Saturday, January 31, 2015

ObamaCare and Growth Imperative

I do not know if you noticed but both the Senate and House have voted unanimously to exempt veterans from the employer mandate that requires small businesses to pay penalties for not offering health plans if they expand and have over 50 employees.

This Congressional move was a rare show of bipartisanship and may be a forerunner of an effort to end the employer mandate altogether and to give businesses an incentive to grow.

What’s at issue here? The economic growth imperative.

The credo of capitalism is that if the economy is not growing, it’s failing. This applies to corporate and individual success and to middle class incomes.

It is the basis for complaints that the GDP has grown only 2.2% under Obama versus the usual 3% to 4% growth following a deep recession, the slowest recovery since World War II; that ObamaCare has impeded economic growth for small businesses by limiting that growth past 50 employees; and that it has resulted in middle class income stagnation and a record law participation (62.5%) in the job markets.

On the flip side, the pick-up in growth in 2013 to 2.6%, with a spike to 5.0% in the third quarter is primarily responsible for President Obama’s approval rating rising from the low forties to the high forties and to 50% in some polls.

This rise in approval ratings has not gone unnoticed by either political party, hence the Obama agenda to raise the national budget by 7% with a series of measures to help the middle class, and the Republican incentives to help businesses to grow by lowering health care costs for businesses by ending the employer mandate.

The growth imperative comes down to this: how to grow? In health care, will it be through government mandates investing more in promote growth? Or will it be through private entrepreneurship and limiting government involvement?

According to Forbes magazine, keys to growth are flexibility, investment, technology, and entrepreneurship. U.S. healthcare needs more freedom and entrepreneurship to grow, not more government controls. We need an “entrepreneurially venturesome economy full of experimentation and discovery.” We need something akin to fracking in health care to unleash our health care resources. This unleashing may come in the form of alternatives to employer and individual mandates and to evergrowing and crippling Medicare and Medicaid burdens.

We need a confident, incentive-based, pro-growth message, based on American values of freedom of individuals, choice, innovation, and experimentation, such as decentralizing health care, such as turning the system away from government and back to patients and physicians to let me decide how much to spend and how much to do.

Growth is our biggest problem, and our greatest opportunity. A rising tide can lift all boats but only if you don't overload the boots with too many taxes and regulations and poke too many holes in the bottom of the boats.

Friday, January 30, 2015

Health Reform: Is Consolidation the Answer?

I meant no harm. I most truly did not.

But I had to grow bigger. So bigger I got.

And I’m figuring

On biggering,

And biggering,

And biggering.

Doctor Suess, The Lorax

This afternoon I read Steven Brill’s January 19, 2013 Time Magazine muckraking article “what I learned from My $190,000 Surgery.”

The article is about his heart surgery, his hospital bill, his interviews with CEOs of three large integrated hospital systems –Steven Corwin of New-York Presbyterian, Delos Cosgrove of the Cleveland Clinic, and Jeff Monoff of the University of Pittsburgh Medical Center; the high price of MRIs, artificial hips and knees, back pain; and how to fix health care and to cut 30% off the U.S. health care bill.

Brill is an ObamaCare supporter, and says high health costs are nothis fault. It’s the fault of those deals he had to cut with health plans, drug companies, and others to get the bill passed.

Brill’s answer on how to fix the system and cut the costs is simple: have the government consolidate, then regulate the system.

He sums up his recommendations for a fix with these six regulations.

1. Hand the system over to large, fully-integrated health systems providing less-expensive storefront urgent-care centers and customer-friendly services.

2. Cap the profits of dominant systems at, say, 8% compared to the current 12%.

3. Cap the salaries and bonuses of an those who are hospital employee and who did not practice medicine.

4. Streamline appeals for patients who believed they were denied adequate care or were pressured to skimp on care.

5. Make it a requirement that these government-regulated oligopolys have as a chief executive a licensed physician who has practiced medicine for a minimum number of years.

6. Cut out those middlemen, the insurers, and if you can’t, make a rule they can’t charge the uninsured more than the insured.

The result of these regulations, instituted by liberal-minded government reformers, would save 20% of nongovernment health care costs and maybe $100 million for Medicare and Medicaid, with a total savings of $500 billion.

Brill does not say how much it would cost to support the bureaucracies needed to to enforce these various regulations or how government would develop its own insurers to replace private insurers. But never mind the details.

Says Brill, “The momentum for consolisation I have in mind is clearly there. We just need to seize it rather than resist it, and then control it and push in the right direction,” which is the left direction.
Orwellian Thoughts on Health Reform

Big brother is watching you.

George Orwell (1901-1950), 1984

In God we trust. All others bring data.

