ObamaCare Preserved; Medicine Pickled; Democrats Gleeful; Republicans Relieved

ObamaCare Preserved;
Medicine Pickled; Democrats Gleeful; Republicans Relieved


Leonard Zwelling

         Exactly as predicted by your favorite blogger, the Supreme
Court ruled 6 to 3 that Obama Care will stand. What they really said was that
the federal exchanges established for the purchase of health insurance because
many states would not establish their own exchanges, have the same standing
with the IRS as the state exchanges in that those earning between 100 and 400%
of the federal poverty line will qualify for premium subsidies as tax credits regardless of
which exchange they bought their new policies on.

         This is essentially a victory for sanity and certainly for
President Obama.

         It is also a victory for the insurance industry that might
have lost 6.4 million new customers who could no longer afford its product
(doesn’t that say something about its pricing) if the subsidies defraying the
cost of insurance acquired in federal exchanges disappeared. That would also
undermine the mandate to buy insurance which is negated if the cost rises above
8% of someone’s income, which it would have.

         So Obama Care with its guaranteed insurability, community
rating, mandate to buy insurance, subsidies for many Americans (about 87% of
those purchasing coverage in the exchanges) and the computerized exchanges themselves,
is preserved. There is now a question of whether any state need bother with
having its own exchange.

         None of this will save medicine.

         Health care costs, while accelerating less steeply than
previously, are still going up faster than inflation. Quality is an
unmeasurable commodity that everyone claims he or she has and no one can really
prove what it is or how much of it they’ve got.

         Doctors are retiring faster. The recent survey results from
the Physicians Foundation (http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf) indicates doctors are less content with their
profession and surely are limiting access to their practices depending on
patients’ ability to pay. This suggests that certain forms of insurance,
especially Medicaid, are less welcome and that access to insurance is not
access to health care at all, something the President of United States doesn’t
quite grasp. Expanding Medicaid in a state, even if the cost is defrayed by the
federal government, won’t yield more care if the doctors refuse to see the
patients, which is their right.

         The ACA may have given more people access to insurance, but
insurance isn’t health care. Whether the overall health of the nation is altered
by the ACA remains to be seen.

         The Democrats are gleefully giddy with triumph that their
President’s most critical legislative achievement is preserved. They shouldn’t
be. Given the manner in which this legislation came to be, its flouting of
regular order in both houses of Congress (see my book), and its truly
remarkably poor rollout, the ACA has yet to prove its merits and the Democrats
should be a bit more circumspect in “victory” given this victory has since cost
them control of both the House and the Senate. Obamacare will be an issue in
the 2016 Presidential contest.

         The Republicans, however, are giddy in defeat. Why? If the ACA
had been overturned by the Court, the GOP as the leaders of the Congress would
have had to devise a plan to either get subsidies to the 6.4 million who would
have lost them, and with them their newly acquired health insurance, or come up
with an entirely new health reform framework. They didn’t have the money to do
the former as they have flushed that down the toilets of Iraq, Afghanistan and
the $600 Defense Department commode seats. If they could have done the latter,
they would have 5 years ago. They had no health care reform ideas then and they
have none now.

         So everyone is happy with Chief Justice Roberts and
Associate Justice Kennedy for saving ObamaCare. The doctors are still deeply
troubled by what has happened to their profession. They needn’t be troubled.
It’s their fault for sitting on the sidelines when Obama Care was being brewed.
They too need a better plan, but it will have to be one with smaller houses,
smaller cars and less pricey suits for the docs. I know, I know. It kills me,
too, but that’s life for doctors in the rest of the civilized world and
undoubtedly will be for all but the best of Hollywood plastic surgeons soon
enough. Why do you think half the docs don’t want their kids to go into

         The Dems may be dancing around the May pole in June, but
they still have not really addressed the rising cost and sinking quality that
plagues medicine due to over use of technology and under use of judgment, particularly in the care of the elderly, infirm and dying. How about we provide them real humane
care consistent with what they want instead of more CAT scans on the ICU?

         The GOP will go on bitching about the ACA and run on it in
2016. They may be surprised to learn that more people actually like Obama Care
than don’t because on the whole, it was a net plus, even if just by a hair.

         Once again the Congress made a mess, the President lied
(“you can keep what you’ve got”—NOT) and the Supreme Court saved them all.
Chief Justice Roberts may be getting tired of being Superman to the Obama
Administration’s Lois Lane.

         Me? I’ll just be Jimmy Olsen and write about it. It is much
safer on the sidelines.

4 thoughts on “ObamaCare Preserved; Medicine Pickled; Democrats Gleeful; Republicans Relieved”

  1. I wonder how many people who expected the "freebie" will raise a ruckus when they can't get a physician to see them. Then what will be the response to the ruckus, and how will that play out in doctor's offices all over?

  2. Hospitals don't see it as a problem at all; for most of them, the ER is a profit center and they are actively promoting people to use it as a walk-in clinic by having billboards or apps alleging 5 minute wait times, etc.
    Of course, most or all of your care will be with a non-MD provider. But the old concept of "trying to keep people out of the ER" has gone 180 degrees, in alignment with the prime directive of American medicine to always follow the money.
    I recently heard a health care lawyer speak who is putting together an ICO (Integrated Care Organization) for a regional hospital. ICOs are necessary for the ACOs and Medicare MIPs, etc coming down the pike, the whole "value based" payment systems. He personally believes these 'pay for performance/quality' systems will be the major conduit within 5 years, and then after another 5 years private insurance and Medicare will deem them unworkable and simply go to a capitated system where a given network of doctors/hospital will get one lump sum for 'x' covered lives and who/how it's distributed will be the networks affair; insurance and gov't will bow out of the active quality metrics game themselves.

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