The problem with Obamacare is that it doesn’t do enough

Obamacare is here. It’s really here.

You might be wondering what’s been going on in the hospital or office — the contact points where health care actually happens.

The funny thing is: nothing seems any different.

And this is the problem with Obamacare. It hasn’t, won’t, or perhaps couldn’t, change the fundamental problem with US health care. Namely, that it is too big, too disruptive, and too devoid of nuance. In this way, health care mirrors modern American culture. We put in too little, expect too much and can’t seem to get by with less.

I realize, that seems awfully negative. So let’s be heart-healthy, and begin with the positives.

Obamacare does many good things. It was a national embarrassment that we knowingly allowed large groups of fellow humans to go without basic health insurance. Germany, Britain, Netherlands and many other countries provide their citizens health care. So should we. Removal of the pre-existing condition barrier to getting coverage may be a challenge from an insurance perspective, but it’s necessary and right.

When Mr. Clinton spoke to us at the Heart Rhythm Society sessions this year, he was right to say we needed change. Not only is our current system financially doomed, it is neither compassionate nor fair.

My problem with Obamacare is that it’s like so much of medical care these days: it doesn’t address the root cause of the problem. Does a cardiologist who stents a blockage in an artery fix the problem of atherosclerosis? Does a heart rhythm doctor who medicates a stress/obesity/alcohol-related rhythm issue fix the problem? How do we reward a proceduralist that finds a safe cheaper way to do a procedure, say by avoiding use of an expensive ultrasound catheter? We dock his and his hospital’s pay.

So nothing is changed where the rubber meets the road. In fact, it’s worse. I spoke with a doctor who poignantly spoke of how she spends hours teaching her patients about basic health care behaviors, like good sleep, good food and good exercise, and her productivity has plummeted. “It’s far better to do than to educate,” she said.

Another thing that hasn’t changed is the metastasis of misplaced incentives. Rather than incent caregivers to provide gentle nuanced care, policy makers have imposed dreadful regulations that have only created a culture of checklists. Nothing has been done to curb the fee-for-service model. This is a huge problem because FFS punishes caregivers that practice minimally disruptive care. Do hospitals that employ physicians (and operate on razor-thin margins) want their doctors doing fewer procedures and ordering fewer CT scans and MRIs?

I’m an optimist though. Let’s assume that emergency care remains intact. We’ve always been good at taking care of the sickest. Obamacare will not change that.

In the care of chronic diseases, the main health issue in America, I ask you to look around and consider whether we could do any worse? Consider mammogram and prostate cancer screening failures, over-treatment of the elderly, the promulgation of unproven drugs for cholesterol and the many pharma-created disease-states. The list of unproven, aggressive and expensive care is endless.

I’ve never been more convinced that good health cometh not from health care. The change will be tough, change always is, but Americans will learn that if they take better care of their minds and bodies, they won’t need as much medical care.

The health of our citizens will not go down as access to care decreases. Based on what I see every day, it’s more likely that less access will improve our health.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • Ron Smith

    John, did you really believe that Obamacare was intended to *improve* healthcare? Surely not.

    Whatever cruft its authors throw out about it is inconsequential. It is intended strictly as a political tool to change the government into a (the) controlling entity in another aspect of each person’s daily life. It is social engineering at its worst.


    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Johanne Von Kay Raus

      Proof of his insincerity in wanting to actually fix health care is the lack of any meaningful med-mal reform in the bill. This bill is just more of the same; politicians protecting the financial interests of their most valuable donators.

  • Margalit Gur-Arie

    I agree that it doesn’t do enough, but I would be OK if it took a small step in what I believe is the right direction, and I don’t think it does.
    Take for example the preexisting conditions. Why is that such an insurmountable problem? For the vast majority of Americans that get health insurance through an employer (large group coverage), preexisting conditions play no role. As long as you move between medium to large employers, nobody can deny you coverage and nobody did. So obviously, in that market segment (large groups), preexisting conditions were not a hardship on insurers, and did not cause premiums to skyrocket.So the simplest solutions to preexisting conditions is much larger pools. [Warning! Liberal talk: One big huge pool for all of us would probably drive premiums into the ground].
    So I appreciate the “elimination” of preexisting conditions, but I don’t appreciate the hype surrounding a suboptimal solution. Note that health insurers seem to love health care reform.

