The Clare Spark Blog

October 10, 2012

Obamacare–One Last Time (James Pagano, MD)

Filed under: Uncategorized — clarelspark @ 6:00 pm
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James Pagano, M.D.

[For previous blogs by Dr. Pagano, see This has link to the first blog.]

As the election draws close and the race tightens it seems a good time to take one more look at what is about to befall us as patients and consumers of healthcare.  In the past I’ve spoken from my perspective as a career Emergency Medicine specialist, a physician for over thirty years, practicing at the precise point where the worlds of medicine, politics, and public policy collide.  I have been, and continue to be, a part of the safety net everyone pays lip service to but few truly understand.  I have had a lot to say about why I think Obamacare, (an acceptable appellation since the president himself adopted it during the recent debate), is a disaster.

But, having recently entered my seventh decade, I have new concerns.  Not as a provider of healthcare, but as a consumer.  A patient.  A soon-to-be- senior on Medicare.  Having spent the bulk of my productive life providing first-rate care to others, what is going to be available to me in the years ahead?  Well, that depends.

Both Governor Romney and President Obama agree that under the new healthcare law 716 billion dollars will be removed from the current Medicare budget.  Starting now.  Romney calls it a cut in Medicare spending.  Obama calls it a savings.  It is a ridiculous distinction if you believe that all money is saved the same way.  Whether it is from ones childhood allowance, the family household budget, or the government-sponsored portion of healthcare, money is saved by not spending it.  Despite all the bluster and obfuscation it really is that simple.  A penny saved is…well, you get it.

So let’s call it a savings.  Fine.  How, exactly, does Obama think this savings is going to be realized?  To understand that we must take a look at what gets paid for under Medicare.  Doctors, allied healthcare providers, hospitals, drug manufacturers, the retail outlets that sell the medications to Medicare beneficiaries, and device manufacturers—think about the titanium hip that could be in your future—are responsible for just about all of Medicare’s budget.  Note that there are no jewelry stores or exotic car dealerships on the list.  We won’t be saving a dime by not paying for frivolities.

What, then, will not be paid for to achieve these savings?  Obama cites overpayments to providers and hospitals as being a principal source of savings.  The problem with that is the fact that Medicare already pays less than most insurance plans now.  Under the current fee schedule many physicians, particularly surgical subspecialists—there’s that hip again—are not accepting new Medicare patients.  If the proposed fee cuts scheduled for this January are allowed to go into effect, Medicare will look a lot like Medicaid.  In that scenario you can expect more physicians to not only refuse to take new Medicare patients, but to possibly opt out of Medicare altogether.

Hospitals, too, will have to reconsider their participation in the program.  They are currently paid according to a DRG system—Diagnostic Related Groups.  Every diagnosis is given a dollar value and a maximum in-patient length of stay.  For the hospital to make money, it must not spend more on the care of a patient than it will be reimbursed.  If your DRG says you can stay for 2 ½ days and the total cost will be $4300, then to make money the hospital has to keep you for sometime shorter and spend something less.  Cutting the amount allowed will lead to fewer services being provided.

To date hospitals have managed to do well in the Medicare system, and many are looking to Obamacare to provide additional revenue by covering the uninsured, who currently pay nothing for their hospital care.  However, drastic cuts, I mean savings, in the Medicare program combined with a massive influx of underinsured Obamacare patients will, I think, change things.

One of the biggest sources of ‘savings’ will come from something no one currently supportive of the healthcare law wants to discuss—healthcare rationing.  Like the systems in Canada and Great Britain, certain services will not be made available to certain patients.  If you need a hip, but are overweight, you might not get it until you reduce, if at all.  If you have cancer, but it is going to cost more than, say $47,000 per year of ‘quality’ life to treat, you won’t be treated.

The decisions about what constitutes ‘quality of life’, what therapies will and will not be made available, who, basically will live a while longer and who will not, will be made by a 15-member board, the great majority of whom not medical professionals, appointed by the president and not answerable to congress or the people whose lives they will control—patients on Medicare.

Much of this may not have been clear to many when the law was enacted, and much was still unclear when the Supreme Court voted to uphold the law—while specifically stating they were not in the business of protecting the People from their own bad political decisions—but it should be clear now.  If you are currently on Medicare or will be soon, you are in trouble.

We have heard a lot from this administration about the Republicans’ ‘wars’ on a variety of things—the alleged ‘war on women’, the ‘war on the middle class’, the ‘war on immigrants’, and it has become tiresome.  Phony wars devised by this administration to hide from view the only real war being prosecuted—the war on Medicare recipients.  The war on seniors.  It is real, it is happening now, and Obamacare is its name.

Romney’s healthcare plan will change nothing for those of you on Medicare now, or the rest of us age 55 and older who expect to be on Medicare sometime in the next 10 years.  We who have worked, planned, and saved according to a social promise made years ago will be able to reap that benefit in full.

For those younger than 55 there will be money given to offset the cost of buying an insurance plan.  The amount provided will vary according to need, as it should.  The Romney system mirrors that currently available to members of congress and their families.  It allows for choice, puts patients and their doctors in control of their healthcare decisions, and keeps Medicare viable into the entire foreseeable future.

As always, there will be a safety net for those who fall through the cracks.  And, as always, there will be someone like me providing that care.

Obamacare was never about healthcare in the first place.  It was about wealth redistribution using government-controlled healthcare as the means.  If it was about improving healthcare, and if it was to be his signature piece of legislation, why was implementation delayed until after the re-election bid?  If it is so good, why not implement it before the election so it’s wonderfulness could be touted as a reason to re-elect?

Whether or not you share this administration’s desire to redistribute wealth, I am fairly certain you would like to maintain your current level of healthcare quality and access.  You would like to ‘keep your doctor’.  The only way that is going to happen now is by voting Obama out of office.

James V. Pagano, MD, FACEP

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: 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.

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