Tuesday, September 30, 2014

Quote to Note: ObamaCare Giveth and ObamaCare Taketh Away

Collectively, more than 400,000 people who enrolled in health plans using HealthCare.gov have data- matching problems regarding their income or citizenship or income status.

There are a lot of people counting on their refund to pay for Christmas charges and instead are paying back their tax credit.

White House officials pointed to the health law’s requirement that people who are proven to be ineligible for subsidies have to pay them back.

Stephanie Armour, “Health Subsidies At Risk For Many, “ WSJ, September 30, 2014

Comment: This payback requirement glitch has the makings of a major PR and political negative ObamaCare blitz. What will happen when the poor and uninsured cannot pay back government on whose promises they depended?

Texas in Perspective

When you’re from Texas, it’s hard to be humble.

Texas saying

Texans think big. Texans think of Texas as the land of growth, enterprise, and opportunity.

Texans think economic growth trumps social inequality. They believe in compassionate conservatism.

Texans think energy in the form of fracking and natural gas trumps but complements wind and sun. You can have it all.

Texas believe in the Jeffersonian creed: government is best that governs least, government rules at the consent of the governed, equality of opportunity, and the best will follow – high employment, high wages, affordable living, low taxes, and social quality and justice.

Texans talk big and believe business is more important than government . This may be why the national media and progressives say Texans have no compassion, ignore society, lack intelligence, and are all hat and no saddle. This may be why the likes of governor Rick Perry, senators Ted Cruz and John Coryn, and Tea Party Representative are down played and put down, and the social problems of the uninsured, Medicaid, and Hispanic immigrants are highlighted.

Economic results not social occupy Texas citizens. The important thing is Texas is growing, business is booming, unemployment is dropping, and everybody, including Californians, Northeasterners, and physicians, are moving to Texas ( Les Christie, “Why Everybody Is Moving to Texas,” CNNMoney, September 29, 2014).

CNN says more Americans have moved to Texas in recent years than any other state – 387,000 according to the 2013 census. Austin is America’s fastest growing major city. Five of the 20 fastest growing large cities – Austin, Houston, San Antonio, Dallas, and Fort Worth – are in Texas. Why? Number one – jobs. Number two –affordable housing. Number three – cheap cost of living. Number four – friendly business climate. Number five – low taxes. Number six - few rules and regulations.

The BBC lists ten reasons.

1. Jobs

2. Affordable living

3. Homes

4. Low taxes

5. Choices of places to live

6. Austin in particular

7. Family friendly

8. Fewer rules

9. Normal people and cohesive society

10. Permanent residents

Maybe, after all is said and done, it’s Americans following the Jeffersonian creed.

• Government is best that governs least.

• Government following the consent of the governed.

• Equality opportunity, not equal results, for all.

• Economic growth, not government, as best distributor of social benefits.

As for doctors who are flocking to Texas in record numbers. They like the friendly and fair malpractice climate, the political strength of independent practitioners, the demand for physicians, and the presence of world-renowned medical centers.

Monday, September 29, 2014

Physicians As Pawns in Health Care Chess Game

The chess board is the world, and the pieces are the phenomena of the universe, the rules of the game are what we call the laws of Nature. The player on the other side is hidden from us. We know that , to our cost, that he never overlooks a mistake, or makes the smallest allowance for ignorance.

Thomas Henry Huxley (1825-1895), A Liberal Education

Physicians increasingly feel like pawns in a society chess game.

Chess is a game played by two persons, each with 16 pieces, on a chess board. Each person has eight pieces: one King, one Queen, two Bishops, two Rooks, two Knights, and eight Pawns.

The Pawns are the most numerous pieces on the board, also the weakest. They can be moved one square at a time vertically but be captured diagonally. In the society chess game, pawns are defined as something or someone to be used or manipulated for another person’s purpose.

The most powerful piece on the board is the Queen, who can move any unobstructed distance in any direction, The most important piece is the King. The object of the game is to trap the opponent’s King so that its escape is not possible.

The endgame is to trap the King. Then the King is said to be checkmated.

The other pieces on the board are limited in the directions they can move, vertically, horizontally or diagonally.

For the purposes of this blog, the Government is considered the Queen, and the Marketplace is considered the King.

The idea is to checkmate the King and his pawns, consumers and physicians.

In the endgame, the King cannot move and cannot jump over another piece.

I have, of course, oversimplified the very complex health care chess game, but there are parallels.

It is a game that can be won or lost by the moves of its various pieces. It pits one player, the Government, against another player, the Marketplace. It limits the moves of one player against another.

The Government is most powerful player because it is the biggest payer with 117 million Americans under its direct control (50 million in Medicare, 65 million in Medicaid, and 7 million in the VA).

The King, who oversees multiple moving parts, is in the process of being checkmated by rules and regulations and an all embracing health care law.

Physicians regard themselves as being used and manipulated as pawns in the process. They feel, well, rooked.

Physicians are trying to escape by contracting directly with consumers and businesses, but they fear the endgame is in sight, in which they will be mere pawns of the Queen.
California’s Narrowing Physician Networks

Yes, man is broad. Too broad, indeed. I’d have him narrower.

Dostoevski (1821-1881), The Brothers Karamazov

California is a wonderful place to live, if you happen to be an orange.

Fred Allen (1894-1956), American Comedian

If you live in California, home of one of nine Americans, you are likely to have a narrower choice of doctors in 2015 (Chad Terhue, Sandra Poindexter, and Doug Smith, “ObamaCare Networks to Stay Limited in 2015, “LA Times, September 28, 2014).

The state’s largest insurers are narrowing their networks, and the state health care exchange, Covered California, is too. The exchange isn’t even providing a directory to help consumers match their health plans with doctors.

You are on your own when it comes to finding a doctor. This year, 1.2 million Californians will seek to renew thier ObamaCare policies. And 30,000 Golden State residents will face health exchange enrollment delays, or dropped coverage.

Health Net, one of biggest state insurers, is dropping its PPO and switching to a plan with 54% fewer doctors and no out-of-network coverage. Health Net and other major California insurers – Anthem Blue Cross, Blue Shield of California, and Kaiser – insist restricted networks are necessary to avoid steep hikes in premiums.

Covered California, the state health exchange plan, says it will pay doctors less and reward remaining doctors with more patient volume. If doctors lose money with each patient, so be it. Presumably they will make it up with more volume. Covered California has no central doctor directory and refers patients to insurer websites, which are inaccurate about which doctors are in and which doctors are out.

Dozens of individual policyholders are suing Anthem and Blue Shield, saying the plans have misled them about participating doctors. To add to the confusion, many insurers have instituted more restrictive policies, known as EPOs, Exclusive Provider Organizations, which do not cover out-of-network physicians, whose charges consumers must pay.

Insurer customers are unhappy with these arrangements. Blue Shield consumer, Heidi Shertiff, 53, says her gynecologist and her gastroenterologist, are not covered under her new plan. Two new doctors listed in her new plan don’t offer coverage, and a third hasn’t accepted a new patient in three years.

Shertiff asks, “Where was the state in protecting people for these false promises? I’m not getting what I paid for.”

Mary Edwards, 63 from Mar Vista, complains, “This is the part of the Affordable Care Act that doesn’t quite work yet. This game of who’s in and who’s out is tiresome.”

Except health coverage isn’t a game. It’s about your health, and it makes a difference even in California, the state of milk and honey, Apple, Google, Silicon Valley, warm climate, and salubrious life styles.

This tale brings to mind the words of Robert Frost (1874-1963):

I met a Californian who would

Talk California – a state so blessed,

He said, in climate, none had ever

died there

A natural death, and Vigilance Committees

Had had to organize to stock the


And vindicate the state’s humanity.

Sunday, September 28, 2014

Medicaid without Doctors

Enrollment of Medicais is surging as a result of the Afforable Care Act, but the Obama administration and state officials have done little to ensure that the new beneficiaries have access to doctors after they get their Medicaid cards, federal investigators say in a new report.

Robert Pear, “For Many New Medicaid Enrollees, Care Is Hard to Find,” New York Times, September 28, 2014

What happens when the federal government and the states have split responsibilities for caring for Medicaid beneficiaries?

Not much, other than casting blame on one another or on doctors for not providing the care.

Buried on page 26 of the front section of today’s New York Times is a story about Medicaid patients not finding doctors or having to traveling long distances to find one. It says a federal inquiry finds access rules vary and are rarely enforced.

To the Times, this may not be a front page story, but for poor patients who signed up for Medicaid with high hopes and the implied promise of finding subsidized care for neighborhood doctors for neglected obstetric, primary, and specialty care, it is a big story.

Lack of doctors for Medicaid patients raises the question: What good is federally subsidized care if no doctor exists to provide it? The answer is not a simple care or no-care matter. Medicaid patients can still go to hospital emergency rooms or community clinics, both of which are legally obligated to treat them. And they may be able to seek out a nurse practitioner or other health professional.

These steps, however, fall short of the implied promise of ObamaCare to provide first-rate, convenient, private doctor access. The futile hunt for a doctor who will accept them brings up another question: Why do one third to one half of physicians, depending on which region and state of the country in which they practice, not accept Medicaid patients?

The answer to these questions varies from low Medicaid reimbursements, to onerous Medicaid bureaucratic regulations, to a general disdain for ObamaCare by about two-thirds of American physicians.

The Obama administrations could address these issues by paying physicians more to see Medicaid patients, by rewarding health plans to create networks of doctors seeing Medicaid patients, by lightning regulations for physicians who accept Medicaid patients, or, most drastically, by making accepting Medicaid patients a condition for medical licensing.

