No One Would Ever Promote The ACA As Some Perfect Solution...

[HuckleB]

... or even as the best solution we could have gotten at the time. Still, as health care provider who is seeing many new patients who need to be seen, and who are relieved that they have coverage, I'm not going to flush the baby out with the bathwater.

I'm not even sure if that metaphor is accurate, but I'm not particularly focused on that.

I have always pushed for single payer. I have always taken on the uninsured in my practice. I have always spent too much time on the phone obtaining prior authorizations for medicines, many of which are medicines the patient in question has taken with benefit and without side effects for years.

Alas, those things have not changed. They need to change, but we need to ensure that things do not move backward from the mild progress we have obtained. I hate to make such a statement. I really do, but the history of health care coverage from the '70s until now makes that something that we cannot ignore.

We need to fight those who would take away these mild gains, while continuing to fight for what should be.

That's really all I have to say.

[VanillaRhapsody]

1. Thank you for some well reasoned man in the trenches perspective.....the ACA has saved lives...

like or lump it...that is a fact!

[Autumn]

2. I find your post to be very refreshing and compassionate compared to posts

by other health care workers that I have seen posted here. Thank you. You are correct we need to fight to hold these mild gains, and yes they are mild while continuing to fight for what should be.

[HuckleB]

4. +1,000,000 ... 000

I work in a clinic where the billing folks who deal with the insurance companies acknowledge that single payer would make so much more sense, even though most of them would probably lose their jobs. Still, most of them also have much cheaper insurance under the new law. It's hard to bag on that.

[nadinbrzezinski]

3. Not baby with bath water

but there are a few things that need improvements just for cost control... like not many formularies, but one, negotiated at the federal level for all ACA programs.

That ain't gonna happen though. I don't expect it.

[HuckleB]

5. It's not going to happen soon.

Still, it's more likely to happen eventually, because of the ACA.

I hate baby steps. I really do. But let's not give ground.

[nadinbrzezinski]

7. But in the meantime we have people (a minority mind you)

Who will pay a huge price.

In EMS we used to have a saying, they still do, changes in policy are written in blood. Modify that to real lives.

It is a hobby of mine to study health systems at a policy level. Maybe I should get an MpH. But I keep saying we need to draw lessons from outside the US and stop this we are exceptional talk. I could bore you to pieces as to why I think potentially we are going down Mexico's path, and take my word, that is not a good path.

[HuckleB]

9. There's no question that a minority still pays a huge price.

I used to think the US was going to follow Spain, and I mean the old Spain of Kings and Queens, focused on military culture. I suppose I still might not be that far off, and I can see your Mexico metaphor in that, as well, but I've been around the world enough to know that the US has no stranglehold on exceptionalism.

Yes, we can learn from others. Still, as a health care provider, I'm still waiting to be impressed by any system. Yeah, I suppose I should fight against my tendency for perfectionism, though I tell myself that's what I'm doing with this OP.

[nadinbrzezinski]

10. Well, look at France for perfectionism

At least per the WHO.

I look at my county for example. You need an ER, or just a GP, and you are in the coast, you are golden. Rural poor East of El Cajon....availability is actually worst than in the rural areas of Tijuana.

Now that scares me since I cover that part of the County.

And trust me, we really do not need to draw lessons. But just clinic availability, and my state still invests in medical care.

[HuckleB]

12. France has some positive things that should be adopted.

Especially on the ground floor of practice, but I'm not as impressed with the execution and, certainly, not impressed with the country that has always focused on getting the science right, becoming the Portland (I live there) of Europe.

Yes, I'm partially being facetious, but any system has to assess the science behind the system and the treatments, and that's where France doesn't show as strongly as it once did, IMO.

[nadinbrzezinski]

14. WHO needs to review the data

But we still have a lot to learn.

Potentially the ACA could look more like Mexico in twenty years. A severely undercapitalized Balkanized medical system, (seguro social. Issste, petroleos, seguro popular, hospitals generales,) with a private system that is anywhere from ok to don't get me started. Sprinkle NGOs like the Red Cross for good measure. That is my nightmare scenario.

I told you I study these as a hobby. Now the US could really draw lessons from both Germany and Switzerland, since they still have a private system that works. But a few things like the formulary, is far from Balkanized.

[Enthusiast]

34. PLUS ONE! I had to withdraw my OP recommendation.

[pnwmom]

19. I'm not sure that would have fixed Will's problem, though -- not if the drug he wanted

wasn't on it.

But as it is, there are a number of other plans' formularies that he can look into -- unless he continues to think that's a waste of time.

[nadinbrzezinski]

21. If you have a single formulary that contains all drugs

Approved by FDA in it, negotiated by FDA, two things would happen, the cost of all medications would crater, see Canadian example, pennies on the dollar. The medicine his wife takes is in the formulary since it has been approved by FDA.

If the drug was experimental, NIH should take the tab after acceptance into clinical trials.

