Obamacare: What does it mean for America? (Part III of III)

July 31, 2012

Mark L. Friedman, MD, FACEP, FACP

What will be the effect of all these changes in insurance coverage on the access to and delivery of health care in America under the Affordable Care Act (ACA) / Obamacare?

The first effect will be an immediate injection of volume (patient visits) on the order of 10 to 15 percent into a system that has little, if any, excess capacity. We saw this happen in Massachusetts when the state version of universal healthcare (aka Romneycare) was put into effect. Those who fail to learn from history are condemned to repeat it.

Visits to hospitals, emergency departments, and clinics (which accept all insurances) will increase significantly, as will waiting times and lines. Doctors and clinics that accept Medicaid and low-paying insurances will be overwhelmed by the volume and new appointments will take longer, or simply be unavailable on a regional basis.

Private physician practices, some clinics, and even hospitals will become choosey in terms of which insurances they will accept. In certain instances they may demand cash payment up front and let patients deal with their insurance reimbursement (or lack thereof) on the back end.

This is only the beginning. As Medicare is eventually forced to reduce reimbursement (it currently pays physicians 27 percent more than the actual authorized fee schedule based on periodic "fixes" that extend the deadline on fee reductions), physicians will abandon the Medicare system in droves -- as they have already begun to abandon Medicaid. Physicians as a group are demoralized, dispirited, and as many as 40 percent may elect to retire or otherwise leave their practice within the next three years.

Opportunities will appear for telemedicine, medical tourism, "focused factory" providers, and other innovative models based on the scarcity of medical services under the conventional model.

Self-care and self-help will become an increasingly important part of medical care. Nurse practitioners, physician assistants, optometrists, pharmacists, and other ancillary providers may cull the vacuum created in primary care and other niche areas.

Continuing trends of increased demand and increased cost may combine to create a crisis situation. Whenever supply and demand are out of balance, prices adjust to maintain equilibrium. While government may try to influence this dynamic through regulation, supply and demand will ultimately dictate costs.

The bottom line is that medical care will become harder to access and more expensive. It may well evolve into a two-tier system of public versus private care, where significant costs will be redirected back onto patients.

Originally published Jul 31, 2012 1:47:18 PM.