Wednesday, March 24, 2010

On the passage of Democratic Health Care Reform Legislation

I write this essay as much for my personal friends who have supported this bill, as the readership of dailykos.  Unlike previous diaries (as essays are referred to) , there is no intention to change anyone's mind on this, but only to express my own thoughts. I'm putting it on this site since I've written dozens of diaries on this subject, and hundreds more on other issues over the last three years or so.  For a long explicit essay on my objections, many of them based on independent research, (along with some duplication of this one) there is this link.

Each of us has our own unique experiences that form who we are, and we are all in different personal situations....stage of life, family, health, wealth and social name a few. It would be silly for me not to acknowledge that these things affect my thinking on this issue.  I believe that I view this bill outside of these individual circumstances, but, of course, this is impossible.

Most everyone who really understands this bill, even those uber-liberals in the congress such as Dennis Kucinich and Jerold Nadler acknowledge their profound disappointment with the concessions that were made that make it far from the progressive ideal.  Yet, they, along with Howard Dean, Keith Olbermann and others have come around to supporting passage.

Only those outside of the party, such as Ralph Nader and Michael Moore, still articulate how this bill, far from representing liberal-progressive values, is the greatest corporatist power grab in our history.  It is almost comical that Republicans, clueless as always, continue to depict this bill as a "giant government takeover of 17% of our economy."  Actually, it is quite the opposite, a bestowing of a federal imprimatur on the Private Corporations and Professional Associations that control this vast segment, that will soon be enlarged to an even greater proportion of GDP.

Hidden decrease in Medicare service, slipped in the final bill with no discussion

We currently have, and will continue to have under this law, a shortage of providers of medicare, mostly inherent in the long expensive process of imparting the requisite skills on physicians, but exacerbated by overly rigid gate-keeping to maintain exclusivity by the protected professions.   The general payment for a given procedure is highest for those with private insurance, and then drops for Medicare and even more for those on Medicaid.

This makes Medicaid, in spite of it covering a wide array of health care that medicare does not, such as dental treatment and full pharmaceutical formulary, less desirable.   It is so because it is more difficult to find providers to accept this level of reimbursement, and those that do are often less skilled than others.  

This relative value of Medicare and Medicaid was very much in play during the evolution of the Health Care Reform bill, in the equalization of payment levels between the two programs for primary physicians.   This was included in the House Bill and not in the Senate bill.   When the plan for reconciliation was adopted after Democrats lost the ability to overcome a filibuster after the Massachusetts election, the original letter of the compromise sent out by President Obama was based on the Senate bill with some itemized changes.   This equalization was not in this letter.

Only when the 150 page plus bill was submitted, only days before the vote was the equalization clause included , Section 1202 of the reconciliation bill HR 4872.   What this means is that those on Medicare, who even now find it difficult to find primary physicians in certain regions, will now compete with every Medicaid clients, including those new ones who are added by this law.    Medicaid will continue to provide full drug coverage, and dental care, that will not be included in regular Medicare.

The signing of this Health Care Reform act has arguably made Medicaid, a service for the indigent that is paid for by the taxpayers, including ironically those on Medicare, a more extensive and perhaps preferable service than Medicare.

This substantial dimination of the services, and thus the value of Medicare, was made with no announcement or discussion in Congress or in the media, that I have been able to discover as of this writing. 

Democratic Party as party of Insurers and Pharmaceutical Industry.

Many months ago I wrote a diary, Harpers Magazine, "Understanding Obamacare  It reported on an editorial by this oldest liberal publication that eviscerated the public motivation of the Democratic party's sponsoring of HCR summarized here:

The real battle in Washington is seldom between conservatives and liberals or the right and the left or "red America" and "blue America." It is nearly always a more local contest, over which politicians will enjoy the privilege of representing the interests of the rich.

This was before the public option had been rejected, and the excise tax on high price policies were watered down.  It was also before there was what to me was a litmus test of Harpers premise, which was the Democratic rejection of the amendment to prevent the Pharmaceutical Companies from charging a higher price to Americans than any other advanced country, even those with higher per capita incomes. 

There is no pleasure in my condemnation of the Democratic party for the passage of this bill.  We happen to have a two party system in this country, and the other party has defects equal or greater than Democrats. I'm aware that the final argument that won over those such as Kucinich was that even if the bill is unworthy of passage, it had to be passed for the sake of the party. I understand how that can be convincing for a professional politician, one who has used his party affiliation to achieve both his personal and ideological goals.  But I, as a voter and citizan happen to take a different slant.

The blatant fraudulence of CBO assertion of bill lowering deficit 

The bill is fundamentally dishonest. The purported reduction is the deficit in the next two decades is as illusory as is the depiction of the CBO as "non partisan, as shown here, and here (with a completely different result by the previous "non partisan" head of the CBO).

Specifically, one of the major elements of such fraud is projecting a cost for payment of physicians under government programs that are acknowledged to be false, as the agreement has already been made to increase them to the amount of a quarter of a trillion dollars in this decade.   This is from Medscape, a publication for medical professionals. 

For the sake of winning enough votes, Democrat-sponsored legislation is now designed to keep the cost of healthcare reform at $900 billion or less and to reduce the deficit. To hit their numbers, Democrats in both chambers have omitted the SGR fix and its $200 billion-plus price tag from their reform legislation and addressed the Medicare payment problem instead in separate bills — H.R. 3961 in the House and S. 1776 in the Senate.

Rather than being compassionate, helping those most in need, this bill will enfranchise private insurance companies and pharmaceutical companies in perpetuity.  This reform, with many of the nominal 33 million added to Medicaid, where even without this increased demand often do not have actual access to medical care, is more than counterbalanced by allowing private insurers to have their hand in the till forever. Far from being compassionate, it will legitimize the permanent reduction in the funds, public and private, that could actually go to reducing suffering and saving lives. 

