ObamaCare’s Golden Sickness Rule

Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of sickness.

Susan Sontag (1933-2004), Illness as Metaphor

ObamaCare is growing sicker because of one of its golden rules; One shalt not exclude those with pre-existing conditions from insurance.  

This rule is compassionate, but it has financial consequences

The most common pre-existing conditions are hypertension, coronary artery disease, and diabetes, which together  eventually account for many, if not most deaths from myocardial infarction, heart failiure, stroke, and kidney failure

A Blue Cross report indicates 25% of those signing up for health exchanges are more likely to have hypertension, 32% are more likely to have coronary disease,  94% are more likely to have diabetes,  and a whopping 72% are older than 34 when those with these pre-existing conditions are more likely to develop chronic  diseases with high morbidities and co-morbidities.

The golden rule protecting those with pre-existing conditions  has turned into a demographic time bomb – leading to high premiums and deductibles for the well and to billions of dollars in bailouts for insurers.

For the government  there is no easy choice – either one  takes a deep breath,     coughs up the money, deepens the federal deficit,  bails out insurers,  or changes the rule.   It’s a cruel choice,  and there is no middle road. 

We live in the kingdom of  reality – and in the kingdom of the middle class of the sick and the well,  there is resistance to ObamaCare’s golden rule because it costs them dearly.    As George Bernard Shaw said in Maxims of Revolutionists,  “ the golden  rule is that there are no golden rules.”

Rules are made to be broken,  and this particular rule might be broken if ObamaCare is repealed .

 

On Sixth Birthday,  ObamaCare’s Snuffed Candles

Out, out, brief candle!

Shakespeare,  MacBeth

On its sixth birthday,  these ObamaCare candles were snuffed out because of losses.

• $1.2 billion in startup loans for ObamaCare's 12 (out of 23) failed insurance co-ops.

• $1.5 billion in failed or unrealized state-run health exchanges — and not one of the remaining 14 is fully functional, according to a government audit.

• An estimated $45 billion for the 165 million hours that businesses and individuals spent trying to comply with ObamaCare's 106 new regulations.

• $750 million in public subsidies to more than 500,000 people who weren't eligible for coverage.

• $3.5 billion diverted from the Treasury to insurance companies to help cover their losses.

For all thegovenment's happy talk about gains in the public's insurance coverage (except, of course, for the unfortunate folks who signed up with one of the government's failed insurance co-ops), the reality is a burgeoning, unsustainable government bureaucracy that is on pace to cost considerably more.   As with most government ventures,  it's something gained, something lost.

Oh, well, it’s only $52 nbillion of taxpayer money – and the time and effort of businesses and individuals who supported or sought to comply with the health law.

New Normal – Slow Economic Growth and Medical Innovations

New Normal is a term in business and economics that refers to financial conditions following the financial crisis of 2007-2008 and the aftermath of the 2oo8-2012 global recession. The term has since been used in a variety of other contexts to imply something what was previously abnormal has become commonplace.

Definition of the New Normal

A prominent feature of President Obama’s administration has been slow economic growth.  Growth has averaged  2.0% to 2.5% over the last 6 years.   This is roughly half that of previous recession recoveries, and is the slowest since World War II. 

Critics say this stagnant growth stems from the administration economic policies.   They cite anti- business policies (high corporate taxes, onerous regulations, and the employer health mandate), anti- innovation policies (high startup costs, medical device taxes, and bureaucratic impediments),   and high taxes on the rich  and entrepreneurs, and regulations that discourage skilled foreign innovators from entering the U.S.   

Physicians say federal regulations increase costs of doing business by demanding doctors gather quality data on costly electronic health record systems,    by discouraging new practice designs, by creating byzantine coding systems, by insisting upon time consuming credentialing,   by developing unworkable payment systems,   and by discouraging tort reform.

Progressives insist many of these problems would go away if we only had a single-payer system covering all citizens and treating them equally.

Economist Robert Gordon, in his new book The Rise and Fall of American Growth (Princeton University Press),  believes  slow growth is  inevitable because of the lack of   major  new society-wide economic  inventions and "headwinds," i.e. social and cultural forces causing economic slowdowns.

