Obama’s Health Care 2009

It’s been several months since I typed anything related to health care. Honestly, there truly hasn’t been anything new to write about, but also because I was waiting until the historic moment when our Senators and Congressman made fools of themselves and passed this forest-killing universal health care bill. Not only did they do it in high profile fashion as both were passed on Saturday nights, right about the time Saturday Night Live was beginning (fitting, don’t you think?)

The behemoth spewed from the bowels of congress, late in the weekend evenings of November 2009, is a mere 2077 pages long.  Small by Federal standards and still much, much less than the current tax code (the tax code is actually more than 13,000 pages and 22 volumes).  But give it time.   At the rate that Washington produces garbage, the health care bill will catch up very quickly to the tax code, and make about as much sense.  Of course, 2077 pages is way too much to digest and report here in one post, so I’ve decided to review the entire Bill in more easily managed “tidbits”.  Over the course of the next several weeks, I’ll take a look at the Bill in sections, and hopefully make it though all 2077 pages.  No small feat, but I’m sure that I’ll make it through the entire Bill before Congress produces one more document about healthcare and, after I finish, I’ll have read the entire Bill.  I doubt that any member of Congress has done that yet.

And yet, most Americans simply want healthcare.  Free or cheap, inexpensive or provided by work, the government, whomever.  They just want healthcare.  While we do have “universal” healthcare now, it is expensive and inconvenient for those who choose to take advantage of this “free” option.  Most middle school children will tell you that what is needed is something universal, affordable, simple, accessible, and for whatever my two cents is worth, easy to administer.   Clearly, Congress must need to go back to middle school and pare down their 2077 pages.  Harrison’s textbook of Medicine, the bible for Internal Medicine physicians, is only 2754 pages in length and encompasses ALL of Internal Medicine. The health care bill contains nothing specific, is full of generalities and may not even survive in its current form to make it into law.

I’m afraid that what will emerge is an inefficient health care program, providing less coverage, greater expense, more bureaucracy and an enormous national debt that even our grandchildren will not be able to repay.

Doc B.

My opinion is free.
Advice is worth exactly what you pay for it.

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Obama’s Health Care Bill 2009

It’s been several months since I typed anything related to healthcare. Honestly, there truly hasn’t been anything new to write about, but also because I was waiting until the historic moment when our Senators and Congressman made fools of themselves and passed this forest-killing universal healthcare bill. Not only did they do it in high profile fashion as both were passed on Saturday nights, right about the time Saturday Night Live was beginning (fitting, don’t you think?)

The behemoth spewed from the bowels of congress, late in the weekend evenings of November 2009, is a mere 2077 pages long. Small by Federal standards and still much, much less than the current tax code (the tax code is actually more than 13,000 pages and 22 volumes). But give it time. At the rate that Washington produces garbage, the healthcare bill will catch up very quickly to the tax code, and make about as much sense.

Of course, 2077 pages is way too much to digest and report here in one post, so I’ve decided to review the entire Bill in more easily managed “tidbits”. Over the course of the next several weeks, I’ll take a look at the Bill in sections, and hopefully make it though all 2077 pages. No small feat, but I’m sure that I’ll make it through the entire Bill before Congress produces one more document about healthcare and, after I finish, I’ll have read the entire Bill. I doubt that any member of Congress has done that yet.

And yet, most Americans simply want healthcare. Free or cheap, inexpensive or provided by work, the government, whomever. They just want healthcare. While we do have “universal” healthcare now, it is expensive and inconvenient for those who choose to take advantage of this “free” option. Most middle school children will tell you that what is needed is something universal, affordable, simple, accessible, and for whatever my two cents is worth, easy to administer. Clearly, Congress must need to go back to middle school and pare down their 2077 pages.

Harrison’s textbook of Medicine, the bible for Internal Medicine physicians, is only 2754 pages in length and encompasses ALL of Internal Medicine. The healthcare bill contains nothing specific, is full of generalities and may not even survive in its current form to make it into law.

I’m afraid that what will emerge is an inefficient healthcare program, providing less coverage, greater expense, more bureaucracy and an enormous national debt that even our grandchildren will not be able to repay.

Doc B.

My opinion is free.
Advice is worth exactly what you pay for it.

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‘‘Patient Protection and Affordable Care Act’’ Part I

So lets get started. The actual meat of the Senate version of the health care bill starts on page 16. Pages 2-15 are an “index” of section numbers, much like page numbers but with specific reference to certain portions of the text and not an actual page number, per se. My review is based on page numbers; mostly because it’s easier for me. If a section crosses page numbers, I’ll complete that section and pick up the remainder of the page in another post. If you would like to follow along as we review together, here is the link to the bill from the democratic senators website.

