Sunday, December 13, 2009

A liberal's reasons why current HCR must be rejected

As someone who identifies with the Democratic party I write this for anyone who is inclined to support the current Health Care Reform, but is having doubts.  

Any HCR law will, in fact, increase the number of people with health insurance cards, and as such, this particular group who were previously uninsured will have improved health care. So, it is in the interest of such individuals to support this legislation, irrespective of any adverse effects on other groups or society at large.  Yet, surprisingly, according to a recent poll, described in this essay.  
Even among those who presumably stand to benefit most from a major restructuring of the insurance market -- the nearly one in 5 adults without coverage -- there are doubts about the changes under consideration. Those without insurance are evenly divided on the question of whether their care would be better if the system were overhauled.

Beyond this, all the touted benefits are unproven, while the unintended consequences, actual societal harm can be illustrated.

Although there have been isolated serious news reports about the meaninglessness of increasing insurance for a limited provider base, that you can give out all the health insurance cards you want, but this does not manufacture a single health facility or provide a single new doctor, this has gotten no media traction.  There is no short term fix for this shortage, as expansion of human or material medical resources, doctors and hospitals, have lead times of a decade at the least.  Furthermore, since President Obama vows to finance this from within the Health Care System, if this promise were to be kept, there would be no additional money, per capita, for the health care system than we now have.

Provider shortages will be exacerbated by this bill

The difference is after HRC passes there will be more people vying for the same resources. This was expressed well in this article by the President of the San Diego County Medical Society

There is already a growing shortage of physicians, particularly in primary care, as primary care physicians are compensated less than specialists. It has become difficult to recruit physicians to San Diego County, despite its lifestyle benefits. Those physicians who continue to practice may try to see more patients, but that only goes so far without compromising quality. While physician extenders, such as nurse practitioners and physician assistants, provide beneficial services, they should complement, not replace, the knowledge and decision-making skills of the physician.

With greater demand and fewer physicians, wait times will increase. To add millions of the currently uninsured to the Medicaid rolls, as proposed by the House of Representatives, without having sufficient numbers of physicians to see them is not a realistic solution. Chronic underfunding of the Medicare and Medicaid systems threatens the viability of the safety net.

Costs are difficult to reduce, especially in this age of advanced diagnostic and interventional technologies, lifesaving but expensive drugs, and the desire and expectation of patients for immediate diagnosis and return to health.

This article Giving Primary Care More Respect from the N.Y.Times about the travails of being a primary physician included dozens of responses by those in or anticipating being in this field of medicine. Here's one comment from a physician that is illustrative:

In some surveys 45% of primary care doctors are extremely dissatisfied with their jobs and want to leave the field. If even 10 million of the quoted 37 million uninsured get insurance and start knocking on primary care physicians’ doors, no reimagining of a “medical home” will make care of those patients possible. We can’t even care adequately for the patients who have insurance now (the main reason ER’s are so overcrowded now). The dearth of primary care physicians was a decade in the making and won’t be easily improved

The Doctor Drought describes how  quality of care will decline as doctors will be replaced by nurse practitioners

It is clear that if we end up with an expensive health insurance expansion that tries to pay for itself by cutting hundreds of billions from Medicare and extending Medicaid while asking the states to pay for it, physician and hospital reimbursements will be cut drastically as a result. The only way doctors and hospitals will be able to stay in business will be by seeing more and more patients while providing fewer services. Nurse practitioners are cheaper (their average salary is $88,000, compared with nearly $150,000 for a primary care physician) and will be used to make up the difference. Doctors and hospitals will hire them to "farm" their patient populations.
Quality of care will diminish along with the availability of our latest technologies, which only specialists are trained to administer. I believe nurse practitioners are useful, but I also believe my four years of medical school and three years of residency count for something. If primary care doctors become extinct, so will the kind of care our patients are used to receiving.
This explains how it will be possible to increase the number of patients by a third-- by reducing the training and skills of those who diagnose the ill.   This could actually be a reasonable approach if it were part of a concerted plan that acknowledged that this will happen, and defined the responsibilities of the various levels of primary cafe givers.   But because denial of this expected change in skill level of primary care givers, how this will be achieved, who will gain and who will lose, is uncharted territory.