Gordon  notes from 1750- 1830, we had sweeping  transforming  things  like steam engines, cotton gins, and railroads.   From 1830 to 1900 we had the telegraph, electricity, internal combustion engines,   and running water.  From 1900 to 1950, we added airplanes, concrete road systems, and added and refined communications, developed industrial machines, and introduced corporations.   In the 1940s we introduced sulfonamides, penicillin, blood transfusions, and modern anesthesia and surgical techniques. From 1950 to 1970 we added air conditioning,   house hold appliances, and the coast-to-coast highway system.   Starting about 1960 we developed computers and the Internet which peaked in the late 1990s.     Today we have cell phones, big data, and smaller and faster mobile devices, and the ubiquitous social media (Face book, Twitter, Integra, Tube),   and cloud computing.

But unlike previous inventions, Gordon  argues these computer-based technologies will not significantly increase human productivity nor speed up economic growth.

Overall,  because of such economic “headwinds” as an aging population,  rising inequality  between the top 1% and the rest of us,  dropping wages become of foreign competition,  cost inflation of higher education, poor secondary schools,  environmental regulations, and government intervention into consumer and business affairs,   Gordon predicts economic growth will average only 1.4% from 2007 to 2017.   In other words,  1.4% annual growth will be the new normal.

Gordon is not particularly impressed with health care with the history of health care or its contribution to economic growth,  to wit:

”By the 1920s, we had pretty much gotten to a professional stage of medicine where people went to medical school. Medical schools were quack organizations in the late 19th century. And a man named Flexner wrote a famous report which damned the education at existing medical schools and completely reformed the education of doctors and hospitals.”

“And much of the improvement in health, remember, was the curing of infectious diseases. It was things like cleaning up the water and getting rid of diphtheria and other kinds of infectious diseases back in the 19th century. That was the key to curing infant mortality, was the conquest of infectious diseases.”

“Medical invention I would say reached its peak in the 1940s with the invention of penicillin and antibiotics. By 1970, we had identified smoking as a source of both cancer and heart disease; we had identified chemotherapy and radiation as cures for cancer. So, I would say that the core period for reaching the level of modern medicine was between about 1940 and 1980. We've been making very slow progress since then.”

Gordon does not think health reform or innovation will contribute to economic growth.

“And so, I have a fairly progressive middle -- I would call it middle left-wing view of economic policy. I differ with Senator Sanders on several issues, while not overtly supporting Secretary Clinton. In particular, I think it's simply too late for the United States to adopt a single-payer medical care system. We've had decades of Medicare incentives to make our whole medical care system more expensive. We pay 18 percent of GDP on our medical care system. And for all that money, we get life expectancy that's about at the bottom of the top developed countries.”

“And so, I think it's just simply too late. There's no way you can destroy the entire private health insurance industry or no way you can take over-bloated health providers in hospitals and group practices around the country and suddenly impose on them the kind of rules that in Canada and the U.K. keep medical care costs so much more moderate.”

Given current ObamaCare reforms, I agree with Doctor Gordon.  Government reform will stimulate economic growth.  It may even slow it down.  The major trends uninitiated by the administration: accountable care organizations, consolidation at every level of the system, bundled payments between hospitals and physicians,    pay for performance based on evidence-based outcomes,  mandatory electronic records,  employer and individual mandates will not promote growth.

But I believe the electronic revolution and other factors – decentralization of the system, remote monitoring through new devices, telemedicine and virtual visits, and patient engagement. will make health care more efficient. 

 I believe information technologies will speed diagnosis,  will improve health and wellness status ,   and better prognosis and human productivity.  It is currently possible to establish a diagnosis by having a patient enter symptoms, complaints, and history  to create a computer algorithm giving the right  diagnosis 90% of the time; to use a drop of the patient’s blood, coupled with vital signs and a stress test using expelled breath gases  to establish cardiac and pulmonary status, and  use remote and wearable monitoring devices  to define the state of the patient’s fitness and wellness compared to peers,  and to deploy  historical information and  DNA information from blood or saliva to predict and improve  long term prognosis -  and to do all of these things from a patient’s home or other locations outside the usual medical setting.   Many other medical problems – dermatological, ophthamological, surgical, and orthopedic conditions will require examination and evaluation by physicians.

Will these medical innovations improve overall economic growth?  Maybe at the margins.     Other factors besides health care are involved as Gordon indicates – narrowing  of income differences,  better  and less expensive education,  lower taxes,  fewer regulations,  more market-based enterprise.  On the health care front,  repealing ObamaCare,  allowing purchase of health care across state lines,  allowing deduction of insurance from taxes, expanding HSAs,  requiring transparency of  medical goods and services,  state block grants for Medicaid,  and freer markets for pharmaceutical purchases may be required.

