ObamaCare: A Physician’s Point of View On The Negative Ramifications of America’s Affordable Health Choices Act of 2009

Friday, July 24, 2009 21:40

Healthcare reform is obviously the hot button topic of the day, and unfortunately, as a good (and well educated) friend of mine admitted today, the sum of the average American’s knowledge about the current healthcare bill comes from the nightly news.  From their perspective, ObamaCare sounds pretty good.

I’d like to share my take on this issue, but first, before the inevitable attacks begin, I’d like to share some things that shape my point of view.  Despite the letters after my name, I don’t come at this from the viewpoint of a doctor who is worried about their bottom line.  If you’ve been around for a while, you know I don’t practice medicine, as a result of having a child with multiple healthcare needs.  I am also not a Republican.  If you must know, I’m not a member of any political party.

I do, in fact, come at this issue from the perspective of a self-employed person who is all too aware of the pitfalls of trying to get health insurance for someone with a pre-exisiting condition.  I am very familiar with shortcomings of individual health insurance plans in the US.  I also know what happens to household finances when a critical illness occurs, and your health insurance leaves you footing most of the bill. But, above all, I am an American who believes in small government and individual freedoms.

Despite the shortcomings in the US healthcare system, I stand opposed to HR 3200, otherwise known as America’s Affordable Health Choices Act of 2009.  Since the bill is 1018 pages long, this post could probably go on forever, but instead I’ll list a few of the biggest problems I have with this bill.

  1. ALL Americans will be forced to obtain health insurance, and unless they qualify for Medicaid, they will PAY for it.  The public plan is not a free ride.  There are premiums and “cost-sharing” charges associated with medical visits under the public plan.  In fact, the basic plan will only cover 70% of the calculated value for anything beyond preventive care (pg 29 lines 23-25).  Opting out and paying for your healthcare elsewhere will not be an option, unless you have a lot of money, because if you don’t carry an approved plan, you will pay a 2.5% tax on your adjusted income as a penalty (pg 167 lines 18-23).
  2. If you do qualify for Medicaid, you must be enrolled (pg 102 lines 12-18).  If you somehow manage to budget well enough to afford individual insurance, it will not be an option.  This means you will have no choice, no control, and you will be subject to whatever limitations the government decides to put on the care Medicaid will pay for.  If you can’t find a doctor in your area which is accepting new Medicaid patients, and the number who do is dwindling, you will have to move or travel long distances to find a doctor who does.
  3. There will be a system called Individual Affordability Credits which will decrease the premium and cost sharing responsibility for people whose income is between 133% and 400% of the federal poverty level.  Unfortunately, for the first two years of the plan, people who qualify for these credits will only be able to receive the basic level of public insurance.  In year three, they will work out a system that will allow you to cover the difference between your affordability credit and the enhanced or premium plan options, but until then, only the relatively wealthy will get that option (pg 131 lines 13-24).
  4. Private health insurance companies will no longer be able to deny people coverage for pre-existing conditions (pg 19 lines 18-25), or deny renewal of a policy.  They also won’t be able to charge people with pre-existing conditions a higher premium.  In addition, under the bill, no one can be charged a premium higher than the one designated for their age and location (pg 17 lines 1-7).  This sounds really good, until you realize that in order to remain solvent, health insurance companies will just raise the rates for everyone across the board.
  5. If you don’t have a private individual health insurance plan before the public plan goes into effect, you won’t be able to get one.  After that date, private insurers will be prevented from writing new policies.  The only exception will be for dependents of those who are already insured by an acceptable plan (pg 16 lines 11-20).  So, if you start out on the public plan because it’s a little less expensive, but find out you hate it, you’re stuck.
  6. Hospitals will need government permission to expand the number of beds, operating rooms or procedure rooms they have beyond the number accounted for on the day the bill goes into effect (pg 317 lines 21-25 and 318 lines 1-3).  If they do meet the numeric criteria for expansion, the decision will still require public commentary.  If they are denied, there is no administrative or judicial review (pg 325 lines 21-25).  The government will therefore be able to limit the availability of healthcare in a given region.
  7. There are too many pages covering this next part to list them all clearly, but the government will be forming various bodies to decide what healthcare we should be getting, and what types of care our scientists should be researching.  They will be using these panels to determine what type of care the government will pay for, based not only on evidence, but also on cost effectiveness and overall benefit.  They will use similar criteria to decide where research should focus, thus putting up major obstacles against researching and treating rare diseases.  The decisions of these panels could lead to a person being denied care because they are too old to get enough benefit, or the treatment doesn’t have a high enough success rate to justify the cost.  Imagine the impact this could have on treatments for aggressive forms of cancer, so-called orphan diseases or diseases of the elderly.  For the preemie parents out there, imagine what this panel would do with the recent study data that less than 5% of 24 weekers are unimpaired as toddlers.  Do you think they’d see the million dollar NICU bill that baby incurred as beneficial or cost effective to the whole?

