When I first read Obamacare, my reaction was, "Whoa! These guys don't get around much."
Obamacare (formally the Affordable Care Act) was greeted by critics and supporters alike as something radically different. The exchanges are a noble experiment, and computers were long overdue for this sleepy industry. But the underlying structure of care delivery remains very much the same. Doctors track your health and refer you to tests, imaging, surgery and specialists. In the rarified world of analysts, statisticians and scholars, this template is called "gatekeeping."
Father knows best.
And he frequently does.
With annual check ups, trend lines of your mishaps and surgeries, previous test results, medications, allergies, preferences and idiosyncrasies your "primary care physician" is ideally suited to guide your visits with specialists and surgeons, your admission to the hospital setting, advanced treatments for difficult health problems and new medications that may fit your profile. He's been around for centuries. A variation on the theme is the group practice and health maintenance organizations. Kaiser Permanente, an outgrowth of the World War II shipyards, is the quintessential health maintenance system: your doctor attached to a network of hospitals and specialists. Father Knows Best meets All in the Family. Gatekeepers all.
If gatekeepers can keep you in, they can also keep you out. From what I see in the trenches with HMOs and Medicare Advantage-type plans, the ethical standard is high. Decisions are largely made on merit. I do hear complaints that they take a long time to move you through the system and often denials of care must be appealed. Their reimbursement system is based on weeding out excessive care, and sometimes that incentive can blur the lines between excessive and necessary.
More to the point, gatekeeping is being superseded on the ground by several converging patterns that circumvent the traditional model. Even as the intellectual gentry in the think tanks were putting together the new and improved gatekeeping venues of Obamacare, Accountable Care Organizations, Medical Homes and Interdisciplinary Teams, outside the think tanks patients were taking control of their health in a way not envisioned by planners inside.
Emergency rooms have become 24/7 community clinics, turbo charged as the Emergency Medical Treatment and Labor Act of 1986 finally gains widespread use. This Act prohibits emergency rooms from denying care to anyone without the ability to pay. This Act has morphed by regulations and case law into full hospital services for the uninsured. All of a sudden, CAT scans, MRIs, ultrasounds, exotic blood tests are available to all at your local ER.
Meanwhile, we are pushing the limits of life expectancy, and the general public has become very sophisticated in the latest in technology, pharmaceuticals and surgical procedures. Those I'd least expect are asking me about the latest Hepatitis C pill or same-day spinal surgery... and some of them are now are educating me from what they have picked up on the Internet. They expect access to 2D Doppler, 3D MRI, overnight cardiac cures, miracle cancer treatments, and the latest superdrugs. And, in the absence of any common understanding of Obamacare, people will come to believe that this is what they are entitled to... not a visit to an interdisciplinary team in Lake Wobegon.
In his fascinating story of health care across the world (The Healing of America), T. R. Reid devotes a full chapter to the French way of doing things.
They have done away with the gatekeeper model altogether. You have a health ID card and, with this in hand, can choose any doctor you'd like... or go to the surgeon of your choice.
They also have the best health care in the world.
More and more of the insured -- as well as the uninsured -- in America are taking the initiative to shop for what they want. In my practice and in my personal life I come across many early experimenters who invest time and effort into tracking down the newest herbal remedies, the latest high tech treatments, the best hospitals on hospital compare.
Obamacare should serve us well for a generation or so, bringing everyone up to speed on individual responsibility and providing a safety net for millions.
But, like Prohibition, the gatekeeping model may turn out to be too paternalistic for the public in the long run.