Repeal and Replace the ACA?

I have been reading a lot lately about the challenges the 115th United States Congress is having with a “Repeal and Replace” strategy for the Patient Protection and Affordable Care Act (the PPACA, commonly referred to as the ACA or “Obamacare”) law. Given the new administration’s struggle to even grasp the scope of the ACA, I can only imagine that it’s like climbing Everest or rowing across a small ocean.

Partisanship is the tendency for representatives and senators to vote on legislative measures as dictated by the letter that designates them as (R) or (D). However, I don’t think that party affiliation is the true nature of Congressional difficulties with the ACA, regardless how much their members may protest it. The lines are well-drawn between the aisle on many fundamental issues, and despite the fact that the ACA was the darling of the former President and his party, there can be no denying that it has proven disastrous for middle-class Americans.

I also don’t believe the complexity of the law itself (its rules and regulations written by the Secretary of Health & Human Services with virtual carte blanche control over its content) is the cause of the difficulties – despite containing over 2,000 original bill-signed-into-law pages and its thousands of subsequent pages of regulations. It is very easy to say, “This thing is far more complex than a simple repeal and replace”, and place the blame on the self-imposed vastness of the law.

I have only a few acquaintances who have benefited from the passage of the ACA, based on the fact that they now have “affordable” health insurance. However, most of the people with whom I have come in contact have experienced negative effects, including;

  • Loss of their working policies, as employers were forced to cut coverage
  • Prices that escalated quickly to unaffordable levels, and/or
  • Penalty taxes imposed for being unable to afford an “acceptable” (i.e., federally-approved) policy.

There is very little that is Affordable about the Affordable Care Act. I must also point out that in addition to not being affordable, the ACA is not (as no law could ever be) Care. Care is provided by medical personnel, not by insurance and not by laws. So the only true-to-its-nature aspect of the law’s name is Act. And I believe that therein is where the difficulty arises.

In March of 2015, I traveled to Washington DC to be a part of a Healthcare Coalition composed of practicing physicians of all specialties from across the nation. We came together to design and present to Congress a one-page proposal of “How practicing physicians would ‘fix’ the healthcare system in this country.” It only took us less than one morning to compose the proposal – three hours, tops. Since it is near-impossible to get even two or three physicians to agree on much of anything, that mere three hours it took to gain consensus between the 30 of us in the room is nothing less than miraculous. But the point is this: were able to do in one morning what Congress has failed to do during numerous sessions, across multiple years.

We printed our one-page proposal and set out that same day, to present our historic proposal to Congress via their legislative assistants. Across our two days of meetings, these staffers were – for the most part – kind and silently attentive, offering very few questions. Feeling great and patting ourselves on the backs, we left with high hopes for progress.

Little did we know that – at the same exact moments we gathered around conference tables and in hallways (and even getting kicked out of South Carolina congressman Trey Gowdy’s office) – those same elected representatives were quietly and quickly passing MACRA, the Medicare Access and CHIP Reauthorization Act.

Touted by the major physician organizations as the “Doc Fix,” MACRA is the completion of the ACA. It is the How the ACA will complete the Single Payer System that the architects of the ACA envisioned. It is also a tool to force independent physicians and other healthcare providers into the big systems, while driving private insurance companies into oblivion. It’s no wonder the legislative assistants were being so polite and listening so intently. “Let’s keep these doofus physicians who think their opinions matter busy so they don’t find out what our bosses are doing.” Their courtesy was just a smokescsreen.

I came back from our nation’s capital with a single message to my friends, colleagues, patients and family: Washington, DC is not about to give up any control. While they handed over responsibility to the Secretary of HHS to define the language of the ACA and MACRA, the control still lies in Federal hands, and they are NOT going to relinquish willingly that power over their constituents. They are NOT going to put control back in the hands of the individual sovereign States, nor into the hands of the People themselves. They may not even fully understand their own reasoning, but control – once locked in federal hands – is hard to wrench away.

Keep this truth in your mind when you hear of the difficulties they are having on Capitol Hill. If they so willfully disregard an educated recommendation from practicing American physicians to pragmatically shift responsibility and control of patient decisions to the patients themselves, just imagine the derision and contention if they were asked to repeal control of those decisions altogether. Our leaders clearly feel that you and I are not equipped to govern ourselves, much less make big decisions about our own health, safety and wellbeing.

