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The Republican Misguided Alternative to Obamacare


Stanley Feld M.D., FACP, MACE

Several important ideas can be derived from the Republican’s preliminary alternative to Obamacare.

Obamacare had been poorly conceived. Its execution has been worse.  Obamacare was developed by academic policy wonks that had no idea of  the culture of the physician practice community.  

These academic health policy wonks designed a system that is rigorous in the sense that outlines how all physicians should practice medicine. Physicians should use algorithms outlining this year’s best practices as developed by the interpretation of this year’s best clinical studies.  Obamacare was designed to measure physicians’ performance and inhibit physicians’ judgment. Healthcare policy wonks decided that the only way to accomplish this was by demanding an integrated care.

In order to effectively measure physicians’ efficiency, physicians must be under one hospital system. Physicians’ efficiency should be measured by a hospital’s bureaucrats. The government should control the rules and regulations. The set-up was satisfactory to President Obama because his goal was always central control of the healthcare system along with a single party payer (socialized medicine)

 If a hospital system performs better than some goal set the year before it gets a modest reward and shares it with the physicians on staff.  If their performance is more costly than the previous year they will be penalized.

This is a bad formula because success depends on the hospital staff, the physician staff and patient performance. Patient performance is not measured in Obamacare. No one even considers the patient’s responsibility to effectively improve outcomes of care.

patients are being treated as commodities. Physicians are being treated as commodities.

Patients are run through a bureaucracy with various physicians and physician extenders. They do not have one doctor caring for them.  The system is not going to improve patients’ knowledge of their disease or improve their outcomes. Patients must have ownership in their diseases.

All one has to consider is President Obama’s lie “if you like your doctor you can keep your doctors,” along with the tremendous growth of concierge medicine and out of pocket medical expenses since Obamacare was passed.

Concierge medicine adds $2,000 to $10,000 dollars to consumers’ out of pocket expense for the patients desire to have the ability to have contact with their their doctor and their desire to have the ability have questions answered and care coordinated by their doctor.   

Positive physician/ patient relationships will improve outcomes and decrease the cost of care.  

Most of the practice of medicine and surgery has been performed by independently practicing physicians. 

No one in the Obama administration has asked leading physicians in the practicing community what they think should be done to fix Obamacare.

Neither has the Republican Party listened to leading physicians in the practicing community about what should be included in their alternative to Obamacare.

I suspect the Republican leadership in the Senate is ignoring the few Republicans in the house and senate who were practicing physicians.

I know Rep. Michael Burgess, MD (R-TX-26) OB/GYN. Both Michael and his father used to send me Endocrine consultations when we all were in practice. I think the Republican leadership in the Senate has probably marginalized Michael  and the nine other Representatives  in the GOP House’s Doctors Caucus.  

Michael knows what has to be done after Obamacare is repealed and replaced. So far the GOP house caucus has only produced generalities.

he GOP Doctors Caucus: Utilizing medical expertise to develop patient-centered health care reforms focused on quality, access, affordability, portability, and choice.

House Energy and Commerce Chairman Fred Upton along with Senate Finance Chairman Orin Hatch and Senator Richard Burr have outlined what is, at least for now, the Republican alternative to Obamacare.

The Republican congresspersons as well as President Obama and Democratic congresspersons have left out the most important elements necessary for real healthcare reform.

The maintenance of the physician/patient relationship, with built in consumer responsibility for their own healthcare maintenance plus consumers’ responsibility for their own health and healthcare dollars, whatever their income, is the key to Repairing the Healthcare System.

Congress should pass a law with a light bureaucracy that provides a subsidy for the qualified indigent to receive healthcare insurance and financial incentives to stay healthy as well as education to learn to manage their chronic disease.

Effective Healthcare reform must include financial incentives for consumers to remain healthy.

I will review the Republican Party’s proposal in my next blog. They have some good ideas.

However, the Republican Party totally misses the key elements needed to  Repair the Healthcare System

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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King vs. Burwell

Stanley Feld M.D.,FACP,MACP

 In January 2015 fifty-six percent of the population surveyed knew nothing at all about the King vs. Burwell case to be heard by the Supreme Court in March 2015. Only 5% said they knew a lot about it. Nine percent said they knew something about it. Thirty percent of those surveyed said they knew only a little about the case.

I could not believe these numbers. So I decided to do a little personal survey of college graduates I ran into during the week. These people, in my opinion, are educated people. They would not consider themselves low information voters. Some, informally surveyed, were physicians.

To my amazement the numbers in the Kaiser survey taken before the Supreme Court hearing were similar to my informal survey taken after the Supreme Court hearing.

The leaders of the Republican Party are hoping the Supreme Court will uphold the challenge to Obamacare. They hope a favorable decision will subsequently cause Obamacare to collapse. The Republican Party would rather not have a open public debate about the federal health exchange’s unconstitutional subsidies.