W. Edwards Deming (1900-1993), American statistician

ObamaCare critics fear government will control their lives, redistribute their incomes, invade their privacy; expose their data for all the world to see; and limit their choices of doctors, health plans, and hospitals. There is some truth to all of this, but the fears are overblown.

There is also the optimistic belief that computers, the Internet, and social media, descending down from the algorithmic Cloud, will be the magic lever that will provide a cure for cancer, lift health care to a rational level and end the uncertainties and gray zones of medicine and turn it from an Art into a Science.There is also some truth to this set of beliefs.

It is already feasible , for example, to use algorithms to study body language, voice inflections, body rhythms, demographic data, interactive medical and social histories, genetic DNA patterns, to arrive at a precise diagnosis before doctors even examine the patient.

There is the reality that that information technology is not limited to use by the “good guys.” ISIS, other terrorists, hackers, greedy marketers, and foreign governments are capable of using and exploiting the Internet for their own ends.

Finally, strong and persuasive human personalities can overcome , neutralize, or supplement data. Roger Ailes, founder of Fox News, recently noted personalities of Bill O’Reilly and Megyn Kelly, contributed to their success as much as their beliefs. This is true of political leaders as well as media personalities if you look at Ronald Reagan, Bill Clinton, Barack Obama, and other persuasive personalities.

The cult of personality is just as important as the cult of data. As Carl Jung, MD (1875-1961) observed,” The meeting of two personalities is like the contact of two chemical substances; if there is a reaction, both are transformed (Modern Man in Search of a Soul (1933).

Thursday, January 29, 2015

Topsy-Turvy: An Interview with a Medical Market Guru

Q: Why do you call yourself a Topsy-Turvy Medical Market Guru?

A: Because the medical markets are turning upside down. The top is where the bottom should be, and everything is inverted or reversed from where it ought to be. A guru, of course, is someone who knows everything about everything. That’s me.

Q: Explain. Please.

A: Well, everything is consolidating at the top, in hospitals, health exchanges, health plans, and government but they are decentralizing at the bottom in the form of patient-centered, consumer-driven care with removal of those “silos” between different parts of the health system. Everything in the future will be “coordinated” and dictated by data, evidence, and value, as defined from the top-down but resented from the bottom-up.

Q: Examples. Please.

A: Take hospitals. They’re getting bigger and bigger and will soon employ 70% of all doctors and 90% of young doctors, but hospitals are setting up offices and clinics outside their walls to make their services more convenient. Of course, all hospitals and all doctors will have electronic records. Meanwhile doctors at the bottom in private practice are a dying breed.

Take health exchanges. They are a perfect example of top-down government. By February 15, the end of their 2nd sign-up period, the exchanges will have 10 million members. Yet 250,000 doctors at the bottom have decided not to accept health exchange members.

Consider Medicaid. It is growing like Topsy. It will soon top 70 million membership. Even conservative states, like Indiana, are reeling in more Medicaid recipients. Yet some 30% to 40% of doctors, depending on the state, refuse to accept those in Medicaid or health exchange plans. And as many as 20% no longer accept new Medicare patients, who are growing in numbers at the rate of 10,000 a day. Bottoms-up are is down.

Think about ObamaCare as a whole. It’s a budgetary sink hole , the main driver of our soon-to-be $20 trillion national debt. Yet ObamaCare is approaching a state of no return, of not going back, of irreversible government gains. It is now a creature of the IRS, who will have every American filling out a form about their insured or uninsured status, and who will penalize 6 million of us for not having a health plan.

Q: So?

A: Well, the Republicans at the top want ObamaCare reversed or repealed, but they can’t because at least 5 million uninsured are now being subsidized in federal health exchanges, and 10 million will be on the exchange.s So, if the Supreme Court in June rules federal health exchanges as invalid or illegal.

Republicans say the top pillars of ObamaCare – individual and employer mandates – will collapse, and the whole thing will come tumbling down. Democrats claim "massive disruption" would ensue, and hospitals and health markets would suffer terrible economic consequences.

The GOP claims ObamaCare is like Humpty-Dumpty. Critics say once Humpty-Dumpty falls off the Wall, all the President’s horses and all the President’s men won’t be able to put Humpty-Dumpty together again.

Q: Do you buy that argument?

A: No. A Peter Pan analogy is better. Peter Pan was the story of a boy who never grew up. As long as he could fly and sprinkle magic dust on everything, everything would be “fair,” and everything would come out OK for everybody. Everyone would have their "fair share"of society's cake and could eat it too.

Six of 10 Americans believe in Peter Pan and magic dust. If the Supreme Court disassembles federal subsidies, 60% of people in a Kaiser poll say government should restore the subsidies and Humpty Dumpty can be put together again.

Q: Oh, Guru, are there other factors that may destroy these fairy tale myths?

