Gut Obamacare or Get On Board?

Publish Date: October 22, 2012

By: Matthew Wallace

“Day one. Job one. Repeal Obamacare.”

Political campaigns woo and wow with pithy promises, but, as Walter Mondale once said to Ronald Reagan, “Where’s the beef?”

Could Mitt Romney really get rid of the Affordable Care Act, that gargantuan piece of healthcare reform legislation, which—for all its 2,000+ pages—still requires rulemaking, clarifications and HHS pronouncements that variously make people happy or crazed? Well…yes and no.

Since the ACA is an act of Congress, it could be repealed as a law, but that is very unlikely because it would require both houses of the legislature, which are divided in support over the law. There are two alternatives that are most likely: defunding it, which won’t be very difficult to do; and effectively eviscerating it through executive order and inaction. Let’s look at both very briefly.

Defunding: The president has the duty to send a budget to Congress each year. The House of Representatives (Republican controlled) then allocates and authorizes money to be spent on different programs. Many of the elements of the ACA, particularly the health insurance exchanges, are expensive, and the states have been passing the program back to the feds hand over fist—some telling the federal government to go ahead and set up an exchange in their state at federal expense, some refusing to fund the giant gap in coverage for the poor that was created by the reform law, and some doing nothing at all or applying a combination of partial actions. Without federal funding, many of the elemental programs cannot go anywhere, and alternative solutions for health insurance will have to be found.

Executive Action: A Romney administration could attack the law from its end in the executive branch by selectively changing rules and enforcement. The ACA is full of nebulous, broad statements and fiats that—when implementation time comes—are found to be more gaseous than concrete. That has meant that the Department of Health and Human Services and other federal agencies have had to step in and make rules that facilitate actual design and effectuation of programs. These rules and regulations have generated a great deal of backlash from individuals, businesses and state governments. As they say, “The devil’s in the details.”

What Doctors Can Expect: In the short run, doctors can expect things to continue as they have been trending. Payments to providers, especially those controlled in whole or in part by Medicare and Medicaid reimbursement fee schedules, will experience downward pressure. Costs will continue to rise. Patients may become more cost-conscious, inquiring about fees, negotiating with doctors, and rejecting treatments that are too expensive for their tastes or budgets. Electronic reporting requirements will require investment in technology. Small practices and sole practitioners will continue to get squeezed on costs, payments and regulation, and the trend toward joining a healthcare grouping, such as an HMO, hospital group or large practice will persist. And accountable care organizations will variously stumble, succeed, or ball themselves and their patients in knots of errors, omissions and red tape.

Some good has come from the ACA. Consumers by and large like that their dependent children can remain on parents’ coverage until age 26, and many people agree that those with preexisting conditions should not be disqualified from insurance coverage. Beyond that, there’s not much agreement, and nothing in the act reduces costs, which has been the biggest problem confronting the nation.

On the dark side, the ACA may effectively, if not intentionally, cause people to seek less medical care, since almost all coverage options under the law cost the consumer more than traditional, employer-sponsored group coverage. That cost-shifting could, and probably will, mean more consumer apprehension about going to the doctor and filling costly prescriptions. The hope is that patients will be more judicious about their use of medical care and products, but the reality may be that patients don’t get the appropriate care early enough or often enough to control conditions or respond to injuries that lead to disability.

Disability Implications: As the effects of consumer behavior become manifest, we will probably see an upward trend in disability claims. All practitioners in the medical care field need to put this likely development on their radars and conscientiously, proactively address potential health problems before they evolve into a disability.

By discussing chronic conditions and their long-term effects with patients, medical care providers can nip the development of disability in the bud. These discussions aren’t isolated to doctors, either. Nurses, physicians assistants, pharmacists and massage therapists often have more interaction with patients than the doctors themselves and can identify potential problems to the doctor and directly to the patient.

The short list of issues includes prevention and management of back and joint pain, stress, headaches and head injuries, depression, obesity, diabetes, high cholesterol, vascular disease like phlebitis, digestive disorders, drug/alcohol abuse, and upper respiratory illness and conditions—e.g., flu, asthma, emphysema. There are dozens of other disabling conditions, so medical staff should be trained to spot symptoms, including sleeplessness, chronic fatigue, irritability, anxiety, and notable weight gain or loss.

Understanding the patient’s lifestyle and workday is fundamental in making good diagnoses. Despite the performance and cost pressures faced by those in the healthcare industry, the patient’s welfare has to continue to be the paramount concern. Work on your business model so that awareness pervades all levels of care and information moves fluidly from one tier to the next. Coordination within a provider’s office should be enhanced by a planned, routine collaboration with patients’ other healthcare providers.

It’s true that this is a particularly demanding time for physicians and other doctors and medical care professionals. The Affordable Care Act, federal guidelines, state actions and patient behavior are all moving targets, but one thing that remains constant is your dedication to delivering excellent healthcare. While all of the uncertainty and pressure can be distracting, costly and annoying, it can also present opportunity for professional growth in the way you run your practice and approach your patients. Those doctors who tap into that potential will come out ahead of the game in the end, providing better patient care, a better consumer experience and a model for how healthcare nationwide can be improved.