The Republican Party does not want to be blamed for Obamacare’s collapse. They are also afraid to present Obamacare’s defects to the American people in simple terms. They are afraid to provide the leadership necessary to create outrage by the populous to stimulate public pressure to repeal this awful law.

  King burwell picture

King vs Burwell is a very simple case. The Affordable Care Act was passed into law by a partisan vote. The ACA did not receive one Republican vote.

None of the stakeholders approve of it. President Obama has made temporary modifications to the law to prevent a united popular outrage against the law.

The lawsuit by King against the Obama administration’s head of HHS, Sylvia Burwell, is that Obamacare (partisan passed law) is not upholding the letter of the law.

 The law clearly states that only states with a state health insurance exchange can provide subsidies for the purchase of healthcare insurance.

The Obama administration is providing subsidies through the 39 federal health exchanges. There are 39 federal health exchanges because 39 states refused to participate in the formation of a state insurance exchanges.

The law was written that way to encourage states to set up the exchanges. There is plenty of profit built into the state exchanges for the debt-ridden states to decrease its deficits.

As a result of the poor state response, President Obama even promised to fully fund the program for three years. He received little state response to that proposal.

The states that did not set up state exchanges exercised their states rights. Those states could visualize the losses they would incur when the first three years were over. It would necessitate the states to raising taxes on their citizens in order to avoid bankruptcy.

These states were also opposing a federal take over of the authority given to the states by the constitution.

A few state exchanges have closed down all ready even with total federal funding. In many cases people were not signing up because the insurance was too expensive.

The issue before the Supreme Court is simple.

The job of the executive branch of government is to implement and enforce the law as written. The executive branch of government cannot change the law without the consent of congress.

The lawsuit against the Obama administration is a constitutional question. It is nothing else.

If the court rules for the Obama administration, then President Obama has set a precedent so laws can be rewritten by the executive branch of government without the consent of congress.  

In reading the extensive coverage of the New York Times by Margot Sanger-Katz  everything but the constitutional issue is discussed.

All sorts of emotional issues are discussed such as 7 million people will loss their healthcare insurance subsidy and in turn lose their healthcare insurance coverage.

As stakeholders have tried to adjust to the law, they have discovered ways to profit from the law. Now some of the stakeholders now do not want the executive order to be ruled unconstitutional because it will harm their vested interest.

The administration’s argument focuses on everything but the core issue in this case. The executive branch (President Obama) cannot change the letter of the law. The legislature is the only body in our checks and balances system that can change the law. Therefore, President Obama’s action is unconstitutional.  

Worse yet, the Obama administration by itself and through its surrogates, such as the mainstream media (New York Times), have been muddying the water in an effort to intimidate the Supreme Court and its decision.

The Obama administration has begged the constitutional question in favor of having the public generating pity for the 7 million people who could lose their healthcare coverage.

Many of those 7 million people cannot afford the healthcare coverage provided by the health exchanges.

President Obama has also said, over and over again, that the Republicans have not provided a better plan to influence the court in considering  the simple constitutional issue.

The solution is simple. The Obama administration should ask congress to change the law.

The administration should ask a Democratic congressman to amend the law to changing the language of the law so that the federal healthcare exchange can provide subsidies.

If the executive branch is permitted to change a law, America could be on the path toward a dictatorship.

The Obama administration has announced that is has no contingency plan if the Supreme Court rules against it.

This could be interpreted in two ways. President Obama believes he is on the right side of the constitution. He feels that the Supreme Court judges have no choice but to agree with him.

The second is the Supreme Court will be intimidated by President Obama and modify the reading of the constitution to have a broader interpretation.  The court will let the executive branch change the law as written to one that fits the President’s agenda.

I do not believe the Supreme Court will be intimidated. I do not believe the media will affect the decision of the Supreme Court.

In fact the Obama administration has been working secretly with alternative plans. Unfortunately these plans are intended to bypass a Supreme Court decision and not execute the Supreme Court’s decision.

This is a very important constitutional issue.

The Republicans must start to educate and heighten awareness of this decision by the public.

It is unacceptable and sad that only 53% of the public is aware of the case much less the importance of the decision.

  Skeleton Republican

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Let’s Do The Numbers : Another Obama Trick

Stanley Feld M.D.,FACP,MACE

Have the increased Obamacare taxes added enough value to the healthcare system to be worth the costs?

The answer is no.

Are the increased taxes becoming painful yet?

The answer is yes.

The yearly cost of Obamacare has not been transparent.  There have been multiple delays in the implementation of Obamacare.

Favored businesses and unions have received waivers and exemptions from the laws required coverage. All the while taxes have increased and less than 10 million people have received healthcare coverage from the healthcare insurance exchanges. Eighty-five percent of those people enrolled are receiving federal subsidies.

