The Clare Spark Blog

December 1, 2013

Reflections on the Affordable Care Act

demondoctor“Obamacare” is rightly the domestic issue that is upsetting the nation, so although I am neither a lawyer, nor a physician, I will lay out some of the difficulties that I see in the debates to date. In no particular order, then

First, the Democratic Party’s obliviousness to the enforced changing of doctors is indicative of a pandering and incompetent mind-set: Compassionate beings that they claim to be, Democrats would never argue that it is no big deal to change mothers. The benefit of a doctor who knows your history, and is invested in your good health, is comparable to the trust we place in our mothers (and present loving fathers).  How to explain this blind spot? Society (like the body) is not a machine, with interchangeable parts, though some political groupings seem to be.

Second, to what degree are we responsible for our health? With the body, we can choose not to drink to excess, not to smoke, to practice correct hygiene, to eat for maximum nutrition and to exercise. It is not so clear how we can control our mental states, which in turn impact our immune systems and the degree to which we take care of ourselves. I cannot understand why these matters are not taken up in our school curricula and in the media, though I suppose that religious diversity plays a large role, with some belief systems rejecting the physiological lessons of modernity.

Third, don’t look to the hip universities to be sympathetic to either medicine or psychiatry. At the university where I received my graduate training in history, the history of science encompassed the history of medicine and psychiatry, and the Foucauldians and the Left were in charge. Science was held to be a joke, and amusing, just as eighteenth century quacks were to be written about and mocked. The radical historicism I encountered at UCLA could not possibly distinguish between antique fads and misconceptions and modern medicine. Post WW1 German Expressionism has a grip on many academic mentalities–those sports who inhabit “the dark side” or, who are irresistibly drawn to the femme fatale.

cabinet of doctor caligari

Fourth, when I was much younger, I recall the responsibility that doctors and dentists alike felt for the poor. So they volunteered at free clinics, or might travel to the central valley in California to treat farm workers. Medicine, like dentistry, was held to be a noble profession, perhaps because parents or grandparents were immigrants.  Nowadays, many doctors expect to be multi-millionaires; ironically, their wives and children benefit from a life of luxury, while the physician (male or female), is expected to care for too many patients. This is a world I did not know in my youth, and do not like now.

Finally, the chant from ACA boosters that the Republican Party is simply obstructionist and has no alternative proposals, is tiresome and ludicrous.  Tort reform and competition across states lines for insurance companies are only two of oft-repeated suggestions. I would be even happier with the ACA opposition if they proposed changes in the curriculum that would put health, physical and mental, at the top of the list in curriculum reform.  That will never happen here until outdated notions such as demonic possession and/or fallen flesh are finally banished from our public schools and related institutions.

fallen flesh

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December 14, 2012

James Pagano MD on healthcare chaos: Updated

Filed under: Uncategorized — clarelspark @ 9:27 pm
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James Pagano, M.D.

James Pagano, M.D.

[See two earlier blogs: https://clarespark.com/2012/03/29/james-pagano-m-d-on-affordable-care-act/,  https://clarespark.com/2012/07/09/james-pagano-m-d-on-effects-of-obamacare/, including the comment section where Pagano lays out his suggestions for improved care. For Pagano’s website see http://jamesvpagano.com/.]

I asked Dr. Pagano what his plans were for the future, given the current flap over the Affordable Care Act. Here is his update, September 29, 2013:

Since the evening of Obama’s re-election I’ve been considering the future, ours in general, but mine in particular, and what part the practice of medicine will play in it.  I’m still not certain, mainly due to the fact that the situation is still fluid, but I can best answer your question by making a few assumptions.

So, lets first assume that Obamacare will roll out as written and on schedule.  This is almost laughable considering the amendments and exemptions that have already taken place, most notably the one-year reprieve for some businesses and the exclusion of Obama, his family, the House and Senate, their families, their staff, and their families from this law.  (The big labor unions, once so vocal in their support of Obama and his health care law will be the next large group seeking relief from it now they’ve had time to figure out what it entails.)  But we need to start somewhere.  If all goes as initially planned, there will be a massive enrollment of previously uninsured individuals, as well as previously well-insured but now no longer insured individuals due to their employers opting to drop their coverage, in the new exchanges.  Whether they enroll in the Silver, Gold, or Platinum plans makes little difference.  It is all basically Medicaid which means choices of physicians, hospitals, medications and ancillary health services will be limited.

