Understanding Obamacare: Travails of Implementation, Notes of a Health Reform Watcher

Copyright © 2013 Richard Reece.

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ISBN: 978-1-4908-2054-5 (e)

WestBow Press rev. date: 4/15/2014

Contents

Endorsements

Books by Richard L. Reece, MD

Dedication Page

Quotation Page

Preface

This Book

The Blogs

My Position

Introduction, On ObamaCare Implementation

1.   In Final Analysis, It Is Implementation, Not Ideas That Counts

2.   Messaging and Implementation Difficulties

3.   $1.05 Billion for Mandated Implementation

4.   An Uncommunicative Bureaucracy’s Uncertainties

5.   Implementation Blues

6.   Media Messaging

7.   Uncertainty, Physicians, and Health Reform

8.   Caution: Train WreckApproaching

9.   Selling America on ObamaCare

10.   Can Obama Be Trusted?

11.   American Culture and Reform Train

12.   The New Commencementarians

13.   Is Congress Guilty of Hypocrisy?

14.   Reform Radar Detector

15.   Second Thoughts

16.   Signing Up Young and Healthy

17.   ObamaCare Starts in 100 Days

18.   Selling ObamaCare: Will It Ever Work?

19.   Employer Mandate Delay

20.   Prophecy Revisited

21.   The Health Reform Future

22.   Metaphors Describing Employer Mandate Delay

23.   The Employer Mandate – A Losing Battle

24.   Murphy’s Law and Obama’s Law

25.   Collapse of Three-Legged Stool?

26.   Obama’s Law: Everything will go right because I say so

27.   Republican Reform Switcheroo

28.   Seven Computer Bugs in a Hub

29.   Hardening of Political Arteries

30.   Hospitals and Doctors Hang Together to Keep from Hanging Separately

31.   View from 30,000 Feet

32.   Confusion Reigns Over Health Exchanges

33.   Privacy Nightmare

34.   New York Times Headline Tells It All,Legacy on Line in Fierce Drive on Health Law

35.   Latest Polls: Will Will of the People Prevail?

36.   Marketing Health Law to Young and Cashless But Not Clueless

37.   Accountable to Whom?

38.   Those For and Against

39.   Will ObamaCare Collapse of Own Weight?

40.   Is Ending Fee-For-Service Key to Lowering Costs?

41.   Just Because It’s OK for Them Doesn’t Mean It’s OK for Us

42.   Lack of Cost Controls and Lack of Market Competition

43.   Ten GOP Targeting Strategies for ObamaCare

44.   ObamaCare Health System-Physician Computer Game

45.   Obama Mocking of IRS Scandal

46.   Time, Physicians, and ObamaCare

47.   Physicians and Their Reputations

48.   Medical Device Tax, Hip Implants, and Warsaw, Indiana

49.   A Deal Congress Can’t Refuse

50.   ObamaCare in Danger of Losing Unions as Core Constituents

51.   Challenge Facing ObamaCare: The Percentages

52.   Excuse Me? GOP to Blame for ObamaCare’s Unpopularity and Rocky Implementation?

53.   Casey Stengel, Marv Thornberry, and Re-Envisioning of the Fouled Up U.S. Health System

54.   Town Hall Meetings’ Voices of Dissent

55.   Text of President Obama’s Remarks on ObamaCare Implementation at August 9 Press Conference

56.   ObamaCare: Train Wreck or All Hands on Deck?

57.   Health Exchange Navigators

58.   Disruptive Innovation, Publishing, and Health Care

59.   Will Obama Care Rollout Be Smooth or a TraIn Wreck

60.   Another Day, Another Delay

61.   Will ObamaCare Rollout Be Smooth or a Train Wreck?

63.   Postponing Day of Reckoning

64.   On Doctors and Having the Courage to Practice Independent Direct Care Medicine

65.   Choice of Health Plans and Doctors Narrows

66.   Red States Make Sibelius See Red

67.   National Debt: US National Debt According to US Debt Clock, org

68.   Obama’s Point of View as Revealed in August 17 Weekly Address.

69.   Hampering of Health Care Innovation

70.   ObamaCare Outcome: TBD (To Be Determined)

71.   Flaunting and Flouting Health Law

72.   ObamaCare: The Hodgepodge and Ripple Effect

73.   Twelve Health Reforms for Consideration

74.   Acts of Quiet Desperation

75.   The Computer As Health Reform Tool

76.   ObamaCare: Rhetoric Versus Reality

77.   ObamaCare and Chief Business of Business

78.   California Could Delay Opening of ObamaCare Exchange, Washington Free Beacon, August 22, 2013

79.   Shootout at the Government’s OK Corral

80.   Out of Sight, Out of Mind