No one has explained how a tax credit becomes a federal subsidy.

The public has no idea what the costs of Obamacare are or will be in the future. The CBO has revised its estimates several times.

Are all the Obamacare pronouncements confusing?

Yes. I believe they are intentionally confusing.

All the stakeholders are dissatisfied. Neither President Obama nor his administration is listening to the primary stakeholder (patients). 

Why are there so many waivers and exemptions being handed out by the Obama administration? I believe it is because President Obama is listening to his political base.

He is delaying the implementation of his agenda so his goal of socialized medicine is not obvious to all Americans.

President Obama and his administration have mislead us about the exact number of enrollees since the very beginning of the first enrollment period,  October 1,2013.

The American public was mislead about ,


  1. The disastrous website development, reason for website crashes and cost of website development.
  2. The exact number of enrollees the first year. (9.5 million correct to 8 million and then down to 6.8 million)
  3. The resulting further correction by a decrease in 800,000 more people losing insurance because of discovered ineligibility for subsidies.
  4. Decreasing the original predicted enrollees for 2015 from 13.5 million to 9.5 million.
  5. The change in the start of enrollment from October 1,2014 to November 15th to avoid discussion of enrollment around the time of the November 2014 elections.
  6. Extending the 2014 enrollment three months.
  7. Extending enrollment for 2015 for one to three months.
  8. Finally in 2015 announcing the back end of the website sending information to the IRS was still not complete.
  9. Rehiring CGI the same Canadian company that built the disastrous to fix the back end of the website.
  10. Discovering that 1.2 million were counted that should not have been because they got dental insurance bringing the number of enrollees down from a recalculated 8 million to 6.8 million enrollees for 2014.
  11. Announcing that 11.5 million people have enrolled for 2015 (these numbers seemed shaking at the time of enrollment. It seemed to be closer to 9.5 million or less.)
  12. Eight hundred thousand (800,000) enrollees lost their subsidy because they lied on their application
  13. Announcing that the group market Obamacare enrollment is being delayed a year or two while the mandate penalty for employers was to start January 1,2015.

Along the way I got the feeling that none of the enrollment numbers could be trusted.  HHS and CMS keeps on modifying and lowering them.

The Obama administration keeps telling us how great the enrollment is and that Obamacare is a success.

However, only ten million people have Obamacare insurance. Eighty five percent of those on Obamacare are receiving subsidies and still cannot afford the deductibles.

The rest of the enrollees have a pre-existing illness. They cannot find private insurance to buy. What about the 330 million people who might have subpar healthcare insurance? How many employers might discontinue employee insurance?    

After five years with all these new Obamacare taxes, I would not call this a successful healthcare reform program.

All of these enrollees were in the individual market. These numbers do not include the group insurance market.

14 million lost their healthcare insurance on the individual market. 10 million gained insurance on the healthcare insurance exchanges.

Several states healthcare insurance exchanges have failed.

An unknown number of enrollees in 2014 did not re-enroll in 2015 because of the loss of the subsidy and the high deductibles.

Other enrollees did not sign up again because they could not afford the high deductible.

The following is President Obama’s next trick play.

At the end of 2015 enrollment the Obama administration declared that 11.5 million people were enrolled.

On March 16,2015 the administration said about 16.4 million people have gained health insurance coverage since the Affordable Care Act became law nearly five years ago.

Please notice the tricky wording. The Obama administration is counting children under 26 that now can be included in their parents’ group insurance plans and the additional Medicaid recipients added by some states.

The count is not only the people who enrolled in Obamacare through the healthcare insurance exchanges.

The present discussion is about the success of the healthcare insurance exchanges not the increase in Medicaid coverage.

Confirmed Exchange QHPs: 11,699,473 as of 3/18/15

Estimated: 11.95M (9.06M via HCgov) as of 3/18/15


Estimated ACA Policy Enrollment: 33.1M
(10.46M Exchange QHPs, 8.20M OFF-Exchange QHPs, 330K SHOP, 14.1M Medicaid/CHIP)

There are two possible reasons for the Obama administration’s pronouncement at this time.

The first is the Republicans are about to announce its alternative plan to Obamacare. The administration’s goal would be to blunt the impact of the alternative plan by announcing the false success of Obamacare.

The second reason is to play mind games with the Supreme Court.

Justice Kennedy’s questioning at the hearing of King vs. Burwell expressed his concern for 85% of 10 million people who would loss their federal subsidy. Justice Kennedy did not address the letter of the law in his questioning.

Only the state healthcare exchanges can provide subsidies not the federal exchanges according to the written law. This is executive overreach of power granted by the constitution. President Obama should have asked congress to rewrite the law’s provision.

In an attempt to pressure the Supreme Court to vote in President Obama’s favor the administration has given the impression of confidence the Supreme Court will act in its favor.

