Sunday, November 30, 2014

GOP Lawsuit Against ObamaCare Focuses on Cost-Reductions

In mounting the latest court challenge to the Affordable Care Act, House Republicans are focusing on a little-noticed provision of the law that offers financial assistance to low- and moderate-income people.

Robert Pear, “Suit on Health Law Puts Focus on Funding Powers,” New York Times, November 29, 2014

In April, the Supreme Court will hear the case the GOP House has lodged against the Obama administration.

Insurance companies are now reducing co-payments, deductibles and other out-of-pocket costs for some people in health plans purchased through 37 federal insurance exchanges. The federal government is reimbursing insurers for these “cost-sharing reductions.” But these reimbursements may be illegal under the wording of the health law.

In their lawsuit, House Republicans say the Obama administration required , but never sought, nor received, Congressional approval to make these payments to insurance companies nor does the Law say they can. As a result, they contend, the spending violates the Constitution, which says, “No money shall be drawn from the Treasury, but in consequence of appropriations made by law.”

Nevertheless, the administration has been making the payments, using money from a separate account established for tax refunds and tax credits.

“Under a standard insurance policy, for example, consumers might have to pay a deductible of $2,500 before the health plan starts to pay. But with cost-sharing subsidies, the deductible could be reduced to $750 or just $100. And the co-payment for a doctor’s office visit could be cut to $15 from $45.

The lawsuit, House of Representatives v. Burwell, is the latest battle in a political war over the Affordable Care Act, adopted in 2010 without any Republican votes.

Once again, President Obama, who considers himself a Constitutional scholar, has chosen to go around the GOP and the Constitution, to establish or change the law as he sees fit under his executive powers.

The House suit was filed two weeks after the Supreme Court agreed to hear a separate case challenging the tax-credit subsidies in three dozen states that rely on the federal insurance exchange.

The health care law says the tax credits shall be available to people buying insurance on an exchange “established by the state.” The Internal Revenue Service has allowed tax credits for plans bought through the federal exchange as well, saying that is what Congress intended.

The Obama administration and the IRS may have had the best of intentions, but their cost-reductions for co-payments, deductibles, and out-of-pocket expenses, may be illegal under the Constitution and wording of the Health Law.
Primary Care Pay Protocols

Our life is frittered away by detail..Simplify, simplify.

Thoreau (1817-1862), Walden

I see in the New England Journal of Medicine that Medicare proposes to pay primary care doctors by protocol (S.T. Edwards and B.E. Landon, “Medicare Chronic Care Management Payment – Payment Reform for Primary Care,” November 27, 2014). The idea is you pay doctors $40 a month for patients who have 2 or more chronic illnesses if they scrupulously follow federal protocols.

This is necessary, say CMS officials , because fee-for-service is not up to the job of offering continuous across the diagnostic, clinical, and treatment spectrum.

Or to put it in more elegantly as the NEJM authors do , “The fee-for-service system…is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medical refills, and care provided electronically or by telephone. “

“Chronic care management (CCM) is a critical step forward in recognizing the essential features of primary care – continuity, whole person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination.”

Therefore, primary care practices caring for Medicare patients with 2 or more chronic diseases expected to last last at least 12 more months that have a risk of death, decompensation or functional decline (more than 2/3s of beneficiaries) can receive a monthly fee of about $40 per patient) provided they stick to the CMS protocol.

This payment assumes the primary care physician will follow a rigid protocol ( scope of services required to bill Medicare for Chronic Care Management (CCM) services). Requirement include having an electronic health record (EHR), 24/7 communication access, a documented patient-centered plan, and a problem list, including documents outlining, expected outcome and prognosis, measurable treatment goals, symptom management plan, planned interventions, medication management plan, list of community and social services ordered, plan for directing and coordinating outside services, identifications of persons responsible for each intervention, requirements for periodic review and revision of care plan.”

In short, more paperwork, more of the government document obsession , with the thought that more documentation will improve quality and will result in a “value-oriented health system.”

In the NEJM authors' opinion, the government’s protocol is unlikely to work for a host of reasons.
I concur.

The federal Care Management protocol, with all of its folderol and additional investments required, will drive primary care doctors out of traditional practice into concierge practices, into the arms of hospitals, or into retirement.

The Devil, behind the coming failure of chronic care management (CMM) protocol, will be in the Details.

CMS would explain:

“Modern clinical protocols are needed to identify, summarize and evaluate the highest quality evidence and most current data about prevention, diagnosis, prognosis, therapy including dosage of medications, risk/benefit and cost-effectiveness. Then they must define the most important questions related to clinical practice and must identify all possible decision options and their outcomes. Some guidelines must contain decision or computation algorithms to be followed. Thus, they must integrate the identified decision points and respective courses of action with the clinical judgment and experience of practitioners. Many guidelines place are needed as the treatment alternatives to be placed into classes to help providers in deciding which treatment to use.”

To which I say, in the words of W.S. Gilbert in The Mikado, This is “merely corroborative detail, intended to give verisimilitude to an otherwise bald and unconvincing narrative.”

Saturday, November 29, 2014

And Who Shall Profit from Caring for the Sick? The Case of Generic Drugs

In 1988, I wrote a book And Who Shall Care of the Sick? The Corporate Transformation of Medicine in Minnesota.

It was a collection of editorials I had written as editor of Minnesota Medicine.

My concern in the book was that corporate medicine would diminish the role of independent medicine. I said corporations had these advantages over independent physicians : 1) access to capital to finance growth; 2) effective mechanisms for dealing with bureaucratic phenomenon; and 3) the skills of management – organizing complex technology, mazimizing talents of specialists, and bringing together different people from different professions to deliver service as a team.

What I did not say was that corporations had the ability to maximize profit on a massive scale. Profit is necessary to stay in business and to grow, but it must be coupled with social responsibility.

Well, medicine has become a big business, a $3 trillion dollar enterprise in the United States, and some companies, like United Health, which originated in Minnesota, have $10 billion in annual revenues and over 100,000 employees . Many CEOs of hospitals make over $1 million a year, and certain medical specialists average over $400,000 in income. In the main, independent practice has retreated into the weeds with more than half of physicians becoming employees, mostly of hospitals.

In 1981, the late Arnold Relman, M.D., then editor of the i>New England Journal of Medicine, warned about the medical-industrial complex with its accompanying for-profit companies would ruin the image of health care and drive the cost of care out of sight.

For some observers, particularly liberal lawmakers, “profit” has become a dirty word. The latest example is the generic drug industry ( “Lawmakers Look for Ways to Provide Relief for Rising Cost of Generic Drugs,” November 24, New York Times.)

Prices of common generic medications has soared over the last 18 months. About 10 percent more than doubled in cost. Some medicines rose over 500 percent, including the thyroid replacement hormone, the antibiotic doxycycline, the heart pill digoxin and the asthma pill albuterol. Many generic drugs in the United States have surpassed those of their brand-name equivalents.

These skyrocketing prices are not the case in Canada, where the government regulates drug prices.

According to the New York Times, 90-day supply of the generic heart medicine digoxin sells for $187 in New York; the branded version, Lanoxin, sells for $24.30 in Canada. A month’s supply of a generic steroid to treat inflammatory bowel disease sells for $1,625 in the United States, while the branded version sells for $155.70 in Canada. A three-month supply of the generic cholesterol lowering drug pravastatin costs $230 in this country, but $31.50 for the branded drug Pravachol in Canada.

There are many reasons that generic prices may fluctuate. The price of a key ingredient may increase markedly, or competition may decrease as manufacturers leave a market, leading to price rises.

Some states have been taking matters into their own hands. Last fall, a new law in Maine began allowed residents to mail order prescription medicines from licensed pharmacies in Canada, Britain, Australia and New Zealand.

What to do? The Senate has responded by holding hearings to get generic drug makers to explain why prices have risen so dramatically and why U.S. generic manufacturers should not compete with foreign generic manufacturers.

As the American humorist, Josh Billings (1818-1885) explained, the generic drug makers “have got some ‘splainin to do!”

Friday, November 28, 2014

Entrepreneurship: The Difference Between U.S. and European Health Care

What is happening in the United States is something quite different: a profound shift from a “managerial” to an “entrepreneurial “ economy.

Peter F. Drucker (1909-2005), Innovation and Entrepreneurship, Harper and Row, 1986

In 2007, I wrote a book Innovation-Driven Health Care. In the book, I quoted Peter F. Drucker, who, among other things, said,”The American development (entrepreneurship) is unique. Nothing like it has happened in any other country. Western Euro[e during the period 1970 to 1984 actually lost jobs, 3 to 4 million of them. In 1970, western Eruple still had 20 million more jobs than the United States’ in 1984, it had almost 10 million less.”

Today this pattern is being repeated. According to the Grobal Entrepreurship Monitor, the percentage of adults involved in early entrepreneurial activity is 5% in Germany, 4.6% in France, 3.4% in Italy, and 12.7% in the U.S.. There is another negative factor in Europe as well, the fear of failure, the percentage of people age 18-34 who say fear of failure stops them from opening a business. This fear is 45.1% in Spain, 41.9% in the European Union, 40.% in Asia, and 31.4% in the U.S. Scarce capital, an interventionist bureaucracy , and cultures deeply averse to risks have suppressed startups in Europe.

It’s not easy being an entrepreneur in Europe, where unemployment is rampant among the youth (23.7% in Spain), economies are stagnant (with 10% to 50% less growth than in the U.S), and where Europeans are turning to private enterprise alternatives to socialized health systems, and where even religious figures like the Pope are calling for health care and economic reforms.

