Thursday, May 31, 2012

 Selective Omission  of Data to Judge Physicians, Lower Costs, and  Improve Health Outcomes
Not only our actions, but our omissions become our destiny.
Abraham Verghese, MD, Cutting for Stone (Vintage Books, 2009)
May 31, 2012 -  Lies, damned  lies, and  statistics " is an overused  phrase describing the persuasive power of numbers, particularly the selective use of data  to bolster weak arguments.  
I prefer a variation of Mae West aphorism, “It’s not the men in your life that matters,  it’s the life in your men.”

In the case of health care,  desicatted data does not tell the story of what's occurring on the front lines of care, in the lifes of people or thier doctors.

I would paraphrase  the  Mae West line  to read,“It’s not the data that matters, but how the data is used that matters."
Health system and physician critics selective omit  data to condemn the U.S. health system.  
·         That   the U.S. compares unfavorably to other nations in longevity.  True enough, if you omit the fact that if you include our homicide and accident rates.  If you include these statistics,  we rank right up there. 

·         That the U.S. lags behind most other nations in overall care, when in fact we do better in prompt access to specialists and high tech care and in our outcomes in treating diabetes, heart disease, and cancer.

·         That American physicians make more than physicians in other nations is often bewailed.   Again, this is true, unless you include the prohibitive costs of U.S. medical education, often resulting in $200,000 medical education indebtedness of doctors entering practice,  and malpractice premiums,  often exceeding $100,000 for high tech specialists.  Subtract these costs from American physician incomes, and you get an entirely different pictureI
The selective use of data is often used to subtly portray American physicians as fee-for-service gold diggers prospecting for money by doing more unnecessary procedures to bolster their income(Joe Klein,  “Accountable Health Care,” Time Magazine,  May 29, 2012).
The argument for accountability goes: If only we could make physicians more “accountable” by placing them on salaries, devoid of personal gain'  if only they would practice in accountable care organizations as part of teams delivering coordinated, continuous data-based care based on comparative outcomes,  all would be well. U.S. health cost statistics compared other nations would improve, incomes for doctors would drop, health outcomes would improve
This is persuasive stuff. It is the essence of Obamacare and the regulations, mandates, and sanctions it would impose upon physicians,    But it creates tensions among the policymakers, academics,  and progressive-minded journalist who would have physicians do things their way.
Kevin Pho, MD,  America’s foremost physician blogger, beautifully captures the the dilemma is this blog post.
The Tension between Physicians and Health Policy Experts
By Kevin Pho, MD, in
"There’s an underlying tension between physicians and health policy experts."
"Health policy experts take subtle jibes against physicians in their analyses, with many feeling American doctors are overpaid, which exacerbates health costs. They tend to be politically progressive, and generally dismiss the issues that most doctors care deeply about. Medical malpractice, tort reform and the cost of medical education, for instance."
"And doctors can be antagonistic to policy experts. As most wonks are not physicians themselves, doctors generally discount their opinions, since they haven’t gone through the rigors of physician training, and are shielded from the day to day realities of practicing medicine."
"Yes, I’m generalizing, but those are the themes I’ve observed from the health reform conversation over the past few years"
"But if we are to fix our health system, both sides need to come together."
"Consider a recent NEJM piece, which asks the following:"
Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.
Merrill Goozner, a progressive policy commentator, answers:
The short answer, of course, is no. If they were public spirited, would they lobbying as hard as they are to restore physician pay — the so-called “doc fix” — which will cost the government another $300 billion for Medicare over the next decade."
I"t’s a subtle physician-antagonistic response that policy wonks on the progressive side — Goozner, Ezra Klein, Maggie Mahar, and Paul Krugman, to name a few — occasionally make that only exacerbates the discord."
"Yet, to successfully reform our health system, doctors need to be at the forefront, not policy experts. And I’m not saying that because I’m a physician myself. The data says so."
"A Gallup poll, conducted in 2009, found that physicians garnered the highest level of public trust when it came to health reform."
"Patients still trust their doctors. Which is why it baffles me when policy experts don’t give doctors many olive branches when making their health reform arguments. Given the rancor surrounding the debate, it seems that reformers could use all the support they can get."

