Cheers and jeers

It has been a busy week, but it is, I guess, time to put some thoughts on paper.

Two important United States Supreme Court decisions were announced this week, King v. Burwell, the “Obamacare” case, and Obergefell v. Hodges, the gay marriage case. The internet, Twitter, and Facebook have been filled with cheers, jeers and rants from both sides (along with some calm and reasoned voices, where you can find them).

I believe that the Constitution is the law of the land. I also believe that it is written in reasonably understandable English, and that it means what it says. In addition, when it is silent on a subject, no additional reasoning can be inferred from its text. If the country wishes to add or subtract from the original text, there are prescribed ways of changing it. Indeed, we have amended it 27 times. I also believe that laws written by Congress (or state legislatures) should mean what they say. The King decision is quite frightening. Whether you are a fan or a foe of the Affordable Care Act should not matter. If the law does not read as Congress intended when they passed it (perhaps reading it before passing it would be helpful), then Congress can go back and fix it. In this decision, SCOTUS has decreed that a majority of an un-elected committee of lawyers can determine what Congress intended. This is a major blow against rule of law.

With cries of jubilation and accusations of bigotry and hatred on the one side, and weeping and gnashing of teeth and condemnation of the sins of others from the other side, Obergefell has aroused the passions of many. This decision, like Roe v. Wade, was based on feelings and opinions, not law. Marriage is not mentioned in the Constitution at all; if the people wish to regulate marriage, then laws should be passed to do so. Having five justices rule by decree, whether the majority of the citizens agree or not, is antithetical to democratic government.

The underlying problem with the same sex marriage debate is that we are not all talking about the same thing. There are two definitions, or aspects, of marriage in play. First we have the religious aspect . Marriage, as a religious institution, was established by God (“For this reason a man will leave his father and mother and be united to his wife, and the two will become one flesh.”– Ephesians 5:31). Pretty straightforward, and as long as marriage remains a religious rite, then religion should make the rules (or in the case of Christians, follow the rules given by God as spelled out in the Bible).

Then there is the legal aspect of marriage. Government has intervened, and we are required to have a license to be “legally” married. Our tax rate is partly determined by our marital status. Health care decisions, employment benefits, and succession are determined by marital status. I can completely understand wanting those benefits legally. A civil partnership between two people (or more—believe me, that is coming) that establishes these benefits seems completely fair. If you want to have such a civil arrangement with your gay partner and call it marriage, go for it.

What Obergefell should not do, however, is force churches, or their members, to recognize or participate in such arrangements. The majority opinion was pretty vague about protecting religious rights. The First Amendment protects our right to the free exercise of religion. For me, and many Christians, that means we strive to live our daily lives according to our religious beliefs, and requiring us to not only tolerate non-Biblical activities, but agree and participate in them, is infringing on that right.

One more thing…it distresses me to see disagreement labeled as hatred or bigotry. The angry voices coming from both sides are not helpful. As Jesus said, “A new commandment I give to you, that you love one another, even as I have loved you, that you also love one another.”—John 13:34

I know that there are some people, dear to me, who will disagree with some of my thoughts, and that is okay– I will still love you unconditionally. Let us treat each other with kindness and respect.

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A doctor’s declaration of independence

It’s time to defy health-care mandates issued by bureaucrats not in the healing profession.

I don’t know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not. We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine.

Now is the time for physicians to say enough is enough.

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A win for freedom of religion

Catholic groups have been fighting the HHS contraception mandate provision, a regulation written for the Affordable Care Act, and there have been numerous court cases with various results. Now a federal judge in New York has ruled that the mandate forces the Catholic Church and its associated organizations to curtail religious expression; the judge’s ruling enjoins the HHS from enforcing the mandate.

I am not Catholic, and I do not ascribe to the idea that the Bible prohibits contraception, but I applaud the court’s ruling. This is a victory for all religions, faiths and denominations.

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The revolt of the kulaks

Back in 2009, Professor William Jacobson wrote an article about the new Tea Party movement. He compared it to the agrarian producers of the early Soviet Union, the kulaks, who resisted Lenin’s collectivization efforts. We know how that turned out. In that article, Jacobson concluded, “In the end, as must all economic redistributors, Obama either will have to resort to repressive measures, or he will have to abandon his redistributive plans.”

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Today Prof Jacobson recalls that prediction in noting the developments with the Affordable Care Act. Under the provisions of Obamacare, millions of uninsured people will be moved onto Medicaid. that is one solution for many of the working poor, but is it a workable solution?