As I’ve read articles today, and worked my own way through HR 3200, I’ve spotted many more potential problems out there.  In the end, what I hate the most is the aspect of government control and oversight over pretty much every aspect of healthcare.  I hope you’ll use the highlights I’ve listed above as a jumping off point, and take a look for yourself.  I also urge you to contact your representative to tell them where you stand on healthcare reform.

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15 Responses to “ObamaCare: A Physician’s Point of View On The Negative Ramifications of America’s Affordable Health Choices Act of 2009”

  1. Rose says:

    July 27th, 2009 at 7:26 pm

    Thank you for the great summary of points. This bill really scares me. I have several friends in Canada and their tales of the hoops they run through to get basic health care are horrible.

    A doctor I know says one thing that bothers her is that nothing in it deals with reforms to the legal system and the impact lawsuits have on the cost and availability of healthcare.

  2. Kristie says:

    July 27th, 2009 at 7:40 pm

    It scares me too. As much as I would like to see changes to our healthcare system, this just isn’t going to bring the results we need. I’m pretty sure it will end up doing the exact opposite.

    The issues surrounding malpractice suits, the skyrocketing rates of malpractice insurance, and the way it impacts how doctors treat patients is a serious issue as well. If doctors are going to have their reimbursements/wages controlled by the government, they are going to have to do something to address those issues as well.

  3. Joe Maisano says:

    July 28th, 2009 at 4:00 am

    Good points made… nice to have something simplified to show others. I know of two area cab drivers that regularly pick up Canadians and take them to U of M for procedures that they pay out of pocket for here because they can’t get. I thought me soon losing my Traditional BCBS plan for a PPO or HMO was scary enough when it comes costs covered with preemie related issues. Scary to think that care would of possibly been completely denied.
    I found john Stossel on 20/20 had some interesting points on American healthcare(pre- HR 3200). http://www.youtube.com/watch?v=aEXFUbSbg1I

  4. Kristie says:

    July 28th, 2009 at 8:22 am

    Thanks Joe! I’ve lived near the Canadian border as well, and I really don’t think most people realize how common it is for people to cross into the US for healthcare.

  5. Joni Gaston says:

    August 11th, 2009 at 4:04 pm

    Could you possibly elaborate a little on how this bill in your opinion will affect the hundreds of premature babies born in this country. I have a 20 month old granddaughter that was born at 27 weeks, who by the way is perfectly healthy and normal. But would she have had a chance if born after this bill is, if it is passed

  6. Kristie says:

    August 12th, 2009 at 10:56 am

    I can’t tell you for certain what will happen, but if I had to pinpoint areas of concern a couple come up. First, when the committees decide what treatments they will pay for based on benefit, cost effectiveness and existing outcome data, I’m concerned about what they will decide about very premature babies , especially those born before 25 weeks. At this point, most hospitals give parents the right to decide whether these babies are resuscitated, but although a fair number of these babies are surviving, studies show that many, if not most, have significant impairments that are costly and resource intense.

    This leads right into my second area of concern. What will happen to the amount of resources available? Preemies can require a lot of special care, including early intervention resources like physical and occupational therapy, etc and expensive items like specialized walkers and wheel chairs. They also tend to see more specialists than other kids and spend more than the average amount of time in the hospital. Will all of this be available in sufficient quantities to go around under the new system?

