Health Care

 

                              Health Care

The Americans talk wistfully of their independence from government but the numbers, and the subtle influences, do not necessarily support that. For example, Health Care:

Medicare and Medicaid cover nearly 1 out of every 3 Americans – that’s more than 100 million Americans.

Medicare Enrollment – 19 million in 1966; 45 million in 2014; 61 million in 2019.

Medicaid provided coverage to over 75 million people in 2019. This includes working men and women, pregnant women, children, people with disabilities, and older adults.

Medicare was used to desegregate hospitals after the Civil Rights Act went into effect. If hospitals wanted to receive federal funding, they had to comply with the Civil Rights Act and desegregate.

10,000 Americans will be eligible for Medicare every day over the next 20 years.

81 million Americans will be enrolled in Medicare by 2030.

In the Academic-Political DMZ

Betsy McCaughey was born in Pittsburgh, Pennsylvania. Her mother was an alcoholic. She had a twin brother who was a serious asthmatic. She attended public schools in Westport, Conn. through the 10th grade, received a scholarship and transferred to a private Massachusetts boarding school, the Mary A. Burnham School, for her last two years of high school. She received a scholarship to attend Vassar College where she majored in history. She wrote her senior thesis on Karl Marx and Alexis de Tocqueville, won several fellowships, and received her B.A., with distinction, in 1970. McCaughey went on to graduate school at Columbia University in New York City, earning her M.A. in 1972 and her Ph.D. in constitutional history in 1976. She won Columbia's Bancroft Dissertation Award in American History in 1976. In short, she looks like a serious woman.

 

She became interested in health care, campaigned against HillaryCare, joined several boards of science companies and became a member of several think tanks, all conservative. In the '90's she ran with Pataki as Lieutenant Governor of New York and won. Then things get a bit murky. She was kicked off the reelection ticket, became a Democrat, and wrote a book about ObamaCare.

 

Her research into Hillary's plan was believed responsible for much of the negative response. She appears occasionally as a TV analyst but has mostly faded from the public scene. One of her successful projects was the creation of the non-profit Committee to Reduce Infection Deaths (RID) in reaction to the rise in anti-biotic resistant staphylococcus aureus and other hospital-borne infections. She has been in the midst of that difficult area of the academic-political DMZ. She has been able to have a scholarly look but is clearly politically inclined. She has never been able to shield herself in Hoover Institute or Brookings Teflon. Apparently she also had the poor sense to appear on the John Stewart Show and got clobbered.

She wrote an editorial recently about the coming fallout with ObamaCare and it contained these points:

--Workers in retail, hospitality and home care will lose on-the-job coverage and, in some cases, their full-time status, according to forecasts by the ADP Research Institute. The law mandates that employers with 50 or more full-time workers provide an "essential benefit package" that costs about twice what these industries currently offer. Employers will drop coverage.

--There will be noticeable hospital cutbacks. Cuts to Medicare pay for over half the law, and this will mean $247 billion less for hospitals over the next decade. Section 3000A of the law awards bonus points to the hospitals that spend the least per senior. Hospitals will even be penalized for what Medicare patients consume 30 days after discharge, including physical therapy.
--The crossover into social activism will be a problem. Consumers directed to a state exchange will worry about handing their Social Security number and 15 pages of financial and family information to exchange "assisters," temporary workers often from community groups. Civil rights activists in California resist background checks for "assisters" because it would disqualify too many minority men with prior convictions.

Her thesis is that there will be political fallout against ObamaCare as early as 2014. While the election in 2012 showed the public preferred Obama over Romney, it also showed antagonism towards ObamaCare. All the exit polls showed a majority favored repealing it. She feels in 2014 this discontent will coalesce, lead by younger voters. People in their 20s and 30s will be hit with 100% or higher premium hikes, insurers report. Nineteen percent of the president's 2012 voters came from this age group. McCaughey thinks there will be a coherent enough backlash to give the Republicans a strong win in the off-year election.

All this assumes, of course, a rational electorate with reactionary voting tendencies--an electoral circumstance the last election does not support.

