ObamaCare: The Fine Print

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I decided to read the new ObamaCare law. I started with the Patient Protection and Affordable Care Act (PPACA). It’s 906 pages, and it reads like the legalese on my widescreen TV warranty. I think I understand what it covers, but my stomach tells me I won’t know for sure until something breaks — when customer service starts reading things to me from the fine print section. So instead of trying to understand entire sections (or even paragraphs and sentences), I concentrated on certain individual words, whose importance became evident as I read, simply counting their occurrence. Although it did nothing for my indigestion, such a quasi-statistical approach greatly enhanced my understanding of the new law.

ObamaCare creates over 100 new government commissions. Some estimates are as high as 159; no one seems to know for sure. But judging by the 4,231 occurrences of the word “shall,” the commissions will be very busy, whatever their number. And they will be everywhere, all the time.

According to the PPACA, commissions shall establish procedures; promulgate regulations; provide for efficient and non-discriminatory administration; prescribe regulations, rules, and guidance. They will be identifying health quality measures, monitoring outcomes, allotting money to states, awarding grants to entities, participating in rigorous federal evaluation of activities, ensuring that hospitals are representative of the spectrum, establishing a national strategy to improve healthcare, aggregating consistent data on quality, consulting with other commissions. They will be conducting demonstration programs, computing benchmarks, establishing geographically adjusted premiums, negotiating reimbursement rates, determining contingency margins, conducting competitive bidding processes. All this is barely the tip of a colossal, dizzying, and nebulous iceberg of healthcare command and control — so who needs the Public Option?

Luckily, someone had the good sense to include lots of studies (222 instances of “study” or “studies”). Besides, you can’t have commissions without studies. Since ObamaCare is a new program of unprecedented scale that will radically transform one-sixth of the economy and affect every citizen (not to mention up to 20 million noncitizens), studying it after enactment only makes good sense. Nancy Pelosi would, no doubt, consider it a corollary to her “we have to pass it to find out what’s in it” advice.

And what good are studies without reports? Reports are needed to document the objective and unbiased findings of their lobbyist authors. They also document recommendations, including that one most unabashedly important recommendation, shamelessly common to any self-respecting government study — the one for more funding. With 1,037 instances of “report” or “reports” or “reporting,” it looks like commissioners will have plenty of official-looking documents to make them look intelligent at healthcare meetings and hearings. And this will give them something to wave passionately above their big heads at their staged press conferences.

The frequency of the word “shall” is also an indicator of commission activity. But in many instances, it pertains to nongovernment healthcare participants — as do the words “require” (1,303 instances) and “comply” or “compliance” (143 instances). Consequently, doctors, patients, hospitals, insurance companies, and so forth are also going to be very busy. And they had better be meticulously compliant. If an investigation (57 instances) finds you to be in violation of ObamaCare, you will be subject to penalties (186 instances). Clearly, ObamaCare is serious about enforcement and tacitly urges compliance as a general rule to follow upon encountering a “shall” that may apply to you. That is obviously good advice when “shall” falls in the range from blatantly coercive to routinely coercive. For ambiguous “shalls” and seemingly innocuous ones, consult the nearest commission, the IRS, or a lawyer from the soon-to-be burgeoning ObamaCare litigation industry.

The early sections of the PPACA include many good words, but quickly switch to many not-so-good words in

the “fine print” area. For example, Title I is called “Quality, Affordable Health Care For All Americans” — an excellent heading except for the “Quality,” the “Affordable,” and the “For All Americans” parts.

Quality

Section 2717, “Ensuring The Quality Of Care,” is illustrative of ObamaCare’s innovative ideas. For example, reporting requirements and reimbursement structures will be developed to

“improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage.”

Who knew that quality reporting would ensure quality healthcare? And isn’t it about time doctors started managing cases effectively, coordinating care, and improving disease management? I bet they can’t get away with inferior stuff in Cuba. Surprisingly, there was no mention of the “anger management” that will surely be needed for doctors whose intelligence, professionalism, and dedication are insulted by these and many other sophomoric attempts to coerce them into the ObamaCare way of medical practice.

