Inside The Affordable Healthcare Act

February 20, 2012

Speaker Nancy Pelosi famously said about the health care bill legislative process, “.... we have to pass it so that you can find out what’s in it....” We have now passed it, with it being approved as constitutional-with one major caveat-and we are learning what it is and what this means to the country and individuals.  I wrote several detailed articles opposing tfhe bill on Dailykos, even connecting with the head actuary of Medicare,  but as Pelosi said, I couldn't study every clause of the evolving versions of of the two thousand page bill.  As I learn more about the details, beyond my opposition being confirmed, I now consider it a fiscal and social disaster for reasons that I will do my best to describe to all who are interested-- which should be every American, especially those who are aging, or expect to.

The  N.Y. Times recently posted an OpEd, The Health Benefits That Cut Your Pay, by David Goldhill, that focuses on the unexamined actual costs of this program.  He avoids any mention of the party that promoted this legislation, which is why it was acceptable to this particular newspaper.  Yet, just as the previous president and his party were responsible for the fiscal and geopolitical disaster of the Iraq War of 2003, so to the Affordable Care Act, ACA, was the product of one party and its leader.

As Goldhill states, "Even after decades of financial engineering, including both the already-implemented and the planned aspects of the ACA the American health care system can be called successful mainly in its ability to hide its enormous cost."  He then goes on to explain how the many unrealized expenses--payroll taxes, income taxes, newly mandated insurance coverage, deductible payments etc--all add up to the estimated $1,800,000 of lifetime health care cost (in today's dollars) of an average new college graduate employee.

Goldhill limits his discussion to the fiscal consequences of all that is lost after subtracting this newly bloated healthcare segment, not touching on  another deeper issue of the human and cultural changes that must make this possible. Expansion of seemingly "free" medical care for all is neither free nor necessarily healthful. This legislation was passed by analogy--  that if other countries can do this, why not the United States.  Ignored is the entrenched power of various interests associated with health care that our particular political system has no capacity to reshape, neither now or in the foreseeable future.

Two professions with the most political influence are physicians and lawyers, each with the resources and clout to protect their prerogatives to impact health care in a strangely perverse way.  None of those other countries with universal healthcare have anything like our malpractice procedures, with resultant defensive practice perniciously being a response as well as a justification for excessive and even harmful tests.  It is a win-win-lose situation, with only the public taking the hit.   The fecklessness in challenging this malpractice system in the ACA is a preview of what will come, and why our cultural values must be revised, our world view changed, so that the Medical Establishment can prosper.  There are many well meaning individuals within the medical industry who need the help of the citizenry if this seeming inexorable trend is to be countered.

This change in our mentality so far has gone unnoticed, as it is packaged in the form of more vibrant longer life, and better yet, that it will come at no cost at all, rather paid for by future efficiencies. The deceit of this is epitomized in the increased medicalization of aging, most specifically its universal manifestation, which is a diminution of short term memory.  This is a universal that is as ubiquitous as decline in balance, height and strength.  It's called aging, something that societies have dealt with from the very beginning, which always includes acceptance of the inevitable decline-- ending with death.

As I was writing this essay, trying to make a rather subtle point,  I made a discovery that shocked and then angered me first from The Journal of Family Practice,  Assessing for cognitive impairment is now mandated as part of the Medicare Annual Wellness Visit.   Finding this requirement in the actual text of the law is difficult but it can be located beginning on pp 1154 of the text.   The Affordable Care Act stipulates that clinicians must assess individuals aged 65 and older for cognitive impairment as part of their annual wellness visit .

This paper by the Alzheimers Association describes this requirement and their recommendations for the testing.  It included this paragraph:

These comments are supported by a number of studies showing that cognitive impairment is unrecognized in27%–81% of affected patients in primary care. The use of a brief, structured cognitive assessment tool correctly classifies patients with dementia or mild cognitive impairment (MCI) more often than spontaneous detection by the patients’ own primary care physicians
(83% vs 59%, respectively).

Now think about this for a second.  The ACA does not say that physicians may include assessment for cognitive impairment, but that they must if you choose to have the Annual Wellness Visit.   Note, this is a "visit" not an examination, meaning there is no hands on biometric testing.  This is the medical management of the elderly patient where the cognitive analysis is required while the end of life planing, because of the objections from the right, is optional.

Note in the paragraph above that the range of those who do not recognize such impairment ranges from 27% to 81%,-- an interesting degree of variance for studies of the same phenomenon.  I won't go into all of the permutations of the data, but there will be a goodly number of elderly people who were going about their lives, maybe even laughing about their memory decline as we do often, who will be told that this condition is nothing to joke about, rather a disease that must be monitored by physicians.

And by the way, there are studies that show that such information leads to depression, maybe even suicide, but not to cure-- as none exists.  It will also lead to more physician visits, maybe a few to specialists such as neurologists or psychiatrists if the depression gets severe.  There will be Medicare billing codes for each visit, including any medication that comes along, no matter how minimal the effect on memory or how severe the side effects.  (see Aricept for an example)

And so we have finally found out exactly what this legislation will do, as Pelosi predicted we would.  It will take functioning older people, like the ones I play tennis with, who laugh at our memory lapses and even share a sense of camaraderie over our facing the trials of aging, and change who they are.  If they want to have a relationship with a physician to treat conditions that are treatable, they will be told, as if they were children, that they must take a test to determine their cognitive health.  This is elder abuse at a monumental scale!

This is the ACA, the Affordable Healthcare Act, all its glory.  It is a forced transfer of wealth-- not so much from the rich to the poor, but to every citizen to the Medical Establishment,  who in this example will damage the well being of an entire group of seniors who are declining in memory just as they are in height, balance and strength.  This is not simply universal healthcare, but it entails a change in our cultural understanding of aging, reflected in the false statement by the Alzheimer's Association that memory loss is a myth, only changed when I personally initiated a modification several years ago. (see link below)

I prefaced this essay by brandishing my liberal sentiments, which I now feel have been betrayed   To add injury to insult, this cognitive evaluation will be done by primary physicians-or even paraprofessionals, either by their impression  or with a three minute test that will give results that they may have no psychological training to evaluate.  They will have the authority, actually a requirement in California and other states, if they are so inclined to report any sub average score to the DMV, which could initiate the loss of your drivers license, which in California is the end of independent living. All of this, the uncertainty of qualifications, the interpersonal chemistry between evaluator and patient are undefined; and the person who is expecting to have a wellness "visit" is being subjected to a test without any express explanation of the consequences nor the right of refusal.

There will be few who walk out of this innocuous sounding Annual Wellness Visit without a referral in hand to a specialist of one sort or another, which gets us back to Goldhill's article on the vast untold expense of the ACA.  There is absolutely no evidence that this will result in healthier, much less happier elderly people, which is another essay, that will have to wait to the next episode.
Another perspective that looks at this thrust as a type of "war"  like the ones against drugs and poverty.

Concierge Practice is growing.  Those without the resources to pay an annual fee may not have physicians available.  Ironically, those in such practices may be using upstream specialists disproportionately also,  a premise yet to be researched.

Why excesses of treatment can't be decided by physicians: New Poll: Doctors favor Medicare payment for futile treatment.

Changing Alzheimers Association description of normal memory loss

My Alzheimer's Screening, personal narrative and technical discussion

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