Tuesday, May 4, 2010

Dr. Reece’s Pieces, May 4, 2010, Obamacare Mandates

Keywords - U.S. Constitution, individual rights, State rights, government mandates, Obamacare mandates, individual mandates, business mandates, physician mandates

I am not a constitutional scholar, nor am I a lawyer. But I am a student of American culture and history. As such, the Tea Party movement and other political forces asking to “Repeal and Replace”Obamacare do not surprise me.

This country rests on the concept of individual liberty. Our Constitution serves as a backstop against Big Government dictating and constraining how we live as citizens and what rules we play by. The Constitution is about individual rights as well as State Rights as checks against federal power.

As Obamacare, “The Patient Protection and Affordability Act, “ enters its implementation phase, it should surprise no one that individual citizens and State Attorney Generals are talking of “taking our country back” and of challenging the constitutionality of the health reform bill passed on March 23.

Obamanites say constitutionality is no problem, for the bill is for the common good. The so-called “mandates,”they say, are nothing more than taxes, penalties, rules, and regulations to assure compliance with federal law. Someone has to be in charge,”and that is Government with a capital “G."

But polls indicate 60% of Americans oppose Obamacare, 71% disapprove of Congress, and 58% think the country is headed in the wrong direction. Apparently, individual health care mandates do not yet translate into a federal mandate to forge ahead with reform and a massive overhaul of the private sector by government. Ordinary citizens are saying the problem with government spending is sooner or later you run out of other people’s money, namely, “their” money and the money of their children and grandchildren.

In health care, one reason behind this political malaise may be frequent use of the word “mandates.” Words mean something, and mandate means “an official command or instruction from an authority.” Mandates festoon Obamacare. When government officials say increased costs are due to a tax, or a penalty, or a regulation, and not a mandate, it’s a mandate.

• Individual mandates that citizens must buy insurance or be penalized and pursued by the IRS.

• State mandates that states must set up and pay for high risk health exchanges.

• Mandates that health plans must provide mandated federal benefits.

• Employer mandates must cover employees or result in penalties.

• Mandates on health plans, drug firms, and device manufacturers in the form of higher taxes.

• Mandates on corporations cancelling the benefits of providing drugs for retirees, raising their taxes by $350 billion, giving them cause to drop those benefits.

• Physician mandates in form of Medicare payments for doctors, mandated incentives for installing EMRs, coming mandates on what government will pay for as revealed by comparative effectiveness research, and by “quality” performance and outcomes.

Mandates, in other words, as far as the eye can see, mandates only metrics can measure, and mandates only federal authorities can dictate.

I do not question the good intentions behind these mandates. I question their limitations. The April 29 NEJM has three articles that address my point.

The first (1) says half of patients do not take their medicine as prescribed. The second (2) says half of specialists consider their practices as patient-centered medical homes and resist the idea of primary care mandated medical homes. The third (3) says specialists are not engaged by the idea of Performance as a basis for being paid.

American patients and doctors resist mandates imposed from above. This is the nature of our cultural creed, that government is best that governs least, that majority rules but temporarily, that equality of opportunity is more important than equality of outcomes.


1. D. M. Cutler and W. Everett, “Thinking outside the Pillbox- Medical Adherence as a Priority for Health Care Reform” NEJM, April 29, 2010
2. L.P. Casalino and others, “Specialty Physician Practices as Patint-Centered Medical Homes” NEJM, April 29, 2010.
3. J.O. Greenberg, J.C. Dudley, T.G. Ferris, Engaging Specialists in Performance Programs, ” NEJM, April 29, 2010.

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