Affordable Care Act

Medicaid For All Will Make Health Care Just Another Commodity. So What!

I finally agree with what health care policy writers have been saying for months—An American Medicaid or Medicare For All program may be imminent. I reach this conclusion not because of the recent failure by the Republican-majority Senate to repeal and replace the Affordable Care Act (aka Obamacare), but due to the comments of many doctors following this failure. Medical providers sense the change in attitudes away from a for-profit, insurance company driven health care system, and they want to make sure that their role is safe from public backlash and government changes.

And to make it clear on where they stand on this impending new health care world, they are reviving their
objections to the “provider” label. Although decades old, doctors hate the provider label now more than ever. They find the use of the term condescending because it links them with other medical care professionals like nurses and physician assistants—people not at their level of expertise. But the primary reason many doctors dislike being called “providers” is that they see it as a “commoditization of the doctor-patient relationship” and now you’re messing with their money.

Commoditization refers to the process by which goods become so similar that their only distinguishing characteristic becomes price. The development of tablets and smartphones are an example of commoditization. They all have the same or similar features like touch screen and syncing with other devices, etc. And even though I prefer Apple products and give the company credit for pioneering much of the technology now available on other devices, I know that I could accomplish pretty much the same tasks with a non-Apple tablet, phone or computer and at a much lower cost.

Apple is not afraid of commoditization; it expects and thrives in this type of environment. It sees the competition as good for customers because it pushes the company to innovate more. Doctors, on the other hand, hate the idea of commoditized health care. They don’t want to compete on service or price. In fact, the real reason doctors and hospitals don’t want electronic medical records or to publish their prices has nothing to do with costs but because they are afraid a competitor will “steal” their patients if they had access to this data. And, of course, doctors think that their product (health care services) is unique

To date, we have protected doctors and hospitals from real competition and allowed them to charge whatever they want for their services. A Medicaid or Medicare For All single payer health care system that includes electronic medical records and price transparency will force doctors and hospitals to compete on price. This type of system is good for the public because it’s one of the few ways, other than forced price reductions, to make health care affordable. Doctors and hospitals won’t like this more transparent health care system, but who cares; it’s coming, and they know it.
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Medicare For All Requires New Health Care Industry Players

It seems everyone working in the health insurance and health care industries feels entitled to large profits. And they will do or not do just about anything to get their share of the multi-trillion dollar a year health care "market." Doctors thumb their noses at "low" Medicare and Medicaid payments, limiting the number of patients in these programs that they will treat. Health insurers balk at insuring the very sick without government subsidies to reduce their financial risk. Pharmaceutical companies threaten to curb drug innovation unless they are allowed to impose astronomical markups on existing products and enjoy long patent periods. And hospitals do whatever the heck they want to make a buck--different prices for the same care with no transparency or explanation. And these are only four of the big players in the health care market; there are many others elbowing for their share.

Under these conditions, American health care reform that tries to lower costs is dead on arrival. The powerful groups benefitting from our overpriced health care system aren't going to accept a pay cut. Some may suggest incentives to get doctors to accept lower reimbursements, like subsidizing their student debt or even reducing the requirements and the number of years it takes to become a doctor. Others may suggest performance bonuses, like the ACA tried.

There are a lot of good sounding suggestions for lowering health care costs, including drug re-importation, universal use of electronic health records, value-based health care pricing, hospital consolidation, competitive bidding for supplies, focus on tertiary care, etc. You name a health care cost cutting idea, and great minds have already penned it.

One health care cost cutting idea receiving more attention is allowing future American doctors to enroll directly into medical school instead of first getting a 4-year undergraduate degree. Medical students and the country would save a lot of money, and their student loan excuse to demand high salaries falls away. Many countries with similar or better health care outcomes require 5-6 years of schooling to become a doctor versus 8 in the U.S. But American doctors won't easily give up the prestige of being a doctor and, therefore, will continue to demand higher salaries.
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Medicare For All Could Save Life And Limb


I recently heard a story of a diabetic Medicaid patient that developed gangrene on her foot and leg. Gangrene occurs when tissue decays or dies due to a loss of its blood supply or because of a bacterial infection. It's a concern for many people with diabetes because of how diabetes affects the body--including possible damage to the nerves and weakening of the immune system. Treatments for gangrene include surgical removal of the decaying or dead skin, amputation of the affected body part or antibiotics.

The first surgeon that examined the diabetic Medicaid patient's foot and leg concluded that amputation of the affected area was the appropriate course of care given the severity of the gangrene. He immediately scheduled surgery for later that day. Fortunately a second surgeon disagreed—concluding that the gangrene could be treated with surgical removal of the dead and dying skin. The surgery to remove the dead skin was performed by the second surgeon and the patient still has all of her limbs and is being monitored.

I won’t speculate why the first surgeon prescribed amputation to treat the gangrene, but I did wonder if the patient’s insurance coverage had anything to do with his rush to cut. And there is evidence to back up my worries. There is lots of evidence that
diabetic amputees are more like to be poor and minority. Or course, this is not entirely the fault of doctors. Many poor minorities don’t seek regular or preventive care to treat their diabetes, making some amputations necessary. But not all of them…

And there’s more… A disease management program designed to help minority diabetes patients revealed the difference in blood testing rates between whites and ethnic minorities. Blacks and Hispanics had lower testing (to determine how well their diabetes is being controlled) rates than whites. A study of this
vendor-based disease management pilot program for Medicare patients concluded that it did “not appear to improve diabetes care or mitigate racial/ethnic disparities among these patients…” The program failed.

But what’s a problem without a solution? Fortunately, health care reform is already addressing the diabetes crisis. A pilot diabetes prevention program run by the YMCA received praise and dollars from a grant program established by the Affordable Care Act program. According to an
article on,

It's the first prevention program to meet requirements under the Affordable Care Act to gain Medicare coverage, HHS says, including undergoing an independent audit to confirm that it's effective and saves money. The Obama administration is recommending that Medicare cover the program for at-risk Medicare beneficiaries. Continue Reading...


What's The Purpose of Health Plan Surveys?


Get ready. We are about to get knee deep in the annual benefits open enrollment season. This includes open enrollments for Medicare, and private sector health plans.

This is also the time of year that health care and health insurance policy wonks and writers comb through the latest health insurance surveys. The producers of these surveys include non-profits dedicated to health research and policy; employee benefits consulting firms, private research firms and human resource management associations

Some of the organizations providing these surveys include:

  • Kaiser Employer Health Benefits Survey
  • Bureau of Labor Statistics Employee Benefits Survey
  • Marsh & McLennan Mid-Market Group Benefits Survey
  • SHRM Employee Benefits Survey
  • Mercer's National Survey of Employer-Sponsored Health Plans
By far the most quoted of these surveys is the Kaiser survey. You can count on seeing references to Kaiser in nearly every major written publication between now and the end of the year. But back to health plan surveys in general.

The Surveys Are Detailed, But Are The Responses…

The data for these surveys comes from hundreds of employers willing to complete detailed survey questionnaires. The surveys can take hours to complete but the most challenging part is deciphering the meaning of some of the questions. I know. I completed more of these surveys than I care to remember.
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