I want to clarify three points: I am not so much a fan of the ACA as I am a believer that it is better than what we had before. My personal preference actually runs more along the lines of Medicare-for-all. And if I identified any flies in the ointment, it was definitely advertent. Finally, as much as I am fascinated with Ian Malcolm and chaos theory, it’s that other Ian, Ian Shoales, who has had a greater influence on my world view.

Can’t wait to do this again in three years.

I am pleased to see Dr Wilke’s forum return in its second stage. He is obviously passionate in his desire to extend the benefits of health insurance to the widest numbers of Americans as possible and expresses his belief that ACA is the vehicle that will accomplish that goal. Thus, his instincts are to defend the act and excoriate those who would starve it of funds or find its key provisions unconstitutional.

At the same time, however, in his facile and amusing journey through the pop cultural and political environments in which ACA is to be implemented, Dr Wilke has either inadvertently or deliberately identified some of the squirming flies in the ACA ointment.

Although he professes to believe in Churchill’s pronouncement that Americans, after exhausting all other possibilities, will eventually choose the right course of action – in itself a bit of a tautology, since the right course of action is being defined by whomever has chosen to employ the Churchillian epigram (Supreme Court Justice Antonin Scalia and Congressman Ron Paul might have something quite different in mind from Dr Wilke) – he reveals his fascination with Professor Ian Malcolm’s explanation of the “butterfly effect” to the distinguished tourists to Jurassic Park.

If one cannot predict the ultimate consequences of a tiny butterfly flapping its wings in China, what about the “cobbling together” of a massive piece of legislation that affects virtually all of the American population, that almost surely will have unintended consequences for both the nation and each individual American?

In reflecting on the events since Dr Wilke’s original 2008 forum piece, I concede that the unexpected political (Arab Spring and Tea Party) and tectonic forces (Fukushima) that engulfed us are worthy of note, but I think there are other forces at work that may decide the fate of the ACA.

Despite the impression of unrelieved gridlock, there is an example during this period of the two parties, led by the coordinated policies of the successive G. W. Bush and Obama administrations, that resulted in massive restructuring of the housing and banking sectors – the Federal Reserve’s response to the simultaneous collapse of Lehman Brothers, Bear Stearns, Washington Mutual, Countrywide, etc.

Here the political leadership of both parties cooperated. The results were breathtaking and transformative. It’s my personal belief that it has been all to the good.

But there was collateral damage far beyond the Detroit and Vegas neighborhoods of multiple foreclosures. The idea of massive federal intervention in the economy in the one sector has generated a massive counter-reaction. The reaction is clearly at the heart of the Tea Party’s founding and has some resonance in the Occupy movements as well.

Then, as the idea of direct action against an out of control government came to be fashionable through social media and candidates willing to articulate the messages and contributors with big bucks to diffuse them, there emerged the disorderly spectre of a profligate Greece, with the seeming capacity to destroy all of Western Europe.

For the first time in my memory, a sizable portion of the American electorate seems predisposed to taking account of what things cost and of worrying whether there is enough money, even if every tax that can be conceived were passed, to pay for all the commitments made so far.

The French philosophe Montesquieu and the American patriots who incorporated his ideas into our constitution created multiple checks and balances to frustrate the totalitarian approaches to governance. It seems messy, and as Dr Wilke points out, it could well prevent some good ideas (and some bad ideas) from being implemented quickly, but, given the choice of living in Syria, Greece or the United States, I plan to stay where I am.

Regarding the future, Dr. Zervanos is certainly correct that costs must be addressed. He repeats the widely held view that we should make “the patient the center of how money is spent for medical care.” Echoing the sentiments of many others, he suggests that much waste is due to patients going to doctors for “frivolous reasons,” and that they demand too much expensive and inappropriate care. Contrary to popular belief, these reasons account virtually none of the higher health care costs in the United States. (John Nyman has written extensively on the flawed application of the theory of “moral hazard.”)

European nations cover everyone at an average of half of the costs in the United States. Yet they have not had to use the policy of making patients “informed shoppers,” by being personally responsible for more than a token amount of their health care costs.

Our colleague, Joshua Freeman, today (1/20/12) posted an entry to his blog: “One thing to NOT worry about: paying for health care — in France.” He describes scenes from a Finnish/French movie, “Le Havre.” It is the story of Arletty, the wife of a shoeshine man, who suffers severe abdominal pain. Her husband’s main concern is how he will get her to the hospital.