"Take the contentious issue of physician salaries, for instance. Most progressive wonks feel that American doctors are overpaid, and in their ideal world, would like a single payer system where doctors are on a salary in line with the rest of the world. Ezra Klein, for instance, continually points to France to illustrate this point."

Well, it’s no surprise that doctors are hostile to that worldview. Of course, no one likes to get their pay cut. But, why not balance the argument by including the cost of American medical education? Yes, American doctors are paid more than any other physician in the world. But look at what it costs to train them:
"If policy experts included medical education reform (or medical malpractice reform) with their arguments for paying doctors less, it would be better accepted by the medical community. I’ve written before that more than a few doctors would exchange medical school debt relief in exchange for a strict salary. Or medical malpractice reform in exchange for less pay."

"I appreciate the data-driven arguments that policy wonks present to illustrate, and potentially solve, our dysfunctional health system. But charts by themselves cannot convince the public, whose acceptance is key to any variation of health reform."
"To do so, health reformers need doctors on their side. Why policy experts don’t make more of an effort to sway more doctors is a mystery to me, and a tragically missed opportunity."
Tweet:  Health policy makers selectively omit data to put the U.S. health system in a bad light.

Wednesday, May 30, 2012

On Government Vs Markets in Picking Health Care  Winners and Losers
The ultimate good desired is better reached by free trade in ideas – that the best test of trust in the power of thought to get itself accepted is the competition of the market, and that truth is the only ground upon which their wishes can be safely carried out. That at any rate is the theory of our Constitution. It is an experiment, as life is an experiment.
Oliver Wendell Holmes, Jr. 1841-1935, Abrams v. United States, 1929
Winning isn’t everything. It’s the only thing.
Saying, 1953, Attributed to football coach, Vince Lombardi

May 30, 2012 -  Ekekiel Emanuel, MD, formerly President Obama’s medical advisor, agrees with the Obama administration that government is capable of  picking economic winners and losers based on their political philosophies and comparative effective research data, as long as the latter is not applied to politial allies. 
President Obama and his advisors, backed Solyndra, the California solar panel maker, as a winner and  provided it with $575 million in federal loans, only to see the firm go bankrupt despite warnings of its approaching insolvency.   Markets and consumers are not yet ready for green energy products as market winners.
In his New York Times blog, Dr. Emanuel blasts the da Vinci  robot as a “fake innovation” for performing prostate surgeries (“Opinion: In Medicine Falling for Fake Innovation, “ May 30. 2012). He cites a study showing people who underwent robotic surgery had  less complications and blood loss in the short run, but who  later experienced more incontinence and erectile dysfunction (Jim Hu, et al, “Comparative Effectiveness  of Minimally Invasive Vs. Open Prostate Surgery, “ JAMA, Octobrt 24, 2009).  “In other words, “ Emanuel concludes, “this is  pseudo-innovation.”
Not so fast, McDuff.  The market believes in robotic surgeries. In a March 6, 2012 blog,  I wrote:
“Marketing of surgical robots have been remarkably successful. In part, this is because it’s in the human DNA to jump ahead of your competitors, your creditors, and your rectifiers.  As of June 2011, the manufacturer had installed 1,933 robotic systems. By June 2010, surgeons had performed 278,000 robotic-assisted surgical procedures, up 35% from 2009. The company projects one million assisted procedures will be performed in the United States over the next few years (Investor Report 2011). To reach this goal, the manufacturer will continue to market to smaller hospitals and surgeons, who it is assumed, will, in turn, market to communities and to patients.”
Emanuel argues, the Affordable Care Act,  through the strength of  data based comparative outcome research,  will end such marketing activity. Government  will pay  only for  cost-effective and outcome-documented  government-endorsed  tests and procedures.   
I would remind Emanuel that tests and procedures once considered as mere “flashy” Johnny-come lately innovations  are now considered medical standards.  In his words, “We have benefited tremendously from medical innovations like MRI scanners,  cardiac stents, and powerful new drugs, and we should celebrate the United States as the leaders in developing medical technologies.”
Indeed, we should.  And we should stop labeling market-tested innovations  as “fakes” and “pseudo-innovations,” and we should stop pretending the government can weed out winners from losers.  Over time, the market place will do that.

