On "ObamaCare"

With the Affordable Care Act ("ObamaCare", as it is also referred to in the news media) back in the news cycle, I have been asked several times a day what I think of it, or how it is affecting me.

So far, I have no sort of problem with it.

• It has improved "doughnut hole" coverage for MediCare patients with Part D plans (medication coverage).  This has been good because I have a lot of MediCare patients and accept new MediCare patients. They are all on fixed incomes, and this has helped to ease the burden of their medication costs.
• It has allowed 18 year olds to stay on their parents' insurance until 26 years old, whether they are in college or employed or not.  This has been very helpful, since the job market out there for people in this age range is very poor.  I can now see these patients in my office, as opposed to them hitting the ER in crisis mode, which is more dire and more expensive to everyone.
• The SCOTUS has ruled in favor of the requirement for all citizens to carry health insurance.  Whether you wish to regard this as a mandate or a tax is irrelevant.  Simple math demonstrates that insurance systems that allow people to opt out will fail.  This is apolitical and simply due to human behavior.  In a system where people can opt out of health insurance, the ones who will carry it are predominantly people with existing conditions (which are expensive).  People without health conditions often opt out.  When they become ill or need care, the cost of their care is then assumed by the taxpayers. In the mean time, the insurance companies have to levy higher premiums because of the disproportionately high percentage of people they cover who are expensive to cover.  This makes relatively healthy people disinclined to carry insurance because of its cost.  And so on, and so on...
• Yes, this assumes that uninsured people needing medical care will nevertheless receive medical care.  That is going to remain the case unless we all accept the idea that doctors and paramedics and nurses are not morally or ethically (let alone legally) required to render care.  Aside from the fact that this would be contrary to the Hippocratic Oath, we should not really want medical professionals to be able to refuse care on the basis of risk that it will not be profitable!
• I received $600 in reimbursement for this year as a small business owner who has provided medical insurance to my employees.  I imagine other small business owners who insure their employees are OK with this, too.  I'm comfortable with this.  Now, if I can also get reimbursement because I also offer dental coverage and retirement...
• I can't see that requiring states to create single websites that make it easy for consumers to comparison shop for health insurance is any problem.  Sounds like Google Shopper or Amazon to me, and insurance companies certainly aren't making it easy to compare coverages and prices on their own.  Hopefully, this will eventually work into a way for individuals and small businesses to combine into larger shared insurance pools, since the premium costs would be much lower.
• Requiring insurances to provide birth control?  Can't see why that's even controversial: undesired pregnancy is expensive to everyone, and there is no requirement of women to take any form of birth control here.
• Insurance companies can no longer refuse to insure you because of already existing medical conditions or pregnancy, and they can no longer look for ways to drop you if you develop a medical condition.  Can't say I see any problem here either, since these behaviors have been scandalous and, in the latter case, illegal and unethical.
• Insurance companies must spend a certain proportion of their expenses on actual medical care.  That would be nice; it's what they're supposed to be doing. Perhaps it will incentivize them to make administration more efficient.  Right now, over 30% of US medical costs are administration and paperwork.

As stated in earlier postings, I welcome any attempt to improve the delivery of medical care in our country which until now is the 47th best in the world, while outspending the top 10 by 300% per capita and committing the most medical errors of the top 19 world economies.  Frankly, I would have preferred an approach like Germany which has a cradle-to-grave basic entitlement insurance and a very active, competitive and strongly regulated commercial insurance industry where anyone can buy as much (or as little) additional health insurance as they wish.

The only things missing or under-utilized in the Affordable Care Act are critical elements that are present in objectively and measurably better healthcare systems; federal regulation of insurance companies, and government-sponsored medical treatment and device testing.  These were discussed, but went largely off the table due to cries of "big government" and "socialism".

I think Germany's approach is sound here: the German government does not permit insurance companies to raise annual premiums by more than 5-6%/year unless they can prove that the increase is warranted due to actuarial costs.  This keeps them from simply increasing premiums for pure profit motives. The lack of this regulatory oversight in the US could result in insurance companies increasing their premiums to defray the costs of changes required by the ACA.

Clearly, it is not good to have a medical research system as we do in the US in which the majority of medical research is funded by drug companies.  It is certainly known that drug companies only fund applied studies that might be to their benefit, and do not publish studies that result in unfavorable findings.  Nor would one expect a publicly traded for-profit corporation to do otherwise. I do not object to drug company sponsored research, but I think it is the role of federal government to fund or perform academic research, and also studies of head-to-head comparisons of different drugs or treatments and to make the findings widely known to doctors and patients.  It is telling that one of the largest US insurance companies (United) routinely sends its doctors such study findings based on UK research and not US research for exactly this reason.

At the individual level, the Obama administration's concerns for primary care doctors and especially rural ones has resulted in a satisfying increase in MediCare payments which I think is only right since rural primary care doctors have been historically the most lowly paid of all doctors in the US.

Have a great weekend!