Vital Signs Diminishing for Obamacare Is Life Support Imminent?

Moody's: Uncertain healthcare landscape leads to negative outlook 

for US health insurers

Global Credit Research - 23 Jan 2014

Insurance companies, long held in high ESTEEM in the finance world, because of their wide base of investment and astute leadership are beginning to feel the effects of ObamaCare even before they begin paying reimbursements to providers, hospitals, and enrolled providers.

Moody's Corporation is an essential component of the global capital markets, providing credit ratings, research, tools and analysis that contribute to transparent and integrated financial markets.

Moody's changed the outlook for US health insurers to negative from stable, as implementation of the Affordable Care Act (ACA)continues to create uncertainty for the industry, says Moody's Investors Service in its new industry outlook "US Healthcare Insurers: Outlook Changed to Negative from Stable."

The ACA—signed into law in March 2010—seeks to increase affordability of health insurance and expand both public and private insurance coverage through a number of mechanisms including exchanges, mandates and subsidies.Uncertainty over the demographics of those enrolling in individual products through the exchanges is a key factor in Moody's outlook change, says the rating agency. Enrollment statistics show that only 24% of enrollees so far are aged 18-34, a critical group in ensuring that lower claim costs subsidize the higher claim costs of less healthy, older individuals. This is well short of the original 40% target based on the proportion of eligible people in this cohort, says Moody's.

Looking forward, Moody's expects reduced net earnings margins of approximately 2% in 2014, compared to an average of 3% the previous year and smaller overall membership growth of approximately 1%, down from 3% in 2013, with company strategies continuing to focus on revenue and income diversification.

Still, these changing dynamics will have an uneven effect on insurers, as the impact of these factors will vary by market segment and geography. Moody's view continues to be that the larger and more diversified insurers will be better positioned, both financially and strategically, to meet the challenges facing the sector.

Earlier this week, the conservative American Action Forum released a report which found"that after accounting for subsidies and cost-sharing, 6 out of 7 uninsured, young adult households will find it financially advantageous to forego health coverage, and instead pay the mandate penalty and cover their own health care costs.

*A reader points out that there's a difference between a negative outlook and a formal downgrade, which is what I originally implied. A credit downgrade is likely, but has not yet occurred.

Nevrtheless the Perverse Incentives of the Obama Care Act (Affordable  Care Act) come into play to increase the shortfall of funding health insurance for all, with no limitations..

The American Action Forum prints a readable and understandable explanation of how ObamCare is supposed to work.

This short infographic illustrates the reverse logic for young people

The Fear about IPABs in the Affordable Care Act

The fear of 'death panels' may be overaggerated but do pose an ominous warning to us all. The concept of an IPAB (Independent Patient Advisory Board) looms in an uncertain way during these perilous times of intertwining and complex changes to a complex health system.

The very recent experience of a child who was declared 'brain dead' exemplifies the problem of determining 'what is death' ?

The LA Times Headlines on Januray 21, 2014  read:

McMath attorney: Jahi's family aren't fools; they deserve better than ignorant attacks

Brian Franklin, left, attorney for Children's Hospital Oakland, and Christopher Dolan, attorney for Nailah Winkfield, mother of Jahi McMath, speaks during a court hearing to discuss the treatment of Winkfield's daughter in Oakland. Among those in the courtroom were Martin Winkfield and wife Nailah Winkfield, behind the attorneys.

"I am the attorney who answered a call for help from Jahi McMath's family in December. I have represented them for free — starting 10 hours before the first order to turn off Jahi's ventilator at Children's Hospital Oakland — as they have fought for their right to make medical decisions for a beloved child."

Despite the incendiary, hateful public rhetoric that has surrounded this case, I believe that self-interest alone should lead most Americans to thank Nailah Winkfield, Jahi's anguished mother, for her courage..............