These are tough measures to implement in light of mounting national and state budget deficits, increasing political resistance to Big Government and Big Brother policies, and in a democratic nations where physicians are still free to practice where they please and to accept patients whom they want to accept.
The inspector general of the United States, Daniel Levinson, says federal Medicaid officials should require states to develop standards for physician access in addition to standards for urban and rural areas and for state officials to call doctors’ offices to check whether they are taking new Medicaid patients.

These policies may not do much good if physician shortages in places where Medicaid recipients live and work, continue to grow. Soon one of four Americans will receive Medicaid assistance.
The Physician and the Autistic Savant

A person with autism who in mentally disabled and who has a low IQ but who is exceptionally gifted in a specialized field like mathematics.

Definition, autistic savant

The computer is an autistic savant, but it is not a person. It is an exceptionally gifted powerful took for processing information but outside of that information it is a moron.

This thought is not original with me. In 1967, Peter Drucker expressed it an essay, “The Manager and the Moron.” A computer cannot think for itself. It can only process information submitted by a human being, and the human being is the only one who can usefully use or interpret that information.

According to a new book by Walter Isaacson, The Innovators: How a Group of Hackers, Geniuses, and Geeks Created the Digital Innovation,” we are still far from the “thinking” machines envisioned by computer pioneer Alan Turing (1912-1954). Turing was considered the father of computer science and artificial intelligence who insisted computer would ultimately be able to “think.”

Isaacson should know the limits and power of innovation. He is chief executive of the Aspen Institute and has authored biographies of Benjamin Franklin, Steve Jobs, and Albert Einstein. Isaacson’s position is this: Today’s biggest innovations spring from a combination of human creativity and computer processing power.

Unfortunately, a mindset is emerging out there in the field of medicine and health care that computers can “think” for physicians and can dictate what needs to be done for patients based on computer-generated megadata and expressed in computer algorithms and protocols. This data, theoretically, even when blindly applied, will improve the overall “population health” of Americans.

This may be. But there is a much more likely possibility “that the combined talents of humans and computers, when working together in partnership and symbiosis, will indefinitely be more creative than any computer working alone.”

IBM, with its computer Watson, is pursuing this symbiosis by working together with oncologists as partners to develop more rational approaches to the treatment and cure of cancer.

I have long believed that the computer is useful in providing physicians with information they can consider, use, or reject based on their knowledge of the patient. Thirty years ago, with the help of Russell Hobbie, PhD, a professor of physics at the University of Minnesota, I developed a computer program that generated a differential diagnosis based on a patient’s gender, age, and comprehensive battery of laboratory tests. Our list of diagnoses included the probable diagnosis 80% of the time.

In today’s computer environment, this percentage would easily rise to over 90% given the information available on computer apps and electronic medical records. It would also be possible to calculate the patient’s level of health based in the patient’s physical measurements (weight, height, pulse, blood pressure, response to exercise, and key blood tests), all of which could be gathered during an office visit).

But I have one huge caveat about the use of this information. The physician, in concert with the patient, should be free to interpret or reject the computer-generated information. Artificial intelligence has limits. These limits should be respected or rejected in light of the patient’s emotional appetites, desires, drives, and instincts.

Saturday, September 27, 2014

ObamaCare Will Cost You

Agree, for the law is costly.

William Camden (1551-1623), Remains

It remains to be seen, but ObamaCare is proving to be more costly than originally estimated. A new study from Bloomberg Government found federal spending on Obamacare and related legislation has cost taxpayers $73 billion.

Add in projected spending on the law’s Medicaid expansion bring federal costs to more than $90 billion. The study’s estimate is even higher than the Congressional Budget Office’s “high” cost projection for the law -- $71.2 billion by the end of 2014.

Throw in the cost of healthcare.gov, which has cost taxpayers more than $2 billion, over twice the $834 million the Obama administration claimed it cost in an August 2014 report.

And project your thinking out to 2024, at which time, the best guess is the bill will be $2,43 trillion, according to some Congressional sources, and pretty soon, you’re talking about some real debt. New taxes will cover $1.30 trillion and new debt $1.13 trillion.

By the end of the Obama administration in 2016, the national debt will exceed $20 trillion.

And God only knows what it will cost American taxpayers, but it will require the present and future generations to pay it off. The current national debt is $58,000 for each single American. and next gneration

Can you escape the ObamaCare octopus taxpayer incubus? Probably not. If you choose not to participate in the Affordable Care Act in 2014, the penalty for a family of five will be as high as $12,240, rising sharply in 2015 and 2016.

Is the $9000 cost of covering each uninsured in the first 4 ½ years of ObamaCare to pay for subsidies of 10 million of the uninsured worth the cost to society of loss of choice of health plans and doctors along with cancellation of millions of health plans with replacement by more expensive plans?

This is an alarmist scenario, but it plays into the fears of those who warn of the hazards of Big Government. Whether such talk will have an effect of the November 2014 midterms and beyond, no one knows. But there are those who think it might (Lahee Chen, “Runaway ObamaCare Spending Will Cost Democrats,” Bloomberg News, Septmeber 26, 2014).

Friday, September 26, 2014

Physicians Foundation Poll of 20,000 Physicians

The rains descended, and the floods came, and the winds blew, and beat upon the house, and it fell not; for it was founded upon a rock.

Matthew 7:25

The Physicians Foundation was founded to advance the cause of the private practice of medicine – still the foundation of American medicine. To do this, the Physicians Foundation periodically performs national surveys to find how physicians are feeling and acting. In its latest survey, 20,000 physicians responded , 3% of those polled.

The survey indicates that the private independent practice foundation of American medicine is eroding as more physicians, particularly the young and the female, become employees, mostly of hospitals; as older physicians see fewer patients, spend less time with them, and as these older physicians accelerate retirement plans.

Here is a brief summary of 22 key physician findings.

1) 81% feel overextended.

2) 44% plan to reduce patient access.

3) 72% believe a physician shortage exists.

4) 35% consider themselves to be in independent practice, down from 49% in 2012, and 62% in 2008.

5) 53% are hospital or group employees, up from 44% in 2012 and 25% in 2008.

6) 29% would not choose medicine again, down from 35% in 2012.

7) 44% have positive views of future of profession, up from 32% in 2012.

8) 50% would recommend medicine as profession for their children or young people.

9) 69% believe their clinical autonomy is limited or compromised.

10) 24% limit access to Medicare patients.

11) 46% give ObamaCare a D or F grade: 25% an A or B.

12) 85% have electronic medical records, up from 69% in 2010.

13) 40% say EMRs reduce efficiency; 24% say EMRs increase efficiency.

14) 7% are in concierge practices: 13% plan to be.

15) 38% do not see Medicaid patients.

16) 49% see either Medicare or Medicaid patients.

17) 33% participate in health exchange plans; 25% have not plans to do so.

18) Physicians on average work 53 hours a week, down from 58 hours in 2010.

19) 56% believe transition to ICD-10 coding will cause turmoil.

20) 20% spent time on non-clinical paperwork.

21) Younger and women physicians are positive about changes in health system; older physicians, male physicians, specialists, and practice owners less so.

22) 39% plan to accelerate their retirement.

Thursday, September 25, 2014

Strains in Hospital-Physician Relationships

Doctors are losing influence. Hospital systems are growing more powerful as they bulk up by buying physician practices, nursing homes, urgent-care centers, and other hospitals. Insurers and the federal health care overhaul are squeezing hospital and doctor payments and shifting doctor payments and reimbursement from how much health care is given to how effective it is.

Jonathan Rockoff, “New Medicine: As Doctors Lose Clout, Drug Firms Redirect Pitch," WSJ, September 25, 2014

As hospitals grow bigger, drug companies are concentrating their marketing on hospitals rather than doctors.

There is no mystery as to why this is so. You get more bang for your buck in dealing with employers rather than employees. Drug companies, insurers and government would rather deal with a few large organizations rather than a myriad of doctors.

The percentage of doctors employed by hospitals has risen from 31% to 42% over the last three years, and the percentage of doctor practices owned by hospitals has gone up from roughly 20% to about 60% over that same period. (Sources: Hospital Strategy Group and Cegedin Relationship Management).

These rises have coincided with the passage of ObamaCare, which in various ways, is pushing the concepts of Accountable Care Organizations to coordinate and consolidate care, shift payment from fee-for-service to bundled care, and shift emphasis from individual treatment to population health management.

These developments have created tensions between hospitals and physicians. These tensions are inevitable. As a hospital administrator once said of physicians, “ You can’t live without them and you can live with them.”

Hospitals and doctors often compete. This competition has intensified as technology advances has made it possible to treat 80% of surgical procedures safely on an ambulatory basis outside of hospitals. The problem for hospitals is that inpatient surgeries have often been a profit-center that covers the cost of services such as mental health, emergency rooms, and non-collectible payments for the uninsured and Medicaid.

Hospitals have responded by decentralizing and setting up their own ambulatory care centers and by hiring and owning physicians practices, both primary care physicians and the surgical specialists to whom they refer; and by raising prices, sometimes by 50% or more, for seeing physicians in hospital-owned physician practices.

Physicians have reacted by creating concierge practices and direct pay ambulatory care centers and by encouraging self-funded business to directly contract with physicians at lower costs. Physicians claim these practices are more direct, more convenient, more efficient, less costly, and avoid administrative expenses of hospitals and other third parties, and the problems of hospital-borne infections.