The Obama administration has announced, a few times, that it does not have an alternative plan if the Supreme Court rules against it.

This is not true. The Obama administration has at least three alternative plans in the works.

It looks as if President Obama cannot help himself from trying to manipulate the American public and now the Supreme Court.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Obamacare Tax Hikes That Are Forgotten

Stanley Feld M.D.,FACP,MACE

Americans have forgotten the increase in taxes written into President Obama’s Healthcare Reform Act. There are 20 hidden taxes in the law that effect citizens earning less than $250,000 dollars a year.

According to Grover Norquist there will be ½ trillion dollars ($500 billion) in new taxes collected from the group of people making less than $250,000 a year.

These new taxes contradict President Obama’s promise that “anyone making under $250,000 a year will not pay a dime in new taxes.” Many of these taxes on businesses have been passed on to consumers in the form of higher prices.




I am not talking about the increase in taxes on capital gains and dividends that seniors rely on to survive. I am talking about all the other taxes that affect purchasing power.

In 2012, Grover Norquist wrote an excellent summary of those new taxes for the public to review. President Obama’s hypocrisy toward the American people is obvious.

The traditional media have ignored these new taxes and Mr. Norquist’s summary.   No one is talking about how these taxes are hurting seniors and the middle class economically.  

Since the recent Supreme Court decision has managed to keep Obamacare alive, it is vital that voters in all income brackets understand the new taxes imbedded in the law.

President Obama was not telling the truth when he said people earning under $250,000 would not pay one single dime more in taxes.

I suggest everyone watch President Obama’s lying and defending of his lies. After the first You Tube let it keep playing to hear subsequent You Tubes.

Grover Norquist is president of Americans for Tax Reform, a coalition of taxpayer groups, individuals, and businesses opposed to higher taxes at the federal, state, and local levels. The coalition organized the Taxpayer Protection Pledge, which asks all candidates for federal and state office to commit themselves in writing to oppose all tax increases.

In my blog “ The Supreme Court And Obamacare” I said Obamacare is the largest tax increase in American history. As things go sour for Obamacare the government is going to have to raise taxes even further.

Taxpayers earning under $250,000 will experience the burden of the $500 billion dollar increase in their taxes.

Mr. Norquist’s article appeared in 2012.

“Obamacare contains 20 new or higher taxes on American families and small businesses. 

Arranged by their respective effective dates, below is the total list of all $500 billion-plus in tax hikes (over the next ten years) in Obamacare, where to find them in the bill, and how much your taxes are scheduled to go up as of today:

Taxes that took effect in 2010:

1. Excise Tax on Charitable Hospitals (Min$/immediate): $50,000 per hospital if they fail to meet new "community health assessment needs," "financial assistance," and "billing and collection" rules set by HHS. Bill: PPACA; Page: 1,961-1,971.

2. Codification of the “economic substance doctrine” (Tax hike of $4.5 billion). This provision allows the IRS to disallow completely-legal tax deductions and other legal tax-minimizing plans just because the IRS deems that the action lacks “substance” and is merely intended to reduce taxes owed. Bill: Reconciliation Act; Page: 108-113.

3. “Black liquor” tax hike (Tax hike of $23.6 billion). This is a tax increase on a type of bio-fuel. Bill: Reconciliation Act; Page: 105.

4. Tax on Innovator Drug Companies ($22.2 bil/Jan 2010): $2.3 billion annual tax on the industry imposed relative to share of sales made that year. Bill: PPACA; Page: 1,971-1,980.

5. Blue Cross/Blue Shield Tax Hike ($0.4 bil/Jan 2010): The special tax deduction in current law for Blue Cross/Blue Shield companies would only be allowed if 85 percent or more of premium revenues are spent on clinical services. Bill: PPACA; Page: 2,004.

6. Tax on Indoor Tanning Services ($2.7 billion/July 1, 2010): New 10 percent excise tax on Americans using indoor tanning salons. Bill: PPACA; Page: 2,397-2,399.

Taxes that took effect in 2011:

7. Medicine Cabinet Tax ($5 bil/Jan 2011): Americans no longer able to use health savings account (HSA), flexible spending account (FSA), or health reimbursement (HRA) pre-tax dollars to purchase non-prescription, over-the-counter medicines (except insulin). Bill: PPACA; Page: 1,957-1,959.

8. HSA Withdrawal Tax Hike ($1.4 bil/Jan 2011): Increases additional tax on non-medical early withdrawals from an HSA from 10 to 20 percent, disadvantaging them relative to IRAs and other tax-advantaged accounts, which remain at 10 percent. Bill: PPACA; Page: 1,959.

Taxes that took effect in 2012:

9. Employer Reporting of Insurance on W-2 (Min$/Jan 2012): Preamble to taxing health benefits on individual tax returns. Bill: PPACA; Page: 1,957.

