Well, UnitedHealthcare has announced that it’s pulling out of the health insurance exchanges because of huge losses. This may be the mortal wound. It is apparent that health care reform is undergoing a slow-motion implosion. Most of the Affordable Care Act has been delayed or canceled, including the individual and employer mandates, the independent payment advisory board (thank goodness), Medicare Advantage payment cuts, the Cadillac health insurance tax, and auto enrollment. Half the insurance co-ops have failed, and the remainder are running at a deficit. The exchange-plan premiums are increasing dramatically. In fact, with 71 cancellations and delays, health care reform has already effectively been repealed.

Insurance coverage has increased by about 8% (10 million more into Medicaid, 80% of all new insureds), particularly of the poor. On the flip side, millions have lost their old insurance, now have very high deductibles, and have lost their doctors. High-deductible insurance means that patients really aren’t going to be able to use their insurance, unless they have a catastrophic event and are hospitalized.

High-deductible insurance that pays at Medicaid rates, and Medicaid, are a particularly bad mix for dermatologists. Medicaid does not even cover the cost of overhead in the office setting, and many patients cannot afford their high deductibles. Almost all of the cost-efficient in-office curative procedures we offer cost less than the deductible. We are all seeing patients delay and delay treatment until the end of the year, hoping they won’t have to meet their deductible.

Many patients, excited that they finally have health insurance, are bitterly disappointed to find that they really don’t, except for their annual physical exam and the emergency room. The doctor is put in the poisonous position of explaining insurance policy limitations, and being collection agent. Poor Medicaid patients, who get free care at the hospital, go to the emergency room for minor complaints that would be much more efficiently handled in the office setting. This clogs emergency rooms, and is ferociously expensive. This is the opposite of what health care reform was supposed to do.

Insurance premiums are rising rapidly because somebody has to pay for coverage of the millions who could not formerly qualify for health insurance because of preexisting conditions. The current exchanges allow dropping in and out of insurance coverage and, with the elimination of preexisting conditions, this allows patients to game the system and wait until they fall ill to buy insurance. Historically, almost all were in the pool of insureds and the risk was predictable.

There is no way for politicians to go back and remove millions of chronically ill from the coverage rolls. Imagine the nightly news. As a physician, it is impossible not to feel compassion for these chronically ill patients, but it would have cost a lot less to just make them eligible for Medicaid to begin with.

OK, it is easy to complain, but what are possible solutions? Patients need health care savings accounts for a sizable portion of their deductibles. Physician rosters need to be real time and accurate. Networks need to be adequate (another column, another day). Medicaid rates need to increase to Medicare levels, as they did for the initial 2-year teaser period for primary care physicians. Exchange plan payment rates need to match their commercial insurance wrappers, instead of Medicaid rates, so physicians can afford to accept them. Stricter enrollment periods are needed, so patients cannot game the system, signing up only when they get sick or want a joint replaced. If you are going to provide health insurance for all, then make sure the health insurance is real, not hollow.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at dermnews@frontlinemedcom.com.