Ken’s Take on the World


Healthcare: Privilege or Right?

As Republicans struggle to obtain enough votes in the US Senate to pass their version of a bill (Better Care Reconciliation Act) that was originally brought forward to repeal, and replace, the Affordable Care Act (ACA) much focus has been placed upon the economic costs and the personal costs to those who would be affected should this legislation become enacted into law.  As one who has paid attention to the debate over healthcare access for the past three decades, I have been thinking of a much deeper question that we should be asking of ourselves as it would, perhaps, better drive the debate over this legislation.  The question that each of us should ask is this:  Should healthcare be considered a privilege, a commodity, that should be available only to those who can afford such care or, should it be considered a necessary right for every person that must be protected, and assured by government?

 

When I have posed this question to those who express opposition to the ACA, the most common response that I receive is that healthcare should be treated as any other service that a person would seek out.  The most common support offered for this position is that every person receiving services should be required to pay for such services.  To bolster this claim, these critics argue that it is not fair to expect others to pay for services that they receive.  On its face this appears to be a reasonable argument that must be considered.  After all, you wouldn’t take your car to a mechanic and not be expected to pay for repairs or maintenance on your vehicle.  You don’t take your family to a restaurant and expect to receive free food, do you?  You wouldn’t call an air conditioning repair person and expect to not receive a bill for the parts and services provided, would you?  These criticisms appear to suggest that healthcare services and products are no different than whether or not your vehicle or your heating and cooling systems at home are functional.  This is a false and illogical argument.

 

When one dines out at a restaurant, one knows what they can afford and if they are unable to afford to dine at a certain establishment they simply eat dinner at home or at a less expensive restaurant.  When your air conditioner is on the fritz, if you do not have the money available for repairs, you will need to open your windows, use fans, or other methods of staying cool.  For those with underlying health conditions in which extreme heat is dangerous, communities provide cooling centers, or family and friends are often able to step in to provide temporary shelter until the air conditioning is repaired.  Even if a new central air system must be installed, the cost is almost always going to be less than $5,000 USD.  Many heating and cooling companies will also finance this amount to keep costs manageable.  Similarly, if you need repairs on your automobile, you can determine what are the most crucial and pay for those and defer other repairs until later.  Or, your community may have decent public transportation available.  Or, you may be able to car-pool to work or use a ride-sharing service.

 

Healthcare, unlike these other services, is not a commodity that can simply be delayed in many cases.  I have frequently likened the provision of healthcare as an essential service that must be available to every single person.  Similar to a community that provides fire departments and trained personnel to operate this life-saving equipment.  Or, law enforcement agencies that respond to safety or criminal complaints.  Or, military agencies like the Coast Guard who respond to emergencies on our nation’s waterways.  We don’t bat an eye when we are asked to fund these critical services.  As a society, we have come to realize these are critical pieces of infrastructure that exist for the benefit of each of us even if we never need to directly use these services.  Why, then, do we look at healthcare differently?

When I have attempted to discern how so-called conservatives continue to maintain the position that healthcare is a commodity, and not a right, in addition to the arguments about paying for services and the burdens of having to pay for those who cannot afford these services, they remind me that healthcare services are already provided to people in the nation’s Emergency Departments (ED) regardless of one’s ability to pay for such care.  This, then, implies there is, in fact, some existential right to healthcare.  When I point out this inconsistency in logic, one person actually mentioned that fewer (uninsured) people seek medical care as if this implies lower costs to taxpayers.  The problem with this (il)logic is that while uninsured individuals are far less likely to present to a primary care physician in the community setting, they are far more likely to present to an ED for treatment of conditions that can be much more effectively, and economically, managed in a community setting by a primary care physician.  This translates into significantly increased healthcare costs for all of us.  The average cost of an ED visit in the United States is nearly $2,200 based on a study described in “The Atlantic.”  Compare this to the average cost to a primary care provider (PCP) in the US which is only $100 based on an Agency for Healthcare Research and Quality (ARHQ) study by the Department of Health and Human Services (HHS).

