Tuesday, July 12, 2016

National Health Reform: The End Game
After writing  these 250 to 400 page  books on health reform -
·         And Who Shall Care for the Sick?  The Corporate Transformation of Medicine in Minnesota (1988), 

·         A Managed Care Memoir: A Physician’s Whistle-Stop Journal : 1983-2003 (2003),  

·         Voices of Health Reform- Interviews with Health Care Stakeholders at Work: Options for Repackaging American Health Care (2005),

·         Obama, Doctors, and Health Reform: A Doctor Assesses Odds for Success: The Health System, from the Top-Down to the Bottom-Up,  As Seen Through the Lens of Complexity (2009), 

·          The Health Reform Maze; A Blueprint for Physician Practices (2011),
From these books and observations on the evolving health care reform scene I have come to this belief:   I am a pragmatic believer in  America’s pluralistic society.   For practical and pluralistic  reasons from my studies of health reform,  I am convinced  that our  various religious, ethnic, racial, and political groups should be allowed to thrive in a single society,  free of government mandates but free to choose a government option if they please.
With this conviction and my books in mind,  I envision the following  health reform end game in mind, with end game being defined as the final stage of an extended process or course of events  over the last 50 years -  stretching from the introduction of Medicare and Medicaid in 1965-1966, to the HMO Act in 1973,  to the Clintons’ failed health reform  effort in 1992, to the 2010 Patient Protection  and Affordability CareLaw in 2010.
 I  find myself asking- What’s the Health Reform  End Game? 
Where do we go from here, after most  possibilities have been exhausted?  
Do we proceed to universal health care, which liberals want but taxpayers don’t want to pay for? 
Do we choose the Medicare-for-all road,  conservatively estimated to cost $15 trillion over the next decade?  
Do we throw up our hands in despair,  repeal ObamaCare, and throw the system open to free-market competition, excluding Medicare, Medicaid, and the VA of course?  
Do we keep the good parts of ObamaCare and continue to subsidize the 20 million newly insured?  
Do we follow the Europeans and other Western nations with aging populations who no longer afford open-ended entitlement programs and open the system up to private options?
I  do not know precisely what will happen,  but  what I have observed of American culture and its response to what has occurred so far,  I  feel confident in predicting what will not happen.
As a nation, we are not going:
·         To change  these cultural values – the desire for choice of doctors and hospitals, access to the latest in medical technologies , the obsession with more Internet-generated health care information,  and reliance on medical specialists.

·         To end Medicare as we know it. If you give the matter any thought of all,  you will realize ObamaCare was a last-ditch effort to save Medicare.  Of all federal program, including Social Security,  Medicare and its little sister Medicaid, are closest to bankruptcy, and are growing the fastest – with the two now costing government over $1 trillion of the $3 trillion spent on health care.

·         To phase out Medicaid, which has expanded exponentially under ObamaCare.  It will be extended to other states, but with this caveat -  states will be granted block grants to manage the unique  needs of Medicaid  recipients  in their states.  One of four Americans will soon be in Medicaid programs.
·         To transform the various members of the Medical-Industrial Complex from for-profit organizations to not-for-profit entities.   These organizations are simply too big,  too large as employers,  and too vital for the economy ,  to be structurally changed to please government elites.      Members of the Complex include drug companies,  device manufacturers, insurers, hospitals,  integrated health companies,  physicians, and supply chain companies.

·         To subjugate doctors to the will of the government on how they should act, order tests and procedures, or be paid .    Doctors will continue to congregate in metropolitan regions, just like other professionals.   They will continue to specialize in more highly paid fields with time off for their families.   More will continue to reject  or slow acceptance of Medicare, Medicaid, and ObamaCare exchange patients,  simply because  payment schemes of these  entities do not pay for the expense of staying in business.   More physicians will leave traditional practices to enter hospital employment or cash-only practices devoid of 3rd party hassles.

·         To respond unanimously in all health care sectors  to calls for more not-for-profit integrated entities , for more Evidence-Based Medicine based on data,  for more Health Savings Accounts in which patients spend more of their own money,   for more physician and hospital pay on pay-for-performance and outcome results,  for more bundled payments  to accountable care organizations with rewards and punishments for risk-taking,  and for universal commitment and collaboration for precise technologies and genetic testing  early in life to predict and prevent later diseases.    These are noble commitments, and I applaud them,  but they will  evolve slowly.

      With the preceding thoughts and caveats in mind,  I  foresee this end game for  U.S.  health reform -  a pluralistic half-government half-market system,  with the government-side focusing on risk-based  bundled-payments, accountability, outcomes,   pay-for-performance,  and precision medicine advances,  and the market-side concentrating on profit-making from innovations,  patient-convenience,  organizational restructuring , and decentralizing of services to attract more customers. The medical-industrial complex will remain a powerful force economically.   No matter who is elected President,  I do not think we will have a Public Option.   Medicare will be incrementally reformed with advancement of entry age to 67 and lessening of benefits for the well-to-do.   The states will  be given Medicaid   block grants and be allowed to manage their Medicaid populations  given their budget constraints.   The ACA provisions  forbidding exclusion of those with pre-existing disease and young adults under their parents’ plans will be retained, and so will subsidies or some other support for those in health exchange plans.  As a political force,  physicians will become more influential because of physician shortages and demands of growing numbers of the insured.  

ut they require

government interventions and will be slow to evolve.

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