The Pope is saying Europe is “elderly and haggard… We encounter a general impression of weariness and aging, of a Europe that is now a ‘grandmother,’ no longer fertile and vibrant, the great ideas that once inspired Europe seem to have lost their attraction, only to be replaced by the bureaucratic technicalities of its institutions.”

The Pope cited the E.U.’s treatment of immigrants, soaring young unemployment, and ‘uncontrolled consumerism.’ He blames his situation on free-markets, with abandonment of the elderly, a lost generation of young people, and disparagement of the poor.

But at the same time, he calls for “joining market flexibility with need for stability and security for workers.”

Presumably, the Pope means balancing compassionate socialism with purposeful capitalism.

This is no small trick. The high taxation required on the general population to cover all health care ills and the bureaucracy needed to implement universal coverage tends to sink all boats rather than lifting them.

What the Pope doesn’t say is that the U.S. economy is performing much better than that of Europe, that most of the major innovations (the Internet, social media, hydraulic fracturing , and medical innovations ) contributing to economic growth, youth employment, and technological innovations for treating illness have come out of the U.S. have resulted from private entrepreneurialism rather than government regulations.
Black Friday and Meaning of Color Black

I don’t care what color it is, as long as it’s black.

Henry Ford (1863-1947), on the color of the Model-T

The color black conjures up different images for different people.

For retailers, it’s the day after Thanksgiving when retail profits for the year begin to turn from a loss (“in the red”) to a profit (“in the black.”).

For consumers, it’s an exciting night and morning with the risk of being turned black and blue in riotous sales openings.

For many American blacks, it’s about the gloom and dark rage following the failure to the grand jury to indict Officer Darrell Wilson in Ferguson, Missouri.

For progressives, it’s about the evils of huge corporations exploiting the poor for profits of CEOs and shareholders.

For American small businesses, it’s about a bleak future blighted by huge expenses and penalties of employer mandates.

For young Americans, it’s about finding a full-time job in an increasingly part-time economy.

For physicians, it’s about transitioning from an autonomous profession relying on clinical judgment to an employee dependent on data-driven algorithms.

For Democrats, it’s about finding a way out of the midterm debacle and crafting a new message to the numerous American middle class while being compassionate towards the less numerous uninsured and under insured.

For the majority of Americans, it’s about charting new paths to prosperity, opening up new opportunities, capitalizing on innovations such as fracking, engendering hope for the middle class, creating an environment consistent with the American dreams of freedom and independence and entrepreneurship, and recreating the image of America as world leader and beacon of light and liberty.

For all of us, it’s about a return to a more colorful future, for a redefinition of black from something lacking color, soiled, dirty, gloomy, dismal , sullen, hostile, pessimistic and dark to something more shiny, glossy, red, white, and blue.

Thursday, November 27, 2014

Unraveling of a Presidential Turkey's Sweater

Deep into the darkness peering, long I stood there, wondering, fearing,

Doubting, dreaming dreams no mortal ever dared dream before.

Edgar Allen Poe(1809-1849), The Raven

I had a sad Thanksgiving dream last night of a great unraveling.

At the center of the dream was a live gigantic, gobbling , gobbledegooking turkey lying on its back dressed in a giant multicolored sweater.

Various creatures bearing name tags had pinned the turkey down.

It was like a scene out of Gulliver Gulliver’s Travels, the Giant Insect in Kafka’s Metamorphosis, and the Headless Horseman in Washington Irving's Sleepy Hollow.

Each of the creatures was pulling out a strand of yarn from the sweater.

One bore the name tag “President,” and his piece of yarn was called “Broken Promises.”

The second name tag said “Health Plan Executive #1- Rise in Premiums.”

The third name tag read “Health Plan Executive #2 – Narrowing of Networks.”

The fourth name tag was “Overseer of Disastrous Launch.”

The fifth name tag simply said, “Gruber Obfuscation.”

The sixth name tag exclaimed, “Schumer Confession.”

The seventh name tag explained, “Excluder of Middle Class and Redistributor of Wealth.”

The eighth name tag blared, “Republicans and Midterms.”

The ninth name tag bled,”Keeper of the National Budget.”

The tenth name tag mourned, “ Tracker of Slow Growth Economy.”

Each of these Lilliputian-like creatures, who privately considered themselves Giants of the Realm, was yanking hard on their thread of yarn, and the sweater that had kept the turkey alive and warm was unraveling.

The dream ended with the turkey headless, cold, and cooked with his sweater a discarded pile of yarn.

Wednesday, November 26, 2014

HHS Downplays Healthcare.Gov Estimates

Downplay – To treat or speak of something as to reduce its importance, value, strength.

Under its new secretary, Sylvia Mathews Burwell, HHS is being modest about expectations for this second signup for It has a lot to be modest about. In the first sign-up period, it said it had signed up 7 million people, but critics have challenged that number, saying it was padded by dental plans, and 400,000 who were later found to be ineligible. Now the actual number is said to be 6.7 million.

This time around, in the 12 week November 15 to February 15 signup period, HHS is being cautious. It says it expects to enroll a total of 9.9 million, perhaps as few as 9.1 million. These would be added to 2.9 million to the original 6.7 million. This is a considerable downplay from the 15 million, the CBO originally forecast to be signed up by the end of 2015.

In the first week of this new signup period, HHS announced 222,000 new people signed on, and 200,000 signed on the first time renewed. On December 15, HHS will automatically renew those who did not renew. Many of these will find that their plans have higher premiums. HHS expects a rush of new enrollees before the December 15 deadline and the final February 15 deadline.

Let’s back off for a moment and consider the 222,000. If you multiply 222,000 times 12 weeks, it comes to 1.850, 000 million. Add that to 6. 7 million, assuming that 6.7 million pay their premiums and keep their plans, and you get 8.55 million, a modest downplay from the projected 9.9 million, now projected by some federal guessers to be closer to 9.0 million. That would be 43.0% less than 15 million, and 13.6% less than 9.9 million.

There would, however, be a 9 million dent in the 36 million uninsured when ObamaCare passed in 2010, not bad when one knows ObamaCare was to take 10 years to reach its final goal

This time around, federal officials, with the 2013 disastrous start even in mind, are being cautiously pessimistic, even humble in their predictions.

Secretary Burwell, says after this first week, is off to a “solid start."One person's solidity, I suppose, is another persons' fluidity.

Maybe solid start will end with a flourish, but I am reminded of what Winston Churchill said of Clement Attlee, his successor as Prime Minster. When told Attlee was a modest man, Churchill commented, “ He has a lot to be modest about.” Modesty is not a trait usually associated with the Obama administration, but perhaps they have learned a lesson.
ObamaCare: You Can’t Outsmart the Middle Class

That which in England call the middle class in America is virtually the nation.

Matthew Arnold (1822-1888), A Word about America, 1882

America is a middle class nation. About 85% of us, 240 million, fall into that category.

When President came into office, he made a critical error. He decided to focus on the 36 million people, 12% of the population, without health insurance on the lower rungs of the economic ladder rather than those in the middle of the ladder.

Jonathon Gruber, arguably the “architect” of ObamaCare claims proponents of the health law thought they could pass it by outsmarting stupid voters in the middle class. This may be too cynical a view. The intent may have been to advance the "social good," as defined by the elite.

The middle class was not impressed. From the onset, voters in 2012 and 2014 midterms rejected the law. Today 37% favor the law while 56% oppose it.

President Obama and the Democrats may have outsmarted themselves.

In a speech at the National Press Club yesterday, Sen. Chuck Schumer (D-NY) says Democrats "blew the opportunity the American people gave them" in 2008.

"After passing the stimulus, Democrats should have continued to propose middle-class oriented programs and built on the partial success of the stimulus."

"Unfortunately, Democrats blew the opportunity the American people gave them. We took their mandate and put all of our focus on the wrong problem -- health care reform."

"The plight of uninsured Americans and the hardships caused by unfair insurance company practices certainly needed to be addressed, but it was not the change we were hired to make. Americans were crying out for the end to the recession, for better wages and more jobs, not changes in health care.”

Schumer said the focus on Obamacare was wrong because it would only affect a small portion of the electorate, concluding it was not beneficial to the Democratic party to focus on health care reform.

"The Affordable Care Act was aimed at the 36 million Americans who were not covered. "It has been reported that only a third of the uninsured are even registered to vote. In 2010 only about 40% of those registered voting. So even if the uninsured kept with the rate, which they likely did not, we would still only be talking about only 5% of the electorate."

So today, the Obama administration is faced with a middle class revolt. The law has been disastrous for the middle class – who have seen their premiums climb, their plans drop, their incomes decline, their future blighted, their hopes dashed.

It is not a pretty picture. It is why the midterm electorate voted to put Republicans back in charge of the economy. ObamaCare’s mandates, taxes, and regulations have harmed the economy and medical care of the middle class, the backbone of America.

Tuesday, November 25, 2014

Quote to Note: “No Sex, No Lies and Videotape. Gruber Saga Continues." Letters to Editor, Wall Street Journal , November 22-23, 2014.

Just as Robert Bork’s name became a verb (borked), so should Jonathon Gruber’s name become a verb meaning “lied” – “I grubered”, “He told a gruber”, “ Don’t gruber to me,” “Thou shall not gruber,” in fact. “ Gruber is a gruber.”

To these gruberisms, I would add “Romneyscare,” “Obamanation,” and “Grubergate.”
Rationing By Waiting, and Four Laws of Human Economics

All things come to those who wait.

But sometimes they come too late.


More people will receive care under the health law, but there will be fewer doctors to care for them. Many of these people will receive subsidies. This means health care will be rationed by waiting rather than price, for the supply of care (number of doctors) will not meet the demands of the newly insured, nor will the supply of federal monies be sufficient to meet the new costs of care.