Professor Gordon may be right that the new normal  is slower economic growth,  and that  the  Internet and its spin-offs will not significantly  speed economic growth.   But it may be wrong too, and the techno-optimists among us may be right.  Maybe ordinary citizens, armed with information and riding the electronic wave, will help America return to economic growth.

Political Niceties

Mike Hukabee, the erstwhile GOP presidential candidate, said words to this effect of President Obama,” He thinks if you’re nice to your enemies,  they’ll be nice to you. What naiveté! ”

This statement led me to look up quotes on “nice” and how these quotes might apply to politics.

·          “Nice Guys Finish Last.”  Leo Durocher (1905-1974), title of his book.   This could also be the title of Donald Trump’s next book.

·         “Be nice to people on your way up because you’ll meet them on your way down. “ Wilson Mizener (1876-1933).  Ted Cruz should take this to heart. 

·         “Into a stew, a nice little, white little missionary stew.”  T.S. Eliot (1988-1965).  As Marco Rubio can attest, one minute you’re on top, and then you’re in the missionary stew.

 

·         “A nice man with nasty ideas.” Jonathan Swift (1667-1745).  This could apply to President Obama and his nasty remarks about Republicans, or to Donald Trump , who insists he’s a nice guy.

·         “Nice work if you can get it and you can get it if you try.”Ira Gershwin (1896-1983).  Unfortunately, trying isn’t enough to get it if you’re a Presidential candidate.  Ask those 16 Republicans who tried and failed.

·         “What are little girls made of?  Sugar and spice and everything nice.” Nursery rhyme.      But what if little girls turn out to be big girls made of bitters and ice, and everything  e-vice?

Surprise! Surprise?  ObamaCare Costs Rise as 22 Million More Enroll in

Medicaid

Health exchanges and Medicaid are costing  more than anticipated because those enrolling in both  programs are older and sicker than projected.  This influx of these older and sicker folk rather than the young and healthy have caused health plans,  including UnitedHealth, to announce they may withdraw from  exchanges in 2017,  and some states are not participating in the new Medicaid programs.   No  matter what occurs,  all predict  government will be forced to bail out money-losing plans, which will  add to taxpayer burdens and the federal deficit.  

None of this comes as a surprise.  But what does surprise is that the  22 million enrolled in Medicaid are nearly twice the number  joining health exchanges.    

This wave of new Medicaid enrollees will drive up costs to the federal  government by $110 billion  in 2016, and by $1.4 trillion by 2016,  or $136 billion over original estimates.  
Democrats are rejoicing.   This huge jump in Medicaid enrollment,  they  maintain,  shows the law is righting the wrongs of social injustice.     But GOP governors are balking at the costs to their states.   Democrats retort by  observing: “What’s $136 billion among friends?   Just send the bill to taxpayers and  those working for a living.”

That Medicaid raises costs should not surprise.

CMS programs historically mount to the skies.

Critics complain this adds  to the budget crunch.

Recipients explain there is such a thing as a free lunch.

Not to worry,  social justice is worth any price.

Making the Unaffordable Affordable and Affordable Unaffordable

This week marks the sixth anniversary of the Patient Protection and Affordable Care Act (ACA). But it’s hardly anything to celebrate. The ACA was intended to make health coverage affordable using an age-old strategy referred to as OPM (other peoples’ money). For instance, ACA regulations require insurers to accept all applicants — including unprofitable ones — at rates not adjusted for their health risk. Premiums can vary somewhat based on age, but not health status. A plethora of new taxes (mostly on medical care and health insurance) are supposed to somehow make coverage more affordable. Other funding mechanisms include draconian cuts to Medicare and higher deficits to expand Medicaid.

Devon Herrick, PhD, Senior Health Care Economist,  National Center for Policy Analysis, “The Unaffordable Care Act Turns 6, “ March 23, 2016, The Health Care Blog

What Doctor Herrick went on to say was that when you make health insurance affordable for  those who previously found health insurance unaffordable-  the 12 million who signed up for the ACA health exchanges and the 22 million new Medicaid enrollees, most of whom are sicker than the general run of the population, 220 million or so, you often make previously affordable health insurance unaffordable  for  the general population, i.e. the health young and middleclass, because they must spend  their taxpayer money  on higher premiums and deductibles  to make health care insurance affordable for those who previously found that insurance unaffordable,  i.e., they no longer find  affordable  the unaffordable higher premiums and unaffordable deductibles for routine care.