I applaud Mr McMath who so eloquently discusses the conundrum of family vs a medical system stressed financially and the importance of medical providers and hospitals to act as fiduciaries of their patients.

Signing up for the Affordable Care Act

Step one:

Access your Health Benefit Echange on the Web.  Register, if you want to (or can) Write down your user ID and password.   It may not matter since your user id and password may not be saved in the system.  Rather than using  your SS number or case number they want  you to make up a user id and/or password you will likely forget.

Expect to receive  a message the site is down, we want to help you try again later. blah, blah, blah.
Once you are able to access the site the page loads will be irregular, very slow  to load and may disconnect.   Your best time to reach a site is between mindinte and 5  AM,  however  you also may receive "the site is down for maintenance'... try during our regular business hours.

When you resort to calling.  Set your telephone auto dialer and begin calling at five minutes before the exchanges open.  I receive a message that my wait time would be 5 minutes....I waited 45 minutes.  This was after ten attempts during regular business hours. If  you do not call before ten minutes after the phones are on....forget it.


Step two:

Once I accessed a human being, things went very well. The agent was more than helpful and spent 30 minutes going over enrollment.  In fact because my first attempt went so badly even with help I had to re-enroll in a different insurance company.  Some of the least expensive plansl have very limited provider and hospital access.

Because I am a retired MD I know many of the physicians that were listed as providers. The providers were often foreign medical graduates, spoke multiple languages, such as Vietnamese, Tagalag, Hindi, and Spanish. The FMGs were multicultural.    Also most of the providers in Covered California were predominantly former Med-Cal providers and familiar with Medicaid patients and reimbursement.

The printed subsidies were complicated and many times the subsidy rates made no sense for some policies. The best approach is to wait an receive your invoice, then call if you have a question.  Be certain it is correct because once you pay your premium you are locked in for one year, except for life-changing events such as additon to famly, loss of employment and/or changes in income. The next entrollment period is October 2014.

My advice is to not rush. Delaying enrollment will only mean your activation date is delayed a month. Spend a lot of time going over all your options for your income level. Search from   high to low premiums to assess the differences,  which can be subtle with deductibles, co pays for drugs and providers. Some have high co pays for medications. Plan on spending several hours to study it and assess your needs.  The web site is very good for comparing   how much  medical care you use annually, and the number of prescription drugs you use.

Now that my wife is enrolled I am relieved....15 years with her being uninsurable, with a very high copayment for her disability Medi-caid coverage was terrible, and inhumane.

Regardless of the Affordable Care Act. having an insurance cared will NOT cure our problems. The ACA does not address accessibilty, uniformity of coverage, or qualty of care.  Most of the law addresses insurance companies, and does nothing to relieve providers from a terrible and overriding responsibility for their patients with little help or cooperation from the bureaucrats.

Media reports indicate there will be a serious and committed effort to make major amendment, additions to, or repeal the Act.  Most responsible leaders who are not political idealogues are in favor of this course.

Ideologues and Unrealistic Expectations

Comments from Gary Levin MD are underlined and italicized:

Today I am amazed at an enthusiastic article about the Affordable Care Act by Eugene Robinson from Tallahassee.com.

His unbridled enthusiasm in the face of many difficulties that have nothing to do with health care exemplifies those who designed this law and passed it without reading it.

Here are some of his unsubtantiated claims and perhaps 'wishful thinking'

Eugene Robinson:  Washington Post

"Now that the fight over Obamacare is history, perhaps everyone can finally focus on making the program work the way it was designed. Or, preferably, better.

The fight is history, you realize. Done. Finito. Yesterday’s news.

Any existential threat to the Affordable Care Act ended with the popping of champagne corks as the new year arrived. That was when an estimated 6 million uninsured Americans received coverage through expanded Medicaid eligibility or the federal and state health insurance exchanges. Obamacare is now a fait accompli; nobody is going to take this coverage away."