We would not have this dance of one company uses one formulary, another another...or worst, formularies vary by plan even within the same company.

That is how that solves the problem. Civilized nations do this, even national systems that are a hybrids (like in theory the US) see Germany and Switzerland. Both have private insurance, but they don't have this problem. Truly, it's time we look to the next step, and that includes fixing this matter. The faster the better, because that will go a long way in cost control.

By the way, both pharma and insurance will fight it.

[pnwmom]

24. I don't know of any formulary anywhere that contains ALL drugs, do you?

Medicare and Medicare don't cover all drugs, and neither do the national health systems in Canada or the UK. Are you certain that in German and Switzerland all drugs are covered by their health system?

http://www.femeba.org.ar/fundacion/quienessomos/Novedades/formulariterapeutico_basado_ft_oms.pdf

[nadinbrzezinski]

28. I am sure Canada does

I am also certain France and Italy do.

What they have is tiers. The cheapest med is used first. They try generics before brand, things like that. We do as well. But the formularies are extremely flexible and do not need the song and dance we do in more advanced systems. And ours is not that advanced in day to day care. Where we excel is in urgent care, you could say we have lots of practice.

If you are intending to get shot, do not get shot in Europe. Any large trauma center in the US, on the other hand...we have lots of practice.

The same goes for non trauma urgent care, we got lots of practice.

Medicare does not, but that is a weakness of the Balkanized American system.

There is a reason we stand where we stand in outcomes. We really are far from exceptional at day to day maintenance. And our formularies are almost written in stone.

[pnwmom]

30. Here is what I found out about Canada. It doesn't sound like great coverage to me.

In fact, it sounds a bit "Balkanized."


http://www.healthpaconline.net/rekindling/Articles/Glasser.htm

Provincial governments have developed many programs that help particular groups to pay for their prescriptions. The programs vary among provinces. Nearly all are parts of publicly funded social welfare efforts; none of the costs are shared by Ottawa. All provinces help the elderly, the disabled, and the very poor receiving welfare benefits. Some help other low-income persons. Two provinces (Saskatchewan and Manitoba) are universal for all citizens without means tests. The universal programs have patient cost-sharing.

[nadinbrzezinski]

31. Yes, but the cost of medicines is negotiated by health Canada.

Here

http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php

They have issues, all health systems do. But the ACA, Medicare, VA and Tricare should negotiate a single formulary just for starters. That would crater the cost, and stop this dance. I would prefer if all state systems placed that negotiation in federal hands.

Why?

Cost control and inclusion. One reason our meds are so expensive compared to even Mexico, is that pharma can jack up with us because there is no unified front. Think about this one, metmorfin, with insurance I pay forty bucks, a month. In Mexico, same dosage, ran me twenty. Without insurance in the states that is $700.00.

If you can explain the logic behind this one, and by the way both are generics.

Oh and many sold in Canada are made in the United States. How I found that one? You are going to laugh, I bought a bottle in Mexico City imported from Canada due to a shortage in Mexico City. The drug was manufactured in the US. So health Canada is negotiation for the same med at 1/4 of the price or less. Yes, I did raise this issue with my member of Congress during the ACA discussions. Of course I read the damn bill, all five versions of them...yyeeehhaaaw those were some long nights. I got my doubts her staff did.

I make a point of getting an extra month of prescriptions when I go down there for disaster preparation. So you could say, I am always supplied.

[pnwmom]

32. I completely agree that we should be negotiating drug prices directly with the manufacturers

just as other governments do. I'm sure you realize that was another reform filibustered by the Rethugs.

But there will never be a formulary that includes every drug sold, no matter how effective (or ineffective), how new, or how expensive.

If we end up with single payer, it will be like what we have with Medicare and Medicaid -- a list of approved drugs that have been proven to be effective, but not all of the newest, most expensive, or experimental drugs.

[nadinbrzezinski]

33. I know the politics of this

And you should include a few blue dogs in that by the way.

And you might believe that. I know our system had a few improvements, but the jury is still out. The jury won't be in until early longitudinal reviews (ten years from implementation) are in. And our pols will not want to touch it for major futzing for another generation. I know, Mary sunshine and all that.

As I told the OP, I fear this could lead us the way our neighbors to the south have gone, not the way other advanced systems have gone. Needed qualification, the politics of the whole thing and southern states and yes, conservadems. It is the system stupid, not one individual.

[Enthusiast]

35. PLUS ONE! nt

[Capt. Obvious]

6. Heritage Foundation did. I'm sure Max Baucus would agree.

And really, the reactions of some here sure come off as promoting it as the perfect solution.

It's a kleptocratic solution to a major problem. Better than nothing, sure but still rotten.
Maybe someday we'll join civilized countries in offering universal healthcare but until then, we got this at least.

And no offense - I keep reading the subject line and picturing Condi Rice saying that.
"No one could have predicted..."

