Who really benefits from President Obama’s health reform plan?

I don’t know about you, but as I watched coverage of President Obama signing the health care bill three months ago, it was hard not to notice the constant ads for power wheelchairs. Emblazoned across the ads was a flashing notice reminding viewers: Medicare may cover this!

Don’t get me wrong. As a primary care doctor who takes care of low-income patients, I was glad to see something being done to address the appalling health disparities that exist in this country. But as the president signed the legislation, I had the queasy feeling that he was essentially writing a big fat check to several hugely influential, multi-billion dollar interest groups – including, most notably, the pharmaceutical and insurance industries.

And so, the persistent flashing ads for power wheelchairs seemed a bit ironic. As heavily marketed devices that cost the system thousands of dollars individually – and earn millions in profits for their parent companies – power wheelchairs exemplify what’s wrong with the system. Individually, they’re a small part of the overall picture, but in aggregate, they cost a lot. And though they’re clearly necessary for patients whose arms and legs are paralyzed, they’re often prescribed inappropriately for people who would be better off getting intensive physical therapy and using a manual wheelchair instead.

(To be fair, under the new healthcare law, Medicare will only pay for renting, and not purchasing, power wheelchairs in many situations – which should cost the system slightly less money).

From my vantage point in the trenches of public primary care, here are a few of the good things about the new health plan.

It pours more money into neighborhood health centers, which have a long track record of making primary care accessible to low-income people.

It will put more doctors, dentists, nurse practitioners, and physician assistants in these clinics by expanding the National Health Service Corps.

It will encourage primary care doctors and general surgeons to work in low-income areas by offering a bonus.

The law also promises to make it easier for low-income people to get general medical care by paying primary care doctors the same amount for patients with Medicaid as for those with Medicare. (But it won’t do anything to raise Medicaid payments for specialists, meaning primary care providers will still be scrambling when our patients need a cardiac catheterization or other intervention).

The law also raises the Medicaid income cap to 133 percent of poverty level . Many governors are kicking and screaming about this provision, but it will help a lot of people who do jobs that, while important, pay poorly. For example, under the new rules, a single home health aide with two kids who earns $21,500 annually (approximately the average wage for that job ) should qualify for Medicaid coverage. Under present rules, only 10 states, and the District of Columbia, provide Medicaid to a single mother with that income. More than half of the states in this country don’t provide Medicaid to adults without children.

On the flip side, the law will push millions of people to buy expensive insurance policies from private companies. Many of these policies will have steep deductibles, so having insurance won’t necessarily protect people from financial ruin if they develop a serious medical condition. It’s also likely that expanding the private insurance system will make people’s care even more fragmented and difficult to navigate, since, in my experience, the private companies are far more likely than public programs to restrict what tests and medications the patient can get, and where they can get their lab tests done.

To subsidize these policies, the government will pay millions to private health insurance companies, many of which are for-profit. This is a bitter pill to swallow, when you consider these companies’ chief executive salaries and when you keep in mind that these companies make their profits by minimizing what they pay health providers and denying payment for as many services as possible. Just this week, a surgical colleague told me of a heavily marketed local Medicare HMO (with a multimillionaire chief executive) that routinely denies coverage for complicated cancer procedures. “They make it impossible,” he said.

The law is also a triumph for the pharmaceutical industry, which blocked efforts to allow Medicare to negotiate what it pays them for medications. (In contrast, Medicare tells hospitals and doctors exactly what it will pay for specific services – and requires lots of documentation to prove that those services were provided). One policy analyst told the Associated Press that he predicts a $30 billion increase in revenues over the next decade for the drug industry, adding, “I don’t see how they could have done much better.”

And so, my feelings are mixed. I’m really hoping that after the law goes into effect, I won’t see more cases like the nurse’s aide who declared bankruptcy after the bills came in for her CT scans, or the mechanic who couldn’t pay the upfront costs for the colonoscopy to figure out why he had blood in his stool. But I’m not so sure. And I worry that the plan is just an expensive, complicated way to address the symptoms of our broken health system, not a daring cure.

Erin Marcus is an internal medicine physician.  This article first appeared in New America Media.

