This cartoon was sent to me in an e-mail.
Overly simplistic, but illustrates the issue. Credit here.

The Supreme Court decision on the Affordable Healthcare Act threw us a curve ball. Many people who predicted the outcome of the ruling swung and missed – including me.

The Court agreed with the government’s argument that the individual mandate contained in the Affordable Care Act was not a tax … for purposes of the Anti-Injunction Act (which would have prevented a lawsuit regarding assessment or collection of the mandate and forced those bringing suit to sue for a refund after paying it).
At the same time, the Court declared that the individual mandate contained in the Act was a tax … for purposes of validating and enforcing the mandate.
To me that’s a stretch. That’s like legal argument defending a dog bite lawsuit by simultaneously alleging that (1) I don’t have a dog, (2) you weren’t bitten, and (3) my dog didn’t bite you.

President Obama has declared the Supreme Court decision as a “victory” but this victory is largely Pyrrhic.

The Supreme Court’s decision will become a rally cry for the 41% of Americans who believe the law should be overturned and the 27% of Americans who believe the mandate should be overturned. Romney’s campaign will emphasize Romney’s commitment to repeal the law – whether or not he truly intends to do so. While some argue that “President Romney” wouldn’t have the ability to repeal the law, President Obama’s decision not to enforce our country’s immigration laws shows that an executive order refusing to enforce laws can have the same effect as repealing a law. A dog with no teeth can’t bite you.
In addition, President Obama and all the legislators who supported the ACA have essentially approved the largest tax increase in US history … in an election year. How many voters will be happy at the thought of a new and expanding tax that coerces us to purchase a commercial product which we may not even be able to use? The growing public backlash in this regard is probably the reason that the White House is backpedaling and stating that the mandate really isn’t a tax … even though the same White House stated that the mandate was a tax in the media and during oral arguments on the issue. The mandate stands because it is a tax and now President Obama and our legislators have to live with the consequences of their decision. In case you were wondering, here are how each of the House members and the Senators voted on ACA.

But many people will think that the tax … er, um … penalty is OK because our government is going to provide us with insurance. Millions of more patients will be INSURED! If you’ve read WhiteCoat’s Call Room on a regular basis, you know why this is such a false and empty promise. Insurance amounts to a series of promises. First there is a promise that, in exchange for a premium payment, someone else will pay for your medical care. Then there is a promise that someone else will provide your medical care. Finally, there is a promise that you will be provided with the medical care you need when you need it.

While the government wishes to expand the number of patients who receive our government-mandated “insurance”, many states are planning to restrict the eligibility for the “insurance” that our government wishes to provide to us. In other words, states don’t want to pay for your insurance. A House Ways and Means survey showed that 71 of the Forbes 100 companies could save a total of $28.6 billion in 2014 by dropping health care coverage for their employees. The Affordable Care Act creates a financial incentive for your employer not to pay for your insurance. It shouldn’t be surprising that thirty percent of employers are planning to drop health care insurance for their employees when the Affordable Healthcare Act is implemented.

Now think about the effects of just these few fact patterns. When those employees lose coverage, what will happen? Perhaps the employees will be able to afford to purchase a private insurance plan. Even if they did, it is likely that the plan would be high-deductible so that the employees could save money on premiums. Perhaps the employees earn so little that they will be eligible for government “insurance” – if the states don’t cut the eligibility. That leaves a large group of people who earn too much to get Medicaid but who don’t earn enough to purchase decent “insurance.” What will happen to them? They will pay the tax … er, um … penalty and end up with no insurance. When employers drop the insurance benefits for their employees … and they will … their employees will receive less coverage because less coverage will probably be all that they can afford. Sure, the Affordable Care Act will provide “insurance” to an additional 30 million indigent patients, but the Affordable Care Act will also create more uninsured and underinsured patients from the group of people upon whom our country depends the most – our work force.

