American Elephants


The ObamaCare Battle Has Just Begun. by The Elephant's Child

On this one, I’m with Justice Kennedy. I cannot see the difference  between overthrowing the mandate, and then  doing the same thing and calling it a “tax.” Roberts rejected the mandate, then wrote a new law himself. A big mistake.

I am far more concerned, however, with what a remarkably bad law the Affordable Care Act, (with the Orwellian name) is. It is not affordable, and is going to be a huge tax increase on the middle class. Justice Kennedy writing the dissent said:

What is absolutely clear, affirmed by the text of the 1789 Constitution, by the Tenth Amendment ratified in 1791, and by innumerable cases of ours in the 220 years since, is that there are structural limits upon federal power — upon what it can prescribe with respect to private conduct, and upon what it can impose upon the sovereign States.  Whatever may be the conceptual limits upon the Commerce Clause and upon the power to tax and spend, the cannot be such as will enable the Federal Government to regulate all private conduct and to compel the States to function as administrators of federal programs.

The Supreme Court is upholding as a tax something that the Congress and the President swore was not a tax —allowing them to enact as a tax something that if it had been presented as a tax would never have passed Congress.

I don’t know if people are assuming that they are going to get free health care. I think some are. All those formerly uninsured people are supposed to be funneled into Medicaid, but we are already short over 50,000 physicians, with more doctors leaving  daily. I know four who have departed recently. One went to Africa, one to Montana, one simply vanished and one went to work for the Diabetes Foundation, and I know a couple who do not accept insurance at all. Our Medical Schools are unprepared to turn out significantly more doctors, which means that emergency room use will go up significantly, increasing costs.

The tax on medical devices (everything from stents and catheters to wheelchairs and diagnostic machines) is sending some companies out of the country, some are forced into massive layoffs, and some are just cutting back.  There will be significantly less innovation. Drug companies are already moving their labs abroad because of excessive regulation and long timeline for drug approvals.

The ruling was a real surprise. Opinion was very much expecting the law to be overturned. Intrade bets were over 70% that the law would be struck down. As the ruling was announced, the stock market dropped, and Mitt Romney raised $300,000 in the first hour, and is up over a million on the day.

The new law will insure more Americans, it will still fall far short of universal coverage. It is estimated that by 2019 there will still be 21 million uninsured.  The legislation will cost far more than advertised, more than $2.7 trillion over 10 years with full implementation, and will add more than $823 billion to the national debt in the first ten years. Taxes will increase by more than $569 billion between now and 2019, and the burden it places on business will significantly reduce economic growth and employment. Care will undoubtedly be rationed, for there won’t be enough doctors. As expenses grow, through the system rationing will be general.

Under the guise of implementing the law, the IRS has announced it will impose a tax of up to $3000 per worker on employers whom Congress has not authorized a tax. Yet if the IRS doesn’t impose the tax, the whole law could collapse.

Credits are available only in states that create insurance exchanges themselves. The federal government might create exchanges in states that decline, but the government cannot offer credits through its own exchanges. If there are no credits, there is nothing to trigger that $3,000 tax.

The way to ge rid of this deeply troubling piece of legislation is to get rid of Obama, and elect a Republican Senate. ObamaCare is very unpopular, and as people learn ‘what is in it’ it is sure to become even more unpopular. The fight will not be easy. Have courage.



Obama Will Send the IRS To Make You Accept ObamaCare! by The Elephant's Child

The Obama administration is not going to await the Supreme Court decision on whether the Affordable Care Act should stand. They are busy at work to ensure that the president’s health care law is implemented. The White House has allocated half a billion dollars to the IRS to put ObamaCare in place. The Hill reports that :

The Obama administration is quietly diverting roughly $500 million to the IRS to help implement the president’s healthcare law.

The money is only part of the IRS’s total implementation spending, and it is being provided outside the normal appropriations process. The tax agency is responsible for several key provisions of the new law, including the unpopular individual mandate.

The Hill also reports that the White House is spending other funding allocated under ObamaCare.

The law contains dozens of targeted appropriations to implement specific provisions. It also gave the Department of Health and Human Services (HHS) a $1 billion implementation fund, to use as it sees fit. Republicans have called it a “slush fund.”

HHS plans to drain the entire fund by September — before the presidential election, and more than a year before most of the healthcare law takes effect. Roughly half of that money will ultimately go to the IRS.

HHS has transferred almost $200 million to the IRS over the past two years and plans to transfer more than $300 million this year, according to figures provided by a congressional aide.

