The Obama Stigma and Dogma

Any stigma will do to beat a dogma.

Phillip Guedalla (1889-1944), British barrister and popular writer

GOP attack ads on ObamaCare,  38,000 of them,  are taking their toll.  In poor states,  in Appalachia and elsewhere, generally in the South,  people are not signing up for private plans on the health exchanges. (Jackie Calmes,  “In Poorer States, Political Stigma Is Depressing Participation in Health Law, “ New York Times, April 26, 2014).

The Obama administration and Democratic candidates for Congress are being stigmatized by the Republican attack ad campaign.   Of  38,000 GOP ads so  far,  76% have been negative about ObamaCare.   The ads say costs are up, healthcare.gov is a disaster,  premiums are deductibles are out of sight,  people are losing their health plans,  businesses aren’t hiring,  new workers are mostly part-time,  doctors are hard to find, economic growth is stagnant – all because of ObamaCare.

In poorer states,  especially in a state like West Virginia,  the GOP  bad news stigma appears to be beating the Democratic good news dogma.  That dogma says the law is bringing down overall costs, the number of uninsured is dropping,  minorities and the poor are finally getting coverage,  ads paid for by those evil Koch brothers in undermining the good things inherent in  ObamaCare, and all those those  negative stories about plans being cancelled are either concocted anecdotes or outright lies.

According to the Times writer,  the failure of good news to beat bad news is due to a combination of factors – unremitting hatred for President Obama, unfamiliarity with insurance, computer illiteracy,  lack of cultural sophistication,  misunderstanding  about costs and subsidies,   and, by implication,  sheer ignorance of what ObamaCare brings to the health care table.

How are Democrats reacting to this bad news-good new, this stigma-dogma imbroglio? 

By not talking about it.  
 

 In 50 Democrat candidates websites, only  11 mention the law by name, and half don’t mention it at all.  Among Democrat senate candidates, 14 of 20 avoid the subject altogether.

Not bringing up the subject makes sense when you consider that in 458 national polls since 2009, 95.5%  say they don’t like the law,  65.3% by double digit margins,  and when you take these factors into account:

·         A health law that requires 2700 pages to explain may be inexplicable.

·         A health law that requires 10,535 pages and 1.15 million  words  to enforce  its new regulations may be unenforceable.

·         A health law that requires $2.5 trillion over 10 years to implement (OMB estimate) may be unaffordable.

Tweet:   ObamaCare stigma,  as portrayed by the GOP,  may, in the public's  mind,  outweigh  benefits described by Obama dogma.

**( If you wish to comment, email me at doctor.reece@gmail.com or call me 1-860-395-1501.  I am available for writing columns or commentary and for speaking engagements.)

Delay in Pre-Existing Insurance Plan: The Crown Jewel of ObamaCare**

The most prized asset of an organization or political group

Crown  Jewel Definition

The Obama administration has stopped taking applications for its Pre-Existing Condition Insurance Plan (PCIP),  the crown jewel of ObamaCare, for 30 more days,  due to lack of funding.   

 To date,  PCIP has served 135,000 people.    PCIP joins other ObamaCare delays:   the employer mandate, delayed until 2015,  delays of caps of out-of-pocket spending,  delays on penalties for those whose plans have been cancelled.

Is nothing sacred with the health law?   This is only one of more than 30 changes the administration has made in the law.  But this change may be the most telling.   From the beginning,  insurers were made the scapegoat for denying policies  for  Americans suffering from pre-existing conditions.    The numbers said to suffering from these conditions were said to be 135 million.   But it was never clear how many of these 135 million  had actually ever been denied coverage, and it was never clear how much this provision would drive up premiums.

But one thing was abundantly clear.   Removal of insurers’ ability to deny coverage for pre-existing conditions was immensely politically popular.  It was always the first explanation out of the chute when justifying ObamaCare.  Even Republicans embraced it,  saying they would keep the PCIP provision  even if ObamaCare were replaced or repealed.    Denial of coverage for PCIP simply appealed to the Americans sense of fairness on all sides  of the political aisle.   

But PCIP may be one of those issues that really  has little to do with health reform costs, but everything to do with political palatability.

Tweet: The Obama administration has delayed for 30 days applications for Pre-Existing Condition Insurance,  ObamaCare’s crown jewel.

**(If you wish to comment or need more information,  email me at doctor.reece@gmail.com, or call me at 1-860-395-1501.  I am available for writing columns or articles  and for speaking engagements.   I would be happy to publish your comments on my blog, which is currently getting 4000 to 6000 page views each day.)

If Not ObamaCare, What Next?**

When we look at revolution, we find outward acts against the old order are invariably proceeded by the disintegration of inward allegiances and loyalities.  The image of kings topple before their thrones do.

Peter L. Berger (born 1929),  American Sociologist,Invitation to Sociology

Next: The New New Thing

Michael Lewis ((born 1960),  American financial journalist, Title  of his 2001 book,  W.W. Norton. Inc.

It may be that government and health plans are about to be partially replaced by independent direct contracting between patients and doctors and between self-funded corporations  and doctors.

“Next” is a powerful word, a forerunner and a forewarning  of  an incoming wave of what  comes next.  What comes next may be direct contracting in health care while cutting out government and health plan middlemen for outpatient  primary care and specialty care contracting.

This is happening because American people and their doctors are unhappy with ObamaCare.   In 458 ObamaCare polls since 2009,  95.5% of people oppose he health law, 65.3% by double digit margins.   About 60% of physicians oppose the law, and 90% are advising their children and other young people not to enter the profession.

