Obamacare Predictions for 2013

Prediction is very difficult, especially if it’s about the future.

Neils Bohr (1885-1962), Danish Physicist

Weather forecast for tonight: continuing darkness for tonight with scattered light by morning.

George Carlin (1937-2008), American Comedian

December 31, 2012 – It’s come at last, the last day of 2012, and nearly the first day of 2013, which promise to be an unluckily numbered year for Obamacare and  for most American citizens,  if one excludes the young covered under their parents’ policies,  the preferred thousands covered for pre-existing illnesses , and certain seniors falling into the dreaded Donut Hole.

I  will trust  that  things work out better than I predict, that these predictions are not self-fullfilling dark prophecies, that I am not akin to  the proverbial groundhog that makes its statement, then disappears until next year.

I will avoid the obvious – that taxes are going to rise sharply in 2013 – by 2.3% on total revenues of device manufacturers, by 0.9% on the payroll tax for Medicare, by limiting deductions for medical expenses to  7.5% to 10% of income,  by 3.8 % on incomes for couples making $250,000 or more, by a variety of surtaxes on capital gains, dividends, estate taxes, and other items;  and by $1.76 trillion from  2012-2021,  and $2.5 trillion form 2014 to 2023.   

These are facts, not predictions.

I will touch briefly on my series of books -  New Voice of Health Reform – Rhyme, Rhetoric &  Reality, with the emphasis on Reality, which will begin appearing in 2013.

And I will make these dark predictions which may be accompanied by scattered light.

·         Employers will begin dropping workers from coverage and converting full-time workers to part-time workers  at they realize they can no longer afford comprehensive government plans with “guaranteed issue” for every worker,  young or old, healthy or ill, able or disabled.

 

·         Implementation of health exchanges, the core Obamacare issue for covering Medicaid and subsidizing those under 4 times poverty, will be rocky and difficult because of failure of 30 or more states to set up their own exchanges and to hand over the job to the federal government to run the state-shows.

·         Premiums will spike by 20% to 30% for most Americans, even double says Aetna’s CEO. 

·         The physician shortage will intensify as reimbursements fall and  regulations skyrocket. 

·         Physicians will go to work for hospitals in droves, and this will result in soaring costs to see a doctor for ordinary visits and extraordinary reasons.

·         Consolidation of hospitals and large physician groups, with waves of previously unthinkable mergers and acquisitions, will occur, as providers seek ways to cope with Medicare cuts,  and administrative, technological, and regulatory challenges. 

The good news is that the bad news will be good news for consultants, government bureaucrats, auditors, accountants, and IRS agents who will be required to take care of and to track developments on multiple reform fronts.

Tweet:  2013 promises to be a dark year for Obamacare with scattered patches of light for certain population segments.

High Tech-High Touch- High HIT

Whenever new technology is introduced into society, there must be a counterbalancing human response – that is, high touch –or the technology is rejected.  The more high tech, the more high touch.

John Naisbitt, “From Forced Technology to High Tech/High Touch,” Megatrends, 1982

The limits and shortcomings of Big Data technology are building. Listening to the data is important, but so is experience and intuition.  After all, what is information at its best but large amounts of data of all kinds filtered through the human brain rather than a math model?

Steve Lohr, “Sure, Big Data is Great, But So Is intuition,” New York Times, December 30, 2012

December 30, 2012 – Periodically, I review my blog’s “hits” – reader clicks  - to see what interests people

By far, the greatest number of hits are on a May 9, 2010 post, “Americans and Their Medical Machines.” It opened with this paragraph,

“Obsession with medical technologies and machines characterizes American’s cultural expectations. We tend to think of our bodies as perpetual motion machines, to be preserved in perpetuity. If the face of our machines sag, we lift our faces up. If our pipes clog, we roto- rooter them out or stent them. If impurities gum up our machinery, we filter them out. If our joints give out or lock up, we replace them. If we want to remove something in the machine’s interior, we take it out through a laparoscope. If the fuel or metabolic mix is wrong, we alter the mix or correct the metabolic defect with drugs If anything else goes wrong, we diagnose it and rearrange it electronically.”

Over the last 20 years,  a new phenomonon – high HIT – has been added to the cultural landscape mix.   HIT stands for “High Information Technology.” HIT also parades under the name of “Big Data.”   With HIT and Big Data, we have come to expect we can define trends, outcomes, and efficiencies and what works best for our society.  Numeric collectivism, a high information society,  is replacing individual choice and intuitivism.  HIT is said to be a smarter way to conduct health care - smarter, better, more efficient, with superior decision-making.

