On The Affordable Health Care Act of 2008


Here is the website for Dr. Levin’s highly biased personal  opinion.



Dr. Levin is a conservative pundit that interprets and spins political issues according to his personal opinion, not accepted as mainstream by many other physicians.


Here is an alternative opinion:  I have read “Obama care” from stem to stern as it will directly affect everyone when fully implemented. Technically it’s formal name is the  “Affordable Heath Care Act of 2008” (AHCA 2008).  The cold reality: there is absolutely nothing in it (except in the mind of Dr. Levin and other wing-nuts) that proscribes treatment for needy patients of any age. What the law does include is an end-of-life facet, commonly misinterpreted, usually intentionally.


The law allows payment for physicians to include discussions of end-life care preferences and what’s available to them, not what they are mandated to do. That means that a discussion of whether such aggressive measures as CPR, endotracheal intubation and mechanical ventilation, dialysis, vasoactive medications to stabilize blood pressure, IV medications for cardiac arrhythmias and other similar measures are desired under the circumstances of admission or if the patient suddenly or unexpectedly deteriorates.


That means that if I land in the trauma bay at age 68, and I’m all other factors equal in pretty good baseline health and I have good family support systems, and I get operated on and I land in an ICU for a while, the discussion of my care would be what modalities were available, what could be effectively applied and what my expected outcome would be. The discussion of  “end-of-life” would ONLY occur to determine my  (prospective) wishes should I suddenly and unexpectedly have a cardiac standstill, or major full hemispheric stroke, or big intracranial bleed…….something that dramatically changed my potential for an  outcome I or anyone else would want. I would have an opportunity to determine what my wishes might be in such circumstances BEFORE I became incompetent to speak for myself. Then that discussion would revolve around goals of care, what it’s surmised that I might want for myself, what my wife would want for me.  Does that sound reasonable?


Would I want to be fully maintained with a tracheostomy, feeding tube  and skilled nursing home admission on the long shot chance I might  unexpectedly get better? Or would I or my wife want to opt for “comfort  measures”, letting nature take it’s course as it will anyway.  It’s all about choice, not demands of arrogant surgeons that some politician is mandating something or nothing.


The “Death Panel” ploy was originated in 2008 by the impeccably ruthless, self-promoting political opportunist Sarah Palin who knows nothing about any health care formulation. Palin took the above and bastardized it to a tortured interpretation.  That discussions of  end-of-life care necessarily allowed the Federal Government to use those  discussions as a foot-in-door, then inform the patient or their family  that the physician would deny care unilaterally by some structured  mandate. She then famously told audiences that Obama would have let her kid with Downs Syndrome die, which should give you a pretty good view of what she’s capable of.  There is not a single syllable in the AHCA of 2008 that even remotely suggests that ANY needy patient will be denied care on the basis of their age or any other objective factor.


And thereby hangs a dilemma.


The United States is the ONLY country in the global village that allows patients and their family’s wishes to drive the health care industry.  That’s good news and bad news. The good news is you can pretty much name your poison.  The bad news is that in allowing this, the cost of health care is unbelievably expensive and increasing arithmetically every year, actually every month.  What that means as a practical matter is that someone somewhere is eventually going to have to start making decisions about the appropriateness of flying 95 year old Hunt & Hess grade 5  (unresponsive) intracranial bleeds to hospitals like mine in helicopters so they can run up a big bill before we stop the nonsense. We have the ability now to pretty accurately access outcome for virtually any disease process. That means that sooner or later, patients and their families desiring extremely long shot cures for vanishingly small outcome potential are going to have to back off or pony up the cash.  Who will make those decisions?


Unlikely I will, nor should I.  Traditionally my role is as a patient advocate. I am expected to defend my patient against the vicissitudes of any bureaucratic body tending to use them as isolated cost-savers. That means that it’s a conflict of interest for me to have anything to do with conservation of resources at the macro level. My job is to do the best I can with what I have to work with. In a perverse way, Palin is right. Death Panels will probably eventually arrive, but it won’t be for the purposes of saving the government money. It will be because it’s medically inappropriate to spend money on patients without a meaningful potential to survive with a quality of life any normal hominid would desire. That day is coming, but it wasn’t Palin that accurately predicted it.