But if ObamaCare falls or falters badly, what’s next?  What’s the next health care frontier?  What’s next?

·         An ObamaCare fix – keeping the good, throwing out the bad?

·         A GOP marketplace- based  alternative plan?

·         A blend of government regulations and market regulations?

What is the next  incoming wave?  

It may be patients and and businesses contracting directly with direct independent  primary and specialty practices, acting in tandem, to reduce costs, increase convenience, reduce complexity  and bureaucratic impediments,  and make health care more personal,  by cutting out 3^rd party middlemen for routine primary care and specialty care outside of hospitals.   In hospitals,  catastrophic insurance-mediated care will likely remain intact.

Primary care, routine 0ffice-based care outside of hospital and specialty care, comprises only 6% of total health costs, but is important because it is where most health problems can be first most efficiently addressed and  because it serves at the gateway to hospital and specialty care.

Specialty care, in offices, ambulatory surgery centers, hospitals, and after-care facilities and nursing  make up roughly 50% to 60% of total costs, when one factors in associated hospital and followup care.

Management, regulation, and compliance costs , through government and public insurers, contributes  30% to 40% of  total costs.  No one knows precisely how much.

But physicians know this -  50% to 60% of their overhead can be traced to regulation and compliance issues and to their  costs  contributing  to doing business.   And major self-funded corporations know that costs of  direct contracting  for procedures like hip and knee replacements offer  dramatically  lower costs than those costs done through insurers. 

And doctors and specialists are keenly aware that the cost of going through insurers or Medicare or Medicaid programs consumes 25% or more of their time – time that would be better spent spending time with patients, diagnosing, listening, and treating them rather being parked behind a computer, hiring scribes to enter data for them, or on the phone pleading for authorization.

Direct pay independent practice, is, well, more direct and less costly, not only in terms of  money but in more personal relationships.

**(If you wish to comment or need more information,  email me at doctor.reece@gmail.com, or call me at 1-860-395-1501.  I am available for writing columns or articles  and for speaking engagements.   I would be happy to publish your comments on my blog, which is currently getting 4000 to 6000 page views each day.)

Tweet:  The next wave of the health care revolution may be direct patient contracting between patients,  self-funded businesses, and primary care and specialty doctors.

The Unaccountable Care Act**

The Other Stealthy ObamaCare  Menace: The Center for Medicare and Medicaid Innovation Exists to Impose Price Controls and Limit Payments To Providers

Title of OP-Ed article,  by Lanhee Chen and James Capretta,  Wall Street Journal, April 23, 2014

Another title for the health law, other than “The Patient Protection and Affordable  Care Act, “ might be “The Provider Rationing  and Unaccountable Care Act.”

As  Lanhee Chen of the Hoover Institution and James Capretta of the American Enterprise Institute observe:

“The Affordable Care Act’s Independent Payment Advisory Board  has been so heavily criticized for being an unaccountable body with the power to effectively ration Medicare services that many congressional Democrats no longer support it.”

It is unaccountable for good reason.   The Independent Advisory Board and its bureaucratic cousin, the Center for Medicare and Medicaid Innovation – never has to go back to Congress to get an appropriation.  ObamaCare  gave it $10 billion , upfront, to cover its first 10 years, and after that, it can get another $10 billion – no questions asked.  Meanwhile it will grow from its initial 68 employees to 440 full time workers by 2015.

And what has the Independent Advisory  Board (IPA) and the Center for Medicare and Medicaid Innovation  (CMMI) done to justify this lavish expenditure?

The IPA has done nothing.  Its so-called 15 “experts,” who were to be charged with the duty of limiting hospital and physician reimbursements, have yet to be appointed.

The CMMI has been busy promoting  Accountable Care Organizations (ACOs),  herding doctors into hospital-physician organizations to “save” Medicare and Medicaid money,   talking about “bundling” hospital-physician services,  and engaging in slashing  payments to Medicare Advantage plans, to which 30% of Medicare recipients belong.    

The IPA-CMMI agency’s mindset is that the federal government is best positioned to lead a medical innovation effort through demonstration projects.

At this effort,  it will surely fail.     As I pointed out in my book The Health Reform Maze: A Blueprint for Physician Practices (Greenbranch Publishing, 2010), government is poor at innovation.

Why?

·          It cannot manage failure.

·         It  seldom abandons a project.

·         It is not gambling with its own money.

·         Its success is measured with good intentions, not results.

·         It succeeds by growing too big to fail and too influential to stop.

·         It cannot go out of business, can print money to keep going, and is propped up by taxpayer money, and does not understand risk - the basis of American capitalism.”

To this list I would add,  government  is secretive,can hide behind its bureaucratic shield  and its media protectors. 

Innovation comes in many forms- electronic, organizational. communicative , and technological.  Lately, social networking through Twitter, Facebook, and  YouTube have gotten the greatest play. Government is not destined to win any innovation honors.   Paradoxically,  at least in the government’s eyes, only deregulation and  market-competition,  which  government elites abhor, not  bureaucratic micromanagement, will achieve what government says it wants to happen.

Tweet:  2 government agencies, Independent Payment Advisory Board and  Center of Medicare and Medicaid Innovation,  will fail to contain costs or to innovate.

**(If you wish to comment or need more information,  email me at doctor.reece@gmail.com, or call me at 1-860-395-1501.  I am available for writing columns or articles  and for speaking engagements.   I would be happy to publish your comments on my blog, which is currently getting 4000 to 6000 page views each day.)