Tweet:  The U.S. medical marketplace has embraced surgical robots as an innovative, effective new advance although all evidence is not yet in.

The American People and the American Political Zoo
Americans were a People. They were the first self-constituted, self-created People in the history of the world.
Archibald McLeish (1892-1992),  The American Cause
Q: If you find so much that is unworthy of reverence in the United States, then why do you live here?

A: Why do men go to zoos?
H.L. Mencken (1880-1956),  Prejudices, Fifth Series
May 30, 2012 – If a foreigner were to visit the United States during this presidential election season,  he might compare its politicians and its citizens to inhabitants of a zoo.
There are:

--         Donkeys and elephants who wallow in the mud and wild kangaroos who jump from one trough to another and from  one cause to another and back again;

--     Elites who fly above the rest of us and who inhabit isolated bird cages and nests  of their own making in New York City,  Boston, Washington, D.C. and Hollywood;

--   common, ordinary, and extraordinary species who live and roam free in the wilds and prairies  outside the Beltway;

     --- idealistic creatures who think people in the US are no different than the rest of humankind and who have no right to hog 25% of the world’s energy and 27% of the world’s GDP;

     ---  them who regard Americans as an exceptional people, who comprise only 5% of the world’s people, but who supply 50% to 80% of the world’s movies, radio programs, Internet sites, innovations, and Nobel Prize winners- mostspoken and written in English,the world's diplomatic, telecommunivations, and broadcast language.

 --  the intelligentsia in  academis, policy making, and journalism who look askance at Tea Party Animals ,  assertive wild  creatures who make no sense but keep on  winning elections;

---    those who insist the American Constitution is a living document that ought to revered as the guiding beacon for American freedom while others say it is dated, even dead, and ought to be revised or ignored.

 --   those who respect,  even worship,  the zoo keepers while others shout – “Jeepers! Creepes! Get them out of there!”;

--- those who insist that Americans have the best health system in the world, the wonder of the world, while others maintain the system is a moral disgrace and stigma because government does not cover all.

Welcome to the American Zoo!  May its diversity, productivity, energy, and inventiveness  continue to lead and astonish the world.
Tweet : America is a zoo, composed of diverse people with different opinions, united in its belief in individualism  and free expression.

Health Reform and Taxes on Medical  Devices
If  left to their own devices, some will  not be controlled and will do what they want.
Idiom: Left to Your Own Devices
May 30, 2012 -  I see the Obama administration has devised a tax to explode innovation in the medical device industry (“Improvised Explosive Device Tax, Wall Street Journal, May 28, 2012).  The device tax is  a 2.3% excise tax on the gross revenues on companies making medical devices -  cardiac defibrillators,  artificial joints,  stents,  MRI Scanners.  
Mind you.  This is not a tax on profits, but on sales and gross revenues.  If you have, for example,  $10 million in sales, and $50, 000 in profits – a 5% margin -  you still  pay $230,000 to the government.   A windfall for the government, a wipe-out for the medical device company, and a total disincentive for the medical device industry, which is composed mostly of startups and medium sized enterprises.
This onerous  tax is supposed to raise $28.5 billion to offset costs of Obamacare, now estimated to be between $1.76 trillion to $2.5 trillion from 2014 to 2024 by government the CBO and OMB. 
Instead it is likely to stifle innovation in innovation hubs like Boston and Minneapolis.  This is why liberal politicians like Elizabeth Warren in Massachusetts and Al Franken in Minnesota are saying there has to be better way to support Obamacare.    Traditionally excise taxes are used to raise money on gas, cigarettes, liquor, beer, and wine, guns, and tires – not on live-saving and lifestyle-restoring complex medical devices,
Tweet: Obamacare’s 2.3% excise tax on the gross revenues of medical device makers  in under fire because it stifles, even kills innovation.

