The Numbers if Supreme Court Rules Against Federal Subsidies

None of us really understands what’s going on with all those numbers.

David Stockman (born 1946), Director of Management and Budget under President Reagan

Just give me the numbers. I will understand.

Anonymous

Here are the numbers for you out there seeking to understand what happens if the Supreme Court renders an adverse opinion on subsidies in federal health exchanges.

13 states operating their own exchanges would be unaffected.


87% enrolled in 37 states with federal health exchanges would be affected,


9.3 million could lose $28.8 billion in subsidies.


150 million who pay taxes would gain from loss.


Number of uninsured could rise by 8.2 million.


Premiums could rise by 47% with a 70% drop in enrollments.


Supreme Court decision would take effect in 25 days.


Congress could make decision go away by striking 1 phrase out of current health law “established by the state.”


Neither of the 2 sides, Democratic or Republican, has yet articulated a comprehensive alternative.


If the 2 sides do articulate an alternative , if I may quote Dr. Seuss, “You will see something new. Two things. And I call them Thing One and Thing Two.”

Apocalypse, Armageddon, or Just Plain Politics

Wild, dark times are rumbling towards us, and the prophet who wishes to write a new apocalypse will have to invent new beasts.

Heinrich Heine (1797-1846), German romantic poet

Obama Care supporters and critics alike are projecting an image of Apocalypse, of Armageddon, the final battle between Good and Evil, with Evil winning, if the Supreme Court rules against federal exchange subsidies for 6 million people.

New beasts will roam upon us. Chaos will ensue. Insurers will descend into bankruptcy. Premiums will soar. Hospitals will close. Six million subsidized citizens will die in the streets. Chemotherapy will be turned off for 12,000 people. Dialysis wards for 10,000 will go dark.

If you doubt this scenario, read today’s news, (Joshua Green, “Is Washington Ready for the Death of ObamaCare,” Bloomberg Politics), or Senator Ben Sasse (R.Nebraska), “ A First Step on the Way Out of ObamaCare,” Wall Street Journal).

To Democrats, such scaremongering is understandable. Death of ObamaCare at the hands of the Court is so unthinkable, they do not mention an alternative or whisper that defeat is possible.

Republicans fear they will get what they wished for, the collapse of ObamaCare, and they will take the political blame for its untimely demise with cataclysmic results in the 2016 elections.

In their heart of hearts, both sides seem to be anticipating defeat or even death of ObamaCare . The Court itself is mum on the subject, for it has yet to read all the amicus briefs or to hear the oral arguments for or against.

It is clear if federal subsidies go down, for the sake of humanity, there will have to be a transition period out of ObamaCare and in the interim those previously subsidized will have to be subsidized . Senator Sasse of Nebraska recommends an 18 month period of transition until Democrats and Republicans get their act together, compromise, and craft an acceptable alternative plan that combines governmental and market-based principles.

The plan will not be one-size-fits-all plan, but various sizes-fitting most of the people most of the time-– depending on their need for government assistance - and their desire for freedom and choice.

Who Is Teetering and Who is Tottering? ObamaCare or the Supreme Court?

Teeter Tottering, in Washington, D.C. lingo, is perceived as swaying, seesawing, tipping up and down, and wobbling under political pressure. For me, teeter tottering evokes the image of children on the ends of a teeter totter, shifting their weights and positions to raise or lower themselves.

I thought of teetering and tottering when I read the CNN Report headline, “ObamaCare Is Once Again Teetering Before the Supreme Court.”

Its author, Ariane de Vogue, CNN’s Supreme Court Reporter, begins,

“The Obama administration most significant legislative achievement is now, once again teetering before the Supreme Court.”

The health law is presumed to be teetering because ObamaCare itself teetering. It is still looked upon with disapproval by the majority of Americans, and a Republican Congress has voted to repeal by the 30th time. It is also assumed to be tottering by the Justices, who are often split in 5 to 4 decisions, with Justice Roberts and Kennedy being the most common swingers. The Justices are caught between a rock, the phrase “established by the state, “ indicating subsidies are only available in health exchanges established by states, and a hard place, that 6 to 7 million citizens subsidized in federal exchanges might have to pay back or lose their subsidies if the health law teeter totter goes down, while the conservative and Republican side of the teeter totter goes up.

ObamaCare critics say the word of the law is the law and “opens the door to hundreds of millions of additional spending,” roughly $30 billion a year by my count.

ObamaCare supporter retort writers of the health law always intended to make subsidies available to all who qualified. Solicitor General Donald Vericelli, Jr. will subsidy spending for all was “abundantly clear” what Congress, i.e. Democrats, always mean and that a negative ruling would result in a “death spiral,” not only for the insurance industry, but for hospitals and patients without insurance as well. Besides, he may assert, the four plaintiffs who brought the case before the court do not have “standing” because they were not hurt by the health law.

I did not learn anything from Adriane de Voge’s article that I did not know already. She correctly states that there are tremendous stakes riding on the Supreme Court outcome, including the fates of 6 million who will become uninsured and the President’s legacy. Nor do I whole buy into the teeter tottering argument. We have now had 5 years of ObamaCare, and its benefits and consequences are well known. Neither its advocates or supporters are teetering or tottering. They are not children on a teeter totter, nor are the Supreme Court Justices, who are mature attorneys unlikely to be easily swayed by facile arguments from either side of the political aisle.

Six Simple Minded Supreme Court Solutions

For every complex problem, there is a answer that is clear, simple, and wrong.

Henry Mencken (1880-1956), political commentator known as the Sage of Baltimore

On March 4 the Supreme Court will hear arguments in King v.Burwell with a decision expected in late June.

Observers has suggested and are lobbying for six solutions to the complex health care law.

One, no change in law whatsoever. This appeals to be the Obama administration position. It has put forth no alternative.

Two, a simple change in the text of the law, namely, delete “established by the state” and make it clear the law applies to both state and federal exchanges.

Three, keep good provisions in law. Repeal and replace. Have states distribute “health checks” via state governments for those who received subsidies. Return control of exchanges and Medicaid to states.

Four, go with Republican alternative plan, which ends mandates and exchanges, retains some aspects of law, and stresses market-based competition.

Five, exercise the “freedom option.” If you like ObamaCare and its subsidies, keep them. If you don’t, you are free to dump ObamaCare and to buy the insurance you need. (Phil Gramm, “A Simple Cure for ObamaCare: Freedom," WSJ, February 23, 2015).

Six, none of the above. Go with Medicare or Medicaid for all.

None of these simple options will take place in their pure form. ObamaCare , with all its virtues and faults, is too complex, Its vested interests are too entrenched, too partisan, and too fixed in their ideologies. But one can dream that somewhere out there looms a clear, simple solution in that never-never land between private freedom and choice and federal control and coercion.

American Court of Opinion: Liberal Amicus Briefs

Amicus briefs educate the court on points of law that are in doubt or organize information to raise awareness that the court might not otherwise be aware of on social issues.

Definition, Amicus Brief

As is my custom, I read the New York Times Sunday Week in to see what the left is thinking.

Among the pickings these week arel

A puff piece on 81 year old Ruth Bader Ginsburg (Gail Collins, “The Unsinkable R.B.G.: The Nonretiring Justice Ginsberg”) , who is “planning to be on the bench when the Court decides mammoth issues like the future of the Affordable Care Act and the national right of gay couples to marry.”



On page 14 of the front section (Robert Pear, “Flood of Briefs on Health Law’s Subsidies”) on why America’s hospitals, insurance industry, and other health industry stakeholders are deluging courts with briefs to convince them to maintain federal subsidies on the health care exchanges.





An article in in the Week in Review section by Steven Rattner on why ObamaCare has improved the quality of health care and largely delivered on its promises. *For Tens of Millions , ObamaCare Is Working”.)



Among the facts on ObamaCare’s achievements, according to Rattner, are these.



A drop in the number of uninsured from 42 million by 13.4 million to 28.9 million.



A drop in “inferior plans,” i.e. those not meeting ObamaCare’s 10 essential benefits standards.





New benefits for 31 million Americans who signed up for health exchanges, became recipients in expanded Medicaid plans, or participated in plans in which they were previously denied coverage for pre-existing conditions or in which young adults under 26 could nto participate in their parents’ health plans.

Rattner concludes:

“The program still faces challenges – notably a Supreme Court decision in June that has the potential to undermine the program in many states. There are disappointments , too: millions of Americans faced higher premiums after being forced off substandard plans.”

Rattner might have added, for tens of millions ObamaCare is not working too: for American small businessmen who must drop full-time and part-time employers from coverage, for the young and healthy forced to pay higher premiums for older and sicker Americans are pay penalties they can ill afford, for the American middle class forced to pay higher premiums and deductible and to switch from their current health plans and doctors with which they are satisfied, for American physicians who can no longer afford to stay in private independent practice because of mandated EHRs, cuts in reimbursement , and regulations, and American taxpayers who must pay $500 billion so far and an estimated $1,5 to $2 trillion over the next decade.

