Monday, June 29, 2015

A Funny Thing Happened on the Way to the Health Care Forum

Democrats and liberals rejoiced. The nation had embraced tolerance on social issues.

Republicans celebrated. They were now free to pursue economic and national security problems without being labeled bigots.

In Charleston, South Carolinians demonstrated what true Christianity is all about – love and forgiveness rather than hate and bigotry.

To further end the charges of Southern bigotry, the politicians of South Carolina vowed to take down the Confederate flag from the state capitol grounds and put it a museum. Mississippi and Alabama public officials made similar vows. For the South, this was a healing time.

Jonathon Martin of the New York Times (“As Left Wins, GO.P. Reflects”) wrote, “ A cascade of events suggests that 2015 could be remembered as a Liberal Spring: the moment when deeply divisive and consuming questions or race, sexuality and broadened access to health care were settled in quick succession, and social tolerance was cemented as a cornerstone of American public life.”

Which brings me to the definition of tolerance, “A fair and objective attitude towards those whose opinions differ from one’s own: freedom from bigotry."

These days far too often, resistance to mainstream liberalism is labeled “bigotry,” which politically correct circles is defined as “stubborn and complete intolerance of any freed , belief, or opinion that differs from one’s own.”

While acknowledging that the country had become more tolerant and, in some ways, culturally liberal, many Republicans contend that America is still receptive to a more conservative approach approach on economics and social security.

Obama says it’s here to stay. But it will need fixing. Last week the Republican House overwhelming passed a bill repealing the Medical Innovation Tax and the Independent Patient Payment Board. These repeals await a Senate vote. And the GOP says it will still repeal ObamaCare if it wins in 2016. And it says it will seek to passed a market patient-centered plan in 2017 0r 2018 after it repeals ObamaCare with its individual and employer mandates . In the meantime, it will chip away at ObamaCare by denying funding, prevent he bailout of insurers who lose money on subsidies, and softening the employer mandate on comapies with over 50 employees.

In an editorial today “The Fight for Health Care Isn’t Over,” the Times acidly comments on this and GOP efforts in 21 states resisting Medicaid expansion, “The Republicans, gripped by irrational hostility (italics mine) to helping the poor, would rather hurt the uninsured and damage their state economies by refusing federal money. Federal money always comes with strings attached - loss of control, compliance with federal regulations, and unforeseen expenses.

A Funny Thing Happened on the Way to the Health Care Forum

A Funny Thing Happened on the Way to the Health Care Forum
A funny thing happened this week after the Supreme Court OKed federal subsidies and gay marriage.
Democrats and liberals rejoiced that the nation had embraced tolerance on social issues. Republicans celebrated that they were now free to pursue economic and national security problems without being labeled bigots. In Charleston, South Carolinians demonstrated what true Christianity is all about – love and forgiveness rather than hate and bigotry.
To further end the charges of Southern bigotry, the politicians of South Carolina vowed to take down the Confederate flag from the state capitol grounds and put it a museum. Mississippi and Alabama public officials made similar vows. For the South, this was a healing time.
Jonathon Martin of the New York Times New York Times ( “As Left Wins, GO.P. Reflects”) wrote, “ A cascade of events suggests that 2015 could be remembered as a Liberal Spring: the moment when deeply divisive and consuming questions or race, sexuality and broadened access to health care were settled in quick succession, and social tolerance was cemented as a cornerstone of American public life.”
Which brings me to the definition of tolerance, “A fair and objective attitude towards those whose opinions differ from one’s own: freedom from bigotry.
These days far too often, resistance to mainstream liberalism is labeled “bigotry,” which politically correct circles is defined as “stubborn and complete intolerance of any freed , belief, or opinion that differs from one’s own.”

“While acknowledging that the country had become more tolerant and, in some ways, culturally liberal, many Republicans contend that America is still receptive to a more conservative approach approach on economics and social security.
Obama says it’s here to stay. But it will need fixing. Last week the Republican House overwhelming passed a bill repealing the Medical Innovation Tax and the Independent Patient Payment Board. And the GOP says it will still repeal ObamaCare if it wins in 2016. And it says it will seek to passed a market patient-centered plan in 2017 0r 2018 after it repeals ObamaCare with its individual and employer mandates . In the meantime, it will chip away at ObamaCare by denying funding, prevent he bailout of insurers who lose money on subsidies, and softening the employer mandate on comapies with over 50 employees.
In an editorial today “The Fight for Health Care Isn’t Over,” the Times acidly comments on this and GOP efforts in 21 states resisting Medicaid expansion, “The Republicans, gripped by irrational hostility (italics mine) to helping the poor, would rather hurt the uninsured and damage their state economies by refusing federal money

Saturday, June 27, 2015

Headline Hunting for Supreme Court Impact on ObamaCare

I’ve gone hunting for headlines to see how media is responding to Supreme Court upholding federal health exchange subsidies.

Left-leaning publications are joyous. Right-tilting media are either furious with Chief Justice Roberts or happy Republicans are now free to pursue repeal.

Here is a sample of today’s headlines.

“Supreme Deliverance for Republicans,” Fox News

“Twisted Logic of John Roberts Ruling,” New York Post

“ Health Law Nightmare is Just Beginning,” National Interest

“Health Care Ruling a Landmark Victory for White House,” Real Clear Politics

“ No Easy Road for Health Law: Troubles Remain: Still Highly Unpopular with Significant Structural Issues,” Politico

“Krauthammer: No Question GOP Will Repeal if They Win”

“Supreme Court Allows National Health Care Subsidies,” New York Times

I was particularly interested in what the headlines were in the Wall Street Journal, long a harsh critic of ObamaCare. Here are 11 WSJ headlines and subheadings.

“High Court Saves Health Law: Justices in 6-3 Ruling Uphold Provision of Obama’s Signature Program; Republicans Vow To Continue Fight.