Medical insurance is only as good as the health care professionals who are willing to provide care under the terms of the insurance policy. accept the insurance as payment. Suppose you had a million dollars worth of Japanese yen in your pocket and you were in a rural Kansas coffee shop trying to buy lunch. You may be rich, but no one accepts your money. Similarly, if a doctor that you need to see using your new government mandated magical insurance plan doesn’t accept your insurance, then you either pay out of pocket for your medical care or you find someone else who accepts your insurance as payment. If few doctors take your insurance, you wait for an open appointment. It’s that whole fast care/free care/quality care triangle. Pick any two.
By now you should know that many doctors refuse to provide care to patients who are on government insurance. In Texas, one third of all the physicians don’t take Medicaid “insurance” due to low reimbursements and governmental red tape. Mayo Clinic in Arizona stopped accepting Medicare patients in 2010 after losing $840 million in 2009 due to low reimbursement rates. Patients with Medicare in the Raleigh, North Carolina area are finding that physicians who accept Medicare patients are “scarce.” All of these people have the magical medical insurance plan that so many more people will be receiving, yet many of the “insured” patients still cannot find medical care. Even though you will coerced by the IRS to buy into the concept that health insurance and health care are synonymous, they aren’t and they never will be.
The health care that you are able to obtain with your “insurance” may less than adequate, as well. Walter Reed Army Medical Center was just one of the government hospitals plagued by allegations of patient neglect and shoddy medical care. And you won’t find any government hospitals on the government’s own Hospital Compare web site. Ever wonder why?

Finally, keep in mind that medical insurance is also only as good as its covered benefits. Your medical problems just might not be a covered benefit on your insurance plan. Even though you have paid into the insurance plan for dozens of years, your covered benefits can change at any moment. Ask patients who have had to depend on their government “insurance” for care of their cancer or injuries, or asthma.

So our elected officials have foisted what amounts to a medical Ponzi scheme upon us and most of them will be long out of office before the medical insurance house of cards collapses. Tough luck, suckers.

Perhaps the thing that concerns me the most about the Supreme Court’s decision is the precedent that the ruling sets. Our highest court has now held that it is permissible for the federal government to impose a tax … er, um … penalty upon citizens in order to force citizens to purchase a private commercial product. In oral arguments, Justice Scalia joked about next creating a mandate that everyone purchase gym memberships to make sure that people stay healthy. Wasn’t funny. His point was spot on. Where do the new taxing … er, um … penalizing powers of our government end? I fear that we will only learn the answer to this question after the election.

The Supreme Court’s ruling and the implementation of this law are another example of how the Court and our legislature are hopelessly out of touch with the needs of the people and how to meet those needs. If President Obama’s actions and the Supreme Court’s decision don’t make our citizens realize that we need a profound change in the governance of our country, then woe to us all.

What a disappointment we will have been to our forefathers.

By Birdstrike M.D.

Yesterday, my 2 year old asked me, “Daddy, do clouds make rain by forming condensing nuclei of water vapor which act to form droplets which fall to the ground?”  I said, “No, son.  No.  You’ve got it all wrong.  Actually, those drops of rain are the tears of our founding fathers crying over the recent Supreme Court decision on Obamacare.”

As I predicted it would many months agoon Student Doctor Network, the Supreme Court upheld the

Supreme Court upheld the Affordable Care Act (ACA).  I was against “Obamacare” as it has come to be known, from the very beginning.  I am still against it, for reasons too numerous to count.  On the face of it however, the entire rationale for declaring Obamacare unconstitutional was absurd, and rather disingenuous.  Amongst the 2000 pages of this behemoth of a law, the one portion that makes the most sense is the “individual mandate”, which is the single portion that actually attempts to require all Americans to take at least a sliver of responsibility for the cost of their own health care expenses.  This is the one and only portion of it that is actually revolutionary and acts to reverse the central core of what is wrong with the health of our people, and our healthcare system itself: the complete lack of responsibility of so many individuals for their own health, and healthcare expenses.

