3 reasons to be against Obamacare

If you are a staunch conservative who believes that free markets should solve health care, or that poor people should work harder and have more skin in the game, or that governments should stick to building armies, you don’t need to read this post, unless of course you enjoy being aggravated by liberals.

If you are one of the talking heads posing as a progressive, while repeating the slogans of Obamacare (e.g. no one can be denied care any longer, children under the age of 26 can stay on parents’ plans, not perfect but a good a first step, etc.), you should probably not read this either, because you are far beyond the point where independent thinking is an option.

If you are none of the above, and have a few minutes between updates on the completely irrelevant status of the Obamacare website, you may want to read on.

Obamacare strengthens Medicaid

Medicaid is the public health insurance plan for the poor. Medicaid’s continued existence is an affront to human decency. Unlike Medicare, Medicaid is administered by the states. Subject to certain minimums, the states get to decide what medical services are covered, which medications are on formulary, how much money hospitals and doctors are paid, and who is eligible for Medicaid in the state. Some states have the gall to run lottery systems for choosing the lucky poor that are covered by Medicaid, while others have first-come-first-served brief enrollment windows. States are at liberty to decide that they will not cover certain conditions and certain medications, or other therapies, not because these are medically unsound, but just because they can. People on Medicaid have a Medicaid insurance card to let every hospital and every doctor know that they are poor, and that services will be reimbursed with peanuts, if at all. Obviously, many physicians do not accept Medicaid.

Having poor people segregated in a defective insurance plan, separate and hardly equal, should be no more acceptable than any other form of segregation. Medicaid needs to be dismantled and all beneficiaries along with all the funds, including states responsibilities, should be funneled into Medicare, the federally administered insurance plan, for those who cannot, or will not, purchase private insurance. Instead, Obamacare pours billions of dollars into keeping Medicaid alive on one hand, and privatizing its operations on the other (e.g. managed care, health exchange vouchers, etc.), with a net result of transferring a few more Medicaid cents from health care delivery to private corporations.

Obamacare voucherizes health insurance

The Obamacare health insurance exchange is a marketplace where individuals and small businesses can shop for insurance plans that meet new minimum standards. The plans are sold by private insurance companies, and a formal exchange is needed because Obamacare will pay the private insurance companies a portion of the premiums. The federal subsidy, or voucher, amount is calculated based on means testing. Those who are poor (but not poor enough for Medicaid) will receive a larger voucher than those who are better off financially. This is in effect a progressively defined contribution. Let’s illustrate this with an example.

Say the Jones family, which is not completely destitute, received a $2,000 premium discount. Mrs. Jones goes and uses her brand new insurance to have a mammogram which according to the law carries no cost sharing. Say they find something that should be biopsied. This procedure is subject to the Jones family deductible. If the Joneses have the cash to pay for everything until the out-of-pocket maximum is met, Mrs. Jones will get the treatments she needs. If they don’t have the money, the story will have a different ending. So the benefits are not predefined, but the contribution is. This is the definition of a voucher.

Obviously, if this is good enough for the federal marketplace, it should be good enough for the employer sponsored group market as well. Private exchanges, where employees get a fixed voucher contribution, are already operational and will most likely flourish in the future. I haven’t heard of any pay increases for workers sent to private exchanges to “shop” for a plan that best fits their “needs.” Eventually, as the contributions fail to keep up with costs of care, all health insurance will become just catastrophic insurance. And as middle class wages keep going down the drain, catastrophic insurance premiums will inch up, because those who cannot afford routine care will be experiencing lots of catastrophes. If you want to talk about death spirals, this is a perfect time to do so.