How does the money get spent? There are all sorts of new taxes and fees in ObamaCare, and the IRS is responsible for collecting those as well as for enforcing the mandate.  The IRS wants to hire 300 new employees next year, and has requested funding for another 537 new employees to administer ObamaCare’s new subsidies for low-and-middle income individuals to purchase insurance.

HHS plans 133 new ObamaCare-related rules as of last fall. Rulemaking related to ObamaCare legislation concerns more than 150 federal agencies, bureaus and commissions. Rules are changing faster than regulators can write them down. Administrators have granted nearly 2,000 waivers to the new regulations, and the long-term care  program CLASS, has been dropped as unworkable.

Obama has demonstrated over and over that he has no respect for the Constitution, nor for the separation of powers. He considers the Court and Congress to be impediments to his plans that must be conquered. He has no intention of meekly obeying direction. He is the One, and he intends to get his way.

 



The Rules Are Bad, Badly Written, And Devastating In Their Impact. by The Elephant's Child

You will often hear the complaint that there is no difference between the two political parties, a complaint that merely shows that the complainers aren’t paying attention.  Liberals, or Progressives as they choose to be called now, want to bring about an improved world by exerting more control over American citizens.  Conservatives want to remove unneeded regulation. Our current regulatory code tops 165,000 pages, with more regulations coming every day.  The Wall Street Journal reports today that “independent students of regulation say the quality of the many rules they’re putting out seems to be at all-time lows.”

Regulatory quality isn’t the same as content—though bad rules are usually badly written, as seems to be the case here. Rather, quality refers to a deliberative process: defining the problem; measuring costs, benefits and risks; weighing alternatives, making trade-offs, avoiding duplication; and giving the public opportunity to comment. If all goes well a quality rule will promote or at least not impair “economic growth, innovation, competitiveness and job creation,” as Mr. Obama’s January 2011 executive order on regulation had it.

A growing body of evidence suggests that the Obama administration is ignoring the basic due diligence practices that have been commonly accepted by whichever party is in power. Each regulation in the Affordable Care Act that cost over $100 million a year has been analyzed by scholars at the Mercatus Center at George Mason University.  They found the “federal government used a fast-track process of regulatory analysis that failed to comply with its own standards, and produced poorly substantiated claims about the act’s benefits and costs” that included a bias that assumed benefits would perform well, and costs would decline.

So you have rules that are assumed will perform well, and somehow cost less than expected. They got grades that were not just bad grades, they receive Fs on the regulatory curve, lower than the scores of the rules that HHS was putting out in 2009.

Here’s an example from physician Scott Gottlieb of the American Enterprise Institute:

Under the Patient Protection and Affordable Care Act (PPACA), a previously obscure government advisory body has acquired vast authority to decide which health care services Americans will have access to. The United States Preventive Services Task Force (USPSTF) was created in 1984 as a government advisor with the mission of assessing the clinical utility of preventive health measures such as screening tests and issuing nonbinding recommendations about which measures doctors should incorporate into routine medical care.

PPACA gives the USPSTF’s recommendations the force of law, making them de facto mandates on which preventive services private health plans and public programs such as Medicare must pay for. Services that do not make the USPSTF grade are unlikely to be covered at all. The USPSTF was not designed to wield this kind of sweeping and binding authority. It does not maintain the transparency, deliberative process, appeal process, or requirements for public notice and comment that are hallmarks of sound regulatory policymaking.

The Preventative Services Task Force now wields great power to decide what health services doctors should provide, yet has few checks on its sweeping authority. Doctors may go to school for years to learn how to best care for patients, but a bunch of bureaucrats in Washington will decide what they can do and what they can’t.  Cost is sure to become a major factor. In 2009 this agency decided that women age 40 to 49 should not get routine mammograms.  The USPSTF was weighing the benefit of breast cancer screening against the burden of allowing some additional cancers to go undetected. Physicians had championed earlier, more widespread screening, and the new analysis seemed callous and poorly conceived. Their advice may even conflict with the Center for Disease Control.  Now it has recommended against routine screening for prostrate cancer with a widely used blood test.

Progressives are conflicted. On the one hand, they want to add all sorts of services that seem “nice,” and raise the costs off medicine dramatically, yet the entire thrust of the healthcare program becomes one of controlling costs. Questionable statistics will rule over individual patient needs.

The supposed reason for the passage of ObamaCare was the skyrocketing costs of health care. Yet ObamaCare is dramatically raising costs even before it goes fully into effect. The main reason behind the increases in the cost of health care was the effect of government regulation — mandates imposed by Washington.

