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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