I read with a mixture of delight and amusement David Brooks' article from today's NYT.
http://www.nytimes.com/2011/01/07/opinion/07brooks.html?_r=1
He is concerned about challenges to and weaknesses in the current health care law. I wrote back in February and March that no one was paying any attention to Tenncare as a model of what is going to happen to Obamacare. Congress also ignored what is happening in Massachussetts. Both these programs have had the problems that Brooks describes in his article. My comments follow his text.
"The courts. So far, one judge has struck down the individual mandate, the plan’s centerpiece. Future decisions are likely to break down on partisan lines. Given the makeup of the Supreme Court, this should concern the law’s defenders. "
Yes, it should. I think the constitutional challenge is quite valid, and likely to succeed. This will force a new, and hopefully more civil and productive discussion than in 2010.
"False projections. The new system is based on a series of expert projections on how people will behave. In the first test case, these projections were absurdly off base. According to the Medicare actuary, 375,000 people should have already signed up for the new high-risk pools for the uninsured, but only 8,000 have."
Basing billions of dollars of spending on projections of how people will behave has always been suspect. Is anyone surprised the projections are off? What is the incentive for signing up for these pools? There is a clear disincentive- the law is likely to be sacked, and no one likes it. Also, there is a stigma associated with being in a 'high risk pool', just as there is in being covered by Tenncare. finally, much infrastructure to execute the new law is not ready. Even people who want to sign up can not.
"More seriously, cost projections are way off. For example, New Hampshire’s plan has only about 80 members, but the state has already burned through nearly double the $650,000 that the federal government allotted to help run the program. If other projections are off by this much, the results will be disastrous."
Wow, what a surprise. Anyone who has read the most basic material about Tenncare and Masscare knows these programs are well over budget. Tenncare is being sharply limited simply to avoid breaking the state over its costs. Whenever behavior is severed from responsibility behavior is not improved, and services are overused. ER utilization by Tenncare patients is notoriously high. Many patients use an AMBULANCE to come in for a headache, because Tenncare pays for the ride. They don't have to spend gas money, and if you think the motivation is any deeper than that you are quite mistaken.
"Employee dumping. This is the most serious threat. Companies and unions across America are running the numbers and discovering they would be better off if, after 2014, they induced poorer and sicker employees to move to public insurance exchanges, where subsidies are much higher.
The number of people in those exchanges could thus skyrocket, especially as startup companies undermine their competitors with uninsured employees and lower costs. The Congressional Budget Office projects that 19 million people will move to the exchanges at a cost of $450 billion between 2014 and 2019. But according to the economists Douglas Holtz-Eakin and James C. Capretta, costs could soar to $1.4 trillion if those who would be better off in the exchanges actually moved to them. The price of the health care law could double. C. Eugene Steuerle of the Urban Institute, who has been among those raising the alarms about this, calls the law’s structure “unworkable and unfair.”
Our politicians were asleep at the switch when this issue was raised. and it is not done just by employers. Insurers in Tennessee decline patients for all manner of conditions because they know there is an insurer of resort. Employers will do exactly the same thing. I know what my business pays for health insurance, and it is outrageous. We, and all small businesses, would love to lose that burden, especially for sick or elderly employees. This may be a blessing for such employees and for their companies, but it is a financial disaster for the government.
"Health care oligarchy. Since the law passed, there has been a frenzy of mergers and acquisitions, as hospitals, clinics and doctor groups have joined together into bigger and bigger entities. The drafters encourage this, believing large outfits would be more efficient. The downside to this economic concentration is there could be less competition and cost control. In many places, the political power of these quasi-monopolies would be huge, with unforeseeable results. The law bans doctors from starting up hospitals to increase competition."
I think the liberals who drafted Obamacare assumed everyone would like it, and would not mind being forced into certain behaviors. Of course, this is a persistent, idiotic fantasy of such individuals. Certain they know best, they assume everyone else will see their wisdom, the light of their values and plans. Wrong. People see their own interests.