Taxes that take effect in 2013:

10. Surtax on Investment Income ($123 billion/Jan. 2013): Creation of a new, 3.8 percent surtax on investment income earned in households making at least $250,000 ($200,000 single). This would result in the following top tax rates on investment income: Bill: Reconciliation Act; Page: 87-93.


Capital Gains











*Other unearned income includes (for surtax purposes) gross income from interest, annuities, royalties, net rents, and passive income in partnerships and Subchapter-S corporations. It does not include municipal bond interest or life insurance proceeds, since those do not add to gross income. It does not include active trade or business income, fair market value sales of ownership in pass-through entities, or distributions from retirement plans. The 3.8% surtax does not apply to non-resident aliens.

11. Hike in Medicare Payroll Tax ($86.8 bil/Jan 2013): Current law and changes:


First $200,000
($250,000 Married)

All Remaining Wages

Current Law

2.9% self-employed

2.9% self-employed

Obamacare Tax Hike

2.9% self-employed

3.8% self-employed

Bill: PPACA, Reconciliation Act; Page: 2000-2003; 87-93

12. Tax on Medical Device Manufacturers ($20 bil/Jan 2013): Medical device manufacturers employ 360,000 people in 6000 plants across the country. This law imposes a new 2.3% excise tax. Exempts items retailing for <$100. Bill: PPACA; Page: 1,980-1,986

13. Raise "Haircut" for Medical Itemized Deduction from 7.5% to 10% of AGI($15.2 bil/Jan 2013): Currently, those facing high medical expenses are allowed a deduction for medical expenses to the extent that those expenses exceed 7.5 percent of adjusted gross income (AGI). The new provision imposes a threshold of 10 percent of AGI. Waived for 65+ taxpayers in 2013-2016 only. Bill: PPACA; Page: 1,994-1,995

14. Flexible Spending Account Cap – aka “Special Needs Kids Tax” ($13 bil/Jan 2013): Imposes cap on FSAs of $2500 (now unlimited). Indexed to inflation after 2013. There is one group of FSA owners for whom this new cap will be particularly cruel and onerous: parents of special needs children. There are thousands of families with special needs children in the United States, and many of them use FSAs to pay for special needs education. Tuition rates at one leading school that teaches special needs children in Washington, D.C. (National Child Research Center) can easily exceed $14,000 per year. Under tax rules, FSA dollars can be used to pay for this type of special needs education. Bill: PPACA; Page: 2,388-2,389

15. Elimination of tax deduction for employer-provided retirement Rx drug coverage in coordination with Medicare Part D ($4.5 bil/Jan 2013) Bill: PPACA; Page: 1,994

16. $500,000 Annual Executive Compensation Limit for Health Insurance Executives ($0.6 bil/Jan 2013). Bill: PPACA; Page: 1,995-2,000

Taxes that took effect in 2014:

17. Individual Mandate Excise Tax (Jan 2014): Starting in 2014, anyone not buying “qualifying” health insurance must pay an income surtax according to the higher of the following


1 Adult

2 Adults

3+ Adults


1% AGI/$95

1% AGI/$190

1% AGI/$285


2% AGI/$325

2% AGI/$650

2% AGI/$975

2016 +

2.5% AGI/$695

2.5% AGI/$1390

2.5% AGI/$2085

Exemptions for religious objectors, undocumented immigrants, prisoners, those earning less than the poverty line, members of Indian tribes, and hardship cases (determined by HHS).Bill: PPACA; Page: 317-337

18. Employer Mandate Tax (Jan 2014): If an employer does not offer health coverage, and at least one employee qualifies for a health tax credit, the employer must pay an additional non-deductible tax of $2000 for all full-time employees. Applies to all employers with 50 or more employees. If any employee actually receives coverage through the exchange, the penalty on the employer for that employee rises to $3000. If the employer requires a waiting period to enroll in coverage of 30-60 days, there is a $400 tax per employee ($600 if the period is 60 days or longer).Bill: PPACA; Page: 345-346

Combined score of individual and employer mandate tax penalty: $65 billion/10 years

19. Tax on Health Insurers ($60.1 bil/Jan 2014): Annual tax on the industry imposed relative to health insurance premiums collected that year. Phases in gradually until 2018. Fully-imposed on firms with $50 million in profits. Bill: PPACA; Page: 1,986-1,993

Taxes that take effect in 2018:

20. Excise Tax on Comprehensive Health Insurance Plans ($32 bil/Jan 2018): Starting in 2018, new 40 percent excise tax on “Cadillac” health insurance plans ($10,200 single/$27,500 family). Higher threshold ($11,500 single/$29,450 family) for early retirees and high-risk professions. CPI +1 percentage point indexed. Bill: PPACA; Page: 1,941-1,956

© 2012 Newsmax. All rights reserved.

