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"My office manager and med business guru have calculated that this is just the beginning. Tax rates are going to go through the roof with additional Obamacare taxes AND the expiration of the Bush tax cuts," he added. "And most analysts think reimbursement rates for docs will go down about 20-25% the next 2 years, and that is BEFORE Obamacare really kicks in."

dermdoc wrote that he feels "kind of feel like the Hollywood lib directors who wouldn't give parts to conservative actors."

"The most interesting thing was seeing the reactions of other employees who came to the startling realization that their support of a guy who hurts my business could cost them their job," he wrote.

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But maybe that is part of watching history up close. Fifty years from now, if we are not a fully-owned subsidiary of the Chinese (we won't be) I suspect the story will be something much more bland: "Americans, in a time of economic turmoil, recognized the need for every citizen to have access to adequate health care, and despite several deep currents of anxiety, rallied to pass the first iteration of the current system." Etc. The jeers, the rancor, the lies about "death panels" will all be part of the small details that only the specialists pay attention to. Watching the process last night, watching each aye vote, you had the sense that, yes, these people knew they were making history. I'm not naive. I know the bill is flawed. I know there's a lot more to be done, and I know that the vicissitudes of the public mood may mean that it takes longer to get the important things fixed than it should. But last night was historic, and everybody knew it. So, actually, yes, it made me proud to be an American. We're slow to act, we're easily confused, we often fall prey to fears to which we should know better than be susceptible, but mostly we will do the right thing. Eventually. Piece by piece. And sometimes that's good enough.

And now, more process.

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This is a payment from the North Dakota Department of Human Services to a physician licensed and practicing in the state. It is payment for medical consultations for ten patients that, by the physician's estimate, accounted for about 25 hours of work time. (Those payment and time estimates do not account for the additional surgical procedures that several of the patients required.)

To render these services at the hourly rate of less than $1, this physician went to four years of medical school and did an additional four years of residency. For this work the physician was paid about $35,000 per year. The physician now carries a couple hundred thousand dollars in school debt and faces annual malpractice insurance costing tens of thousands of dollars. (Doctors elsewhere, and in other practices, pay a multiple of this.) Maintaining a staffed clinic is not cheap.

The insidiousness of the tactic at work here is not immediately evident. Politicians get heartburn when faced with cutting funding for Medicaid (or, especially, Medicare). It makes them look like scumbags. But they need to save money somewhere and they will try to do it on the backs of the most destitute and poor (who probably don't vote anyway) before proposing any tax increase at all. And a more politically expedient and villainous way to cut Medicare and Medicaid expenses is to allow cuts in physician reimbursement.

What this does is force medical professionals to be the bad guys. They can choose to provide services at a loss-or be assholes and choose not to. Not surprisingly, patients who could get a doctor last year but cannot this year come to see the doctor as the problem-not the underfunded program and the legislators who make it so. This scam also unnecessarily stresses doctors, especially a shrinking pool of primary care and family practice physicians, who seldom go into the profession for the money.

Adopted by Congress in 1997, the same year Cameron gave us Titanic, the Sustainable Growth Rate formula is a method for legislators to prevent Medicare and Medicaid payments from growing too quickly. The SGR formula affixes physician reimbursements to changes in the gross domestic product. As health care costs wildly outpace GDP growth, the SGR formula actually functions as a reimbursement cut.

Congress has avoided any actual cuts by repeatedly voting for extra funding. (Of course, there have been cuts in the form of cutting coverage; the cheapest reimbursement is the one you never have to make, right?) But after years of avoiding it, the SGR formula is now in debt-more than $200 billion-and dictates a 21% cut in reimbursements. This will happen in March unless Congress votes for the health care reform bill or passes a special funding override (again).

Indeed, a great deal of the American Medical Association support for reform that the Democrats so enjoy trumpeting is because of promised permanent SGR reform. In this leaner economic climate, passing this spending is tougher and has already failed once in the Senate. With a new distribution in the Senate, spurring another round of posturing over reform all over again, time is running out.

Part of what Republicans shamefully call an increase in spending in the House's health-care reform bill is actually just a canceling of the SGR cut. So this "increased spending" is basically just a market-determined funding of Medicare and Medicaid. That is important to know because one in every four Medicare patients is now having trouble finding a primary care physician.

As reimbursements shrink, fewer physicians are willing to take on new Medicare/Medicaid patients. The Mayo Clinic, that bastion of medical service held up as a model, even by the White House, of "how it can work"? It is no longer accepting a number of Medicaid and Medicare patients.

In some cases, after factoring costs, physicians are paying to provide treatment. Is any fan of market economics willing to step forward and defend such a system? Should one blame doctors for altogether stopping care for so many when it produces a loss?

Many don't care. Politicians get to deliver on pledges of "no tax increases." And poor and old people? Who gives a shit about them anyway, right? The poor ones are probably poor because of something they did (they should go get a job with health insurance, right?). Everyone wants a entitled handout! And the old ones should be lucky they get anything at all.

For those who feel or act that way, they should ask themselves: do you "support the troops"?

Health care reimbursement for military retirees and dependents of both active and retired servicemembers through Tricare, run by the Department of Defense's Military Health System, is based on the same Medicare SGR formula. Failure to change this formula either via the reform bill or through another permanent solution is fundamentally an unwillingness to provide the troops with a reliable system of health care.

Sure, call the AARP a self-interested group of fogies... just like The Military Officers Association of America, which considers the potential cuts an emergency action item.

You don't support Medicaid/Medicare SRG reform via the House health care reform bill or through other permanent spending increases? Then you don't support the military.

Of those ten patients mentioned above, for which the physician received that check for $25, sure enough, one of them was military. And the North Dakota physician did not receive the check just by itself. It was accompanied by a letter that said that, effective Jan 1, 2010:

"ND Medicaid will no longer allow/reimburse physicians (MD/DO) and other non-physician practitioners for outpatient and inpatient consultations."

So from here on out, that $1 per hour rate of patient care, if considered a "consultation," will now be reimbursed at the rate of $0.

"Ethically I'd feel terrible to drop them," the doctor said. "I'd probably take as many as possible. But I would still need to pay my bills. There are costs. I can't treat them from a tent on my lawn."

Abe Sauer most recently wrote about USC's branding trouble and the right's take on Obama's first year.

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