WELCOME TO OBAMACARE

Personally I do not like the term “ObamaCare being used in place of the Affordable Care Act. President Obama’s  name creates an immediate political and sociologic issue for many Americans.  Some may notice I often title my posts “ObamaCare”  Why ? My rational has been  “Obamacare” has a very high rank on search engines, such as Google, Yahoo, or Bing. It makes it easy to find “Health Train Express”.

Even the title of the law is deceptive. It is not affordable, either for patients, employers, or the taxpayer. The subsidy is a hidden tax, and the Supreme Court of the U.S.  recognized this when it determined the issue was not a constitutional conflict. John Robertson, the Chief Justice in his statement stated this in his decision.  It is not designed to ‘care’ for Americans. Caring is an individual matter, and the broad sweeping broad law is an attempt to address many divergent problems such as abortion.   The complexities of health and life are an individual challenge financially. Some Americans use lots of medical care in short mild illnesses and some have catastrophic illness with only one or a few very expensive encounters.

The ACA is inadequate because of short term thinking and a need for a quick “political’ fix.

During the past several months we have been focused on the ‘negative’ about the Affordable Care Act.  The number of articles and discussions criticizing Obamacare are overwhelmingly opposed to the law. Some are written by Democrats but most are written by Republicans. It has nothing to do with the content, nor goals of the law, but is now a purely political tension. Ultimately this problem is the upcoming mid-term election and the eventual Presidential Election in 2016.

In our already complex health system the Affordable Care Act adds further confusion, and bureaucracy and expense. The goal of decreasing health care expense is far outweighed by the added layer of HIT and new agencies designed to control use by limiting benefits and preventing access by high co-pays and deductibles.  The Act flies in the face of it’s stated goals of prevention and early care of potentially serious conditions.

Who was it that said “Nothing Good Comes from …….?  The same can be said to sum up my opinions about a mixture of health and politics.

Backlash already appeared as Hillary Clinton cancelled her planned appearance as the headline speaker at next week’s Western Health Leadership Academy in San Diego due to planned protests over her failed leadership involvement in the Benghazi attacks.  Ironically President Obama was denied coverage by all 3 major networks refusing to grant him airtime for a ‘victory lap’ to announce that Obamacare had reached 7.1 million enrollees.

Das Blawg

My conclusion regarding health reform was confirmed by the congressional budget office today. With the present plan there will be no savings.  The plan as proposed does nothing to eliminate the parasitic bureaucratic insurance environment, nor the regulatory environment, In fact the plan would merely transfer these costs to the government.   Unfortunately the AMA in an effort to boost it’s credibility came out today to support the House Bill.  No surprise there….just when most sensible people rose up and told congress it’s too expensive.

I Obama is creating a ‘health care crisis’ much as he did with the financial markets promising to pull it out with ‘stimulus funding’.  Congress is begiing to say “enough is enough’.No one is going to be panicked into a hasty decision. Obama wants all or nothing at all.

It seems saner heads are prevailing, as well as the skeptical response of the public in general.  

Unfortunately health care will have to wait further to see just how our economy will (if) recover. As evidenced by the state of affairs in California even those well established programs such as SCHIP are being curtailed or eliminated, and this in the largest and perhaps most affluent state in the country.

Nevertheless changes do need to be made, and sooner rather than later.  The cry of ‘emergency’ and crisis are beginning to sound like crying ‘wolf’.  That only goes so far….banks, equity firms, mortgage crisis, credit crisis, and financial scandals .   Obviously all those responsible were not playing with their ‘own money’  This too would be an enormous problem with a universal, or public program.

The most imminent medical issue is that there are a lot of providers who are about to quit, retire, or find some other less stressful financial vehicle, even if it means living under a bridge.  

Virtuality

Perhaps no more than any other misfire, the health.gov website has set back consumer and provider confidence in HIT for at least a decade.

Providers have always been skeptical regarding EHRs, and many who have already implemented systems are planning to replace them as the HHS/CMS deadlines for meaningful use approach approach. The conversion from ICD-9 to ICD-10.                                                                        is also on the horizon.

The requirements for more complexity follow rapidly one upon the other. Mingling with these changes is the affordable care act, which will cause fallout and expected increases in insurance premiums, copays and deductibles.  The expected fall out will take several years to become apparent.

