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Doctors, Patients, and the Future of Obamacare
The individual mandate isn’t even the worst part.


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Marc Siegel

Imagine if the government mandated that you buy an expensive certificate to eat at a certain restaurant chain, but you quickly discovered that this chain only provided you with limited food options and didn’t hire additional chefs or waiters to cover the new volume of customers. Moreover, what if the waiters who already worked there recognized the voucher holders as poor tippers and provided them with poor service?

Welcome to the world of Obamacare.

As objectionable as the new wrinkles of Obamacare are — the individual mandate, IPAB, etc. — perhaps its worst feature is the way it takes the most harmful aspects of our current health-care system and expands them, rather than cutting them back. Whether or not the individual mandate is struck down by the U.S. Supreme Court as unconstitutional, the way most Americans in a new Gallup poll think it should be, we still face a situation in which we won’t have anywhere near enough doctors to care for the expanded volume of patients that Obamacare will create.

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Even without Obamacare, doctors are already overwhelmed with low-paying, highly restricted insurance that lets a patient demand to be seen whenever he or she wants to, but restricts the tests and treatments a doctor can order, while paying us less and less to provide the service.

The individual mandate may be the glue that holds Obamacare together by shoehorning in young healthy people who don’t need health insurance to pay for the sick and elderly who do, but an even greater problem than the mandate lies in the unwieldy insurance itself, and the fact that America has a shrinking number of doctors willing to work with it.

From a doctor’s perspective, insurance is a big problem, and government insurance is a bigger one. Obamacare will make things much worse by increasing the number of people who are insured, expanding the procedures and other items (e.g. contraception) that are covered, and enlarging the government’s involvement in running it all.

Add to that the persistent liability concerns associated with performing high-tech procedures if they fail, and you can understand why the best and the brightest are no longer flocking to medical schools. There has never been a greater obsession with health-care delivery than we have now, yet the number of medical-school applicants is actually down, from 46,965 in 1996 to 43,919 in 2011. And those who graduate from medical school are not choosing to become low-paying primary-care doctors, such as internists. Studies have shown that our ranks decreased by 32 percent from 1985 to 2008.

This is because our health-care system is broken, with a bias toward rewarding high tech but not hard work. And instead of addressing the essential problems that many doctors face (too many patients, too many restrictions, diminishing reimbursements, increasing expenses, the ever-present threat of malpractice litigation), Obamacare just extends these problems to more patients.

Increasing the number of Americans with access to health care is a laudable goal, but simply decreeing it by expanding coverage won’t work. You can make a case for the federal law mandating that emergency rooms must not turn away sick patients, but instead of providing actual medical services to the poor and needy — for instance, by building more government-run clinics or expanding the National Health Services Corp. — Obamacare just extends an easy-to-overuse insurance that doesn’t guarantee anyone access to actual care.

The Association of American Medical Colleges estimates that the U.S. will be 160,000 doctors short by 2025. But as overwhelming as this number is, it doesn’t take into account all the doctors who have stopped or will soon stop seeing patients who use Medicaid, Medicare, or HMOs that no longer pay us enough to cover our bills.

Whether or not the individual mandate is struck down, there isn’t a doctor out there now in the medical trenches who wouldn’t prefer to accept cash rather than work with insurance. But only if the so-called Affordable Care Act is dismantled can we begin to address the excessive costs and the doctor and patient discontent that lie at the heart of what is wrong with our health-care system.

As has been said, if the federal government wants to defy the Constitution and force my patients to buy something, it should have started with nutritious broccoli. At least broccoli will improve our health, whereas Obamacare won’t.

If the individual mandate is upheld by SCOTUS, doctors will continue to drop out of insurance, probably at an accelerating pace, and I expect the feds to next create a mandate for all doctors to accept Obamacare insurance. If that bleak day comes, perhaps doctors will finally be ready to revolt.

 — Marc Siegel, M.D., is a professor of medicine at NYU Langone Medical Center. He is a member of the board of the Fox News Medical A Team and the author of The Inner Pulse; Unlocking the Secret Code of Sickness and Health.



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