I said in a recent post that juxtaposition can sometimes qualify as serendipity. It’s now just happened again.Last week I got a letter from my doctor of the past dozen years informing me that he was changing his practice’s modus operandi. He’s joining some new group that offers direct email and telephone access to patients, and more and better screening procedures for preventative healthcare in association with a highly respected clinic in Cleveland. He’s also limiting his practice to just 500 patients so he can spend more individual face-to-face time with them. But, to keep him as my doctor and get all these new services, I (and others) will have to pay a $1,650 fee a year, every year, for the privilege. At $1,650 per year and 500 patients that’s $825,000—not bad (not that I’m suggesting that all of that money will go directly into the doctor’s pocket).No one suggests that insurance will cover that fee, and no one in his right mind expects the fee will stay the same as the years go by.I told my doctor, who is also a friend (our children know one another….), that to me this sounded like a shakedown: Pay me more money or I dump you. His reply was very polite and fetching, but in the end, yes, it’s a shakedown.Hold that in mind while I convey the gist of a Robert Pear article on the front page of today’s New York Times: “Lower Premiums to Come at Cost of Fewer Choices.” The essence here is that in the healthcare exchanges about to go into effect, lower-income people can buy health insurance for cheaper-than-otherwise prices (especially if they’re entitled to Federal subsidies), but will have to put up with much narrower networks of doctors and hospitals than are available in normal commercial arrangements. People with complex or pre-existent conditions cannot be excluded from these networks, but the networks can be so narrowly built that such people are forced to go “out of network” at very high costs. Networks can obviously be constructed, too, in such a way as to maximize the keep-out rate of such patients, so that they will not be breaking the letter of the law, only its spirit.Moreover, the article notes that many medical providers will be paid at Medicare or lower rates in order to keep costs and premiums down. It is therefore inevitable that many higher-quality providers will simply opt out, especially, as the Pear article illustrates, if they have to supply services below their costs. So the exchange networks will not only be smaller, but they will also likely be limited both in the range of diagnostics and care they can provide and in the quality of that care.It’s certainly better that lower-income Americans have limited insurance than no insurance, especially for their children. But this isn’t what people were told during what passed for a debate three and four years ago. And no one seems willing to call what is going on by its real name: class-based triage, or rationing, of medical care.We can see this more clearly if we put these two data points together: We are slowly (or not-so-slowly) but surely moving toward a much more finely gradated class-based system of healthcare. Compared to where we were before Obamacare passed, the top is moving up and the bottom is moving down faster than ever, leaving a thinner middle where most Americans with employer-provided health insurance have typically been—somewhere in the murk between HMOs and PPOs of various descriptions. Now, those who can afford it will increasingly pay more and get more. Those who cannot afford it will pay less and get less.Now, there is nothing surprising about this, and it’s what happens in most countries with some form of government-mandated universal health care. There are always private healthcare options in those countries, for people who can afford it, to detour around the public option. But it is not what Obamacare advertised.Alas, this is what happens when political chicanery at the promising stage runs headlong into reality at the implementation stage. Get used to it: there’s lots more of the same to come.
Published on: September 23, 2013Class-Stratified Healthcare Triage Is Here