The Clare Spark Blog

James Pagano, M.D.

[This is Dr. James Pagano’s latest guest blog on the drastic changes in health care policy just declared constitutional by the Supreme Court. His second blog can be found here: https://clarespark.com/2012/03/29/james-pagano-m-d-on-affordable-care-act/. Don’t miss the comments where Pagano lays out his suggestions for fixing the problems with pre-ACA health care.]

[Pagano:] On March 29th of this year I wrote about the Affordable Care Act and some of the effects it would have on the availability and quality of healthcare in this country should it be allowed to stand.  At the time it seemed as though there was a better than even chance the Supreme Court would find it unconstitutional as written and we would be spared from its damage.  As it turns out, it was.  But we have not been spared.  Chief Justice Roberts, through a tortured and convoluted logic and for reasons about which we can only speculate, found the individual mandate unconstitutional as written but then re-wrote the law.  He determined the mandate to be a tax, precisely what the authors of the law and President Obama claimed it was not at the time the bill was being debated, and thereby constitutional.  The law stands.  Hooray for democracy.  I think.

So now we have a bad health care law, a bad legal precedent, and a monstrous new tax.  The States are scrambling to either set up health insurance exchanges, expand their medicaid programs, and make a grab for the Federal subsidies, or use the Roberts decision to scale back their medicaid programs and herd their citizens into the Federal exchanges.  Which, at last glance, don’t yet exist.  Physicians and their patients have all but been ignored.  Those of you who believe the federal government is a benign guardian of your health and well-being, committed to doing what is right, with no other political agenda, can stop reading now.  You are about to get what you so richly deserve.  I wish you all the best.  Good luck.

If you are still reading my guess is you have some doubts.  You should.  The ACA is designed to provide a lowest common denominator health care delivery system.  One size fits all.  It will be overseen by a panel of government appointed, non-physicians, beyond the reach of congress and the people affected by their decisions.  They will decide who qualifies for what sort of treatment, what treatment options are allowed, and which are not, who will be paid, and how much.  If you have an HMO plan, you are already familiar with this type of system.  You need authorizations for referrals, for special tests.  You are discouraged from using the emergency room because it is expensive, and because your HMO cannot control the treatment you receive there.  You are probably also familiar with the common practice of primary care doctors working in HMO’s actively referring their patients to ER’s to bypass the authorization process.  If you need a CT scan and your doctor feels you can’t wait three weeks to get the OK, just go to the ER and it will be done.

This is not optimum, but it is better than what you are about to receive.  Now, you have doctors making treatment and rationing decisions.  They are making these decisions based on their knowledge of you and your unique set of medical problems.  You have a physician advocate.  In the brave new world of the ACA those decisions will be taken away from your doctor and moved to that politically appointed panel in Washington D.C.  Whether or not you will be allowed a certain treatment will be based on statistics, your age, whether or not you are still a ‘productive member of society’.  You will not have the option to bypass the system and go to the ER.  Doctors will be held accountable for the tests they order, the treatment plans they design.  If their practice falls beyond the guidelines established by the panel, not only will they not get paid, they will get fined and quite possibly sent to prison.  I’m not kidding.  The law is that Draconian.

In order to make the law even theoretically affordable there will need to be healthcare rationing on a grand scale.  If you are a senior, or about to become one, this is especially worrisome.  You are now entering the period of your life when you expect to wind things down a bit, take it a little easier, maybe retire altogether.  You are about to become a less productive member of society.  You deserve it.  You’ve worked your entire life to be able to do just that.

You are also entering that phase of life during which you can expect your need for healthcare services to increase.  You aren’t worried.  You have Medicare to help you with that.  You’ve paid a small fortune into the program during your working years and now it’s time to reap the benefit.  Unfortunately, things have changed.  Over half a trillion dollars is earmarked to be removed from the Medicare budget to help pay for the subsidies going to the new medicaid enrollees.  Your benefits have just decreased.  You are also not at the top of the list to receive expensive treatment modalities.  You are too old.  Society can’t afford to carry you.  The very young and very old are expendable according to the new credo.

What can you do?  In the past I’ve limited my discourse to the law itself, apart from politics.  Now, though, the only thing standing between you and the monster that is the ACA is politics.  We tried throwing out only the bath water, but the Roberts decision quashed that effort.  It is now time to throw out the baby.  The healthcare system in this country needs to be fixed.  No argument there.  But it needs to stay in the hands of those who understand medicine and the needs of patients.  It needs a market-based restructuring, with perhaps some government funding for the safety net but private management.  I can go into some details in a later posting.

The only way we are going be able to achieve these goals is by voting President Obama out of office.  He is committed to the lowest common denominator.  We deserve better.