The case against Obamacare

The Senate has taken its first step to repeal Obamacare.  By a final party line vote of 51-48 the Senate approved a budget resolution setting the stage for rolling back much of the Affordable Care Act.

Consternation reigns among Democrats who have closed ranks and promise catastrophe.

Bernie Sanders, the top democrat to lead the resistance said “I think it’s important for this country to know this was not a usual thing, this is a day which lays the groundwork for 30 million people to be thrown off their health insurance… And if that happens, many of these people will die.”

And so it is that a complex problem comes to be painted in black and white.     To oppose Obamacare is to be for a medical holocaust.  Genghis Khan reincarnated would be unable to wreak a devastation as complete as repeal of Obamacare.

The insidious fact is that this simple phraseology is used as a cudgel by those who well know that the tentacles of a program as complex as Obamacare defies such a simple duality.  Understanding the effect of Obamacare is to understand how politicians flapping their wings in Washington DC creates a hurricane in California.

Consider this news item in the Los Angeles times from January 6th.

“The University of California exploits a visa loophole to move tech jobs to India”

The column relates a story of the University of California (UCSF) outsourcing 20% of its IT jobs to India. The thrust of the column is to discuss misuse of the H1B program meant to allow American companies to hire foreign workers with unique talents.  As alleged, the H1B program is misused by companies who seek to replace equivalent american talent with cheaper labor from abroad.  In this case, UCSF struggling with a shortfall of $42 million dollars on revenue of $3.4 billion looked to the IT department to achieve budget neutrality.  We should be happy, I imagine, that software developers were chosen over nurses, physicians, scribes or medical assistants.

Regardless, what should pique everyone’s interest is not the potential misuse of the H1B program, but the reason UCSF finds itself in this predicament.  The red ink UCSF finds itself awash in is partially a result of expansion of Medi-Cal, California’s Medicaid program.  Expansion of Medicaid lies at the very heart of expanded coverage through Medicaid nationally.  Of the 20 million people that have gained coverage after the Affordable Care Act, 14.5 million gained coverage through Medicaid or CHIP (Children’s insurance).  There are many that crow about the expanded coverage, but as UCSF found out, Medicaid expansion is no panacea for providers.  The problem lies in reimbursement –  Medi-Cal reimburses $24 for a routine established follow up visit (99213)  I am, in general, skeptical of estimates from hospital bosses, but given this level of reimbursement, I can believe their estimate in this case that each Medical patient generates a loss of 40 cents for every dollar spent on treatment.

This is not news to providers that have long understood the financial challenges of delivering care to Medicaid patients.  In fact, I grow more certain every day that there are braying donkeys that have more to add to the debate on health care than those who discuss health care coverage without discussing how to pay for said coverage.  So while I share the concern of those worried about the vague Republican plan that will replace Obamacare, I am flummoxed by the lack of concern about the Left’s Medicaid-will-solve-everything-solution.  If I was forced to sell this as a solution I would be using incredibly fine print.  But the Democrats, no doubt emboldened by the massacre predicted on November 8th, used their standard bearer – the most qualified human ever to run for the -office of the President and wear a pant suit – and the hallowed pages of the New England Journal of Medicine (NEJM) to make the case for Medicaid expansion to further expand coverage.  The Medi-Cal model is simply financially untenable.  UCSF may be able maneuver by replacing John from San Jose with Raj from Mumbai.  Your local primary care practitioner has considerably fewer options.

Nuance and granularity purposefully escapes politicians intent on marshaling people to a side.  In the health care debate, ideology rules.  It is easier to paint those opposed to a broken model of expanded health care coverage as soulless ignorant deplorables willing to let millions die on the streets than answer real questions about how to actually deliver healthcare.  For many providers, the real disaster would not be repeal of Obamacare, but a failure to evolve beyond Obamacare.

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