Thursday, October 30, 2014

Complexity May Kill ObamaCare

Complexity stalks through the land.


If ObamaCare follows the path of Prohibition , and dies off, or is repealed, it will be because it cannot keep pace with complexity – its inabilities to deal with complexities of regulating the law, enforcing its mandates, collecting its penalties, monitoring its billions of transactions, reducing health care costs, and preventing its frauds and abuses. It will be because ordinary consumers, policy experts, and health care providers are unable to comprehend, coordinate its promises, and to subdue or cope with its complexities.

The Hospital - An Example of Unbridled Complexity

A good example of the difficulties is the modern hospital. Peter F. Drucker (1909-2006) observed, “The hospital is the most complex form of organization ever devised.” It is made up of scores of specialists, each with a different agenda, different skills, different equipment, different jargon; its work forces, its managers and its health professionals, including its work force, 80% of whom are nurses, have different cultures; its customers, physicians and patients, have different sets of expectations, its supply chains are fragmented and it moves to the beat of different sets of regulations – local, state, federal, and professional.

Two Paths around Complexity

As I see it, there are two ways to circumvent or to minimize these complexities.

One is by reducing complexity and the technology that feed it. This can be done by escaping the confines of the hospital, and delivering care outside the hospital in decentralized settings. This is being carried out today in various ways – by setting up independent outpatient facilities, by treating ambulatory patients differently from bed-bound sicker patients, and in the case of physicians, by acting independently of the hospital, and providing direct pay, independent outpatient care free of third party rules and regulations.

Two is by using technology to simplify and consolidate existing technologies. This may seem like a contradiction in terms. But, according to a company called SAP (, it is possible to use technology to simplify technology. SAP is a cloud –based company serving 20,000 organizations and 263, 000 consumers in 190 countries. Its CEO, Bill McDermott says, “We can’t let complexity win.”

I cannot personally vouch for SAP, nor do I have affiliation with it. But I like SAP’s premise: that you can use technology to beat technology. To date, technology has both simplified and complicated our lives. If complexity can be reduced, from a platform in the clouds, as an overall simplifier, and if it can be used to save us from ovwerwhelming complexity for all rather than having complexity kill us all, I am all for it.

In the case of SAP, which just ran a full two page ad in the WSJ, I admire the work of its ad writer.

Here are samples of his/her prose:

• “The exponential proliferation of mobile devices, social media, cloud technologies, and the staggering amount of data they produce have transformed the way we live and work.”

• “Complexity is becoming the most intractable issue of our times, an epidemic of wide-ranging projects, affecting our lives, our work and even our health.”

• “Complexity comes at enormous costs – sixty three percent of executives cite complexity as a primary issue in escalating costs.”

• “If we simplify everything, we can do anything. We just need to run simple...It will generate new opportunities for innovation."

Wednesday, October 29, 2014

Quote to Note: Post-Election Timebombs

“With the midterm elections looming, the White House has delayed controversial decisions and appointments...All of these matters have been high profile and potentially deeply divisive. That is why the White House is postponing any announcements. When the administration finally does speak, it will unleash a political storm, even if Democrats hold the Senate. If Republicans win, those winds will reach hurricane force, since the president will likely try to ram everything through a lame-duck Congress. If that happens, consider boarding up the windows.”

Charles Lipson, Professor of Political Science, University of Chicago, “Obama’s Post-Election Policy Blowout," WSJ, October 29, 2014

ObamaCare’s Delayed Political Time Bombs Set to Explode

Delay is preferable to error.

Letter from Thomas Jefferson to George Washington, 1792

President Obama is a master not only of timely executive action but of timely executive delays.

He has initiated 38 delays at last count. These delays have time fuses, most set to go off just before or just after the midterm elections. These delays of what to do have a strong political flavor rather than a medical coloring, the naming of Ron Klain, a lawyer and political insider, as Ebola “Czar” being the latest example.

