Picking up after Obamacare

Whether Obamacare continues to implode or dissolves under a Republican landslide in next year’s Congressional and 2016 presidential elections, the debris it leaves behind will be horrendous.

It presents new problems for a vast U.S. medical health care system already marginally dysfunctional before Pres. Barack Obama’s misguided intended reform. And one of the most frightening prospects is that even some of Affordable Care’s fiercest opponents are now considering writing another, new “comprehensive” solution. Common sense dictates remodeling a sixth of the economy which touches every citizen directly can only be undertaken through incremental and remedial measures.

In fact, the pre-Obamacare medical scene for all its failings was at least a satisfactory system for many if not the majority of Americans. Sufficient evidence exists to refute the oft trotted out argument of Obamacare advocates that the U.S. spent much more on a per capita basis for health care than other industrial societies. Statistics in many critical areas indicate those costs could be justified in human terms by superior rates of recovery and morbidity, for example, in breast cancer.

But there were enormous problems.

Rising costs which critics used as their most powerful argument for a comprehensive overhaul of the system were without doubt No. 1. There were three principal reasons for the rising bill, all of them complex and difficult of solution:

  • “Defensive medicine” resulting from huge awards by sympathetic juries and judges for malpractice and the attendant high costs of insurance for physicians, treatment facilities and staff.
  • The rapidly growing scientific breakthroughs in diagnostic technology offering “break-through” but expensive testing and pharmacology, increasingly employed by physicians for the right and the wrong reasons..
  • The use of hospital emergency rooms by large numbers of uninsured which often might have been avoided with less expensive preventative care and which were far more costly than normal physician’s services..

Central to the problem of rising costs and insurance premiums was the Democratic Party’s mutual love affair with the trial lawyers who blocked proposed changes in common law civil justice systems. These would have capped damage awards and thereby the growth rate of litigation for malpractice. There had been some success in some states for doing just that. But, for example, the possibility of such lawsuits has mean Florida obstetrician and gynecology specialists must lay out $120,000 a year.

Diagnostic judgment calls increasingly have weighted heavily toward expensive tests, in large part because of this threat of such malpractice litigation. Diagnostic guidelines produced by the medical profession itself had reduced some of this propensity to go to more and more technology. Some older doctors lament the abandonment, largely, of semiotics, that is, the intensive study of symptoms – some relatively simple, for example, breath odor as an indicator of liver or kidney ailments – as a guide to diagnosis. Those of us among the elderly know the Solomonic quandary well: whether in a situation where symptoms suggest a severe or even mortal illness, does one go to an expensive technical test, perhaps one only recently invented which might eventually proved unnecessary?

In the pre-Obamacare era, tens of millions either chose not to take insurance because they had other priorities or found it beyond their budget for living expenses. These uninsured often used hospital emergency rooms as their physician which by law cannot turn away patients. This sometimes resulted in their overuse but more often in permitting preventable maladies to deteriorate requiring even more expensive treatment. These costs were passed back through the hospitals – many of them so-called privately owned with exaggerated administrative costs — to the taxpayer or to other insured hospital users.

But other structural problems were of equal importance in delivering medical services to as large a part of the population as possible. One was the diminishing ranks of what used to be called general practitioners, now referred to as family doctors. The lure of higher income along with their growing number of opportunities through increasing professional differentiation has drawn more medical students and graduates to specialization. Not only has this added to costs but it has deeply wounded the diagnostic process. [“Oh, I have a good left thumb specialist I can send you to.”]

Critically, it is the family physician that must perceive the holistic condition of the patient and must try to identify the problem before it is assigned to a specialist. Growing costs, diminishing rewards and increasing downward pressure on both Medicaid and Medicare payments – the two large government programs for the poor and the aged – plus the growing burden of paperwork has encouraged family physicians to take early retirement. That trend accelerated just as their recruitment has fallen and Obamacare with its bureaucratic overload may have permanently increased that trend.

