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Obamacare: Understanding the Affordable Care Act

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  • Obamacare: Understanding the Affordable Care Act

    The following articles offer different understandings to this new health care law:

    Doomsday Machine Creating More Uninsured

    Many years ago I saw a Star Trek episode (the original one with Leonard Nimoy and Denny Crane, I mean William Shatner). There was a giant tube aimlessly bouncing around the galaxy gobbling up and destroying everything in its path. It was called The Doomsday Machine. Apparently it was left over from some long forgotten alien war and was still mindlessly destroying everything in its path. Even planets. It was uncontrolled and uncontrollable. I don't remember how they dealt with it. But ObamaCare has taken on the aura of The Doomsday Machine. Since the Roberts Court let the law stand on the basis that the penalties are really a tax, but took away the ability of the federal government to coerce states into expanding Medicaid, ObamaCare is like that giant tube, bouncing around the US economy destroying everything in its path. It is uncontrolled and uncontrollable.

    Or it is like the end of Dr. Strangelove when the Russian sets off the Doomsday Machine - a series of uncontrolled atomic explosions. Believe it or not, they used to speculate the Russians had such a device. My father who was a Chief Engineer at Boeing attended seminars about such a device. He said at the time, "It is a big waste of time because if they have it and use it, there will be nothing to plan for." As we later discovered, the Russians weren't as suicidal as we had been led to believe. But ObamaCare is kind of like that, too. Remember that the "Medicaid Coercion Factor" was voted down 7-2, meaning Chief Justice Roberts got two of the liberals to go along (Breyer and Kagan). The ObamaCare plan was to dump as many patients as possible into Medicaid and over time convert that into the single payer. Liberals have long had a fantasy love affair with the idea of Medicaid, which by the way, is an awful program.

    Now there is a distinct possibility that ObamaCare will actually increase the number of uninsured. The Congressional Budget Office (CBO) is projecting there will be 30 million uninsured after the implementation of ObamaCare. What's up with that? I thought for all the effort, we would be insuring everyone. That assumes everything goes according to plan. But it could get worse. Since companies may end up paying a fine of a few thousand dollars, many are itching to dump their workers onto either Medicaid or the exchanges. But with no ability of the feds to make states pay for Medicaid, those workers will be out in the cold. As in "no insurance." Also, giant cracks are showing up in the IRS plan to collect taxes for ObamaCare. There appears to be no ability to collect the taxes written into the law. That was ill planned, too.

    If a company pays $10,000 dollars to insure a worker, but can pay $2000 and dump them on Medicaid, that is what they will do. If the state doesn't have Medicaid, then the worker becomes uninsured. There is no provision that forces a state to create an insurance exchange. That is up to the feds. But the feds can't pay subsidies like the states can. Considering there was never anyway to pay for ObamaCare from the start, things have just gone downhill. The Class Act was a harebrained scheme whereby people would buy nursing home insurance in their 20s and 30s. That money was to finance ObamaCare. The Class Act got dropped last fall. No one was signing up for it. Duh! Add in all the double booking of spending, the increased expenditures called "cost cutting" and the "tax" that isn't a "tax" - it is looking worse by the minute.

    Tony Francis, MD
    Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

    "You're just a jaded cynical mother****er...." Jeffpeg

    (more comments in my User Profile)

  • #2
    Surprisingly, from an expected "more liberal" sort of web site, Zimbio. It has a good discussion of the "mandatory" aspect of Obamacare:

    When President Obama was selling health reform, he often talked about providing universal coverage. But a Congressional Budget Office report out this week finds that goal getting more elusive. The report found that despite ObamaCare's $1.2 trillion price tag, it would only cut the ranks of the uninsured in half, leaving 30 million without coverage. That's seven million more uninsured than the CBO first projected in March 2010.The latest downgrade comes in the wake of the Supreme Court ruling, which gave states the freedom to reject ObamaCare's massive expansion of Medicaid. Since then, governors in more than 25 states have said they will refuse to expand Medicaid or are leaning in that direction, despite the generous federal contributions.

