Fixing Obamacare: Not Such a Good Idea

By Bradley "Brad" Allen

This Editorial explains why fixing Obamacare is not really possible, and explains how I believe we should fix our healthcare system.

The ACA is not simple legislation; it has many pieces which are innumerably interconnected and interdependent. Changing one part unavoidably alters another, often creating new problems; as we see each time the president unilaterally imposes a modification.

The ACA devastates Medicare by cutting $716 billion to fund Medicaid expansion, slashes $150 billion from Medicare Advantage, and establishes an "advisory board" to make further cost reductions. These cuts were delayed by the President until after the 2014 elections, but what then? Currently, Medicare only reimburses doctors 70-81 percent of their costs. Add the cost of the additional paperwork to the pending reimbursement cuts and it's no wonder the number of doctors refusing to accept Medicare tripled in 2012. Left unchecked, this will devastate care for seniors.

The ACA's new regulations will significantly increase physician's administrative costs; none more so than the cost to implement the new ICD-10 diagnostic codes, which will expand the current 13,000 codes, to a staggering 68,000 codes. A 2014 study projected the cost for implementing ICD-10 to be up to $226,105 for a small practice, $824,735 for a medium practice, and $8,018,364 for a large practice.

Washington delayed the ICD-10 mandate until 2015, but how will physicians meet expenses if they accept lower paying patients, such as those with Medicare, Medicaid, or insurance through the ACA exchanges? California's exchanges offer one of the lowest government reimbursement rates in the country -- 30 percent lower than federal Medicare rates. An insurance study found 70% of California doctors are boycotting the exchanges, and many of the Countries top hospitals are opting out for the same reasons.

Then there is a looming doctor shortage, which the ACA is exacerbating. This will make it even harder for these patients to find a doctor. Moreover, the shortage of specialists is predicted to be even higher, and they can't be replaced by nurse practitioners. So how do we fix this?

We were promised that those who liked their doctor could keep their doctor. But many people were forced into the exchanges because the ACA destroyed the individual insurance market. Well, over the next few years the ACA will do the same to employer based insurance, as even its chief architect, Ezekiel Emanuel, recently admitted in the NY Times. This means millions more will soon lose their doctor.

Want more? The ACA shifts full time workers to part time, dampens job growth, limits healthcare choices, increases premiums, raises taxes --the list gets longer every day, but you get the point. The ACA is like a Rubik's cube, with the number of needed fixes almost endless.

Perhaps most important, it appears that expanding Medicaid provides little benefit to the uninsured, supposedly the primary reason we needed the law. About 50% of physicians already refuse new Medicaid patients because reimbursements don't cover expenses. Adding millions of patients will worsen the problem. They might get insurance, but good luck finding a doctor. Health insurance is not healthcare.

Numerous studies have also shown no advantage to having Medicaid. A 2010 study of 893,658 patients undergoing a major surgical operation, and a 2011 study of 13,573 patients undergoing coronary angioplasty found that Medicaid patients actually did worse than those without insurance. These studies also controlled for socio-economic and cultural factors to equalize the variables.

Still, the gold standard of clinical studies is a randomized controlled trial. Enter the Oregon Health study, which in 2013 found giving the uninsured Medicaid didn't improve any measurement of physical health (hypertension, cholesterol, or diabetes control) compared to staying uninsured. Equally important, Medicaid didn't limit costs, as those with insurance visited the emergency room 40% more often.

So if Medicaid provides so little benefit, why even try to fix a law that may be unfixable, and is destroying healthcare for so many?

Fixing the pre-ACA system would be much easier, and could be done using targeted, incremental solutions, to address the specific needs of each insurance group separately. This approach avoids construction of a complex interconnected matrix, making future changes easier, and creating fewer unintended consequences. It also avoids creating a huge new government bureaucracy, and keeps the government out of the doctor-patient relationship.

Costs could be reduced and quality improved for the 85% that have insurance by employing what has worked in virtually every economic sector--deregulation and market competition. Other changes such as malpractice reform, and allowing insurance purchase with "pretax income", across state lines, and as groups, would further reduce prices and allow portability. We don't lose our life insurance when we change jobs, get sick, or move, why should health insurance be any different?

Those who can't get insurance because of pre-existing conditions represent only about 2 million people. They could easily be covered by a combination of changes to HIPAA laws to better allow people to keep their coverage when they switch jobs or insurance, and developing newly structured, well designed, high-risk pools.

There are many options to cover the uninsured and improve their care over traditional Medicaid. One is to give states Block Grants with Medicaid exemptions so they can innovate and test different ideas to determine the best way forward. Both Democrat and Republican governors are pleading with Washington for this flexibility. Rhode Island has such an exemption, and they have cut Medicaid costs and improved care while adding patients. Florida and Indiana have similar experiences with other models.

But we need to decide our course soon. In 2015, the employer mandate will begin adding 20-40 million people into the exchanges, making it almost impossible to "undo" the law, no matter what the problems or unintended consequences. Shouldn't people who think it's fixable prove it before we reach this point?

As a doctor, I understand the need to constantly re-evaluate and alter a diagnosis and treatment as test results come back, and the facts change, otherwise patient's die. I can't blindly pursue a belief and ignore the facts. As a government we need to be willing to do the same, for in this case, our patient is the American people, and the consequence, is our healthcare.