All politics aside, it would be safe to say that some consider the Affordable Health Care Act (aka Obama Care Insurance) the crowning achievement of an amazing president while others consider it the worst piece of legislation passed in decades.
People are very passionate about both sides of the debate, but the people I have talked to do not really understand what this law has done and the ramifications in the future. If you’re really interested in putting forth a logical argument as to why this is the best thing since sliced bread, then you need to educate yourself on exactly how the ACA interacts with a sick country like the United States.
This article will cover many aspects of this law, including:
- Positive aspects of the Affordable Health Care Act
- Serious problems with Obama Care Insurance
- Not part of Obama Health Care, but how the 21st Century Cures Act will worsen the scenario
- Possible solutions to the mess created.
Positive Aspects of the Affordable Health Care Act
I certainly don’t think that our health care system prior to the passage of Obama Health Care was all rosy and perfect. But I also think that something as massive as changing the health care in the United States was too big to take on in a single bill.
Health care spending in the US is so massive that it constitutes the FIFTH LARGEST ECONOMY ON THE PLANET. That’s massive. $2.9 trillion a year (as of 2014).
Anyone thought it was a good idea to try to “fix” health care in a single bill should’ve been institutionalized immediately and maybe we wouldn’t be left with this mess.
So what WAS good with the Affordable Health Care Act?
Coverage of Dependents Under Obama Health Care
It seems like a no-brainer for insurance companies to cover dependents up until their 26th birthday. It’s not an expensive group of people to insurance, so the overall cost to the insurance companies is not a burden.
It also gives new college grads some time to get into an occupation and move up the pay scale to a point where affording their own health insurance premiums is possible.
On the other hand, this could’ve been handled in a simple, one paragraph mandate. We didn’t need 1,000+ pages of other fluff to get this done.
The Elimination of Lifetime Limits
I would sincerely hope that this aspect of the law has no relevance to you and that you’ve read enough of my blog articles to understand how to NOT exceed $1,000,000 in care (a typical pre-Affordable Health Care Act policy cap).
But there are a very small handful of cases where lifetime caps may come into play. Organ transplant is the first one that comes to mind and hemophilia is another (the meds cost some $150K / month to help manage this condition).
While the number of insured patients who exceed their policy maximums was small, it is still a very expensive proposition for health insurance companies to have to continue ongoing payments for these patients.
No Denial for Pre-Existing Conditions
Now, before I jump up and down and talk about how awesome this aspect of the law is, I do need to clarify some things.
Some of the pre-existing scenarios that occurred prior to the passage of Obama Health Care were a little beyond ridiculous.
I had patients come across this in my practice. Someone who had knee pain or low back pain would have care denied for these conditions even years later. While this is not the same as not even getting insurance in the first place (pre-existing denial versus a pre-existing clause), some of the standards were ridiculous on the part of the insurer.
While this is a good idea, this is probably one of the most dangerous financial aspects of the ACA. Patients with conditions like cancer, diabetes and heart disease are notoriously expensive and drive the costs of insuring a population through the roof.
Prior to the Affordable Health Care Act, even if insurers allowed a patient into a health insurance plan with a pre-existing condition, the premiums for these people with pre-existing conditions were higher, allowing the insurance companies to factor in the overall increased costs that these patients will inevitably incur.
With all of this in mind, I DO believe that Obama Health Care should allow for higher premiums for certain situations, with smoking (which is currently allowed) and obesity. This will be covered in more detail in the Obama Health Care Solutions section.
Calorie Labeling by Restaurants
On this surface this sounds like it might actually be another good aspect of the ACA. But, just like pretty much every other law on the books, a deeper look will surely lead to the need for Pepto-Bismol.
One should of course question how the heck the wording on this aspect of the Affordable Health Care Act even got snuck into the law. It’s just one of those aspects of politics that happens behind the scenes and would make us all run to wash our hands with a 50/50 blend of antibacterial soap and acid if we knew it all.