The delays include:

• Delay of the employer mandate and $2000 penalties for violating that mandate

• Delays in the individual mandate and paying the $95 penalty for not being insured

• Delays in announcing premium increases in key election states, such as Colorado, Iowa, and Florida

• Delays until after midterms in announcing those millions of health plan cancellations

• A delay in starting that second health care exchange enrollment period until November 15, 2014

• Delays in Medicaid and health exchange expansions, which will expand the national budget deficit

These delays are understandable politically, for their implementation would manage Democrat political prospects.

But like all time bombs, the delays have time fuses that cannot be delayed indefinitely and have an end point.

That end point is the November 4 midterm elections. How to switch from delays to implementation or continuing the delays or even repealing or replacing the health law with a market-based alternative will depend on the outcome of the elections on the national Congressional level and at state houses.

Tuesday, October 28, 2014

ObamaCare Horse Race

Gwine to run all night!

Gwine to run all day!

I’ll bet my money on the bobtail nag-

Somebody bet on de bay.

Camptown Races(1850)

As we enter the home stretch of the midterm horse race, Democrats and Republicans are spending unprecedented amounts of money on political ads and voter mobilization.

Each party has different views. That’s what makes political horse racing possible. If everybody.including TV stations and political victors, had the same view, nobody would make any money.

As Mark Twain observed, “ It is difference of opinion that makes for horse racing.”

For Republicans, opposition to ObamaCare in the horse race is a winning bet. They see nothing but red ink and public dislike for the law, and in red states , they are pummeling Democrats who voted for ObamaCare. If the GOP had a horse in the race, they would likely call it Big Red.

For their part, most Democrat candidates are mum on ObamaCare because of Obama’s low approval ratings and his political toxicity. Their horse may be named Big Avoid, or Big Blues.

Although most Democrats have been silent, the New York Times has now spoken out on the ObamaCare issue. On October 26, the Times published “Is the Affordable Care Act Working?”

Yes, says the Times, for the most part, the law is working. The Times team of seven reporters gives this seven part analysis.

One, the number of uninsured Americans is down 25%.

Two, federal subsidies has lowered costs for people, although some have seen premium rises.

Three, the jury is out whether it will improve outcomes, but in the long term, it may.

Four, exchanges in the next year may even work, but there will be challenges.

Five, Wall Street analysis see a financial boon across much of the health care spectrum.

Six, Twenty three of fifty states have balked at Medicaid expansion, but eventually they will see the light.

Seven, the trajectory of costs has leveled off for many reasons, not all attributable to ObamaCare, some due to economy stagnation and the slow recovery.

The Times and its coterie of seven reporters concluded:

“After a year fully in place, the Affordable Care Act has largely succeeded in delivering on President Obama’s promises, an analysis and data research shows. But it has also fallen short in some ways and given rise to a powerful conservative backlash.”

The reporters did not comment on President Obama’s three main failed promises: You can keep your doctor, you can keep your health plan, and your premiums will drop by $2500 for each family.

In any event, So speaketh observers and analysts on Planet Obama.

As for the rest of us on Planet Earth, we caste our ballots, we pays our money, we takes our chances, and we make our choices.

Monday, October 27, 2014

Simplicity, Simplicity, Simplicity: New Health Care Mantra

Simplify, simplify.

Thoreau(1817-1862), Walden

KISS (Keep It Simple, Stupid!)

American Idiom

In the wake of ObamaCare, the incredibly, unbelievably, and massively complex health law, a health care counterrevolution has surfaced – direct pay independent medical and surgical practices.

ObamaCare has ushered in a series of confusing uncertainties – whether you can keep your doctor or your health plan, how soon and when your health plan might be cancelled, how high will be premiums and deductibles in your old or new plan, if you will have to pay co-pays, co-insurance, and deductibles before you see the doctor or enter the hospital, if you will be obligated to return your subsidies if your income or citizenship papers are not up to snuff, when those delayed penalties will kick in you or your employer are not covered, and in the greater world, how long ObamaCare will survive given its enduring unpopularity and uncertain political fortunes.

To complicate matters, surveys indicate 6 of the 10 Americans, particularly the uninsured, do not understand the language of health insurance, and 9 of 10 are unaware of new health exchanges start-up signups begins on November 15, 2014 and lasting until February 15, 2014.

