On ObamaCare Anger

Anyone can become angry – that is easy, but to be angry with the right person,  to the right degree, at the right time, for the right purpose, and in the right way – that is not easy.

Aristotle (384-324 BC)

Anger hangs heavy in the air everywhere.   Anger is behind Donald Trump’s populist movement against the establishment.   Anger dominates the presidential debate, with both sides hurling insults.  There is anger over the slow growth economy,  the worst recovery from a recession since World War II.   There is anger over the drop of median incomes.

There is even anger over ObamaCare,  supposedly a good thing since it covers 20 million uninsured Americans, bringing the rate of uninsured down from 16% to 9%.  But as a consequence,   premiums are soaring,  insurers are incurring heavy losses and are ending coverage in exchanges,  the ObamaCare exchange pool is smaller, older, and less healthy than anticipate.  Everybody seems matter than health except of course for the newly covered, who comprise 6% of the total population.

The Magnitude of Anger

If you doubt the magnitude of this anger for much of other 94% of the populace, I invite you to consider the following headlines.

·         “ObamaCare Sticker Shock: Why Average Premiums are Soaring 18% to 23% across the Country,” Wall Street Journal,  August 13-14, 2016

·         “Taxpayer Anger over ObamaCare Penalties Set to Boil Over,”  NewsMax,  February 2, 2015

·         “The Dilemma: Anger at ObamaCare; Angrier without It,” Real Clear Politics, May 10, 2015

·         “Anger over Narrow Networks, “ Politico, July 22, 2014

·         “Just How Angry is Justice Scalia over ObamaCare Ruling,”  The New Republic, June 22, 2015

·         “ObamaCare: Middle Class Anger over Sticker Shock,” Townhall,  Novemer 4, 2013

·         “ObamaCare Anger: It’s Not about Sticker Shock: It’s about Pillage and Plunder, “  Pwerline,  August 4, 2013

·         “New Health Plans Limitations Anger Enrollees,” USA Today, July 27, 2014

 

The Madded Crowd

Everybody,  right, left,  in the middle, subsidized and unsubsidized, is mad.

·         Consumers, in and out of the exchanges, who are concluding ObamaCare isn’t good value for the money,  as insurers narrow networks of doctors and hospitals and shrink drug formularies.

·         Low income citizens who don’t qualify for the exchanges. Only 2% of people earning over 400% of poverty have joined the exchanges.

·         People in 664 of America’s 3007 counties have only one insurer to turn to, making a farce of the argument that competition will lower premiums.

·         Dissenting Supreme Court judges who sought to declare  ObamaCare unconstitutional .

·         Middle class , the  young and healthy, and taxpayers , upset over redistribution policies that favor others over themselves.

·         ObamaCare progressives  and elites who are confounded at witnessing their cherished health law and compassion being challenged by the unwashed masses.

·         Insurers,  big and small, for-profit and not-for-profit, who are suffering heavy losses and bankruptcies because they are unable to predict premium levels until losses occur.

·         Physicians,  hamstrung by  punitive regulations declining reimbursements,  and rising expenses of 40% or more, often  tied to IT documentation requirements.

·         The young and healthy who are angry at the individual mandates,  its penalties, and the unaffordable policies  they are being forced to join.

·         Small and medium sized employers, burdened by more than 600 major new regulations, and feeling victimized by the employer mandate forcing them to insure employees who works more than 30 hours a  week.

 

At the Root of It All

At the root of this pervasive and widespread discontent are the realities, that modern health care in inherently expensive, that everybody wants access to the best technologies and best doctors and best hospitals,  that members of the medical industrial complex  must operate at a profit to stay in business,  that the sluggish economy is funneling more patients into state and federal safety nets, and that ObamaCare promises, that you can keep your own doctor,  health plan, and hospital while paying lower premiums are not being met.

The bottom line?   With health care, you cannot have your cake,  the best and latest in personal health care, and eat it too when the cake is smaller than anticipated , and when the eating is not a sweet as thought when the cake was baked.

