The Tragedy of 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 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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8 replies »

  1. Wait a sec – i’m not saying that. I quoted Bernie… and yes even repeal without replace would not result in millions dying..

  2. Maybe Republicans will resurrect the old Dick Cheney quote: “Deficits don’t matter.” Then they can put more money into the subsidies and the high risk pools needed to make could on Trump’s claim that we will “cover everybody.” We’ll see.

  3. “To oppose Obamacare is to be for a medical holocaust. ”

    Strawman. It is the repeal without replace that is worrisome. As Joe notes in his column, the numbers just don’t add up. The GOP can’t do what it has promised. So the lack of an apparent plan reflects a real problem. I predict we get a magic asterisk to make things work.

  4. If health care costs keep rising while providers (and investors) keep getting get rich then I guess we’ll all be on Medicaid or uninsured.

  5. I would suggest that physicians shouldn’t celebrate the outsourcing of IT jobs too much, because every fired American is another potential Medicaid “beneficiary”.
    Physicians have been rather silent (or dismissive) on the subjects of workers’ exploitation, outsourcing, offshoring, and the resulting rise in poverty and inequality. This Medicaid thing is a direct result of that. It used to be Medicare for all.
    When good stuff doesn’t trickle down properly, nasty stuff starts to trickle up. As I said many times before, there is very little money to be made from being doctors for the poor.

  6. Yes, we can quibble over exact numbers, but even politifact and liberals would agree majority of expansion from Medicaid is a true statement. Regardless point is that medicaid price points financially untenable.Certainly medicare reimbursements are survivable – which is why despite the bellyaching most medicare beneficiaries have a much easier time with access than medicaid folks. Uwe Reinhart and co. are upset about about the lack of a repub solution, but how is the left’s solution make any sense here. I swear – i’m not partisan in this debate – anything that works would be nice. 🙂

  7. Seems your numbers are not as cut and dry as Paul Rand or the Heritage Foundation would have us believe.


    So what if you’re right, there’s still more people with coverage that weren’t getting it before ACA. I guess what your point is, are the reimbursements not high enough for Medicaid. I’ll agree, but would you be happy with Medicare reimbursements instead?