Huge holes exist in the health reform law

Huge holes exist in the health reform law you can drive an 18-Wheeler through. These holes are not “devils in the details.” They are so obvious nobody talks about them. They are the proverbial elephants in the room. I suppose this makes sense. It takes an 18-wheeler to transport an elephant.

Here are my six candidates of the biggest health reform holes.

One, the government’s lack of leverage over health insurers. President Obama and Kathleen Sibelius can talk all they want about the evil health plans and how they are outrageously raising premiums, on average by 10% to 20%. But other than jawboning and demonizing, the Obama administration have little control over the rates. It is fine to say the health plans must cover those with pre-existing coverage, young people up to age 26 under their parents’ plans, and to remove caps on lifetime expenses, but the plans can ignore the government and set the rates to cover the increased expenses engendered by government mandates.

Two, the government’s lack of appreciation that the U.S. is center-right not a center-left nation. At its core, America is a middle-class country that believes in limited government, limited taxes, and limited intervention in private affairs and private behavior. Two particularly sore points are; one, the individual mandate, which requires everyone to pay at least $700 , or 2.5% of income, and two, the provision that every business must submit a 1099 for every $600 spent for supplies or deserves, whether or not related to health care. In both case, the IRS may crack down and pursue non-compliance. These two things strike Americans as government meddling. These government actions, in my opinion, accounts for much of the lack of approval of the Obama agenda and for the rise of conservatism, the Tea Party movement, and the embrace of the GOP over Democrats. The public wants Washington to swing to the center.

Three,
the government’s lack of price controls. Everybody but Washington seems to know you cannot expand coverage for the uninsured by 32 million(and Medicaid by 16 million) and save money while cutting Medicare by $575 billion. And you cannot save money when 58 million baby boomers, starting in 2011, will start becoming eligible for Medicare. Saving money under these circumstances is simply counter-intuitive. Congress lacks the political will, and no combination of taxation, fines, penalties, and punitive savings imposed on the health industry will make up for the deficit.

Four, the government’s incompetence in containing fraud and abuse. Fraud and abuse costs Medicare an $60 billion a year, over 11% of its budget, and that may be an underestimate. Someone has calculated that Medicare fraud and abuse consumes 7 times more money than the combined profits of the 14 largest health insurers, who are largely free of rampant fraud and abuse characteristic of Medicare. Medicare is too tempting a target for criminals who can use stolen Medicare IDs, and who know that Medicare is obligated to pay claims in 30 days.

Five, the inability of the States to pay for millions of Medicaid recipients scheduled to join the state rolls in 2014. Millions more may enroll before then when patients with current plans learn their new plans must meet government mandates that require comprehensive coverage and higher premiums they cannot afford. About 70 million will be required to change plans, and many of them will switch to Medicaid. Few Americans appreciate the Medicaid burdens States must shoulder. In California, Medi-Cal, its Medicaid program, cover 1/3 of children and 1/10 of adults under 65, 2/3 Of nursing home residents, and 2/3 of expenses of public hospitals, while costing the State of California. $46 billion.

Six, the failure of government to act to correct the looming access problem to physicians. This access crisis is already being felt in Massachusetts, said to be the model for Obamacare. There patients now have the longest waiting times in the nation to see a doctor or to seen in emergency rooms, and half the primary care physicians in the state no longer accept new patients. This is primarily a supply-demand problem. There are not enough doctors to see the flood of new patients, and the reform law does virtually nothing to increase the supply of doctors.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

Submit a guest post and be heard on social media’s leading physician voice.

email

Comments are moderated before they are published. Please read the comment policy.

  • ningem

    Plus the ability of politically-favored groups to exempt themselves from the law.

  • http://Www.twitter.com/alicearobertson Alice

    But other than jawboning and demonizing, the Obama administration have little control over the rates. It is fine to say the health plans must cover those with pre-existing coverage, young people up to age 26 under their parents’ [end quote]

    This ignores the fact that the very result from the legislation was raised premiums to cover the perks the writers placed in the legislation.

    Legislation adds to the cost…indeed, necessary when the free market doesn’t play fair….but just because doctors do not like dealing with insurers, or want money made easier without the lowering of reimbursement that is driving them batty…the end does not justify the means.

    Insurers are some of the most regulated businesses out there. Some doctors want them regulated out of business…that is not conducive to better health…just easier income for doctors…who are going to find themselves shot in the foot by more regulation on them.

  • http://Www.twitter.com/alicearobertson Alice

    Six, the failure of government to act to correct the looming access problem to physicians. This access crisis is already being felt in Massachusetts, said to be the model for Obamacare.[end quote]

    While I agree with much of your analysis…I struggle with your call for more regulation. We know that SS, Medicaid, Medicare are going to be hit with necessary budget cuts…people will ge hurt. Not sure we can afford more government regulation both monetarily and rights wise.

    On one hand the mandates are necessary to make it work….as Clinton’s Solicitor General said…healthcare is the only area an American can take up to a million dollars in goods and services without paying into the system. Our center minded President used to agree when he said you shouldn’t force people to buy..was it a house? As a lawyer he knew the constitutionality of the mandate rests of the consensus of whoever is interpreting law at that moment in the Supreme Court….and knew it is a rights issue. The more government involvement…the less rights of the common man.