1. The fight is not history, we are barely through round one and all the points go to the opponents of the ACA.

2. Six million Americans have not received coverage from the ACA. Registering is only the first step. It took me over ten hours of fumbling on the web site, and on hold via telephone. How many will be able to pay premiums by deadlines, or negotiate the difficult process of acquiring a provider. 

"There may be more huffing, puffing and symbolic attempts at repeal by Republicans in Congress. There may be continued resistance and sabotage by Republican governors and GOP-controlled state legislatures. But the whole context has changed."

The upside of the ACA is that all previously uninsurable patients now are enrolled no matter what pre-existing condition they have A+++++.

Can the ACA be improved?  Most definitely. The argument should not be Republican against Democrat.  Political party does not immunize one against illness.

I wholly agree with Mr. Robinson's analysis regarding the eventual goal of a uniform health system.  To call it universal care is a misnomer.

"The real problem with the ACA, and let’s be honest, is that it doesn’t go far enough. The decision to work within the existing framework of private, for-profit insurance companies meant building a tremendously complicated new system that still doesn’t quite get the job done: Even if all the states were fully participating, only about 30 million of the 48 million uninsured would be covered.

Yes Obamacare does not go far enough, however that is not the principle flaw. There is no one principle flaw, if there are any that is the poor analysis  and proposed implementation of a major expenditure that will effect most businesses,  all patients, and our national budget, and come up short.  If we are intent, committed and dedicated to these goals then let's get it right (or mostly right the first time)

Obamacare does establish the principle that health care is a right, not a privilege — and that this is true not just for children, the elderly and the poor but for all Americans.

Throughout the nation’s history, it has taken long, hard work to win universal recognition of what we consider our basic rights

This is a political and philosophical statement, not about health care. We need to keep these issues separate.  I agree with him about the tenet that all people should have health care financing.

Our first step should be to put on hold further mandates while the act is re-evaluated. Repeal is not an option, however amendment is a reality and not an 'existential' argument.

Mr Robinson's  article is not objective, nor unbiased. He totally neglects the weaknesses of the law which will require amendments.  Placing the issue in terms of a 'battle' between political parties does disservice to dedicated professionals who have  been in the system,  and who were neglected during the planning process.

To ignored the flaws would be a fatal mistake, health care costs will soar and there will still be large gaps in the insured population

Contact Eugene Robinson ateugenerobinson@washpost.com.

Contact Gary Levin MD at gmlevinmd@digitalhealthspace.com

Survey on the Affordable Care Act

Following the botched rollout of the affordable care act, people are dazed (perhaps a better term would be "shock and awed' by the limp and incompetent rush to open the exchange on time rather than do  it right the first time.  Having to do it  over must have cost big time !

The good news for those of us who see the ACA as a mis-step toward uniform health care (note I did not call it Universal Health Care.   An inadequate and poorly constructed Universal Payer Plan is not necessarily uniform.

The very public event has opened the door for much discussion and now the time is ripe for changing the plan to something much better, less expensive and equitable, not designed to redistribute wealth. That is not what health care is about.  Obama's plan is deceitful in most ways..  The only redistribution of wealth would be to insurers, big  pharma, and the U.S. government at taxpayer expense.

Freedom Works has just released a survey that you should look at and participate.  This is your chance to participate with new ideas.

Freedom Works is an organization now intent upon  health reform and maintaining the underlying freedoms we as all Americans cherish.

How will Freedom Works support our goals for health reform? Freedom Works not only is interested in health care, it also  works across a wide variety of niches with a consistent underlying standard based on our most fundamental beliefs of freedom and constitutional law.

An email arrived in my inbox from Freedom Works that i would share with all my readers, providers, patients, employees of our health system and leaders in Congress.

This is your chance to weigh in on improving the Accountable Care Act.  Take the Survey constructed by Freedom Works.