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Vice Versa

It’s six of one, half dozen of the other.

It’s the reverse, one way or another,

With the health law, it’s your freedom and choice,

Versus coercion and a more compassionate voice.

It ‘s a left of center president.

In a nation towards the center bent.

It ‘s the urban, bicoastal elite.

Versus folks who move to a common beat.

It ‘s domestic homeland security,

Versus immigrant’s amnesty surety.

However you put it, one way or another,

As seen by Big Brother or Blood Brother,

One person’s passionate reason,

Is another person’s personal lesion.

The Physician Shortage: ObamaCare’s Achilles Heel

Not even Achilles will bring all his words to fulfillment.

Homer (700 BC), The Iliad

The next big political are crisis will be lack of access to doctors. This will be aggravated by 78 million baby boomers entering Medicare in 2011 and a dramatic expansion caused by millions of uninsured citizens entering the market.

Richard Reece, M.D., Obama, Physicians, and Health Reform, 2009

It‘s one thing to promise health care coverage to all Americans, the underlying goal of ObamaCare.

It’s quite another to give them access to physicians.

Coverage, unfortunately, is not the same as access. the two are not equated. ObamaCare expands coverage but exacerbates the access problem.

Because of a series of factors - expansion of Medicaid, increase of health exchange plans for the uninsured, the aging population with 10,000 more Medicare patients each day, accelerating hospital employment of physicians, rapid declines in physician private practices, larger numbers of women physicians, young physicians seeking more balanced lifestyles, rising medical education debts of $150,000 or more, persistent unpopularity of primary care among medical school graduates, the lid on federal funding of residency programs, the inability of American medical schools to expand fast enough to meet the demand for doctors – an access crisis is upon us.

A daunting, often cruel dilemma for patients, newly covered and seeking a doctor, confronts the health system and the Affordable Care Act.

What good is expanded coverage for the uninsured without doctors to cover the wave of 32 million new patients looking for doctors to treat them?

As Richard “Buz” Cooper, MD, an expert on physician shortages, trenchantly remarked in a Health Affairs 2002 article, “Without adequate numbers of physicians, the health system cannot function.”

The demand for new medical residency graduates is staggering. Physicians now graduating from U.S. residency programs report receiving 50 more recruiting inquiries. The American Association of Medical Colleges reports a shortage of 50,000 qualified physicians. That number is expected to peak at 150,000 to 200,000 over the next decade. American medical schools graduate 17,500 new physicians each year, not nearly enough to meet demands.

The U.S. has room for 30,000 physicians residency programs, but Congress has capped federal funding for these programs. To fill the gap, residency programs must be discontinued or filled with foreign medical school graduates. This is already occurring in many programs. And, of America’s practicing physicians, 25% are foreign-trained and that percentage may grow to address the shortage.

Solutions vary as to what to do. U.S. medical schools are ramping up enrollments by 30% or more. Nurse practitioners and physician assistants numbers are growing exponentially, and some are entering independent practices, supplementing or replacing physicians. Off- shore medical schools in the Caribbean, 18 of them, have turned out more than 15,000 graduates, and U.S. hospitals have had positive experiences with these graduates and are happy to have them, Cell phones containing health care guidance are being touted as partial replacements for physicians. Retail clinics are sprouting every day in pharmacy chains and in discount stores in malls. And locum tenens doctors are roaming the land, trying to fill in the gaps created by physician shortages.

I have been aware of the mounting physician shortage for more than 30 years. I wrote about it in my 1988 book, And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota m, in my 2009 book Obama, Doctors, and Health Reform, and I have written over 30 blogs on physician shortages in my Medinnovation and Health Reform blogs. The physician shortage is a multidimensional problem. To see what I have written about the shortage, to my blog and enter the phrase “physician shortage” in the search box.

Healthcare.Gov Glitches and Sons of Glitches

Glitch: An unexpected and usually minor problem with a machine or device (such as a computer: a false or spurious electronic signal. From the Yiddish, glitsh, a slippery place.

I see by the news that healthcare.gov has developed another glitch. This glitch provides false tax information to 800,000 people receiving subsidies. Reports announcing this news are:

--Robert Pear, “800,000 Using Healthcare.Gov Sent Incorrect Tax Information,” New York Times, February 20, 2015.


--Louise Radnosky, “Obama Administration Extends Health Care Sign-Up Through April,” Wall Street Journal, February 20, 2015.

The federal responses, as usual and as expected are:


1) Delaying penalties for not having a health plan for another 7 weeks to the glitch can be corrected

2) Creating more exemptions to defuse political angst

3) Claiming the number of taxpayers involved are insignificant

4) Saying “We’re working on problem and will get it fixed evertually.".

On the latter point, some 11 million have signed on via healthcare.gov, and 800,000 of 11 million amounts to only 7.4% of the total, and only 0.5% of 150,000 filing federal tax returns. According to the Wall Street Journal, the actual error rate, or the glitch rate, if you prefer, is roughly 20% for those receiving subsidies, if you include family members.

If you are an ObamaCare advocate, you will probably buy into the adminisration's communication strategy - announcing the good news with the bad news. ObamaCare, everybody recognizes, is a huge undertaking, involving 320 million Americans of every race, color, creed, health, and income status. Mistakes will inevitably be made, and glitches will crop up.

On the other hand, if you are a critic, you may point to the law of large numbers that says the more experiments you conduct involving large numbers of people the greater the probability you will get it right.

Unfortunately, as a matter of political pragmatism, you can only have so many delays, backtrackings, backings and fillings, revisions, corrections, redoings, undoings, revampings, extensions, surprises, headaches, extensions, waivers, exemptions before you get it right or before you arouse suspicions you don't know what you're doing.

But the political defusing process seems to be working. Only 2% to 4% of those receiving exemptions will end up paying a penalty for not having a plan.

If you are ordinary citizen , you may ask: Who, Oh Who, is responsible for these glitches? Why, Oh Why, do these glitches keep occurring? How, Oh How, and When, Oh When, will these glitches be corrected?

John Glenn, America’s first astronaut, defined a glitch as a spike or change in voltage of an electronic beam. With space travel, a computer glitch can be fatal. Here on earth, a computer glitch is merely politically embarrassing or economically discomforting, even devastating, to the small numbers involved.

“Health Checks” As Practical Way To "Fix" ObamaCare

You’re either part of the solution or part of the problem.

Leroy Eldridge Cleaver (1935-1998), Civil rights activist

I recently received an e-mail from Grace-Marie Turner of the Galen Institute. The e-mail contained an article from the February 13 New York Times – “A New Fix for ObamaCare," by Grace-Marie Turner and Diana Furchgott-Roth).

The Op-Ed piece argues that “health checks” might solve a looming dilemma – what to do for 6 million people subsidized in federal exchanges should the Supreme Court in June rule their subsidies illegal and a violation of the health law.

It is a daunting dilemma. One cannot abandon these people and leave them uninsured. One cannot renege on federal promises, even if those promises were ill-founded. One cannot merely criticize, one must offer solutions.

So what do Grace-Marie Turner and Diana Fuchgott-Roth propose?

Health Checks.

“Beginning in June,” say the authors, “instead of subsidies, the 37 states without exchanges could receive a new capped allotment from the federal government that we call health checks.”

Using the existing state and federal infrastructure to disburse funds for the Children’s Health Insurance Progra, which covers 9 million children, the states could distribute federal checks to offset costs of lost insurance subsidies.

Health checks would return control to the states, pleasing politicians and legislators in the states; preserve the ACA’s present extension of coverage, placating the Obama administration; and provide a practical way to deal with the political fallout should the Supreme Court rule against federal exchange subsidies.

For Republicans and Democrats alike, it would be a bipartisan solution. It would be better to be part of the solution rather than part of the problem.

President Obama and The Right Stuff

The idea was to prove at every foot of the way up that you were one of the elected and appointed ones who had the right stuff and could move higher and higher and even –ultimately, God willing, one – that you might be able to join that special few at the very top, that elite who had the capacity to bring tears to men’s eyes, the very Brotherhood of the Right Stuff itself.

Tom Wolfe (born 1931), The Right Stuff

Is President Obama made up of the right stuff? What will his legacy be?

If today’s news that a Texas federal blocked his immigration amnesty decree, and tomorrow’s potential news – that this climate bill and federal hhealth exchanges may not pass legal muster, pan out, it just might be that the courts, not Obama, will decide what the right stuff is.

Obama’s legacy rests in the hands of federal judges. There’s a certain irony in all of this. Obama is a lawyer. He taught constitutional law at the University Chicago. He knows the 3 branches of government are there to assure checks and balances. Yet here is Obama is, stranded and swinging in the wind on the end of his limb, placed there by strokes of his own executive pen and abut to plunge into limbo.

