Sunday, December 9, 2012

Physician Independence from Medicare and Obamacare: The Stubborn Facts
Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.
John Adams (1735-1826), Argument  in Defense of British Soldiers in the Boston Massacre Trials (1770)
December 9, 2012 -  I am for as much independence from government top-down control for physicians as anyone, as it pertains to Obamacare and Medicare, but we cannot ignore these stubborn facts:
·         Medicare has existed since 1965 and is wildly popular.  It will not go away, and changing it – even in such commonsensical ways as advancing the age of entry to 67 or saving it from bankruptcy or bankrupting the nation, through premium support or vouchers – will not be politically difficult. 

·         Obamacare has been the law of the land since March 2010, and many of its provisions will be implemented because of the positive Supreme Court decision on its constitutionality and President Obama’s re-election. 

·         Some of Obamacare’s provisions – such as state-run health exchanges, the Independent Payment Advisory Board, federal-run Medicaid programs, and the 2.3% tax on profits of medical devices – are vulnerable but the bulk of the law will remain intact.

·         As  the biggest payer of health care,  Medicare will continue to set the pace for change in the private sector,  and, indeed, private insurers will still follow the Medicare lead in establishing physician, hospital codes, and compliance standards.

·         Obamacare  will not cause states to secede from the Union, but the Supreme Court decision gives states the leeway to withdraw from Washington and set up  their own health exchanges.

·         Physicians still have options to minimize the impact of Obamacare, such as not seeing Medicare or Medicaid patients or participating in other federal programs – and opting for  cash-only  or concierge practices or not accepting 3rd party federal payments.
I’ve been thinking about these stubborn facts as I read David McCullough’s John Adams (Simon &Schuster, 2001). Adams played a crucial  role in the committee that edited Thomas Jefferson  drafts when he wrote the Declaration of independence.
I trust this preamble put the following  parody of the Declaration of Independence,  which I wrote  on July 4, 2012, in context.
Declaration of Professional Independence

July 4, 2012

“When in the Course of human events it becomes necessary for One Profession to dissolve political bands which have connected it with its government to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Professional Independence and Happiness — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the Profession, to alter its relationship, and to institute a new relationship, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.

Prudence, indeed, will dictate that Relationships long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by altering the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Regulations , it is their right, it is their duty, to step aside from such Government, and to provide new Guards for their future security. — Such has been the patient sufferance of this Profession; and such is now the necessity which constrains them to alter their former Relationships.

The history of the present President of the United States is a history of repeated regulations, usurpations, taxations, and penalties, all having in direct object the establishment of an Absolute Control over this Profession. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Autonomy of the Profession the most wholesome and necessary for the public good.

He has encouraged his Political Party to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to Government only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their Public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has ignored Representatives of the other political Party repeatedly, for opposing with manly firmness his invasions on the rights of the people, thus Poisoning the Political Process.

He has refused for a long time, after ignoring their desires for consultation, to cause others to be elected, whereby the Legislative Powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws for Natural Opposition; refusing to pass others to encourage their migrations of Power and Choice to Private Parties and raising the conditions of new Appropriations of Funds

He has made Judges dependent on his Will alone for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Bureaucrats, and sent hither swarms of Bureaucrats to harass our people and eat out their substance.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his Assent to their Acts of pretended Legislation:

For imposing Taxes on us without our Consent:

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. Nor have We been wanting in attentions to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity.

We, therefore, the Medical Profession of the United States of America, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That this Profession, ought to be Free and Independent, that Absolved from all Allegiance to an unjust Law, and that most political connections between Government and the Profession, is and ought to be dissolved; and that as as Free and Independent Profession, we ought have full Power over our Professional Destinies and to do all other Acts and Things which Ian ndependent Profession may of right do. — And for the support of this Declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor.”

I am not suggesting physicians abandon care for recipients of federal programs, who number over 110 million, but that physicians insist upon autonomy and relief from burdensome regulations that distract from patient care.

Tweet:  Before declaring independence from Obamacare and Medicare, physicians should consider certain stubborn facts b\that bind them to government.

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