Friday, April 11, 2014

Unaffordable Care Act


Many think President Obama's Affordable Care Act (ACA) has provided a medical salvation to a large proportion of the 47 million heretofore uninsured non-elderly Americans. In fact, it has compelled perhaps 1.6% more people to buy insurance in 2014 than were insured in 2013.

Even taking the rosier figure of 5.4% of the number of previously uninsured, this is hardly a success story.

Moreover, having insurance coverage is not the same thing as being able to pay for actual healthcare. To risk stating the obvious: Beyond paying one's insurance premiums, one must then pay for the actual medical care one seeks. It should seem obvious that many of the people who failed to buy health insurance failed because the cost of seeing a doctor was beyond their purview.

The big story, however, is the "ugliness of spirit" (to quote Paul Krugman from his "Health Care Nightmare") in the United States which the ACA has revealed. Over half of our State's governor's are rejecting additional Medicaid coverage, Florida's Gov. Rick Scott being one. Odd considering our not-compassionate conservative Governor Rick Scott made his money in the legally contentious, once-largest for-profit health care company in the U.S. (Columbia/HCA); one would think he had a heart for such issues.

From Krugman's piece:

The health economist Jonathan Gruber, one of the principal architects of health reform — and normally a very mild-mannered guy — recently summed it up: The Medicaid-rejection states “are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.” Indeed.
Florida CHAIN, a group lobbying for "increasing the access to affordable quality healthcare, published an informative piece on what the legislators "hope you don't read and remember." From that brief round-up is this on the "spite tax":

  • $500 million: A conservative estimate of the “spite tax” that Floridians will pay in 2014 – i.e., the amount of STATE taxes and fees that Floridians must redundantly pay to block access to what they already paid for with federal taxes

How Obamacare has played out in Florida is that the Medicare - Medicaid population can no longer access medical care from the same doctors they had previously seen. Bottom line: doctors are unwilling to accept the 80% remuneration from Medicare when they will not have access to the 20% previously covered by Medicaid. (Meanwhile, many of those accepting full Medicare reimbursement grow rich from providing often unnecessary procedures or prescribing unnecessary or unproven medications hawked by their friends representing the interests of Big Pharma.)

What is the linkage between Obamacare and the refusal of doctors to accept patient who are enrolled in both Medicare and Medicaid?

Whatever the linkage, signs were in place in doctor's offices in 2012 stating that should the healthcare act pass, they would no longer be treating their patients who were dual Medicare + Medicaid recipients. These are the patients who will neither be able to afford the ACA coverage nor the medical care itself -- our neediest citizens who should be protected by such governmental programs.

The best parsing of the 1,163 pages of the “Patient Protection and Affordable Care Act” (HR3590) and the 337 pages of the “Health Care and Education Reconciliation Act of 2010″ (HR4872)—known collectively as the Affordable Care Act— can be found at this post on Dr. Lickerman's blog. A liberal M.D., he explains clearly why the Act will not be a boon to the average health insurance customer.

There is no need to compress his compression, but this is an example:

"Consumers currently have almost no ability to “vote with their feet. Thus, no competitive pressure exists to motivate insurance companies to lower their premiums at all (remember, just because there are multiple plans on the exchanges doesn’t mean they’re being offered by as many companies)."

The insurance companies grow rich, the doctors grow rich, and the poor go without care. A Federal mandate that people buy health insurance ≠ being able to afford health care.

Medicare patients who also qualify for Medicaid are being turned away from their doctors in Florida -- is this how Obama's vision was supposed to play out?

We need a new law that requires all doctors to honor Medicaid patients (bureaucracy rules.) If Congress would provide this legislation, then then Mr. Obama should use his flanking policy by issuing an Executive Order. If a doctor accepts Medicare, he should be required by law to provide care to Medicaid patients. To do otherwise is simple money-grubbing.

Ranger will bet the farm that our leadership class does not have a problem finding premium health care, paid for with our tax dollars.

