A big day tomorrow.

The US Supreme Court will probably announce the decision on Obamacare, known by its supporters as “the affordable care act,” tomorrow. If it is overturned, as I sincerely hope, there will be the need to provide an alternative. I don’t trust Obama to accept the verdict anymore than he accepted the partial victory for Arizona. His antipathy to that state is palpable and is demonstrated by this laughable headline.

Official: Obama administration will enforce its priorities, not Arizona’s

The fact that Arizona’s priorities include US law enforcement notwithstanding.

Obama administration officials said Monday the federal government would not become a willing partner in the state of Arizona’s efforts to arrest undocumented people — unless those immigrants meet federal government criteria. And they said the administration is rescinding agreements that allow some Arizona law enforcement officers to enforce federal immigration laws.

The administration made the announcement hours after Monday’s Supreme Court decision on whether states can enforce immigration laws.

The fact that Arizona wants to enforce a federal law that the feds are not enforcing is ignored. There is a reason why CNN was called “The Clinton News Network” in the 1990s.

I expect something similar if the Court strikes down Obamacare. The law is massive, unwieldy and still a mystery to most of those affected.

Opinions on the law and its provisions are available here. Topics include age based medicine. Here is where rationing will be applied in spades.

It is unfortunate that one cannot engage in a dispassionate and objective analysis of the Progressives’ ideas on age-based medicine and end-of-life healthcare without being immediately accused of invoking “death panels,” and thus of displaying the dearth of sophistication, the lack of understanding, and the primitive logic commonly attributed by Progressives to Sarah Palin.

I must remind my readers that I have yet to use the term “death panel” to refer to any of the multitude of expert commissions created by Obamacare, whose charge will be to dispassionately examine the scientific evidence in order to determine which patients will get what, when and how. These bodies, in fact, will be explicitly aiming to optimize the medical outcomes of the entire population (titrated to the amount of money we’re allowed to spend on healthcare), and not actively prescribing death for anyone.

Judging from the histories of governments which have adopted a collectivist philosophy, if death panels should appear on the scene they will not be aimed at determining which patients may live or die. That job, of course, will fall to the doctors at the bedside, who will offer or withhold medical services according to the dictates (i.e., “guidelines”) handed down by those sundry expert commissions. Rather, any death panels which might eventually materialize will more likely be aimed at keeping those doctors themselves (and any other functionaries whose job is to do the bidding of the Central Authority) in thrall.

So why has the term “death panel” caught on to such an extent that conservatives so often use it as shorthand to express what they see as the “sense” of Obamacare, and Progressives so often use it to accuse rational and mild-mannered critics of Obamacare (such as your humble author) of belonging to the Neanderthal persuasion? Read the rest.

Anyone who has done some reading about health care in other countries, such as the UK or the Netherlands knows what this means. In the Netherlands, ten years ago, any physician who admitted a chronic lung (COPD) patient to ICU with respiratory failure would be looking for a job the following day. The burden will always fall on doctors, which is why we are so interested. The stories of delay in admitting critically ill patients to the ER in the UK are another cure for boredom.

The French have some interesting ideas about such issues as pre-existing conditions, which will no doubt be a prominent issue if the USSC acts tomorrow as I expect. In the French system, certain conditions that affect insurability are covered by the plan 100%. However, the coverage is ONLY for the condition, such as Diabetes, and not for unrelated conditions, such as appendicitis.

Some cases are eligible for exemption for co-payment. Serious medical conditions such as diabetes, cancer and AIDS are exempt. The exemption pertains only to the diagnosis and other conditions require co-payment. A cancer patient with appendicitis, for example, must pay the regular rate for the surgery. More complex services and hospital stays over 31 days are also exempt. The exempt class of patients, such as children, maternity and war pensioners are the third category.

I spent some time several years ago analyzing alternatives to what became Obamacare. Those blog posts are here. The history and evolution of the French health system are included. I think it offers the best model for the US to us for reform. Of course, Obamacare has nothing similar to the French plan. It was designed to appeal to rent seekers in the health care industry.

