ObamaCare will not make us sick…

On day 1 of ObamaCare, the headline in our paper said “SHUTDOWN.” It’s here; it’s really here.

You might be wondering what’s been going on in the hospital or office–the contact points where healthcare 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 healthcare. Namely, that it is too big, too disruptive, and too devoid of nuance. In this way, healthcare 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 healthcare. 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 healthcare. 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.

JMM

P.S. My electrophysiology colleague, Dr Wes Fisher, had the same idea I had this morning. He also penned some thoughts on our new healthcare landscape. Always candid, Wes’ take is worth your time.

16 comments

  1. John, thank you for your thoughtful article. This is just one of the ways you are making a difference. Physicians, as a species, tend to focus on the problem in front of them. Usually it is a lab value, a specimen, or a living breathing human being. But there is another problem (i.e. a “forest” – not a tree) right before us – the Affordable Care Act. is our #1 job. We need to get outside our comfort zone and take up leadership roles in the evolution of our country’s healthcare. Our patients believe we are already doing this; they expect this of us. Have we risen to the task?

    1. That’s great advice. Thanks JPM. Editor’s note: Dr Murphy is the current president of Greater Louisville Medical Society – GLMS

  2. Thanks John. Many people fail to distinguish between “healthcare” and “healthcare insurance”, and I believe it’s an important separation. I agree, treatment of the root cause rather than signs/symptoms is paramount, and someone needs to explain to me why that’s a bad idea. I guess a good thing is that maybe the ER will not be serving as the primary care physician to the extent it already is in some dense areas.

    My problem with ACA/Obamacare/whatevercare, is the the way it did – or did not – come together. Still begrudgingly living in CT, I went to our state’s healthcare exchange website looking only for the premium of the various plans. No such information was apparent, which I believe is emblematic of this rollout. It’s a huge order, and politically I believe the process was bastardized and used to excoriate any defectors, critics, or others not in agreement with the current philosophies.

    Regardless, it’s here, or at least will be pending legislation to delay, repeal, etc. I’ll still hit the gym, still run half-marathons (maybe a full someday), still try to mostly eat right, and still take my meager supplements. My fear is that the medical infrastructure may burst under this new weight, my providers may opt out, and costs will spiral out of control like so many government – mandated programs. As I consider what could constitute a perfect storm in this situation, I look only to the DMV on a rainy Saturday morning, with 17 new drivers taking their tests. God forbid.

    Best to the family-
    Jay

  3. Great post, as always, except for the last two sentences. Access to care is a big problem for those millions of individuals without health insurance, and seems to be a detriment to good health. Though I couldn’t agree more, that healthier lifestyles will lead to less need for healthcare in general, and for an individual specifically.

    1. David…Read the last paragraph of Jay’s comment. He speaks of continuing to live a balanced healthy lifestyle. This action–on his part, not his doctor’s–will help reduce his chance of needing care. But in the event he (you) get sick, our system will always be good at intervening acutely. Sick care is not–nor will it likely ever be–our problem in this country.

      On the contrary: One of the major problems we have now is that easy access to doctors contributes to sick care in the absence of sickness. One of the themes I spend most of my working hours doing is removing sick care. Stopping meds, advising against procedures and promoting healthy living takes up more than half my day.

  4. What we had before was just untenable. People who had to buy their own insurance were in such a precarious position. Leaving a job, leaving a state, any major change in their health status and they lost all coverage. That’s not right or moral. The implementation of the ACA is unfortunate, what could have been really good has been handed to lobbyists, insurance companies and empty suits. Why President Obama did not push for single payer is beyond me.
    My rant is always the same. It’s not insurance, it’s a pre-paid coverage plan. I don’t insure for oil changes, why not let the routine stuff be out of pocket? Make prices known before hand. I just had an MRI on my foot, and for awhile it did not appear that insurance would cover it. Do you think I could find out what it would cost me? No. What kind of business operates like that? Post the prices. Let the market decided. Medical pricing is just beyond opaque.
    Ok, off soap box. Time for oatmeal with flax,and a brisk walk.