"Hot" HIT Trends

If I read the literature right, the top ten “hot” HIT trends are these.

1.       Continuing growth of electronic health records as the source of Big Data

2.      Tablets everywhere  with everyone connected intimately to high tech solutions 

3.      Pressure to carry devices on part of everyone in the various health care sectors for instant information for health care betterment

 

4.  Mounting fear of cybersecurity threats with endangerment of personal privacy 

5.      Ubiquitous apps for every health care consumer for every imaginable condition 

6.      Point-of-care technologies for every patient and every doctor with less reliance on personal intuition and experience 

7.      Molecular genomic (DNA) imaging and sequencing for predictive, precision, and curative purposes 

8.      Neuroscience devices to ease, assist, and even cure neurological disorders 

9.      Tissue engineering and regenerative medicine to repair injuries and even grow new organs

10.   Robots to improve surgical and medical  outcomes

Counterbalancing Trends

No doubt,  high-tech- high HIT is useful and powerful.   But it is not, in many cases of human health care, the final solution.  It will not solve the inevitability and decline of aging and chronic diseases that accompany aging.    It will not end violence or destructive behavior. It will not eliminate mental illness or diabilities.

What will the counterbalancing high-touch responses?

My top nine high-touch candidates are:

1)      More home care, self-care, assisted care, and companion-care

     

2)      More integrative care centers, and alternative medical care,  particularly for diseases like cancer or end-stage neurological disorders

3)      More hospice care, as we acknowledge that pain-free comfort is important as death approaches

4)      More decentralized care , outside of hospital and institutions

5)      More telemedicine related  and monitored care, as people seek to combine high tech and humanism and convenience 

6)      More online and offline support groups and matching services, more searches for human togetherness 

7)      More retreats to simpler medical practices, such as concierge and cash-only practices, retail clinics, with and without high-tech devices

8)      More “personal care” with more concern about personal privacy 

9)   More escapes from care settings where the emphasis is on data gathering and aggregation.

Tweet:  Will widespread web-browsing, clever computer algorithms, and Big Data analysis replace doctor-patient relationships? Doubts are growing.

Past and  Now Innovations

Time present and time past

Are both perhaps present in the future

And time future continued in the time past.

T.S. Elliot (188-1965), Four Quartets – Burnt Norton

In the decades ahead, the pace of biomedical discovery will accelerate.  The state of the individual person will be characterized with increasing precision from the molecular level to the genomic level to the organ level and by interactions with medications, nutrients, the microbiome, therapeutic devices, and the environment.

Isaac Kohane, Jeffrey Drazen, and Edward Campion, “A Glimpse of the Next 100 years in Medicine,” New England Journal of Medicine, December 27, 2012

December 29,  2012 -  It’s that time of year-  to comment on 2012’s major innovations – and to speculate on innovations to come, in 2013 and thereafter.

So here's the lay of tmedical nnovation land,  in the words of  Cleveland Clinic investigators and Wall Street Journal writers.

·         Cleveland Clinic’s top 10 innovations for 2012.

1. Catheter-based renal denervation to control resistant hypertension: Resistant hypertension is high blood pressure that requires four or more medications to control, or high blood pressure that doesn't respond to medical treatment and remains elevated despite medication and lifestyle changes. Renal denervation, a new 40-minute procedure,  inserts a catheter-based probe into the femoral artery  and threading it into the renal artery near each kidney. The catheter probe delivers low-power radio-frequency energy to surrounding nerves. Disrupting the nerves has been shown to cause blood pressure levels to drop.

2. CT scans for early detection of lung cancer: In June, the New England Journal of Medicine published long-awaited data from the National Lung Screening Trial that validated the diagnostic use of low-dose spiral computer tomography as a screening tool for lung cancer. The scan is more effective than standard X-rays in detecting tumors, even small ones, earlier, when they are more treatable with surgery.

3. Concussion Management System for athletes: These tools establish an athlete's baseline cognitive and motor skills at the start of the athletic season. At the moment of contact, the tools can detect brain injuries right away. Afterward, the athlete's cognitive and motor skills are re-tested to see when it is safe for an athlete to return to his or her sport.

4. Medical apps for mobile devices: Thousands of software applications on the market let health professionals and consumers get medical resources on their smartphones and other mobile devices.

5. Increasing discovery with next-generation gene sequencing: New sequencing machines are smaller, faster and cheaper than previous versions used to sequence the human genome as part of the Human Genome Project.

