Emotions and Health Reform Law

A metaphysical brothel of emotions.

Arthur Koestler (1905-1983), Darkness at Noon

And so each venture

Is a new beginning, a raid on the inarticulate

With shabby equipment always deteriorating

In the general mess of imprecision of feeling

Undisciplined squads of emotion.

T.S. Eliot (1888-1965), The Quartet

ObamaCare has unleashed emotional waves– raw tides of partisanship – over national health reform. These emotions are impossible to articulate precisely. But they are there. They are powerful. They are pervasive. And they are sometimes ugly. This is not an attempt to explain these emotions, but to simply list the issues around which they swirl.

1. The unilateral clandestine passage of ObamaCare, its incomprehensible complexities, uncertainties, and consequences

2. The balance of political power between the federal government and the states

3. The redistribution of health benefits between the lower and middle classes

4. The burden of federal regulations on physicians with subsequent losses of autonomy

5. The costs of reform, higher taxes, and growing deficits

6. The ideological conflicts between the President and the Congress

7. Government competence to manage health care and implement technological solutions

8. Misunderstanding and popularity of Health Law among Americans

9. The meaning and significance of stonewalling of government scandals

10. Role of government and free markets in reforming and delivering health care.

11. Everybody must have an ObamaCare approved health plan, whether you like it or need it or not.

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Physicians’ Declaration of Independence

The idea that men are created free and equal is true and misleading; they lose their social freedom and their individual autonomy in seeking to become like each other.

David Riesman (1909-2002), The Lonely Crowd (1950)

The American Association of Physicians and Surgeons is holding their annual meeting in Charleston, South Carolina, this week. On the agenda will be talk of direct pay independent practice, a national movement towards direct pay independent practice.

Physicians are seeking autonomy, the freedom and independence to practice to do what they were trained to do, take care of patients without outside interference. Independent physicians , however, are becoming an increasingly lonely crowd with less than one third now practicing independently of large organizations. The health law calls for physicians to practice a homogenized brand of medicine, under one-size-fits-all health plans, with a standardized set of benefits.

Physicians are resisting these reform trend. They do not think one-size-fits-all, nor should it.

The new president of the American Association of Physicians and Surgeons, Richard Amerling, MD, a nephrologist from New York City, last year issued this clarion call for Physician Independence.

A Physician’s Declaration of Independence

When in the Course of Human Events, it becomes necessary for the members of a Profession to dissolve the Financial Arrangements which have connected them with Medicare, Medicaid, assorted Health Maintenance Organizations, and diverse Third Party Payers and to assume among the other Professions 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 the Physician’s primary responsibility is toward the Patient; that to assure the sanctity of this relationship, payment for service should be decided between Physician and Patient, and that, as in all transactions in a free society, this payment be mutually agreeable. Only such a Financial Arrangement will guarantee the highest level of Commitment and Service of the Physician to the Patient, restrain Outside Influence on Decision-Making, and assure that personal information be kept confidential.

The Financial Arrangements between Physicians and the Third Parties have become so destructive to the Patient-Physician relationship, and to the Medical Profession as a whole, that it is the Right, and Obligation, of the Members of the Profession to abolish them.
Prudence will dictate that arrangements long established should not be changed for light and transient causes; and accordingly all experience has shown, that Physicians are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed.

But when a long train of abuses and usurpations evinces a design to reduce them under Absolute Despotism, it is their Right; it is their Duty, to throw off such arrangements, and to provide new Guards for their future security.

Such has been the patient sufferance of the members of this Profession; and such is now the necessity that constrains them to alter their former Financial Arrangements. The history of the present system is a history of repeated injuries and usurpations, all having in direct effect the establishment of an absolute Tyranny over the Medical Profession. To prove this, let Facts be submitted to a candid world.

• The Tyranny began during the Second World War, when the Government gave tax subsidies to Employers who offered Health Insurance Benefits, thus penalizing and disenfranchising individuals.

• The Government created and subsidized the Health Maintenance Organizations---Entities designed to ration Health Care by Capitation; These incentives set Patient against Physician, thus destroying the Sacred Trust between patient and physician.

• The Government, in 1965, going far beyond its Powers as set out in the Constitution, decreed that the Poor and The Elderly should receive Health Care Benefits funded by the Taxpayer. Thus came into existence Medicaid and Medicare, massive Entitlements that are bankrupting the Federal and many State Governments.

• Alarmed by the rising Health Care prices that it had engendered, the Government set out to restrain fees to Physicians. These Price Controls increased Health Care Spending, as Volume of Services increased, and Quality decreased. No other Profession in the United States is denied the ability to raise fees to cover increasing costs of doing Business.

• The Government enacted the fraudulently named 'Health Insurance Portability and Accountability Act' (HIPAA), forcing physicians, medical offices and hospitals to spend billions to comply with its provisions, with no positive effect on either Portability or Accountability, and many negative ones, especially on privacy.

