I don’t know about you, but as I watched coverage of President Obama signing the health care bill last month, it was hard not to notice the constant ads for power wheelchairs. Emblazoned across the ads was a flashing notice reminding viewers: Medicare may cover this!
Don’t get me wrong. As a primary care doctor who takes care of low-income patients, I was glad to see something being done to address the appalling health disparities that exist in this country. But as the president signed the legislation, I had the queasy feeling that he was essentially writing a big fat check to several hugely influential, multi-billion dollar interest groups - including, most notably, the pharmaceutical and insurance industries.
And so, the persistent flashing ads for power wheelchairs seemed a bit ironic. As heavily marketed devices that cost the system thousands of dollars individually - and earn millions in profits for their parent companies - power wheelchairs exemplify what’s wrong with the system. Individually, they’re a small part of the overall picture, but in aggregate, they cost a lot. And though they’re clearly necessary for patients whose arms and legs are paralyzed, they’re often prescribed inappropriately for people who would be better off getting intensive physical therapy and using a manual wheelchair instead.
(To be fair, under the new healthcare law, Medicare will only pay for renting, and not purchasing, power wheelchairs in many situations - which should cost the system slightly less money).
From my vantage point in the trenches of public primary care, here are a few of the good things about the new health plan.
It pours more money into neighborhood health centers, which have a long track record of making primary care accessible to low-income people.
It will put more doctors, dentists, nurse practitioners, and physician assistants in these clinics by expanding the National Health Service Corps.
It will encourage primary care doctors and general surgeons to work in low-income areas by offering a bonus.
The law also promises to make it easier for low-income people to get general medical care by paying primary care doctors the same amount for patients with Medicaid as for those with Medicare. (But it won’t do anything to raise Medicaid payments for specialists, meaning primary care providers will still be scrambling when our patients need a cardiac catheterization or other intervention).
The law also raises the Medicaid income cap to 133 percent of poverty level . Many governors are kicking and screaming about this provision, but it will help a lot of people who do jobs that, while important, pay poorly. For example, under the new rules, a single home health aide with two kids who earns $21,500 annually (approximately the average wage for that job ) should qualify for Medicaid coverage. Under present rules, only 10 states, and the District of Columbia, provide Medicaid to a single mother with that income. More than half of the states in this country don’t provide Medicaid to adults without children.
On the flip side, the law will push millions of people to buy expensive insurance policies from private companies. Many of these policies will have steep deductibles, so having insurance won’t necessarily protect people from financial ruin if they develop a serious medical condition. It’s also likely that expanding the private insurance system will make people’s care even more fragmented and difficult to navigate, since, in my experience, the private companies are far more likely than public programs to restrict what tests and medications the patient can get, and where they can get their lab tests done.
To subsidize these policies, the government will pay millions to private health insurance companies, many of which are for-profit. This is a bitter pill to swallow, when you consider these companies’ chief executive salaries and when you keep in mind that these companies make their profits by minimizing what they pay health providers and denying payment for as many services as possible. Just this week, a surgical colleague told me of a heavily marketed local Medicare HMO (with a multimillionaire chief executive) that routinely denies coverage for complicated cancer procedures. “They make it impossible,” he said.
The law is also a triumph for the pharmaceutical industry, which blocked efforts to allow Medicare to negotiate what it pays them for medications. (In contrast, Medicare can negotiate with hospitals and doctors by telling them exactly what it will pay for specific services - and requires lots of documentation to prove that those services were provided). One policy analyst told the Associated Press that he predicts a $30 billion increase in revenues over the next decade for the drug industry, adding, “I don’t see how they could have done much better.”
And so, my feelings are mixed. I’m really hoping that after the law goes into effect, I won’t see more cases like the nurse’s aide who declared bankruptcy after the bills came in for her CT scans, or the mechanic who couldn’t pay the upfront costs for the colonoscopy to figure out why he had blood in his stool. But I’m not so sure. And I worry that the plan is just an expensive, complicated way to address the symptoms of our broken health system, not a daring cure.
Dr. Erin Marcus is associate professor of clinical medicine at the University of Miami Miller School of Medicine. A Doctor's Word is supported by a grant from the Ford Foundation.