[HuckleB]

8. Yes, Heritage did a long time ago.

Now, they want to stop even this.

Each proposal from the '70s onward was less palatable. I can't imagine what would be the next proposal, if this dies.

[Cha]

11. Heritage Foundation has been instrumental in the REPEAL Attemps against Obamacare..

those who are stuck in trying to attach their name to it.. need to keep.

[HuckleB]

13. Yes, and... ? -eom-

[Doctor_J]

16. Heritage would take whatever is offered and move three steps to the right

just because they claim to dislike the AA doesn't mean it's a right-wing fascist giveaway to the 1% and Big Insurance. They just want even more.

[pnwmom]

18. So what? Nixon's health care plan looks very progressive in 2014.

The country moved to the right after the demise of the Soviet Union. This is what we're dealing with. The rise of extreme capitalism.

[Capt. Obvious]

40. And you should eat your peas

Stop complaining.

[HuckleB]

44. Huh?

[HuckleB]

42. Exactly.

[sheshe2]

15. Thank, well said. nt

[pnwmom]

17. Exactly. Fight to maintain the gains we've made and fight for what should be.

But don't join in the chorus that would like nothing better than to repeal the ACA.

[HuckleB]

20. You're trying to make me agree with you, for once!

WTH?

[adieu]

22. I have always argued that the ACA

was just a stepping stone. The option "zero" was to stay as it were, and that was clearly not the right thing to do. We were 37th in the world among countries for life expectancy and other clear measurements, yet we paid the most by far for our health care. That is a terrible result for the amount we paid. It's like paying four-star hotel prices for a flea-bitten Motel-6 room.

So, we needed to take a step. A step in ANY direction. The ACA was a politically smart move, if not a medically or healthcare smart move. (Personally, I know it was a bad policy because it was a Heritage Foundation product.) But it's acceptable because it gave us a second point. When you have two points, you can measure whether things are better or worse. Under certain metrics, it's better, like having coverage for pre-existing conditions and other items. It's not better in that we're giving insurance companies unbridled revenue.

But that's all all right because it gives us a vector. The vector points in the wrong direction, then we will know which direction to take: the opposite. Without taking the step with ACA, we would still be lost in what direction to take.

[HuckleB]

23. Agreed.

Still, more people do have health insurance they can afford now than before. It's not the right health insurance, and it is still too costly for many. As a provider, it's nice to know that I can make my recommendations knowing that there is a good shot that insurance will cover those recommendations, when, in the past, it was about piecing together things from here and there.

It's not that I'm not still piecing things together for some people, but the numbers in that boat are decreasing.

[treestar]

38. When people say it is a Heritage Foundation idea

I have to wonder. Why would that foundation agree ever to anything involving government in anything?

[nationalize the fed]

41. The mandate came from the Heritage Foundation

That is why it's so confusing when supported by Democrats

The health insurance mandate in the 2010 Patient Protection and Affordable Care Act is an idea hatched in 1989 by Stuart M. Butler at Heritage in a publication titled "Assuring Affordable Health Care for All Americans".[22] This was also the model for Mitt Romney's health care plan in Massachusetts
http://en.wikipedia.org/wiki/Heritage_foundation#Policy_influence

Surely you're not surprised that the Heritage Foundation loves the fact that everyone is now mandated to buy non government, profit based private insurance?

Keith Olbermann doesn't like it

[DeSwiss]

25. You mangled the crap out of that metaphor.......

...but your heart is in the right place.

- And that's all that matters.

K&R!

''I come to say to you this afternoon, however difficult the moment, however frustrating the hour, it will not be long, because 'truth crushed to earth will rise again.' How long? Not long, because 'no lie can live forever.' ... How long? Not long, because the arc of the moral universe is long, but it bends toward justice.'' ~Martin Luther King Jr.

[Brigid]

26. Some years ago, when I lived here before . . .

I remember reading a newspaper article about a large practice here with over 50 doctors. They employed eight people who did nothing all day but wrangling with payers on the phone. I don't think ACA will change that. Only single payer will.

[HuckleB]

43. Unfortunately, you are correct.

That part of the system is going to continue to remain bloated and expensive.

[Vashta Nerada]

27. Why does this country have to go through baby steps while many other countries in the world

are so far ahead?

At this rate, we'll have single payer in 2300.

[JI7]

29. other countries went through steps also but they just started earlier

most of their systems that are in place now took time to get there.

[treestar]

37. Interesting question

Not that simple. I would hypothesize: Parliamentary system (makes it easier to pass what a majority wants at the time), lower and more cohesive populations, less of a self-reliant independent anti-government attitude overall.

[treestar]

36. We got what we could and it's a big undertaking

One person having something go wrong, which could happen under any system, does not overbalance the gains made.

[Bluenorthwest]

39. I just have to say that one 'throws the baby out with the bathwater' because so few

bath their babies in a toilet. The image has burned itself into my mind. Flush that bathwater!