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Obamacare: The Losers

In last week’s Health Tip we reviewed the groups that have done remarkably well with the passage of the Affordable Care Act (ACA), also called Obamacare. Unfortunately, three of the four big winners are industries enjoying record profits as a result of the new law–the health insurance industry, hospitals (and the physician practices they now control), and Big Pharma.

In terms of the actual patients the ACA is meant to serve, the two winning groups are people who’d been denied health insurance in the past because of a pre-existing medical condition and people living at poverty level or below who are lucky enough to live in a state that accepts federal funding to offset insurance premium costs.  Sadly, other people at poverty level are definite losers. There are still four million Americans with annual incomes below $11,000 who are denied access to health insurance because of ideologue governors.

But others are also unhappy with the ACA, and their reasons are perfectly understandable. They’re paying much more money for much less insurance coverage than they previously had.

Loser #1: Self-Employed Healthy People
The biggest losers are self-employed healthy people making too much money ($60,000 and over) to qualify for any government subsidy or tax credit. This group is compelled to purchase coverage they don’t want or need. Pre-Obamacare, they may have had an inexpensive policy that worked for them, but when the ACA passed they received a notice from their insurer announcing that the policy had been cancelled and they had to buy a new one. This group then discovered a landscape of higher premiums, fewer physician choices, and deductibles so high that except for health catastrophes they’d be paying out of pocket for most of their regular healthcare needs.

It’s not uncommon to hear the woes of a healthy self-employed 40-something paying $5,000 a year for health insurance coverage that has a $2,000 deductible. In the past, she may never have spent more than $500 a year on health care (annual physical, Pap test, mammogram). Now that all three are included as a “benefit,” however, but a benefit with a $2,000 deductible, she essentially has no insurance until she develops a serious condition.

“I’d rather pay for my annual physical and Pap smear with my own money and be able to apply the costs to a more reasonable $500 deductible.” I agree 100%.  Perfectly reasonable except for one sticking point: the insurance industry’s profits would drop if she were allowed to do this.

Loser #2: Job-Related Health Insurance Holders
Another group likely to experience ACA unhappiness are those who get some health insurance benefits via their jobs. As health insurance premiums rise, many large companies are simply shifting a greater proportion of healthcare costs onto their employees in the form of higher payroll deductions, higher co-pays, and higher deductibles.

Loser #3: Physicians
Physicians themselves make up the third group that expresses a lot of unhappiness with the ACA. Doctors are finding themselves faced with mind-boggling administrative bureaucracy. The Harvard Business Review pointed out that the real growth in health care hiring and training has been in medical administration rather than physicians. The ratio is currently pegged at ten administrators for every physician.

Further, with most medical practices currently using electronic medical records (EMRs), insurance companies can monitor a physician’s “performance.” This monitoring is based not on patient satisfaction, but on the thoroughness of the doctor’s ability to enter data into the EMR. (One reviewer told me I hadn’t been entering “height of patient” often enough.)

Depending on compliance with the EMR system, doctors can be financially punished or rewarded. The ACA term for a doctor’s commitment to cooperate is “meaningful use” under the terms of the Meaningful Use Incentive Program (MUIP). It’s a little hard to explain except by offering a single example (out of thousands).

Let’s say your doctor’s EMR spots that your cholesterol is a bit high. Your physician receives a notification from your insurer about it, followed by a suggestion entitled (unbelievably!) a “medication opportunity” to prescribe a generic (definitely a cheap generic) statin drug. When your next cholesterol test result comes back in the normal range, you and your doctor have achieved “meaningful use” from the electronic medical record system.

Your doctor herself will receive a small financial uptick for her cooperation. She’s using the EMRs in a “meaningful” way. Some physicians tell their insurers to take this idea and shove it.

In my view, not enough physicians are opting out of this insanity. Instead, one of two paths is usually taken:

  • Your doctor cooperates 100%, enters all data, and follows all recommendations. She’s rewarded with a modest rise in income.
  • Exhausted by endless data entry, your doc simply throws in the towel, sells her practice to a hospital system, and becomes a salaried employee who must follow all the rules of their game. She’s joined an entity called an accountable care organization (ACO). It’s “accountable” in that all the doctors in the group practice “meaningful use” medicine using the group’s EMRs.

The doc is told what to do on all fronts: what specialists she can refer to, what tests or medications she can or cannot order, and what hospital she can admit her patients to (the one that owns the practice, naturally). The administrator can decide whether or not your doctor is a “team player” and if not, may ask her to leave the group. In the process of selling her practice to join the ACO, however, she’s signed a non-compete agreement. This means that when she leaves the group, she has to leave the region and practice elsewhere. If you’ve been seeing at doctor at one of the larger systems like Northwestern and suddenly she’s gone without a trace, she’s not wearing cement boots. She’s moved elsewhere and Northwestern punishes her by not providing any forwarding address.

