family practice issues and general life events

Posts tagged ‘ACA’

Obamacare Faults

Yesterday, I made half the country mad because I actually agreed with an aspect of ObamaCare or the Affordable Care Act.  Today, I am going to try to make the other half mad, and discuss what I view as its biggest faults.  Since it is 2,200+ pages, and I have read them all (didn’t say I understood all of the legalese but I did go through it) first of all it is too big and has a lot of crap that has nothing to do with healthcare in it.  Why the hell is there anything to do with the student loan industry in a healthcare bill?  Now I understand we are dealing with Washington and this is politics as usual, but it highlights what is wrong with Washington and politics as usual.

First of all, it adds for the increase in 16,000 IRS agents.  Now when I think of compassion, I think of the IRS.  Wait no, no I don’t.  !6,000 new IRS agents, and 0 doctors.  No monies for training programs, nothing to address that while the rural areas are already short physicians for those currently with coverage and you have potentially increased the amount who have coverage, it fails to address this need.

No it adds 16,000 IRS agents to make sure you are either paying your insurance premiums, your company is, or the fine.  Now I don’t know about you, but having the IRS messing around in healthcare, not exactly my cup of tea.  And the Supreme Court just ruled it was a tax.  A tax for choosing to do nothing.  Which also makes me leery, will they now be able to tax me because I don’t like cauliflower and refuse to eat it?  Maybe with cheese, but I think slathering cauliflower in fake processed cheese ( I do like Cheez Whiz) takes away most of the health benefit.  If my BMI gets over a certain amount, am I now going to be taxed?  This allowing for taxes to be done for not purchasing a product is very disturbing to me.

Additionally, the penalty, $500 a year for an individual, $1500 for a company over 50, was this drafted by someone who has never actually purchased insurance.  You just told the companies, if you don’t cover your employees, well your fine is less than what you would have paid for coverage.  And those companies are more likely to drop coverage.  They are currently already playing games with their policies hoping to come in with crappy plans that can be grandfathered in before the deadline, though I am not certain that the deadline hasn’t already passed.  So in one sense the plan has decreased coverage for many who were previously covered.

And as to the biggest fault, which I alluded to before, it does not address the biggest problem facing healthcare- the doctors.  And while there is a shortage of specialists, those residency slots are filled, it is the primary care slots that while still open, even if you were to fill them completely full (which they are currently increasing medical schools and class sizes) it is estimated that the open slots would not be able to cover the amount of physicians that will be needed.  I focus on the physician and not the midlevels, who while they will be helping to cover this role, CMS has the data showing that primary care physicians coordinating the care tend to lead to better outcomes.  While they can refer as necessary they are better equipped to handle many of the more complicated medical care in their office than a midlevel.  These reports can be found on the CMS website going back as far as 2006.

In fact, in the ACA funding for the program cuts money from Medicare.  That being said, as the largest voting block is starting to become eligible for Social Security and Medicare, I doubt that these cuts will ever take effect, without a major overhaul of the system that ends up either privatizing or transforming into something completely different.  I doubt that the drafters of ACA actually spoke to any of the physicians that are currently in practice.  Sure they spoke to the AOA and the AMA and their lobbyiests, but the problem with leadership in these groups is that to get to those points they have often either been in an academic practice for years, or no longer practice daily. This leads to gaps between what those practicing see as a need, and what those representing us view as a need.

And for those practicing in academia, well let’s just say outside of those in residencies they can often cherry pick their patients, and therefore compliance is very good.  Had they spoke to those in practice, one thing that needed to be addressed was the flawed SGR formula in the Balanced Budget Act of 1997.  This is how Clinton and Congress were able to express that Medicare would be sustainable and there in the future.  What is the SGR?  It is the sustainable growth rate which was put in place in an attempt to control the growth of the medicare fees by limiting what it pays for physician services.  It is calculated based on what expected expenditures were in comparison to actual expenditures and adjust rates accordingly.  Since its inception, it has also supposed to have gone down.  In fact, had there not been a yearly fixed, physicians would have seen a cut in pay of 37% since its enactment.  And this is why ever December or every other (depending on whether Congress deems it necessary for a year of not having to worry) physician groups yell out about dropping their Medicare patients. And those that don’t have Medicare join in the fight because insurance contracts base their rates on Medicare, so anyone who is not concierge, well they all have a reason to worry.  Anyway, Congress despite being asked repeatedly choose to kick the can down the road.

Current payment models, actual encourage procedures rather than physician visits.  As primary care, most of my money actually comes for the visits, and the more complex, they more I get paid, up to a point.  I don’t however, have unlimited time with a patient as I would like.  However, I live in an area where access to specialists are limited, not as bad as many areas, but wait time for a neurologist often borders on 6 months, so I have to take care of all, at least until I can get an opinion.  The ACA does not help this.  It does not help with the increased wait time to get an appointment for a physician.  My wait time for new patients was sitting at a month.  I was able to decrease that slightly by not taking lunches and in the fall, I am going to add evening hours.  It is all that I can do, but I still need to be a parent to my kids.  Hopefully, in a year, I will have room to hire another physician to help with this issue, but the problem is finding someone who wants to go to a rural area and practice primary care.  For all that it claims to increase access to physicians, it has done nothing to increase the number of physicians to see them, and it may result in an increase of ER utilization until that problem is addressed.