More will be added tomorrow.

UPDATE: Well, we now know that the Court upheld the constitutionality of Obamacare. This is disastrous for the health care system that we have, although it has deteriorated since 1978 when the government began trying to rein in health care costs under the guise of “improving quality.” The rationale for approving it was that the “Mandate” is a tax, not a fine. The politics of the decision are not yet clear and may not be before November.

No doubt Obama and his supporters will hail the decision as a victory and it may well be so. My concern is with the effects of the law, itself. It is not reform and it is not workable. The question I have is whether the law will be recognized as unworkable before it has destroyed the present system. I fear not. For those who want to understand the effects, I suggest reading this explanation of health insurance and why the insurers supported Obama. Note this statement:

In return for its support in the healthcare reform battle, President Obama offered the insurance industry the graceful exit strategy it so desperately needed. Under Obamacare, for at least a few years the insurers hope to get One Last Windfall – namely, profits from the influx of previously-uninsured Americans whose premiums will be paid, or at least subsidized, by taxpayers. Here, the insurers are relying on the likelihood that the inflow of new premiums will, for a year or two at least, greatly outweigh the outflow of money they will have to spend caring for these new subscribers. Obviously, they will use every trick in their well-worn book to stave off expenditures for these new subscribers for as long as they can, but if they actually knew how to avoid paying healthcare costs indefinitely, they wouldn’t be seeking a government bail-out today. In any case, an inflow of new subscribers will be a very temporary source of profit for insurers. Hence, at best it is One Last Windfall.

What happens to the insurers after they exhaust this last windfall is still up in the air. Obamacare may, of course, eventually transition to a single-payer system, an outcome which many conservatives desperately fear, and many liberals fervently desire. In this case, there may very well be some final compensatory buy-out (or a buy-off) for the insurance companies. But more likely, the insurance companies under Obamacare will continue to exist essentially as public utilities. That is, they will exist as companies chartered by the government, which administer healthcare under the direction of the government, with the products they may offer, the prices they may charge, the profits they may keep, and the losses they may incur, determined solely by the government. It’s not glorious, but it’s a living.

This, in fact, is the business plan of health insurance companies. They view HSAs and other conservative attempts to control costs by modifying behavior as the enemy.

Tags: , , ,

3 Responses to “A big day tomorrow.”

  1. Fair Distribution of Life-Years

    Yuri N. Maltsev – 06/22/12  [edited]
    === ===
    Ezekiel Emanuel is director of the Clinical Bioethics Department at the US National Institutes of Health and an architect of ObamaCare. His brother is Rahm Emanuel, Obama’s former Chief of staff.
    Ezekiel Emanuel wrote in The Lancet medical journal Jan 2009  [edited]:

    Allocation of healthcare by age is fair, unlike allocation by sex or race. Even if people aged 25 receive priority over those aged 65, everyone who is now 65 was previously 25.
    It would be ageist to treat 65-year-olds differently because of stereotypes or falsehoods. It is fair to treat them differently because they have already received more life-years.
    === ===

  2. Mike_K says:

    “It would be ageist to treat 65-year-olds differently because of stereotypes or falsehoods. It is fair to treat them differently because they have already received more life-years.”

    I think some treatment options should consider age. I once had an interesting discussion of this with an elderly priest. I had been called to revise his dialysis shunt for the second or third time. He was 90 and lived in a monastic cell at the Mission of San Juan Capistrano. Quality of life on dialysis is not good and the most common cause of death for dialysis patients is suicide.

    As I prepared to surgically fix his clotted shunt, I asked him, “Father, why are you asking me to do this ? I should think you would be ready to see God.” His answer was the equivalent of, “Shut up and fix it !”

    The next time he had a clotted shunt he called another surgeon. That was OK with me.

  3. carol says:

    I distrust younger people’s bravura about death, because they often act a lot differently when it is at their door. Even people already in th eir 70s can change their attitude later on.