Saturday, June 1, 2013

American Culture and Obamacare

I have been working on a new book.  Here is the frontispiece.

Title Page

American Culture and Obamacare

Caution! “Train Wreck” Approaching

Given Its Awkward Fit with American Culture, Continuing Unpopularity, the Poisonous Political Climate, Unfulfilled Promises to Date,  and Opposition of GOP Governors, Business Leaders, and Physicians,  Can and How Will Obamacare Be Implemented?

 Dedication Page

Dedication: To physicians and Americans dedicated to freedom to choosing what health care suits them, what they can afford to pay for, and how to make it sustainable for all citizens.

 Quotations Page

I just see a huge train wreck coming down.

Senator Max Baucus (D-Montana) at April 16, 2013 budget hearing in remarks to Kathleen Sibelius, HHS Secretary,  on Obamacare implementation troubles.

The road to hell is paved with good intentions.

Samuel Johnson (1709-1784), in The Life of Samuel Johnson by James Boswell

As in much of medical care, the best of intentions can go awry if the plan is not thought through or correctly executed.

David Cutler, PhD, and Leemore Dafnay, PhD,  “Designing Transparency  for Medical Care Prices,” New England Journal of Medicine, March 10, 2011

If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so weave a less arbitrary social fabric, one in which each diverse human gift will fine a fitting place.

Margaret Mead (1901-1978)

The central conservative truth is that it is culture, not politics that determines the success of a society. The central liberal truth is that politics can change a culture and save it from itself.”

Daniel Patrick Moynihan (1927-2003), American Democratic Politician



I  have been writing books on health reform for over 25  years.

·         In 1988,  in my book, And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota, I led off in this way,  I shall discuss the struggle now going on for control of health care.   This struggle is mainly between the management of corporations and physicians.  It is a struggle for power. To be effective in the marketplace, corporations have to harness physicians to corporate goals, thus creating internal disciple and compliance; to be independent professionals, physicians have to be free to choose what they want for patients.” 

In my 1988 book, I was speaking about the struggle between doctors and HMOs, who served as the 3rd party intermediaries for corporations.  Today, with advent of Obamacare in March 2010, the power struggle is on a much larger scale.  Health reform has shifted to a titanic battle between the U.S. private sector and the U.S. government.  Health care now comprises 20% of the U.S. economy.  U.S. employers who offer health coverage to 160 million Americans.  Thanks primarily to Medicare, government accounts for 50% of total health care spending.   

For context, the U.S. economy is $16 trillion. The National debt, with Medicare as the biggest driver, is $17 billion.  The debt is growing faster than the economy.  The private sector is four times larger than government (Charles Wolf, Jr, “Austerity and Stimulus – Two Misfires,” Wall Street Journal, May 22, 2013) and supplies most of the jobs for Americans.  That is why uncertainties over Obamacare and its suppressive effect on hiring and innovation are so important.  It may be the intent of Obamacare – near universal coverage – will be worth the wait, but its successful implementation remains shrouded in doubt. Given the fact that Obamacare subsidizes care for 32 million Medicaid and other previously non-paying  patients,  it is understandable that certain health sectors – hospitals,  pharmaceutical companies, and health plans – would  embrace Obamacare and Medicaid expansion.

·         In 2005, I produced another book, Voices of Health Reform” Interviews with Health Care Stakeholders at Work: Options for Repackaging American Health Care.  It consisted of 40 interviews with prominent national health leaders.  In 2005 there was much talk but little action about consumer-driven health care, as exemplified by health savings accounts with high deductibles in which consumers spend their own tax-exempt money up to the deductible with the remainder set aside for retirement.  This approach did and does not sit well with liberals, who believe government, not consumers know best.   In any event, here was my final overall conclusion:

“Our health system is a creature of our culture.  When asked what Americans believe, Gary Orren, professor  of political science at Brandeis, who polls for the New York Times and the Washington Post, said, “A good place to start is to remember we are pro-democracy and anti-government It comes down to ideas that are essentially anti-authority  and tend towards self-regulation. .  If there were an American creed, it might begin.

 - One, Government is best that governs least.

- Two, Majority rule.

