By Bernadine Healy, M.D.
Change is coming to medical care in America, and it may be a done deal by summer's end. From Capitol Hill to the White House, enthusiasm is running high for President Obama's plan to morph with lightning speed the current patchwork, private-public blend of healthcare into something closer to a single-payer, government-run system. Steadfastly promising to bring high-quality, affordable care to everyone, the president assures people that they will keep their own doctor and insurance if they want, see a return of some $2,500 to their pocketbook, and become decidedly healthier. But restructuring will inevitably call for sacrifice on the part of most individuals. Today, Sen. Ted Kennedy introduced a 600-plus-page bill, the first of several bills that will be issued in a flourish in the next few weeks. Since full details of what might make it into the final legislation won't be known until later this month at the earliest, barely a month is left for any kind of public discussion before a July vote. Enough common threads have emerged, however, to indicate that people should start looking beyond the headlines now for an idea of how the new system will affect them personally. For starters, here are seven ways that your healthcare experience is apt to change:
1) You've had a heart attack or lost your job? No matter what, you'll always have access to affordable health insurance. This equates to peace of mind not just for the estimated 46 million now lacking coverage but also for those who have insurance. The economic downturn is a chilling reminder that under the current system, virtually anyone facing a run of bad luck could be quickly wiped out by medical bill collectors.
The new plan would compel employers of any decent size to offer health insurance that meets certain government specs or face penalties. If you don't like your employer's choices, you will be able to take the money and get coverage on your own through a new national health insurance exchange, accessible online. Companies that sell health insurance will be obliged to register their products and offer them to all comers regardless of age, work status, or health. Competition for customers in this national bazaar should create a buyer's market—a big improvement over today, when people hunting for insurance on their own lack any coverage guarantees and any bargaining power whatsoever.
The exchange would become especially competitive if it were to feature a public insurance plan, a kind of Medicare for all. This part of Obama's vision has been hugely controversial, since a public plan could be a Trojan horse, sneaking in a single-payer system; federal powers to undercut prices and regulate the industry could, in a heartbeat, knock out private insurance choices. Regardless of its fate this go-round, the public plan will stay on some drawing boards.
2) Despite the promise of savings, your wallet will take a big hit. By law, you and your family will be required to have health insurance—a mandate Obama now supports. On your annual IRS filing, you will swear that you are covered; deadbeats will be fined. Taxpayers will also shell out whatever it takes to help those who can't afford coverage buy in, a cost estimated at $1 trillion to $2 trillion over the next 10 years. And this could spiral upward depending on the richness of the mandated minimum health package or the inclusion of new programs such as a long-term disability plan featured in the Kennedy bill.
Where does this money come from? Everyone. You'll owe more income tax, and your social security and Medicare taxes will rise as tax breaks geared to help people manage their health expenses are reduced or eliminated. The largest of these is the tax-free status of premiums paid by your employer, a benefit as venerable as the home mortgage and the backbone of most private health coverage now. You're bound for sticker shock once you look at the numbers: The Kaiser Family Foundation reports that the employer share of the average family policy amounted to $9,326 in 2008.
Also on the chopping block are deductions for sizable medical expenses that come out of your pocket and the tax-free flexible spending accounts that you might have with your employer. If you are one of the several million people who have catastrophic-care policies coupled with tax-free health savings accounts to cover lesser medical items, expect those plans, too, to be curbed.
Uncle Sam is also taking aim at your sinful pleasures. You'll be paying new excise taxes on sugar-sweetened drinks (even if you are skinny), and on beer and wine (even if you take but a heart-healthy glass a day). Federal tobacco taxes were already raised in April by 62 cents per pack to cover the recent expansion of children's public health insurance. As the feds look for new sins to tax, who knows? They might be persuaded to legalize marijuana.
3) If you live in Albuquerque and get desperately sick in Philadelphia, your entire medical history will be accessible in a few clicks on the Philly ER computer screen. Health reform takes visions of electronic medical records on smart cards tucked into your wallet or on microchips under your skin to a new level: a national record system available online. Your record will never be lost and is available wherever you go, reducing delays and unnecessary repeat tests. In return, your most intimate history will be available for medical research and analysis, including comparative-effectiveness research, a line of study central to health reform that analyzes which treatments work best at what cost.