 

A review of multiple studies has demonstrated that access to health insurance is correlated with significantly improved health outcomes.  The review, published recently in the “New England Journal of Medicine” (NEJM), documents that improved healthcare outcomes are especially notable among pediatric patients.  Further, this review notes that not only are healthcare outcomes improved, but other measures of quality of life, including educational achievement, are improved with access to health insurance.  Other studies have demonstrated the significant economic consequences associated with illness.  I am not only speaking of the direct costs associated with providing medically-necessary care, but the impacts that illness and preventable injury have on individual and societal economic stability and growth.

 

I believe we must frame the debate over access to health insurance as one of a necessary right that must be protected by government actions.  Only then, will we be able to determine the most effective means of financing healthcare in the United States.

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Defunding “Obamacare?!”

Among a string of poor public policy positions advocated by members of the Republican Party, the recent decision to attach an amendment to a Continuing Resolution (CR) that would fund the government but withdraw all funding for various components of the Affordable Care Act (ACA) is among the dumbest.  There are several reasons for arriving at this conclusion.  The most dangerous is that it will potentially lead to a partial shutdown of government which affects every single American.

 

First, the amendment that was attached to the Continuing Resolution striking funding for the ACA is purely a political gimmick designed to appease a small, extremely regressive, faction of the Republican base.  It is highly unlikely this amendment will be attached to a Senate resolution for a floor vote.  If it is offered as an amendment, it will likely not be approved.  This means the Bill goes into a Conference Committee.  This will put the House of Representatives into a showdown with the Senate and pushes us closer to a deadline which will result in the stoppage of essential government services.  Think Social Security checks, Military paychecks, the Centers for Disease Control and Prevention (CDC) which is gearing up for flu season!

 

For the sake of argument, let us say that the amendment does become a part of the final Bill that is presented to the President.  It is extremely likely the President the President would return the Bill to Congress with a bright VETO stamp across the top.  Republicans do not have the votes to overturn a veto and would be left holding the bag on a smelly collection of dog excrement when the deadline for government operational funding passes.  American citizens do not like when there is no one answering the telephone at the Social Security Office!  I personally would be quite pissed off if I found that our Military service members were not getting paid!!

 

Let’s enter the world of a Republican wet dream for a moment.  The amendment that defunds the ACA is passed through both chambers of Congress and the President accidentally signs this wrong-headed piece of legislative bovine-manure.  The Republican Party collectively orgasms all over themselves and claims they have achieved a monumental victory!  Orthopedic surgeons in the Beltway will be extremely happy for with all of the folks patting themselves on the back there are sure to be a few Rotator Cuff tears to deal with.

 

What happens next?

 

This amendment does not repeal the Affordable Care Act.  It does not block the implementation of any of the rules and regulations promulgated by the ACA.  It only does one thing.  It eliminates funding for any of the provisions of the Affordable Care Act.  So, what?

 

Hospitals have begun to implement Electronic Health Records (EHR’s) using money provided under the ACA.  Study after study has demonstrated that EHR’s reduce medical errors and have the potential to reduce costs.  The ACA requires that hospitals and physicians adopt the EHR as part of a goal to improve patient safety.  Doctors and hospitals are now left solely on the hook for the expense of this technology.  Failure to comply will result in a loss of eligibility for Medicare and Medicaid reimbursement.  The hospital I work at receives more than 40% of its reimbursement from these two programs.  Fortunately, we have already completed adoption of an EHR system.  I do not know about all of our affiliate physician groups and individual practice physicians, however.  If our surgeons cannot operate on Medicare patients, a huge piece of our revenue stream disappears.  Hospitals generally operate on extremely thin operating margins (gross revenue over expenses), typically 1 to 3%.  Many hospitals have a much higher percentage of Medicare and/or Medicaid patients and would be impacted even more by a loss of access to these revenue streams.  Loss of Medicare funding will mean the demise of a number of independent hospitals and loss of funding for EHR technology will mean that most independent practice physicians and many physician groups will cease to exist.

