Cardiologist Anish Koka always knew he wanted to be a doctor. An immigrant kid growing up in Pittsburgh, PA—his family moved to the United States from India when he was 10 years old—he was surrounded by physicians, and found himself especially inspired by those who provided health care to communities in need, where doctors were few and far between. 

“Patients were just so gratified,” he told IW Features, recalling his experience shadowing a rural gastroenterologist. “So that always kind of stuck with me, that immediacy of being able to help people.”

For Dr. Koka, who runs his own practice and is married to a hematologist-oncologist he met in residency, patients come first. So when he initially saw the Affordable Care Act in 2010, he said, he was enthusiastic about it, believing the ACA would just be about insuring the needy.

But, as a patient-facing doctor, he very quickly saw the ACA for what it actually was: a disaster in the making. This became his “redpill” moment, he said. 

“The architects of Obamacare wanted to fundamentally change how health care was delivered, and they had all these grand plans,” he said, noting that they were academic theoreticians rather than clinicians with experience practicing medicine. “And they had no idea what they were doing.”

Today, Dr. Koka opposes the legislation he once supported and hopes Republicans will continue to oppose extending what were supposed to be temporary ACA subsidies during the COVID era. Democrats rejected the Republicans’ plan last week to keep the government funded through November 21, shutting the government down in order to attempt to push Republicans into extending these temporary subsidies. While Democrats have claimed that letting the subsidies expire as they were meant to would make health care more expensive, Dr. Koka’s experience suggests otherwise. Focusing on subsidies as a proxy for health care misses the point, he said—and it actually raises healthcare costs instead of lowering them.

“Obamacare has made health care more expensive. And if health care is more expensive, then health insurance is going to be more expensive. And then you have a chicken-and-egg problem,” he said. “COVID-era subsidies really should expire, because if we learned anything from the Obamacare era, it’s that simply focusing on health insurance coverage is not going to make health care cheaper. If anything, if you simply focus on paying a bunch of money to health insurance companies, health care actually gets more expensive.”

Dr. Koka also referenced how the ACA’s medical loss ratio, which mandated that insurance companies spend 80-85% of premium dollars on medical care, backfired: “All that did was say that your revenue is going to be tied to your gross amount. So the only way to grow your revenue from year to year is going to be to increase healthcare costs.” 

For instance, said Dr. Koka, a procedure that might have cost $100 in the absence of the provision might be marked up to cost $1,000 because of it. And of course, insurers are incentivized to pass the cost to consumers—that is, to patients.

This system also incentivizes unnecessary interventions and procedures, while disincentivizing private practices in which doctors can actually get to know their patients. 

“Now every health system knows the way they have to make money and advance and stay afloat is by doing as many procedures as possible on as many patients as possible,” Dr. Koka said. “So patients have become widgets for reimbursement.”

Dr. Koka recounted a story of a patient he’d seen at a hospital, an 87-year-old with dementia living in an assisted living facility who was admitted for a urinary tract infection. Because of the shift away from family practice doctors and toward huge conglomerates that bounce patients around from specialist to specialist, he was consulted on whether or not this patient should undergo a certain procedure. Dr. Koka concluded the patient—elderly, living with dementia, unable to get out of bed—was far too high risk for this particular procedure, but also noted that similarly high-risk patients are often needlessly put through this same procedure.

“Back in the day,” he said, “when you had a practice that wasn’t centered around the non-profit health systems that are there to do procedures, when it was centered around your doctor that was down the street from you, he was the real quarterback for your care and he knew you.” 

The architects of Obamacare assumed it was the private practice doctors who were driving up costs. And yet, said Dr. Koka, because they pushed American medical care toward a nonprofit, large health system model, “things are way, way worse now, because you don’t have that quarterback who’s looking out for you, who’s been with you for 20 years.”

It is exactly this intuitive, humane approach to medicine that has been decimated by the bureaucracy the ACA created—a bureaucracy that currently includes the temporary subsidies that Democrats are attempting to use as their leverage to keep the government shut down.

As for the Republicans, Dr. Koka has some advice: “Don’t blink.”

If the government refuses to subsidize health insurance the way it currently is, he told IW Features, patients will be better off in the long run. 

“Without these subsidies, providers will not be able to continue charging these ridiculous rates. You’re going to create a better, more transparent, more efficient system if you take away these massive federal subsidies,” he said.