Friday, April 18, 2014

ObamaCare in Context

For me context is the key – from that comes the understanding of everything.

Kenneth Noland (1824-2010), American Artist

As President Obama spikes the football and runs his victory laps over the 8 million enrollees in his health plan,  it is important to keep matters in context.

First,   8 million is 2.5% of 315 million,  the U.S. population.

Second,  the original goal of 7 million was a made-up manufactured political number.  The idea was to set up a number you realistically  expected to meet, then to cheer if you exceeded it.

Third,  a lot of unknowns remain – how many were young and healthy,   how many were old and sick, how many were insured, how many were previously uninsured,  how many actually paid, and how high premiums will be when announced in May.

Fourth,  the cheer leading, fist pumping,  and highfying  is all about better positioning Democrats for the November midterm elections, which they need to win if ObamaCare is too remain viable.

Fifth,  the final returns are not yet in.  The latest average on the health law show 39.8% in favor,  52.3% opposed, and those numbers have remained roughly the same since the law passed in March 2010.

Sixth,  this enrollment period is the first of many.  The next is November 15 of 2014, which will follow the midterms.  ObamaCare implementation is a multiple year process.

Seventh, President Obama has 2 1/2 years  left in office, and other issues – the speed of the economic recovery, the rate of unemployment,  foreign policy outcomes –  will affect ObamaCare acceptance or rejection.

Eighth,   there are a series of imponderable requirements  that  need to be put in  context.
           Anything that requires 2700 pages to explain may be inexplicable, hence confusion will continue.
·         Anything that requires 2500 pages of regulations to enforce may be  unenforceable.

·         Anything that requires $2.5 trillion to implement (OMB estimate)  may be unsustainable and  unaffordable.

·         Anything that results in more than 150 consecutive negative national polls over a 4 year period may be politically untenable.

Tweet:  The fact that 8 million Americans have enrolled in the health exchanges should be put in political context before being declared an unqualified  success.

Thursday, April 17, 2014

Disappointed Direct Care Coalition: Forces at Work, For and Against

Don’t fight forces, use them.

Buckminster Fuller (1895-1983),  Shelter(1932)

Here I shall have a go at describing  forces at work  for and against primary care physicians – an endangered species,  and direct care without 3rd party meddling - who and what  everybody seems to want but nobody seems to know how to organize or back with support and capital.

Hospitals -  Hospitals need primary care doctors for referral to specialists,  their main source of income.   That is the  principle reason why hospitals  have acquired hundreds of thousands of primary care practices and why they now employ over half of the nation’s primary care practitioners.   As government systematically reduces payments to hospitals for Medicare and Medicaid patients,  however, down the road, hospitals will be forced to  lay off many of these physicians and to discontinue their services. What then?

Government -  Government’s answer to the primary care physicians  seems to be to place them as leaders of “teams” in  medical homes or accountable care organizations in order to cut costs and to "save"  Medicare and Medicaid,  by rationalizing care and cutting down on specialty referrals.   Primary care doctors,  partially replaced by nurse practitioners, physician assistants, and others, will, government reasons,   cut costs.  Primary care physicians are skeptical, for they know “teams" cost money and boost overhead.

Patients -  A sizable proportion of patients,  no one knows how many,  want  to be seen directly, quickly, and confidentially by personal doctors, who have time to spend with them without constantly looking at their watches in order to “process” them to get to the next patient,  so the doctor can ends meet with reduced government and private health plan payments. At the moment, many patients, both insured and uninsured, are realizing they cannot afford premiums and deductibles in ObamaCare exchange and private plans.

Doctors -   Primary care doctors want to practice medicine,  a skill that took  them 12 to 15 years and a $500,000 or so to qualify for, without spending 25% of their time punching data into computers, coding,  hassling with 3rd parties,  or dealing with bureaucratic regulations, all while devoting 50% of their practice overhead to these activities.  They want to spend their time talking to, listening to patients,  and examining them rather than being glued to a computer screen.  Primary care doctors  seek to make a reasonable income while practicing what they have been trained to do.  These doctors know they are not the source of soaring health costs, for primary care consumes only 6% of total health costs.

Employers – Employers want to cut health coverage costs for workers,  costs which have doubled or tripled over the last 10 years, without cutting benefits, raising workers’ premiums,  or paying stiff penalties to the government for not offering comprehensive “essential benefits,” which many workers do not need or wish to pay for.  They want their workers to have a choice of reasonable plans, and to have personal incentives to shop for care using part of their own money with rest left over for a rainy day in the future.

