The President's Broken Promise to Physicians and Patients

It turns out that President Obama’s promise (made when he was selling the Affordable Care Act to the public) that Americans would be able to keep their existing health insurance plans had no basis in reality under the rules and requirements of the ACA. Many people are now finding out that the second part of the president’s promise—that they could also keep their current physicians—was equally misleading and false.

In 2009, the president said, “No matter how we reform health care, we will keep this promise: if you like your doctor, you will be able to keep your doctor. Period.” That was a potent sound bite designed to reassure a skeptical public that the parts of our health care system that were working would continue to do so under the ACA. However, as Time’s Swampland blog has pointed out, “It’s not that simple.”

The president’s promise is running into the harsh realities of the insurance market under the ACA, because in order to participate in the ACA’s health-insurance exchanges, insurers need to “find a way to tamp down the high costs of premiums. As a result, many will narrow their networks, shrinking the range of doctors that are available to patients under their plan.” The President’s claim that he was unaware of the business ramifications of the ACA is, at best, an indication of his total detachment from the consequences of his signature legislation.

Physician’s organizations such as the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians have raised concerns over this. The Wall Street Journal reported that representatives from these groups recently met with White House officials to explain that physicians “are worried that new insurance plans under the Affordable Care Act offer only limited networks of providers and low reimbursement rates for doctors, and that could make it difficult for millions of those enrolled to actually get health care.”

Marc Siegel, MD, a practicing internist and an associate professor of medicine at NYU Langone Medical Center, saw the president’s promise for what it was from the start. In a column in the New York Daily News, he wrote, “President Obama’s promise that you would get to keep your doctor was propaganda to me from the first time I heard it. Health care doesn’t work this way. How can you keep me as a doctor unless I decide to keep you as my patient? Don’t I have the fundamental right to choose? What happens if your health insurance plan pays me too little and overly restricts the prescriptions I write or the tests I try to order for your benefit? How can you keep me as your doctor if your new Obamacare insurance policy doesn’t include me in its shrinking network and restricts out-of-network payments?”

The bottom line, according to Siegel, is that “If your insurance is ‘comprehensive’ but your high-quality doctor is paid little for working with it, it is likely that you will have to change doctors.”

These concerns are not just based on conjecture; some insurers are already taking action to reduce the size of their provider networks. According to a recent article in the Wall Street Journal, UnitedHealth Group, “the nation's largest provider of privately managed Medicare Advantage plans, has dropped thousands of doctors from its networks in recent weeks,” telling many of them that the company’s actions are due to “significant changes and pressures in the health-care environment.” The primary source of this financial pressure is the $150 billion reduction in Medicare Advantage payments called for over the next 10 years by the Affordable Care Act.

UnitedHealth Group is one of the largest Medicare Advantage providers, with nearly three million people enrolled in its plans.

Because of these cuts, UnitedHealth Group said it expects its Medicare Advantage physician network “to be 85% to 90% of its current size by the end of 2014.” Austin Pittman, president of UnitedHealth's networks, told the WSJ that, “It’s no secret that we are under substantial funding pressure from the federal government.”

To offset the expected decline in Medicare Advantage payments, UnitedHealth and others (Aetna, Humana, etc), are doing what any business would do‑‑namely, cutting costs and working to provide services more efficiently. One way to do that is to reimburse physicians and hospitals at lower rates, and drop those providers who won’t accept this.

Insurers are excluding some of the top-ranked hospitals in the country. The Washington Post reported that “insurers are creating networks that are far smaller than what most Americans are accustomed to.” In fact, “a number of the nation’s top hospitals — including the Mayo Clinic in Minnesota, Cedars-Sinai in Los Angeles, and children’s hospitals in Seattle, Houston and St. Louis — are cut out of most plans” sold on the exchanges. This will have a devastating impact on the severely ill patients who need high-quality treatment.

This is business as usual in the insurance industry, as companies compete to provide comprehensive services while controlling costs. And that’s what has caused the Obama administration so much trouble. It should have been entirely predictable to the president and his advisors that insurance companies would respond to provisions in the ACA that reduce the payments they receive by enacting compensatory cost-cutting measures, including dropping physicians and hospitals that will not accept lower reimbursement rates.

Avik Roy, writing in Forbes, summed it up: “Given the fiscal unsustainability of the Medicare program, it’s a good thing that insurers are doing everything they can to keep costs down. But keeping costs down will involve shutting thousands of doctors out of the physician networks that private insurers use.”

President Obama surely knew this would happen (or at the very least should have known this), and yet he still proclaimed, “If you like your doctor, you will be able to keep your doctor. Period.” Given the predictability of the insurance industry’s response to the dictates of the ACA, he never should have made such a categorical statement to the public, for it was a disingenuous promise the president could never have sincerely intended to keep.