Medical care in America has reached crossroads

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Like all legislation, the Patient Protection and Affordable Care Act is good, bad and maybe a little ugly. But who knows?
The act is more than 2,000 pages long.
The massive novel “Moby Dick” is about 600 pages long. “Gone with the Wind” only has about 1,000 pages. I haven’t read those novels. Nor have I read the 2,000-page PPACA. However, I’m in good company. Because neither have the congressmen and senators who voted for it acknowledged reading it cover-to-cover. Nor apparently had our president read it front to back before he signed it into law. So I am in pretty good company of folks that don’t do their homework either. The term “pig in a poke” comes to mind. The ACA also has 1,000 references to questions that will be answered or regulations issued later by the secretary of the U.S. Department of Health and Human Services.
The people it will significantly benefit are the millions without health insurance. Children can continue to be on their parent’s policy into early adulthood, insurance companies cannot deny coverage based on previous illnesses, a major percentage of insurance company revenue must be expended on direct health-care needs, etc. These and many other inclusions are all good things. Every day I see patients who have no health insurance and thus limited access to health care. That should not happen in the most powerful and developed country in the world.   
Vicious cycle
The hospital system I work for is strongly supportive of indigent care and patient-centered care, regardless of financial status. I am proud to work for them. However, the overhead cost of giving that care has not diminished in the 40 years I’ve practiced medicine. The only solution for the physician to keep up financially is to see more patients, order more procedures and tests, thus generate more income. It is a vicious cycle that began back in the ’90s with managed care that has never worked except for the insurance companies.
There is rarely perfect legislation generated from our government. That is democracy and thank God we live in a democracy. The ACA has good and bad parts. The American Academy of Family Physicians has endorsed the ACA primarily because it will provide millions of patients access to health care. I favor that access.
However, I do not understand where the new patients in 2014 are going to obtain access. The card they receive will entitle them to care paid at Medicaid rates. Those rates pay less than non-physician overhead to see the patient. The physician is actually paying a part of the overhead expense to see the Medicaid patient and donating his service to the patient. My perspective has always been that the services I perform to help Medicaid patients is actually a tithe of my business efforts. However, we must monitor our business responsibility, realizing that if the physician is having to pay out of pocket for services to a significant portion of his patients, it will not take long for the practice to fold. That is what is happening across America. Seventy percent of United States physicians are employed. Private practice in our current environment is extremely difficult to support.
Emergency care expensive
Patients with government-sponsored, low-pay health care, both Medicaid and Medicare, are beginning to find the only place to receive health care without restriction is in government-sponsored health clinics, indigent clinics or the emergency room. The ER is the most expensive and inefficient place to receive any care except for true emergencies.
One concern is that those with the new card will have a natural sense of entitlement to health care, but limited or no access except through emergency rooms. Beginning in 2014, the national expenditure for health care is expected to skyrocket.
With med schools becoming increasingly more expensive, students are not going into primary care. The cost of doing business in primary care is greater than these young folks can bear with $200,000-plus debts to pay. Med students are going into specialties that train them to do procedures that are better paid than the cognitive work of family medicine.
The “economics” of medicine is out of control. When I began private practice in the mid-1970s, my office charge was $18 for any regular visit and I made a reasonable living seeing less than 30 patients a day. As managed care introduced “coding” for office visits, I had to add a lab, X-ray, procedure training, etc. just to keep up. The bank was not interested in reducing my debt payments. Duke Power would not reduce my power bill and my staff was interested in raises.
I absolutely love the practice of medicine. God granted me the privilege of calling me into the practice of medicine. I want to do nothing else in life. I look forward each day to going to a personally and professionally rewarding job. However, the economics of medicine can become the focus rather than concentrating on the complexities of patient-centered care.
rationing a reality
What we may experience in health care after 2014 is rationing. Rationing is already happening as we daily have to obtain third-party approval for necessary patient testing and meds. Limitations of service (rationing) is a way for the government to limit costs and put the responsibility back onto the local physician because the physician is the only person the patient has direct access to.
When I went to med school, students never discussed money. It was not an issue. Back then, family practice income was not much less than the general surgeon. There was not enough margin to go into surgery unless you really wanted to do surgery. Today, med schools teach classes on economics. Students joke that the “ROAD” to success in medicine is radiology, ophthalmology, anesthesia, dermatology.
I teach junior and senior med students in my office. Many want to be family docs, but realize they cannot afford to because of their huge debts. So they are choosing procedural specialties. However, those specialties are having problems because procedural reimbursements are now declining.
The joy of medicine is patient care. It is not economics. The ACA will give health-care access to millions of people who are now without. That is good and right. However, most commercial things in life are worth what the individual pays. If patients are given a card entitling them to “free” health care, that care is naturally going to diminish, either in quality or access. I have experienced that in every socialized system of health care around the world I have worked in over my 40 years.  
Set up a tiered system
The current health-care system cannot support free access at sub-cost reimbursement. The only way I see the ACA working is for a tiered system of payment by all, based on financial need, but with some equity paid by everyone. The system we have now to support indigent care is basically like giving a teenager a credit card without financial limits or personal responsibility. That would not make sense. Neither does it make sense for our government to say they are giving free, unrestricted health-care access without personal liability to millions. All Americans should have reasonable access to reasonable health care. And all Americans should pay a reasonable amount to  receive and support that care. Not only does that give all Americans the dignity of personally caring for themselves and their families, but it also supports the basic American truth that all are “created equal.”
These are my thoughts. They are neither all correct, nor all incorrect. Medical care in America has reached a crossroads. To sustain the best health-care system in the world, all eligible citizens should have reasonable access and reasonable accountability. The Patient Protection and Affordable Care Act is a good beginning. However, we won’t know the ending of the story until someone reads all 2,000 pages and answers all 1,000 questions. I am praying for a happy ending to this story. I hate to read a long story with a bad surprise ending.