“Roberts Charts Own Path: Frustrated Conservatives Again”

“Insurers and Hospitals Breath Sign of Relief”

“Ruling Caps a Week of Wins for the President

“Decision Pushes Health Care to Fore of GOP Campaign”

“Companies to Take Aim at Law’s Fees”

“Disputed Ruling Has Long Backstory”

“ObamaCare Debate Begins Anew”

“The Political John Roberts: The Chief Justice Again Rewrites ObamaCare to Save It”

“ObamaCare Wins One, America Loses”

“Antonin Scalia Dissents

There you have it. For some, Supreme Court ruling is a resounding victory. For others, it is a Pyrrhic victory, destined to last only until 2016, if Republicans win. For most, ObamaCare’a structural problems still lurk - soaring premiums and deductibles, unpopularity among public, losses of choice of doctors and health plans, and negative impact on economic growth.. The decision is good in short term for Obama, uninsured, hospitals, and insurers. But it is bad in many respects for some people who want prompt access to care they need, from a doctor, hospital, and health plan they choose, at a price they can afford.

Thursday, June 25, 2015

As VA Goes, So Goes ACA?

So it goes.
Kurt Vonnegut, Jr (1922-007), Slaughter House 5

ACA critics are wont to compare ObamaCare to the VA health system. The cite the VA as an example where a single-payer government-run system might lead – a mindless unaccountable bureaucracy with rationing and long waiting lines.

The VA has the nation’s largest integrated, coordinated health system connected by a single health information system. But last year the VA’s problems became glaringly apparent, with veterans said to be dying while waiting for months to be seen and a widespread shortage of physicians, nurses, and other care givers.

Things aren’t getting any better. Demands for VA services is up 50% this year, costs are growing because of a growing population of aging veterans with dementia and chronic disease, costs of new drugs for hepatitis C and cancer are mounting exponentially, and the VA faces a $2.7 billion budget shortfall. Access has expanded with 2.7 million more appointments and authorization for 900,000 people to see physicians outside the VA system. Physician workloads have grown by an average of 21% across the system, but no supply of more physicians is in sight.

The principal VA problems are increased demand, shortages of physicians and nurses, lack of office space, and a complicated, seemingly intractable, querulous, whistle-blowing bureaucracy full of infighting and finger-pointing superimposed on a larger political debate about the size and role of government and its inherent inefficiencies.

And so it goes. Whether ObamaCare is headed in the same direction is unknown. But so it goes with the VA.
Supreme Court Rule 6-3 in Favor of Federal Subsidies

Today’s Supreme Court ruling favoring federal subsidies assures ObamaCare survival until the 2016 election and beyond. The decision is a political victory for the Obama administration and a defeat for Republicans who sought to gut the law or repealed.

What does the ruling mean?

It means the Court has now ruled twice, the first time in 2012, that ObamaCare is constitutional.

It means liberals will be pleased and conservatives displeased with the decision.

It means hospitals will be pleased because some of the uninsured hospital expenses will now be paid.

It means institutional federal laws giving a legal right to health care - Medicare (1965) Medicaid (1965), Emergency Medical Treatment and Active Labor Act (EMTALA 1986) Children’s Health Insurance Program (CHIP1997), and Patient Protection and Affordable Care Act (ACA2010) – will continue to consume more federal dollars.

It means federal entitlement programs will continue go grow, as they have over the last 50 years.

It means that the 6.7 million Americans on federal subsidies will continue to receive $3,312 per recipient per annum or $222 billion in all. More people will be subsidized to consume health care at middle class taxpayer expense.

It means hospitals, which heretofore had to absorb costs of the insured who could not afford care, will have a new source of federal revenues.

It means less uncertainty for health plans, who feared a death spiral and other disruptive effects if the Court had ruled against federal subsidies
It means those unpopular individual and employer mandates will remain in place.

What the ruling not mean?

It does not mean the controversy over the law has ended. It will continue through the 2016 elections.

It does not mean that the law is working as intended. Yes, it reduced the number of uninsured by 16 to 17 million out of 50 million. Yes, it helped 6.7 million uninsured and low income people below 4 times the poverty rate, less than 3% of the population.

But it may not help the middle class, who in 2016, are projected to see their health premiums, deductibles, co-pays, and out of pocket costs soar by 10% to 30% and who may see their plans cancelled and their doctors and hospitals declared out-of-network.

And it does not mean America’s uninsured will jump on the health exchange bandwagon. According to a survey sponsored by the Robert Wood Johnson Foundation, 38% of insured get their medical care by paying out of pocket, 28% us fee-low-cost clinics, 26% go without care, 20% buy discount medications, 14% use the ER, 9% negotiate their bills down, and 4% go to another country for care.

The largest group of people who remain uninsured, 45% of them, forego coverage by choice, even though the law guarantees them they can get coverage on their own or through a job.

Many of the uninsured are confident they can get their care cheaper and manage it better without health insurance: 56% on doctor visits, 53% on prescription drugs, 52% on checkups, 48% on emergency care, and 42% on preventive tests or screening. Many Americans, in short, are getting their care the old-fashioned way – cash, barter, or charity. They believe they can get a better deal without insurance. They prefer to pay ObamaCare’s penalty mandates rather than enroll in Obama Care sponsored and approved health plans

Saturday, June 20, 2015

Transition from ObamaCare to Free Market Care

Senator Ron Johnson of Wisconsin, anticipating a Supreme Court rejection of federal ObamaCare subsidies in 34 states, has set forth the following proposal to transition from ObamaCare to a free market subsidies.

He stresses his proposal is not a substitute for ObamaCare, but would have support among Republicans and the American public, because it is realistic, would create a financial bridge to a new system, would lower costs, decrease impact on the $18 trillion federal deficit, would decrease premium costs and increase choice for health plans and providers for the middle class, and would protect 8 to 10 million Americans who already have subsidies.

Essentially, his plan buys time to transition to a new system

The plan, which he calls “If You Like Your Health Plan," You Can Keep It Act, contains the following elements.

• A grandfather clause allowing those with federal subsidies to keep those subsidies for 2 years.

• Ends the unpopular individual and employer mandates.

• Ends insurance company bailouts.

• Offers health care tax credits for all by equalizing tax credits for everyone.

• Allows people to shop for insurance across state lines.

Again his plan is not a panacea. It recognizes reality, that you cannot abruptly end a law that has already been implemented. You cannot immediately repeal all of its elements, such ending subsidies for 10 million or so citizens or removing provisions that protect those with pre-existing illness, said to number over 100 million.