Long waiting lists for care are common in countries with universal care. Longer waiting lists are also more common in Massachusetts, where people wait over 30 days to see a family doctor and 48 days to see an internist, even though Massachusetts has more primary care doctors per capita than any other state.

Growing waiting lists will also become the rule rather than the exception in the United States (Austin Frakt, “When Health Coverage Means Longer Waits for Doctors,” New York Times, November 24, 2014).

There are various explanations for long waites: a static or shrinking number of doctors entering primary care, the entry point for patients into the health system, more than half of existing primary care doctors are not accepting new patients; of those doctors taking on new patients, fewer still are accepting patients on health exchanges or receiving subsidies from those exchanges.

The solutions to this pervasive and growing waiting problem are : one, reduce waste and increase productivity within the system, something government is not noted for; two, increase the number of primary care physicians by paying them more or allowing nurses to substitute for primary care physicians; or three, increase the number of visas for foreign-trained primary care physicians.

All of these things take time and have controversial downsides.

According to John Goodman, a conservative economist who created and heads up the National Center for Policy Analysis in Texas, rationing by waiting has its own costs.

“What I call health policy orthodoxy is committed to the idea that waiting for care is always better that paying for care for low-income patients. In other words, if you have to ration scarce medical resources somehow, rationing by waiting is always better than rationing by price. Yet, whenever the poor and the non-poor compete for resources in almost any non-price rationing system, the poor always seem to lose out.”

They lose out because their illnesses may become worse while waiting. They lose out because doctors often do not accept them because doctors find government pricing too low and government bureaucracy too cumbersome and too time consuming.

Goodman says market-based alternatives are cutting through the rationing-by-waiting time warp: walk-in clinics, telephone and email consulting services, surgery centers, free-standing emergency centers, retail outlets, and concierge practitioners - all of whom will see patients on short notice or the day they call or need care and who ask for cash for care.

Why is rationing by waiting such a common feature of government programs? Because of certain laws of human economics.

One, the Law of Supply and Demand. When the demand for care goes up, and the supply of doctors goes down, price and costs go up, and rationing by waiting becomes inevitable.

Two, the Law of Time and Money. Time is money, and there is only so much time. Doctors, already overloaded, have limited time, so they ration care by prolonging waiting times.

Three, the Law of the Free Lunch. There are never enough doctors to meet the demands created by the promise of free care, or enough middle class taxpayers to finance those demands, so time is rationed.

Four, the Law of Competition and Cash. The only way to disrupt the Laws of Supply and Demand, Time and Money, and the Free Lunch, is through the practice of the Law of Competition and Price. People understand lower prices offered by competitors, and they understand that direct cash transactions without intervening middlemen are a visible and viable way of saving time and limiting rationing. Money talks, and lower prices offered by competitors talk even louder

Monday, November 24, 2014

Defining and Defying Reality

A leader’s role is to define reality and to give hope.

Napoleon Bonaparte (1769-1821), self-proclaimed emperor of France

Ken Chenault, CEO of Amex, the third African-American CEO of a Fortune 500 company, and Harvard Law School graduate, often quotes Napoleon’s maxim about leadership.

Chenault should pass on Napoleon’s advice to the White House.

President Obama is aggressively defining reality on his own terms. Without consulting or working with Congress, Obama has announced a climate deal with China, seeks to order more carbon-emission cuts , says he will close Guantanamo Bay, vows to veto any changes in health law mandates, raise the minimum wage for all Americans, and shield five million undocumented immigrants from deportation.

He is being petulant in defeat. He is creating a legacy that will be remembered for short-term gain, and long-term pain.

He is building a second term defined by unilateral action rather than bipartisan reality. He has struck a defiant tone about his powers to act on his own. He is inviting confrontation rather than compromising .

Exit polls after Obama’s midterm drubbing indicate compromise is what the public wants.

On ObamaCare, the Public wants the health law to be fixed and modified, not repealed. The citizenry wants the President to back off and deliver on his promises - keeping their doctors and health plans, expanding choice, lowering premiums, lowering overall costs, covering the uninsured and underinsured. He may have done the latter but not the former through massive redistribution of benefits.

In addition, the Public wants less government not more. They want economic growth, more hope for the middle class, more full-time job opportunities and less regulations, less meddling with small businesses, fewer health plan cancellations, more access to health plans and doctors of their liking.

More than anything else, they want more hope for themselves, their children, and their grandchildren.

They want a realistic, not a defiant, leader. They want a President, as defined by the Constitution, not an Emperor, as defined by Himself.

Sunday, November 23, 2014

My Favorite 12 Sources of Health Reform Information

There is no accident in our source of reading.

Francois Mauriac (1995-1970), Memoires Interieures (1958)

You can tell a man’s bias by his sources, and what he picks from those sources. We are all creatures of habit. It is my habit to scan these 12 sources before I sit down to write a blog.

1. Real Clear Politics - This blog features a cross section of political opinion. I like its average of polls on Obama approval ratings, direction of country, and health care law popularity.

2. New England Journal of Medicine - I am lifetime subscriber. I read its “Perspective” section. Each weekly edition contains four to five "Perspective"articles, which generally support ObamaCare and reflect the views the Harvard academics.

3. Wall Street Journal - Most widely read newspaper. Conservative. Arch opponent of ObamaCare mostly because of its conservative ideology and its baleful effects on economy.

4. New York Times - Editorial board is fierce advocate of ObamaCare. Board’s comment today, “Republicans are not interested is improving the Affordable Care Act. They are bent on destruction” is typical. Other writers, like Robert Pear, are more balanced.

5. Grace Marie Turner, Galen Institute - Conservative, Opposes ObamaCare. Favors market-based approach. Writes for various publications.

6. - Calls himself “the social media’s leading voice. “ Internist. Blog features his opinion plus other physician’s comments and blogs, including mine.

7. The Health Care Blog - Comes out of San Francisco. Has many physician blogs. Tends to be liberal and supportive of managed competition as seen from left coast.

8. Kaiser Health News - A daily compilation of health care news from major news organizations. Also has longer reports by its editorial staff.

9. Health Leaders Media - Has solid editorial staff who write what health care leaders, often hospital based think. Also contains list of clickable articles on health issues from elsewhere.

10. Washington Post - Mix of articles, pro and con on ObamaCare, as seen from inside the Beltway. I am fond of reading Charles Krauthammer and George Will columns.

11. Fox News - Dominant Cable News TV channel. Source of hard news. Critical of Obama administration and ObamaCare.

12. Myself - Whatever comes into my head. Tends to be center-right, pro-democracy, pro-voter, pro-market driven and patient centered care, pro-physicians, and pro-innovation. As E.B. White said in Elements of Style, “All writing is communication. Creative writing is revelation – it is the Self escaping into the open. No writer remains incognito.”

Saturday, November 22, 2014

Surgical Safety and Quality in Hospitals and Ambulatory Surgical Centers

Clearly quality, like beauty, is in the eyes of the beholder.

Humphrey Taylor, Chairman of Harris Poll and Harris Interactive, in The Health Care Blog

On the public's eye , safety has moved from and center since the recent death of 81 year old comedian Joan Rivers in a New York City ambulatory surgical center (ACS) from a seemingly minor biopsy procedure of her vocal cord.

Her unexpected death has raised this question: Are ambulatory surgery centers as safe as hospital surgical suites, where theoretically, resuscitation teams and resuscitation equipment are more available? This has lead to articles like “Quality and Safety in Ambulatory Surgical Centers” (Cheryl Clark, Health Leaders Media, November 18. 2014).

The question may be irrelevant. Hospitals are moving quickly to set up ambulatory surgical centers of their own, often in joint ventures with physicians, outside of hospital walls, in response to public demand, dangers of hospital-borne infections such as Clostridia Difficile, MRSA, and other antibiotic organisms, healthy consumers flocking to ambulatory centers, and hospitals suffering from competition from physician-owned ambulatory surgery centers.

The rapid formation of ACSs is made possible by faster, better anesthesia, less invasive procedures with small incisions, greater efficiencies and lower costs, public awareness that hospitals are dangerous places, and the simple reality that most surgeons prefer to operate in ACSs, when the patient is able, younger, needs a less complicated procedure , requires only a short length of stay, or has limited funds.

There’s another factor as well. Safety is not the same thing as quality.

Safety is freedom from occurrence of risk , injury, and complications.

Quality is a different animal. It resides in the eyes of the beholder- the patient, the physician, the supplier, the insurer, and the government overseer.

• Patients who use ACSs define quality as getting as much care as you get – the more the better, especially when it quicker, simpler, cheaper, more direct, more personal, friendlier, with more bedside matter, more amenities, such as valet parking; more modern facilities . That’s why consumers tend to prefer detached new ACSs over older centralized hospitals.

• Employers who send patients to ACSs look upon these centers as getting more bang for the buck for employees and retirees, as offering quicker, more direct care for common procedures for otherwise healthy workers, without building a corporate team to deal with the complexities of an overly complicated system.

• The Institute of Medicine and other judgmental organizations regard quality as avoidance of medical errors and implementation safety systems, which are invisible but necessary.

• Surgeons who work in ACSs think of quality as good outcomes, happy patients, a hassle-free environment, lack of restrictions and obstacles to care, greater efficiencies with more time for the job to be done and less time devoted to paperwork, your choice of surgical tools and nurses devoted to your cause, and less worry about how you’re to be paid with direct pay for what is done.

• Drug companies equate quality with use of their latest brand name drugs , a high level of compliance, and strict adherence to drug regimens, and access to physicians who use their drugs and influence other physicians.

