The Rockin Johnny B

Tuesday, January 26, 2016


Here are the facts:
  1. The Patient Protection and Affordable Care Act mainly aims to secure universal health insurance coverage – but lack of coverage is only a part of the issue. Spiraling costs are the bigger issue. Aside from creating an Independent Payment Advisory Board for Medicare (which is only empowered to make recommendations to Congress) and a
    Center for Medicare & Medicaid Innovation which has a mandate to conduct certain demonstrations for new payment and service delivery models (but would require Congress to act on the results), the act does very little to address the rising costs of doctors, nurses, and hospitals.
  2. It adds additional layers to an already highly dysfunctional market. We already have insurance companies AND in most cases employers standing between the relationship patients and doctors. The rising cost of health care costs has increasingly forced insurance companies to become more like health subscription providers. I am a big fan of the exchange concept, but that's not the only thing that the law does; Obamacare sets coverage requirements on plans – which adds yet another layer to a business relationship that should ideally be direct pay as much as possible.
  3. Throwing subsidies and payment middlemen into the mix is a really foolish way to address cost increases. Those things historically tend to lead to MORE cost increases – which is the opposite of what we want. We want greater insurance coverage and participation – but less need for people to actually have to use their insurance coverage to pay for services.
  4. A lot of supporters like to point to the "success" of the 2006 Massachusetts Health Care Reform. While it has been successful at expanding insurance coverage, what it has NOT done is reduce the cost of care. From NPR: Health Care In Massachusetts: 'Abject Failure' Or Work In Progress?; From ABC News: Evaluating Romney care In Massachusetts; From the Boston Globe: ‘Romney Care’ — a revolution that basically worked
  5. Up until now, the basic reality of employer-sponsored healthcare in the U.S. has been driven by a massive carrot in the form of the employer healthcare tax deduction. Under the PPACA, employer-sponsored healthcare becomes mandatory at the Federal level (once you have more than 50 employees, and assuming that you don't qualify for any one of countless exceptions). Despite Municipalities and States already having their own local mandates, this is a pretty significant imposition on businesses at the highest level. On that note, the number of exceptions and waivers is aggravating since that alone indicates that the law is not equitably designed. (Everyone must do this! Except.... you...and you...and you and you and you...)
  6. The Medicaid expansion is a significant expectation placed on States with tight budgets as it is. Medicare is entirely Federal; Medicaid is State-run with Federal support. States and their citizens tend not to like it when the Federal Government orders them to spend money.
  7. That brings us to the question of the individual mandate. Those of us who live in population-dense urban environments are much more accustomed to having to deal with Government regulations and requirements in our daily lives; the underlying concept of the Individual mandate may not feel like a big deal. Government is frequently a good thing since it provides formal mechanisms for all of these people living on top of one another to not trample on one another. For those who live in more population-sparse rural settings, there is a lot less need for Government activity and intervention since there's simply less people – and more space for people to do their own thing. For them the individual mandate, requiring people to engage in a private commercial activity, is a pretty big change in the relationship between the individual and the government – and conservatives are wary of such changes. To be conservative on a given issue, you're generally invested in conserving the status quo. (Realistically, the individual mandate + penalty was a contrived series of rhetorical backflips in order to not have a "Federal Health Insurance Tax" and then allow people with insurance to waive the tax. The Democrats didn't want the word tax being hurled at them in the 2010 U.S. Elections. The gymnastics didn't help them much.)
I'd personally rather step forward into something new rather than stick with an approach to providing care that is definitely broken and has been for nearly fifty years – but I can understand why some would strenuously object to changing from something broken to something else that's still broken.
With regard to other ways forward.
I'll borrow from a comment on Health Care Policy: What does the private health insurance industry contribute to the health care of Americans? and add a few more. What I offer here is directional – not comprehensive.
