Sunday, April 01, 2012

If Obamacare Falls

Until last week, the government's confidence on the constitutionality of the Patient Protection and Affordable Care Act (PPACA) seemed all but certain.   Now, they're not so sure it might stand. 

Of course, most American's are wondering: "Okay, if it gets repealed, then what?"

First, it is unlikely things will change right away.  Many of the changes we've seen in health care with funding of the electronic medical record and forcing the collaboration between doctors and hospitals were created by the earlier economic "Stimulus" package funding, not the PPACA.

But for those of us involved in health care, a whole host of opportunities arise for our health care system if the PPACA falls.  It is no secret that the biggest problem of our health care system is its rising cost relative to inflation.  While the constitutionality of Obamacare may become its immediate undoing, the continued runaway costs that were not managed by the creation of such a gigantic new system would have eventually destroyed our health care system (and perhaps our economy) anyway.  Already, new 10-year cost estimates far exceed original estimates.

If the PPACA is struck down, legislators will have an opportunity to address the problem of cost sustainability head-on to our health care system.  The current health care ruling, if it plays out as anticipated, will need a viable, solvent alternative. The alternative will be a challenge to construct as special interests spend millions to lobby our legislators.  But Congress should be increasingly aware that they are viewed by most Americans as divisive and largely ineffective; this could be a chance to change that perception for there is much both sides of the aisle can agree upon.    They understand the need for affordable health care for the most needy.  And most understand the cost conundrum must be addressed.

So what should Congress do?

In many ways, the answer might be easier than we all think: 

Fix what's broken first. 

Rather than creating a new, larger government health care system based on an 2700-page nearly unreadable health care law that creates at least 115 new agencies and winds between countless government agencies and disconnected bureaucracies, we should move to fix what's broken with Medicare and Medicaid first with an eye toward fixing what matters most to Americans.

If we've got waste, fraud, and abuse to the extent we are told, then fix it.  We don't need new agencies to do so.

Admit there are limits to what can and will be paid for, set a budget, and stick to it.

If we care about our kids being uninsured, then fix it.

If care about people with pre-existing conditions not being insured, then fix it.  But be honest with limits.

If people with sufficient means aren't contributing enough for their health care, fix it, but don't restrict what care those folks can obtain on their own nickel.

If doctors are saying they are overburdened with documentation requirements that don't improve patient outcomes or safety, then fix it.  Stop perpetuating wasteful documentation mandates that add nothing to patient outcomes.

If we care about families going broke from health care expenses, then fix it.  As a corollary:
if people don't know what things cost until it's too late to avoid bankruptcy, then fix it.

If costs are too high for medications, then fix it.  Don't allow direct-to-consumer advertising and save a billion dollars (or more) for consumers.  Open overseas markets to generic medication manufacturers that can prove the quality of their product.  Things like this make patients the priority, not special interests.

If we don't have enough people caring for our population, then fix it.  But move with caution - quality must be maintained: consider the costs of truncating supervised clinical training in favor of producing doctor mills.

If prices for materials and goods are held artificially high by government's fee payment schedule, then fix it.  Legislators should ask themselves: do we really need pharmacy benefit managers and group purchase organizations that add no value for the patient?    Can you say "i-n-t-e-r-n-e-t?"

Rather than trying to fixing exerything that ails our system all at once, take it piece by piece.  Vet the issues openly rather than behind closed doors.  Since prices are the priority, make prices for elective procedures and medical equipment available online to patients AND doctors.   Patients must be the priority to our new initiatives, not special interests.  Most of all, make the lower cost of health care and quality of health care the priorities and stop promising that the quantity of care we provide can remain unlimited to all. 

Improvise.  Adapt.  Who knows: we might just overcome our current health care crisis bit by little bit.

But the one thing that Congress should absolutely NOT do is kick the health-care-cost can down the road any further.  Otherwise, any new measure to preserve our health care system will be just as worthless to the sustainability of health care and our economy as the paper they're printed on.



Lisa said...

I so wish you could write the new policy.

Jodi C said...

