Unsustainability: Obamacare, Medicaid Expansion and the Destruction of the “Art” of Medicine

During this last week of Thanksgiving, I began to reflect on the last year and the many good things that we have all been blessed with in healthcare.  I have the opportunity to serve patients and their families every single day.  I have the privilege of making a difference in the lives of others.  However, As I reflect, I am greatly troubled by what looms in the year ahead for physicians and their patients.

As Obamacare continues to roll out (or stumble and crawl out as the case may be), other programs such as medicaid are expanding as well.  In less than a month, already overwhelmed US healthcare systems are going to be flooded with new patients.  Experts argue that the medicaid expansion will allow for “timely access” for all new patients.  However, once again, the Obama administration has failed to look at one of the core problems with expansion–Who the heck is going to treat all of the new patients?  The current expansion of medicaid (in concert with the Obamacare mandate) is likely to result in long wait times for primary care office visits, limited subspecialist access to those with the worst insurance (medicaid) and ultimately poorer outcomes for patients.

Some experts predict a significant shortage of physicians (both primary care and specialists) as we race to meet the flood of newly insured patients.  During the design of the expansion of medicaid, no one with actual experience in caring for patients has seriously considered how the care they plan to provide will be delivered.  Traditionally, medicaid reimbursement rates are significantly lower and the payment process is filled with bureaucracy, paperwork and red tape.  As discussed in the Wall Street Journal this week, the medicaid expansion in California is underway.  Over 9 million people will enroll in the medicaid programs expanding all across the US very soon.  But many doctors will be unable to accept medicaid patients due to the low rates of payment included with the program–for example–in California where we have one of the largest medicaid populations in the US, only 57% of physicians will accept medicaid.  Many subspecialists will not–financially it is not feasible to pay increasing overhead costs, increasing malpractice premiums and receive reimbursement rates that are even well under traditional Medicare rates.  In fact, many physicians in California who have traditionally accepted medicaid patients will no longer be able to take on new ones.  In response, the government has issued “incentives” to persuade physicians to accept new medicaid patients.  These incentives include “higher” reimbursement rates for two years (then the rates revert back to the mean at that time)–what they do not tell you is that the increased rates are still below standard CMS medicare reimbursement.

How is this Changing the Landscape of Healthcare Delivery?

Clearly, we must provide care to all Americans. We must, however, do it in a way that makes good financial sense.  The practice of cutting rates for physicians and expecting them to continue to work 60+hour weeks, sacrifice family time and meet increasing demands of electronic documentation and higher patient loads is unsustainable.  As physicians, WE are part of a noble profession and we all care deeply for our patients.  Our passion is to help others battle disease.  We consider much of what we do to be SERVICE and the rewards for service to others are immeasurable.  However, physicians sacrifice a great deal of time to become expert in their respective specialities.  Some of us have endured as much as 10 years of post MD graduate training with low pay and long hours.  Many have mountains of school loans and debt to repay.

From a business perspective, many physicians are finding shelter under the cover of large healthcare systems and hospitals–both private and university based.  The private group or traditional private practice is becoming extinct.  Competition is beginning to dwindle in many markets as hospital systems gobble up other institutions and other groups that once competed for patients–essentially forming monopolies of healthcare delivery.  Add to the realignment of groups and hospitals the newly formed Exchanges that have limited choice and healthcare prices are no longer subject to free market competition.

What are the options?  Healthcare is a business, right?  Or is it simply another government program?

I certainly do not claim to have all the answers.  However, I do recognize that the course that the Obama administration has set upon is unsustainable.  We will soon be facing a crisis of physician shortages throughout the US.  Medicine, although a noble and honorable profession, is no longer an attractive option for many of our brightest young minds.  Of the physicians (like myself) that continue to practice and care for our patients with passion, burnout is common.   If we continue to limit reimbursement and increase workload physician burnout will continue to rise at levels much higher than in the past.

Maybe the answer is for the government to create a federally run health service.  In this model, the government selects prospective medical students and funds their medical training–pays for medical school and living expenses during internship, residency and fellowship training.  Once training is completed, the young physicians are then obligated to practice in a government owned hospital or clinic for a number of years (commensurate with the number of years that they benefited from government support).  The government would control their salary, their work hours and their practice location.  All patients who are signed up for medicaid are then assigned a clinic and a physician from which they will receive their care.  Those who choose not to participate in government clinics will most likely be a part of “boutique clinics” and concierge medicine.

Is this really what we want?  A single payer, socialist society?  

