Thursday, April 17, 2014

Sobering Talk On Obamacare

If people ask me if I have an agenda I say I do: we should not be fucking people. And if someone asks me why I am appalled by Obamacare that is the reason why. In its totality it is the greatest economic betrayal in American history. The right wingers "hate" Obamacare politically but absolutely love its economics of the largest shifting of cash into private corporations ever. Left wingers also love it for political reasons while remaining willfully ignorant on a religious scale of the consequences of these new outrageously destructive corporate chains.

The window dressing of this large scale burglary is that of giving a nickel to the victim after seizing all possessions. So we hear "Hey, I got a nickel" stories while ignoring the bigger picture. The cognitive dissonance is breathtaking and so massive as to be generally considered impossible by your average person. No one wants to admit when lying to themselves but that's exactly how you end up in a no-win situation.

Joel Zinberg is associate clinical professor of surgery at the Mount Sinai Hospital in New York City and is a trustee and past president of the New York County Medical Society. Reprinted with permission of the Manhattan

Proponents of the Affordable Care Act insist the law will extend health insurance to millions, expand access to healthcare, and improve Americans' overall health. But, as The New York Times recently reported, at least 20 percent of the new enrollees have not paid their premiums. They therefore do not really have insurance.

But even for those enrollees paying premiums, having health insurance is not the same thing as getting good healthcare, or any healthcare. In fact, it doesn't matter how many Americans obtain insurance under the ACA. Most will have difficulty finding a physician.

Many Americans could lose their employer-provided insurance if firms decide that paying the ACA penalty — and maybe giving small raises to their employees — is cheaper than offering health insurance as a benefit of employment or reduce workers' hours (the ACA does not mandate coverage for part-time employees). These newly uninsured workers will either have to enroll in Medicaid, if their income is low enough, or purchase a plan on one of the state and federal insurance exchanges. Those eligible for exchange subsidies may end up better off economically as their premiums will be so low, but both the exchange and Medicaid options are fraught with problems.

States already are struggling under huge budget deficits from their existing Medicaid programs. Since states lose federal funding if they adjust their Medicaid eligibility guidelines, their only option for reducing deficits is to cut already-low Medicaid reimbursement rates.

It's considered "pragmatic" by some to let corporations write our laws because that way the laws will get passed. In other words, if we can't stop theft pass a law making it legal. A win-win! But the outcome of that is perfectly foreseeable. As long as you say you're doing something for the greater good, people will allow almost anything. Everyone wants to be seen as an angel - and that's what we are: angels. The world is in the shape it's in because it's full of angels.

Physicians already are reluctant to treat Medicaid patients under current rates that are a fraction of private and Medicare rates. Cutting reimbursements will exacerbate the physician-access problem and could lead to closures of so-called "safety-net" hospitals that care for many of the poor and uninsured. These hospitals have long depended on federal Disproportionate Share (DSH) payments to offset the cost of caring for the uninsured. But the ACA severely cuts DSH payments on the assumption that the uninsured will gain either Medicaid or private insurance. If large numbers of patients remain uninsured, the financial difficulties of safety-net hospitals will be compounded by their obligation to provide uncompensated care.

Those who do get coverage through the exchanges and pay their premiums will also struggle to get medical care. The ACA requires insurers to accept every patient regardless of risk, provide expansive benefits packages, and eliminate caps on lifetime benefits. Looking to control costs, most insurers are offering exchange plans that severely limit the number of doctors and hospitals patients can visit. Some state exchanges — including New York's — don't offer a single plan that covers visits to out-of-network doctors or hospitals.

Many people will not be able to see the physicians who have treated them for years, use facilities providing the most appropriate treatment, or access care within a reasonable time and distance from their homes. Some specialty hospitals have been excluded from all exchange plans.

Everything about this law caters to the short term. The-powers-that-be know that once you get the chains on - by hook or crook - there's no way of taking them off again. They know the outrage that is coming when this finally collapses. But since we are a provable oligarchy the bidding of the people is of no consequence - especially when the morons self-enslave themselves to be powerless.

If this scenario sounds familiar, it's because we've seen it before, during the failed managed-care experiment of the 1990s. Patients and physicians quickly became disenchanted with the restrictions and bureaucratic complexity of Health Maintenance Organizations. At least patients had options then. They could avoid HMO restrictions by buying broader, more expensive insurance plans. Many plans available now on the state exchanges are highly restrictive, HMO-like networks.

Patient choice has been further compromised by the haphazard implementation of the exchanges. Patients have reported trouble determining which physicians will participate in which plans. Doctors, too, are often unaware whether they're listed in particular insurance networks and what the reimbursement rates are. Many find themselves arbitrarily excluded from plans in which they had previously participated; others are getting listed on plans without their knowledge.

Worst of all, insurance coverage under the ACA is unlikely to improve health outcomes. The much-noted Oregon Medicaid-expansion study found that new Medicaid enrollees showed no improvement in health outcomes compared with the uninsured. Other studies have shown that Medicaid patients have worse outcomes compared with privately insured patients (though why this happens is not well understood). The health outcomes of many exchange patients will suffer as a result of not being able to see their regular physicians or access the most appropriate specialists and hospitals.

The drafters of the ACA presumably had noble intentions, but the law is failing in all of its intended goals. Unless the ACA is redrafted to provide insurance coverage that most physicians and hospitals will accept, many patients will find that when they need medical care, the doctor is not in.

"You can see if what I'm saying is true." 
One day, millions will claim otherwise!

The most obvious hole in Obamacare is that it is health insurance not health care. The amount of wishful thinking around this mandate is higher than Mount Everest. The inherent greed built into the structure of this catastrophe will will create a tsunami of economic woes. Between government funneling guaranteed tax dollars to insurance companies for any losses sustained to the fact we already have too much of our economy spent on health care now, much less as time goes by with the continuing flood of cash into the system can only leave us one result.

Some people want to be conned. I get that. They feel as long as they can claim later, "I meant well" they have a license to do just about anything. That's how we sell ourselves on the bad things we do. We meant well murdering Iraqis. We mean well with our drone strikes. And some day we'll be scrambling to proclaim of our "noble intentions" on one of the greatest fuckings of our lifetime. "If only I had known!"

But we do know. We exactly know. For our health system to work, greed must be removed from the equation. There is no way around that, you cannot compromise on that, removal is the only pragmatic way to proceed. All greed based answers are doomed to fail. We have these continuing mock discussions on how many holes we should put in this boat of ours that carries us. The only answer to that is zero. But that answer is considered "radical, shrill, traitorous, immature" and whatever else sin someone wants to self-identify. Lennon was right. When America falls, she'll fall from within.

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