ObamaCare is a train wreck. I wrote a book about it by the same name in 2014. Since then, it has only gotten worse. Costs continue to rise and the Democrats keep pushing more government subsidies to make it more affordable. This is throwing good money after bad. What can we do about it?

John C. Goodman, healthcare economist, has some suggestions. He says that Congress is making three missteps to fixing the problem:

• On the buyer side, we have been trying to force people to buy insurance they would never buy with their own money.
• On the seller side, we have been trying to force insurers to enroll people they do not want to enroll.
• On both sides of the market, we have created inverse incentives that cause costs to be higher and quality lower than would otherwise have been the case.

Goodman explains: “The difficulty of trying to force people to buy something they don’t want to buy became evident in year one. Fast food restaurant chains were forced to offer their employees insurance that was so comprehensive, we were led to believe it would cover the cost of a million-dollar premature baby. For self-coverage, employees had to pay 9.6 percent of wages, and out-of-pocket spending could be as high as $6,350. To cover a spouse and children, workers were asked to pay the full premium.”

The problem is people have no interest in coverage for low-probability medical events that could cost a million dollars. They figure they’ll never happen and if they do someone else will end up paying the bill.

Goodman tells us In the years that followed, Obamacare insurance became increasingly unattractive. Average premiums for marketplace plans have grown twice as fast as they have in a typical employer plan.  Last year, the average deductible in the most commonly selected exchange plan was $4,572, more than twice as high as in an average employer plan ($1,787). The maximum out-of-pocket expense in the average exchange plan was also more than twice as high ($9,450) as in the average employer plan ($4,750).

The current controversy concerns a second tier of federal tax subsidies for marketplace insurance. Although created during the COVID-19 era, the real reason for these enhanced subsidies was not COVID-19. The unsubsidized part of the market was in a death spiral. The healthy were dropping out in droves. As the pool became sicker, premiums kept rising to cover the higher cost.

What’s the solution?

Let people buy the insurance they want! KFF (formerly Kaiser) says that premiums could be cut in half for most people if they could buy the type of insurance that was generally available before there was Obamacare.

What if they choose a plan that fails to cover an unexpected problem (like substance abuse) that is required coverage in the Obamacare exchanges? Let them immediately switch to a silver exchange plan that meets that need. Keep Obamacare insurance in place for people who need it, when they need it. But let most families have cheaper and better insurance if it meets their current needs.

On the seller side, it should come as no surprise that insurers are not anxious to enroll people whose premium payments are well below the expected cost of their care. To solve this problem, look at the Medicare Advantage (MA) program. This is the only place in our health care system where doctors who discover a change in a patient’s condition (say the emergence of cancer) can send that information to the insurer (in this case, Medicare) and receive a higher premium payment to cover the expected increase in treatment costs. The result is MA plans welcome patients with costly health problems – patients that insurers in other market try to avoid.

Lastly, Goodman tells us there are perverse incentives in some plans. Because subsidized premium payments are capped as a percent of the enrollee’s income, most enrollees bear no personal cost when they choose a more expensive health plan. The extra cost is paid by the taxpayers. And since enrollees are not price sensitive, insurers don’t really compete on price.

To solve this problem, consider the federal employees’ health benefits program (the one Congress gets to use!) The employer subsidy is a fixed amount, independent of the employee’s health plan selection. If the employee chooses a more expensive plan, the extra cost comes out of the employee’s pocket, not some other pocket. Because this system makes buyers price sensitive, insurers in this market compete on price and quality just like they do in other insurance markets.

These solutions are not that difficult to implement, but Congress has a problem: Democrats won’t admit that ObamaCare has a problem – because they created it! Like an alcoholic who can’t get help until he admits he has a problem, Democrats won’t work with Republicans to fix ObamaCare until they face up to the failures of the healthcare system they created.

You might expect that medical students today are learning more than ever about medicine as time, research, and experience improve our understanding of human health. You might expect our medical schools would be producing the finest doctors ever with all this new knowledge. You would be wrong.

What’s wrong? Dr. Stanley Goldfarb, writing in The Wall Street Journal, says DEI is what’s wrong. Dr. Goldfarb is chairman of Do No Harm and a former associate dean at the University of Pennsylvania Perelman School of Medicine. He’s been an outspoken critic of woke medical education and his articles have been referred to before in this blog. (Woke Medical Education Update)

For those of you unfamiliar with DEI, it stands for Diversity, Equity, and Inclusion. Those are fancy terms for what amounts to reverse discrimination; a misguided attempt to undo past discrimination against people of color. Rather than heed the words of Dr. Martin Luther King, Jr. to judge people by the “content of their character, not the color of their skin,” DEI attempts to judge people only by the color of their skin, and white is always wrong.

How has DEI impacted medical education?

Dr Goldfarb explains, “For years, medical schools have emphasized discrimination and indoctrination at the expense of merit and excellence, to the detriment of patients. While the Trump administration has taken steps to right this wrong, a more far-reaching response is needed. For the sake of every American’s health, the president should reform the accreditation system for medical schools. The crisis in medical education is directly connected to DEI. For years, the Liaison Committee on Medical Education, which accredits M.D.-granting programs, required medical schools to establish programs “aimed at achieving diversity.”

Goldfarb goes on to tell us medical schools responded by embracing diversity in hiring and admissions. They changed their curricula to teach economic and social lessons that ladder up to the false claim that America is systemically racist. The LCME has tacitly approved this shift by issuing vague standards that give medical schools far too much leeway. The resulting lack of rigor allows unprepared students to slide through undemanding courses while undercutting the preparation needed to become excellent doctors.