Free enterprise, entrepreneurship, and competition are what makes medicine in the US great.  We must carefully consider the impacts that the decisions currently being made in Washington concerning our healthcare may ultimately affect our freedom.  The time to get involved is now.  Let your voice be heard.  Advocate for your patients and your family.  Let’s get back to practicing the “art” of medicine and re-focus on what matters most–the care of the person suffering with illness….




26 responses to “Unsustainability: Obamacare, Medicaid Expansion and the Destruction of the “Art” of Medicine

  1. Well said! I cannot imagine why our government officials in Washington cannot see this! I am extremely concerned about our health care future.

    Sue Lee

  2. I didn’t vote for him. No one will want to go into medicine, even under the plan you suggested. Unless they want to be owned for years by the government. It is a mess. How did Massachusetts do it? Are you familiar with that?

    • Ms Molle,
      I agree totally with you. The plan I suggest is not a viable alternative either. It is a shame that such an honorable profession is now becoming completely undesirable due to politics and the greed of elected officials. Why is it OK to impose a mandate on the American people and then exempt lawmakers from that mandate? If the plan is so wonderful, shouldn’t those who crafted it want to participate?

  3. ”Free enterprise, entrepreneurship, and competition are what makes medicine in the US great”great oxymoron.Medicine in the US is far(light-years far) from being ”great”,and those three factors you mention might be the reason US healthcare is a model to be avoided by ANY other country in the world.

    It might be true that Obamacare has several flaws but at least it comes from the acknowledgement that the US healthcare system is not the healthcare system a country like the USA deserves.

    • In response to your comment:
      First of all, thanks so much for taking time to read and respond to my blog.

      Actually, people travel from all over the world to receive care in the US. Obamacare is filled with problems–not the least of which is the website and the inability to sign up patients at all. I believe in providing healthcare to all is a top priority. However, the current proposal is unsustainable and will not be effective at the goal. My recent blog addresses more than Obamacare–it addresses the ways in which a government run healthcare system will destroy the art of medicine.

      Best regards,

  4. Dr. Kevin
    With all due respect, sir, WEALTHY people come from all over the globe to receive care US citizens cannot because of the rampant lack of access to this so-called “great” system. Pointing to outliers to justify our dismal performance compared to the rest of the world is really sloppy logic.

    In answer to your final question, YES, many of us DO want a single-payer system. I really do not care if you want to slap the perjorative (in the US, not in Scandinavia or many other parts of the world) “socialist” on it. All I know is I had far better health care as a foreign resident of a nearly third-world country than I ever had in the US when I was too poor to buy insurance.

    • Thanks so much for taking the time to read and respond to my blog. It is only through debate and engagement that we will collectively solve our nation’s healthcare problems. I do not debate the fact that wealthy from abroad utilize our system widely. However, there are inherent dangers with a single payor systems–for instance, who is going to work for reduced reimbursement and limited autonomy (where are these doctors going to come from?). In addition, when will we (at the national level) accomplish tort reform? YOu cannot expect doctors to continue to practice and continue to pay escalating malpractice premiums so that they are protected against the “John Edwardses” of the world.

      Competition and innovation are what drives new medical breakthroughs. I agree the status quo is unacceptable–but the current proposed solution will eventually implode–it is not sustainable. No Republican, Dem or independent can make a flawed OBamacare function in the US in its current form.


    • With all due respect DuckLady, they used to. Now they are going to Asia and Europe. I suspect you are a Internet troll, not a real person. Nonetheless the ACA is financially untenable and will be a disaster. As a real doctor, I know all to well. We live in a corrupt Republic and the collapse will happen soon enough in health care.

      Btw. I too have lived abroad extensively. Get rid of EMTALA, reform education and the Tort system and we might have a chance. Won’t happen and we all know it n

  5. DR Campbell, at 70 and my wife at 67, we have been well served by the Advantage programs we have had. I would suggest, though, that actually ‘concierge care’ would be the best model and I would give up Medicare for just a Medicare ‘A” Major Medical policy and concierge care for the day-to-day medical needs, tests etc.

    • Mr Quinn
      Thanks so much for responding to my blog post. I am happy to hear that Medicare Advantage has served you well. I am concerned that others may not be as fortunate as we continue to implement the liberal policies of Obamacare. Hopefully, those like yourself will continue to speak up and advocate for the future of our country. I agree that ultimately, concierge care may be the best option but I am concerned that those who cannot afford it will suffer under the ACA

  6. “Is this really what we want? A single payer, socialist society healthcare system?”

    Yes, yes it is.

