ObamaCare Transformation Difficult and May Fail

Life is short, the art long, opportunity fleeting, experiment treacherous, judgment difficult.

Hippocrates (460-377 BC)

If Hippocrates were alive today,  he might be describing ObamaCare.

Its life will be short if Republicans win election and repeal ObamaCare, the opportunity for implementation will be fleeting if health exchange market assumptions continue to collapse,  its experiments with doctor payments and regulation will be treacherous as physician shortages mount and doctors refuse to accept more Medicare and Medicaid patients,  and if its judgments of how to fix it if the new Congress does not pass a Public Option provision.

At least that’s how I interpret today’s health care news.

·         “As ObamaCare Choices Shrink, Feds Face Consumer and Political Backlash,”  USA Today

·         “ ObamaCare Markets Are in Trouble: What Can Be Done,” 

New York Times 

·         “ObamaCare Economic Assumptions Collapse, Real Clear Politics

It’s really not as complicated as it is sometimes portrayed.  Insurers  need to make a profit to stay in business.   To make a profit,  insurers need the right mix of the healthy and the sick and the young and the old.   That mix is not forthcoming.  Major insurers – United, Aetna, and Humana – are pulling out of markets.   Government-run Consumer Operated and Oriented Plans are going bankrupt.  For consumers,  choices are disappearing,  prices are rising, markets are too small to predict profitable premiums, the rules are too complicated to comprehend,  too few people , half of what predicted, are joining the exchanges,  and the government’s economic assumptions, that consumers would welcome government intervention with subsidies for the have-nots and higher-taxes for the haves.

There’s another factor as well.  A country-wide health care transformation with disruption and lower revenues for most health care providers is not progressing as planned.  Many clinicians and hospitals are not cooperating or are resisting its provisions.   As Richard Bohmer of the Nuffield Trust in London observes,  a health care transformation is hard work (New England Journal of Medicine, August 25, 2016).    Such a transformation  requires  redesign of the entire system, the redesign teams are typically led by clinicians “Clinician-led teams take control of patient-facing organizations subsystems and reform clinical protocolas and operations and make modifications, review performance data and make modifications.. and actively create the local system needed to provide the best possible care.”  This sounds good in theory, but in practice,  many clinicians distrust government,  revolt against protocols, guidelines, and algorithms robbing them of their autonomy and income ,  and do not see quality and efficiencies  promised by reformists.   “The most substantial hurdle,” to health care reform, “ is a change in mindset.”  That change has not yet occurred among most of America’s  independent physicians in private practice.