A doctor’s perspective on fatal flaw of ACA: ‘Coverage does not equal care’

Healthcare is at an epic turning point. 

Now more than ever, Americans need honest guidance from practicing physicians.  Patients deserve to know exactly what will happen to them in exam rooms across America, as opposed to hearing scored projections or actuarial numbers. 

The Affordable Care Act (ACA) defined the solution as granting all Americans health insurance.  A one size fits all plan.  Problem is, healthcare is personal; every American has different needs and one size will not fit most.

But is health insurance a help or an obstruction in care?  Insurance, by definition, should help people in extremes. However, over decades, it morphed into “cover everything” and when this became too costly, deductibles skyrocketed to maintain insurance profits.  Now insurance is an expensive obstructive middleman. The flaw of the ACA is the premise that coverage equals care.  It does not.

Of course, healthcare was broken before the ACA.  But currently patients are experiencing the ill effects of the more than 20,000 pages of regulations added by Obamacare, regulations that allow the insurance lobby to profit from Obamacare at the expense of the patient.

Step into an exam room for a representative example:

A young pregnant mother of two brought her sick child to urgent care, unable to get an appointment for days with her doctor.  Her pediatrician had changed several times, as her childrens’ coverage had restricted who they could see. Consequently, she didn’t mind using urgent care; they had no care continuity.  After treatment, she asked why it was so difficult getting a primary care appointment.

“Well,” said the doctor, “though most Americans are paying more for insurance, the insurers are paying doctors less by denying payments, and creating a mountain of busywork that a doctor must do in order to justify their patients’ visit. Doctors now spend twice as much time on paperwork as they do seeing patients.  They don’t like it any more than do you. After 11-18 years of secondary education, they are bullied by insurers and government bureaucracy.  THIS compromises your child’s care. It’s harder to do what we love… to take care of you."

The mother told the following story of her own:  After losing her job, she was forced to purchase an ACA plan.  The plan had her listed as a man, and though she had made a dozen phone calls, on hold for hours, she could not get the problem fixed. Her ACA plan refused to pay for her prenatal care, since it deemed her a man.  The hospital conglomerate who oversaw her care, had not been paid by this insurance, so they sent collections after her, compromising her credit.

The gender mix up is unusual, but the ineptitude of large government agencies is not. We can all relate to waiting on hold with no results. And this woman is far from alone in not being able to get her child care: During my urgent care shifts, I see dozens of patients from across the whole economic spectrum and most of them are there because they cannot get a timely appointment with their child’s doctor.

Americans need to know that the insurance companies defining care is the problem, not the solution.  Insurance lobbyists wield power in Washington D.C. , and undoubtedly influenced the crafting of the ACA.  They set the model that coverage is care, big insurers profited handsomely and now most Americans carry an insurance card that grants them no access to their doctor.

Why is this not widely known? Sadly, the well-intentioned Affordable Care Act was passed secretly.  One of the plan’s architects, MIT professor Jonathan Gruber, stated, “Lack of transparency is a huge political advantage…call it the stupidity of the American voter…”

The American people are not stupid, they are misinformed. The patients of this country are suffering, as big insurance companies and other powerful groups use money and power to further their influence. 

Coverage is not care.  When we the people come to this realization we can start to unravel the excessive insurance company power and begin the path to affordable care.

Marion Mass, a pediatrician in the Philadelphia suburbs, is co-founder of a new advocacy group, Practicing Physicians of America. Mass can be reached at marion@practicingphysicians.org.


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