Where did this learned man, this graduate of Harvard Law, this gifted politician, go wrong? Or has he? Has he overestimated his power? Is he doing the right stuff? Or is this the stuff of hubris?

I suppose his fate will depend on his definition of “stuff” and “right stuff.” You won’t find the answers in the dictionary. My dictionary contains 28 different definitions of “stuff.” It says nothing about the "right stuff".

The “right stuff” resides in his head.

To President Obama the "right stuff" is the “big stuff”:

Thw "big stuff" is:

One, controlling the earth’s climate so the seas don’t rise, coastal cities don’t flood, weather extremes don’t parch the land, and pollutants don’t poison the planet.

Two, offering universal coverage to the disadvantaged to maintain health, prevent and cure disease among the huddled masses and minorities by raising taxes, imposing mandates, and redistributing wealth.

Three, withdrawing from U.S. responsibilities around the globe, avoiding war at all costs, not arming your allies, assuring your enemies it’s not their fault but our fault, appeasing and pleasing them by not offending them, and giving them the benefit of doubt, and temporizing when strong actions are required.

The president says he will not do “stupid stuff,” compromising with political opponents, offending foreign enemies by calling them what they are, putting soldiers in harm’s way.

And he definitely does not like to sweat the “small stuff” – overseeing healthcare.gov or other government programs before they launch, listening to the advice or warning of his Secretaries of Defense or his generals, auditing the bureaucratic activities of the Veteran’s Administration or the political activities of the Internal Revenue Service, or paying attention to the adverse effects of ObamaCare on the economy, small businesses, and middle class health consumers.

President Obama no doubt knows his stuff. His problem is the small stuff and the dumb stuff keeps getting in the way of the big stuff and , the right stuff.

Euphonic and Dysphonic Electronic Health Records


It’s not as bad as it sounds.

Mark Twain on Richard Wagner’s music

Electronic health records (EHRs) may not be as good as they sound (Jeffrey Singer, MD, “ObamaCare’s Electronic Debacle,” Wall Street Journal, February 17, 2014).

To Washington policy makers who created the the $800 billion 2009 stimulus bill, EHRS sounded good, felt good, and therefore had to be good.

EHRs were objective. EHRs produced data – fuel for Internet geeks and policy wonks. EHRs told you what was done. EHRs allowed you to track physician performance and patient outcomes.

Above all, EHRs were “evidence-based.” What was not to like?

Furthermore, EHRs had been tested in the real world. Organizations like Kaiser Permanente and the Veteran’s Administration were using EHRs to coordinate care, connect all participants in that care, vertically integrate that care, and, it goes without saying, manage that care.

EHRs were perceived as the solid management foundation on which to rest federal health reform. Management dogma proclaimed, if you can measure care in real time, you can form negative and positive feedback loops, you can track doctor and patient behavior, and you can improve both.

Sound too good to be true?

According to Jeffrey Singer, MD, a general surgeon in Phoenix and an adjunct scholar at the Cato Institute, EHRs are not as good as they are cracked up to be.

EHRs distract from patient-interaction. EHRs split attention between the computer screen and the patient. You cannot look at both at the same time. Doctors in one survey say they wasted 48 minutes a day entering data or complying with EHR instructions.

EHRs cost money, $162, 000 to install for the typical 5 person group, and $85,000 to maintain the first year.

EHRs are not “user-friendly.” In a 2014 Medical Economics survey, 67% of doctors found EHRs to be dysfunctional . Yet the government will penalize doctors who do not use EHRs when treating Medicare patients by cutting reimbursements 1% in 2015, increasing to 5% by the end of the decade.

These factors are driving doctors into hospital employment where the hospital installs and maintains the EHR. In addition, fees for patients going to hospital-employed doctors rather than independent practitioners are significantly higher, sometimes as much as 50% higher.

Finally, there’s a “quality “ problem if you define quality as spending time with patients or having access to doctors. Doctors working for hospitals often switch to hospital employment so they have a more “balanced life style,” which translated, means more time spent with family, on personal matters, or in a 40 hour work week, rather than the average 53 hours in independent practice.

To contain costs, health plans are narrowing physician networks. This makes it harder for patients to find doctors. To compound the problem, because of lower Medicare, Medicaid, and health exchange reimbursements and the increased costs of mandatory EHRs and other regulations, doctors are accepting 20% to 50% fewer patients in federal programs. As many as 20% of primary care physicians are switching to direct care, concierge practices to escape the rigors, expenses, and other time consuming costs such as EHRs and ICD-10 coding, another federal requirement.

Where have all the doctors gone? They have gone to spend more time with EHR data entry, more time with paperless records, more time in hospital employment, more time with their families and personal lives, or more time in concierge practices where they can spend more time with patients.

Second ObamaCare Enrollment Period Ends, or Does It?

The greatest challenge in life is an unhatched egg.

E.B. White (1899-1985), American essayist and sometime farmer.

For multiple reasons, the end of the 2nd ObamaCare enrollment period, which supposedly went from November 15, 2014, to February 15, 2015, reminds me of chicken metaphors.

First, a Little Background

At this point, we do not know many things: How many people enrolled. 9 million? 10 million? How many paid their first premium? How many were automatically re-enrolled? How many were newly enrolled?

We do know these facts. The federal and state exchanges have extended the deadline for enrolling, sometimes for a week, a month. It depends on federal and state exchanges. Millions of people, some say as many as 5 million, do not even know they would have to pay penalty of $95, which will grow to over a $1000, by 2017, if they do not have a health plan.

These people, known as “constituents” to politicians, will be enraged when the IRS informs them of their penalty for not being insured.

To many constituents, paying a penalty will seem counter-intuitive: If they could not afford to buy health insurance, how can they afford to pay penalties for not being insured?

The constituents will quickly learn there are 30 or more exceptions, waivers, or extensions, that effect over 30 million people, and the phone lines to the IRS will be clogged to learn how to dodge the penalties.

Half the people calling the IRS will get no return call, and the other half will have to wait 30 minutes or more to get through.

The IRS will complain it can’t respond because its budget has been cut, and HHS will complain penalties were its main source of funding ObamaCare.

So where do the chicken metaphors come in?

Don’t count your chickens before they hatch. The number hatched were supposed to be hatched by February 15, but because we don’t know how many eggs were left unhatched, we will simply extend the hatching period.

The chickens always come home to roost. Here the chicken is the individual mandate, which involves ever American. Have a health plan, or pay the Rooster, whether you can afford to or not, whether you want to or not.

Mad as a wet hen - This aptly describes how people who were unaware of the penalty will feel when they get their IRS refund or lack of it will feel when they find they have been docked for not having health insurance.

The Rooster rules the roost. The rooster, of course, is the federal government, and when he says you have to have a health plan, and he won’t take No for an answer you'd better listen. In fact, you are mandated to listen.

Running around like a chicken with head cut off - This may apply to President Obama, who, after the initial disastrous roll-out, said the government had laid an egg, but he was personally unaware of the problem and had not been informed there was an oversight problem.

With the impending Supreme Court decision on the legality of federal exchange subsidies, the hatching period of ObamaCare could come to an abrupt end , with nothing left by smashed eggs and an uncooked omelette.

Synopsis of ObamaCare Story

I am now in the process of writing and completing my tetalogy of books on ObamaCare, one man’s story of this nearly 5 year old health law. It is not easy to sum up what I have said about this confusing, complex, controversial law whose history has yet to be written and whose future may hinge on the Supreme Court ruling on federal subsidies in June 2015.

My four books are titled : 1) The Road to Hell is Paved with Good Intentions; 2) There Is No Such Thing As a Free Launch; 3) The Party’s Over; and 4) Alive and Still Kicking.

Each of the books consists of blogs organized into 12 to 14 chapters covering these subjects: up-and-downs of implementation of the Patient Protection and Affordability Act; Obama mindset and philosophy; two health exchange rollouts; impact on physicians and hospitals; consequences for consumers; political fall outs; the roles and influences of the media and the bully pulpit; individual and employer mandates; technologies and innovations; Veteran’s administration scandals; implications of Professor Jonathon Gruber’s revelations; health system changes; interviews with physicians and others engaged in concierge medicine; ObamaCare and the Supreme Court; and various personal and miscellaneous observations, including interpretive poems.

I shall not try to summarize what I have said in over 500 blogs written daily during the heat of ObamaCare’s confusions, controversies, and uncertainties, The blogs stretch over 1000 pages. It’s too complicated a matter to deal with in this short synopsis.

For a taste of what I have said, you may want to order The Road to Hell Is Paved with Good Intentions: the ObamaCare Story, now available on Kindle.

Campaign to Win Hearts and Minds of Supreme Court Justices

Political campaigns are decidedly made into emotional orgies which endeavor to distract away from the real issues.