Monopolistic and other unfair trading practices among the health insurance companies also characterized the pre-Obacamcare scene. It was no accident, as the Communists used to say, that some of the large, bureaucratic health insurance conglomerates like AARP climbed on the Obamacare bandwagon while the legislation was being ramroded through a Democratic controlled Congress. Obamacare from its outset promised increased and higher payments and profitability for the health insurance vendors, a solution with the scent of fascist corporatism. [When the insurance executives had their recent emergency meeting with the President, they were ushered out the White House rear entrance to avoid the media.]

Furthermore, with insurance under the state regulation, applicants often were denied access across state lines to other perhaps cheaper policies. Obamacare may have reinforced this problem by creating state exchanges, either federal mandated or created by the states themselves, which were to offer the insured access to a supposed variety of new policies – often more elaborate, more expensive and therefore more profitable policies. The outrageous example of non-childbearing women and men without small children being forced into pediatric coverage suggests what was afoot.

One of the most serious deficiencies of the pre-Obamacare era was the failure of the American medical system to meet the needs of the mentally ill. After the extensive 1950s media campaign against real and imagined abuses in mental institutions [then commonly called “insane asylums”], the great majority were disbanded. The promised extension services never materialized. Furthermore, as Sen. Pat Moynihan wrote, rationalization for no treatment was part of the general American intellectual movement of “defining deviancy down”. And as a result, we have had for more than two generations the phenomenon of retarded or psychotic individuals wandering the streets or overly zealous rules against familial institutional commitment. The recent epidemic of massacres in schools and other public places by obviously mentally disturbed individuals who either were never diagnosed or whose treatment failed is undoubtedly another result.

Even before Obamacare, the growing taxpayer burden of Medicaid and Medicare, constituted an enormous problem. The former increasingly ensnarled in federal requirements – which Obamacare intensified – on state budgets. The latter, originally intended to be itself an insurance scheme, was underfunded, particularly with the advent of the demographic swell of Postwar Baby Boomers reaching retirement coupled with the extended American lifespan.

It is probably Medicaid where the hangover from Obamacare will be felt mostly state governments, who unlike the federal government cannot print their way out of unbalanced budgets. They were faced with the dilemma of accepting large federal handouts [to be matched by state funds] with an assurance they would be continued indefinitely. That promise, several of the Republican governors reasoned, was not ironclad and their state would be mortgaged to a vast new enrollment which would eventually have to be funded exclusively by state revenues.

One of the greatest costs to Medicare and one which presented the most difficult moral issue facing the American health system on the eve of Obamacare was the growing number of persons with dementia  As lives lengthened, one 2010 study estimated that almost 15% of those over 70 suffered from some form of dementia. The annual cost to families and society as a whole was estimated annually at between $31 and $56 thousand dollars for each individual with a total cost of between $157 and $215 billion.

In the post-Obamacare era, these two elements of the total medical picture may assume the greatest importance. The obvious necessity to make “co-pay” a part of the Medicaid commitment, even for the poorest recipient, would appear part of any solution. An increase in the 20% of Medicare which now must be paid by the insured may well be necessary to refinance that system. But neither will be easy for an electorate, promised so many freebies by Obamacare.

Growing obesity and other manifestations of the American lifestyle presented an even greater challenge – and will continue to do so – in any effort at prevention rather than treatment. That is going to demand a mobilization of public opinion long after the squabbles over Obamacare are historical footnotes.

Hopefully in a more realistic environment occasioned by Obamacare’s demise, reason and common sense will prevail. And, as always, scientific breakthroughs may be around the corner, particularly for Alzheimer’s. [British scientists announced such a breakthrough in October 2013 in experiments with rats although they cautioned application to humans would be some time off.]

But there again tightened budgets, in no part the result of the Obama Administration’s campaign against competition and the traditional concept of equal opportunity [rather than Pres. Obama’s redistribution of wealth for guaranteed equality] would be the touchstone.



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