History of ObamaCare

Democracy is a great word, whose history, I suppose, remains unwritten, because that history has yet to be enacted.

Walt Whitman (1819-1892), Democratic Vistas

When my history of Patient Protection and Affordable Care Act, otherwise known as ObamaCare, is written, it will consist pf 4 books.

Book 1 – The Road is Hell is Paved with Good Intentions, March 2010 to October 2013

For 1oo years, universal coverage had been the America Left’s dream. It was President Obama’s fondest dream when he took office in January 2008. He had a Democratic House and Senate, and he acted accordingly. After passing a massive $1 billion stimulus bill to save the country from a deep recession, by March 23, 2010, the Obama administration had crafted and passed ObamaCare . From the start, Americans opposed the health law by double digit margins. Not a single Republican voted for it. Over the next 4 years and 9 months, its implementation became a form of political Chinese water torture, with dribs and drabs and drops of negative daily news being dropped on the foreheads of a restrained public and a minority Republican party.

Book 2 - Broken and Misleading Promises End in Disastrous Healthcare.Gov Launch. October 1, 2013 to March 31, 2014

The second book records details of launch of healthcare.gov and the 6 month sign up of about 6.7 million people in state and federal health exchanges and Medicaid. No one knows the exact numbers of those legally enrolled . The numbers are still being disputed. But it is generally agreed the first 6 months of health care.gov created and cemented an image of the Obama administration’s incompetent management , its failure to deliver on promises of keeping your doctor and health plan and lowering costs, and misleading of the people on the consequences of the ACA.

Book 3 - End of Initial Launch to Midterm Elections. April 1, 2014 to November 4, 2014

This 7 month period was essentially a heated and partisan campaign. The 3 main issues were a stagnant economy, negative ObamaCare effects , and botched foreign affairs. Republicans focused on Obama deleterious effects – rising premiums and deductibles, plan cancellations, and the Jonathon Gruber affair. In a series of videos, recorded before academic audiences, Gruber, often referred to as “the architect” of ObamaCare, proclaimed as such by prominent Democrats and a frequent visitor to the White House, said writers of the health law obfuscated its contents and its message in order to fool “stupid” voters. Those Senators who had voted for ObamaCare in 2010 were swept out of office, and the GOP gained 8 Senate seats (soon to be 9 if Mary Landrieu loses in Louisiana) to gain control of the Senate. They also added 12 seats to their majority in the House, gained control of 31 governships, and dominated most state legislatures. Of the 50 Senators who voted for ObamaCare in 2010, 29 are now gone, and their leader, Max Baucus of Montana, is ambassador to China. The strategic plan of the GOP Congress will probably be to have a symbolic vote to repeal ObamaCare and when that is vetoed to chip away at defunding the health law and delaying its Individual and Employer Mandates.
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Book 4 - The Party’s Over, November 4, 2014 to November 4, 2016

The future of ObamaCare has yet to be played out or determined . It will feature further debate, delay, and defunding of ObamaCare, more controversy on Grubergate (Gruber is scheduled to appear before Congress on December 6, 2o14), results of the outcome of the 2nd healthcare.gov sign up from November 15 to February 15, and the decision of the Supreme Court, to be announced 0n late spring or early summer of 2015, of whether the Obama administration violated the health law by extending subsidies to 37 federal health exchanges.

Health Care Cost Squeeze

A “squeeze”, according to my dictionary, is to extract something by crushing it: for example to squeeze juice from a lemon.

For patients and doctors, this comes down to squeezing care out of the ObamaCare lemon without crushing one's budget.

The Bureau of Labor Statistics, says the middle class is caught between a rock and hard place with a lemon in-between.

The rock is stagnant income, 0.2% from 2007-2013, which is declining income when you factor in inflation.

The hard place is rising costs over that same 6 year period for these items.

1. Food at home, up 12.5%

2. Education, up 22.9%

3. Health care, up 24.2%

4. Home rent, up 26.0%

5. Health insurance, up 42.1%

6. Cellular phones, up 49.1%

7. Home internet, up 83.1%

These are basics you can’t do without in the computer era, if you want to eat, become educated, have a roof over your head, maintain your health, treat your illnesses, and remain connected in a social media world.

So what’s person to do?