The reality is, of course, that both hospital and outpatient care are needed at one time or another. Most patient care occurs at the edge between doctors’ offices and hospitals, and coordination is needed. Many complex operative procedures can only be performed in hospitals, some require lengthy hospital stays, some demand equipment available only in hospitals, some require hospital teams and a concentration of medical-surgical specialists.
ObamaCare Genie

To allow something to happen which cannot be stopped (American idiom); A magic spirit that would do whatever the person who controlled it wanted (Arabic story).

Genie out of the bottle definitions

Is the ObamaCare genie out of the bottle, never to be repealed or replaced or seriously altered?

Indeed, is there any feasible alternative?

Is ObamaCare like toothpaste, once out of the tube, you can never shove it back in?

Once the health care of millions is subsidized, will it be possible to reverse those subsidies, or the subsidies of millions more to come?

Is ObamaCare, like the Internet, once global with a smart phone in every hand, a computer in every household, will there be any turning back?

The Obama administration is betting the genie out and here to stay and to grow. It is betting it will cover 13 million people, 6 million more than now, to the insured list by the end of 2015, just enough to keep premiums low. It is betting the outcome of the midterms will have no impact on these numbers. It is betting you can never put the Obamacare genie back in the bottle.

And the administration says health insurers are on their side. HHS secretary Sylvia Mathews Burwell says more insurers are participating in ObamaCare next year – a 25% increase.

This is a sign, she maintains, the administration is make “historic progress” in covering the uninsured.“When you consider the law through the lens of affordability, access and quality, the evidence points to a clear conclusion: The Affordable Care Act is working,” Burwell said at the Brookings Institution in one of her first major speeches as secretary. “And families, businesses and taxpayers are a better off as a result.” (Jennifer Haberkorn and Brett Norman, "Insurers’ Bigger Role Suggests Confidence in ObamaCare,” Politico, September 23, 2014.

United Healthcare has announced it will offer plans in as many as two-dozen states, Other big insurers already in some markets have said they will move into more states as well, including Cigna and Aetna. The administration's message is that the health care law is working — a phrase Burwell repeated throughout her speech — despite the long-lingering political debate between Republicans and Democrats in Washington.

Overall, 77 new insurers will join exchanges next year in the 44 states that had available data, HHS said. On the federal HealthCare.gov, there will be 57 new issuers, a 30 percent increase from the 191 on the exchange this year, according to an HHS report released Tuesday. In the eight state-based marketplaces with data available, there will be six more issuers, marking a 10 percent increase.

Republican opponents think Obamacare beg to differ. They cite government reports that found insurers are selling ObamaCare plans without separating abortion funding from taxpayer money, an apparent violation of the law’s prohibition on federal funding of abortion. And they blame the health law for raising costs, limiting choices and, through what they cite as security flaws in HealthCare.gov, endangering people’s privacy.

It’s not insurer growth across the board In Minnesota, PreferredOne, which covered more than half of the individuals in the state exchange, announced it was pulling out last week. At least 13 other insurers across the country are dropping out, too.

Still, even critics admit: The more people subsidized on the exchanges, the more people dependent on government, the harder it will be to put the ObamaCare genie back in the bottle.

Wednesday, September 24, 2014

Obama Success and Failure Stories

Success depends on three things: who says it, what he says, and of these three things, what he says is the least important.

John Morley (1838-1923), British liberal statesman, writer, and editor

I was never afraid of failure, for I would sooner fail than not be among the great.

John Keats (1795-1821), English poet

The times are approaching when history will consider ObamaCare a success or a failure – the 2014 midterms and end of the Obama Presidency in 2016.

Success Story

According to Farzad Mostashashi, MD, former national coordinator for HHS and President Obama, and founder of Alledade, a venture capital firm which works with primary care physicians to help them save Medicare money through Accountable Care Organizations, and Ob Kocher, a partner in Venrock, a venture firmthat invested in Alledade, the results of a McAllen, Texas, ACO founded in 2012, the results in McAllen have been “stunning,” with $20 million in Medicare savings (“A Health Care Success Story,” New York Times, September 23, 2014).

Doctors in the Texas ACO achieved these savings by focusing on diet and lifestyle savings and quick hospital follow-ups to teach patients about prevention. From 2012 to 2013, control of diabetes rose 11.8% and vaccinations went up 12.2%. Nationally 360 ACOs now serve 5.3 million Medicare beneficiaries, and similar results are expected across the nation.

Mostashari and Kocher predict “ A continued slowing of health care cost growth will ower a great deal to this revolution in how we pay for health care. It is a transformation is now being played out throughout the country – even in the little Texas town of McAllen.”

What Mostashari and Kocher do not say is that physicians are not happy with ObamaCare with 46% giving it a D or F grade and only 25% giving it an A or B grade. ACOs are important in the ObamCare scheme of things. but they are usually least important in the eyes of physicians.


Meanwhile critics of Obama and ObamaCare are hard at it. They are criticizing the President on many multiple fronts. John Hawkins in the September 23 issue of Townhall gives six reasons Barack Obama is a failed president.

1) He was unprepared for the job

Hawkins says of Obama: “ He had never run a business. He had never been a governor. His performance as a state senator in Illinois and during his very brief time as a senator was undistinguished. There was nothing about Barack Obama’s background that should have led anyone to think that he would be up to the job of being President and as it turns out, he isn’t.”

2) His aims are ideological and political, not practical:

“ Obama starts with the assumption that anything that’s good for him, the Democrat Party, and for liberalism must be good for the country by default. Sadly, the long line of broken promises, mishaps, and disasters that have defined his presidency say otherwise.”

3) He doesn't know how to work with Congress:

“Obama’s standard modus operandi is to propose something he knows Republicans will oppose, then trash them non-stop, refuse to meet with them, and cap it all off by complaining that they won’t work with him on anything.”

4) He's narcissistic:

“Obama is always primarily interested in himself. Leaders in this country are supposed to be servants of the people, not their masters. Having a man like Obama, who views the great power he has as a way to serve himself is dangerous for our country."

5) He’s a poor planner who doesn’t think things through:

“This is not a man who spends a lot of time thinking about the consequences of his actions before he makes a decision, which is a pretty scary trait for the President of the United States.”

6) He's habitually dishonest:

“When you’re dealing with a bald faced liar like Barack Obama, you always know that nothing he says means anything more than, “If you like your health care plan, you can keep it.”

This are harsh assessments, and I do not agree with much of them. But neither do I agree that ObamaCare is an unqualified success.

Hell’s broken loose.

Robert Greene (1560-1592), Farewell to Folly

At best, the renewal of broken relationships is a nervous matter.

Henry Brooks Adams (1838-1918), The Education of Henry Adams

As I write, everything appears to be broken - foreign relationships, the health system, reform of the system, the economic recovery, faith in President Obama’s leadership.

These are nervous times.

• Democrats are nervous about losing the Senate.

• Republicans are nervous about what they will do if they win the Senate.

• President Obama is nervous about what he will do in the remainder of his Presidency.

• The Western World is nervous about winning the war against ISIS.

• Americans are nervous about the economic recovery (William Galston, “The Recovery That Left Almost Everybody Out,” WSJ, September 24).

• Ordinary citizens are nervous about losing their health plans (John Goodman, “Why You Are Likely to Lose Your Health Plan, Forbes, September 24, 2014).

Fear not, said Samuel Eliot Morison (1887-1976), American historian, “ Americans are a tough but nervous, tenacious but restless race; materially ambitious, yet prone to introspection and subject to waves of religious emotion.. A race whose typical member is eternally torn between a passion for righteousness and a desire to get on with the world.”

We will figure out what to do. We have to. There is no other choice.

With health care, the choice is between ObamaCare, modification of its mandates, repeal and replacement, or as yet some unidentified middle and higher ground.

Keep the faith. Remember the farmer’s maxim: he who breaks ground gains ground.

Broken ground can be fertile ground.

Tuesday, September 23, 2014

Hospitals V. Doctors: Advantages and Disadvantages

To what advantage would it be?

Cicero (106-43 BC)

Prudence consists of power to recognize the nature of disadvantage.

Machiavelli,(1469-1527), The Prince>

One of those things you hear little about is competition between hospitals and doctors. In the minds of the public, the two are supposed to collaborate rather than compete.

The subject of collaboration comes to mind for two reasons:

One, the competition between hospitals and doctors for their share of ambulatory surgery market. Because of higher hospital rates for ambulatory surgeries, the desire of surgeons for more direct control and efficiency of outpatient surgical procedures, and the search of payers, employers, and patients for lower costs, direct pay ambulatory surgery centers are actively competing with hospitals for the outpatient surgery business.

Two, hospitals are seeking ways to lower costs because of insurer and government pressures and lower reimbursement rates. One effective way of doing this is to standardize physician behaviors (Jeanne Whalen,”Hospitals Cut Costs by Getting Doctors to Stick to Guidelines, Wall Street Journal, September 22, 2015).

This is part of hospital push to reduce costs by standardizing care. The idea is end overuse of tests and procedures - like routine cardiac monitoring or MRIs or CT scans for headaches or lower back pain. Some doctors resist this standardization, saying they sometimes must order these tests or procedures to avoid being sued.

In the competition-collaborative tug of war, hospitals have most of the advantages. Hospitals have scale. They are large organizations with political and marketing advantages, they lie at the center of most communities, and physicians as a rule must belong to hospital staffs to be legitimate health care providers.

Doctors, on the other hand, say they must reserve the right to do what is necessary for the health and survival of patients, and retain the flexibility to exercise their best clinical judgment. In the case of outpatient surgical procedures or concierge practices freed of the restraints and expenses inherent of third party regulations, physicians claim they can control time spent with patients, can use the most appropriate tools and procedures and staff, and can exercise the necessary autonomy to do what they are trained to do.