But you can highlight the flaws in the bill, retain its benefits, and limit. its damages. And you can put forth a proposal that will unify Republicans and appeal to the majority of Americans.
What Price Freedom?

The U.S. is one of the freest nations on earth. We extol freedom. Freedom is the hallmark of our constitution. The search for freedom is why we attract immigrants. A mix of those escaping poverty come here, looking for a better life, seeking to capitalize on their skills and to contribute to mankind.

But freedom has a price - gun violence, limited access to health care for some, unhealthy behavior by many, sometimes hateful speech, unequal opportunities, uneven economic outcomes, and never ending debates on the regulatory, taxing, and war-making powers of government and individual freedoms and rights of privacy.

When will it ever end? It won’t. That why we call America “the land of the free.” Freedom has its upsides and downsides. It involves good and bad choices, rational and irrational people, loving and hateful people. Freedom is the price we pay for being human and having differences.

President Franklin Roosevelt said there were four essential freedoms: one, freedom of speech and expression, two, freedom of worship, three, freedom from want, and four, freedom from fear.

We have fallen short on all four. On the speech front, one of the prices of freedom has been “political correctness,” or p.c. If you are a liberal or a Democrat, too often you are labeled an elitist or a socialist. Or you are a conservative or Republican, you are deemed a racist or a bigot. This is too bad, for you are likely neither. You are seeking common ground in the center of politics and humanity.

To be p.c. or not to be p.c. is not the question. The question is: what is best for American freedom of expression, freedom of worship, freedom from want, and freedom from fear. All of these freedoms are at stake in one way or another in the upcoming Supreme Court decision. Let us not over “politicize” the decision, whatever it is.

Thursday, June 18, 2015

New England Journal of Journal Takes Stock Before Court Decision New England Journal of Medicine article “The Affordable Care Act at 5 Years,” by David Blumenthal, MD, MPP, Melinda Adams, and Rachel Nuzum, MPH.

The lead author, Dr.David Blumenthal, is a quintessential ObamaCare supporter. He received his undergraduate, Medical, and Health Policy Degrees from Harvard. He served as professor of medicine at Harvard Medical School. He was Obama’s first National Coordinator of Health Information Technology. He was chief information and innovation officer at Partner’s Health System. He played an important role in developing RomneyCare, the prototype for ObamaCare. And he is now president of the Commonwealth Fund in New York City, a national philanthropy whose mission is to promote an support a high performing health system offering greater access, improved quality, and greater efficiency for society’s most vulnerable low income , uninsured, minorities, children, minorities, and young adults.

Given these characteristics, What do Blumenthal et al and the New England Journal have to say about the Affordable Care Act? Blumenthal is on the board of editors of the The Journal. All of these constituencies support the ACA and yearn for its success. While they are cautiously optimistic, they are also guarded as evidenced by their careful wording about its prospects.

They note the ACA 11.7 million have selected a health plan under health exchanges, that 10.8 8 million have enrolled in Medicaid since ACA enactment, that 3 million young Americans have gained access under their parents’ plans, that 8 to 12 million have benefited from regulations that prevent discrimination for people with pre-existing condition, and that 30 million now have insurance under new sources of coverage.

But they are also aware of ACA problems, the botched launch, cancelled politics, narrowed networks, and substantial increases in premiums, copayments, and deductibles.

And they strike these cautionary notes.

“The heated political debates over the ACA and lack of definitive evaluations for so many of its numerous programs complicate efforts to assess its track record at the 5-year point.”

“Profound philosophical objections to federal initiatives in health and other policy areas have deep roots in American political discourse and will probably persist, guaranteed that the ACA will remain controversial

They end with the usual optimistic view that people will like the ACA once they get used to its benefits.

“Time will tell whether the contributions of the ACA will moderate these philosophical objections and create the kind of broad public support for the ACA that Medicare and Medicaid – also controversial when they pass – now enjoy.”

They are hoping for the best but fear for the worse while whistling in the dark.
ObamaCare Drives Consolidation: What It Means for Consumers and Doctors

And I’m figuring
On Biggering
And Biggering

Doctor Suess, The Lorax

When the history of U.S. health care from 1965, when Medicare and Medicaid were enacted, to 2015, is written, it will say : Government matters, money matters, market share matters, size matters.

Government is now the largest healthcare payer. Medicare and Medicaid pay over $1 trillion annual of the $3 trillion Americans spend on health care. The 5 biggest health insurers – United ($130.5 billion), Anthem ($73.9 billion), Aetna ($58 billion), Cigna ($34.0 billion), and Humana ( $48,5 billion) – spend $347 billion, largely to carry out standardized government mandates. That adds up to $36 billion, and these are just the top five of 120o health plans. And there are more to come, as hospital systems create their won insurance plans.

Since 2005, the percentage change in annual enrollment by coverage type has been;

• Medicaid, + 52.2%, 69,7 million people

• Medicare, + 31.1%, 54,4 million people

• Individual, including Medicare supplemental and health exchange plans, +25.4%, 25.2 million.

• Employer sponsored plans, -3.5%, 172 million

In other words, government sponsored and mandated plans dominate U.S. health care and are the fastest growing health market segment.

What do this trend portend? It means government entitlements are exploding, along with the national debt of $18 trillion. It means once government is in charge, it standards benefits. Every government plan must contain 10 essential benefits. It means health plans can’t adjust risk for pre-existing conditions. It means insurers lose the freedom to design products to adjust to costs of sicker patients, it means narrowing of physician and hospital choice, it means higher cost and premiums and deductibles and out-of-pocket costs, it means survival of every payer in the medical-industrial complex depends on enrollment volumes and market share, and it means consolidation at all levels of the system – among hospitals and physicians, among health plans, among pharmaceutical companies among device manufacturers.

Among physicians, it means those who pay them will be driven to consolidate . Everything will grow bigger – government programs, hospitals, health plans and physician discounts. It means doctors will go to work for hospitals, community clinics, and accountable care organizations. It means consolidation begets consolidation. It means private practices will shrink or morph into direct pay concierge practices and independent diagnostic and treatment centers to cut overhead and maintain their clinical autonomy. It means the delegation of health care to large organizations run my managers and organized for perpetuity. It means government is bend on biggering and biggering its role in health care.