These patients will increasingly access hospital-based emergency departments for their primary care, or less-than-emergency-care, needs.  It is happening already in LA county.  Thousands of patients previously covered by MediCal have been herded into new MediCal managed care products, like Healthy Way LA.  They are assigned to a ‘medical home’, with a primary care physician to oversee their care and arrange for any specialty consultations they might require.  The problem is that most of these people either can’t get in to see their primary care physician in a timely manner, or prefer to be treated on an episodic basis with no appointments needed.  They go to the ER because they know they must be seen, no financial questions asked, and they must be proven not to have an emergency medical condition prior to being discharged, regardless of how much testing is required to do so.  Viva EMTALA.

As this practice becomes more pervasive ER’s will become increasing crowded.  Despite heroic efforts by the CMS, hospitals, and ER physician groups to legislate, regulate and mandate that wait times and lengths of stay not only remain as they are but actually go down, such is not likely to be the case.  Speaking as an ER physician this is good and bad.  The pressure to see more patients in less time while maintaining diagnostic and treatment accuracy at 100% and high patient satisfaction scores is more than a little annoying.  But, the fact that a higher percentage of these patients will have some means of paying for the care they receive could result in some small net positive, income-wise.  At least for the first year or two, until other aspects of the law kick in–like the one demanding parity between Medicare and Medicaid reimbursement.  At that point the ER doctor will be seeing more patients, more regulations, with fewer consultants and specialists on call, for less money.  It seems clear that a number of them, particularly those in the latter parts of their careers, will be heading for the exits and an early retirement.

Now let’s assume the House is successful at either defunding the law or getting it postponed in its entirety for another year.  As noble a goal as this is, it seems at best unlikely and at worst suicidal considering the stakes–a government shut-down–involved.  Still, we should consider the possibility.  The thinking here seems to be that putting it off past the next election cycle could allow the Republicans to gain more seats in the Senate while maintaining control of the House and a chance thereby to scuttle the entire ugly mess.  That would be wonderful, provided that at the same time some serious work got done to actually reform healthcare, and not, as Obama and the Democrats have done, merely expand the role of the federal government and redistribute wealth at the SAKE of good medicine.  For the next year things would limp along essentially as they are: ER’s would be crowded but manageable, physician reimbursements would go down, but probably not precipitously, and insurance companies will continue to be good investments, because they will do well with or without Obamacare.

Despite passionate remonstrations from the Left, capitalism actually does work.  Free markets have a way of anticipating the future and finding ways to profit from changes.  The healthcare market is no different.  In the past few years a new version of an older healthcare delivery model has arisen and will, I think, become an important piece of the system.  Urgent Care Centers, owned and operated by residency-trained, Board-certified emergency medicine specialists are becoming prevalent in places like LA and New York City.  Once staffed by general or family practitioners with an emphasis on occupational medicine, the modern urgent care center is now attracting the well-insured and well-healed with problems that would have required ER care a few years ago, but which can now be handled on an episodic, no-appointment basis by a trained emergency medicine specialist.  Point of care lab testing, imaging studies, and transfer arrangements to a near-by hospital for those who need a higher level of care are making this type of urgent care center the ideal venue for those with non-life or limb threatening medical conditions.  No crowded ER, no inflated ER bills.

So to answer your original question, I’m not completely sure what I’ll be doing a year from now, but if I had to guess I’d say I’ll be working part-time in one of the new urgent care centers and spending the rest working on my next novel, next guitar CD, and perfecting the gnocchi.  Unless, of course, healthcare actually does get reformed, in which case I might be in the ‘Pit’ a while longer. [End, Pagano update 9-29-13]

[The original blog starts here:] The fuse has been lit, the bomb is ticking, the ship has hit the iceberg—whatever silly metaphor you might want to use, the fact is Obamacare is off and running. Unfortunately it seems to be running amok.  This might be a good time to give you some insight into where, exactly, it seems to be going and how it will affect the delivery of healthcare to you, the hapless patient, and to other Americans.

Let’s start with millions of newly ‘insured’ individuals on the Medicaid rolls with nowhere to go, millions more on MediCare living the dream that they have managed to save their entitlement by voting Democrat, and doctors heading for the exits.  What?  Nothing seems different to you?  Why am I being so ‘negative’?

I’m not.  I’m being honest.  I know this must be difficult for many of you who’ve been feasting on lies for the last two years.  But try it.  Just a little.  If you don’t like it you can stop reading and go back to whatever version of reality makes you feel comfortable and validated.