Obamacare creates a tiered medical system

Much has been said about the transparency of the health insurance marketplace, where for the first time people can get clear information about health plan choices and make apples to apples comparisons. Well, it’s not really the first time, but it helps that plans are labeled by actuarial value, and it helps that there are navigators helping folks make sense of a very complex transaction. However, while you can get information on the costs of insurance, there is no information about the product itself. Health insurance is basically a financial arrangement for paying for health care. Health care is the actual product being bought. Unless we believe that health care is a commodity, then in order to evaluate the product, we need to know who is delivering care. I’m not sure if shoppers on the marketplace are aware of the fact that the financing instruments they are purchasing on the exchange will only work with increasingly narrower networks of health care providers.

This is similar to buying a new television set, hooking it up and finding out that it can only receive and display channels 501 through 550. You may get lucky and these are the channels you watched anyway, or maybe these are very good channels, but then again you may not be so lucky. Now, there is nothing inherently wrong with selling TV sets that have limited channels, if people want to buy them, but there is plenty wrong with purposely hiding this particular information from buyers. And there is plenty wrong with a government advertising free and discounted TVs that have bigger screens and better picture than your dinky old TV, without telling you that you may not be able to watch premium channels on many of them.

Of course, if this little marketing maneuver works on the federal exchange, it will quickly spread to the private group exchanges, and soon we will have clinics and hospitals for the well-heeled and larger institutions for the shoeless. It’s anybody’s guess where the better doctors will be found. No, not really. Narrow networks are designed by insurance companies to put pressure on physicians and hospital to lower their charges, either for the sheer privilege of being in-network, or for the additional promise of filling out all seats, with plenty stand-by customers, just in case. This is strictly about money, and has nothing to do with excellence or quality. Exclusive networks of high quality delivery systems are usually more expensive (see Kaiser plans in California).

So basically Obamacare is taking another step towards privatization of health care financing, and the inequitable distribution of resources inherent to private markets. Some conservatives became concerned that if Obamacare does not work as expected, the progressives will have a field day instituting single payer in its place. I wouldn’t worry too much, because Obamacare is great for those who extract profits from health care, and they won’t let it fail. Besides, progressives have lost their way long ago, and single payer is not in the cards for the foreseeable future. If it were, the Obamacare bureaucracy nightmare would have been replaced by folding Medicaid into Medicare, and the insurance marketplace would consist of Medicare, and its defined benefits, as the only game in town for all.

So if your beliefs are on the conservative side, you should support Obamacare. You may have to wait a few years, but it’s going where you think it should go, where the Heritage Foundation wanted it to go. If you happen to be a liberal, and feel compelled to support an embattled president, just because he is better than the alternative, remember DOMA, GLBA and PRWORA. Were you cheering for Bill back then too?

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • Cedric Dark

    Lots of sarcasm but great analysis. Politically, Obamacare sounds horrific to conservatives but it really is moving things in the direction they want. Bronze plans are essentially high-deductible health plans. The private, for-profit insurance industry is alive and well. And no one will want “government healthcare” in the form of Medicare-for-all as long as the Healthcare.gov fiasco continues.

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

      Thank you. Practically all plans come with high deductibles. Bronze plans, with a 60% actuarial value, are essentially catastrophic.
      That broken website can be easily thrown away, and I read somewhere today that insurers are asking that people are allowed to enroll directly with payers. I actually think it’s a great idea (not sure why we need to run every application through Homeland Security).
      This thing is a conservative dream come true.

      • James_04

        If people want taxpayer subsidies (welfare), it has to be run through the government. How is a private insurance company going to verify whether or not someone is eligible for welfare?

        If the government were to just hand every American they deem to be “low income” a voucher for health insurance, and tell them to spend it wherever they want, that could work. But as long as the government is handing out welfare as part of the insurance-buying process, in order to make the rates look artificially “low” (because the taxpayer is picking up most of the tab), someone has to verify that the citizens getting welfare actually qualify for welfare.

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

          Insurers can verify/calculate the subsidy, and the IRS can take care of the tax credit. I am not convinced that we need one centralized website.

          They are in fact giving people with “low income” a voucher to spend any way they want. The problem is that the voucher value needs to be calculated for each person individually. I don’t know why we can’t have a table like the one the IRS has on the back of every 1040 form and get it over with.

