Who gets left out of Obamacare? | DIRECT primary CARE JOURNAL

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1. Ms. Lieberman makes a good case for why there are many gaps in ObamaCare and the limited role of Medicaid to fill the gaps; if you accept our present system as the new normal or the only way forward.

   When I say, “present system”, I mean the one where prepaid care via a third party (private or public) masquerades as insurance and a system where health care costs are measured largely by the price of insurance premiums, not by the true cost of rendering care directly. Here is the irony: It is these same high premiums that keep costs high because it is the tool that finances them! It is a racket folks; kind of like a mob boss that tells the business owner what to charge his customers, limits competition and then takes the profit off the top!

   This is why moving away from, not toward, more third-party paid care is the solution. Focusing on “coverage” rather than a cost-effective primary care model, is what has got us into this mess in the first place. Trying to make coverage “affordable” by using someone else’s money to subsidize it creates an illusion of affordability. It also kicks the reform can further down the road for someone else to deal with while enriching the Government-Medical industrial complex that stands to benefit from maintaining the status quo.

   Yes, one potential “fix” would be to expand Medicaid, but I believe that is only represents a bandaid on a sucking chest wound; it doesn’t go far enough down the financial “root” of the problem.

   Medicaid is flawed by design. There is virtually no negative consequences for individuals who choose to over-utilization and Medicaid does not provide any incentive to stay healthy or to shop for quality and value. What little cost-sharing that exists with Medicaid is backwards. It should cover most preventative services at the front end and the non-moral hazard issues plus emergencies on the other. The fluff and abuse in the middle should not come without a price. That is why issuing vouchers for the elective and non-urgent outpatient services (and making it legal to pay for services out of pocket) would be a better use of taxpayer monies and benefit the recipients as well. Recipients would have a healthy amount of “skin in the game” but without barriers to basic essentials of care.

   Not only does Medicaid not involve any real consumer-patient choice and very little consequence to utilize it, but reimbursements are very low and it is illegal to charge a medicaid patient any additional fees for “covered” benefits. Even if states expanded Medicaid, it does not follow that there would be a proportionate increase in the number of primary care doctors and specialists that participate in order to provide the care. Many docs that participate in Medicaid currently have “closed’ their practice and don’t accept any new Medicaid.

   Maybe even a more important issue to society is that more entitlements are not sustainable from a budgetary standpoint. We already don’t have the resources to pay for promises that we have made to Medicare and social security recipients beyond about 2030; the deficit continues to deepen and the debt is reaching/reached the point of being impossible to repay. Only HUGE changes in tax, regulatory and energy policy which in turn create lots of jobs and true economic growth will be able to get us out of this fiscal mess and thus provide REAL sustainable health care to the poorest among us.

   From a social safety net standpoint, Singapore does it right. Check out their model.
   http://robertnelsonmd.co/2013/09/05/medisave-accounts-in-singapore-john-goodmans-health-policy-blog-ncpa-org/

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