Addendum: Yesterday's press covered the death of young Florida mother Charlene Dill who collapsed at one of her three jobs for want of healthcare for her documented heart condition. She fell into the "Medicaid Gap" because she lived in a state which would not expand Medicaid coverage. Her case is not an isolated one.

--Jim and Lisa

[cross-posted @ RangerAgainstWar.]


  1. jim-

    What the ACA does not create is an actual "health care system" nor does it establish "health care policy". It was simply a Rube Goldberg patch to an intrenched insurance industry that funds an intrenched medical services and supplies industry. What it should have been named was the "Increasing the Medical Industry's Funding Act". It does not make it easier nor routine for the average person to see a physician, as high deductibles still discourage the poor from seeing a physician for other than serious problems. With a typical "full physical" or checkup for an upper respiratory infection costing upwards of $500, including lab work, how many more people will seek this form of care, when it will come totally out of pocket?

    The ACA does not do a demographic study and allocate health resources accordingly, as is the case in nations with far less expensive national health care. "The Market" does that in the US, and the money available to poor people to influence "The Market" does not get much attention. Even Canada's single payer plan does a less costly and more medically effective job of getting affordable private care to its people.

    The US medical industry is all about generating revenue. I had a friend fracture his arm in Italy. His wife insisted it simply be stabilized and then cared for at Stanford Medical Center, where their insurance program covered them. Why take free Italian care? So, in a nice cast, Italian x-rays and medical referral in hand, they call Stanford orthopedics for an appointment. "Sorry, but if the injury was the result of an accident, you must enter via the Emergency Room. They will then refer you, if appropriate." So $2,500 of their $3,000 deductible was consumed by the Stanford Emergency Room staff confirming the Italian orthopedic surgeon's referral and then allowing them to request an orthopedic appointment. That's just the tip of the cost iceberg he suffered by turning down free Italian care. I won't bore you with the impact of the insurer only being willing to pay for the cheaper surgical procedure, which resulted in a year of pain and then the more expensive fix (which the Italian Dr was prepared to do), all at significantly increased cost. You don't get a discount if the first try fails.

    As Krugman noted in one of his pieces, there was no way Obama could have taken on the insurance and medical industries, so he cobbled together ACA allowing the existing players to sell more insurance at a profit and providing government funds to underwrite some of it.

    Until the US has a policy and system for health care, cost will continue to rise and care will continue to deteriorate. It's simply a business, and what's good for business is what drives the train. If that provides some good for some people, that's a byproduct.

  2. Al,
    1st-i'm not a t bagger,but i have serious reservations about ACA and these hinge on some of the issues that u mention.
    I seem to have a disconnect in that i can't understand how a law that has the intention to expand medicaid is in fact actually screwing those folks already on medicaid here in FL.
    It ain't pretty.
    As i see the law it's unconstitutional in that each state is mandated to have state systems by the fed law. I 'm not real smart but isn't this intrastate commerce AND NOT interstate commerce.!!??!If each state has a distinct set up then how does the interstate commerce clause apply, and what power does the fed have to control intrastate doings?
    I also have a feeling that movement from state to state will suffer.
    I also wonder about tradesmen registered in FL as workmen, but doing actual work in Oregon being able to access med care when in tdy status.FL insurance is not Oregon insurance,or so i understand.
    I also wonder if any of our leaders read and understood this law before voting on it.I have the same question concerning most laws to include THE PATRIOT Act.
    The bottom line for me is-what do poor medicaid eligible people do when Drs. won't accept their medicaid coverage?
    Also what happens if a medicaid person from FL has a heart attack in Oregon?
    In closing one observer says that this is not socialism , but rather communism b/c the gov't determines the rates of exchange with out actual market data, and contra to the propaganda it's hard to see any market influence in what i read about the law.
    And that's what brought the Soviets to ruination.
    Thanks for commenting.

    1. "I seem to have a disconnect in that i can't understand how a law that has the intention to expand medicaid is in fact actually screwing those folks already on medicaid here in FL."

      Because the administration didn't anticipate that (a) the Tea Party-run states would be that batsh*t crazy and evil and that (b) the Roberts court would pull a ruling out of their *sses.

