Health Care Reform, HCR, can now be defined more clearly as any bill that encompasses the range of provisions of the House bill and the one that Harry Reid is about to put on the Senate floor. For purposes of this diary, whether or not it has a Public Option is immaterial. Such a law will, in fact, increase the number of people with health insurance cards, and as such, this particular group will have improved health care. Beyond this, all the touted benefits are unproven, while the unintended consequences, actual societal harm can be illustrated.
This is a detailed essay, and while it is unfortunate that some of it has been marshaled by those who don't have the desire to explore the options, all of my source material is from respected sources such as the N.Y. Times, Washington Post, and various universities. Some of my points, specifically that subsidies to the middle class based on reported income well above the median, will be a corrupting influence for tax evasion, has not been discussed as far as I know.
I'll start this diary with a commentI made, along with the informed responses of other members of this community:
Actually, this is a fundamental issue.... (4+ / 0-)
this diary is taking the approach that to improve medical care you start with creating greater supply of services. Instant Care Facilities is only one way, but this should be the approach, which includes training more primary physicians, nurse practitioners etc.
The HCR that will be pass ignores the reality of a fixed supply handling an expanded demand of new clients, as described in this WaPo article. The existing client base demographic groups: wealthy, medicare, medicaid or private insurers-- will be bidding up the price of existing fixed supply, resulting in Medicare clients will no longer being the attractive volume segment, desired in spite of lower payment.
There will be no better aggregate medical care, only different people who will go without. And as immutable economics shows, such shortages will result in increase, rather than reduction of costs. It's a shame this little problem is being ignored.
My nurse co-workers and I been talking (4+ / 0-)
about that very same issue since the HCR proposal came on the scene. Many of my patients I've spoken to seem to think their access to medical care will somehow improve when in fact it will be the exact opposite. s
Shh. Don't tell too many people (2+ / 0-)
that HCR will have that effect. How else would expanding coverage to more people without increasing the supply of services actually end up?
No one is talking about this reality, that you can give out all the health insurance cards you want, but this does not manufacture a single health facility. And there is no short term fix, as expansion of human or material medical resources, doctors and hospitals, have lead times of a decade at the least. Further, since President Obama vows to finance this from within the Health Care System, if this promise were to be kept, there would be no more money, per capita, for the health care system than we now have.
The difference is after HRC passes there will be more people vying for the same resources. This was expressed well in this articleby the President of the San Diego County Medical Society
There is already a growing shortage of physicians, particularly in primary care, as primary care physicians are compensated less than specialists. It has become difficult to recruit physicians to San Diego County, despite its lifestyle benefits. Those physicians who continue to practice may try to see more patients, but that only goes so far without compromising quality. While physician extenders, such as nurse practitioners and physician assistants, provide beneficial services, they should complement, not replace, the knowledge and decision-making skills of the physician.
With greater demand and fewer physicians, wait times will increase. To add millions of the currently uninsured to the Medicaid rolls, as proposed by the House of Representatives, without having sufficient numbers of physicians to see them is not a realistic solution. Chronic underfunding of the Medicare and Medicaid systems threatens the viability of the safety net.
Costs are difficult to reduce, especially in this age of advanced diagnostic and interventional technologies, lifesaving but expensive drugs, and the desire and expectation of patients for immediate diagnosis and return to health.
Doctors and those in the Medical Establishment will be among the big winners in this HCR as they will have enough customers to refuse more of the lowest payers, those on Medicaid and Medicare. Pharmacy companies will do fine, as the incremental cost of most drugs is low, a fraction of the cost for those under patent, so they can lower prices ten percent and still make more on the greater volume of a given drug. Private insurers will also do fine, unless the removal of the preexisting condition restriction is not matched with universal mandate. Then the very best policies will soon attract the sickest people due to adverse selection, which will cause them to be eliminated.
HCR, exemplified by the 1900 pages of complex law in the house bill, with dozens of sections each worthy of a book unto itself, is not going to be dissected in this diary. What is not being resolved, or even addressed, in the bill or in public discourse are the immutable verities of supply and demand, that this will increase demand without any restriction on what the suppliers of this demand may charge.
It's as though when we went to war in 1941, we didn't bother to issue ration stamps or impose price controls. This HCR is the embodiment of Joseph Hellers brilliant "Catch 22" It reflects a world where the public can be deluded by a health insurance card with a phone number that is not connected to actual health care structures, since the law that provided the cards never considered the laws of human nature.
Every analysis of this bill that I know of makes the erroneous assumption health care providers will not actively resist attempts to reduce their income. The "scoring" of these bills are static analyses that would only apply in a police state, and even then would be defeated by black markets.
There are other ways to conceptualize aggregate quality of a nation's health care. There is quality of medical engagement, average cost per appointment or access delay to physicians or hospitals. These will probable remain the same or get worse, on average, for reasons described below.
