Obamacare: Storm Coming

There may be a debate over whether Obamacare’s individual mandate is a penalty or a tax, but there is no debate among doctors and their patients about the fact that Obamacare will be bad for America’s health.

The climate in my medical office is changing; my patients sense that a storm is coming. They are worried, and there is little I can do to reassure them. They are used to my office manager getting approvals for the CT scans, mammograms, PSAs, and MRIs I order, and they realize that many of these tests will no longer be covered by insurance once Obamacare’s committees — which look at so-called comparative-effectiveness research and review current guidelines — are through with them.

Last week, with the Fourth of July looming, I was able to get a quick CT scan to rule out appendicitis for one patient, and an ultrasound of the legs to quickly diagnose a blood clot for another. Tests like these — ordered solely on the basis of my medical intuition – may not be possible in a few years. Since in both cases the symptoms weren’t “textbook,” I would probably have had to appeal to some Kafkaesque committee, wasting precious time; in an extreme instance, this could even cost a patient his or her life.

My patients know that their premiums will be going up and that, paradoxically, they will be receiving less service for their money. This is what happens when more people enter the system and are covered with easy-to-overuse insurance. Patients who overuse services will ultimately crowd out legitimate use for the group, as more regulations are imposed by both public and private insurers to preserve their bottom lines. Unfortunately, this process jeopardizes the art of medicine and real medical treatments, as doctors are pressured to conform to guidelines and insurers refuse to cover creative solutions. Obamacare caters to the worried well by allowing anyone to use the insurance, whether he or she is sick or not, with lower co-pays and deductibles and therefore no incentive against overuse. My patients also realize that I will be paid less for seeing them — first by Medicare and Medicaid, and then the private insurers will follow suit. Patients anticipate longer waits in my office and less time to spend with me. No one is asking me any more when I will change my office carpet or paint the peeling walls.

My patients know that there is a doctor shortage, and that many of the doctors who are practicing medicine today are not accepting their insurance. They know that this reality applies to specialists as well as primary-care doctors. Nurse practitioners are well trained and have a focus on nutrition and prevention that many doctors lack, but my patients know they are not interchangeable with me.

My patients are smart, and they can see into the Obamacare future, but there are a few things they may not anticipate. First, I believe our newest technology is in jeopardy because it is made for targeted, super-specialized treatment. We have been leaving the age of one-size-fits-all solutions and entering the age of personalized genetic and immunological treatments for cancer and other chronic diseases. Not only are these treatments expensive, but they also won’t work with an insurance or government-run model of care, which cannot justify a big expense for a treatment for a small group of bpatients (known as an orphan drug). This problem already exists in the current health-care world (Avastin and other targeted treatments for cancer, as well as the latest surgical techniques, are not always covered), but it will only get worse with Obamacare, which has strained to throw the insurance blanket over more and more people.

Second, there will be fewer and fewer opportunities to pay for health care out of pocket. Flexible-spending accounts will be reduced to less than $2,500 per year beginning in 2013, and tax deductions for medical services will be harder to get. Paying out of pocket makes a patient more aware of what he or she is getting for the money and, even with the tax deduction, less likely to see a doctor unless the need is real. Reducing these options is one of Obamacare’s big mistakes.

Third, as long as doctors practice in a climate where frivolous lawsuits are a constant threat, they will be particularly vulnerable to the whims of Obamacare. Remember, if I believe you should have a test for your prostate or your lungs or your breast but insurance won’t cover it, I am the only one liable if there is a bad outcome, not the insurance company, and not the government agency that issues guidelines insisting the test isn’t necessary. Even if I were simply following a government guideline, I could still be sued frivolously for a bad outcome.

Of course, there will still be doctors who consider medicine a calling rather than a business, doctors who will continue to practice medicine with the same careful, caring approach, no matter how it affects their bottom lines. This may be the only way for doctors to continue to feel good about what they do, but unfortunately, it is not the most practical way to survive the Obamacare storm.

— Marc Siegel, M.D., is an associate professor of medicine at the NYU Langone Medical Center and medical director of the center’s Doctor Radio. He is a member of the Fox News Medical A Team and the author of The Inner Pulse: Unlocking the Secret Code of Sickness and Health.

"Last week, with the Fourth of July looming, I was able to get a quick CT scan to rule out appendicitis for one patient, and an ultrasound of the legs to quickly diagnose a blood clot for another. Tests like these — ordered solely on the basis of my medical intuition – may not be possible in a few years. Since in both cases the symptoms weren’t “textbook,” I would probably have had to appeal to some Kafkaesque committee, wasting precious time; in an extreme instance, this could even cost a patient his or her life."

Apparently the incidence of appendicitis drops with age. I had to spend 24 hr in the ER as a geezer trying to convince the system that I had acute appendicitis.

After going into the ER in the afternoon I was still in the waiting room at midnight and went home for a night's rest.

I started in at the ER again the next morning and spent nearly all day waiting around and trying to convince someone that I had an issue. Finally the head of the ER (it's a teaching hospital) said he would give me a CT scan against the recommendations of his (highly trained) staff. Sure enough, within 15 minutes the surgery team stopped by to inform me that I was going upstairs immediately. Then they asked why I had waited so long! But for the little talk with the old Doc, I'd have never gotten the operation.

Under 0care, I'd have been toast.

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