A Doc speaks out on Obamacare

by Marc Siegel, MD, Associate Professor of NYU, appeared in Politico, October 15, 2013.

My patients are not signing up for the new Obamacare insurance at the New York State exchange. Not a single patient so far. A few have tried, but they haven’t managed to get past the bureaucracy and come away with anything real.

One of my patients, 45 years old — a computer expert who has insurance through his employer but is afraid of losing it — spent two days trying to get through but couldn’t. Supposedly more than 50,000 people have signed up for the new Obamacare policies in New York State alone, but no doctor I know has seen any of them. Luckily, most of our patients already get their insurance through their employers or through Medicare or Medicaid and so won’t have to rely on the overburdened, underperforming exchanges.

The biggest problem with the Affordable Care Act, however, is not the new state health exchanges per se but the false promise they represent. Beyond just the exchanges, Obamacare will impact already overburdened doctors’ offices like mine by limiting access to actual health care rather than extending it as intended. Twenty-seven new programs and requirements will be enacted in 2014 alone, including the recommendations of the new Medicare Independent Payment Advisory Board.

Let me show you how these changes will affect my patients. More than half of them are on Medicare, and the elderly on the whole have more health problems and require more tests and treatments than do my younger patients. In 2014 it will become more difficult for the elderly to receive care as reimbursements are slashed further based on IPAB recommendations.

A 69-year-old smoker I saw for the first time this week was already seeing a cardiologist — whom she couldn’t reach when her heart sped up. Her gastroenterologist didn’t answer a phone call about her diarrhea. I guarantee you that Obamacare is not going to encourage these doctors to answer the phone faster or schedule appointments sooner. Just the opposite — as Medicare fees continue to drop, getting the care you need will only get harder. My new patient may now be “entitled” to a screening colonoscopy and a mammogram under the Affordable Care Act, but I am going to have the problem of trying to schedule these tests for her on top of fighting for a screening CT chest scan if IPAB doesn’t approve it.

Over on the employer-based health-insurance side, unless you have a policy that grandfathered in before 2010, you will be faced with new plans that restrict the number of tests and treatments I can order while paying me less and less to see you. This is how insurers plan to save money. Like the failed HMOs of the 1990s, they will shrink the networks of participating providers to those of us who are desperate enough to work within these limitations or are crooked enough to have concocted some medical mill to make money despite them.

Keep in mind that Obamacare mandates that employers cover at least 60 percent of your premium while the most you, the patient, can be asked to contribute is 9.5 percent of your yearly income. The policy deductibles are also being limited to $2,000 per year or $4,000 per family. Coverage for preexisting conditions, no lifetime limits, and no dropping a policy for illness are now mandatory. All this coverage is expensive for the insurer to provide — something has to give. If the premiums go too high, then employers can quickly drop you from their insurance plan (since President Obama deferred the business mandate for a year) or cut your hours so that you’re a part-time employee. So insurers restrict tests and cut fees to keep premiums down, and the impact in the doctor’s office is huge. Here is one disturbing example. Can you believe that as flu season begins, one awful but popular insurance plan is no longer reimbursing me for flu shots? The same insurer pays me less than $30 per visit, and only $5 for an EKG. How can I possibly continue to work with this insurance and give high-quality care, especially when all the specialists I generally refer to are running away from it?

My employed patients — including that 45-year-old computer expert — are worried that they will lose their coverage and be forced onto the dysfunctional state exchange. I can’t blame them for worrying. At the health exchange, according to the Kaiser Family Foundation, the national average for a silver plan for a non-smoking family of four with a $52,100 annual income is $8,290, and $3,669 even after the federal subsidy kicks in. Forgetting the drain on the taxpayer, do you know many working families with this kind of income who can afford $3,669 a year? If such a family chooses a bronze plan with a higher deductible in order to qualify for a lower premium, they will discover that Obamacare has delayed the out-of-pocket spending caps for at least a year. So if you choose the bronze plan because the price tag on the silver frightens you, you could end up with a premium you can afford but, when you get sick, be asked to fork over more cash to pay for your illness than you have in your bank account.

Can you find a doctor or a patient who believes that Obamacare has really addressed the problem it was intended to — providing health care for those who didn’t have it? I can’t. Even if you were uninsured before and now manage to get a policy at the state exchange, you are likely to find that your doctor or his hospital or the network of doctors he generally refers to are not accepting these new policies. This was the problem with restricted HMOs in the 1990s, and it drove many practicing doctors to begin to cherry-pick the policies they accepted. Even if I take your bronze or silver plan, the orthopedist or hernia surgeon or psychiatrist I am used to referring to may not. What are you going to do then?

If the feds really wanted to help uninsured patients instead of snowing us with false, expensive promises, they would have encouraged and even incentivized more talented people to go into medicine. Instead, they gave us Obamacare, a tumor growing on our economy and our health-care system. The American public is hungry for a cure.