Monday, September 22, 2014

Free Market Medicine and Reality

Reality is things as they are.

Wallace Stevens (1879-1955), The Necessary Angel

I am a big fan of free market medicine. I am also a realist.

Free market medicine is a reality. It has an association, the Free Market Medical Association, with physician members in all 50 states, and more than 1000 participating businesses interested in cutting their health care expenses and promoting convenient care for their employees.

The Free Market Medical Association holds its first annual conference in Oklahoma City this Friday and Saturday. It will play to a full house.

Its theme is: “Thinkers, Doers, and Users: Forecasts, ideas, and how to create a free market health care practice How to practice free market medicine and how to use free market care to save money and get better results".

Speakers, all of whom are active in the direct pay independent practice movement, will address the following topics:

• Why the Free Market Boom

• Concierge Medicine – Direct Pay and Health Care Leadership

• Samaritan Ministries – Free Market Users

• Legal Green Lights and Red Lights

• Why I Posted My Prices

• How the Market Works

• MedaBid and Changing the Way We Buy Health Care

• The Free Market – Now, Next Year, and in Five Years

Charles Sauer, who is now executive director of the Free Market Medical Association; Keith Smith, MD, an anesthesiologist who co-founded the Surgery Center of Oklahoma; and Jay Kempton, CEO of the Kempton Group in Oklahoma City, who helps Oklahoma City employers find the best, most appropriate, most convenient, and least costly care for their employees, together co-founded the Free Market Medical Assocition and organized its first annual conference.

As I realist, I know direct pay independent practices, as exemplified in concierge medicine, ambulatory surgery centers, and other forms of cash-related practices without third party involvement are growing rapidly throughout the nation.

As a realist, I am also aware these direct –pay independent practices are ideally suited and work best for ambulatory patients, outside of settings directed by third party administered, regulated, and directed care.

ObamaCare News of the Day

This news in old enough, yet it is everyday’s news.

Shakespeare (1564-1616), Measure for Measure

The new news for ObamaCare is old news remains bad news.

The news as reflected in these three articles all say ObamaCare is headed for a fall in the November midterms.

1. Robert Ehrlich, “Affordable Care Act Lies, Baltimore Sun, September 20

2. Jeffrey Anderson, “Voter Intensity Strongly Against ObamaCare,” The Weekly Standard>, September 20

3. David Gergen, “ISIS Rollout Resembles Launch of ObamaCare,” The CNN Report, September 21

• Ehrlich, former Maryland Governor, former member of Congress, and now a law partner, reels off these ObamaCare “lies.”

1. Young people will love it.

2. Everybody will finally become covered.

3. Health reform will have little impact on employment.

4. You can keep your insurance if you like it.

5. The medical device tax is a moneymaker.

6. The health law will appease the progressive consciences.

7. The typical family will save $2500.

8. Nobody will deny you coverage for pre-existing conditions.

• Anderson, editor of the Weekly Standard, cites a poll indicating voters who consider ObamaCare “very important” oppose the health law by 70% to 30% and those who deem it “somewhat important” are against it by 51% to 47%. Those personally affected by ObamaCare or who have friends or relatives personally affected, say the affect been very negative (46%) or very positive ( 24%). By 71% to 27%, voters favor repeal of ObamaCare with replacement by a market-based system with health plans competing for price and individuals shopping for the best price.

• Gergen, senior CNN contributor, adviser to four Presidents, Harvard Law School graduate, and director of the the Center for Public Leadership at Harvard Univesity’s Kennedy School of Government say the President and his administration ought to get its act together:

“ With one hapless episode after another, The rollout of the President’s plan is beginning to rival the less-than-splendid debut of the ObamaCare website..In coming days, through his time at the United Nations and back in the White House, the President must dramatically seize the reins of leadership.”

Sunday, September 21, 2014

Patients, Physicians, and Pluralism

The theory that even if there is one basic principle many particular and distinct entities exist.


I belong to the school that says.

• America is basically a conservative right of center pluralistic nation that cherishess economic growth more than in political egalitarianism.

• America believes in equality of opportunity but not necessarily in redistribution of wealth to achieve equality of results.

• Diffusion of electronic communication technologies is making top-down autocratic homogenization of population behavior difficult, even obsolete.

• Conservative politics generate economic growth but result in inequality while left-wing politics redistribute wealth to achieve equality but produce economic stagnation.

• Finally, I believe these political philosophies will always swing back and forth in never-ending political and economic cycles with neither side ever convincing the other of the rightness of their respective causes.

At this moment in history, the U.S. and the world are caught up in the causes of pluralism vs. separatism. This dispute is exemplified by the struggle of who should control health care in the United States, the collective government or individual markets, by the Scottish referendum over whether Scotland should be independent or dependent on Britain, and by the Middle Eastern battles over which political entity should govern in that region of the world.

In his essay in this morning’s New York Times, Thomas Friedman backs pluralism over separatism “Three Cheers for Pluralism over Separatism.” Friedman argues everybody’s interests have be served and balanced with “no victor, no vanquished” among major players.

Friedman goes on to say America has always been a pluralistic country and concludes by saying we ought to have the wisdom to pass an immigration reform bill that enriches our pluralism.

Like most hot political issues, integrating the interests of those with different points of view is easier said than done.

As Peter F. Drucker (1909-2005), noted in his prophetic 1969 book, The Age of Discontinuity, in a chapter “The New Pluralism”:

“The private sector does not understand the government’s logic. Each rubs the other raw trying to work together, each resents the attitude of the other and is deeply suspicious of it, and yet each other is dependent on the other…Medical men see individuals. Indeed, none of us would want to be treated by a physician who treats ‘averages.’ But no government can handle anything but large numbers or go by anything but averages.”

But work together we must in a nation where 280 million of our 315 million citizens are dependent in one way or another on government subsidies: 65 million on Medicaid, 50 million on Medicare, 9 million on the VA, 7 million on ObamaCare exchanges, and a whopping 149 million on corporate health care tax credits for employers .

We must do so to preserve a society that is both competitive but cohesive despite our differences

Saturday, September 20, 2014

Electronic (E) Technology Doxology

Praise E-technology, from whom all blessings flow.


In God we trust, all others bring data.

W. Edwards Deming. 1900-1993.American statistician

Electronic (E) Technology has become a religion.

It's E-Technology here, E-Technology there, E-data here, E-data everywhere for every season and every reason as far as the Electronic Global eye can see.

It’s computer, mobile, and Internet apps. It’s Alibaba, the giant China E-commerce company. It’s Facebook, Twitter, and Amazon. It’s “Technology Lights Up Health Innovation Forum.” “It’s the Apple iPhone Takes Over the Street.” It’s “Leapfrogging the Democrat’s Tech Advantage.” It’s “Three Ways to Take Advantage of the Cloud.”

It's viral. It spreads through the ether, through the Cloud, from E-mail to E-mail, from Website to Website, from person to person.

It’s the multiplier, emusifier effect.

Why fool around with hundreds of thousands in the long term when you can reach millions, even billions, and disperse the information all at once?

Why wait for results when you can measure outcomes instantly with real data ?

Why be subjective with feelings when you can be objective with data?

Why guess when you can make others know?

Why wait to become a billionaire when you can do in a twinkling with Twitter?

Or connect with billions with Facebook?

According to three dozen experts who gathered this week in Boston for an innovation conference, a tsunami of health care innovations is sweeping the globe.

These innovations, say the expert schemers and dreamers, will be cost-effective and will boost wellness, prevention, precision treatment, personal and decentralized care at the iPhone, social media, personal, and home-bound levels.

It will be an E for an E, an E-click for an E- click, and an E-bite for an E-bite, one on one for millions.

Well, we shall see.

We shall see innovation and 3000 troops on the ground wipes out Ebola.

We shall see if the over all and individual health of Americans improves.

We shall see if the results match the rhetoric.

We shall see if innovation creates necessary economic growth, requisite market competition, needed consumer choices, and required price transparencies.

And we shall see whether collectivist governments have the wisdom to abet the innovative process or strangle it because it generates that dreaded thing called profit – a universal incentive for prosperity and the betterment of humankind.

Friday, September 19, 2014

President Obama's Judgment V. the People's Judgment

Any social order which can function well with a minimum of leadership will be anathema to the intellectual

Eric Hoffer (1902-1983), American longshoreman, moral and social philosopher, In The True Believer (1951)

I collect Eric Hoffer books. I think of him as "His Earthiness", a man with his feet solidly on the ground.

Among other things, Hoffer has said you cannot trust an intellectual to be President because he does not reflect the sentiments of the people.

Obama considers himself as one of the elite, who knows what needs to be done.

President Obama has inpeccable academic credentials – Columbia University, Harvard Law, and Professor of Constitutional Law at the University of Chicago. He is smart. He is a real, genuine, certified intellectual, with two best-seller books on the New York Times book list. He is a smooth talker. He is facile with words, especially when reading from a teleprompter. He is quick with concepts. He absorbs data and information like a sponge. He is an integral inseparable part of the Media-academic-Washington-elite-policy Complex.

But he may be out of out of touch with the populace, as evidenced by these latest Real Clear Politics polls based on average results of major national polls.

• Obama Job Approval, Approve 41.3%, Disapprove 53.4%

• Direction of Country, Right direction, 27.4%, wrong direction 64.6%

• Approval of Health Law, favor 41.3%, oppose 51.4%

Is it possible the President lacks wisdom and judgment on how best to lead the country, how to get the country behind him on critical issues relating to the economy, to joblessness, to health care, to foreign affairs? Is it possible the President is too long on rhetoric but too short on results?