The ‘algos’ will devise statistical anaysis to show how much healthcare spending has been reduced by the affordable care act.

California has been spotlighted by the relatively high numbers of enrollees as compared to most states.  California is one of the states that agreed to expand Medicaid using temporary federal subsidies.  Governor Jerry Brown saw this as an opportunity to grab federal funding for an insolvent state. These federal subsidies will end in 2016, with a complicated analysis of how much of the federal largesse has been spent so that states can repay and excess spending in excess of the federal allotments.

Californians seem to leap before they leap..It is similar to building a ‘bullet train in the central valley, where the population density is low, for the sake of ‘easy’.  In a state that is insolvent it makes little sense to ‘borrow money’ to expand medi-caid.  Neither has anyone elaborated on what that means?  If eligible for medi-aid do applicants go through an additonal eligibility process at their county public social services agency? Is there a share of cost for those who make more than $ 900.00/month?  Details have not been forthcoming?  Medi-caid operates on a monthly financial status which results in an almost impossible method of accesssing health care. In addition Medi-caid has far fewer eligible providers and reimbursement rates are far lower than the lowest subsidized insurance plans. Coverage is far from uniform between medicaid and subsidized policies.  The devil is in the details.

California, Texas and Florida rank the highest in uninsured. Texas however has refused to expand it’s medicaid program or accept federal subsidies to do so. These are border states, although Florida is not, but has a large immigrant population from Cuba and Central America.   

The American Association of Physicians and Surgeons (AAPS) has listed ten reasons to not enroll in ObamaCare.

Here are their top ten reasons for not enrolling and what you might do instead. Weigh the pros and cons, then decide the cost-benefit balance best for you for you

1. Obamacare Health Insurance cost signifianlhy more-likely more than the penalty (tax) in the first several years.  Most people can expect their monthly premiums to double. This may vary from state to state.

2. Obamacare health insurance policies limit your choice of doctors.

3. Obamacare health insurance policies limit  your choice of hospitals.  Some centers for excellence and national cancer centers are included.

4. Out of pocket costs will skyrocket, Obamacare Health Insurance Policies have double and triple the deductibles, and higher copays you must pay before coverage kicks in.

5. Much of your medical privacy is lost, despite HIPPA, and control of your information is in government hands. (IRS administration of premiums and tax penalties)

6. Health.gov website is an unfinished tool with no linkage to insurers, and has not yet been demonstrated to be secure.

7. If you use an ‘Obamacare Navigator” their credentials are far less than an insurance broker who is certified, and expercienced in explaining insurance to consumers.

8. Open to question are the protection of Second Amendment rights as medical databases expand and collect information on such things as sexual preferences, and gun ownership

9. Obamacare enrollees are finding it very difficult to cancel or change their plan once enrolled if they find a better plan.

10. Obamacare policies are basically ‘managed care, with limitations on your options and reward incentives for providers to restrict care.

Continued

If you fall into the Medi-caid eligibilty determine what your share of cost will be each month. Usually maintenance allowance is about $900.00 for the first person and increases about $ 400.00 for each eligible beneficiary    This is good catastrophic coverage but if your income is above the poverty threshold expect to pay for your own medications, and doctor visits.  Remember this share of cost is a monthly amount, it is not a truly annual  deductible.    Medi-caid also has a limit on assets for eligibilty.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

Physician-Administration Tensions

The Affordable Care Act and development of Accountable Care Organizations increases the critical need for improving communications between physicians, clinic administrators, and hospital CEOs.

A tension has always been present between clinicians and bureaucrats.  When  you consider the physician mind-set is one of decision making autonomy, and dealing with new events. The concepts are not always congruent with the mind-set of the practice administrator.  In the operating room the surgeon is always thought to be ‘captain of the ship ‘.  The administrator is trained to focus on the complexity of coordinating multiple practice issues inside the office, or the hospital.  This coordination requires a set of skills not taught in undergraduate medical school curriculum.

MDs who desire non clinical responsibilities usually obtain a business degree such as an M.B.A. or M.P.H.  Some develop these skills on the job.