Unintended consequences of more demand on limited supply

Doctors and those in the Medical-Industrial Establishment will be among the big winners in this HCR, as they will have enough customers to refuse more of the lowest payers, those on Medicaid and Medicare. By the way, such de facto refusal occurs by simply lessening the slots for given category, assigning appointments so far in the future to be irrelevant to the existing medical exigency.

Pharmacy companies will do fine, as the manufacturing cost of most drugs is low, a fraction of the cost for those under patent, so they can lower prices ten percent and still make more on the greater volume of such drugs. Private insurers will also do fine, unless the removal of the preexisting condition restriction is not matched with universal mandate. Then the very best policies will soon attract the sickest people due to adverse selection, which will cause them to be eliminated.

Cynicism that this bill is actually designed for the benefit of the powerful members of the Medical Industrial complex was made stronger by not only the rejection of an amendment that would have lowered pharmaceutical costs, but that the vote was not even reported by most of the media, as I described in this essay.  In this example, the "suicide" of the Democrats would not be to the advantage of Republicans, or anyone else, since loss of faith in our system of government will harm us all.

Business Model of Health Insurance will not mean better Health Care

Most insurance has a straight line relationship between number of customers and expense. If life insurance were to be mandated, profit would only increase by the percentage of new clients, since there would be the same incidence of deaths which is the occasion for paying the principle of the insurance.

Health care is different. Payment is not on the occasion of disease or accident, but rather on actual medical care. If there is a shortage of providers, which is the actual case, a large influx of new clients will not be reflected in commensurate expenses. If doctors or hospitals are not available, or if appointments are so far in the future so that effective therapy is useless, the expense will be lower, as care will be reduced for all. Links to articles on such increasing shortages even in the absence of this expansion are in the section on Supply and demand and in reference section.

HCR exemplified by the 1900 pages of complex law in the HR 3962, with dozens of sections each with detailed references to existing law and other clauses in the bill. This makes it all but indecipherable to even those who study and report on it's details. The one group who understands each clause intimately are the special interests that are ostensibly being controlled by the language, and they have the clout to ensure that they the law will not affect their bottom line, and the controls will be ineffective. This was illustrated in this article from the Washington Post, Health insurers could bypass some key reforms.

It took two weeks after passage of the bill in the house and probably months after this was written for a reporter to see the actual defects of this single complex section. With 1900 pages in the house bill, and a new bill written with major imput by special interests in the conference committee, we can only imagine how the final bill will be distorted to de-fang purported controls on industry. And this final bill will be voted on by both houses in a matter of days, with no time for the actual shortfalls to be even discovered, much less made open for public debate.

And it took more than three weeks after the Senate bill had been submitted for this simple contridiction to be noted by the press.  Annual Insurance Caps were no Loophole

This is complex legislation, and rushing this through in days after a major revision subverts democratic principles.

ERISA and its malignant effects 

this is the one area in this log that I have not personally researched, it is based on this dailykos essay.

Why do insurance companies act the way they do?
Because they can.
The vast majority of people who have health insurance, nine out of ten according to the WSJ, get that coverage through their employment.  Therein lies the problem.  The federal law which governs employment based-coverage (including life and disability as well as health insurance) – the Employee Retirement Income Security Act (ERISA) – not only fails to prohibit bad behavior by insurance companies, it affirmatively encourages it.
It appears that nothing in either house of congress current proposals will change the above.

Boutique Practice--when increased demand meets fixed supply prices go up

One method doctors can dramatically raise their fees in by switching to boutique, or retainer practice in more wealthy areas. I describe in this diary how they can cut the number of patients, predominantly the poorer ones, while focusing on those who can pay an upfront fee, $2000-$5000 per year for more extensive service. This will also included facilitated visits to specialists, all paid by medicare, and perhaps some other benefits that the rich can provide. This the concept of universal equal care for all seniors will be subverted....even faster than it is now.

It's as though when we went to war in 1941, we didn't bother to issue ration stamps or impose price controls. This HCR is the embodiment of Joseph Hellers brilliant "Catch 22" It reflects a world where the public can be deluded by a health insurance card with a phone number that is not connected to actual health care structures, since the law that provided the cards never considered the laws of human nature.

Every analysis of this bill that I know of makes the erroneous assumption health care providers will not actively resist attempts to reduce their income. The "scoring" of these bills are static analyses that would only apply in a police state, and even then would be defeated by black markets.