    The debate rests on human rights that are evolving as the boundaries become more broad…yet taxes cannot sustain these ideological, well intentioned, yet, intrusively legislated dreams.

    • Richard L. Reece, MD

      Alice: I agree. Regulation and the health reform bill raises costs. That does not make either demons. We have to live with government and health plans.

    • Richard L. Reece, MD

      Alice: It is true that the health reform bill is ideological and well-intentioned. The flaws flow from the fact that it was passed in haste without thinking through the consequences and giving the opposition any say in the matter.

  • DougPete

    Dr. Reese,
    You just don’t get it. The whole Obamacare plan is designed to fail so we’ll end up with the government’s single payer plan where all of the insurers are drummed out of business. Then we will all become indentured slaves to the government who will control our food, how we stay in shape, and how we die.

    Just wait for the national campaign to make sure everyone stays within their proper weight group because it will become a “crime against the state” to squander more than your fair share of health care dollars. Just wait until we all have to be drug tested to make sure we are living pure lives. Just wait until every doctor can check those Federal records to make sure we’re taking our Xanax and Ridolin. And that’s not to mention that granny has lived too long. It might be a good thing if she dropped dead because her medications cost an arm and a leg. You know, she’s lived a good, long life so she should help control health care costs by going into the back 40 and letting nature take its course.

    • Family Doctor

      “Then we will all become indentured slaves to the government who will control our food, how we stay in shape, and how we die.”

      You add nothing to this important & pivotal national debate when you over exaggerate, provide illogical examples, & present no evidence to support your extremist, fear-mongering. We ALL need to be involved in this national debate, but only logical conversation is productive. If you really believe what you say, please provide the CONCRETE evidence to support your views. I am neither a Democrat or Republican (non-partisan actually) & very well read on the national healthcare debate and I have read NOTHING that supports your inflammatory views.

      But I’m willing to listen. Please share. You really might have some information of which i am unaware.

      Regards

      • Richard L. Reece, MD

        I do not mean to be inflammatory. i have written 1700 blogs and ten books on health reform, and I tent to take a middle-of-the road approach. I simply think the Obama plan so far isn’t working very well – 10% increase in costs, waivers to over 1000 health plans, and 67% of Americans favoring repeal. I am involved in the debate and have just produced a book , tentatively titled The Health Reform Maze, which will be published in 3 months by a reputable publisher well-regarded by physicians.

    • Richard L. Reece, MD

      I tend not to be as apocalyptic as you. I think we need reform but not reform so top-down, government controlled, and bureaucratic. There’s a decent chance for defunding and repeal if Obama loses in 2112. The average of 10 national polls shows 30.9% favor the law and 52.0% oppose it. With that public sentiment, I doubt the bill will be fully implemented. I am doubtful it is a precursor to single-payer, though it may be a futile stab at it.

      • DougPete

        I hadn’t planned to respond to this thread. I can live with the sanctimonious “Family Doctor” thinking I’m angry, exaggerating, and add nothing to the debate. Then along came the April 1st article in the WSJ which wasn’t an April Fool’s Day joke: http://on.wsj.com/fnFdik

        So “Family Doctor,” do you still think what I wrote is hyperbole? Arizona’s proposed $50 “Fat Fee” (a Republican proposal, not part of Obamacare) is just the beginning. I’m sure all of the cash strapped states will enact similar plans that will probably be with higher fees to fill their dwindling coffers, all for “our own good,” of course. It’s always for our own good. How can we argue with that?

        This is what I meant by “enslavement.” If the government holds all of the healthcare purse strings, they can decide how we treat our bodies. If we aren’t treating ourselves the way bureaucrats feel we should, they can force us to behave ourselves through public shaming and confiscatory taxes/fees like they’ve already done to smokers.

        You can argue it’s “good medicine” to help people live longer, healthier lives. Exactly how long should that be? Who decides? Does our view of *quality* of life count in this equation? Can we snarf down hot fudge sundaes three times a day and die young or MUST we all live to be 87 instead? Can I eat a slab of ribs once a week or just once a year? I’m sure my government has great plans for my life, liberty, and pursuit of happiness but, being selfish and all, I’d like to make personal decisions in consultation with my doctors so they fit what I deem is important.

        Dr. Reese: Don’t think my comment was critical of your very fine article. We differ only in that I personally believe the flaws in the healthcare program are intentional so single-payer can ride in on a white horse to save the day as a simpler solution. Obama stated in 2007 he favored single payer although he felt it wouldn’t happen as a first step. (He later recanted, but I don’t believe him.) What better way to achieve single-payer than to design a system so ponderous and convoluted with bureaucracy that it simply cannot be implemented? While our current healthcare system needs refinements to address serious issues, it certainly doesn’t need to be scrapped. I’m hoping more people realize that in the near future, and the medical community is more vocal with their opposition than they have been in the past.

