Non-Participation: The Antidote to the Affordable Care Act

Now that the Supreme Court has upheld The Affordable Care Act, the final piece of the puzzle is in place. We will begin the inevitable slide to the end of patient driven healthcare – individualized medicine led by independent doctors in consultation with their patients.

In order to understand where we are now and, more importantly, know what needs to be done to get out of this situation, it is imperative to understand how this started.

The rise of insurance companies has been carefully cultivated as early as 1971 when the Rand Corporation, funded by The US Department of Health, Education and Welfare, developed and ran a study known as the Rand health Insurance Experiment. The conclusions found that increasing patient costs via cost-sharing (making patients responsible for 25%, 50% or 95% of their medical costs through co-insurance deductibles) with a maximum out-of-pocket expense of $1000 led to reduced “overutilization,” but more importantly it led to reduced “appropriate or needed” medical care. This was a concrete example of the detrimental effect that removal of the free market system would have on the delivery of healthcare to patients.

The theory that controlling patient behavior could control costs without consequences is fundamentally flawed. In 2012 we find ourselves in the position of patients now having higher out-of-pocket costs, yet healthcare costs are continuing to spiral out of control. A rising number of patients now find themselves in the untenable position of having health insurance, but being unable to afford to use it. The Obamacare mandate exacerbates this by forcing Americans to buy into a system that has the power to deny recommended treatment based on what an insurance company deems “inappropriate or unnecessary.” Treatment is not based on what is determined by the doctor and patient, but instead it is based on what actuaries deem to be most cost effective for the insurance company. The government placing punitive constraints on Americans based on the welfare of private corporate interest smacks of cronyism at best and fascism at worst.

Those who support “Medicare for all” as the panacea either know nothing about how damaging government has been to the delivery of quality healthcare, or they simply don’t care. In short, those who think Obamacare is the advent of socialized medicine need to look closely at Medicare. It was part of the Social Security Amendment (HR6675) passed in 1965. It was set up as socialized medicine for senior citizens. Like Obamcare, it was crafted by bureaucrats, politicians and special interests without the input of patients or doctors. Under the guise of beneficence, it forced working Americans to pay into it, conscripted doctors, and over the last forty-six years it has become bloated and wasteful, promoting the concentration of money and power in the hands of favored players such as hospitals and insurance companies at the expense of physicians and patients.

One only needs to look at the state of medicine now to see this. Initial examples include: 1) the use of the diagnosis related group (DRG) which drives how much a hospital will be paid for a particular disease and therefore affects the length of time a Medicare patient can stay in the hospital; and 2) The Medicare Payment Advisory Committee (MedPAC ) passed in 1997, an advisory panel advising Congress on what should be paid under Medicare. Due to the inevitable creeping of government control under Obamacare this has morphed into the Independent Payment Advisory Board (IPAB) which has the power to independently set Medicare payment and coverage guidelines with Congress only able to reverse the rules with a supermajority (courtesy of an amendment by Senator Harry Reid). The IPAB is essentially the rationing board (see page 18, 27). For those who think this only applies to Medicare don’t worry, it will eventually affect those with private insurance since private insurers routinely adopt Medicare guidelines for coverage and payment.

Where does this leave doctors and patients? If they don’t take a stand they will both be servants forced into a system that strips patient privacy and choice while forcing doctors to practice collectivist medicine sacrificing individualized patient care.

The Affordable Care Act forces doctors to ask themselves whether they will honor their sacred Hippocratic oath to do no harm or serve the interests of a government that mandates that cost control is more important than an individual’s right to determine the course of their healthcare. Dr. Curtis W. Caine beautifully sums up the argument for non-participation in a system that is unsustainable economically, and is both morally and ethically bankrupt.

It is important to recognize that the system will not work without doctors and patients. Instead of depending on Congress to repeal Obamacare, doctors and patients need to work together. These are some steps that doctors and patients can take to regain their freedom:

1. Physicians can stop participating in Medicaid and Medicare.  Under current Medicare/Medicaid guidelines doctors are treated as guilty until proven innocent. Between physicians being being targeted for fraud, waste and abuse (a felony), and recovery audits which claw back money for services already rendered it makes it very difficult to practice good medicine while always looking over your shoulder.
2. Physicians who plan to stop participating should initiate conversations with their patients about why they have chosen to put patient care above all else.
3. Medicare patients who have physicians who no longer participate should have a conversation about costs. They will find that many physicians are willing to significantly discount services.
4. Patients who have insurance with high deductibles and co-insurances should consider foregoing their insurance for routine visits and tests and go to independent physicians that offer fee-for-service. These doctors are likely to offer significantly discounted services. In addition, using free standing facilities (i.e., non hospital based labs, surgery centers, and radiology facilities) can offer significant discounts.
5. If you are healthy, consider getting catastrophic coverage and add supplemental insurance (e.g., AFLAC). Most healthy patients see a doctor 1-2 times a year and the average yearly cost is about $400 dollars. Depending on where you live, the average yearly premium is ($2,200-$4500) for an individual and ($5000-$11,200) for a family with a further $3000 deductible and $5000 deductible respectively. For plans with no deductible costs of premiums can be significantly higher. It may be more advantageous to buy a low premium/high deductable policy and save money monthly towards your own private health savings account (for example saving $300 per month would mean $3600 to spend any way you wanted without the risk of denials).
6. If you can’t get into a doctor and have a non life threatening problem consider going to an urgent care. Get to know the urgent care centers in your area. Many are now staffed by ER trained physicians and offer excellent care at a fraction of the price of going to a hospital based ER with a significantly shorter waiting time.

The healthcare system is broken, but The Affordable Care Act is not the solution. Instead of depending on Congress and waiting for an election to bring change, it is up both doctors and patients to work together to take back our power.