Enough word play.    According to President Obama,  in a recent statement in Argentina to a group of students,   this redistribution of income makes no difference and depends on what you think is necessary to advance what kind of social goal you are trying to achieve and what kind of society you want to live in.  It depends on whether you want social justice with a slow growth socialist economy or if you want social inequities with a faster growing economy.  It depends on what is practical and what works.

It depends, in short on your experience.

As poet Ogden Nash said.

For sterile wearience and drearience,

Depend, my boy, on experience.

Here is the President’s statement to students.

"So often in the past there has been a division between left and right, between capitalists and communists or socialists, and especially in the Americas, that’s been a big debate. Oh, you know, you're a capitalist Yankee dog, and oh, you know, you're some crazy communist that's going to take away everybody's property."

"Those are interesting intellectual arguments, but I think for your generation, you should be practical and just choose from what works. You don’t have to worry about whether it really fits into socialist theory or capitalist theory. You should just decide what works," he added. "And I said this to President Castro in Cuba."

“I guess to make a broader point, so often in the past there's been a sharp division between left and right, between capitalist and communist or socialist. And especially in the Americas, that's been a big debate, right? Oh, you know, you're a capitalist Yankee dog, and oh, you know, you're some crazy communist that's going to take away everybody's property. And I mean, those are interesting intellectual arguments, but I think for your generation, you should be practical and just choose from what works. You don't have to worry about whether it neatly fits into socialist theory or capitalist theory -- you should just decide what works.”

“And I said this to President Castro in Cuba. I said, look, you've made great progress in educating young people. Every child in Cuba gets a basic education -- that's a huge improvement from where it was. Medical care -- the life expectancy of Cubans is equivalent to the United States, despite it being a very poor country, because they have access to health care. That's a huge achievement. They should be congratulated. But you drive around Havana and you say this economy is not working. It looks like it did in the 1950s. And so you have to be practical in asking yourself how can you achieve the goals of equality and inclusion, but also recognize that the market system produces a lot of wealth and goods and services. And it also gives individuals freedom because they have initiative.”

“And so you don't have to be rigid in saying it’s either this or that, you can say -- depending on the problem you're trying to solve, depending on the social issues that you're trying to address what works. And I think that what you’ll find is that the most successful societies, the most successful economies are ones that are rooted in a market-based system, but also recognize that a market does not work by itself. It has to have a social and moral and ethical and community basis, and there has to be inclusion. Otherwise it’s not stable. “

“And it’s up to you -- whether you're in business or in academia or the nonprofit sector, whatever you're doing -- to create new forms that are adapted to the new conditions that we live in today.”

Diabetes – The 800 Pound Guerilla Among Diseases

It’s no contest.  Among diseases, diabetes is the 800 pound guerilla.    

 In the U.S., 86 million are at risk for diabetes.  Medicare spends 1 of 3 dollars on diabetes related conditions.   One of 3 adults has prediabetes.  And diabetes is the cause of 2 deaths every 5 minutes in American. Directly or indirectly,  diabetes is the leading cause of deaths heart disease, stroke, obesity,  blindness, kidney failure, gangrene with amputations, neuropathies,  and diseases of large and small blood vessels.

Because of these stark statistics,  Medicare is spending $11.8 million dollars for grants to launch counseling programs for prediabetics in YMCA across the country. The programs will feature a lifestyle  coach who will advise patients on more physical activity, better diets,  weight loss as preventive measures.  Meetings will be held once a month  to see if patients are adhering to preventive measures.    The hope is that an ounce of prevention will be worth a pound (with prediabetice many pounds) of cure.

Diabetes is a sneaky disease. People go for years without knowing they have disease or are at risk for having it.  Its most common precursor is obesity, which in now rampant among Americans.  More than one-third (35.7 percent) of adults are considered to be obese. More than 1 in 20 (6.3 percent) have extreme obesity. Almost 3 in 4 men (74 percent) are considered to be overweight or obese. The prevalence of obesity is similar for both men and women (about 36 percent).

Diabetes  is guerilla disease.   It  can strike any organ or any limb containing  small  and large blood vessels – arterioles, capillaries,  small and larger arteries – which is everywhere in the body.   It  carries with it other harmful metabolic substances – such high blood sugars,   out-0f-control blood fats.   It is often insidious,  leading to slow blindness, or kidney failure,  or subtle neuropathies with pain,  tingling,  or loss of sensation.   But it can be dramatic as well,  causing heart attacks, strokes,  seizures from hypoglycemia,  or coma from excessive blood sugar levels.