  1. Many more Retail Health Clinics/Convenient Care Clinics. Convenient care clinic,Will CVS, Walgreen's retail clinics replace physicians?, Popularity of 'Walk-In' Retail Health Clinics Growing: Poll, Analysis: Obama Care will bring flood of retail health clinics - The Hill's Healthwatch  This also requires continued expansion of who can serve as primary care providers. We need to make sure that state-level licensure for Nurse practitioners and Physician assistants allows for them to do work that they are perfectly qualified to do. Pharmacies ought to be hiring Registered Nurses to take vitals, conduct a basic check-up, and draw blood for send out to labs Unfortunately, the AMVVA and other groups that advocate for doctors are rather protective of their turf and reserved authorities. Anyhow, let's get Walmart (company), Target, Costco, Walgreen's, CVS, Publix, Safeway, Albertsons, Kroger, Sears/Kmart, whomever wants to deal with Westfield, and so forth all competing in this area. People should be able to walk in, get a routine check-up, pay $25 - $75, and that's it. Not a $25 - $75 co-pay; $25 - $75 total. A lot of these chains are already providing vision exams, so it's not a huge stretch.
  2. An end to our system of employer-sponsored insurance coverage. The "system" is an outgrowth of the wage controls that were imposed during World War II as corporations competed for labor, but weren't allowed to raise wages. Health insurance in the United States, Employer-Sponsored Health Insurance and Health Reform As a consequence, the individual market is inflated and non-functional. As I've said elsewhere, I have solid hopes for the health care exchanges on this. The chance to unwind employer sponsored care is probably the biggest reason that I ultimately support the PPACA. (That is correct; I support the Act not just for what it seeks to fix, but because of what it might break and provide a better path forward on.)
  3. Public disclosure of negotiated rates between hospitals and insurers. There's now disclosure of the "charge-master" rates, which is a step, but it's not an accurate reflection of the market. Procedure pricing should be as transparent as publicly traded stock prices. See One hospital charges $8,000 — another, $38,000. Also, here's a timely column from our very own Dan Munro: Healthcare Pricing Transparency Gains Momentum
  4. Standardized & portable electronic medical records that can either be self-maintained or used with a secure (and certified as such) data management service. These could be modeled after stock brokerage houses, who maintain sensitive information – but can transfer that information between one another when a client wants to change. I could also potentially see private insurance companies offering this service.
  5. Medicare reform. There are a lot of critiques out there, but ending the fee-for-service reimbursement model is the big one and everyone already knows it. However, there's a lot of entrenched resistance to actually doing anything about this. (See #1 on my first list.)
  6. We need a mechanism to directly account for the requirements of the Emergency Medical Treatment and Active Labor Act, rather than forcing hospitals who take Medicare patients to absorb and distribute those costs. There is a really whacked out economic incentive here that is leading some hospitals to close their Emergency Rooms as they try to trim costs. States who that are looking to trim budgets – most notably Texas (state) – are also limiting Medicaid reimbursements for "non-Emergency" Emergency Room visits. (Emergency Room Closures Hit Minorities, Poor Hardest; Factors Associated With Closures of Emergency Departments in the United States.) This is one where getting universal insurance coverage for actual emergency/catastrophic situations is important – but, to echo my point about retail health care & convenience care – we need way better, more actually affordable options for primary care.
  7. Finally, there is a big hairy social/economic issue that we need to deal with: Death and Dying. We've gotten stunningly good as a society at prolonging people's lives over the past 50 years. As a social imperative, it is moral and correct to try to preserve and prolong life...right??? (Imperative enough that the PPACA bans lifetime caps on insurance payouts.) Unfortunately, the moral imperative is very very very expensive. The most expensive care that people typically receive is in the final three months of their lives. Perhaps only people who can afford it should have every possible measure taken to extend their life... which is unlikely to strike any sane person as remotely just or the kind of society we collectively want to be. Science and medicine have gotten ahead of our ability to tackle this question as a society; we need to collectively catch up and reset our expectations. Maybe it's something like requiring certified EMR providers (see #4 in this list) to collect Advance Health Care Directives??? That at least gets people to have the conversation. This is tough Gordian Knot, and I'm currently short on brilliant ideas on how we go about slicing it. (I will note that when Republican politicians and pundits worked people into a foolish frenzy over "Death panels," it was a sad setback for this public conversation.) Humanity has had a philosophically tough relationship with mortality since the beginning; now we're at a point where it's economically tough.
Bottom line: universal insurance coverage is a noble goal, but we ought to focus a lot more on the core care costs so that insurance pools can be called on less frequently to pay out for things. In principle and design, people should be buying insurance to mainly deal with serious risks – not to handle everything that ought to be routine.

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