Tuesday, October 4, 2016

Why ObamaCare Faces an Uncertain Future

With the presidential elections rapidly approaching, both candidates admit ObamaCare is in trouble due to public unpopularity,  heavy losses among insurers in health exchanges,   insurer withdrawals in multiple states leaving only one choice in 6 states, and soaring premiums (up to 67% in Minnesota.

Brief History of Modern Health Reform

In 1965, Congress passed the Medicare Act, which was quickly coupled  with Medicaid legislation.  That was the beginning of modern health reform.    The HMO Act of 1973  followed with DRG legislation close behind.   ObamaCare became law in 2010.   In 2016,  ObamaCare’s fate will be determined by the Presidential election, with Hillary Clinton promising to fix it and  Donald Trump pledging to repeal it.

ObamaCare Unraveling

With spikes of average premiums of 23% for individual health exchange markets  scheduled for 2017,   17 of 23 non-for-profit consumer-oriented plans collapsing,   and major insurers, including Blue Cross Blue Shield plans , withdrawing from health exchange markets,  ObamaCare may  be unraveling. 

This may happen no matter who wins the Presidency, even if the Obama administration pays $5 billion to 175 insurers  from the obscure Treasurer’s Judgment Fund to rescue “risk corridors” to satisfy legal claims against the government and to circumvent Republican opposition.

A Great Idea in Shambles

In the eyes of progressives,  ObamaCare remains  a great idea, a giant step forward towards universal coverage. 

What went wrong?   In a September 29 Health Care Blog,   “Fail to Scale: Why Great Ideas in Healthcare Don’t Thrive Everywhere.,” Jeff Goldsmith , a National Advisor to Navigant Healthcare,and Lawton Burns, a professor at Wharton,  put their finger on a central flaw in the law.  

No Single Bullet, Sweeping  Solutions Nationally

“A failure to understand and respect the role that local culture and market conditions for health system innovation profoundly limits the effectiveness of “single bullet” policy solutions….Perhaps a healthy respect for non-economic factors in health system behavior—often rooted in local and regional circumstances and in institutional culture—might be a corrective for those who see sweeping ‘national”’ solutions to complex problems.”

No Replicable, Expandable Regional Models

Policy makers and economists failed to recognize that there is no model for health reform that is replicable and expandable  to other sections of the country. What works in California (Kaiser’s top-down  integrated model with owned hospitals and physician employees),  may not work in the Midwest, South, or East( provider-led-organizations (IPAs) practices),  or  in the Southwest an , or with hospital dominated systems (Connecticut), or with academically-rooted large practices ( Harvard,  Johns Hopkins, Duke).

U.S.  A Pluralistic Populist Culture

The U.S. has a pluralistic, populist, polyglot health system.  Its citizens and its physicians cherish individual choice and privacy.  Physicians instinctively  reject condescending lectures from elites in Washington about what is morally right.   No single model works well in every region of the country.   It is political arrogance to think that centralized government can impose a single model or structure of care, e.g. Accountable Care Organizations, upon physicians or health care organizations. It is political ignorance that you remove all insurance risk by accepting all comers regardless of their pre-existing conditions or that you can pass a national health law without a single Republican vote.

Political and Social Forces at Work

Yet  the U.S. can no longer sustain rising costs of  health care  which will soon consume 20% of the national budget.

Political and social forces are at work in both the government and private sector in a search for solutions to rising costs and uneven quality.

ObamaCare has enrolled 8 million largely subsidized people its health exchanges and 5 million in Medicaid;  it has implemented data-based value systems to measure what it will pay doctors and hospitals; it has tried to expand Accountable Care Organizations; and it has forced physicians and hospitals to collect data through widespread use of electronic health records.   

Provider Reaction

The private sector has reacted with unprecedented hospital and medical group consolation, and with proliferation of urgent care centers, retail clinics,  direct pay concierge medicine,  and other outpatient centers and facilities.   

In the process, it has aggravated growing physician shortages,  and it has produced a system in which primary care physicians are being replaced or supplemented by physician extenders (physician assistants and nurse practitioners.

How Physicians Have Responded with Uncertainty : Physicians Foundation Survey

How have physicians responded to these sweeping changes? 

According to the just released 2014 Physicians Foundation national survey, which follows 2012 and 2008 surveys, the reaction has been mixed . 

The 2014 survey has over 17.000 responses to 650,000 questionnaires sent to practicing physicians. 

Of those who responded.

46% gave the ACA a grade or D or F, while 25% gave it an A or a B.


 81% said they were overextended or at full capacity, while  only 19% said they had time to see more patients.


50% would still recommend medicine as a career.


53% indicated they were employees of hospitals or medical groups, and only 17% were solo practice while 35% were in independent practice.


44% said they planned to take steps to reduce patient access,    24% did not take Medicare or limited it, and 38% did not see Medicare patients or limited their access.


33% participated in ObamaCare health exchanges, and 28% had no plans to do so.


They said they spend an average of 20% of their time on non-clinical paperwork.


85% had electronic health records,  46% said EMRs increased their efficiency, while 24% said it decreased their efficiency.


26% participated in Accountable Care Organizations but only 13% believed ACOs would enhance quality or  decrease costs.

Responses Not All Negative

Not all responses were negative. 44% said morale was up, an increase of 12% since 2012, and young physicians under 45 were more optimistic than their elders. 

A Changing of the Guard

Clearly there is a changing of the guard – from independent practice to hospital and large group  employment, from fee-from-service to data-based reimbursement,  from individual responsibility to measured accountability by government and corporate entities and employers.  


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