This is not the first time I have written about diabetes as a guerilla disease.  

What follows is a blog I wrote in 2013.

JUNE 8, 2013

Diabetes – A Disease of Overeating

We are digging our graves with our own teeth.

Thomas Moffet (1820-1908), Irish Poet and Educator

It today’s world, many more people are dying from overeating than from starvation.

Jesper Hioland, Senior Vice-President  Novo Nordisk, world’s largest maker of diabetic drugs

Prosperity has its price.  In the realm of disease, that price is diabetes.   The price of diabetes -  blindness, gangrene, amputations, kidney failure, neuropathy,  diseases of large and small arteries, and premature death.   Among the world’s peoples, 371 million have diabetes.  Many of these people are in poor and developing countries where people are adopting urban lifestyles and consuming western foods.

Diabetes  is rampant in American Indians,  immigrants to America,  Pacific Islanders, Arab countries,  and in Vietman.  Today’s New York Times features an article “Prosperity in Vietnam Carries a Price; Diabetes.” 

The price of diabetes  in Vietnam is an epidemic of amputation  of gangrenous limbs.  Diabetes is a disease related to genetic predisposition, rich  diets,  lack of exercise, and obesity.   In Vietnam,  diabetes occurs in both the fat and the thin, and afflicts especially those who move from the country into urban areas.  In the U.S, diabetes in more prevalent in obese,  sedentary individuals.

Diagnosing and treating diabetes is like guerilla warfare.  Diabetic guerillas can strike at any time in unexpected locations in almost any organ in the body, often with little warning.  You can be born with it, but more often it comes later in the life in the form of type 2 diabetes.   In the morbidly obese (those 100 pounds or more overweight),  you can treat it surgically by shrinking  or partially bypassing the stomach.

Controlling diabetes is medical guerilla warfare.. You have to approach it from different directions – high tech and high touch, prevention and maintenance. Many high tech approaches, which are essential disruptive innovations – insulin, inhaled insulin, insulin-pumps, monitoring devices, other drugs, and transplants – have been tried and work for many but often fail to stem the tide of complications.

But   For most doctors, controlling diabetes demands attention to preventive details and instructing patients ( To get the attention of his patients, Stanley Feld, MD, an endocrinologist in Dallas, had his diabetic patients sign a contract saying they would either abide by his rules or not be his patients. He also issued patients T-shirts bearing the words: “In Control!”).
For doctors, prevention entails,

•Precise blood glucose control.

•Inspecting the bottom of patient’s feet – something many obese diabetics can’t do for themselves.

•Assessing loss of sensation in feet and lower limbs.

•Monitoring blood pressure.

•Checking blood lipids, blood creatinine  and creatinine  clearance, and urinary albumin.

•Protecting the kidney with new drugs.

•Making sure patients take oral diabetic agents and insulin correctly.

•Instructing patients on proper diets and having a nutritionist or dietician re-enforce their message.

•Encouraging patients to lose weight and exercise (obesity is considered the main  precursor to most adult diabetes).

•Managing complications – blindness (the leading cause of adult blindness), heart disease and stroke (causes 65% of deaths among diabetes), kidney disease (accounts for 44% of case of kidney failure), and amputation (more than 60% of lower-limb amputations occur in diabetics).

Among diabetics and their physician friends, there are few miracles, because old habits are hard to break, and treatment regimens are hard to follow. But there are disruptive innovations on the horizon. Until these disruptions mature and take hold, the physicians’ best bet for controlling the vascular catastrophes associated with diabetes is strict adherence to best practice guidelines and rapt attention to clinical details.

Diabetes is reaching epidemic levels in many countries  due to overeating and life style changes relating to urbanization.

ObamaCare’s Sixth Birthday – Six of One, Half-Dozen of the Other

Yesterday, March 23, 2016, marked ObamaCare’s sixth birthday.   It passed without widespread celebration or condemnation.

The Supreme Court is taking up the case of the ObamaCare contraceptive mandate  and its right to impose it  on the Little Sisters of the Poor.

The administration argues ObamaCare policies must be seamless, standardized, and homogeneous, covering all of the people all of the time.    You cannot, in other words, make exceptions to mandates for any particular group or government policies will become unworkable.  Therefore, if religious organizations choose not to provide contraceptives  and related services, government must make insurers must provide these services,  for “free,” of course, even if the services are of modest cost to women.

