Curmudgeon's Corner

When Will They Decide?

Posted by Al Campbell on June 11, 2012

U.S., Healthcare, Quality of Life

When will they decide and what will they decide? 

The U.S. Supreme Court is thought to be close to issuing its decision on ObamaCare, the Patient Protection and Affordable Care Act (PPACA).  Just when they will decide ranges from today through the end of June.  Just what they’ll decide ranges from totally killing ObamaCare to taking some mitigating steps toward modifying that law.

Interestingly, some 67% of Americans polled think the entire law ought to be overturned.  Whether that will have an effect on the Justices remains to be seen, but I would tend to think that won’t have a big impact, if it has any impact at all.  These nine people have become accustomed to their approval by just 44% of Americans according to some of those same polls.

Among the most often mentioned things that might be ruled to have over-stepped Congress’ authority is the requirement that all people must purchase health insurance coverage or pay fines, etc.  That is felt by many to have very significant implications.  This is required to be able to fund the program, and there is no 'severability' clause in the law.  Many have voiced concern that if this were permitted to stand, it would give Congress express authority to tell us what else we had to purchase or couldn’t purchase so far as that goes. Congress has demonstrated that it would happily engage in such rulings; it appears to believe it has an endless source of funding to right all the perceived wrongs it can identify. 

On the other side of the argument, there is the feeling by many Americans that health care is a right, an entitlement, and that there is no need to buy insurance or to otherwise participate unless and until there is a medical emergency or distinct medical need.  That, of course, ultimately leads us into socialized health care as has been the case in many other countries around the globe.

I suspect that, if ObamaCare is restructured, parts will be kept in place and parts will be modified, and parts will be eliminated.  If it is killed outright, then Congress will rush to bring new legislation that will revive some parts since it would expect to otherwise suffer the wrath of the populace.  This would then become a major part of the campaign for the presidency this summer and fall.

There are pieces that probably would continue without any real fanfare.  In group health plans, there would be no annual or lifetime benefit payment limits.  In group plans, dependents to age 26 would continue to be able to be covered under the parents’ plans. 

In some cases, there would be time (waiting periods) required before coverage became effective simply to preclude what happened in Massachusetts when people bought ‘guaranteed issue’ policies when they became aware of a medical problem and then dropped the policies when they had had their surgery or when the condition had been otherwise cured.  They knew they could repeat that process anytime something was discovered.  The current penalty built into ObamaCare doesn’t begin to cause people to re-think this kind of activity.

The underlying concept of insurance is that those who are covered contribute whether they have an immediate need or are simply protecting themselves in case of a future need.  This concept goes back to the ‘town mutual’ insurance programs that farmers initiated so there would be a pool of money to help rebuild a neighbor’s barn if lightning struck it.  Since that was a random occurrence, the idea of creating that pool of money made sense...but those who didn’t pay into the pool were not given a ‘free’ barn if they were hit by a lightning strike.

We are an awfully long way away from that time.  That was a time when we saw our neighbors almost every day; a time when we rushed to help our neighbors whenever a calamity beset them.  Unfortunately, we have become a less-trusting people and, in too many cases, a far more self-centered people who believe we are entitled to anything we want no matter the expense to others.

No matter the Court decision made, there will be an ample number of oxen that get gored.  If ObamaCare remains unchanged, our health care world will have been changed forever.  Some will say that is for the better, at least until they find themselves on the short end of a skinnier stick but by then it will be too late.  There are some things in place today that will be difficult to change as mentioned above.  There are things that must be dealt with, but I am a believer that the free market can do those things better than can government.

The free market will have to be incented to want to make those necessary changes.  That can be accomplished by rewarding newly developed efficiencies, as well as by penalizing old inefficient and ineffective treatment modalities.  Effective and efficient providers will have to be identifiable to the public, and they will subsequently be rewarded by increasing patient loads.  Those providers who refuse or are unable to become part of that group will suffer and eventually go out of business. 

We have examples of private sector employers who have gone a long way toward alleviating their issues, but that hasn’t been accomplished overnight or without significant investments of time and dollars.  We have examples of very well run health care organizations that stand in contrast to others that are not so well run.

We people who use, and abuse, the health care system will have to take responsibility to do the best we can to avoid the need to use it, but knowing that “when lightning strikes our barn” our neighbors will be there to help us out from the fund to which we contributed throughout the time when it was someone else who needed to help.  This is the truly biggest impediment to making our healthcare system more affordable.  Obesity is epidemic and fully 25% of our population is either diabetic or pre-diabetic, and that percentage climbs every year. 

That is but one small example of the issues we have created for ourselves.  Among those who are treated but who do not contribute dollars to a pool are the tens of thousands of illegals who walk into emergency rooms all across America every month.  Those unpaid bills get passed on to us in the form of increased insurance premiums for health insurance, or in the form of increased taxes.  ERs were never intended to deliver efficient and cost effective primary level health care but they are used for just that too often.  We’d be ahead if we simply paid for more neighborhood public health facilities to deliver good primary care.

Payment for episodes of care for which costs are bundled will help a great deal.  If we continue to reward the health care system for each ‘thing’ they do, they will naturally do more and more ‘things’.  If we reward them for the full episode of care, they will re-focus on being much more efficient and effective in treating the full episodes rather than on delivering more ‘things’ that can be individually billed.

There are prospective solutions available today that we can rely upon if ObamaCare is killed outright or modified significantly, but the free market is better at those solutions if it is simply incented to do that.