On the Senate Hangs Obama’s Hangs Obama's Legacy and ObamaCare’s Fate

Things are where they are, and, as
fate has willed.
So shall they be fulfilled.

Aeschylus (515-456 BC), Agamenon

I have said repeatedly that Obama’s legacy and the fate of ObamaCare hang on the Senate midterm elections. It was born a partisan bill, and it will die a partisan bill.

If Democrats win the Senate, ObamaCare will hang on until 2016 and beyond in an altered form.

If the GOP wins the Senate, Republicans will seek to sink ObamaCare and will cripple it, and then repeal it if they win the Presidency in 2016.

To me, it is as simple as that. But it is not simple, because the outcome is still very much in doubt.

The current seats are: 53 Democrats, 45 Republicans, 1 Independents.

The projected seats are: 52 Republicans, 48 Democrats. But projections are weak and subject to outcomes of current controversies and events.

The projected seats are far from certain, as indicated by the these projections on the relative strengths of the two parties.

• Alaska – weak Democratic hold

• Arkansas – weak GOP hold

• Colorado – weak Democratic hold

• Georgia – weak GOP hold

• Iowa - weak Democratic hold

• Kentucky – weak GOP hold

• Louisiana – weak GOP hold

• Michigan - moderate Democratic hold

• North Carolina – weak Democratic hold

• South Dakota – strong GOP hold

• Maine – strong GOP hold

• Oregon – strong Democratic hold

When you go over the list, you will see the Senate is still up for grabs – with 6 Democratic and 6 GOP leaning states.

As the pundits like say, control of the Senate is still too close to call, especially in those states with weak holds on the electorate.

San Pedro Sula, Honduras, and the Immigration Crisis

I have a son, Spencer, a poet and a priest,
Who spent a year in the Belly of the Beast,

In San Pedro Sula, Honduras largest city,
Where poverty prevails and life is gritty,

It is the murder capital of the world,
Where mayhem upon people is unfurled,

Spencer went there to teach orphan girls poetry,
So they could express their inner despair mostly,

Out of his year came three communications,
Showing the girls’ levels of quiet desperation,

A book of poems, a website, and a documentary.
Revealing childrens’ human needs as elementary.

Causing parents and kids to cross Mexico,
On foot and in smugglers’ trucks in stow.

To escape murder, prostitution, and crime,
Spencer thought their anguish could be told in rhyme,

To see why, visit the orphanage website, Our Little Roses.
And you will see what goes under our Border’s noses.

And why those who live there,
Will do anything to get here.

What Do I Really Think about President Obama?

The question came from out of the blue from a fellow physician. What do I really think about President Obama?

The question came just after I read Peggy Noonan’s appraisal in the July 3 Wall Street Journal “Daydream and Nightmare.” Her conclusion? Obama is weird and strange, waiting for history to judge his greatness. As a former Ronald Reagan speechwriter, Noonan may not be the most objective judge.

Nevertheless, Obama’s greatness is presently in question. In this week’s Quinipiac poll, the public says he is the worst president since World War II.

I would not go that far. I agree with Obama, who has said, “Let history be my judge.”

As a physician, I frankly do not think he likes physicians. He does not believe we are important cogs in his health reform machine. I get the feeling he believes other health professionals could easily replace us, and if the doctor shortage persists, good riddance. We make too much money anyway and suck too much power out of Washington.

He does seem to care much about the middle class either. Let their premiums increase. Let them pay for the poor and the uninsured. Let them carry the redistribution load. Let their taxes rise to match my ideas. If the economy stalls, so be it.

On the other hand and on the positive side, the President is a very important symbolic figure, especially for minorities who can clearly see how far a black can rise in our society and for the affluent liberal elite who see him as someone who can erase inequality and make government all powerful, especially when they, the elite, are in charge.

The only problem with his being black is that he has become untouchable - a lighting rod to be used to criticize critics as “racists” or politically incorrect tea-party “extremists.” He cannot be deemed as someone not up to the job, incompetent or detached and disengaged from governance. With President Obama, there is too much PC (Political Correctness). Let us judge him on his merits, not his color, on his results, not his rhetoric.

I find him self-righteous, dismissive of Republicans as less than ordinary mortals and too wrapped up in himself and his grandiose ideas to share or consult with fellow Democrats. With him, nothing is negotiable. He regards the House of Representatives and the Supreme Court as enemies , rather than as co-equal branches of government. He seems to think of himself as the smartest man in the room and on the planet with the others being misguided and dead wrong. His dismissive attitude takes the form of ridicule, scorn, sneers, mockery, and taunts, unbecoming of a President but no doubt satisfying to him. He is giving narcissism a bad name.

But as a human being, Obama has his positives. He is a handsome figure, superb speaker, a fine father, and an engaging personality. He gets along beautifully with fellow celebrities and the culturally and entertainment elite.