    But the uninsured problem under ObamaCare could be much worse than the CBO projects. What the report doesn't cover is the fact that the other legs of the ObamaCare stool designed to expand insurance coverage — the individual mandate, the employer mandate and the state insurance exchanges — are also buckling. As a result, ObamaCare will likely cover far fewer uninsured than advertised. There's even a chance that, if all goes wrong, it could actually make the uninsured problem worse. The individual mandate, for example, is a cornerstone of ObamaCare's effort to expand coverage. But tax experts who've studied how the IRS will enforce the mandate conclude that it's likely to be ineffective, because the law makes it virtually impossible for the IRS to collect the tax penalty from those who don't pay it. Under normal circumstances, the IRS has broad powers to collect taxes from those who don't pay what they owe. It can charge civil and criminal penalties, impose liens, and seize assets and bank accounts. But ObamaCare specifically blocks the IRS from using these enforcement tools when it comes to collecting any unpaid ObamaCare tax penalties. These restrictions "make it unlikely the IRS can effectively enforce the individual mandate," according to a detailed analysis of the tax penalty by Jordan Barry and Bryan Camp, law professors at the University of San Diego and Texas Tech University, respectively.

    "The individual mandate," they conclude, "may not actually be mandatory after all."

    The problem is that if the mandate doesn't work, ObamaCare could make the uninsured problem worse, at least in the individual insurance market. That's because ObamaCare's insurance market reforms — called "guaranteed issue" and "community rating" — force insurers to cover anyone, regardless of their health status, while forbidding them from charging the sick more than the healthy. ObamaCare's designers knew that without an effective individual mandate, these market reforms could cause a "death spiral" as healthy people dropped coverage knowing they could get it — guaranteed — whenever they got sick. This death spiral, in fact, is just what happened in states that tried those market reforms without imposing a mandate. ObamaCare backers say that generous subsidies offered through the ObamaCare "exchanges" will more than make up for a neutered mandate. But Obama's solicitor general, Donald Verrilli, admitted before the Supreme Court that without an effective individual mandate, "guaranteed issue and community rating will, as the experience in the states showed, make matters worse, not better. There will be fewer people covered; it will cost more."

    In addition to problems with the individual mandate, there are increasing concerns about the effectiveness of the employer mandate at maintaining the employer-based system of coverage, through which 154 million get insurance. Studies consistently predict that around four million people will lose workplace coverage as a result of ObamaCare, despite the fines imposed on businesses that don't offer insurance. But the most recent analysis from the Congressional Budget Office says the number could be as high as 20 million. And a study out this week by Deloitte finds that almost one in 10 businesses expect to drop coverage, with another 10% saying they weren't sure. A 2011 McKinsey & Co. survey found that 30% of companies "definitely or probably" would drop health benefits under ObamaCare. Finally, there's a potentially fatal flaw in ObamaCare's insurance exchanges, which are designed to let individuals pick from a variety of government-approved health plans and get subsidies if their incomes are below certain levels. As written, the law only allows state-run exchanges to offer subsidies, according to an analysis by Jonathan Adler and Michael Cannon published by Case Western Reserve University School of Law. Federally run exchanges, they concluded, aren't allowed to. If federal exchanges can't provide subsidies, that would dramatically undermine ObamaCare's efforts to cover the uninsured, since as many as half the states might leave it to the feds to set up their exchanges. The lack of subsidies at federally run exchanges would mean far fewer could afford coverage. The CBO expects 25 million to join the exchanges, assuming all of them can offer subsidies to the 80% who would be eligible. It would also mean that businesses in those states would be exempt from the employer mandate.
    Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

    "You're just a jaded cynical mother****er...." Jeffpeg

    (more comments in my User Profile)


    • #3
      From Forbes, obviously a more conservative way of thinking, but still an enlightening article:

      In order to guarantee insurance to all, regardless of age, health or pre-existing conditions, the framers of the plan concede that it is essential that the young and healthy (who are less likely to be heavy users of health care) pay into the insurance pool. The surplus generated from their premiums compensates for the money lost to those receiving more in services than they pay in premiums (e.g. older people and those with medical conditions). The ACA has given these healthy people a “Get out of Jail Free” card that many of them are sure to play. Most healthy young people know that they are losing money to insurance providers, at least in the near term. That is the nature of insurance. You pay to prevent costly exposure to an unlikely event. And just as homeowners wisely pay for fire insurance even though they don’t expect their homes to burn down, given the high cost of medical care it is also practical that healthy young people buy health insurance.

