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All items for May, 2015


Double Digits Increases In Obamacare Insurance Rates Proposed

Stanley Feld M.D.,FACP,MACE

Thirty-seven states refused to setup Obamacare State Health Insurance Exchanges. Thirty-seven states refused because of the expected cost burden to those states and citizens. States are required to balance their state budgets. Most states have deficits and do not have balanced budgets. Obamacare’s requirements would simply add to their budget deficits. States would be forced increase state taxes.

The 37 states felt that the Obamacare State Health Insurance Exchanges were an attempt, by President Obama, to decrease the federal cost burden and shift it to the states.  

It was also a states’ rights issue.

None of those states felt that Obamacare State Health Insurance Exchanges could work and not become an increased cost burden.

The Supreme Court ruled in 2012 that states have the right under the constitution to refuse to create a State Health Insurance Exchange.

In June 2015 the Supreme Court will rule on King vs. Burwell.

Can the Federal Health Insurance Exchanges subsidize applicants the same way State Health Insurance Exchanges can subsidize applicants.

The law’s language is specific. The Obamacare law specifically states that only the State Insurance Exchanges can subsidies applicants.

The Obama administration media manipulation machine is already spinning the truth in case the Supreme Court rules against the federal government.

Eight million people will lose their subsidy. There are 330 million people in America. There are as many people uninsured in 2015 as there were before the law was enacted. In five years we are no closer to the promise that Obamacare would provide universal care.

Obamacare is failing because it is a bad law in many respects.

The essence of the Obama administration’s spin is that if the Supreme Court rules against the government the cost of insurance will escalate to unaffordable levels for Federal Health Insurance Exchange purchasers.

Subsidies that made insurance plans affordable face a crucial test with decision expected in June.

The truth is the cost of healthcare premiums are going to skyrocket for Obamacare applicants because the only people who signed up have pre-existing illnesses and had to buy insurance or the very poor because their insurance was fully subsidized.

 The adverse selection and the financial accounting rules for the healthcare insurance industry allow them to raise the premiums.

President Obama’s subsidies for Obamacare premiums expire in 2016.


Megan McCardle writing in Bloomberg says;

Insurance companies have been bullied by the Obama administration into keeping rates as low as they are, even though they can't make any money.

For sheer survival, most companies will begin to charge enough so they at least don't lose any money, or leave the exchanges altogether.

For those of you who have followed my blog carefully, you know President Obama has provided the healthcare insurance industry a subsidy in order to get them to participate. It guarantees that it cannot lose more than 2% of its expected profit.

The insurance industry determines its expected profit.

The insurance company subsidy is about to expire. The guarantee in Obamacare, of not losing any money, is going to evaporate. In addition, only the sickest and poorest people have obtained insurance from the federal and state health insurance exchanges. The federal and state exchanges have lost a great deal of money.

These losses are slowly being revealed.

The State Health Insurance Exchanges are starting to publish their losses at the same time the healthcare insurance industry is reporting their potential losses for next year. Those potential losses are reflected in the proposed premium increases.

Moda of Oregon says that its claims were 139 percent of revenue.

CareFirst of Maryland says claims were 120 percent of revenue.

Tennessee told the Wall Street Journal it lost $141 million on exchange plans last year.

 State of New Mexico says it lost $23 million on revenue of $121 million.

 The states that signed up for the State Health Insurance Exchanges are losing money. Maybe the states that did not sign up were right. It would be a financial burden on those states.

The clause in the law permits only those states having a health insurance exchange to provide subsidies to their applicants. It excludes all others, including the federal government.

The only question the Supreme Court has to consider is, can the federal health insurance exchanges provide subsidies to applicants according to the law as written?

The law was written to encourage states to create health insurance exchanges. It did not include the provision of subsidy to applicants for  federal health insurance exchanges.

If the federal exchange would be permitted to provide subsidies, the law should be amended by congress.

A Republican congress would have to amend the law.

Obamacare is an apparent disaster to consumers, insurance providers, hospitals and physicians.

The majority of Republican are calling for Obamacare’s repeal.

It is unlikely that a Republican congress will change that provision in the law.

The “States only provision” in the law has backfired on President Obama and those states creating health insurance exchanges.

The cost of setting up and administering this new bureaucracy was enormous. The healthcare insurance offered by Federal and State Health Insurance Exchanges were either too expensive for healthy or young consumers or had too many unnecessary benefits for those consumers.

The only consumers who signed up were people who were too sick to be able to buy private insurance or too poor to be able to buy insurance without being subsidized.

Those consumers comprise 85% of the applicants. The result has been an adverse selection pool.

If the Supreme Court rules against President Obama he is going to say that private insurance does not work. The federal government must create an entitlement to everyone.

The result will be socialized medicine with the federal government being the single party payer controlling rationing of care, access to care and the cost of care to consumers.

I believe it will make healthcare coverage even worse than it is now.

Why no one is considering my concept of consumer driven healthcare with my ideal medical saving account is beyond me.

Rather than making consumers actively responsible for their health, healthcare dollars and healthcare, we are on the road to making them passive recipients of their healthcare.

America is going to be further down the Road to Serfdom.

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

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It’s Daniel Time!

Stanley Feld M.D.,FACP,MACE

Readers of this blog know I try to spend a weekend each year alone with each of my sons Daniel and Brad.

I spent Memorial Day weekend with Daniel. Both my boys are great kids. Actually, they are not kids any more. Daniel is 46 and Brad is 49.