          • GT

            Obamacare “navigators” have been instructing people to lie on their Obamacare applications in order to scam extra taxpayer dollars out of the government. There are no checks and balances, Obama illegally changed the law so that it works on the “honor system” now. HAH!

            When you’re throwing around “free money”, you need some systems in place to keep the crooks (democrat “community organizers” and Obama-supporting insurance companies) and the entitlement junkies (“Imma get me as much as that free chit as I can!!!”) from rorting the system.

  • ninguem

    Only three, Margalit?

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

      My three :-)

  • lord acton

    “Oh what a tangled web we weave, when first we practice to deceive.” – Sir Walter Scott

  • ninguem

    If the Administration wants single-payer (they’re on record saying that), then propose single-payer and have an honest debate.

    Washington State signed up 35,000 “obamacare” people, 31,000 are Medicaid. The remaining 4,000, many benefit from a mistake in calcuation, so Washington State calculated income as monthly, Washington DC, the Feds wanted data as ANNUAL income.

    A well-to-do person making $120,000 reported a $10,000 MONTHLY income as requested by Washington State, the Feds thought that was a $10,000 ANNUAL income, and subsidized premium generously.

    So that 4,000 number will likely shrink when the sticker shock hits.

    If all we’re doing is signing up Medicaid, we didn’t need “obamacare” to do that. Just increase funding and liberalize eligibility rules. The system was already in place. Then fund from general taxation.

    Don’t pick and choose disfavored groups to tax.

    My Medical Board fees in the aggregate for all doctors in the state,are far higher than the Board’s budget. The excess goes to the State general fund.

    If you want increased coverage, then increase coverage and don’t hide the funding stream.

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

      I couldn’t agree more.

      The “public option” should have been kept and debated, instead of the completely pointless debate we did have, and the individual mandate should should have been a tax, without constitutional manipulations. And it shouldn’t have been up to the States to decide who is or isn’t eligible for Medicaid. All above the board and in the open. Transparency….

      We haven’t had a liberal administration since Josiah Bartlett on TV. A friend of mine suggested that Obamacare should be renamed to AHIPcare. I agree.

      • Cedric Dark

        Obamacare = AHIPcare. Like it.

    • James_04

      “Don’t pick and choose disfavored groups to tax.”

      Punishing their enemies and rewarding their supporters is what Team Obama is all about.

      It’s the Chicago Way.

      This was never about health care, ever. No more than Obama’s “green energy plans” (billions to his cronies like Solyndra and GE, while hobbling coal, oil and gas) were about a cleaner environment.

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

        Let me try something here, James.

        This country is at least 50% conservative, and probably more. Leaving out the lunatic fringes on both side, here is my opinion. I don’t think that conservatives are evil, uncaring, racist, or whatever else is usually thrown at them. I think conservatives must be concerned about the same things liberals are (e.g. half of babies in the US are born to mothers poor enough to need Medicaid and over 20% of our children live in poverty, and a host of other “liberal” issues). We only disagree on strategies to solve these things, and even those strategies are not a matter of principle, but more of degrees.
        We all think free markets are good solutions to many things, but not all. No conservative I know would suggest that free markets can solve security for example, or that people who never drive at night should not pay for street lights. And no conservative I know, is suggesting that we should let hungry children die. From here on, it’s just a matter of compromise, of working together to find the best way to solve things. Sometimes the conservative way will be correct and sometimes the liberal solution will be best. Historically we tried both over time. For some reason, we decided to not try anymore and be content with hurling insults in every direction. This is not going to work.
        We need to get money out of politics and push those on the fringes back where they belong on the sidelines. I think the majority of Americans can work things out together.

  • Anthony D

    What Dr.’s office wants an endless stream of patients whose insurance
    reimburses less than the cost of the service that is rendered? That is a
    recipe for bankruptcy.