6. Implantable device to treat complex brain aneurysms: A new FDA-approved device -- a flexible braid mesh tube -- is implanted directly into the carotid artery, the major blood vessel that supplies blood to the brain. The device redirects blood flow away from the aneurysm to the undamaged part of the blood vessel, allowing a clot to form, preventing the aneurysm from rupturing.

7. Active bionic prosthesis, wearable robotic devices: This lightweight, durable and computerized bionic leg uses microprocessors, sensors, a motor and a carbon-fiber spring to mimic natural motion. A battery-powered motor replaces the function of missing muscles and Bluetooth technology allows a person to adjust settings easily with a smartphone.

8. Harnessing big data to improve health care: Innovative companies are answering the call to begin mining massive amounts of medical information in a format that's easy to access and share, while at the same time assuring patient privacy.

9. SGLT2 inhibitors as diabetes therapy: A new class of drugs called sodium-glucose co-transporter 2 protein inhibitors reduce blood sugar by causing it to be excreted through urine. The once-a-day medication blocks the protein, and the return of high levels of glucose in the body. The SGLT2 inhibitors also contribute to weight loss.

10. Genetically modified mosquitoes to reduce disease threat: Researchers are exploring new ways to eradicate mosquito-borne diseases such as malaria, dengue, yellow fever and West Nile virus by creating sterile, re-engineered male mosquitoes to mate with wild female species.

·         Wall Street Journal’s six picks for  future innovations, "The Future of Medicine is Now, December 29-30, 2012

1. Growing a Heart - Getting A Kid's Heart to Pump

Surgeons at Boston Children's Hospital have developed a way to help children born with half a heart to essentially grow a whole one—by marshaling the body's natural capacity to heal and develop. About 1,000 babies are born in the U.S. each year with a condition called hypoplastic left-heart syndrome, the result of a genetic anomaly that leaves them without a functioning left ventricle, the heart's main pumping chamber. Without a surgical repair, the defect is almost always fatal.   A new surgical strategy has helped children grow half a heart into a whole one.  Surgeons at Boston Children’s  devises a technique strategy to open obstructed valves and repair other malformations to direct blood flow to the left ventricle instead of away from it. That triggers biological processes that promote the heart's growth.

2.      DNA Sequencing for Routine Checkups- Making DNA Analysis Quick and Inexpensive

Since the first sequencing of the human genome was completed in 2003 at a price tag of over $2 billion, the speed, price and accuracy of the technology have all improved. Illumina Inc. ILMN -1.19% has dropped its price for individual readouts to $5,000; earlier this year, Life Technologies introduced a sequencer it says can map the human genome for $1,000. The smallest machine is now desktop-size. New  sequencing devices,  designed to be even smaller and more affordable, are helping speed efforts to make gene sequencing a routine part of a visit to the doctor's office. DNA molecules are exceedingly long and complicated; that makes them hard to read.

3.      Matching a Tumor to a Drug - Targeting Tumors with Specialized Drugs

Understanding  the human genome poses a challenge: How to use that data to change the course of disease. Consider cancer. As seen through a gene-sequencing machine, some cancers can appear as at least a dozen different genetic diseases, some of which have been shown to respond uniquely to a specific drug. But how do cancer doctors quickly match a patient's tumor with a drug that targets it? One answer is a test developed by Foundation Medicine Inc., a Cambridge, Mass., startup. The test, launched last June, enables doctors to test a tumor sample for 280 different genetic mutations suspected of driving tumor growth. This changes "everything in terms of how we approach patients with cancer," says David Spigel, director of lung-cancer research at the Sarah Cannon Research Institute in Nashville, Tenn. He used the test in one patient with advanced disease and few apparent options. She turned out positive for an alteration in a gene targeted by several drugs currently in development. She was signed up for one of the studies. A short time later, "she's like a new person," he says. "She's off pain medicines. She gained her weight back."

4.      Letting Your Body Fight Cancer - Setting Antibodies Loose on Cancer

Few advances in cancer care are generating more enthusiasm than harnessing the power of the immune system to fight the disease.. Tom Stutz is one reason why. Last April, the 72-year-old retired lawyer was confined to a wheelchair, struggling for every breath, and required help with simple tasks such as eating, all because of a previously diagnosed skin cancer that had spread to his lungs and liver. "I was ready to check out, to be honest," he says.