  • Finn

    Perhaps “Obamacare” will make it possible for you to get treatment for that paranoia, DougPete. “Crimes against the state?” Really? No matter how flawed, the health care bill is not going to turn the US into the USSR.

    • Richard L. Reece, MD

      I do not think of the Patient Protection and Affordability Law as socialism run amuck. On the other hand, in my opinion it;’s title is a bit of an oxymoron. It neither protects most patients with existing plans or makes those plans more affordable.

  • http://Www.twitter.com/alicearobertson Alice

    Okay…Finn…even if it is hyperbole the outcomes outlined are a good red flag. Personal choice is a freedom I like….we have civil laws to contain man’s immoral or harmful behavior….just how far will our loss of personal rights and liberties be taken away if we do not stop screaming for the government to use the big guns?

    What bugs me is people who proclaim they do not mind taking a hit….some false altruistic, self-created, dreamlike state that does not allow reality to enter for fear they may awaken and realize they are on the dreaded waiting list (that was foretold) and part of a budgetary nightmare that makes the insurance companies look like a memory of fairy tale proportions.

    • Richard L. Reece, MD

      One man’s meat – i.e. a centralized government-run system – is another man’s poison, i.e, a market-based system with unlimited personal freedoms.

  • pcp

    “the U.S. is center-right not a center-left nation. . . Two particularly sore points are; one, the individual mandate . . .”

    The individual mandate was a part of every major Republican health reform plan until January 20, 2008.

    • Richard L. Reece, MD

      The personal mandate is a sticking point and is looked upon with disfavor with 67% of voters and federal judges like Roger Vinson. My position is: let the Supreme Court decide – and soon. We can live with the consequences of the decision.

      • gzuckier

        The individual mandate was a feature of the plan when it was essentially taken over wholesale from its most recent formulation by Bob Dole and Howard Baker, carried over from its previous formulation as John Chafee’s counter to the Clinton plan, in 1993. Because, up until the advent of the “heads I win, tails you lose” approach to the free market, whereby the attitude that you can keep everything you gain “by your own efforts” but be recompensed for everything you lose “through no fault of your own” became “conservative” dogma, Republicans and conservatives used to be opposed to people gaming the system by not paying for health insurance until they got sick, at which point they couldn’t afford to pay for it. The concept of “personal responsibility” meant providing for the inevitable medical bills, not being free to shirk them.

    • http://Www.twitter.com/alicearobertson Alice

      There is a chart here and a bit of a transcript with President Obama sharing about Hilary’s mandated healthcare proposal. His original vision was against mandates….he understood the law and repercussions.

      Maybe some Republicans desired mandates…but it does seem to have the overall support among Republicans. And our President, obviously, changed his mind…so he saw the value in the warnings from Republicans against it…some see it as an economic tool of survival where civil rights do not matter.

      http://healthcarereform.procon.org/view.resource.php?resourceID=004182

  • http://Www.twitter.com/alicearobertson Alice

    The individual mandate was a part of every major Republican health reform plan until January 20, 2008.[end quote]

    Ezra Klein shared this tid bit recently……I am going to look into this (because he so strongly supports single payer and other liberal causes he often leaves major facts to the wayside while building his case). Just a little bit of political skepticism goin’ on:). The Republicans did have a response to the Clinton bill….it was defeated and government healthcare silently grew into an albatross.

    The mandates are pragmatic…but……I guess we will see…I am not keen on the current condition of the Supreme Court…and I wish they were not mandated life terms.

    Another poster, rightfully, pointed out unions are not being mandated because of waivers….so we have a hodge podge of ideals and deal
    breakers because we are on the threshold of a huge election. The same reason Medicare wasn’t hit….hoards of middle class angry voters who feel they are entitled will base their votes not on what is good for others…but themselves….who cares that the budget can’t be balanced or future generations? Isn’t that the usual result of entitlements with no means test? But it understandable when you pay in….not sustainable because so many do not….hence…back to the mandate to make it supposedly sustainable…but again even with a mandate it is not.

    • Richard L. Reece, MD

      Keep in mind the PPACA has many mandates – on individuals, on states, on the medical industry, on physicians, on hospitals, on employers, on health plans. Mandates, by their very nature, are threatening, which is why the health reform bill has provoked such a negative reaction by so many players.

    • pcp

      “Another poster, rightfully, pointed out unions are not being mandated because of waivers”

      The majority of the waivers (for only 12 months) have gone to service industries, mainly the fast-food restaurants, who aggressively campaigned against the ACA.

      • http://Www.twitter.com/alicearobertson Alice

        Are you sure? I read differently, and the number grows daily…but on some levels it seems states are empowered.

  • PAULMD

    Paranoid people get chased too. DougPete seems angry and extreme but does that make him wrong? It may not be found in a journal or textbook or taken seriously in the rareified air of the illuminate but if, as Reece has suggested and apparently supported, that the current plan defies intuition, this could be the outcome. He (DougPete)is certainly not suffering from a lack of imagination and I find it refreshing.