81.   Who Killed Health Reform?

82.   ObamaCare and Health Exchanges: Four PowerPoints of View

83.   The Mobile Device-SmartPhone Gold Rush and Its Problems

84.   President Obama’s Holier Than Thou Insult

85.   The Last Word: ObamaCare Explained

86.   Lobbying for ObamaCare on K Street

87.   ObamaCare Fraud Formula Flawed

88.   ObamaCare Implementation Dates

89.   Defund or Delay ObamaCare? The Humpty Dumpty Question

90.   ObamaCare’s Biggest Impact

91.   Why Doctors Are Wary about Swapping Horses in Midstream

92.   Unions Seek ObamaCare Repair

93.   Understanding ObamaCare-Premise, Promises, Consequences

94.   On Curbing Enthusiasm about Medical Innovation

95.   An Emotional Understanding of Health Reform

96.   Converging Health Care Landscape

97.   Different Premiums in Different States:

98.   Clinton Urges Americans to Sign Up for Health Exchanges, New York Times, September 4, 2013

99.   ObamaCare Law, Irrefutable or Mutable?

100.   Health Exchange Navigator Alligators

101.   IBM To Move 110,000 Retirees to Private Health Exchange

102.   Now, Instant Diagnosis on Drop of Blood

103.   Time for Quiet On The ObamaCare Front

104.   Notable and Quotable:50 Year Old Assumptions Drag Down ObamaCare,Paul Howard, Forbes, September 9, 2013

105.   Health Reform and You

106.   Is It Worth $1 Million to Become a Doctor?

107.   The Train Wreck

108.   A Big F—kingDeal!

109.   Self-Funded Health Plans Threatened with Extinction

110.   Health Reform Hits Academic Health Centers (AHCs)

111.   Tamping Down ObamaCare Expectations

112.   No Perfect Health System

113.   Why ObamaCare Is Like an Elephant

114.   Health Reform, Inside, Outside the Beltway and Below the Belt

115.   Health Information Technologies and the War on Costs and Disease

116.   With Two Weeks To Go Before Sign-up for Exchanges, Obamacare Still a Tough Sell

117.   Are GOP House and American Public Extremists in Opposing Health Law?

118.   The Leave-It-Alone Strategy, Now and Then

119.   What’s Your Obamacare EQ (Emotional Quotient)?

120.   GOP Threatens to Throw Down Gauntlet

121.   Peter Roff, ObamaCare Is Going to Come Tumbling Down, US News and World Report, September 17, 2013

122.   Those Who Chose Not to Follow the Piper

123.   Reform Law Changing Health Benefit Climate

124.   Government Shutdown: State of Play

126.   The PR Quest for a Piece of Your ObamaCare Mind

127.   Cleveland Clinic Cuts Jobs and Expenses in Response of ObamaCare

128.   September 23-30: A Week For Health Reform Consensus

129.   Obama Drama

130.   Summing Up: Ten Reasons Why Obamacare Remains Controversial

Endorsements

Dr. Richard Reece does help add clarity to the ACA. His essays provide insight about the law that threatens the very fiber of American medicine. I think doctors and their patients should read this collection of essays which may provide enlightenment to future of American medicine if this plan goes forward.

Dr. Neil Baum

Clinical Associate Professor of Urology

Tulane Medical School

Author of Social Media For The Healthcare Profession

In his latest illuminating dissection of America’s changing healthcare system, Dr. Richard Reece lays bare the intricacies and potential unintended consequences of Obamacare. This is a clear-eyed, common-sense look at a complex subject from an industry insider with a unique perspective. Physician, patient, and seasoned analyst, Dr. Reece presents both a big picture overview of healthcare reform and reveals the telling details that bring his subject and his conclusions to life. A must read for anyone interested in this timely and essential topic.

Phillip Miller

Vice President, Communications

Merritt Hawkins

In his newest book, Dick Reece covers exactingly the many facets of ObamaCare, and he does so in a very unbiased manner. Recommended reading for those who want to understand more about the Affordable Care Act.

Tim Norbeck

Chief Executive Officer, Physicians Foundation

Richard Reece MD, physician, blogger, and healthcare guru, has a long and enviable legacy of insightful yet humorous ruminations on the most pertinent medical issues of the day with a more recent laser focus on healthcare reform.

