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My Opinion on Obamacare

I have been getting a lot of questions recently from patients about how I feel about Obamacare. My position on the Patient Protection and Affordable Care Act (PPACA), as ‘Obamacare’ is formally called, does not come from a political point of view. Rather, it developed pragmatically by my work as a physician in private practice and formerly in emergency departments; and also in my work in an academic practice as a clinical instructor.   I have been involved in a small way in the politics of the legislative process on the local, county and state levels. I also work with hospital CEOs, and CEO’s and medical directors of insurance companies.  All of these experiences have contributed to my perspective.

In my opinion, here is the central reason that PPACA is needed: we are already providing medical care for people who do not have insurance.  Back in 1986 the federal government passed a law called EMTALA. In the law hospitals and physicians were mandated to see patients and provide medical care (at least to get them stable) WITHOUT REGARD FOR the patients ability to pay.  One could also argue the morality of denying healthcare because of inability to pay. You can read more about EMTALA here.

Quite simply, if you have a heart attack or a stroke and you get to the hospital, you will get all the care you need, without regard for your ability to pay.

The hospitals that provide care for patients that cannot pay get tax breaks (in the form of lower property taxes); and they get counties to pay directly for some of the cost. That money that the county uses comes from the taxes we pay. The hospitals pass on the costs of patients who cannot pay, to those who can pay – the insurance companies – in the form of higher prices. In turn the insurance companies pass those costs to consumers in the form of higher premiums.

So we are already providing, and paying for, the care.  We are paying for that care in the form of higher prices for the consumer, tax breaks to the hospitals and higher taxes for the rest of us.

In part, that is why the American Medical Association (AMA), the American Hospital Association (AHA) and the pharmaceutical companies lobbying group (PhARMA) all support ACA.

The biggest challenge I have faced in practice – by a long shot – are uninsured patients. It is very difficult for patients to get preventive care and medications without health insurance. And many of my patients cannot afford even basic policies. As PPACA is implemented, out-of-pocket expenses for health insurance will decrease (this is according to most non-partisan studies and the Congressional Budget Office).

Another headache is Medicare patients who experience the ‘donut hole’. That is a gap in coverage for drugs after Medicare pays a certain amount. Some Medicare patients hoard meds, take ½ doses, or come to see me halfway through the year to readjust their medication plan. This, of course, leads to medical problems.

Those are my concerns, here are some of the other concerns I hear from patients:

You are allowing the government to take your freedom.  Please. The state government already mandates that I have car insurance.  It also tells me that I need to have Workers’ Compensation insurance. And you know what? Those are both good and important things to require. I suspect that many businesses would forgo them if not required. And yes those are state government laws.  And yes, I am not required to drive nor own a business.  I would certainly prefer that this was done at State levels. But it did not happen that way. The stage was set for federal involvement in health care reform after passage of EMTALA.

Everybody hates it, nobody wants it.  When I ask my patients about individual parts of PPACA they are always surprised at the actual provisions of the bill, and generally think they are good ideas. Do you think insurance companies should cover preexisting conditions?  Should you be able to keep your kids on your policy longer? Should insurance companies be able to drop your coverage when you are sick? Should we get rid of the donut hole? Should we make insurance companies more accountable? In the end the AMA, AHA, PhRARMA all support it; and polls show more Americans feel the law should implemented rather than repealed.

What about the costs. As I said we are already paying for the healthcare. The Congressional Budget Office has projected a cost SAVINGS for both the overall budget and for individual out-of-pocket expenses after PPACA is fully implemented.

Aren’t you afraid that the government will be making medical decisions for you? What about ‘Death Panels’. No. There is nothing in the PPACA that allows the government to make individual medical decisions, or to start ‘death panels’. In fact there is specific language in the law (Section 3403) stating that the law cannot make healthcare recommendations. There IS a panel and it is tasked with finding and recommending ways for the Medicare SYSTEM to save money (that’s how the death panel myth got started).  Doctors do not like to be told what to do – even by other docs, much less the government. Do you really think the AMA would support this law if it allowed the government to start making medical decisions? Despite dwindling enrollment AMA still wields significant political power, and is still looking out for doctors’ and patients’ best interests. Again, the AMA supports the PPACA.

Nobody knows what is in the law. This is simply a lie I hear on broadcast news.  Again, I have been somewhat involved in the legislative process. Everybody with any interest in this has had staffers pore the entire bill. Do you really believe the AMA, the AHA and PhARMA would support a bill that they did not read? You can read it yourself HERE.

If this is so great why are my premiums going up?  Yes my premiums are going up too (and ironically my salary as a physician has actually been going the other direction).  My premiums have gone up every year. One of the reasons the rates are going up more now is that some costly provisions of PPACA are coming into effect before the personal mandate. Insurance companies are covering more right now, before they are able to adequately spread the risk over a larger pool of insured lives.

Congress and the Senate and the President are exempt! That’s not fair. Yeah, well it is not true either. You are ‘exempt’ as well if you have employer sponsored health insurance. Click here for more information. 

Politics has been described as the art of the possible. PPACA is what’s possible at this time. So as a reasonably well informed physician with experience in business, academics, and politics, I am cautiously in favor of Obamacare/PPACA. Is it perfect? No. Are there things I would have done differently? Perhaps.

What do you think?


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