In this case, the average legislator is less intelligent and educated than the average doctor. Doctors feel they have been abused by payors, including governmental payors, for some time. Did Congress really imagine they would not be aching to respond, or would not be bright enough to use every aspect of the law to their advantage? Having long since created an oppositional environment between doctors and payors, it is optimistic to the point of folly to expect eager cooperation. The issue is about wringing a living from an environment where our fees are discounted, our work is disallowed, our ethics and ability questioned. Brooks is dead on. Please, let us form large groups that can affect contractual prices, because whether we make a good living or not, no other profession has to suck up enforced 'discounts' of up to 75% for their services.
"Public hostility. Right now about 53 percent of Americans oppose the health care law and 43 percent support it, according to an average of the recent polls. Complaints are especially high among doctors. According to a survey by the Physicians Foundation, 60 percent of private practice doctors say the law will force them to close their practices or to restrict them to certain categories of patients."
Given what I have written above, there should be no surprise over the opposition of doctors. We are not sitting passively waiting for more reductions in payments, more mandates on content and character of care, more forms and inspectors. November's vote should have shown these fools how people feel. Instead, they choose as minority leader the very embodiment of their arrogance and disconnection.
Lots of patients, patients who are people and voters, feel the same way. They are frightened and disgusted by requirements to buy things, and of the thought of losing their doctor-patient relationship.
Getting this law to the Congress required deals with the AMA, and a grotesque buyoff to the pharmaceutical industry. But most doctors are not AMA members, and do not feel the AMA speaks for them. Citizens are revolted by watching sanctimonious politicians tell them they know better, while employing tactics no different from bribery and extortion. We simply call it a 'deal' when such behavior is for 'our own good'.
Obamacare faces stiff opposition, and for good reason. And I am a SUPPORTER of universal Federal level care. But not like this. Take a look at systems which work- Germany, Singapore. And please, stop imitating the policies of Europe, which is going through a painful economic and entitlement contraction. We're better than that. Our politicians should be as well. And our government and laws, too.
Ted
http://www.nytimes.com/2011/01/07/opinion/07brooks.html?_r=1
He is concerned about challenges to and weaknesses in the current health care law. I wrote back in February and March that no one was paying any attention to Tenncare as a model of what is going to happen to Obamacare. Congress also ignored what is happening in Massachussetts. Both these programs have had the problems that Brooks describes in his article. My comments follow his text.
"The courts. So far, one judge has struck down the individual mandate, the plan’s centerpiece. Future decisions are likely to break down on partisan lines. Given the makeup of the Supreme Court, this should concern the law’s defenders. "
Yes, it should. I think the constitutional challenge is quite valid, and likely to succeed. This will force a new, and hopefully more civil and productive discussion than in 2010.
"False projections. The new system is based on a series of expert projections on how people will behave. In the first test case, these projections were absurdly off base. According to the Medicare actuary, 375,000 people should have already signed up for the new high-risk pools for the uninsured, but only 8,000 have."
Basing billions of dollars of spending on projections of how people will behave has always been suspect. Is anyone surprised the projections are off? What is the incentive for signing up for these pools? There is a clear disincentive- the law is likely to be sacked, and no one likes it. Also, there is a stigma associated with being in a 'high risk pool', just as there is in being covered by Tenncare. finally, much infrastructure to execute the new law is not ready. Even people who want to sign up can not.
"More seriously, cost projections are way off. For example, New Hampshire’s plan has only about 80 members, but the state has already burned through nearly double the $650,000 that the federal government allotted to help run the program. If other projections are off by this much, the results will be disastrous."
Wow, what a surprise. Anyone who has read the most basic material about Tenncare and Masscare knows these programs are well over budget. Tenncare is being sharply limited simply to avoid breaking the state over its costs. Whenever behavior is severed from responsibility behavior is not improved, and services are overused. ER utilization by Tenncare patients is notoriously high. Many patients use an AMBULANCE to come in for a headache, because Tenncare pays for the ride. They don't have to spend gas money, and if you think the motivation is any deeper than that you are quite mistaken.