Mr. Norquist left out the worst tax of all. The “tax” is under everyone’s radar. It has not been mentioned in the traditional mainstream media. It is the tax on Seniors who are on Medicare.

"The per person Medicare Insurance Premium will increase from the present
Monthly Fee of $96.40, rising to:

$104.20 in 2012

$120.20 in 2013


$247.00 in 2014."


All seniors are means tested. This means the greater your income from any source including work income, pension income, capital gains and interest or dividend income the higher the baseline premiums become.


This “tax” had been decided by a Democratic controlled congress that had not read the bill or understood all of its consequences.  

These are provisions incorporated in the Obamacare legislation, purposely
delayed so as not to anger seniors during President Obama’s 2012 Re-Election Campaign.


Please send this blog to all the seniors you know and their children. It is important for them to know that President Obama is throwing seniors under the bus.  Obamacare must be repealed.

Everyone must stay focused. President Obama is going to try to change the conversation.

Some of these taxes have already gone into effect. If the Republicans win the House and the Senate as well as the Presidency, Obamacare could be repealed.   

Everyone interested in America’s economic future must tell a friend. President Obama has deceived Americans.  

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Nobody Seems To Care About The Increases In Obamacare Taxes

Stanley Feld M.D.,FACP,MACE

There are at least two ways to balance the budget. Increase taxes or decrease spending.

If you increase spending without increasing taxes, you increase the budget deficit. If taxes are increased enough the budget deficit might be reduced.  

It was the Obama administration’s hope that if taxes were raised slowly, Americans would not notice the increases.

This is exactly what President Obama and the tax and spend Democrats are doing.

A frustrated reader writes about the slow rise but unrelenting rise in taxes.

“Here is a message from my buddy Brad.

As Jim Naybors/Gomer Pyle used to say – "surprise surprise."

Here is what happened on January 1, 2015:

Top Medicare tax went from 1.45% to 2.35%

Top Income tax bracket went from 35% to 39.6%

Top Income payroll tax went from 37.4% to 52.2%

Capital Gains tax went from 15% to 28%

Dividends tax went from15% to 39.6%

Estate tax went from 0%to 55%

Remember this fact:

These taxes were all passed only with Democrat votes, no Republicans 
voted for these taxes.

These taxes were all passed under the Affordable Care Act, aka 

The problem is taxes are at the tipping point. The rich and the middle class are now noticing the yearly tax increases. They are starting to shout, “no new taxes. Where is the value of these new taxes?”

A problem in America is an increasingly large  group of people who pay no taxes. These people have no choice but to accept government handouts to survive.

It has been reported that government handouts are equivalent to about a $50,000 a year post tax income. The entitlements blunt incentives to take the initiative and find work in order to be productive citizens.

Working people are experiencing the increased tax burden and are unhappy.

I have written a few articles listing Obamacare increases in taxes. President Obama has steadily increased taxes each year for the last six years.

The most irritating thing about the increased taxes is Americans are not getting value for their money.  All they are getting is lies and failed programs.

Administrator Marilyn Tavenner is resigning her post overseeing Obamacare just months after she admitted that the Obama White House’s highly publicized 8 million Obamacare enrollment figure was inflated by at least 1.3 million.

There is always a fall guy. It is never President Obama or his policies that are at fault. There is never full disclosure or transparency about these failed programs.

A vivid example of the lack of transparency is a recent disclosure by the budget committee about the Obama administration’s using unauthorized funds to pay for Obamacare cost overruns. Congress is supposed to authorize the use of funds according to the constitution.

Obamacare was having trouble getting insurance companies to participate in Obamacare’s health insurance exchanges. President Obama activated the government guarantee reinsurance program to subsidize the insurance industry. The goal was to induce the healthcare insurance industry to participate in the health insurance exchanges. The Obamacare reinsurance program guarantees the insurance industry that it cannot loss money in providing insurance through the health insurance exchanges.

 The Treasury Department has rebuffed a request by House Ways and Means Chairman Rep. Paul Ryan to explain $3 billion in payments that were made to health insurers even though Congress never authorized the spending through annual appropriations.

At issue are payments to insurers known as cost-sharing subsidies. These payments come about because President Obama’s healthcare law forces insurers to limit out-of-pocket costs for certain low income individuals by capping consumer expenses, such as deductibles and co-payments, in insurance policies. In exchange for capping these charges, insurers are supposed to receive compensation.

What’s tricky is that Congress never authorized any money to make such payments to insurers in its annual appropriations, but the Department of Health and Human Services, with the cooperation of the U.S. Treasury, made them anyway.

There are several other incidences of money shifting without congressional appropriation.

President Obama continually forgets that the constitution provides for three independent branches of government. They were formed in order to maintain checks and balance so one branch does not become all powerful.

The apparent disregard for the constitution is ubiquitous in the Obama administration.

If anyone is bothered by these actions by the Obama administration, please write to your representatives in congress.