Personally, I can’t decide if all this is more reminiscent of George Orwell, Franz Kafka, or Monty Python.

WholeHealth Chicago’s experience
Here at WholeHealth Chicago, we’ve seen three trends in the wake of the ACA. We don’t like it that the serious winners are hospitals, health insurance companies, and Big Pharma. We do believe everyone should have access to the health care they choose. For ourselves, we’re neither winners nor losers, as follows:

  • We’re happy to be seeing a lot of new patients who previously postponed making appointments because they didn’t have health insurance (“My insurance card arrived and the first thing I did was make an appointment at WholeHealth Chicago.”  Believe me, that’s nice to hear!).
  • However, we’re also seeing patients unhappy that their insurance covers less than they thought it would. This is a system-wide phenomenon and not limited to WHC. It’s occurring because deductibles are higher than ever.
  • Because of these high deductibles, a common patient complaint is that we’re too expensive. In fact not only are our professional fees slightly lower than average for the Chicago region, but we’ve not raised our physician fees since (ready for this?) 2000. I’d bet neither your hair salon nor your pizzeria can say that.

Be well,
David Edelberg, MD


Leave a Comment

  1. calle says:

    I knew this would happen.
    Less care, more drugs, more Big Pharma profits, Unions win. Entrepreneurs lose big time.
    Welcome to Russia.
    Soon young people will choose other fields.
    Why be a factory doc when there are Ins companies to work for.
    This isn’t good care, but a dictatorship.

  2. Joe says:

    Hi David,
    This was a very interesting read. I’m glad I came across it. Would you have any advice for a young professional (HR) trying to break into the healthcare industry? Like yourself, I too have been disappointed with healthcare companies more driven by profits than making people well again. Would you have any advice on what organizations to look for, for someone looking to make a difference? Non-profits? Thanks!

  3. John says:

    I know I have a good doctor when he not only finds something positive in such a wretched system but actually puts the positive points first in his analysis. I see an analogy with patient treatment.

  4. calle says:

    I remember the days when only big things were covered, like we deal with on car and house ins.
    Now everyone thinks we need a hang nail removal paid for by ins.
    The ins and Big Pharma decide our healthcare.
    Our family uses very little haealthcare.
    Today the laws dictate it all so we spend our money on good food, natural herbals and self care.
    I do not trust the system with my records or care.
    We pay way over $6,000 for something we do not use.
    Only if we needed the ER would we use it.
    Our trust in doctors who only know how to use an RX pad is gone.
    They have messed up our guts, and do not use the brain they were given.
    Those that do think off the beaten path can fear for their lives.
    Learning to take care of your own body as our pioneers did is a skill we all need.
    We over vaccinate our pets, and over medicate our kids.
    Today I learned that Oyxcontin can be given to children as young as age 11.
    My mom was on that and it is dangerous!
    Where are the brave who will stand up to this system?
    Our congress won’t as they all get money in some way shape or form from this new cash cow for themselves.
    I read of late how it has worked in their favor.

  5. John says:

    That’s what we get for letting the insurance industry largely write the ACA, and not really including any patient (or doctor) input. It seems like overall that ACA has helped some people and also created a system that isn’t sustainable. More change is ahead. We can only hope we do it more intelligently next time.

  6. Beth says:

    In 1990 when I was forty, I was paying 500 per month and had a large deductible (self-employed), and this was during the era when “over-testing” was considered bad. Perhaps this phenomenon has increased but it’s not new to the self-employed. I couldn’t get needed tests, so I finally paid out of pocket and received a diagnosis, with advanced symptoms. Not good at all. I’m sorry this is still going on. In France, where health care is the highest rated, private insurance companies are the source of coverage, but they are highly regulated by the govt, as are drug prices.

  7. Mary says:

    It appears as if we are worse off than before this law was passed. It doesn’t seem to benefit anyone as a patient. What was the point of this law but to make medicine into even more of a bureaucracy and more expensive for just about everyone. I would appreciate at this point the government staying out of my health care.

  8. Toni says:

    Please tell me the next president can change this law (I think I’ll be moving to France soon)

  9. Don says:

    The ACA is a noble but flawed attempt to fix a terribly broken health care system. The solution lies in eliminating the insurance industry all together and take a close look at how other industrialized nations are able to deliver first class medical care with better results at half the per capita costs for ALL their citizens.

  10. calle says:

    Many medical people know how to run their own practice.
    Return it to no inflated prices.
    HSA’s allow you to spend your health care dollars the way you choose.