James Henry Robinson (1863-1936), The Human Comedy

The United States has never seen anything quite like it – the political campaign to win the hearts and minds of Supreme Court Justices, especially the heart and mind of Chief Justice John Roberts, prior to the King v .Burwell, the case involving the legality of federal subsidies in 36 states.

The issues are the moral -, legal -, and business -related. They hinge upon what happens if the Court rules against federal subsidies.

• Says the moral school, it would be inhumane, cruel, and heartless to remove subsidies from 7 million uninsured who make less than 4 times the poverty level. Removal would cause these unfortunates to get sick, go bankrupt, or die.

• Ridiculous, shouts the legal school, it is ludicrous to equate subsidy removal with moral deprivation. You cannot disregard the plain language of the statue, which says subsidies apply only to those in exchanges “established by the state,” not to federal exchanges. One must always follow the letter of the Law.

• Get real, claim those in the business sector, ending federal subsidies would create irreparable damage to the insurance industry, cause thousands of hospitals to close, and reduce the flow of new drugs from profit-starved pharmaceutical companies. In a biting editorial on the hypocrisy of the health industry, “Until King Dumb Come,” WSJ editors assert, “ObamaCare’s industry allies are shaking the tin cup at the Supreme Court.”

The hope among these various schools of thought is that their arguments will influence the hearts and minds of the Supremes and cause them to shift their votes.

King v. Burwell is not a strictly moral, legal, or business issue . It is all three issues wrapped into one. It entails answers to two explosive political questions: what happens if ObamaCare disintegrates? What are the human consequences? What is a humane and sustainable replacement?

The answers are complicated by two simultaneous current events:

One, the public is souring on the health reform law with a record low approval rate of 37%.

Two, the Obama administration’s strategy of highlighting penalties for not being insured - $95, in 2014; $395 in 2015,$695 in 2016- is working: 10 million are now expected to enroll by February 15.

The idea of winning hearts and minds of the Supreme Court justices brings to mind a new concept of selling one’s argument: Emotionomics.

This is a psychological term introduced by Dan Hill in his 2010 book by the same name. Hill says business success rests more on people’s emotional decision making rather than rationality and efficiency.

This is true of political success as well. In the current campaign to sell ObamaCare or to undo it, “winning hearts and minds” is a form of domestic propaganda – information spread widely to help or harm the health reform movement, and its main vehicle, ObamaCare.

With King v. Burwell, the question is: will emotional arguments intimidate the Court to disregard the law and to focus instead on its intent and business impact?

It may depend on Robert’s Rules of Order in his heart and mind.

On Smoking and Early Croaking

To Croak, Slang: To Die

The general public associates smoking mostly with lung cancer. But the truth is that smoking also contributes to increased death rates with 21 common diseases.

A report from the Epidemiology Research Program, of the American Cancer Society, after studying deaths in 412,378 man and 532, 651 women aged 55 years or older, puts it this way;

“Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked. Most of this excess mortality is believed to be explained by 21 common disease that have been formally established a caused by cigarette smoking.

Brian Carter et al, “Smoking and Mortality – Beyond the Established Causes, New England Journal of Medicine, February 12, 2014
These are the 21 diseases with the relative risks for either women and men or both is more than 2 times the risk than among non-smokers.

1. Lung cancer, Women, 22.9, Men, 25.3

2. Laryngeal cancer, Women, 103.8, Men, 25.3

3. Aortic aneurysm, Women, 10.1, Men, 7.5

4. Chronic Obstructive Lung Disease, Women. 25.0, Men, 27.8

5. Esophageal Cancer, Women, 5.1, Men, 3.5

6. Urinary Bladder Cancer, Women, 3.9, Men, 3.9

7. Ischemic Heart Disease, Women, 3.0, Men, 2.6

8. Other Arterial Diseases, Women, 5.6, Men, 5.3

9. ischemic Diseases of the Intestine, Women, 6.1, Men, 5.6

10. All causes, women, 2.8, men, 2.8

11. Liver Cirrhosis, Women, 2.6, Men, 3.6

12. Total Stroke, Women, 2.1, Men, 1.9

13. Atherosclerosis, Women, 2.1, men, 5.0

14. Liver Cancer, Women, 1.8, Men, 2.3

15. Other Heart Disease, Women, 1.9, Men, 2.0

16. Pneumonia, Flu, T.B, Women, 1.9, Men 2.0

17. All Infections, Women, 2.5, Men, 2.2

18. Cancers of Unknown Site, Women, 2.7, Men, 3.2

19. Hypertensive Heart Disease, Women. 1.9, Men, 2.9

20. Essential Hypertension and Renal Hypertension, Women, 2.4, Men, 2.6

21. All Respiratory Diseases, Women, 1.9, Men,,2.0

The authors conclude, “Our results suggest that the number of people in the United States who die each year from the results of smoking cigarettes may be substantially greater than currently estimated."

So, in the words of a country Western song, you may want to Smoke! Smoke! Smoke! That Cigarette! but when you do, you run a much greater risk of premature death than previously thought; you stand a greater risk of developing a number of common diseases other than lung cancer; and you can expect to live 10 fewer years than non-smokers

Book Review: The Internet Is Not The Answer

By Andrew Keen, Atlantic Monthly Press, 2015

I have long been a health care cyberskeptic. I do not believe the Internet axiomatically improves the human condition, nor should all doctors have electronic medical records, nor can all doctors be judged by data, nor does data automatically better the health system.

Andrew Keen, a transplanted Englishman. executive director of Silicon Valley's FutureCast, and a regular commentator on all things digital, confirms my worst suspicions. Data, he asserts, may be part of the answer for improving society, but it is not the total answer and is often destructive in undermining our culture and our economy.

In his 272 page, 8 chapter book, Keen delivers an authoritative history of the Internet, examines the dimensions of its worldwide networks, shows how it has destroyed many major industries, creates a culture of personal narcissism, makes the U.S. a winner-take-all 1% economy, turns the Web into a giant spying machine, destroys personal privacy, and causes deepening economic and social inequalities.

The Internet is masterful at creative destruction of major industries and social institutions. Look at what has happened to newspapers, bookstores, malls, brook-and-mortar stores, local businesses, the music industry, photography firms like Kodak.

Keen devotes one chapter to the plight of Rochester, New York, where digital photography drove Kodak into barnruptcy and destroyed 145,000 jobs and pensions of 50,000 people.

Keen is particularly instructive on the Internet as a vehicle for unemployment. Amazon, for example, requires only 14 people to generate $10 million in sales while brick-and-mortar stores need 47 people to generate $10 million. Google, now the second most valuable company in the world after Apple, with a market cap of $400 billion, has 46, 000 employees but General Motors with a market cap of $55 million, hires over 200,000 to make its cars.

The digital revolution is like the industrial revolution on steroids. In less than 20 years, it has produced the world’s biggest and fastest growing companies – Apple, Google, Facebook, Amazon, and Twitter. Many of these company’s CEOs have a personal net worth of over $30 billion each. Before 2020, 60% of the world’s population will be connected in one way or another to the Internet.

The secret to success of these big companies, which Keen calls “data factories,” is that their users supply the data for “free” for the privilege of using their services. And the more data the factories accumulate, the more valuable their data becomes.

It’s a winner-take-all economy with Silicon Valley entrepreneurs, mostly young white males, becoming richer and richer and the middle class becoming poorer and poorer. The economy has been dubbed the “donut economy” because of in giant hole in middle incomes and jobs. “ The Internet,” says Keen, “is actually compounding this inequality and deepening the chasm between a handful of wealthy guys and everybody else.” It is a dehumanizing race between computers using artificial intelligence and ordinary mortals, between a very few valuable companies with very few employees and middle of the road companies with a great number of employees.

The Internet, of course, is not necessarily bad, with its universal access to information and its data-management capacities, but it is not necessarily good either, for those of us in the middle. In his preface, Keen observes of the Internet, “Rather than promoting fairness, it is a central reason for the growing gulf between the rich and the poor and hollowing out of the middle class…the principle abuse of our structural unemployment crisis…\"

“No,” Keen adds, “The Internet is not the answer.” My only disappointment with the book is that Keen says government intervention and regulation may be the only answer. Until that happens, the Internet will grow and grow and grow as a central reality in all of our lives.

Sixteen Planks in GOP Alternative to ObamaCare

You load sixteen tons and what do you get,

Another day older and deeper in debt.

Saint Peter, don’t call me because I can’t go.

I owe my soul to the company store.

Sixteen Tons, Lyrics to Sixteen Tons by Tennessee Ernie Ford

An article on the Internet in form of numbered or bullet point lists, generally with a cardinal number in title.

Listicle

I have a new word in my vocabulary: “Listicle.”

A listicle is a creature of the Internet. A listicle combines the words “list”and ”article”. A Listicle is designed for short articles on the Internet for readers with short attention spans and no time to share.

Enough preamble.

Here is a listicle by Bob Lawzewski, a well-known and respected health insurance analyst on his take on the Republican alternative to ObamaCare should the Supreme Court declare federal subsidies illegal .