Recognizing the War on Pain Medication

Recognizing the War on Pain Medication

There is a war on physicians—and therefore on patients. However, there is another attack on the medical profession—the war being waged against pain treatment. Pain medications in particular are under the scrutiny of both the US Congress and in state legislatures.

For the last several years, there has been a push in Jefferson City, the state capital of Missouri, for the establishment of a Prescription Drug Monitoring Program, one that would track prescriptions for controlled substances in the state. One of the biggest arguments for this program is that Missouri remains the last holdout in the Union to not have one of these programs. But apparently, these programs are not sufficient: just look at the long list of bills introduced in this US Congress alone regarding pain medications:

HR 1725/S. 480 /

  1. 483

HR 953/S. 524 /

  1. 636

HR 2805/S. 1134 /

HR 2298

  1. 1392
  2. 1431

HR 3719

HR 3677

HR 3899

HR 4396

  1. 2479

HR 4447

HR 4499

  1. 2543

It is clear to see from this list that the United States Congress thinks it is the job of the federal legislature to “control” not only medications, but also who may write the prescriptions, mandate a protocol that must be utilized, create a master list of patients who take the prescriptions, enable access to a patient’s prescription record, and limit access to certain pain medications for Medicare beneficiaries.

I cringed to read the summary of HR 3719 that requires the department of Health and Human Services to coordinate with the DEA, the Department of Defense, the Department of Homeland Security and the US Attorney General to develop “best practices” guidelines. PLEASE NOTE THAT NONE OF THESE INVOLVE PHYSICIANS OR PHYSICIAN GROUPS.

HR 3677 would establish “peer review” process—this is equivalent to having physicians spy on other physicians regarding their prescription writing. From reading over the summaries of most of these proposed legislations, it is obvious that our congressmen and women feel it is their responsibility to “take on” the misuse of prescription pain medications. While that may seem a noble cause, you may rest assured that means more regulation, more loss of privacy, decreased access to these prescriptions and most likely decreased access even for physicians still willing to prescribe them.

When I was in medical school, there was a push to include a pain scale as another “vital sign.” That meant we should ask about EVERY patient’s pain, have the patient scale it one to ten, and record it in the beginning of all our notes along with other vital signs: blood pressure, heart rate, respiration rate and temperature.  We were chastised if every single note in a patient’s chart did not provide this scale, even if pain was not one of the complaints. By residency, I had learned enough to make Tylenol and/or Ibuprofen an order for every hospital patient, because I knew the likelihood of being called for “something for pain”, and generally at 2:00 in the morning. We were instructed on which narcotic pain medications tended to work best for different kinds of pain, which were safe in pregnancy and breastfeeding, what “schedule” each one had (whether they required a paper prescription, could be faxed, called in or could have refills) based on the regulations of the DEA.

Pain is strange. It is a totally subjective problem, meaning: there is really no outward sign, no testing that can be done to scale it and it is totally dependent on the patient reporting it. We always ask a patient to “describe the pain”: location, intensity, what does it feel like (burning, stabbing, aching), does it come and go, what makes it worse, what makes it better?  These questions help us understand from where the pain may be coming, what may be causing it and if there is something else going on that could be disastrous or fatal. It also helps us understand whether we as physicians need to treat it. Sometimes it is best to let the pain go untreated, as it can guide us. Some people do better with pain than others. Depression will make someone feel more pain, and pain can be depressing. Pain raises blood pressure. It causes the excretion of stress hormones, such as cortisol, which works against insulin; so, diabetics with pain will tend to have higher blood sugars. Pain can cause nausea and vomiting. It can alter a person’s thought processes and can cause anxiety. Pain is not necessarily a benign symptom.