One of the two problems with this aspect of the ACA is that it is very expensive for companies to determine calorie count, create new labeling and loses advertising spaces on menu boards.
Even this would be OK if it weren’t for the second problem. Calorie counts on menu boards just don’t seem to make any difference on people’s buying decisions. Most of the patients I talk with will say that they don’t walk into McDonalds to look at the caloric content of the foods on the menu.
So, while it sounds like a great idea on the front end, all this added cost on the part of business is not likely to translate to better buying decisions.
Serious Problems with the Affordable Health Care Act
At the surface, it sounds great to have health care for everyone. Other countries have it, including both our neighbor to the north and our neighbor to the south (everyone talks about Canada’s health care and seems to glide over the fact that Mexico also has universal health insurance).
Most countries in Europe have some form of universal health care and the US is one of the few developed nations that is not on the worldwide list.
There are reasons why we SHOULD not be on the list. Two in particular jump to mind as being critical reasons why, as things currently stand, universal health care in the United States would be a disaster. I’ll cover these later.
For now, we have Obama Health Care.
And man, are there some issues with the law as it stands.
Affordable Health Care Act and Wellness?
Obama Health Care set up a Prevention and Public Health fund to the tune of almost a billion dollars.
That’s a lot of money to go towards prevention.
This is, however, where my skepticism comes in. Many of the organizations who are getting this money (like Alzheimer’s disease prevention and research) are funding research on future drug development. This is NOT wellness. Rather, it just continues to promote a drug-pushing society.
A very large chunk of this money also goes to increasing vaccination coverages. Wellness, however, does not have a downside. There is no downside to exercise or eating more broccoli or avoiding enriched wheat flour. It’s all upside.
But vaccinations are still drugs. They are manufactured in a lab and contain additional chemicals that are involved in the development, preservation and production of the vaccine. They are designed to function in a manner that is different than would happen naturally.
When you mess with human beings in this way there is ALWAYS a potential downside (feel free to read through my prior article on vaccinations by clicking here). To me, wellness approaches do not include a downside. Therefore, funding increased vaccination research is not true wellness and technically doesn’t count.
There is NO argument that a massive chunk of the healthcare dollars spent in this country are on lifestyle diseases. Diabetes and heart disease top the list, with cancer being another major contributor.
We could pretty much eliminate a huge chunk of healthcare spending if our country just took care of ourselves. This means that wellness should be THE priority for any health care system on the planet.
While wellness is about education, there also needs to be tools on getting patients to make better decisions. After all, how much more “awareness” do we need about tobacco cessation? When was the last time you pulled the rug out from underneath an unaware smoker by informing him or her that smoking was bad for health?
It takes some serious tools to get people to make lifestyle changes.
I firmly believe that a big chunk of the problem with people making lifestyle changes is medicine itself.
People with health conditions like diabetes, high cholesterol or high blood pressure somehow think they are “safe” when the important numbers are brought under control with medication.
News flash: There IS NO “UNDER CONTROL” when medicines are doing the work.
Lowering blood pressure with medications will not miraculously lower your risk of stroke and heart disease. Lowering cholesterol with cholesterol lowering medications doesn’t do squat for really lowering your risk of a heart attack or death.
It’s all a house of cards held up by medications.
Lifestyle changes are the only approach that holds merit. Period. But society thinks that a medication is going to swoop in on a white horse to save the day and ward off a heart attack, stroke or cancer. So long as this belief remains, wellness will not be the solution used by most people.
We won’t see true change until doctors are willing and able to look a patient in the eye with high blood pressure and tell him or her that there is nothing medicine can really do to derail the elevated risk of a heart attack and / or stroke.
Yes, I am advocating that we do nothing for the vast majority of patients with stage one high blood pressure, high cholesterol and pre-diabetes / diabetes.
While this sounds harsh, the reality is that pharmaceutical treatment of these conditions does very little to change the outcomes anyway. Heart attacks and strokes still occur at very high levels with medications. And this does not even begin to address the side effects that many of these medications cause.
