The Audacity of Change: Obama's Healthcare Gambit

Starting in the late 1980s and early 1990s, I began to hear an increasingly alarmed cry from certain political sectors about the fate of healthcare. As early as 1987, health care costs rose from #15 to #7 in the list of Americans' top worries about the future and  that only got worse. As the '90s wore on and into the '00s, I continued to hear two things:

1. Because of the baby-boom, health care and retirement programs were going to run out of money.
2. Because doing anything about it was complicated and fraught with risk, no politician was going to do anything about it until it was too late.

Pundit after pundit proclaimed this second point on the left and the right with all of the conviction of optimists slowly ground down into cynics by the repeated failure of their politicians to do anything challenging that would risk their political futures.
In 1993 and 1994 the Bill Clinton administration attempted to push the Health Security Act through congress. This was a true overhaul of health care in the United States, which provided for a set of regional health care alliances which managed the interaction between health insurance providers and consumers. It avoided the controversial "mandate" of Obama's plan by making health care premiums a tax which funded regional alliances.

Obamacare has to go

I think most Americans will agree with me that Obamacare needs to go. It's a dangerous and uncertain plan that looms over American businesses at a time when this country needs growth in order to extract itself from a terrible financial crisis. However, I also think that the majority of Americans understand that the status quo in healthcare isn't working, and we need to fix it. Thankfully, we don't need anything as radical as Obamacare in order to fix it.

The problem with our current health care system is that it pretends not to be a universal health care solution, but it actually tries to function as one. Medicare acts as a catch-all, paying for those who cannot afford health care when they are brought to an emergency room. Sounds reasonable, since that's a life-or-death decision, but in reality, people who can't afford coverage wait until their conditions are life threatening, and then the go to the emergency room, there to be covered by Medicare. They don't do this because they want to live off of the public dole, but because it's the only option they have.

So we end up paying far more in emergency room expenses than we would otherwise (vastly more) because these patients can't afford the cheaper coverage before hand that would let them see an out-patient doctor for an infection or broken bone.

Obamacare tries to patch this up by intruding into people's lives with a giant government plan. Instead, what we need is to involve the free market. Open up options to people to allow them to subscribe to the plan of their choice where they can afford it and to provide some kind of market-sourced solution, not a giant government bureaucracy, when they can't. To help individuals to work together to get costs down, we can leverage employers by having larger employers who can already afford insurance, subscribe to the plan of their choice from the provider of their choice. Again, the market will solve an awful lot of these problems for us.

For smaller employers, we need to remain hands-off so that they have the chance to grow and flourish to become the Googles or the Amazons of tomorrow!

There are some other concerns. No matter what side of the abortion issue you're on, I think it's fair to say that Americans are divided enough that our national health care strategy should't go to pay for it. Resolving contentious issues should never be done through giant bureaucracies!

Also, the existing Medicare system should be modified to work more closely with this new, market-driven plan. That allows the government to save a substantial amount of money on Medicare and transition those services to the lower-overhead system.

To everyone who's giving me an "amen" on this anti-Obamacare rant, I'd just like to say one thing: I kind of lied. The above is a description of the Obama Health Care Plan. All of the cries of "uncertainty" and "government takeover of health care" are basically just a smoke screen to prevent you from thinking rationally about what is really the only rational solution for a country that is so heavily invested in the idea of the free market. If that were not the case, we could cut costs and improve quality of care by going to a Canadian or British single-payer model, but there's no sense pushing such a model in the U.S. right now.

The limitation of the Obama plan is that it doesn't really address many of the outstanding issues with Medicare and Medicaid coverage, but that makes it an incomplete plan, not a useless one.

If you want to understand the Obamacare plan better, and really have a handle on where it does and doesn't live up to what we should expect, see my previous article about the bill before it became law.

Following the Health Care Bill

I've been trying to catch up on the state of the health care bill... it's not easy. There are some good sources, though. PBS has a really excellent comparison on the House, Senate and reconciliation versions of the bill and the Washington Post has a very informative timeline of the changes that the bill will bring. There are some details there that I hadn't realized previously:

All employers over 50 employees would be required to provide insurance for their employees or pay a substantial fine per employee (though you don't pay for the first 30, even if you're over 50). Most people will be required to get insurance if they don't get it from their company, but there will be exceptions (those now covered by Medicaid, those who file a waiver for religious reasons, etc.)

The religious reasons exemption kind of bothers me. I understand that there are those who don't want to seek medical care because they feel that their deity of choice doesn't approve. That's fine, but I don't get to opt out of paying for highways because I don't have a license... and I'm fine with that. It's just one of those infrastructure costs. If the fees for not getting insurance were about the same as the cost of insurance, then I wouldn't see any problem with removing the religious exemption.