The reason everything seems fine for now is because nothing much has happened. Yet.  It’s like the guy who, having jumped off the top of the Empire State building, is asked ‘How’s it going?’ as he sails past the fiftieth floor and replies, ‘So far, so good’.  But just as the pavement is waiting to greet the jumper the beast that is Obamacare is right behind the door, waiting for you to walk inside.

The very best parts of the health care law have already been put into place.  Coverage for pre-existing conditions is now the law.  Good.  Dependent children can stay on their parents’ policies until the age of 26.  Fine.  Those reforms would have taken about three sentences to legislate.  So what about all the stuff in the extra twenty-seven hundred pages?  It’s coming.

First will be the exchanges.  It is unclear to just about everyone what they are going to look like and how they are supposed to function.  From what little I’ve been able to see so far it would seem that ‘ugly’ and ‘not very well’ are fair descriptors.  The exchanges will be entities that sell subsidized health insurance to those who qualify.  Those who do not qualify will be picking up the tab through taxation.   The product they sell will be, essentially, Medicaid.

Medicaid does not reimburse physicians well enough for them to meet their costs.  To entice physicians to accept these newly ‘insured’ patients the federal government has offered to pay at MediCare rates for the first two years.  What happens after that time is anyone’s guess.  My guess is that by then Medicare rates will have been reduced dramatically, and the government will be paying for both classes of patients at deeply discounted rates.  Letters will be sent to patients explaining that their doctor no longer accepts their ‘insurance’ plan and they will need to find another who will.

If this seems overly harsh consider this: California’s MediCal program has one of the lowest reimbursement rates for doctors and hospitals in the entire country.  It is also a state with one of the highest costs of living.  Just yesterday the 9th Circuit Court of Appeals issued an opinion that will allow California to cut its MediCal rates by 10%.  MediCal is California’s version of Medicaid.

So as I was saying, two years from now things are going to get difficult for the seniors.  Unless they get difficult a lot sooner.  There is a thirty percent cut in MediCare reimbursement set to go into effect January 1, 2013.  It is part of the fiscal cliff problem.  This has been an issue over and over in the past.  There has always been a last minute ‘fix’.  This time is different.  The sense is the cut may be allowed to finally stand.

If it does, and MedCare reimbursement drops by 30%, you can expect a number of physicians to drop out of the program.  Seniors on MediCare will look too much like Medicaid patients from a financial standpoint.  Seniors, who were lied to and frightened into voting Democrat to ‘save MediCare’ will learn that they actually killed it.  Whether it dies in 2013 or two years later is not significant.  The point is that Obamacare had the demise of MediCare built into it from the start.  Obama lied by accusing Paul Ryan of throwing Granny off the cliff.  Truth is, Granny was already in free fall, thanks to his healthcare plan.

Where, then, will all these patients go for their care needs?  The answer can be seen in what is already happening here in Los Angeles.  In anticipation of Obamacare the County has been furiously assigning existing MediCal patients and patients new to the system to MediCal managed care plans.  Things like Healthy Way LA, Healthy Families, LA Care, and other euphemistically titled HMO’s place these patients in ‘medical homes’—multi-specialty provider groups contracting with the government either directly or through a third party intermediary to provide care for this patient class.  The problem is that these practices are already overwhelmed and underfunded.  Patients are being referred to the emergency room in ever-increasing numbers.

For instance, a woman with abdominal pain is somehow able to see her primary care doctor.  He suspects a gall bladder problem.  He tells her to ‘go to the emergency room’ where the ER physician will be obligated to run expensive tests, like lab work, ultrasounds, and CT scans to rule out an emergency medical condition.  The cost for this will be borne by the hospital and the reimbursement it receives will be the Medicaid managed care rate, something like 85% of the Medicaid rate.  The ER doctor will likewise be paid a nominal sum for his efforts.

The more patients there are enrolled in these types of ‘insurance’ plans the more often this scenario will play out.

But let’s look at the bright side.  Let’s assume that the Medicare rates don’t drop next year and seniors actually will be able to keep their doctor.  Problem solved.  Obama saved MediCare.  No.  Ask yourself, when was the last time the federal government took control of anything, paid less for it, and got more for its money?  Right.  Never.  Remember the 750 billion dollars we are going to save by not spending it on MediCare so we can pay for Obamacare?  Where do you think that’s going to come from?  It comes from providing fewer services to seniors.  It’s called health care rationing.