• Government technocrats, policy makers and wonks, public health advocates believe quality resides in population health measures, wellness with avoidance of smoking and obesity, high immunization rates, longer life expectancy, and wider use of data and evidence-based medicine.

These health care stakeholders are like the Six Blind Men of Indostan, who, after feeling the various parts of the health care elephant, have their own impressions of what constitutes quality. Each is his own way is right, each is partly wrong, and each has a limited view of quality or the system as a whole.

Friday, November 21, 2014

President Obama’s Immigration “Shadows” Speech

All of us take offense to anyone who reaps the rewards of living in America without taking on the responsibilities of living in America. And undocumented immigrants who desperately want to embrace those responsibilities see little option but to remain in the shadows, or risk their families being torn apart…You can come out of the shadows and get right with the law.

President Obama, in November 20 speech promised to pull five million undocumented illegal immigrants “out of the shadows.”

As I listened to President Obama’s speech last night, I thought of a quote from Homer’s Odyssey, “Himself a shadow , seeking shadows.”

After his humiliating and decisive midterm rejection, Obama is a shadow of his former promising self, who was going to transform America and transcend partisan politics. He is limping into his second term, beset by a public that opposes his policies and who is asking for compromise.

Besides, Obama needed a bold stroke to redeem himself with his progressive political base. He felt he needed to act dramatically , some say brazenly, to confront the Republicans while winning Hispanics over for future Democrats. His apparent strategy is to cast blame on the GOP as the party who keeps immigrants furtively hiding in the shadows , out of the bright sunlight of American mainstream life.

The reaction to the speech, which as usual, was eloquent and powerfully delivered was mixed along party lines. What impact it will have is, well, shadowy. It puts Republicans in a dilemma how to respond and not to overact. But they will be in power come January, and they are likely to pursue one or all of three options: pass an immigration act of their own, underfund the Obama proposal, or sue the President for executive overreach.

In reading the various commentaries, the comments of David Gergen, a senior political adviser at CNN and now at the Harvard School of Government and adviser to four presidents, most impressed me.

Gergen begins his commentary: “There is something deeply troubling about President Obama’s decision to grant legal safe haven to unauthorized immigrants by executive order… It isn't the underlying policy that is troubling. Just the opposite. We have known for years that we would never deport some 11 million people from our midst. Many have become hard-working, productive members of our society, and Congress, working with the White House, should long ago have provided them a safe pathway out of the shadows.”

Gergen then ticks off his oncerns.

The immigration problem is not an emergency. It has been around for decades. While the President's impatience is understandable and his anger at Republican intransigence is well placed, that does not justify abandoning traditional ways of addressing hard public problems.

It is against the spirit of the Constitution. It certainly violates the spirit of the founders. They intentionally focused Article One of the Constitution on the Congress and Article Two on the president. That is because the Congress is the body charged with passing laws and the president is the person charged with faithfully carrying them out.

It is a bad way to start with new Congress. The midterm elections were a clear call for a change of course in Washington, starting in the White House. A new Wall Street Journal/NBC poll finds by 53-40%, Americans feel positive about the election results; by 56-33%, they want Congress to set policy for the country, not the President; by 57-40% they favor a pathway to citizenship for illegal immigrants but by 42-32%, they disapprove of Obama overhauling immigration through executive order. We have an action from the White House that will cast a dark shadow over prospects for legislative cooperation.

The President action has no direct effect on ObamaCare for undocumented immigrants. But in the future, it might ease their access to Medicaid, “The Sleeping Giant of ObamaCare.” For more information on the latter, see, where my blog on “Medicaid – the Sleeping Giant” appears tomorrow, November 22, 2014

Thursday, November 20, 2014

Health Reform: It’s The Diversity, Stupid!

It’s the Economy, Stupid!

James Carville, President Clinton Adviser, 1992

Since James Carville created his 1992 slogan, political slogans ending with “Stupid!” have gained political currency.

“Stupid!” is usually a positive rallying cry, but since Jonathon Gruber said ObamaCare passed because of the stupidity of American voters, Republicans claim “It’s the Stupidity, Stupid!” is one reason ObamaCare passed. We are a nation of whites, blacks, browns, yellows, blues, and reds, and it wise to be color blind but to keep in mind whites are still a majority of the mix.

“It’s the Diversity, Stupid!” would be a more appropriate reason why ObamaCare is faltering and may fail.

Previous Presidents have hailed diversity. John Fitzgerald Kennedy said in a 1963 address,” If we cannot end our differences, at least we can help make the world save for diversity.

In 1988, in his acceptance speech, George Herbert Walker Bush declared, “ We are a nation of communities, of tens and tens of thousands of ethnic, religious, social, business, labor unions, neighborhoods, regional and other organizations, all of them varied, voluntary and unique. A brilliant diversity spread like stars like a thousand points s of light in a broad and brilliant sky.”

When President Obama and Democrats passed ObamaCare, they made a critical mistake. They ignored diversity. The passed the law against unanimous Republican opposition and majority public opinion.

They forgot about diversity – the mainspring of American democracy. They forgot the majority of American people rule. They forgot we are a nation of the balance of constitutional powers – checks and balances, center right versus center left.

This forgetfulness may be why ObamaCare is in such danger. It caters the left while ignoring the right. It gravitates towards government control, away from private contributions. It does not acknowledge we must balance excellence, access, choice, and cost.

This balance is fragile. I wrote about it nearly ten years ago in a now forgotten book , Voices of Health Reform: Options for Repackaging American Health Care (Practice Support Resources, 2005).

The book featured interviews with 42 major health care stakeholders.

It ended with this overall conclusion,

“Our health system is a creature of our culture. When asked what Americans believe, Gary Orren, a professor of political science at Brandeis, who polls for the New York Times and Washington Post, said,

“A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and tend towards self-regulation.

‘If there is an American creed, it might begin.

One, government is best that governs least.

Two, majority rules.

Three, equality of opportunity.’

“This seems about right to me. It explains why Americans prefer local health systems, why they reject federal government-mandated universal coverage with rationing, why they prefer they prefer pluralistic payment systems, why they allow market-based and public-based institutions to co-exist and compete, and why they permit doctors to behave democratically, seeking their own locales to practice, often acting independently of hospitals, health plans, and government, and making their own decisions , free of fetters of others.

Democracy is a messy business.”

President Obama, when unilaterally passing laws or issuing executive decrees, should keep in mind the American creed, culture, and diversity.

Wednesday, November 19, 2014

Corporate Corruption of Medicine

Make hay while the sun shines.

English proverb

There’s a disturbing trend out there.

It goes by different names – one-size-fits-all, population health, and corporate care.

It shares the notion that large corporate entities can force doctors to act in the financial interests of the corporate organization.

In a New York Times opinion piece (”How Medicine Is Being Corrupted”, November 18, 2014), Pamela Hartzband. M.D. and Jerome Groopman, M.D., husband and wife and professors at Harvard Business School, nail the problem.

“Financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks, and regulatory groups have put in place rewards and punishments that can powerfully influence your doctor’s decisions.”

Among these are:

• Contracts that “pay for performance.” If doctors meet certain metric targets, e.g., lowering blood pressure or cholesterol, they are rewarded with bonuses or high placements on insurer website. If they fail to meet these targets, payments are reduced or they are given low website ratings.

• Insurers reward or punish patients by giving higher or lower co-payments doctors for using specific drugs or doctors or doctors for following certain pathways for treating patients.

Insurers, and government officials, contained that “it is obsolete for the doctor to approach each patient as an individual, Medical decisions should be made on the basis of what is best for the population as a whole.”

This, argue Hartzband and Grooper, is not only wrong but immoral. It ignores clinical judgment and patient preference, and it may harm the patient.

Power, say the two authors, now rests in the hands of insurers and regulators, and in the minds of patients , in part because they rely on information provided on corporate websites.

Hartzband and Grooper propose as a solution a new public website, similar to the one provided for Physician Sunshine Act, which exposes financial ties between pharmaceutical companies and doctors. The new website would reveal the hidden coercive forces that specify treatment and limit choices for doctors and patients.

Perhaps it is time for a little sunshine on corporate interests as they make hay at the cost of patient and doctor choice. by forcing doctors and patients to follow corporate dictates on treatment.

Tuesday, November 18, 2014

What Is Gruberism?

Maybe it is Gruberism: the belief that everybody else is slightly dumber and less well-motivated than oneself, and therefore politics is more about manipulation than conservation.

David Brooks, “Obama in Winter” New York Times, November 17, 2014

Just what is this concept called Gruberism?

Well, to begin, it’s a tried and true neologism.

It’s getting done what needs to get done,

It's how the health law’s language was spun.

It’s being thought of as an objective outsider,

When you’re in reality a subjective insider.

It‘s conning the gullible public on this fact,

A tax on them isn’t a tax when it’s a tax.

It’s being called a detached analyst,

When you’re a biased political catalyst.

It’s believing you’re smarter than the herd,

After and above all, you’re an academic nerd.

It’s thinking your motives are nobler than most,

As you collect millions on's gold coast.

Gruberism is a political hot potato.

It has become a media rotten tomato.

Gruberism was once a healthcare algorithm.

Now it is a leaking digital aneurysm.

It's being a former Democratic party hero,

Where now his recognition nears zero.

Gruberism is not knowing Gruber

When he turns out to be a party pooper.

Monday, November 17, 2014

Obama Doubles Down

Double, double, toil and trouble

Fire burns and cauldron bubbles.

Shakespeare (1564-1616), Macbeth

Better never trouble Trouble

Until Trouble troubles you;

For you may make your trouble

Double Trouble when you do.

David Keppel (1899-1939), American poet, Trouble

President Obama has returned from his Asia trip in a defiant and combative mood after his party’s crushing election defeat.

