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escrito por nada

escrito por nada
Somewhere Special, United States
November 22
Mostly amiable
I've lived a good life studying people and gathering wool. My apologies to the Spanish speakers among us. My screen name might have better been "escrito para nada". Anyway you say it I'm not getting paid for writing.


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APRIL 22, 2012 5:42PM

What If Barack Obama Was Playing Poker

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Before the 2008 elections someone made the point that a choice between Obama and McCain was a choice between a poker player and someone who liked to shoot craps.

There is no suggestion that the Affordable Health Care Act (AHCA) referred to disparagingly as Obamacare was anything other than a desperate act, on the part of the president, to pass a conservative healthcare plan that would please Republicans.  The plan, after all, was modeled on a plan devised by the Heritage Foundation to protect the private insurance market in the name of free enterprise.  Piloted in Massachusetts by, then governor, Mitt Romney it seemed an acceptable alternative to a single payer health insurance system.  It proved unacceptable to Republicans because it was proposed by a Democrat.

All attempts on the part of the progressive voice in the Democratic Party to have a single payer system were thwarted.  The possibility of a government run insurance plan as an option to private insurance was similarly anathema to conservatives and the Republican Party.

The poison pill in the AHCA as it turns out was the individual mandate in which there would be a penalty for not having private insurance.  Had the word penalty been replaced by tax, there would have been no question of constitutionality.  The senate at the time had 60 Democrats, a couple of independents, and a moderate Republican.  There was simply no way to push through what is undoubtedly the best and which will prove to be one of the two remaining options, universal healthcare with a single payer.  The other option which has worked in other countries is a two tiered system.  Americans have problems with the fairness of having two levels of care at the same time that many will accept a system with multiple levels of care ranging from excellent to non-existent based on ability to pay.

What if healthcare reform was a high stakes poker game played out over years, over presidential terms, rather than a single hand played over a few months?  What if our president, being a constitutional lawyer, knew that the individual mandate would fail and that the only remaining solution for the present healthcare system, which will bankrupt America in the short term, was a single payer, Medicare for all, system?

Republicans, many whom have signed the Grover Norquist “no new taxes” pledge, could not allow the word tax in the AHCA language.  Excited about having language that would provide for a constitutional challenge, they may have handed the president an immediate win, and ultimately, the win that was being looked for. 

Who knows the mind of anyone?  This would be an audacious move more akin to the kind of long term planning seen in Asian cultures where one’s reputation or “face” depends on the legacy that is left in dealing with, and providing for the welfare of, others under one’s protection.

Maybe too much is being read into the way the hand has been played.  Americans just don’t think past this month’s rent, and corporations don’t think past the next quarter’s earnings.

Assuming that the conservative Supreme Court plays into the President’s hand and strikes down the individual mandate, the AHCA makes no sense and will have to be redrawn.  If the court strikes down the whole act then we have to go to plan B, or the unlikely Plan C.

What Plan B would fix:

The healthcare system that the U.S. had prior to the AHCA has been expensive, inefficient, and defied basic views of fairness.  Healthcare reform under AHCA will only fix the last problem.  It will still be expensive and inefficient because there is no system for fixing the first two except “market forces” which have been, and will be, completely ineffective.  The U.S. health system is the most expensive system in the world, costing individual Americans almost twice what the next most expensive system costs per year while providing care that at last calculation ranked 37th in the world. 

There is oversight of hospital systems by a great many agencies, but the oversight is aimed at safety, insuring a single level of care once a person is hospitalized and detecting fraud.  For physicians the oversight is primarily against fraud.  True, states have the right to withdraw a doctor’s license to practice, but the license will not be withdrawn unless the level of poor care becomes very low.  The tort system is no guarantee of good care.  The patient has to recognize that they got poor care – being unsatisfied with the outcome is not evidence of poor care - and the system favors the side that hired the best lawyer, not justice.


There is only one organization, to my knowledge, that has worked to find the most efficient way to treat patients and make recommendations for change, the Institute of Medicine.  The IOM is an arm of the National Academy of Sciences, and has existed as such since 1970.  The National Academy of Sciences was chartered under Abraham Lincoln’s presidency.