Wednesday, June 17, 2015

Donald Trump’s Bluff and His House of Cards

Tell the truth – or trump, but get the trick.

Mark Twain

In announcing for President, Donald Trump portrayed America as a House of Cards ready to collapse.

Trump said, “The American dream is dead.” As evidence, he cited Mexico as our business enemy number one; Iran as malevolent devil developing nuclear weapons to obliterate Israel; our crushing and growing $18 billion, soon to be $20 trillion or even $24 trillion; national debt; jobs exported abroad due to our leader’s bungling business incompetence; the incompetent handling of the Pacific trade agreement that will take over American businesses and steal our money; the “lie” of ObamaCare and the growing entitlement overreach; duplicitous double-talk by politicians and both sides of the political aisle.

The announcement was a big bluff. It was rich in card-playing metaphors – the collapse of the House of Cards, apocalyptic forewarning of hard truths as in inside straight, the flamboyant body language and patriotic background indicating a winning hand. All of this in a bluff to win the first trick, which is gaining a place on the first New Hampshire debate as one of the top ten polling Republicans.

The announcement was a clever use. Trump knows Americans are hungry, even desperate, for straight no-nonsense talk about what’s wrong with America and simple solutions on how to fix it. No sugar-coating. No beating around the Bushes. Just the hard truths as Trump sees them. It was The Art of the Deal on the national state. It was a bet that the public will dismiss critic’s arguments of Trump as a self-aggrandizing, confrontational, unrealistic bigot.

We shall see if Trump wins the first trick. We shall see political opponents trump Trump. We shall see if Trump becomes the Energizing Bunny or sinks as a Mad Hare from Alice in Wonderland.

Tuesday, June 16, 2015

President Obama’s Character and the Road to Health Reform

This last weekend I read The Road to Character by David Brooks (Random House, 2015, 300 pages). Brooks is a New York Times columnist and a regular on the PBS NewsHour.

Mostly his book is about the shift in American culture since World War Ii from one of self-denial, self-sacrifice, self-effacement, humility, and communities uniting behind a common cause – to a culture of selfies, self-expression, facebook gossip, self-expression, rampant individualism, and self-serving entrepreneurship.

Of this transformation, Brooks comments “We have seen a broad shift of culture what might be called The Big Me into a culture that encourages people to think mainly of themselves as the center of the universe.”

As I soaked in these world. I thought of the character of President Obama and his efforts to reform American health care. It seems to me his intentions are noble. After all, ObamaCare is a crusade to protect the poor and make health care more affordable .

But instead, in the main, if you exclude the 20 million who have gained access to subsidized care through the health exchanges and Medicaid, health care has become unaffordable for vast swathes of the middle class. ObamaCare has raised premiums and deductibles, limited choice and access, and imposed mandates and penalties. Something has gone wrong with Obama’s “transcendental presidency” and his efforts to expand coverage, equalize outcomes, lower costs, improve quality, and to do it all in one fell swoop.

Why the uneven results of the health law?

Part of it may simply be trying to do too much too soon given limited resources. Part of it may be you can’t turn around the Queen Mary (the $3 trillion medical-industrial complex) on a dime, or, for that matter, in a decade. Part of it may a spoiled American people with their penchant for simultaneous individualism, unlimited access to the best, and government dependency ( I want what I want when I want it while the sun shines). Part of it may be the American legal system with its quest for million dollar Casino jackpots at the end of rainbow.

And, part of it may be President Obama’s character: his narcissistic self-centerness; his rhetoric about cooling the ear, stopping sea level rises, and changing the climate; his self-isolation in a White House bubble surrounded by sycophants; his frequent signals that he is unwilling to compromise his ideological beliefs; his purposeful and transparent dislike for the other branches of government, the opposing political party, and business and medical interests; and his disinclination to establish relationships with members of his own political party.

In her June 14 New York Times column, “Flickering Greatness,” Maureen Down, a staunch long-time ally, describes the current situation succinctly, “The Obama White House has managed Congress poortly, with arrogance – or even worse, neglect. –Obama castes him as a man alone in the arena, refusing to let Democrats sand on the stage at key moments or even given them a lift in his memo.”

In the end, ObamaCare may succeed because of its need and its nobility of purpose. But it may fail because of flaws in Obama’s character.

Saturday, June 13, 2015

ObamaCare: A Neutral Point of View

Amidst all the controversy of whether the Patient Protection and Affordable Care Act has worked or not worked, here is a neutral point of view as presented by Wikipedia.

Neutral Point of View

Here is a neutral point of view of ObamaCare, as presented by Wikipedia.

“The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or colloquially "ObamaCare", is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act amendment, it represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.”

“The ACA was enacted to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of healthcare for individuals and the government. It introduced mechanisms like mandates, subsidies, and insurance exchanges. The law requires insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of pre-existing conditions or sex. In 2011 the Congressional Budget Office projected that the ACA would lower both future deficits and Medicare spending.”

“On June 28, 2012, the United States Supreme Court upheld the constitutionality of the ACA's individual mandate as an exercise of Congress's taxing power in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the ACA's Medicaid expansion under penalty of losing their current Medicaid funding. Since the ruling, the law and its implementation have continued to face challenges in Congress and federal courts, and from some state governments, conservative advocacy groups, labor unions, and small business organizations.”

“In March 2015, the Centers for Disease Control and Prevention reported that the average number of uninsured during the period from January to September 2014 was 11.4 million fewer than the average in 2010. In April 2015, Gallup reported that the percentage of adults who were uninsured dropped from 18% in the third quarter of 2013 to 11.9% in the first quarter of 2015.”

This summary may help you sort out the facts and fantasies surrounding ObamaCare. If you are interested in the facts and fantasies as interpreted by the President in his own words, and by one of his adversaries, Stephen Moore of the Wall Street Journal and the Heritage Foundation, you may want to read "the Fallacy That ObamaCare Is Working, Forbes, June 12, 2015.
And Who Shall Organize Health Care?

In 1988 I wrote a book And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota.

My answer was that in the future health care corporations, or managed care corporations, and doctors working for these organizations, would be caring for the sick.