If you’re a patient, how do you squeeze care out of the ObamaCare lemon, or water out of a rock in 2015.
You can:

1) Postpone or forgo care, as 1/3 of Americans are now doing (see reference #2).

2) You can go ER, be treated, and pay thousands of dollars later or try to fend off the hospital collection agency.

3) Pay increased premiums and deductibles, and co-payments, now the rule rather than the exception.

4) Go “naked,” without health insurance, trust your health holds up and no accidents occurs, and count on the Obama administration to delay penalties for 3 more years as it has proposed.

5) Sign up for the first time for a bronze, silver, bold, or platinum plan on the exchanges with the forlorn hope your plan will be affordable.

6) Don’t renew your plan by December 15, but allow the government to automatically renew it and pray you can afford the new expense of the old plan.

7) Try to qualify for Medicaid and hope your citizenship and income papers are in order and are acceptable.

8) Proceed directly to a retail clinic, walk-in clinic, or community clinic.

9) If you lucky and have an health savings account, shop multiple providers for lower costs or negotiate a lower price with your current physicians.

10) Consider going to a concierge physician or a surgeon for a direct cash or retainer transaction without insurance but with lower costs than available under your health plan.

Now comes the rock, physicians who are the bedrock of the health care system.

If you’re a physician, you can:

1) Retire early, see fewer patients, or work part-time.

2) See Medicaid or health exchange patients at a loss because these plans pay only 60% of private plans.

3) Limit Medicare patients, 65% of whom have 2 or more chronic conditions, for which Medicare pays 80% of what private plans pay.

4) Refuse to accept health exchange patients, with their low pay and heavy regulations, an option 25% of physicians have chosen.

5) Go to work for a hospital, integrated health care system, or a large medical group as a salaried employee.

6) Work harder, suck it up and accept a lower income, and a lower standard of living.

7) Become a concierge physician or a surgeon in an physician-owned ambulatory care center.

8) Remain loyal to your current patients, no matter what the economic consequences or the bureaucratic hassles, and tell them, in the words of Oliver Goldsmith (1728-1774), “I’ll be with you in the squeezing of the lemon.”

Sources

1. Ryan Knutson and Thor Francis, “Basic Costs Squeeze Families; Surging Price Tags for Health Care, Other Essentials Leave Less for Spending Elsewhere, “ Wall Street Journal, December 2, 2014.

2. Rebecca Riffkin, “More Americans Forgoing Health Care: in U.S. 33% have put off medical treatment because of costs; more put off serious conditions than non-serious; more with private insurance put off treatment in 2014 than 2013, Gallup, December 1, 2014.

Healthcare. Gov’s Small Options Program (SHOP) for Small Businesses Off to Slow Start

Profound as psychology is, it’s a knife that cuts both ways.

Dostoveski (1821-1881), The Brothers Karamasov (1879-1880)

ObamaCare has a provision known as SHOP that was designed to usher small businesses into the largest health care expansion in the history of America. That was SHOP's intent.

SHOP was a positive psychological move to bolster confidence among small businesses in the Obama administration.

This provision was reasonable. Small businesses, with less than 50 employees, and more often with less than 25 workers, are the bedrock of American capitalism and hire 54% of all Americans. But alas, the cost for small businesses for offering health insurance for employees is becoming prohibitive.

Businesses , particularly large corporations have been the main conduit to health insurance, covering more than 150 million Americans. But only half of businesses with less than 50 employees cover workers, and in those with 25 workers or less, less than one quarter of employees receive health insurance.

SHOP was to create a marketplace where small businesses could band together to offer, better, cheaper health plans with greater choice. SHOP was limited to a few exchanges in 2014, but after demonstration projects to work out glitches and kinks, SHOP is now open for business in multiple exchanges.

In 2014, only 76,000 businesses opted for SHOP, a tiny fraction of the CMS estimate that over 2 million businesses out there might sign up. This year, an even smaller fraction are signing up. We don't know how many. CMS is mum on the numbers.

Business owners cite technical problems, as well as limited choices, and difficulties for the scant numbers enrolling in the second November 15 sign on period.

The problem may be more psychological than technological. Small businesses simply don’t trust the Obama administration, not only because of disastrous 2014 launch but because of its deep-seated anti-business bias.