    When you make the decision to become a “preferred provider” you are
    basically saying that you will take a reduction in your fee in exchange
    for the insurance company sending patients your way (by listing you as a
    preferred provider or telling patients that out of pocket expenses are
    less if you see an “in network doc”) Now it becomes a numbers game.

    If my fee is cut by 30% how many more patients do I need to see in the
    same time frame to cover the cost of running my business? This is one
    reason we spend all day waiting in the doctors office. Funny that my
    patients would never accept a 40% pay cut in their job but think that I
    should take a pay cut in mine, for helping them no less.

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

      There are plenty more reasons to not like Obamacare from a physician perspective. But we need to clarify that it’s not your patients that want you take a pay cut, it’s the insurance company – public and private. This is not good for doctors and it’s equally, if not more so, bad for patients. We need to stop fighting with each other (doctors vs. patients, specialists vs. primary care, poor vs. not so poor, etc.) and get rid of the overlords.

    • dontdoitagain

      I’m going to play devil’s advocate here and tell you why your patients may want YOU to have a cut in pay…they arrive on the bus or in their cheap car and walk past your Mercedes parked near the door with your name emblazoned upon the parking spot. (or some variation)

      Currently we have the politics of envy. Do they care if you worked at Burger King, nights, so that you could go to college? Nope, and they probably assume that your wealthy parents paid for your education. (so what if they did?) I have talked to a lot of people in the lower rungs of society (which describes me as well) and there is a pervasive air of grievance and the idea that although they never worked at their education, are perhaps hostile workers (too good for the job they do) and feel that they are absolutely entitled to a “share” in others hard work.

      They want you to suffer with them. The ACA feeds into this. Health care is a “right” and doctors, insurance companies, rich people, business owners etc. are all STEALING that right from them. It’s just not fair. It’s racist or whatever. Doctors hate poor people. I’ve heard it all.

      I hate the ACA because it’s intrusive, cumbersome and it has caused my hardly ever used insurance premiums to skyrocket for less and less care. I don’t need doctor visits covered, I need major medical. Can’t get that without the out of control premium spikes. It’s all good that I could get a “free” mammogram, but if I can’t afford follow-up, what earthly good is it?

      I have car insurance in case of a wreck. I pay for tires, oil changes and the routine maintenance. Keeps my insurance down and it does alter my behavior because if I do things like get tickets, my insurance goes up. It appears to be the opposite with health care. The routine maintenance is covered, but the “wreck” isn’t.

      • querywoman

        Most doctors just can’t get it out of the fact that they live high! It’s not our fault if they must have expensive this and that, and teeter on the edge of bankruptcy.
        Doctors do need a reliable car to get to the facilities, but that doesn’t mean a Mercedes. Nor do they have to have 5 bedroom homes with 3 baths.

  • Robert Luedecke

    The big question is, what are the characteristics of a plan the author can support. It is much easier to throw tomatoes than to propose a plan that will work.

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

      Oh, that’s really simple. Medicare for all. At least an option for anybody who wants to buy into Medicare. And by Medicare, I mean the traditional fee for service, pick your doctor, Medicare.
      I have no objection to administrative entities, like they have in some European countries, for managing the financial portion of health care, and I have no objection to supplemental, for profit, insurance for fancy elective stuff.
      Also, the way Medicare sets fee schedules today needs to change. Not in the direction of more insane regulation and dumping risk on physicians, but in a direction more similar to what the Europeans do. And by Europeans I don’t mean the UK or the formerly Communist countries in Eastern Europe. I mean the wealthy bankers in Zurich….

      Bottom line would be, tax everybody for health care, negotiate fair and fixed prices with the delivery system (and suppliers), let doctors decide how to practice medicine, let patients decide which doctors/hospitals they want to go to.

      Perhaps we could start with this being optional and instead of a mandated and inappropriate tax penalty, give people a tax credit if they buy private insurance. Try it out and see where it goes…. Can’t be much worse than what we are seeing now, can it?