• The Government passed the Sustainable Growth Rate formula which lowers Medicare Physician Payment when total spending and volume increase, assuring a downward spiral in Payments.

• The Government and HMOs now limit fees to Physicians by "Payment for Performance," based on "Practice Guidelines." Beyond insulting our Ethic, this destroys our Professional Autonomy.

• Our Leaders compel ongoing Maintenance of Certification that costs us time and money and does not improve patient care in the Least.

• A Temporary Democrat Congress and President have conspired to completely take over all aspects of the Health Care System, with all patient encounters feeding into a National Database. The so-called Affordable Care Act forces citizens to buy expensive “insurance,” subsidizes some, massively expands the Bureaucracy, and Empowers the corrupt Internal Revenue Service to oversee Private Health Care.

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. A System whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a Free Profession.

We, therefore, the undersigned Physicians of the United States of America, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name of our Patients solemnly publish and declare, that we will withdraw our participation in all above-described Third Party Payment Systems. Henceforth and Forever, we shall agree to provide our services directly to our Patients, and be compensated directly by them, in accordance with the ancient customs of our Profession. The Patients’ medical interactions with us will remain confidential. We pledge the highest level of Service and Dedication to their Well-Being.
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.

Richard Amerling, MD, New York, NY
July, 2013

ObamaCare Triology

Every reform, however necessary, will be... carried to excess, that itself will need reform.

Samuel Taylor Coleridge (1772-1834)

I am in the midst of writing a three book summary of the history of ObamaCare.

Book One – From Enactment to Enrollment, March 2010 to October 2013

Book Two - The First Enrollment, Start to End, October 2013 to April 2014

Book Three - End of First Enrollment to Midterm Elections, April 2014 to November 2014

These books represent distinct stages in ObamaCare’s evolution – the most dramatic expansive reform of the health system in U.S. history.

No one doubts reform was needed. But how it was done – unilaterally without consulting the opposition party, which represents nearly half of the American people and 60% of the states, is open to debate.

The first book sets the stage for implementation.

The second book describes the gaffes, confusion and uncertainties of implementation.

The third book asks the question: Is ObamaCare dead or alive?


Setting aside the rhetoric about covering the uninsured as a moral imperative for a civilized nation, consider the reality that the majority of the American people, particularly the Middle Class, bear the burden of reform. From the beginning to enactment to the present, Americans have opposed ObamaCare by double digit margins(currently 13% in the average of national polls).

“ObamaCare: Dead or Alive?” is a reasonable question to ask. American democracy, after all, is based on the consent of the majority of the governed.

Who should decide, the temporary governing politic party or the majority of consumers, who reform is to be carried out?

The Muddy, Up-Hill Road for ObamaCare

Should have read that detour sign

Detour there’s a muddy road

Detour there’s a muddy road

Should have read that detour sign.

Detour, popular song, 1945

Does the road wind uphill all the way?

Yes, to the very end.

Will the day’s journey take the whole long day?

From morn to night, my friend.


Christina Rosetti (1830-1894), Up-Hill

At this point, the road ahead for ObamaCare looks muddy and up-hill.

• Midterm prospects increasingly point to a GOP takeover over of the Senate. This would not prove fatal for ObamaCare, because of Obama’s veto power. But it would be more slow-going for the health law. The President would have to compromise on certain provisions, like pulling back of penalties for businesses with 50 or more employees and repealing the 2.3% excise take on medical innovation businesses .

• The upcoming second November 15 enrollment in ObamaCare. With a Republican Senate win and a vote for repeal, the prospects for enrollment would be muddied. Obama forces hope for a 5 million enrollment on top of the 8 million sign-ups from October 1, 2013 to March 31, 2014 but that may be an up-hill struggle for several reasons: one, further confusion over healthcare.gov sign-up process, two, the short-sign period of 3 months compared to the previous sign-up period of 6 months, and wide and wild swings in premiums spikes.

• The Halig-Burwell Supreme Court decision. It is not yet known if the Court will take up the Halig matter, the controversial D.C. appeal court decision that the Obama administration could only offer subsidies to State exchanges. But if the Court were to take up the matter and to rule that the appeal court was corrent, it would be a political stake in the heart of ObamaCare a victory for the so-called Textualists, those judges who believe the words of laws, not their intentions, are sacred.

• Then there are the externalities, those events outside of ObamaCare that influence but are not directly related to the health law itself. These externalities might include a stock market downturn, collapse of President Obama’s foreign policy, racial rioting in America, a terrorist attack on American cities, a dramatic slowdown of the economy.

There is always the other possibilities – that President Obama would seek compromise and negotiations with his political opponents; that he would press for passage of the Keystone pipeline and repeal the tax on U.S. medical innovation companies, favored by both parties; that he would push for reduction of America’s corporate tax, the highest in the world; that he would further delay or even scrap ObamaCare’s individual and employer mandates; that he would authorize attacks on the Syrian headquarters of ISIS; that he would send direct military aid to the Kurds and the Ukrainians.

