28 June 2012


So this is great news and a great day. My quick reactions:

First of all, CNN & FOX. Once again proving that being first is a higher priority than being right. How embarrassing. At least their soon-to-be-fired producers will be able to get health care coverage.

Second, Roberts: I have to give him a little credit. I fully anticipated him to be a partisan hack and invalidate the law. Perhaps the burden of history weighed heavily on him, perhaps the delegitimization of the court influenced him, or perhaps the sheer radicalism of Scalia's dissent drove him to uphold the law. Regardless, he got it right. Make no mistake, though, he did what he could to advance his long-term agenda by slowly restricting the reach of the commerce clause.

While most of the focus centered on the the Heritage-Foundation-developed mandate (aka the greatest threat to liberty ever), it's important to note that the 4 conservatives wanted to invalidate the entire law, and there is far, far more than the mandate in Obamacare. 12 million Americans will get rebates from their insurers this year based on the ACA's insurance regulations. Rescissions of policies is now prohibited. In a couple of years, pre-existing conditions will be covered under the guaranteed issue provisions, and the moribund individual market will be resuscitated by the insurance exchanges. All of these huge reforms survived and will transform healthcare in a good way.

The mandate itself may work, or people may prefer to pay the "tax" penalty and go without insurance. We will see. If enough people opt out and insurers are experiencing serious adverse selection in a few years, perhaps the partisan rhetoric will have died down enough that Congress can tweak the incentives at bit. One can hope, anyway.

The Medicaid ruling was disappointing but not fatal. The gist is this: the ACA expanded eligibility for Medicaid all the way up to 133% of the poverty line. This is significant because in many states, the eligibility thresholds are very stingy, and in some if you're male and without dependents or a disability you are never Medicaid eligible no matter how little you make. So this is a very large expansion of coverage. It is still allowed under this ruling, but no longer can the Feds make it compulsory for the states.

So what does that mean? Not clear. Most states probably will implement the Medicaid expansion, which is for the moment fully funded by the feds. There are concerns that the feds may shift the costs back to the states in a few years, but that's not clear yet. I can see some GOP governors refusing to implement the expansion on these grounds (really just to be recalcitrant dicks; I'm looking at you Scott Walker), but there will be huge pressure on them from their medical community to accept what is essentially free money. If they do refuse, then it's going to leave a large portion of their lower classes without access to health insurance.

For the ER, I predict little will change. ER utilization has been going up nationwide for two decades, and that trend will not change, regardless of the fate of the ACA. When, in five years, ERs are busier and more overcrowded, I predict it will be held that this is a consequence of the "failure of Obamacare" and I'm going to call BS on that in advance unless it is shown that the rate of ER volume growth accelerated after 2014.  Which is possible, but I don't think is super likely. Many of the soon-to-be insured are already coming to the ERs as no-pay patients, and the only difference is that we will be reimbursed for those services that we are already providing.  Some of them may be diverted to PCPs' offices, though the limited capacity of the primary care network sadly ensures that will be a small number.  To the extent that ER volumes do increase, it's a failure on the part of the system to create enough primary care capacity, not the expansion of coverage.

It's worth noting that the ACA does contain a 10% boost to primary care providers' reimbursements. So that may help improve access to primary care, and there are also significant expansions of Community Health Centers.

Cost control is where ACA is weakest, and more will need to be done to bend the curve of health care inflation. Sure, the IPAB may have some effect, if it is ever implemented. Medicare is already putting into place other reforms such as value based purchasing and others. But this is certainly the point where the ACA is only a start. Wether Congress can get it together well enough to add onto it in a productive fashion is to be seen. 

The saddest element of this whole kerfuffle is that liberals and policy wonks are celebrating the survival, by the thinnest of margins, of reforms which in the best-case scenarios will leave the US with the worst access to health care and health insurance in the OECD, with the highest cost per capita in the developed world, and with the worst outcomes in the industrialized countries. The passage and survival of the ACA are big wins, but they still leave the US with the worst health care in the world, and one party is hell-bent on dragging us backwards. So I will celebrate the win and spike the football and all that fun stuff, but tomorrow morning we've got to get up and keep working to reform our system further. Because what we have is not good enough.


  1. The passage and survival of the ACA are big wins, but they still leave the US with the worst health care in the world

    Wow, I think this wins hands down as the stupidest sentence on the internet today.

  2. Every ER should have a satellite 24 hour Urgent Care clinic attached where people can go who do not REALLY need emergency room treatment. This would leave the ER for the people truly in need, but still make services available in the middle of the night for the feverish baby, etc. The ER can triage the patients and send the low-level 'emergencies' to the urgent care clinic instead.

  3. Further to my earlier comment, I note that Kaiser Permanente in the San Jose area does this...

  4. Anonymous said...
    Wow, I think this wins hands down as the stupidest sentence on the internet today.

    The irony... you must be an American, anonymous, to say something so vacuous about your country's poor state of affairs when it comes to health care.