The only way doctors could exert their independence, I said, would be to form organizations of their own. Medicine had become a big business, and only organizations with access to capital, the skills to deal with management and bureaucratic issues, the scale to market to populations, and the ability to mobilize technologies and specialists to address issues of disease prevention, wellness, the ills of an aging population, and organized and led by managers and executives for perpetuity would survive.
But who shall organize these organizations? Who should take the vows of organization fealty, to be loyal to the organization in perpetuity above all else – even if one has to sacrifice individual freedoms of doctors and patients.

Shall it be government? As a social organizer dedicated to equalizing benefits and access to health care for all, President Obama thinks the role of organizing health care belongs to government.

Shall it be managed care organizations, working in concert with government and carrying out the mission and programs of government? These organizations have capital and organizational skills to do the job.
Shall it be hospitals acting as integrated health organizations, dominating their community and regional markets, employing physicians; setting up diagnostic, treatment, surgery centers, rehab, and emergency facilities; owning hospitals, even insurance companies? It’s beginning to look like that’s the way it’s going to go.

Shall it be physicians themselves? Not likely. They do not have the management skills or the capital, and their traditions of autonomy, independence, and professional rivalry make the formation and maintenance of large organizations difficult.

Shall it be consumers, patients, and voters? It’s a possibility. Consumer-driven care has been the mantra for a decade now. We are a consumer-drive society. And by exercising choice on a massive scale, consumers could certainly tilt the scales towards organizations of their choice.

Or shall it be information technologists, those soft-ware wizards, those digital networking genies and and gurus, who, over the last 10 to 20 years, have remade American society by making it possible for everybody with access to computers and the Internet to connect with each other, with the population at large, with health care organizations, to help all gain health care information, and theoretically to judge what health care providers are good or bad, and what is good or bad for their health?

I would not discount the latter as the clue and the glue to the future. I have been reading a book The Wikipedia Revolution: How a Bunch of Nobodies Created the World’s Greatest Encyclopedia (Hyperion, 2009). The book describes how thousands of idealistic software nerds, acting voluntarily, usually without pay, have made it possible for every single person to have free access to the sum of all human knowledge. Every person can freely edit Wikipedia. Its founders say Wikipedia has five pillars that have made it the rival of Google, Microsoft, and Facebook in terms of online traffic. These five principles are: 1. Wikipedia is an encyclopedia. 2. Wikipedia has a neutral point of view. 3. Wikipedia is free content. 4. Wikipedia has a code of contact, and 5. Wikipedia does not have firm rules.

Wikipedia is community-based. It reflects community-oriented interactions. It is relatively free of partisanship,, and pessimistic nay-saying. It assumes the hundreds of thousands of software nerds, editors, and contributors who work on Wikipedia are trying to help it, not hurt it; and it avoids accusing others of harmful motives.

Above all, Wikipedia is neutral. And it believes any problem can be fixed through collaboration, consensus, and bold actions to get things right. All contributions must be factual, reliable, and verifiable.

Thursday, June 11, 2015

Obama Administration – No Action if Supreme Court Turns Down Federal Subsidies

Sylvia Burwell, HHS Secretary, has announced the Obama administration will take no action if the Supreme Court rules against federal subsidies in 37 states.

The strategy is clear: shift blame to Court conservatives and to the GOP for depriving some 8 million subsidized citizens of health care coverage.

This lack of an ObamaCare contingency plan will force conservatives to come up with a humane alternative, which will probably consist of a one year or more extension of federal subsidies while Republicans scramble to come up with a comprehensive alternative to ObamaCare before President Obama ends its 2nd term and before the 2016 elections.

Only one thing is certain. Nobody is neutral. President Obama and his liberal allies, such as the New York Times, say there is no going back. The ACA is an irrevocably entrenched part of the social fabric of America. Republicans and Wall Street Journal editors, will continue to insist that the ACA is deeply flawed, that nobody read it before ramming in through Congress in an act of political arrogance, and that it remains unpopular among the American public.

It is hard to find a neutral opinion once the Court rules. But if you are looking quickly for such an opinion, you will probably find it in Wikipedia. This online encyclopedia now rivals or exceeds Google, Microsoft, Facebook, and Twitter in online readership and as a source of News. Wikipedia’s leaders and voluntary contributors, which now number in the hundreds of thousands, insist, above all, Wikipedia is quick and neutral and non-opinionated and represents an up-to-day encyclopedia of the the collective wisdom of humankind.

In case you didn’t know, “wiki” is an Hawaii word for “quick,” and “wiki-wiki” means “quicker and quicker.” President Obama, of course, is a native of Hawaii. We shall quickly see on Wikipedia his signature domestic achievement has legislative legs or is destined to be relegated to the world of the quick and the dead.

Tuesday, June 9, 2015

The Petulant President

"This should be an easy case. Frankly it probably shouldn’t have been taken up. It’s important for us to go ahead and assume that the Supreme Court is going to do what most legal scholars who have looked at this would expect them to do. I’m optimistic the Supreme Court will play it straight. Congress could fix this whole thing with a one-sentence provision.”

Obama’s pressured the Justices: Do you really want to kill a law that is now a routine part of American life?
“Five years in, what we are talking about is no longer just a law. It’s no longer just a theory. It isn’t even just about the Affordable Care Act or ObamaCare. This is now part of the fabric of how we care for one another. This is health care in America.”

“Once you see millions of people having health care, once you see that all the bad things that were predicted didn’t happen, you’d think that it’d be time to move on. “It seems so cynical to want to take coverage away from millions of people, to take care away from the people who need it the most, to punish millions with higher costs of care and unravel what’s now been woven into the fabric of America. It is not something that should be done based on a twisted interpretation of four words.”

President Obama, in June 8 Press Conference in Germany, on impending Supreme Court decision on federal subsidies

The President is entitled to his opinion, but not to belittling the Supreme Court’s judgment or that of a Congress who wrote the law. In the U.S, with its 3 branches of government and its checks and balances, it is not the President's way or the highway, it is what the Court decides about the limits of the executive and legislative branches and what is constitutional. It is not about questioning or ridiculing the Court. It is about awaiting the Court's considered opinion.

Monday, June 8, 2015


War is peace. Freedom is slavery. Ignorance is strength.

