The Unintended Consequences of Obamacare

I guess nothing is more complex and maddening than our current system of health care delivery. Believe me, I live and work in it every day, and have done so as an Ear, Nose, and Throat surgeon for 20 years. I am commonly asked what could be done to make things run more smoothly, efficiently, and with less waste. We need major improvements; no one would disagree. My own opinions as to what might help will need to occupy some other editorial, however, as we are currently and immediately presented with at least a partial solution, by President Obama and our Congress. The actual details of this potential health care overhaul are not available, but some aspects of what is being considered are becoming clear, and there is little enough time for us to consider the issues, much less try to influence our legislators one way or another.
Everyone has heard that Medicare is going bankrupt. There are apparently no reserve funds (that have not been spent by Congress), and the financial burden of picking up the tab for a burgeoning number of beneficiaries falls to a working class that is not growing at the same rate. Congress has not found the will to reform Medicare, and what we have been seeing is a pattern of slowly allowing reimbursements to providers to stagnate, gradually transforming Medicare into a less desirable payor. Perhaps some of you on Medicare have been experiencing increasing difficulties being seen by Physicians, especially in primary care. In the absence of effective reform, these difficulties will only increase.
Part of the overhaul of health care currently being considered is tax payer funded health insurance for the currently uninsured. Part and parcel to this massive new capital outlay is a near 25% reduction in Medicare fees to Physicians, hospitals, and other providers. I would expect the reimbursements under any new federally funded health insurance program for the previously uninsured to be about the same as for Medicare. Ditto for Medicaid. Obviously, this would have further profound effects on access to care for Medicare patients, and would accelerate the decline of Medicare as a desirable second party payor.
In fact, these changes would lead, over the course of a few short years, to a two tiered system of health care delivery in the United States, with the lower tier occupied by patients dependent on federally subsidized programs. This lower tier would eventually evolve its own, separate network of providers and hospitals, and would be characterized by longer waits and a more limited menu of services rendered perhaps by less qualified providers. In addition, there would be the usual impersonal governmental bureaucracy to contend with. The upper tier health care system would, of course, be accessed by patients who are able to afford health insurance products that provide more market realistic reimbursements, and would be characterized by much quicker access to care and more cutting edge treatments and technologies. Unburdened by the requirement to “cost shift” the care of patients who now occupy the lower tier of health care, we might finally expect true market forces to begin to have their natural competitive effect on health care costs and efficiencies in this upper tier of health care, to the obvious advantage of this group of patients.
Up until now, patients of all payor sources, including those with no payor source at all, have basically been forced through the same health care delivery system, more or less. This process has allowed for almost everyone to access the same care, (if sometimes more haphazardly for the uninsured), and is in part responsible for the profound complexity and inefficiencies of our health care delivery system.
So, the legislation currently being considered will, if passed, likely create very suddenly a large group of “second-class” consumers of health care, and they would likely be relegated ultimately to a separate health care delivery system. The only thing that would then prevent the rapid rise of a market based upper tier of health care delivery would be another bit of legislation that is being considered. I’m referring to the possible creation of a tax payer subsidized health care product that would be placed in competition with private health insurance products. Obviously, because it would be heavily subsidized, this product would be very competitively priced, and would have the potential to drive competing products from the marketplace. The ominous outcome could be a situation in which the federal government has complete control of health care in this country, ironically using our own tax dollars to enslave us. In this circumstance, we would all be doomed to the same, lousy health care system, perhaps forever.
You pay with your money or you pay with your time. This has been an axiom of health care delivery, and it will not be violated by any of these new proposals. Does anyone else feel any skepticism about the federal government being able to provide cheaper, better, more efficient healthcare? In what other endeavor has it ever been able to accomplish such a thing?
We are all irritated, sometimes infuriated by the issues that plague health care in our country. Believe me, it could be worse. In my opinion, further government takeover of our system will not make it better. The real question goes to how we can make our health care delivery system more market and competition based, so that it can benefit from the same pressures that drive quality up and costs down for the other goods and services we purchase.

Terry McMillan MD