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What If Obamacare Were Found Unconstitutional?: Musings in the life of an internist, cardiologist and cardiac electrophysiologist June 16, 2011
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Westby G. Fisher, MD, FACC About the Author
Westby G. Fisher, MD, FACC

Provided by Dr. Wes

Health care is a sensitive issue politically. 

And as things would have it, it now is a sensitive issue legally.

So my thoughts now are not meant to be partisan, but rather a "ground-floor" perspective on what would happen if the Patient Protection and Affordable Care Act were found entirely unconsitutional.

What would happen?

Would a bunch of post-college aged kids ages 21-27, promised insurance beginning this year, suddenly no longer be eligible for care? Probably not. Most insurance policy constructs last a year, so changing coverage would take a while. Still, there will remain a need for some type of insurance coverage for this group outside of classic employer-based insurance since jobs are few and far between for this group. Irrespective of whether the PPACA is enacted or not, employer-based insurance is becoming a thing of the past. 

Would doctors who sold their practices lock, stock, and barrel to large health care organizations be able to disband from these large health care organization superstructures (and their associated non-compete clauses) to restablish independent practices? No way. For doctors who performed imaging procedures in their offices at a discount to what hospitals charge, CMS claimed "self-referral" incentives for these procedures, and stopped paying for them in the outpatient setting (but interestingly, not for hospitals). Consequently, by banning payments to doctors for these services, independent physician practices no longer were viabile, except those in affluent neighborhoods where concierge medicine could establish a foothold. The employed physician model and more hospital consolidation seems inevitable going forward irrespective of the outcome of legal challenges to the PPACA.

What about people with pre-existing conditions? It would seem that care would be delivered as it is now for this group. Charitable care, ER care, Medicaid programs would likely have to expand putting even more pressure on our state budgets. But then, isn't this why many states are concerned about the PPACA in the years ahead anyway?

Will the electronic medical record and electronic prescribing, the cornerstone of purported cost savings and efficiencies under the PPACA suddenly disapppear? Of course not. The EMR has been wedging its way into medicine since at least 2004 (that's the last year we had paper inpatient charts at our institution). Newly minted doctors today have never manually written inpatient orders, have never had to walk to radiology to "pull the films" to see a chest x-ray, or go to the microbiology lab to review culture results. They are wired. They expect instant test results. They expect to be able to read outpatient notes. They expect to be able to find another responsible doctor in the care history of a patient. In fact, novelty patients now are those who have never had an entry in their electronic medical record: "Gee, no one's seen this guy before!" Bottom line: an unconstitutional PPACA won't derail the electronic medical record.

It has been estimated by the CBO that repealing the PPACA would cost $210 billion dollars if this occurred between 2012 and 2021. What that money would be used for is anyone's guess (legal and political PR fees?). We have to wonder. But common folk like most of us are not privvy to the intricacies of government self-serving budget-making. 

So what if the PPACA is found unconstitutional? 

It. Won't. Matter. 

Irrespective of the outcome of the pending legal battles for or against the PPACA, we continue to have a huge cost of care crisis in America. Our problem (hate to say it) was never a need for "insurance reform." It remains a problem of costs. And the PPACA does little to help us understand where cost savings would be realized. Why is this?

The legislation was authored by powerful interest groups who were "brought to the table" to feast on the last vestiges of fee-for-service health care. To date, they continued to gorge themselves. I'm not seeing a concern about costs. I'm seeing a consolidation of monster health systems accross our land. Much as the insurance industry found profits by eating their own before, so now are hospitals. Bigger, more doctors, more huge facilities gobbling up their competitors until the last Great Health System can claim the "Too-Big-To-Fail" prize. And why not? Our jobs and economy depend on it. We continue to want the best of care without compromise (though there are responsible rumblings out there about end-of-life care.) Bigger systems running more smaller systems. Not only will it be bigger, more efficient, but safer, too! Our wonderful Utopian vision of the future. Costs be damned. We've got to build for the future and the influx of newly-eligible health care customers!

There is no interest in shrinking the middle man.

Instead, our entire system is cloaked in financial secrecy as we continue to build our Health Care Hindenburg under the auspices of the PPACA, or not.


Dr. Wes
Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005. DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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