Confusion and uncertainty stalk the health care land.
Because of the two-headed confusion and uncertainty monster, a new form of medical practice has reared its head. It goes by the name of direct pay, independent practice, and its hallmarks are simplicity, simplicity, simplicity.

• Simplicity in that you do pay directly without worry about co-pays, deductibles, or co-insurance. You simply pay your doctor or your ambulatory surgery center in cash, and the health care service or surgical procedure is provided on the spot. Furthermore, you know upfront, either by asking the doctor or consulting the practice website what your care will cost.

Simplicity in that no insurance company or government program is involved. Your care in between you and your physician and surgeon. Between you decide what is necessary or appropriate. No delayed notices, no waiting for the bill, no collection agencies, no wading through a bureaucratic maze to see if you qualify for care, or if your procedure or test or treatment is “authorized” by powers-that-be-far-removed-from-the patient-physician evaluation-and-treatment-site.

• Simplicity in that your health care services are generally “bundled” – in a primary care office, most services will be offered for one fee, which may be under a monthly or annual retainer, which may include discounted fees from specialists to whom the primary care doctor refers; in ambulatory surgery center, the fees include the anesthesiology fee and the fee for the facility and the recovery room.

For more information, consult Google for concierge or ambulatory surgery centers in your area, or order Direct Pay Independent Practice – Medicine and Surgery, an E-Kindle book now available on

Sunday, October 26, 2014

Whither, Wither, Obama, ObamaCare

To what place? Where? To what end, point, action or the like? What place? To which place?


To dry up and shrink wilt, fade, or decay, to loss freshness of vitality.


With nine days left before midterms, I’ve been groping for words to describe President Obama’s and ObamaCare’s future. Two words came to me in the middle of the night, and they were Whither and wither.

Whither poses questions about the future. Wither describes the current state of affairs. The Democrat’s state of affairs at the moment look grim, with 64% to 87% of prediction models forecasting a GOP Senate victory, hinging on President Obama’s unpopularity with a 40% approval rating.

Consequently, Democrats are distancing themselves from the President. A headline in today’s New York Times reads “ On Campaign Road, Uneasy Democrats Show Obama Their Tail Lights.”

The campaign road, however, could easily take another fork. Many of the Senate races are extremely close, with polls indicating less than 4% differences between contenders. Favorable news could switch odds in favor of Democrats. But the road could fork the other way too, with more U.S. Ebola cases, a 500 drop in the Dow, and ISIS threatened capture of Baghdad. The political situation remains fluid.

Republican Senatorial candidates continue to hammer at ObamaCare, citing broken promises about keeping your doctor and health plan, rising premiums and deductibles, and waves of hundreds of thousands health plan cancellations.

With a Republican Senate victory, the questions remain: whither or wither?

Whither will we go with ObamaCare in face of certain Obama vetoes over such issues as Individual or Employer or Contraceptive Mandates or compliance with those 10 essential benefits with every health plan, or those financial penalties for failing to comply. Whither more ObamaCare marching forward or if market-based policy changes such as ending the $2000 penalties for not covering 50 time employees in businesses, excise taxes on medical innovation companies, restrictions on health savings accounts, tax reform with leveling of health care tax deductions for individual will wither ObamaCare.

Will Obama power wither? Maybe we will return to the Constitutional Checks and Balances, but the odds are the President will continue to try to act autonomously and to more heavily exercise his powers of executive privilege.

Thomas “Mack: McCarty, forme chief of staff for President Clinton, believes President Obama will step up to the plate, exert leadership, and save his presidency (“How Obama Cans Salvage His Last Two Years,” October 20, Wall Street Journal).

Charles Krauthammer, MD, psychistrist turned political commentator, disagree ( “Barack Obama, Bewildered Bystander,” Washington Post, October 24, 2014), Krauthammer does not believe the President, by this background and his previous actions as president, has the capacity to lead the nation out of the political and crisis-laden wilderness.