A Follow-up July 4 To A Previous Toast to The President

Preface: In my 2009 book, Obama, Doctors, and Health Reform (IUniverse), I gave this toast (in bold print) to President Obama, then the new chief executive, 18 months ago. In parentheses are my follow up critiques.

• To the fulfillment of your dream ( May it continue to be as good for the nation as for you)
• To the content of your character ( Which I have never doubted)
• To hope (At this stage, 18 months in, I am losing hope)
• To change (It’s not yet the change we can believe in)
• To vision ( Your vision seems to be big government at any cost)
• To audacity (Your health bill passed against the will of the people. Now that’s audacity)
• To equality ( Which comes down to redistributing income and benefits to future Obama voters)
• To selflessness (This I have never questioned, but I’m wavering )
• To respect for others ( Your comment about “kicking ass” doesn’t help)
• To unity ( An unfilled legacy - with partisanship at an all time high)
• To fairness (Which is in the eyes of the beholder)
• To idealism (You get a pass on style)
• To realism (You get a fail on substance)
• To coverage for all (Nice try)
• To access for all ( Too few doctors will be there to serve)
• To more doctors for more access (Your bill doesn't produce more doctors)
• To the Patient-Centered Primary Care Collaborative (It’s part of the bill, but has yet to gain traction)
• To the Physicians’ Foundation (You have yet to acknowledge its existence, though it represents all doctors in all state medical societies)
• To healers of every specialty and every group (To these you give lip service)
• To the sick in need of care ( Medicare recipients aren’t buying,if polls are any indication)
• To affordable care (C-. Premiums will rise 10% this year for many middle-class Americans who previously could afford care and now may become wards of the state. For uninsured,an A-, but not until 2014)
• To health care savings ( F. Your health bill kills HSA growth, though HSAs are now owned by 10 million Americans and have slowed cost growth for HSA owners)
• To clinical information systems ( You’re betting $20 billion on universal interoperable EHRs, which may be inoperable and may go down as the biggest gamble in IT history and greatest boondoggle of all times)
• To workable clinical computers (So far, a D+ to C- in the eyes of most independent practitioners)
• To more prevention ( C+. Noble goal. Worth a shot. So far it hasn’t turned the tide of obesity and diabetic epidemics)
• To personal responsibility (Ultimate solution. Main incentive would be having patients spend more of own money. Penalties for smoking and obesity might help)
• To the right foods ( Michelle is doing good job promoting)
• To more exercise (Of the physical rather than the verbal variety)
• To no smoking (Unfortunately, your personal example doesn't help)
• To less obesity and diabetes (Fat chance - 30% of Americans are obese and 20% are diabetic or pre-diabetic, and numbers are still rising)
• To less chronic disease (Not promising in aging population with entrenched habits and wear and tear of a lifetime)
• To better outcomes ( Depends on reliant doctors as well as compliant patients )
• To comprehensive care (This is major problem and will remain so as long as Americans rely on specialists more than generalists)
• To coordinated care (Ditto)
• To top-down dispensation (Top-down mandates rarely work)
• To bottom-up innovation (Works, but requires time and risk/reward incentives, too few in your bill)
• To patient responsibility (As in following doctor’s orders and personal behavior changes)
• To doctor accountability ( Translated: follow government rules and regulations)
• To financial transparency ( A high-sounding but elusive dream)
• To multicultural fluency (Different cultures and different medical expectations don’t always mix)
• To freedom to choose (Not in Obama’s long term game plan)
• To freedom to pay ( Not going to happen as long as private contracting with doctors forbidden by federal rules)
• To free exercise of clinical judgment (Likely to be less in future with rationing and rationalization of care through protocols and rules-based evidence medicine)
• To revamped Medicare doctor pay (Congress has given waffling, fiddling, and dithering a bad name)
• To reasonable Medicare reimbursement (Not likely if history is prologue)
• To decent Medicaid reimbursement (Not in our lifetime, not with radical cuts in state budgets required by your bill)
• To malpractice reform (Not in Obama’s tenure)
• To MD to MD cooperation (Not as rare as critics say)
• To clinical collaboration ( In medicine we call it professional courtesy)
• To respect for markets ( No respect)
• To health savings accounts (No respect)
• To less intrusive government (No respect)
• To feasible individualism (no respect)
• To reasonable collectivism ( Not likely with Big Government mindset)
• To less regulations and hassles ( You’ve got to be kidding)
• To fewer unneeded frazzles (With Obama, it’s dazzle-frazzle)
• To a sustainable health system (Not under this health bill)
• To the end of free entitlements (Not with 32 million more in Medicaid and 78 million more qualifying for Medicare over next 15 years)
• To economic recovery ( Most still see only darkness at the end of the tunnel)
• To the future (Which looks dark too)
• To 2009 (Gone, but not forgotten)
• To doing the right thing (I’m sure this is your intent)
• To knowing what the right thing is (I question your judgment here)
• To celebrating what counts most ( To this, let's raise our glasses high)
• To you and your family (And a beautiful family it is, including your Portuguese Water Dog)
• To your health ( and many more good years)
• To the health of the nation (Amen)
• To fiscal sanity (Not as long as you spend, spend, spend)
• To the preservation of capitalism ( Not so a wild dream. Unfortunately,corporations are sitting on an unprecedented mountain of cash, which they are not investing because of uncertainty of your motives and because their CEOs regard you as anti-business at your core. This may not be true, but perception has a way of becoming reality))
• To the economic recovery (Still waiting. Try an across-the-board tax cut. It works every time, as Presidents Kennedy and Reagan proved)

Mr. President, you need our respect. You have it at the moment, but you need to earn it. We only have one president at a time. It's a tough job, and it's complicated. We ask only for balance. We ask only that you respect our desires for a less intrusive, more financially responsible government, for the virtues of capitalism and its power to create jobs, for belief in the motivations, experience, and competence of medical professionals. and for as much and as many personal freedoms as feasible.