However, because narcotic pain medication is easily misused, because people can claim to have pain when they do not, and because physicians have been trained to help alleviate pain and treat it as one of the main vital signs, there are a lot of prescriptions for pain medication.  Pain relief is often one of the main reasons people seek help from physicians in the first place. Pain is the body’s way of telling us something is amiss, and it comes in various shapes, sizes and styles. People have different tolerances for pain. In spite of all these variances, because of a handful of people who use their medications incorrectly, because of the thieves, the addicts and the greedy, it has become nearly impossible for physicians to adequately treat pain in today’s medical atmosphere. Further regulations, as well as both state and federal drug enforcement agencies want to be able to reach into medical records, physician prescription habits and patient privacy and consider anyone who either prescribes, fills prescriptions or accepts prescriptions from the pharmacy as suspects.

I fully believe there will be a day that I can no longer prescribe any pain medications for patients.  It may initially be patients on federal or state insurance programs; then it may extend to those privately insured. Eventually, it will hit the cash-paying uninsured patients. And at that time, I suspect that the only way to obtain pain medications will be on the black market.  Because, as we are all well aware, what is made illegal does not simply go away—it just goes underground.









Direct Primary Care vs. Insurance Lobby: Score One for Free Market Medicine

On July 2, 2015, Governor Jeremiah “Jay” Nixon signed Missouri House Bill 769 “relating to direct health care services” into law (PDF).

MO HB 769 makes Missouri the twelfth state in the Union to enact such a law recognizing the legitimacy of direct-pay medical practices and defending the model against regulation by the state department of insurance.

The most outspoken opponent of this bill was the insurance lobby. Now, why would that be? The direct health care services model is ideal for those who are uninsured—those who either can’t afford insurance, feel they don’t need it or for those with high deductible health insurance coverage, which is designed to help with burdensome, bankruptcy-causing medical bills. It stands to reason that insurance companies don’t make much, if any, money on these folks. And, if those who are fully insured choose to utilize a direct pay practice for their primary care, it is out of the insured’s own pocket, not at cost to the insurance companies. So, how could this be of any potential concern or harm to the Insurers?

Since there is now a national “law” that states all must have health insurance, one might wonder why an enterprise such as a cash-pay model of primary care is necessary, or at the very least important enough to warrant a state law. How can there be any uninsured patients? If you don’t have insurance, aren’t you now breaking the “law”?

Let’s use an example of a healthy 30-year-old woman. She is single and makes three times the poverty level. She received an exemption this year, because she doesn’t make enough to afford any policies on the exchange. Yet, she also can’t afford any high deductible insurance. So she just hopes life doesn’t deal her a bad hand. Is she a law-breaker? If so, this criminal element is perfect for a direct pay model of medical care. She needs “maintenance” to make sure she doesn’t break down alongside the road, and to keep an eye on anything that might run in her family. Is it reasonable to require her to pay for a product or service solely to compensate for those who receive the subsidies and get the bargains? So much for being affordable for all.

What about the “underinsured? The underinsured are those who have a high-deductible health insurance plan. Some deductibles may be affordable for one, but not for another. Most of these plans pay for very little until the deductible is met for the year. These consumers must pay for primary care and medications out of pocket. The model of direct-pay primary care provides affordable office visits, labs and even some medications for patients. It takes up the slack so the uninsured and underinsured do not have to wait until a problem becomes urgent or emergent, which will inevitably cost more than the original preventative measure or early detection.

So back to the question: why would the insurance lobby be opposed to this bill? Their overwhelming presence was felt at the committee hearings in both the state House and Senate. I believe the answer is a concern for public understanding. The American people have been fed a great lie. Insurance is insurance and nothing more. Insurance cannot get to know you. It cannot hold your hand or give you a hug. It cannot know that because of your anxiety a different type of inhaler would help you more than another. It cannot know that your living situation may preclude therapy effectiveness. It cannot guarantee you a same day office visit. It cannot promise, “If you like your doctor, you can keep your doctor.” Or if you like your nurse, or if you like your receptionist, or if you like your clinic, you can keep any of them. It cannot place sutures in a laceration. It cannot stop bleeding. In other words, it is insurance, but it is NOT care and it is NOT access. You can have the best insurance plan on the planet, but if no one bills it, of what worth is it? If the public were aware of this, that the mandate to have an insurance plan to cover “healthcare” will not make you healthier, or more wealthy or happier, We The People might consider taking a closer look at a the national “law.” We might then find some problems in the “law.” We might start looking back at who supported it and how they benefitted from its passage. We might also find at whose expense the entire system has been shifted.