The IOM conducts studies, many of which come as a result of mandates from Congress.  The IOM has looked for systems of care that will provide for better patient outcomes.  Congress, of course, is looking for lower costs for Medicare patients.  In the event that both ends are met Congress enacts laws that provide penalties to those who do not demonstrate steady progress toward achieving the recommendations of the IOM.  So far, so good.

The inefficiency and poor compliance has come from the fact that hospitals and doctors practice under different sets of reimbursement rules by HCFA, the organization that provides for payment for Medicare patients.  In many, maybe most cases, reimbursement is reduced to hospitals for inability to achieve the IOM goals.  The responsibility for meeting those goals, however, is placed on physicians.  Furthermore, meeting the hospital’s goals often results in decreasing physician reimbursement.  The two entities are set at cross purposes.

In order to correct this problem there has been a move across the U.S. on the part of hospitals to hire their own in-house doctors to provide care once a patient arrives in hospital.  Of course, there are problems with this plan.  Hospitals don’t want to pay much for the medical care.  They may hire doctors who have “problems”.  They hire doctors from “temp” agencies who work long shifts, often days at a time and then fly on to another hospital or go home for a few days off.  There are often only a few doctors replacing the many who used to be in and out of the hospital seeing their own patients.

On the plus side, these in-house doctors don’t have to come from across town to see patients who suddenly develop problems while in the hospital.  It’s just that the in-house doctors have so many patients to keep up with and have no personal connection to them.

Meanwhile, the “town” doctors can stay in their office all day, where they can see patients more efficiently without interruptions or cancellations.  If doctors got paid as much for hospital care as they do for office care they might have been able to work with the hospitals to achieve the IOM’s quality initiatives.


The evolution of this system is still in play.  The change in the way healthcare is delivered has been great in the past 10 years and will continue to change rapidly regardless of the final solution to the healthcare problem.  One of the great problems is that under the present free enterprise system of healthcare the only way in which change can be accomplished is through the stick of reducing payment.  Fines and decreased reimbursement are blunt weapons that often achieve poor outcomes for patients.


Prior to AHCA uninsured patients could get medical care by showing up in the emergency department of a not for profit hospital.  Hospital emergency physicians were bound by law to see them.  Some reimbursement was provided by HCFA for seeing these “indigent” patients.  The problem with this system was that care was very expensive, aimed at treating only serious and life threatening conditions, and, unless the person was hospitalized there was no provision for follow-up care.

Many of the people without insurance were working part time, or for companies that did not provide health benefits as part of the condition of employment.  In most of these situations individuals or families had to buy insurance at full price, not receiving the reductions seen in group insurance plans.  The cost of insurance often exceeded the cost of rent or the house payment and was unaffordable.

The real insult came, however, when the patient got the bill for the inefficient expensive care received in the emergency department.  In insurance covered plans a copayment is agreed upon, usually 20-40%.  The insurance company is responsible for the rest.  The insurance companies use a heavy hand to force hospitals and physicians to accept about 50 cents on the dollar, so for an emergency charge of say $5000.00 the patient pays $1000-2000.00 of that charge and the insurance company pays $2500.00.  For the uninsured patient there is a charge of $5000.00.

Meanwhile, the patient can’t get in to see the doctor whose name was given for follow-up because they have no insurance.  The prescription for the antibiotic, without insurance, is a couple of hundred dollars. 

Under the AHCA this problem would ostensibly be solved.  Obamacare, though, is a house of cards, and removing the individual mandate may cause the house to fall down.

Whether it is under Romney or Obama the pre-AHCA system is unfair, and horribly expensive, and will have to be replaced.  Of course, the intent of conservatives is to put all of the cost of care on the individual so that only the wealthy can get good care.  The rest would get no care.

If Medicare For All were to be instituted there would also have to be a system in place that examined the efficiency of any particular treatment plan, instituted controls on the use of prescription drugs for various conditions, and enforced those controls.