    • PCPMD

      While the individual employee doesn’t immediately recognize the financial cost of subsidizing others’ pre-existing conditions, it does absolutely impact their monthly premiums and the cost their employer pays for the group policy (which in turn effects the companies productivity and the resources they have left to pay for salary, benefits, etc). Its one of the many reasons that employers have started “incentivising” healthy behavior such as smoking cessation, weight loss, etc. – not only does it reduce things like sick leave and improve productivity, but it directly impacts their group policy costs – insurers will charge them less when their employees, as a whole, are healthier. But extension, the individual cost each employee pays will also be less if everyone is healthier, and higher if everyone is not. There’s no such thing as a free lunch.

      • Deceased MD

        I think the Healthcare industry’s propaganda is that we are all subsidizing others such as illegal immigrants and the disabled and the pre-existing. Although no one can argue that all these factors add cost, what they leave out are the most substantial. Big pharma makes money buying off their generic competitors. There is no transparency in costs in all of healthcare. Hip replacements can range from $11,000 to $125,000. I could write a book about this. In economics I believe the term is rent seeking. Charging much more for a product than it is really worth. I would argue this is the central reason why are costs are so high vs any other developed country. In Germany I don’t think they are fighting over the last bread crumb.

        • Guest

          “Rent-seeking” in economics is when a company, organization or individual uses their resources to obtain an economic gain from others (usually through government fiat) without reciprocating any benefits back to society through wealth creation. It has nothing to do with simply “charging much more for a product than it is really worth”, in a free market (otherwise the makers of designer clothes would be guilty of rent-seeking, for in no world is a dress actually “worth” $15,000 or more).

          An example of rent-seeking is when a company lobbies the government for special treatment (i.e. corn growers lobbying government for mandatory ethanol inclusion in fuel, or insurance companies lobbying government to force all citizens to buy health insurance). These activities don’t create any benefit for society, they just redistribute resources from the taxpayers to the special-interest group.

      • Margalit Gur-Arie

        Sure, everybody is subsidizing everybody, but somehow in the large group market, this did not translate into exclusion of sick people and the premiums were/are generally lower than the ones in the individual market, so preexisting conditions is a problem of organizing the pools.
        As to the costs to employers, and productivity issues, I would note here that average productivity of American workers has been steadily increasing, while wages have been stagnating, and the discrepancy cannot be explained by a few hundred dollars a month in insurance premiums. I am also willing to bet my last dime, that if tomorrow, the government picked up all health insurance costs, you will see no increase in workers’ wages. Employers will just pocket the difference.
        This is also pertinent to “wellness” scams because most employers with penalty programs for unhealthy status are self insured, and either way making the worker pay more for health insurance for whatever reason, is good for both employers and insurers. It’s a different racket than preexisting conditions, but a racket nevertheless.

        • PCPMD

          1) Almost by definition, employer-provided insurance pools are not that diverse, as they almost universally exclude

          a) People > 65
          b) Those too disabled to work enough to maintain benefits
          c) Those who need healthcare so often, that they cannot practically hold down a full-time job.

          When you eliminate those people from any group, the overall insurance risk for that group will diminish significantly. Furthermore, employment itself is a negative risk factor for morbidity and utilization of health care resources. So yes, “pre-existing conditions” in that pool are not as costly to ensure as they would be in the nemployed/unemployable/minimally employed group (or anyone unfortunate enough to be lumped into that group).

          This is more than a technicality. What it means is that if you wanted relatively lower premiums, you had to demonstrate to insurers that you were a productive member of society (by…well, being a productive member of society). Its similar to how car-insurance companies use your credit report as a way to gauge your car insurance premiums, even though on the surface, one would not appear to have anything to do with the other.

          2) There has never been a requirement for employers to provide healthcare insurance. That many do so for their full-time employees, has always been a voluntary act as a means of recruiting and retaining talent.
          If, as healthcare costs continue to outstrip the rate of inflation, employers are become less reluctant to absorb those costs, is anyone surprised that employees are seeing their share of the premiums go up?