    When Hitler was elected cancellor of Germany, he did not write down and discuss his plans with the populace. People, some or most, not Chamberlain perhaps knew it didn’t pass the sniff test. It is just as logical an assumption regarding the ultimate motives behind the ACA. I am not suggesting or equating anyone or any plan with Hitler but that motivation, agenda, ability, and opportunity is highly suggestive of a course of action with intended results. When the “intended results” are percieved to be factually impossible or unintuitive, the consequence of failure may be the truly intended result. This is not rocket science, this is common knowledge supported by history.

    As for his other concerns regarding government control, time will tell.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Did it ever occur to anybody that ACA was not the original intent of this administration? Instead it is a piecemeal shadow of its creator, put together by ad-hoc compromise and necessity to gather enough votes to pass “something”.
      However ill conceived such strategy will prove to be, it is hardly a result of a premeditated sinister assault on freedom.

    • Richard L. Reece, MD

      Obama is no Hitler. His intentions are good, but I do not think he understands the complexity of the diverse American culture.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        “…the complexity of the diverse American culture”

        Not sure I understand what this means….?

        • gzuckier

          That the combination of knee-jerk tax-cut Republicans added to those who view education and intelligence as elitism alien to the true America, plus those who cannot stomach a black man as president (even if they can’t admit it to themselves so they flounder around with wild fairy tales about Kenyan births, Muslim upbringing, and socialist intentions) is why it is obviously impossible for America to do what every single other half-decent country has managed to pull off without too much fuss so it’s immoral to make the effort.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    I can see how all six points are indeed big problems, and I can see how government intervention can lead to too much government intervention, but I cannot see how the one and only solution offered by Republicans (in various shapes and forms) is in any way sustainable – treat health care as a free market and let those who can afford to participate and consume enjoy the market, while the non-consumers (i.e. the poor and increasingly impoverished ex-middle class) ….. are “free” to not consume, I guess.

    • Richard L. Reece, MD

      I believe some Republican suggestions – shopping across state lines, tax credits for all, health savings accounts, and tort reform – make a lot of sense. To dismiss them out of hand is not the mark of a mature mind. Health consumers are very smart people and will be responsible when using their own money. Incidentally, health savings accounts have worked very well in Medicaid populations.

      • pcp

        “shopping across state lines”

        Sounds good, but I’ve never gotten an explanation how that works in the real world.

        I practice on the East Coast, and have carefully negociated contracts with the 7 largest insurers in my state. If someone shows up in my office with Insurance XYZ from Alaska, they pay cash no discounts, as they will at any lab, radiologist, specialist in the area.

        How is that insurance a viable product to market in my area?

  • ErnieG

    I think the most likely outcome of this piece of legislation is the realization that insurance companies will be unable to meet the demands of the population without becoming larger villains. The problem with medical care is the third party payer system and the large influence of pharmaceutical companies. People will turn toward the government to solve the problem by expanding Medicare to all. This will probably bankrupt the federal government. While DougPete’s outcome is possible (as a resort to keep the federal government solvent), I think that it will be so unpalatable compared to pushing costs down the line to future generations- the federal government is the only entity that can basically ignore debts. I agree whole heartedly with PaulMD’s sentiment about unintended consequences- history is so full of them and this piece of legislation is fundamentally flawed (that’s not to say there are parts that are good or desirable). I don’t think there is a particular individual villain (like Hitler) with hidden motives, but I think it is clear that Obama was more interested in making headlines than creating substance.

    • Richard L. Reece, MD

      I do not look for villains e.g overeaching government or overly greedy health plans. To me it is all about structure. Health plans executive must report to boards and stockholders, and their aggregate profit of 2.2% is not excessive. The 5 largest health plans made $12.2 billioni in profit last years while the government says it lost $70 billion in fraud and abuse on its combined Medicare-Medicaid budget of $750 billion. The goals of health plans – a small profit to say in business – and government – covering more people to stay in power with or without a proft- are fundamentally different.

      • pcp

        “their aggregate profit of 2.2% is not excessive”

        Their profit, combined with their overhead, is very excessive in relation to the value they bring to the system.

        • gzuckier

          Hardly, or they would not be able to stay in business; the value they bring to the system is that their size allows them to contract for rates so much lower than what providers charge the uninsured, that the 25% or so overhead including profit is well worthwhile.

      • gzuckier

        That being the case, why would you oppose a mandate which required the public to purchase whichever plan they choose from whichever private insurer they choose? One might suggest that such a situation offers a better free market model where the majority are required to choose from a small number of plans offered by a single insurer, chosen for them by their employer.

  • http://hotmail.com Art

    I guess if you repeat the same lies over and over again, they will be accepted as true. Where do you get the $60 billion number?

    At the HC Summit, everyone agreed that $1 of every $3 was waste, fraud and abuse and was 18% of our $14.6 trillion GPD, which amounts to $2.7 trillion, a third of which is $900 billion, not $60 billion.

    This amounts are confirmed by testimony of the Government expert Malcolm Sparrow who stated that frud alone is hundreds of billions of dollars a year and by the article WASTE IN THE U.S. HEALTHCARE SYSTEM PEGGED AT $700 BILLION IN REPORT FROM THOMSON REUTERS which separates these amounts all as waste with fraud listed as $125 to $175 billion each year with the remaining $500 billion being caused by physicians.