Looking Back at 2013

This report is somewhat late due to last minute projects at the end of 2013 and the confusion about the individual mandate, the botched launching of health benefit exchanges and some other unexpected tasks

We reviewed the 'best"  Health Train Express posts of 2013 as measured by the number of comments and our analytics.

IRS VIOLATES HIPAA FACES LAWSUIT BY A "J Holiday Message for Health and Wellness WHY AREN'T DOCTORS INVOLVED IN HEALT Does Obama really want the Affordable Care Act Covered California What They Said Before the Train Wreck: The To Sebelius will be a no-show at Obamacare hearing The Beginning or The End to the Affordable Care Act There were many more 'favorites".  The highest number of page views was in the category of the Affordable Care Act. This was to be expected, given the high ranking of the ACA for search engines. Visit the sites on Health Train Express for many more interesting topics. Health Train Express has archived our posts dating back to 2005.  The focus of posts has changed over the  years, and reveals the dynamism of health care and reform.

IRS VIOLATES HIPAA FACES LAWSUIT BY A "JOHN DOE"

HealthCare IT News reports  The Internal Revenue Service could now be facing a class action lawsuit over allegations that it improperly accessed and stole the health records of some 10 million Americans, including medical records of all California state judges.

According to a report by Courthousenews.com, an unnamed HIPAA-covered entity in California is suing the IRS, alleging that some 60 million medical records from 10 million patients were stolen by 15 IRS agents. The personal health information seized on March 11, 2011, included psychological counseling, gynecological counseling, sexual/drug treatment and other medical treatment data. 

"No search warrant authorized the seizure of these records; no subpoena authorized the seizure of these records; none of the 10,000,000 Americans were under any kind of known criminal or civil investigation and their medical records had no relevance whatsoever to the IRS search. IT personnel at the scene, a HIPAA facility warning on the building and the IT portion of the searched premises, and the company executives each warned the IRS agents of these privileged records," the complaint continued.

If the allegations are true, the IRS is in trouble,” wrote Jim Pyles, Washington-based healthcare privacy lawyer, in a statement to Healthcare IT News. “By both constitutional law and HIPAA, then I think we have a problem.”

The Department of Health and Human Services recently stated that the ACA does not grant the IRS open access to Americans' medical records with no cause. "The Affordable Care Act maintains strict privacy controls to safeguard personal information. The IRS will not have access to personal health information,” said HHS spokesperson Erin Shields Britt, to Kaiser Health News.

The IRS refused to comment when questioned.

The present plan is for the IRS to verify and document income and the consumer's insurance status.  This is contemplated to begin in 2014 in order to determine the consumer's insurance status.  The result will be used to determine a fine or penalty in lieu of insurance.

Thus far we have seen extreme difficulty with the mandate for October 2014,  wherein the Health Benefit Exchanges would be accessible to the public. This did not occur, as planned.

The vagaries of having two large governmental agencies coordinating their  tasks is worrisome. HHS has demonstrated problems with their own agency, and this behavior by the Internal Revenue Services raises serious questions about HHS and the IRS conforming to HIPAA regulations.

The roll out of the ACA has been fraught with difficulties, and the majority of Americans are not  in favor of continuing in it's present form.  Some want the ACA repealed, others want major amendments to the law.

Despite law our executive branch makes unilateral decisions, ignores mandate dates, and has caused major upset to insurers and patients, alike.

Trust and faith have much to do with acceptance of laws, and the doctor-patient relationship. As physicians our duty is our patients. Most patients do not understand the  inner workings of the system until it goes wrong.

It is our ethical responsibility to inform our patients how the system  works, and the inherent and probable dangers of the affordable care act.

Celebrities and Public Health.

Whether your  favorite celebrity knows anything about health may be open to question.

However given the visibility of celebs such as Angelina Jolie and the topic of breast cancer; or  type II diabetes (such as Tom Hanks) many want to contribute their celebrity either due to a personal involvement with the disease or for charitable purposes.

Somewhat open to question are those who endorse a specific treatment,rather than elevating the public awareness of the disease or treatments.

