Reflections on social insurance and health care

Dr. J. Joshua KopelmanJ. Joshua Kopelman, MD, immediate past District VIII chair

As we enter the first full year of ob-gyn practice under the Affordable Care Act, I am celebrating the 50th anniversary of my graduation from the New York University School of Medicine. Because I have a long-term perspective of the social insurance aspects of US health care, I would like to share my thoughts on the subject. It already has and will continue to dramatically affect the manner in which medicine will be practiced by the majority of ob-gyns in District VIII and throughout the nation.

I had just completed an internship in straight medicine and started my residency in ob-gyn in 1965 when Medicare legislation was enacted to insure the health care of America’s senior citizens age 65 and older. The reaction of the private practice community, with few exceptions, was extremely negative. I had little opportunity to participate in the rollout of Medicare as I was drafted out of residency and served as a general medical officer on active duty until 1967. When I resumed my residency training, which I completed in 1971, Medicare was functioning well and also funding postgraduate medical education in teaching hospitals across the country.

The attitude of organized medicine toward Medicare rapidly changed to acceptance, and even enthusiasm, as it became clear that the previously underinsured or uninsured elderly were now a source of increased income to physicians and hospitals. Over time, Medicare expanded to cover younger patients with chronic end stage renal disease and amyotrophic lateral sclerosis. Eventually, it expanded to cover disabled patients of any age. Prescription coverage for Medicare enrollees became an additional benefit in 2008.

Unfortunately, due primarily to lack of adequate oversight in the initial legislation and the greed of unscrupulous providers, Medicare rapidly became the victim of massive fraud and abuse. In addition, with changing age demographics in our country, the increasing cost of advancing medical technologies, and several downturns in the nation’s economy, the viability of Medicare became tenuous, and its ability to support graduate medical education was considerably eroded.

Congress came up with programs like managed care and the sustainable growth rate (SGR), which were supposed to control costs by reducing physician reimbursement for the care of both privately insured and Medicare patients. SGR turned out to be the source of an unsustainable, never-to-be-implemented loss rate, which Congress has yet to repeal because it cannot (or chooses not to) fund the $117 billion it will cost to end and replace the program.

Despite the unsolved fiscal problems posed by Medicare, to say nothing of Medicaid, Congress and the Obama administration proceeded to pass the Affordable Care Act. The patient protection aspects of the act will, I believe, improve patient safety and broaden access to health insurance to the majority of the uninsured in our country. It will do so at great expense and after separating providers of health care into those who may no longer care for their clients as hospital inpatients and those who provide care exclusively in the hospital setting.

Whether or not those legally bound to purchase the proposed insurance deem it affordable is another matter. Moreover, there will be substantial numbers of newly insured patients who discover that they cannot afford to pay, out of pocket, the deductible amount required for the affordable care they hope to obtain.

I foresee the government needing to subsidize not only postgraduate medical training, but medical school as well. Perhaps those costs and the huge student loans with which most newly minted physicians in this country are now saddled will be forgiven by the federal government in exchange for agreements to provide care to underserved (ie, remote and undesirable) areas of the nation for specific periods of time.

These young doctors are likely to be relatively poorly compensated, as are many rural primary care practitioners today, and will have limited ability to move to other areas, except as employed physicians in large hospitals or insurance-owned provider groups. This will eventually benefit the population poorly served by our current health care system.

As I enter retirement, I continue to believe that medicine remains a noble calling, attracting women and men who, like those of us who have volunteered time and talent to the work that ACOG does, remain strong advocates for our patients and the high quality of care that they deserve.

Change is inevitable, and realistic expectations combined with careful planning will allow our members to continue to provide high-quality women’s health care. But this statement will only be true as long as physicians, not politicians, remain in control.