Pharmaceutical treatment of lifestyle-caused diseases is a crutch upon which a medicated society relies upon. Until that crutch is removed and patients understand that they need to make real lifestyle choices or face the very real possibility of an early death or disability we won’t see society change.
So what does “wellness” really mean? Everyone throws around the term, but few of the things we consider “wellness” qualifies. Cancer screenings, vaccinations and going to see your doctor are not wellness.
Wellness is something that involves only you. Dietary choices, exercise, stress management and avoiding chemicals in the environment are all parts of wellness that don’t exactly fall under the category of a group effort.
Why Wellness Approaches Likely Wouldn’t Work
There are 2 main reasons why true wellness approaches would not likely be palatable to the American public. The first of these is my opinion. The second has been shown to be true in medical research studies.
Manipulating the American Public Doesn’t Work
Even if it’s for the collective benefit, the American Public does not like to be forced to do anything. Maybe it’s programmed in us to be leery of anything that’s forced upon us by government.
We’re OK if our doctors tell us to quit smoking or exercise more. But how would you feel if your employer pulled you into the office for a face-to-face meeting and had the same conversation?
While the uproar seems to have calmed down, when employers started not hiring smokers because of their higher healthcare costs (a very well-established fact and one of the few things under the Affordable Health Care Act that will cost you more in premiums) smokers were outraged and screamed discrimination.
But “smokers” are not a protected class.
Let’s step back a minute and think about this from an employer standpoint. As the decision maker at a large company, you’ve got two excellent candidates for a job opening. But one’s a smoker and will cost the company far more in health care costs. In good conscience can you hire the smoker??
The US has come to accept that smoking can affect your job status and “hirabilty”.
But what if your belly hangs out over your waist?
“Pump the brakes, bro!!” You can’t do that!!
In Japan they can.
In 2008, Japan passed the Metabo Law. The law mandates that local governments and employers add a waist measurement test to the annual mandatory check-up of employees who are between 40 and 75 years of age.
For men and women who have larger waists (men above 35.4 and women above 33.5), they are required to attend a combination of counseling sessions, monitoring through phone and email correspondence, and motivational support depending on the severity of their condition.
While there are no penalties for the individual employee, there are consequences for the employer (fines related to current health premiums).
Do you think, for even a second, that the United States employees would accept a program like this? This is purely my opinion, but if you look at a recent filing by AARP, I’m pretty sure you’d agree with me.
The Equal Employment Opportunity Commission updated their rules in 2015 to allow employers to fine (up to 30% of the premium amount is allowed under the Affordable Health Care Act, up from 20% that had previously been allowed under HIPPA) employees who do not participate in a workplace wellness program and give this same level of incentive for those that do participate.
In October of 2015, AARP filed a lawsuit alleging that 30% penalty is unlawful. While this was thrown out by a judge on December 29, it does give the impression that large advocacy groups are going to push back against these wellness programs. Whether or not the penalties will stand remains to be seen, but you can be sure that there will be future challenges.
US Worker’s Don’t Incentivize Well
Carrots are generally a good thing. They are used to get us to do something we otherwise might not be interested in doing.
On the surface, most of us would agree that money is a great carrot. But the reality does not quite hold out that well.
Although a hefty 85% of large employers in the US have a wellness program, only 60% of employees even know their company has one, and of these, only 40% participate in it. That’s 24%.
In general, there is too little participation in workplace wellness programs. A study published in January of 2016 looked at whether a $550 incentive could prod obese workers to lose 5% of their body weight.
Didn’t work.
The sad part is that this is not the first study to find that financial incentives don’t work as well as we would like. I have no doubt that there is something that can motivate people to make healthier changes, but I’m just not convinced that money is it.