He vows to take a sharp turn to the left. He will poke a stick in the Republicans’ eyes, poison the well, and wave red flags in front of the GOP bull.

He threatens to do this by:

• vetoing the Keystone XL pipeline if it passes;

• issuing an immigration decree giving amnesty to six million illegal immigrants;

• fighting ObamaCare changes, replacement, or repeal with a veto;

• touting his climate change agreement with China and continuing to regulate coal mining and other carbon-emitting industries;

• making a deal with Iran allowing them to continue their uranium enrichment program and letting up on sanctions;

• regulating the Internet under the guise of “net neutraility” and an obscure 1934 Title II law.

It’s an ambitious agenda that invites open confrontation, law suits over executive authority and constitutional overreaching, impeachment proceedings, and shutting down the government.

This approach to governing is being dubbed “doubling down.” This term comes from the gambling game of Blackjack, where, when your\ are in trouble, you double your wager. In the world of finance, stock investing, and politics, “doubling down” has come to mean engaging in risky behavior when you are in a dangerous or desperate situation.

Doubling down is not new to Obama. He and his team employed a doubling down strategy in the 2012 presidential campaign, as described by Mark Halperin and John Heilemann in their 2012 bestseller Double Down: Game Changege. And doubling down was a tactic social organizing exprt Saul Alinsky set forth in his book Rules for Radicals. Alinsky's double down rule read: “Attack, attack, attack from all sides, never give the reeling organization (in this case Republicans) time to rest, regroup, or re-structure.”

Doubling down just might work. Obama may think he has no other choice, given the magnitude of his midterm defeat. Republicans are perceived to be disorganized and uncertain as to what to do with the feisty President. They don’t want to shut down government. They know impeachment is out of the quearion. And they don’t have the numbers to override a Presidential veto except perhaps for the Keystone XL Pipeline and the excise tax on medical innovation companies. On ObamaCare the favored strategy at the moment seems to be systematic defunding of health exchanges and chipping away at the individual and employer mandates.
ObamaCare and JonathonGruber Cannot Escape History

My fellow citizens, you cannot escape history.

Abraham Lincoln (1809-1865), Second Annual Message to Congress (1862)

In 2009, when President Obama took office, it was clear something had to be done about health care. Costs were going up, the number of uninsured were rising, the economy was in free fall, Medicare and other entitlements were the biggest contributors to the federal budget deficit.

But what to do and who to do it? Democrats were the obvious choice to do the job. They controlled the three branches of government. Republicans were in disarray and held responsible for the Great Recession.

There were two paths to curing the health care crisis: government or market reform. And there was one model that seemed to have worked, Romney Care in Massachusetts. The so-called “architect” of that model was Jonathon Gruber, an MIT economics professor. That model had some political credibility because it was passed under the aegis of Mitt Romney, a Republican governor.

There were also two ways to institute reform: comprehensively and all-at-once without consulting Republicans or incrementally and piecemeal by building the reform infrastructure behind closed doors.

President Obama chose the first way. He was bold. He regarded himself as transcendental and transformative - a President of Manifest Destiny. But he was smart too. He and Democrats knew the nation’s voters would not accept reform that raised taxes or smacked of “socialized medicine” with total government control . So they acted clandestinely, mixing government and business reforms, persuading or buying off major players – the drug industry, health plans, the AMA, votes from states whose Senators they needed – Nebraska, Louisiana, and Connecticut among them – through Medicaid deals. To allay fears, they promised voters that they could keep their doctors and health plans and that their premiums would be lowered.

To seal the new deal, they wrote the Affordable Care Act in such a way as to make it “tortuous” , full of legalese, stretching over 10 years, lengthy , hard to decipher, and ambiguous, e.g, subsidies to the uninsured could only be offered in health exchanges “established by the state,” when they really meant exchanges created by the federal government. You could fool most of the American people, who did not have the intelligence to know what was going on.

The money involved in this political herculean effort was enormous – officially $983 billion, soon to grow by various government estimates to $1.5 trillion to $2.5 trillion over the next 10 to 15 years. But never mind the details. It was the principle, providing affordable care to the uninsured masses, and not the money, that counted.

But that fickle beast, history, intervened. Premiums rose, plans were cancelled, confusion and uncertainty reigned, the economy stalled.the health exchanges proved to be a nightmare, and the middle class objected to the transfer of resources from the uninsured to the insured classes.

We will probably never knew the identities or roles of the various players who met behind closed doors and who composed the health care sausage known as ObamaCare. But we do know the most widely heralded “architect” was Jonathon Gruber.

Among Democrats, his role is now being downplayed by the President and prominent Democrats. President Obama yesterday said, “ I just heard about this,” and Nancy Pelosi denies ever knowing Gruber, though she is on video praising him in 2009. David Axelrod, Obama's former principal political adviser, called Gruber "stupid," and Rush Limbaugh weighed in by saying Gruber's comments unveiled a massive "con game" perpetrated on the American people.

Now this news is breaking : Gruber has collected consulting fees of $5.9 million, from federal and state governments, $6.7 million, if you include fees paid by California and Massachusetts. In a series of six videos , Gruber is shown talking to academic conferences and like-minded audiences about how the law was passed and how misleading language was used to assure its passage so “stupid voters” would not know what was going on. Yesterday, on Face the Nation, host Bob Schieffer asked Gruber point-blank, “If all this is bad as you say, why did you take the money you earned. Is it too late to give it all back?”

This, of course, will never happen.

Why not? I suppose there are two answers: one, when you say it’s the principle and not the money, it’s the money; and two, as H.L, Mencken (1880-1956) noted, “No one ever went broke underestimating the intelligence of the American people.”

Maybe so. But according to the latest Gallup poll, ObamaCare approval has reached an all-time low of 37 percent and Republicans now control the House and Senate and 31 State governments. Video histories can be a political nightmare.

Sunday, November 16, 2014

Health, Government, Social, and Individual Goodness

There is no odor so bad as that which arises from goodness tainted.

Thoreau (1817-1862), Walden

Sunday is a day of goodness and forgiveness.

It is a day off from human meanness, political correctness, and plain greediness.

It is a day of doing good and being good.

From the Ideal to the Real

So much for the ideal world, now on to real world revelations on other days of the week.

When Jonathon Gruber made his statements of motives behind the passing of the Affordable Care Act, he set off a firestorm of negative comments about the motives of President Obama and his administration.

Personally, I give crafters of the Patient Protection and Affordable Care Act and the President the benefit of the doubt.

I believe they had good intentions consistent with their political ideology.

They thought they were doing good for the people because the people themselves did not know what was good for themselves and other people, i.e., society as a whole.

The people, in their view, do not know what was good for themselves and their health and the rest of us.

Hence, the government had to step in to do what it believed was good for society.

At one stroke, the Patient Protection and Affordable Care Act was intended to save the people from themselves and in the process, to achieve social goodness.

Conservatives' Disbelief

Conservatives did not believe this liberal version of events. They saw passage of the health law as an act of warped idealism, of a grab for political power, of liberal arrogance.

One critic quoted Mae West, who, in reply to someone's comment on the huge ring on her finger, exclaimed “Goodness, what a lovely diamond!” responded, “Goodness had nothing to do with it.”

I do not believe in this cynical interpretation. I believe those who wrote the law and believed in it had good intentions.

They thought they were doing what was good for all of us.

Gruber and his fellow followers never believed bewildered, benighted, beleaguered individuals could ever manage their own health care.

That took brains, data, and high IQs, ingredients the masses did not possess.

That’s why government had to intervene to make basic health care decisions for people, such as what benefits a health plan must include and what doctors and hospitals people should go to.

That’s why they could not let consumers choose how to spend their own money, or to decide what treatment courses to take, or to negotiate with doctors or hospitals about that mundane thing called money.

That's why they opposed Health Savings Accounts, which assumed people could fend for themselves when it came to their own health care.

That’s why they could not let people fall into the hands of those big, bad corporations and big, bad health plans, and and the big,bad medical industirla complex, who had the audacity to try to maximize shareholder value and to make enough profit to stay in business and together with other big, bad corporations and even small, bad businesses to generate economic growth and prosperity.

The people, they believed, were unwilling , unable, and incapable of making those inevitable choices that advance the social good and social goodness, such as transferring wealth, health and other resources, from the young, healthy, willing, and able to the old, sick, unwilling, and disabled, all of whom, for Goodness Sake, should and ultimately would depend on government for their health care decision-making and economic well-being.

Note: I am indebted to Lanhee Chen, a fellow at the Hoover Institute, for some some of the ideas expressed here (Lanhee Chen, “Liberal Arrogance at the Core of ObamaCare,” Bloomberg View, November 14, 2014).

Saturday, November 15, 2014

The Wall Street Journal’s Satire on Jonathan Gruber

As a rule, Americans don’t like to be called “stupid” as Jonathan Gruber is discovering. Whatever his academic contempt for voters, the ObamaCare architect and Massachusetts Institute of Technology architect deserves the Presidential Medal of Freedom for his candor about the corruption of the federal budget process.

Review and Outlook, “Jonathon Gruber’s “’Stupid’ Budget Tricks,” Wall Street Journal, November 15-16, 2014

I saw a bumper sticker today , “Satire: Man’s natural defense against Stupidity.”

When I read it, I thought of the Wall Street Journal’s satirical OP-ed and recent article on Jonathon Gruber, an MIT professor of economics.

As expressed in the opening quote, the WSJ's editors said that Gruber deserves the Presidential Medal of Freedom. This is the height of satire . Instead,of course, what Gruber said on multiple occasions encroached on the freedom of American voters and their right to choose their doctors and health plans.