After listing these 16 components of the Republican repeal and replacement plan, Lawzewski concludes:

“And, therein lies the Republican challenge––convincing people that their complex health insurance reform ideas provide people with more health insurance security than the problematic and complex Obamacare plan does. Take it or leave it––ours or theirs.”

“Again, I think Republicans would have been far better off taking a big gulp and accepting ObamaCare as the baseline in health insurance public policy and then use many of their ideas to tell the American people how they could make it work a lot better.”

“After all, isn’t that what most people really want?”

Here is Laszewski's list of the 16 components of the Republican alternative plan.

1. Full repeal and replacement of ObamaCare.

2. No individual mandate to buy health insurance or an employer to offer coverage.

3. Return to pre-existing condition limits.

4. Default enrollment.

5. High risk pools for uninsured.

6. Affordable insurance policies.

7. Tax credits to buy coverage.

8. Tax credits only up to 300% of poverty.

9. Flat amounts tax credits by age.

10. No more ObamaCare state and federal health exchanges.

11. No limits on kind of insurance policies that could be offered.

12. Capping the tax credits of employer provided health insurance.

13. Moving towards defined contribution of health insurance.

14. Medical malpractice reform.

15. Repeal Medicaid expansion.

16. Empower poorer consumers by giving them mainstream health plans.

Presumably this plan would lighten the growing national debt, which will load $20 trillion tons of debt on future generations by the time Obama leaves office. By then we will owe our souls to the government store.

Obama – The Most Polarizing President Ever

During his four years in office an average of 86% of Democrats and 10% of Republicans approve of the job Barack Obama did as President.

Gallup.com, “Obama on Track to Become the Most Polarizing President Ever,” February 10, 2014

Barack Obama has the dubious distinction of becoming the most polarizing president in modern history.

In this 4th year as President the party approval gap between Democrats and Republicans is 76%. That percentage ties George W. Bush, but if things continue as is , Gallup says the gap will reach its historic high by the end of Obama’s term, surpassing even George W. Bush. The approval gaps of previous Presidents in their 4th year were: Clinton 61%, Reagan 60%, Eisenhower 45%, Nixon 44%, and Carter 29%. This is striking because Obama was elected on his promises that he would be a unifying president.

Why the differences?

It may be because times have changed and the issues differ.

One of the most striking changes has been the impact of the Internet on journalism.

We now have a 24 hour news cycle, with multiple news organizations competing for public attention. To gain attention, these organizations have become more partisan and branched out into show business, opinion-mongering, and make-believe. The so-called mainstream media, talk radio hosts, left-and-right wing bloggers, comedy central satirists, the social media, and organizations like Fox News create controversies, compete for demographic market share, and see how many books they can hawk in their respective venues

Another change has been the emergence of covert class warfare. Obama, the brilliant social organizer, has exploited the Internet, the social media, his rhetoric, and his status as the first black President to win over minorities – blacks, Hispanics, gentry liberals, single women, and young voters – into a winning coalition that turns out in greater numbers to win Presidential elections, but not mid-term elections, where the middle class, the elderly, and white males prevail. Divide and conquer among the classes may be a temporary winning strategy s but it is not a lasting or winning strategy in America.

Yet another change has been ObamaCare. Obama is the first President to pass a national health reform bill. But he passed the health law under dubious circumstances with tricky parliamentary procedures, Medicaid bribes to key Senators, and against the unanimous opposition of Republicans. The public has opposed ObamaCare from the beginning by double digit margins, although they like certain features , the end of discrimination against people with pre-existing conditions and the coverage of adult children under their parents plans.

ObamaCare has other problems as well. Americans do not like radical change, being mandated as to what they cannot or cannot do; being told what plans and doctors to choose; having plans cancelled because the plans did not comply with federal standards; being called “stupid” by an Obama acolyte, who claims the “stupidity” of American voters is why the ACA passed; having promises of keeping your own doctor and health plans and lower premiums and lower costs broken; and witnessing the disaster of the healthcare.gov launch and general confusion and managerial incompetence surrounding enrollment and re-enrollment.
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Finally, there is the “personal” issue. Nothing is more personal than health care. Of all government issues those affecting health care are the most personal. It is not like other government policies. What health care to buy, to have, and to gain access to, is a potentially life and health threatening decision about your Moms and Dads and kids. According to David Simas, Obama’s senior advisor on selling health reform, “ Health care is personal. It is completely- completely- different.”

Encryptic Remarks about Anthem Blue Cross Hacking

To change information from one form to another to hide its meaning. On the Internet, to read an encrypted file, you must have a secret key password that enables you to decrypt.

Encrypt , or Encryption

John Irving, executive editor of The Health Care Blog, sent me the following email, a recent entry into his blog. Fred Trotter, a health care journalist wrote the blog. Like most people, I was alarmed when I learned Anthem Blue Cross and its 80 million members had been hacked, and their social security numbers, demographic data, and addresses revealed . Anthem has been under attack for not encrypting its data. Here Trotter comes to Anthem’s defense.

Anthem Was Right Not to Encrypt

By FRED TROTTER

The Internet is abuzz criticizing Anthem for not encrypting its patient records. Anthem has been hacked, for those not paying attention.

Anthem was right, and the Internet is wrong. Or at least, Anthem should be “presumed innocent” on the issue. More importantly, by creating buzz around this issue, reporters are missing the real story: that multinational hacking forces are targeting large healthcare institutions.

Most lay people, clinicians and apparently, reporters, simply do not understand when encryption is helpful. They presume that encrypted records are always more secure than encrypted records, which is simplistic and untrue.

Encryption is a mechanism that ensures that data is useless without a key, much in the same way that your car is made useless without a car key. Given this analogy, what has apparently happened to Anthem is the security equivalent to a car-jacking.

When someone uses a gun to threaten a person into handing over both the car and the car keys needed to make that care useless, no one says “well that car manufacturer needs to invest in more secure keys”.

In general, systems that rely on keys to protect assets are useless once the bad guy gets ahold of the keys. Apparently, whoever hacked Anthem was able to crack the system open enough to gain “programmer access”. Without knowing precisely what that means, it is fair to assume that even in a given system implementing “encryption-at-rest”, the programmers have the keys. Typically it is the programmer that hands out the keys.

Most of the time, hackers seek to “go around” encryption. Suggesting that we use more encryption or suggesting that we should use it differently is only useful when “going around it” is not simple. In this case, that is what happened.

The average lay person, as well as the average clinician, do not bother to think carefully about security generally. Making an investment in the wrong set of defenses serves to decrease and not increase the overall security of the system. This argument is at the heart of the arguments against the TSA, which serves to make us “feel” more secure without actually increasing our security. The phrase for this is “Security Theater”.

You see encryption at rest, unlike encryption in transit, comes with significant risks. The first risk is that keys might be lost. Unlike car keys, once encryption keys are lost there is no way to “make new ones”. Of course you could backup your keys, securely, off-site, but that is extra costs, extra steps. Second, if encrypted data becomes corrupted, it is much more difficult to recover than unencrypted data.

In short, there are cases where encryption-at-rest can be dangerous and there are only a few cases where it can be helpful.

For clinicians, it is easy to make a parallel: the risks associated with unneeded testing. A lay person assumes that if there is any chance that the “CAT scan might catch it” then they should have a CAT scan. The clinician understand that this tests comes with a cost (i.e. increased long-term cancer risk) and is not as “free” as the patient feels it is. The public only becomes aware of this when a test scandal occurs like the famous PSA test, where the harm was massively larger than the good provided by a given test.

Both “Human Body” and “Information Technology” are both complex systems, and in general do not respond well at all to oversimplified interventions.

Moving back to Anthem.

Anthem has a responsibility, under HIPAA, to ensure that records remain accessible. That is much easier to do with unencrypted data. The fact that this data was not encrypted means very little. There is little that would have stopped a hacker with the level of access that these hackers achieved. Encryption probably would not have helped.

By focusing on the encryption at rest issue, the mainstream press is missing the main story here. If indeed Anthem was targeted by sophisticated international hackers, then there is little that could have been done to stop them. In fact, assuming international actors where involved, this is not as much as failure for Anthem as a failure of the NSA, who is the government agency tasked with both protecting US resources and attacking other nations resources.

As much as the NSA has been criticized for surveilling americans, it is their failure to protect against foreign hackers that should be frequent news. Currently, the NSA continues to employ a strategy where they do not give US companies all of the information that they could use to protect themselves, but instead reserve some information to ensure that they can break into foreign computer systems. This is a point that Snowden, and other critics like Bruce Schneier continue hammer: the NSA makes it easy to spy, for themselves and for others too.

It is fine to be outraged at Anthem and I am sure they could have done more, but I can assure you that no insurance company or hospital in the United States is prepared to defend against nation-state level attacks on our infrastructure. In fact, Anthem is to be applauded for detecting and cutting off the attack that it did find. Hackers are much like roaches, if you can spot one, there are likely dozens more successfully hiding in the walls.