That month, he began taking an experimental drug known as MK3475. Six weeks later, he started feeling better. Today, Mr. Stutz has jettisoned the wheelchair and regularly walks a 3.5-mile loop near his home in Los Angeles. "I feel terrific," says Mr. Stutz, who learned after a checkup in the fall that his tumors had shrunk by about 65% so far. For decades, cancer researchers have wondered why the immune system typically doesn't treat tumor cells as invaders and target them. Part of the mystery was recently solved: Tumors protect themselves by hijacking the body's natural brake for the immune system.MK3475, being developed by Merck & Co., is among a new category of drugs that release the brake, unleashing an army of immune cells to hunt down the cancer. A recent report from a trial in which Mr. Stutz participated said that of 85 patients who took the drug, 51% saw their tumors significantly shrink; in eight cases, the tumors couldn't be detected on imaging tests.One reason for the excitement is that most "solid" tumors—colon, lung, breast, prostate—use the same or a similar mechanism to hide from the immune system. Obstructing that mechanism may have a broad impact across a variety of malignancies.

5.  Health in the Palm of Your Hand - Performing your Own EKG at Home

There's a good chance that you already own one of the most ubiquitous health-care innovations: a smartphone. Last month, the FDA cleared a new iPhone add-on that lets doctors take an electrocardiogram just about anywhere. Other smartphone apps help radiologists read medical images and allow patients to track moles for signs of skin cancer. "I see the smartphone as one piece of how we're going to try to get health costs under control," says David Albert, the Oklahoma City-based inventor of the just-approved AliveCor electrocardiogram application. At $199, AliveCor consists of a case that snaps onto the iPhone, with electrodes on the back. It reads heart rhythms and relays the recording to an iPhone app, allowing physicians to read the data. Dr. Albert says a $99 version should be available soon that will let patients capture their own heart data, documenting sometimes-fleeting arrhythmias when they feel symptoms or tracking the success of lifestyle changes at curbing heart troubles.

6.      Rejigging Your Genes - Turning Gene Therapy into Reality

After years of controversy, gene therapy is poised to become a viable option for a variety of often life-threatening medical conditions, especially those resulting from a single defective gene. Last month, the European Union approved Glybera for treatment of a rare genetic disease, making it the first gene-therapy medicine approved in the Western world. The approval comes amid a flurry of research showing broader promise for the approach in a range of disorders, from a rare form of blindness to hemophilia to heart failure.Though outright cures are still elusive, gene therapy "is beginning to emerge as a meaningful clinical" strategy, says Stephen J. Russell, director of molecular medicine at the Mayo Clinic in Rochester, Minn.Gene therapy's tantalizing attraction is that a single treatment has the potential to cure lethal diseases by enabling normal genes to take over for defective ones. The treatment involves loading a functional gene onto a fragment of a deactivated virus that transports the gene to a cell's nucleus, where it is intended to take over.

Tweet:  2012’s major innovations and those now evolving can best be categorized as high-technology, information rich, and genomically guided.

New England Journal of Medicine, the Future, and the Fog Index

The Fog Index measures the level of reading difficulty of any document. The formula for the index is as follows: ( (average number of words per sentence) + (number of words of 3 syllables or more) ) X 0.4 = Fog index The Fog Index level 'translates' the number of years education a reader needs to understand the material. The "ideal" score is 7 or 8; anything above 12 is too hard for most people to read. Definition of Fog Index December 29, 2012 – When I’m having trouble understanding a piece of writing, I apply the Fog Index.  This was the situation as I read “A Glimpse of the Next 100 years in Medicine” in the December 27 New England Journal of Medicine. The following passage befogged me.  “The size and complexity of this multidimensional characterization will lead to far more complex diagnostic and prognostic categories than are currently in use.  The multivariate categories of large populations will allow stratification of a kind seen only in the most recent genomically informed clinical trials.  Massive data crunching will yield analytic or algorithmic formulas that will be useful for clinical purposes even though they defy easy summary in a language most of us can understand.  Complex but empirically validated algorithms will be embedded in EHR systems as decision support tools to assist in everyday patient care. These management algorithms will evolve and be modified continuously in accordance with inputs from ongoing clinical observations and rom new research. Clinical support algorithms will be derived entirely from data, not expert opinion, market incentives, or committee consensus. The huge amount of data available will make it possible to draw inferences from observations that will not be encumbered by unknown cofounding.” Why was I having troubling digesting these 157 words? Perhaps it was because of the high Fox Index.  The average sentence length was 22. 2 words.  The number of three syllable words per 100 words was 30.1. The Fog Index was 22.2 + 30.1 X 0.4= 20.9.  This means it would take 20.9 years of education to grasp the essence of what was being said.  I suppose this is about right for New England Journal of Medicine readers. Four years of high school, four years of college, four years of medical school, and 5 years of post-graduate training adds up to 17 years of education. Still, I wonder if it could have been said more simply.