My thoughts on ObamaCare- insurance exchanges

If you are anything like me, your Facebook page, twitter feed and everyone you meet have some opinion on the Supreme Court’s decision on the Affordable Care Act, otherwise known as ObamaCare.  And it is either the best plan ever or the worst decision and Justice Roberts is a traitor to his country, and blah, blah, blah.  Well that was Thursday.

Friday, it was well if we don’t overturn this mess, I am moving to Canada, Australia, Costa Rica, or other English speaking, industrialized nations all with some form of Universal Healthcare or Socialized medicine.  Also countries with a tougher immigration policy than we have, so I am not sure that unless you are super wealthy that is actually an option.

And then there is the stand by the Republican governors to not enact an exchange because they will fight this to the bitter end.  You all know that the exchange was originally a republican idea don’t you?  And probably my favorite part of the bill.  Why?  Well because I own a small business, I have 8 employees, when I started I had two employees, my husband and I, which accounted for a pool of 4 people.  Why does that matter, because when I went to purchase insurance in 2005, I was 7 months pregnant, covered under a policy which I COBRAed through the hospital that I did my residency in.  At $750 a month.  Now I was just out of residency and started my practice on my own, and well $150,000 in debt from medical school, with a new baby on the way.  So I looked for something, and the best I could find that would cover that baby was $1500 a month.  They could not deny me pregnancy coverage as pre-existing at the time, because I live in a states that if I had insurance that previously covered a condition within the last 6 months, there was no pre-existing condition.  However, do NOT ever shop for insurance when 7 months pregnant.

I called 4 insurance agents, and several companies on my own, the best that I could do was to COBRA my current policy ($750 a month) until the baby was born and then start the following month with the new insurance.  Though I actually COBRA for one additional month, because there was some question as to coverage of the brand new baby.  Anyway, this policy I could afford was roughly $400 a month per person in pool, oh and it didn’t cover pregnancy.  And I had an employee who would like to have a baby, so we changed our pool to three, and I covered her on an individual policy, that would cover pregnancy a year after it started.  (Which didn’t work because as it happens, she stopped trying to get pregnant and she had a baby 11 months after the policy started, and ended up on Medicaid for the pregnancy anyway)

Now being as I had insurance for all but my 3rd year of medical school (I had gotten married and could not stay on the plan, and well we couldn’t afford it until my husband started his internship year and it was covered) I could not believe the difference in rates.  I saw what had been taken out of my check at the hospital while I was employed, and it was not that much.  I talked to others as to what they paid working for bigger companies, and the talked the agent, and what the answer was the size of the pool.  My pool was three, and one was diabetic, I was a bigger risk, than those with thousands of employees, who could afford better coverage for less.  But if I got to 5 in the pool, or 10 the rates drop significantly, and then if I have 50 employees, well that is an even better drop.

But with an insurance exchange, here is the deal.  Let’s say your exchange becomes the state for instance.  Larger states might decide to have multiple pools, or smaller states might decide to join into a regional pool, doesn’t matter.  The pool becomes big enough that smaller businesses or the individual could choose a plan that actually works for them within their budget.  If you want to cover pregnancy care, great, here is the plan for you.  I don’t cover it for my employees because it would increase my costs $200 a month per employee, and that includes the two males, who if they become pregnant, I think I would sell their story, me who has had a tubal, and another employee or two that are menopausal.  There was only two of my current employees that would even desire pregnancy, and well at $1600 a month, well it is not even affordable for me to do so.  And as it stood before, they could not even add the coverage as an option because my pool is too small.

While I would have preferred for the market to develop something like an insurance exchange on its own, it is highly unlikely under today’s highly politicized system, it ever would have.  An insurance exchange would allow for those healthier to choose coverage to benefit them better, would allow for people to choose coverage for preventative care.  At least it would ideally, but it would also allow for those with diabetes and other chronic conditions to find a plan that would cover them.  I didn’t say that they all had to cost the same in my world, but prior to ObamaCare finding a plan with a pre-existing condition was impossible without high deductibles, and being astronomically expensive.  And then there was a year of paying for the plan before it would cover any pre-existing condition, so you can understand the frustration for those that tried, and for those that decided against buying insurance.

Like I said, I look at it from a small business who while not required thought that it was right to cover my employees.  I am in healthcare after all.  I actually like this part of the ACA, there is much of the plan that I don’t.  But the opposition to this part, is something that does not make sense, yes the free market should have produced it, but it didn’t.  But this is a natural progression of medicine since the development of Medicare and Medicaid, a natural progression from EMTALA.  I find myself frustrated at both sides on this issue, the surprise that the bill stood, the gloating that this bill is the best thing ever (it is not).  In the last 6 months it was obvious it was going to stand, and if not most of the major components were going to be put in a new bill.  Besides an estimated 60% of the costs in the infrastructure to support the system had already been put into place.  Repealing it would have been of little use.

That is just my two cents worth.  But what do I know, I merely own a small business and see patients everyday.  Do I agree with the plan in whole, no.  But I don’t see the alternative offered by the other side as much different.

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