Tuesday, April 14, 2015

The Missed Opportunities of the Affordable Care Act

Despite the optimistic statements of those who passed the Affordable Care Act who have been designated left wingers, the truth is far different from what is published and stated. Obamacare was and remains a shortcut with no ending, and certainly does not bring us any closer to the stated goal (affordable and accessible). It is neither, nor is it a universal health care system.

Much of our health system remains mired in old ideas and institutions, such as the Veterans Administration, Community Clinics, private practice, university centers, and military medicine. Networks and managed care have grown into another barrier to access care, rather than simplifying it has made it more difficult to negotiate. Health Networks are far from uniform for accessibility largely due to institutional selectivity based upon which system is less onerous, with either reduced reimbursement, increased bureaucracy, and patient accessibility.

The primary care provider remains a gatekeeper in most managed care settings. A cafeteria system of benefits and premiums offer differing copays, deductibles, and scope of services. The relationship is inverse between premium and copays and deductibles. The current version of Obamacare has overall made premiums rise. As we progress lower and lower in income into the population that is close to the poverty level the system deteriorates further.

Those on the edge of subsidy land often have a subsidy which is inadequate for them to purchase a policy. Those who fall into the range of medi-caid face greater obstacles,sometimes making medical care unobtainable except in a life threatening emergency, in which the old system already provided  a safety-net.

Health care has become even more politicized and one is identified by which side of the argument you are on. As physicians we have always ballked at being politicized, for obvious reasons. Political actions will always threaten the quality and consistency of health care. Medical care is not obtained by voting. No one can restore health by voting one way or another. Health care can not be legislated, it can be funded, sometime.

The California Health Care Foundation tracks population health statistics.

Republicans and a few Democrats are using "Repeal Obamacare" as part of their political platform and campaign agendas.

Unwinding Obamacare will be a challenge. The Affordable Care Act created new self interest groups, for HIT, Accountable Care Organizations, and many others in additon to overriding legal costs and new contracting arrangements for insurers, and hospitals.

If Obamacare is repealed or amended, then what ?

Perhaps the most beneficial aspects of the Affordable Care Act is the elimination of pre-existing causes  as a reason for denial.  Standardization of the profit margin ceiling removes some of the profiteering by insurers,  however it is no guarrantee that will remain true. Large institutions have a way of 'cooking the books' transferring any visible profits to another category.  The motive is financial survival and lowering risk of losing assets.  Those are powerful incentives.

The CHCF outlines the Uninsured in California,
The Private Insurance Market in California, 2013, many insurers are in perilous financial condition
While Obamacare has gone into effect, valid long range statistics are still a wild guess. 
If you are still a proponent you can find reasons to state it is successful. A more neutral opinion would state 

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