Now that the government shutdown is over, it’s time to focus on the Affordable Care Act.

Many have written about website sign-up difficulties including the apparent mother of all the bad ones,

Here are some issues that may not have received as much attention.

My daughter, who has a master’s degree in mathematics and has been buying insurance for her family for 7 years, has noted a few problems.

She is uncertain what plans she is eligible for because she and her husband are both independent contractors, and their combined income is highly variable year-to-year. It is not clear what the income threshold is going to be based on—this year, last year, or what.

It’s going to be a tricky gamble between the lower deductibles offered by the exchange and the lower premium offered by her current insurance.

With her current private policy, she can opt out of maternity coverage, which is not possible with the exchange plans.

If a knowledgeable consumer is undecided, how are first-time insurance buyers going to fare?

Of course, I have not read the ACA (has anyone?). I am not sure if there are any provisions for controlling expenditures.

Look at these recent headlines.

CT, MRI Overused for Headache, Study Finds” and the story says “Despite current guidelines that recommend against CT or MRI for uncomplicated headaches, primary physicians have been ordering nearly $1 billion worth of scans per year.”

Florida doctors prescribe way more drugs than Colorado doctors” and the difference is only partially due to the fact that Florida has more sick elderly people.

The Thousand-Dollar Pap Smear” tells a tale of inflated charges and unnecessary testing for women in a community health center.

Someone I know had a partial mastectomy followed by radiation for an early breast cancer. She had a mammogram 6 months later. She received a phone call from her surgeon asking her to come for an office visit to discuss the mammogram result. The individual who called would not tell her what the interpretation of the study was. She made an appointment. The next day she got a written report in the mail from the radiology office stating that the mammogram showed only normal postoperative changes and no sign of any cancer. She suspects that the surgeon wanted her to be seen in the office so that a visit could be charged for.

A man was suffering from migraine headaches. Workup, including a brain MRI, was negative. He was referred to a neurosurgeon by his primary care physician. What could a neurosurgeon possibly add to the diagnosis or treatment of this patient?

The addition of 30 million newly insured patients, many of whom will be subjected to the unneeded testing, drugs, and referrals noted above, may add huge amounts of costs to the already inflated healthcare budget, especially if the newly insured are not aware of the implications of a deductible. I have discussed deductibles and patient naivete in a previous post.

An article in the Boston Globe points out that it is just about impossible to find a primary care doctor who is accepting new patients in the Boston area. Massachusetts already has nearly universal healthcare coverage.

Assuming they can get past all the website glitches and then figure out what coverage to get, will the 30 million newly insured be able to find a doctor who will see them?

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at and tweeting as @SkepticScalpel. His blog averages over 1000 page views per day, and he has over 7200 followers on Twitter.