ObamaCare Without The Mandate

Andrew Sullivan asks, "What happens if the mandate is ruled unconstitutional but the rest of the law is left intact?" It's not a pretty picture. (Via Dr. Art Fougner.)

Avik Roy discusses a similar example, "Want to See a Health Insurance Death Spiral? Visit Washington State"

Quick Links: Employment, Awakening, Washington Medicaid

Michael Randall tells his personal experience of problems caused by government linking health insurance to employment.

(And I very much appreciated his citing my earlier PJM piece, "Free Market Lessons from Contraception Fight".)

Dr. Meg Edison of Docs4PatientCare has created a nice short video, "Awakening of the American Doctor":



Dr. Doug Perednia discusses, "Denying payment for unnecessary emergency room visits". In particular, he highlights the perverse thinking behind the new guidelines in Washington state:

So here's the actual logic underlying this new Washington Medicaid initiative:

* ER docs and hospitals are required by federal law to see and evaluate anyone who walks in – at their own expense if necessary.

* If a Washington State Medicaid patient walks into the ER with a non-emergency and the doctors and hospitals see them as required by law, Medicaid will refuse to pay on premise that the provider are "abusing the system" and being lousy "stewards of care and safety and the public resources"

* Since the doctors and hospitals are abusing the system by simply being there and doing what the federal government has said they must, they should not even be allowed to try to bill the patient directly for the visit.

Washington State ER Medicaid Trap

The 2/7/2012 Seattle Times reports, "State Medicaid to quit paying for ER visits deemed unnecessary".

From the article:

Medicaid officials say the program will no longer pay for any medically unnecessary emergency-room visits, even when patients or parents have reason to believe they're having an emergency...

They would apply to all adults and children on Medicaid, with no exceptions, such as someone being brought in by ambulance or from a nursing home, or when patients have neurological symptoms or unstable vital signs...

Under federal law, patients that show up at the ER cannot be turned away, at least not until the treating physician determines they are not having a medical emergency. But for many conditions (which includes neurological impairment or unstable vital signs), it can be unclear whether or not there is a true emergency until after a fair amount of skilled testing and evaluation.

As the article notes:

For Medicaid patients, Schlicher said, the plan suggests that even before heading to the ER, they should know what their ultimate diagnosis will be.

"If we don't know without an X-ray or CT scan, how can they know it?"

For doctors, the plan could place them in legal jeopardy, Schlicher said.

If they turn patients away, "it's not good care and it doesn't meet the legal standard," he said. "I can't tell any provider to commit medical malpractice, no matter how much the state wants us to do that."

So in essence, the state will compel ERs and doctors to render medical services to these patients, then penalize them economically if the government deems that the condition wasn't a real emergency.

Note the trap: The government tells doctors, "We don't want to tell you how to practice medicine. But we have to control what gets paid for, for the good of 'society'." Doctors no longer have genuine freedom to practice medicine as they see fit, and patients suffer as a result.

(Read the full text of "State Medicaid to quit paying for ER visits deemed unnecessary".)

Right now, this affects only Washington state. But don't be surprised if we start seeing similar proposals in the rest of the country.

(Seattle Times link via a reader.)

Rationing Abroad and At Home

Because of the debt crisis in Greece, government-run hospitals can't pay their bills.

Hence, patients aren't receiving medically necessary drugs. As Avik Roy notes, "Our future is Greece's present".

Closer to home, physician-blogger "Shadowfax" describes the proposed new indirect rationing system in Washington state.

Medicaid patients in WA are being told that if they use the ER for non-emergency purposes, then the state won't cover their costs. So this puts the hospitals and doctors in a tricky position.

The ER doctors could turn away those patients. But then they might run afoul of EMTALA laws which require the ER staff to evaluate the patient sufficiently to determine whether or not there is a genuine medical emergency.

Or they could see these patients and provide some level of services -- but risk not getting paid. (The hospital can attempt to bill these Medicaid patients, but realistically they almost certainly won't collect anything.)

So the proposed non-payment rules essentially put the ER doctor in a no-win position of rationer-by-proxy. The government will punish him financially if he doesn't save money for the government, but punish him legally if he fails to provide medically necessary emergency services.

To make matters worse, the list of supposedly "non-emergency" medical conditions the state won't cover includes:

Chest Pain
Abdominal Pain
Asthma Exacerbation (acute)
Acute Cholecystitis
Hypoglycemic Coma
Pneumococcal Pneumonia

Do you want the government deciding that a coma isn't a true emergency?

Or if a patient comes in with bad chest pain, neither the doctor nor the patient can always distinguish between something serious (like a heart attack) or something more benign (such as severe indigestion) without a variety of tests.

If it turns out that the patient's chest pain was just an unusually severe case of indigestion, the state gets to say to the hospital, "See it wasn't really anything too bad, so we won't pay you for performing all those unnecessary tests. They weren't really cost-effective use of scarce resources for indigestion."

Of course, the problem is that you don't know until after you run the tests that it wasn't anything too serious. The government gets to claim the benefits of 20-20 hindsight that it impossible for a doctor at the time the patient arrives in the ER.

Do we really want this kind of government-run medical system?

Otis On WA Regulations

Maryallene Otis of Lynwood, WA responds to her state regulators forcing insurers to sell child-only policies.

This is her LTE in the October 19, 2010 Seattle Times:

State regulator orders Regence to reinstate child-only plans

Profit motive more dependable than government bureaucrats

State insurance commissioner Mike Kreidler has ordered Regence BlueShield to resume selling child-only insurance policies ["WA orders Regence to resurrect child-only plans," seattletimes.com, Oct. 15].

Regence (and insurance companies across the country) recently made the sound business decision to stop selling these policies because of the new federal law forbidding them to exclude children with pre-existing conditions.

To force a company to sell policies without considering pre-existing conditions, means that what Regence would be selling would not be insurance. Insurance takes risk into account. Kreidler is forcing Regence to make a bad business decision, on which they cannot possibly make any money.

Government is strangling the business of medicine and the business of medical insurance with more and more regulations. Then, when the regulations create a disaster, bureaucrats vilify medical professionals and insurance companies for wanting to make a profit.

Capitalism, the political system that protects individual rights to property and contract, is the moral and practical way to provide goods and services. I would far rather depend on the profit motive than the whim of a bureaucrat.

-- Maryallene Otis, Lynnwood

I especially liked how she linked the specific regulatory issue to the broader theme and proper definition of capitalism.

Thank you, Maryallene, for speaking out in Washington state!