  11. Dr E says:

    Hi Don
    I am in agreement with you 100%

  12. Michael says:

    Thanks for this commentary on the new ACA system. I was just ranting to my wife about all of this, almost echoing what is stated in this piece. With so many patients and healthcare professionals negatively affected by this change, there has to be a way to band together and take steps to make the changes necessary to make the program better for everyone. One way is to get rid of the lobbyists that have directed the gain solely to the health insurers and drug manufacturers. If Americans didn’t see this coming from the onset, they were just fooling themselves or taking sides based on political ideology. It is maddening!!!! The politicians running this country, for the most part, are all bought by these lobbyists. I just dropped BCBSIL because they were quoting me a family premium of just under $30k/year. Fortunately I have taken a new job that offers comparable coverage, but still will cost me over $12k/year. This is unsustainable for the average American family!! Something has to change.

  13. Sue says:

    Hard to understand why I had to pay “the medical device tax’ on my handicap van!

  14. Terry says:

    As a self employed individual for 15 years, I know that things haven’t changed much with ACA. I still have the same premium and high deductible. The insurance companies deciding how much the doctors and hospitals can charge for services and what tests they will cover – nothing new there. They were always the winners on that. More paperwork for providers leads me to believe that is part of the measure to stop fraudulent Medicare and Medicaid billing, which was a major suck on the government. So now some medical “professionals” refuse those patients. The thing that is downplayed by Dr. E. is that ACA has made it possible for millions of people with pre-existing conditions to be able to shop for insurance and not be tied to a terrible job because of its insurance benefits. I was one of those people, back when I was corporate and that rider not covering my condition, for which I needed insurance, could have bankrupted me. Remember all the people bankrupted because they got sick? That doesn’t happen anymore, right? And my friend who has had cancer for the past ten years, her treatments (outrageously priced to support the big business of cancer), are all covered. While I agree ACA isn’t the best answer because congress stripped it of its best parts, it is a step in the right direction.

  15. Eric says:

    Be careful what you wish for Don – the Veterans Administration is an example of a government run health care system and I doubt anyone thinks its provides quality care or cost efficiency.

    • Don says:

      I made no such socialistic
      recommendation. Like most civilized health care systems around the world that rely upon privately run providers, I propose a single payer system like Medicare for all.

  16. Doc,
    i have been a loud vocal defender of this president and am troubled by this turn of events. it is hard for me to believe he or his people saw this coming. is this a result of congress/lobbyists mukking up the care act or is this on the Pres?
    at any rate thank heavens for medicare.

  17. Mary says:

    I have friends that live in Arkansas. They were on public assistance before Obamacare. The State of Arkansas did not participate in the exchanges. They decided to simply buy BlueCross BlueShield for the poor in Arkansas. My friends said they never had it so good. They claim it was cheaper for the State to simply buy them insurance instead of participating in Obamacare.
    As for my husband and me, it’s jacked-up our insurance costs, and diminished our coverage. I work at a nursing home on the south side of Chicago. There are women who are the sole-bread winners for their families. They say they can’t afford Obamacare and are for the first time without insurance. Some of them have expressed concern of what they ae going to do when the fines are increased (I can’t remember the schedule or the amounts but it’s supposed to sky-rocket). The working poor are really getting stiffed by this administration.

  18. calle says:

    It is not health care, it is sickcare.
    If they were really smart they would pay for “wellcare”!

  19. Joanne says:

    The origin of Meaningful Use (aka MU or, officially, CMS’s EHR Incentive Program) is not “ObamaCare” (the Patient Protection and Affordable Care Act (ACA) signed in 2010, the stated purpose of which was to provide American access to affordable health insurance. Rather, “MU” was the result of the HITECH Act, a part of the American Recovery and Reinvestment ACT (ARRA)signed in 2009. The purpose of the ARRA was to stimulate the economy during the recession and the HITECH Act focus was to encourage national adoption of electronic health records that would allow sharing of information with patients (patient engagement) and with other providers (improved healthcare coordination and patient safety). The “MU” Program itself only calls for (a) incentives to providers billing to Medicare and/or Medicaid and (b) possible penalties for providers billing to Medicare. Providers who bill to neither Medicare nor Medicaid are not included in the ”MU” Program. That being said, other insurers or non-government parties may choose to ask their preferred providers to meet some or all of the standards, but that is not part of the “MU” Program itself. This posting is made as a point of correct attribution; I am not commenting on the merits / demerits of either ARA or HIGHTECH Act. Best regards, Joanne

  20. Dr E says:

    Hi Joanne
    Thanks for the correction
    Dr E

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