Gyroscopic Investing

The possibility that the U.S. Supreme Court will soon eliminate federal subsidies for people buying health insurance through the Affordable Care Act is the biggest story in politics and economics that no one wants to talk about. But the stakes in King v. Burwell, which the court will hear on March 4, could scarcely be higher: If the plaintiffs prevail, millions of people in 34 states who bought insurance on federal exchanges would suddenly lose the subsidies that make it affordable. Consequently, most would lose their coverage. A Rand study pegged the number at 9.6 million people, with premiums soaring 47 percent for those still able to afford them. “Everyone agrees this would be a cataclysmic hit to the insurance market,”? Michael Kolber, a health-care attorney at Manatt, Phelps & Phillips, said at a Feb. 13 Bloomberg Intelligence panel on King v. Burwell.

The immediate effect of a ruling against the ACA would be to hurl the political system, and no small part of the economy, into chaos. Yet there’s little sign that Washington is preparing for that scenario. Democrats won’t talk about what they would do because they don’t want the court to believe they could contain the fallout. Republicans don’t want to talk because they’re loath to admit that, even after voting 67 times to repeal or defund the ACA, they have no plan to help the millions who would be affected. (But they’d sure love the court to kill the law anyway.) Hospitals and insurers understand that bewailing their financial plight might not help their cause. Instead, they’ve channeled their warnings into amicus briefs.

Read the rest here...
http://www.bloomberg.com/politics/artic ... e-i6m1baro

A few conservatives do seem to be slowly grasping that the implications of killing Obamacare via the judiciary could be serious.

As a self employed small business owner with an un-spectacular income, my brother relies on Obamacare's assistance - his health insurance would be over $800/month without the subsidies.

He was complaining about how screwed up the California exchange is.  Somehow, it decided that his daughter was the head of household, not him.

"Sorry sir, we need an authorization from <daughter's name> before we can process your application or make you head of household."

"But...she's THREE YEARS OLD!"

"Sorry, we can't do anything without her authorization."

However, despite all the bureacratic bungling, he does not want to see Obamacare ended.  Basically it's too late:  not giving someone a benefit is a whole lot easier than taking one away that millions of people have come to depend on.

If I were in charge of the Republican party (dream on!) I'd quit trying to kill Obamacare.  Instead I'd push the idea of removing routine and minor care from the insurance system, to let the free market take over and start driving down prices.  Also maybe limit subsidies to high deductible health plans.  That would have a ripple effect on services covered by insurance.  It also would remove a very large burden from many physicians and outpatient medical offices, who could realistically go [back] to a streamlined cash-based practice instead of having to deal with the incredibly onerous CMS (Medicare/Medicaid) rules.  No more requirements for electronic records, no "PQRI", ICD-10, insane CPT coding requirements, and on and on.  Among other things, it might allow physicians to start enjoying their jobs again, instead of the current situation where practically everyone I know is trying to figure out how soon they can quit clinical practice.  The Democrats might do well to pay attention to the fact that without physicians, you can't exactly have a health care system.

WiseOne wrote: However, despite all the bureacratic bungling, he does not want to see Obamacare ended.  Basically it's too late:  not giving someone a benefit is a whole lot easier than taking one away that millions of people have come to depend on.

Unfortunately, that applies to government, insurance companies and claims processors as well.  There is a snowball's chance in hell the Republicans would ever pay more than lip service to their free market ideology and reform Obamacare instead of preserving corporate giveaways (including Obamacare).  All hat, no cattle.

Things will have to crash and burn and then only by a miracle of sheer randomness, coincidence or luckyness, reform will get done sensibly that should have be done from the very beginning.  How often does that happen in politics?

WiseOne wrote: Basically it's too late:  not giving someone a benefit is a whole lot easier than taking one away that millions of people have come to depend on.

Yes, that was the whole idea behind Obamacare. Also Social Security, Medicare, welfare, and every other government program.

What that means, of course, is that the whole system will collapse.

The big question, as always, is timing.

Libertarian666 wrote: What that means, of course, is that the whole system will collapse.

The big question, as always, is timing.

That's easy!

[align=center][/align]

Back to the thread title:  Is Washington Ready for the Death of Obamacare?

