Keep Your Wallet Nearby: Insurance Won’t Pay for Everything

What the 'repeal and replace' plan really means for patients, doctors and health care

After six years of promises, an Obamacare repeal and replace bill emerged from the hallowed halls of Congress this week. Speaker Paul Ryan (R.-Wis.) and President Donald Trump like it. Sens. Rand Paul (R-Ky.) and Ted Cruz don’t (R-Texas). Conservative groups like Heritage Action and Freedom Works gave it a thumbs down.

But what about the most important constituency? Not politicians. Not hospitals or physicians. Not insurance companies — patients.

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What does this repeal mean for actual patients and their ability to see their doctor, obtain their medicines, and continue their current care? It might mean the difference between life and death. Or in my world, vision and blindness.

First off, the bill removes the requirement that everyone purchase health insurance or else pay a penalty. Also gone is the requirement that employers provide insurance to employees — meaning that individuals will have to take more personal responsibility for either finding insurance or taking their chances without it. You’ve got to figure out how to stay healthy or pay some large medical bills.

Also gone is the requirement that employers provide insurance to employees.

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Young adults can stay on their parents’ plan as before (for now), and preexisting conditions won’t exclude you from obtaining insurance, which is a relief to those with chronic diseases. But that doesn’t mean individuals can game the system, buying insurance only when they need it and then canceling the policy when they are well. If people take a break from insurance and premiums, they will pay 30 percent more when they resume their insurance.

A major relaxation of regulations has been promised, although this is not in the current bill. Allowing purchase of insurance across state lines, for instance, would resul in more competition and lower costs.

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Medicaid will be offloaded to the states, which can then figure out how best to provide medical care to their poorer residents. Don’t like how your state runs Medicaid? Move to another state.

Under Obamacare, all insurance companies were required to offer the same benefits — which created doctor and hospital networks to save money. These were narrow networks in many cases. If you liked your doctor, you may not have been able to keep your doctor if that physician was out-of-network.

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More competition means more choices, including doctors and hospitals. Remember that having insurance is not the same as having medical care. If no doctor accepts your insurance, you either pay out-of-pocket — or you are out of luck.

Independent of Obamacare and any replacement is the general overregulation of doctors through onerous rules and quality measures. These go by government-sounding names like “MACRA” and “MIP.” What they lead to is the doctor spending more time looking at his computer screen than talking to his patient. A doctor will be looking over his shoulder, making sure he does everything in accordance with government edicts, instead of thinking about his patient’s illness or disease and how to address it.

Physicians are smart, motivated individuals. Most won’t put up with being a hamster running on a spinning wheel. Many will find other more rewarding, less frustrating ways to earn a living — leading to doctor shortages, longer waits for appointments, or medical care downloaded to pharmacists, nurses, physician assistants or other non-physicians.

The details are still a work-in-progress, but patients must realize the government seldom changes in a big way.

The good news is that access to health care is an important political issue. Members of Congress facing the voters in 2018 won’t leave millions of voters out in the cold without access to health care. The details are still a work-in-progress, but patients must realize that the government seldom changes in a big way, especially when curtailing entitlements; instead, it tends to nibble around the edges.

Bottom line: Health care delivery will move in a more free-market direction. How much is uncertain at this point. But patients will by necessity have to take more personal responsibility for their health care. That means more consideration of one’s diet, exercise, smoking and other lifestyle choices; shopping for insurance; making prudent decisions about when to see a doctor and when to consult the internet for medical advice; and accepting care from non-physicians or perhaps waiting longer to see a doctor. And when a patient does see a doctor, he or she will need to understand the doctor may be distracted by the ever-present computer and medical record.

Lastly, people will need to keep their wallet nearby — insurance won’t pay for everything.

Brian C. Joondeph, M.D., MPS, is a Denver-based physician and writer.

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