Medicine, says Dr, Gottlieb, is undergoing industrialization, where doctors are becoming owned commodities of large hospitals and health plans. In the 1997 Balanced Budget Act to cut the deficit, the Clinton administration and the Republican Congress capped total payments to doctors and implemented a system of price controls for their services. Once the work of physicians was priced by a fixed government schedule instead of rewarding the quality of their service, the only way for doctors to increase their income was to increase the volume of patients they saw and reduce the level of service — enter the 15 minute office visit.

President Obama has chosen to blame the medical insurance industry and rich doctors and big hospitals for the high cost of health care, and insisted that he could add another 46 million uninsured to the government insured rolls and yet somehow make health care cost less.  An estimated 10 million of those are illegals, the number who simply choose not to have insurance is unknown.

We had the best health care system with the best outcomes in the world. Democrats have passionately wanted single-payer government controlled health care for years. Not, as they attempt to claim because they are compassionate, but because if the citizens depend on the government for their health care, then they will reelect that government in perpetuity and return them to power. What we will get is increasingly poor care, doctors and hospitals who are forced to make cost their guideline rather than patient care.



ObamaCare Is Not a Patient-Centered System of Health Care. It’s Important to Keep That in Mind. by The Elephant's Child

How should we approach the problem of health care?  We want it to be low-cost, or as low-cost as is possible, and we want high-quality care.  Is it possible to have both?

There are two basic ways of addressing health care: a bottom-up, market-based approach and a top-down command-and-control approach.

  • A bottom-up approach is based on competition, free markets and economic incentives. It gets the incentives right for all of the individuals in the system, but doesn’t try to predict the final outcome. It tries to free people to achieve what works for the individual.
  • The top-down command-and-control version is based on rules and mandates, regulations, fines and penalties to force compliance.  It decides in advance how medicine should be practiced, and attempts to impose those results on the doctors, their patients, and on health care suppliers.
  • In the top-down command-and-control version large numbers of bureaucrats, who will never contact a doctor or a patient, will decide how medicine should be practiced, and what treatments must be used, and what treatments are too expensive and must be denied or rationed.  It depends for its success on a small group of “experts” having all the right answers. It depends for its success on the ability of those in charge to select people who are actually expert, rather than just political appointees.
  • A bottom-up approach does not know how medicine should be practiced. Competition will draw out the best practices and best practitioners. It depends for its success on the training, intelligence, creativity and innovative ability of thousands of doctors, nurses, hospital personnel, and from the industry that supplies the health care practitioners.

In the competitive, free-market world 778,000 doctors, 2.6 million registered nurses and thousands of hospital and facilities personnel get up every morning focused on how they can save or improve another life, and keep the costs down — because in a competitive world that is how they succeed.

In the top-down world, that same number of people get up every morning trying to figure out how they can squeeze another dollar out of the third-party reimbursement formulas. Because reimbursement formulas are the major way of saving money, doctors must squeeze more patients into less time.

The thing is we are dealing with human beings, and they just aren’t all the same.  In two instances of the same surgical procedure, one patient may be frail, allergic, have other problems;  the second , while needing the same procedure, may be otherwise in excellent health. To the command and control bureaucrat  the procedure gets the same reimbursement.

“Approximately one in five hospitalized Medicare patients is readmitted for a problem related to the cause of the original surgery.  The readmissions are costly and can be life-threatening.  The Medicare bureaucrats have decided, on their own, that there are 10 readmission conditions that it won’t pay for, including catheter-associated urinary tract infection and stage III-IV pressure ulcers. This has saved Medicare something less than 1/300 of 1% of all Medicare spending that year.”

Barack Obama’s stated vision of health reform is to find out what works and then go implement it. The Affordable Care Act is making millions of dollars available for pilot programs and demonstration projects. This is misguided. We know what works, the problem is replicating it.  There are examples of high-quality low-cost medicine.  If everyone went to Intermountain Healthcare in Salt Lake, the nation could reduce its health care spending by one-third, according to studies.  If everyone went to the Mayo Clinic , we could reduce spending by one-fourth. But we don’t know how to copy either one and spread it around the country.

This post is derived from John Goodman’s Health Policy Blog at the National Center for Policy Analysis.  John Goodman is the “father of health savings accounts,” a money-saving policy that has been extremely  popular with both participants and employers.  Dr. Goodman is the president and CEO of NCPA , and has been a tireless expert in the campaign to communicate patient-centered alternatives to a government-run health care system.  This blog is an excellent source for informed, thoughtful studies on the problems and potential of health care.  You can subscribe, as I do.




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