    Gee, if this is true, all the amounts required to cover everyone can be gained just by eliminating the noted problems, yet nobody wants to “correct” these and argue about the amounts and who case them!

    • Richard L. Reece, MD

      The $60 billion came from a 60 minute report on CBS and from government sources who put the number at $70 billion. Fraud and abuse is not the same as waste and duplication, widely estimated at 30% of health spending, or $750 billion if you put total health spending at $2.5 trillion.

  • http://Www.twitter.com/alicearobertson Alice

    Republicans (in various shapes and forms) is in any way sustainable – treat health care as a free market and let those who can afford to participate and consume enjoy the market, while the non-consumers (i.e. the poor and increasingly impoverished ex-middle class) ….. are “free” to not consume, I guess.[end quote]

    But that is not how it works. The poor can get care…they may need tenacity to get it, but it is there. It is there at such a rate it’s killing those who do put in. This is where this article made a good point about price controls.

    If you look at other countries with socialized care the best care is still privatized via a free market.

    • Richard L. Reece, MD

      I would rather not comment on the relative merits of socialized vs. market based care. Instead I will quote Winston Churchill who said “the inherent vice of capitalism ist he unequal sharing of blessings; the inherent virtue is the equal sharing of miseries.”

      • http://Www.twitter.com/alicearobertson Alice

        I do love Churchill…and as others can attest I take his cry to never, never give up to heart. But….I’m thinkin’ his glass was half empty at that time!:). Why do I find the scenario of a Churchill v Rand debate so, utterly, delightful?

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Tenacity? Why is it that we always require more “character” from those who have less money?
      I would submit that even those who “put in” can’t get much out anymore. Yes, price controls are imperative, but price controls, as needed here, are not exactly a feature of so called free markets. So perhaps we don’t really need a free market.
      Gold plated care, which nobody really needs (but some want) is perfect for private markets.

  • DCPharm

    Alice says: “but just because doctors do not like dealing with insurers, or want money made easier without the lowering of reimbursement that is driving them batty…the end does not justify the means.” Doctors have had to hire more admin staff to process all the insurance red tape, while having payment rates continually dropped… hmm how do we pay the overhead? I KNOW! Let’s do expensive in office procedures, many not necessary, but pay is good, keeps lights on. And before anyone says this is the rare doctor, I will attest it is the rule not the exception. SO all the ads telling people to protect their medicare numbers?? A waste. The fraudulent billers aren’t getting the numbers from individuals. SO, I think Art is right, waste by doctors is a much larger problem than fraud, but, in my opinion, much harder to put your finger on.

    • http://Www.twitter.com/alicearobertson Alice

      Where I live private practice is a dinosaur. Most doctors sold out to Cleveland Clinic, or work for the university hospital affiliated with Case Western. The doctors are salaried and would not relate to your examples. But they do receive bonuses….and the hospitals charge faculty fees the insurance companies will not pay. It is $25 – 65 per visit. Admittedly, Cleveland Clinic is gorgeous….but I can do without the granite and opulence….and egos…..but that said they do a lot really well and the doctors there are either really content, or good actors.

    • http://Www.twitter.com/alicearobertson Alice

      DC….to gain what you desire how much do you think it will cost the average taxpayer?

  • http://www.twitter.com/alicearobertson Alice

    I doubt the bill will be fully implemented. [end quote]

    Isn’t it a type of “all or nothing” type of deal because the legislation lacks a severability clause that leaves them unable to severe it up?

  • http://www.twitter.com/alicearobertson Alice

    I do not think of the Patient Protection and Affordability Law as socialism run amuck. On the other hand, in my opinion it;’s title is a bit of an oxymoron. It neither protects most patients with existing plans or makes those plans more affordable. [end quote]

    I tend to agree with this, but when taken to it’s logical conclusion where does all this government regulation lead? I tend to think the government does little well…..thinking lately about what used to seem so radical….the libertarian ideologies of abolishment of certain governmental departments…many feel the Surgeon General is pretty useless…the Dept. of Education a failure…the Agriculture Dept. etc. (for another day).

    Although, you are right this act in itself is not socialism, eventually all roads are going to lead to Rome…and I, personally, don’t want to go down that road.

  • imdoc

    I tend to agree with those that see the ACA as a slow road to single payer. In effect it will set up the insurance entities for failure and create an unaffordable rate spiral. In time, everyone will capitulate to an over-arching federal program. Curiously that will likely happen at a time of record federal debt, so delivery on the promise is in jeopardy.

  • doctor

    For me, the ugliest aspect will come from the “fine” imposed on business for non coverage of employees. Because the price of a policy will increase markedly, for their employees lower on the totem pole, the businesses will be encouraged to pay the fine and send these employees to the exchange, where they will get pseudo medicaid coverage not accepted by most physicians. It is essentially taking people with decent coverage and giving them poor coverage, probably making them change doctors. (Recall: “If you like your doctor, you can keep your doctor.” )

    • http://Www.twitter.com/alicearobertson Alice

      Some side effects of the panacea posted today on a liberal site I visit:
      Certain “grandfathered” plans selling individual coverage are exempt from the law’s requirement to cover kids. The Thompsons’ plan was one. That meant they would have to apply for a whole new policy, and the mother, a breast cancer survivor, was unlikely to be accepted.