    I can’t predict the future, but when I look at the babies from Canada who are sent to U.S. NICUs because there aren’t enough beds in their own country, I worry.

  7. Claire says:

    August 12th, 2009 at 5:32 pm

    Thank you for taking the time to read the bill and to post your thoughtful insight. I’m glad for healthy debate. I am a family physician practicing in Pennsylvania, and I disagree with your reasoning.

    #1 Opting out and paying for your healthcare elsewhere IS an option, provided you carry an approved plan. If you carry only cheap catastrophic insurance, then you are not trying to stay healthy and therefore costs society more.

    #2 I’d be surprised if any significant number of people on Medicaid can afford any other insurance. The supposed lack of choice is just fear-mongering for 99% of Medicaid patients.

    #3 Ditching the healthcare plan with this complaint doesn’t make sense. At least it’s an option, while not perfect, it’s better than what 20% of Americans have now, which is NO coverage for basic healthcare. And in 3 years, it will likely be improved.

    #4 That’s because the private insurers are wasteful. Medicare spends 3% on administration. Private insurance spends on average 15% on administration. If they get their act together, stop generating excessive paperwork by denying tests, or paying their CEO $3 million + $750 million in stock options, then they will be just as competitive.

    #5 Your interpretation is wrong. Note that it says “grandfathered.” In lawyer-speak, that mean if your current health insurance doesn’t meet the provisions in the new laws (like not being able to drop you at a whim, not covering a pre-existing condition, or not cover preventive care like an annual exam), then you can still keep it because it’s “grandfathered.” You can OF COURSE still buy your own private health insurance! You actually have more choices.

    #6 I don’t like that the government has excessive power either. But look, the benefits of the bill still outweigh the problems. Perhaps that clause will be stricken or not enforced.

    #7 I’m glad they will be looking at cost effectiveness. Our country (its individual citizens and the federal government) need to control our spending in all areas. The government is in debt because WE are in debt. Stop pointing fingers. Do you have your house paid off and all bills settled? I know I don’t. Is your net worth in the red or in the black? It’s been 8 years since I graduated from med school, and I’m still in the red. Unless we change, our government can’t change.

    I know you disagree with this, and this is my own opinion. Some very young NICU babies live a horribly disabled life and cause severe anguish for their parents. Some of those NICU babies are from young drug-abusing mothers who could not possibly give them adequate loving care. And if the parents manage to care for them into adulthood and they would will have to place them in a group home when they get too old. If the parent feels guilty or just really wants to save a 24 week old preemie, then they can certainly foot the bill on their own. If my elderly mother had cancer and just wanted to die a natural death rather than live through the torture of multiple ICU stays, I would respect that. Similarly, if I had a 24 week preemie, I know it would lead a tortured life in and out of hospitals, required various surgeries that it would not understand and would suffer through, causing frequent anguish for me and my husband and other kids. I would give it the grace of death, not life at all cost. In my opinion, it’s the humane thing to do.

  8. Kristie says:

    August 12th, 2009 at 7:48 pm

    Thanks for taking the time to comment in a constructive way. I’ll address what you said about the bill when I can put more careful thought into it. Unfortunately, I do have a serious problem with your last paragraph that I can’t let lie tonight. I don’t think you should assume that you know how I personally feel about neonatal resuscitation. I actually have very strong opinions about the issue, and they are reflected in the choices and plans I’ve made in subsequent pregnancies after our second daughter was born at 31 weeks. My readers and I do not always agree on these issues though, and my blog focuses more on educating people who are already past that point in their journey.

    As far as a parent footing the bill goes, have you seen a typical NICU bill for a 24 weeker? How about the combined bill for multiples born at 24 weeks? There are few families in this country who could foot those bills, even if they were given a lifetime to pay.

    As for drug addicted young moms, that is an entirely different issue, and I’ve written before about how I feel about extreme measures for extremely premature infants who essentially have no functioning family. That is irrelevant to all of the moms of micros out there who are normal, productive women somewhere in their 20s or 30s, who had infections, preeclampsia, or some other pregnancy complication.