These things would require an ideological detour.for the President; that he would take a sharp turn to the right, and that he would seek lead from the front rather than the back, to clear the muddy road and to make its incline more downhill than uphill.

The Health Care Organizational Machine and Human Beings

View your system through the lens of complexity – Health organizations are not like a machine or military organization. Reform is about dealing with complex, often fickle, human beings.

This is not a program that you roll out in organizations with banners and coffee mugs. It is a new way of thinking and seeing the world – and, hence, a new way of working with real organizational and health care issues.

Edgeware: Insights from Complexity Science for Health Care Leaders, by Brenda Zimmerman, Curt Lindberg, and Paul Pisek, VHA, Inc, 1998

With health care organizational machines, the wheels are aligned, the gas tanks are filled, the gears are engaged, the motors hav been fine-tuned, and the GPSs are set.

The trouble is, of course, that health reform is not a machine. It involves variable, individual human beings, each with a mindset of how things ought to be done.

Nevertheless, despite the resistance of the status quo and the reluctance of human beings to change their ways of doing and thinking about things, the wheels of health reform are in motion.

The wheels are embodied in these movements.

One, the movement towards bigger, more consolidated organizations. The big are getting bigger. The bigger organizations engaged include hospitals, health plans, government, and physicians. It takes an organization to get things done. Formerly independent physicians have recognized this and forming concierge organizations to combat health reform trends.

Two, paradoxically, a movement away from centralized organizations towards smaller , independent, free standing institutions – emergency rooms, urgent care centers, surgery and diagnostic centers. The large institutions often control these free-standing entities, but the smaller entities are geographically removed from the center. The entities cater to consumers and offer convenience and easy access. They also tend to be more efficient than what takes place at bloated centers of care.

Three, again paradoxically, the movement of physicians and surgeons towards creating their own free-standing groups and diagnostic and surgery centers. These free-standing groups and centers are formed so physicians can control their own economic and clinical matters .achieve greater efficiencies, and market directly to consumers.

Four, the movement towards marketing and branding. Marketing of hospital services and physician services has become the order of the day. Hospitals tend to vigorously market their medical groups via TV and stress their high-end surgical and cancer services. Physicians may collaborate in the hospital marketing effort, but increasingly are doing so on their own.

Five, the movement towards alliances of major medical groups and cancer and orthopedic with other other hospitals. The Mayo Clinic and Sloan Kettering are spearheading these alliances.

Six, the movement towards the use of megadata to determine treatment approaches and to improve outcomes rather than intuitive and clinical experience at the point of care. This is a quantitative rather than a qualitative mindset. It is a spin off the expression, “In God we trust, all others use data.” It is often expressed at value-based or evidence-based care as opposed to volume-based or empirically-based care.

ObamaCare Chain of Events Affecting Health Care Premiums

Chain of events is a number of actions that are contiguous and linked together.

Definition, Chain of events

In writing about ObamaCare, it is important to recognize that one thing leads to another.

The health law and the health exchanges have created a chain reaction:

• The older and sicker enrolled at the cost of the younger and healthier.

• The law’s one-size-fits-all coverage accepted all comers and prohibited questions about health status.

• These two factors created financial winners (the poor and the sick and hospitals) and financial losers (the older, the healthier, and the health plans).

• The health plans, anticipating losses, did two things: they struck a deal with government to bail them out against losses, and raised premiums for much of the middle class and most of the small group or individual markets.

• The government, to prevent heavy losses, priced premiums for health exchange plans, at Medicare or Medicaid levels well below private rates.

• Many physicians and physician groups, leery of government pricing, declined to accept members of the new health exchange plans; and health plans narrowed physician choice, by not accepting physicians with histories of charging higher rates: both events aggravated the already existing physician shortage.

• Many consumers, perhaps one of five, decided to go without health plans, and an estimated one of ten physicians began to abandon traditional practices for direct pay independent practices without third party coverage or to accept cash in addition to insurance.

• Some consumers elected to go directly to direct pay physicians because of lower rates, quick access, and absence of bureaucratic controls.

• ObamaCare enrollment in 2014 and anticipated enrollment in 2015 and beyond was projected to be 26 million by 2016.


• Health care premiums rose at an accelerated, but variable rates, throughout the land, along with the cost of businesses for covering them, more patients enrolled or were dumped into Medicaid, which grew at 15% or more a year.

• The insurance industry, at the request of consumers who could not afford higher rates and higher deductibles, began to rapidly offer more policies to supplement its health policies. The commercial insurance industry started to mimic Medicare, with its robust supplement policies offered through AARP and others.

• Businesses, which had previously insured 150 million workers, began to either cease coverage or minimize benefits, to cut losses, stay profitable, and satisfy investors.

In the words of a sage, “ You can never tell what will happen, with one thing always leading to another.”