Besides, give the President credit, he has climbed to the top the “greasy pole” of politics, as Benjamin Disraeli put it. He is political animal with great political skills, whether those skills will place him on the historical greasy pole remains for historians to judge.

More Self-Evident Truths on Independence Day

We hold these truths to be self-evident, that all men are created equal, that they are endowed with certain inalienable Rights, that among these are Life, Liberty, and the pursuit of Happiness.

Declaration of Independence, July 4, 1776

Today, all over America, families and friends are reuniting to renew ties, enjoy each other’s company, and celebrate our Nation’s birthday. It is a day when liberty and laughter go hand-in-hand – when we can acknowledge that, oh yes, we have our faults, and lots of problems too, but we’re happy and proud because we’re free, and we know the best of America is yet to be.

President Ronald Reagan’s “Message on the Observance of Independence Day,” 1981.

Today is the 4th of July – a good time to review the Declaration of Independence’s self-evident truths in light of recent events reflecting our unhappiness over our lack of economic growth, which hovers around 2% and spills over into our unemployment and health care unhappiness.

As John H. Cochrane, professor of finance at the University of Chicago , observes:

“Sclerotic growth trumps every other economic problem. Without strong growth, our children and grandchildren will not see the great rise in health and living standards that we enjoy relative to our parents and grandparents. Without growth, our government’s questionable ability to pay for health care, retirement and its debt evaporate. Without growth, the lot of the unfortunate will not improve. Without growth, U.S. military strength and our influence abroad will evaporate.”

Without growth, the new truth is that all men may not be created equal. Indeed, some, as George Orwell noted, are more equal than others. This lack of equality comes from a number of factors.

• Certain people, by virtue of native endowments, family wealth, genetic health, place or residence, and access to health providers and facilities, are more equal than others. Equal opportunity never equals equal outcomes.

• Men, because of their impregnability, their physical strength , and the nature of their jobs, may, in certain situations, be more equal than women, even though women maybe smarter and better educated. It’s unfair, but that is reality.

• Those who work for corporations or organizations, or organized monopolies, such as labor unions or large health care organizations, are more equal than individuals who must fend for themselves, although organizational people may sacrifice independence and autonomy, they have economic security.

• Then, there are those inalienable but abstract Rights – Life, Liberty, and the pursuit of Happiness.

What is Life? It is how you live. It is what distinguishes you from inanimate objects and dead organisms. It is manifested by growth, metabolism, reproduction, and the power to adapt yourself to your environment. It is health.

But is Life about“inalienable Rights” - Rights not capable of being transferred from one person to another? Therein lies the rub. Can health be mandated as a Right? Is it a Right that government can dictate – even though health inexorably declines as we age, and some are destined to be healthier than others?

And what about Liberty as a Right? Individual Liberties versus Government Control is what is at stake with ObamaCare. These Liberties include religious Liberty to practice what one preaches, Individual Liberty to be free of government penalties for not having a health plan, and Employer Liberty of not having to cover all employees when one may not have the means of doing so.

The pursuit of Happiness? If one is to judge from a Quinnipiac poll this week, Americans are unhappy with the policies our Government is pursuing.

The set of negatives in the poll include,

- Negative – 55% to 40% for Obama’s handling of the economy.

- Negative – 57% to 37% for foreign policy.


- Negative – 58% to 40% for health care.
-
- Negative – 51% to 44% for terrorism.

- Negative – 2% trust government “all of the time” and 12% trust government “most of the time” to do the right thing.
Nonsense about all these negatives, say the Obama people. Today’s news indicates unemployment has dropped to 6.1% and 288,000 gained jobs. Yes, say critics, but the labor department fails to mention millions have dropped out of the labor force, the effective unemployment rate is 12.1%, teenage and black unemployment exceeds 20%, and 500,000 lost full-time jobs, and 799,000 of the new jobs are part-time. It’s hard to know what statistics to trust.

If pursuit of Happiness translates into Happiness with Government, the Obama Administration is in trouble.
But cheer up. As President Reagan said in 1981, “We can make America great again by putting the destiny of this national back in the hands of the people. And why shouldn’t we? Because, after all, we’re Americans.”
We Americans have access to another self-evident truth.

We can always cast our ballot to show our unhappiness.

Hooray! Hooray! This is the good old USA.

Everything is going to be OK.

You can define the other self-evident truth.

With your ballot in the voting booth.

Ambulatory Surgery Centers (ASCs) on Direct Pay Edge

A little knowledge is a dangerous thing;

Drink deep , or taste not the Perian spring;

There shallow draughts intoxicate the brain,

And drinking largely sobers us again.

Alexander Pope (1688-1744), An Essay on Criticism

Other than having 4 procedures performed on myself and a family member at ambulatory care centers and writing a E-book on Direct Pay Medicine and Surgery, I have no deep knowledge of Ambulatory Surgery Centers.