Clinic

The lost and windblown, the inarticulate and the speechless, people who don't take their meds, people who take their neighbor's meds, dangerous people looking out from passive eyes, cheerful and grateful people, a fifteen year old mother of two, criminals in handcuffs, old soldiers with watchful family caretakers, men with sexual obsessions, some with new knife wounds, a man with prostate cancer who has been denied insurance coverage because his insurer has him listed as a female, men with old bullet wounds, a young man who has burned the word "BITCH" in the skin over his left deltoid with match heads because he "wants to own a motorcycle", self conscious hookers for "a checkup", meticulous and dignified old black men, brain damaged young men from institutions living in wheelchairs and wearing helmets, girls in tight clothing built like wasps, soft speaking street toughs, men and women working under the table, some healthy people who come for the friendly atmosphere, Arabs struggling with the language, students who want an exam under an alias, a man paralyzed by a bullet with a strangely distant acceptance, small business men who don't provide insurance for their employees either, sick people "lost to followup", many who have never had anyone nice to them or care for them ever.

Health Care, Medical Care and Managers

Several articles have appeared, conveniently, raising the question of the possible shortage of medical personnel in the next years. Some state that disaffected medical people will leave the profession, some that the increase of patients will overwhelm a stable physician population. One article suggests the rise of "physician extenders" (PA's, nurse practitioners) to make up the deficit.

The physician problem is already here. Every office offers anecdotal reports with significant declines in insurance reimbursement. Inefficient offices will be collapse; physicians who are already burdened because of time demands, age detriments or simple morale fatigue will likely leave. This new health scheme was created with little input from anyone (it would be interesting to know who wrote the bill) but physicians had the least input of any involved group (other than patients.) The reason, of course, is that this plan is not concerned with medical care, it is concerned with health costs. When confronting costs, as Wal-mart can testify, quality is the first to go.

A generation ago I spent some time in what was then East Germany and met a number of medical students. They were all in a two year program out of high school. All were women. When I asked where the male students were I was told, "The men here go into engineering. Medicine is women's work." This is the product of one of government's fondest wishes: The belief in incrementalism. If there are varying levels of expertise in any system, there must be a very high and a very low quality that is necessary. Thus much of the routine medical work can be done by low quality personnel. After all, medics are superficially educated and they see a lot of serious injuries first. So do EMT's. Consequently the belief that the lower rung of medical complexity can be managed by lower rung personnel. The problem in medicine is that the first encounter usually determines the complexity. And stabilization is a lot different than management.

We are entering a very different time in medicine, the time of the manager. Medicine is extremely complex. It is a true profession; its foundation is vows. It is only incidentally a product. It now will become primarily a product, subject to all the stresses and pressures of others. That will solve a problem for the managers as a profession will not allow compromise in quality or motive. If the profession is destroyed or diminished, everything is negotiable. Soon medicine will be less available; then good medicine will be less available.

Finally real medicine will be scarce and available only to our betters.

On the Road to Erineus

I am unsure where all of this is leading. Certainly the federal control of health care stems from one thing: their unfunded liability to the Medicare commitment. It is over 37 trillion dollars right now if they cut it dead. It is strange to see an organization that has failed in its initial project respond by trying to absorb the rest of the medical system but I suppose the logic is they can control the part if it is within the whole. Moreover they will not have to admit failure. I have not heard a single concern over the unfunded liability; only the uninsured, or small business burden or the rising costs of health care. This is the reason: http://www.usdebtclock.org/. So, to hide their previous failure-- ill conceived, poorly administered and gigantic--they will take over the rest of the medical system.
What will be created is any one's guess. I suppose it will be a distorted cobbled monster with the usual disastrous unintended consequences. Certainly the main activity will be contraction: To fix the price to the available budget. That will have no influence on the cost however and the distortions will follow. Resources will be reallocated to the politically connected and the symbolically secure. The medical profession, now a utilitarian organ of a cost and graft obsessed power, will be destroyed. The overall objective, the Medicare obligation, will be achieved economically if not morally.
Then we can turn to the next failed promise: Social Security.