You want to be scared?  I’ll give you a good scare. A family of four,  Mama, Papa both work to make ends meet, two kids both in grade school  making a combined income of under US$50,000/Year. They make ends meet as long as there are no unforeseen emergencies, but it’s tight. In this kind of job market, it’s highly unlikely either of them receive any meaningful health care indemnification from their jobs. Jobs that pay these kinds of wages rarely offer affordable medical insurance. If it is offered, it’s extremely expensive and increasing in price anywhere from 9% to 15% a year. They probably don’t opt for it in order to afford kids clothes and school expenses.  Then the patriarch has a car accident, lands in a trauma bay, ends up in the operating room.  Worse, they look up and and see ME. Neurological injuries are particularly devastating and expensive. A three hour neurosurgical procedure later, they land in  a Neuro-ICU intubated and it takes three days to get them extubated,  then another week treating other disasters, transfer to the ward for  another three days and home but unable to work for a while due to  residual deficits. Then expensive physical rehab.


Now this family is running on ONE income, less than half the funds available before the accident just about what it takes to pay the  mortgage on their modest home. Now they are in a DEEP financial bind, and since the patriarch is not in a union and there is no right to work  law, they give his job to the next in line and he’s out of work. THEN the hospital presents them with a total bill for about US$100,000 and demands a payment schedule be set up about the same as purchasing a  Mercedes. The hospital then issues a legal claim and gets a judgment allowing them to garnish the wages of the one remaining worker.


This scenario happens every day and it breaks my heart. I never send anyone a bill for anything. I am an employee of the medical center and I deal with everyone and everyone that comes my way. I don’t know nor do I care what their financial status is which one of the reasons I’m here. It’s the hospital that acts as the bad guy and they have no problem with it.  It’s cold, impersonal business.


The reason I support the AHCA of 2008 is not because it’s perfect. It isn’t. I support it because it does SOMETHING to rectify the outrageous inequity of people getting sick and ruining the rest of their lives. The AHCA of 2008 adds 31 million hard working needy persons to the roles of an indemnification plan that literally saves their lives in the event of   medical emergency. It forces greedy and heartless insurance companies to quit cherry picking only healthy clients, ignoring those most likely to need medical care, and it also forces them to stop arbitrarily and capriciously refusing to pay for care after it’s already been rendered.  It’s a start and it’s better than what we have now.  You don’t see any members of the aforementioned family out in Tea Party lines carrying  “repeal Obamacare” signs. You see idealists that don’t understand the situation, or don’t care about their fellow Americans.

Because of Clark’s Law, there is a whole contingent out there dedicated to opposing everything and anything the current sitting President does,  including anything that might be beneficial. A lot depends on if he is re-elected, which as a practical matter is likely when the smoke from the Republican circular firing squad clears. If the AHCA clears the Supreme Court, which its likely to all other factors being equal, I think it will be beneficial for the public. If not, the current stockholder driven health care insurance companies will continue to drive the price (profit) to unaffordability for all.


Worried about the cost of the AHCA/2008?  Worry more about the cost without it.  Something like the AHCA of 2008 is necessary to protect the public from exorbitant costs of health care in the USA. The rates are exorbitant because they’re geared to the insurance trade, which pays ten cents on the dollar, so if they bill ten times more than they expect to get, they break even. But for the uninsured, they pay the ten times rate. Access to health care is DIRECTLY related to indemnification.  Paying up front for them is cheaper than paying MORE for them once they put off medical care and get sicker. Because of HIPPA and COBRA, EVERYONE must be treated when they show up.  As soon as they land in an ER, they must be treated, admitted and kept till they can be put back on the street. Taxpayers are going to pay for them in any event. If the health care services get them earlier, the taxpayers pay lass for them.

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