      ACA makes it illegal for insurance providers to deny coverage to anyone for any reason. This allows healthy people to drop insurance until they actually need it without incurring any risk. It’s like allowing homeowners to buy fire insurance after their houses burn down. To counteract these new free rider incentives, the law imposes “no insurance” penalties (also defined as taxes by the Supreme Court). The problem is that these “penaltaxes” (for lack of a better word) are insufficient to the task. In fact, Chief Justice John Roberts ruled the law constitutional precisely because the burdens were not high enough to compel behavior. (In other words, he thought the law was constitutional because it will be ineffective.) The numbers support his arguments. On average, in 2010, a typical healthy young person paid at least $2,500 per year for insurance (for a plan that would still involve significant out of pocket expenses). In some areas of the country, premiums were more than twice as high. When the program takes effect in 2014 the penaltaxes will be the greater of $95 or 1% of household income. A single person earning $40,000 per year who chooses to go uninsured would then be subject to a $400 penaltax.

      The decision would be an easy one: drop the insurance, incur the penaltax and pay for any routine medical services out of pocket. In the unlikely event that he gets cancer or is hit by a bus, he can always buy insurance in the ambulance on the way to the hospital. Even in 2016, as the penaltax increases to the greater of $695 or 2.5% of household income, it will still not make sense for many people to buy insurance. The penaltaxes are capped at levels that equal the full cost of an average health plan. So even high income individuals are no worse off financially for not buying insurance. In addition, the IRS’ ability to actually collect these penaltaxes is limited to garnishing income tax refund checks. If an individual is not getting a refund, the IRS is impotent.

      The law places no requirements for businesses with fewer than 50 employees to offer insurance. So when younger workers realize the benefits of dropping insurance, they will naturally gravitate to savvy businesses that offer higher pay instead of insurance. This will drain more premiums from the insurance pools.

      In contrast, the burdens placed on employers with more than 50 workers are complex, onerous and unpredictable. Those that don’t offer insurance would be subject to substantial (and open ended) penalties if at least one employee receives an insurance tax credit or a government subsidy to an insurance exchange. If they do offer insurance, they will also be subject to substantial (and open ended) penalties if the plan fails to cover 60% of employee health expenses, or if premiums for any employee are more than 9.5% of family income. It has been left wholly unexplained how employers are supposed to accurately determine these triggers which involve knowledge of family income, not just employee income. Smaller employers will look to avoid these headaches by staying below the 50-employee threshold. Though it should be obvious, there is plenty of evidence to support this tendency. French law involves significant regulatory requirements for businesses that have more than 50 employees. As a result, there are currently 2.4 times more French companies that have 49 employees than there are with 50. Incentives for businesses to stay small will hurt the economy and will further shrink the numbers of people paying into the health insurance pools.

      Employers will also be incentivized to avoid hiring lower paid workers who would be more likely to trigger the penalties tied to household income. As a result, many small companies will likely look to replace lower rung employees with temps, automation or outsourcing, further raising the barrier to workforce entry for lower skilled workers. The unemployable workers will then qualify for free health insurance, further draining the system. Unless the penaltaxes are raised significantly, far too many needed premium payers will drop out. As they do, insurance companies will try to recoup the lost revenue by raising premiums for the customers who remain. As the gap between the relatively low penaltaxes and the high cost of health insurance premiums increases, so too will the incentive to drop coverage. This self-reinforcing dynamic will render the entire plan non-viable.

      It is a foregone conclusion that the Obama Administration and its congressional allies are already planning to raise the penaltaxes. Although such increases would render the plan unconstitutional if they compel behavior, according to Roberts’s analysis, I do not expect the Supreme Court to ever rule on this case again. The Court has a history of opening small cracks in the Constitutional barn door for the bureaucratic horses to stampede.
      Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

      "You're just a jaded cynical mother****er...." Jeffpeg

      (more comments in my User Profile)


      • #4
        Turning health care into an adversarial arena:

        A System for Patients to Report Physicians' Medical Mistakes Is in the Works

        Federal healthcare experts have long viewed patients as an untapped resource in the effort to improve patient safety. Patients have potentially vital information that could help to more fully answer questions such as why medical errors -- including drug mix-ups and wrong-body-part surgeries -- occur, these officials say.

        But if collecting accurate data on medical errors generally has proven difficult, collecting such data from patients in particular has proven even harder. For one thing, no formal mechanism has been put in place for patients to report safety events -- until now, that is, according to a report on[1]

        A pilot program proposed by the Agency for Healthcare Research and Quality, part of the US Department of Health & Human Services, would supplement safety reports now forwarded by providers, including doctors and hospitals, with those from patients and their relatives. In the proposed reporting system, these patients and family members "would report medical errors and near misses through a Web site and in telephone interviews." For each incident, the government would seek to learn the basic facts, including details of the event, whether there was harm and what type, and whether the patient reported the incident and to whom.