 

ObamaCare in Abeyance- The Big Picture

Everybody knows ObamaCare is in a state of suspension.   Nothing much is being said about it because other issues -  Hillary Clinton’s  emails,   Donald Trump’s misstatements, the differing economic plans of the two – have taken center stage.

But everybody knows ObamaCare’s future hinges on the election.  And everybody knows on November 1, big  premium increases ranging from 10%  to 50%,  will be announced, and the fourth signup for health exchanges begins.   If not enough of the young and healthy sign on,  an ObamaCare meltdown looms,  and it will up to the new President to clean up the mess and prevent a death spiral.

The Nation’s Biggest Business

Why is ObamaCare reform so difficult?

In my opinion,  the main reason, is only partly  ideological but mostly  because health care is the nation’s biggest business, soon to consume 20% of the GNP and still relentlessly expanding.    Health care reform depends on transforming am embedded system that has grown from 5% of GNP to where it is today

In any given city,  such as New York City,  Boston, or Minneapolis,   or any given geographic region,  health care is likely to be the single biggest employer and the single biggest revenue center,  outstripping manufacturing  or service industries like finance. 

Fiendishly Complicated

Furthermore, health reform is “fiendishly complicated,” pitting the government’s bureaucracy, which cannot go out of business, and CMS against entrenched for-profit, medical industrial complex, that complicated network of physicians,  hospitals, drug companies,  chains of suppliers,  nursing and  rehabilitation facilities.

Lack  of Compromise

To complicate matters,  a spirit of compromise is lacking between the forces of government and the forces of commerce.  President Obama has mastered the art of executive actions,  and the Congress has responded in kind  with legal actions and political blockades.    Much of the political conflict  revolves around the U.S. Constitution ,  possibly the world’s  best example  of  high level compromise,  and the Constitution’s   immutability, what the founders intended,         and what flexibility and change is possible .

Unanswered Questions

Several reform questions remain unanswered.  

Does ObamaCare  increase quality?   

Do its countless regulations impair economic growth, or cripple small business startups? 

Does it contribute to exploding physician shortages? 

Who should make decisions at the point of care – government or clinicians? 

Do government reforms, aimed at using data to determine”value, ”in part by herding doctors into integrated large groups and networks, making them easier to control, work or simply make care impersonal and bureaucratic?  

Do these reform spell the death knell of autonomous private practice,  or open the flood gates for concierge and other forms of direct cash medicine? 

Can consumers afford to keep their private physicians?  

Will the present problems and the attendant frustrations cause voters to throw up their hands in despair and opt for government –controlled universal health care?

November 1 and Ensuing Three Months Will Rouse Sleeping Dogs

For now,  these questions and the other issues of health reform,  are sleeping dogs in the presidential campaign.    Premiums increases on November 1, the week before the election,  and failure to sign up enough of the young and healthy over the three months of the fourth exchange signup,  will rouse the sleeping dogs.

For Whom Does the Health Access Bell Toll?

No man is an island, entire of itself, a piece of the continent, a part of the main…I am involved in mankind; and therefore never send to know for whom the bell tolls, it tolls for thee.

John Donne (1572-1631), Devotions upon Emergent Occasion

Recently  I had a house guest a friend of my son,  who had served as an administrator for Medicaid in New York City and who now administers research funds for a New York City academic center.

He and I discussed the American health system at length.  Although we did not agree on most things,  we did agree on one subject: the problem of access – how to best provide access for whom and to whom.

A Tricky Proposition

Access to health care is a tricky proposition.  For example,  universal  insurance does not mean timely  universal access to care.  This is true because many physicians do not accept Medicare and Medicaid patients.  And even when they do, shortages of physicians leads to long waiting lines,  to postponement  of procedures from months and even years, and , in the case of the Veterans Administation death while waiting.   

Timely Access to All Not Possible

Give the lack of resources and personel,  no nation,  no matter how wealthy or well intentioned cannot  provide timely access to all of the people all of the time.   Medicare, Medicaid, the VA,   ObamaCare, and U.S, hospitals (which must accept the needy and the sick)  now theoretically provide access to roughly half of the U.S, population through a variety of programs.   Progressives insist with universal coverage and with doctors on salary in large integrated systems,  the access problem would go away.    But even when health care is declared a basic human right and everyone is under the thumb of government,  access does not go away.  