Tuesday, May 29, 2012

Notable and Re-Quotable: Grace Marie Turner, “What Will the Supreme Court Decide?”National Review Online, May 29, 2012
“If the Court upholds the whole law, it will quickly become clear that the law simply can’t work. The American people will resist its intrusion into their lives, the states will find new ways to fight back, lawsuits will proliferate, and Congress will be forced to protect taxpayers from its budget-busting entitlements.”

“If the Court strikes it down, the nation will breathe a collective sigh of relief that we now can get on with the business of real reform that is consistent with our Constitution, our liberty, and our market economy.”

The Winter of Physician Discontent over Obamacare
Now is the winter of our discontent.
Shakespeare (1564-1616), Richard III
May 29, 2012 -   To say that physicians are discontented over the health reform law is an understatement. 
Physicians direct much of their discontent at the Obama administration but also at the AMA, which, they feel, “sold us out” by supporting Obamacare.    Multiple extensive surveys, by  the Physicians Foundation,  and other organizations  document this discontent.
If you want a more vivid, visual  view of  the extent and reasons for physician unhappiness,   go to You Tube and download a seven part video series by Jill Vecchio, MD, a practicing Colorado radiation oncologist and co-founder of    The series is replete with powerpoint slides backed by explanatory talk.  
Dr. Vecchio explains in plain language that:
·       AMA membership has dropped from 70% to 17%.

·        The AMA derives $111 million from its coding monopoly and only $20 billion from membership dues.

·       65% of physicians oppose the affordable care act,  and 45% say they will retire or see fewer patients if it is implemented.

·       71% of doctors say there is “no way” they  can care for 47 million more patients at lower costs  under present conditions.

·       The argument over Obamacare is not between “the right and the left” but  between  "ther ight and the wrong.”

·        75% of Americans oppose the new law.

·       Under Medicare and Medicaid doctors are paid less and less for more and more work.

·       Each year 35.000 doctors retire while only 25,000 enter the physician workforce.

Market-based competitive principles would expand access and raise quality.
Dr. Vecchio’s presentations,  first developed in 2010, are sometimes dated. but their thrust is crystal clear. She accurately expresses physician discontent.  
For more recent educational material on Obamacare and its affect on doctors, you might want to watch live stream video of the June 6 Lehigh Valley’s Educational forum (www.usstream./channel/coalition-for-health-care-reform. 
in this educational forum, four health care professionals – two doctors and two nurses – will provide insights into how reform rules, regulations, and cost initiatives will reduce access to care, inhibit  doctor-patient relationships, and take decision-making out of the hands of medical experts and place it in the realm of government experts directing care in the names of  “essential benefits” and “best practices.”   
You should also be on the look out  for results of a Physicians Foundation e-survey of 650,000 physicians regarding the impact of health reform on their practices.

Tweet:  For educational  information on how health reform impacts physicians,  view 7-part video series by Dr. Jill Vecchio on You Tube.

Monday, May 28, 2012

Health Reform Paradoxes
The idea that the central government – one huge mainframe – is the most important part of governance is obsolete.
John Naisbitt, Global Paradox:  The Bigger the World Economy, the More Powerful Its Smallest Players, William Morrow and Company, 1994
 Chunking – Grow complex systems by chunking by allowing complex systems to emerge out of the links among simple systems that work well and are capable of operating independently.