The Fallacy of “Covered”
I’ve heard all kinds of numbers thrown around. Newly insured. Percentage uninsured. Percentage insured. Percentage who receive subsidies. Sign-ups versus actually paying (this one kind of surprised me—it’s people who signed up but never paid and it’s a high percentage).
But, for the purpose of this article, a very important statistic is just how many people are signing up for the Bronze and Silver plans. The average deductible for the bronze plan is just over $5K and just under $3K for the silver. Even the gold plan has an average deductible of almost $1300.
This is, of course, on top of the actual costs for premiums and coinsurance.
With an incentive (more on this later) the average cost for the silver plan was $2280 at the lowest end (New Mexico, but this goes up to $2496 in Vermont). This is for a $40 year-old non-smoker making $30K / year.
Now, math was never my strongpoint, but this means that, someone who is by no standards “rich,” will be paying $5280 per year before insurance even pays a dime. These numbers would be worse for the bronze plan.
That’s an extra $440 per month that essentially does not pay for healthcare. Do you think that $440 / month is a drop in the bucket for this $30K / year employee?
Add in family coverage and it gets sickening.
This is not “coverage.” It is paying for insurance that most people will never use because it’s too pricey to use. Yes, it is there for catastrophic illnesses, but couldn’t these people already find care prior to the Affordable Health Care Act? Did we actually turn away cancer patients who needed care or open heart surgery patients?
No, we did not. Maybe they didn’t get the Cadillac version of healthcare, but they could find resources when needed.
The Hidden Danger of Incentives
Any time the discussion on Obama Health Care premiums comes up, someone always sneaks in the cost of the premium with the incentives factored in. For 2017 premiums, the tagline was that premiums WITH INCENTIVE only increased about $4 over last year. The actual premium, however, if you bothered to pull aside the curtain, went up WAY more than that.
This means that, year over year, it will require more and more money to keep this program running because nothing in the Affordable Health Care Act will actually make us healthier. It was mis-named. It’s a Health PAYMENT Act, not a Health CARE Act.
The government is generally very good at creating programs that dupe the American public. Take taxes, for instance. If you are self-employed, you darn well know what you pay in taxes by April. But, the average employee will only know what he or she GOT BACK, not what was left behind. By the way taxes are structured, people are duped into being happy with a refund check (which, if I’m not mistaken…was the employee’s money to begin with) and not focusing on what was paid.
I had a discussion with my sister and she was completely unaware of what her premium actually was. She had a good idea of what she was paying, but not what the true cost of her health care plan was.
In 2013, I paid $140.57 for my health care coverage through Golden Rule for like a $2600 deductible (don’t quote me on the exact deductible, though). NOW, with the crappy plans available here in Arizona, my premium is $512 for a $6000+ deductible.
That’s a 360% increase for worse coverage. And I have NEVER made a claim for health insurance benefits, so it’s not like I was a cost driver for this change.
Regardless of how much you actually pay, you NEED to be aware of how high your premiums have become under the Affordable Health Care Act.
And you should be outraged. The entire American populace should be outraged. This is money that is essentially going into the health insurance company’s pockets. Obama Care insurance has essentially paved the way for insurance companies to massively hike premiums while the majority of the American public lets out a collective “wheh” and thinks about how he or she dodged the bullet of actually paying out of pocket for these outrageous premiums.
Paying for Wasteful Medicine but Not Health
This section is likely to cause the most dissention but is the most important section of this entire article.
I have said this before and I will say it again here. The main thing that the Affordable Health Care Act did was increase people’s access to drugs.
But these are life-saving drugs, right?
Hardly.
It’s not to say that someone with the blood pressure of 186/110 is not going to be helped by blood pressure medications, but a huge chunk of drug use in this country creates more problems than it solves.
There are a lot of people who got insurance for the very first time and ran to make an appointment with their primary care doctor. Most would think that this would be a good thing; these visits allow doctors to help identify and treat hidden conditions and save lives.
That’s the generally accepted dogma. But when researchers finally looked at this ages-old advice, they found that the “annual medical visit” did nothing to avoid deaths from cancer, heart attacks or any other cause.
