Buckeye, I'm surprised at this post. After all, not too long ago, you had a well-timed post against your being taxed at an unreasonable rate (see "Welcome to the Real World"). Why the change of heart? An additional tax on those making $200,000 and more, reduced Medicare reimbursements, new, expanded Medicaid obligations in state budgets, a 40% tax on existing "good" medical plans, new excise taxes on tanning salons, pharmaceutical companies, device manufacturers, and health insurers (ultimately passed on to the end users). Buckeye, if any significant amount of your business is Medicare, your reimbursements are going down while your taxes go up.
This bill proposes a shotgun fix in the wake of a majority in both houses of Congress and the midterm elections. This is not a problem that can be solved by this bill. The American Academy of Family Physicians predicts a 40,000 shortage of their own pedigree by 2020. Let's consider the numbers further: it takes at least 7 years to train a physician. Our current physicians are expected to take on 32 million new customers by 2014. Nurse practitioners and PAs are looking to fill this gap in care, making doctors in primary care less relevant. In fact, nurse practitioner programs are transitioning to offering only doctoral programs to "be on the same parity of respect with doctors." Nurse anesthetists on average now earn more than the average family practitioner.
The mandate for insurance has few teeth. For an individual, a $95 penalty in 2014 increasing to $695 by 2016. Is there a health plan that costs $695 a year? Guaranteed issue of health insurance only works with enough payees, and this penalty is not exactly an incentive to purchase a policy.
The solutions are not pretty, but when taken in small doses, like sips of alkaselzer, you have measurable progress. First, fund more residency positions in primary care to take on the additional patients. Then implement guaranteed issue of health insurance with a stronger purchase mandate. Leave the feds out of modifying health premiums, otherwise every federal official will run on lower health premiums without regard to solvency. Allow states to recover if adopting the unfunded mandate of expanded Medicaid eligibility and greater reimbursements. Oh, and what about tort reform?
J's points are well taken. There's no doubt that health care reform, in its present iteration, will not be a financial bonanza for physicians. It will alter our income expectations for the next several generations. We'll pay more taxes. Reimbursements will steadily decline (how do you think this bill will be able to maintain any illusion of fiscal sanity?). There's no tort reform (other than $50 million set aside for the study of undefined "pilot projects"). There's nothing in it to permanently address the medicare SGR cuts. Subsidies for medical school education and financial incentives to entice medical students into choosing primary care are curiously absent. There was no special interest group involved in this year's long HCR debate who came away from the final deal with less than us physicians. We got hosed. Some of it is our own fault. We're a disjointed, politically diverse group of professionals. Furthermore, our big lobbying arm (the AMA) proved itself to be an impotent, ineffectual voice at the bargaining table. What's done is done.
So why do I still support the passage of Obamacare? This is going to sound awfully pretentious, but I can't help it--- the moral argument for reform, any sort of reform, is just too powerful. Basic health care ought not to be dependent on market cycles or employment or whether or not you have a pre-existent disease. Americans ought to be able to go the hospital, see the doctor and not worry that the treatment they receive could potentially lead to financial ruin. It's just not right. I have a young patient right now who is going to benefit enormously from the passage of the bill. She's a 21 year old physics major who wants to go to grad school and eventually teach at her local community college. A few months ago, she presented to the hospital with free air and peritonitis. She had perforated her colon, secondary to what ultimately was determined to be Crohn's disease. She has a colostomy and wants to have it reversed as soon as possible. Her health insurance through her mom is due to run out in May. But with the passage of the bill, she can stay on her mom's plan until she's 26. We don't have to rush the colostomy reversal surgery. We can take our time. Make sure she's completely healed. Furthermore, let's say she gets that PhD in physics in a few years but she doesn't score a job right away. Maybe she teaches for a year or two at a private high school on a contingency basis, without benefits. How is she going to buy her own health insurance as an individual? She has Crohn's disease! Who would insure her?
Closer to home, my own mother lost her job at Akron Children's Hospital last year. She'd worked there 25 years. She's not quite old enough to qualify for Medicare. Her COBRA plan runs out in the fall. What is someone like her supposed to do?
We have to help each other out, dammit. It's more than tax brackets and socialism and redistribution of wealth. This is health care. It's life. It's the people around us, the ones we love.
Is it a perfect plan? Hell no. But it would be more useful to look at it as a stepping stone to something better. What I'm hoping is that the Republican Party uses this perceived defeat as motivation to renounce their heretofore obstructionist, denialist stance and get off their asses to propose additional reforms. The GOP hates Obamacare. That's been clear enough for a year. So do something about it! Add to it. Make it better. Get tort reform in there. Do something about the primary care/general surgeon shortage and medical school debt. This HCR bill is a paragon of centrist principles. There's no single payor. This is not government takeover. It isn't anything like what the noise machines on Fox and Rush Limbaugh would have you believe. It's simply an initial foray into a more just society...
David Frum (conservative pundit, American Enterprise Institute fellow) has a nice piece on CNN articulating a possible GOP game plan in response to the passage of Obamacare.