You go to a fine restaurant and order a prime steak, or for us heart-healthy cardiologists, a grilled plank salmon. The server brings you a two-day-old charred hamburger on a moldy bun. You look at the plate and say, "That's not what I ordered." The tone of your voice and your volume are proportional to how disgusting the thing is that you are supposed to swallow.
For healthcare reform, "THAT WAS NOT WHAT WE ORDERED!!!"
What was ordered?
What was ordered was (a) protecting our health by access to medical care, what we needed when we needed it; (b) access to that care through insurance which we could afford; and (c) national spending on healthcare that would not bankrupt our country. THAT was what we ordered in the healthcare reform Law. Indeed, that was what we were promised. Recall its original name: Patient Protection and Affordable Health Care Act.
In high-sounding speeches, the President said his signature program--Obamacare--would deliver those benefits to all Americans, carefully ignoring the 15 million Americans who are not U.S. citizens. He promised to eliminate the stain on our honor of the "uninsured"; that "You could keep your doctor," if you liked him or her; that your out-of-pocket insurance costs would go down; and that he would harness the power of the market to reduce healthcare spending. So, he ordered what we ordered, or so we thought.
When is an order not an order?
An order is not an order when what we told the waiter is not what he tells the cooks.
We ordered reduced spending but Obamacare spends at least $1.7 trillion. This is, of course, money that we do not have, which adds to already bloated national deficit.
I am 100% certain that we ordered more jobs and more money in our pockets. Yet Obamacare's Medical Device tax deters innovation and crushes start-ups. Its so-called "Cadillac" Tax will hit hardest on schoolteachers, police and firemen, construction workers and small businesses. And businesses, trying to cope with ACA's huge price tag, are not hiring anyone; firing people to get below the magic number of 50; and reducing full time employees to part-time workers in order to make them ineligible for employer-supported health benefits.
Obamacare is increasing jobs, just not the ones we ordered--in the private sector. ACA is hiring (and spending tons of "healthcare" dollars) on bureaucracy, regulation, oversight, and administration, and of course, in the IRS.
We ordered better access to medical care. Obamacare cuts payments to Medicare doctors by $716 billion, meaning there will be fewer doctors and less service. We ordered elimination of the uninsured, yet tens of millions of Americans will still get care yet remain uninsured based on citizenship (lack thereof); religious affiliation (Amish, Mennonites, Scientologists, and maybe Muslims); prisoner status; and political connections.
We ordered affordable, meaning less expensive, health insurance. What did we get? Premiums have gone up 18-30% already, depending on where you live. Some actuaries are estimating a 50% increase while others fear premiums could double. Then there are the additional taxes, such as the Cadillac Tax, that hits people who cannot afford a car at all. This is definitely not what we expected and why are some people exempt for these higher costs that the rest of us must pay?
The issue of waivers or exemptions from Obamacare costs is particularly galling when the President says he wants to restore "fairness" to American society. Why is it fair to impose Obamacare on some but not on others, like Congress? I am dead sure we did not order that!
So, when is an order not an order? When the server taking the order is the President.
What is the best way to ruin an order?
True, our order was completely changed by the waiter. But believe it or not, things can get worse. How do you make an already bad order worse? With "change orders."
You start by telling the cooks in the kitchen to create something different from what the customer wanted. Then, while they are preparing the meal, you repeatedly change the order. Yes, the customer wants it hot and spicy. No wait, the customer has an ulcer. The customer in seat 12 wants to start with soup. The customer in seat 12 doesn't want an appetizer at all. Table six wants white wine, or was that table nine?
We ordered help for those needing long-term medical care, so Obamacare contained the CLASS (Community Living Assistance Services and Support) Act. Shortly after passage of Obamacare, there was change order #1. The Act was cancelled. Sen. Kent Conrad, the Democratic chairman of the Senate Budget Committee, called the CLASS Act "a Ponzi scheme of the first order, the kind of thing Bernie Madoff would be proud of."
Then was the promise to cover those with pre-existing conditions especially chronic (read expensive) illnesses: ACA's PCIP or Pre-Existing Condition Insurance Plan. This was cancelled--change order #2--after less than a third of the eligible citizens were enrolled. All the allotted money had been consumed by administration and bureaucracy. So States like my own (New Mexico) found that Washington had left our most vulnerable people out in the cold with no care and empty promises.
Speaking of empty promises, there was the shell game (worse than a change order) played on the unions. Their promised protection against the high costs of Obamacare seems to have vanished. Complaints were heard from the United Food and Commercial Workers International Union, the Operating Engineers Union, the International Brotherhood of Teamsters, and even (talk about irony) the IRS employees' union. The President of the Union of Roofers, Waterproofers, and Allied Workers called for repeal: "I am therefore calling for repeal or complete reform of the Affordable Care Act."
Of course, there change orders #4, #7 and #9 (I lose track). These were delays in payments to the States; waiving the penalty for non-compliance on big business; and delay in capping out-of-pocket health care expenses. How does this jibe with the President's promises to help the middle class, to support the average American?
I should not forget one of the biggest change orders. Over and over, the President talked about our responsibility to provide care, his commitment to caring for the weakest among us, and the need to reform a "broken" healthcare system. Even its two names, Obamacare and Patient Protection and Affordable Health Care Act, refer to CARE. Yet after the ACA was passed, President Obama changed the word care to insurance. He was reforming health insurance, not health care. This is clearly a change order we did not want. Was this a bait-and-switch?
Let's demand what we ordered.
As is clear, our order got distorted, mangled and repeatedly changed. What we are being served bears absolutely no relationship to what we ordered. If it does (have a relationship), then it is the exact opposite of what we ordered.
We need to send back this unpalatable, frankly inedible meal that is being forced down our throats. We then need to demand our order just as we wanted it in the first place: more access to medical care and less spending on healthcare.
For those who say better and cheaper are mutually exclusive, I can point to a host of examples where it is happening right now and in my own State. To avoid chauvinism, I will give you one from Camden, N.J. Dr. Joel Brenner proved that he could make chronically sick people healthier and save large amounts of money at the same time.
Deane Waldman MD MBA is a member of the Board of Directors of the New Mexico Health Insurance Exchange, Adjunct Scholar for the Rio Grande Foundation (policy think tank), and author of "Uproot US Healthcare" as well as "The Cancer In Healthcare" (September 2013).