Amy Orbach and Breast Cancer

Katherine Zeta-Jones and Bipolar Disorder

Tom Hanks and Type II Diabetes




Celebrities can use their enormous stage presence and visibility to the general public far more than millions of dollars spent by government in public health advertising or announcements.
Who does not know more about HIV and AIDS due to the Bill and Melinda Gates Foundation, or Michael J. Foxx and Parkinsonism. The list goes
on.






Kim Kardashian and the HIPAA Scandal at Cedar-Sinai



Actress Angelina Jolie explained her decision to undergo a prophylactic double mastectomy to significantly reduce her risk of inherited breast cancer,

   




 The effects of the so-called "Angelina Jolie effect" even have reached across the pond, where breast cancer charities have reported a four-fold surge in women asking about having their breasts removed since Jolie announced she'd had the procedure, according to Daily Mail. And the number of calls Cancer Research UK's helpline received about a family history of breast cancer increased from 13 in April to 88 in May, the article noted.
In response to Jolie's breast cancer media bombshell, doctors acknowledged not all women need genetic testing but all women should discuss it with their doctors, FierceHealthcare previously reported.

Kim Kardashian brought to light the importance of privacy and confidentiality in the health space and protected information by HIPAA.Some hospital employees in Los Angeles may have gone too far in their quest to "Keep Up with the Kardashians" and now have to face the consequences.

Five workers and a student research assistant at Cedars-Sinai Medical Center (Calif.) were fired over privacy breaches involving patient medical records--and there is speculation that the patient was Kardashian, who gave birth to her daughter with rapper Kanye West in a birthing suite at the hospital on June 15, the Los Angeles Times reports. This event publicized HIPAA rules for the public and providers.

News correspondent Amy Robach announced that she has breast cancer and would undergo a double mastectomy--after reluctantly agreeing to have a mammogram live on-air for Good Morning America. Had she followed the United States Preventive Services Task Force 2009 guidelines for screening, it's likely she wouldn't have undergone her first mammogram until a decade later. Robach is just 40 years old and has little history of breast cancer. This brought to life the controversy of statistical evidence for screening for many diseases.

     Obama's camp took to popular comedy site Funny or Die to get the word out about the Affordable Care Act, with skits featuring Jennifer Hudson, Amy Poehler and Olivia Wilde. Parodying TV's Scandal, Jennifer Hudson plays a "fixer" who offers up the simple (well, it should be simple) solution of signing up for coverage on Healthcare.gov to clients presenting their problems.

     The first lady stepped into the public health spotlight with her "Let's Move" campaign, encouraging schoolchildren to eat healthier foods and exercise daily--she even enlisted Sesame Street characters Elmo and Rosita to help her promote eating fruits and vegetables during an official press conference

    In fact the Obama campaign used many celebs to raise awareness of Health.gov the national website to enroll in the Affordable Care Act. As health care professionals we should not take for granted our knowledge base as compared to the public.  The Obama effort has some very funny videos that made even me laugh, and the ACA is no laughing matter.

Katherine Zeta-Jones revealed she had bipolar disorder back in 2011, shortly after husband Michael Douglas was diagnosed with stage 4 cancer. Zeta Jones commented on her struggle with bipolar ll (which is less severe than bipolar l), in 2011,

Yet there is a conflicting report that her disclosure had little if any effect on the number of BCRA tests following her announcement

And then there have been comments from people such as Jenny McCarthy when McCarthy told Oprah Winfrey she "graduated from the University of Google," to come to this idea, but she's been spreading her view that vaccinating young children for diseases like mumps results in autism in books, newspapers and on TV--much to the dismay of doctors, scientists, researchers and other celebrities.

Health Reform Doing the Right Thing ?

