Best Healthcare Plan

Professor Laurence Kotlikoff’s recent article on Bloomberg news, “Health Law’s Demise May Permit Best Plan,” yields several points regarding healthcare reform, which I want to critique. ( http://www.bloomberg.com/news/2010-12-29/health-law-s-demise-may-permit-best-plan-commentary-by-laurence-kotlikoff.html ) In this discussion, italicized sections come directly from this article and are followed by my own discussion.

It’s a sad legal system that confuses linguistics for principle. But adherence to original language may trump concern for original intent, even on appeal to the Supreme Court. Here, Professor Kotlikoff is discussing that different wording of the individual mandate for health insurance would have avoided the U.S. District Judge’s ruling that this is unconstitutional. Perhaps so, but I am much more interested in the words, original intent. Rather than castigate the legal system, I would suggest that the 111th Congress and President Obama used linguistics and 2000 pages of Washington DC hieroglyphics to obfuscate their intents: 1) A massive increase in their, the federal government’s, power and control over everyone’s life (via our healthcare system), at the expense of the people, who actually pay taxes and buy health insurance individually or through their employer, the latter’s benefits package being part of the employee’s wage; 2) a huge increase in the Medicaid entitlement population, which translates to a voting block, which will keep them in power.

It (Obamacare) adds another expensive entitlement–federally subsidized health exchanges, with no solid cost controls- to Uncle Sam’s continually skyrocketing Medicare and Medicaid obligations. I agree that these health insurance exchanges, which are said to be new competitive health insurance markets, a place for easier, more understandable, one-stop shopping for health insurance ( http://www.hhs.gov/ociio/initiative/index.html ), will likely not provide any solid cost control for the businesses operating within our healthcare system. I also doubt that they will make purchasing health insurance any easier for the bewildered layman.

More important, I feel, is the reference to Uncle Sam’scontinually skyrocketing Medicaid obligations. This leads us into the argument of cost-shifting, as an explanation and justification for the continually increasing health insurance premiums and deductibles, which both individuals and employers face. The cost shift is systematically higher prices (above cost) paid by one payer group to offset lower prices (below cost) paid by another ( Dobson, A. et al. The Cost-Shift Payment ‘Hydraulic’: Foundation, History, and Implications. Health Affairs, 25, no.1 (2006): 22-33 http://content.healthaffairs.org/content/25/1/22.full ). Whether you believe the cost-shift argument or not, Obamacare enables and enhances health insurance companies’ greed-driven agendas by giving them a boat load of ammunition in the form of expansion of the Medicaid population (payments lower than reported cost) and thus the cost-shift argument, which leads to progressive narrowing of what insurance companies will pay for, as well as increasing premiums and deductibles and thus more and more people unable to afford to buy health insurance. Why were the 111th Congress, completely controlled by Democrats, and President Obama, a socialist-leaning Democrat, unable to deliver the ‘public option’ as a direct way of achieving their original intent, which is presumably stated in Title 1 of the Affordable Care Act: QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS? If this was really their original intent, why were they unable to achieve it? I think they didn’t achieve it because it really wasn’t important to them. What was more important for them was to promote a massive increase in their power and control over the American people; to have those Americans, who actually pay taxes and buy health insurance (individual or via employment) pay for this expansion of power and control; and to keep themselves ensconced in Washington, DC. And they used 2000 pages of linguistics and rhetoric to accomplish these agendas.

Given the way the health-exchange subsidies and employer fines are structured, the law will likely lead to the unraveling of employer-based health care, leaving the government paying the bill of the entire population. First, getting employers out of the health benefits business could be a very good thing. Their overhead could decrease drastically, and they might be able to hire many more people. Second, the government doesn’t pay for anything. The tax paying Americans and businesses, who send money to the federal government, pay for everything. So, if there was a properly and transparently administered ‘public option’, to which everyone was required to contribute, then a fundamental fairness in our health care system could abound.

Professor Kotlikoff distinguishes our current system from ‘Socialized Medicine’. Although by standard definition this distinction is correct, the effective meaning of socialized medicine (my view) is that the payer, whether private or public, decides how medicine is practiced by deciding which illnesses and to what extent are covered and which methods of practice will be compensated and to what extent. Thus our entire system is in actuality already ‘socialized’, i.e., controlled by the payers, unless you are one of the fortunate few, who have enough money to override the progressively restrictive agendas of both private and public payers.

This understanding is crucial because Professor Kotlikoff goes on to say that everyone needs a basic health plan. This is the thinking that I fundamentally disagree with. It puts the payer in charge. The nebulousness of the word, basic, makes this concept dangerous. What everyone needs is clear and equal access to sound, ongoing, non-conflicted doctorpatient relationships, within the context of which, medical decision making occurs. The function of the payer, whether private or public, is to administer payment of the bill, not to describe health plans (basic or otherwise), which control, ‘socialize’, the functioning of these relationships. In America, we privatize the business of medicine and are trying to socialize, control, the medicine of medicine, the doctorpatient relationship. For wonderful healthcare reform, it is this concept that needs to be changed. It needs to be reversed. Control, ‘socialize’, if you prefer that word, the business of medicine and let the doctorpatient relationship alone, to develop unobstructed, while ascertaing that it functions in a sound, ongoing, non-conflicted manner. The quest for the dollar bill needs to be placed as a secondary goal in our healthcare system. Thus, I disagree with Professor Kotlikoff’s voucher system to buy a basic health plan from an insurance company because it places the insurance companies in charge of the practice of medicine. It allows them to influence the practice of medicine to suit their own agenda.

A panel of doctors determines what’s covered by the basic plan within a strict budget. Who would these doctors work for? Who would be paying their salary? Do they have a crystal ball, which would tell them what the decision making within individual doctorpatient relationships would be? This is simply socialized medicine with the central controller being the insurance companies as opposed to the government. I disagree wth it completely.

The concept in Professor Kotlikoff’s voucher system that it combines public health-care finance (all who can pay do pay through their taxes) with private health-care provision, is onerous to all those people, who do pay taxes and buy health insurance. Why should they have to pay twice to keep the insurance companies in business? And private insurers contracting with the doctors and hospitals we choose for our care, (which already happens) can compromise the functioning of the doctors and the hospitals. The insurance companies become their employers instead of the patients.

I doubt there will be wonderful healthcare reform, beneficial to everyone including healthcare businesses, until effective control is brought to the business of medicine (hospitals, insurance companies, managed care companies, doctors’ practices, other healthcare businesses) and until clear and equal access for everyone to the medicine of medicine, (the doctorpatient relationship functioning in a sound, ongoing, non-conflicted manner) is seen as the primary goal of our healthcare system.

R. Garth Kirkwood, MD

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