Medical Care in 2018: Ring Out the Broken Promises and Bring In Solutions

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By: Marilyn M. Singleton, MD, JD

The U.S. “health care system” continues to be a costly behemoth. Health care costs were the number one financial concern for 17 percent of families in 2017—tthe same level as it was in 2007 pre-Affordable Care Act era. And only 18 percent of those polled said the Affordable Care Act helped their family.

The ACA did not work as promised.

“If you like your health care plan, you can keep it.” Unfortunately, health insurance companies canceled plans for 4.7 million people. Many insureds chose to have inexpensive, limited plans to cover major expenses. These plans however were not ACA-compliant as they did not contain the mandated 10 “essential health benefits” with no copays or deductibles. While many of these required “benefits” are medically useful, many (e.g., pediatric vision and oral care, maternity care, breast cancer genetic screening, mammograms, and female contraception) are superfluous for childless unmarried men.

“I’ll also bring Democrats and Republicans together to provide every single American with affordable, available health care that reduces health care costs by $2,500 per family.” Kumbaya? The ACA was passed in the dark of night with only Democrat votes. Affordable? Overall costs to the consumer have risen dramatically.

In 2008, the cost of the average employer-sponsored family plan was $12,680, with an employee share of $3,354. The 2016 cost topped out at $18,142 with a $5,277 employee cost. In the individual market, the biggest losers are those who earn a little too much to qualify for federal premium subsidies, particularly the self-employed in their 50s and 60s. For a bronze-level plan with a health savings account, a three-person family can pay $15,000 a year in premiums and paid out-of-pocket for the first $6,550 of medical expenses for each family member.

Moreover, many insurers have requested—and will likely receive—double-digit premium increases for 2018. Nationally, the increases between 2017 and 2018 for unsubsidized premiums for the lowest-cost bronze plan averaged 17 percent, the lowest-cost silver plan averaged 32 percent, and the lowest-cost gold plan averaged18 percent.

We’ll start by increasing competition in the insurance industry.” That was a colossal failure. Overall, the number of insurers in the individual market has decreased since 2014. In 2017 UnitedHealth Group eliminated ACA Exchange plans in 31 of 34 states and Aetna remains in only four states. Humana and Aetna plan to exit all ACA Exchanges in 2018.

Agreed, some Americans gained health coverage. Medicaid and the Children’s Health Insurance Program (CHIP) accounted for 14.5 million of the 20 million of newly covered. The 2014 cost per nondisabled adult and child enrollee was $3,955 and $2,602, respectively. Some 27.5 million people remain uninsured with cost cited as the main problem.

Further, being “covered” was meant to keep emergency departments (EDs) from being used as an alternative to primary care. But according to the federal Agency for Healthcare Research and Quality (AHRQ), the number of emergency department visits covered by Medicaid increased by 66.4 percent between 2006 and 2014, outpacing population growth by a factor of two, making Medicaid the leading payer for ED visits.

These data tell us we must have a serious conversation, not intellectually lazy political slogans, like “Repeal and Replace!” Instead of ruminating about how to modify the government’s involvement in medical care, Congress and policymakers should ask how can we take better care of more patients and be open to all suggestions.

One successful model is direct primary care (DPC) mainly seen in solo and small medical practices. Here, patients pay a monthly fee (generally ranging $75 to $150) directly to the physician’s office for 24/7 access, and in many cases, basic labs and medications, and steep discounts on radiology and pathology services. Also growing are direct pay specialty and surgical practices where the fees for the operating room, surgeon, and anesthesiologist are included in one low price. And yes, many of these practices (even in California) offer sliding scales and charity care without running afoul of rigid federal regulations.

With DPC, patients spend more quality time with their doctors and physicians can shed the administrative burdens of government programs and insurance companies and treat patients according to their best judgment. A testament to the success of this model is the University of Michigan offering such a program this spring. Hopefully, the big boys won’t ruin a good thing.

ObamaCare’s individual mandate is dead. It’s time to use our healthcare dollars wisely and pay for the medical care, not the middlemen.


Dr. Singleton is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) Board member. She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law.  She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.

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