      • Robert Luedecke

        You say tax everybody for healthcare. Would this be an optional tax that would not happen if you did not want to participate, or a tax for everyone?

        How would your optional system take care of the problem of those who do not have insurance who have a severe accident or illness and run up huge bills at hospitals that those of us with insurance end up paying?

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

          Tax for every one. Universal care. If you decide to get your own insurance (at least as good as the public one, so we don’t get stuck with your huge hospital bills) you get a tax credit. This should resolve your second question as well. Basically, we pay for health care, just like we pay for highways and bridges. And no, it’s not government run health care, because the delivery system is private. It’s a government run financing system.

          • Robert Luedecke

            So you don’t think some people would object to paying more taxes if they were happy with no insurance?

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

            I’m certain they will object. We all have certain things we would prefer to not spend tax money on, but we do anyway, because we are one nation, indivisible, and all that liberty and justice stuff for all….. :-)

          • Robert Luedecke

            If some would object, why is your idea better than Obamacare with its objections?

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

            Because a national program eliminates the insurance paradigm (and its costs), and because it provides the same level of care regardless of ability to pay (with obvious exceptions for the very wealthy), and because it provides freedom to pick your doctor, and because it pays fair prices for physicians’ unit of work, and because it removes much of the expensive bureaucracy and undue profit taking from the system, thus freeing plenty of resources to provide the so called best health care in the world to everybody.
            Basically, I think the notion of health insurance as a financing instrument for medical care is flawed. We just need to purchase medical care for everybody. There is no need for insurance because on a national level, we know exactly what it’s going to cost every year, so we negotiate prices, make a budget, collect taxes and just pay for it directly.
            We need to get over the belief that poor children not seeing a dentist is somehow advantageous to the “middle class”.

          • Guest

            Even countries with fully socialized medicine like the UK and Australia don’t cover routine dental care. It would break the bank.
            If there’s no repercussion to not bothering to clean your teeth, or to train your children to clean their teeth, if you feel entitled to just get yours and your children’s neglected teeth fixed up “free” every time, that’s a moral hazard issue. Most dental issues are 100% preventable.
            There has to be SOME cost associated with abject neglect of your own care, otherwise some people will NEVER bother to look after themselves and their children.
            We grew up pretty poor, and mom scared us into taking good care of our teeth by telling us that if we needed a filling, she was going to have to spend our Christmas money on it, and so we wouldn’t get presents that year.
            I don’t want my taxes to go up even more and my paycheck used to reward people for eating and drinking junk and never bothering to brush or floss.

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

            First, I think that the “richest country in the world” should be able to do better than the UK and Australia, or anybody else for that matter.

            Second, do you really think that providing small children with regular dental care creates a moral hazard? Unfortunately, we don’t get to pick our parents, so should children be penalized in order to teach parents lessons in responsibility? Is it truly in our best interest to perpetuate poverty and poor health for generations to come? Will this reduce your future tax burden?

          • querywoman

            I disagree that dental problems and/or various medical problems are 100% preventable. Some people are born with lousy calcium structures, like bones and teeth.
            Illness is part of the human condition. If prevention were better than cure and feasible, we wouldn’t need dentists and doctors.

          • Jim Miller

            Quite a lot of health problems actually CAN be prevented by exercising basic hygiene.
            And it’s true that most countries with universal healthcare don’t provide free dental care for basic things like fillings, root canals, etc. Because it would bankrupt them/. At SOME point you have to draw the line and say, hey, you need to brush your own teeth and wipe your own bot-bot.

      • querywoman

        WHOOPEE! A tax credit! Another thing to complicate an income tax return!

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

          Folks that would claim this credit, usually have an army of accountants doing their taxes. They should be fine.

          • querywoman

            Not an army of accountants doing taxes, just a drone keying it in a form on a computer. The poor will pay lots of money just so they can get their refunds faster.