- Three, equality of opportunity.
“That seems about right to me. It explains why Americans prefer local health solutions, why they reject federal government-mandated university coverage with rationing, why they feel capable of making  their own health care decisions, why they seek equal opportunity access to high technologies, why they prefer pluralistic  payment systems, and why they allow market-based and public-based institutions to co-exists and to compete.”

·         Enter Obamacare and five year period leading up to it.   From 2005 to 2010, costs were still rising, the number of uninsured were up, technologies were taking greater and greater bites of health care spending, and Medicare was clearly unsustainable.  Obama was elected in 2008, with promises to somehow enact near universal coverage.  He said he preferred a single payer system.   The Affordable Care Act, aka. Obamacare, passed on March 23 2010 under questionable circumstances – late minute Parliamentary shenanigans, the buying of votes  of three Democrat Senators with Medicaid bribes,  and most egregious of all,  passage without a single Republican vote.  That had never happened with a major legislation bill that effected every American.  The  unilateral vote poisoned the political well. This act of political arrogance caused the GOP to dig in their heels. Ever since,  Republicans  have undermined, underfunded, and criticized  Obamacare at every turn. They voted   to repeal it in one form or another 37 times in the GOP dominated House, which was elected in November 2010,  principally because of conservative and Treat Party resistance and rallying against Obamacare. 

A fog hangs over Obamacare.  The law contains  has so many moving parts that  no one really knows what implementation will entail or whether it will occur.  Polls indicate one-half of Americans do not know how it will effect  them: one-fifth think it has already been repealed  Meanwhile, businesses in 2014 with over 50 employees will face a $2000 fine for each employee not covered; the uninsured will have penalties of $95 going to $695 by 2016 if they did not buy a policy, and employers  are busily revising their business models to minimize the impact of Obamacare.

·          As of this writing, June 1, 2013, both political parties are campaigning with the outcome of November midterm elections in mind and at stake.  The IRS scandal targeting of Tea Party members and conservative groups complicates matters for Democrats.  If the GOP wins the House and Senate in 2014, Obamacare implementation will be in grave danger, even if President Obama vetoes a Congressional repeal.
It is my belief that Obamacare is in trouble  because of  four factors: 1) complexity, namely;  a health law that no one fundamentally understands, or has even read, and that means different things to different people at different times; 2)  the  four years between introduction and formal implementation which allowed opponents to undermine it at every turn; 3)  the failure during those four years to deliver on its promises – lower premiums; lower costs,  greater access, keeping your doctors and your health plan, and higher quality care;  4)  lack of economic growth and the contribution of Obamacare to lower hiring because of uncertainties about cost; and 5) the resistance of majority small and large businesses and the physician community to vague, ambiguous, and ever greater bureaucratic regulations.
American Culture and Health Reform
Every society’s cultural values shape its health system.  In America, these values are based on the belief that the U.S. is an exceptional nation – exceptional in the sense that we offer opportunities for all,  freedom to pursue those opportunities,  a belief in equal opportunities but not equal outcomes,  and a commitment that each of us should be given the opportunities to rise to our level of human potential. 
We are a democracy, but we are also a bottom-up meritocracy, not an elitist policy-making aristocracy.  This means some people rise above others, and some are more equal than others. All of these opportunity-based beliefs rest on the foundation of free enterprise freely pursued in pursuit of American dreams of happiness and individual achievement.  This book is about America – the land of high expectations.  Among these expectations is access to the best technologies medicine has to offer,   freedom from oppressive government bureaucracy, and the right to behave as one wishes, short of harming one’s fellow citizens. 
A note about this book’s organization.    The book consists of  blog posts I have written on American culture  health reform in my blog  since November 2006. These posts are arranged chronologically and are separated into three sections:  Section One, November 2007, when I began my blog, to March 2010, when the Affordable Care Act passed; Part II. March 2010 to November 2010, when a GOP house majority was elected largely because of  opposition to Obamacare, to November 2013, when President Obama was re-elected for a second term; and Part III, November 2012 to the president, when implementation of Obamacare began in earnest and concerns about its workability repeatedly surfaced.
Richard L. Reece, MD
June 1, 2013


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