          Regarding the flattening of wages, there are far too many variables in the supply/demand of labor vs goods to make a simple generalization.

          However, if the health-care part of the total benefits package has been rising by 7-10% per year, then it would be expected that the wage portion of the benefits package would not go up very much as a result (you only have so much money you can alot per employee, whether its in health-care premiums or wages, or some combination of the two)

          • Margalit Gur-Arie

            Regarding 1): I think we can safely eliminate a) and b) since people over 65 and those with enough disability are covered by public insurance. Which leaves c) and yes those are driving costs up, but preexisting conditions come in many flavors from higher premiums, to exclusions, to outright denial. Lots of folks falling under the preexisting conditions rubric are gainfully employed and fully insured at the same rates as their healthier coworkers. I am not saying that the few that are too sick to work won’t add something to the costs, but not as much as people are made to believe.

            Regarding 2): The problem here is that employee compensation, including health and retirement benefits, as a share of national income is at its lowest in fifty years, and it’s probably worse because the portion going to the highest paid employees has also increased. So it’s not that employers are paying more, or even the same per employee. They are paying less, while corporate profits are increasing just fine, most likely because productivity per employee is steadily climbing (23% in the first decade of this century).
            Yes, there are all sorts of factors at work here, not the least of which are technology and outsourcing, both of which are coming to a hospital near you really really soon, because that’s what health reform is really all about. The insurance thing is a diversion…

  • ninguem

    The architects of “obamacare” are all on record at one time or another, advocating a single-payer system along the lines of Canada or the UK.

    Not least of which, is Obama himself. He is on record saying there will need to be an intermediate step between here, and there.

    So, of course “obamacare” doesn’t go “far enough”.

    And we know where it’s going, our leadership has made that clear for twenty years.

    • Margalit Gur-Arie

      What Mr. Obama says and what the President does, are unfortunately two very different things.
      I would love to see a single payer system, not like Canada, and definitely not like the UK, but more like the other European countries, which is better described as single collector system. The one thing Obamacare could have had that would have made it an interim step to universal care, would have been the “public option” or the opening of Medicare to people to buy into.

      Neither of those were left in Obamacare, and now we have a fantastic gift to private insurance, seeing how millions of new paying customers are delivered to them on a silver platter (a.k.a. taxpayer funded subsidies, including a good portion that goes to profits, empire building and executive highway robbery).

      • ninguem

        I’m not sure what you mean by “single collector”.

        Aren’t France, Germany, as examples, private insurance in a tightly regulated system? Who “collects”, is it the government with a pass-through to insurance? Or maybe I misunderstand those systems.

        • Margalit Gur-Arie

          They vary. France actually finances most health care expenditures with tax money and manages the “sick funds” too. Germany relies on an employer/employee system, plus tax revenues to help out, and independently managed “sick funds”. Italy, which surprisingly has one of the best systems, pays mostly from tax revenue. In Sweden it’s mostly public funds. And there are all sorts of other variations, and everywhere there is private supplemental insurance available.
          What makes this different is that insurers or sick funds don’t get to set their own prices and don’t get to make any profit. They are really just glorified administrators, and in some countries not even that. Physicians are mostly in private practice.

          • ninguem

            Then what would be the difference between that and, say, Medicare?

            Medicare is tax money, administered by a contracted insurance company. Currently Blue Shield in my area, and about 15 years ago, it was Aetna. The insurance company runs the traditional Medicare. Adjudicates claims, and then the payment comes from a regional Blue Shield Medicare office.

            Sounds like the systems on the Continent. Except, I suppose, the nonprofit thing. Not sure if Blue Shield is still a “nonprofit” organization.

          • Margalit Gur-Arie

            Right, it is like Medicare….. for all.

          • Deceased MD

            So it sounds like there is no insurance involved in Europe ( except privately I’m sure). I bet that makes a huge difference. So do you know, are physicians in private practice paid a set fee?
            No RUC?
            Get me on a plane to France. I’m getting out my Rosetta Stone.

