Repeal vs. reality.
THE ATTEMPT by House Speaker Paul Ryan and other Republicans to "repeal and replace" the Patient Protection and Affordable Care Act (ObamaCare) ran into a buzzsaw of opposition from both sides of the aisle. Most proponents of the American Health Care Act concede that the Act was "not perfect," but there is "political reality" to consider--what can make it through the congressional sausage-making machine? Already Congress is telling us the most important consideration for them: staying in power. The 2018 election will be a "bloodbath" for Republicans if a second version of AHCA is not passed--or, actually, even if another itineration is passed.
The outcome of the midterms supposedly depends on how unhappy the American people are, but the political reality is that the happiness of the donor class is far more important. Most of the donor class resides in the infamous swamp. Perhaps the best thing to say about AHCA is that it had the right enemies: the American Medical Association, big hospitals, and some big insurers (who all favor ObamaCare).
It is very difficult to take away an entitlement, and ObamaCare entitlements have had seven years to take root and spread. Coverage is not the same thing as care. Denizens of the health care swamp adroitly confuse the two. Coverage often blocks care--as with narrow networks--and inevitably drives up cost. Government cannot provide care. Increasingly, it cannot even finance care, as government at all levels are mired in deficit spending.
ObamaCare forcibly redistributes a decreasing pool of assets. Guaranteed issue (no "discrimination" against people with pre-existing conditions) is not insurance. It destroys insurance; low-risk individuals will not buy it unless forced to do so.
Ohio Gov. John Kasich said, "We cannot turn our backs on the most vulnerable. We can give them the coverage ... and make sure that we live in a country where people are going to say, 'At least somebody is looking out for me.'"
Actually, Gov. Kasich, your congressmen, the CEO of UnitedHeath Group, CareSource in Ohio (probably the chief beneficiary of Ohio's Medicaid expansion), and the AMA are not looking out for your voters--but do not mind using you to promote their own interests. The Medicaid expansion brought in far more new enrollees than the 5,500,000 predicted, including 11,500,000 able-bodied adults. Since resources for providing care were not expanded, funds are being diverted from the disabled and needy.
AHCA did not get rid of the basic flawed premises of PPACA. Arguably, it would have cemented them further--but would it have been a step in the right direction? The answer to that question ultimately depends on whether it would have permitted a free market to develop outside the comprehensive managed third-party pre-payment model. If it ever has to endure competition, that model will fail, and vast resources now diverted to the rapacious health care swamp can be freed up for actual care.
The question was--and is--not whether people will "lose coverage." According to the Congressional Budget Office analysis, most of the increase in the number of uninsured would have stemmed "from repealing the penalties associated with the individual mandate. Some of those people would choose not to have insurance because they chose to be covered by insurance under current law only to avoid paying the penalties, and some people would forgo insurance in response to higher premiums."
In other words, millions of Americans see PPACA insurance as such a bad deal you have to force them to buy it. They would choose to reject it.
There were a few good features and many bad ones in AHCA. Tax "credits" are subsidies if people do not owe taxes, but if credits refund payroll taxes, ending discrimination against people who buy their own coverage would have been a step toward fairness and freedom. The same would have held true with the liberalization of health savings accounts--especially if people have savings because they are freed from requirements to buy expensive comprehensive coverage and to pay for people who decline to purchase insurance as long as they are healthy. The AHCA penalties for failure to maintain continuous coverage--like those in Medicare Part B--would have helped to discourage system gaming. However, any credits must go to patients, not third parties, and the government needs to stop dictating the terms of voluntary insurance contracts, including premiums.
Freedom is possible only if people are responsible. The worst feature of AHCA was perpetuating the myth that "nondiscriminatory" coverage for preexistings is insurance rather than a pipe dream.
We had hopes that AHCA--if properly amended--would have been a wedge of freedom rather than a weigh station on the road to a full crony capitalistic government takeover. The ultimate goal must still be the restoration of a free market. We need to get rid of the subsidies, mandates, and regulations that feed the swamp and prop up ObamaCare. PPACA needs to die. The unshackled free market needs to kill it, before or after Congress repeals every last word.
Jane M. Orient is director of the Association of American Physicians and Surgeons, Tucson, Ariz.; president of Doctors for Disaster Preparedness; chairman of the Public Health Committee of the Pima County (Arizona) Medical Society; and author of Your Doctor Is Not In: Healthy Skepticism About National Health Care and Sapira's Art and Science of Bedside Diagnosis.
RELATED ARTICLE: Dr. Obama remains on call--for now.
Suppose you are a surgeon who is called to see a patient who is bleeding from his abdomen. You are to consider exploratory surgery to try to find the bleeding point and stop the hemorrhage. The problem is that the patient has widely metastatic cancer. He mostly has depleted the blood bank's supply of his blood type. His clotting factors have gotten so diluted that it will be hard to control bleeding from surgery. He already is on the brink of multi-organ failure. His cancer is untreatable.
Should you tell the operating room to get ready? You might have a successful surgery and keep the patient going a few months longer. Maybe the Obama Cancer Moonshot will have discovered a cure by then, but almost certainly the patient either will die on the operating table, or a few days or weeks later, during which time some alleged error or complication will have occurred--and the surgeon, without doubt, will be blamed.
So, the surgeon most likely will decide that the patient is not an operative candidate. If unwilling to say so, he might just send the patient for more tests until the inevitable makes the question of surgery moot.
The Trump Administration and the Republican Congress is faced with a crisis in the Patient Protection and Affordable Care Act. Most of the co-ops are gone. A large portion of the exchanges have only one plan to "choose" from. The money appropriated for shoring up insurance companies that experience losses is used up, and the Obama Administration's illegal attempt to take money from other sources, such as the Judgment Fund, has run into a court challenge.