    • Thanks so much for responding to my blog. However, I will simply say….be careful what you ask for…one day, when the system implodes and healthcare rationing and higher taxes are the only answer, I suspect many will say “what were we thinking…”


    • Enjoy your “single payer” system. I just wonder where the rich Canadians will go. Better hope you are genetically blessed because over the age of 60, nothing will be done you can’t pay for.

  7. 100% agree. Great article. I hope the physicians of the US stand and rebel against it. The government has tried to usurp 1/6 of the US economy. We have a dictator at the helm. Couldn’t be gone soon enough.

  8. David M Gimlett, M.D.

    Oh Kevin, Oh Kevin. It is free enterprise, entrepreneurship, and competition (among hospital, HMO’s, insurance companies and pharmaceutical companies) that has already made U.S. medicine twice as expensive as anywhere else with lowest percentage of the population covered in the industrialized world. It’s the cost that is unsustainable.

    • Dr Gimlett
      Thanks for taking the time to read and respond. The best thing about our country is the fact that (for now, at least) we are able to disagree and debate. I do in fact agree with the fact that insurance companies as well as medical device companies, pharma companies AND lawyers (see tort reform) have driven up prices in the US. However, the current plan by the Obama administration does little to address any of this. In fact, Obamacare is counting on the young and healthy to foot the bill for everyone else. These are my kids….

  9. We already have a single payer system after age 65, Medicare and it is exactly at that age demographic that the US rises from 30th place in cost effectiveness to number one in the industrialized world…hmmmm

  10. Thank you for your well thought out letter. It’s not only Physicians and their patients who are going to lose, but the nation as a whole.

    Social security will be bankrupt in less than 20 years, medicare in less than 10. The response from the leadership of this country is more ‘manditory spending’! Our Nation is over 17 trillion in debt. We have 90 – 150 Trillion in unfunded liabilities. The feds (and most states) have been spending $hundreds of millions of Dollars more (this president, trillions more), than they take in for decades. China is a net seller of our debt. Europe is bankrupt. Asia will not lend us more. The Middle east hates us. Our credit line is overlimit and closed. Why else would the FED be buying $85 billion of long dated debt/month, every month? That’s roughly the same amount the feds ‘borrow’? They are not borrowing any more, they are printing money to pay the deficit; this is absolutely unsustainable The end game is approaching. WHEN / IF THE US DEFAULTS, ECONOMIC DISASTER WILL PREVAIL LIKE NEVER SEEN IN HISTORY. Our money will be worthless. Pick up a real history book. This has happened before, just not on the massive scale and this time with no-one to rescue, bail out the dummies, for we our them. We allowed this to happen!!!

    I have lived in 2 countries that failed while I was there. Both had “free” medical care. Most everybody lost everything. Pensioners were left with nothing but worthless paper money. Businesses and gov’t offices closed with frightening speed. The few Physicians who stuck around were no longer paid by the state, so patients needed to show up for treatment with currency; preferably hard currency, family heirlooms – something tangible. The Doctor would tell the patients what was needed for treatment, and they’d go out and try to find those items. Not much was available. Many died due to this the lack, some committed suicide for having lost everything they had.

    What’s so frightening to me is the level of polarization in this country AND the fact that its encouraged by the leadership right up to the president! In such a society, one that also demonizes anyone who tries to make practical suggestions based in sound (not Leninist), economic principles, it seems unlikely that we will get out of this without suffering some major pain. All because we refused common sense. Most people understand that there are no ‘free lunches’.

    • Thanks so much for your well thought out response. It is rewarding to know that individuals such as yourself read and digest my blog. I agree with your commentary and I am hopeful that our citizens and our leaders will “wake up” and begin to understand that the problems surrounding healthcare in the US are bigger than one man or one party’s ego (or legacy). We must learn from our own mistakes and not make the same mistakes made by other nations. We must care for our citizens but do so in a fiscally responsible way.
      Again, thanks for your well placed response.