Edgeware: Insights from Complexity Science for Health Care Leaders, VHA, Inc, 1998

May 28. 2012 -  Yesterday  at the local library,  I stumbled upon John Naisbitt’s 1994 book Global Paradox.    As I scan it on this Memorial Day,  I remember it was Naisbitt  in his 1982 classic, Megatrends,  who reminded us what America is all about.   We are a a"bottom-up" society rather than a "top-down" nation,    yet  we believe ,through our miltiary,  in protecting the rights of individuals around the world. 

In Megatrends,  Naisbitt said we are going from:

1) an industrial to an information society
2) forced  technologies to high tech/high touch
3) a national to a world economy
4) short term to long term thinking
5) centralization to decentralization
6) instiutional to self-help
7) representative to participatory democracy.
8)heirarchies  to networking
9) northern to southerm  U.S,
10) either/or to multiple choices

These trends continue to the present,  and it is wise to keep them in mind as we try to impose  Obamacare reforms upon Americans.   Some  of its provisions limit choices and individuual freedoms. 

Accurate Track Record

Naisbitt has a historical track record of accuracy.   In Global Paradox,  he asserts “There will be no real union of Europe.” He predicts the European unit will fail because each country will seek to preserve its own identity, language, and customs.  

This struck me as prescient, so I read on.
 “As the world integrates economically , the component parts are becoming more numerous and smaller and more important...The almost perfect metaphor for the movement from bureaucracies of any kind  is the shift  from the mainframe to PCs, with PCs linked together…The desire for balance between the tribal and the universal has always been with us. Democracy and revolution in telecommunications  have brought  need for balance between tribal and universal  to a new level….E-mail is for tribe makers,  Electronics makes us more tribal  at the same time it globalizes us.”
Naisibitt’s observations 18 years ago highlight the paradoxes of the faltering European Union and of Obamacare itself.
·         People want to retain their independence and individualism ,i.e,, their national customs and language, even while they are becoming more dependent on government. 
·         Cultural differences are important, even more so than the homogeneity and wealth distribution sought and engendered by idealistic progressive governments. 

·         The information revolution empowers individuals to seek information outside of government, to garner information by connecting each with one another, which in some cases, makes government-sponsored programs and information irrelevant.

·         People seek solace in more intimate relationships with each other and physicians, rather than with government-sponsored programs offering all things to all people.

·         People, according to Gallup polling,   trust each other and doctors more than big government or big health plans – even if big data indicates otherwise.

·         “We are, Naisbitt says, in the Western World,  in a ‘political crisis’ because leaders have ceased to become very important. Politics will remerge as the engine of individualism. It is a global shift from the state to the empowerment of the individual riding the wave of the telecommunication revolution, and the opportunities for individual freedom and enterprise are totally unprecedented.”
I do not want to overstate the case for individualism or for the Internet as health reform’s only change agent,  but I do think Obamacare may have overemphasized the importance of universal coverage at the price of individualism.   

A more incremental patient-centered approach, tethred to the individual rather than government,  may have worked better.
Naisbitt concludes,”A new technology is allowing companies to deconstruct, to radically decentralize, to push power and decision making down to the lowest possible point. Now citizens have the power to radically decentralize into direct democracies – free-market democracies. Centralized governments – in the metaphor, mainframe governments – must now yield to the periphery, to the PCs, the new leadership required in the world is to facilitate entrepreneurship, the contributions   by individuals, to facilitate the sort out of what will remain local and what will be global, what will remain global and what will be universal.”
Tweet: Health reform is a paradox in that individual empowerment, triggered by the  Internet,  has become more important than government itself in driving change.

