affordable care act

Discussion in 'Ask Dr. Dave' started by Anonymous, Sep 19, 2014 at 9:24 AM.

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  1. Anonymous

    Anonymous Guest

    Dr Dave, now that the affordable care act has been in effect for a little while, what is your impression. Are you seeing anything good? Is your overall impression good or bad?
     

  2. DrDave

    DrDave Member

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    In primary care in my area (rural Virginia), I don't think much has changed for patients themselves, mostly because the VA legislature has not supported Medicaid expansion. (Though I consider myself a small government advocate, I find it strange that so-called conservatives in our state feel that Virginians' tax money should go to the federal government for literally nothing in return while other states reap the benefits.) The insurance plans available on the exchange generally have very high deductibles, so access to primary care is still limited in the financial sense with the ironic twist that insured patients generally cannot access charity programs, drug assistance programs, etc. I'm sure there are patients with serious chronic and catastrophic illness who have benefited, of course. I don't have a sense of the magnitude of that number, but for them, I'm sure the ACA is a godsend.

    From the physician end, speaking as an employee of a health system, there is a much greater emphasis on "meaningful use" of our electronic medical record. Some of this is good for patients (focus on medication reconciliation, attention to coordination of care), some of it is just mindless box checking (one of my colleagues refers to this as "meaningless hoops"). However, I more or less accept this as part of the deal when you take government payments (Medicare, Medicaid).

    My view is that ACA is well intentioned but inadequate solution to the big picture problem - there is no true free market dynamic in health care any more. Health insurance should be like car insurance - for wrecks, not oil changes. If oil changes had the administrative overhead of insurance coverage, they would probably cost $150, much like a basic primary care office visit or a month supply of prescription heartburn medicine. The high deductible component of the exchange plans is a move in the right direction in a sense, but there is still so much inflated cost in the health care landscape, those with high deductibles are still functionally disenfranchised.

    When I was a child in the 70s, my parents paid for primary care doctor's visits - the whole visit, not a co-pay - when we checked out, and if there were medical expenses covered by insurance, my dad submitted the claim himself. They were high school graduates with middle income earnings at most. The system was not perfect, I'm sure, but I don't think my view that it was better is entirely nostalgia driven.

    Thanks for your question, and I look forward to the comments of others!
     
  3. Doc Who

    Doc Who Active Member

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    " I find it strange that so-called conservatives in our state feel that Virginians' tax money should go to the federal government for literally nothing in return while other states reap the benefits"

    Was then Gov. Bob McDonnell involved in the process? It seem to me he held his personal interests over that of the people of Virginia.
     
  4. DrDave

    DrDave Member

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    I'm sure the governor has influence that could linger, but McDonnell is out (about as out as you can get!), and the legislature still won't move on this.
     
  5. Anonymous

    Anonymous Guest

    Thanks for your reply Dr Dave. I agree that the states that did not vote to expand Medicaid are not doing their citizens a favor. And I am always surprised that the very people who would be helped by such measures constantly support those who vote against them. But that is another story.

    In reference to the absence of a free market dynamic, do you think this would help hold down healthcare costs? If so, where do you see the waste in the current system? I do think that many medical bills are too high, but I don't really know where the main source of the excess exists.
     
  6. DrDave

    DrDave Member

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    Obviously, this is a very complex situation that could generate days, even weeks of discussion in the right forum, but I'll try to give you some examples of what I mean. With the caveat that I am no expert in the economics of health care:

    In most other marketplaces, the person purchasing a good or service makes a decision before or at the point of sale - is this worth it? One can research, get advice, etc., but in the end, the consumer balances the pain of money leaving the wallet with the benefit of the purchase. Putting aside emergencies and catastrophes (what insurance is for), the economics of health care have these examples of dysfunction:

    -The patient has the perception that their health care is pre-paid, which I understand at some level since insurance costs are quite high, or that paying for it is someone else's responsibility;

    -Charges are inflated to cover the discounts that major insurance carriers negotiate with physicians and health systems; consequently, the customer who is willing to pay cash in full at point of sale for a service pays the highest price;

    -Prescription drug prices vs. out-of-pocket consumer cost vary dramatically due to a similar dynamic, with, once again, the cash payer being the most disadvantaged;

    -Re basic imaging technology, in health care, over the last 15 years the technology is a little better (how many serious illnesses were missed on the MRIs of 15 years ago but found today? I don't think that many) but a lot more expensive. Contrast that with the free market of computers - compared to the computers of 1999, the computers of 2014 are significantly better AND cheaper because there is market pressure for this to happen.