Defensive Medicine
December 28, 2012

Obamacare As A Verb

I am not a thing – a noun. I seem to be a verb.

Buckminster Fuller (1895-1983),  philosopher, systems theorist, archictect, and inventor

December 28, 2012

When it comes right down to health reform,

I am unequivocally, irrevocably,indisputably not a noun.

I am not a bureaucracy, agency,  payment board,

commission,  department, or government thing.

I do not believe in top-down

command and control as nouns

or those  other  government nouns -

compliance, regulations, rules, and re-regulations,

electronic health or medical records, data, checklists,

algorithms, procedures, and SGR formulae,

As Holy Grails without fail.

I do not like physician dictates or berates.

or Washington  elitist wisdom

 over patient common sense.

Instead, I think of reform as a verb,

to persuade, incent, and inspire.

to innovate before it's too late,

to set doctors and patients on fire,

to bring them closer together,

to think, to improve, to aim higher,

to balance data aggregation and intuition,

to have patients and doctors know true cost of things,

to have patients account for their own savings.

to set money aside for retirement and IRAs.

to decide wht to do based on  judgment

to make personal choices rather than

to rely on Washington invoices.

Reform should not a government noun.

Reform should be a  personal verb.

Paradoxes: What Happens If Doctors Fall Off Fiscal Cliff?

A paradox is an argument that produces an inconsistency or absurdity, typically without logic or common sense.

Definition of Paradox

December 27, 2012 – A “doc fix” is unlikely in the next four days.  If a deal is not struck, doctors will fall off the fiscal cliff.  For physicians, this means a 26.5 % SGR cut and a 2.0% sequestration reduction,  on top of a 12% to 13% hike in income taxes for the typical doctor.

According to the tax policy center, going off cliff will produce these tax increases.

·         Incomes of $75,000 to $100,000 - $3688 increase

·         Incomes of $100,000 to $200,000 -$6633 increase

·         Incomes of $200,000 to $500,000 - $14,643 increase

It can be argued, of course, that it’s about time government redistributed income from the “haves” to  improve the lot of the “have-nots” -  those on Medicare and Medicaid and with income 4 times below the poverty line.

Still,  there is something inconsistent, illogical, noncommonsensical, and pradoxical  about this approach, which Obama seems to favor.  

It is paradoxical  that his administration refuses to cut entitlements – the major factor behind the budget deficit.  It is  paradoxical in a capitalistic economy that historically raising taxes always decreases government revenues to help the poor.

The third paradox is that if doctors lose 28.5% of Medicare revenues by going  over the cliff, some 30% to 50% of physicians will respond by stopping  seeing Medicare and Medicaid patients since reimbursements from these sources will no longer meet their practice expenses – all of this just as 78 million baby boomers and 30 million to 40 million are becoming Medicare and Medicaid eligible.  

Physicians are being told by some politicians, that none of this will ever happen.  A “patch” will be found.

These paradoxes and the patch theory  remind me of the old slave song,  “Rabbit in De Briar Patch,” which goes like this.

Rabbit in de briar patch,

Squirrel in de tree.

Wish I could go huntin’,

But I ain’t free.

Rooster’s in the hen house,

Hen’s in de patch,

Love to go shootin’,

But I ain’t free.

Rooster’s in de hen house,

Hen’s in de patch,

Love to go shootin’

But I ain’t free.

Rooster’s in de henhouse,

Hen’s in de patch,

Love to go shootin’,

But I ain’t free.

Doctors may no longer be able be free to see patients on entitlement programs who need their services,  and patients may be unable to find doctors to provide those services.

Tweet: If doctors go over the fiscal cliff, they may be unable to afford to see Medicare and Medicaid patients.

Ten Impure and Complex Primary Care Truths

The truth is rarely pure and never simple.

Oscar Wilde (1854-1900), The Importance of Being Earnest (1895)

It’s like the patient is bleeding faster than we can transfuse.

“Where Have All the Primary Care Doctors Gone? Pauline Chen, MD, New York Times, December 21, 2012

December 26, 2012

One -  No matter what Obamacare proposes or does, the primary care shortage will keep relentlessly growing.

