Every day I hear it from someone. Sometimes it comes with a knowing smile of condescending sympathy. Sometimes it is a searching line, looking to see if I agree or not. Sometimes it is a statement of confidence, and my opinion is not needed for reassurance. However it comes across, it is some formulation of: "Obamacare is going to be hell for you doctors, isn't it?"
When the statement comes from a patient, as it does most of the time, I try to shrug it off. Discussing politics with a patient is one of the most useless things I could do in my medical practice. It has nothing to do with medicine, and it introduces an element into the doctor-patient relationship that I do not want to contend with. If we agree, everything is fine. If not, we eye each other suspiciously, and I still have to ask them to turn their heads and cough.
To them I say, "There are a lot of problems in medicine. Obamacare is a very small part of it. It won't affect me much."
When the statement comes from a friend, acquaintance, or family member, I am a little more brusque. "Obamacare won't effect me," I say. "Unless you consider having more patients with insurance a big change. But ethically I am supposed to treat my patients the same, regardless of how much money they have."
And that's it.
That really is it. Obamacare is the biggest non-event of the year if you are a doctor. There are no new copays or changes in reimbursement schedules. The billing regulations don't change. Malpractice insurance stays the same. There is no such thing as an Obamacard. Doctors will examine, treat, and bill for services in exactly the same way that they always have.
Which is why I am so perplexed about the apprehension. Obamacare is not a new insurance entity. It is not a new Medicare or Medicaid, and not a single policy, rule, or regulation that controls either one of these two largest government programs will change, not at all, not one iota.
Here is what Obamacare changes: it increases the number of citizens who will be able to get health insurance. First of all, it expands Medicaid so more people can get it. And those who do not qualify will be able to buy private insurance at a lower cost (and sometimes with government assistance) through statewide insurance exchanges, which are nothing more than public risk pools that allow individuals to buy insurance for themselves at group rates. The end result is that there will be more insured patients. More Medicaid, but also more privately insured. The insurance plans these patients will be on will be similar to traditional private plans, with all of the same benefits.
And that's it.
As for the general calamities Obamacare is supposedly ushering in, I don't know. Will Obamacare encourage more people to abandon private plans and switch over to Medicaid, because it is free? It might, but I doubt it. A lot of doctors don't take Medicaid, and people who have Medicaid don't have access to as many services as the privately insured people do. Medicaid is very low-paying compared to private plans, and patients who give up private insurance for Medicaid will quickly discover they are abandoning Jeep Grand Cherokees on the side of the road for 1982 Fiats. There may be a movement, but no stampede.
Will Obamacare break the fiscal bank? I don't know, but I doubt it. Healthcare costs have been rising at double digit rates without Obamacare. It is hard to see how they can rise any faster. Obamacare is supposed to save money by getting people in for preventative care before they suffer catastrophic illness, which could save money in the long run. It also will push younger people into the system and get more people paying into the insurance pool. This is supposed to reduce upward pressure on premiums by spreading risk out among larger groups of healthier people.
But no matter how you look at it, the point is this. We won't know unless we try. Medicine is full of ideas, and some of them pan out, some don't. That's what science is about -- experimentation.
Years ago, doctors thought aggressively transfusing hospitalized patients to keep their blood counts near normal was a good idea. Makes sense: if you want to reduce physical stress on a sick patient, you keep their blood counts high, which eases stress on the heart, lungs, and kidneys. This practice was followed for a very long time, until someone tested the theory out and found that patients in intensive care die at higher rates when they are given more units of blood. So now we let ICU patients run anemic, much more anemic then we ever would have considered a decade or so ago, and they do fine. They do better, in fact. Sometimes things turn out to be different than we expect. That's what science is for, to test ideas out.
No one knows if Obamacare will help American health care or not. My main worry is that it is a half-measure, that it will achieve mixed results because it was not aggressive enough. But no matter. The law was passed, and it is ready to go into effect. The experiment is about to start.
And like all good scientists, we need to look at the results as they come in. We need to evaluate the data impartially, scientifically, and see if we are better off under the new laws. Once we decide that, as good scientists, we accept the findings and live by them. If Obamacare works, we run with it, we improve it. If it doesn't, we go back to step one and devise a new approach.
But what we do not do, what is criminal behavior in my mind, is to sabotage the program or fudge the results to fit a political agenda. We can know whether the Obamacare experiment is successful or not. The question is, do politicians have the courage to accept the results as they are?