You can offer all the federal programs you want,

all the community health and Indian health clinics you want,

all the incentives you can devise to incentivize doctors to serve in underserved areas.\. 

 all the telemedicine services you can think of,  people  will seek the best care, the most advanced technologies,  the quickest access to the best doctors and best facilities  the country  has to offer. 

This is true of all developed nations, even those with guaranteed universal coverage  supported by hefty taxes and an expanding safety net.  With the Internet and the galaxy of social media outlets,  people now have the ability to seek out the best services, online and offline. 

To expand personal access and to avoid unaffordable costs,  people will frequent retail clinics,  will  indulge in self-care and alternative medicines,   will embrace probiotics and herbal remedies,  will go to the Internet to find answers, and will go to concierge private  physicians  in search of personal attention.  A third and even fourth tier of health care will involve, centered on patient engagement.

The compulsion  to provide welfare for all and sprawling bureaucracies  and countless regulations will not solve access problems.   It will simply make access more complicated.   People will seek out the best care.

 

Has the Insurance Death Spiral Gone Viral?

Aetna has joined the other five big insurers -  United Health, Anthem,   Cigna,   Humana, and Blue Cross Blue Shield – in withdrawing from  ObamaCare exchange markets.   All report billion dollar losses which they say are unsustainable and unpredictable.

The dreaded insurance death spiral has gone viral.    The big insurers are following the rule of the inevitable -  you cannot insure the sick if you don’t have a counterbalancing population of the well.

Another rule at play is:  you cannot survive as a corporation   in capitalistic society without profit, return on investment,  investors, and a healthy stock market.

A third rule is:  the compulsion to provide a comprehensive welfare state  and personal economic security as a basic right comes at a price:  erosion of profits,  slow economic growth, and economic anxiety for the middle class (“A low-Growth World: One Key to Persistent Economic Anxiety,” NYT,  August 7, 2016). 

The basic problem with ObamaCare is that its policies have proven unattractive  not only to the healthy and wealthy but to the subsidized well and chronically sick.    That’s because premiums,  deductibles, and co-pays keep going up,  as insurers try to stem their losses.   Insurer actuaries say they cannot estimate these losses because they must take on the uninsurable, those with pre-existing conditions who comprises 80% of costs (Holman Jenkins, Jr, “ObamaCare Death Spiral Update, “ WSJ, August 6-7, 2016).

There are other perversities as well. 

For consumers with no skin in the game and  no knowledge of what things costs, there is the  incentive to avail themselves of care as long as someone else is paying.    Increasingly, the only customers for ObamaCare are those who are already sick.  This is a losing game for insurers.

For physicians,  hospitals, and all those other providers,  the incentive is provide as much care as possible as long as the government is paying for it. 

For government, the incentive is to promise more care to gain  and maintain political control.   As yet, among the governing party,   there seems to be no concern for the $19 trillion deficit, which may grow to $21 trillion by the end of Obama’s term. Debt may not tarnish his legacy, for his intentions were honorable.    National debt is something best left to others to clean up.  Others  will have the unpleasant dirty  job  denying  government  benefits and rationing.   

Crooked Hillary Versus Crazy Donald

As I pondered what to title this blog, I struggled between “Trump in Mouth Disease,”  “Trump Bull in China Shop,” and “Crooked Hillary Versus Crazy Donald.”

After reading Peggy Noonan’s WSJ piece today,  “The Week They Decided He Was Crazy,” and witnessing Trump’s plunging poll numbers,   the “Crazy Donald” title won out.

Through his crazy off-beat and off-the-cuff comments on the U.S lawyer of Mexican heritage,  the Muslim Gold Star family, the “rigged” election,  attacks on potential GOP allies like Paul Ryan and John McCain,  Donald has gone off the main rail.