You can get a look at health care solutions from both sides by going to the "Left & Right" section at

The best thing about America is the innovative spirit. There are physician groups who have already been working toward solving two of the most pressing primary care problems - cost and access. Read their stuff, it's inspiring. Not only do they expand affordable care to the high risk and uninsured, but also to those here undocumented. What a great model to build upon.

mdaware said...

The recent CBO and JCT increased cost estimate of the ACA is misleading- in fact, their prediction was a slight decrease in the deficit. It mostly has to do with shifting the window of the estimate, explained well by Paul Krugman here

Jodi C said...

The only way the deficit reduction happens is all of the "savings" and "revenues" are actually realized, which both CBO and CMS both predict to be difficult to achieve and/or sustain.

Here are the specific CBO and CMS statements:

CBO reported budget deficits would be reduced ($210 billion over the 2012–2021 period), in their estimation, if the new health care law remains unchanged throughout the next two decades. However, the law would maintain and put into effect a number of provisions that might be difficult to sustain over a long period of time. Whether any of its provisions—and if so, which ones—might be changed in the future is not for CBO to judge.

CBO estimates that the effect of the new health care law would be to reduce federal budget deficits during the 2020s relative to those projected under prior law—with a total effect during that decade in a broad range around one-half percent of gross domestic product (GDP). That calculation reflects an assumption that the provisions of the legislation are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation.

the longer-term viability of the Medicare update reductions is doubtful. Other provisions, such as comparative effectiveness research, are estimated to have a relatively small effect on expenditure growth rates.

Reductions in payment updates to health care providers, based on economy-wide productivity gains, are unlikely to be sustainable on a permanent annual basis.

If these reductions were to prove unworkable within the 10-year period 2010-2019 (as appears probable for significant numbers of hospitals, skilled nursing facilities, and home health agencies), then the actual Medicare savings from these provisions would be less than shown in this memorandum. Similarly, the further reductions in Medicare growth rates mandated for 2015 through 2019 through the Independent Payment Advisory Board may be difficult to achieve in practice.

Under current law, payment rates for physicians’ services under Part B of Medicare are slated to decline by 29 percent and by additional amounts in later years. The President’s budget proposes to avoid those reductions by freezing payment rates at their 2011 levels for the next 10 years. That policy would increase net outlays by $298 billion over the 2012–2021 period, CBO estimates.

Medicare provider productivity adjustments could become unsustainable even within the next 10 years, and over time the reductions in the scope of employer-sponsored health insurance could also become an issue. For these reasons, the estimated reductions in National Health Expenditure (NHE) growth rates after 2016 may not be fully achievable.

Verify all of these statements at, Left & Right on health care.

Esjaydee said...

Dr. Wes,

I am sincerely hoping for the PPACA to be upheld and go forward.
I've been without insurance for 10 yrs. Mid-50's, mine and my husband's employer do not offer insurance. This puts us into the individual marketplace which is simply out of our price range. Fully half of our take home wages would go just for insurance (not including deductibles and co-pays). Under the ACA, we will be subsidized and pay about $160 a month (last quote for insurance was $1200 a month -Kaiser)

However, as much as I want this law to be upheld, I agree with many of your points above about "fix it".
I'd be happy with states taking on the issue, as long as I live in one of those states. (I do- Oregon)

Aggressively going after fraud and abuses in Medicare/Medicade will save a ton of money. That's a start.

Anyway, I'm rambling on, and I do have a question for you.

How about if we managed to eke out a system like Norway's, where everyone has access to basic medical care, and those who wish to can purchase additional private insurance to cover more expensive and extensive care?
Use more P.A.'s and Nurse Practioner's for basic care and leave the specialties (such as cardiology)for those who truly require a MD?
This could save billions of dollars.
Rather than expensive care for colds, ear aches, well care and such, why not use less expensive clinics staffed by professionals-just not MD's?

I think of my last doctors office visit for a sore throat which I suspected was strep. $168 + the cost of strep test. That is 3 days of wages for me. Wouldn't a simple and inexpensive neighborhood clinic for such things be a better choice?

Shelley in Portland