Sunday, May 27, 2012

Size Matters: Hospital Consolidation and Physicians
I think no virtue goes with size.
Ralph Waldo Emerson (1803-1882), The Titmouse
May 27, 2012 -   As health reform evolves,  I’ve been watching multihospital systems grow in size and power and speculating what their gigantic size means.
Here, as of 2008, were the 10 largest systems in revenue size 
1.      Veterans Administration Hospitals,   $40.7 billion

2.      Hospital Corporation of America,  $28.4 billion

3.      Ascension Health, $12.7 billion

4.      Community Health,  $10.8 billion

5.      New York Presbyterian, $8.4 billion

6.      Tenet Health, $8.3 billion

7.      Catholic Health Initiatives,  $7.8 billon

8.      Catholic Health West,  $7.6 billion

9.      Sutter Health, $6.9 billion

10.  Mayo, $6.1 billion
What strikes me about this list are that such giant systems like Kaiser, the Cleveland Clinic,  Johns Hopkins,  Duke, and Health Partners in Boston don’t even appear, and the large  number of Catholic multisystem chains.  The revenues of multihospital systems has undoubtedly grown since 2008.   In 2011, hospital  mergers and acquisitions hit an alltime high.   More than half of all hospital admissions , 60% to be precise, occur in the 200 largest hospital systems,  hospitals now own more than half of physician practices, and large hospital systems are gobbling up rural and smaller hospitals at an accelerating rate.
Reasons behind the growth are self-evident:
·         market and monopoly power to become dominant  preferred providers in geographic regions
·         administrative flexibility  in coping with reduced federal reimbursements, triming duplications, and creating hospital-physician bundled billing  organizations

·         Need to expand into outpatient markets by acquiring physician practices

·         More ability to negotiate higher payer prices, particularly from private insurers

·         More capacity to invest in  health reform demands for quality, safety and electronic systems

·          Enhanced abilities to direct referrals and to build high tech centers for imaging, cancer, heart and orthopedic centers

·         Anticipation of influx of 32 million more paying Medicaid recipients in 2014 and 78 million new baby boomer Medicare eligibles over the next 18 years.

Critics'  Worries
Critics  worry that consolidation:
·         will create monopolies that will drive up prices and costs for government and consumers;

·         will make hospital owners of physician practices the real economic masters of the health system,  rather than government or physicians and their organizations.
As Humpty Dumpty said in Through a Looking Glass, “ The  question is: which is to be the master, that’s all.”  The  new question is: In the physician world,  will hospital systems, now the dominant physician employer,  dictate and direct what physicians can do, rather than physician organizations?
For insight into what a reform-minded government thinks about this and other matters,  I will like to quote the words of Ekekial  Emanuel, MD,  who was one of President Obama’s principal physician advisors from his perch at the National Institutes of Health before his present position as the professor of medicine at the University of Pennsylvania,  as cited by David Nash, MD, head of population health at Jefferson Medical College in MedPage today.
“Initiatives launched under the Patient Protection and Affordable Care Act (ACA) of 2010 are key to the solution:
  • Patient-Centered Medical Homes: The Group Health Cooperative of Puget Sound model (1,800 patients per primary care physician with nurses and pharmacists doing chronic disease management and outreach) has already achieved both clinical success and cost effectiveness (a 1.5: 1 return on investment).
  • Accountable Care Organizations (ACOs) focus on value-based care delivery and payment systems: Bundled payments – a veritable "prix fixe" – forces collaboration among all providers. Sacramento (CalPERS) ACO's Acute Care Episode demonstration project (i.e., payment bundles for coronary artery bypass grafts, pacemakers, and 8 orthopedic procedures) may be the prototype for a national program.
A former Washington insider, Emanuel believes that unless the Supreme Court does something completely "wacko," the U.S. will have universal coverage (with the exception of undocumented persons and refusals).
Costs will decrease and -- with advances in interoperable electronic medical records (EMRs), comparative effectiveness research, reporting, and medical error reduction -- quality will improve.
Changes in the delivery system will serve as catalysts
Within the next 10 years, Emanuel predicts that:
1.Checklists will be used routinely for intravenous therapies and surgery
2. Electronic medical records, health-related smart phone apps will become the norm
3. Remote monitoring of metrics such as weight, blood pressure, glucose levels will facilitate the management of chronic illness.
4. Health insurance as we know it will disappear”
Not My Opinion

That is Emanuel’s opinion.  I believe the Surpreme Court may indeed do something "wacko," like strike down Obamacare.   