Kindergarten Lesson

Everything I really needed to know I learned in kindergarten.

Robert Fulghum (Born 1937)

The United States Government has three branches.

The President of United States, POTUS.

The Congress of the United States, COTUS.

which is split into two parts,

the House of Representatives the United States, HROTUS,

the Senate of the United States, SOTUS.

Supporting and helping POTUS

Are the Vice-President of the United States, VPOTUS

And the First Lady of the United States, FLOTUS.

And sometimes the Secretary of State of the United States, SSOTUS.

The three branches are equal except then there’s a FUSS,

Then one may try to throw the other under the BUS.

That’s all you really need to know in this first session,

That is all I trying to teach you in this first lesson.

Public Relations War if Supreme Court Rules Against ACA Subsidies

The American Enterprise Institute has just released an 1160 word report “If SCOTUS Rules Against ACA Subsidies “on what happens if the Supreme Court rules federal subsidies in 37 states affecting 5 million people are illegal. For public relations and political reasons, it is generally agreed these people will have to be covered until the end of 2015 by some alternative plan rather than having their subsidies abruptly dropped and having the insurance industry descend into chaos. Preparations are underway in Congress to create such a plan, but the administration, anticipating a favorable SCOTUS ruling says it has no plan.

The authors of the report , Thomas Miller of the American Enterprise Institute and Grace-Marie Turner of the Galen Institute make this comment in the course of their 1100 word commentary.

“ The public-relations wars over the pending Supreme Court decision already have begun: Families USA is leading the effort on the left and will try to show how many people will be harmed if the subsidies are struck down. Supporters of free markets and limited government are mounting their own serious media-outreach effort to show the harm that this law is doing, emphasizing the soaring cost of health insurance, the threat of mandate penalties, the labor-market disincentives, the disruptions in previous coverage, and patients’ reduced access to their preferred medical providers. Critics of the IRS rule need to explain very clearly that Congress is ready and willing to act to take care of the people who will lose their coverage if the Supreme Court decides not to allow subsidies on the federal exchanges.”

Hold onto your hats and fasten your seat belts. The war has begun.

Believer

He is a believer in the divine truth of things; a seer, seeing through the shows of things; a worshipper, in one way or another, of the divine truth of things.

Thomas Carlyle (1795-1881), On Heroes and Hero Worship

David Axelrod (born 1955), is coming out with a book Believer: My Forty Years in Politics, to be released on February 10 by Penguin Press for $25.55 in hardcover and $12.99 on Kindle.

Axelrod, former senior advisor to President Obama, is now a political consultant and director of The Institute of Politics at the University of Chicago. Axelrod prides himself on being an advocate of racial equality, a champion of social organizing of minorities, and an admirer of President Obama.

Axelrod and Obama rode the right horses to fame and glory, and the horses were not high horses at the time they saddled them. Their horses were, if I may mix a metaphor, underdogs.

The President, as the moment, is riding a number of horses – foreign policy horses, like Ukraine and ISIS: domestic policy horses, like immigration and ObamaCare.

At last week’s prayer meeting in Washington, the President said we should not get on a Christian “high horse” in judging other believers. We should put things in historical context. We are all sinners and should not caste stones.

In his words,

"Lest we get on our high horse and think this is unique to some other place, remember that during the Crusades and the Inquisition, people committed terrible deeds in the name of Christ.”

True enough. But that was 900 years ago. The tragic lesson today is that one’s beliefs still drives evil actions, including beheadings and burning people alive. The President believes he cannot change the action of others.

Government can only do what it can do. With the President and Axelrod, the belief is in the power of government’s central role is domestic: to change society, achieve equality of outcomes, and shape social justice. Government cannot be all things to all peoples, but it can try to do too many things for too many people. There are never enough rich people, for example, to support any general welfare program.

The President's beliefs result in certain attitudes and policies – humility, even guilt and apologies, about America’s place in the world, empathy towards the actions of various religions, and higher taxes and more regulations of the have’s versus the have-nots.

There is nothing wrong with these beliefs, of course, but government initiatives and actions do have consequences – some positive, some negative .

Individual freedoms, private entrepreneurship, consumer choices, and market-driven economic growth and prosperity are equally important. So are pride in one’s country, its culture, and its exceptionalism.

I look forward to David Axelrod’s book, particularly his portrait of Obama , what the believes in and what he thinks his hero’s legacy will be.

Replacement Conundrum

When I am dead, you’ll find it hard, says he,

to find another man like me.

What makes you think, as I suppose you do.

I want another man like you?

Eugene Ware (1841-1911) , Kansas newspaper man , in He and She

This verse came to mind as I read New York Times articles on Republican plans to replace ObamaCare and Democratic struggles to retain it. Democrats say Republicans will find it hard to replace ObamaCare, but the public wants something different from the old health care law and only the Republicans can provide it.

I reserve Sunday for reading the New York Times to see what it has to say about ObamaCare.

Generally its editorials favor the health law’s continued existence as is , but in the wake of continuing stories expecting the Supreme Court to rule against federal exchanges, its reporters have begun to express doubts about its survival.

The reporters know Republican lawmakers offer comprehensive alternatives, the Congressional Business office estimates federal and state health exchanges subsidies will cost a trillion dollars over the next ten years, and middle class health consumers are reacting negatively to rising premiums, deductibles, co-payments, and out-of-pocket costs, physician shortages, and narrowed networks.

The articles to which I am referring are:

• Robert Pear, “GOP Lawmakers Propose Alternative to ObamaCare,” February 5.

• Robert Pear, “Health Law Case Poses Conundrum for Republicans, “ February 8.

• Elisabeth Rosenthal, “Insured But Not Covered, “ February 8.

The basic conundrum Republicans face is how not to make the ObamaCare replacement cure no worse than the ObamaCare disease, and the puzzle Democrats confront is how to defend an increasingly unpopular law ( 39% approval and 51% disapproval in latest polls).

A Republican Senator, John Barbasso, MD, of Wyoming, explains,

“We want to help people who have been hurt by the President’s illegal actions (federal exchange subsidies), but we don’t want to help this terrible law.”

His Democratic counterpart, Ron Wyden of Oregon, counters,

“ I find it ironic for Republican Senators to argue that the federal exchange subsidies are illegal and then demand that the administration explain how it plans to repair the damage that will be done if their argument is successful and the Supreme Court rules in their favor. It’s like throwing gasoline on a fire, then indignantly asking the administration for its plan to put out the fire.”

The fundamental problem politicians face is what to do with the 6 million or so people who in good faith have signed up and qualified for federal subsidies.

Should the Court rule in their favor, Republicans will have to come up with a contingency plan allowing consumers to keep their subsidies during a transition period. The GOP will come under pressure to from constituents , hospitals, and insurers to replace the subsidies with something that doesn’t leave people out in the cold hard world of the uninsured.

Which leads to this verse.

Dems will claim ObamaCare is irreplaceable,

For humane reasons it is virtually unerasable.

The GOP will say subsidy costs are inconceivable,

One trillion dollars, that's simply unacheivable.

Is Compulsory ObamaCare "Compassionate" and "Fair"?

Compassion is not weakness and concern for the unfortunate is not socialism.

Hubert Horatio Humphrey (1911-1978), Remark

Fair is faul, and foul is fair.

Shakespeare (1564-1616), Macbeth

In June the Supreme Court will decide whether federal health exchange are legal based on the health law’s text.

It will be a monumental decision. If the Court rules against federal subsidies, ObamaCare followers will cry “Foul!” It will be considered a crime against compassion. Compassion lies at the heart of liberalism (and federal political control). Compassion is a feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune accompanying a strong desire for relieve the pain and remove its cause. Compassion is admirable. It is said to be a moral imperative.

At issue for the Court is not only the legality of the ACA but the authoratative compulsion that drives it. The law compels citizens to have a federally-approved plan and for employers to offer a plan or pay restitution to an all-powerful government.

Is such compulsion fair?

Is it fair for everybody to pay their “fair share,” even if enforcing that “fairness” is “unfair” to the rest of society.

After all, is it “fair” when providing federal subsidies to 7 million people who incomes are 3 times below the poverty line causes plan cancellations, plan switches, and higher premiums and deductibles for the rest of us.

Is it “fair” for 7 million , 2.2% of the population, while 313 million, 97.8%, suffer some degree of economic discomfort?

Is it fair if it discourages small businesses from hiring workers?

Is it “fair” if it restricts freedom of individuals to choose a private plan, not meeting government standards, or no plan at all?

Is if “fair” for government to command and demand an all-for-one, one-for-all, and one-size-fits-all plan?

Is it “fair” to reject any alternative to President Obama’s Utopian vision of an equitable society achieved by redistribution of wealth even if it is against the public will?

Maybe, maybe not.