Two – Medical students know primary care doctors work longer hours , make half as much as specialists, and hve more balanced lives.

Three – Medical students’ medical school mentors and heroes  are specialists, whom they follow and emulate.

Four -  Congress has put a funding lid on primary care residencies.

Five- Society tends to respect the specialists’ opinions and technologies more  and to reward specialists more than primary care doctors.

Six -  Medical homes and accountable care organizations, designed to empower primary care, are unproven concepts.

Seven -  Given average educational debts of $150,000,  medical students pick higher paying specialties.

Eight -  Primary care is more difficult to master than specialty care because of the overwhelming amount of information required.

Nine -  One practical way to equalize specialty care pay is for primary care doctors to perform more procedures (see National Procedures Institute).

Ten  -  Another practical way to enhance primary care is to cut expenses and to increase revenues by switching to concierge and cash-only practices.

Eleven –  The AMA, CMS, and specialists stack the  deck against primary care by controlling the Reimbursement Update Committee (RUC), which sets the codes for Medicare and Medicaid.

Tweet:  Eleven  factors stunt the growth of primary care and make it likely the primary care shortage will escalate.

Twas the Night Before Fiscliff

December 24, 2012 -  I opened the Internet this morning  to find the following verse online by Bill Frenza on Real Clear Politics.  Bill Frezza is a fellow at the Competitive Enterprise Institute, and a Boston-based venture capitalist

Twas the night before Fiscliff, when all through the House

Not a stateman was stirring, not even a grouse

Nither bills nor amendments have much of a prayer

Since hope and chagne fever brought gridlock to bear.

 

The citizens pondered in fear and in dread,
What will happen if off the cliff we go instead?
Obama was sure he set Boehner a trap
To force taxes higher, give rich folks a slap.

When on CNN there arose such a clatter,
I sprang to the set to see what was the matter.
Wolf Blitzer was shouting, he had a news flash,
Was a formula found that would scare up fresh cash?

Top of Form

Bottom of Form

The gloom had sent stock markets gyrating so,
While the luster of gold lured all those in the know.
When, what on the six o'clock news should appear,
But a fat helicoptering cash bombardier.

With a bearded bald driver, both facile and quick,
It must be the man with the Keynesian shtick.
Like a fire hose shower, liquidity came,
As he whistled, and shouted, and passed out the blame.

"Now Geithner! Now Sperling! More interest rate fixing!
On, Krugman! On, Goolsbee! It's cash we'll be mixing!
We must make sure aggregate demand won't fall!
Now spend away! Spend away! Spend away all!"

If you give me control of the money supply,
I will make the debt grow 'til it reaches the sky.
If this starts to give you stimulus déjà vu,
Just you wait ‘til you see infinite QE2.

So have no fear, kick the can, you don't need proof.
Go ahead and let spending go right through the roof!
By this point my head was fast spinning around,
When fat Ben Bernanke came up with a bound.

He was dressed all in greenbacks, from head to his foot,
That must have stuck to him, their value kaput.
A bundle of cash he had flung on his back,
Like every historic inflationist hack.

His eyes, how they shifted! His glibness so merry!
Pretending to be a prudent actuary.
"I know what I'm doing!" his words much did flow.
"My magic will make unemployment go low."

How easily this man can lie through his teeth,
Yet the smoke he was blowing gave me no relief.
He turned to make yet one more speech to the telly,
His statements as firm as a bowlful of jelly!

Then back to his copter, as quick as a whistle,
He unleashed one more fiat currency missile.
And as he took off, all heard just what he said,
"In the long run remember that we are all dead."

Despite reality, try to have a Merry Christmas and Happy New Year.

To which I have added this short copy-cat version.

Twas the night before Fiscliff, when all through the House,

And the Senate and the White House,  not a creature was  there.

They were all resting and not stirring at home in their native lair.

 Meanwhile physicians in fear and in dread said,

What if we go off the Fiscliff, will our careers be dead,
What if the SGR goes live and is not repaired.
What is from the sequester we are not spared.

 When on TV from Hawai,  there arose such a clatter,

I sprang to my set to see what could be  the matter.

Obamaclaus bearing gifts in a six o’clock news flash
Said, It’s all the GOP’s fault, Medicare they would slash.

He added, it's greedy physicians who make costs soar

They insist only about patients they are in the know,
When what on CNN and other channels should appear,
But a big fat debt clock ticking away loud and clear.