Only the report by the Chief Actuary of Medicare, that I write about extensively in this essay, confirms that active resistance to lowering re-embursement is to be expected, with the effect of higher prices and shortages of service.

There are other ways to conceptualize aggregate quality of a nation's health care. There is quality of medical engagement, average cost per appointment or access delay to physicians or hospitals. These will probable remain the same or get worse, on average, for reasons described below.

"Mandates"  one word for two different issues.
This N.Y. Times article, describes the two distinct issues both, confusingly enough using the same term. The first mandate is the requirement that individuals purchase insurance:

The proposals now before Congress would require just about everyone to buy health insurance or to get it through their employers — which would generally result in lower wages. In other words, millions of people would be compelled to spend lots of money on something they previously did not want, at least not at prevailing prices.

This relationship between the need to pair subscription with coverage, either everyone is forced to buy a policy or you can't have universal coverage, was so clear that Paul Krugman castigated candidate Obama for fudging on this. In fact he felt strongly enough to support Hillary Clinton for being honest about the need for such universal requirement to purchase insurance. But Krugman, Academic credentials and Nobel Prize not withstanding, has wavered, becoming more a partisan democrat then the economist.

This proposal for mandates to buy insurance. is naturally onerous and resented by most Americans. So over time the Democratic majority has watered down this requirement. It had been a firm mandate, backed up by criminal penalties, but this did not poll well. So in a bit of partisan flim flam this was gutted, by having the same bill that had been proposed and rejected by Republicans in the Senate Finance Committee reintroduced by Democrat Charles Schumer. It was then accepted by Democrats thus passing almost unanimously. Even Professor Paul Krugman criticized this, but oh so gently, as I described here.

Other "Mandate" issue, what must be included in every health policy, This is usually determined by political clout rather than scientific principles. The insurance policies that will be mandated (1st usage) to be purchased by every individual, and subsidized by the taxes of all Americans is a complex packages of services. A portion of these are based on scientific verification of efficacy, that part of MDs actions that are verified by "evidence based" principles. The rest is the grab bag of traditional doctor's practice, including demands of patients for such things as useless antibiotics for colds, or the hand-holding placebo function of physicians, which certain people enjoy and others would prefer to get by speaking to their minister, family or the guys at the bar.

More about such provision mandates from the Times article:

A further problem is “mandate creep,” which we’ve seen at the state level, as groups lobby for various types of coverage — whether for acupuncture, alcoholism and fertility treatments, for example, or for chiropractor services or marriage counseling.

There are now about 1,500 insurance mandates among the various states, and hundreds of others are under consideration. The dynamic at work here is that the affected groups have a big incentive to push for mandates, while most other people are unaware of the specific issues and don’t become involved.

Because mandates don’t stay modest for long, health insurance would become all the more expensive. The Obama administration’s cost estimates haven’t considered these longer-run “political economy” issues.

So under this HCR law we will all have to pay for insurance, our own and those whom we subsidize, that include unproven practices mentioned above, but exclude abortions and dental care---something that those who must buy these policies will now find even less affordable. Every mandate is a choice, that had been made by the individual, but now is made by the government for every citizen. Every mandate increases the price of insurance, which means that since there will be a requirement that everyone purchase this, it has the effect of lessening the ability of the every American to have resources to purchase that which is not mandated.

By not mandating Abortion, and going further and according to the house bill having an Negative Mandate, a proscription for this service, it will deny a given number of women the right to an abortion by diverting funds that could have been available to purchase insurance. The post HCR policy will have other services, such as marriage counseling, which is a cruel joke to the pregnant unmarried woman who does not want to carry her fetus to term.

Such mandates will only grow even more under the federal government, which, unlike states, have the authority to "print money" to cover its excesses, thus keeping insurance rates low....right up until the harm to our fiscal integrity reaches the point of no return. In the name of prevention of individual disease, we court economic catastrophe, a national disease, we won't recognize until irreversible economic collapse.

