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

In "War" against Alzheimers, we elderly will be collateral damage

The strategy is laid out in this paper, NATIONAL PLAN TO ADDRESS ALZHEIMER’S DISEASE, that from the beginning shows the confusion of using Alzheimers, or AD as the generic term for senile dementia which has many etiologies.  It is broad based and similar to our national wars on Drugs, Terrorism and Poverty; based unfounded optimism and unrealistic expectations.

The "war word" is a quick way of changing our culture-- energize the mass of Ameicans to make sacrifices that usually demolish civil liberties, as is the case with traditional wars against enemies of the state.  In such hot Wars, accuracy is not required as optimistic approaches-- whether it was Hitler claiming victory was just around the corner a few weeks before Berlin fell, or General Westmoreland. claiming to see the light at the end of the tunnel in Viet Nam shortly before we withdrew from that country in defeat-- is a universal element.

From Section 1C of the report linked above:

"Accelerated research will improve and expand the application of biomarkers in research and practice. Such improved expansion of biomarkers have shown that the brain changes that lead to Alzheimer’s disease begin up to 10 years before symptoms. "

This is factual, as such biomarkers can provide more accuracy of the course of senile dementia- as contrasted with the following statement:

"Identifying imaging and other biomarkers in presymptomatic people will facilitate earlier diagnoses in clinical settings, as well as aid in the development of more efficient interventions to slow or delay progression."

This is hypothetical based on assumptions that have been challenged by biologist in the field.  We do know that the brain does shrink with aging, but unlike global warming, there is no evidence that this is "anthropogenic"  since it is ubiquitous in humans and other primates. See Antagonistic pleiotropy for those interested in this explanation of aging   Thus it could be part of the the normal process of senescence that has no possible intervention as it is part of the complex process of conception, maturation, decline and death that is common to our allied species.

Without any public discussion ACA, otherwise known as Obamacare has included the the requirement of a cognitive assessment without the opportunity of opting out, in Annual Wellness Visit that will be fully paid for with no co-payment.  This evaluation by physicians unfamiliar with the latest research in this area,  or even their assistants  will become part of the new electronic records that are part of this law, which have minimal security to invidious inappropriate access.  If a 25 year old doctor's assistant thinks you are slow on the uptake based on his or her own values, it will be in your record.

While there were open discussions of other elements that were proposed for these visits, end of life discussions specifically, this aspect was not brought to the publics attention.   There certainly could be public health advantages for this type of accumulation of data of what is a universal aspect of aging, yet the social costs of this process which has been dealt with by differing cultures since time immemorial has not been brought into the public discussion.   Those who would rather avoid thinking about their declining memory, will now have it harder to pull off.

The medicalization of something that large numbers of seniors do not choose to place in such a context, the serious legal consequences of being deemed mentally incompetent that will occur among large numbers of older people has not been discussed, while proceeding with this program predicated on unproven scientific-medical value.

This article from the Journal of Family Practice, Identifying cognitive impairment during the Annual Wellness Visit: Who can you trust?  aknowledges the mandate to report symptoms of dementia and includes this:

Results of this study demonstrate that patients referred for specialized memory evaluation had virtually no idea of the degree of their cognitive impairment. Patients, on average, rated their function in 5 critical areas of cognition and behavior as “good.” While 80% of these patients demonstrated dementia on formal evaluation, more than 95% rated themselves as having good or very good cognition. Their ratings did not correlate with any objective memory measures or expert clinician opinion.

Please read the above over, and maybe a second time.  Let me paraphrase it :  a group of older people, having been directed to this study by a trusted physician think that they are doing O.K.  They know, of course, that their memory is getting bad, I myself can tell you a dozen jokes we tell each other as we hang out together, maybe after a game of tennis or golf.  Sure, we are getting older, and we know it, and we have learned to cope and to help each other face this reality.  We don't focus on our disabilities, but what we have learned, who we are, and what we can share with each other.

Now they went to this medical setting described above, and guess what, they have found out that 4 out of five of these guys, my guys, my friends have a disease called "dementia."   Maybe they didn't even know that this was what was on the agenda, since nist people don't want to know, because we know what doctors and researchers do not readily acknowledge,  that there is no cure, and won't be in our life times.  Sure, some of us do buy these miracle cures advertised on the Internet, and I personally don't try to tell them it doesn't work, since it makes them feel better and probably doesn't hurt any.

But now these elderly are getting results from physicians, and they are told that they have a "condition"  and perhaps they should sign up for an research experiment, and that maybe there will be some cure.  I actually did some participatory research by going to a dementia screening that I go into extensively in this essay.  The testing was sloppy, and the outcome for those who score poorly is dire.

Not only didn't I enlist in this war against Alzheimers.   I am against it, the same way I was against the War against Iraq in 2003, that by the way has made that country into one of Iran's main allies and whose people are still living in the chaos of internecine battle. And how's our war against poverty and drugs coming along?  Good intentions with little thought and much enthusiasm often cost vast sums and bring unexpected negative consequences.