The Tribune Democrat, Johnstown, PA


August 26, 2012

DR. DAVID ARMSTRONG | A doctor's perspective on health-care reform

Health care in the United States is the envy of the world. Dignitaries and citizens from countries around the globe travel to this nation in search of the best hospitals and physicians in the world. The health-care payment and insurance industry is another matter and what is currently under reform.

None of the changes in the Affordable Care Act (ACA) have anything to do with the direct practice of medicine. The act, however, will fundamentally change how medicine is practiced and delivered – and not for the better.

The system as it stands needs to be improved. We have a large number of people who have no insurance, use the medical system and drive the costs higher. Currently, there are over

300 million citizens in the United States. Forty-five million people in this country have no insurance and approximately 10 million are here illegally. That represents about 10 percent of the citizens of the U.S. who are not insured.

There are 22 million noncitizens in the U.S. Ten million have no insurance. The current reforms bring the uninsured into the system at great expense to the others.

Are we, as a country, responsible for providing medical care to citizens of other countries who are currently living in the United States either legally or  illegally? We, as a society, need to find a way to provide care to the uninsured and in need without scrapping the parts of the current system that work.

There are several ways to do this that have been discussed but are not part of the current reform bill. They will be discussed later and are common sense, no-cost improvements.

The ACA has used the case to insure the uninsured but has morphed into a government reorganization of the entire health-care industry. President Obama’s own words in 2008 were to bring about reform with the ultimate goal of creating universal health care (socialized medicine) for all Americans. In order for the reforms to work with the cornerstones put in place by the administration, all Americans will have to purchase health care. They have no choice. A penalty (tax) will be levied in the event that one doesn’t purchase insurance.

In this fashion, young healthy Americans will buy into the system to fund the people in need of care. This was the essence of the Supreme Court challenge by 27 states. The final decision was that the individual mandate (all must buy insurance) was not considered constitutional unless it was considered a tax.

There are 20 new taxes that are included in the reform bill. Seven of them will affect all Americans making less than $250,000. There is a tax on tanning booths and on investment income. There is a Medical Cabinet Tax that eliminates reimbursement of expenses for over-the-counter medications. The Medical Itemized Deduction Hurdle will eliminate deductions for medical expenses, which will directly affect the middle class. A tax and restriction on health savings accounts will eventually eliminate them. These accounts allow patients to control how they spend their health-care dollars.

There are over 150 regulatory boards created in the ACA. We don’t know how they will function as the regulations are not written yet. There is an IPAB (independent payment advisory board) made up of appointed members that will unilaterally decide how doctors and hospitals will be compensated for care. These are not elected officials, there is no mechanism to remove them if we don’t approve of their actions.

If someone chooses not to buy insurance, they will be fined. Employers who employ more than 50 employees are required to provide insurance for their employees or pay a penalty. The penalty is less expensive than the insurance, almost guaranteeing that the insurance will be dropped. Those employees will then have to purchase insurance through an exchange controlled by the government.

Eventually the government will control most, if not all, health insurance. A single-payer system is a government system – socialized health care. Imagine if the health-care system was run like the post office.    

When universal health care exists, it will be enormously expensive. Resources will be outstripped by demand and rationing will begin. This currently exists in the countries that have socialized medicine, such as the United Kingdom, Sweden and Canada. Currently in the U.S., rationing already exists in Medicaid plans. Patients are allowed only seven medications. They must choose which ones are most important. This is a difficult task for any physician, let alone a patient with no medical training.

The VA and the military health-care systems ration care as they can’t possibly care for all the people eligible with limited funding. As one ages, the need for care increases, as does the cost. At some point, it will not be cost effective to provide care for an elderly patient and the decision will be made by a bureaucrat as to when the money will be better spent on a younger patient with a longer projected life span. This is very scary.

Let’s talk about physicians. Most are not in favor of this reform but acknowledge the need for some change. The critical point is that there is too much interference in health-care delivery, and this affects the doctor-patient relationship. On a daily basis, insurance companies and Centers for Medicaid and Medicare Services, i.e. the government, require pre-approvals for medicines and procedures that take up enormous amounts of time and resources, allowing less time for doctor-patient interaction.

The insurance industry has now become a middle man in the whole process and controls many of the decisions that are best discussed between the doctor and the patient.

By disallowing payment for medications and procedures, the insurance companies are influencing medical decision-making while hiding behind the fact that they are immune from any recourse (malpractice actions). Many patients will not get a medicine or procedure if it is not covered.

Insurance companies use the term “not medically necessary,” which implies a medical decision. The more obstacles that get between the doctor and the patient, the less control either of them have in the ultimate care plan.

The ACA was passed along party lines. There were many compromises (“bribes”) made to garner support. The “cornhusker kickback” and the “Louisiana purchase” are two of many. Since the bill has been passed, there are more than 2,000 waivers granted to businesses that believe the cost will be prohibitive. Where does that leave the rest of us? If the bill was sound and lived up to its hype, coercion wouldn’t be needed to pass it and companies would be eager to embrace it. Obama promised that the bill would not cost more than $1 trillion over 10 years. The Congressional Budget Office now projects the cost over 10 years to be well in excess of $1.7 trillion, and the costs of the program don’t begin until 2014.

Seniors, in particular, will be affected by this health-care overhaul. Over the next 10 years, Medicare is facing progressive cuts every year to a total of $17 billion. There is another $716 billion cut from Medicare to fund Obamacare.

These cuts cannot be sustained without reducing benefits. The Medicare Advantage program will be abolished. This program is very popular because of its increased benefits for seniors. Even if you do have insurance, that doesn’t guarantee care. The Congressional Budget Office has projected that, when the plan takes effect,

15 percent of doctors and hospitals will not participate with Medicare because of the lower reimbursement rates.

In addition, more than half the physicians in the country currently do not accept Medicaid patients, as the reimbursement rates are excessively low.  Many doctors who are close to retirement will do just that. There is a projected doctor shortage by 2020, not taking into account these additional losses. Delays in receiving care will occur. This is what happens in countries now with nationalized health care. Again, medical decisions have been removed from the doctor and patient. Again, very scary.

What can be done to replace the current ACA? Health insurance should be purchasable across state lines. As it stands, health-insurance companies cannot sell their policies from state to state. This, in essence, creates near monopolies in each state. Competition in the marketplace drives prices down. Competition would allow companies to offer patients with pre-existing conditions competitive rates and would allow parents to include their children up to age 26 on their policies.

Both issues are currently favored by most people.

The best way to improve a complex situation is to work collaboratively to implement certain changes. Once the changes take effect, they can be reassessed and additional changes can be made. The good things can be improved upon and others eliminated. In this fashion, I believe we can make the best health-care system in the world even better with the patient and the doctor in control of the process, not politicians and government.

My sources are:;;;;;;;;

Look them up and decide for yourself. Don’t take my word for it.

Dr. David Armstrong is a board-certified otolaryngologist with Ear Nose and Throat Associates of Johnstown, Inc.

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