Affordable Care Act: Affordable for whom?

Entering its third annual open enrollment period, Obamacare is the subject of cacophonous political acrimony, again, championed by its supporters and vilified by its opponents. Each side presents its own “metrics” of success or failure, echoing the great Irish conservative Edmund Burke that, “In ascending order of treachery come lies, damned lies and statistical lies.” How apt a quotation when the Obama administration is now urging people to sign up for The Affordable Care Act, lauding the low premiums now available on the law’s new marketplaces. The President himself has said most Americans can find an option that costs less than $75 a month. The Secretary of Health and Human Services reaffirmed this promise saying 8 out of 10 returning customers will be able to buy a plan with premiums less than $100 a month after tax credits. Given the statistic that the medically uninsured rate in the United States has fallen from 15.7% to 9.2% since the law was enacted, it seems Obamacare has lived up to its hype.


Except the true cost of health insurance comprises not just a front-end monthly premium, but a back-end combination of deductibles and copays paid by the patient whenever the insurance is utilized. In many states, more than half the plans offered through the federal online marketplace have a yearly deductible of $3,000 or more. Median deductibles are actually greater in Miami, FL ($5,000), Jackson, MS ($5,500), Chicago, IL ($3,400) and Phoenix, AZ ($4,000). Granted, these are the Federal markets, not Medicaid expanded, income-sensitive state plans where financially needy participants can get cost-sharing reductions. Still, the Kaiser Family Foundation avows that average employer-sponsored plans have annual deductibles of only $1,320 for individual coverage. These sky-high back end patient financial outlays are making many consumers feel just as vulnerable as they were before they had coverage. Paradoxically, people can afford to have insurance, but cannot afford to actually use it.


These high deductibles are not just the avaricious pricing of the insurers participating in the marketplace. The sustainability of Obamacare is predicated on mandatory universal coverage providing large pools of younger and healthier people with little medical need to offset the health resource utilization of the debilitated and elderly. The costs to the insurance industry are reflective of the health profile of the composite insurees. The initial pricing system was, by necessity, guess work. After two years of accumulating real data, the insurance companies could and should better formulate a business model reflective of the healthcare needs and costs of their customers. There is pressure to keep premiums down, but if that does not pay for care actually rendered, then the difference has to be made up at the point of service with copays and deductibles. Ergo, the patients have to bear more of the financial burden than the low premiums they were quoted. Given this scenario and the recently released data that health spending grew 5.3% in 2014, the largest jump since 2007, and that this accelerated growth far exceeded that of GDP, the true “affordability” of the Affordable Care Act is not a faite accomplie, but a work in progress.

By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton


Why Would a Doctor Abandon a Steady Paycheck to Become an Entrepreneur?

As physicians, we are expected to be compliant with rules, restrictions, and regulations. We are expected to be risk averse. We are expected to be “providers,” but not necessarily innovators or leaders. As the healthcare system becomes increasingly consolidated into large overcrowded clinics, we are required to perform to the standards set by bureaucrats and clinic managers. These rules are often at odds with the best interests of patients and with our sanity.

The Alienation Of America’s Best Doctors

The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage.

Better to Live and Die in the U.S.A.

The United States healthcare system is often berated for how it treats patients near the end of life. They are purportedly attached to tubes and machines and subjected to unnecessary invasive procedures that cause inordinate pain with no potential benefit, there is underutilization of more compassionate hospice services. This “travesty” is expensive, as the care of dying seniors consumes over 25% of Medicare expenditures. We hear this story so often; it is almost taken as gospel-- but is it actually true? Is it more expensive and invasive to die in America than in other developed countries?

Gun Ownership and Doctors?

According to the Pew Research Center, there are approximately 32,000 gun-related deaths annually in the United States; 19,000 are suicide, 11,000 are homicide, and the rest are accidents, police shootings or of unknown causation. Moreover, there are more than 78,000 nonfatal gun wounds each year. Given the disproportionate number of victims that are less than 40 years of age, the morbidity and mortality of gun violence is significant. Physicians are involved with many types of public health issues, but few are as controversial or divisive as gun safety. Is it really an issue that falls within the medical domain?

O Tempora, O Mores: Affordable Care Act - Big Dream or Big Let Down?

I confess I was a strong proponent of the Affordable Care Act. My reasoning was subtler than the hallowed pantheons of its staunch supporters and the apocalyptic predictions of its detractors. Forty years after graduating medical school I concluded, after many stutter steps, the American healthcare delivery system was economically unsustainable and the citizenry was neither living longer, nor better, despite medical expenditures that dwarf any other developed nation. My career also allowed me to personally interact with cardiac surgeons from all continents and see that their clinical results and research efforts were laudatory by any standards.

High Depression Rates in Resident Physicians — Fact or Fiction?

The December 8, 2015 issue of JAMA had a startling key clinical point; the prevalence of depression or depressive symptoms among resident physicians in training was 28.8%. The data was generated by meta-analysis of 31 cross-sectional and 23 longitudinal studies published in peer-reviewed journals involving 17,560 trainees. Two-thirds of the trainees were in North America, but the others were from Asia, Europe, South America, and one from Africa. Sensitivity-analysis confirmed that no individual study affected overall prevalence by more than 1% and that the incidence of depression was not influenced by study design, continent of origin, surgical vs nonsurgical program nor level of residency year.

Can a Robot Outperform Your Surgeon?

In the current competitive environment, healthcare providers often attempt to separate themselves from their competition by marketing themselves as using the newest technologies for their procedures. This is an age defined by finding the next best thing and the American public responds to this strategy. My personal experience has been in cardiac surgery, but the principles are equally applicable to other specialties, particularly tertiary referral practices.

Hospital Administration Attempts to Cut Costs and Increase Quality at Expense of Physicians

A nonprofit hospital care system in Oregon with 450 beds has been in an acrimonious negotiation with its staff hospitalists for the past 2 years. The mounting economic pressures on this small, community oriented institution have had the expected consequences of hiring new administrators to implement the latest trends to rein in the budget and effect efficiencies of healthcare delivery-- as if that has been so successful in the rest of the country. The battle has really centered over the physicians losing control of their work time allocation, individual decision-making for diagnostic and treatment plans, as well as bristling at bonuses based on the administration’s definition of quality.

Michigan Physicians Society Supports Inner-City Education

Yesterday afternoon I had the privilege of helping to honor the graduating class of 2016 at Experiencia Preparatory Academy. They have 3 graduates this year that have overcome a special set of challenges, including moving from Mexico to the United States and having English as a second language.

Big Pharma Using Mail-Order Pharmacies to Maintain High Prices

The United States has the dubious honor of paying the highest prescription drug costs in the world. Many healthcare economists attribute this to relatively lax cost regulation compared to other wealthy countries; however, a decade of insurers paying only for generic drugs when available and limiting drug choice in specific formularies has had little modulating effect.
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