The first section tells us that insurers are not allowed to establish lifetime limits of coverage or set “unreasonable” annual limits on beneficiaries, but fails to tell us what “unreasonable” is. If a service is not part of the basic essential package of benefits required, insurers may impose lifetime and individual limits for those services. This section also says that an insurer cannot rescind a members benefits once enrolled, unless that person commits fraud or makes an act of intentional misrepresentation. But they can cancel your insurance with prior notice, as permitted under section 2702(c) or 2742 (b). So in effect, they can cancel you with prior notice.

This next section is even better. Instead of paraphrasing it, I decided to include it in it’s entirety so everyone can see just how ridiculous this is. I’m also including the link to the Task Force they mention. You definitely need to read that. Look through the list and pick a disease or diseases that you or someone you know may be concerned about. Check the recommendations for screening. Wow!

SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES. ‘‘(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for—
‘‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;
‘‘(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and ‘‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

‘‘(b) INTERVAL.— ‘‘(1) IN GENERAL.—The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline. ‘‘(2) MINIMUM.—The interval described in paragraph (1) shall not be less than 1 year.

The previous section is saying that any new recommendation made by the task force must wait at LEAST one year before being included as a covered, no “cost sharing”, benefit. By that time the research and literature will have likely changed and we’ll all be receiving a free benefit that covers an outdated treatment or recommendation. It could actually be found to be harmful. Thanks!

Sec 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM
EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS.

Wow! Really big words that mean that all of the insurers are going to be forces to provide members or insureds (you) with a complete, concise summary of benefits and coverage, that is culturally appropriate, not smaller than 12pt type, contain insurance and medical definitions, description of coverages including those requiring cost sharing, deductibles, copays, renewals and only be four pages long. The bill took almost four pages to say what had to be contained in the four pages and didn’t go into any detail. It also states that it must be culturally appropriate and able to be understood by a typical plan participant.

They cant tell the insurers what to do in less space than they want the insurers to do it, with much greater detail and under penalty of law or prohibiting them from participation. What the hell are they thinking?

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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Who Should Be In Charge Of Fixing Health Care?

I consider myself to be pretty handy with most household repairs.  In fact, I actually remodeled a kitchen in one of my early homes by myself, a bathroom in another and built a mahogany wet bar in my current one.  But when it came done to the detail work, I called an expert.  For the kitchen remodel, I called an electrician to rewire my circuit breaker box, run the additional wiring for the new lighting and upgraded cook top. I also had someone come out and measure, cut and install the counter top.  I knew better and wanted the finished product to not only look fantastic, but functional too.  The wet bar is a beautiful raised panel design.  I did all of the rough carpentry and paneling.   But when it came time for the crown molding, I called a professional.  It looks fantastic.  I appreciate anyone who knows their limitations and knows when to call a professional to supplement their work or complete an important project.  As a physician, I have no problem telling my patients that I don’t know, but I follow that up with “I’ll find out for you”.   And I do.  I could never imagine myself going to Washington, sitting in on a Congressional meeting and then commence to tell them, not only what they are doing wrong, but telling them how to fix all their problems that I just described for them.  But this is exactly what THEY are doing with health care. Who are they to tell such a large percentage of our GDP what to do?  What expertise, or day to day experience, do they have to tell anyone in health care what is wrong or what needs to be done in order to fix it?  None.

One comment that Mr. Obama made in his speech the other day was that the reforms he wanted to put into place would decrease medical errors and increase quality and one way of measuring this quality was by monitoring the re-admissions of patients. I’m afraid that is NOT a measure of quality in my experience, but a measure of the severity of a patient’s illness, a measure of the number of associated medical diagnoses and a measure of patient compliance.

For example: A 65 year old white female admitted with shortness of breath is found to have congestive heart failure. She is treated appropriately with diuretics, angiotensin converting enzyme inhibitors, nitrates and beta blockers.  She has an echocardiogram to measure the heart’s ability to pump blood.  The hospital and doctors order all of these in order to comply with Medicare’s “core measures” of quality (yes, they watch each case that closely). She is discharged after 5 days in the hospital feeling much better.  She goes home and the next morning slips on some spilt tea, and falls to the ground.  She is readmitted to the hospital with a hip fracture.  Is this an issue of quality?