Increase in income levels for subsidies-societal effects

To the best of my knowledge has not been discussed in any media before this diary on November 2. This HCR law represent a hidden expansion of those who will become recipients of government benefits based on annual income, by including subsidies for those earning up to three times the poverty rate, around $88,000 for a family of four. This will increase the value of unreported income, currently estimated in this report at over 2 trillion annually. This means a family who earns 90K a year of reportable income will end up subsidizing those millions who may earn even more if a portion is unreported, as it the case for many small service providers.

Every government program is predicated on widespread acceptance of the legitimacy of our ability to fund programs, otherwise known as taxation. The ultra wealthy can afford the best tax lawyers to skirt the regulations, but for 99% of the population it is just another injustice that is accepted. Under this law, insurance subsidies will extend to those families earning up to $88,000, making the temptation to convert earnings to "off the books" that much greater. That swath of earners, too rich for subsidies and too poor for "creative" tax lawyers, will be the ones to pay, and to become even more antagonistic to government in general.

This legislation will have the effect of creating a line between those who are taxed for subsidies and those who receive it where before there had been a socio-economic gap. (subsidies will be provided for families making $88,000 a year) The middle class were willing to be taxed for those on Medicaid since they were those who, through unknown but perhaps innocent bad luck, were worthy of sympathy. This perception was facilitated by their being different, in a different neighborhood, eating at cheaper restaurants, living without the benefits of those who have "made it."

This law will not only eliminate the gap, that I see as facilitative of acceptance of being taxed for those on Medicaid, but given the acknowledged underground economy, will result in many people actually being taxed for those who earn more than they do, and are living better than they are able to live.

Malpractice Policy is a window on this Bill 

It can be found in a single section 2531 of HR 3962.  It acknowledges the defects in the current system, by appropriating funds for states that require a "certificate of merit" before a case can even be brought to court. However boldly mandating universal care is defined in this bill by the federal government, it is strangely diffident in addressing this hot button issue of malpractice.

It does not even require such a certificate of merit, acknowledged in the bill to be advantageous, to precede any tort by preemptive federal mandate. One of the hopes, the justifications of this bill is that it will shift our country's health care to more effective, evidence based procedures. A powerful tool to reach this end would be providing safe harbors for any doctor who follows such procedures.

Malpractice policy is more than limiting high doctor's insurance for this, or preventing excess "defensive practice," it could be a tool for promoting the practice of evidence based medicine that acknowledges the limits of any practice and the potential for bad outcomes even give proper procedure.

This article, Is "No-Fault" the Cure for the Medical Liability Crisis?, by David E. Seubert, MD, JD published by the AMA shows how a replacement for the current judicial based system can promote the long range goals of Health care reform.

A no-fault system of compensation for medical injury similar to the workers’ compensation and automobile insurance models may be the answer to the medical malpractice crisis omnipresent in the United States today. Allowing physicians to come forward when an error occurs and join forces with their patient(s) and the hospital system could improve the entire network of health care. The current conspiracy of silence carries great risks for society. Suppose the error that has harmed a patient lies in a faulty system and has potential to do much more damage? Silence and lack of investigation of the problem can have greatly deleterious consequences.

A no-fault system encourages health care professionals to identify the system malfunction and take a proactive approach to fixing it. At the same time, where a patient has suffered harm, the no-fault system must assure appropriate compensation. Such an approach accomplishes two goals: first the patient is compensated for the injury, and, secondly, society’s health care is upgraded and enhanced by fixing an error in the system. Such an error may in fact be a physician with a deficit. The no-fault process can identify this deficit and allow for physician retraining and rehabilitation.

It is interesting that the long articulate refutation of the above article by a malpractice litigation firm at the end of the link above, includes this:

Reforms to the existing system, such as fostering increased communication of errors, limiting the use of juries for determinations of fault but not for determination of damages or using neutral medical experts, may prove more advantageous to both patients and physicians.

This happens to express my proposal pretty exactly. Yet, this pending bill ignores the opportunity to transform this politically defined system, in this case protecting the constituency of plaintiff's lawyers, thus impeding the very goals that are used to justify this comprehensive reform.

Seniors on Medicare will have sharply reduced health care

It is far from proven, or even shown to be probable, that this law will result in aggregate improvement of medical care for the people of this country. More likely it will benefit the currently uninsured by disadvantaging others, most severely medicare patients. The lack of concerted resistance by seniors can only be understood by the conflict of interest of AARP, the organization ostensibly dedicated to their well being. AARP has a clear conflict of interest, as a majority of their profit comes from licensing their name to private insurers, as described in this article. And this segment will grow under this bill:
Rather than destroying the private insurance market, data from the non-partisan CBO show that, under the House bill, private insurance plans will actually grow over the next 10 years – with 15 million MORE Americans enrolled in private plans in 2019 than would be otherwise.