A leader on health care reform, Alameda County could get penalized for doing too much

By Matt O'Brien

     The Affordable Care Act will do little to decrease health care costs overall, and early analysis shows that premiums have risen as well as deductibles.  This will reduce markedly the amount of disposable income for families, and  businesses.  Those who can afford 'premium' insurance policies will be penalized by a tax specified in the Affordable Care Act. 

Reducing disposable income effectively impacts other areas of the GDP (Gross Domestic Product), thereby increasing the relative amount that healthcare contributes to the GDP.  At the moment health care spending amounts to 16%,  or 1/6th  of the entire economy.

The Contra Costa Times reports:

 Long before President Barack Obama made universal health coverage a national priority, Alameda County earned accolades with its mission to ensure decent medical care for all its nearly 1.5 million residents. A tax hike approved by voters a decade ago fortified an expansive safety net of public hospitals and primary care clinics.

So why are local health leaders so worried as the new federal law takes effect in January? An arcane state funding formula, they say, will soon penalize the county for its commitment to treating everyone, including the poor and immigrants denied health insurance because they are in the country illegally.

An arcane state funding formula will soon penalize the county for its commitment to treating everyone, including the poor and immigrants denied health insurance because they are in the country illegally.

A liberal Bay Area county that positioned itself as one of Obamacare's California standard-bearers, beating out most others in laying the groundwork and pre-enrolling the poor, is now running into problems because of its generosity.  But that voter and taxpayer contribution is counting against Alameda County as the state is about to take away $11 million in health care funds and could grab more than $30 million in the coming fiscal year. The cuts are based on the state's expectation -- Briscoe says an overly rosy one -- that expanding federal benefits will lessen the burden on urban hospitals and nonprofit clinics because more people will qualify for free or low-cost care through Medi-Cal.  

Since 1991, state health care funding has been channeled into counties from a pot of state sales tax revenue and vehicle license fees. But Gov. Jerry Brown signed a law in June that orders counties to cough up 60 percent of their annual allotment or submit to a complicated formula that puts Alameda County at a disadvantage.

The state's reasoning is that the growing population of insured patients will be a boon to medical providers. Yet local providers anticipate about 150,000 Alameda County residents will remain uninsured because they do not or cannot sign up for Covered California, the state's version of the new federal health exchange. As many as 60,000 are immigrants without documentation whom the county is determined to keep caring for despite their exclusion, by law, from signing up for health insurance. Alameda County's mission to leave no one untreated contrasts with counties such as neighboring Contra Costa, which explicitly denies county-supported care to immigrants here illegally.

Alameda County in California has some unique features about their Safety Net. The California HealthCare  Safety Net prepared an award ground breaking documentary, "TheWaiting Room" putsa spotlight onpatients and public hospitals in California. 

The Physician's Plight Some doctors back away from Obamacare

In the Press Enterprise

BY LAURIE UDESKY  CHCF Center for Health Reporting  December 20, 2013; 

The Affordable Care Act has placed most physicians in a state of conflict. I don't know any physicians who would not want all their patients to have good health and wellness.  Wellness is always a less expensive alternative and pursuing it adds to the quality of life immediately.

While the Affordable Care Act has these components as part of the basic standard many physicians cannot participate in the roster of providers who will accept patients in Covered California, the state exchange.

Surveying other exchanges may reveal the same situation repeated 50 times.  Much of it depends upon the rates for reimbursement set by insurers, and is individualized by each insurer.

The California Health Care Foundation did a survey of physicians in California and found that 70-80% of physicians who studied the reimbursement plans,  (about 70% of the Medicare rates) decided to not participate in Covered California (the Health Benefit Exchange run by the state. 

Medicare rates have already been decreased almost 50% since 1988.  This in spite of inflation and skyrocketing administrative costs for providers due to increased regulatory requirements in order to be an eligible provider for CMS.

Dr. Steven Larson, the CEO of the Riverside Medical Clinic (140 providers), said he was taken aback when he saw what insurance companies were willing to pay. “The rates were 70 percent of Medicare [reimbursement]. It doesn’t leave room for making a living,” he said. “It’s potentially a huge problem,” said Larson, who also is the chairman of the California Medical Association Board of Trustees.