Of course, given our history of fines, lawsuits, and coercion to control costs it will be hard to think outside of that paradigm.

In some countries, such as Finland, there is a national formulary of drugs that may be prescribed.  Ineffective drugs and harmful drugs are removed.  In the past when it became clear that Erythromycin and the antibiotics in that entire class were no longer effective they were simply no longer available.  This avoided the cost of testing a particular bacteria for sensitivity to the antibiotic, and the loss of time that occurred when those drugs were administered, found to be ineffective and the patient was started on a different antibiotic.  This sort of “Socialized Medicine” would be hard to accept by physicians, but it would save money and give better care.

I’m not a poker player.  This may have been a poor analogy.  It may be more like fencing where there is a feint causing the opponent to expose himself to the thrust.

It is a high stakes game, whatever the case.

  Butterfly closeup

                                 Tiger Swallowtail Butterfly

This beautiful butterfly reminds me that there is always hope.

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We are in a hold pattern awaiting the verdict of the Supreme Court. Does it really take the justices 21/2 months to make a decision, or is this simply timing directed at influencing the outcome of the presidential election?
Before anyone asks. The photograph was taken at the mailbox by me.
Won't comment in detail, you've pretty much hit the nail on the head.
jmac1949, no one is commenting. That always makes me nervous. Boring? Said it all? Don't agree? (that usually fires 'em up.) Just never came by worries me the most. I'm so insecure...
If Barack Obama was playing poker, he'd lose -- he's too easily bluffed. Oh, and he's not near audacious enough. That said, the qualities of a riverboat gambler are not what I desire in a President. That's what we had with Obama's predecessor, and look where that got us.

And not by the way, anyone who examined the resume of Bush the Least should have known that's who and what he was. Too bad so many millions of voters never bothered to look at his resume before hiring him -- twice.
I'm not a poker player but I have used the poker face when needed.

Egads! Obama doesn't seem like much of a gambler. 'course, I could be wrong and that would totally suck.
Love the purple coneflower cover, sir. :) I prefer using common names over scientific ones...sometimes.
Belinda T., you are right. Echinacea sounds to medicianl for something so pretty.
You make your case well. Why aren't health care professionals speaking out more? I tried to engage three of them recently, and only the youngest one--a former student in her first year of med school--had much to say. She recognized the need for massive overhaul in how medical services are provided for the entire population, but then her student loans aren't a reality to her yet. My new doctor is in her 30s, a new mother. I assumed her loans have come due because she squirmed when I brought up the subject. Maybe some of the younger physicians would be more involved in the dialogue a provision addressing their student loan debt was part of the solution. Just a thought...
Beauty1947, good point. We have a daughter who is past 40, finishing a bachelors, who will need an M.S. to work. She can't think about how long it will take her to pay off her loans.

France, number one in the view of the WHO in medical care, has no lack of young doctors who will probably never make an equivalent of $100,000/yr. who are happy. Happy because the system doesn't require them to be a businessperson as well as a physician. They don't have to worry about lawsuits or a number of things that hang over the heads of U.S. doctors day and night.
I hope your daughter is happy in medicine. It was a great profession in this country and my hope is that it will be again.
thank you, you explained the pros and cons and share the fact that the current system was in failure- higher deductions to pace increasingly expensive care, no fund to pay for the uninsured who still receive care, too many forms, coverage by what is offered instead of needed, huge regional disparancies, and cost rise far outpacing inflation and wages. but is there hope that it can be tuned as the needs show? Will the long game be single payer? Fencing is very difficult with idiots- they seldom can be trusted to respond intelligently to a feint
This is a great article, and I really appreciated the information. While of course being aware of the healthcare debate, I confess to having been somewhat uninformed about much of the detail. It strikes me that this country often doesn't care about the fairness part. People are in terror of sacrificing a moment of time or a shred of what they see as the absolutely highest quality care that can be attained so that somebody else could get even the most basic of services. Also, it seems we always operate via the stick when it comes to any provision of public or semi-public services. All the carrots are saved for enterprises that already have more than they could ever possibly use.