BTW, the above quote is from the house web site that describes the benefits of the bill.

Medicare clients, who by the way include rich and poor who have been paying into this for decades, will not be included among those new patients, including those who could have a family income of $88,000 and actually be subsidized by them. While the original house bill would have given Public Option subscribers priority over medicare, by mandating that they pay more to providers, the current one will be worse.

By allowing administrators of the public option, and private insurers for that matter, to negotiate with providers, the rates they pay could be substantially higher than medicare payments, which for an under supplied geographical region or specific specialty would mean even longer delays than already exist for medicare patients.

As I wrote in the section above on Supply and Demand, illustrated by personal stories of those in the medical profession, with this bill there will be longer waits for appointments, which will be fatal for many. For every uninsured who would get an appointment with a scarce primary provider, a medicare patient will go to the back of the line. And sadly, the improvements in efficiency that could redress this are only suggestions, with no teeth at all to enforce them.

Even without a new group of previously uninsured who will pay providers more than medicare, this group of seniors are being cut out by providers. The Mayo Clinic, often cited as the benchmark of excellence in medical care has just cut out Medicare clients from their services in some sites, as described in their press release. With the bulk of saving that are promised in the house bill coming from reduced Medicare payments, the facilities that will be available to such clients will be even more sharply curtailed. The Washington Post  article, Report: Bill would reduce senior care,  describes a report Richard S. Foster of the non partisan Centers for Medicare and Medicaid Services that confirms the foregoing.

There is a better approach to universal health care

The argument that seems most compelling for passing this HCR law is, "We can't go on like this, and this bill  is a first step that must be taken." I disagree, as does Howard Dean, someone who is just removed enough from politics to view choices objectively.   There are different approaches, that do not build on the current distorted profit based political model. There could be a parallel system of single payer, that would transform a part of every emergency ward into a federal system for providing basic health care.

Just as the VA preempts state licensing law for it's professional staff, such a national system could also do so. Rather than malpractice prevention being in the judiciary, with it's acknowledged excesses, there could be a better system, where those who report malfeasance would not fear their own legal liability. It would be a blow to plaintiff lawyers, who would be replaced by a system of experts, who in the process of reducing poor medical practice could also foster rational procedures.

This provision would hurt a major Democratic constituency, but there would be other aspects of this program that would sacrifice the interest of traditional republican supporters. This is what bipartisanship really means, sacrificing party interest for the sake of the country.

This parallel universal system could work incrementally, growing with the increase in providers, eventually incorporating existing successful non-profits such as Kaiser Perminante into this network. It would actually realize the ideals of this current bill, cutting waste, promoting evidence based medicine and expanding coverage-- without trying to do the impossible, which is to pander to the existing powerful interests that are perpetuating our current health care defects.

This would be transformative and actually politically possible. Professionals in this system would be chosen by aptitude, responsive to demand for specialized training. As an example, free medical education would be available to those willing to dedicate their career to this system. Unwarranted escalation of professional educational requirements, something that creates artificial shortages, would be tackled frontally, to the benefit of consumers.

It would be a parallel and effective means of providing health care to all


Unlike the 1993 Clinton attempt, President Obama did not design this reform in an academic think tank, but tossed it into the political cauldron of congress, with results that could have been anticipated. Every title, clause and section is designed to appease wealthy interests, what I call the Medical Industrial Complex. The other criteria beyond raw financial clout is public perception, that every aspect must poll well, not necessarily work well. The disconnect, the absurdities, inconsistencies and hidden traps, will be lost in the thicket of thousands of pages of this law. So, while this politically designed bill may, in fact, become law, it is every citizens obligation to seriously evaluate the product, to see whether this particular "sausage" should be required to be consumed by every American.