If this had been passed by Republicans, as was Part D of Medicare, there would have at least been hope that the party of the people would regain a majority and rescind it, remove the hand of private insurers, and the excess profits of drug manufacturers.  With this bill we now know that this is impossible.  Not only did President Obama never have this goal, but the few who did, such as Denis Kucinich has been defanged and co-opted, and lost his legitimacy as a leader of the now moribund progressive movement.

I prefaced this essay by saying this is a personal diary, and as such I don't have to be consistent.  So, after just decrying the bill for being too corporatist, I have to be clear, I do not want universal health built on the present free market medical system that we have in this country. Actually, this bill will fail because of making this attempt.

For those who find the term "socialist" pejorative, there is a substitute with less baggage, communitarianism.  It is like reform Judaism is to orthodoxy, keeping the flavor without the rigidity.  This HCR bill is built on Communitarian principles; but we do not have a Communitarian country, society or economy.   This bill is predicated on increasing the numbers of people who will have access to physicians, yet (in spite of being called a government takeover) it does not begin to impede the right of physicians to change the nature of their practice to see even fewer people.   They can raise their prices to those who can afford to pay for first class as third class becomes more crowded. 

This is happening right now, under the process of boutique or retainer medical practice, something that will accelerate under this bill, yet has never been discussed in congress.  This is a real specific issue, but it is also emblematic of an unintended consequence of this bill that will actually lessen health care and raise prices as a result of a reaction by health care professionals.

I've had my own primary physician announce that I could only continue to see him if my wife and I paid a $4,000 retainer, for which he would still charge medicare for each of our visits.  But, you can be sure he would make sure that his patients were treated for every complaint by specialists, since they would be a considerable profit source. Each individual under this system pays more for his/her primary care, yet also costs the public more with increased utilization of specialists.  For this reason this had been deemed illegal breaching the rules of medicare, but it was not enforced under the previous Republican administration and seems to be condoned under the current one.

I also for a short while used one of the few dentists in the area who accepted medicaid clients.  He told me that dealing with them was always a problem since they thought nothing of not showing up for appointments without calling to cancel.  And there was no down side, as they could find another dentist in a different area to see them.  He is of Hispanic origin as were most of the medicaid clients, so I doubt that he was indulging in any stereotypes, rather he was given his experience, that the cost of helping this population will be greater since they are not paying anything for it.

This bill builds on the illusion that good health has the same value for all people; that we should help all our fellow citizens because they are just like us.  Well, obviously they're not.  There are risk takers who will choose to go down the triple black diamond slopes during a storm, or race a motor cycle on a dirt raceway.  It's their right!  Or it is as long as they are willing to pay for the consequences if they are grievously injured.   

There are those carriers of genetic diseases who don't care to know whether their fetus is afflicted with a life long debilitating condition, they want this child and are certain that God's will shall prevail.  Once again, it's arguably their choice, but certainly not mine or society's....that is unless I accept paying for the life care of such an tragic birth. 

Freedom and personal responsibility are inextricably joined.  As a more mundane example, someone has every right to dedicate his/her life to being a world acclaimed novelist, tennis player or scientist.  It's the individuals choice whether to pursue a dream or accept a "practical" compromise that will provide an income and security.  That too is freedom of choice, but if he/she take the risky path, do I underwrite it?  Is it my obligation to care for the person who went for the brass ring and missed.

And then on a different plain, there are differences about how we feel about our own ontogeny, our individual lives in the context of our, nation and species.  There are those who want nothing more than the fullest longest of lives.  For this goal,  medical care is the agent of their desire, and more of it is always better.  Every P.R release or advertisement for a new drug, or a new medical discovery stokes this focus on our own existence to the exclusion of the costs to the future. 

But there are those who think differently.  Many of our ancestors have sacrificed their own health and well being for their children, their descendants.  They would gladly give up an extra year of their own life to send their child to college, to ensure them a fuller life.  This too is an individual choice, or it had been in this country. 

Under this health care reform now universally cheered by those whose ancestors may have sacrificed for them, such sacrifice for the future is impeded.  Certainly the individual may still do so, but not the polity, as the norm defined by this bill is to focus resources to prevent suffering, to extend the life, of those now alive, without consideration of the cost to be paid by those of the future.  This is so ubiquitous that is all but invisible. 

If everyone had my values, I could certainly support legislation that made everyone follow our communitarian norms.  But everyone does not have my values, nor would I even wish it.

So, that's my explanation why I am not cheering over the passage of this legislation.  The bill goes too far in assuming common values that are anything but common; while doing far too little to even make provision of health care more effective. It is misleading to the point of deceit in describing the aggregate fiscal effect, and rather than representing a new dawn of progressiveness is actually the death knell of it, including the virtual destruction of the last leaders of the party that represented these ideals.

Passage of this bill is painful for me on many levels.  First I feel it is wrong based on my own values that I tried to describe here.  I also believe it can't achieve the very "communitarian" goals that it gives as the justification, based on the unintended consequences described, but rarely debated.
Threre are other essays on this web site that go into more detail.    The future for our personal medicare is dire, as there will be an increase in those at this payment level of all the new people under medicaid.   Doctors will not be able to maintain their practice beyond a certain proportion of such lower paying clients, so will the percentage of the newly enlarged medicare/medicaid segment who will find actually find doctors will be considerably smaller.

The bill has now become law, and the consequences shall play themselves out.  My greatest hope is every concern that I describe,  with the corresponding reasons for them, will be overcome to the benefit of our country.  This is one time when I sincerely hope I am wrong.

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