By Dr. Marc
Patients would ultimately be more frugal and cost conscious if they had some skin in the game and their doctors had less.
Back in the 1930s, at the heart of the Great Depression, the biggest health concern of poor Americans was how they were going to pay for their sudden and severe illnesses. Then the American Hospital Association created the Blue Cross plan for hospital costs in 1933 and followed it up in 1939 with the Blue Shield program, which covered medical and surgical costs. This was a major breakthrough in terms of health care because health insurance in those days was used to underwrite lifesaving care, and was based entirely on an illness-oriented hospitalization-covering model.
But times have changed. These days the focus is more on prevention, and health insurance is frequently fear-driven and is used routinely to cover non-essential services for the worried well. It’s one thing for patients to be aware that uncontrolled cholesterol and blood pressure can lead to heart disease, or that without a screening colonoscopy or mammogram cancer can go undetected. But patients also worry that every cold could turn to pneumonia and every headache could be a brain tumor.
Doctors’ offices are overwhelmed, and we are paid less and less per visit even as we are compelled to document more and more on our computers. We must see more patients to make ends meet, yet we are afraid to argue against excessive patient demands for fear that a poor outcome, no matter how remote the risk of that outcome occurring, will lead directly to a complaint or a malpractice claim. Under the current system, the patient’s fear of something being missed feeds into the doctor’s fear of being sued while the insurance companies profit financially and the government profits by claiming credit for covering more people.
But wouldn’t it be cheaper with less pressure on the overburdened doctor’s office for more services to be paid for out of pocket, with tax deductions attached? And if a doctor wasn’t worried about being sued, wouldn’t he or she be far less likely to order extensive tests and treatments? Surely catastrophic insurance is needed to cover hospitalization and severe illness just as it was essential in the 1930s, but beyond this, patients would ultimately be more frugal and cost conscious if they had some skin in the game and their doctors had less.
Insurance covers most of the medical care I provide my patients, both necessary as well as unnecessary. Obamacare made this problem worse by extending to 25 million more people (including 10 million from the Medicaid expansion) the kind of insurance that unthinkingly covers too many services and pays doctors too little. Of course premiums rise when young healthy people are smart enough not to participate in a Ponzi scheme where their expensive premiums are used to pay for the comprehensive high-tech care of older sicker patients.
President Trump, backed by a Republican Congress, may now ironically attempt to utilize the same budget reconciliation process that sent the Affordable Care Act to final passage in the first place. We are likely to see an attempt to at least partially repeal the law, putting in jeopardy the mandates, the Medicaid expansion, the subsidies, and taxes such as the one on medical devices. What will remain are the most popular pieces of Obamacare, where you can stay on your parents’ policy until age 26 and you can’t be denied coverage because of pre-existing conditions. This is a good thing.
But cutting away some of the most expensive and poorly working pieces of Obamacare is only step one. Replacing any part of it would require popular bipartisan programs that could command at least 60 votes in the Senate while passing the Republican-controlled House.
Tort reform should be a crucial part of any Obamacare reform, where frivolous lawsuits can be blocked by panels of doctors or a loser-pays system as in Great Britain. This will allow doctors to act more as gatekeepers who separate essential from non-essential care. Both doctors and patients can receive incentives for focusing on real prevention, including diet and exercise. Doctors can be rewarded for keeping patients well, not just for scrambling through multiple problems when they are sick.
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All health payments should be made tax deductible. Expanded Health Savings Accounts, which are transferable from one member of a family to another and can even roll over from one generation to the next, as President-elect Trump proposes, will help rein in health care costs by making patients more frugal and discerning before they spend. High deductible insurance that is geared to cover severe illness like in the old days fits well with HSAs to pay for non-essential services. We doctors much prefer thinking, paying patients to those who consider our offices a supermarket of health care services for which they pay little or nothing.
In an ideal health care world, the government would provide catastrophic insurance for the have-nots, while expanding the National Health Service Corp of doctors to treat those who lacked insurance altogether. This would take needed pressure off doctors’ offices like mine. We would have more time and a greater incentive to focus on solving real health problems.
Marc Siegel, MD, is a clinical professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center. He is a member of the USA TODAY Board of Contributors and a Fox News medical correspondent.
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Republican Falsehoods About Obamacare
A repeal of the Affordable Care Act, which the Republicans have been threatening for years, would obviously be unpopular with the 20 million people who have received coverage under the A.C.A.
But Republican leaders don’t seem too concerned with those people. Instead, they are trying to convince people who don’t rely on the A.C.A. that repeal of the law would leave them better off.
Paul Ryan, for instance, said on on Fox News on Thursday, that “because of Obamacare, Medicare is going broke.” That statement is false. According to the Medicare trustees, cost controls in the A.C.A. are one of the reasons that the system’s hospital trust fund is projected to remain solvent through 2028 — 11 years longer than before the A.C.A. was enacted.
Tags: Affordable Care Act, doctors, Expanded Health Savings Accounts, extensive tests, health care, health insurance, health problems, health-care services, healthcare, high risk, high risk Americans, HSAs, Medical, Medicare, New York Times, obamacare, Paul Ryan, poor Americans, prevention, Republican Falsehoods About Obamacare, Trump