Why Is Obamacare blowing up with higher prices and fewer choices of plans in the exchanges?

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obamacare-logo_full Why Is Obamacare blowing up with higher prices and fewer choices of plans in the exchanges? The Affordable Care Act, AKA Obamacare may be imploding, with fewer choices on the exchanges, costs rising as much as 25% according to USA Today. Is Obamacare the problem or the symptom?  To keep the conversation non partisan, we need to look at what Obamacare does.
  1. Expands the rolls of Medicaid
  2. Supplements the current system by giving people money toward the cost of insurance through state or federal exchanges. This has expanded the amount of people on Medicaid, a plan most doctors in NJ are not participating in due to the low levels of reimbursement. Most of the clinic's and some free standing walk in centers participate in this plan.
  3. Mandates rules for what is and isn't covered.
  4. Continues to make insurance pools smaller by not allowing insurers to cross state lines.
  5. Gives free preventative services such as Colonoscopies which can prevent colon cancer.   Has free preventative medical services build into it with the belief that this keeps people healthier.
  6. Avoids a public option such as Medicare which has a proven track record with people 65 or older.
  7. Has ideas such as the Medical Home and ACO's (Accountable Care Organizations) that are mainly Medicaid and have failed to show any significant savings.
  8. Allows insurance carriers to sell plans with higher deductibles, with no real transparency on why the costs to the consumer through insurance continues to escalate.
  9. Has the 80/20 rule which enriches insurance companies who continually raise premiums.  The higher the premium, the higher their income since the 20 percent gets larger as we pay more.
  10. Expanded the work load in many doctors offices requiring extra people to call on denied claims, and forcing doctors to use Electronic Health Record systems that are time consuming and distract from their job which should be taking care of their patients.
  11. Create larger healthcare systems which we see in NJ with systems such as the recent Robert Wood Johnson and St. Barnabus merger.
What is has failed to do
  1. Reduce the cost of care.  There is a huge problem in our country that has been accelerating with HMO's being at the forefront of low reimbursement levels for primary care, resulting  in the 10 minute office visit.   Doctors who are successful in business will have a volume practice, since 10 minutes is often no enough on a complex case.   Geriatricians are at risk financially since their clients usually are more time consuming.  Most doctors will order more tests and do more referring with this current model which is a huge cost driver.  Fragmented care, more than anything is why healthcare in the USA is less effective and more expensive.
  2. Use less expensive providers for pain.   Chiropractors are often underutilized but get great marks for their work with back and neck problems and other problems in the musculoskeletal system.  They are more qualified than the average doctor in the evaluation and treatment of musculoskeletal pain, with higher levels of satisfaction than physical therapists or most primary care physicians.  They are beginning to assume the role of primary spine.  The Opioid problem is clearly a failure to manage.  Most people are unaware that most medically trained primary care providers have a poor training in the musculoskeletal system which is 55% of the body and many symptoms of internal disease processes such as stomach complains may actually be musculoskeletal resulting in expensive and invasive tests that are normal and people who are on drugs that may actually cause more problems.
  3. Change the reward system in hospitals and in doctors offices.   Our current system is procedure based.   This works for some specialties but for others, has been abused especially through hospital systems.  As the systems get larger, and employ more people, they also have more fragmentation.  Hospitalists who have grown as the insurance companies stopped paying primary care doctors to visit their patients have raised the cost of care and often poorly communicate with the patients doctors, while adding little to the care.  Perhaps, there should be hospitalists assuming the role of primary care in the hospital which would eliminate most of the consults which often result in more tests, more risk and often are expensive and wasteful.   Employing doctors of chiropractic in Emergency rooms has worked well in some hospitals as many people who have musculoskeletal pain may be attended to better without drugs, expensive tests or invasive procedures.
  4. Reduce the cost of prescription drugs and look for transparency in pricing.   How much does your drug company spend on sales, advertising and sales people vs. research vs. the cost of production.   As we have recently learned through debacles such as Milan and the Epipen, the search for outrageous profits does not fit in well with healthcare for all.  We should clearly also question the idea of pain management in the absence of understanding why someone is in pain. This is how we ended up with the Opioid mess in the first place.
  5. End of life counseling.  There is a point where all of us are going to succumb to something, and making choices while you still can reduce the costs at the end of life, while not prolonging suffering.   End of life counseling may be an intelligent way to do this.   Some states are also looking at assisted end of life options, so someone who is at the end stages of life can legally decide when they had enough.
  6. Simplify the paperwork doctors need to do.   Even Medicare is now looking at a different system of reimbursing providers which may result in a back lash as providers, who already are overburdened with costs do not want more administration and more micro management.  Some sources are suggesting that doctors may decide to drop out of Medicare if these changes go into effect.  While some specialists are very well paid, others are not.    It was estimated a few years ago through Humana that Medicare spent just 11% of their dollars for doctor visits and services.  Where did all the other money go and for what?  Medicare has a low deductible, and very low administrative costs.   Isn't simplification of having one plan a better idea?
  7. Clearly look at what types of procedures are clearly necessary. Many medical procedures are expensive and other non surgical options may have better long term value.
  8. Develop a more holistic idea on how doctors should practice.  As we have seen, having groups of doctors in a large practice is not less expensive, especially as they treat the body as parts instead of contiguous systems.   Primary doctors need to have more time and have better training in the musculoskeletal system.   40 years ago, when doctors spent the time and did some basic procedures, costs were much lower.  Today, we are more advanced, but spend way more and get way less for our healthcare dollar.  The system needs a reboot.
Clearly, the current system is crashing under its own weight.   You can blame Obamacare, however every country who uses a system similar to ours has rising costs.   Perhaps, how we look at people and health needs to be fully questioned and the non holistic approach we currently use for care with the symptoms approach simply is bad for us.   Preventative problems such as knee and hip joint damage is clearly ignored until we need to replace the joint.   Organs should not be disposable and the reasons things go wrong in the body often revolve around dysfunctional systems, rather than a disease process and the lack of a drug working.  Inflammation is responsible for most of the heart attacks, arterial dissections and even gut related problems as well as autoimmune problems which often start in the gut, yet our approach is expensive drugs rather than understanding why first and then treating the source of the problem.   What we see with the current Obamacare problems is clearly a failure to manage and failure to reimagine our system. Perhaps, healthcare needs an interrupter such as an Amazon.com did in the marketplace.   It clearly is not going to come from any stakeholders in the system who clearly up till now have held all the cards.  We need a reboot. While I do applaud Obamacare for increasing our rolls of the uninsured, the problems with the way we practice are the cancer and right now the patient is terminal.