        The government also wants to glean why a medical mistake occurred -- or, more accurately, why patients think it occurred. To help them along, a draft online questionnaire offers some possible reasons, including:

        "A doctor, nurse, or other healthcare provider did not communicate well with the patient or the patient's family."

        "A healthcare provider didn't spend enough time with the patient."

        "Healthcare providers failed to work together."

        "Healthcare providers were not aware of care received someplace else."

        The draft questionnaire also asks patients for the name and address of the doctor or healthcare worker involved in the mistake and for permission to share the report with that provider so that he or she "can learn about what went wrong and improve safety." Federal officials have said they will keep reported information strictly confidential.

        Patient safety advocates have praised the proposed reporting system. "Patients and their families are a potential goldmine of information," said Martin J. Hatlie, Chief Executive of Project Patient Care. "They see things that busy healthcare workers don't see. Doctors are in and out. Nurses are in and out. But relatives are there continuously with the patient. They often know how to fix errors that cause errors."

        For the most part, provider groups have also been supportive of the idea. "It's a great concept," said Nancy E. Foster, Vice President of the American Hospital Association. "The idea is welcome."

        But Kevin J. Bozic, Chairman of the Council on Research and Quality at the American Academy of Orthopedic Surgeons, has stressed the importance of matching information in patients' reports with that in the medical record. Said Bozic, "Patients' perceptions and experience of care are very important in assessing the overall success of medical treatments. However, patients may mischaracterize an outcome as an adverse event or complication because they lack specific medical knowledge."

        The American Medical Association is still studying the proposal, which must receive White House approval in order to move forward.
        Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

        "You're just a jaded cynical mother****er...." Jeffpeg

        (more comments in my User Profile)


        • #5
          How the patient population doesn't help:

          "I Don't Believe You -- I Don't Have Diabetes."
          Brian Fishman, DO, General Practice, 09:12AM Mar 25, 2013

          I've always found it amazing that people can be in such denial about their health. Just this past week alone, I've seen three patients who put off getting a colonoscopy into their 70s and 80s who presented with recurrent rectal bleeding that turned out to be cancer. I know a pulmonologist who takes cigarette breaks. Even my own father, an oncologist who should know better, had chest pain radiating down his arm, knew he had had an MI, and only told someone three days later when a nurse asked him why he looked so terrible.

          A few days ago, I saw a patient who was admitted for recurrent bilateral lower extremity cellulitis. She had multiple chronic non-healing ulcers on the dorsal surface of her feet, neuropathy, DVTs, and MRSA infections. She had a 40-pack-year history of smoking and an HbA1c of 12. When I asked her if she'd ever been diagnosed with diabetes, she scoffed and said of course not. Then I asked her if she was aware that her blood glucose that morning was 236, and her response was, "that's normal, isn't it?"

          Later that day, I went to see her again with my attending to change the dressings on her legs. He started giving her the you-need-to-quit-smoking and the you-need-to-take-your-diabetes-medication talks. He told her that the majority of her issues - the chronic wounds, her COPD, bronchitis, neuropathy, and DVTs - were all because of her smoking and noncompliance with diabetes medications. Her response? "I don't believe you. Every doctor tells me that my problems are all because I smoke or because I'm fat." That's a direct quote.

          There's only so much you can do to help people who aren't willing to at least try helping themselves. Noncompliance is one thing. There are tons of patients who are noncompliant with medications for one reason or another. Usually, it's because their medications cost too much or they can't get to their doctors' office. This was the first time I'd seen a patient who was just so obstinate that she refused to believe she even needed treatment.

          What are we supposed to do now that we're moving to a system where physicians will be paid based on patient satisfaction? This woman is obviously going to complain about whatever treatment she receives. Then when she refuses to take her medications, she'll wind up back in the hospital, and the hospital will get docked because the patient was readmitted so quickly after she went home. No health care system is perfect, but sometimes I feel like ours is broken beyond repair.
          Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

          "You're just a jaded cynical mother****er...." Jeffpeg

          (more comments in my User Profile)


          • #6
            i dunno what i wanted to comment now all i can think about is my fury for that public speaking cunt
            "did you ask me to consider dick with you??" blooming tianshi lotus


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