      • Dorothygreen

        You confuse me – you are all over the place in in what you say. How does the Swiss system look to you? Looks like a good place to start. We do need regulations/negotiations on prices, and rates. Switzerland has worked out many points but certainly not all. I agree to get rid of Medicaid but it could be part of the not for profit insurance for basic care like Switzerland. Subsidize insurance. Let the rich, if they wish buy the supplemental insurance perks instead of paying docs for concierge medicine. The ACA does cost too much and is not comparable at this point to the Swiss system. Someone needs to do the side by side comparisons to show where the ACA is lacking. Vermont seems to have a start at some significant issues like diabetes II cost sharing. They may be in the lead to get it right.

        Maternity and pediatric care costs to those without kids pales in comparison to what we are all paying for excesses of providers and profits for insurance.

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

          The Swiss system is good and the French system is one of the best in the world. They are different in many ways, except that profiteering from disease is not allowed and all citizens are in the same system. There is no separate system for the poor. The U.S. is a much bigger and more diverse country, so I would assume that universal care here would look different too.
          We can do comparisons and analyses, and we should, but until the profit issue is resolved, and until we stop looking at health care for some citizens as if it were charity care, I doubt we can be successful.
          By the way, our so called non-profit insurers don’t fit the description very well. As to “providers”, if you mean hospitals, then yes, that’s a problem too.

          • Dorothygreen

            Right, we need to get the profiteering out of health care. That means negotiations/regulations of all players with our representative government – physicians, hospitals, labs, equipment, pharma and insurance companies. This is the only way for any country to have a universal affordable health care system”, irrespective if the government pays (more gov’t employees) or insurance pays (private sector employees)/,

            Then we can stop all this bantering and get on with the making of a healthy population by reforming our eating culture. This will reduce health care costs even more.

      • Duncan Cross

        Your OP sounds like you are against single payer, but Medicare for all would be a single-payer system. I’m not ‘for’ Obamacare, but your post seems designed to antagonize people who would support Medicare for All.

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

          With all due respect, I think you are misreading it. Not only I support Medicare for all, I support Medicare fee-for-service, pick-your-doctor, no-preauthorization-games, for all, without the profit extraction imposed by “free market”, managed care, narrow networks, Medicare Advantage schemes.
          Not only will this be better for patients, but I am convinced that it will actually be cheaper.

          • Duncan Cross

            I appreciate what you are in favor of, and I am on your side. I apparently did misread it — but it was easy to infer from your article some antagonism towards progressives: namely, this sentence: “Besides, progressives have lost their way long ago, and single payer is not in the cards for the foreseeable future.” It was not at all clear that this was something you yourself supported. Now that I know your position, it makes sense, but the first time around it was not clear what you were advocating.

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

            I’ll try harder next time, Duncan :-) Thank you.
            I just lost all faith in the Democratic party and the neo-liberal media that goes blindly with it…. I’m sorry…. Maybe Elizabeth Warren…. :-) Maybe not…. I don’t know anymore.

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

    Yes, a bit of wishful thinking on my part… :-)

  • querywoman

    I absolutely refuse to use Medicare Advantage. I need a dermatologist and an endocrinologist.
    But, this author advocated traditional Medicare.

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

    Freemium :-)

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

    Sure, I don’t expect Joe Plumber to be able to access the same level of service as Senator Rockefeller, but I do expect a very generous definition of “basic” care to include all medically appropriate services, as prescribed by Joe’s doctors without interference from accountants.

    As to the enormity of the costs, if we simplified the administrative/regulatory environment, we could save a huge bundle. Add to that the profit margins (or empire building margins of the non-profits), and we have a little more cash to play with.

    Taking money out of politics, as in campaign finance reform and reversal of Citizens United, should not be considered utopia, unless democracy itself is now an utopian term. Granted, you can’t take all money out of politics, but what we have now is preposterous.

