all be the same in all states.

The Rollout of ObamaCare Was/Is A Disaster

And that is being nice about it.  It was a good three months after the exchanges were set up before they worked fairly reliably and, with time, they will continue to improve.  There is still a lot more improvement needed in the software, but I fully agree that for a signature piece of legislation that the Obama administration hoped to leave as its main legacy, it was an inexcusably rocky start, certainly.  But I maintain that terrible implementation is a short term problem and not a reason to condemn and reject an entire program.

Significantly Reduced Access to Physicians

As more and more people have health insurance, there will be a marked increase in demand for medical care, and the country will require more and more physicians to keep up with the increased access.  There are many reasons for the shortage of primary care physicians, in particular, in the United States: geographic misdistribution; oversupply of specialists relative to primary care physicians; and underutilization of Advanced Care Practitioners (nurse practitioners and physician assistants) to name a few. But when people tell me that they fear access to physicians will become worse with more insured patients, what they are really saying is, “Immediate access for ME will become more difficult.”  Patients who do not have insurance now have very limited access to physicians. This is a problem that does need to be addressed, but again, this is a problem independent of ObamaCare.

The Benefits are Too Rich

This complaint says that the plans, as offered by insurers, have benefit levels that are too rich, making ObamaCare more expensive than it needs to be. I would agree that there could be benefit changes made to the packages guaranteed by ObamaCare, but I maintain that this is a detail, not a structural problem with ObamaCare.  If the country wasn’t trying to operate under such a dysfunctional Congress, we could make the adjustments that need to be made. We could fix the baby without throwing it out with the bath water! Republicans just want to vote to repeal the law, and Democrats don’t want to admit that there is anything in the law that needs to be changed.  There is more than enough blame to go around, and there are plenty of improvements that need to be made.  Hello, Congress? Pay attention to your constituents! Get it together and do your job! Debate, argue, defend, parry – but at the end of the day, COMPROMISE and come up with some solutions that are not so fundamentalist in nature that only the hard-wingers on both sides are heard.

There Will Be Burdensome Tax Increases Due to Obamacare

There are numerous tax increases that were put in effect to pay for expanded Medicaid coverage and health insurance premium support for lower income purchasers.  In my belief system as a physician and an ethical member of the human race, I believe that consistent preventative medical care as well as quality affordable critical care, resulting in improved health for all our residents, is a valid use of tax dollars.  A dysfunctional political system keeps us from tweaking the actual taxes to pay for this program.

I believe I have covered many of the most often repeated objections to ObamaCare. I contend that the biggest objection I hear – and in no way can counter — is that it is considered to be ObamaCare — not the Affordable Care Act.  Polling shows that how a person feels about Barack Obama personally is the strongest factor coloring their opinion about The ACA. It also clearly shows that most Americans have little idea what is actually in the law.  Poll Results.

In my next post on Obamacare, I am going to be your Navigator and explain the major aspects of ObamaCare in a back-to-basics ObamaCare Primer.  But next week I go back to Vienna, Georgia, to tell a story about an event that affected me as much as anything in my early medical career.



2 thoughts on “Obamacare–The Why Nots

  1. John Post author

    From the people I have talked to their experience with Navigators has been quite good so I guess it depends on to whom you speak. You are incorrect on your views of Cobra. They require evaluation and stabilization, which means treatment, for maternity and serious medical problems regardless of the patient’s ability to pay. I disagree that the when the government has regulations and rules that means they run the industry. They have rules about power plants and food processing plants, but they don’t run Duke Energy or Tyson Food. Medicare is not a disaster and I think is relatively well run, but certainly could be better as far as fraud and abuse is concerned. The VA is government run, but again, that is not the topic here and I don’t believe that Blue Cross is run by the government or any of the hospitals that you or I go to when we are sick. Nothing like the VA. As far as the Democrats method of putting the law in place without Republican input–that’s politics. Take a look at what laws are being passed in North Carolina where the legislature and governor are Republicans. That is what happens when you control all houses of government. I think the Bush tax cuts were initially put in a similar manner. I do want universal health care. Obamacare gets us closer to this, but not there yet. If you think the states will run things better take a look at Medicaid which is state run. Medicaid is a mess just about everywhere. All policies on the exchanges require copayments and coinsurance but they are also affordable. Obamacare is not the answer to having everyone insured, but it is a lot closer than where we were. And interestingly since Obamacare took affect, doctor visits and consumption of medical services are down from prior years. This is not because of Obamacare, but the world didn’t fall apart in January.

    I am not a libertarian and while I respect that point of view, I just don’t subscribe to it. Thanks for reading and commenting.

  2. johnadams1782

    John, I am glad you have volunteered to be a Navigator. From what I have heard from people who have dealt with Navigators in the past, the advice they were receiving was bad. You should be a bright spot on that horizon. In your first paragraph, you state that medical care is not a right and I, of course, agree with you. But our country is not an entity, we, the people are. If the populous wants universal health care – and are willing to pay for it, I am fine with that. The problem I see is that people usually want the benefits but want someone else to pay. Like the person who says favored every tax in the world, for which he didn’t have to pay. Your next point regarding COBRA is true in the example you used. But the intent f the law, as I understood it, was to be sure no one was refused emergency care before they had an opportunity to figure out how they could pay for further treatment. In other words, to save a life – not preserve it. We all agree that medical costs will continue to rise in the manner that healthcare is practiced in the U S currently. If you don’t think ACA is being run by the Government, how do you justify: individual and corporate mandates and one size fits all policies? Do you consider that VA healthcare is run by the Government? I do, and it is hand has been a mess for many years which is deplorable. I completely agree with you about that. After all Medicare was a disaster too. So much for the efficiency of the government. I feel that the shortage of doctors is and has been a problem and ACA is making it worse. My two primary care physicians have quit practicing and they are younger than you are. So far as the benefits too rich, why would a 28 year old single male have to have a policy including maternity benefits? So far as Congress compromising, I believe both parties have forgotten that word. Not to be partisan about it, but your beloved Democratic party didn’t help the situation by the sneaky, morally repugnant manner in which they got ACA passed in the first place, without input from the Republicans. How many bills have come from the House to the Senate to never be brought up? But, from the Democratic side, the Republicans are obstructionists You may note that I skipped the part about the role of Government. I am basically a Libertarian, and will vote accordingly, if a Libertarian candidate ever becomes viable. In the meanwhile, I tend to vote Republican because I feel that party does less harm than the Democrats do. To prove the point, I voted for Perot as did several of my Democratic friends. I believe the country (as a whole) would be far better off with no governmental social programs, including Social Security, Medicare, Medicaid and all other welfare programs. Back to my first point, if we want universal health care, then let’s have it. The only way to do this is to mandate it for every legal resident of the country. Now, how the heck do we pay for it? With an IVA tax on every good or service sold, (no exceptions.) Could the government handle it? Not in my opinion. So who could? Well, just about any entity would do a better job. I would opt the States run it on a reimbursement basis. To prevent excessive unnecessary us, there has to be some cost (to every [patient) for each service. The State would have to be sure that these deductibles were not being “eaten” or padded, which is prevalent with insurance claims. There must also be some coinsurance cost so that hypochondriacs will not destroy the economics of the program. Insurance companies could offer supplemental plans to be purchased similar to extra medicare coverages. As becomes apparent, ACA as presently constituted does not meet your goal of affrordable healthcare for all. In my opinion, the net result of the law without drastic change will be a nt minus in the overall quality of health care. But, then, that’s just one old non-medical man’s opinion.