By Chris Nussbaum, MD, FHM

By now, the debate over the Affordable Care Act (ACA) has made just about everyone scratch their heads. Americans have never had a greater dialogue or witnessed a bigger furor over the future of healthcare and medical insurance. The very constitutionality of the law was challenged, claims and counter claims abound and few feel certain about what will happen next. How will the ACA affect the future of healthcare? While no one may say for certain, a few things seem likely.

More people are coming into the already overburdened system. If government predictions are on target, there will need to be primary doctors for 35 million more insured fairly soon. Primary care is an already overloaded specialty. About 16 million of the 35 million people new in the system are expected to be driven into Medicaid. Similarly overburdened, the availability of care will be impacted by limited Medicaid resources, facilities and caregivers.

Choice may give way to imperatives of availability and covered vs. non-covered facilities and providers. This has been the case for many years and may deeply intensify. It is safe to say that there will be limits placed on availability of care in a broad manner – read that as rationing. Citizens of countries using socialized systems have long attested to the fact that access is often slow, choice is limited and cost control is king in a highly subsidized system, which, like it or not, our lawmakers have created.

The Independent Payment Advisory Board (IPAB) is an agency funded by our government whose mandate is to rigidly control Medicare/Medicaid costs going forward. Among their primary tools is the reduction of reimbursement to hospitals, nursing homes and doctors – effectively rendering more and more services “uncovered.” It is at best fuzzy logic to expect healthcare costs to remain flat or shrink as enrollment vastly increases. The IPAB is empowered to recommend withholding of care to achieve cost targets. The ACA also focuses on enrollment in managed care, long notorious for denial of coverage, payments or treatments.

Throughout the country, VIP or “concierge” medical practices are rapidly spreading, along with “direct care” (no insurance company middleman) models. These membership based practices charge a flat fee, with broad variation from affordable to exorbitant, to join. All are offering improved access and greater attentiveness to the individual’s needs. Removing much of the paperwork and restrictive burdens of Medicare and Managed Care, doctors in these models have found more time to be doctors and return to old school values and patient care. Several subspecialists in Tampa Bay have also adopted this model.

It’s true that pre-existing conditions will not be a reason to deny a person care, and many who have never had meaningful access to a complex healthcare system will find entry. This is a noble and worthwhile endeavor. It remains to be seen whether the high cost, hidden taxation and burgeoning government involvement will bring desired results.

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