"Employee dumping. This is the most serious threat. Companies and unions across America are running the numbers and discovering they would be better off if, after 2014, they induced poorer and sicker employees to move to public insurance exchanges, where subsidies are much higher.
The number of people in those exchanges could thus skyrocket, especially as startup companies undermine their competitors with uninsured employees and lower costs. The Congressional Budget Office projects that 19 million people will move to the exchanges at a cost of $450 billion between 2014 and 2019. But according to the economists Douglas Holtz-Eakin and James C. Capretta, costs could soar to $1.4 trillion if those who would be better off in the exchanges actually moved to them. The price of the health care law could double. C. Eugene Steuerle of the Urban Institute, who has been among those raising the alarms about this, calls the law’s structure “unworkable and unfair.”
Our politicians were asleep at the switch when this issue was raised. and it is not done just by employers. Insurers in Tennessee decline patients for all manner of conditions because they know there is an insurer of resort. Employers will do exactly the same thing. I know what my business pays for health insurance, and it is outrageous. We, and all small businesses, would love to lose that burden, especially for sick or elderly employees. This may be a blessing for such employees and for their companies, but it is a financial disaster for the government.
"Health care oligarchy. Since the law passed, there has been a frenzy of mergers and acquisitions, as hospitals, clinics and doctor groups have joined together into bigger and bigger entities. The drafters encourage this, believing large outfits would be more efficient. The downside to this economic concentration is there could be less competition and cost control. In many places, the political power of these quasi-monopolies would be huge, with unforeseeable results. The law bans doctors from starting up hospitals to increase competition."
I think the liberals who drafted Obamacare assumed everyone would like it, and would not mind being forced into certain behaviors. Of course, this is a persistent, idiotic fantasy of such individuals. Certain they know best, they assume everyone else will see their wisdom, the light of their values and plans. Wrong. People see their own interests.
In this case, the average legislator is less intelligent and educated than the average doctor. Doctors feel they have been abused by payors, including governmental payors, for some time. Did Congress really imagine they would not be aching to respond, or would not be bright enough to use every aspect of the law to their advantage? Having long since created an oppositional environment between doctors and payors, it is optimistic to the point of folly to expect eager cooperation. The issue is about wringing a living from an environment where our fees are discounted, our work is disallowed, our ethics and ability questioned. Brooks is dead on. Please, let us form large groups that can affect contractual prices, because whether we make a good living or not, no other profession has to suck up enforced 'discounts' of up to 75% for their services.
"Public hostility. Right now about 53 percent of Americans oppose the health care law and 43 percent support it, according to an average of the recent polls. Complaints are especially high among doctors. According to a survey by the Physicians Foundation, 60 percent of private practice doctors say the law will force them to close their practices or to restrict them to certain categories of patients."
Given what I have written above, there should be no surprise over the opposition of doctors. We are not sitting passively waiting for more reductions in payments, more mandates on content and character of care, more forms and inspectors. November's vote should have shown these fools how people feel. Instead, they choose as minority leader the very embodiment of their arrogance and disconnection.
Lots of patients, patients who are people and voters, feel the same way. They are frightened and disgusted by requirements to buy things, and of the thought of losing their doctor-patient relationship.
Getting this law to the Congress required deals with the AMA, and a grotesque buyoff to the pharmaceutical industry. But most doctors are not AMA members, and do not feel the AMA speaks for them. Citizens are revolted by watching sanctimonious politicians tell them they know better, while employing tactics no different from bribery and extortion. We simply call it a 'deal' when such behavior is for 'our own good'.
Obamacare faces stiff opposition, and for good reason. And I am a SUPPORTER of universal Federal level care. But not like this. Take a look at systems which work- Germany, Singapore. And please, stop imitating the policies of Europe, which is going through a painful economic and entitlement contraction. We're better than that. Our politicians should be as well. And our government and laws, too.
Ted
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