      And given that the administration *barely* got the law passed, they didn't have a lot of margin to play with.

  3. jim-

    I would hardly call ACA, Medicare or Medicaid socialism nor communism. Doctors and hospitals are free to accept or reject the reimbursement rates of any and all insurance providers. Ever had private health insurance that charged you a stiff penalty for using an "out of network provider" who won't negotiate a low fee rate with the insurer? And I know doctors that reject patients covered by some private insurance due to that insurer's fee schedules.

    Point is, jim, the focus has never been on providing a stated, consistent level of health care to the population. It has only focused on funding schemes.

    Medicare and Medicaid are funding programs. If their funding rates are too low for the desires of a given doctor, then the doctor will not do business with a Medicaid or Medicare beneficiary. That is pure and simple "Market" as much as a car dealer not being willing to sell you a car at a low price you want to pay. The propaganda aspect is that it is Medicare and Medicaid that is being blamed for certain doctors' refusal to accept a given fee schedule. That no doctor nor hospital has been able to offer a rational basis for the bizarre range of fees they all charge for the same service or medicine seems to escape us.

    As I said, the US does not have a health care system, nor a health care policy.

    BTW, the next time you buy groceries, keep in mind that the end price includes the cost of employer provided health insurance for every step in the chain from raw materials to the shelf, plus a mark up for profit. You are paying those premiums and getting nothing in return.

  4. In Canada, we have a (very) few doctors who opt out of the nominally single payer system. They are free to charge whatever they want to whoever they want.

    However, if they want any money from the government for doing a government paid service, they can only charge what the government pays. The ban on "extra-billing" caused a lot of distress amongst doctors when it was introduced in the mid 80's.

    Needless to say, very few patients/insurance providers are willing to pay full fare for services that are paid for by the government.

    I suppose that it is still a "free market" in some technical sense of the word but only in a few niches.

    Note that I *have* paid for services to jump a queue in one of those niches. My wife hashed up her knee in a ski accident. It was going to take six weeks to get a MRI done (Staffed MRI machines were rare in those days and they were all booked up taking pictures of people sicker than those merely with banged up joints) and then it would take another six weeks to schedule surgery if serious surgery was needed. Thus it would take about 3 months to start remediation if the worst possible situation would arise. But in three months, the knee would have been healing wrong (and also, losing use of one of your knees for half a year (3 month wait + 3 month recovery with physiotherapy) is a major quality of life issue). So we paid $500 to a sports clinic MRI operator to get a scan done the next day.

    With the MRI in hand, the doctor determined that surgery was not needed and my wife went straight into physiotherapy.

    That $500 saved us six weeks of pain and worry. Worth it to us. However, the system was clearly broken and many people (including us) complained to our politicians.

    The politicians responded by giving more money to focus on shortening waiting lists. This has helped, but it is like playing whack a mole, you bang one thing down and something else pops up somewhere else.

  5. Jim, I understand (at least partly) your problems with how the system is being implemented in Florida. It sounds pretty ugly from where I stand.

    But I'm sure that at least part of the problem is the Florida Republicans who dislike Obamacare have a powerful motive to sabotage the system. My (Democratic) state has had some problems but hasn't seen anything on the scale you're describing.

    1. The US system of governance has a massive number of blocking points. And with a party dedicated to helping the rich and deliberately f-ing the poor and working class, that party has a natural advantage.

      Recall that Gov. Rick Scott defrauded the federal government of billions, and still became governor.

  6. Aviator,

    You are correct in that the ACA merely enhances "an intrenched insurance industry that funds an intrenched medical services and supplies industry."

    "The US does not have a health care system, nor a health care policy." I could never understand why anyone would back mandatory single-payer health insurance -- it is such a scam, and something not befitting a Democratic President to endorse.


    I understand half of the States are declining Federal offers of increased Medicaid funding, and this totally countermands the idea that the ACA will somehow "expand" healthcare coverage. Besides being mean-spirited (as the spokesman in the Krugman article calls it), it merely ADDS to the taxpayer's burden.