  5. Well, thank you Justice Roberts for ruling that Obamacare (scratch that), Obama's HealthCare Tax is unconstitutional by way overreaching the Commerce Clause, but somehow HAS to make it survive by making up some bullshit about it being a tax. Even Dear Leader himself said that it wasn't a tax. Justice Roberts, I ask you, exactly what kind of tax is it? You did not actually address that issue in your statement. Obviously, he wanted the law to stand, so he made up some crap to make it do so. Sooo, thank you Der Fuhrer for the largest tax increase in the history of mankind. Right after you said that those "folks" making under $250,000/year would not have one cent raised on them. Right in the middle of a great recession - good for you Barry! Shadowfax and the rest of you liberal retards have absolutely no insight whatsoever. The effect on small businesses is going to be catastrophic. The Government is now going to tell insurance companies what they can charge. They're going to tell Physicians how to practice medicine. Starting to sound very USSR-like. Well, in way that's good, because once 60% of the current physician workforce quits and you wind up with Arun Pkjhjkhiunjhjhjhiuh from who knows where who graduated the Upstairs School of Medicine in Uruguay, he'll have some direction on how to practice from Bwahny Fwank. Cost Controls are a problem?? Really?? Just look at Medicare, it's bankrupt. So celebrate now libtards, when 2010 is repeated this will get trashed on Day 1 and on Day 2 the Gun Owner's Mandate, I mean Tax, will get passed. Smith & Wesson thanks Justice Roberts. By the way, 15 years as an EM Physician and I'm out. Thank you Dear Leader and Justice Roberts for making my decision easy.

  6. I can only hope that Physicians wise up and stop accepting medicare, medicaid, and the exchanges. That will end this disaster immediately. Sort of like getting a drivers license but there are no cars. Honestly, this is going to be a big boost for the Republicans in that the majority of America still hates this law, 2010 was the referendum on it and everyone knows what happened there. Sorry Shadowfax, we've had 3 years to "see what's in it," and the majority still hates it. You certainly are NOT smarter than the majority of America (the same majority who elected your Blamer in Chief).

  7. Roberta,

    Thanks for a constructive comment (as opposed to our anonymous trolls). To your point, I agree but there are obstacles. First of all, the reimbursement for urgent care based services is lower, which makes it hard to justify the high fixed costs of 24/7 operations. It can be done, but is challenging with lower volumes and with intermittent volumes (both of which apply to overnight time frames).

    Second, the implication for most (I'm not saying this is your implication) with the urgent care concept is that UCs are exempt from EMTALA and could ask for payment up front or only accept patient with funds/insurance. This selection is what makes most UCs economically viable. We could do that, but it's not right for our community. We have a shortage of PCPs and so many uninsured and underinsured patients that if we were to turn them away, they would have no recourse. Alternatively. If we accepted all patients for free at the 24/7 UC, includinng charity patients, it would not be sustainable financially. The only solution that works for us is to maintain the ER, which is more expensive to those who can pay, and cost shift for the uninsured.

    Maybe once ACA is fully implemented, we could do a more efficient system like the one you describe.

  8. Great rant on the Ed Scultz radio show today by guest host Mike Papantonio: tore Anton Scalia a new one. Terrific. Check it out.

    I'm just glad to hope I'll be able to continue recieiving maintenance & replacement on my prosthetic leg.

  9. I think this decision almost certainly guarantees Obama a one tern presidency and a serious swing to the right in congress come November. Over the next two years much of "ObamaCare" will be dismantled before before it really get's implemented.

    This decision will be a powerful motivation to those on the far right, especially the extreme religious folks to support Romney. People that would have stayed home due to their hatred of Mormons will be coming out of the woodwork and putting their full support behind Romney.

    Probably the best thing for the law would have been for the mandate to be struck down. That would have motivated the left in a similar fashion and Obama could have pushed through a single payer set up or some other alternative over the next two years and gotten what he wanted.

    IF this law now does get fully implemented in will mean having a single payer system in a few years anyway. No insurance company will be able to survive in an environment where there is no limit on what they have to pay out but severe limits on what they can charge. Now everyone with serious health problems now on Medicare or Medicaid will go to private insurance and be charge the same rate as everyone else while forcing the insurance companies to spend billions of dollars they don't have.

    In the end this law would force us all onto medicaid, or perhaps into a VA like system yet to be developed.

    One of the things that confuses me is that everyone on the left seriously believes that somehow the government will do it better. That somehow if the people that run medicaid, the VA, the TSA. How can anyone not see that the only possible end point of this is a massive bloated inefficient bureaucracy where bureaucrats spend most of their time protecting and expanding their fiefdom? Is there any single example in government where this hasn't happened? IF we stay on this road we are putting the minds that bring us the TSA in charge of healthcare. Does that not scare the crap out of anyone?

  10. Vince and Elisha - you hit the nail on the head. More bureaucracy is never the answer. All you have to do is look at Medicare and Medicaid. Two bloated, inefficient programs, one of which is on the road to bankruptcy. Yes, I am scared to death of what is going to happen when the government takes over. I never understood the desire for single payer system - it hasn't worked anywhere (and yes the NHS is bloated and inefficient). Why can't the free market reign here? Single payer advocates say that the free market system didn't work, but as it was, it was highly inefficient based on the lack of portability. Let the companies nationalize, carry your plan with you everywhere (much like your car insurance) that alone will keep premiums down based simply on the number of people they can enroll. Advocates for Obamacare will say that private insurance companies can still exist, BUT, they can only do so at the approval of the government. Going to a single payer system is disastrous, especially if it is going to be run like the VA which (according to my military friends) is horrendous, to the point that they want no part of it. They use their private insurance whenever possible. They care they receive is far below subpar, and they should know - they're all in the health care field.

