Three and Out

Obamacare is approaching its 10-year anniversary. Like a marriage, the initial honeymoon phase has been squashed under the weight of work, children, family, and finances. And though some marriages grow stronger, others strain under the weight of new realities. Obamacare is in the latter category.

We saw major changes to the US healthcare system in 2018, as President Trump continued to pursue his campaign promise to repeal and replace Obamacare. Congress had other ideas. On a July night in 2017, the late Senator John McCain gave his famous “thumbs down” vote to the “skinny repeal” of Obamacare which then failed to pass by one vote. Congress did, however, manage to strike down the mandate that forced individuals to purchase healthcare insurance, whether they wanted it or not. In December 2018, a US District judge dealt Obamacare a potentially fatal blow, declaring Obamacare unconstitutional. Once again, the legislative branch of the US government abdicated its role to the judicial branch ­­–not the proper process for a representative republic, but that is another story.

In 2012, the US Supreme Court ruled that Obamacare was indeed constitutional and that the individual mandate could be construed as a tax ­­– a legitimate power of Congress. The problem is that the mandate is now gone, meaning that the tax is reduced to zero and can no longer be considered a tax. No tax means no mandate and, as such, the constitutional basis for Obamacare comes tumbling down, rendering the entire law invalid. It is worth mentioning that this lawsuit wasn’t brought on by a rogue judge in a single state; it was brought by 20 states. This ruling is not final, however, and will be appealed ­­– undoubtedly, all the way to the Supreme Court who, based on its previous ruling, may have difficulty reinterpreting the law once again.

We are now left with a national healthcare scheme that may not only be unconstitutional, but also deeply flawed. Insurance premiums have priced health insurance beyond the financial reach of many Americans. Cost sharing provisions – meaning deductibles and copayments – have made medical care unaffordable for those able to purchase, but not use, their insurance as intended. Narrow provider networks have separated patients from their doctors and hospitals, while insurance regulations and red tape are frustrating providers, leading to physician burnout and early retirement.

So what’s next? As far as I can tell, 2019 will be shaped by a split Congress, with the House now under Democrat control and the Senate still in Republican hands. Given the hyper-partisan atmosphere in Washington, DC, it’s unlikely that any meaningful reform will emerge from Congress. Many Democrats instead are pushing for a single-payer plan, called Medicare-For-All. Cost estimates for such a plan are daunting, even for a Congress quite comfortable spending far more money that it has, creating a national debt of over $20 trillion.

If single-payer came to be, the cost would be three quarters of the annual federal budget, leaving little money for anything besides healthcare. Funding would necessitate doubling of individual and corporate income taxes, smothering a currently robust American economy. Not only that, physicians would be paid 40 percent less than they are under current Medicare rates, driving most out of business and exacerbating an already present physician shortage. And these are all estimates ­­– how many government programs actually meet projected costs?

The real Medicare system, when created in 1965, was predicted to cost $12 billion per year in 1990. The actual cost was $90 billion. Aside from this, the question remains: will Americans tolerate long waiting lists, limited drug formularies, and other care rationing that is common in countries with similar government run single-payer schemes? It is hard to say.

Ophthalmology faces its own challenges. Many insurance companies are mandating step care for intravitreal injections, requiring the use of bevacizumab first for macular degeneration or diabetic retinopathy. Branded, more expensive drugs can only be used after ill-defined “treatment failure,” requiring ophthalmologists to waste time and effort jumping through hoops to the satisfaction of the payers. Meanwhile, there is continued regulatory scrutiny on compounding pharmacies, potentially limiting access to the same lower cost drugs that ophthalmologists are required to use first. It is a classic Catch-22 scenario.

Several new drugs or delivery systems are working their way through the FDA approval process, and are likely to be priced at or above existing therapies. With downward cost control pressure, these new options may not be readily available to patients. And let us not forget big data. Physician pay may soon be based on how we compare with our peers under cost and outcome metrics. Who will want to care for the challenging patients and their poorer outcomes then?

Opioids, not often used in ophthalmology, are now being scrutinized and restricted to the point that patients in legitimate need may often be denied access to them at all. Cybersecurity also remains a concern for small practices and large hospitals, with mentally stretched physicians now required to keep track of numerous frequently changing passwords. Lastly, there are numerous disruptive forces entering the healthcare market, with both Amazon and Walmart building their own integrated systems. When they have their own hospitals, providers, insurance and patients ­­– and they will, in time ­­– what will happen to independent practices?

There are no easy answers to the questions I have put forward, but there is one thing I know for certain: we, as ophthalmologists, must be forward thinking to remain relevant in today’s rapidly changing healthcare landscape. Good luck to you all.