As far as other more meaningful measures of effectiveness, even for single payer in an advanced country, Taiwan, it is difficult to show benefits:
Has this translated into better life expectancy or lower complication rates from major diseases?
There is evidence of positive health results for select diseases, like cardiovascular disease and kidney failure. But overall, it’s really difficult to say that national health insurance has improved the aggregate health status, because mortality and life expectancy are crude measurements, not precise enough to pick up the impact of more health care.
The above was from the series Prescriptions in the N.Y. Times that looks at HCR from every angle showing the positive and the negative effects
Then there is the problem of mandates, analyzed in this N.Y. Times article, of two distinct issues both, confusingly enough using the same term. The first mandate is the requirement that individuals purchase insurance:
The proposals now before Congress would require just about everyone to buy health insurance or to get it through their employers — which would generally result in lower wages. In other words, millions of people would be compelled to spend lots of money on something they previously did not want, at least not at prevailing prices.
The insurance policies mandated to be purchased by every individual, and subsidized by the taxes of those who will not be the recipients of such subsidies is a complex packages of services. A small portion of these are based on scientific verification of efficacy, that part of MDs actions that are verified by "evidence based" principles. The rest is the hand-holding placebo function of physicians,which certain people enjoy and others would prefer to speak to their minister, guru or the guys at the bar.
But this bill does far more than expand treatments based on scientific principles
More from the Times article:
A further problem is "mandate creep," which we’ve seen at the state level, as groups lobby for various types of coverage — whether for acupuncture, alcoholism and fertility treatments, for example, or for chiropractor services or marriage counseling.
There are now about 1,500 insurance mandates among the various states, and hundreds of others are under consideration. The dynamic at work here is that the affected groups have a big incentive to push for mandates, while most other people are unaware of the specific issues and don’t become involved.
Because mandates don’t stay modest for long, health insurance would become all the more expensive. The Obama administration’s cost estimates haven’t considered these longer-run "political economy" issues.
So under this HCR law we will all have to pay for insurance, our own and those whom we subsidize, that include unproven practices mentioned above, but exclude abortions and dental care---something that those who must buy these policies will now find even less affordable.
Such mandates will only grow even more under the federal government, which, unlike states, have the authority to "print money" to cover its excesses, thus keeping insurance rates low....right up until the harm to our fiscal integrity reaches the point of no return. In the name of prevention of individual disease, we court economic catastrophe, a national disease, we won't recognize until irreversible economic collapse. .
This HCR law represent a hidden expansion of those who will become recipients of government benefits based on annual income, by including subsidies for those earning up to three times the poverty rate, around $88,000 for a family of four. This will increase the value of unreported income, currently estimated in this reportat over 2 trillion annually. This means a family who earns 90K a year of reportable income will end up subsidizing those millions who may earn even more if a portion is unreported, as it the case for many small service providers.
It is far from proven, or even shown to be probable, that this law will result in aggregate improvement of medical care for the people of this country. More likely it will benefit the currently uninsured by disadvantaging others, most severely medicare patients. The lack of concerted resistance by seniors can only be understood by the conflict of interest of AARP, the organization ostensibly dedicated to their well being. As this WaPo articlepoints out, they stand to benefit vastly from the increase in business for private insurers under this bill.
Sadly, Democrats have avoided a substantive debate on this issue by deflecting all arguments against this bill as partisan political attacks. This seems to be effective, due to the particularly low public opinion the other party. So what dialogue does occur is with the major beneficiaries of this bill, private health insurers and pharmacy companies for instance, who will both benefit greatly and want to keep it that way.
President Obama did not design this reform in an academic think tank, but tossed it into the political cauldron of congress, with results that could have been anticipated. Every title, clause and section is designed to appease wealthy interests, or to poll well, not to work well. The disconnect, the absurdities, inconsistencies and hidden traps, will be lost in the thicket of thousands of pages of this law.
Electing a candidate on faith is one thing, passing a bill where the elements have a predicted effect, such as shortageof providers, that are being ignored is something quite different. Campaign promises are expected to be "aspirations," whereas a massive law such as HCR will actually change our society.
As someone who is on Medicare, I can accept that changes must be made that will adversely affect those in my situation. And, believe it or not, I could accept it, even welcome it, if it were really going to improve health care for all segments of society in an equitable manner. Such a reform can never be constructed by those who depend on financial support from the industries that they must reform, as is the case with congress.
If this passes, from all that I have researched, from all those that I have spoken to in the field, it will be not only bad for the Democratic party in the long run, but worse for our country.
REFERENCES:
Journal of American Medical Association articledescribing why health care is higher than other countries, and their solutions. These are not addressed specifically in current HCR.
Dartmouth Study of wide discrepancy in medicare expenses per patient, includes links to commentaries. This N.Y Times articledescribes the current debate in house bill in dealing with this, and why the solution is not as simple as it may seem.
N.Y. Times series called Prescriptions, hundreds of articles and comments that give a realistic view of what can be expected from the current incarnation of Health Care Reform.