Readers, I find myself again in a state of outrage. Screed to follow. The subject is once again healthcare. The frustration is that Obamacare, and now Medicare reform, is totally reform, and not at all revolution. Not even mini-mini-revolution. What I mean by that is, the power that be are the powers that will be.
The Institute of Medicine has listed areas of potential savings in health care. Here they are:
Unnecessary services $210 billion
Inefficiently delivered services $130 billion
Excess administrative costs $190 billion
Prices that are too high $105 billion
Missed prevention opportunities $55 billion
Fraud $75 billion
To me, this list is interesting because of the categories. Notice – you can’t say from this list just who is responsible for all this. It is a list asking for technical fixes. It underplays just who is doing what.
When you’re not talking revolution, you’re saying that them that has is them that gets. And them that has gotten is them that keeps getting. Where is the power? In hospitals, in academic medical centers, in procedural specialists, in pharma, in technical equipment companies. Where is it not? In patients and primary care doctors. I’d also say that the power is with the emerging power of community health centers, and probably nurses, because they are organized interests, the nurses as a powerful union that has for years constrained entry to their ranks and now holds the hospitals hostage, and in the case of CHC’s a government-friendly socialistic movement with a strong lobby.
Where is the fabled AMA, you might ask? Nowhere. The AMA doesn’t count anymore. Doctors are totally fragmented.
So, where are we going with health care reform? I have to refer you to my previous post on High Deductible Health Plans, which are the fastest growing plans in the country. A recent report says that 15% of large companies are going to offer only HDHPs this year! I think the most popular plans on the Health Insurance Exchanges will be the bronze plans, and they will probably be basically HDHPs. Who do these plans screw? Patients – more out of pocket – and primary care doctors.
The ideologues of the right wing, without relevant experience in health care, think Americans have too little insurance, not too much, which leads patients to indulge themselves in the “moral hazard” of overutilization. That’s just ideology. Patients are the least powerful element in the equation – they are the cause of over-utilization of, say, back surgery, when orthopods and hospitals profit enormously from these usually useless procedures? Give me a break.
The problem of overutilization is too much primary care? Again, give me a break. It just doesn’t make sense. Yet that is the cause prosecuted by HDHPs.
What does make sense is this: if you don’t think about rationality in health care, if you don’t think about equity, if all you think about is protecting your turf and decreasing costs without decreasing your own profit, and if you have the power – then you will increase deductibles, so patients pay more, and primary care takes it on the chin. And that’s what is happening.
So – and here’s the outrage – what does the Obama Administration start to offer as a concession to the Republicans in trying to reach a budget agreement? You know what it is, if you have been reading this screed with even minimal attention. They are proposing to consider the Republican proposal, from that icon of disinterested intelligence Eric Cantor, that parts A and B of Medicare be combined, so that there is one (large) deductible, and patients get to pay more. So the pressure builds again to reduce primary care visits, just what the doctor of rational reform didn’t order, but which was instead ordered by the political gods, the hospitals, and the procedural specialists.
Obama is basically a health care illiterate, and the people around him are obviously just conventional politicos. Or they figure there is nothing to be done with the basic powers that be, and they have to just bow down to power. There is no deep thought, there is everything about obeying the powers that be – the ones responsible for the state we are in. That’s why I’m thinking that the Obama years will be regarded as a benefit mostly because of the worse outrages they prevented, rather than what they actually did.
God help us.