The latest average of Real Clear Politics< polls show a 39.3% approval of the health care law with a 51.3% disapproval.

What part public approval will play in the Court’s ruling is unknown. Perhaps none. But it is known there is something wrong with the economic and health system. Poverty is at its higher level since World War II, post-recession economic growth is as a sluggish 2.2%, the middle class is shrinking and under duress, and 30 million Americans remain uninsured.

How do we create a “fair” and “compassionate society?

Through government fiat, taxing the rich and middle class, restricting choice, redistributing wealth, economic growth, free-market capitalism, socialism?

High taxation (49% in Europe versus 36% in the U.S) and universal coverage has not worked in most European countries. Economic growth there is either negative or less than 0.5% versus a current 2.6% in the U.S.

Whatever the solution, as Stephen Moore of the WSJ says, “Inarguably, a top priority of U.S. economic policy should be to expand opportunities and raise the earnings of those stuck at the bottom. It’s been said that the measure of a society’s compassion and the effect of economic policy is how well the poor fare in society.” (Stephen Moore, Who’s the Fairest of Them All? Encounter Books, 2012)

Let us hope the Supreme Court helps clarify the alternatives for society.

Same ‘Ol, Same ‘Ol, Except the Price

Imagine you’re a Medicare patient, and you go to your doctor for an ultrasound of your heart one month. Medicare pays your doctor’s office $189, and you pay about 20 percent of that bill as a co-payment.

Then, the next month, your doctor’s practice has been bought by the local hospital. You go to the same building and get the same test from the same doctor, but suddenly the price has shot up to $453, as has your share of the bill.

Margot Sanger-Katz, “When Hospitals Buy Doctors’ Offices, and Patient Fees Soar,” New York Times, February 6, 2014

In the example cited above, the Medicare patient’s fee for an ultrasound goes in one month from $37.80 to $90.60 – a 140% jump.

What’s going on here?

As a Medicare patient, you go to the same building, proceed to the same office, get the same test, receive the same level of service, and the prices goes up nearly 2 ½ times.

What’s going on is something called the “facility fee.” Under Medicare rules, something done in a hospital “facility,” even if that facility is far removed from the hospital grounds, is entitled to a larger fee than in an independent physician’s practice. And the cardiologist is entitled to a larger fee too.

But how could this be? It isn’t fair.

Well, back in 2009, Medicare cut what it paid cardiologists by about one-third for procedures done in the office. But it paid the same cardiologist more if a hospital employed the cardiologist. Medicare simply assumed that hospital care, by definition, costs more than independent care, wherever it was done.

So what did cardiologists do? Logically, they went to work for hospitals. From 2009 to 2014, the number of cardiologists in independent practice fell from 59% to 36%, Another 31% are engaged in merger talks with hospitals. Other specialists are migrating to hospital employment as well.

The Obama administration has calculated it could save Medicare $30 billion if it charged the same for ambulatory hospital doctor-owned cardiologist practices as independent practices. An administration’s budget proposal would essentially end different prices for the same services. Medicare would pay the same for any visit, test or procedure offered by doctors who work in private practice and by those who work in off-campus practices owned by hospitals. Doctors who work in the hospital building could still be paid the higher hospital rate. But the free-standing practice that suddenly changes hands would not continue to be paid more.

Consolidation, in federal logic, is OK for the same procedure if it is done within the hospital, but not if it occurs outside hospital walls.

Will this federal proposal save money? I doubt it. I can easily envision hospitals building tall buildings to accommodate new and old physician employees. I can also see this switch might cost more than the present arrangement.

It’s a trade-off, but it sounds logical from the top-down. There will be contrary views, of course, from the bottom-up from hospitals and cardiologists. But as Tweedle-dee said, “Contrawise, it is was so, it might be; and if it were so, it would be; But if it isn’t, it ain’t. That’s logic. (Lewis Carroll, Through the Looking Glass.)

ACA News of Day

GOP outlines plan for ObamaCare replacement. The new plan would, among other things, offer some subsidies for those who could not afford coverage, delete individual and employer mandates, retain coverage for pre-existing illnesses, end requirement for 10 essential benefits for all health plans, allow shopping for health plans across state lines, offer universal tax credits, and transform Medicaid into a system with block grants for states. Meanwhile, the Obama administration says nearly 10 million are expected to enroll in federal and state exchanges by end of 2nd enrollment period on February 15 (7.5 million in federal exchanges and 2.5 million in state exchanges.) The numbers do not include those who have paid premiums. The Congressional Business Office estimates that, by end of 2015, 13 million will be enrolled in exchanges, 4% of the U.S. population. The HHS chief says an adverse Supreme Court ruling on federal exchanges would be “devastating.”

There Is No Such Thing as a Free Launch

It is far easier to introduce a government program than to get rid of it. There is almost always a good reason for introducing it, but the program will not go out of existence if the initial need for it passes. The road to Leviathan is paved with good intentions.

Milton Friedman, in Two Lucky People, Milton and Rose S. Friedman Memoirs, University of Chicago Press, 1998

I am pleased to announce the second of my tetralogy of books on the ObamaCare story, There Is No Such Thing As A Free Launch, will be available later this month. This book, like the first book, The Road to Hell Is Paved with Good Intentions, is a Kindle E-book.

The title of this second book is a play on words of Milton Friedman’s oft-quoted line, “There is no such thing as a free lunch.” Friedman (1912-2006), a conservative economist, won the Nobel-prize for economic science in 1976. He wrote two classic books with the help of his wife, Rose, also an economist, Free to Choose (1980) and Capitalism and Freedom (1962).

The Friedmans believed capitalism, with the freedom of individuals to choose, propelled by economic growth, was more efficient and humane than Keynesianism , government stimuli and control with economic stagnation.

The contrast between these two belief systems is what the conflict between Republicans and ObamaCare supporters are all about. Republicans believe private citizens and the private sector should be free to choose their doctors and health plans and to set health care fees while the Obama administration insists government should be in the driver’s seat in designing the system, dictating the rules of engagement between doctors and patients, and controlling the fees.

Higher taxes with redistribution of incomes and benefits, Obama believes, are more “fair” and are necessary to increase federal revenues and expand the safety net. The Friedmans thought a robust free economy was more reliable way to increase revenues, grow the economy, and shrink the need for a safety net.

This second book does not choose one system of care over another.

It seeks to explain why ObamaCare’s implementation and healthcare.gov rollout has been so rough.

It documents the chronology of daily events that followed the healthcare.gov launch and the first six months of those events, from October 1, 2013, to March 31, 2014.

It sets forth difficulties of an activist government managing massive change of a complex health care system making up 1/6 of the U.S. economy.

It comments on Americans’ resistance to fundamental changes that upsets traditional relationships between government, employers, and caregivers and that impacts every American.

It dwells on the politics and clashes between conservatives, liberals, and ideologues of other stripes and their different world views.

It dives into the nuts and bolts, pratfalls, pitfalls, and bear traps of top-down government command-and-control versus bottom-up entrepreneurship and individual freedoms with choices.

It reveals broken promises and unintended consequences.

It outlines the restructuring of American health care.

It speculates about the future.

We do not, of course, know the future. We know that healthcare.gov so far has cost $2.1 billion and may run $40 billion or more in annual subsidies; that, as of yesterday, three Senate Republicans outlined an alternative to ObamaCare; that Congress this month again voted to repeal ObamaCare; that President Obama has vowed to veto any repeal; and that in June, the Supreme Court will rule if federal health exchanges are legal under the language of the health law. Speculating beyond these knowns into the unknowns is beyond anybody's depth perception.

Point of No Return

At what point does ObamaCare reach the point of no return – when there is no turning back, when the health law must go forward, when it must be repealed or replaced?

Those are the questions that are boggling political minds.

Will the point be? Are we there yet?

• Will it be when ObamaCare health exchange enrollment reaches 10 million? We will be nearly there by February 15, when the 2nd enrollment period ends. People will ask, how in the name of humanity, can we divest 10 million previously uninsured of their subsidies when subsidies are their only path to health insurance?

• Will it be when hospitals and health plans, who have bet billions of dollars and their financial futures on the success of ObamaCare and the health exchanges, rise up to defend ObamaCare and unleash their lobbyists in the halls of Congress?

• Will it be when the mainstream press, in spasms of righteous indignation, blasts the Republicans and all who would shred the government social welfare safety net?

• Will it be when American public opinion turns against taking back subsidies the government has promised and given, or contrarily, will be when anger erupts among the subsidized over the unexpected penalties they must pay on April 15?

• Will it be when the middle class and the young revolt against the redistribution policies of the Obama adminstiration?

• Will it be when the Supreme Court rules in late June that federal health exchanges are illegal, and by so doing, pull the rug out under individual and employer mandates, the two main pillars of ObamaCare and massively disrupt the entire insurance system?


• Will it be when President Obama vetoes GOP ObamaCare repeal, and the GOP has no politically acceptable alternative to cover the unininsured?