George Orwell (1903- 1950), 1984

As I listen to Josh Ernest, Obama’s spokesman, and Obama himself, explain how the U.S. is winning the war on ISIS as ISIS captures one city after another and gains more territory in the Middle East and Africa and as ObamaCare is such a resounding success, despite dashed promises on keeping your doctor and lowering premiums, I cannot help by think of George Orwell’s fable , to wit:

War is peace. The ISIS war is peace for we have no combat troops in the region.

Freedom is slavery. Freedom enslaves us to capitalists.

Ignorance is strength. What you don’t know can’t hurt you.

Withdrawal is advance. Withdrawal advances America’s cause because you become the world’s nice guy.

Facts are fiction. Don't believe your lying eyes.

Nonstrategy is strategy. You just wait and see.

Defeat is victory. No matter what military critics say.

Losing is winning. Your enemies will respect you more for losing.

Secrecy is transparency. To be perfectly clear is perfectly ridiculous.

Weakness is diplomacy. Look weak and others will give the benefit of doubt.

Blame is elsewhere. Setbacks are always someone else’s fault.

Promises are temporary. They are made to be broken.

Disapproval is approval. When the majority disapprove, you must be doing something right for the minority.
America’s Health Outcomes Depend on Smoking and Obesity Rates and Subsequent Chronic Diseases, Not on Health System

One of the enduring myths about health care is that a nation’s health depends on its health system. In his 2011 book Excellent Health: Setting the Record Straight on America’s Health Care (Hoover Institution Press), Scott W. Atlas,MD, professor of radiology at Stanford, dispels this notion in an exhaustively researched book featuring 78 figures, 32 tables, and 18 pages of references, Doctor Scott Atlas, a senior fellow at the Hoover Institute, presents evidence that America’s health system is superior to government-controlled counterparts in other parts of the globe.

Doctor Atlas's thesis is straightforward. America’s health outcomes, if measured by longevity and infant mortality, are in the middle of the pack compared to socialized countries, but these outcome measurements are subjective and insensitive to what happens on the ground and do not reflect the U.S. excellence compared to these countries. Americans with chronic diseases, says Atlas, have superior access to treatment, more effective results, and longer survival for these diseases.

The truth, based on evidence on the medical literature, is that America’s health outcomes are dictated by our culture, specifically by our unhealthy behaviors, our heavy smoking history, which exceeds that of other nations, and our overeating,lack of exercise,and other factors, which causes us to lead the world in our obesity rates.

And yet, when it comes to survival rates for chronic diseases, such as cancer and health disease, superior control of risk factors for those diseases, and better access to treatment, the American system is excellent compared to government controlled systems. America’s problem is not its health system, but the prevalence of smoking and obesity, which is often beyond control of doctors and the health system.

Atlas’s final sentence is his book reads:

“It is quite a tribute to the quality of U.S. medical care that Americans have superior outcomes for many of the deadly diseases associated with destructive behaviors like cigarette smoking and obesity, given that there is such a startling inequality in the underlying health liability of the population due to extra burden of biological risk factors for these dissases before medical care is even initiated.”

Saturday, June 6, 2015

Message to Vermont: Single-Payer Medicine Not in America’s DNA

In Vermont, Frustration Mounts over Health Law

Abby Goodnough, title of June 4 New York Times article

Vermont, America’s most socialistic state and its 625,000 residents, must be frustrated. In December 2014, Vermont’s Democrat government, Peter Shumlin, said Vermont was scuttling plans for a state-run single-payer system. While doing so, the governor declared, “ It was the biggest disappointment in my political life.”

Shumlin had little choice. A Vermont single-payer system would require a 11.5% increase in payroll taxes, a 9.5% hike in sliding scale income taxes, and an overall tax rise of state income taxes from $2.7 billion to $5.2 billion.
This, in a state that had already spent $200 million in developing its state-run health exchange, mostly in funds from the federal government.

Now, Vermont, one of 14 states with state government health exchanges, might have to carry on as one of the few states with estate-run exchanges.

Why the frustration? Maintaining a state exchange is expensive. Besides, Vermont has already instituted ObamaCare changes - prohibiting insurers from charging more for pre-existing condition, running one of the nation’s most generous Medicaid programs, helping low-income people in private plans, and proposing a plan to pay providers based on outcomes rather than fee-for-service. Other than a philosophical kinship with the health law, Vermont had little to gain from either its expansion or its demise.

Now, if the Supreme Court strikes down federal subsidies for health exchanges, Vermont faces the prospect ObamaCare may die an untimely death, and with it the dream of a single payer system, in which government covers all medical costs rather than letting private insurers do it.

Not that Vermont has given up on its dream. One of its senators, Bernie Saunders, is running for president as a socialist; and the other Patrick Leahy, is a far-left Democrat and a staunch ObamaCare fan..
Vermont must now confront another reality: full-bore socialized single-payer medicine is not in centrist America’s DNA.

Not when America’s free market capitalism leads the world in economic growth, even with a progressive Obama agenda and paltry GDP growth of 2% under Obama over the last 6 ½ years.

Not when Europe’s centralized social welfare programs are dragging its member nations down into an economic quagmire, and its members are experimenting with privatized solutions to satisfy its members.

Not when ObamaCare has failed to live up to its promises of keeping your doctor and health plan and lowering costs.
Not when insurers have announced premium increases of 10% to 50%, including 26% in Vermont, to compensate for the delusional dream of expanding access and benefits while reducing costs.

Not when deductibles average $6000 for ObamaCare silver plans and $10,000 for bronze plans.

Not when the American public disfavors ObamaCare, often by margins of 10% or more, in multiple national polls over the last 6 ½ years.

Not when the health law drives doctors out of private practices and precipitates growing physician shortages.

Not when ObamaCare mandates demand that health plans over all essential benefits whether you need those benefits or not.

Not when the young and healthy must pay dramatically more to subsidize the old and sick.

Not when small businesses avoid and evade health law penalties by placing more employees on part-time rather than full time work.

Not when meta-data defines quality rather than clinical judgement.

Not when doctors must spend more time collecting patient data for data-hungry government systems rather than spending time with patients.