Inquiring minds want to know, so we should all ask Bill, "he is probably the most famous liar of all time",    according to this article:

http://www.msn.com/en-us/news/politics/ ... ar-BBi9uxi

... Mountaineer

MachineGhost wrote:

Libertarian666 wrote: What that means, of course, is that the whole system will collapse.

The big question, as always, is timing.

That's easy!

[align=center][/align]

Very impressive precision!
Of course, precision != accuracy.

Libertarian666 wrote: Very impressive precision!
Of course, precision != accuracy.

7 months to go to find out.  Man the hatches!

WiseOne wrote: As a self employed small business owner with an un-spectacular income, my brother relies on Obamacare's assistance - his health insurance would be over $800/month without the subsidies.

He was complaining about how screwed up the California exchange is.  Somehow, it decided that his daughter was the head of household, not him.

"Sorry sir, we need an authorization from <daughter's name> before we can process your application or make you head of household."

"But...she's THREE YEARS OLD!"

"Sorry, we can't do anything without her authorization."

However, despite all the bureacratic bungling, he does not want to see Obamacare ended.  Basically it's too late:  not giving someone a benefit is a whole lot easier than taking one away that millions of people have come to depend on.

If I were in charge of the Republican party (dream on!) I'd quit trying to kill Obamacare.  Instead I'd push the idea of removing routine and minor care from the insurance system, to let the free market take over and start driving down prices.  Also maybe limit subsidies to high deductible health plans.  That would have a ripple effect on services covered by insurance.  It also would remove a very large burden from many physicians and outpatient medical offices, who could realistically go [back] to a streamlined cash-based practice instead of having to deal with the incredibly onerous CMS (Medicare/Medicaid) rules.  No more requirements for electronic records, no "PQRI", ICD-10, insane CPT coding requirements, and on and on.  Among other things, it might allow physicians to start enjoying their jobs again, instead of the current situation where practically everyone I know is trying to figure out how soon they can quit clinical practice.  The Democrats might do well to pay attention to the fact that without physicians, you can't exactly have a health care system.

Maybe I missed it but why do all the doctors want to leave clinical practice?  And why don't they?

Thanks for the link MangoMan!  Interesting thread, although only a couple of posts dealt with the changes that are driving physicians out:  the increasing regulatory burdens from multiple fronts:  CMS (Medicaid/Medicare), the draconian version of the HIPAA law that passed as part of the stimulus package and has been enormously expensive, and private insurance companies.  All the stuff about how expensive medical school is and how hard doctors work and how you have to make life and death decisions every day...well, duh, but that's not the problem.

The problems with the regulatory burdens are:

- They're a sump of unintended consequences; quality of care breaks even at best, while they dramatically increase the time required to handle documentation.  Since the day is not getting any longer last I checked, this comes out of face to face patient time and home/family time (or sleep time) - and it all feels like a pointless waste of time.  Residents suffer the worst; they spend easily 3/4 of their day on documentation work that didn't even exist a few years ago.  As a result their education is hampered and the results of that are increasingly obvious.  (Note to my future self:  don't get sick.)

- A corresponding crop of administrators has sprung up, whose salaries and fancy offices we must pay for, and whose job it is to find even more ways to restrain us than the government has mandated.  (good example:  the "Lake Wobegon" RVU system, where everyone has to post earnings that are above average to justify below average salaries.)

- Our professional lives are increasingly at the mercy of people with high school diplomas.  More and more we're being treated like janitors, and less and less like professionals.  This alone is thoroughly demoralizing for many.

I heard from a colleague today (imho an extremely good physician) who was complaining about several things related to the above.  She's also following the save-for-FI and get-research-funding plan.  Those who (like me) became physician-scientists with at least 50% time devoted to research are far happier than full time clinicians - except for one of my friends with stellar organizational and people skills who decided to aim for administrative glory and is now a dept vice chair, and another who took the option of a full time job reading studies from home.

Hope that's answered your questions...would like to know if the other MD's on this board agree.

WiseOne, remind me how this all time wasting came about...  was there a crisis that precipitated it, or is it just the usual and inevitable government expansion?

MachineGhost wrote: WiseOne, remind me how this all time wasting came about...  was there a crisis that precipitated it, or is it just the usual and inevitable government expansion?