          • Margalit Gur-Arie

            Well, there is insurance involved, but it’s either public, completely neutered, or regulated to have no profits, and prices are set. Physicians in private practice are paid set fees, but specialists in most places are still paid more than primary care, and all are paid a lot less than they are paid here.
            There is of course private insurance and lots of people get supplemental coverage. In Germany, if I recall, rich people are exempt from compulsory insurance altogether (but they still have to pay those high European taxes :-)).

          • Deceased MD

            Thanks for explaining. I think many do not realize what a difference in cost there is between private insurance here and the system you describe in Europe, I think it is easy to compare Medicare as a government run plan with Europe’s HC system and it indeed sounds much more transparent and cost contained over there.

          • Dorothygreen

            How about mix of Switzerland and Germany. A model closer to that. In every other country as I know it, prices are negotiated up front with the government – like Medicare but with Big Pharma added to the negotiations. And in Switzerland the insurance company rates are negotiated for basic services and it is the same basic rate for all. There are 90 insurance companies in the country which do all the administration – not the government. They can however, sell supplemental insurance for profit. So called alternative care, for private rooms, access to top docs. No one gets wealthy off sickness but the pay is reasonable. Everyone has to have insurance and the only way to get it is on the exchange. Yes, there are subsidies to the the poor, but for insurance.

            Switzerland health care system costs are high but half of what the US is.

            We must also do something about the strangle hold of Big Ag and Big food on what we eat. This is really the biggest driver of costs. And, it is time to talk about a RISK tax – an excise tax on processed sugars, refined grains, unnatural fats inclusive of oils with with over 50% O omega 6 and high sodium in processed food, This is not the government telling us what to eat, it is a public health issue, an individual health issue and an income taxpayer issue.

          • Margalit Gur-Arie

            I would take the Swiss system any day, because what they refer to as “basic care” is actually very comprehensive care and pretty much up to physicians and patients to pick and choose. France is significantly more centralized, but I think it was rated by OECD as the best system at one point.
            And yes, let’s tax corn, wheat and all other junk, take the money and subsidize fresh produce and sustainable local farmers.
            Not going to happen….

  • Anthony D

    “I’m an optimist though. Let’s assume that emergency care remains intact.
    We’ve always been good at taking care of the sickest. Obamacare will not change that.”

    When we have millions more entering the system AND a number of doctors
    retiring because of Obamacare (and some that are not have decided they
    will go to “cash only” and will not accept insurance due to the massive
    and cumbersome Obamacare law) you won’t be able to average one day for
    an appointment like you and I can now. Be ready for weeks if not months
    delays in appointment.

    And it MUST be that way. Adding millions of new patients but REDUCING the number of doctors and, well, you do the math.

    • southerndoc1

      And once again I ask you to specifically identify what in Obamacare makes dealing with insurance companies more difficult for physicians? The for-profit insurers have already done a great job of that on their own.

      • Mika

        This is true. I was seeing doctors start to move to direct pay models, especially if they were in socio-economic areas which could support that, since well before the ACA became a reality.

        The one slim silver lining I can see in Obamacare is that it may well accelerate the process of physicians and patients cutting Big Insurance (and Big Government) out of the mix altogether.

        Especially with so many health insurance policies having such huge out of pocket expenses ($10,000 in the case of many ordinary middle-class families), I can see direct pay looking a lot more attractive to many basically healthy young families.

        • Noni

          A question I have though is who can afford that? Now we are required by law to purchase health insurance (let’s say that’s $400/mo). On top of that who can afford to pay for concierge care? Don’t get me wrong, I am at a point where I’d love to stop doing business with these insurance criminals. But I wonder how the average or even above average Joe can pull it off.

          • Jess

            For that matter, who can afford to pay $10,000 out of pocket after shelling out 7 or 8 hundred dollars a month in health insurance premiums?

            I think a lot of people are going to fall through the cracks here. Those who are able to get subsidies, on the one end, and those who are able to buy themselves out of “the system”, on the other end, will be okay. It’s those in the middle who are going to get squashed.

  • Deceased MD

    I learned an old adage years ago; One of Murphy’s Laws. “The secret of success is sincerity. Once you can fake that you’ve got it made.” I would say what is confusing is Mr. Obama looks earnest as he is explaining the need for his bill and his concern for the medically ill without insurance. Behind the scenes, with EHRs ,he has agreed to exploiting pt’s private medical information under the guise of HIPAA with 18 de-identified
    data points for good measure.