Does he lack the wisdom to lead the country? Does he understand wisdom of crowds, whose support he needs and who must live under his leadership? Is the President like the man described by Albert Camus (1913-1960), who said, “An intelligent man on one plane can be a fool on the others.”

To Peggy Noonan, a staunch Republican writing in yesterday’s Wall Street Journal, “ The Unwisdom of Barach Obama – Is He Weak? Arrogant? Ambivalent?"

Noonan say the President’s problems– his being out of touch on economic issues, health care, foreign affairs, his own advisers and generals – is not lack of wisdom.

It is simply poor judgment , of not seeing the domestic and global forests as seen by others while looking too intently at his own trees.

“He has very poor judgment. Maybe all this is the president's clever way of letting time pass, letting things play out, so that in a few months the public fever to do something—he always thinks the public has a fever—will be over. And he will then be able to do little, which perhaps is what he wants.But none of this looks clever. It looks like poor judgment beginning to end.”

For President Obama, his day of judgment is approaching in 46 days with the November 4 midterm elections. We shall see then whose judgment prevails - his or that of the people.

Thursday, September 18, 2014

ObamaCare in Perspective

Everything we hear is an opinion, not a fact. Everything we see is a perspective, not the truth.

Marcus Aurelius (121-180 AD)

These days I am spending a lot of my time trying to keep things in perspective.

I am watching the excellent PBS series on the Roosevelts and the different perspectives on Theodore Roosevelt, a Republican Progressive. and Franklin Roosevelt, a Democratic Progressive, both pitting their parties against the rich, and I am reading Karl Rove, “Why A GOP Majority Is Still in Doubt,” WSJ, September 17. The reason, says Rove, is that Democrats have more money and are outspending the GOP $109 million to $85 million on negative TV ads.

This discrepancy makes me wonder, who is the party of the rich?

My aim is to keep matters in perspective, rather than going off half-cocked.

It isn’t easy.

Take the ISIS beheadings of 3 innocent hostages. The beheadings are gruesome, but they may not foretell of the unraveling of Western civilization, an argument advanced by Robert Cohen of the ew York Times
)”The Great Unraveling, September 15).

Or consider today’s Scottish referendum whether to declare independence from England. I doubt this is the end of Scotland if they vote Yea ( Niall Ferguson, “Alone, Scotland Will Be a Failed State," The Telegraph, September 18).

Or, for another matter, take the ObamaCare political situation. The three beheadings, ISIS aggression, and speculation about troops on the ground have pushed ObamaCare into background. ObamaCare, say the pundits, has become a nonfactor in the Senate election (David Nasher, “ObamaCare from Game Changer to Background Noise, “Politico, September 17).

From my perspective, the Senate outcome may or may not seal the fate or keep ObamaCare alive.

• Whether Democrats or the GOP wins the Senator or a tie occurs, given Obama’s veto power, gridlock will continue for the rest of the Obama presidency.

• As pointed out in yesterday’s blog, ObamaCare exchanges cover only 7 million Americans, just 3.2% of the population, and even if 5 million are added in the next enrollment go-around starting November 15, only 3.8% will be insured. If ObamaCare goes as predicted until 2013, 30 million of 9.5% of Americans will be left uninsured.

• The American public opposes ObamaCare but does not want it repealed and wants certain changes kept (young adults covered under parents’ plans and coverage of those with pre-existing conditions). To date, the number of uninsured has been reduced a scant 2%.

• Despite all the hubdub, we sometimes forget a nation’s health system accounts for only 15% of a nation’s health status; life style is 30% and other factors – poverty, inferior education, income differences, and lack of social cohesion ofor the other 55% (Satcher, D, and Pamies, R, Multicultural Medicine and Health , McGraw Hill, 2006),

We forget too that since 1965, when Lyndon Johnson declared the war on poverty, we have spent $15 trillion on poverty and the rate of poverty remains at 15%, the same as it was then.

And finally we tend to neglect the fact that under President Obama, income inequality between the rich and the poor has widened, and income of the middle class has fallen 10%. To paraphrase George Orwell, despite progressive politics, all humans are equal but some remain more equal than others.

Wednesday, September 17, 2014

Quote to Note: Who Says America Is Not a Compassionate Nation?

"The non-surprise revealed here is that ObamaCare turns out to be just another subsidy program, throwing money at health care. In economics, you can't subsidize everybody but we're trying: 50 million Americans get help from Medicare, 65 million from Medicaid, nine million from the Department of Veterans Affairs, seven million (and counting) from ObamaCare, and a whopping 149 million from the giant tax handout for employer-provided health insurance."

Holman Jenkins, “ObamaCare and American Resurgence,” Wall Street Journal, September 16, 2014

P.S. This means 280 Americans out of our 315 million population or 88.9% receive health care subsidies in one form or another from the federal government.
Population Health Management Era Arrives

The Affordable Care Act, as well as changes in how employers and insurance companies address health care, will try to change these disincentives (individual fee-for-service overuse) and encourage health-care providers to manage populations. A population may include a company’s employees and their families, a union’s members, a group of individuals who purchase a like product on the insurance exchange, or a group of Medicare or Medicaid beneficiaries.

Kenneth Davis, MD, CEO and president of Mount Sinai Health System in New York City, “Hospital Mergers Can Lower Costs and Improve Medical Care," Wall Street Journal, September 16, 2014

We are now in the Population Health Management Era.

The big data revolution made it inevitable. You can now connect instantly connect everything with everybody. You can calculate outcomes for different conditions for different populations. You can measure the overall health of different populations in different states and regions under different health systems. You can compare results. You can evaluate the impact of health reform. Above all, you can “manage” care for large groups of people rather than deal with individual problems. Managing populations and their health is said to be easier, less costly, and more efficient than directing and controlling health of individuals.

What’s not to like? Population health management is rational. It is objective. It is controllable. It lends itself to large organizations, like hospitals, who can now coordinate care, get hospital departments and specialists to work together with caregivers, measure health care improvements.

Besides, as Doctor Davis says, “Physicians participating in larger networks will be able to learn more about the best treatments because they will have larger populations from which to draw conclusions.. one can apply supercomputer resources to mine the data and create predictive models of disease….help individuals better understand their risk of illness, and customize preventive or treatment strategy.”


It is a very persuasive and seductive argument, but it has downsides – loss of personal privacy, narrowing of personal choices, erosion of physician autonomies, and an over reliance on data and actions of policy makers and health executives rather than clinical judgments of patients and their physicians.

Carrying out population health management programs is expensive. It requires major technology investments, faith that electronic medical record system will bring efficiency rather than impediments, a belief that various computer system will flawlessly communicate with one another, and “an army of care coordinators to serve as a backbone of an integrated care team.”

Patients and physicians are not yet convinced that population health management, as envisioned by the Obama administratio and large health sysems is the way to go. Four and one-half years after ObamaCare’s enactment, the public consistently opposes the health law by 10 % to 15% margins. And a just released survey of 20,000 U.S. physicians indicates only 24% say electronic medical records have improved efficiency while 46% say they distract from patient care, and only 25% give the Affordable Care Act an A or B grade while 46% give it a D or an F.

Tuesday, September 16, 2014

ObamaCare and All That Jazz

All That Jazz

Song, Chicago, a stage play, 1975

Here, “All that jazz”refers to the health law bureaucracy and its intricate rhythms. When asked to explain jazz rhythms, Lois (Satchmo) Armstrong (1900-1971) replied, “Man, it you have to ask you’ll never know.”

What follows is daily commentary of the day so you will know.

The Political Gift That Keeps on Giving

Scott Rasmassen, “Health Law is Obama’s Gift to Republicans for 2013,” Real Clear Politics, September 15. Rasmassen explains people who seek to renew health plans will feel burned by higher rates. And in 2017, government will no longer cover costs of insurers’ losses. Ergo, insurers will automatically raise rates to cover expected losses. The higher rates, then not government guaranteed, will be announced in the summer of 2016, just in time to damage the Democratic presidential candidate. Off-setting this will be the 13 million or so of the uninsured receiving subsidies.

Caveat Emptor

Robert Pear “Health Law Has Caveat in Renewal of Coverage, “ New York Times, September 15, 2014. In 2015, consumers will receive notices their policies have been renewed. The notices will contain facts on their new monthly premiums, but they will not be told about new subsidies, new co-payments, new co-insurances, or new deductibles based income. Why not? Because of technological flaws in the healthcare.gov, the government does not know. Consumers, especially those 8 million or so who enrolled in 2013 and 2014, on health exchanges will have to revisit healthcare.gov to find out. They will not be happy about higher premiums or revisiting healthcare.gov with all its bureaucratic jazz.

• More Health Plan Cancellations

Investors Business Daily (IBD). IBD, no friend of Obama and his health law, has just run this headline in a September 14 editorial “Another ObamaCare Cancellation Wave Approaches.” IBD notes 250,000 Virginians have learned their health plans have been cancelled if they bought their policies before ObamaCare was enacted on March 23, 2010. According to Kaiser Health News, other consumers in other states received the same notices. These cancellations, opines IBD, will be “fresh reminders of the extraordinarily high costs of the ‘Affordable Care Act,’” which it implies, is not so “affordable” after all.

Notices to Immigrants and Those with Unverified Incomes

• Louise Radnodsky, “Tens of Thousands of Immigrants May Lose Coverage” Wall Street Journal, September 15, 2014. 115,000 immigrants could loss coverage because of missing September 15 deadline to prove legal residence. In addition, federal officials will send notices tp 279,000 whose income cannot be verified but the feds will give until September 39 to submit further verification. Both of these problems are said to be due to technological glitches in healthcare.gov website whose backend is still being fixed. It must comfort Americans to know that Big Brother is still watching even though his computer lenses are sometimes flawed and foggy.

