President Obama guaranteed Americans that after health reform became law they could keep their insurance plans and their doctors. It is clear that this promise cannot be kept. Insurers and physicians are already reshaping their businesses as a result of Mr Obama's plan.
The healthcare reform law caps how much insurers can spend on expenses and take for profits. Starting next year, health plans will have a regulated "floor" on their medical-loss ratios, which is the amount of revenue they spend on medical claims. Insurers can only spend 20% of their premiums on running their plans if they offer policies directly to consumers or to small employers. The spending cap is 15% for policies sold to large employers.
This regulation is going to have its biggest impact on insurance sold directly to consumers—what is referred to as the "individual market." These policies cost more to market. They also have higher medical costs, owing partly to selection by less healthy consumers.
Finally, individual policies have high start-up costs. If insurers cannot spend more of their revenue getting plans on track, fewer new policies will be offered.
This will hit Wellpoint, one of the biggest players in the individual market, particularly hard. The insurance company already has a strained relationship with the White House: Earlier this month Mr Obama accused Wellpoint of systemically denying coverage to breast cancer patients, although the facts do not bear that out.
Restrictions on how insurers can spend money are compounded by simultaneous constraints on how they can manage their costs. Beginning in 2014, a new federal agency will standardize insurance benefits, placing minimum actuarial values on medical policies. There are also mandates forcing insurers to cover a lot of expensive primary care services in full. At the same time, insurers are being blocked from raising premiums—for now by political jawboning, but the threat of legislative restrictions looms.
One of the few remaining ways to manage expenses is to reduce the actual cost of the products. In healthcare, this means pushing providers to accept lower fees and reduce their use of costly services like radiology or other diagnostic testing. To implement this strategy, companies need to be able to exert more control over doctors. So insurers are trying to buy up medical clinics and doctor practices. Where they cannot own providers outright, they will maintain smaller "networks" of physicians that they will contract with so they can manage doctors more closely. That means even fewer choices for beneficiaries. Insurers hope that owning providers will enable health policies to offset the cost of the new regulations.
Doctors, meanwhile, are selling their practices to local hospitals. In 2005, doctors owned more than two thirds of all medical practices. By next year, more than 60% of physicians will be salaried employees. About a third of those will be working for hospitals, according to the American Medical Association. A review of the open job searches held by one of the country's largest physician-recruiting firms shows that nearly 50% are for jobs in hospitals, up from about 25% five years ago.
Last month, a hospital I am affiliated with outside of Manhattan sent a note to its physicians announcing a new subsidiary it is forming to buy up local medical practices. Nearby physicians are lining up to sell—and not just primary care doctors, but highly paid specialists like orthopedic surgeons and neurologists. Similar developments are unfolding nationwide.
Consolidated practices and salaried doctors will leave fewer options for patients and longer waiting times for routine appointments. Like the insurers, physicians are responding to the economic burdens of the president's plan in one of the few ways they're permitted to.
For physicians, the strains include higher operating costs. The Obama health plan puts expensive new mandates on doctors, such as a requirement to purchase IT systems and keep more records. Overhead costs already consume more than 60% of the revenue generated by an average medical practice, according to a 2007 survey by the Medical Group Management Association. At the same time, reimbursement under Medicare is falling. Some specialists, such as radiologists and cardiologists, will see their Medicare payments fall by more than 10% next year. Then there is the fact that medical malpractice premiums have risen by 10% to 20% annually for specialists such as surgeons, particularly in states that have not passed liability reform.
The bottom line—defensive business arrangements designed to blunt ObamaCare's economic impacts will mean less patient choice.