It’s the psychology, not the technology. Once you have lost trust, it’s hard to regain it.

Consider the Obama and Democratic business track record.

On July 13, 2012, in a campaign speech in Roanoke, Virginia, President Obama famously declared, “You didn’t built that.” He was implying government not business owners was responsible for the very existence of successful businesses.

On October 24, 2014, in a fundraiser in Boston, fellow Democrat, Hillary Clinton, his erstwhile Secretary of State and a candidate for the Presidency , pronounced “ Don’t let anybody tell you corporations and businesses create jobs.” Who does? Certainly not government, and not ObamaCare, which punishes businesses with $2000 fine for each full time worker not covered.
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In 2011 and 2012, President Obama appointed Bill Daley, mayor of Chicago, and later, Jeffery Immelt , chairman and CEO of GE, to patch up relationships and to build a laison with the business community. Both men were frustrated with micromanagement from the Obama inner circle (Valerie Jarrett, David Axelrod , and others) and from sniping liberals who felt the masses were vulnerable and helpless victims of capitalism.

The business community harbors the notion that President Obama, as a social organizer and left-of-center politician, has never run a business, and furthermore is a “lousy boss,” and “incompetent manager, “ having left a number of competent but frustrated appointees in his wake, always casting blame and never assuming responsibility for his failed policies and the stagnant economy. He discourages the XL pipeline and fracking. Both are well on the way to making the U.S. energy independent and creating hundreds of thousands of new jobs while dramatically lowering the cost of gasoline, effectively a tax cut for hard-pressed Americans.

Based on their experiences to date, uneven spikes in premiums and deductibles, higher taxes and burdensome regulations , ObamaCare and other Obama policies raise the cost of starting businesses, staying in business, and thriving in business, small businesses are not rushing into SHOP.

Rage! Towering Rage!

Rage! Rage! Rage!

You see it everywhere.

You see it in the 2010 and 2014 midterm results.

You see it in the Tea Party rebellion.

You see it in a recent Gallup poll, which showed only 27% of working class Americans, non-college educated, 65% of the population, support President Obama.

You see in the white middle class, 75% of the population, who feel they have been thrown under the economic bus.

You see it among the young and healthy , who, in the quest for equal outcomes and wealth redistribution, feel abandoned, underemployed, with a bleak future, and left to pay for the old and sick.

You see it among American blacks and other American minorities, who feel unjustly disrespected, oppressed and left out of mainstream American life.

You see it in Senator Charles Schumer’s recent speech, where he said Democrats have placed their chips on the wrong thing, health reform for the few rather than the welfare of the many.

You see it among the Republicans, who have boiled with rage since 2010 when President Obama left them out of health law negotiations and rammed the health law down their throats.

You see it among critics of American foreign policy, who are outraged by our perceived weakness and appeasement of our enemies.

Something is badly wrong here. Americans feel it in their gut. They are acting with rage towards the Washington establishment and the armies of the status quo.

They want actions, corrections, and solutions, not words to calm their collective outrage.

Poets in the past have said it best.

• Rage, rage against the dying of the night. Do not go gentle into that good night.

Dylan Thomas, Do Not Go Gentle into That Good Night, 1952).

• It looked as if a night of dark intent,

Was coming, and not only a night, an age

Someone had better be prepared for rage.

Robert Frost, Once by the Pacific, 1928

• What if the breath that kindled those grim fires,

Awaked , should blow them into sevenfold rage,

And plunge us into flames.

John Milton, Paradise Lost, 1667

GOP Lawsuit Against ObamaCare Focuses on Cost-Reductions

“In mounting the latest court challenge to the Affordable Care Act, House Republicans are focusing on a little-noticed provision of the law that offers financial assistance to low- and moderate-income people.

Robert Pear, “Suit on Health Law Puts Focus on Funding Powers,” New York Times, November 29, 2014

In April, the Supreme Court will hear the case the GOP House has lodged against the Obama administration.

Insurance companies are now reducing co-payments, deductibles and other out-of-pocket costs for some people in health plans purchased through 37 federal insurance exchanges. The federal government is reimbursing insurers for these “cost-sharing reductions.” But these reimbursements may be illegal under the wording of the health law.