Monday, September 15, 2014

Apple Watch and Survival of the Fittest

The expression used by Mr. Herbert Spencer 0f the Survival of the Fittest is more accurate.

Charles Darwin, The Origin of the Species

Apple has done it again.

It has come up with a product that fits the Apple image of innovation to a T.

It has designed something that the public didn’t know it could do without and will not do without in the near future.

It is the Apple Watch, the latest in watch and wear gear.

It is beautifully designed.

It fits the fashion world. It is a fashion plate.

It is highly visible. Wear it on your wrist for all to see, and they will notice.

It fits the fitness mood of the times. if you are young or old, stay fit, you will live longer and feel better if you are fit.

It fits the movement towards wellness.There are already 20 million, soon to be 30 million people out there, running, walking, bending, stretching and moving about in quest of personal health and fitness.

Just look at your watch, and you will know where you fit into the movement.

It fits into the work of other major IT companies and health care companies – among others, Samsung, Google, Microsoft. Mayo, Kaiser.

It is fit to be tied into and can be integrated into other health and fitness apps that measure blood pressure, cholesterol, other lipids, weight , height, response to exercise, and all that other data on electronic health records.

It fits all generations – young and old – who believe they can grow younger with exercise despite age or chronic disease.

It fits all understandings, things anybody can understand. Monitoring the heart makes sense. It makes sense to keep track of your heart rate and rhythm, seeing how many steps you take each day, being reminded to stand and get off your chair, being encouraged to take brisk walks, and above all, to integrating all that information with data currently available on most electronic health records.

The Apple Watch is more than a passing fantasy to me. Thirty years ago, I helped develop the software for the HQ, the Health Quotient, a measure of health and wellness, with a normal range of 80 to 120. If your HQ fell below 80, you could always take steps to improve your HQ. If your HQ was above 120, you were doing something right. In both cases, you knew where you stacked up against your peers.

The Apple Watch is ideally suited to display similar useful information, even if one has to recharge the batteries every night. It's your life you're recharging.

So hats off to the Apple innovators.

Here’s to the crazy ones, the misfits.

The rebels. The trouble makers.

The round pegs in the square holes.

The ones who see things differently.

They’re not fond of rules and

They have no respect for the status quo.

You can quote them, disagree with them, glorify, or vilify them.

But the only thing you can’t do

Is ignore them.

Because they change things.

They push the human race forward.

And while some may see them as

The crazy ones, we see genius

Because the people who are

Crazy enough to think

They can change the world.

Are the ones who do.”

Watch out. The Apple Watch is in.

Sunday, September 14, 2014

Questions to Ask about Health Reform

What can I contribute?

Peter F. Drucker (1909-2005), The Effective Executive

A question not to be asked is a question not to be answered.

Robert Southey (1774-1843), Poet Laureate of England, The Doctor XII

Are you asking the right questions?

The management guru and social historian, Peter F. Drucker, was famous for saying effectiveness is not about doing the right thing but finding the right thing to do by asking the right questions.

Drucker said effectiveness was all about asking: What can I contribute?

• For patients and the public at large, the contribution questions might be.

How can I improve my health? Literally, what steps should I take? 10,000 walking steps a day? What foods should I eat? How much sleep should I get f? What weight should I seek to maintain? How do I lose weight? What bad habits should I avoid? What measures of my health should I seek so I can improve upon them?

• For physicians, the questions might be.

How can I best improve the health of my patients? By telling them that improving their health is up to them, not to me? How can I communicate with them better? By spending more time with them? By making access to me more convenient and more open? By sharing with them the limitations and risks and options of medical procedures? Is it socially and morally responsible for me to opt out of government and insurance programs in order to provide direct access and more time with me by becoming an independent direct pay physician? Should speak out against counter-productive government reforms?

As the midterms grow near, and as we as a nation ponder whether to keep ObamaCare or to change it, should I encourage patients and colleagues to be more open and vocal about asking these questions.

• After six years, have results of the health reform law meet its rhetorical promises?

• Have your health care premiums gone up or down?

• Is your health care more affordable than it was in 2010?

• Do you feel more protected against health care debt than in 2010?

• Have you been able to keep your doctor or your health plan?

• Are you experiencing difficulties in finding a primary care doctor?

• Do you have more or less confidence in the government’s ability to manage your health or protect you from medical debt?

• Who should be primarily responsible for maintaining your health – the government or yourself?

• Should government protect citizens against catastrophic health care debts?

• Do you think you should be able to choose your own health plan – and willingly pay for what you think you need?

• Do you believe that you ought to be morally obligated for paying for health care subsidies for those who do not have the means to pay for their own health care?

• Do you believe that those who do not take care of their health should pay the same premiums as more responsible citizens?

• Should health insurance be more like auto insurance – competitive shopping across state lines, high deductibles, based one one’s personal driving records?

• Do you believe health insurers should be forced to accept all comers and not ask questions about health status, even though these verboten things will raise health premiums for you and others?

. As a physician, do you feel the health reform law has improved your effectiveness as a doctor or has made your patients healthier?

Saturday, September 13, 2014

Joan Rivers and the Future of Ambulatory Surgical Care Centers

Yesterday is history, tomorrow is a mystery, today is God's gift, that's why we call it the present.

Joan Rivers (1933-2014)

When comedy legend Joan Rivers died suddenly and unexpectedly at age 81 of a cardiac arrest at a New York City ambulatory care center specializing inendoscopy, it may have set in motion a series of events that will threaten free-standing physician-owned ambulatory surgery centers.

There are now 5300 of these centers in the U.S., and their numbers have been growing as much as 20% each year. The centers performed 23 million surgical procedures last year, and deaths were less than one in a million. Usually complications occur in obese patients, patients with prior cardiac surgery. those with history of stroke, or in the frail elderly. None of which existed in Joan Rivers who was active until the very end.

The Yorkville endoscopy center, where Joan suffered her cardiac arrest, has been open since February 2013 and had performed 18,000 procedures. It hasreferred only 4 patients to a nearby hospital.n The center said Ms. Rivers was pre-screened by a gastroenterologist, an anesthesiologist, and a nurse. The center had 4 board-certified anesthesiologist on duty and said it was prepared for just such an emergency.

The reasons these centers' numbers are growing are crystal clear: the centers are much more efficient than hospital surgical units, surgeons can create their own teams, use their own tools, schedule their own cases, deliver care more efficiently for themselves and patients, save as much a 50% for the health system, patients, insurers, and self-funded companies, and make more money and get a return on their investment.

Some surgical care centers, like the Oklahoma Surgery Center, have statistics showing they can perform ambulatory surgeries more safely than hospitals, which are prone to be havens for hospital-acquired infections.

The death of Joan Tivers of 81 of a cardiac arrest at a site removed from a hospital, throws the merits of ambulatory surgery centers into doubt. The doubts center on the myth that the endoscopy center was ill-prepared for the arrest and had no resuscitation plan. n the Rivers case, there are also doubts that the surgeon who was to remove a lesion on Ms. Rivers vocal cord was not certified to do so, that she experienced vocal cord spasm, and that she may have received too much of an anesthesia or drug to prepare her for the excision.

No one knows at this point precisely what occurred, but the suspicion exists that this was an unnecessary death.

Certainly this tragic event will play into hospital strategies to label doctor-owned independent ambulatory centers as unsafe, and it may well lead into more extensive and expensive certifications and regulations to avoid future tragedies. It may slow the relentless tide towards decentralization of the health system. And it may cost the health system money, for costs for procedures done in a hospital are inevitably more than those in free-standing units, whose owners do not have to bear the burden of paying for non-profitable services like emergency rooms, burn units, and mental care and psychiatric units.
Doctors’ Chief Complaint: Too Little Time with Patients

Endlessly entering data or calling for permission for prescribing or trying to avoid Medicare penalties – when should I see patients?

Mark Sklar, MD, solo endocrinologist and assistant professor of medicine at Georgetown University Medical Center and at George Washington University Medical Center, “Doctoring in the Age of ObamaCare,” Wall Street Journal, September 11, 2014

Every doctor knows a physical examination begins with the chief complain- why the patient has come to see you – followed by the history – the patient’s story with their list of symptoms.

Doctors’ chief complaint is too little time for patients because of because of the bloated incomprehensible in comprehensible federal health regulations.

Patients feel this lack of face-to-face time with doctors as well. Some say nurse practitioners and physician assistants and virtual e-mail or video communication can replace face-to-face visits and relationships, but doctors and patients are skeptical.

The doctors’ chief complaint and story goes back to March 23, 2010 when ObamaCare passed in a straight party-line vote against public opposition, which remains to this day in both the doctor and patient sectors.

The doctors’ complaint centers on these symptoms: 25% more time spent on paperwork, data entry, and third party hassles than with patients.

Add to this money needed to be spent to set up an electronic health system. These system often incompatible and cannot communicate with EHRs of hospitals and other doctors. More money and time goes into training new staff to enter data and maintain EHRs, anticipating and prepared interpret the 70,000 new ICD-10 codes which will have to entered correctly into EHRs at the risk of severe Medicare penalties, and you have ingredients of formula for physician burnout and disillusionment, retirement, hospital employment, refusal to see more Medicare and Medicaid patients, retirement, and a switch to direct pay independent practices unchained from third party insurance and involvement with unlimited time devoted to patients.

Maybe doctors doth protest too much. Maybe doctors should just set their chief complaint aside , accept the inevitable, and place their trust in a well-intentioned , compassionate government.