    1. I had a conversation with a plastic surgeon yesterday. I complimented their practice model. He beamed. “It’s normal economics.” Think about that: In a plastic surgeon’s office one understands exactly what the cost will be. The fee of the surgeon, anesthesiologist and hospital are known. Patients can choose to have x procedure, y procedure or no procedure.

      The argument against making medical care more transparent is that medical care is more ‘necessary’ than plastic surgery. Yes and no. It’s true in some ways, but much of medicine is in fact elective, or at least, preference sensitive. Here, transparency and a little ‘skin in the game’ would help patients make more informed decisions. Arthroscopic knee surgery comes to mind. If both physical therapy (which is hard and requires personal action) and surgery (passive on the patient’s part) are equivalent medically but surgery is more expensive, what is wrong with asking patients to pay more for the more expensive option?

  5. Despite that health care in the US has problems, would you give up your insurance for that reason? I am certain you would not. I have a friend walking around with a hernia for several years now–homeless and no insurance. Another friend on the verge of homeless suffered with terrible stomach pains for a year. She went to the ER countless times because there was no other choice. I realize our system is not perfect, but if one has medical coverage at least there is hope for that person.

    1. It is mind-boggling to me that the UK, Canada, Germany, Netherlands, etc provides insurance coverage to all citizens. Critiques of these models point to access problems and wait times. Yet, these countries rank higher than us in many health outcomes categories. This doesn’t mean things like waiting to see the doctor, less access to brand-name drugs and more emphasis on personal health choices are the only reason why these countries excel in health outcomes, but it makes you think.

      When I was in the Netherlands and had dinner with a normal Dutch family, an 18 year-old friend of one of the kids was bemoaning the fact that he had to buy health insurance. He said he would do it because it was his responsibility to have coverage, though he complained that it was just a bare bones plan. He still had to pay for routine care, like dental visits.

    2. The thing is, that if you are not insured through work, health INSURANCE is usually so crushingly expensive that buying it means you’ll have nothing left in your bank account with which to purchase health CARE, not to say clothing and utilities. Unless you have a catastrophic illness, you could have socked away a small fraction of that $12K the insurance company will charge your family and used it to pay the full costs of any needed visits, tests, or treatments. Obamacare just says: “Buy it anyway, and if that means you can’t afford the copays and coinsurance to get treated at all [or to pursue non-allopathic means of health care such as eating better food], tough.”

      1. I am sympathetic to your point of view. However, few people can pay the “full costs of any needed visits, tests, or treatments”, and more importantly the costs of catastrophic illness. Because this is true, coverage is important, and it is important to the young healthy person who could easily be in an auto accident, develop cancer, hurt a knee in athletics, etc. Deductibles and co-pays are a part of life for those of us who have had employer paid insurance plans. As for the very low-to-no income individuals, the co-pays for Medicaid are under $5 per visit–not too bad. The Affordable Care Act lowers the cost of insurance for those who must pay.

  6. Dear Provider Mandrola (the whole “doctor” thing is so pre-Obamacare, isn’t it?),

    As always, this is a thought-provoking post, and great comments. But here is one statement I think missed the boat:

    “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 healthcare. Namely, that it is too big, too disruptive, and too devoid of nuance.”

    The inaptly named PPACA will certainly change US healthcare fundamentally — by making the entire healthcare bureaucracy bigger, by making the entire industry more disruptive, and by eliminating whatever nuance exists today. What outcome other than a bigger bureaucracy could the addition of tens of thousands of IRS agents solely to police insurance purchases possibly lead to, to say nothing of the billions of dollars added to the HHS and DOL bureaucracies? What effect other than disruption on a grand scale could the perverse incentives built into the law — to eliminate full time employment, to drop group health plans, and transfer the costs of healthcare from the people who use it (older people) to the people who don’t (younger people) — possibly have? And what result other than the destruction of nuance could the Orwellian “Independent Payment Advisory Board” — the deliberately unaccountable cost reduction panel charged with rationing care based largely on one’s age and bureaucratically measured “quality of life” — possibly bring about?