    • C T

      “I do expect a very generous definition of “basic” care to include all medically appropriate services, as prescribed by Joe’s doctors without interference from accountants.”
      So you think that government bureaucrats will do a better than accountants? That they won’t limit doctors in their practice of medicine? You display ignorance of the practices and current financial problems faced by the UK’s NHS, which you really should not be ignorant of, considering the UK is the most like the USA (diverse, common legal and cultural background, high levels of entrenched poverty in many areas, etc.) of all the countries that have national health care. The reality of finite resources forces all kinds of restrictions on the health care services the NHS provides (or often fails to provide).
      You exhibit great naivety to think that money can be taken out of politics. Politics is all about gaining power, power to take other people’s money by taxation and regulation, and money will always be involved in it. I appreciate your desire to fix serious problems, but you appear to lack a grounding in reality.

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

        I don’t know why the NHS is always the chosen yardstick for universal care. The simple fact is that all developed countries have universal health care. All of them. And yes, all have problems juggling finances, but none have problems or expenditures as big as ours. So why not improve our situation? Should we just sit and wait for perfection to be invented elsewhere?
        Same logic for money and politics. I did acknowledge that not all money can be taken out of politics, but a large amount can and should. This is not a new problem in this country (and others), but I think it’s reaching new records in our times.
        Reality is not a static thing. Reality is meant to be changed. The only question is by whom, and I am not naive enough to be optimistic.

        • Rob Burnside

          Standing O, Margalit! Common sense at its very best. Wish you could be cloned. Don’t forget Columbus. Take heart!

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

    I understand the difficulties, and I don’t think that we can trash 17% of our economy with one legislative stroke. But we could have taken a step in the right direction. Instead of the convoluted and now backfiring strategy of tinkering with private insurance, we could have opened Medicare up a little a bit. Say, for all the folks that have preexisting conditions and those that are eligible for subsidies, and maybe those over 55. If we must subsidize, then let the subsidy flow back into Medicare. If private payers don’t want the old and sick, then let Medicare take them, and get a little cash infusion in the process. The private individual market is very small. We could have done all this without changing the rules for the group market, which does not care about preexisting conditions anyway.
    So basically, if you have insurance through your employer, great. If you don’t, and can’t afford to get insurance on your own, or are old enough, then you can get help in the public system. Pretty simple, I think….

    • Jim Miller

      “So basically, if you have insurance through your employer, great.”
      Obamacare is going to screw up that market as well, it’s just that he delayed that mandate until after the 2014 elections. Because he KNEW just how bad it would be. Because come on, if he really thought it was going to be hunky-dory, he wouldn’t have DELAYED it until his comrades in Congress got re-elected. If we were following the L-A-W LAW as it was passed, tens of millions of people who are used to getting insurance coverage through their employers would be crying too right now.
      People shouldn’t be depending on their massa to give them healthcare anyway, that’s just an antiquated holdover from the disastrous Democrat wage controls of WWII. Everyone should be in the individual market, as they are for car and home insurance.

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

        Actually, they should be crying right now, but they won’t until they have to use medical services next year. There is a shift in the employer market, starting with large employers that have lots of low wage employees, to fixed vouchers on private exchanges. Just look up Aon Hewitt and Tower Watson for example.
        Booz & Co. have a good whitepaper on this http://www.booz.com/media/file/BoozCo-Emergence-Private-Health-Insurance-Exchanges.pdf

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    My dad taught me,”I dont know what fair is… there’s no such thing as FAIR, But son, I promise you i’ll be consistent.”

    Our politicians have got to stop trying to be “fair” and start being consistent. that is the only option to return this country back toward real freedoms.

    how about this for a possible fix.

    do away with medicaid and medicare and offer a nation wide catastrophic coverage for EVERYBODY!
    pick a number… let’s say 10K. everyone is responsible for the 1st 10k of their own healthcare, after that, the government steps in with a Medicare-like coverage for the rest of the year. of course the governments care would not be preferable and people would want to avoid at all cost…

    no one goes bankrupt over healthcare.
    everyone benefits (not just winners and losers that politicians arbitrarily choose.)
    People are free to choose, take the risk and pay out of pocket for care or buy a health insurance to cover the 10K window (which would be AMAZINGLY cheap.)

    and if democrats like my arbitrary number of 10k, then fine… base it as a percentage of income.

    either way… this plan would be at least CONSISTENT, easy to administer and EVERYONE would benefit…

    the truth is that the vast majority of people would never reach the government catastrophe threshold. and if they “easily” do, then we are already paying for them now anyway….
    I can not fathom that this system would be any more expensive than the ridiculous system we have now.

    just an idea…. but not that the politicians are even listening.

