This article first appeared on CSA Online First on November 21, 2011
The Supreme Court announced last week that it will hear a challenge to the constitutionality of the 2010 health care reform act, known as “ObamaCare.” Before we pop open the champagne, we should take a moment to consider what this may mean for California physicians and for anesthesiologists in particular. “Whatever Court Rules, Major Changes in Health Care Likely to Last,” claims a recent New York Times headline. Should we believe that forecast?
The Court is allowing a remarkable five and a half hours for argument, as opposed to the one hour that it traditionally permits, because of the complexity of the questions it will decide. The first and arguably most important question is whether or not Congress has the constitutional power to require people to purchase health insurance or face a penalty: the “individual mandate.” This twist on taxation clearly infuriates many people. Whereas taxes support public services, this provision would pressure all of us to buy a product that not everyone wants.
Another key question is whether or not the rest of the law—the Patient Protection and Affordable Care Act (PPACA)—will stand if the individual mandate is struck down. The law forbids insurers to turn away any applicant or charge more for pre-existing conditions, assuming that new revenue from healthy patients would balance out the costs. Without the individual mandate in place, anyone could wait to buy health insurance until an accident happens or disease strikes, and insurance companies wouldn’t survive.
Uninsured patients are everyone’s problem, and we all pay—directly or indirectly—when they turn up in our emergency rooms, and we have to provide anesthesia for them. There’s a certain appeal to insisting that everyone pay something into the health care system that will be responsible for scooping them up from the freeway after a car wreck. Certainly here in Los Angeles we have our share of personal trainers and aspiring actors who have smart phones and cars but won’t spend the money to buy health insurance.
So let’s consider possible consequences of the Supreme Court’s decisions. If young, healthy people don’t have to buy health insurance, we’re back to the starting gate in terms of figuring out how to pay for trauma care. Here in California, changes in state law have already been made to align with the provisions of PPACA, and would be unaffected by the law’s repeal. The withdrawal of some proposed insurance rate hikes has saved consumers millions, though I’m willing to bet that doctors have absorbed more of that hit than the insurance companies, as fee-for-service reimbursements continue to shrink.
If the entire law is repealed, many physicians hope to see a return to happier days for the private practice of medicine. I doubt that’s realistic. Too many changes have already taken place: the absorption of small practices into large groups, and consolidation of hospital systems. Medical staffs are no longer composed of physicians only, but may include nurse practitioners and other mid-level providers who can provide cheaper care. The drive to have fewer anesthesiologists supervising more cases is only going to escalate.
For anesthesiologists, it would be wonderful to see the repeal of PPACA’s Section 2706. This is the innocent-sounding provision that prohibits discrimination by insurance companies against health care providers as long as they are acting within the scope of their licenses. This “non-discrimination” clause has opened the door for non-physicians to open clinics without physician oversight and bill insurers directly for anesthesia nerve blocks, epidurals and other complex pain management procedures. Putting a stop to that would truly be a service to public safety.
But the repeal of PPACA doesn’t answer the question of what we are going to do with our unaffordable health care system. As the recession drags on, more people are joining the ranks of the long-term unemployed, and their COBRA coverage is running out. America isn’t going to let the bodies of uninsured people pile up in the streets, so we will continue admitting them to hospitals. Without some motivation to alter the status quo, we will continue to “do everything possible” even for terminally ill patients, and waste billions in the process.
At some level, I think most of us realize how unsustainable the current system has become. My 89-year-old father who lives in South Carolina is as conservative as anyone. His idea of a nice Saturday afternoon is to take a walk around the statehouse grounds to see the monument to Senator Strom Thurmond and the Confederate flag. But when we were discussing health care, he said, quite seriously, “You know, when your mother and I lived in Canada for a couple of years, the government paid all our medical bills. We had good doctors and it worked fine. Why doesn’t the U.S. just do the same thing?”
I winced. “Dad,” I said. “Would it be OK if we wait to do that until I have the last child through college?” He agreed. But in the long run I fear that if the Supreme Court rules against ObamaCare, we may be moving that much closer to a single-payer system as the only way out of our current dilemma. I hope I’m wrong.
I am curious what you would propose to “fix” the system if you are toasting the end of Obamacare, yet I think I can infer that you do not want bodies to pile up outside hospitals and do not want a single-payer system. It is, no doubt, a terribly complex issue.
My *young* family is an insurance company’s nightmare. My 30-yr old husband was diagnosed with terminal but long-term cancer. Without insurance through employers, we would be unable to insure our family now if the healthcare act is struck down. We are highly educated, high earners, diligent taxpayers, and home-owners with a mortgage as our only debt. Responsible Americans. Still, STILL, we would have had to declare bankruptcy without insurance. Very few people could afford $750000 for brain surgery, hospital stays, medication and radiation. There was nothing we did to bring this cancer on our family. It is bad luck that struck before even middle age. Do we as a society say screw the poor and sick? Most people say no when that question becomes “screw my family?” and they actually are or know someone in such a situation.
Really, I would like to know what you think would work better than the current system, the new healthcare act about to be struck down, or a single-payer system.
I don’t pretend to be a policy-maker; I’m a physician in full-time clinical practice. That’s probably why my article doesn’t reach any definite conclusion, or come out squarely for or against repeal of PPACA. Ethically, I believe that we as a society have a responsibility to provide catastrophic care for all Americans, to cover exactly the situation you describe in your family. PPACA was not well thought through and is deeply flawed; that is why there is a good chance that the Supreme Court may overturn one or more of its key provisions.
To me, it would make the most sense for the U.S. to provide catastrophic health insurance for all Americans by means of additional personal income tax. This would provide security for cancer patients as well as provide trauma care for the 20-year-old who runs his motorcycle off the road. Beyond that, I don’t favor a system of single-payer, government-run health care. The reason why American medical care has led in research and initiative for the past 100 years is because the rewards led intelligent, ambitious people to go into medicine. As soon as you put all physicians on flat salaries, that motivation will go away just as it does any time you eliminate a free market. People should budget and pay for non-catastrophic medical care just as they do for all other expenses in life. If they were to choose not to buy additional health insurance above the basic, catastrophic-care government plan, then that would be their decision and they would have to deal with the risks and benefits.
It’s hard to find the perfect middle ground between a free society and one that neglects its most vulnerable people. Yet that’s the challenge we face.
I want to thank you very much for taking the time to write, and I certainly wish you and your family happiness and better times ahead. I can’t possibly imagine what you have been going through.
All the best,
Thanks for your reply. It is true that incentive drives innovation. Money is a strong motivator for people choosing career paths. I see that in my professional life as a college chemistry professor as I work with many students who aspire to become medical doctors. If helping people was the only motivation, certainly there are many other rewarding and, dare I say, less time-demanding career choices available. The path to becoming a physician is not and should not be easy to ensure high quality providers. In light of this, I strongly agree that doctors and other healthcare providers should be fairly rewarded for their expertise and the time/effort/money spent training to develop their skills. To me, though, the most serious issue that you mention is that this country has a state of the art healthcare system, but it is not accessible to everyone, only the privileged (including myself). There is no way that this adds up to being right. I hope that we can extend healthcare to more/all of our population in a way that preserves the best of our current system. I am not optimistic given what I have heard and read in the news, media, and blogosphere this week. Best of luck to you as your profession changes.