If you think it is important that everyone in the U.S. should 
know these things, feel free to pass this on.

If there is value to the healthcare system with Obamacare, a debate about the need for increased funds is appropriate.

Most Americans do not like Obamacare. Most physicians do not like Obamacare. America’s budget cannot stand Obamacare.

President Obama loves Obamacare. Isn’t President Obama supposed to represent the will of the people?

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Where Are Your Actionable Points To Replace Obamacare?

Stanley Feld M.D.,FACP,MACE

 Some have criticized me for always criticizing Obamacare. There is plenty to criticize. President Obama has asked if anyone has a better idea than Obamacare please let him know.

The question asked by some readers is where are your actionable points to repair the healthcare system.

My answer is, “you have not been reading my blog.”

Democrats and President Obama have not read my blog.

The Republicans have been searching for an alternative plan. President Obama has mocked them for not having an alternative than Obamacare.

Republican leaders have not read my blog either. If they had and really thought about my plan they would conclude it could work.

 My plan aligns all the stakeholders’ incentives while reducing the cost of healthcare coverage to consumers. It also decreases secondary stakeholders’ costs and increases their profits. It is very democratic. It would provide universal care without government interference.

These actionable points have been clearly described in many of my blog posts. It is a “consumer driven healthcare plan.” The real customers in the healthcare system are consumers, not physicians, insurance companies, hospitals or the government.

Below are some of the links that provide actionable points to Repair The Healthcare System.

The first link is an overview using a slide presentation. It outlines the business model for 2020.  The details of each specific point can be found in the links in the slide presentation or in the websites search engine.

Obamacare ignores many of the key points. Obamacare will fail because of the absence of these key points. Simple things must be done for an alternative to Obamacare to succeed.

The second link is My Ideal Medical Savings Account is Democratic. My ideal Medical Savings Account can cover and motivate every socioeconomic group. It provides incentives for all consumers to remain healthy and take care of their chronic disease. It promotes consumer responsibility.

Consumer self-responsibility is an essential element in the Repair of the Healthcare System.

My Medical Savings Account is different that a Health Savings Account.

Self-management of chronic diseases is a vital element necessary in a law that attempts to Repair the Healthcare System. It requires education and incorporation of all the spokes of the wheel in the link above to the slide presentation.

President Obama has done some pilot studies using the wrong groups (political groups) to study the self-management hypothesis.

They have all failed because the administration picked the wrong groups to do the pilots.

Systems of care must be developed to teach patients to self-manage their chronic disease to decrease the complication rate of those diseases.

Eighty percent of the healthcare dollars are spent on treating the complications of chronic diseases. Twenty percent of patients have a chronic disease that is not well controlled and will lead to complications eventually. This can be solved with a properly executed Systems of Care by physicians using information technology as an extension of their care patient.

Obamacare does not seriously consider any of these vital corrections necessary to create an affordable healthcare system. The hospitals and/or physicians cannot be responsible for consumers’ behavior to avoid the complications of chronic diseases. Accountable Care Organizations are based on the fact that the hospitals and physicians are responsible for better outcomes.

 Hospitals and physicians have to have the infrastructure to teach patients to become “professors of their diseases.”

Another simple action point is to provide equal tax deductibility for the individual insurance market and group insurance market.

At the moment employers providing insurance to employees can deduct premiums from revenue. An individual buying insurance for himself and his family does not get the same tax deduction. This discrepancy can easily be cured by providing the individual market with the same tax deduction as the group market.

The above links to blogs I have written are just some of the important actionable points necessary to Repair the Healthcare System.

Please study these action points in the links and try to understand how vital they are to maintaining a viable healthcare system.

Obamacare’s complicated rules and regulations have only driven the healthcare system to further dysfunction and increased costs while only having less than 10 million people really signed up after 2 years of enrollment and 6 years of increased taxes.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Simple Fixes

Stanley Feld M.D.,FACP,MACE

Republicans are trying to figure out what to change in Obamacare to make it work. I believe Republicans should change all the perverse biases built into Obamacare. The result would be a small but important dent in Repairing the Healthcare System.

It is best to start all over again with a bill that puts consumers in charge of their healthcare dollars. Consumers must be responsible and own their healthcare decisions and healthcare dollars. Consumers must drive the healthcare system in order to have reduced costs, increased efficiency of care and competition among stakeholders.

Obamacare is a political strategy by progressives to get more power. It is not about improving delivery of healthcare.

It is about  "redistribution of wealth"… or, by its more common name, "SOCIALISM.

Republicans do not understand this. They don’t have the courage to call out President Obama or the Democrats.

Democrats cannot or do not want to understand the power of market based consumer driven healthcare because their ideology of central government control of healthcare does not allow it.

Consumers, taxpayer and voters must drive the change to a better, more cost efficient and less dysfunctional healthcare system.

