Saturday, August 31, 2013

Understanding Obamacare-  Premise, Promises, Consequences
Thirty one days from now,  October 1, 2013. Obamacare will enter a critical implementation phase – signing up for health exchanges.   Ninety days after that, on January 1, 2014,  the bulk of Obamacare’s other major provisions will become operational.  

It is now  three and one half years since Obamacare, aka The Patient Protection and Affordability Act, became the law of the land on March 23, 2010.   Now is a good time to review the progress of the law to date.
The  law’s premises are apparent in its title, “The Patient Protection and Affordable Care Act.”  The law was designed  to protect Americans against abuses and to make health care affordable.  To some extent,  it has achieved these goals.    It has assured coverage of those with pre-existing illnesses and young adults under 26 under their parents’ plans.   It has helped subsidize seniors falling into “donut hole.” It has made certain preventive tests “free” for Medicare patients. 

But it has fallen short on affordability. Premiums have steadily risen for most Americans.    And the overall direct and indirect costs – in taxes, penalties, and regulations – have exploded.   Over the decade of its planned implementation,  costs may be double or even triple the original cost estimate of $984 billion.   Politics is the art of reaching sustainable goals  from reasonable  premises.  In the case of Obamacare,  the premises, for the moment at least,  seem insufficient to meet the demands of universal coverage at an affordable price.
The most memorable  of Obamacare’s promises are these:   “If you want to keep your doctor, you can keep your doctor.”   “If you want to keep your health plan, you can keep your health plan.”   And, of course, there is the underlying promise that access to health care will be available to all Americans. These promises are in disarray for various reasons.    Health plans and employers are narrowing networks of doctors which they offer.    If your doctor is not in the network,  and you want to retain him/her, you will have to go “out of network” at a higher cost.  

According to the Congressional Business Office,  employers will be dropping coverage for as many as 7 million, possibly even 20 million, workers.  Older doctors are retiring or seeing fewer patients.  Others are quitting practice and going to work for hospitals.  Others are entering concierge, retainer, or cash only practices and reducing their “panels” of patients from 2000 to 500 or so.  And moe and more doctors are not accepting new Medicare or Medicaid patients.
I am reminded of the lines of  Robert Frost poem, “The woods are lovely, dark, and deep, But I have promises to keep, And miles to go before I sleep,  And miles to go before I sleep.”   The health care woods are lovely deep, dark, and complex, and President Obama has miles to go and promises to keep before his second term runs out.   The woods seem lovely when one is promising expanded coverage at reduced prices, but getting there is a long and tortuous process when you have promises to keep.
Robert Ingersoll (1833-1899), an American politician and orator, once observed, “In nature, there are neither rewards nor punishments – there are consequences.”   These consequences may be unintended and adverse, when a law affecting all Americans is passed hastily under questionable circumstances against unanimous political opposition.  The consequences are political polarization,  multiple delays,   missed deadlines,  waivers and favors for political allies,  and lack of cooperation among those whose cooperation you need to  make  the health reform law workable.  

Mitch Daniels, Indiana’s Republican governor, said it well,
Obamacare) will likely be a nightmare of missed deadlines, public confusion, inconsistent exceptions, and dashed expectations. Every claim made for the bill will be shown to be false: health costs will go up, not down; government spending and debt will go up, not down; the economy will be injured, not benefited; people in the millions will in fact lose their health insurance they have and like.”

Alienation of Allies and Potential Helpers
Governor Daniels might have added: alienation of vitally needed political allies.   American unions are up in arms at the rapid decline of the 40 hour work week and the unexpected quick replacement of full-time workers by part-time workers.   The governors and legislatures of 34 states have decided to opt out of Medicaid expansion and to leave it to the federal government to do the implementation dirty work.  The big insurers are pulling out of many state health exchanges.  The business community has responded to Obamacare uncertainties by hiring less and dropping coverage and benefits.
Tweet:  Premises, promises, and consequences of Obamacare, 3 ½ years old, are becoming apparent. The realities do not always match the rhetoric

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