PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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Obamacare: Examination and Response
An appraisal of the Affordable Care Act and-- with some guesswork-- its tricky politics. Then, a way to capture major new revenue, even paying down existing Medicare debt, without raising premiums or harming quality care. Then, an offering of reforms even more basic, but more incremental. Finally, the briefest of statements about the basic premise.

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Clintoncare and Obamacare: Historical Foreword

Twenty years after their Health Proposal was withdrawn from Congress in 1994, the Clintons can thank their lucky stars they withdrew it. One thing is clear; the Obama health insurance mandate followed a surprisingly similar early trajectory, beginning with a protracted flurry of publicity and astonishing promises that never materialized. But the Clinton plan was quietly sabotaged without much explanation before it got this far, nowadays almost pretending the subject had never been mentioned. In both cases, a President had proposed an adventure which the American public didn't want to undertake, but only one of them backed off.

As of this writing, the Affordable Care Act is a law actually in force, even though the party in opposition is determined to eliminate it as soon as it regains control, whereas the other party acts determined to conceal its real content for as long as it can. From its behavior, the Obama administration seems willing to provoke a Supreme Court contest, rather than conciliate a retreat. It seems unlikely the public will abandon its Constitution in order to preserve a health insurance plan, particularly when the President is running out of time to make it successful. Even if he could rescue a failing program, both foreign affairs and the financial crisis seem more urgently in need of his time and attention. We like to see signs of competitiveness in our President, but accomplishing what the Clintons, Harry Truman and Theodore Roosevelt could not accomplish, does not strike most people as sufficiently useful. Some cynics feel his real strategy amounts to what they call in football, "playing for the breaks". Wait until your opponent makes a mistake. This book is written in the hope that both parties are as confused as they seem, remaining open to new ideas rather than rigidly following a playbook. Somewhere along a newer path, we might reset our compass to eliminating disease as the route to reducing disease costs, instead of tinkering with insurance while we watch costs go up. For thousands of years, the elimination of disease has been an impossible dream. Not any more.

Let's begin with brief mentions of the Clinton Plan, because it apparently set the original pattern. At its center was a national blueprint for Managed Care, called HMO (Health Management Organizations.) Leaders of large business, already intrigued by the notion of constraining national healthcare costs by clever management of the health insurance they provided their employees, had originally played along with the Clinton administration. As did their reluctant agents, the large-group health insurance companies. Together, Big Business and Big Insurance had previously taken a step away from state-regulated Blue Cross systems toward a nationally regulated ERISA system, in order to cross state lines more comfortably. Insurors were also having problems with their turf: the hospitals and the unions. Originally, hospitals had once, ninety years ago, joined with business to form locally based health insurance, often with small business and charitable foundations in the lead. However, insurance and the federal government eventually dominated (but underfunded) the health payment scene, with everybody unrealistically expecting business to pick up escalating costs that business could no longer control. And while business had to get along with its unions, it was disquieting to business leaders to find so much union influence infiltrating nonprofit insurance leadership. Hence they were uneasy to find so much interest in unionizing hospitals, so much involvement in partisan politics. Furthermore, the old actors were uneasy with the new actors looking for control, hence the subtle change of "medical care" into "health care", as a way of wig-wagging new allegiances. Finding a hospital-centered model increasingly worrisome, leaders of business had been briefly intrigued by the concept of shifting the control center to HMOs, which seemed to act more like businesses, and thus might be a better buffer with the feds. One of the main problems with dragging out major reforms over decades is that old alliances grow stale, old promises become invalid, when new combatants join the battle. Gradually a number of disillusioned businesses quietly withdrew their support from the original Clinton proposal as they learned more of its new realities. In the view of the business and insurance world, national politics of some sort would soon cripple a complex HMO idea that needs good management, most of all. If the rest of the "health" world didn't feel it retained any debts to the pioneers of pre-paid health insurance, well, big business had other things to do.

Congressmen understood the general direction of this mixed message and, at least as defined by "HMO", the floor leaders of the Clinton Plan found they no longer had the votes to pass the health bill. The Clinton Administration yielded and let Big Business go its way. Businesses then undertook the HMO project themselves, only to get burnt fingers when they discovered the HMO concept, without physician or patient enthusiasm, was doomed to failure no matter who co-sponsored it. The public, even their own employees, resented the regimentation of HMO systems, except perhaps for union political machines on the Atlantic and Pacific coasts. To the interior of the country, the enduring California image of HMOs was not an asset.