Chief Justice John Roberts disagrees.   He says government has “hijacked “ the Little Sisters of the Poor’s health plans.   Liberal Justice Stephen  Breyer counters federal mandates must be applied to all.  It is “the price of being a member of society.” And so the individual versus collective dialogue  goes.  The administrations has exempted churches and other houses of worship form the contraceptive mandate,  why not include religious  affiliated colleges, charities, and other groups, like the Little Sisters of the Poor,  who are dedicated to taking care of poor priests and nuns.  Freedom of religion, after all, is one of the cornerstones of the Constitution and American Democracy.  Yes, but  there are the collective rights of all members of society to be considered.

It comes down to the question of whether ObamaCare’s mandates – individual,  employer, and religious – are worth sacrifice of individual and group rights,   or whether universal coverage is a right, part and parcel of a seamless society.

Mandates have consequences.  Some good , 12.7 million uninsured become insured, coverage of those with pre-existing coverage,  children,  those below poverty line,  and young adults under their parents’ plans.   Some bad – an average increase of 15% in premiums and an 8% spike in deductibles  in health exchange plans,  narrowing of choice of doctors,  huge losses for insurers, widespread physician shortages.

It’s not just six of one  and half-dozen of the other.  It’s  individual choice versus government control.    It’s managing the balance of  government power versus  collective and individual rights.  It’s deciding what a “free society” is all about.

 

 

Political Correctness and Political Incorrectness in Wake of  Brussels Terrorists Attacks

Political Correctness is telling people what you think they want to hear in an ideal world.  Political incorrectness is telling people what they are reluctant to believe in the real world.

The terrorist attacks in Brussels highlight the differences between political correctness and incorrectness.

One 

·         It is politically correct to say ISIS poses no existential threat to the U.S. and its isolated attacks can be handled legally.

·         It is politically incorrect to say ISIS has declared war on Western civilization, threatens its very existence, and must be destroyed.

Two

·         It is politically correct to say that restricting Syrian immigration into the U.S. is a war against all religions and reflects bigoted racial intolerance. 

·         It is politically incorrect to call for a pause in this immigration because the immigrants may harbor terrorists.

Three

·         It is politically correct to refrain from calling terrorists jihadist terrorists for fear of being condemned as enemies of all Muslims. 

·          It is politically incorrect to call a spade a spade, namely  that most terrorists to date have been Muslim  terrorist extremists.

Fou

·         It is politically correct to call the building of a wall as racially intolerant  and instead to assert we should be building bridges.   

·         It is politically incorrect to say a wall would act as a barrier to  illegal immigrations, would support the rule of law,  and justify the existence of the U.S. as a nation with borders.

Five

·         It is politically correct to say illegal immigration is an act of desperation and love of family and that would ought to support and fund these immigrants in sickness, health, education, and to lift them out of poverty. 

·         It is politically incorrect to deport immigrants who have committed crimes and to shut down sanctuary cities.

Six

·         It is politically correct to protect human shields and innocents in ISIS concentrations of power and ISIS controlled cities by not bombing to prevent collateral damage.   

·          It is politically incorrect to seek to obliterate ISIS in spite of collateral damage.

Seven

·         It is politically correct to apologize for America’s past policies as capitalistic  transgressions  and to make concessions to one’s former adversaries  while asking for nothing in return.   

·         It is politically incorrect to call these policies as one-sided appeasing acts.

Political correctness and incorrectness also applies to the health system.

ONE

• It is politically correct to believe that everyone, no matter what their class or income or health status, deserves and should receive government guaranteed health coverage.


• It is politically incorrect to say that this is difficult in America because it superimposes a cumbersome, politically unpopular reform upon a complex, fragmented system without controlling costs.


TWO

• It is politically correct to say that the U.S. health system compares unfavorably to health systems of other developed nations.


• It is politically incorrect to say that the U.S. health system is a creature of our culture that reflects America’s values.

THREE

• It is politically correct to blame high health costs and discriminatory policies of profiteering health plans that exclude those with pre-existing illnesses, children, and disadvantaged individuals and social groups.


• It is politically incorrect to point out that profits are necessary to run a health plan and satisfy stockholders, the new law with its taxes and rules will raise premiums, and government plans could not function without health plan administrative help.