    • Margalit Gur-Arie

      He also looks very earnest and concerned when he explains why the military needs to keep all Americans under illegal surveillance for no good reason. I voted for him twice, and enough is enough…

      • Deceased MD

        I voted for him too. But what choice was there? Can you imagine if Romney won? His comments at his fund raiser cinched the deal. And don’t forget. To paraphrase “If you’re not happy with your health insurance just leave it.”

        • Margalit Gur-Arie

          That’s exactly the problem. There are no good choices. They keep saying stuff to get money or votes, including most likely Mr. Romney’s remarks at a fundraiser event and no matter who we vote for, the same things keep happening. Talk about a system that’s broken… Health care is child play to fix, by comparison.

          • Deceased MD

            Good point. And it’s interesting how the focus at the moment that is shutting down government is health care. You know there was a recent article here you may have read by Allen Frances and he was actually saying that in order to address healthcare it starts with the government. At first glance it seemed a bit of a stretch, but then, they are both probably related. Our government is so corrupt at this point, I imagine it all trickles down.

          • Margalit Gur-Arie

            Yes, I read that. Frankly, at this point, I don’t care if the government is labeled conservative or progressive. I just want someone with integrity, willing to make a personal sacrifice and be a public servant. The rest will sort itself out, including health care.

  • Anthony D

    According to the Article 1, Section 7, of the United States Constitution,
    any legislation to create a tax to be collected by the federal
    government must originate in the House of Representatives. This is known
    as the Origination Clause. PLF claims that the original bill that was
    used to create Obamacare originated in the Senate and not the House,
    thus making Obamacare illegal. Based on this information they are now
    moving forward with the case in the court system.

    • amohtap

      John Roberts didn’t buy that argument the first time.

      • Jess

        The Supreme Court is not infallible. Think “Citizens United”.

  • lance martin

    Would a two term limit to every office in the country help anything? No Boehner, no Reid, no Pelosi… Just normal people being public servants and then returning to public life. I realize that we are in a quagmire, but this seems like a logical step. At least the large companies would have to buy more people.

    • safetygoal

      From your lips to God’s ear, Lance. I wish for that to happen!

  • Deceased MD

    “They also will demand that you stop doing certain activites which could adversely affect “the taxpayers” who are helping pay the bill. Goodbye motorcycles, skiing, skateboarding, football, drinking, smoking, the list is endless. Just to protect our health and force us to give them every last dime we have. I’m not feelin’ the love.”

    Sounds like something you have heard or read. Where did you hear that? And from what you wrote, how in the heck would they enforce that?

    • dontdoitagain

      Easy to try to enforce once they have all your records. Have you heard about the “war on drugs”? The CDC keeps on making more and more things into a “disease” that needs lots of regulataions to stamp out. No I didn’t hear it or read it, I have a lot of time to think when I’m at work.

  • flowerdocs

    Beautiful article. Agree that the main thrust of the Affordable Care Act is to provide access to health care for the vast majority of Americans. But as long as we remain an insurance-based fee for service industry, we will never achieve improved health. Other countries have accomplished that with national health systems that reward physicians for their time, not for their procedures, and put strict controls on pharmacy, interventions, and testing. On the other hand, given the nature of our rabidly capitalist society, perhaps this less than ideal first step is the only way to move forward toward national health care. Hopefully, the limitations that become apparent will force the health care system to evolve into a single payer model that is effective in rewarding care and discouraging harmful over treatment.

    • doc99

      The way you improve health is not to be found in the doctors’ offices or in the clinics but rather in the schools. We have systematically converted our kids from active lifestyles outdoors to couch potatoes playing video games and watching tv. To blame the doctors for this cultural shift is akin to blaming the town crier for the murder spree of Jack the Ripper.
      Obamacare is neither healthcare nor reform. It’s a grab bag of party favors for many special interests, sold by Joe Isuzu to the AMA and others by a “transformational” idol with feet of clay. The late NY Governor Al Smith said it best. “No matter how you slice it, it still comes out baloney.”

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