The problem is, fewer and fewer doctors are willing to take Medicaid patients because the reimbursements are so low.

I have met numerous doctors who tell me they either refuse Medicaid patients or restrict them because the reimbursements do not cover their costs. They also double and triple book, because so many Medicaid patients who make appointments don’t show up. As to Medicare the payments currently are bearable, but only because private insurance payments for other patients make up the shortfall.

Increasingly, doctors are abandoning the government payment train wreck, and going all cash or some hybrid. This all was foreseeable and was foreseen.

The millions of new Medicaid patients will have insurance, just no doctors to see them. That is a feature, not a glitch, to those who want single payer. Obamacare is proceeding accordingly to plan.

Friday, a Virginia Democrat called for forcing doctors to accept Medicare and Medicaid patients. Currently, there are not enough doctors to see all of these patients, and the 20% of physicians who are over 60 will be retiring. I suspect that the shortfall will be made up with independently practicing nurse practitioners and physicians’ assistants. There is a place for mid-level practitioners, but most Americans will prefer a physician to provide their care.

The government really has only one way out of this mess–single payer. And if physicians want to stay in the profession, they will have to play the government’s game.

Let them try to implement Obamacare

I have spent a lot of time in thought, and waited until now to write about the end of the government shutdown; who won and who lost, and what small government advocates should work toward at this point. Many of us voted for, and elected, representatives who pledged to stop the Affordable Care Act, or Obamacare. In fact, the House of Representatives has voted 41 times (so far) to repeal the ACA. The attempt to defund Obamacare and fund the rest of the government has failed. I will leave it to wiser heads to tell you why it failed, but I think the proximity of the debt ceiling did not leave time for a victory on the Continuing Resolution front.

As of October 1st, the Obamacare exchanges have opened, and all Americans have until January 1st to buy health insurance, or pay a tax (penalty). The battle may have been lost, but the war against Obamacare is still undecided. I think the best thing we can do is let them try to implement it.

The rollout of the exchanges has been an unmitigated disaster. The government had three years to put together the infrastructure to match up buyers with a policy that they could afford (including government subsidies, if qualified). The site, Healthcare.gov, is supposed to get the consumer a quote on a policy. It does not even come close to achieving that goal. Even industry experts do not know when, or if, that will occur accurately and reliably. In the meantime, healthy young people who try to enroll, and are not successful, will probably not go to the trouble of navigating the labyrinth to purchase a plan. Folks who have serious pre-existing conditions and have been uninsurable in the past, will stick with it until they are successful. They are motivated, whereas a healthy 25 year old may say, “To heck with it” and pay the penalty. If there are too many sick folks and not enough healthy folks in the mix, the insurance companies will have to raise premiums, or go broke.

Another problem is that Obamacare assumes that government knows more about the healthcare needs of Americans than they do. There are numerous horror stories out there about healthcare premiums skyrocketing, or policies being cancelled. What happened to “If you like your current healthcare plan, you can keep it”? Obamacare dictates what services must be covered by your insurance plan, even if you do not want that coverage. I am single, and I have a 16 year old son who lives with me. I have to buy the “family” plan to cover the two of us. Plans now have to cover contraception and family planning, which I obviously do not need.Why would I want coverage for mammograms? I have to pay for it, even if I do not need it, and that costs money. When many people who already had adequate health insurance discover how much it is going to cost them directly, they may rise up in protest.

Then there is the security issue. The system, as envisioned, would connect multiple databases with our personal financial and healthcare information. This is a hacker’s dream, and a nightmare for the rest of us.

There are many reasons why most doctors do not like Obamacare, but many people will not really care about that until they realize how it will affect patients. One of the methods of covering the uninsured is to move more of the near-poor to Medicaid, now up to 138% of the poverty line. Reimbursement from Medicaid is already abysmal, and most doctors in this area do not accept Medicaid. Many more will drop Medicaid patients, or refuse to accept new ones, as reimbursement decreases further. The same may occur with the other lower benefit plans of Obamacare. It will benefit few folks to finally have health coverage, and not be able to find a doctor. Many will flood the already overcrowded emergency departments, the most expensive place to get medical care. Again, rates will rise, to cover the additional cost.

So, let them try to implement the Affordable Care Act. Its supporters will find that the ACA is not only unaffordable, but completely unworkable, as well.