The Winners and Losers in Health Care

Before we turn the calendar to 2016, we should digest what happened in health care this year.

The Affordable Care Act (aka Obamacare) isn’t going to be repealed anytime soon. As Winston Churchill once said, “Criticism may not be agreeable, but it is necessary. It fulfills the same function as pain in the human body. It calls attention to an unhealthy state of things.”

Given that, here, in my opinion, are the winners and losers in health care in 2015.

The Winners

Insurers
Since early 2009, the Affordable Care Act has provided a tremendous bonanza to investors who possess health insurance stock. Since that time, the large Obamacare health insurance companies (Aetna, Anthem, Cigna, Humana, United Healthcare and WellPoint) more than tripled in value, with the price-to-earnings (P/E) ratios remaining under 20.

Amazon and Apple should do so well. Putting aside quality, quantity and costs of the ACA, the health care law has proven very profitable to those owning these companies and their CEOs.

Health IT Companies
More than 75 percent of all hospitals are now using an electronic health records system (EHR). The explosion in adoption of this since 2009 is in large part due to the EHR Incentive Program, which compensates hospitals and health systems for using health IT to improve patient outcomes. Despite ongoing issues with interoperability, cost and usability, Cerner and Epic (two health care IT vendors) have inked billions of dollars worth of contracts in 2015.

Patients with Pre-Existing Illnesses
These patients increasingly make up a greater proportion of ACA enrollees. They are getting more out of their health insurance than they are putting in.

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Concierge Doctors
As medicine becomes more corporate, some primary care doctors have shown the gumption to follow their hearts and detach from the hamster wheel that primary care has become. In larger metropolitan areas, accepting insurance reimbursement alone is simply not financially tenable.

Among the most well-known is MDVIP, a personalized health care program in which people pay a retainer fee of $1,500 to $2,500 to be part of a panel made up of 600 or fewer patients. For complicated patients or the worried, the system works well. MDVIP has shown better outcomes compared to non-MDVIP patients specifically in the Medicare-age group. This positions it well for a future in which quality will be more than a buzzword for insurers. The fewer insurance plans doctors participate in, the happier they are. Go figure.

The Losers

Obamacare Co-Ops
Of the 24 Obamacare co-ops funded with federal tax dollars, one (Vermont’s) never got approval to sell coverage, a second (CoOportunity, which had policyholders in Iowa and Nebraska) has already been closed, and nine more will close forever at the end of this year. Why the 46 percent failure rate of these nonprofit co-ops?

The goal was to increase competition by stimulating the creation of new health insurers. The co-ops failed miserably for several reasons. Experts at other companies were barred from serving on their boards; the only capital access they had was from the federal government and none of those funds could be used for marketing; any nominal profits couldn’t be used to fund future growth; and finally, they were required to focus “substantially all” of their activities on the individual and small group health markets.

The markets were in rapid flux, so the lack of actuary support and inexperience was fatal to many. Obamacare has made health insurance more costly and the business more risky. Large companies with diversified businesses and strong actuarial support are in the best position for the future — not these start-ups.

Most Patients
American patients are increasingly finding that their doctor is “out of network.” Oh, you can keep your doctor, but don’t expect that you won’t have to pay more to do so.

Consumers who earn too much to qualify for Obamacare subsidies are obliged to purchase insurance but without the benefit of a tax credit. Young, healthy patients with high incomes who were getting inexpensive individual insurance also lost. Increasingly, both groups are rethinking the finances of “going bare” versus getting health insurance that cost more yearly and provides less and less real financial protection.

In a famous scene from “Star Wars: The Empire Strikes Back,” Lando Calrissian, who has made a bargain with Darth Vader, says in frustration, “This deal is getting worse all the time.” This Obamacare deal is getting worse all the time.

Dr. Ramin Oskoui, a cardiologist in the D.C. metropolitan area, is CEO of Foxhall Cardiology PC. This is the first of a two-part look at the state of health care in America.