    I think that when the government draws a line, either forcing or refusing resuscitation, it is bad policy. We should be focusing on medical reality in the specific case, not bureaucracy. There’s an interesting book that touches on this subject, written by a mom of 23 week twins who were resuscitated against her wishes because of California law. It’s called This Lovely Life, and I think it’s a must read for OBs and neonatologists. I’m actually going to be blogging about it sometime in the next week.

  9. Tonya says:

    August 13th, 2009 at 5:13 pm

    Kristie,
    Thank you so much for your excellent post. In reading the bill I have reached basically the same conclusions. My son was born at 25 wks and is now a happy healthy 10 year old boy who is interested in robotics and how DNA works. He has ADHD and is dyslexic, but that can’t all be attributed to extreme prematurity as other family members have similar issues; horribly disabled he is not! If this expansive government program is instituted I am very concerned that, as with most bureaucracies, decisions will be based on strict rules rather than leaving decisions in the hands of doctors and patients where it belongs. This is especially true given the cost cutting mandates found throughout the bill. Also regulations tend not to keep up with medical innovation, so if a new technology is developed it can take a long time to be accepted. Like turning a ship, the larger the vessel, or organization, the harder it is to change course. We experienced the advantages of dealing with a smaller organization when my son was born. My husband works for a company with 20 branches in different states and even though it is a good size organization they are self insured. While there is a third party administrator the final decision rests with the board on whether to approve items that are not addressed in the plan. In our case while my insurance was primary they agreed to pick up additional costs as a secondary, in our state most insurance companies won’t serve as a secondary. In addition once they took over as primary, I went to part-time, they paid for Synagis shots. These shots help prevent RSV and were quite expensive; at the time quite a few insurance companies did not yet cover this cost. BTW, my husband is not any kind a manager and the company isn’t union, so this is an average employee perspective. Can you imagine trying to address these things with a government bureaucracy?! I am not saying they are always behind the curve, but if your case happens to be the unusual one that is not addressed in the manual, good luck. Regarding Claire’s comments, I am sure you will be able to give a more comprehensive response, but in reading the bill it seems to me that plans are only “grandfathered” until the plan changes in some way. This includes “benefits and cost-sharing” per section 102 of the bill, so apparently if your co pay changes or they drop a minor benefit you are no longer “grandfathered.” Also, the number of 3% for Medicare as compared to 11% for private plans is questionable, as it doesn’t take into account the actual type of claims paid or the number of claims paid. One number that might help in making an accurate comparison would be how much they spend on administrative costs per claim processed as there is a cost for handling each claim regardless of amount. If one entity processes twice as many claims, but for smaller amounts this would have an impact on the results. You also have to look at the amount that each party spends fighting fraud. If private companies are already spending larger amounts in this area and Medicare is not addressing the issue yet it will have an effect. For example if Medicare increases administrative costs to combat fraud and in turn this lowers pay outs, their percentage of administrative costs would go up in relation to payouts. In other words let’s say today they would pay in the range of $3,000 administrative costs for $100,000 worth of claims (going with Claire’s 3% amount). Now let’s say they decide to get tough on fraud (as is mandated in this bill) and hire additional workers raising their administrative costs to 10%. If they were to find that 10% of the $100,000 is fraud and waste they would still come out $1,000 ahead even with administrative costs at 10%. Obviously these are not the actual numbers, but just an example of how many factors can come into play when looking at statistics. Percentages can be often misleading if one is not willing to dig deeper to get additional information. Thank you again.

  10. Kristie says:

    August 13th, 2009 at 8:00 pm

    Tonya-

    Thanks so much for taking the time to share your experiences. I’m glad to hear that your son is doing so well. Cases like your son’s are exactly why I feel resuscitation really needs to be a decision parents make with the help of their doctors, and not one made by a government bureaucracy. Your ship analogy is perfect on that point.

    As far as the comments about the bill go, I agree with your reading of the section on grandfathered private insurance plans. I’m definitely not a lawyer, but as far as I can tell it will be very difficult to stay on a private plan for very long without something changing that will cause the policy to become unacceptable. Aside from that, the bill also says those plans cannot write new policies after the date the bill goes into effect, which means if you aren’t signed up already, you can’t. The only exception I see is for new children born to a parent who is already on a plan.