Gruber was caught on seven videos, mostly at academic conferences, saying that the Obama administration conned fellow Democrats and American voters into creating misleading language in the Affordable Care Act to help it pass. In subsequent statements, President Obama said 31 times words to this effect. “You can keep your doctor and your health plan, period.”

Gruber said the law would not have passed if deemed a tax. That would have been “politically impossible, ” and “I’d rather have this law than not.”

“This bill,” he went on , “ was written in a tortured way to make sure CBO did not score the mandate as taxes. If the CBO scored the mandate as taxes, the bill dies."

In a November 12 WSJ piece, James Taranto wrote an OP-Ed “An Honest Man: In Praise of Jonathon Gruber.” The title may be a satirical play on words of the title in James Agee’s famous book Let Us Now Praise Honest Men. But, alas, to quote Lady Montagu (1689-1762), “Satire should like a polished razor keen, Would with a touch that’s scarcely felt or seen.”

Taranto does not yield a razor. He uses satire more like an ax to bludgeon Gruber, and to discredit ObamaCare.

“Gruber himself had asserted on multiple occasions that it was Congress’s intention to limit the subsidies to state-established exchanges. In that view, Congress’s intent was to make it so attractive to set up an exchange that no state would refuse. Lack of transparency is a huge political advantage. And basically, call it the stupidity of the American voter or whatever, but basically that was really critical for the thing to pass.”

Taranto argues that Gruber gave plaintiffs the basis for the Supreme Court’s decision to hear the case of King vs. Burwell. If the Court rules in favor of the plaintiffs, the decision may destroy ObamaCare, “ The plaintiffs rest their argument on the plain language of the statute, which limits subsidies to taxpayers ‘enrolled in [policies] through an Exchange established by the State.’ The administration’s defenders, including Gruber, have argued that the plain-language interpretation is counter to congressional intent and that the limitation is a mere ‘typo.’ That claim is nonsensical. Even if it was a drafting error, it was far more serious than a mere typo.”

Typo or not, implies Taranto, Gruber gave the Republicans and the Supreme Court on a silver platter, or perhaps I should say a loaded gun chamber, the ammunition they needed to undermine and perhaps destroy ObamaCare by killing it of the credibility it needed to pass the smell test of the American voter. The health law has been unpopular from the beginning. Without the Affordable Care Act, Obama’s legacy and American liberalism would lie in tatters.
Hooray! Hooray! Starts Again Today

Hip! Hip! Hooray! Healthcare.Gov starts again today. Everything’s going to be OK.

Health Exchange Cheerleader’s Cry cranks up today for its second enrollment go-around. It follows the first signup of October 1, 2013 to March 31, 2014, which netted 7.3 million enrollees.

This time ObamaCare officials say the rollout will be simpler, faster, and more intuitive.

Just to be sure, the government has been testing the site, pouring millions into upgrades, while hedging that the technology may not be perfect and no website is perfect.

Government, health plans, consumers, and small businesses are waiting with baited breath, nervous as cats on a hot tin roof to see if Big Brother and the little Brother states get it right this time.

Consumers’ health plans will be automatically renewed, but their old plans may have higher premiums and deductibles and new physician and hospital networks. To avoid higher premiums, consumers will have to go online or through a navigator by December 15 and switch plans. Many will be loath to do this. They like their old plans.

Insurers openly wonder if’s backend is ready, particularly if consumers switch to a different consumer. Will consumers get two bills? Will irate consumers flood health plan switchboards and health web sites? And what if insurers aren’t notified by exchanges if consumers switch? What about consumers in formerly state-run sites, like Colorado and Nevada, who are switching to federal websites. This and other switcheroos are cause for concern.

And what , as a consumer, do you do if you have insurance through your job, if you are on Medicare or Medicaid. If you buy your own insurance, if you don’t want to buy insurance, if you don’t have a computer to go online?

It’s complicated – and confusing. Your premiums might be going up. Your subsidies may be going down, or they may be going away if the Supreme Court rules against subsidies in 37 health exchange states. You may have to pay to pay a penalty for not having a policy. You’re on your own. You may be able to get help from a federal navigator if you call 1-800-318-2596 for help. Calling 911 will not help.

Friday, November 14, 2014

Medicaid - ObamaCare’s Sleeping Giant

One that has great but unrealized or newly emerging power.

Sleeping Giant, Merriam Webster

Everyone has their own version of a sleeping giant.

Sleeping Giants

To economists, China is a sleeping giant powered by the world’s largest population, numbering 1.357 billion in 2013.

To Internet watchers, cloud computing is a sleeping giant, capable of cutting costs and managing websites and information technology systems anywhere.

To conservative alarmists, the federal bureaucracy is a sleeping giant operating by pygmies.

To political cynics , Washington is a sleeping giant who regards the world as a giant monopoly board.

To international rivals, the United States is a sleeping giant - an island of freedom, achievement, wealth, and prosperity oblivious to the rest of the world.

To observers of U.S. foreign affairs, ISIS is a sleeping giant – a muslim volcano that is about to erupt and swallow us all.

Medicaid as Sleeping Giant

To me, Medicaid is ObamaCare’s sleeping giant – the enabler of federal power and control over the health system. It is a far more powerful enabler than health exchanges, which have gotten most of the publicity. It surpasses the number of uninsured and underinsured that the exchanges have enrolled.

In the next year, four million more Americans will joing Medicaid’s rolls. It already covers one third of America’s uninsured. Under ObamaCare, it now covers anybody earning up to a third more than the poverty level, about $15,000 a year. Medicaid spending will double from $450 million in 2013 to $919 billion in 2023. Medicaid now covers 68 million people, surpassing the 53 million in Medicare.
In ten years, according to the Congressional Business Office, Medicaid will cover 93 million people, one in four Americans. The federal government will pay !00 percent of newly eligible Medicaid recipient’s cost through 2016, 90% thereafter.

For this and other reasons, including a stagnant economy with no wage growth and rising unaffordable premiums, deductibles, and co-payments for many, many of those in the middle class are joining the Medicaid ranks.

What’s not to like? You get federal handouts for free. Sure, the rest of us will have to pay higher taxes and endure higher costs, but what heck, if you need care you can now get it for free.

But can you? Only 30% of doctors now accept Medicaid patients, and their numbers are growing. There’s a shortage of at least 50,000 primary care doctors, and the federal government says it needs to recruit 28,000 of them for the VA. There are too many Medicaid and VA recipients chasing too few doctors.

o what good is coverage without medical doctors or other providers to offer the care? And what are doctors to do if they cannot maintain their practices at Medicaid rates, which has 20% lower than private care rates? And what if the hospitals or states cannot afford the facilities and providers needed to care for the tsunami of new Medicaid beneficiaries? And what are these recipients to do in those 27 states that have opted out of Medicaid expansion?

The sleeping giant has an enormous. unsatiable appetite. Its eye is sometimes bigger than its belly. Sometimes, as Ronald Reagan said, “Government is like a big baby – an alimentary canal with a big appetite at one end and no responsibility at the other.”

Obama Doomsday Scenarios

Doomsday is near; die all, die merrily.

Shakespeare (1564-1616), King Henry IV

Once an election is won or lost by crushing margins, doomsday scenarios set in.

Republicans are saying ObamaCare and liberalism and the Democratic party are dead. Merrily march on. Turn right. Pass the XL Pipeline. Kill the medical innovation tax. Repeal ObamaCare.

Democrats and Obama are saying there is life in the Old Girl yet. Take a sharp turn to the left. Defy the GOP Grim Reaper. Declare amnesty for five million illegal immigrants. Close Guantanamo. Conclude Iran nuclear deal. Tell the world you have solved climate change problem. Announce a series of executive orders and vetoes in advance.

But whatever you do, you Republicans and Democrats, do something, or you’re out of there in 2016.

Replace ObamaCare with something simpler and more understandable. Replace it with something that offers choice of doctors and health plans, shopping across state lines, lower premiums, lower deductibles, lower co-pays, benefits tailored to the individual, catastrophic insurance, and more coverage of the uninsured at lower costs than ObamaCare.

There are ways of doing this (see “Getting There: How to Transition from ObamaCare to Real Health Care Reform,” James Capretta and Yuval Levin, Weekly Standard, September 22, 2014 ). There's always Doom for Improvement.

Thursday, November 13, 2014

Imaging Technology and Pandora’s Box

Planners say those who run scanners are not calculating enough about balancing diagnostic yield and cost.

Richard Reece, M.D., “On Having Your Head Examined,” Minnesota Medicine, 1980

A source of extensive and unforeseen troubles or problems.

Definition, Pandora’s Box

Back in 1980, I wrote an editorial in Minnesota Medicine saying CT and MRI would start a radiology revolution despite government protests that these new images cost too much.

How right I was.

Today CT and MRI scans are routine in diagnostic workups, in ER evaluations for trauma, in office visits of back, neck, in joint, abdominal and chest pain evaluations, in insurance evaluations for minor accidents, in questions asked by malpractice lawyers (“Why wasn’t a CT or MRI scan done, doctor?”. And in the minds of health care consumers, who regard images as an integral and necessary part of the treatment regimen.

I once had an elderly man tell me, “You know, I have had four MRIs, and I feel a lot better." Another person, a physician friend of mine, says interns and residents often order imaging studies before taking a history or doing a physical examination.

I thought of this when I read in Massachusett General’s Journal of Computer Assisted Tomography that in a pilot study radiologists now meet directly with patients who had images. The radiologists review that images, answer questions, and explain the implications of incidental findings.

The incidental findings occur in.

• 34% of trauma findings receiving CT scans.

• 31% of patients receiving abdominal CT scans.