      “We would have had to start over with me – and I can’t start over,” said Thompson. A social worker helped get Emily into Medicaid.

      In neighboring Missouri, an insurance company’s campaign to get small businesses to sign up by taking advantage of new tax breaks has yielded mixed results.

      One of the chief promoters of the idea is Ron Rowe, an executive of Blue Cross and Blue Shield of Kansas City. With some 150 previously uninsured businesses offering new coverage, his company’s efforts earned the praise of Obama administration officials. But Rowe says many business owners found the math didn’t work for them.

  • http://Www.twitter.com/alicearobertson Alice

    Speaking of cutting costs. I read late at night and write items of interest down. Sometimes by the morning I am unsure of the source…this may be from Weekly Standard?

    Republican Counter Revolution
    Summation:  Block grant Medicaid to the states while suspending the maintenance of effort regulations that tell Governors how to spend the money sent from Washington. Allow the Governors to use the block grant money to set up private exchanges where Medicaid recipients use benefits to shop for private insurance plans.

    Cut the red tape in Medicare that prevents doctors and hospitals from finding new ways to treat patients at a lower price. For Americans 55 years old or younger, gradually move to a system where patients use a fixed Medicare payment to chose the approved plan that is best for them.  But we need a Republican President to not veto.  So they need to build now… the ground must be laid out.  If we can save billions now the potential to save trillions more should lure voters.

  • Par Towb

    Amazingly, very little discussion here about how other advanced nations are handling these problems. One major source of my knowledge about the health care financing issue was “Sick Around the World”, a Frontline special. I personally would prefer a single payer system.

    I am currently on track to become a military doctor, and thus will be part of one of the larger “single payer systems” currently in existence in the US. Are any people out there willing to comment on the level of care provided by the military medical system?

    Overall, I find it hard to imagine that people with sufficient funds will not be able to purchase whatever level of medical care they desire in our society. What is at stake is whether those with limited means will be able to purchase a bare minimum level of medical care. I have worked in a company supplying self employed individuals health insurance; i’d say the average monthly premium for an individual was $500 (in 1991). Most people with “good” coverage these days only have this coverage because they are part of a large company or collective that can negotiate lower insurance rates. Logically, the entity that can negotiate the best rates, and still ensure good service, is the one with the largest number of individuals – all of us.

    • Jon3

      Here is how other countries deal with it:

      In the Czech Republic, specialists and GPs out of residency make less than $20k a year, working 60 to 80 hours a week, barely enough to cover rent.

      In Germany, GPs make $60k a year, barely a little more than nurses. Meanwhile the typical German CEO makes over a million euros a year.

      Many Czechs and German doctors are emigrating to the UK and Netherlands.

      Single payer is just code for screwing you the physician, so that bureaucrats and administrative executives can have cushy desk jobs and make more money than you.

      • http://Www.twitter.com/alicearobertson Alice

        The UK? Yes, there are many immigrant doctors there.

        If you consider what a GP makes in the UK it is not as good as here. The cost of living there is outrageous. If I could find our receipts I could be specific…but I think gas was $10 a gallon, friend’s that smoke paid about $12 a pack. Minimum wage is in pounds what our’s is in dollars, etc.

        You need to understand what the true cost of living is because just a dollar comparison will not be accurate. And their jobs are not easy. My relative called the GP at midnight and when he got there (unpaid because he receives a monthly stipend per patient…not a per visit reimbursement) the GP was, rightfully, annoyed…..asked why this could not have been handled during the next day. Our relative was trying to show off to the Yanks that he had control over his healthcare and could get a free visit at midnight. The GP was limited…wrote a prescription that could not be filled until the next day…there were no 24 hour drug stores in driving distance…we were not impressed…the GP was upset…his next day would be ruined from exhaustion.

        All this to share there are variables….bureaucrats are being tamed in Britain…huge cuts…loads of rioters today. I support David Cameron amd his cuts…but not for healthcare in an already ailing country.

    • http://Www.twitter.com/alicearobertson Alice

      The WSJ covered this recently…the best care is provided in countries that keep the private sector growing and available. Just a snippet, but is interesting how Switzerland amd Netherlands are pulling this off regionally with insurance companies involvement and compliance, and patient control and choice.

      http://online.wsj.com/article/SB10001424052748704893604576200724221948728.html?mod=googlenews_wsj

      However, it is in the U.K. that arguably the biggest changes need to be made. The government of Prime Minister David Cameron is determined to reform the 63-year-old National Health System. It is undergoing a massive overhaul in an effort to save £1.7 billion ($2.7 billion) a year. Under the proposed plans, general practitioners are set to take control of commissioning services for patients. The government is proposing to scrap strategic health authorities and primary care trusts, which currently commission services. The government argues it does not have a choice. The country’s budget deficit is soaring and the NHS is one of the biggest drains on its resources.

  • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

    A novel approach to health care reform.
    Put communities in charge:

    http://www.idealmedicalcare.org/blog/patients-reinventing-hospitals/

    Pamela Wible MD

  • SidewaysShrink

    Alice stated. “Insurers are some of the most regulated businesses out there. Some doctors want them regulated out of business…that is not conducive to better health…just easier income for doctors…who are going to find themselves shot in the foot by more regulation on them.”

    I would argue that health care providers are far more regulated than insurance companies. We spends years and years in training accruing $150,000 – 400,000 in personal, non-corporate, non-bankruptcy-able debt, we are licensed by the state we practice in, we are nationally boarded in our specialties and re-examined regularly. We practice by strict laws, ethics, and principles. In my state, to discharge a patient from our care, we must provide a patient with one month of emergency follow up care whether we will or have ever been paid by that patient. Events in our
    personal lives can effect our licensure.
    As others have argued, getting money from insurance companies is not easy.
    And what the current policy makers and people who think this job is done by greedy doctors should think about is how to make medicine an
    endeavor gifted young people want to give their lives to practicing. Because if things continue in the present direction I would tell my children to run, if asked.

  • http://Www.twitter.com/alicearobertson Alice

    I think it is a minority of doctors who are greedy. Our daughter just received a denial letter yesterday from her insurer. Her daughter’s doctors tried very hard to get it covered. I will have to pay a few thousand now.

    But that said…..why are doctors and insurers so regulated?

  • http://www.healthcaremarketingcoe.com Simon Sikorski, M.D.

    Take a look at what’s going on in Massachusetts … perfect example of major flaws:

    Government requires people to buy 3rd party insurance plans and yet does not care about the fact that people in MA are actually avoiding seeking medical services due to the out of pocket costs associated with mandated insurance plans! Frankly, people are not insured at all and yet are forced to pay premiums without any real coverage (at least for the basic plans and high deductible plans)

    Patients in MA are flocking to neighboring states where they’d rather pay cash for health care services instead of inflated insurance prices which they have to pay out of pocket.

    Legal? Ethical? Rather not. Yet the common message is: “good luck repealing this”

    • http://Www.twitter.com/alicearobertson Alice

      The axiom…hard cases make bad law comes to mind.

  • PAULMD

    I CAN speak with utmost authority on the thoughts and wishes of THIS health care provider. Regarding reimbursements/payments, regulation, EMTALA, hospital bylaws, ACAs, PHOs, HITECH, TYPING, TYPING, TYPING, RAC BOUNTY HUNTING, TORTS….these meats grind into a sausage that I do not want.
    I will retire from medicine as soon as I can afford to.

  • Brian

    This line always amazes me:

    “Two, the government’s lack of appreciation that the U.S. is center-right not a center-left nation. ”

    Now let me understand this. Obama won 53% of the vote in 2008. This is the guy that was branded socialist etc etc.before the election Yet the majority of the country voted for him by 6%.

    And you say for sure that this is a center-right nation?

    This is the country that has Social Security still that Bush couldn’t privatize. The country that likes Medicare. The country that favors the minimum wage. That now favors gay marriage etc etc.

    Saying that the US is a center right country is a false premise. A throwaway line that makes no sense.

  • http://Www.twitter.com/alicearobertson Alice

    Brian….have you read recent stats? Our President knows how the country voted a few months ago…..we are not leftists. The President recognizes this…he is center minded.

  • SidewaysShrink

    Alice you state:
    The debate rests on human rights that are evolving as the boundaries become more broad…yet taxes cannot sustain these ideological, well intentioned, yet, intrusively legislated dreams.

    Though you are talking about the federal mandate, your philosophy does seem to capture the essence of something I have recently been thinking about that has never gained traction: means testing for Medicare or at least a lifetime or yearly deductible that wealthy seniors must spend before becoming eligible for Medicare benefits. That would save a tremendous amount of money and pump money into private insurance companies because these people are highly unlikely to ho uninsured. Also, at present the biggest loss in the Medicare system is in giveaways to Medi-gap insurance companies who provide insurance for the upper middle class and above and do nothing to contain costs.

    I enjoy hearing disparate points of view (my first degree was in philosophy) but I thought about your philosophy and from whence it springs. It seems obvious the posters here who are medical providers but if you would not take it as impertinent, was is your stakeholder role in healthcare that leads you as an individual or part of a family to feel that the competition offered by health insurance companies and the profit they make and the decisions they make to increase that profiibex going to give you better health care than the alternative. The alternative being medical providers either organizing themselves into groups or for health insurance companies to be non profit risk pools so no one person or medical practice goes under should severe illness strike. Without third party profit makers and without the government as a payer, wouldn’t you trust doctors?
    I know this idea is not discussed much but I think that is because of the demographics of many physicians who are burned out on the idiotic system and waiting to retire and of the AMAs complicity.