  11. Wait. There’s a great health care system in the country in which you practice? Well, what country are you practicing in, because it’s clearly not America. I’ve been in practice for almost a decade, and I number of patients I’ve treated who have presented to the ED with advanced disease because they have no insurance is mind blowing. I recall one patient who walked into the ED complaining of abdominal pain and bloating. He was diagnosed with hepatitis C years before this presentation, but never followed up because he couldn’t afford insurance due to his pre-existing condition. Tests quickly revealed he was in fulminant liver failure. Cat scans showed multiple masses throughout his liver, his lungs and brain. This man literally WALKED into the ED thinking he had an ulcer or something similarly treatable. He died 5 days later with his wife and 5 children and about 15 other family members sobbing in disbelief at the bedside. This is just one of the many ways the health care system is failing so many people in this country. And your fears of the development of a nightmarish 2 tiered health system are unfounded because it already exists. In that very same hospital where the uninsured use the ED as a primary care service, there exists on the 8th floor a completely different world for the wealthy, well connected and well insured. It’s different from the special separate menu and wait staff to the floor to ceiling windows over looking the Atlantic to the glossy mahogany floors. And the doctors round there early and often. Same hospital, different care. In the 2 tiered healthcare scenario under AHCA that you posit, at least people in both tiers have some kind of insurance. I agree that the AHCA is flawed, but the old system was untenable. Discharging patients without insurance who are unlikely to receive follow up is almost unconscionable to me. And it’s terrible for society as they will likely return to the ED in some kind of extremis for more patch-it-up care that we all pay for in the form of higher health care costs and insurance premiums. So what’s the answer? I don’t know, but continuation of the status quo ain’t it. Now THAT is unsustainable.

    • Thanks for taking the time to read and respond. I have been practicing for well more than a decade. I am not an ER physician and I see patients over time rather than in snapshot emergency visits. My patients struggle under the current system but many fear the new reform. Many of my patients fear that they will not be allowed to see me for continuity of cardiovascular care. Many of my patients are being dropped from their insurance plans and cannot sign up for the Exchanges due to the incompetent roll out of the website.

      I certainly agree that the status quo is not acceptable and have clearly stated this in all of my previous blogs, comments, responses etc.

      However, it is NOT sustainable to proceed with Obamacare. How do you envision paying for the care of those with chronic disease? How do you suggest we recruit bright young minds to dedicate decades to training only to be left with falling reimbursement rates, zero autonomy and algorithmic care? How will we solve complex medical problems in the future with zero incentives?

      The great thing about this country is that we (at least for now) have the freedom to debate–to engage in discourse and discuss both sides of an issue. The ACA was formulated and implemented by a single party–a single entity–the current administration won the election by a small majority–that means that nearly 50% of Americans disagree with the current policies.

      I hope that somewhere in the future we are able to craft a sustainable reform. One that is good for BOTH doctors and patients.


  12. Dr Kevin

    I don’t normally respond to responses, however I’d like to clear up a few things. I’m not and ER doc. I’m a hospitalist. As such,in an ideal world, my view of a majority of patients should be snapshot-esque. However, because of our dysfunctional health care system, I find that I have the dubious honor of seeing the evolution of many peoples disease processes because they have no insurance. For too many, I find myself in the role of pcp. However, instead of preventing or slowing down the disease process, I find myself running to catch up to the disease, trying to reign it in so that the patient is just stable enough for discharge. You stated that you worry that your patients won’t be able to follow up. Well, I don’t worry about this, because I
    KNOW that many of my uninsured patients will get no follow up and will likely be returning to the ER a little bit sicker and less whole than they were before. You ask who will pay for these patients health care under the ACA. Well, I ask, who is paying for the uninsured under the old system? The answer is us. We’re already paying for it, dearly. You also mention that Obama was re-elected by a small margin and this is evidence that nearly 50% of the electorate considered the 2012 election to be a referendum on ACA. I would like to suggest that this is not the case and that there were many reasons that people voted against Obama that had nothing to do with ACA. There have been many polls that show that when you break the ACA down into its individual components (and you don’t call it Obama care), a vast majority of people support the legislation. As I stated in my original comment, I don’t have all of the answers, but some thing has to change.

    • Dr
      I am so very glad that you did respond! It is vital that we all debate these issues in order to improve care. I respect your opinion and very much admire your dedication to your patients. ALthough I disagree with your assessment of the population’s support of the ACA (as evidenced by several recent polls in the media –not just Fox News) I do AGREE that something has to change in order to BOTH provide care for all and SUSTAIN a universal healthcare system. It is my hope that the current Congress will NOT be re-elected–irrespective of party–and that those with true vision and LEADERSHIP (which includes actual compromise across the aisle) will be put into place.

  13. Bruce Fisch, MD

    There are so many ways to make a lot of money on Obamacare, be you a provider, medical device maker, or hospital. Like all subsidized purchases, such as Medicare services, the subsidy will lead to inflation and overpricing, fraud, and lack of accountability. The real endgame must therefore be, as the article implies, a socialist system with authoritarian price controls. This is the ultimate goal but I personally doubt it will get there. As was predicted when this passed: “all future elections will be about healthcare”. This is true and eventually the party who completely opposes Obamacare will come to power and hopefully eliminate it. If not, we will surely have a two-class system: basic care by the government versus luxury care for those who decide to pay for it.

    Finally, I can’t see how any major program like this can succeed without being bipartisan, which there never will be.

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