I am aware that technological advances and positive results have caused the number of procedures done in ASCs to multiply, that growing numbers of surgeons are operating in ASC facilities, and that ASCs sometimes threaten profit margins of hospitals. I am aware, based on an interview with Keith Smith, MD, founder and director of the Okahoma Surgery Center in Oklahoma City, that demands for ASC procedures can upset a hospital-dominated surgical market’s apple cart.

As I dig deeper into the direct pay movement, the potential benefits of direct pay become clearer.

These benefits include:

• Immediate access to routine surgeries that can be performed safely on an outpatient, one-day basis.

• Transparent pricing, usually bundled and including anesthesiologists, nursing, and brief rehab stay.

• Fewer complications, such a facility acquired infections, which are more prevalent in hospitals.

• More operating room efficiencies, secondary to specialization and focus on efficiencies of scheduling.

• Quality care with superior outcomes, as performed by board-certified surgeons in the community.

• Certification by Medicare and other regulatory agencies.

Most Ambulatory Surgery Centers (ASCs) are members of the Ambulatory Surgical Care Association, located in Alexandria, Virginia. More than 5400 ASCs exist in all 50 states, the majority are certified by Medicare, and 20 or more are joining each year. Those ASCs run by hospitals in outpatient settings charge higher facility fees than free-standing ASCs.

In general, ASCs tend to perform cataract surgeries, colonoscopies, laporoscopic procedures, endoscopic extractions, such as gallbladder or parathyroid adenoma removals, cystoscopic procedures, arthroscopic and minimally invasive joint or back procedures, and a growing list of other procedures that can be performed safely on ambulatory patients.

To my limited knowledge, only a handful of ASCs charge direct cash without intervening third party arrangements, though I suspect the list is much longer.

Nine ASCs known to charge direct cash include:

• Daytime Outpatient Surgery Center (Fort Worth, Texas).

• Manitowoc (Wisconsin) Surgery Center,

• MEDARVA at Stony Poinht Surgery Center (Richmond, Virginia.

• Monticello Community Surgery Center (Charlottsville, Virginia).

• Northwest ENT Surgery Center (Woodstock, Georgia).

• Ocean Surgery Center (Torrance, California).

• Regency Healthcare (New York City)).

• Surgery Center of Oklahoma (Oklahoma City).

I suspect these 9 centers are just the tip of the direct pay surgery iceberg. The number of these direct pay ambulatory care will grow as consumers and self-funded corporations learn of dramatic lowering of costs due to lower overheads, quicker access, less bureaucratic bungling, and superior outcomes. Surgeons will welcome the scheduling and specialized efficiencies outside hospital settings.

The direct pay movement will never become more than marginal if it does not include both primary care physicians and specialists. Ambulatory care centers are a good place to start to recruit specialists.

ObamaCare “Inconsistencies”

A foolish consistency is the hobglobin of little minds, adored by little statesmen and philosophers and the divine. With consistency a great soul has simply nothing to do.

Ralph Waldo Emerson (1803-1882), Self-Reliance

President Obama prides himself on being self-reliance and on having a great soul.

In his mind, he represents the collective souls of oppressed minorities, unprotected women, idealistic millenials, and 99% of dispossessed Americans. That being the case, he feels he can do what he deems appropriate.

It is a heavy burden to carry, but carry it he must. With his great soul as his guide, why be consistent? Why abide by restrictions of the constitution? Why heed the House of Representatives or the Supreme Court?

He has a God-given mission to save America’s soul and rescue the uninsured. His political adversaries with their loose talk of checks and balances have little minds fit only to be taunted, scorned, sneered at, and accused of political “stunts.”

So President Obama proclaims. Go ahead. Sue me. I am too big a man to tolerate such a petty gesture.

As for the constitution, I interpret it as a “living document,” subject to change at my whim. It is a dead document created by our fallible founding fathers over 238 years ago in another time under different circumstances.

As a constitutional lawyer in my own right, I know what the first Supreme Justice, John Marshall (1755-1835) said in McCulloch v. Maryland (1819):

“Let the end by legitimate, let it be within the scope of the constitution, and all means which are appropriate , which are plainly addressed to that end, which are not prohibited , but consistent with the letter and spirit of the constitution, are constitutional."

I will decide what is constitutional and what is the letter and spirit of the law. What I am doing, executing executive actions bypassing Congress and ignoring the Court, is constitutional and consistent with my belief that I must save the soul of America by covering the uninsured. That’s what matters.

Never mind that I have had to change the law 23 times to make it politically palatable. Never mind that 85% of ObamaCare’s inconsistencies can’t be fixed ( New York Post, July 2, 2014). Never mind that federal officials, can’t resolve 2.9 million “inconsistencies” in ObamaCare applications which qualify applicants for federal subsidies and tax credits. Never mind that we can’t verify the eligibility for those subsidies and credits for those enrolled in qualified plans.

My administration is doing what is needed to salvage the soul of America by redistributing America's wealth and health benefits. That is what really counts, not the consistency with which it is carried out.