The clinics serve 300,000 patients under a variety of plans, including many Medicare patients who are not affected by the new exchanges. But the patients who want their care covered under a health exchange plan will now to have to look elsewhere for a doctor.

 In some cases they are trying to decide whether to join. In other cases they are finding that they have been dropped from plans. And many are just trying to get information about whether they are listed in an exchange plan or not.

Covered California maintains that the plans offered through the exchanges include 80 percent of the state’s physicians. “We arrived at the 80 percent by comparing our network to the two largest commercial networks,” said Covered California spokeswoman Anne Gonzales.  This reveals the lack of expertise and knowledge that state health agencies have about health care in the market place. A recent survey of California Physicians showed that 70-80% would not participate.

About a year ago numerous insurers (or Covered California ) sent out letters of intent asking providers if they would participate in the exchanges.  At that time there were no  speciffics as to reimbursement or other provisions, which are left to the insurers as long as their policies conformed to the ACA benefits.

This amounted to asking providers to sign a 'blank check'.

Recent analysis of insurer directories reveal they are inaccurate for many reasons. The directories are prepared annually with many months of lead time. California Medical Association President Dr. Richard Thorp. “Many times when we look at their physician directories, they include names of people who have moved out of state, are retired or dead. ”Some physicians have even  been listed in the exchange after they refused to participate because of the low reimbursement rates.
The challenges to participate in Covered California are as great for providers as it is for patients.

The scenario is unbelievable, except that it is fact.

Health Train Express reviewed California Health Care Foundation statements as well as the California Medical Association. The following are some of the examples:

Insurers are required to notify doctors if they’re included, according to Lisa Folberg, vice president of medical and regulatory policy for the California Medical Association.

That hasn’t always happened in Riverside, according to the executive director of the Riverside Medical Society. “Basically doctors don’t know if they’re in or out of the network,” she said. The society has told doctors to call the plans directly.

If the present situation is confusing, unfortunately the future, despite the government's intention to organize health reform, looks even more grim.  Insurance c ontracts are usually an annual renewal. At any time after the first year and later as the system matures it will be in the purvey of these "guardians of Covered California' to alter the rates.  Debt ceilings, national catastrophe, conflicts will all effect health.

The current GDP incorporates the sixteen percent due to health enterprise.  The ACA has added more levels and administration to an already bloated health system.

The United States of Affordable Care (Act)

Health Care Financing would seem to be a long way off from the patient waiting to see their physician.

In today's world the quantitiy and qualitiy of care depends very much upon the type of health insurance the patient has to use.   The care may be far different according to region, or state.

The term 'public health ' is a misnomer. The public health system is not accessible to all people for a number of reasons.  Many perceive public health as inferior to the 'private system of health care", and only would access a center if there were no other option. Many current users of public health and/or Federally Qualified Health Centers would not even know how to access ' private care'. Learn more about them here and here and  here.  I particularly like the last one. No one home --

The resource cannot be found.

If you are successful, the rules are as long as the Affordable Care Act.

A new term which may be unfamiliar to most providers and/or patients is the "Federally Qualified Health  Centers".  These centers are found more commonly in areas of low economic assets and amongst many people who fall in the range of the Federal Poverly Level (FPL).  And here are the numbers which are both unrealistic at the lower end and even more unbelievable at the top end.

• $11,490 to $45,960 for individuals
• $15,510 to $62,040 for a family of 2
• $19,530 to $78,120 for a family of 3
• $23,550 to $94,200 for a family of 4
• $27,570 to $110,280 for a family of 5
• $31,590 to $126,360 for a family of 6
• $35,610 to $142,440 for a family of 7
• $39,630 to $158,520 for a family of 8

We seem to be an impoverished nation in the world of developed countries.