Affordable

Apparently there will be savings (60 instances) that will make ObamaCare affordable. Indeed, there are provisions for excess savings. According to Section 2706:

“An accountable care organization that meets the performance guidelines established by the Secretary under subsection (c)(1) and achieves savings greater than the annual minimal savings level established by the State under subsection (c)(2) shall receive an incentive payment for such year equal to a portion (as determined appropriate by the Secretary) of the amount of such excess savings. The Secretary may establish an annual cap on incentive payments for an accountable care organization.”

So, first you have to achieve savings in excess of some minimum (set by the Secretary), then wait for your incentive payment (set by the Secretary), all the while hoping a cap (set by the Secretary) isn’t applied, siphoning off your portion to fund something else. Surprisingly, there was no mention of the armored trucks that will surely be needed for transporting all the savings to government counting houses.

Another source of savings will derive from increases in productivity. ObamaCare includes ingenious methods for getting slow and lazy doctors to treat patients at faster rates. For example, Medicare reimbursements will shrink to one-third of what private insurers pay. Such methods are sure to get patients flying out the door of hospitals and doctors’ offices. It’s one of those why-didn’t-I-think-of-that ideas, except for two problems: (1) most doctors and hospitals will likely opt out of ObamaCare long before reimbursements fall that low, and (2) after waiting weeks or months to get into an affordable ObamaCare facility, only to be treated hastily in assembly line fashion, most patients flying out the door will be on their way to a quality non-ObamaCare facility.

For All Americans

ObamaCare promises healthcare for all Americans, but some more than others. There are groups that get special treatment: special populations, underserved populations, vulnerable populations, American Indians, and Washington DC, to name a few. Minorities even get their own office and a deputy secretary. As stated in Section 10334,

“…there is established in the Office of the Secretary, the Office of Minority Health, which shall be headed by the Deputy Assistant Secretary for Minority Health . . . for the purpose of improving minority health and the quality of health care minorities receive, and eliminating racial and ethnic disparities. In carrying out this subsection, the Secretary, acting through the Deputy Assistant Secretary, shall award grants, contracts, enter into memoranda of understanding, cooperative, interagency, intra-agency and other agreements with public and nonprofit private entities, agencies, as well as Departmental and Cabinet agencies and organizations, and with organizations that are indigenous human resource providers in communities of color to assure improved health status of racial and ethnic minorities, and shall develop measures to evaluate the effectiveness of activities aimed at reducing health disparities and supporting the local community. Such measures shall evaluate community outreach activities, language services, workforce cultural competence, and other areas as determined by the Secretary.”

Such special populations have special rules. There are special rules for abortions, gender specific needs, children with special needs, widows and widowers, large group markets, low income individuals and families, individuals with disabilities, geriatric and pediatric patients, the homeless, victims of abuse or trauma, individuals with mental health or substance-related disorders, individuals with HIV/AIDS, and many more. As in the case of minority health, these special rules are, no doubt, required to reduce health disparities caused by the bigotry or incompetence of pre-ObamaCare medical professionals. Surprisingly, given such priorities and the availability of grants and contracts to promote the healthcare of special populations, there is no mention of “social justice,” “SEIU,” or “ACORN.”

Not belonging to a special population may not be a problem. With the elimination of annual and lifetime limits, prohibition of exclusions for pre-existing conditions, prohibition of rescissions, extensions for dependents, reinsurance of early retirees, etc., there should be plenty of ObamaCare for non-special Americans.

On the other hand, this may very well be a problem. There are 1,082 instances of the words “eligible” or “eligibility” and 643 instances of “qualified” or “approved.” Once I see a word such as “eligible,” I start thinking about who might be ineligible. And that brings my thought process back to the fine print in my TV warranty. I guess I’ll just have to hope that when I need my ObamaCare I’ll be eligible for an approved treatment at a qualified facility. In the meantime, however, I’ll be thinking, with more than a little concern, about the true meaning of more than a few ObamaCare words, as they play on my growing heartburn.

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