    The imposition of a centrally planned and controlled government health plan on a continental nation of 340 million people, the majority of which opposed the government takeover in the first place and continue to oppose it despite hundreds of millions of dollars of government propaganda promoting it has, will, and can only fundamentally have all of these effects.

  7. I am always reluctant to respond to my son’s blogs, because more often than not the subject matter and his writings are way above my pay grade. I wade into the fray now because there were a few comments that are worthy of expansion and rebuttal.

    Jay’s insightful comment that many can’t distinguish between the healthcare delivery system and the healthcare insurance industry hits the mark squarely. The healthcare insurance industry was founded and exists today primarily because it is the only vehicle that provides access to the healthcare delivery system for millions who do not possess the assets necessary for entry. Yes, it is true that the insurance industry is mostly a for-profit industry, but competition and a limited market of customers has worked to produce good products and services at market driven prices. If reform is to come it must begin with the healthcare delivery system followed by reform within the private insurance market. In the interest of full disclosure Jay is the son of a cousin and dear family member.

    This leads to other comments that what we had was untenable and that the President failed because he didn’t go far enough with reform and should have moved to a universal payer system. The ACA is supposedly fixing problems of pre-existing conditions, higher rates for older insured’s and companies dropping sick patients. Those problems do not exist in the employer based healthcare market where the great majority of Americans (roughly two hundred million) get their coverage. They are problems in the individual market place where millions fewer are insured. The ACA in unintended consequences is causing millions of Americans to lose employer based coverage because companies can’t afford to continue insuring employees and dependents and remain competitive. I’m pretty sure that an unchanged ACA is untenable.

    Finally, I know that many embrace the universal single payer system that exists in the UK and other places. I do not. There are many arguments for and against that concept. For average folks like me it is difficult to judge what is real and what is not. My argument against a single payer system is basic. Single payer is the definition of a monopoly. When I was young, a long time ago, laws existed to prevent corporations from gaining single control of a product or service. History had demonstrated that when monopolies were formed product and service were diminished and price increased. Unquestionably, monopolies are bad for the people. Government monopolies are just as bad. We have already seen the beginning of a monopoly in action with the government dictating under the ACA what coverage’s people must buy and what they must pay. It is done currently in the name of fairness, but if history is to be believed it will not always be altruistic. We should be careful about what we wish for. As Ronald Reagan warned “Freedom is never more than one generation away from extinction.”

  8. Do you car to know what’s really embarrassing?

    The reality that we have doctors with such poor critical thinking that they fall for crisis structures like Obamacare; that they willingly submit themselves to mandated healthcare for everyone — whether we like it or not!

    Submitting yourself in the name of fear is SLAVERY. You got that, good doctor?

    Obamacare is proving to be a national headache, an embarrassment. And so you are you.

  9. I had the pleasure of working with a self-professed “bleeding heart liberal” who I like and respect (I place myself to the right of center). In the spirit of bipartisanship, we think we’ve cut the Gordian knot of healthcare funding reform.

    1. Our proud and a wealthy country should provide universal healthcare, and 2. The highly dysfunctional Federal government should have nothing to do with it, at least until they can balance the budget or even bother to submit one.

    As all politicians want to be liked and reflected, not a one of them will make the tough calls that a single payer system would require. We agreed that we should appoint hard nosed business types (Jack Walsh comes to mind) that everyone already disliked to administer the plan.

    In any case, I think we all realize universal health coverage would require healthcare rationing. In the light of the abuses of the IRS and NSA, I would never trust the current administration to manage such a plan fairly.

    And my liberal friend agreed, kind of.

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