In his latest book, Understanding Obamacare, Dr. Reece brings sensibility and clarity to a very complex subject that has both riveted and confounded the American public for the past several years.

With a style that is at times both light and lyrical, always stimulating and informative, periodically humorous as well as sobering, the author uniquely creates a framework of understanding as he nimbly explores the history of the healthcare maze.

Although not shy about expressing his own opinions, Dr. Reece provides building blocks of carefully researched information to enable the reader to construct his or her own differing opinion if desired.

Reading Understanding Obamacare is highly advisable to anyone who has been or ever will be, a patient in the American healthcare system.

Walker Ray, MD, Former President, Medical Association of Georgia, and Health Care Analyst

Books by Richard L. Reece, MD

A Collection of Editorials from Minnesota Medicine: 1975-1982 (1983)

And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (1988)

A Managed Care Memoir: A Physician’s Whistle-Stop Journey (2004)

Hello Health-Care Consumer: The Transformation of Patient-Doctor-Hospital-Health Plan Relationships (2004)

Voices of Health Reform – Interviews with Health Care Stakeholders at Work (2005)

Sailing the Seven Cs of Hospital-Physician Relationships; Competence, Convenience, Clarity, Continuity, Control, Cash, and Competition, with James A. Hawkins (2006)

Innovation-Driven Health Care: 34 Concepts for Transformation (2007)

Navigating the Maze of Health Coverage and Access: A Quick Guide for Physicians (2008)

Obama, Doctors, and Health Reform: A Doctor Assesses Odds for Success (2009)

The Pros and Cons of Accountable Care Organizations (2011)

The Health Reform Maze: A Blueprint for Physician Practices (2011)

The New Voice of Health Reform: the 3R’s- Rhyme, Rhetoric, & Reality; Book One; Physicians, Parodies, and Poems (2012)

Dedication Page

To Americans seeking to understand health reform.

Quotation Page

The body politic, like the human body, begins to die from its birth, and bears in itself the causes of its destruction.

Edward Moore (1712-1757), The Social Contract

Preface

When eating an elephant take one bite at a time.

Creighton Adams (1914-1974), Chief of Staff, US Army

Likening ObamaCare to an elephant is an apt metaphor.

Like an elephant, Obamacare is a huge political animal, the biggest health care entitlement since Medicare and Medicaid. ObamaCare dwarves these programs in size. It covers every American, not just the old and the poor.

Like an elephant, ObamaCare has a long flexible probing proboscis, capable of seizing and grasping everything and everybody within its reach.

Like an elephant, ObamaCare has a height advantage, overseeing and monitoring every American from on high with its ever expanding surveillance computer systems.

Like an elephant, it has powerful body parts, including a massive central nervous system, replete with a vast array of policy experts, wonks, and other functionaries.

Like an elephant, it has a broad, strong back supported by a $3.6 trillion federal budget.

Lie an elephant, it has four sturdy legs, the pillars of Obamacare – the IRS, Medicare, Medicare, and the Bully Pulpit-capable of trampling anything that gets in way.

And, last but not least, like an elephant, ObamaCare, has a swishing tail that brushes aside adverse consequences should they prove inconvenient.

The only problem is that ObamacCare, like the elephant, is fiendishly complicated. Because of its size and scope, it is impossible for any one person to understand what it holds for them as individuals. That means most of us are like the six blind men of Hindustan, each feeling and describing different parts of the elephant. We are all partly right in our feelings, but partly wrong, too. None of us really see the whole animal or the big picture.

This Book

This book is a daily blog-by-blog, bite-by-bite account of the Affordable Care Act’s implementation. It is now September 15, 2013. ObamaCare implementation starts in earnest on October 1, 2013.

Nearly a month ago, Congress ended its five week break. The break was not a vacation. Democrats and Republicans were sounding out constituents on merits and faults of ObamaCare in town hall meetings. Each party has mounted costly media campaigns to persuade or dissuade the uninsured. More than half are young (aged 18-34). Their choice is to either sign up for health exchanges, or face a penalty of $95 for not signing up.

The critical sign-up period will last from October 1, 2013 to January 1, 2014. Then ObamaCare will kick into high gear. Most of the law’s various provisions will start taking full effect except for the Employer Mandate. That has been delayed a year.

The Blogs

Generally I write one or two, occasionally three, blog posts each day. I often post entries in response to the day’s news. But sometimes I compose posts on a whim, a trend I see developing, less frequently when a verse springs to mind. These daily blog posts are the guts of this E-book. I have arranged them chronologically.

