The Clare Spark Blog

March 29, 2012

James V. Pagano M.D. on Affordable Care Act

Filed under: Uncategorized — clarelspark @ 10:08 pm
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There are a lot of things not to like about the Affordable Health Care Act, including the fact that it isn’t actually affordable, but I feel certain that the great majority of people, those who favor the law and those who do not, would agree that two of its purported benefits are good things.  Those would be near-universal coverage and improved access to medical care.  The problem is that the law does not provide either.

To achieve near-universal coverage the law seeks a huge expansion of the Medicaid program.  Some twenty million people or so will be added to the various state-run programs, which in my state is known as MediCal (i.e., Medicaid).  Proponents of the law call this providing health insurance to those currently without it.  But MediCal isn’t insurance.  It’s welfare.  There’s a difference.

Insurance is something you buy.  You pay premiums, deductibles, and co-pays for a product that, in theory, indemnifies you against large financial losses in the case of illness or injury, helps with the cost of medications, and avails you of the services of a wide range of physician specialists.  Because it is expensive, you use it judiciously.

Medicaid is something provided to the medically indigent as a safety net.  There are no premiums, deductibles, or co-pays.  It is paid for by tax dollars.  As a practicing emergency room physician for over thirty years I can attest to the benefits it provides those who must rely on it for their healthcare needs.  I also understand its limitations.

Reimbursement rates under the Medicaid program are absurdly low.  As a result most specialists, especially surgical specialists like orthopedists and ENT’s, don’t take it.  Increasing numbers of primary care doctors don’t take it, either.  Which leads to the AHCA ‘s second false promise, that of improved access to health care.

Simply having a Medicaid card does not guarantee you will get to see a doctor.  Unless that doctor is working in an emergency room.  We who work in the specialty of Emergency Medicine have always provided care to all comers, insured or not, and the EMTALA law codified that practice when it was passed in 1986.  Under the new health law we will continue to see and treat all who come seeking care, but it will become even more difficult to do.

In the face of twenty million more patients with nowhere else to go our ER’s are going to become more crowded than they already are and waiting times will increase.  Compounding the problem will be patients needing a specialist with no specialist on-call.  This is already the case in many hospitals where trying to find an orthopedist, neurosurgeon, plastic surgeon or otolaryngologist is nearly impossible because these physicians have taken themselves off the ER back-up panels as a means of protecting themselves from having to provide high-risk, uncompensated care.  The Medicaid patient needing a fracture reduced or repaired surgically will be splinted, treated for pain, and parked in an ER bed until a transfer can be made to a County hospital.  That ER bed remains unavailable to another patient until the transfer can be made, and the overcrowding and wait times get worse.

To pay for the new health care law over half a trillion dollars will be taken from the MediCare program.  MediCare is still accepted by most primary care physicians and a sufficient number of specialists and sub-specialists to make the treatment of those covered by it reasonably easy.  Once the MediCare budget is cut, that will change and then seniors and the disabled will find themselves in the ER waiting room alongside the Medicaid patients.

Although there is speculation that the Supreme Court’s decision about the law’s constitutionality might render this entire discussion moot it is nevertheless an important discussion to have.  One way or another our system of healthcare delivery and the way we pay for it is going to be revamped.  If the Court gives us a do-over we must use that opportunity to construct a system that can actually do what the current law only pretends to do, namely make quality healthcare available to all Americans at a reasonable cost.

As I said at the top of this piece there are many reasons not to like the Affordable Health Care Act.  If the Court allows the law to stand I will likely be writing about some of them between now and the November elections, which will then be our only chance to avert this impending disaster.

James V. Pagano, M.D., FACEP

Dr. Pagano is the author of two novels, The Bleed, and The Drain    


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  5. […] care policy just declared constitutional by the Supreme Court. His second blog can be found here: Don't miss the comments where Pagano lays out his suggestions for fixing the problems with pre-ACA […]

    Pingback by James Pagano M.D. on effects of Obamacare « YDS: The Clare Spark Blog — July 9, 2012 @ 5:26 pm | Reply

  6. […] Right that correctly fears government-run “death panels” or other instances of rationing (see They are not paranoid in this respect. In an ironic coalition, God-Squads and Doc-Squads may find […]

    Pingback by Secularism and the Affordable Care Act « YDS: The Clare Spark Blog — April 1, 2012 @ 11:23 pm | Reply

  7. Readers of Dr. Pagano’s blog and his interaction with Roger Froikin below (read the third comment first, then the second, then this one), might benefit from the following email I received today, after asking him for a concrete set of reforms. Dr. Pagano wrote an off-the-cuff set of suggestions:

