Medicaid | judgelondonsteverson

ObamaCare is having a chilling effect on the practice of medicine. Doctors are feeling the chill of the ill winds that blow as they take a closer look at ObamaCare.

After 25 years of practicing medicine, Dr. Tamzin Rosenwasser packed in her dermatology practice in 2011, barely a year after the passage of President Obama’s health care initiative, the affordable Care act, also known as ObamaCare. The timing wasn’t coincidental.

“I have interrupted practicing medicine because of Obamacare,” said Dr. Rosenwasser. “I’d read the bill. I was conversant with what had already happened with Medicaid, and I didn’t want to go down that road with Obamacare.”

The Affordable Care Act isn’t scheduled to be fully implemented until next year, but some doctors already are viewing it as dead on arrival (DOA). The medical rumor mill is abuzz with stories about physicians girding for Mr. Obama’s signature domestic policy achievement by limiting their exposure to Medicare and Medicaid, selling their practices, converting to fee-for-service approaches, or even retiring from medicine altogether.

“Every single day, people are talking about retiring early, getting out of clinical medicine, or going into hospital administration, where you don’t have to think about patient care anymore,” said Dr. Richard Armstrong, a Michigan surgeon and chief operating officer of Docs 4 Patient Care, which opposes the Affordable Care Act.

Not all doctors agree. The American Medical Association endorsed the health care legislation at the time of its passage in 2010, although the group now is pushing for the elimination of the Independent Payment Advisory Board, the cost-control organization at the heart of the president’s plan that became known to critics as the “death panel.”

“Some physicians are all for [Obamacare],” said Dr. Rosenwasser, who had practices in Florida and Indiana and is a past president of the Association of American Physicians and Surgeons, which opposes the program. “They’ve been brought up in the government system. This is what they know.”

Most doctors appear to be waiting to see what happens. “About 90 percent of doctors are completely uninformed about what the government’s doing,” Dr. Armstrong said. “A lot of them are in this free-floating anxiety mode.”

Widespread concern

Even physicians with no plans for career change are worried about the profession for reasons related to Obamacare. A sweeping survey of 13,575 doctors released in September by the Physicians Foundation found that 77 percent were pessimistic about the future of medicine.

The main reason: malpractice lawsuits, which the president’s law did little to address. After that, the top factors cited were “Medicare/Medicaid/government regulations,” “reimbursement issues” and “uncertainty/changes of health reform.”

Craig Garthwaite, professor at the KelloggSchool of Management at Northwestern University, said he has concerns about doctor shortages in the coming years even if speculation about an Obamacare-induced physician exodus proves groundless.

“What you’re hearing now is going to be: (a) anticipatory, and (b) purely anecdotal, because we don’t have data yet,” said Mr. Garthwaite, author of a 2012 research study on projected physician shortages. “You definitely hear doctors saying they’re going to work fewer hours, but I don’t know how much stock you can put in that.”

He said the problem is that as many as 32 million people are expected to be added to the health care system as a result of Obamacare, half of those as a result of the expansion of Medicaid. Many doctors already refuse to accept Medicaid patients because the government reimbursements for services rendered are well below the market rates.

“What’s concerning is the economic incentives,” Mr. Garthwaite said. “A lot of people are going to leave private insurance and go on Medicaid because it’s cheaper, and that means lower reimbursements for doctors because Medicaid is such a poor reimburser. At the same time that we’re increasing the need for more doctors, we’re decreasing the incentives that would normally attract people to the medical profession.”

Opponents of the president’s health care law in Washington, led by the Republican majority in the House of Representatives, concede that November’s elections have largely taken the question of outright repeal off the table. But Republican leaders such as House Budget Committee Chairman Paul Ryan of Wisconsin say resistance from doctors in the field is growing and will help fuel the movement to make the law “collapse under its own weight.”

“Go talk to the people at Aurora, go talk to the people at Wheaton, go talk to the people at St. Catherine’s, go talk to the people at All Saints,” Mr. Ryan said while meeting with constituents last month, according to WisPolitics.com. “They will say the same exact thing, which is, ‘We are getting paid less and less per service for all these people coming in.’ You see, the government is underpaying providers for the cost of care.”

Opting out of med school:

With the prospect of more government regulation and smaller paychecks, top students who normally might choose medical school may look elsewhere.

“A lot of younger people who might go to medical school are saying, ‘Why should I incur $300,000 in debt when I’m not even sure I can make a living?’” Dr. Armstrong said. “You lose some of your best and brightest because they’re smart enough to see what’s going on.”

Analysts agree that the trend of using more physicians’ assistants, nurse practitioners and foreign-trained doctors is likely to accelerate.

“And that’s not necessarily a bad thing,” Mr. Garthwaite said. “But it should be consciously done. It shouldn’t be the unintended consequence of a law.”

One option gaining ground among disgruntled doctors not ready to hit the golf course is going off the insurance grid.

“There are a number of doctors looking for alternative ways to practice medicine by trying to get out of the third-party system and going to fee-for-service,” said Dr. Hal Scherz, a Georgia surgeon and president of Docs 4 Patient Care. “I hear many of these stories. I know one doctor who’s gone to strictly cash. Her prices are posted, her service is better, and her patients love it.”

Pay as you go

That is how it’s done at the Surgical Center of Oklahoma, which accepts no third-party payments from private insurers or the government. The center opened in 1997, long before Obamacare was even a blip on the horizon, but Dr. Keith Smith, a co-founder, said the signs of greater government involvement in medicine were already evident.

“We saw it coming. We assumed there was going to be more tyrannical stuff coming from the government. We just didn’t know what form it would take,” said Dr. Smith, who refers to the health care law as the “unaffordable care act.”