In the new environment of the ACO and ACA, he is just one of the key players. For some MDs this is anathema to  prior education and experience, especially for those who have been practicing for twenty years or more.  New graduates and young clinician are trained with the new paradigm and hierarchy in mind.

Add to this the necessity for change management in reimbursement, quality of outcomes and management of new reporting requirements the stage is set for increasing interaction between  clinician leaders and ‘management’. Without everyone’s cooperation in the practice change results can be compromised.

The principal characters (physicians) belong in several groups .

1. The champions for change who see the goals as beneficial.

2. Those who are neutral to changes, will ignore them and go on about their clinical work

without much thought to change, except to adapt quickly so they can continue their

clinical work with minimal disruption.

3. The saboteurs who will go beyond passivity or ‘foot dragging’ to slow down, delay, or

reverse the change.

In the recent past this third group would accomodate themselves by leaving an institution that was not compliant with their own preferred practice pattern. They would move to private practice either solo or in a group more compatible with their desires.   These opportunities have diminished drastically by the corporatization and more bureaucracy and support structures that are thought to be more efficient . The group mindset prevails since the financial rewards are mandated by the group and ‘political’ pressure on the individual clinician.  In the past clinicians might even leave their community to a region where patterns are different.  Today this is less possible because fewer small practices and the Affordable Care Act.

Health Care Spending: The Flattened Curve is Reversed

Health Care Finance Administrators for the past several years have reported that health care spending had leveled off.  During the fourth quarter of last year health care spending rose 5.6% reported by the Bureau of Economic Analysis last week.

The jump triggered a sharp upward revision in the government’s estimate of consumer spending overall and accounted for nearly a  quarter of the economy’s 2.6% annualizd growth in the last three months of 2013.

Despite the number of inpatient days dipping 1% during the fourth quarter hospital revenues increased 8 billion  (more than all the previous four quarters, combined). During this last period many unemployed went without health insurance and/or limited their spending during the recession and sluggish recovery.

The 2010 Affordable Care Act incentivized hospitals to become more efficient by decreasing readmissions, and shifting costs to patients through high-deductible plans and other measures, encouraging Americans to limit visits to doctors and hospitals.

For the time being those trends may be levelling off, however there are long term upward pressures on health care costs, such as the growth of expensive high tech treatments are re-emerging.  Many uninsured Americans delayed health care treatment until the Affordable Care Act was passed.  This demographic has bottled up demand and a pool of ‘disease’ awaiting treatment that will be treated in the next several years, which will inflate health care spending. It is very likely we will see a significant increase in health care spending as the result of the ACA. Although some new organizational changes have been designed to limit increases in health spending, the proposed and hoped for results are in doubt.

Insurers now are faced with setting rates for 2015.  The time period is very short with less than 4-6 months remaining until 2015 rates are set.  Insurers (Wellpoint) predict double digit increases in rates. The rates may be different in accordance with different rates of enrollment in each state.

In the next several years the acceptance of the ACA will hinge on consumer satisfaction, and true affordability in the daily budget of family finance. The statistical outline for subsidies may be ‘fantasy”. Premium rates may change, increasing in some states and decreasing in others. If there are large increases some Americans could be once again priced out of the marketplace. Fluctuations in personal income will shift subsidy amounts, from year to year.  Some may even involuntarily be penalized if their premium policy is too much.  The new mantra may be “Do I feed my family or be penalized by the ACA”.

While somwhat unclear is an IRS statement that penalties will be taken from a tax refund, and if the taxpayer has no refund they will not pay a penalty. And according to the way the wind is blowing politically the White House may make changes accordingly.  

Although some Democrats are waxing enthusiastic about the ‘numbers’ the ultimate success of the ACA is still open to question.  Only 26% of Americans give the ACA a favorable rating.  

Obamacare When to enroll and don't panic if you have not....Next enrollment is in November 2014

Obamacare and the Affordable Care Act:   Should you enroll this year?

Probably not. HBEs will be around for a long time. There is no regulation saying there will be no further enrollment each year.  This admonition applies to providers as well as potential enrollees.

Despite pronouncements and media marketing the ACA has no track record.  It is still very early and we have seen how many enrollees have paid and have actually seen a provider.

Perhaps no more than any other misfire, the health.gov website has set back consumer and provider confidence in HIT for at least a decade.