A: Two.

One is the power of smart phones and the Internet. In the last quarter, 75 million people bought Apple smartphones. These people, many of whom are millenials and middle class and many of whom resent redistribution of their incomes and health benefits, may change the system bottom-side up by demanding return and evidence for their dollar.

Two is the behavior of physicians. Nearly 50%, actually 46%, give ObamaCare a D or F grade, another 30% to 40% aren’t taking Medicaid or Medicaid patients, and 20% have either switched to cash only practices, dumped third parties, or are contemplating doing both.

If a fairy tale sounds too good to be true, it usually is. Life, you see, isn't fair. You have to work to make it fair, and Government, as hard as it tries, can't speak or act for you. Only you can.

Tuesday, January 27, 2015

Devils in ACA Details

Merely corroborative detail, intended to give artistic verisimilitude to an otherwise bald and unconvincing narrative.

W.S. Gilbert (1836-1911) The Mikado II

ACA’s devil is presence or absence of detail.

One detail was passage with this sad tale,

It was either Dem “head”or GOP “tail”.

That stuck in the Republican entrail.

Another detail was the money trail,

It would cost $2 trillion, succeed or fail.

Cost was proving to be a coffin nail.

For the public cost was beyond the pale,

When they received cancellations in the mail,

And premiums their new plans would entail.

Then there was another troublesome detail,

That might cause or make it go off the rail.

When ACA health exchanges went up for sale,

IRS ruled subsidies could go in federal pail,

But law said just states could get subsidy bail.

What to do? The ACA was the Holy Grail.

To make law work required a judicial sale,

But what if that sale would be to no avail,

Then it was likely Obamacare would derail.

And no one to the Chief would Hail.

And to the Chief no one would likely Hail


An attempt to deceive or persuade on the basis of the merits of something or someone.

Definition, Snowjob

Today Mother Nature dropped 2 feet of snow and the temperature fell below 20 in Connecticut, where I live.

It wasn’t supposed to be this way. Global warming was going to overheat the planet. I must be na├»ve or stupid. I associate warming with heat and sweat, not with cold and snow.


• President Obama signed an agreement with China for the U.S. to cut our carbon emissions right away while China only agreed to do its part by 2020. That sounds to me like China did a snowjob on Obama, while Obama was doing a snowjob on the American public. The public is responding with a collective yawn (Ed Rodgers, “The Planet in Peril, Yawn,” Washington Post, January 22, 2014).

• Then there’s the social media snowjob. By connecting everybody with everybody, social media will purportedly empower individuals. Instead it seems to be empowering terrorists and throwing roadblocks in the paths of brick and mortar businesses.

In health care, social media, it is said, will provide consumers with the information they need to shop for the best care, challenge physician and hospitals bills, collaborate with each other to improve health, manage and improve quality through complex algorithms mimicking clinical judgment, and bring out equitable health reform.

This may be partially so, but it also a snowjob. As Andrew Keen explains in his new book The Internet Is Not the Answer, the social media is also destroying our economy, our culture, and our values through technology overuse and creation of false, loose communities who collectively know not what they are about.

• Finally there are the snowjobs being anticipated in advance of the June Supreme Court decision on whether ObamaCare can subsidize federal exchange health plan recipients.

Obama’s lawyers are preparing a brief offering a “full-throated” defense of the Law challenging the “ strained credulity” of the political opposition, which, it claims “ does not respect the rule of the law. Its case “ rests on an acontextual misreading of a single phrse in two subclauses, ( “Obama Administration Offers Supreme Court Robust Defense of Health Law,” Kaiser Health News, January 23, 2014).

Republicans, who profess to be optimistic the Court will rule in favor of denying subsidies, are adamant. If the Court rules as they think it will and Plan A, repealing ObamaCare failes, they will go to Plan B, which will consist of an alternative to ObamaCare. Their alternative will gut ObamaCare of the individual and employer mandates. Three GOP senators, Lamar Alexander (Tennessee), Orrin Hatch (Utah), and John Barbasso (Wyoming), are now formulating Plan B. B's details of which are not yet known. But says Orin Hatch, never mind “The courts are likely to decide against ObamaCare. The language is totally unambiguous. I don’t see how they can ignore the unambiguous language that is clear-cut.” (Alexander Bolton, “Senate GOP Plots Plan B for ObamaCare,” The Hill, January 27, 2014).
No one knows, of course, whether Plan A, Plan B, or Plan C (ObamaCare stays intact) will prevail.

Meanwhile the political tensions and drama rise, the snowjobs grow to greater heights, and the anticipations build. As Benjamin Disraeli (1804-1881) cogently noted, “What we anticipate seldom occurs; what we least expect generally happens.”