It is not that Trump doesn’t have enough ammo to direct at Hillary -  her untruthful remarks on the FBI director’s comments,  the disastrous foreign policy setbacks,  the ransom for hostage act,   the 1.2% GDP growth the last quarter, 94 million Americans who have dropped off the job market,  the economic  woes of the unraveling  middle class, the withdrawal  of  major insurers from health exchange markets,  the collapse of non-for-profit insurers,  decreased access to private physicians, increasingly unaffordable premiums and deductibles.

What’s gone wrong? 

 

As Peggy Noonan observes of Trump,  “He doesn’t have the skill set needed now – dicretion, carefulness, generosity, judgment… Instead he shows disrespect for supporter, and a bush-league,  pull-it-our-of-your -ear, indulge-your-emotions –attitude….Trump has made vulnerable to Democrat attacks.   “Democrats will attempt to dismantle Mr. Trump piece by piece.  He’s not just reckless, he’s ridiculous – a fraud in business, a screwball, unseasoned, uninformed ..They’’ll  try  to drive him crazy.   They’’ll  do this by misquoting him, putting a twist on what he said, and then denouncing  him.  They’’ll try to get him to whine, whinge, blow his top…They’ll play the picador tormenting the bull, goad him, weaken him, provoke an unfortunate charge.

Judging by polls this week, showing a sharp decline in Trump’s poll numbers after his unfortunate petulant remarks, the Democrats are succeeding.

Pathological Politics

The pathological national politics now  being practiced disturb me.  By “pathological “,  I mean extreme in a way that is not normal and that shows a disease or mental problem,  usually obsessive compulsive behavior. 

There’s something sick, uncivil,  pathological about what’s going on.

Obama

In the case of President Obama,  his decision to declare Donald Trump  “unfit” for the presidency  during a press conference for the leader of Singapore,  is pathological politics.   A lame duck president generally stays out of the politics of who is going to be his successor.  Not Obama.  He refuses to play the role of a lame duck.   To protect his legacy,   Obama is obsessed with declaring Trump  unstable, unpredictable,  and uninformed about the duties of a President,  why Trump  is not qualified to be President,   and what it takes to be President, which it seems, it someone who believes  in man-made  global climate change,  ObamaCare implementation,  withdrawal of the U.S. as a global economic leader, and leading from behind.

Trump

 Donald Trump is preoccupied with reacting to every criticism, no matter how trivial,  by “hitting back,”  calling Obama the “worst president ever,”  giving a litany of bad economic statistics under the Obama-Clinton team,   and calling Hillary Clinton a “pathological liar, ”   “weak,”  and lacking “energy” to do what needs to be done.    He looks upon every presidential action as a “business transaction,” or “the art of the deal”, “whether it involves defeating terrorism,   dealing with Putin, funding NATO,  or delicate diplomatic  negotiations.   Trump would be wise to focus on negative Obama economic results,  not  presidential insults.

Health Law

With the health law,   the pathology involved  concerns the power of big government and its ideas for controlling the system,   e.g.  by consolidating small practices into big practices,  herding doctors into integrated systems,   or  into  accountable care organizations, where doctors and hospitals  are rewarded or punished by  success or failure in meeting Medicare budgets for populations of patients.    If systems or ACOs are not up to snuff,  in Obama’s mind,  it is the fault of the providers,  not the omnipotent  government or its unworkable  policies.  

 Health Exchanges

Then there is the pathology of the health exchanges.   It is now glaringly apparent,   the big major for-profit  insurers -  UnitedHealth,  Humana,   Anthem, and  Cigna – cannot stay in the exchanges,  satisfy their investors, and remain profitable.    The big plans have all suffered multibillion dollar losses  because of the shortfall of the young and healthy to join the exchanges,  and the surplus of older and sicker people to sign up to take advantage of government subsidies, and then to drop out once they have been treated.   A big part of the pathology here is that insurers cannot identify in advance what persons, i.e. those with pre-existing conditions,  are likely to produce losses.   When insurers cannot predict the hazard, chance, or probability of a loss,  they are choosing not to remain  in business to please the government while losing their shirts. The insurers are not about to give government the shirt off their backs.  It is not an equitable exchange when  one side gains and the other side loses.