Providers have always been skeptical regarding EHRs, and many who have already implemented systems are planning to replace them as the HHS/CMS deadlines for meaningful use approach approach. The conversion from ICD-9 to ICD-10.                                                                        is also on the horizon.

The requirements for more complexity follow rapidly one upon the other. Mingling with these changes is the affordable care act, which will cause fallout and expected increases in insurance premiums, copays and deductibles.  The expected fall out will take several years to become apparent.

The ‘algos’ will devise statistical anaysis to show how much healthcare spending has been reduced by the affordable care act.

California has been spotlighted by the relatively high numbers of enrollees as compared to most states.  California is one of the states that agreed to expand Medicaid using temporary federal subsidies.  Governor Jerry Brown saw this as an opportunity to grab federal funding for an insolvent state. These federal subsidies will end in 2016, with a complicated analysis of how much of the federal largesse has been spent so that states can repay and excess spending in excess of the federal allotments.

Californians seem to leap before they leap..It is similar to building a ‘bullet” train in the central valley, where the population density is low, for the sake of ‘easy’.  In a state that is insolvent it makes little sense to ‘borrow money’ to expand medi-caid.  Neither has anyone elaborated on what that means?  If eligible for medi-aid do applicants go through an additonal eligibility process at their county public social services agency? Is there a share of cost for those who make more than $ 900.00/month?  Details have not been forthcoming?  Medi-caid operates on a monthly financial status which results in an almost impossible method of accesssing health care. In addition Medi-caid has far fewer eligible providers and reimbursement rates are far lower than the lowest subsidized insurance plans. Coverage is far from uniform between medicaid and subsidized policies.  The devil is in the details.

If your income is in the Medi-caid eligibilty bracket determine what your share of cost will be each month. Usually maintenance allowance is about $900.00 for the first person and increases about $ 400.00 for each eligible beneficiary    This is good catastrophic coverage but if your income is above the poverty threshold expect to pay for your own medications, and doctor visits.  Remember this share of cost is a monthly amount, it is not a truly annual  deductible.    Medi-caid also has a limit on assets for eligibilty.

California, Texas and Florida rank the highest in uninsured. Texas however has refused to expand it’s medicaid program or accept federal subsidies to do so. These are border states, although Florida is not, but has a large immigrant population from Cuba and Central America.   

The American Association of Physicians and Surgeons (AAPS) has listed ten reasons to not enroll in ObamaCare.

Here are their top ten reasons for not enrolling and what you might do instead. Weigh the pros and cons, then decide the cost-benefit balance best for you for you

1. Obamacare Health Insurance cost signifianlhy more-likely more than the penalty (tax) in the first several years.  Most people can expect their monthly premiums to double. This may vary from state to state.

2. Obamacare health insurance policies limit your choice of doctors.

3. Obamacare health insurance policies limit  your choice of hospitals.  Some centers for excellence and national cancer centers are included.

4. Out of pocket costs will skyrocket, Obamacare Health Insurance Policies have double and triple the deductibles, and higher copays you must pay before coverage kicks in.

5. Much of your medical privacy is lost, despite HIPPA, and control of your information is in government hands. (IRS administration of premiums and tax penalties)

6. The

Federal Health Benefit Exchange website is an unfinished tool with no linkage to insurers, and has not yet been demonstrated to be secure.

7. If you use an ‘Obamacare Navigator” their credentials are far less than an insurance broker who is certified, and expercienced in explaining insurance to consumers.

8. Open to question are the protection of Second Amendment rights as medical databases expand and collect information on such things as sexual preferences, and gun ownership

9. Obamacare enrollees are finding it very difficult to cancel or change their plan once enrolled if they find a better plan.

10. Obamacare policies are basically ‘managed care, with limitations on your options and reward incentives for providers to restrict care.

Continued

Portions of this article are from an online blog “Health Train Express”  (Gary M Levin MD)

The author has been on the faculty of Loma Linda Universitiy School of Medicine, USC-Doheny, and the new UC Riverside School of Medicine. He owned his own medical corporation, and also has practiced in the U.S. Navy, and the Veteran’s Administration.  His medical experience transsitioned from conventional fee for service, health maintenance organizations, IPAs, and prepaid contract medicine.