 Obamacare’s basic theme is built on hospital ownership of physicians’ practices. If hospitals or hospital systems own all the physicians’ practices in a community, the government has to only negotiate prices with the hospital system. The central government can then control a community and decide on access to care and the rationing of care of the community’s citizens.

The hospital receives a bundled reimbursement for a disease encounter. The hospital divides the reimbursement between the doctor and the hospital.

Once physicians are in the employ of hospitals, the government and hospital systems think that the non-compete clause will hold up in court and physicians will be afraid to leave the hospital systems.

Hospitals think they can lower the salary of physicians during negotiations for renewal of physician employment contracts since physicians will be afraid to leave the hospitals’ employ.

I’ll bet if a group of physicians decided to leave at the same time, the hospitals would be in the trap hospitals set to apply to physicians. Physicians should wake up. Some physicians have.

These are some of the perverse biases Obamacare has created against physician practices and patients.

The biases created against groups of private practitioners and to the advantage of hospital systems costs government and healthcare insurers more than it would if there was a level playing field for practicing physicians. It would create market place competition. Consumers and taxpayers absorb these government overpayments. 

A common belief is that the payment system must be changed from a fee for service system to a bundled payment system.

HMOs failed in the 1980’s and early 1990’s because of the pressure of patient and physician dissatisfaction with the quality of care that was provided with a bundled payment system.

Accountable Care Organizations (ACOs) run by hospital systems are the organizations that will take risk and accept a bundled fee. It is similar to the HMO’s that failed previously.

ACOs will fail because it is difficult to predict medical risk.  The increases in premiums are the result of the insurance industry’s miscalculation of risk.

Physicians are not willing to take on the risk of patients’ compliance and adherence. Physicians are not mechanics that put a new part in patients and then patients are fixed.

The popular notion is payment reform requires coordinated delivery of medical care in an Accountable Care Organization in which a single institution owns the physicians.

Everyone knows the physicians are at risk. Much of that risk depends on the patients’ responsibility to understand their illness and their behavior toward caring for that illness.  

Obamacare is biased against less centralized engagements where independent doctors enter into contractual relationships with their patients. The government has imposed less reimbursement and more paperwork for these independent practices to discourage them from remaining in private practice.

Private practitioners cannot afford to participate in reformed payment plans. Private physicians need complex IT infrastructure in order to comply with the rules and regulations needed to participate in the complex payment reform structure that shifts risk to physicians.

“It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.”

The problem is hospital systems cannot control physician’s medical judgments.  Medical judgments are complex and cannot be boiled down to cookbook decision solutions.

Obamacare also provides favorable anti-kickback provisions to hospital systems only when hospital and physicians qualify as Accountable Care Organization. ACO qualification is dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

In the end physicians shouldn’t care to be in an ACO because their freedom to practice medicine according to their medical judgment could be impaired.

However, many physicians still feel compelled to join hospital systems so they are not left out of the “new age.”

Those physicians who do not participate are joining the surge of interest in the fast growing concierge medicine phenomenon. Consumers want someone to relate to them and not to be a commodity in a failing healthcare system.

I know of only one group of physicians in a small city in Texas who have supposedly taken control of the hospital and enjoy government provided benefits for developing an ACO. 

The hospital is dependent on the organized physician group rather than the hospital taking over the physician’s group and dictating how these physicians should practice medicine.

In order for real reform to occur Congress must level the playing field between hospitals and independent private practice physicians. Only then will there be a competitive system where both hospitals and physicians will compete for patient pools.

Congress has to put consumers in the drivers seat, not hospital systems.  

The government could set up a new class of “independent risk managers” to help groups and individual physicians analyze and manage risk.

Managing risk depends on patients assuming responsibility in the participation in managing their diseases.

Hospital systems do not evaluate risk very well. Neither does the healthcare insurance industry or the government.

Government should be the facilitator of improving care, not the manager of the healthcare system.

 “Obamacare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.”

Another simple solution to increasing costs would be to provide physician owned private groups and individual physicians with the same reimbursement provided to hospitals and hospital owned physicians.

Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office.

 Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office.”

This is true in all coding categories. The difference produces a sizable profit incentive to the hospital at a great cost to government.

Hospital systems are driven to buy physicians’ practices to take advantage of the difference since money-making long inpatients hospital stays are becoming a thing of the past with new advances in medical and surgical care.

The profit margin from owning brick and mortar is shrinking and the profit from owning intellectual property and surgical skills is increasing. Hospitals want to take advantage of this phenomenon.

Why is the Obama administration doing this?

Once the hospital own the physicians in the community the government can then squeeze the reimbursement to the hospital system. Hospital systems will have no option but to accept the reduced reimbursement.

It is called “got you in checkmate.”

 It has happened before. This strategy has never worked.

When will the government ever learn?

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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