    Your comments about percentages spent on administrative costs also make an excellent point. In addition to the changes that might take place in order to comply with the bill, I think we also need to consider the larger governmental costs associated with the Medicare program. While Medicare itself may technically spend only 3% of it’s budget on administrative costs, what additional costs for the Medicare program are we overlooking? Somehow I don’t think the time spent in Congress and the Senate writing and debating bills about lowering Medicare reimbursements are included in that figure. Private insurance companies pay their own staff to manage issues and negotiations over reimbursement rates for them, and they are certainly included in their bottom line. I’m sure this isn’t the only example where private insurers incur costs that Medicare doesn’t have to deal with. If we added up those figures and included them in the picture, I think we’d see that the true administrative costs in the Medicare program are actually significantly higher than 3%.

    Thanks again,
    Kristie

  11. paula says:

    August 14th, 2009 at 7:50 pm

    “decisions will be based on strict rules rather than leaving decisions in the hands of doctors and patients where it belongs. ”

    Um – don’t private insurance companies already intrude on these decisions? Why is intrusion OK for companies that have a vested interest in determining what will – and won’t – be paid, but not OK for an organization that makes no profit from denying you and yours medical care?

    “committees decide what treatments they will pay for based on benefit, cost effectiveness and existing outcome data, I’m concerned about what they will decide about very premature babies , especially those born before 25 weeks.” Again, private insurance companies ALREADY have these committees. Not everything that is done in the NICU is covered by private insurance companies. much NICU care is experimental, and hence not covered. I really don’t understand why people are OK with profit-driven insurance executives deciding what care their baby will or won’t get, but get freaked out at the thought of someone from a government agency saying anything.

  12. Kristie says:

    August 15th, 2009 at 8:20 am

    Paula-

    We were talking about a very specific situation, and I am completely unaware of any example where a viable preterm baby born in the US was not resuscitated because their insurance said no. If you have such stories, I’d love to hear about them because that is a travesty. At this point, state law, hospital policy and parent/doctor wishes decide which babies will or will not be saved when they are born at the extreme edges of viability (22-24 or 25 weeks). In the case of the book I mentioned earlier, California law mandated that 23 week preemies be resuscitated because they were born with signs of life. In my case, I was sent home from L&D at 22+ weeks because my hospital did not do anything for any baby before 24 weeks 0 days. These are usually life and death, in the moment decisions where insurance companies don’t really get a chance to weigh in.

    -Kristie

  13. Lisa says:

    August 19th, 2009 at 12:08 am

    “if I had a 24 week preemie, I know it would lead a tortured life in and out of hospitals, required various surgeries that it would not understand and would suffer through, causing frequent anguish for me and my husband and other kids. I would give it the grace of death, not life at all cost. In my opinion, it’s the humane thing to do.”

    I just had to speak to this statement from Claire, because her comment made me tear up. You can’t know that a 24 weeker would lead a “tortured life.” Just as you can’t know a baby born full term will lead a perfectly healthy life. There are no absolutes in this life. I have a former 24 week preemie. He is in PERFECT health. He needed NO therapies, NO surgeries, NO oxygen or monitors or feeding tubes after he left the NICU. He is 4 1/2, and is beginning to read and add simple numbers. It took him about a week to learn the alphabet- at age 3. Letting my baby die would NOT have been humane., it would have been heartless.

  14. Kristie says:

    August 19th, 2009 at 8:24 am

    Lisa! It’s good to see you here, and to here that things are going so well. I hope all your boys are doing great.

    You make an excellent point. For every NICU horror story, there is a miracle story out there. That’s why making decisions about resuscitation is so terribly difficult. There is no magic formula that can tell us which babies will thrive and which will not. I certainly wish that there was.

  15. Kristie says:

    August 19th, 2009 at 8:25 am

    Oh, and by the way, if I could get my 31 weeker to learn a single letter from the alphabet, I’d probably do a back flip. At this point, I think she’s just stubborn, but only time will tell. She’ll be 4 in December.