  11. Stephen said

    The irony... you must be an American, anonymous, to say something so vacuous about your country's poor state of affairs when it comes to health care.

    Stephen, if you are agreeing with Shadowfax when he states that the US has the worst health care in the world, then you are an idiot.

    I assure you, there are many many many places in the world with much worse health care than the U.S. To suggest otherwise is beyond idiotic.

    Oh, and you are correct about one thing. I am indeed an American. I am an American physician currently practicing medicine in a developing country, where I can assure you the health care is nowhere near on par with that in the U.S.

    Sheesh. Talking about "vacuous" and "irony".

  12. I think what is earth shattering is that universal health care is now the rule of the land.

    How its paid for is a minor issue that can be ironed out later. I mean, really, it will be cheaper than the war on Iraq and no one got their panties in a wad over the cost of that.

  13. Meat (or anyone),
    How does the "pre-existing condition" rule work? What is to stop people from paying a marginal penalty until they get a catastrophic disease, and then applying for insurance? This seems like rational behavior that will undercut the whole premise of "insurance". If I could buy car insurance with "pre-existing conditions" I'd never buy it until after I was in an accident.


  14. And ditto on the calumny aimed at "worst healthcare in the world." That's just silly and ignorant.

  15. Previous post was from wrong Google account. If anyone knows here please don't blame Elisha for my silly opinions.

    Hopefully Shadowfax's "worst healthcare in the world" was either misstatement or over the top hyperbole. We's don't see teams of medical missionaries coming to Seattle from Haiti very often after all. Even in the OECD there is Mexico and you seldom see missionaries from there in Seattle either, nor do we see people flooding into Mexico to get free health care (just cut rate dental work and boob jobs).

    Pretty sure he did not seriously mean to say that healthcare is better in Somalia or Burkina Faso than it is in the US.

  16. curious: but all this talk of socialized medicine etc. Did Romneycare (the granddaddy of the PPACA) turn Massachusetts into our first commie/ socialist (or whatever -ist the right is using nowadays) state?

  17. Fair enough: "worst healthcare in the world," could have been more clearly phrased. Since the previous sentence THREE TIMES explicitly qualified the comparison group as the OECD, the developed world, and the industrialized countries (which all mean more or less the same thing) I figured y'all were smart enough to comprehend. OK, fine, you are either dumb or willfully distorting what I clearly intended. I suspect the latter, but hey, who am I to judge?

    So, for clarity's sake, and based on outcome-based measurements and costs, we have the worst healthcare in the OECD, not the entire world.

    I accept your apologies.

  18. Matt,

    You are right that it's possible to free ride by paying the penalty/tax and wait till you get sick to sign up. However, this is balanced by the fact that most people actually *want* insurance, and there is risk of getting sick when you're free riding (your bills won't be covered until you sign up, and the enrollment periods are limited).

    The experience in MA, which has a very similar system, is that only a very small fraction of people choose to pay the penalty -- I think it was like 2% but I could be wrong. Of course, this depends on the insurance being affordable, hence the sliding scale premium subsidies and the medicaid expansion.

  19. @joegrind - Socialism is a real word with a real meaning, not just some word the right is using. It means "state control of the means of production and the distribution of resources". So yes, by that definition Massachusetts is quite socialist, though that predates Romneycare by at least an generation and I'm not sure they are the first.

    When I say socialism or socialist I mean it by the dictionary definition, not as some word to scare people. So do most people that use those words. The difference between us is that I think that state control of the means of production and the distribution of resources is a bad idea and you think it's a good idea but get upset when people use the correct word for it.

  20. It's great that when we disagree with each other we can just slap around insults and sarcasm. If that won't save the world, I don't know what will. I wish people could have an intelligent debate without insults and caricatures. They detract from the real issues.

  21. One thing about the PPACA that I wish had been different is the reliance the act places on commercial health insurers, most of which are for-profit entities. I would have liked to see the Act give a bit of an advantage to not-for-profit health plans. Usually, the profit incentive encourages productivity and innovation, but for health care insurers, it seems to encourage benefit denials, monopolistic behavior, coercive contracting of providers, and all sorts of other manipulations directed at everything but managing care, all to benefit Wall Street investors.

    You might think that the rules in PPACA mandating minimum medical loss ratios (i.e. limiting the portion of the policy premium that goes towards overhead and administrative costs and huge CEO compensation packages) would curtail some of these machinations; but the for-profit health plans have found all sorts of ways to get around these MLR mandates in order to maximize their earnings. I'd love to find a bumper sticker that says: "not-for-profit plans do it better", and the best example of this is in the Medicaid program, where frankly there's just not enough meat on the bone to provide good care and attract quality docs to participate, and at the same time, generate profits for investors.