    Also, I have added a link to the Florida CHAIN piece explaining how this mean-spirited is like shooting oneself in the foot. But I have not known that self-endangerment to stop mean-spirited and ill-informed citizens from their prejudices in the past.

  7. Lisa - yes, the reaction of many state legislatures has been mean spirited. And that has been something I cannot get my head around. But then, I realize that prior to the ACA, insurance carriers could refuse coverage to someone with a "pre-existing condition", even if the person was unaware of that condition at the time they applied for coverage, or had to change insurers due to circumstances beyond their control.

    Only when the industry collapses of it's own over burdensome weight will something productive arise.

    1. "Lisa - yes, the reaction of many state legislatures has been mean spirited."

      Beyond that - I'd call it 'evil'. And there is a further logic - the right has figured out that every time that the Democratic Party accomplish something, it helps them and hurts the Right. Therefore, the right sabotages everything, trashing precedent and custom like a bunch of nihilists. And since the rich like this, the right has the wind at it's back.

  8. What it boils down to is whether a society sees universal access to full spectrum, comprehensive health care as a basic human right or not. If they do, then they tend to have a national health care system that delivers to all.

    Or, if like the US, where health care is a commercial market product, it is delivered to those who have the resources, which may include public assistance. However, the US has never provided a level of public assistance that grants universal access to full spectrum, comprehensive health care. Thus, the healthcare resources available to the general public are limited to that which is commercially viable.

    In Greece we have a mixed National Health Service and private provider system. NHS is responsible for providing full spectrum, comprehensive care to all. Basic NHS general medical care is available near to most people. Specialists will "visit" remote areas on a scheduled basis. Because the full spectrum of care is available at virtually no fee, private provider fees are quite low. I can get a full blood panel, with PSA for $100 US from our local private microbiologist, who is also an MD and can interpret results, make recommendations, etc. A visit to the NHS GP is $6.50 US for any and all services delivered that day. A highly recognized dermatologist here charged us $42 US to cryogenically remove a growth. If you are in serious condition, the NHS center can stabilize you and put you on an air evac to Athens - no charge.

    Greece spends 1/3 per capita on health care vs the US, and has 3.5 times more physicians per capita than the US. Everyone has access to NHS if they need it (to include colds, etc), and that includes tourists. If I walk into the NHS clinic to see a Dr for something routine, the wait is typically 45 mins or less. Of course, I can also call and make an appointment. However, the curtains and waiting room furniture and decorations are nowhere near as nice as in the US. Thus, we do not pay $10.00 for an aspirin administered in a hospital.

  9. Al,
    I do gain benefit from paying for health care in the food handler cycle.
    I get healthy peeps handling my food. Have you seen stats on food borne health hazards?
    I think we both agree that we need a comp health care system here in the states.
    Be aware that my concern is for those on the bottom of the spectrum. When they get to go on sky trips then i no longer concern myself with their welfare.
    My point is that nobody is looking at this strange bubble from the perspective of the bottom of the heap.
    I say again- if a doctor accepts medicare then they should be required by law to accept medicaid.
    To all,
    thanks for adding to the mix.

  10. jim-

    if a doctor accepts medicare then they should be required by law to accept medicaid.

    Absolutely. But Drs limit their practice based on the "business model" they choose. Now, we have "concierge medicine", for example.

    It's not about patients, jim, it's about business. Has been for decades.

  11. Aviator is correct:

    "What it boils down to is whether a society sees universal access to full spectrum, comprehensive health care as a basic human right or not."

    Perhaps due to our Puritanical background, we feel some must be losers in the lottery of life. They are not among the "elect" for one reason or another.

    Our healthcare (not) system is broken. Most of us have our horror stories. I once waited five hours in my local ER with a fever of 104, was never actually seen, though a nurse came out to the packed waiting area and gave me a Tylenol in a plastic cup.

    The invoice for $250 arrived promptly.