• 14% of patients undergoing lung cancer screening.

• 8% of patients receiving imaging for artery disease

These incidental findings can cause problems: neglect for not being mentioned or followed up upon, costly and unnecessary testing causing harm and even death, and exposure to further irradiation or invasive procedures.

Doctor Phillip Young of the Mayo Clinic in the Mayo Clinic Proceedings, noting that incidental findings cropped up in 67% of patients being evaluated before a heart procedure at May and with 10% requiring additional tests, wrote; “It can be a Pandora’s box because when you open it you don’t know what’s going to come out.”

Solutions for closing or at least tightening the lid on Pandora’s box include: meeting directly with patients to explain incidental findings, having radiologists flag incidental findings and then having a radiology team contact the primary care physician to explain the significance of the findings, recommending follow-up testing in four years, having radiologists and primary care physicians share the responsibility for informing patients of incidental findings.
Gruber’s ObamaCare Remarks: Altitude Has Affected Attitude

Their altitude has affected their attitude.

Health law critic’s comment on Jonathon Gruber’s remarks that voter stupidity allowed ObamaCare to pass.

Gruber's remarks, which reflect an altitude and attitude of moral superiority of the liberal elite, remind me of Winston Churchill’s remark, “Attitude is a little thing that makes a big difference.”

With ObamaCare, attitude makes a huge difference, as reflected in these articles in today’s media.

• “Why Jonathan Gruber Won’t Change the ObamaCare Debate”

• “Third Video Shows Health Law Architect Admitting Deception”

• “ObamaCare Built on Foundation of Lies”

• “Gruber’s Confession Impolitic, But Not Newsworthy”

• “In Praise of Jonathon Gruber’s Honesty”

• “Gruber and the Stupidity of the American Voter”

• “Riley vs. Williams on Health Law: Typical Liberal Superiority”

• “Gruber: the Stupidity of the American Voter”

• “Gruber’s Remarks Give Republicans New Ammo on ObamaCare”

These titles are self-explanatory: some defend Gruber’s comments as devious but trivial, others as mendacious and outrageous.

Gruber explains that his remarks were “inappropriate,” but are excusable because they were given at an academic conference. Apparently the academic community shares a “superiority complex” with the Obama administration.

As for me, there is nothing new about this conflict between the elite and voters. I wrote of my attitude in a May 4, 2011 Medinnovation blog, which read as follows:

"If I were to identify two things that turns physicians off about health reform, it would be the altitude, and a set of attitudes.

This altitude and set of attitudes include.

• Big Brother, government and managerial experts, know best.

• These experts, political and social theorists and analysts, know more than individuals at the point of care.

• A centralized health system reflects collectivist compassion, not repression of individual freedoms and choice.

• Statistics on average population behavior are more important than individual heuristics.

• You cannot trust doctors - their training, their experience, their intuition, their motives.

• You cannot trust patients - their knowledge, their instincts, their choices, their decisions on how to spend their own money.

. You cannot trust markets, which express citizen behavior at street level.

• You can trust data, "In God we trust, all others bring data” as the managerial mantra goes.

• Information – truckloads, wheelbarrows, computer drives, and databases full – will solve all problems, empower all people, improve all outcomes.

• Artificial intelligence is the Holy Grail and will ultimately support, supplement, and even supplant human intelligence.

• Physicians do not have the interests of their patients in mind, they only have their personal interests in mind.

• Physicians, hospitals, and other caregivers, not patients. are responsible for most bad disease outcomes.

• Wisdom on health care matters resides at the top of the pyramid, where power is concentrated, rather than at the bottom of the pyramid, where care is created.

• If we make care free to all, impose enough rules to regulate care, and build a big enough bureaucracy, costs and demand will go down, when in truth, the opposite holds true.

• If we lower physician and hospital rates, discourage specialists and encourage generalists through payment reform, coordinate and concentrate care in large organizations, manage, prioritize, and systematize the behavior of all concerned, and transform the culture from individualism to collectivism, all will be well, the physician shortage will ease, and physicians and the public at large will come to their collective senses and reach consensus that what's good for all is good for each."

Attitude is everything.

Wednesday, November 12, 2014

Unsettled and Unsettling ObamaCare Fate: Ten “What If’s”

What has been settled by precedent cannot be unsettled overnig

Benjamin Cardoza (1870-1938), The Paradoxes of Legal Science

In three days, November 15, ObamaCare begins its second enrollment period, scheduled to end on February 15. The Obama administration is giving signals that it will fall far short of its original goal of signing up 15 million by that time. More likely, it says that total enrollment will be 9.9 million or thereabout; that the glitches of have not yet been fixed; that Hispanics and other minorities may have a hard time enrolling; and that it is going to take more time ironing out ObamaCare wrinkles.

During that time, the administration is going to have to deal with some potentially devastating political complications.

• In a surprise move, the Supreme Court announced it would hear the case of whether the government can offer subsidies on the federal exchanges. At issue is whether the Obama law writers meant what they said when they wrote in 2010 health law when they said subsidies could only be offered by exchanges “established by the state” and whether the IRS could legally assume that the law also applied to federal exchanges. How the Court will rule is very much in doubt since it takes four judges to decide if a case can be heard, and five of the nine judges are widely assumed to be conservative.

• As the second signup approaches, a video by Jonathon Gruber, one of the architects of ObamaCare, has gone viral. In that video, recorded at a 2013 academic conference, Gruber says that “voter ignorance” passed ObamaCare and that laws authors deliberately and deceptively wrote the law so as to make it “opaque” and lacking in “transparency.” In the eyes of Charles Krauthammer, this episode illustrates “liberal arrogance”, “deception,” and a way of " leadingthe masses to the promised land.” Gruber’s remarks, to say the least, are embarrassing, and perhaps even devastating.

• There is, of course, another problem – the Republicans’ wave midterm election with a new found Senate majority with 53, probably 54, Senate seats, 13 more House seats, 31 GOP governors, and a solid majority in state legislatures. The GOP won largely on the basis of a stalled economy and a defective health law. The precedent here is that the public from the beginning opposed ObamaCare by double digit margins, a margin that grew to 19 points in a recent Gallup poll. In retrospect, Nancy Pelosi’s comment that "We’ll have to pass the law to see what’s in it” is damning. She clearly meant that she and nobody in Congress had read the law, and that its contents, designed by elites, could be taken for granted. Well, as the law’s adverse consequences become evident people are reading it, and it has become clear its architects knew what was in it – that people would lose their health plans and doctors and that health benefits would be redistributed on a massive scale. ObamaCare was a political gamble, and it may be backfiring. Twenty nine of the Senators who voted for it are gone, and its most visible political driver, Senator Max Baucus of Montana, who warned of ObamaCare as a potential “train wreck,” is now in ObamaCare exile as ambassador to China.

What If’s

This situation leads to series of “What’s Ifs”

1. What if the Court rules that the 37 federal exchanges cannot offer subsidies for the uninsured and others who enrolled in 2014 and who may enroll in 2015. That would gut ObamaCare and cause its collapse.

2. What if Republicans succeed in defunding or otherwise undermining ObamaCare by defunding it, stripping it of the employer mandate for coverage of all employees working over 30 hours, or delaying or repealing the penalties for not having insurance, and ending the excise taxes on profits of medical innovation companies. It would endanger ObamaCare existence by stripping it of its funding mechanisms.

3. What if the November 15 to February signup falls far short of its goals or is glitch-ridden and proclaimed a disaster by Republicans and other critics.

4. What if the Gruber episode proves to be a political disaster, or even a joke, or a travesty of liberal promises.

5. What if the latest addition to The SHOP option that supposedly makes it easy for small businesses to push employees into health exchange plans or Medicaid, falters or proves to be unworkable.

6. What if the remaining uninsured prove too hard to reach because of language difficulties, lack of comprehension about what insurance is all about, or simply if they cannot be tracked or cannot give sufficient information about their incomes or citizenship status.

7. What if confusion and controversy about the Supreme Court’s impending or actual decision muddies the water so much that enrollment drops off dramatically.

8. What if UnitedHealthcare’s decision to enter a dozen or more health exchange markets shows that is indeed marketable and offers more choices.

9. What if Republicans get their act together and offer a unified commonsensical, easily comprehensible, market-based alternative to ObamaCare that cuts federal spending by $1 trillion or more over ten years and covers just as many uninsured.

10. What if economic growth resumes and is robust, and ObamaCare fades into the background.

ObamaCare, as Winston Churchill might say, is a paradox and a puzzle, wrapped up in a conundrum. Or as other wise men of the past have said, “For all the sad words of tongue and pen, the saddest are these, it might have been.”(John Greenleaf Whittier); “O, what a tangled web we weave, when first we practice to deceive. (Sir Walter Scott); or, “Of all the horrid, hideous notes of woe, Sadder than owl-songs or the midnight blast, is that portentous phrase, ‘I told you so.”(Lord Byron).

Monday, November 10, 2014

American Corporations and Health Reform

Corporations cannot commit treason, nor be outlawed, or excommunicated for they have no souls.

Sir Edward Coke (1562-1634), Case of Sutton’s Hospital

Corporations are the bane of liberals, for they say corporations have no soul, no regard for humanity.

I found this sentiment clearly expressed in a book I am reading, The Eagle’s Shadow: Why America Fascinates and Infuriates the World (Mark Hertsgaard, Farrar, Strauss, Gerous, 2002). The author, a published itinerant journalist has this to say about President Ronald Reagan , “Reagan’s larger achievement was ideological. His decisions rested on the very idea that government should not intervene in the economy to assixt the poor and the disadvantaged, regulate corporate conduct, or otherwise pursue a vision of the public interest tha diverged from unrestrained free enterprise.”