The national record system will make you a part of the biggest and most detailed database ever assembled on Americans, stretching from cradle to grave. Although the government will do its best to ensure your privacy, the records will exist out there, accessible to a vast number of users who have nothing to do with your care. It's not evident yet if you'll be able to withhold information that you might deem sensitive—a past abortion, a sexually transmitted disease, a family history of mental illness, or a positive genetic test for Alzheimer's disease, say. Nor is your recourse clear should a mishap or a misappropriation of your health files occur. Lower-tech instances of that have certainly happened.
4) Even though your loved one's cancer very likely would be helped by a $50,000 drug treatment, his doctor might well say no. That would happen if comparative-effectiveness research has ruled that the benefits of the drug to the average patient don't justify its price when compared with yesterday's medicines. In an enormous break with tradition, such cost considerations based on averages will be factored into medical practice guidelines, functioning as an invisible hand that puts a brake on health expenditures even though they benefit certain people.
Comparative studies will look hard at the big-ticket new drugs and technologies that the Congressional Budget Office estimates drive more than half of the increases in healthcare costs. Established practices, like using the annual PSA test to routinely screen men over 50 for prostate cancer, will also be scrutinized and perhaps modified or even ended for some; this relatively inexpensive blood test can trigger expensive and sometimes unneeded treatments.
Standardized practice guidelines will be evident everywhere, even embedded into your doctor's government-certified computer: As described in the Obama budget, computer pop-ups will appear to help your doctor make decisions. (And through the same systems, his or her choices can be monitored for consistency with the guidelines.) More uniform care will certainly improve weak performers, but many experts worry about intruding on the seasoned judgment of the good physician. It remains to be seen how government micromanaging—if not rationing—of care, driven by reasons other than patient well-being, will go down, particularly when that patient has a face.
5) When grandma, who is declining from chronic heart failure, suddenly awakens struggling for air or with crushing chest pain, she may have trouble getting into the hospital. Hospital readmission of elderly patients within a month of a prior hospital stay is a big expense in the Medicare budget and has drawn heavy fire from the administration. The sweeping assumption, as stated by the director of the Office of Management and Budget, Peter Orszag and others, is that doctors and hospitals didn't get it right the first time and so should be penalized with lower reimbursement, which will put a damper on readmissions. Several studies, however, reveal a more complex picture of elders plagued by serious underlying chronic conditions like heart or lung disease that are aggravated by their body 's gradual wearing out. Since over 90 percent of such Medicare patients survive at least a year after their hospital stay and so are not exactly hospice candidates, families may be shocked in the future when such readmissions are categorically discouraged. This effort to pull back on costly treatment is iconic of a broader theme in healthcare reform: a focus on wellness, not sickness.
6) An HMO and a primary-care doctor are apt to coordinate your wellness-oriented care. This change should especially please overworked and relatively underpaid primary-care physicians, now in short supply; the government may well be showering them with bonuses. Tilting the scale towards primary care over specialty care, with your doctor serving as gatekeeper, will shift the ranks of both medical professionals and healthcare dollars from treating to preventing disease.
If you need to see a nephrologist or an orthopedic surgeon, however, the privilege might be harder to come by. With fewer of them, waiting times for their services will be longer and some will turn down government insurance because of continued cuts in reimbursement. It's hoped, however, that the prevention emphasis will bring a drop in obesity and diabetes, smoking and teen pregnancy, heart disease and cancer, reducing the need for more expensive disease-focused care.
7) You might find your doctor prescribing acupuncture for your back pain and a trip abroad for your surgery. Complementary and alternative medicine, often dismissed by mainstream medicine, will be encouraged by your health plan as a low-cost substitute for standard care. As President Obama said a few weeks ago when asked about acupuncture for chronic pain, if there's evidence it works, support it. The British national health system has just approved acupuncture as part of standard care for aching backs. Other forms of alternative medicine are sure to follow.
So will alternative places. Indeed, you may soon be buying your prescription drugs in Toronto for half price with the government's blessing, a practice the Food and Drug Administration has in the past adamantly rejected as unsafe and illegal. And scheduling a coronary artery heart bypass or joint replacement in Singapore or Mumbai may become routine as a way to save insurance plans as much as 80 percent of the cost. Tens of thousands of people without coverage have already pioneered the medical tourism route, paving the way. It's a sure win in comparative-effectiveness studies—and that's a clear signal that medicine as we know it is going to change.