Friday, July 31, 2009

Obamacare - DOA for Now

Reforming the health care system is dead. Cause of death? Blunt trauma administered not by Republicans, not even by Blue Dog Democrats, but by the green eyeshades at the Congressional Budget Office.

Conventional wisdom always makes straight-line projections. They are always wrong. Yes, Obama's aura has diminished, in part because of overweening overexposure. But by year's end he will emerge with something he can call health care reform. The Democrats in Congress will pass it because they must. Otherwise, they'll have slain their own savior in his first year in office.

Charles Krauthammer, MD, "Obamacare in Retreat", July 30, 2009

Why has Obamacare died? Everybody has their theory. I have mine. But besides my pet theory, I have questions. I wonder if the Obama team, mired in their own political mindsets and enraptured by their intellect, ever stop to ask why this death is occuring.

Did it ever occur to team Obama that,

1. 80% of the 85% of insured Americans like their private health plans and fear the public option will replace their plans.

2. Medicare does not have the skills to administer a public option, and would have to turn to the evil private plans to administer a public option.

3. To make a public option “affordable” and to control costs, government bureaucrats would have to use the same tactics now employed by private plans - risk adjustments for age and sex and barriers to expensive care and those, particularly the elderly, with costly chronic illnesses.

4. The dreaded and villainous private insurance companies, 1500 of them, employ millions of people, e.g. United Health is the biggest employer in Minnesota.

5. The American legal system is a huge driver of health system costs.

6. Statins and beta blockers have kept millions out of hospitals and have been
instrumental in dropping death rates from heart attacks from 30% to 6%.

7. America is a center right country and Americans consider themselves more conservative than liberal by a ratio of 2:1.

8. Americans cherish their health care freedoms, even when economic retrictions chain them.

9. A Medicare-for-all system would cut physician fees by 20%, would drive hundreds of thousands of them out of business and would result in massive numbers of doctors not accepting new Medicare or Medicaid patients; in other words, universal coverage with universal access might be meaningless.

10. American health care is not the same product as other countries’ health care, in that America offers prompt access to the latest technologies while other
countries ration these technologies, and therefore cost comparisons are often meaningless. Americans receive superior care, technologically.

11. The cost of medical interventions in the middle aged and early and middle old – e.g. cataracts, angioplasties, bypass surgeries, joint replacements, and diagnostic MRIs - is greater than the cost of end-of-life interventions, and accounts for much of the effective ‘health-scare” tactics, e.g. Grim Reaper Consultations, used by the political opposition.

12. Americans trust their doctors more than data-bearing Government bureaucrats when it comes to their personal health care.

13. Americans do not like government mandates on individuals or businesses that limit care, penalize them, fine them, or otherwise regiment them or restrict their freedom of choice or action.

Easy to be Cynical about American Fears of Government Health System Nirvana

It is easy to be cynical about American naivete about health care as a limited resource and about our proclivity to want everything as individuals rather than paying attention to the overall social good.

To show this side of the social, or perhaps I should say socialistic equation, here is an excerpt from Princeton economist Uwe Reinhardt's July 31 health care blog “ ‘ A Common Sense’ American Health Care Plan.” This is an example of Reinhardt’s potent combination of tongue-in-cheek and sarcastic humor.

The All-American Wish List for Health Reform

1. Only patients and their own doctors should decide what clinical response is appropriate for a given medical condition, even if that response involves unproven clinical procedures or technology.

2. Neither government bureaucrats nor private insurance bureaucrats should ever refuse to pay for whatever patients and their doctors have decided to do in response to a given medical condition. An insurer’s refusal to pay for a medical procedure is tantamount to rationing health care.

3. Rationing health care is un-American.

4. Cost-effectiveness analysis should never be the basis of any coverage decision by public or private third-party payers in health care, for to do so would put a price on human life — which, in America, unlike everywhere else, is priceless.

5. Government should not require individuals to purchase health insurance. Such a mandate would violate the constitutional rights of freedom-loving Americans.

6. Americans have a moral right to life-saving and potentially highly expensive medical care, should they fall critically ill, even if they are uninsured and could not possibly pay for that care with their own financial resources. (Why else would God have created hospitals and their emergency rooms?)

7. Government should stay out of health care. Specifically, government should not control health care prices, nor should it increase its spending on health care, which is out of control.

8. Even small reductions to the future growth of Medicare spending — called “cuts” in Washington parlance — unfairly burden the elderly, along with the doctors and hospitals that serve them and the manufacturers of health products, lest the pace of technical innovation be impaired.

For Americans, Obamacare's DOA boils down to a preference of hackles of capitalism to shackles of socialism, the devil you know tothe devil you don't know, equal opportunity to equal results, individualism to statistical averaging, homogenization, standardization, and Big Brotherism. This may be unrealistic and antithetical to theories of government cost-controls. It is an American belief system at work, and it has anti-Obama consequences.


John said...

#1 Check

#2 Then how has Medicare managed for the last forty years?

#3 I thought the "affordability" question was a matter of tax credits and subsidies for those with incomes under certain defined levels. That's a cost, of course, but not linked with risk and actuarial metrics cited.

#4 This is a valid criticism, but a public option would present a jobs program ideal for experienced insurance pros.

#5 If this is referring to tort reform, malpractice awards account for about 1% of the health care budget.

#6 Good point, but the longer people live the higher their health care costs. Same faulty logic that argues that well visits will lower costs. Not true. Those who die prematurely from untreated conditions may cost dramatically more at the end, but if they die quicker they cost less. Cold-blooded metric, I know, but I can't stand faulty reasoning even when it's not advancing my own agenda.

#7 Check. (maybe even more...)

#8 Check. As long as they never get to see the real costs, they don't care. The real cost of health care has vanished from the minds of those whose premiums are subsidized, either by Medicare or an employer. In terms of Abraham Herzberg, what once was a "motivator" has become a "hygeine" factor, like covered parking or a well-lit work area.

#9 So what happens to the "alphabet" plans once called "medigap"?
#10 American rationing takes the form of allowing a sixth of the population to remain uninsured. And anyone who imagines that group is being cared for with "prompt access to the latest technologies" is living in a fool's paradise. And why else would there be so-called "Cadillac plans?

#11 Check. However, during my last six years working in retirement communities I have seen many examples of needless suffering when palliative care was only used for a few days or weeks prior to death. Old people are not the problem. For the most part they have come to terms with their mortality. But overwhelming numbers of other family members are in denial for far too long.

#12 Check. But the PCP is becoming an endangered species. I'm not aware of any bureaucrat who is or will be in charge of anyone's medical care plan, but I am aware of the "medical home" concept which will be modeled on the old PCP concept, whereby one physician or clinic will be accountable, ombudsman-style, for patient care plans. Mayo, Geisinger, Kaiser and others are mentioned as models of efficiency and good outcomes with lower costs as a dividend.

#13 Check. I hear complaining about everything from helmet and seatbelt laws to municipal no-smoking restrictions. That's who we are. (And don't, by God, make me even think about advance directives.)

John said...

In #8 I confused Abraham Maslow and Frederick Herzberg. My bad.
I developed the idea more fully this morning in a comment at Maggie Mahar's blog.