Many of these centers predominantly serve 'medicaid' beneficiaries. They also serve ( unintentionally) to isolate medicaid and those who are receivng public assistance from the main stream of health care.  Hospitals and providers also treat these patients differently, not so much in terms of the quality of care they receive....rather the accessibility.  Many budgetary decisions by states often effect Medicaid patients first, because large portions of state budgets are allocated to Medicaid.

There is a non-admitted  'caste' system when it comes to medical care.  It largely is secondary to income and location, and in cities there is often a sharp divide between those living in upper middle class neighborhoods and lower class neighborhoods.

The situation is also becoming worse, and there is no sign the Affordable  Care Act will diminish the divide.
Although the ACA specifies preventive medical care  (for free)  Despite being "free", there will be a cost. There are 14 general categories,   22 special categories for women, and 25 categories for children.

A disturbing distinction between public health and private health financing is also more evident with the introduction of health information technology. In order to qualify for Grants for Information systems and operational financing a non-profit status is a requirement, which immediately rules out most entrepenurial systems (ie, private fee for service office and/or clinics, as well as some hospitals.

Health Reform: A Play in Multiple Acts

It is a very exciting and troubling time  for health care in the United States.  The stage is set for multiple acts occurring simultaneously.

For those who have boots on the ground with financial commitments and assets the changing landscape means unknown profits (if any) or losses.  Health institutions and providers charged with improved outcomes and 'less cost' are facing the conundrum of supplying more care with less money.

Leonard Zwelling M.D., a Houston physician who was a congressional staffer during the writing of the affordable care act puts it this way, as he discusses a statement made by

Norman Ornstein, a scholar at the American Enterprise Institute, one of the leading experts on the workings of Congress, summed it up in one sentence during a briefing for the press and politicos in November 2008. He said:

"Every one's idea of health care reform is the same: I pay less."

Where I was trying to get my head around a solution to the three tenets of my idea of health care reform, everyone around me was trying to preserve or increase his piece of the health care payoff pie. I was looking for a legislative solution to assist the country in arriving at the place where the rest of the civilized world was - the provision of some form of universal health care as a right of citizenship. Everyone else was looking to cut a deal that preserved his place at the trough of health care profiteering. Guess who won?

With the full cooperation of the Congress and the White House, health care was not even remotely reformed. The Affordable Care Act is not about health care reform. It is about money, particularly preserving the insurance industry's hold over how health care dollars are spent.

Hospitals and providers had little to do with the Affordable Care Act.

"The Affordable Care Act continued to allow hospitals to jack up prices with no relation to actual costs. Only the doctors gave up something because, unlike the insurance industry and the pharmaceutical industry, medicine did not speak with one voice when lobbying on Capitol Hill and thus could largely be ignored. This is health care reform? I don't think so.

The reason the Affordable Care Act did what it did is because that's what it aimed to do - increase access to insurance for the uninsured, get everyone else to pay for it, and make sure no one currently in the health care business loses a dollar from the amounts they are already extracting from patients and doctors alike.

Complicating Ornstein's comments are the multiple scenes ongoing in the 'reform' efforts

Technological advancements such as

Health information technology which includes electronic health records, health information exchanges, the proposed upgrading of the ICD - 9 to ICD -10, the advances in mobile health, telemedicine and more.......

The increased regulatory arm with meaningful use in 3 steps.  MU is linked with financial  incentives from CMS to offset the expense of providers and hospital acquisition of electronic medical records.

The challenging role of an unproven health benefit exchange system, with an incomplete back end disconnecting the actual payment to insurers.





The details of connecting the dots are only now coming into focus for bureaucrats and congress who badly underestimated the complexity of health care delivery.  The turmoil is clearly more evident among providers, hospitals and the patients who are the "guinea pigs"

During the next 12 to 24 months the 'symphony" will unfold.  Will it be harmonious or an unfinished symphony?