  12. The ACA has at least two very positive elements.

    In the past, a self employed person was at the absolute mercy of the insurance industry, and "mercy" and "insurance industry" are not words one sees together very often.

    The little guy could buy HI on the open market, but only for 12 months. At the end of the 12 months, the insurance company could do what ever it wanted - cancel your coverage, change the terms, raise the premium. On two different occasions, I got a letter in mid December, telling me that my office policy was canceled at the end of the month.

    Then when I went to look for another policy, all preexisting conditions were excluded for 9 to 12 months.

    The ACA killed the preexisting condition rule, and, through the exchanges, made it possible for the self employed to buy insurance at a reasonable price

    I represent Social Security disability claimants. Under old law, it was not unusual to see a self employed person making big bucks whose spouse was a stay at home wife/mother who did not work. That spouse would not acquire Social Security coverage and hence have no access to Medicare. Because the husband made big bucks (and "big bucks is say $50,000.00 a year), the spouse could not qualify for Medicaid.

    And then the spouse would get dreadfully sick and need ongoing expensive medical care.

    She could not get Medicare, she could not get Medicaid, and the husband's policy would get canceled at the end of the year because it was only a one year contract. I've seen a number of such cases, including my own primary care doctor - who had to go to work for one of the hospital chains as an employee to keep his wife covered even though he was 65.

    Then there are disability claimants, a large number of whom are poor and have worked in low income areas. They get sick, lose their company health insurance, if any, and file for disability.

    In a classic Catch 22 (love Joe Heller), the disability rules require current medical evidence to prove the claim, yet the applicant now can't afford to go to the doc.

    In the states that have opted in, that claimant can now get Medicaid coverage, usually within a week of the application.

    And then, under old law, if you had assets, and lost you health insurance, and had no choice but to go to the hospital, you would likely lose everything to the bill collectors.

    The ACA is without a doubt, a mess, in large part due to Obama's comprises with McConnell and gang. But it is a giant step forward in many areas.

    Walter Olin

  13. Walter- No doubt the ACA has improved the situation, and the end of pre-existing condition exclusion was a life saver for my daughter who suffers an autoimmune disease. However, it is still an insurance program change, not a health care system creator, and people with high deductibles will still avoid routine care to avoid the high out of pocket costs. It is this that has created a culture amongst lower income groups that only sees medical services as necessary in case of serious injury or illness.

    A couple of years ago, a local EMT stopped to assist two American girls who has a motorscooter spill. Both had serious "road rash" that needed attention. She told them to hop in the ambulance and she would take them to the NHS center. The girls said they would prefer a taxi, as they had a "high deductable" and their father would kill them over the ambulance costs. He had actually told them that if they got hurt, to take a taxi! Nikoletta, the EMT, had no idea of what a deductable was, and had a hard time convincing them the local ambulance was free, but the kids were in pain and finally gave in. They were taken to the HNS center, treated, stitched up, scheduled for a follow up, given a scrip for antibiotic ointment and were amazed that they didn't have to give any billing info. Later, Nikoletta asked me, "What's a high deductible?" I explained what it was and how much a typical ambulance ride would cost in the US. Her response was, "How can you treat people that way?"

    IMHO, insurance, without accompanying comprehensive health care policy, is not the answer for an allegedly advanced society. The US doesn't want a comprehensive health care policy, as it could be bad for the vested interests of the insurance and medical services industries.

    But at least the situation is improved. However, as jim and lisa point out, it is saddening to see how much contempt some politicians have for the well being of the less fortunate.

  14. Yes, the "contempt" is bilious, and doubly-so in Florida where Gov. Rick Scott made his money ripping off the health care consumer via his now-discredited Columbia/HCA, once the largest for-profit health care company in the U.S.

    Have these politicians no shame? Is there no noxious thing they can do that will keep the poor rubes from voting for them?

  15. Lisa- You are seeking a human centered solution to what is a business situation. I read an article a while back by a physician who was a big proponent of "concierge medicine". He said that the ACA was going to "unleash as many as 30 million new patients on our profession, far beyond the nation's medical schools' ability to provide new doctors". Thus, there would be two choices, either go to a limited "concierge practice" that would allow the physician to be able to commit more time to each patient, or deal in "mass production, low imposed fee" practice using a staff of nurses, physician assistants, clerical staff, etc, with the attendant increased management and overhead costs.