• Will it be when the GOP repeals ObamaCare through the reconciliation process, the same process by which the Democrats passed the Affordable Care Act in the first place?

At what point is the point beyond which we must continue the present course ob OBamaCare when the odds of turning back are politically impossible, financially insurmountable, or overly dangerous for those already subsidized?

Slippery Subject – Health Care Quality

No one means all he says, and yet very few say all they mean, for words are slippery.

Henry Adams (1818-1918), The Education of Henry Adams

Congress will soon vote to repeal ObamaCare, President Obama will veto the repeal, and both will claim their position is based on quality.

Congress will define quality as individual freedom and choice of doctors and health plans. President Obama will define quality as affordable health care for all. Congress will say loss of quality comes from government control of peoples’ lives. The Obama administration will loss of quality comes from high costs. Congress will insist that people should be allowed to choose what health plans suit them best. obama will say only only health plans that comply with our mandates are best.

Obama supporters will maintain only health care experts know what is best.

Health care quality is a slippery subject, embedded irrevocably in the minds and philosophies of the beholders.

One side thinks health care quality is a subjective Art and depends on managing expectations and pleasing patients through individual services and lower costs by discarding bureaucratic impediments. Quality of health is not always measurable, and is often beyond hospital and physician control once patients leave their premises.

The other side believes health care quality is an objective Science and is best managed by use of data to better patient outcomes and control physicians’ economic behavior. Quality is always, in one way or another, measurable statistically.

One side says trust your individual instincts as to what is best for you and trust what you and your doctor and his or her organization decides is best for you. Quality is about trust in individual relationships. Quality is about trusting your doctor to do the right thing. Quality is private confidential matter, not a group effort.

The other side says trust your government and large organizations with population data indicating what works best on average for masses of patients. Quality is about the quantity of data that can be brought to bear. Quality is about the value of the services provided. Quality is about suppressing those services that do not better outcomes. Quality is about data will lower costs but better care.

To patients quality may be something entirely different. It about how the doctor and his/her staff make you feel, how they greet you, how they make you feel, how they explain things to you, how closely they listen to you, how they follow up to see if you were satisfied with your care, whether they meet your expectations.

Quality is slippery. It is a debatable trillion dollar question (“ Quality Is a Trillion Dollar Question” Washington Post, January 30, 2014; “Debate Heightens over Measuring Health-Care Quality; Puts Pressure on Hospitals and Doctors,” WSJ, January 30, 2014).

I close with this terse verse

Government may think it knoweth

What is best for most of us.

But the market often bestoweth,

What is good for the rest of us.

"Adverse Tiering" and ObamaCare Leveling

One of a series of rows or ranks rising one behind or above another.

Definition, Tier

Welcome to the world of two-tier and multi-tier medicine. Two tier medicine is generally thought of as one class of people receiving basic, necessary government health benefits, often rationed and for which they must wait, while the other class in the private sector, who can afford to pay, receives faster better care.

Now we have another tier – “adverse tiering.” Harvard researchers have come up with the term – to describe the practice of insurers to place high-price drugs in the upper tier of costs to discourage people with chronic disease from enrolling in plans so the insurers won’t lose money (Douglas Jacobs, and Benjamin Sommers, “Using Drugs to Discriminate – Adverse Selection in the Insurance Marketplace,” New England Journal of Medicine, January 29, 2014)

“Adverse tiering” , the authors assert, drives insurers to discriminate against those with chronic diseases taking expensive drugs – HIV, mental illness, cancer, diabetes, rheumatoid arthritis, heart disease -- because the insurers fear “adverse tiering” will prevent “adverse selection” – the phenomenon wherein the insurer is confronted with the probability of loss due to risks not factored in at the time of sale.

The Harvard researchers say “adverse tiering” defeats the ACA’s main purpose – to end discrimination on the basis of pre-existing conditions. The ACA mandates that insurers insure all comers, and in combination with premium subsidies and Medicaid expansion, the ACA levels the cost playing field, and in the process, cover an estimated 10 million uninsured people. The authors argue the ACA prevents premium discrimination on the basis of health status and achieves a more equitable health care system.

This might be true in a perfect social welfare world but the reality is we can’t afford the social welfare programs we have. ObamaCare creates a host of other tiers – higher tier payments for the young, the unsubsidized, the middle class, for those who do not want health insurance, and for many of those who must pay for comprehensive essential one-size-fits-all government mandated benefits for all.

To confuse matters, there are three cost tiers within government – Medicare, Medicaid, and health exchange plans - paying 40% to 60% less than private plans. It could be argued Medicare itself has three tiers – regular Medicare, Medicare Advantage, and Medicare supplements, And there are, course, tiers within tiers in health exchange plans – bronze, silver, gold, and platinum, with different tiers for different plans in different states.

All these tiers , in one way or another , are evidence of discrimination based on price and service. To discriminate has another meaning, to select on the basis of choice and value and what is important to you. There will always be different tiers for different folks. That is part of the human condition

Successful Health Care Corporations

Nothing succeeds like success.

Alexandre Dumas (1824-1895)

Successful health care corporations of the 21st century will include:

One, regional hospital-based integrated organizations offering a panoply of services.

Two, physician-led chains of walk-in clinics offering cash and 3rd party covered services.

Three, ambulatory surgical clinics offering a narrow range of minimally invasive repetitive performed procedures.

Four, specialized hospitals covering specific diseases or field of disease, e.g. cancer, heart disease, pulmonary disorders.

Five, retail clinics embedded in large retail outlets offering nurse-practitioner services for minor or chronic conditions.

Six, large regional or national corporations controlling the full spectrum of services - health plans, hospitals, and physicians.

Seven, chains of regional or national cash-only, retainer and non-retainer concierge practices offering bundled services over a full-range of primary care services.

Eight, large regional/national physician groups with full-range of diagnostic, surgical, and palliative services.

Nine, centers specializing in diagnosis and treatment of rare diseases.

These various corporations will have these common characteristics.

One, professional management by health professionals emphasizing perpetuity and growth.

Two, social responsibility for content, standards, quality, performance, and impact of knowledge.

Three, adherence but not dominance by federal regulations.

Four, transparency with bundled or capitated, and value-based services with prices known in advance and back-up insurance.

Five, internet-based marketing and management by data-based protocols and algorithms with reliance on fast, cheap, and universally available information.

Six, social awareness of political trends and social culture with shaping of those trands and culture.

Seven, the ability to organize physicians and other health professionals into teams to gain access to capital, to deal with bureaucracies, to organize complex technologies, to achieve productivity, and advance knowledge and cure of disease.

Eight, as costs shift to consumers, an increasing and systematic emphasis on health education and prevention to lower costs.

ObamaCare’s Special Set of Problems at Tax Time

Many people awarded insurance subsidies for 2014 did not realize that the amount would be reviewed and recalculated at tax time in 2015.Consumers are sure to have questions, but cannot expect much help from the tax agency, where officials said customer service had been curtailed because of budget cuts.

Robert Pear, “White House Seeks to Limit Health Care Tax Problems,” New York Times, January 31, 2014

At tax time, April 15, 2015.the White House is going to have a big problem – how to quell anger of 6.5 million taxpayers who received subsidies through health exchanges in 2014 and who learn they owe more to the government.

April 15 will pose a special set of problem for America’s liberals. In the words of Ross Douthat of The Times, the problem will be " liberalism’s ongoing inability to raise the taxes required to pay for the welfare state we already have.” (“Out Loud, Proud Left,: NYT, February 1, 2014).

Nobody likes paying taxes, especially when,

• the taxes are taxes they didn’t expect;

• they are part were part of a group who can’t afford to pay more, which is why received subsidies in the first place;

• they learn they must report what happened to them month to month rather than yearly;

• they expected subsidies to pay for health care and instead received penalties, often in the thousands and dollars;

• they cannot get answers from the IRS;

• half of their phone calls to the IRS are not returned;

• they have to wait 30 minutes or more when the calls are returned;

• they have to fill out IRS form 8962, which consists of 12 rows with six columns containing a total of 72 boxes to check.

• they may qualify for 30 exemptions depending on in which state the live but requiring evidence to see if they qualify;

• they must know which of 5 health plans categories, such as gold, silver and bronze, based on how generous the coverage is, but to do so, they must calculate their tax credits, the cost of their own policies,he cost of a benchmark plan, the second-lowest-cost silver plan, the premium for the lowest-cost bronze plan in the area in 2014.

If this all sounds bewildering, it is because it is. And it is likely to whip up anger among those who thought they were among the special few who profited from government largesse. It comes at a price. This price, and the level of anger, may be even higher in June, if the Supreme Court rules it was illegal for them to receive subsidies. Then we will learn the truth of Oliver Wendell Holmes, Jr’s aphorism: “Taxes are what we pay for civilized society,”even though it may seem uncivil at times.