Satisfying Constituencies

How to satisfy all these constituencies while providing affordable, accessible, convenient care is a vexing question.

The answer will require private capital and private leadership, a tried and true business model, and overcoming stereotypes of doctor entrepreneurs who decide to go it alone by offering 3rd party-free, personal care, affordable care.   

 The capital may come from self-funded business who want to cut their expenses while offering their patients direct care to local physicians.  

 It is more likely to come from a coalition of forces.  One of these forces is likely to be businesses offering  health savings accounts,  with contracts and contacts with local direct independent  practitioners, including specialitsts, and new relationships with local and regional banks, who would profit from administering  funds for HSAs.   It is more likely come from  a coalition of forces demanding realistic change.

A Coalition for Direct Care

As things now stand,  a number of organizations are coming together behind the concept of “direct patient care,” without parasitic organizations and consultants profiting from direct patient-doctor relationships.   This effort will require a coalition of organizations bringing to light the need and demand for direct care and spreading the word.   

We live in an age of coalitions.  Obama has mobilized a “coalition of the ascendant” – minorities, young people, single women, and college-educated cultural elites.  Opposing them  is a gathering and building of a  “coalition of the disappointed”   - the shrinking middle class, the unemployed,  the uninsured, the working insured,  and primary care physicians – none of whom can afford ObamaCare.

Tweet: A disappointed coalition of organizations, doctors, and patients is growing promoting the need and demand for direct affordable  patient care.

Wednesday, April 16, 2014

How To Cook the ObamaCare  Statistical Goose

How can the government cook its goose to prove it is laying golden eggs?

Question from reader

How do you cook a statistical goose,

When the goose is a political caboose?

One, you can conceal the raw statistics.

You can say you don’t know the logistics.

Two,  you can change census insurance questions,

Make it  hard  to learn past data lessons,

Three, you can emphasize the positive,

Simply eliminate the negative.

Four, you can send critics on wild goose chases,

By constantly changing the subject to save faces.

It is easy to cook the data goose,

Create your own statistical stew juice.


1.       “Cook the ObamaCare Stats: Suddenly the Census Bureau Changes How It Counts Insured,” Wall Street Journal, April 17, 2014.

2.       “Census Changes Will Make it Hard to Gauge Health Law’s Impact. “ Kaiser Health News Capsule, April 17, 2014.

- -    "Numbers Game, " New York Post,  April 15, 2014.

Contradictory Health Reform Talks

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind, and still retain the ability to perform.

Francis Scott Fitzgerald (1896-1940), The Crack-up (1936)

I’ve been asked to give 2 talks in the next 3 weeks – one to a group of hospital chaplains, the other to a group of independent doctors.

The first group, I suspect, leans towards government-regulated universal coverage.  The second group, I know, opposes government regulation as a threat to patient and physician autonomies.

My challenge is to be consistent and true to my beliefs without being contradictory.  No doubt both groups believe in a social safety net for the poor, uninsured, and otherwise disenfranchised, but they differ on how to get from here to there.  This is particularly difficult in a stagnant economy,  when there is no there there for the poor and a shrinking middle class.

One group may see reform as primarily a moral issue.  They believe the path to morality goes through government regulation.  The other group believes the path goes through free enterprise with ensuing prosperity. 

For both groups, I will probably quote Sir Winston Churchill’s aphorism:  "The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.” This would resonate for both groups, for both sides are miserable about the prospects for reform.

No matter how you cook ObamaCare statistics to prove the ACA  works or doesn’t work,  there are no easy solutions, no path to glory, to clarity, no way to prove whose goose is being cooked.

You cannot resolve the two group’s differences.  By you can always say, there is gloom for improvement.  You can always quote another Churchill truism,”You can always count on the Americans.  In the end, they will do the right thing, after they have tried everything else." And you can always say that, at 238 years of age, we are the world’s longest surviving Democracy, where the majority rules,  where we resist authoritative mandates,  where we have checks and balances, and where are a free people who  believe in equal opportunity for all.”

In future blogs,   I will share with you the essence of my remarks before these two group.

Tweet:   ObamaCare evokes 2 sets of beliefs: 1) the path to the social safety net goes through government; 2) the path goes through market-based prosperity.