    Nowhere did he ascribe any societal good to that 30 million people having access to medical care, or how to deliver first rate care to them. Rather, they represented a challenge to decide what kind of business model a doctor should choose.

  16. I gave the wife a capsule summary of this thread, and she reminded me of a comment a Greek Physician friend made a couple of years ago when the "Obamacare" issue was being fought through Congress. He retired as chief of internal medicine at Kings College Hospital in London and came home here to serve another 5 years as an unpaid staff member of our HHS Health Center. While at Kings College, he was invited to spend three years at a major teaching hospital in the US, so he has had a taste of the American health care industry. Basically, he summed it up as follows:

    In the US, the primary concern is mechanisms to insure payment to the provider for any care that is given. In the rest of the world, the primary concern is providing appropriate care to people - all the people.

  17. "In closing one observer says that this is not socialism , but rather communism b/c the gov't determines the rates of exchange with out actual market data, and contra to the propaganda it's hard to see any market influence in what i read about the law."

    Well, jim, couple of thoughts about that:

    1. You and I had a personal, up-close, first-hand look at all that commie medicine. MEDDAC, right? Single-payer, socialized medicine, no fees, no "market"? Seemed to work pretty much OK, no?

    2. And here's the thing; the entire notion of a "market" for medical care is as ridiculous as the notion of a "market" for electrical power. Ain't no such animal, and there can't really every be one.

    First of all, you can't "shop" for medical care. The entire notion of a "free market" involves competing sellers and buyers with both the ability to discern good quality from poor merchandise relative to payement demanded.

    In this case you're sick, or injured. You have no way to assess the value of the treatments, or the skills of the practitioners. You have no way to predict outcomes for one regimen of treatment over another, let alone evaluate effectiveness versus cost. Would you, say, choose a surgery that cost $1,000 out-of-pocket against one costing $10,000 if you knew the former had a 75% chance in resulting in long-term serious pain?

    We accept corner-cutting in "free markets" all the time. Look at things like consumer electronics; nobody repairs electronic devices anymore, it's just not worth it. We as a society and we as individuals made choices that led to manufacturers making electronic devices effectively throwaways; don't repair, replace.

    But how do you cut corners with medicine? How much pain, how high a risk of death or maiming do you accept? How do you "shop" for that?

    Simple answer; you can't. Therefore you have two options; either accept whatever costs the providers decide they believe people will pay - the system we have - or set up a regulatory body to determine those costs.

    Call it socialism or communism if you choose. But the alternative is what we have. It works, yes. It also costs the Heavens and the Earth and distributes not based on even something as equitable as random chance but by who won the sperm lottery.

    Frankly, I'm OK with MEDDAC for everyone if it means an end to that.

  18. FDChief:

    " Therefore you have two options; either accept whatever costs the providers decide they believe people will pay - the system we have - or set up a regulatory body to determine those costs."

    Actually, Chief, MEDDAC is neither of these. It is the provision of medical resources as necessary to serve the population. The provision of a defined level of care is the primary goal, and cost minimization is secondary.

  19. Replies
    1. This adds on to the problem. The ACA had to make it through an elite-dominated system studded with choke points, which are increasingly exploited by a nihilistic faction.

  20. The heath industry is a $2.5+ TRILLION industry that represents almost 18% of GDP. If you don't think that this is a powerful oligarchy, with massive vested interest, in action, you don't understand math nor money. Even the slightest restriction on their ability to set fees as they see fit means many billions, and is going to be resisted aggressively, even if it punishes patients.

  21. Al,
    The disconnect is that we are no longer patients,but rather customers.
    The Hippocratic oath is a bunch of words with little relevance.
    I'm thinking that the metrics are even a false indicator of the ACA. Does it matter that 8 million have signed up if the program is based upon false assumptions?