His practice charges far less for surgical procedures than traditional hospitals — he even posts his prices online — by avoiding third-party payers, he said.

“We are ahead of the curve, but I hope everyone does what we do,” Dr. Smith said. “The cost of care is going up as a direct reaction to Obamacare. The more expensive health care gets, the more people are going to flock to us.”

If and when she re-enters medicine, Dr. Rosenwasser said, she plans to take the pay-as-you-go approach.

“If I do open another practice, it’s going to be me, the patient and no Medicare or Medicaid, no insurance coverage,” Dr. Rosenwasser said. “I’m going to treat my patients how I know they should be treated.”

(Richardson, Valerie; Washington Times, 8 Feb 2013)

ObamaCare was a poorly conceived and is a constitutionally deficient statute. The Supreme Court’s ruling upholding the law has simply made it worse. In the future, that decision is likely to be seen as a prime reason that the federal court judges should just judge and never legislate—even in the cause of rescuing an otherwise unconstitutional law from oblivion.

In the ObamaCare ruling, the Supreme Court correctly held that Congress could not impose the individual mandate as a constitutional regulation of interstate commerce and that Congress could not constitutionally use its spending power to coerce the states to expand Medicaid.

Rather than strike down the law, however, the court construed the insurance-purchase mandate and its penalty as a “tax” on the failure to have health insurance. The justices also interpreted the Medicaid-expansion requirements as optional—permitting states to opt out of these provisions while staying within the traditional Medicaid program. Given that interpretation, the court’s majority upheld the statute as constitutional.

The court’s determination to preserve ObamaCare through “interpretation” has exacerbated the law’s original flaws to the point that it has become palpably unworkable. By transforming the penalties for failing to comply with the law’s requirements into a “tax,” the court has given the public a green light to ignore ObamaCare’s requirements when it is economically beneficial. Law-abiding individuals, who might otherwise have complied with the law’s expensive purchase mandate to avoid being subjected to financial penalties, can simply now choose to pay a tax and not sign up for coverage. There is certainly no stigma attached to simply paying a tax, and noncompliance with the law’s other requirements—such as those imposed on employers—is arguably made more attractive on the same basis. This effect fundamentally undercuts Congress’s original purpose, which was to expand health-care coverage to the greatest number of people, not to improve federal revenues.

Similarly, having reviewed the likely costs and benefits, states are now taking advantage of the court-granted flexibility. Seven states, including Texas, Mississippi and Georgia, have so far opted out of the Medicaid-expansion provisions, and eight (with more certain to come) are refusing to create the insurance exchanges, leaving this to a federal bureaucracy unequipped to handle these new administrative burdens. As a result, a growing number of low-income Americans will be unable to obtain the free or cost-effective insurance that Congress originally meant them to have, although they remain subject to the mandate-tax.

On December 7, New Jersey Governor Chris Christie vetoed legislation establishing a state-run health insurance exchange. This was just after he had visited President Obama at the White House to discuss Superstorm Sandy cleanup costs. Governor Christie said he blamed President Obama for failing to provide answers that he needed to make a fiscally sound decision on the best way to comply with the ObamaCare law.

States have until December 14th to decide whether to establish a state-based exchange. They have more time to decide whether to partner with the federal government or to let federal bureaucrats design and run the state exchange. ((Santi, Angela, Christie Vetoes ObamaCare, Washington Times, Dec. 7, 2012)

Policy problems aside, by transforming the mandate into a tax to avoid one set of constitutional problems (Congress having exceeded its constitutionally enumerated powers), the court has created another problem. If the mandate is an indirect tax, as the Supreme Court held, then the Constitution’s “Uniformity Clause” (Article I, Section 8, Clause 1) requires the tax to “be uniform throughout the United States.” The Framers adopted this provision so that a group of dominant states could not shift the federal tax burden to the others. It was yet another constitutional device that was simultaneously designed to protect federalism and safeguard individual liberty.

The Supreme Court has rarely considered the Uniformity Clause’s reach, but it cannot be ignored. The court also refused to impose meaningful limits on Congress’s power to regulate interstate commerce for decades after the 1930s, until justices began to re-establish the constitutional balance in the 1990s with decisions leading up to the ObamaCare ruling this summer. And although the court has upheld as “uniform” taxes that affect states differently in practice, precedent makes clear that a permissible tax must “operate with the same force and effect in every place where the subject of it is found,” as held in the Head Money Cases (1884). The ObamaCare tax arguably does not meet this standard.

ObamaCare provides that low-income taxpayers, who are nevertheless above the federal poverty line, can discharge their mandate-tax obligation by enrolling in the new, expanded Medicaid program, which serves as the functional equivalent of a tax credit. But that program will not now exist in every state because, as a matter of federal law, states can opt out. The actual tax burden will not be geographically uniform as the court’s precedents require.

Thus, having transformed the individual mandate into a tax, the court may face renewed challenges to ObamaCare on uniformity grounds. The justices will then confront a tough choice. Having earlier reinterpreted the mandate as a tax, they would be hard-pressed to approve the geographic disparity created when states opt out of the Medicaid expansion. But that possibility is inherent in a scheme that imposes a nominally uniform tax liability accompanied by the practical equivalent of a fully off-setting tax credit available only to those living in certain states. To uphold such a taxing scheme would eliminate any meaningful uniformity requirement—a result that the Constitution does not permit.

(The Opening For a Fresh ObamaCare Challenge, Rivkin, David B. and Casey, Lee A.p; WSJ, Dec. 6, 2012)

Posts Tagged With: Medicaid

ObamaCare Is Dead In The Water

Posts Tagged With: Medicaid

ObamaCare Having A Chilling Effect On The Medical Profession

ObamaCare Is Dead In The Water