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  • stargirl65

    “… the law will push millions of people to buy expensive insurance policies from private companies. Many of these policies will have steep deductibles, so having insurance won’t necessarily protect people from financial ruin if they develop a serious medical condition.”

    Currently my health insurance costs $13K a year just to have it. It includes a $3000 deductible. This means that the first $16K essentially comes out of my pocket. Then my health insurance plan will kick in and cover things (minus my copay).

    I can easily see how this could bankrupt people. They might bankrupt just paying for the plan though at $16K per year. Even if they never use it.

  • http://nostrums.blogspot.com Doc D

    Unfortunately for wage earners, the industry and government need tons of revenue to fund health care for those who are not able to pay for their needs.

    That’s the way it works. The money has to come from somewhere: the healthy pay for the sick, and the wage earners pay for the poor.

    I don’t care whether you set up a government-run or a free-market system. Either way it has to be paid for by those who can.

    Health care reform did great on coverage, but contains very little to control costs. See the recent articles on the Massachusetts experience (a close approximation of the US reform law).

  • Doc99

    The new law also guts HSA’s. Moreover, while the law may boost neighborhood clinics, the cuts by state budgest may result in their closing their doors.

  • Jen

    My husband is American (I’m Canadian), and we kept his American health insurance (he’s employed by an American company) for 3 years because he has some fairly serious health issues and he was paranoid about waiting lists. Recently he spent 3 weeks in 2 different NY hospitals, which were for the most part covered by his insurance (he pays $750/month, matched by his employer). Our bill for those was only about $1000, and we consider ourselves lucky.

    After he was discharged too early from the last NYC hospital he made it back to Ontario, and I got our ‘bill’ today (within 12 hours of being discharged from an NYC hospital he was on our back deck having seizures, and was in hospital here for about 56 hours all together).

    Our bill here was:

    Ambulance 45.00.

    CAT scans

    CT scan- Head. 44.55.


    XRay Cervical spine (3) 8.35
    XRay Chest 1 view (6.75)

    Estimated insurance due 15.10

    ONT. Health Insurance Prov. 59.65

    Total 104.65 – 59.65 Ont. Health insurance.

    We owe them 45.00.

    The really funny thing is that he’s taxed at a much lower rate in Ontario than he’s ever been in NY, even with a pretty good take home pay. It’s also been cheaper for us to pay out of pocket for most of his meds (Zegerid, Seroquel, Gabitril) than it is for the insurance premium he pays in the U.S.

    Fortunately next month we’re transferring to private insurance here, which will carry the shortfall that we’ve been paying out of pocket, not to mention the $750 he’s been paying off the top of his paycheque.

    It does seem like Obama’s bill will do something- we had the option of immigrating to the U.S., but with triplets with autism, one of whom is a cancer survivor, I’d be insane to give up our guaranteed health care. I do know some people with autistic children and kids with cancer who think that the Obama bill will help them in the long run, and I really hope it does. It’s pretty distressing when you’re talking online to another family who is undergoing BEP chemo for a germ cell tumor and can’t afford to go to their ER if their child’s temp is over 38 degrees.

    • rezmed09

      This says it all. The Canadian system is simple, costing much less of the GDP and yet we Americans demonize it.

  • http://wellescent.com/health_forum/topics Wellescent Health Forums

    Of all the concerns with the health reform bill, the lack of cost control is the one with the most potential to undermine the benefits of near universal coverage. When 17% of GDP is being spent on health care as compared to 10-11% in other countries with good health systems, there is quite obviously a serious issues of costs that needs to be addressed. Looking after the sick and the poor is not nearly as unpalatable for many if the costs that they will incur are reasonable. Some of the biggest arguments against health care have been based on cost so trying to control them has to be a part of the solution.

  • Sharzi

    Primary care as a career is NIGHTMARE, that will not change with Obama’s effort to put a measly 500 more primary care docs in the system by 2015. It’s all about BALANCE in life and with lives spiraling out of control in health care you can rest assured that any truly intelligent human being making health care a career will surely SPECIALIZE and not be P!mped out by the obama admin and basically be forced to see even more patients not to mention the 40 million plus illegals that are saying I NEED and I WANT!

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