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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.

(www.Philadelphia-Reflections.com/topic/134.htm)

ACA Synopsis, July 4, 2014

The Affordable Care Act, commonly called Obamacare, contains two clashing provisions. Although the public may believe the Act provides for Universal Mandatory Health Insurance for all Americans, it actually only sets standards for minimum coverage. Because of later Supreme Court decision, the applicable section was renamed Section 5000A of . In the same section, it delays applying these standards to employees of big business, and exempts about thirty million others entirely. (Section c). In an independent section of the same law, Section 1251 clearly states that people satisfied with existing coverage may keep it. Even after millions of Americans nevertheless received cancellation notices, President Obama repeated on television that no satisfied person would be required to drop existing coverage. Even disregarding mere verbal assurances, the two written sections did follow the rules for enactment and were signed by the President. just how are they simultaneously possible, to say nothing of workable?

A quick answer would be that the first sentence of the first Article of the Constitution vests sole power to create legislation in a Legislative Branch composed of a Senate and House of Representatives; thereby requiring the agreement of both, for a law to be a product of the entire Legislative Branch. It did not take long before a Conference Committee system was established, where the two Legislative Houses could negotiate any differences. When one party has voting control of both Houses, however, it is occasionally able to create identical language, eliminating the need for reconciliation. According to a book by an intimate, the Clinton administration planned to take this process a little further in their own Health Plan of 1992, including undesired provisions when that was useful to obtain a wavering vote, or otherwise to obscure the true direction of the legislation for extra time. Having complete control of the process, the party in power would later be able to delete undesirable provisions. The true nature of the legislation might thus only emerge at the last possible moment, when timing could be manipulated to make it difficult to object. It is not possible to know whether this strategy has been used in other legislation, but circumstances strongly suggest it was partially implemented in both Clintoncare and Obamacare, and by many of the same people.

In any event, Clintoncare was withdrawn by its sponsors, before a floor vote and for undisclosed reasons. Obamacare was enacted by the Senate, but the death of Senator Kennedy and his replacement by a Republican Scott Brown made it impossible to survive a filibuster on its return for final Senate adoption. To avoid this outcome, the Senate bill was forced through the House of Representatives word for word, and the Senate bill then became the final law, even though it was known to include booby traps. Largely as a result of public outrage, a strong Republican majority was returned to office, and the possibility of further amendment was ended. So that's why we are essentially where we are.

What happens next is much more uncertain, because more actors have an opportunity to initiate events. Setting aside international adventures and financial crises, the Congress could lose control of events by failing to negotiate a solution. After that, it is probably up to the electorate of seven states with tight Senate races, if not the United States Supreme Court, which has its own private agenda. All of these potentials put pressure on Congress and the President to negotiate a compromise. I suggest a simple first step would be to see if the entire section 1251 could become an amendment by addition to section 5000A, That would have the effect of adding a fourth class of exemption (people who don't want to change) to Illegal immigrants, incarcerated persons, and those with religious objections. Alternatively, they could be added to employees of big business as "temporarily" delayed. A case could be made to the Democrats that a smaller initial transition group could be more readily implemented. And a case to the Republicans would essentially be that "nothing is so permanent as the temporary". In both cases, the November Senate races would suggest what the public will support.

The public tends to believe the central agitating issue is health care, but more likely the central issue is state versus national regulation of health insurance. Health care was universally regarded as a local or state issue for three hundred years, and the issues were all technical and peaceful until pre-paid insurance began to be the dominant method of paying for it. No one seems to be noticing that ERISA has peacefully solved almost all of the problems of interstate mobility, which is what agitates interstate health insurance. Essentially, my position is that healthcare regulation can safely return to state control, at least during the period when the techniques and insights of ERISA are copied and experimented with, for health insurance.The public actually has very little interest in the interstate regulation of health insurance, so fifty years of agitation have essentially been over nothing.

With regard to health insurance, I believe we are working with the wrong design. Young working people accumulate savings, and old retired people spend it. Lengthened longevity has created the potential for enormous savings from compound investment income generated by working people, but such savings have been frittered away by using a "pay as you go" payment system. If we created portable systems for saving and investing income during the working years (the Health Savings Account), we could almost dispense with health insurance of the present model until people reach fifty or sixty years of age. Lifetime health insurance would be one approach, but all that is really necessary is lifetime savings accounts. Dispensing money from a fund could be quite adequately managed with a debit card, leaving only the problem of disciplining the fees of investment managers. But the details of such saving, investing and disbursing are of only secondary interest to the public, probably best left to the industry itself, because the industry will be very interested, indeed. As for reducing the cost of health care, we have stumbled along, letting the scientists eliminate disease costs by eliminating disease itself. They still have worms in Africa, and Asia could use some sanitation, But we have reached the point where our fastest-growing age group is over 100, and out biggest unsolved health problem is not dying too soon; it is living beyond our savings.

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