FOUR

• It is politically correct to say 30% of American health care is “wasteful” and “unnecessary” because of regional variations and provider greed.


• It is politically incorrect to say regional variations largely result from poverty and cultural conditions that combine to produce high costs for treating neglected or advanced diseases.

FIVE

• It is politically correct to say that centralized government programs and regulations will save the health system money.

• It is politically incorrect to observe that never in the history of the Republic have government entitlement programs saved money.

SIX

• It is politically correct to believe health outcomes, e.g., obesity and diabetes, are due to physician inattention, failure to advise patients properly, or misguided treatments.

• It is politically incorrect to say adverse outcomes may more often stem from lack of patient compliance, bad personal habits, poor nutrition, and sedentary life styles.

SEVEN

• It is politically correct to say we can solve our health care cost problems by broadening the primary care base and coordinating care.

• It is politically incorrect to say only 2% of medical students select primary care careers, most Americans prefer to go directly to specialists, and concepts like medical homes are untested.

EIGHT

• It is politically correct to say that doctors are responsible for high care costs and if we could only herd them into cost-accountable groups costs would drop.

• It is politically incorrect other factors contribute to high costs, many doctors prefer to practice independently outside of managed groups, and dominant larger groups negotiate favorable contracts not intended to lower costs.

NINE

• It is politically correct to assert that the health system is so complex consumers lack the intelligence, information, and knowledge to select the right doctors or right hospitals.

• It is politically incorrect to say health savings accounts, now owned by 10 million Americans, cut premiums by 20% or more without producing negative outcomes.

TEN

• It is politically correct to say with ubiquitous, interoperable electronic health records, we can standardize and homogenize physician, hospital, and consumer health practices and behaviors.

• It is politically incorrect to say in America, freedom of choice of doctors, open selection of hospitals, latitude to live as one wishes, and personal privacy are considered God-given constitutional rights .

ELEVEN

• It is politically correct to insist a wise and benevolent government can fine-tune, direct, and coordinate care in all economic sectors, including health care.

• It is politically incorrect to point out centralized governments more often produce economic stagnation, unemployment, long health care queues, than dynamic economies reflecting the individualistic , entrepreneurial, pragmatic, adaptable, and innovative nature of its most enterprising citizens.

TWELVE

• It is politically correct to say that within the next ten years (the time frame for implementation of Obamacare) we will know and appreciate government overhaul of health care.

• It is politically incorrect to note Obamacare is patterned after Massachusetts’ four year old universal coverage plan, which has raised premiums to the highest level in the country, produced the longest waiting lines in the land, overcrowded ERs, caused many physicians to close practices to new patients, and doubled state budget costs.

Issues Underneath Reform – Scandals, Crises, Inversions, Taxes

In our concerns over a major health care issue – covering the cost of covering the uninsured without breaking the national bank – we lose perspective over the underlying human issues that lie beneath.    You can gain this perspective by reading the Perspective Section of the New England Journal of Medicine, as exemplified in its March 17 edition.

Waiting Time Scandals

Often the scandals that surface in health reform efforts reside in such issues as prolonged waiting times to get care.   In “Scandal as a Sentinel Event – Recognizing Hidden Cost-Quality Events, “ the author, M.G. Bloche, J.D.,  of the Georgetown Law Center and the Transnational Events in London,  suggests waiting time scandals  usually occur when demands for excellence exceed budgets of the accomplishment of  this excellence.   When this occurs, managers and physicians often “game the system” to save their skin and  to  hide the deficiencies of the system.  This “gaming” has led to scandals  over prolonged waiting times in the Veterans Administration hospitals  in the U.S. and in the British National Health System in the United Kingdom

VA Crisis

David Shulkin, MD,   of the Department of Veterans Affairs, in “Beyond the VA Crisis – Becoming a High-Performance Network,” submits the VA has been asked to do too much given its present structure  and its limited budget.  Give us time, he says, to restructure and to consolidate  into a more coordinated  system with adequate resources and with more flexibility  in spending for services provided by the private sector,  and we will do the job.