Sadly, Democrats have avoided a substantive debate on this issue by deflecting all arguments against this bill as partisan political attacks. Obama's soaring rhetoric, that this is an "historic moment coming once in a generation" ignores the ugly defects of this legislation. This approach seems to be effective, due to the particularly low public opinion the other party, and their desperate exaggerations that are easily refuted. So what real dialogue that does occur is with the major beneficiaries of this bill, private health insurers and pharmacy companies for instance, who will both benefit greatly and want to keep it that way.

As someone who is on Medicare, I realize that changes must be made that will adversely affect those in my situation. And, I could accept it, even welcome it, if it were part of a meaningful comprehensive reform that was actually going to improve health care for all segments of society in an equitable manner. The waste, the excesses of testing and treatment, that President Obama says will be cut out of Medicare is never viewed as such by someone facing life threatening illness. Claiming to fund this program by identifying and then drastically cutting this "waste," is actually a cruel joke. It is made more egregious by not tackling the actual waste caused by existing malpractice system, acknowledged as faulty in this very bill, while refusing to restructure it.

Perhaps, real health care reform can never be constructed by a political institution, those who depend on financial support from the industries that they must reform, as is the case with Congress. Allowing this to be a political product, the proverbial sausage that should never be carefully examined, may in fact get this law passed. For those who never dissect this bill, never put it under a microscope or even take a deep whiff of the odor emanating from it, the title of the House bill alone " America's Affordable Health Choices Act of 2009" may seem like progress.

But for those who examine this bill, whatever their party or perspective, the title will be notable as a cruel parody of what could have been. It mocks the potential had there been the political will to actually dismantle the existing power structures, to build something that actually would transform our distorted system that represents both the best and the worst of medical science applied to the needs of a diverse population.

As a society there are times to rise above partisanship to preserve and yet to restructure vital components of our social fabric. It is tragic that such a moment seems to about to be missed.


1-Journal of American Medical Association article describing why health care is higher than other countries, and their solutions. These are not addressed specifically in current HCR.

2-Why we must ration health care The lead article in the N.Y Times magazine of July 15th by Peter Singer. Provocative and true, affirming the thesis of this diary that this bill is built on refuting the intrinsic irrefutable reality of rationing of the scarce resource of medical care.

3-Dartmouth Study of wide discrepancy in medicare expenses per patient, includes links to commentaries. This N.Y Times article describes the current debate in house bill in dealing with this, and why the solution is not as simple as it may seem.

4-N.Y. Times series called Prescriptions, hundreds of articles and comments that give a realistic view of what can be expected from the current incarnation of Health Care Reform.

5-How this bill will have the unintended consequences of exacerbating shortages of primary physicians and raising prices. It's in this diary, "The secret flaw in Health Care Reform, Boutique Practice"

6-Watering down of requirement for everyone to purchase insurance, something that is seen as necessary for universal coverage, including those with pre-existing conditions. Senate Committee Action described in this diary.

7-My diary, that gives synopsis and link to this powerful New Yorker Article explaining the current approach will not even begin to address the real defects in our medical system.

8-David Leonhardt, the N.Y. Times most prolific writer on health care reform rejects the house bill in this article: Falling Far Short of Reform 

9- HHS actuarial report on cost of HR-3962, pointing out that the estimates for savings on Medicare will either may not be achieved or else result in closing of facilities to Medicare clients, and reduced services

10-From N.Y. Times "Shortage of Doctors....." 
As interesting as the article, describing how this will be a problem for Health Care Reform, are the comments, most of them from physicians describing their own frustrations in the field and trying to make a living.   Lack of Federal licensure would seem an easy fix, as well as more rational malpractice, but the difficult challenges to professional organizations, AMA, are not taken on in the current incarnations of the bill. 

11-Article by the Dean and CEO of Johns Hopkins Medical Center
"Health Reform Could Harm Medicaid Patients A vast expansion of the program will impose unsustainable costs on treatment centers."

12-Here's a link to an early diary that I based this one on, with the same poll.

13-N.Y. Times article describes how medicare savings are counted twice, once to lower the deficit and the second time to increase the duration of solvency of the medicare trust fund. The CBO acknowledges "this is illogical in real life" but does it anyhow.


  1. What a great post! Thanks for helping to shed light on some of the real issues relating to the mess of a bill moving through Congress.

    I also read your article on DailyKos, "HCR on track to pass means Democratic suicide." It's time for me to return to my progressive roots and abandon supporting the Democratic Party.