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.