In their lawsuit, House Republicans say the Obama administration required , but never sought, nor received, Congressional approval to make these payments to insurance companies nor does the Law say they can. As a result, they contend, the spending violates the Constitution, which says, “No money shall be drawn from the Treasury, but in consequence of appropriations made by law.”

Nevertheless, the administration has been making the payments, using money from a separate account established for tax refunds and tax credits.

“Under a standard insurance policy, for example, consumers might have to pay a deductible of $2,500 before the health plan starts to pay. But with cost-sharing subsidies, the deductible could be reduced to $750 or just $100. And the co-payment for a doctor’s office visit could be cut to $15 from $45.

The lawsuit, House of Representatives v. Burwell, is the latest battle in a political war over the Affordable Care Act, adopted in 2010 without any Republican votes.

Once again, President Obama, who considers himself a Constitutional scholar, has chosen to go around the GOP and the Constitution, to establish or change the law as he sees fit under his executive powers.

The House suit was filed two weeks after the Supreme Court agreed to hear a separate case challenging the tax-credit subsidies in three dozen states that rely on the federal insurance exchange.

The health care law says the tax credits shall be available to people buying insurance on an exchange “established by the state.” The Internal Revenue Service has allowed tax credits for plans bought through the federal exchange as well, saying that is what Congress intended.

The Obama administration and the IRS may have had the best of intentions, but their cost-reductions for co-payments, deductibles, and out-of-pocket expenses, may be illegal under the Constitution and wording of the Health Law.

Primary Care Pay Protocols

Our life is frittered away by detail..Simplify, simplify.

Thoreau (1817-1862), Walden

I see in the New England Journal of Medicine that Medicare proposes to pay primary care doctors by protocol (S.T. Edwards and B.E. Landon, “Medicare Chronic Care Management Payment – Payment Reform for Primary Care,” November 27, 2014). The idea is you pay doctors $40 a month for patients who have 2 or more chronic illnesses if they scrupulously follow federal protocols.

This is necessary, say CMS officials , because fee-for-service is not up to the job of offering continuous across the diagnostic, clinical, and treatment spectrum.

Or to put it in more elegantly as the NEJM authors do , “The fee-for-service system…is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medical refills, and care provided electronically or by telephone. “

“Chronic care management (CCM) is a critical step forward in recognizing the essential features of primary care – continuity, whole person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination.”

Therefore, primary care practices caring for Medicare patients with 2 or more chronic diseases expected to last last at least 12 more months that have a risk of death, decompensation or functional decline (more than 2/3s of beneficiaries) can receive a monthly fee of about $40 per patient) provided they stick to the CMS protocol.

This payment assumes the primary care physician will follow a rigid protocol ( scope of services required to bill Medicare for Chronic Care Management (CCM) services). Requirement include having an electronic health record (EHR), 24/7 communication access, a documented patient-centered plan, and a problem list, including documents outlining, expected outcome and prognosis, measurable treatment goals, symptom management plan, planned interventions, medication management plan, list of community and social services ordered, plan for directing and coordinating outside services, identifications of persons responsible for each intervention, requirements for periodic review and revision of care plan.”

In short, more paperwork, more of the government document obsession , with the thought that more documentation will improve quality and will result in a “value-oriented health system.”

In the NEJM authors' opinion, the government’s protocol is unlikely to work for a host of reasons.
I concur.

The federal Care Management protocol, with all of its folderol and additional investments required, will drive primary care doctors out of traditional practice into concierge practices, into the arms of hospitals, or into retirement.

The Devil, behind the coming failure of chronic care management (CMM) protocol, will be in the Details.

CMS would explain:

“Modern clinical protocols are needed to identify, summarize and evaluate the highest quality evidence and most current data about prevention, diagnosis, prognosis, therapy including dosage of medications, risk/benefit and cost-effectiveness. Then they must define the most important questions related to clinical practice and must identify all possible decision options and their outcomes. Some guidelines must contain decision or computation algorithms to be followed. Thus, they must integrate the identified decision points and respective courses of action with the clinical judgment and experience of practitioners. Many guidelines place are needed as the treatment alternatives to be placed into classes to help providers in deciding which treatment to use.”

To which I say, in the words of W.S. Gilbert in The Mikado, This is “merely corroborative detail, intended to give verisimilitude to an otherwise bald and unconvincing narrative.”