EDITORIAL ADVISORY BOARD: Obamacare's ambitious goals hard to realize

2014-03-09T00:00:00Z EDITORIAL ADVISORY BOARD: Obamacare's ambitious goals hard to realizeBy Patrick Bankston nwitimes.com
March 09, 2014 12:00 am  • 

We really do not have a health care “system” in the United States, especially when compared to the European model of a government-run, single-payer system.

Instead we have an odd, hybrid mix, cobbled-together over the past 70 years, of private health care providers paid for service by the federal and state governments (Medicare, Medicaid) or by private insurance through employers or bought by individuals separately.

The result of this Rube Goldberg, third-party-payer construct has been skyrocketing medical costs, unaffordable for any individual, and an incomprehensible system of charges different for every clinic and hospital and variable depending on the payer.

Also, many people, especially younger ones, go without insurance coverage, but can get expensive care at emergency rooms and hospitals, which by another federal law must treat all patients equally without regard to ability to pay. When they can’t pay, these costs are passed on to insurance companies (and hence all of us) through increased charges for private insurance patients.

Fortunately, we have the best health care professionals and institutions in the world, capable of providing the best care in the world. Unfortunately, the combination of unaffordable costs, a large group of Americans without insurance coverage, and our citizens’ poor health care habits has resulted in health care outcomes that match third world countries in some categories.

The Patient Protection and Affordable Care Act, otherwise known as the Affordable Care Act or Obamacare, is an ambitious attempt to rectify some of these problems, while retaining our present health care “system”, but providing better care for more people at reduced costs.

Medicaid expansion: Medicaid coverage was expanded (but not in Indiana and several other states) to cover more low income people in the hope that they would get better care and stay out of expensive emergency rooms with advanced illness. Early results show Medicaid patients still go to emergency rooms in similar or greater numbers than they did before Obamacare, because that’s the way they have always done it. Medicaid patients could get good comprehensive care at the Federally Qualified Health Centers, FQHCs, also expanded under Obamacare. (Northwest Indiana has three of them with multiple locations). A change in culture is needed for these patients, and that will take some time.

Individual mandate: Insurance coverage by the newly formed state or federal exchanges was mandated for citizens without employer-sponsored insurance with subsidies for low-income people not qualifying for Medicaid. Many low- to moderate-income people find the premiums unacceptably high, usually several hundred dollars a month, deductibles huge, thousands for family coverage, and thus are choosing to go without coverage and to accept a small IRS penalty. The ER then remains their primary care provider (but they too could take advantage of the low-cost FQHCs).

Insurance reform: Insurance plans are required to offer plans that cover many routine screening tests with no copay and to ignore preexisting conditions. This has resulted in many catastrophic or low cost minimal coverage plans being cancelled for individuals and only higher cost plans available. Some people in this category will go without coverage rather than pay higher costs and some people will have to find another doctor or hospital because their’s is not included in their new plan.

Pay for performance: Under Obamacare, through the new accountable care organizations and other federal programs, the records of doctors and hospitals are in the process of being gathered and, by a number of mechanisms which will increase over time, payments for services will be based on outcomes of patient care or illnesses prevented, rather than services rendered. In other words, our health care professionals will not be paid to treat patients’ illnesses, but rather paid for the success of treatment and prevention of further expensive care.

This is a profound change in responsibilities of the health care providers, in essence requiring them to help change the health behaviors of patients in order to be paid. This is a tall order to ask providers in America, a country founded by people with a distrust of authority and a disdain for being told what to do, even by their doctor or nurse.

So it’s obvious that this tinkering with our complex and irrationally designed “system” by Obamacare will have much trouble meeting its goals of better care for more people at reduced costs.

Whether this can be sorted out successfully over time is not clear.

Patrick Bankston is associate dean of the Indiana University School of Medicine Northwest and dean of IU Northwest's College of Health and Human Services. The opinions are the writer's.

Copyright 2014 nwitimes.com. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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