    In the end, I think the decision we need to make as a society is: do we want health care insurance to work like car insurance (more or less like it used to be), or do we want a single payer system that covers the same menu of services for everyone. The crazy in-between hybrids with which we have experimented don't seem to work very well.

    I hope this link works - last year Time magazine published a great article about hospital costs. If you've not seen it, you might want to check it out:

    http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf.

    Aside - To be clear about my Medicaid expansion comments - I don't think it's a solution to this by any means; in fact, it's more of the same. My concern is that in Virginia we're paying taxes for the coverage of of other patients in other states but not getting coverage for any of our own citizens.

    Thanks for your question, and I look forward to your thoughts!
     
  7. Anonymous

    Anonymous Guest

    I was shocked this week to receive a letter that my health care coverage has been cancelled for next year. I spent a ton of time carefully considering plans. 1 year and it was done. Has this happened to other people?
     
  8. DrDave

    DrDave Member

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    Wow, sorry to hear that - what plan do you have?
     
  9. Anonymous

    Anonymous Guest

    You offer a very sound opinion on the state of healthcare in America and the ramifications of ObamaCare, Dr. Dave.

    Surely you are aware that America spends about 20% of our GDP on healthcare and it doesn't appear that ObamaCare is bringing that number down. Quite the contrary as ObamaCare (according to all reliable financial reports) appears to be pushing the number up. Nearly all other 1st world nations spend about 9%-14% of their GDP's on healthcare. And the quality of their healthcare is as good, if not better, than ours.

    Don't you believe that the healthcare industry has 'donated' so much money to congress that it has effectively protected itself from free market competition? Do you ever wonder why people all around the world pay significantly less for pharmaceutical products that are DESIGNED AND MANUFACTURED IN AMERICA than WE as AMERICANS do?

    Wishing a wonderful holiday season for you and your family.
     
  10. DrDave

    DrDave Member

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    First off, thanks for the holiday wishes, and same to you!

    I haven't the data first hand re: how much the ACA may be driving up cost, but it is interesting/ironic that, as I understand, was created more as economy legislation that involved health care rather than the other way around.

    Once again, I have to cite the strange hybrid of quasi-free market health care with third party payers that include the government that drives up cost, not quality.
     
  11. Anonymous

    Anonymous Guest

    Dr. Dave, consider the average doctor's office as an example of how anti-free market our health care system truly is. How many other businesses neglect to post a public price list for goods or services rendered to their customers? Free markets are supposed to be consumer driven. How can a consumer make an intelligent or reasonable choice when he or she doesn't even know how much the good or service costs until 4 weeks after it's purchased? Once I asked an MD's office manager how much it would cost to treat a case of strep throat. She looked at me like I was crazy for asking such a question. Same with hospitals. How many hospitals post a public price list for their customers? The concept of price competition is nonexistent in the medical industry. No wonder healthcare costs are so ridiculously high. Just imagine what WalMart's profit margin would be if it was allowed to sell unpriced goods or services that would remain undisclosed until 4 weeks after you purchased them?
     
  12. DrDave

    DrDave Member

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    All I can say is - couldn't agree more.
     
  13. Anonymous

    Anonymous Guest

    The pharmaceutical industry has finagled a way to convince Congress to pass laws that prohibit the reimportation of drugs designed and manufactured in America back into the country that would save US consumers a boatload of money on the purchase price. The State of Maine passed a law a few years ago that would allow State residents to purchase pharma products on-line through five 1st world nations (ie, Australia, Northern Ireland, New Zealand, England, Canada) at greatly reduced prices. Then PhRMA and the retail associations sued the State Maine to revoke the law. It remains in litigation. All other nations allow for the importation US drugs into their countries. But somehow it's not fair to reimport US prescription drugs back into our nation for personal use. Greedy medical players are holding the US consumer captive to a monopolisitic system not enjoyed by any other US industry. It's just not right that Canadians can purchase US made pharmaceuticals at 30%-60% less than we Americans can at our neighborhood drug stores - and then our lawmakers prohibit us from buying our own products back from the Canadians. How crazy is that? They are doing everything possible to make healthcare 'unaffordable' for productive middle class Americans who play by the rules of society. Compliments of the US taxpayers we give free health care to those who violate our immigration laws while placing the onus of the financial burdens on the backs of our productive citizens. It's just plain wrong.