Perversions of Inversions

H.J. Warraich. MD, and K.A. Schulman, MD, of Duke University and Harvard Business School, in “Health Care  Tax Inversions – Robbing  Both Peter and Paul,” comment on Pfizer and Medtronic moves to Ireland to avoid the U.S. punitive 35% corporate income tax – the highest in the world.  The 35% rate compares to Ireland’s rate of 7.7%.   They recommend ways to avoid these inversions.  These include requiring Congress to pass new rules,  such as lowering the U.S. rate and empowering CMS to negotiate prices with manufacturers.  They conclude “Developing new therapies – not avoiding taxes -  remains the most durable way for pharmaceutical companies to remain profitable.  “

Cadillac Taxes

Jason Furman PhD, and M. Fiedler, PhD, from the Council of Economic Advisors, write in "The Cadillac Tax – A Crucial Tool for Delivery-System Reform,”  that the Cadillac Tax – a   40% tax to be levied in 2000 on employer health plan costs in excess of $29,100 for family coverage and $10,700 for individual coverage is a good thing because it will drive employers to make their health plans more efficient.   Presumably the tax will drive workers towards more efficient providers.   The two authors say the Cadillac tax will save $95 billion by 2015 and $500 billion by 2036. Such a statement requires a belief in the federal tooth and truth fairy, which does not have history of saving money.  In 1965, the government promised Medicare and Medicaid costs would not exceed $9 billion by 1990.   The actual 1990 cost was $67 billion - 7.44 times the original projections In 2016  CMS (Centers for Medicare and Medicaid) will cost over $1 trillion, 15 times the 1990 figure.   So much for government promises and projections to keep costs down.

What Happens When You Hold Doctors’ Feet to Fire

To maintain personal, social, political , legal pressure on someone in order to induce him or her to comply with one’s desire, to hold someone accountable for his or her act or promise.

Wiktionary, definition of  “To hold one’s feet to fire”

Primary care doctors are under personal, social, political, and legal pressures to see as many patients without mistakes as possible even though the doctors to not have the time or resources to do so. 

Result?  As documented in a Kaiser Health News report,  “Burnt-out Primary Care Doctor Are Voting with Their Feet.” 

With their burnt feet,  they are seeking shelter and refuge from the reform storm” because they feel they  are unable to do what is being asked from them. 

They are jumping off the burning deck of health reform,  which is sinking under waves of new patients enrolling or qualifying for Medicare, Medicaid,  and ObamaCare health exchanges.

Doctors are under pressure, and many of them are saying  they can’t take it anymore.

Rather than expounding on this overheated subject,  I refer you to the  1753 word Kaiser Health News story and to these quotes in that story which explain what is happening.

·         “Tired of working longer and harder because of discounted insurance payments and frustrated by stagnating pay and increasing oversight, many are going to work for large groups or hospitals, curtailing their practices and in some cases, abandoning primary care or retiring early.” 

·         “Stressed doctors, meanwhile, often mean anxious, dissatisfied patients. Many consumers report feeling shortchanged after waiting weeks or even months for an appointment, only to get a quick once-over and be told there isn’t time to address all their complaints in one visit.” 

·         “A 2012 Urban Institute study of 500 primary-care doctors found that 30 percent of those aged 35 to 49 planned to leave their practices within five years. The rate jumped to 52 percent for those over 50.”

·         “A RAND study for the American Medical Association last year found that nearly half of surveyed physicians called their jobs “extremely stressful” and more than one-quarter said they were either “burning out,” experiencing burnout symptoms “that won’t go away,” or “completely burned out” and wondering if they “can go on.”  

·         “Richard J. Baron, president of the American Board of Internal Medicine, set out to document how much time a doctor spends managing care and discovered that on a typical day, he or she handles 18.5 phone calls; reads 16.8 e-mails; processes a dozen prescription refills (not counting those written during a visit); interprets 19.5 lab reports; reviews 11 imaging reports; and reads and follows up on 13.9 reports from specialists.”

·         Perhaps the single greatest source of frustration for many physicians is a tool that was supposed to make their lives easier: electronic medical records. Many do not merely dislike electronic health records – they despise them. “We were surprised by the intensity of their reports,” said Mark Friedberg, a physician and co-author of last year’s RAND study.”

·         “To ease the burden, some physicians have started using scribes – laptop-carrying assistants who follow them in and out of the exam room. Scribing is one of several proposals to provide greater support to physicians by giving more responsibility to nurses, health coaches and health educators. But adding personnel involves additional costs, which worries physicians trying to limit their overhead.” 

·         “The trend line, meanwhile, is troubling. The Association of American Medical Colleges estimates the United States will be short 45,000 primary-care doctors in 2020, when 268,000 are projected to be practicing. That compares to a shortfall of 9,000 in 2010, with 254,800 practicing.”