Maybe they should heed the words of the late Doctor Harvey Cushing (1869-1939):

“Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity, and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaints .”

In short, stop blowing smoke and suck it up.

But maybe when these “minor aggravations” become major impediments and take time away from patients, doctors should speak out and strike out on their own to serve patients directly without government interference and intervention.

Friday, September 12, 2014

Five Reasons ObamaCare Is in Trouble

What we've got here is a failure to communicate.

Cool Hand Luke, screenplay 1967

As we approach the midterm elections, five things are evident.

Election results will hinge on 1) ISIS, 2) the economy, 3) jobs, 4) ObamaCare, and 5) perceptions of Obama as a leader and his ability to communicate his message to ordinary Americans.

As a leader, Obama is regarded(and regards himself as a cool customer – detached, isolated, dispassionate, rational. On the other hand, others think of him as narcissistic, overly cautious, and ideological to a fault with a distorted image of the world.

In times of crisis, which we are in now, temperament, decisiveness, clarity, and a sharp sense of reality are important, even critical.

President Obama's vision of the future is based on the long game - government as the principle means of transforming America into an egalitarian society, more equal and less dominant compared to other countries

But Americans are an impatient and proud people. They like being the world's number one power. They admire results more than rhetoric. They are more interested in economic growth and prosperity than in economic stagnation in the names of equality and fairness. Six to eight years, in the eyes of many, is too long to wait for the economy to turn around, for our enemies to be subdued, for health care reform to show results.

Outside of President Obama’s favorite constituencies – minorities, environmentalists, the liberal elite, unions, and single women - he has failed to communicate his vision to the broader American public. Consequently his political future and that of the Democratic party and Big Government liberalism are endangered.

With ObamaCare, here are five reasons why his vision of health care has failed to impress the majority of American voters who continue to oppose it by double digit margins.

Incompetence - The rollout of healthcare.gov was a bungled disaster and smacked of administrative incompetence. Although 8 million enrolled after 6 months, many proved to be ineligible and may yet be disenrolled , many have showed up at their doctor’s offices to find their doctor had not be notified of their enrollment, and many have found to be their disappointment and amazement that their doctor refused to participate in exchange problems. There are other “back-end glitches” as well that persist to this day. All of this has taken place despite more than $840 million spent on healthcare. gov, and that does not count the millions more poured into failed state health exchanges.

- ObamaCare requires that health plans meet federal standards. These standards include that plans meet 10 arbitrary essential standards: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management pediatric services, including oral and vision care. Perhaps 5 million policies have been cancelled, and more are certain to come. It is not the insurers fault. They are required to comply with the health law. Health plan holders who pay more in premiums to meet these standards are often resentful because these requirements to not apply to their individual situation, particularly if you are young, healthy, male, single, and childless.

Deceptions - Americans feel deceived. They were promised they could keep their doctor, their health plan, and the hospital of their choice. With the narrowing of networks, changes in the plans they hold, and cancellations these promises have not been kept.

Faileconomics - The freakoecnomics of health care coverage have not worked out planned, particularly for the middle class whose premiums and deductibles and co-pays have gone up unpredictably with the redistribution of benefits and subsidies to those 4 times below the poverty line. Obama promised that premiums for a family of four would drop by an average of $2500 by 2016. Instead premiums have skyrocketed for many with individual or small group coverage. For many these increases come as an unpleasant, unjustified surprises.

Frustrations - For the population as a whole, frustrations abound because of the uncertainties and complexities of the law. One of five Americans have decided not to have a health plan at all. Others are turning to direct cash payments, to retail clinics, to urgent care clinics, to Medicaid, or to care in emergency rooms if necessary because they know hospital ERs are legally required to treat them. Doctors are turning to direct pay to unchain themselves from third parties and government. Businesses are turning to part-time pay, dumping employees onto exchanges or Medicaid, and shifting health costs to employees.

Thursday, September 11, 2014

Mr. President, Listen to the People, They Are Telling You the Diagnosis

Listen to the patient, he is telling you the diagnosis.

Sir William Osler (1849-1819)

Tonight, as I was listening to the President speak about why we must attack ISIS, I thought of Sir William Osler.

President Obama was listening to the people. In countless polls, they have been giving him their diagnosis of what is wrong and right about America.

He is listening because he has to. The people and ISIS give him no other choice.

The people are telling him: Mr. President, beheading two innocent American journalists is wrong.

The beheadings are the last straw.

Mr. President. Attack the bastards. Attack them in the air. Attack them on the ground. Attack them in Syria. Attack them wherever you can.

Do whatever it takes, however long it takes.

Destroy them. Dismantle them. Decimate them. Demolish them. Defeat them. Do away with with them.

They are evil.

Don’t worry about the consequences.

Now is the time to act, not contemplate.

Follow us, Mr. President. We know what to do. We are a can-do, will-do nation.

We are Americans, Mr. President. We lead from the front, not the back.

We are what’s right with the world, not what is wrong.

We are a proud people.

We believe in America.

Our forefathers came here because America is the land of opportunity, where every individual can become what he or she wants to be.

That is why we are a magnet for immigrants from everywhere. That is why we are their number one destination for people seeking freedom, independence, and self-determination. That is why the poor, the huddled masses, and the skilled flock here. That is why foreigners have founded 40% of the start-ups in Silicon Valley. That is why we have the largest economy in the world. That is why we are the most innovative nation on earth.

We are the hope, the beacon, and the example for the rest of mankind. We are a symbol of what is right.

We believe in equal opportunity, not equal results for all. We believe the Government is best that governs least, that responds to the consent of the government, that believes in the wisdom of the majority, that believes that people, not government, not policy experts. The bold and the confident, the optimistic and the brave, not the timid and the cautious, know when to act and when to act decisively. We believe in free enterprise and free expression, self-sufficiency, economic growth, and the freedom to become what one wants to be and in doing what needs to be done.

So get on with it, go for it, Mr. President. Buck up. Be upbeat. You are doing the right thing.

This is no time for dilly dallying, for circumspection, or navel gazing.

We know it, and now you know it.

Wednesday, September 10, 2014

The Zero-Sum Health Care Pie and Lack of Economic Growth

He has an oar in every man’s boat, and a finger in every pie.

Cervantes (1547-1616), Don Quixote

A rising tide lifts all boats.

Phrase attributed to President John Kennedy, used in 1963 speech, when Kennedy advocated tax cuts to stimulate economic growth

Zero-Sum Game- A situation in which one person’s gain is equivalent to another person’s loss, so the net effect on wealth or benefits is zero.

Definition, Zero-Sum Game

Critics often blame ObamaCare as a major factor for slowing economic growth and for making heath care unaffordable.

To wit:

“The Affordable Care Act is weakening the economy. And for the large number of families and individuals who continue to pay for their own health care, health care is less affordable."

So wrote Casey Mulligan, an economics professor at the University of Chicago (“The Myth of ObamaCare’s Affordability, “ WSJ, September 9, 2014).

The conservative argument goes like this:

ObamaCare affects all citizens. Economic growth fosters prosperity. Prosperity distributes health benefits for all. The road to prosperity goes through a series of measures – repeal ObamaCare, cut taxes and regulations, give tax credits for all, promote free market competition and stress America’s strengths – internet innovation, individual initiatives and incentives, free enterprise, increased energy production.

In effect, the conservatives are saying: expand America’s economic pie and the redistribution of health care benefits will take care of itself.

Liberals will counter: Nonsense. That is pie in the sky.

This line of thinking has led to a number of pie metaphors - ObamaCare is a finger in everyone’s economic pie. ObamaCare’s adverse economic consequences are baked into a shrinking pie.

Critics hold these truths to be self-evident:

Over the last 6 years, under President Obama, the U.S. GDP has only grown a measly 2 to 2.5% annually, the slowest growth in 7 recessions since World War Two, and far short of the 3 to 4% required for full recovery. Things aren't getting any better. In 2014, the economy is expected to poke along at 2.5%.

The top 1% of the population take home 30% of America’s total income, and their share of the economic pie continues to grow. The bottom 99% of Americans share a shrinking piece of the total economic pie. In other words, economic inequality is growing .

The middle class share of the pie are shrinking. even more so than those in the bottom economic tiers. Thanks to ObamaCare, the lower classes’ piece of the health care pie is shrinking slower because of health care subsidies and a 15% growth in Medicaid. Meanwhile, the income of the middle class has shriveled 10% over the 6 years, and health care premiums for them have become unaffordable.

According to Casey Mulligan, author a new E-book Side-Effects: The Economic Side Effects of Health Reform, ObamaCare helps the poor by giving them a bigger slice of the economic pie, but diminishes the pie itself and it reduces total employment and the benefits of employment for employers and employees alike.

Employers who wish to expand are threatened with penalties so they do not expand, and place workers on 29 hour weeks so they do not qualify as full-time employees requiring benefits.

As for employees, 35 million work for employers who offer no health benefits, or for employers have reduced part-time work to avoid paying for health benefits. Another 25 million work full-time, making them ineligible for federal subsidies. The only ways to get assistance are to work part-time, find an employer who doesn’t offer coverage, or stop working.

Everyone wants a bigger piece of a bigger pie, but that is impossible in today’s zero-sum economic game.

Only one thing is for sure. By a margin of 59% of 27% in a survey, the Global Strategy Group found Americans prefer candidates who focus on growth rather than fairness, and by 80% to 16%, they prefer economic growth to income inequality.

What Americans want is growth that works for all, not just for a favored pplitical few like the rich and minorities, but for the middle class as well.

