Sunday, March 28, 2010

What Obamacare Is Going to Look Like

In an article on the collapse of Detroit, Gary North has some fascinating comments on what he thinks ObamaCare will look like. He writes:

Obamacare will lead to an expansion of these forms of medicine:

1. Concierge

2. Wal-Mart

3. ER

4. HMO

5. Mexican

CONCIERGE. The rich and very rich hire their own physicians. They pay top dollar. The physicians do not take third-party payments, either from the government or insurance companies. They are independent practitioners. They make house calls. The houses they call on are very large.

For the upper middle class, there are fee-for-service physicians. They take no third-party payments. They do not make house calls.

WAL-MART. These are the walk-in clinics. They are price competitive. They treat minor ailments. They sell services on a one-time basis. They take credit cards. They may or may not cater to the Medicare crowd. They are assembly-line clinics. There are no major surgeries or other high-cost, high-risk services.

ER. Large hospital emergency rooms are mandated by law. The poor get treated there. In a life-and-death emergency, they work. People who would otherwise die in a couple of hours are saved. For walk-in patients, the ERs ration by time. Patients demonstrate their patience.

HMO. This style of medicine is efficient. It cuts costs by cutting services and cutting time. You see the physician on duty. You may not have seen him before. His job is to get you in and out as fast as possible. Time is monitored by the company. Computers make this easy.

MEXICAN. This is off-shore medicine. In Canada, when you can't get treated for months or years, you come to the United States and pay. This will not be possible for Canadians much longer, except for rich ones. Mexico will serve upper middle-class Americans as the USA has served Canadians.

It is possible to get very good surgical care in Asia and Latin America. You have to know who the good practitioners are. Asian hospitals sell for 25% the same level of services. There is less regulation there. Plane fares are cheap. A stay in a hotel is cheap.

There will be entrepreneurs who set up Websites off-shore that direct Americans to practitioners abroad. The Web allows this sort of advertising.

Physicians who practice alone or in small limited liability corporations will find that they cannot compete under the new payment system. Assembly-line medicine will replace the traditional doctor-patient relationship.


Most physicians are trapped. They cannot sell their practices. The price of practices has been dropping.

Foreign-trained physicians who can pass the U.S. tests are coming to America. They are competitive.

Technical Services that can be digitized are being outsourced to India and other Asian nations.

Young American physicians begin with a lot of debt. They need income fast. They will be hired by the HMOs and clinics. They will not reach the salary level of this generation of physicians. They will be upper-middle-class income-earners.

There will be specialists, of course. Plastic surgeons who specialize in making rich women better looking will not be part of the new system. They will be able to do well. But for the typical practitioner, his career options have been dramatically restricted by the new law.

I think most physicians will stick it out until they retire at age 67. They owe money. They need the income. The law's most restrictive provisions will not kick in until 2014. They will adjust...

You had better decide which kind of medical care you can live with. Then you had better locate a practitioner soon. This is especially true if you want a fee-for-service physician. People with money will go to them. They are already hard to find. They charge more. It's not easy to become a patient. They are booked up...

If you have an existing physician, do what you can to become an above-average patient.

You had better start getting into shape. You can no longer afford to be vulnerable to the diseases and afflictions of a flabby lifestyle. ObamaCare has changed the risk-reward ratio. Risk has just gone up. It will continue to go up.

There will be no roll-back of this law. It is going to be enforced for as long as the U.S. government has money.

That may not be as long as Obama thinks.
If this is what ObamaCare turns out to be, we can thank our lucky stars. It will still lower the life expectancy in the country, but it will be a much slower decline. Innovation will be suffocated, so forget about new treatments. But if you are allowed to still pay cash for medical services at the "concierge level," then there is hope for when major medical treatments are required.

But, I think North is an optimist.  It could be much worse.

Here is a pessimistic "adjustment" to North's expectations:

As far as I can tell the current administration thinks in terms of egalitarianism and interventions. As medical prices climb, price controls will be instituted, and if not now, in the very near future ALL doctors will be required to accept ObamCare insurance and the price controls with it.  They will even be forced to accept patients, they otherwise might choose to turn down

Money alone won't work to get better care. It will require connections and money, but even with money and connections the "superior" care will be second rate compared to quality care today.

Any new medical treatments will be influenced by lobbyists, not by real medical demands. What pharmecutical companies come up with will be pushed on the people. Diagnosis will be based on psuedo-disease and threats. Think the H1N1 vaccine. It will become difficult for the average person to determine what is an important duagnosis and what is a lobbyist inspired diagnosis.

Eventually, students coming out of medical schools will be brainwashed in psuedo diagnosis and treatments. Then life expectancy will really collapse. That's the pessimistic forecast.

Bottom line: How long you will live will be dependent on how ObamaCare evolves and how fast.  But top medical care, for the population as a whole, will peak out in the U.S. within the next two years. From there, it is down hill. None of us knows how fast down hill.

1 comment:

  1. HMO's are now "Accountable Care Organizations" and "bundled payment" is the new term for capitation. They are 1990's managed care with a new name and ribbon.