Dr. Freeman writes, “What is not a concern is whether they can afford her medical care. As I am used to being in the US, to caring for people of limited means, of seeing people in the free clinic who cannot afford to go to the doctor or people admitted to the hospital when they finally show up in the emergency room with disease that is far gone because they haven’t sought care, I found this a bit jarring. I was waiting for Arletty to protest that it was ‘nothing’ (she has been in some denial already), for fear that they couldn’t afford medical care. But she doesn’t, and he says nothing about it, and goes off to find transportation. We could see the same thing in an American movie, and we would expect the same thing in our own lives – when your wife is really sick, you take her to the hospital, you worry about the bills later.”

“Except that wasn’t why. They weren’t worried about the bills. Because it was France. With a national health insurance system, where everyone, even the wife of a self-employed shoeshine guy living in a tiny house off an alley, has health coverage. In the film, Arletty is in the hospital for several weeks, but of all the issues that occur, how the couple will pay for it never comes up. Not at all. It is not even a thought in their minds. But it is a thought in mine, and I keep having to remind myself that it is not part of the plot because it is not an issue that French people have to concern themselves with. The illness, yes. Whether she will survive, yes. Whether he will earn enough money each day to buy dinner, yes. But not how to pay for several weeks of hospitalization. Amazing.”

http://medicinesocialjustice.blogspot.com/2012/01/one-thing-to-not-worry-about-paying-for.html

Dr. Zervanos states that he doesn’t object to a “unipayer government subsidized health care delivery system.” In fact, it is precisely because European nations depend on their own government stewards to supervise health care financing that they are much more successful in containing costs while ensuring comprehensive care for everyone, while depending heavily on a strong primary care infrastructure.

Our private insurers and the employers who purchase plans are depending more on controlling costs by erecting financial barriers (cost sharing) to largely appropriate care. Instead, we need policies to encourage appropriate care. We can control costs much more effectively through the proven tools of the single payer model, while actually improving our health care delivery system by realigning incentives to promote family medicine.

I suspect the strategists for the two major American political parties would agree with two propositions: 1) that federal policy had something to do with the crisis in housing prices and the subsequently the availability of mortgages and credit based on housing prices, and 2) that the federal regulatory apparatus proved inadequate to police what many describe as a “housing bubble”.

Of course, since both parties have been in positions of executive or legislative leadership at various times during the build-up of the “bubble” each strategist will be seeking the phrases that inflict the greatest political damage on the other party.

The ensuing battle of sound bites about government involvement in the private sector (the issues in the housing sector resulted in unprecedented federal involvement in the banking system and Wall Street) have caused anxiety for both those who wish to see something changed in health care and those who like the status quo ante. Of course, the sharpest of the political operatives on both sides have found a demand for their services at a time other than the even-numbered election years.

But the political debate has not provided the information to answer Brosnahan’s first question: “Where does all the money/profits go?”, nor to illuminate the “collateral damage” issues that Brosnahan somewhat hazily perceives (mothers separated from infants because their housing costs so much).

I think there is a another question that precedes the Brosnahan question. “Where does all the money come from?” When it is understood how much of that is federal money, through Medicare and Medicaid, and how little thought is given to the policies (or lack thereof) or social consequences of how that federal money is spent, then there may be opportunities to develop a more rational discussion.

2. Just think what happens when you buy a house. A bank borrows our own taxes from the FED at prime (practically free), and then according to “fractional reserve lending” lends 10X that amount back to us with an amortization schedule that collects 95% interest for 20 years on a 30 year note. And this affects business, car, equipment, and school loans.

3. Therefore, the only way to gain principle is for the price of the house to go up. This is a major driver of inflation. And this inflation which affects all sectors of the economy put pressure on families for women to enter the work place.

4. With both Mom and Dad working full-time and noone home with the kids, kids are not having their emotional needs met which leads to addictive and self-destructive behavior, and they are not being taught basic life skills which is the true primary prevention. What doctors due is not prevention but detecting disease early which will make you live longer but all screening and treatment has a QALY. If you die in 6 months or 6 years, the cost of dying is the same.

5. We need tort reform, let doctors tax deduct charity care, allow consumers to buy insurance across state lines, and let doctors bill patients directly and have insurance companies reimburse patients. And set up a more equitable banking/lending system that allows people to barrow and pay back loans easily.