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Thursday, February 16, 2017

Repeal and replace Obamacare--STAT!

Am I referring to Obamacare here or Obama himself?

I am glad that we have a new president. Like most of the country, I was ripe for a change of direction and a new approach to foreign and domestic affairs, and we are certainly getting that. New readers here might erroneously suspect that I voted for Trump. I didn't. For the first time in my presidential voting history, I wrote in my choice for our top two office holders.

I have written multiple posts on my unfavorable views of Obamacare since it was jammed through congress without a single Republican vote. (Do I sound slightly partisan here?) Interested readers are invited to peruse posts on this blog within the Health Care Reform Quality category, if you dare.

There are two kinds of people who oppose Obamacare:
• folks who believe it is wrong on policy grounds
• folks who wield it as a political cudgel to bash Obama.

Some opponents are a hybrid of both of the above.

I was also suspicious that the Affordable Care Act (ACA) was always an interim step preceding a full nationalization of our health care system. Obama is on the record favoring such a policy during his 2008 campaign. If Obama could have achieved this politically in one step, he would have. The ACA represented the political upper limit that he could achieve, hoping that this would make a full would bring us within reach of a government takeover. Some conspiratorial skeptics believe that the ACA was designed deliberately to fail so that private insurance companies would have to abandon it, as they have. Then, the beneficent government would have to step in to rescue Americans who needed medical coverage STAT! While I offer no opinion on this wild charge, there were many smart people who averred when the ACA was delivered to us, that the numbers would never add up. And they didn't.

It is my belief that government is simply not equipped to assume control of the entire health care system and operate it at the highest level of quality possible, while controlling costs. Remember how smoothly the healthcare.gov web site release was? Do you think this would have happened if Google or Facebook was in charge? Which company do you have a higher opinion of in terms of quality and efficiency, the Bureau of Motor Vehicles or Amazon? If folks want to have a government insurance plan like Medicare, I am fine with this. But, give us access also to the free market. I like choice because competition breeds excellence. When FedEx came onto the scene, it forced the U.S. Postal Service to really step up, which they have.

And, we all know that the plan's proponents were somewhat less than truthful. Feel free to Google Jonathan Gruber to become reacquainted with his 2014 comments which make reference to stupid American voters and other niceties. How long did it take the Obamians to admit that the statement, “If you like your doctor, you can keep your doctor,” was known to be false from the outset?

Let's face it. The ACA promised us quality and cost control and in my view it has failed on both counts. I do congratulate the president here, as I have previously, for taking on the challenge of health care reform. Republicans over several presidential administrations failed to seriously confront this challenge. And the plan does cover more Americans, which we all agree is a necessary goal. But, the collateral damage of this achievement warrants a new direction, admitting that it may not be possible to uproot the entire tree.

The replace part is going to be tougher than the repeal part. Will the GOP take a lesson from their adversaries and jam it through without a single Democrat vote?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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1 Comments:

Blogger LoAnn said...

I’m not sure you make a strong argument for repealing the ACA.

In the end, the healthcare policy debate boils down to a couple of fundamental values.

1. Do you believe healthcare is a basic human right or a privilege?
2. Who do you trust to provide healthcare, the government or the private insurance industry (or a combination of both)?

You express your approval of healthcare expansion to millions of previously uninsured Americans under the ACA, which leaves me to assume you view healthcare as more of a basic right, not a privilege. I’d like to think most physicians share this egalitarian view. And in fact, for the first time in American history, the ACA law provides the means for universal healthcare coverage in the U.S. (Side note: the uninsurance rate is not zero, but that’s because individuals and states continue to opt out of the ACA, not because the means to coverage don’t exist).

In terms of the second question, you’ve made your view apparent—keep government the heck away from healthcare! (Except Medicare)! Just to be clear, the ACA is by no means a government-controlled single-payer system (to the dismay of many proponents of a nationalized healthcare system). We still very much have the same hybrid private-public healthcare system we had prior to the ACA law.

Which brings me to my final point—your concern over cost and quality. The structures of healthcare delivery in the U.S. are overpriced and ineffective by most measures. That’s why we spend the most per capita on healthcare, with the poorest outcomes compared to other developed nations. But it is absolutely false to say this is a result of the ACA—these problems have evolved over decades, and are deeply entrenched in the interests of powerful stakeholders. A repeal won’t change the fact that the system remains fundamentally flawed.

Instead, a repeal would mean 30 million Americans lose their healthcare, 1 in 2 patients with a preexisting condition risk denial of coverage, and insurance companies can reinstate annual and lifetime caps on healthcare. It means women go back to paying 30% more in premiums and preventive services, including birth control and cancer screening, are no longer guaranteed free. And despite almost 7 years of opposition, republicans have failed to craft a single healthcare system that will guarantee universal healthcare coverage to all Americans, with the same patient protections, at a lower cost.

So explain to me again why we need to repeal and replace STAT? Doesn't it make more sense to me to build on the progress made and repair the parts that aren’t working?

February 16, 2017 at 8:41 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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