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

      Great idea. I would vote for that, with the means tested amendment you suggest, of course :-)
      But this will make insurance companies shrink into irrelevance, so I am not holding my breath… It’s not the politicians per se. It’s big corporations that are driving us over the cliff.

      • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD


        I just read your most recent blog on the new SGR fix.


        and honestly… i feel asleep at the wheel and a little dazed. it sounds as this thing is real, close to being law, and close to just slipping under the radar with all the other healthcare political crap going on…. wow.

        I read the noted points and can only think… PCP killer.

        as if it wasnt bad enough for us already.

        to bad, I have been preparing myself (and my practice) to stop accepting medicare for awhile now but it is obvious that this may happen much sooner than I had thought.

        are the politicians really so clueless as to completely destroy primary care in this country??

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

          Dr. Stephens,
          It is real and lots of folks are not paying attention. The associations seem supportive in general (here is the AAFP http://www.aafp.org/news-now/opinion/20131113-sgreditorial.html ), which is beyond my comprehension.
          I think the thought process has shifted in regards to what primary care is, and it seems that private practice, particularly of the small kind, is being sacrificed on the altar of some misguided notion of efficiency (and just staying in the good graces of powers to be).
          I am not sure that politicians have an understanding of health care in general, and primary care in particular, so seeing that the associations support the concept, and are only asking for more money, may very well serve as validation.

          • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

            it depresses me.

            There is a great chasm of reality between academic/institutional vs private practice physicians.
            yet, our associations and so called thought leaders are mostly academic physicians, who for the most part have cushy jobs with “research/resident” time and most of them dont even come close to earning their own salaries within their own institutions (at least in the PCP world.)

            yet… they have the gall to claim to know whats best for physicians as a whole.

            why are more private practice physicians not more involved in associations and politics? quite simple, most are just trying to survive and keep their practices open and “aint got no time for that!”

            so that’s where we are… pushed to the corner of the room to die a slow death to the majority of the public.

            I think the train has left the station and I really see no chance of changing course. we are destined for in 5-10yrs.

            1. government subsidized mediocre care


            2. pay for what you get True private practice.

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

            Yes, this is my nightmare scenario as well. Perhaps it’s time to accept this, and concentrate on making the public/insured system be as good (and as small) as it possibly can be. Maybe, eventually, all primary care will be private, and maybe public subsidies will take the form of depositing concierge fees into an HSA or something like that. I don’t know, but at this point, if I were a primary care physician, I would strongly consider making lemonade….

    • Jim Miller

      It would be an excellent system, especially if EVERYONE were required to have some skin in the game when it came to basic for their own basic health needs.
      Some of the masses who flock to ERs with the sniffles might think twice if it COST them something.
      Expanding the number of people who get all their healthcare without paying a cent for any of it is never going to help “bend the cost curve down”.

  • Michael Wasserman

    Excellent summary!

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

      Thank you.

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

    Hi Bob, great to hear from you….
    I think I’m at a point where I want everybody to get off their barricades and come to the table, and I think most of the country wants the same thing. DC is woefully out of touch with those they are supposed to represent, and I don’t expect things to change much before two or even four election cycles. I hope the Republican party moves back to the solid center where it belongs, and in the process it pushes the Democrats a bit left to center, where I am most comfortable. We can do business then… I know this is going to sound insane, but I think we need a solid Republican president for this to happen.

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