Obamacare: For Protection and Affordable Care, Opt Out!

I remember the days of black-and-white television. When color television sets became available, they were expensive and few could afford them. And few networks broadcast in color, since the audience was limited. At a certain point of supply and demand, sets became less expensive, and networks went all-in for color. The same phenomena occurred more recently with the move to high definition TV. And so it will go with private, high quality medical care.

Years ago I penned the Physicians' Declaration of Independence, urging physicians laboring under increasingly abusive third party contracts to opt out, to allow them to return to the unfettered practice of medicine. Increasing numbers of physicians are opting out of Medicare, and few participate in Medicaid (full disclosure: as a nephrologist taking care of dialysis patients, I have not opted out of Medicare). Declining reimbursements and ever-greater paperwork and reporting requirements are driving this trend. To a certain extent, this is also happening in the private insurance sphere, and for the same reasons. But what really limits physician opt out is the relatively small numbers of patients who are "self-pay." With the implementation of Obamacare, these numbers are set to explode.

There are compelling reasons for patients to opt out of Obamacare, Medicaid, and even Medicare. The most important reason is poor access to high quality physicians. Few of these currently accept Medicaid patients, and more each day are declining to accept new Medicare patients. A large element of the Obamacare strategy is to expand Medicaid to families with incomes well above the poverty line. A silver lining in the otherwise horrendous Roberts court decision upholding Obamacare is the ability of states to refuse to expand Medicaid, and a large number have taken advantage of this. The Wall Street Journal points out the idiocy of expanding what is arguably the worst health insurance program in the nation ("Obamacaid," October 8, 2013). "Private" insurance policies available under the Obamacare exchanges will strongly resemble Medicaid, with limited options and poor physician participation. And unless you qualify for subsidies, the premiums will be very high, especially if you are relatively young and healthy. You will be much better off shopping for a catastrophic coverage plan and paying for routine care yourself. Of course, since there is "guaranteed issue," you will always be able to re-apply should you become severely ill.

While participation in Medicare Part A (hospital insurance) is linked to receiving Social Security benefits and is de facto obligatory, this is not the case for Parts B and D (doctors and drugs). Part C, Medicare Advantage, is being dramatically defunded under Obamacare. For seniors who are in reasonable health, it makes sense to opt out of Medicare Parts B and D, and to pay for your routine office visits and medications out of pocket. While the number of doctors accepting Medicare patients is shrinking, I don't know of any doctors who will refuse to accept cash. For about what you would pay to have your car tuned up, or your hair styled, you can see a top physician. There are drug wholesalers where you will be able to get generic drugs at deep discounts, should you need them. In my experience, vast majorities of seniors are over-medicated, and should seek physicians who will try to decrease their medication burden.

Also remember that Medicaid and subsidized insurance is effectively a poverty trap, since you are penalized with loss of insurance for earning above a certain level.

Obamacare is turning out to be every bit of the disaster that many of us predicted it would be. Participation will be costly, exposes you to identity theft and loss of confidentiality, and will limit your access to quality medical care. It is time for patients to declare independence from government health care. This will inspire more physicians to opt out, to meet the increased demand for private care.

Richard Amerling, MD is an Associate Professor of Clinical Medicine and a renowned academic nephrologist at the Beth Israel Medical Center in New York City. He has written and lectured extensively on health care issues and is President-elect of the Association of American Physicians and Surgeons.

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