James Pagano, M.D.
[This is Dr. Pagano’s fourth guest blog: see links at the bottom of the page]
Twice now the Roberts court has reinterpreted the plain language of the ACA in order to keep it in force. The first slight of mind was the bizarre decision that a tax wasn’t really a tax. Now we learn that when congress specifically stated that subsidies should go only to those buying insurance from an exchange set up by a state, what it really meant was the subsidies were available to everyone, regardless of whether the exchange was established by the state or the Feds. As daft as our politicians may be, I’m fairly certain they have the intellectual wherewithal to have said as much had that been what they meant.
One of the duties of the Supreme Court is to protect the people from congressional malpractice. The ACA is a clear case. Thousands of pages, unread by most who voted for it, written in language intended to confuse, excluding from its reach those who wrote it, and sold to a gullible public through a series of bold-faced lies. Rather than protect the people from this atrocity the Court has chosen instead to protect congress from itself.
The majority decision, written by the same logical contortionist who declared a tax wasn’t a tax, stated that the duty of the Court is to find ways to protect the actions of congress, not ways to un-do them. This is frightening, implying as it does that an out of control, single party congress, like the one that passed the ACA, can do pretty much whatever it wants and get legal cover from the Supreme Court.
But enough of the whining. You’ve heard all this before and you either agree or don’t and nothing much is going to change your opinion. Instead let’s consider what might have been. Imagine, if you can, an alternate universe in which the price of something is closely tied to its cost. Those of you in business will recognize this as one of the fundamental relationships in life. Those of you working for the government, try to hang on for a few minutes longer. I think you’ll have some fun.
So, in this alternate world people pay for things they want or need with money. Actual cash. Soap, apples, cars, homes, you name it. Even health care. And because people are paying with real money, they expect the prices they pay to be closely tied to the cost of providing whatever goods or services they are purchasing.
In this world the government has wisely noticed that of all the things people want or need, healthcare is one of the most important and should be available to all its citizens. It has also noticed that healthcare can be expensive. The politicians in this world thought long and hard. Finally, they devised a plan. What they came up with was this:
All citizens would be allowed to create special savings accounts where money could be put aside to cover health care costs. This money would be tax-exempt, and the accounts would be generous—say ten thousand dollars a year per person. Those who could afford this would do so unassisted. Those who could not would get help from the government. These people would get health care credit cards, for an annual amount means-tested to bridge the gap between what they can afford and the ten thousand dollar maximum.
To supplement these accounts people would also be able to buy insurance. If, for instance, someone suffers a bank-breaking illness or injury the supplemental insurance will pick up where the ten grand leaves off. For those without the money to buy supplemental insurance the government will provide Medicaid. While the choices of providers accepting Medicaid might be limited, care would nevertheless be available through a network of providers and through hospital ER’s. Kind of like it was in this world before the ACA. Come January 1st new health care credit cards are issued and those who found themselves on Medicaid at year’s end can once again have control of their health care lives.
If you are lucky enough to have money left over at the end of the year, guess what? You get to keep it! It stays in the bank, drawing interest. (In this world interest rates actually reflect the real cost of money…). And, since the maximum amount you are required to spend out of pocket each year is ten thousand dollars, that left over money becomes a retirement account. When you reach retirement age you can roll it over into an IRA.
A world in which people make their own choices and spend their own money, with a government there to support the truly needy. Insurance companies relegated to actually providing insurance against catastrophic losses. Prices set by providers, drug makers, imaging centers and hospitals to reflect cost plus a modest profit. Why? Because they are all in competition for the same customers. Imagine ads in the paper offering an MRI for $350, (about what it’s really worth, as opposed to the $9000 charged by hospitals, to be negotiated by various insurers), followed the next day for an ad by another imaging center for the same MRI, but for $325. But that’s in the other universe.
Back in this world we are now saddled with a system wherein government and insurance companies set prices and ration care, the newly ‘insured’ are turning to Emergency Departments in ever-increasing numbers for their primary care needs, (patient volume in my ER is up about 35% almost entirely due to Obamacare patients with Medi-Cal managed care insurance and nowhere else to go), where the treatment options will be limited and innovation stifled.
We have lowest common denominator health care and will be paying Cadillac prices for it. We have patients disconnected from their healthcare choices who will remain blissfully ignorant in the arms of a bloated federal government. And the worst is yet to come. Still, there are people seemingly ecstatic that the law was allowed to stand. ‘The ACA is now embedded in our society!’, or something to that effect.
It’s about as absurd as my telling a patient, “Congratulations, the cancer is now inoperable.” What a shame.