Tuesday, September 9, 2014

ObamaCare and a Free Market Alternative Plan

Market competition is the only form of organization which can afford a large measure of freedom to the individual.

Frank Hyneman Knight (1885-1974), economist at the University of Chicago, in his book Freedom and Reform

What the mind of man can conceive and believe in the mind of man can achieve.

Napoleon Hill (1883-1970), Self-Made entrepreneur and advisor to President Franklin Roosevelt, in his book The Law of Success

I shall begin with a series of assertions.

I believe free market forces, driven by desires of consumers for wide access to the very best in medicine, can and will outperform government control of heath care at every turn.

I believe these market forces should include health consumers, patients, physicians, entrepreneurs, innovators, and businesses, large and small, and American voters and their political representatives, acting in concert .

I believe market reform can only be achieved through informed consumer choice, market competition, and disruptive innovation with creative destruction of poor performers. And it can only be achieved with wide acceptance of health savings accounts, marketing of competitive plans across state lines, elimination of insurance and government middlemen, removal of oppressive government regulations which suppress economic growth, and creative use of the Internet and American genius for unleashing the potential of information technologies.

And finally I believe this can only be achieved if we can conceive and believe in plan that can outperform ObamaCare while at the same time providing a safety net for the poor.

A Memo

Yesterday morning, Jeffrey Anderson, executive director of the non-partisan, politically neutral Center for Health and Economy, whose board includes health policy scholars from across the political spectrum, wrote a memo on a “Winning Alternative to ObamaCare.” Anderson says the Center’s alternative would save $1.13 trillion versus ObamaCare over the next 9 years.

Here is the essence of this memo, which I shall quote.

• Six million more Americans would have private health insurance under the Alternative than under ObamaCare.

• Under the Alternative, premiums would decrease in the individual market “in all plan categories for both single and family coverage,” with reductions ranging from 4 to 25 percent.

• Provider access—“access to desired physicians and facilities”—in the individual market would increase by 19 percent in the first year of the Alternative and by 57 percent as of 2023.

• Provider access in the employer-based market would increase by 4 percent.

• Medical productivity—the “efficient use of resources”—would increase by 10 percent in 2016 and would remain at about that level.

• Twelve million fewer people would be on Medicaid, and 6 million people who would have been put on Medicaid under ObamaCare would buy private insurance under the Alternative.

• ObamaCare would cover 249 million people, while the Alternative—without imposing an individual or employer mandate—would cover 243 million, thereby leaving 38 million uninsured under ObamaCare (13 percent of the population) versus 44 million under the Alternative (15 percent of the population)—with all of ObamaCare’s additional coverage coming from increasing the Medicaid rolls.

• ObamaCare would cover 6 million more people (all on Medicaid) than the Alternative but would cost $1.13 trillion more than the Alternative, which works out to $188,000 per additional covered person.

• The Alternative wouldn’t needlessly disrupt the employer-based market—149 million people would have employer-based insurance in 2015 (the year before the Alternative would take effect), and the same number would have it in 2023 (the last year of the scoring).

• The Alternative would promote the purchase of genuine insurance while increasing the use of health savings accounts, thereby encouraging people to shop for value: “The structure of the Alternative’s premium credits encourage catastrophic coverage enrollment, as many households can purchase catastrophic [plans] for less than the value of the [tax credits],” with their savings going into HSAs.

• In sum, the Alternative would cut federal spending by over a trillion dollars, increase the number of Americans with private insurance, reduce premiums, improve medical productivity, and enhance access to doctors and hospitals in both the individual and employer markets.

Monday, September 8, 2014

ObamaCare as a Political Cudgel

Cudgel thy brains no more about it.

Shakespeare (1564-1616), Hamlet

Don’t forget ObamaCare. Replace it with what? First, give individuals and companies the same insurance-purchase tax break so individuals can buy policies without employers as middlemen. Second, remove interstate barriers to buying and selling insurance to increase competition. Third, expand Health Savings Accounts to reduce the role of insurance middlemen. And fourth, keep a safety net for the very poor.

Clark S. Judge, “Countering the Democratic Midterm Push,” WSJ, September 8, 2014.

In liberal media circles, the word is out. ObamaCare has lost its cachet as a cudgel with which to batter ObamaCare and win the midterm elections.

The word is: Obamacare has worked to lower the number of insured; Healthcare.gov is working like an IT charm; appeals courts packed with Democratic judges will head off any Supreme Court ruling on the inadmissibility of federal health exchange subsidies,; ObamaCare will soon become so entrenched nothing the cruel Republicans will be unable to slow it down or stop it.

This may all be true. Unfortunately, politically, Obamacare is a cudgel is short thick stick without enough reach to win the midterms. President Obama no longer carries a big stick. He cannot continue to run victory laps about the 8 million exchange signups while the economy has lost its steam and his foreign policy is unraveling.
And as Peter Drucker in the Washington Times observes. Republican strategists believe ObamaCare remains a central issue: “GOP Not Giving Up on ObamaCare Attacks.”

Why this state of affairs?

• ObamaCare has become a middle class issue because most of its members do not quality for subsidies and must pay for increased premiums, which are a common subject for negative ads in Red states where Democratic incumbents are vulnerable.

• GOP operatives believe ObamaCare is a useful symbol for disgruntled white voters who have lost 10% of their incomes over the last six years, who now comprise 40% of those in poverty, and who still regard cancelled health care policies and healthcare.gov as emblematic of government incompetence and failure to Obama to deliver on his promises of keeping your doctor, your hospital, and your health plan.

An Iowa Republican strategist concludes,”ObamaCare remains an unpopular concept, and it is a cudgel.”

A Cudgel for Whom?

To those who say it works for lower classes.

To those who say it doesn’t work for middle classes,

To both I say: a cudgel for which party?

Tell me that if you’re really so smarty.

What happens when you go into that booth

And it’s your eye versus someone else’s tooth.

You can’t replace something with nothing

If you have nothing, you are simply bluffing

Sunday, September 7, 2014

ObamaCare: Witches Brew

I like this definition of Witches Brew - A fearsome mixture, a medicinal, poisonous, and magical potion, an assortment, concoction, disassemblage, miscellany, miscellaneous, motley, mixed bag, multiplayer, multiplex, salmagundi, and smorgasbord.

This definition fits ObamaCare.

It is a health care potion for the nation.

It is a complex brew and stew with multiple ingredients. some delicious, some nutritious, some pernicious, some suspicious.

It possesses medicinal qualities, especially for those 8 million people who signed up in the first health exchange enrollment period, who are below 4 times the poverty line, and most of whom received federal subsidies and who are now eligible for health care coverage through ObamaCare approved health exchange plans, or the 3 million more who enrolled in Medicaid.

But it may be poisonous for others, particularly for those 5 million or so who had their coverage cancelled, and the untold millions who must pay higher premiums and deductibles and co-pays, who must switch doctors, hospitals, and health plans, who must pay for insurance or pay the Federal Piper, and for businesses who cannot afford to expand beyond 50 employees, and who are responding by hiring part-time rather than full-time workers or not hiring at all, and for for-profit health plans who must satisfy stakeholders.

And, lest we forget, it is magical for those young people under 26 who are now covered under their parents’ plans, for those who cannot be denied, or even asked about their health status, when applying for health plans, for those seek "free" preventive tests, for 3 million or so who just enrolled in Medicaid through the exchanges, and for those seniors who fell into the dreaded drug prescription “donut hole."

The pros and cons of ObamaCare, have been enumerated into 10 good “ pros” and good "cons" (Kimberly Amadeo, “10 Good Points for Each Side," About News, August 14, 2014) and 10 “cons,” (Elizabeth Vliet, MD, “Top 10 Reasons Not to Enroll in ObamaCare, WND Health, September 7, 2014).

According to Dr. Vliet, there are 10 good reasons not to enroll.

1) The ObamaCare health insurance policies cost significantly more – likely more than the penalty (tax). Most people can expect to see their premiums double.

2) The ObamaCare health-insurance policies limit your choice of doctors.

3) The Obamacare health-insurance policies limit your choice of hospitals. For example, several major state-of-the-art, internationally known cancer treatment centers are excluded.

4) Your out-of-pocket costs will skyrocket, with the new Obamacare health-insurance policies doubling and tripling the deductibles you must pay before coverage will kick in.

5) Your medical privacy is lost when you enroll, and your medical information becomes controlled by government agencies.

6) Your personal financial and health information may be seriously compromised by the security flaws in the Healthcare.gov website.

7) You are at risk of identity theft by providing your personal information to the “Obamacare navigators,” a significant number of whom have been found to have criminal backgrounds.

8) Enrolling in the ObamaCare health exchange may lead to compromises of your Second Amendment rights, as medical databases collect information on gun ownership.

9) ObamaCare enrollees are finding it difficult or impossible to cancel their plan if they find a better option.

10) ObamaCare policies are basically “managed care” with limitations on your options – and financial incentives for your doctor to restrict your care.

As an occasional "pro person" but more frequently a"con man', I side with the American public who in poll and after poll have expressed this opinion: “ Mend it but don’t end it” and who consistently oppose ObamaCare by double digit margins.

I am open-minded. I belong to both the end, mend it, and bend it schools. End the individual, employer, and religious mandates, mend it by keeping its good points, but bend it towards market competition and away from government controls, by promoting health savings accounts, by shopping across state lines, by repealing the 2.3% excise tax on the profits of innovative medical companies, by introducing universal tax credits for individuals , by not rewarding or punishing doctors for having or not having electronic health records and judging them on “performance data,” and doing away with the fiction that government can “manage” care at the level of patient-doctor relationships.