Government expansion, although the regulations were justified as a way to solve problems like medical errors and lack of communication among physicians.  The HIPAA law exacerbated the communication problem, and EHRs do nothing whatsoever to solve it.  The medical errors have been a net zero change; EHRs solved some and created others.

Desert wrote:

WiseOne wrote:

MachineGhost wrote: WiseOne, remind me how this all time wasting came about...  was there a crisis that precipitated it, or is it just the usual and inevitable government expansion?

Government expansion, although the regulations were justified as a way to solve problems like medical errors and lack of communication among physicians.  The HIPAA law exacerbated the communication problem, and EHRs do nothing whatsoever to solve it.  The medical errors have been a net zero change; EHRs solved some and created others.

WiseOne, was this government expansion mostly due to Obamacare?

In part.  A lot of it was sneaked into the 2009 stimulus package.  The EHR & "meaningful use" requirement, PQRS, and addition of criminal and large monetary penalties to the HIPAA law all happened then.

Bump.

The rumors of its death have been greatly exaggerated.

http://tinyurl.com/qx4o88g

This loss will help give Republicans a strong campaign issue that should help sweep them into the Presidency, The Senate, and the House. Obamacare has been a great issue for them for years now.

I have no doubt they'll run on it.  Whether that will translate into substantial reform after the election is another matter entirely. 

Some of the political blogs I read like to talk about Republican "Failure Theater". 

Failure Theater is the process by which the Establishment deliberately fails to do achieve anything, but wants credit from the Dumb Conservatives they’re playing to for allegedly “trying.”
http://ace.mu.nu/archives/355300.php

I think that describes politics (on both sides) quite well a great deal of the time. 

The interpretive jiggery-pokery in this ruling is pure applesauce.

dragoncar wrote: The interpretive jiggery-pokery in this ruling is pure applesauce.

Why?  Original intent was that the exchanges would get subsidies, state or federal.  Imagine the jiggery-pokery you would have to go through to disabuse the original intent just to stick to your personal pet political ideology like the three dissenters who are as predictable as the sun rises.

Original intent applies when the text is unclear.  In this case, it was perfectly clear.  And early on, the legislators were using it as a hammer, proving that it really is what they meant.  They were trying to force states to participate, under penalty of having their citizens not get subsidies.

This was a mechanism for states to vote on Obamacare.  They roundly defeated it.  So, of course the literal meaning of the statute must be changed with a wink and a nod.

Xan wrote: Original intent applies when the text is unclear.  In this case, it was perfectly clear.  And early on, the legislators were using it as a hammer, proving that it really is what they meant.  They were trying to force states to participate, under penalty of having their citizens not get subsidies.

This was a mechanism for states to vote on Obamacare.  They roundly defeated it.  So, of course the literal meaning of the statute must be changed with a wink and a nod.

That wasn't the original intent I was talking about.  My original intent was that subsidies would apply to all.  There's no indication the original intent was anything different in regards to state vs federal in the record.  But, if opportunists abused the lack of clarity regarding state vs federal subsidies to their advantage, the pox's on them for being typical political ideologues.

And boy do I ever hate politics in this country.  You can't even pass a common sense piece of legislation (i.e. individual mandate) without there being grandstanding pandering on both sides.  The other countries of the world must laugh at us.  What's the point of continuing to live here where you get the worst of everything and very little of the best?

MachineGhost wrote:

dragoncar wrote: The interpretive jiggery-pokery in this ruling is pure applesauce.

Why?  Original intent was that the exchanges would get subsidies, state or federal.  Imagine the jiggery-pokery you would have to go through to disabuse the original intent just to stick to your personal pet political ideology like the three dissenters who are as predictable as the sun rises.

By "pure applesauce" I mean sweet.  How do you interpret applesauce?

dragoncar wrote: By "pure applesauce" I mean sweet.  How do you interpret applesauce?

Equivalent to stepping in dog shit without being vulgar.

MachineGhost wrote:

dragoncar wrote: By "pure applesauce" I mean sweet.  How do you interpret applesauce?

Equivalent to stepping in dog shit without being vulgar.

I'm pretty sure you have to go by my intent.