The patient named PPACA has been in trouble since the beginning, but Dr. Obama unilaterally intervened to save it with exemptions for powerful players (such as some big companies and a "small business" comprised of congressional staffers) and other types of executive finesse--but now the Republicans have taken charge. They spent a long time promising, and dithering, and delaying, and gesticulating about using the power of the purse to stop this Democrat-created disaster since 2010, but now the whole health system is in trouble as PPACA tentacles are deeply entwined in it, and millions of patients are counting on PPACA health plans. Whatever Congress does will have complications, and if the replacement has Republican fingerprints--of course it will; how can it not--they will be blamed.
A number of Republican ideas were floated, and the differences among them are not trivial. Repeal the new taxes, or keep them but redistribute the takings in a different way? Restore hundreds of billions in Medicare cuts, or keep them in order to stay revenue neutral? Get rid of the individual mandate, or admit that, without increasingly heavy coercion, young and healthy people will not pay the enormous premiums needed to subsidize the chronically ill? The very popular protection for people with preexisting conditions inevitably will destroy insurance.
The Republican Congress is best advised to continue doing what it does best: keep talking. Send the patient for more tests, but the nation's economy, the medical system, and our patients have to be freed from the grip of the [Un]affordable Care Act. That monster should be left to die --of its inherent disease, which was created solely by Democrats, and now that the American Health Care Act has failed to get out of the House, perhaps it will.
Congress should do nothing. It is up to the Executive Branch to embrace its constitutional duty and stop illegal actions that have been resuscitating PPACA and permitting its cancer to spread. Those who like their ObamaCare plan should be able to keep it, but they should not be able to count on younger, healthier subscribers, or current and yet-unborn taxpayers, to pay for it. Once allowed to escape from bureaucratic restraints, most Americans will choose something better.
RELATED ARTICLE: Drain the health care swamp? Not so easy.
In his address to the Joint Session of Congress, Pres. Donald Trump called the Patient Protection and Affordable Affordable Care Act (PPACA, or ObamaCare) an "imploding disaster." His references to soaring premiums, contracting choices, and market collapse all were spot on and, of course, everybody wants "reforms that expand choice, increase access, lower costs, and at the same time, provide better health care." The President wants Americans to be able to choose "the plan they want, not the plan forced on them by the government."
However, what should he have done first and second? From a physician's perspective, first is to make the diagnosis. Second is to remove the cause of the ailment if possible, and that means to drain the swamp.
However, Trump's first was to "ensure that Americans with preexisting conditions have access to coverage" and second to "help Americans purchase their own coverage, through the use of tax credits...."
These "popular" ideas emanate from the swamp, percolating up through lobbyists, think tanks, and congressional "leadership." Correctly translated, these mean to abolish true insurance--and the only reason for buying it when healthy--and to force healthy or higher-income people to pay more than their fair share. A "refundable tax credit" is a disguised subsidy, courtesy of present and future taxpayers.
Who are the swamp dwellers? They are the ones who siphon off a huge portion of three trillion "health care" dollars--perhaps 50% or more--before it goes to anything recognizable as a medical good or service received by an actual patient. They are part of the vast growth in the number of administrators compared with physicians. They include the "nonprofit" hospitals that charge up to 10 times as much for a surgical procedure as, for instance, the Surgery Center of Oklahoma does. They include brokers who "reprice" medical bills--getting a 30% "discount" from a bill that is overpriced by a factor of two or more and pocketing a cut of the "savings." They also include the code writers, regulation writers and auditors, software and hardware vendors, and data aggregators who are selling your medical records for profit.
Denizens of the swamp are self-identifying, as in a Jan. 25 letter to Pres. Trump and Vice Pres. Mike Pence offering to help implement 'Value-based" care. The more than 120 signatories included the American Medical Association (whose main cash cow is the current procedural terminology--CPT--codes that doctors must purchase), numerous other medical trade associations (who help doctors learn how to comply with ever-changing rules), insurers, giant hospital systems, pharmaceutical companies, and self-certified "quality" agencies.
The "resources" they plan to save come from care denied to patients, and especially from the 19% of medical spending that goes to physicians' practices. Instead of paying doctors more if they work more ("fee for service") the system will pay for data collection and protocol compliance, while punishing physicians who order more tests or treatments for patients, and, of course, all those involved in determining 'Value" get paid first.
The health care planners' bane is the 10% of medical spending that goes directly from the person getting the service to the person providing it. None of this leaks into the swamp, and the value is determined by patients who presumably are too ignorant to make complex judgments.
Swamp dwellers generate reams of studies about the resources that go to actual medical care--some of which would be exposed as being of limited value if patients had to pay out-of-pocket for them voluntarily, but such studies avoid mention of the enormous resources that go to "planning," "certifying," "evaluating," "reviewing," etc--which vanish without a trace into the bureaucracy. These agencies like to conflate "care" with "coverage": care is a loss, not a profit center. Even if PPACA demands a "medical loss ratio" of 85%, that means at least 15% is diverted from actual care, and 15% of three trillion dollars is a huge amount of money. If coverage is "comprehensive," third-party managers have access to much more than they would if insurance covered only unpredictable catastrophes.
Trump needs to see through the subterfuge, and drain the third-party ("insurance") swamp before it drains the life out of American medicine.
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|Title Annotation:||Medicine & Health; American Health Care Act|
|Author:||Orient, Jane M.|
|Publication:||USA Today (Magazine)|
|Date:||May 1, 2017|
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