Another great source is the Christian Science Monitor (no relation to my above statements). They've always been a great news source, and that continues to be the case. Their coverage of health care reform includes some interesting insight, including the point that requiring people who don't get coverage through work to buy insurance is partially a way to increase coverage, but also helps the insurance companies as many new customers will be young people who are less at risk for expensive conditions. This means that the insurance companies will be able to immediately recover some of their lost margins due to being forced to insure those with pre-existing conditions. Of course, they'll still try to raise rates in response, but I'm seeing some major resistance to that... my company just announced that they're switching providers, probably due to increased rates, though I don't know for sure. Point being that competition will probably prevent these rates from getting too far out of control, though not as much as if there'd been a public option.

The New York Times has a nice opinion piece that covers some of the bickering that's going back and forth right now. It does a reasonable job of tearing apart some of the talking points on both sides (I like the insight about gaming the C.B.O.)

Of course, you can always browse the top stories from lots of sources via Google news, which I like to do every couple of days to keep up on the twists and turns.

There's an interesting bit on the Wall Street Journal site about how the bill's proposed system "does not adequately pay doctors and hospitals in some areas for treating Medicare patients," but that appears to be an existing Medicare problem that this will would expand by increasing enrollment. Pelosi says they're working that one out, now.

No matter what it will be an interesting ride. You can follow the current odds of passage over at Intrade, which I've always been fascinated by as a predictive tool. They're edging up toward 85% right now, but have recently been below 50%, I assume as a result of various announcements coming out about who's voting which way.

Death Panels AKA Advanced Care Plan: I Finally Get It

For a long time, I really didn't understand the debate over so-called "death panels." I'd read the news. I'd read the text of the law. I'd gone back and forth, but never really got it. Now I see where the mistake was made, and why so many people are (incorrectly) upset. It's a subtle thing, but one that really can't be ignored. I finally got it when I read the recent FactCheck.org rebuttal to former New York Lt. Gov. Betsy McCaughey's comments on The Daily Show.

Here's what the crux of it is: the law (as it stands today) says that doctors can (mind you, *can*) report on some quality metrics and receive some extra payment from Medicare, above and beyond the normal payment. This amounts to a small (2%) bump in what they get paid, and they get to determine what quality metrics to report. There's just a requirement that the report on a minimum number of them. One of the (again, existing) metrics is having discussed how you want issues such as life support dealt with. Right now, that's it. You just have to report on the percentage of patients that you've had the conversation with and who have then either created appropriate documents or signed a statement saying that they don't wish to.

The new law, built into the health care reform legislation, would add a new criteria: you would also report on the percentage of times that those wishes are carried out. Therein lies the rub...

You see, this has been mis-interpreted as saying that doctors will be penalized (e.g. won't get that extra 2%) if they allow you to change your mind. This is not what the legislation says. What it says is that the doctor has to report on their enacting of the conditions of your advance care planning wishes. If you are conscious and able to communicate your wishes, then advance care planning doesn't enter into play, and thus no reporting would ever be necessary, but the way it's being portrayed is exactly the opposite.

Now, there are some gotchas. For example, you might become lucid; say "don't unplug me;" and then go back under. What now? The doctor has to decide if they should honor your stated wishes in writing or your stated wishes in person. Today, doctors and next of kin make that choice together (or should... law or no, there are always abuses). Under this law, nothing would change except for the after-the-fact review which doctors could choose to participate in or not.

This is the "death panel." An optional reporting system which considers any choice by the patient to be equally valid (e.g. your advance care planning documents might well request that every effort be made to maintain your vital statistics, and there's nothing wrong with that). Not much of a "death panel" is it? Personally, I'm disappointed. I expected there to be real, substantive debate over this legislation, but instead we're reduced to blowing minor details out of proportion and then inventing imaginary scenarios under which they become literally life-or-death issues.

This isn't the fault of conservatives. This is the fault of a minority of conservatives who push an agenda of deception and "big lie" propaganda. Don't get me wrong; they're not alone. There are a minority of liberals who enjoy exactly the same tactics. The problem is that neither one of these groups represent the majority of Americans, and we really need to demand that they shut up and let us be heard over the din of their trial-by-shouting form of debate. There are some very smart people capable of propelling this debate forward in useful ways, but they don't get a chance to be heard because they say boring things like, "of course the U.S. should have a baseline of healthcare like every other developed nation in the world, but we need to decide if we want to model it on one of the dozen or so systems that are working out there today, or if we need something unique, and if so what. Then we need to get to work on the hard part: transitioning all of our spread-out healthcare programs into the new plan so that we don't just make the problem worse." See? That has no media "zing." It just doesn't sell. So instead, we have an ill-considered rush to push forward a single, probably flawed plan before anyone can build up enough shouting to get it stopped.

Sad.