What did happen was that there was an increase in the blood pressure medications prescribed and a 20% increase in new diagnosis for the patients and increases in self-reported chronic diseases.
In other words, more medicine but no actual benefit. Chalk a win up for the drug companies (who, by the way, are the REAL winners with the Affordable Health Care Act).
Just in case you think I’m being unreasonably biased, let me give you some more examples.
- Wasted insurance dollars on chemo drugs: of 18 cancer drugs approved by the FDA between 2008 and 2012, none were shown in postmarket studies to lengthen survival. Despite not actually improving outcomes, the estimated annual costs of the 18 drugs ranged from $20,237 (rituximab) to $169,836 (cabozantinib-S-malate). Thirteen of the drugs cost more than $100, 000 annual. The most expensive drug (cabozantinib) did not improve survival and worsened quality of life.
- Interventional cardiology for non-emergency procedures. It has been well established that upwards of 50% of angioplasty / cardiac stenting procedures (in non-emergency situations) are worthless to the patient and worse, put the patient at risk (which then costs MORE money). To say that this procedure costs the system BILLIONS of dollars per year would not be an unreasonable estimate (there are over a million interventional cardiology procedures done per year, with a cost around $13K each).
- Cholesterol lowering drugs. We spend billions of dollars per year on drugs to lower cholesterol and yet, quite frankly, they SUCK at preventing heart attacks and they do nothing for lowering your risk of dying of a heart attack. It’s wasted money on a class of drugs that have a long list of side effects and keep patients from making real lifestyle changes to lower cholesterol levels naturally.
- Blood pressure medication for stage 1 high blood pressure. The research came out several years ago that determined that drugs used for blood pressure under 160 systolic or 100 diastolic did absolutely nothing to lower the risk of heart attacks, strokes or deaths but DID produce a long list of side effects. Despite this, anti-hypertensive medications are still being used in patients with stage 1 hypertension.
- Complex spinal surgery. While this is not as clear-cut as the blood pressure example above, it has been well-established that we do WAY too many spinal surgeries in this country. And, when a simpler, cheaper and less-risky procedure works just as well, surgeons do the more expensive, more complex and more dangerous surgeries. Go figure. Considering that musculoskeletal problems are the #3 cost driver in the health care system, this one is a bigger.
- Unneeded imaging for back pain. This is a big one that I deal with frequently in my office. Providers are way too quick to jump on the idea of ordering X-rays, CT scans and MRIs. Not only does early imaging not benefit the patient, it actually increases the likelihood that the patient will have epidurals and later surgery.
- Routine screening mammography could be put on this list as well, given the heavy controversy associated with it’s use.
This list could go on much longer, but you hopefully get the idea that we waste BILLIONS of dollars on procedures and drugs that have very little value and a strong chance of adverse effects.
If we increase access for millions of people by increasing the number of people with health insurance without making changes to what does and doesn’t work, you can see the mess we’re creating.
More people medicated, more side effects, more problems with overtreatment and overdiagnosis, all of which then costs more money.
Not a “fix” at all.
This ends the problems with the Affordable Health Care Act. In part 2 of this article I cover suggestions for how to fix this mess we’ve created.
Onnie Shekerjian says
Probably THE best summation of the positives and negatives of the Affordable Health Care Act I have read…
James Bogash says
Thanks! I’ll get into some potential fixes next part.
Dr. Bogash
Robin Carbonneau says
While you make many valid points, you lost me with the sentence that the Affordable Care Act is a mess. No. The Affordable Care Act stepped INTO the mess that was the American insurance industry. I totally agree with the idea of promoting wellness, but I am concerned with realities as they exist, not what SHOULD be. The fact is that The Affordable Care Act , while far from perfect, was the best plan that the Obama administration could get passed at the time. It gave millions of people coverage who never would have been able to have any insurance at all, and that can be lifesaving. Sadly, Trump and Republicans are hell bent on destroying the ACA, so this may all be a moot. Since Republicans never came up with any good ideas in 8 years and still seem to have nothing other than the desire to repeal, I don’t see them helping anyone or anything with these actions . Bashing the ACA is fashionable, but I feel that lost in the criticisms is that SOMETHING needed to be done and thank God, Obama presented the beginnings of some kind of universal health plans ; because in a country as wealthy as the United State, millions of people being uninsured is unacceptable.