The traditional medical school curriculum is comprised of two years of classroom study of all the subjects needed to complete a comprehensive medical education. The next two years are spent in clinical applications of those subjects while treating patients.

Goldfarb says the traditional two years of pre-clinical education required to become a doctor has been significantly reduced at more than a third of medical schools. This gives short shrift to the foundational curriculum in genetics, biochemistry, biostatistics and epidemiology. A senior associate dean at Rutgers told the American Medical Association in 2021, “It’s better, to me, to shorten the foundational science curriculum.” That leaves students with a diminished ability to understand medical literature and make health recommendations.

At UCLA’s David Geffen School of Medicine, according to reporting based on interviews with faculty members, more than 50% of students failed basic tests on family medicine, pediatrics and emergency medicine. Nationwide, the percentage of medical students who pass the first part of the licensure exam has fallen every year since 2020, dropping from 97% to 89% for students pursuing an M.D. Clinical skills have declined for years, made worse by DEI’s distraction from clinical education.

President Trump is addressing the problem. He signed an executive order calling out the LCME by name. The committee responded by formally abandoning its diversity mandate. Yet the LCME has kept a separate mandate that medical schools teach students to “recognize and appropriately address biases in themselves, in others, and in the health care delivery process.”

Unfortunately, this committee is sponsored by the American Medical Association and the Association of American Medical Colleges, both of which continue to champion DEI. (The AMA today represents only about one in four medical doctors. I personally dropped my AMA membership many years ago when I couldn’t tolerate their stance on abortion.)

The solution to the current problem is finding a new accreditor for medical schools. The Department of Education should be soliciting applications for a replacement, but this process will take time and the medical licensing exam and graduate medical education programs would also have to acknowledge the new accreditor.

I am proud to say as a Floridian that Florida and five other states are leading the way. They established the Commission for Public Higher Education to accredit their public university systems. They need to add a medical school accreditation component.

Dr Goldfarb says “Florida’s public medical schools are the best candidates for ditching the LCME. They’ve largely rejected DEI and embraced merit. That’s exactly what a new accreditor should do—for the benefit of physicians, patients and public health. Ultimately, this is about ensuring Americans have the best physicians providing the best care. DEI has distracted medical schools from their purpose, and while it’s vital to cure the ideological disease, it’s just as important to refocus medical education on its lifesaving mission.”

The truth about marijuana is finally being revealed. Even the liberal New York Times has been forced to reverse its position on marijuana.

The New York Times editorial board just published an opinion called “It’s Time for America to Admit That It Has a Marijuana Problem.” The editorial board admitted it has long supported marijuana legalization and even published a six-part series comparing the federal ban on marijuana to the prohibition of alcohol, advocating for the ban to be repealed.

Marc Tamasco, writing for Fox News, says the Times admitted “Much of what we wrote then holds up – but not all of it does.” At the time, supporters of legalization predicted that it would bring few downsides. In our editorials, we described marijuana addiction and dependence as ‘relatively minor problems.’ Many advocates went further and claimed that marijuana was a harmless drug that might even bring net health benefits. They also said that legalization might not lead to greater use.”

Despite these prior claims, the Times argued that it is “now clear that many of these predictions were wrong,” and that the legalization of the drug “has led to much more use.” The outlet cited data from the National Survey on Drug Use and Health, which suggested that approximately 18 million Americans have used marijuana almost daily, or about five times a week, in recent years, up from about 6 million in 2012 and less than 1 million in 1992.

This dramatic uptick in marijuana consumption in the United States has “caused a rise in addiction and other problems,” according to the Times.

“Each year, nearly 2.8 million people in the United States suffer from cannabinoid hyperemesis syndrome, which causes severe vomiting and stomach pain. More people have also ended up in hospitals with marijuana-linked paranoia and chronic psychotic disorders. Bystanders have also been hurt, including by people driving under the influence of pot,” the outlet pointed out.

Professor Bertha Madras of Harvard University, in a letter to The Wall Street Journal, tells us cannabis use disorder, or CUD, is neither rare nor benign. According to the National Survey on Drug Use and Health, the prevalence of CUD among adolescents and young adults (15.8%) is comparable to that of alcohol use disorder (14.4%)—even though the number of alcohol users exceeds the number of marijuana users and the proportion of the population affected by CUD far exceeds that of other illicit substance use disorders. An estimated 25% to 30% of users develop CUD, with adolescents doing so at roughly twice the adult rate.

Research published in the journal Psychological Medicine found that a shocking 30% of schizophrenia cases among men aged 21 to 30 could have been thwarted if they had averted cannabis use disorder (CUD). Scientists examined recent cases of schizophrenia, an abnormal interpretation of reality resulting in hallucinations, delusions or disordered thinking. The study’s authors stated that in 2021, CUD played an integral role in 15% of cases occurring in men aged 16 to 49, and in 4% of cases affecting women in the same age range. This new study examined data concerning 6.9 million people ages 16 to 49 collected in Denmark from 1972 to 2021.

The truth is the cannabis being used today is not your cannabis of the hippie era in the 1960s. The concentration of THC is roughly 20 times that of the marijuana in the hippie era.

This is not news to those who have been reading my blog. Previous posts on this subject include High-THC Cannabis Linked to DNA Changes, Marijuana and Violence, Marijuana and Traffic Deaths, and Cannabis and Schizophrenia. These articles can be viewed by using the search engine for my archives.