Not when the opposition party controls 30 of governorships and legislatures of states resisting ObamaCare with many holding back on Medicaid expansions.

Not when progressive government, political, and academic elites define what is “politically correct” rather than what is commonsensical to the majority of Americans.

To be perfect fair, or fairly perfect, for social fairness and quasi-socialism is the Obama doctrine, to quote Winston Churchill, “socialism’s main virtue is the equal distribution of miseries, “ while capitalism’s main fault, is the unequal distribution of blessings.”
Defining “Massive” Supreme Court Damage

“We believe we hold the right position. If that’s what the courts decide ( a negative ruling on federal health exchange subsidies), we can’t undo the damage.”

Health and Human Services Secretary Sylvia Mathews Burwell, June 5, 2015

Obama administrations officials are making last minute statements to indicate a Supreme Court decision would cause widespread disruption of the health system, stripping low income people of subsidies, causing fewer of the young and healthy to sign on to the exchanges, boosting premiums and costs for the unsubsidized middle class, and precipitating a “death spiral” of the health insurance industry . To keep ObamaCare going as a viable enterprise, 34 states would have to create their own exchanges or strike a deal with federal authorities to help them build these exchanges.

Whatever happens, Secretary Burwell is optimistic Medicaid would continue to expand and insurers would have to continue to sell coverage for those with pre-existing conditions and young people under 26 on their parents’ plans.

Ms. Burwell is undoubtedly right when she says the Court’s decision would have a “massive “ effect on ObamaCare. It would be massive political defeat for the health law and President Obama’s legacy. It might also be a massive burden for Democrats in the upcoming 2016 elections, for Democrats “own” ObamaCare. It is their’s alone to perpetuate.

Its negative effects - rising premiums, often in the double digits; unaffordable deductibles; and declining access to doctors - are evident. On the other hand, the health law has reduced the number of uninsured roughly 20 million, if one counts the number signing up for health exchanges and those joining Medicaid. Some 25 million to 30 million remain uninsured.

If federal subsidies go down , Republicans face their own massive problems - how to explain a potential jump in the uninsured, how to avoid an insurance market “death spiral,” how to protect the newly “unsubsidized” until their program takes effect, how to scale back premiums and deductibles, how to present a comprehensive affordable ObamaCare alternative covering enough people to make it acceptable to the majority of Americans.

What may be going on here, according to a new book, A War for the Soul of America, is a cultural contest between “Normative America” - which prizes hard work, personal responsibility, individual merit, rewarding success, delayed gratification, sexual discretion, faith in God, American exceptionalism, equal opportunity but not equal outcomes, and upper mobility of the middle class - and “Sectarian America” – which favors bigger government, higher taxes backed by tighter regulations, universal health care, social justice and social equity, raising the lower classes and minorities and making them more dependent on government, protecting them from business exploitation, more sexual freedoms, less emphasis on religion, and America as just another player on the world stage, not as a world leader or policeman.

Wednesday, June 3, 2015

Defusing the Supreme Court ObamaCare Time Bomb

The race on between Republicans and Democrats on how to defuse the Supreme Court time bomb . The race is about who gets the blame if the Court strikes down federal subsidies and says only states can set up these subsidies.

The time bomb is about how to handle the unhumanity of depriving 10 million people (estimates vary) of their federal subsidies, leaving them without the means of paying for health coverage.

The time bomb is concern is that the young and healthy will choose not to sign up for coverage, leaving the health insurance in a chaotic death spiral.

The time bomb for Democrats is the perception that ObamaCare belongs to them. Thanks to its unilateral passage, the Dems are sole owners of ObamaCare, and as General Colin Powell said, “ If you break it, you own it.” The news that health care premiums are about to go through the roof has lit the fuse. Insurers have already announced big double digit premiums increases, as much as 30% to 50% in key states.

The time bomb for Republicans is what alternative health plan to offer should federal subsidies go down. The health plan has to be understandable and acceptable to the public, and it has to show some degree of humanity for those stripped of federal subsidies in 34 states. If they GOP legislators fail to present a popular plan, they may lose control of the Senate since 22 of the 24 Senate seats are up for grabs in the 2016 elections.

In May, the Milbank Memorial Fund organized a secret 24-hour meeting in Chicago to discuss with state officials how to handle an adverse ObamaCare ruling outlawing federal subsidies. The Fund paid for plan tickets and hotel accommodates for as many as two state officials from effected states. Officials from 16 or 17 states attended. The discussions revolved around how to word around an federal strike-down of federal subsidies and replacing them with state subsidies. The general consensus was that Republican governors in 27 to 34 states effected would be reluctant to substitute state subsidies for federal subsidies, or helping the federal government operate exchanges on the state’s behalf.

Since the meeting was secretive, we do not know what if any conclusions were reached, but we do know the fuse is burning and we Obama administration has announced no contingency plans should the Court strike down subsidies. The administration’s position has been that a strike-down would be unthinkable, a strident and egregious act of Supreme Court partisanship.

Tuesday, June 2, 2015

The Supreme Court June Balloon

Well, here we are, it is the first of June.

This month the health law faces its high noon.

The majority of Court must decide

Whether federal subsidies to override

That is one thing destined to take place,

The other is price hikes consumers face.

ObamaCare is like a big balloon,

When you press down from the D.C. top,

to make sure price rises for the poor stop,

The size of the balloon does not change.

When you lower bottom prices on the exchange,

Costs for middle of the balloon bulge out,

and the middle class take it on the chin,

Though the underclasses are said to win.

Health plans to save their for-profit skins,

Hike costs for investors to make amends,

The size of the balloon remains the same.

In the health care economic game.

Physician Burnout under ObamaCare

This blog has 2 purposes:

One, to weigh in and expand on Doctor Dike Drummond’s post yesterday “Physician Burnout Presents: Differences in Male and Female Doctors” (The Health Care Blog, June 1).

Two, to promote the first of my tetrology of E-books The Road to Hell is Paved with Good Intentions: The Story of ObamaCare ( Amazon, $9.99).

