Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Reflections on Impending Obamacare
Reform was surely needed to remove distortions imposed on medical care by its financing. The next big questions are what the Affordable Care Act really reforms; and, whether the result will be affordable for the whole nation. Here are some proposals, just in case.

(1) Obamacare: Spare Parts for a Book
Maybe these should have been included, but it was decided to leave them out.

ZNOTE: Obamacare Examined


======================== which in turn exercised powerful control over the hospital industry, grown prosperous and monopolistic as a result of, first health insurance, and then government programs. New aspirants for power could be accommodated in a growing medical economy, so nurses and unions aspired for position and prosperity. For a while, union representatives took over board positions at health insurance companies, then hospitals, as business lost interest in what for them began as a charity. Academia enlarged its beachhead of the Flexner Report of 1914 and largely fell into the dominant position in the medical profession by extending the power of teaching hospitals, fed by insurance, research indirect overhead money and philanthropic gifts. Meanwhile, the medical profession largely abandoned its professional control, as overwhelmingly increased practices presented an irresistible alternative for their spare time. The consequence of all these changes was a loss of control by the profession. As the center of political control shifted from state capitols to Washington DC, it became impossible for doctors to take time off from a practice to drop in on political allies, and consequently, many fewer physicians sought office in state legislatures. In most states, there are scarcely more than one or two-physician legislators, whereas there are now over twenty physicians in Congress, and the turnover is rapid. By contrast, most of the Physician-run Blue Shield organizations were started by physicians in the legislature, and most of them have been merged out of existence by hospital-run Blue Cross Organizations, which are in turn bought up by health insurance companies dominated by health insurance professionals. Suddenly making all of this worse was the Supreme Court Maricopa Decision, which by a 4-3 decision upholding a writ of summary judgment, found physician control of HMOs to be an anti-trust violation; no trial of the evidence was ever held.

Thus, federal anti-trust laws entered this murky picture, and quietly big business extended its control of health insurance with the ERISA law, which was fast becoming the dominant health insurance of employed persons, at least until the Affordable Care Act threw matters into limbo. Meanwhile, just about everyone else had to pay income taxes on the money used to pay for health insurance, but employer and ERISA plans have not, for at least seventy years. All of these actions have served in one way or another to shift control and regulation from totally state dominated to steadily increasing federal control of health care. And it continues; recent savings in healthcare costs have been totally absorbed by the Federal Treasury, in spite of piteous pleas from state governments to share some of them.

At least until the recent small decline in spending, no one contended that Federal control was cheaper than State control. In a recent symposium on healthcare costs, there were twelve speakers, not one of whom was a physician. Otherwise, it might have been mentioned that life expectancy has been extended by thirty years, and at least fifty diseases have been practically eliminated. It's hard to see how insurance executives could accomplish this, but nowadays anything is possible.


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