James Bogash says
Robin,
Thanks for the feedback. We totally agree that this whole thing has been a mess for a long time. But all the ACA did was rearrange who was paying for expensive, inefficient care. The plan, as it is set up, created a MASSIVE income to the insurance companies and drug companies. I don’t think anyone is happy about that (at least…those outside of these industries). Now that these companies have managed to get more money out of legislation, it’s going to be very hard to un-entrench them. The ideas for fixing the problem may be more storybook than reality, but only because I don’t think we will ever seen any REAL changes in health care while THIS much money is at play.
Make no mistake–it doesn’t matter what side of the political fence you are on, the law did some good things, but just because people are now insured is NOT an automatic good thing.
Dr. Bogash
Joan Etzenhouser says
“It has been well established that upwards of 50% of angioplasty / cardiac stenting procedures (in non-emergency situations) are worthless to the patient”
I’d like to understand this statement better. Can you please clarify?
James Bogash says
You can follow the link to read the info from the article I was referring to (http://www.lifecarechiropractic.com/blog/cardiology-informed-consent/). But as a summary, a good chunk of these procedures (again–these are NON emergency situations) are just to relieve chest pain. It doesn’t prolong life, lower the risk of future heart attacks or lower the risk of needing a cardiac bypass in the future. Treating the chest pain medically (without a stent) can produce the same outcomes.
Dr. Bogash
Pauline Staeheli says
I’m amazed at how many of my clients think cholesterol is as important as their blood pressure meds (yes, they are usually on both). Last year, my husband’s cholesterol med fell into the Medicare donut hole, causing a rise in copay from a few dollars to well over a hundred dollars. He refused the prescription & started eating healthier- what a concept! And unfortunately one that usually isn’t even suggested by the prescribing physician. Part of the problem is our quick-fix society – easier to take a pill (or 2 or 10) than address the root causes and make lifestyle changes. Another is that often physicians don’t take the time to talk to the patient. So we will continue with our sick care, whether Obamacare or other…
James Bogash says
Pauline,
Yes– it’s sad that lifestyle changes are usually last on the recommendation list. And usually these are not even strong enough to make a difference. Simple things like avoiding fried foods and exercising more won’t make as much of a difference as other changes.
Dr. Bogash
Bob Iversen D.C. says
Dr. Bogash,
Great article, as a practitioner myself for 28 years and now on the other side of the fence (reimbursement) it amazes me how horrible most insurance plans really are. The new year 2017 average deductible is $10,000 with premiums around $3-500 for an individual basically means that you will pay between $15,000-20,000 before your insurance company will pay their first $1.00. No one and I mean no one that makes under $18.00 an hour should even think about being raked over the coals like this.
Fortunately there is an answer: at Redirect Health we put HEALTHCARE FIRST and insurance last. Our group and individual plans start at $105.00 for an individual per month and are less than $400.00per month for a family for our EverydayCare plan. This plan includes 24/7 Care Logistics,$0.00 copays or deductible for Primary Care / Chiropractic visits,as well as all preventive adult/well child care even labs and MEC immunizations.
Check us out at REDIRECT HEALTH.COM
Dr. Bob Iversen
James Bogash says
Dr. Iversen,
Thanks for the info. I’ve heard of some of the co-op options and that the premiums are very reasonable. May be a great option for many people. It’s also my understanding that these plans are grandfathered under the ACA and thus anyone buying these plans will not be fined.
Dr. Bogash
Andy Lockridge says
Great article.