A 74 year old black male with a 50 year history of tobacco abuse, oxygen dependent emphysema, heart disease and high cholesterol.  He is admitted with an exacerbation of his emphysema.  He receives steroids, hand held nebulizer treatments and antibiotics.  He improves slowly and is discharged home.  He refuses his pneumonia and flu vaccines. He is counseled on smoking cessation.  Once home he resumes smoking, catches a cold from his grandson and is readmitted.  He is intubated and placed on a ventilator in the intensive care unit. Is this an issue of quality?

A 67 year old white male with cirrhosis of the liver from life log alcohol abuse, repeated bouts of pancreatitis, chronic anemia, ascites and thrombocytopenia (low platelets) is admitted with an upper gastrointestinal bleed secondary to esophageal varices.  He undergoes endoscopy with sclerotherapy to stop the bleeding, a blood transfusion and medicine for alcohol withdrawal. He is referred to the transplant service for possible liver transplant but is rejected again, because of his ongoing alcohol abuse.  He is discharged home but continues to drink daily.  He is readmitted for an episode of bacterial peritonitis (infection involving the ascitic fluid in the abdomen).  Is this an issue of quality?

None of those scenarios are issues of quality by anyone’s standards except for Medicare. What is truly lacking is common sense.  Just like the restriction on the use of restraints. Patients who are demented and confused, and used to be restrained for their safety, are now denied that safety by Medicare guidelines and allowed to walk, fall down and break a hip.

Why should common sense ever be included in decision making?  I would propose that for every member of Congress, Legislator and member of the Executive Branch who is debating or contemplating health care reform, should have a partner who has practical, hands on experience in the trenches, where patients are actually cared for. What is really needed is practical, common sense, comprehensive reform but with the guidance of experts so the final product will be one we can all be proud of.

Gotta know when to call the carpenter.

Doc B.

My opinion is free.

Advice is worth exactly what you pay for it.

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Health Care Reform: At What Cost?

The initial pieces of the Obama health  care reform, revealed today in excerpts published in newspapers and by Obama himself, show us some of the “how” behind the financing of his health care reform. Of the 634 Billion to be raised on the backs of “upper income” Americans, 318 Billion will come from reducing or eliminating certain tax deductions for upper income earners. All of the examples state that these net tax increases will not effect “families” earning less than $250K per year. Fairness depends on how you define “family”. Take for example the tax filing status of two very common scenarios. First is the “family” definition used by many of the examples sited by Mr. Obama and his spokesmen.  Married filing jointly implies a family of two, one or two income earners, with an income of $250K or less.  This equates to an adjusted gross income (AGI) of approximately $208,850 per year (according to Mr. Obama and company). For that couple, it also means a tax liability of $47,649.

Another very common family scenario is a single adult home with children, called head of household.  Assume the same income with three children of varying ages, all in school.  The AGI for this family is also $208,850 and their tax liability is $51,483.  Include the parent’s health insurance contribution, state taxes, social security taxes and local taxes, leaving about $140,010 (assumes social security and medicare taxes on the first $105K-didn’t include the remainder of the medicare taxes,  state tax rate of 7%,  no local taxes, health insurance contribution of $150 per month). Why would a family household with apparently greater financial needs be taxed at higher rate?  Does the IRS think that it is cheaper to care for children than for two adults? Do they think families with children have more disposable income than two adult households? Perhaps they think the children should all work after school and on weekends to supplement the household income.  Which family do you think will be more heavily impacted by Mr. Obama’s tax increases?

If I were working at Walmart as a cashier, making $32,000 per year, married with five children, I could potentially pay no taxes and with the Earned Income Credit, get a refund of $2,000.  I would also qualify for food stamps, with a maximum allotment of more than $900 per month. I, and every member of my family, would also qualify for Medicaid under the Categorically Needy definition of eligibility, as published by the Centers for Medicare and Medicaid Services. Keep in mind that Medicaid is the most costly of the government run health programs at a whopping $14K per person per year (see my previous post for the cost per person of the different programs). This brings my Walmart family’s total annual income and benefits to $142,800. All tax free.  Talk about a redistribution of wealth!

Under the circumstances, I don’t think it is fair to ask any American to pay one more penny of tax until the waste is removed from our mostly costly programs. First and foremost are Medicaid and SCHIP, with a cost per person of more than $14K per year.  Next is Medicare.  Both government run, government managed (or mismanaged).  Lastly is private insurance and self pay.  Our original scenarios above show how unfair the increase in taxes can be to heads of household.  I think all we really need is some common sense, and a real sense of fair play.  Don’t just look at a household’s income,  Look at the people in that household. They might need every penny.  They struggle.  They earned it. They work and pay taxes.  And the government isn’t giving them any handouts.  The government is wanting to take more from them.  Not fair.

Doc B.

My opinion is free.

Advice is worth exactly what you pay for it.

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