This won’t be evident immediately, either.  The health care law will not be fully implemented until 2014.  It will then take some time for a MediCare patient to develop a problem, seek care for it, and be told that his or her options are limited.  Too old for a new knee, too sick for an expensive chemotherapy drug, not sufficient quality years of life left, according to their calculations, to warrant much of anything.  It will take more time for this to occur often enough to reach the general consciousness.  The media will not be running stories about it, just like they refused to run stories that might have harmed Obama’s chances of re-election.  So it might not be until 2015 or later that the seniors realize they’ve been had.  By then it will be too late.  It’s too late now.

July 9, 2012

James Pagano M.D. on effects of Obamacare

Filed under: Uncategorized — clarelspark @ 5:20 pm
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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.

April 1, 2012

Secularism and the Affordable Care Act

I asked my FB friends what they thought the word “secular” meant, and got a number of responses suggesting that it meant one thing: atheism.

It appears that the culture wars have done their job: to most of the responders, “secular” signifies atheism, which may indicate narcissism, nihilism, and amorality to them. But in its older meaning, pre-culture wars, “secular” simply referred to matters of this world, as opposed to other-worldliness in religions that emphasized heaven and hell. But more significantly, secularism is a political science term that refers to the separation of church and state, meaning that no religion has priority over others, and that no religion is the established state religion. In the U.S. we enjoy religious pluralism. But triumphalist religions have managed to minimize the Founding Fathers’ commitment to the separation of church and state. And culture warriors such as Bill O’Reilly, Glenn Beck, and Newt Gingrich have turned “the secularist” into the bogey man, insisting that the Constitution, like the Declaration of Independence before it, was divinely inspired, rather than the institutionalization of natural rights. But read the Federalist papers and see that Hamilton puts ultimate authority in the people, which is another word for popular sovereignty. Just as (later) in the French Revolution, power, knowledge and virtue had passed from Kings and Church to the People, who would then comprise the red specter to this very day, at least in the U.S. The U.S. Constitution was written to create a strong and effective national government, and owed its inception to epistemological materialism and to the Enlightenment. (See https://clarespark.com/2010/09/02/spinoza-as-culture-critic/.)

Alexander Hamilton was a church-goer, but to his most venomous critics he was not just a bastard-upstart, a foreigner, and a monarchist; he was a crypto-Jew, i.e., a variant of the anti-Christ. Recall that the Reformation convulsed Europe, with protestants (of many stripes) being defined as heretics by the outraged Catholic Church, who went on to purify their practice in the Counter-Reformation, a development that went on to censor such as Spinoza and other freethinkers at a time of burgeoning literacy among the lower orders.  (See Radical Enlightenment, Jonathan Israel’s 2001 book on Spinoza and censorship throughout Europe following the underground publication of his works; there is now a shorter work published in 2009 treating the Radical Enlightenment and the roots of democracy. But I view J. Israel as a social democrat and doubt that we have the same genealogy for democracy and free thought, since my vanguard includes such as Hayek, von Mises, and the Friedmans, but not Maynard Keynes.)

For decades, I have followed the academic assault on empiricism, medicine, and psychiatry (including the “historicizing” and discrediting of all of the mental health practitioners, Freudian and non-Freudian alike). Doctors do not share any one religious or non-religious orientation, but they do focus their training on healing the sick, which means studying the human body in various states of health, trauma,  and disease. Theirs is a secular profession, but one that finds itself in conflict with those religions that see sickness and health as dispensations from God, as part of God’s plan for the individual and for the world. Thus we find unresolved and perhaps unresolvable conflicts over such practices as abortion, contraception, abortifacients, embryonic stem-cell research, and assisted suicide in the terminally ill.

I find it odd that in all the publicity over the Affordable Care Act that these culture war issues have not been emphasized, yet the cost of medical care and what is covered or excluded is related to larger conflicts over appropriate professional intervention in the processes of life and death. Not surprisingly, much of the opposition to the ACA comes from the religious Right that correctly fears government-run “death panels” or other instances of rationing (see https://clarespark.com/2012/03/29/james-pagano-m-d-on-affordable-care-act/). They are not paranoid in this respect. In an ironic coalition, God-Squads and Doc-Squads may find themselves on the same side.

Illustrated: Top: Jonathan Israel, Middle: Spinoza toy; Bottom: Joel Strom DDS, organizer for www.docsquads.org.

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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