    “It is not going to be enough just to toss out Obama care if all we leave is a vacuum. We need someone like Paul Ryan to take control of the process as he did with the budget. The solution is going to be complex but the basics have to include private control, individual patient rights, competition among insurers across state lines, some government oversight without direct government control of services, health savings accounts, fully tax deferred with a high percentage of income deposit allowance per year, able to be invested in ‘safe’ securities, which can be rolled over into a 401k at the time you reach MediCare eligibility, a means for including pre-existing conditions, no recisions, possibly a government sponsored re-insurance program for insurance companies to protect them from catastrophic loss, (this would involve a lot of detail), possibly a cap on profits, (though this isn’t exactly a free market idea), massive tort [malpractice] reform, and much patient education so that sensible rationing can be implemented without being imposed.

    The GOP would do itself a big service just by putting out a position paper outlining the issues involved and a roadmap for getting them done over a reasonable time frame, which would be something like 10-15 years.”

    Comment by clarespark — March 30, 2012 @ 8:13 pm | Reply

  8. Everything you say is true. I chose to limit the scope of my comments to the two issues at the core of the law from the perspective of the consumer–coverage and access. Both will be negatively impacted in a significant way. The medical profession has allowed itself to be portrayed as a smug, affluent, and aloof group of elites. We must accept some responsibility for this. But, it has largely been the work of the liberal media and the legal profession who have managed to drive a wedge between doctors and their patients in the name consumer protection when in fact their motives are the perpetuation of a medical liability system that enriches lawyers and adds hundreds of millions of dollars to the cost of health care in the form of excessive testing, scanning, documentation, procedures and redundant evaluations performed as a means of protecting ourselves from lawsuits. These are costs beyond those more obvious like the insurance and litigation costs these suits engender.

    In this environment it is difficult for many to understand the ways in which the actual practice of medicine is going to be degraded by the health care law. The practice guidelines, rationing, penalties for ‘over treating’ and ‘over testing’, all can be viewed as genuine governmental attempts to streamline the practice of medicine and promote patient safety through best practices. It is only by working within the system that it becomes clear these intrusions will do more harm than good.

    A person’s health is a uniquely individual entity. To best protect it doctors need the license to treat each patient as an individual. At its heart the health care law is an effort by the government to stand between the patient and the doctor. It wants non-physicians to make treatment decisions for individual patients based on statistical models and cost/benefit analyses. This approach might be appropriate if we were making widgets. It starts to feel a little uncomfortable when applied to the care of the individual patient, and terrifying if that individual happens to be you.

    Perhaps our politicians understood this, which is why they exempted themselves from the law. Or maybe it’s just a natural extension of the left’s belief that individuals have no value except as they serve the state. Either way, I’m not buying it.

    James V. Pagano, MD

    Comment by James Pagano — March 30, 2012 @ 6:27 pm | Reply

  9. Good article. Accurate. I could add a few things to it to show how much worse things are than Pagano stated. Example. MD’s who choose to serve their patients’ needs are prevented from doing so by having to risk lawsuits by doing a good job with diagnosis and treatment if they ignore NIH Guidelines that are based on absolutely horribly constructed (but well compensated) research. On top of that, the average physician (I’m excluding surgeons here), has had to face growing costs of exploding office staff and exponentially growing malpractice premiums made necessary by Government regulation based paperwork and redundant record keeping and oversight, all while reimbursements have been reduced every couple years. Net incomes have substantially declined in the larger cities. One beneficiary of these changes — Canada. Candian MD’s used to take their degrees from McGill, etc., and come to the USA for bigger money. That has stopped except for some specialists and some surgeons, leaving the Canadian system to work better with fewer shortages.

    And while the small MD office is dying, Obamacare protects the cost-plus cost structure for hospitals which encourages Hospital Corporations to continue their massive building projects, their giant annual bonuses to administrators, and the practices of theft that are all too common in purchasing. 6 years ago, I was hospitalized, and complained about the mattress and the best (my back was killing me). The hospital administrator told me I should not complain because “these beds are top of the line from this one manufacture, and that the hospital bought 300 of them for $ 6000 each. I said I was shocked. Why, because one month earlier, I bought an identical bed and mattress set, from the same manufacture for one of my disabled veterans, and I paid $ 1850 for the same bed. Where did all the money go? The next day, the Physicians Board assembled in my room at 7:30 AM. I repeated the story. They started an investigation, but it suddenly ended with no answers a few months later. I’ve heard from the Doctors, and they got no answers from the administration, but were basically told to mind their own business.

    Roger Froikin

    Comment by Roger Froikin — March 30, 2012 @ 12:09 am | Reply

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