Like many of you, I wished that the Supreme Court would overturn the law so that we could rebuild it in a way that makes sense both to patients and physicians, and less so to politicians.  However, as much as it pains me, I have to admit that Chief Justice John Roberts’ opinion was courageous and brilliant.  It tears my heart out to write it, but its true.  As I interpret it, what he essentially told America and the opponents of Obamacare was, “Don’t ask me or the spirits of our Founding Fathers to overturn your law, written by your representatives, and approved by your President with some fabricated technicality to fix your ‘Oops!’ Man up, and live with it.  Otherwise, if you don’t like it throw the fools out, elect a new government and start over, or fix it”.

Indulge me for a minute and allow me to play the “What Would Our Dead Relatives Have Thought, Game”:  The Founding Fathers of this country lived under true tyranny.  They were ruled by a tyrant King that would not hesitate to jail or execute someone for speaking an opinion infinitely less offensive that my own, and simply on a whim.  Many of them lost their lives fighting for the right simply to have representation. (Remember your history class, “No taxation without representation!”?)  I’m sure they would conclude that we have that luxury, and many other life easing luxuries they did without.  (You know, real important stuff like electricity, running water, insulin for diabetics, iPhone 4s with integrated Siri personal assistant.)  They didn’t have to worry about 40 million people being uninsured.  Health insurance didn’t exist.  It wasn’t a crisis for them, that only 80% of people could get an MRI.  0% of people got MRIs.  MRIs didn’t exist.  Neither did door-to-doctor times, ED wait-time billboards, sterile technique, antibiotics, cab vouchers or Sierra Mist with a meal tray.

If the “individual mandate” for all Americans to buy health insurance was severed from the ACA and we had to choose between it and the rest of the bill in its entirety, I would choose to keep the individual mandate, and strike down the other 2000 pages from this complex bill, the details of which no single person on Planet Earth has read let alone understands.  Most unknown, are the costs and unintended consequences of this bill.  As Nancy Pelosi has been repeatedly been quoted, so tragically and accurately, “We have to pass the bill so you can find out what is in it.”  This is an irresponsible and dangerous attitude that would never meet the “standard of care” any of us physicians have to live under, yet we are now ruled by it.

For decades I have been required to pay Medicare tax to pay for your Grandma’s health insurance (Medicare).  For decades I’ve been required to pay taxes to pay for your unemployed uncle Ed’s health insurance (Medicaid).  How come these things are not “unconstitutional”, the “Joe’s Grandma Mandate” and the “Billy Bob’s Uncle Ed Mandate”?  Now that the ever so radical concept comes along, of requiring me to pay for the health insurance not only for your Grandmother and your uncle Ed, but also for myself, all of a sudden it’s a cruel violation of my constitutional rights?  Give me a break.  The government can send 58,000 men to die in Vietnam, and that’s constitutional?  The government can take your house, bulldoze it and build a road in its place “for the common good” and that’s “constitutional”?  But to require Joe Six-Pack to chip in a few bucks for his ER course, ICU stay and redo CABG, half of the cost of which is eaten by insurance-buying Americans in inflated premiums, the other half of which is eaten by the doctors that took care of the patient in the first place, is unconstitutional?  Give me a break.

As much as it pains me that Obamacare stands, since I’ll be paying higher taxes, certainly get paid less from Medicare, Medicaid and private insurance all of whom will cut payments to doctors to cover the newly insured, and likely be overwhelmed by the masses of newly insured patients with government insurance that pays pennies on the dollar…. I still think John Roberts did the right thing.  We as Americans, and we as physicians allowed this to happen.  We let them walk right in, take over our house, repaint it, decorate it, rob it and remake it in their own image with nary a fight.  We are amazing healers, but the most hapless complainers and the feeblest of pushovers.  Let this be a lesson to us all.  We have allowed them to raise the stakes to a much greater height and will face a much more epic battle to save God’s profession.