    • http://Www.twitter.com/alicearobertson Alice

      It seems obvious the posters here who are medical providers but if you would not take it as impertinent, was is your stakeholder role in healthcare that leads you as an individual or part of a family to feel that the competition offered by health insurance companies and the profit they make and the decisions they make to increase that profiibex going to give you better health care than the alternative. [end quote]

      Not impertinent at all…..iron sharpens iron…..I have taught debate and tend to thrive on open dialogue. I admire a well thought out difference of opinion.

      My stake in this is, obviously, patient oriented….and doctors are outnumbered on that level…and they are more educated than ever. We can meet a doctor on an intellectual level…no longer an inferior type of level that left us completely captivated by your mere presence!:). this has made your job a bit more persnickety….our expectations from you are higher….doctors feel relegated to paid help status…or maybe just a consultant. We are engaged…you do not have the authority you once had. You need insurance companies for income…you wish you didn’t. Sigh!

      My human rights opinions would be another post that goes beyond the mandates. Not sure if I should take them up privately? I think if you click on my pic my email address is there? If not: arobert6@Juno.com

  • SidewaysShrink

    But let us follow this logic of free market competition through: it was suggested that doctors are greedy for wanting to get paid easily, whereas insurance companies simply terminate a patient’s insurance that month if payment is not received. By the logic of competition, all physicians should go out of network if insurance plans do not pay promptly, do not pay well or require too much needless paperwork. After all our work generates profit for them, but we do not need them to make profit. Unfortunately people fall ill everyday. We have referral networks amongst ourselves. There is the Internet. Patients would find us. What are insurance companies doing for us? We are licensed by our state boards. We oversee ourselves. This is a thought experiment. It doesn’t mean concierge care only for the well to do. We develop risk pools that our patients would have to join for a fee. There are actuaries who could figure this out depending on the variables. Does anyone know if there are public health analysts who have floated this idea?

    • http://Www.twitter.com/alicearobertson Alice

      I, personally, do not think all doctors are greedy, but remember…I use the Cleveland Clinic…the land of salaried doctors (with bonuses), where private practice is but a memory.

      But I do believe doctors like government payments…they seem easier….but that is changing. I have read that, especially among the old, denials are higher than with insurers.

      I guess a part of me sees the auto repairman…pharmacy, etc. So grateful for insurance companies. It is their bread and butter…realizing auto repair companies do not deal with the easier government money.

      I firmly believe private enterprise improves the quality of healthcare…so with all the hair pulling-paperwork patients get better care…isn’t that why you are a doctor? To change lives? To help mankind? Isn’t that the vision?
      So the potholes of your journey are rough, no more placid smooth sailing from yesteryear…but the outcomes from your skill often border on sheer brilliance…I am grateful…..and outrageously impressed with a few of our doctors….I write them often with dramatically, inflected letters of gratitude they find entertaining.

      I really do believe the regulations and insurance problems are with ypur colleagues, not patients. If your predecessors had behaved better we would not need these far reaching regulations…same with insurers….I believe it was doctors who just denied by daughters necessary procedure I will have to put on my charge card to pay for. Doctors who work for insurers disagreed with two specialists at the Cleveland Clinic (doctors at Case Western just worked for a government panel and refused life saving procedures on those over 65 years old…my friend’s husband will now lose his leg, but the wait means the infection traveled through his body and caused a heart attack). Your colleagues at work…and for God knows what? To save a dime on a patient…while the three of them earned great income?

      Who is to blame for this bureaucratic nightmare? The root and soul were your predecessors…not patients….they were harmed….the Internet created a type of outraged patient revolution….and, ultimately…I think patients will get hurt too.

  • http://Www.twitter.com/alicearobertson Alice

    After all our work generates profit for them, but we do not need them to make profit [end quote]

    On the surface this seems disingenuous….but it *could* be true…but not a reality I want to know. I am old enough to remember catastrophic coverage….the type of care that kept you at home until you were too sick to care about the bill. Early diagnosis was almost an anomaly. Lived in the UK with socialized medicine…where my daughter could get free care…but the recently denied procedure isn’t available….I prefer to go into debt.

    I think concierge service is great for the rich….I see that as private enterprise offering a valuable service.

    Doctors depend on payments for survival…they come from taxpayers….individuals…or third party insurers.

  • SidewaysShrink

    You are right in the generational difference between myself and the physicians who have allowed things to get into this situation by not being patient advocates–at least in the hierarchy. In psychiatry, the lowest paid specialty, with specialty loans, it is impossible to accept Medicare and pay back student loans. Jalf of all insurance companies pay in that same range That is why the mean and median ages of psychiatrists are 62 and 64, according to AMA study. That means in 3-6 years there will be few psychiatrists around. I love my patients, frankly, but I challenge the idea that my duty to patients extends to poverty. Younger physicians may have little patience for the belief that we are in the same position as a 60 year old doc who never had student loans and has a house that has been paid for and a retirement waiting for him. We will likely never be in that position given how long it takes to pay back $200,000.00 while starting a family–by then my children will be starting college. FYI: most psychiatrists not only do not take Medicare, they do not take insurance. Psychiatry is mostly cash only–$250-330 per hour on the inexpensive side. So we don’t all need insurance companies.