Unfortunately, Democrats also escaped learning from Clintoncare's flaws by failing to pass it. Most importantly, liberal leaders never quite grasped the message the public was sending back to them: The public's healthcare and its governance belong to us -- not to our employers, nor to our elected politicians. If some group wants to pay our bills for us, Americans would pocket the money. But ownership, transferring real ownership of healthcare to the public sector, had never been considered a serious option by a very large segment of the population. Local control was the main reason healthcare had lagged behind the rest of the economy in the shift from state to federal regulation. The debate was still about healthcare, but it might easily switch to a debate about the Constitution, which the Constitution was not likely to lose.

{top quote}
Powers not granted to the federal government...., are reserved to the States or the people. {bottom quote}
Tenth Amendment: What Part Don't You Understand?
By 2008 under President Barack Obama, we had got used to the rise of foreign economies, but all economies narrowly escaped ruin. Probably because of the "Silo" effect on a full-time politician, our President seemed to think health insurance coverage was a bigger issue than the shaky economy. The biggest connection the rest of the public could see, between healthcare and the recession, was the cost of healthcare itself; even that was a stretch. Our uniquely American system was visibly successful in prolonging longevity in both our own country and indirectly in the rest of the world, but it seemed to require rising costs to sustain it. Many people, here and abroad, were still catching up with increased health and longevity, but the American majority who had already achieved it, had gone on to be worried about its insupportable cost. Because of his race, President Obama naturally appealed to the "catch-up" group; and because of their livelihoods, physicians were uncomfortable about complaining about costs. On the other hand, it is surprising to find a politician of President Obama's stature making the blunder of urging further immigration at a moment when it seemed questionable whether we could afford health "catch-up" for the population we already had. Physicians, who quite naturally favor more health care, were disillusioned early by the rationing device of Sustainable Growth Factor (SGR), now turned into a crude political blackmail scheme, one whose threat was discredited by Congress regularly postponing adjustments of frozen fees, year by year for decades. (To explain, SGR was an unrealistic cap on physician reimbursement which had reached the point of annually threatening a 26% cut in net physician reimbursement added to roughly 50% overhead costs. The prospect of shifting more control of Medicine to Washington was not enhanced by each year getting sympathetic treatment from Congressmen about SGR, but never getting it repealed. It was "like Lucy and the football".) The instinct for compromise finally seemed to evaporate among physicians, when the Affordable Care Act was pushed through in one day without allowing amendments, in plain view of millions of citizens watching on television. A House of Representatives was forced to do a politician's bidding, suddenly acting like a South American dictator. For many physicians, America became a banana republic on that day.

The Tenth Amendment could suddenly be recited by people more characteristically excited by professional football. If there was to be talk of amending the Constitution, perhaps it was the part about Congress making its own rules, which needed changing. State governments, ordinarily regarded as the weakest part of our political system, became a White Hope. Congress itself had become more polarized than at any time in the preceding fifty years. Not to mention the fragile condition of foreign affairs or the bewildering tangles of international monetary policy, it looked to be high time to ditch this health thing of Obama's.

Accordingly, this book roused itself into print. Because, no matter what the final fate of Obamacare, it isn't real healthcare reform, it isn't even serious health insurance reform. One main reason it deserves to raise so much concern is the way polarization is spreading into other basic institutions. A real danger is we may spend so much money, and devote so much of our limited attention span to Obamacare, that we never will get around to some basic reform of health care. No matter how else it may be described, this book is about real reform of health care, including absolutely indisputable reform of the insurance part. But because of the political time-table, I came to feel that there was only half the time I needed to be complete. I cut off the bibliography, had to be satisfied with a mechanical index, and then with great regret, cut out at least half of the "inside baseball" describing the details of healthcare reforms -- as distinguished from Health Reform. Unless this book provokes less controversy than I anticipate, there won't be time to do much but answer it.

George Ross Fisher, MD

Philadelphia

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