My formula for composing these posts has remained the same since the beginning: short title, an opening quote, often historical, a statement of a problem, a brief background statement, then a conclusion, followed by a summarizing tweet.

I use opening quotes, some ancient, because I believe there is rarely anything new under the sun that hasn’t been said better before, or better than I can say it.

I sometimes base a post on a single word. Words capture larger concepts. The typical post is 400 to 800 words. Most are dead serious, but occasionally I engage in word play, insert a little humor, even compose an occasional verse.

My Position

I am pro-physician and pro-patient. In my opinion, physicians and patients, not the federal government, are the guts, heart, and brains of our health system.

I believe America, at its best and its most powerful, is a bottom-up entrepreneurial society, from whence most innovations spring. Government has a role to play. But, in my opinion, government’s role ought to be a peripheral oversight role, not a command-and-control function.

Top-down mandates, forcing Americans to respond to government demands, should not be the foundation of our present and future health system. Government, of course, will continue to manage Medicare, the Department of Veterans Affairs, and to a lesser extent, Medicaid. The federal government ought to share Medicaid expenses and policies with the states. Centralized government cannot manage the entire system well. It is simply too big and too bureaucratic to be anything but a mediocre manager.

Health reform is needed. Costs are higher than they ought to be. Reform is best achieved incrementally, rather than comprehensively, as envisioned in the Affordable Care Act. You cannot and should not abruptly abandon the dance, American capitalism and free enterprise, that got you the most advanced technological health system in the world.

Reform is best achieved through compromises and tradeoffs between the government and market sectors. The health system comprises one-fifth of the economy. It employs one of ten Americans. One should tinker with it carefully before trying to dismantle it.

What is missing and not widely known to the public, not welcomed or even acknowledged by Obama, are credible Republican plans for reform, even though such plans exist. The media has not been helpful in making these plans known. Their merits have yet to be debated.

Health reform is a huge, complicated, sprawling subject. I have approached it from different angles on different major subjects.

Health reform does not happen overnight, or even over the course of decade, even if government endorses or mandates it.

Reform evolves, inside the framework of a nation’s culture and beliefs.

Introduction, On ObamaCare Implementation

Please be assured that as we move along through the implementation of health insurance reform, making sure that we find efficiencies within the existing system, is foremost on the President’s mind.

Valerie Jarrett (born 1956), Senior advisor to President Obama

Whatever one thinks about the Affordable Care Act, aka ObamaCare, its implementation is proving difficult. I have written many blogs about implementation trials, tribulations, and troubles. Over the last seven years, I have composed over 3000 blogs on either medical innovation or health reform.

It has been more than 3 1/2 years since ObamaCare’s passage on March 23, 2010. The health law remains controversial. According to Gallup, only 35% of Americans approve of it. A bare 19% feel they will be better off once it is implemented. Its chief architect, Senator Max Baucus (D-Montana). warned Kathleen Sibelius, Secretary of Health and Human Services (HHS), that an Obamacare train wreck is in the offing. Critics doubt CMS and its computer systems are prepared to deal with the millions expected to sign up for health exchanges on October 1, 2013. Because of the IRS scandal, many feel an increasingly discredited, partisan IRS, operating out of an office in the White House, is the wrong federal agency to enforce its implementation.

As I explained in June 27, 2013 blog post, other reasons exist to doubt ObamaCare’s staying power.

Its unilateral, arrogant, and clandestine passage; its writing of a 2700 page indecipherable bill composed by inside Beltway Congressional staff and lawyers; its expanding of Medicaid by sacrificing Medicare, its deep cuts of hospitals and physicians; its lack of clarity, its obsessive secretiveness, its anti-small business and anti-physician attitudes, its excessive bureaucratic regulations and costs, its broken promises – lower costs, greater efficiencies, and better outcomes; its over-reliance on data and EHRs as tools to make medical care more scientific; its overlong four year introduction designed to mislead public on its costs; its brazen attempt to completely and comprehensively restructure a system 70 years in the making rather than approaching it incrementally; its one-size-fits-all standardization of all policies regardless of age, sex, and needs and its contempt for market reforms such as health savings accounts.

That said, expanded access to less costly, more affordable care for all Americans is a noble and reasonable goal. I hope we achieve it. How to get from here to there – through sweeping federal mandates or incremental market reforms- is what’s in question and at risk.

MEDINNOVATION AND HEALTH REFORM BLOG POSTS, DATES OF ENTRY AND TITLES

1) JANUARY 3, 2007

In Final Analysis, It Is Implementation, Not Ideas That Counts

In