What's Going to Happen to Obamacare?

Republicans have been elected on a single promise over the past few elections -- repeal Obamacare.

Most people have heard the name, but don't know what it means. If you ask them about the benefits of individual provisions of the law, they are in favor of it. If you call it Obamacare -- they hate it.

The problem all along has been that there is no  Republican alternative -- that's because the private insurance based ACA WAS the Republican alternative to expansion of medicare and medicaid.

And just repealing the law would leave 22 million people without insurance -- not surprising then that Trump has softened his stance since the election. 

Five Thirty Eight untangles the thread of what "repealing Obamacare" might actually mean:

The law is built on interlocking provisions; removing one puts pressure on others. That’s what happened when the Supreme Court made the Medicaid expansion optional for states, leaving 2.5 million people in states that chose not to expand in what has been called the Medicaid gap: too poor to be eligible for the marketplace subsidies but ineligible for Medicaid. Leaving in place the mandate for insurance companies to cover people with pre-existing conditions, as Trump said he’s considering, while getting rid of either the individual mandate — the requirement that people get insured — or the subsidies that motivate low-income healthy people to join the insurance rolls could also create instability in the insurance market. Without the necessary mix of healthy people in a plan to offset the costs of insuring people with pre-existing conditions, premiums rise, becoming unaffordable for everyone.

So far there is no prescription of replacing Obamacare that won't result in increasing costs and decreasing coverage. That's the problem with governing -- people feel the effect of what you do and you actually have to follow through with your promises.

Forbes details a lot of things that are going to be bad for health and healthcare on the Republican agenda. If you want a dozen more things to be scared of it is worth reading --  The anti-science crackpots he has in line have all kinds of bad news.

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Required Reading:
What the Republicans are going to do to your health.
What Will Trump Do to Obamacare  538
What will Happen to Obama Care

Keep it Simple - the French Way

Good article on the contrast between care for cancer in France vs the United States.

In it the author talks about cancer care her father received in the US and in his native France.

I also didn’t know what the French healthcare system would be like. I’d read it was excellent, but assumed that meant there was better access for the poor and strong primary care. Not better cancer specialists. How could a public hospital in Paris possibly improve on Sloan Kettering’s cancer treatment?

One way, the health insurance system isn't a maze to trap the ill and dying in. With less focus on paying for care, there is more time and attention that can be paid to the patient.

The French Way of Cancer Care is by Anya Schiffrin and worth reading.

 http://blogs.reuters.com/anya-schiffrin/2014/02/12/the-french-way-of-cancer-treatment/

Regulation vs. Self Interest

Interesting article by Tim Noah at Slate (Anesthsleazeology) regarding the inter-profession conflicts and how they influence healthcare regulation. Noah, like most writers, is pretty confused about a lot of things (the difference between RNs and CRNAs for example) but he brings up a couple good points about the future of healthcare. Alabama  is proposing regulations that would prohibit CRNA's and NPs (and presumably PAs) from doing interventional pain management.: It states:  "The interventional treatment of pain may be performed and provided only by qualified, licensed medical doctors and doctors of osteopathy" because it "constitutes the practice of medicine."


Of course CRNA's do a lot of work in rural areas. I worked at a rural hospital that had a busy surgery running all week. We used nothing but CRNA's and most were fantastic. Noah says the Alabama law is born out of a conflict between CRNA's and Anesthesiologists.

 Unsurprisingly, the Alabama medical board's proposed rule arose from a complaint by an anesthesiologist about a "disturbing situation occurring in several facilities in Alabama where … [a CRNA] was providing epidural steroid injections to patients." The anesthesiologist claimed this practice threatened patient safety and asked the Alabama Board of Nursing to stop it. The state nursing board ruled that the anesthesiologist appeared to have an economic interest in preventing nurses from performing these procedures, said the nurses were authorized to perform them and had been doing so for some time, and told the anesthesiologist to buzz off. The spurned doctor got a more sympathetic hearing from the more physician-centric State Board of Medical Examiners.

There's no evidence that CRNA are any less safe in performing the interventions in question, Noah writes. Indeed he cites evidence to the contrary.

Earlier this year, the peer-reviewed journal Health Affairs ran an article under the self-explanatory headline "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians." The article drew on the experience of 14 states that let nurse anesthetists work unsupervised by doctors when treating Medicare patients.  

Advanced practice nurses are often seen as a solution to two of the big problems in the American healthcare system - cost and access to primary care. CRNAs are well paid, but cheaper both to educate and to pay than MDs. There's also the question of access, Nurse practitioners are increasingly becoming the only accessible primary care providers because more and more MDs specialize and avoid primary care. Similarly, you're going to see more CRNAs out in rural areas that cannot afford to have Anesthetists.

The notion of allowing nurses and doctors' assistants to perform routine medical tasks in order to reduce medical costs and make certain services more widely available is controversial only to the particular doctors whose economic interests are at stake (and not even always to them). It has no discernable left-right valence, and the FTC has promoted it under presidential administrations both Democratic and Republican.