Emaneul  may be right on counts 2 and 3,  but not on 1 and 4. 
I do not believe you can replace clinical judgments and patient desires  with checklists. .  I do not believe Accountable Care Organizations, which are essentially government-directed  consolidation of hospitals and physicians into organizations offering bundled bills, will reduce costs, nor do I believe they will replace health insurances companies. .    That is “top-down”  centralized  command and control government thinking, and  not “bottom-up” behavior in the real world.
Tweet:   Hospitals are reacting to reform by consolidating into bigger systems, employing more doctors, and negotiating higher costs.

Saturday, May 26, 2012

After Supreme Court Dust Has Settled
The drafters and defenders of the health-care law have only themselves to blame for this mess.  With a filibuster-proof Senate and total domination of the House, they did not trouble to build a consensus necessary for transformative legislation of this scope.
Michael W. McConnell, former federal judge, professor of law and director of Constitutional Law Center at Stanford Law School, senior fellow, Hoover Institution, “The Liberal Legal Meltdown over ObamaCare,"Wall Street Journal, May 26, 2012
May 26, 2012 -   We are a nation of consensus and laws centered on and around the Constitution.  Ideally, our president and his party ought to be  Constitutional consensus seekers, but he and his party choose not to pursue that course in passing the health law in 2010. That’s why Obamacare is in deep trouble.   That’s why Supreme Court may strike down the health law on June 25. And that’s why the Court will draw a line in the sand on that date.
If the law is struck down,  what are the  alternatives?  How do we avoid chaos?  How do we cut soaring costs of care without punishing the sick and the needy?  How do we still cover more of the 15% uninsured Americans?  How do build consensus around alternatives without violating the Constitution?   How do we persuade the public change is necessary?
·       We can start by saying the current $16 trillion national debt is unsustainable, and that Medicare and Medicaid contribute the most to its soaring growth and its burdens on our children and grandchildren.

·       We can point  out that health care now costs $2.6 trillion, 18% of the GDP, and Medicare/Medicaid will go bankrupt by 2024 if nothing is done – even sooner if doctors are paid what they need to remain in practice.

·       We can cite the Congressional Budget Office report showing that  employers may drop 20 million employees from their current plans  if Obamacare kicks in as planned in 2014.
·       We can take steps to dramatically expand health savings accounts,  which now cover 11.6 million Americans, reduce premiums by 30% to 50%, and cover 30% of those previously uninsured in companies where they have been introduced.

·       We can give individuals the same tax-free benefits as corporations now enjoy when they insure employees.

·       We can give individuals control over their health plans and allow them to build a tax-free retirement plan by seeking less unnecessary and more costly health care.
·       We can extend Medicare entry age to Medicare to 67 or even 70 over the next 5 years, and means test its recipients  so the well-off pay more.

·       We can give Medicare and Medicaid recipient choices of private plans that fit their needs.

·       We can give the States block Medicaid grants to cover those who need assistance in a flexible fashion that fits the needs of the poor,  disabled, and needy in their individual States.

·       We can empower doctors to create new models of care in new organizations  that offer reduced costs and more convenient access, we can educate patients and give them incentives to seek the best care, and we can inject competition into health markets that allow shopping across state lines  and outside narrow jurisdictions.
·       Or, we can keep deluding ourselves into thinking that government can be all things to all people without people taking responsibility for their decisions and their health.

Yes, we can.
Tweet:   The Supreme Court will decide the constitutionality of Obamacare on June 25. We must begin to think of alternatives should it be struck down.