Hertsgaard did not mention that Reagan oversaw a record boom in the U.S. economy, that he was reelected twice by substantial margins, that he had consistently high approval ratings, or that historians frequently put in the top five of great American Presidents.

This negative ideological attitude towards corporations exist today. This morning on TV and recently in OP-Eds, I see and read about lack of diversity in corporate board rooms and corporate suites, about inequality between corporate CEOs and their workers, and about evil corporate leaders, like the Koch brothers, contributing secret, or “dark” money into the coffers of conservative politicians.

There’s another side, of course. One of the Koch’s brothers is the single largest contributor to the Arts in New York City , Koch Industries employs 60,000 Americans and provides them with generous health benefits, and American corporations offer health coverage to 160 million Americans

There are other sides as well. Corporations could not exist without profits or shareholders who demand those profits. If big things need to be done, like provide health coverage to the 12 million Americans who remain uninsured, the government cannot do it alone. It cannot competently develop the necessary websites, it cannot do administer the VA health system, and it cannot run Medicare and Medicaid without outsourcing the administration of these giant programs to private health plans with the expertise to do the job.

Finally, the public, whether progressives like it or not, as Peter F. Drucker, the father of modern management observed “Every single social task of major impact…is increasingly entrusted to corporation which are organized for perpetuity and are managed by professions whether they are called ‘manges,’ ‘adminitrators,’ or ‘executives.’”

If big things need to be done, people tend to trust corporations or big institutions – like United Health Care, Wellpoint, AARP, or large medical groups – Kaiser, the Cleveland Clinic, or Giesinger- integrated ospital systems. medical device companies, pharmaceutical firms, research companies , with the tools with the tools to get health care jobs done.

Government may resent corporations, they may burden them with the highest corporate taxes in the world, and they may interfere and intervene with their activities with countless regulations, but they cannot live without them, their skill sets, their innovations, the millions of American jobs they create, or the prosperity and economic growth they generate for America.

Sunday, November 9, 2014

Economic Growth : What the People Want

Growth is the only evidence of life.

Cardinal Newman (1801-1890), Apologia pro Vita Sua

In the midterms, the People spoke. They want economic growth. The People let us know they are not dumb, numb, or oblivious to the obvious: lack of economic growth they are not feeling Over the last six years of the Obama presidency, they have taken home less money to support themselves and their family.

President Obama assures us he has added 10 million jobs, but 20 million have given up looking for employment, and they do not personally feel the so-called uptick of the economy.

The people know this is slowest growing recovery from seven recession since World War II. Previous economies have rebounded from recessions with annual growths of 4 % or more. Since World War II, the U.S. economy has had an annual growth of 3.3%.

Here are the annual growth rates during the Obama Presidency: 2009: -2.8%: 2010: 2.5%: 2011: 1.8%; 2012: 2.8%: 2013: 1.9%: 2014: 2.5% (projected). The average growth rate is 1.7%, 2.3% if one takes away 2009. Over the 2009 to 2014, period the average income of the middle class has dropped from $55,000 to $51,000.

Give the resounding 2014 midterm shellacking, it is important to ask: What do the people want?

The want economic growth. In the words of Daniel Henninger: “Low economic growth is the modern U.S. economy is a total, across-the-b0ard, too-to-bottom political loswer ("Why the Democrats Lose, “ WSJ, November 8, 2014).

During the six years of Obama’s first six years of tenure, we learned certain other things the People want.

• The want less Wall Street, less plutocracy, and more Main Street democracy.

• They want less national economic austerity, and more personal prosperity.

• They want less of the health reform shell game, with its attendant redistribution of benefits to the upper and lower classes and higher premiums, deductibles, and copayments to the middle class with loss of health plans and doctors.

• They want less national debt with its transfer to future generations.

• They want less talk about social justice with its accompanying higher taxes (over $1 billion in 2013) and its fictitious wars on women, minorities, and inequality and more talk about the rising economic tide with opportunities for all.

• They want less economic despair and more economic repair of health, tax, and entitlement systems.

• They want less part-time jobs and more full-time jobs with elimination of the $2000 per employee financial penalties for all workers who work more than 30 hours.

• They want less regulation with economic stagnation and more innovation with economic stimulation.

In the end game, which is elections and their aftermath, the Great American Middle want economic growth and opportunity for all, not what policy wonks and elites so glibly prescribe and describe. The Great Middle wants the economy liberated from political gridlock. Sometimes, when it comes to government, less is more. Let the People go.

Saturday, November 8, 2014

Obama Drama – An American Shakesperian Tragedy

An American Tragedy.

Title of book by Stephen Crane (1871-1900)

The Obama Presidency has all of the elements of a Shakesperian tragedy.

Voters have just declared something is rotten in the state of Denmark (America).

America has moody, brilliant, but indecisive Prince (Obama), haunted by memories of his late father who distrusted American colonialism a view the Prince shares. It has a conspiring queen mother (Hillary Clinton) with her consort (Bill Clinton). It has a pair of close-minded, loyal inner-court advisers (David Axelrod and Valerie Jarrett). It has two tell-tale courtiers ( Robert Gates and Leon Panetta). who have questioned the wisdom of the Prince in two book.

It has implacable foes inside government (John Boehner and Mitch McConnell), leading the forces of opposition (Republicans). One of them (Boehner)is suing the Prince. It has outside mercenaries (Vladimir Putin and ISIS). It has a mutinous, dissatisfied citizenry (The American people and its middle class).

And now, four days after the midterm elections, it has its royal court (the Supreme Court) announcing it will take up the case,(King v. Burwell)in March 2015 to be decided by July 2015, that may undermine the very essence of the Prince’s singular passion and most memorable domestic achievement (ObamaCare).

The case is based on the premise that the text of the 2010 health law did not authorize the Prince to set up federal health exchanges but only exchanges set up by the states. There are 12 state exchanges, two are in transition to become federal exchanges, and 36 federal exchanges. To date, the combined state and federal exchanges have enrolled 7.3 million people, 85% of whom the federal government subsidizes to make their health care affordable.

Starting November 15, and ending on February 15, the government hopes to enroll 10 million or so more underinsured and under-insured and to cement the Prince’s legacy, but the government itself warns that its system to sign up individuals and employees of small businesses still contain glitches and may not be ready for the task.

If the court were to rule that the Prince’s government has no authority to subsidize federal enrollees and they must return the subsidies, it would undermine the very reason for the existence of ObamaCare - to reduce the number of uninsured through federal largesse, and it would further sour the public on the health law.

For the Prince, a negative Supreme Court ruling that would be a Shakesperian tragedy of the first order.

Thursday, November 6, 2014

Untangling ObamaCare Healthcare.Gov Website

Oh. what a tangled net we weave,
When we first practice to deceive.

Sir Walter Scott (1791-1832), Lochinar

Sometimes complicated things are simpler than they first appear.

Take the problems of untangling ObamaCare’s website, and its second launch, starting November 15, 2014 and lasting until February 15, 2015.

This second launch, following the first launch, October 2013 to March 31 2014, has multiple looming problems.

• The government has yet to fix the website’s back end problems that crippled its first year of open enrollment (Louise Radnosky, “More Health-Site Bugs Loom,” WSJ, November 15, 2014).

• The second enrollment launch follows in the wake of the midterm elections, in which voters showed they profoundly distrusted government competence and after which Republicans vow to replace or repeal ObamaCare. People are leery of ObamaCare because the President promised they could keep their doctor and their health plans, and this has not proven to be the case, hence the tangled net and deception metaphor.

• Replacement or repeal would pose a formidable political problem – providing a safety net for those seven to eight million, 87% of whom are receiving federal subsidies, after repeal or replacement. The numbers will probably exceed ten million after the second launch concludes. Once government gives awaY something , i.e."the free stuff," it is almost impossible to take it away.

• The Obama administration admits potential glitches lie ahead for about five million who signed up during the first health exchange . People may end up with two health plans, paying premiums on each. The government has yet to figure out what to do with those who moved during the year or who gave wrong information on their incomes or citizenship eligibility.

• Confusion and ignorance exists among the uninsured, people who purchased exchange plans last year, people who plan to buy plans this year, small businesses who want to place employees on the exchanges, and who want to switch plans to avoid high premiums and deductlbles. None of ten of the currently uninsured, which number about 11 million, are not even aware a second launch is about to begin.

The Obama administration has sought to alleviate these difficulties by automatically renewing coverage for those who do not return to the website by leaving people in their old plans. But this does not solve problems of what happens come tax time when the IRS tries to collect penalties for those who did not enroll in plans or switched plans or had improper information on income or citizenship eligibility or who moved to a new address.

It’s complicated for because there are gaps and holes in which has not yet found a way to make it less complicated. It’s complicated for health care consumers too. They must sort through a maze of options – monthly premiums, deductible and copayments, choice of doctors and hospitals, and range of benefits. A Kaiser Foundation study of the first launch found that 76% of people who tried to enroll had difficulties exploring these options.

A family physician friend of mine, Doctor Donald Copeland of Cornelius, North Carolina, explained to me why things are so difficult to consumers.

ObamaCare raises premiums and deductibles for the majority of Americans with health plans, not for all but for about 75% of health care consumers. Even for those 87% of the formerly uninsured, now with federal subsidies, have trouble affording health care.

In Doctor Copeland’s experience with hundreds of thousands of patients, people on average can afford to spend $250 to $500 a year on health care.

Anything beyond that amount, physicians and hospitals will have difficulties collecting. In our slow growth economy over the last six years, the worst recovery since World War II, the uninsured and most of the middle class, people cannot afford to pay, even with federal and state exchange subsidies.