As indicated in Drummond’s blog, physician burnout is real. It is pervasive. It is taking its psychological toll. It is differs in men women and in younger and older doctors. It is contributing to a growing physician shortage. It is related to ObamaCare. It is deeply felt. In a 2012 Physicians Foundation survey of 20,000 doctors, 46% gave Obamacare a grade of D or F.
As Doctor Drummond observes, medical burnout manifests itself in different psychological ways : exhaustion, cynicism, reduced accomplishment, capitulation, employment, or simply withdrawing from practice.

In a recent Washington Post article “Why Doctors Quit,” Doctor Charles Krauthammer, psychiatrist, conservative commentator, and prominent health law critic, after attending his 40th Harvard Medical School reunion, quotes one of his classmates, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else…. a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

Krauthammer’s comment on electronic records leads to my promotion of my first tetraology E- book The Road to Hell is Paved with Good Intentions; The Story of ObamaCare. The book would not be possible without electronic technologies. Indeed, it is a birth child of those technologies. It covers the period leading following ObamaCare’s unilateral passage in March 2010 to disastrous launch in October 2013. It consists of 109 blogs organized into these categories:

#1, One, Prelude to implementation - Blog posts in this section deal with problems of how to sell the American public on ObamaCare’s merits.

#2, Obama, Words and Actions. Here I deal with President Obama’s underlying progressive philosophy.

#3, Uncertainties, confusions, and adverse consequences of a complex, awkwardly worded, and poorly thought-out law.

#4, Media and Messaging - This section describes the workings and attitudes of the mediapolitical complex.

#5, Physicians and Hospitals – These components of the medical industrial complex bear much of the burden of ObamaCare.

#6, Politics - A necessary evil for the conduct of public affairs is politics, which is how we keep score on the progress and setbacks of health reform.

#7, Consumers, patients, the public - The health law is designed to protect the public and provide affordable care, to accomplish the mission near-impossible goal of expanding access while lowering cost.

#8, Employers - Employers cover 149 million American workers, a fact which makes employers vulnerable to the law’s vicissitudes and retards hiring of full-time workers.

#9, Mandates - The health care law contains unprecedented authoritative federal decrees, which do not sit well with Americans.

#10, Miscellaneous and Personal - Not everything in this book follows a set pattern.

#11, Eleven, Health Plans - Someone has to carry out and execute the provisions of the health law and that task falls to health plans.

#12, Innovation and entrepreneurship are what distinguishes America.

#13, Verse - Poetry is sometimes more effective than prose in explaining and crystallizing ideas.

#14, Health System – Humankind often resists systematic thinking because of individualism and desire for freedom.

The book says five things were notable about this first phase of ObamaCare:

1. ObamaCare passed in a straight party-line vote, setting the stage for intense partisanship.

2. So far ObamaCare has failed to deliver on its promises, lower premiums, and keeping your doctor and your health plans.

3. Public opposition by double-digit margins has remained constant since day 1 of passage.

4. All attempts to replace or repeal failed or have not been brought up for Senate vote.

5. Presidential executive orders have resulted in numerous delays, waivers, or modifications of key provisions or mandates.

To these five points, if I were to rewrite what I said then, I would add that ObamaCare’s Achilles Heel has led to demoralization of the medical profession, with losses of autonomy , replacement of clinical judgment by metadata-directed algorithms, and growing doctor shortages.

Monday, June 1, 2015

ObamaCare Blogumentary

Over the past 2 years, I have composed 1700 blogs on ObamaCare. ObamaCare passed more than 5 years in March of 2010. I have been struggling how to put these blogs into a readable form and have settled on the idea of an E- ObamaCare tetralogy under the umbrella title, The Rise and Fall of ObamaCare. The first book is entitled The Road to Hell Is Paved with Good Intentions; second, There Is No Such Thing as a Free Launch; the third, The Party’s Over; and the fourth, to be issued after the June Supreme Court ruling on federal health exchange subsidies, It’s Barely Alive But Still Kicking.

The 4 books will comment on 10 truths I’ve learned along the way.

One, President Obama is a gifted political strategist, a charismatic progressive ideologue, and a powerful and persuasive speaker. He is cool, cerebral, and inspirational, but weak on delivering on his promises, and sometimes inept at governing and compromising.

Two, Obama’s greatest political mistake may have been isolation and arrogance – passing a national program effecting every American without compromising or even consulting with the opposing political party, thereby embittering Republicans and those displaced and disrupted by the health law.

Three, the U.S. has, in effect, a single, big payer system with government setting the rules and the rates of payment for the private and public sectors, covering 150 million Americans in Medicare, Medicaid, the VA, and health exchanges and paying half the health bills.

Four, Obama’s major liabilities are one, a slow growing economy, two, a foreign policy in disarray, and a health law that has failed to deliver on its promises of keeping your doctor and health plan, lowering costs, and improving quality.

Five, the health system’s major problems, are rising costs of premiums and deductibles, narrowing choices of doctors and health plans, a growing physician shortage, and complex rules of entry beyond any mortal’s comprehension.

Six, in the process of implementing ObamaCare, the administration has alienated physicians and small businesses owners, hobbled innovation with regulations, and burdened and undercut the middle class with the costs and inconveniences of health care redistribution.

Seven, the greatest unintended impact of ObamaCare has been to accelerate the corporate consolidation of hospitals and physicians into organizations large enough to monopolize care and negotiate higher prices from the government and insurers. These organizations have the capacity to mobilize technologies, recruit specialists, market their services, raise prices, and deal with bureaucracies.

Eight, Obama’s greatest political accomplishment has been to create a large enough coalition of the young, the liberal elite, young women, and minorities to win election and to use online tools to maintain that coalition.

Obama has misjudged and misread the fundamental nature of the American culture as an innovative, entrepreneurial, individualistic, freedom-seeking society with opportunities for upward mobility.

Ten, many ObamaCare “innovations” – bundled care, primary care initiatives, using metadata to judge and reward performance, and accountable care organizations – are not innovations but coercive attempts to force physicians into organizations in which they can be controlled.

Eleven, the Internet and iphone and the ability to collect metadata has changed rules of engagement between consumers and doctors and doctors and payers by empowering patients, making remote app monitoring possible, and by ushering in new age of telemedicine.

the 2016 elections will be a referendum on big government v. small government, high taxes v. lower taxes, heavy regulations v. reduced innovations, social justice v. individual freedoms.