 

States are required to begin enrolling individuals in Health Insurance Exchanges (HIE’s) beginning on October 1.  Funding to set up these exchanges was allocated through provisions of the Affordable Care Act.  In a number of Republican-led states, the legislature and executive refused to participate in an HIE.  In these states, the Federal government is operating the exchange.  The money to administer these programs is eliminated as a result of the defunding amendment.  Insurance companies are participating in these exchanges anticipating a new influx of customers seeking health insurance.  From a business standpoint, health insurance companies know that having a broad base of customers allows them to spread risk among a broad base of payers.  This means that insurance rates can be maintained at an affordable rate for all consumers.  In a number of states that have already started operating these exchanges, insurance rates, including premiums and deductibles have been lower than suggested by certain folks on the right of the political spectrum.  Many of the folks enrolling are doing so in anticipation of subsidies available as part of the ACA.  Those subsidies are gone as a result of the amendment.

 

Under the Affordable Care Act, which, by the way, remains the law, insurance companies cannot deny coverage or charge exaggerated rates to individuals based on health status.  With the defunding amendment, Health Insurance Exchanges have been hobbled and not able to reach out to customers.  Since they will not be able to obtain, potentially 30 million additional customers, insurance companies will be forced to drastically raise the cost of premiums for all of their customers.  Except for the wealthiest among us, individuals will find they are unable to afford monthly premiums and will be forced to drop their coverage.  Businesses will find it increasingly difficult to afford the cost of health insurance for their employees and will begin to drop insurance coverage.  Instead of stable, affordable premiums, I would anticipate much more expensive premiums.  The result, millions more uninsured Americans!

 

This wrong-headed amendment to defund the Affordable Care Act would be dangerous for patient safety, health insurance companies, hospitals, doctors, taxpayers, and businesses.  The proponents of this legislation have failed to grasp the tremendous negative consequences of such a thing happening.

 

I am absolutely certain the Republican leadership in Congress is fully aware that they are playing political gimmickry with this amendment to defund the Affordable Care Act.  They know, completely, that this amendment will not make it to the President’s desk.  Speaker-of-the-House John Boehner knows this as does every member of the US Senate.  The absolute worst possible outcome for Speaker Boehner, and every Republican member of Congress would be for this to land on the President’s desk as part of a Continuing Resolution and actually be approved by President Obama.  The resulting collapse of the Affordable Care Act will lead to a collapse of the health insurance industry, hospitals and physician practices, and culminate in the establishment of a universal, single-payer healthcare system in the United States.  Speaker Boehner would be credited, single-handedly, with bringing Socialized medicine to the United States of America!



President Obama and the Glass of Water

Tuesday is Election Day, or if you are Dr. Ruth, “Erection Day.”  I for one will be relieved that this campaign season will be over.  The campaigns this year have been particularly over-the-top and there has been more negative campaign advertising thanks to a flurry of unaccountable money that allowed nearly a billion dollars to be spent on the Presidential campaigns alone!

 

When I look at the state of our nation, and of the economy in particular, I look at a glass that is half full.  Of course, I tend to be an optimistic person by nature.  When I listen to Republicans, the message I hear is this:  President Obama has been in office for four years and the glass is still half empty.  The President has failed to fill the glass completely.

 

Think about this.  When the President took office in January of 2009, the glass was completely empty because it had been shattered and all of the water had poured out.  Since 2009, the President repaired the broken glass and began to refill it.  The President repeatedly asked for a fire hose so the glass could be filled faster but Congress would only permit him to have a garden hose to use.

 

Remember to vote on Tuesday, November 6, 2012.  The nation is counting on you!!