The Clare Spark Blog

September 3, 2014

Solidarity on “the Left” vs. disunity on “the Right”

conflictmanagementPOTUS (Obama) delivered his usual mixed message today, first vowing to smash ISIS, then softening his stance to one of “managing conflict.” This blog is about why the Right can’t unify to defeat such typical ‘switcheroos.’

All graduate students in today’s better doctoral programs are marinated in the ideology of “progressivism.” How did this come about? I have traced the origins of managerial attempts to deal with the frightening rise of the “laissez-faire” bourgeoisie that threatened to spread Jacobin-type revolution in the early years of the Industrial Revolution–not because the conservatives were Jacobins, but because the early years of the Industrial Revolution, spawned by an alliance of bourgeoisie and aristocracy, suggested a revolution of the new industrial working class. Class relations in Britain were never the same again.

To review: aristocrats in England bonded with the new industrial working class (drawn from deskilled artisans and peasants) against the bourgeoisie. (See https://clarespark.com/2011/07/16/disraelis-contribution-to-social-democracy/.) Disraeli’s Young England and its Christian Socialist allies provided a model for forward thinking politicians, historians (!), and journalists in the United States after the Civil War (the take-off period for rapid industrialization now that the agrarian South was vanquished). Enter the Progressive movement that skillfully co-opted the anti-elitist populist movement, a movement composed of small producers on the land, and directed against railroads for instance. But the progressives never stood with working class organizations or the dread specter of “proletarian internationalism”—rather, they installed “ethnicity” or “race” as the socio-economic division that mattered, erasing “class” as a category for sorting people’s interests out.

The Nation magazine moved sharply to the left in 1919, to avert bloody class warfare, but they supported populism, not communism. Their stance could not have been more elitist or counter-revolutionary. (See https://clarespark.com/2009/09/19/populism-progressivism-and-corporatist-liberalism-in-the-nation-1919/.) Oswald Garrison Villard’s crypto-organic conservatism or a gentleman’s version of the route to social cohesion is obvious, and no anarchists or communists were taken in by his anti-capitalist fulminations.

You could say, with accuracy, that progressives and leftists hated each others’ guts until the brilliant stroke of solidarity against “fascism” in the mid-1930s that was called “the Popular Front.” Such solidarity between social democrats and hard leftists continues to exist, scandalously in my view, with social democrats controlling the discourse. For no radical of either Left or Right should abandon empiricism and materialism (i.e., Enlightenment) to be absorbed by the alleged management of structural conflicts offered by social democrats (i.e., progressives who don’t like Progress as delivered by relatively unregulated market economies).

Hence, the confusion today over Obama’s “true” loyalties: is he a Leninist or a managerial centrist? Opinion on the Right is sharply divided, perhaps because selected pieces of New Deal reformism still exist in the upper reaches of the Republican Party, for instance in the impetus toward Medicare accomplished during the Eisenhower administration, a statist remedy that would serve as models for other reforms in Big Government, such as Obamacare marching toward “Medicare for all.”

“community”

I cannot blame the Tea Party for its animus against what appears to be the passivity of Congress in resisting the Obama administration’s apparent big lurch to the Left, but I do fault them for unnecessary sectarianism, particularly among the social conservatives who appear to have abandoned the separation of Church and State, and look to a religious revival to repair structural problems in American society, all the  while denying that there is any racism on the Right.

Contra many conservatives, “liberalism” is not a religion, but an ideology that will triumph as long as the pseudo-leftist social democratic managerial discourse dominates popular culture/public and private speech.

“Progressive rock, Italian style

Until the hopelessly corrupt Chicago machine is dislodged, there is no stopping Big Government. Whatever the flaws of the “Republican establishment” it would serve classical liberalism well to take a lesson from the leftist playbook and practice “solidarity forever.” [Update 9-4-14: There cannot be solidarity on the Right as long as mutual hostility exists between small and big business. See http://www.forbes.com/sites/realspin/2014/07/08/the-u-s-government-isnt-friendly-enough-to-big-business/. This argues that [New Deal reformism] favored small business over big business. This will shock many in The Tea Party.]

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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.

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 https://clarespark.com/2012/07/09/james-pagano-m-d-on-effects-of-obamacare/. 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

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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