 I feel like a kid when we hang out together.

 Last weekend was “Its Daniel Time.” We met up in Chicago on Thursday afternoon and walked like crazy from Thursday afternoon until Sunday morning.

Each day was more than a 15,000 steps according to my FitBit. Each day I jumped when the buzzer went off at 10,000 steps.

We stayed at the Hotel Chicago, which is located in a great spot. It is right next to Marina City and the House of Blues.  

 My flight was late. I arrived at the hotel at 4.15 pm. There was no time for a nap.

 We hit the street and ended up at Joe's Steak and Seafood Grille without a reservation at 5.30 pm without a reservation.  It was packed. Who would think the first table was at 9.30 pm.  We were lucky and got a table at the bar.

We ate relatively light in anticipation of what lay ahead. We each ordered a main entrée. It was a mistake because it was too much food for each of us.

 The weather was perfect. It was 65 degrees and no wind. We decided to walk the two miles down Rush Street to North St, then to 1606 N Wells and Second City.

The Second City show was as good as it has ever been. The actors were as clever as I have seen. Laughter is therapy.


 Daniel and I experienced almost three hours of continuous laughter. We were so exhausted from laughing that we had to take a taxi back to the hotel. Next we had to find chocolate ice cream at 11:30 p.m. to complete the day.

 No one at the hotel or in the street knew of a nearby ice cream parlor. We had to settle for Smith and McCormick Steakhouse’s “Gigantic Chocolate Cake” and two scoops of chocolate ice cream.

Dan Gigan cho cake

Friday began at 7 a.m. with exercise. Daniel went to the gym and I stretched in the room with the rubber band.

We did not have breakfast on Friday, just coffee in the room. The next stop was the Chicago Architecture Foundation River Cruise.

 I have taken the Chicago Architecture Foundation’s River Cruse.  Ride several times over the years during my visits to Chicago. It is great. It is a must for any reader has not done it.

  Dan First lady Chicago

In more than 40 years there have been many architectural changes on both sides of the Chicago River. The River Cruise gives you an understanding its evolution and it place in the history of urban planning in Chicago.

The last time I was in Chicago with Daniel on a father son trip it was at the end of March and the tour was not closed for the winter.

At that time we did one of the many architectural walking tours the Chicago Architectural Foundation does in the city. It, too, was great.    

You cannot beat a sunny 60 degree morning on the Chicago River cruise.

Next we walked to Millennium Park.

All this time Daniel and I are talking about life in general, family, politics and the future. These discussions are the most fun for me. It results in a one on one interaction and bonding with my son.

Millennium Park is a brilliant treasure in the middle of downtown Chicago. This time we concentrated on the Cloud Gate sculpture.

  Cloud Gate

We took selfies and our distorted reflection. Who said you are only a kid once?

  Dan Selfie

It was lunchtime and we were hungry. Twenty-five years ago I had pizza in a small restaurant called Giordano’s near the Watertower. I remembered the “Chicago Deep Dish Classic.”  They now has 16 restaurants in the Chicago area.

Giardo pie

Only in America!

We met Don Loeb, V.P. of Development at TechStars who works with Daniel who is V.P. of Operations at TechStars. Our “Chicago Classic” was great. Our animated discussions about Repairing the Healthcare System was an added bonus.

After the pizza we had to have a chocolate ice cream fix.

Dan don stan Baskin Rob
 Dan,Stan,Don at Baskin/Robbins Chicago May 23,2015

We found a Baskin and Robbins two blocks away. Someone ought to tell Mayor Emanuel that downtown Chicago needs a fancy ice cream parlor. Ghirardelli Chocolate Co is the only one we could find on Michigan Avenue.

It was 3.30 pm. It was back to the hotel for naptime. I wanted to cover more territory but we both ran out of gas.

After a beautiful nap we were off to Big Mike’s, Mike Ditka’s Steak House. Daniel and I shared a steak, baked potato and broccoli. It was delicious.


We were so full. We could have Ghirardelli’s ice cream sundae just yet so we walked about a mile north on Michigan Avenue  and then turned back to Ghiradelli’s.


Decedent,Indeed. Oh hell, it’s a father son weekend.

  Dan ic@ ghira

After that we walked from the Water Tower back to Hotel Chicago for the end of the Cleveland Cav’s game and sleep.

Sunday morning was the Memorial Day parade. Before the parade we walked to The Merchandise Mart. We walked in the Mart for about an hour. Then we headed for the new Boeing Building to buy something in the store. It was closed.

 It was 11 am and the parade was to start at noon. We started back to get a good place to watch the parade. It was a nice Memorial Day parade. We only got a glimpse of the mayor because he and his people rushed by to start the parade. I was disappointed. It should have been a grand entry.

  Dan Mem para skyscr

After the parade a light lunch a little more walking around. Daniel decided it was naptime.

Tonight we were going to see Rain and their tribute to the Beatles.



We walked to the theater and back. All we could find was another Baskin and Robbins for another hot fudge sundae to complete the day.


We had to get up early to get an early morning flight so we did not go into the House of Blues.


If you have not tried this kind of weekend with your kids, one kid at a time, I recommend it. It is a prescription for good health.

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

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The Shovel Ready EMR Project?

Stanley Feld M.D.,FACP,MACE

  The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the $800 billion dollar economic stimulus package towards digitizing medical records.

This was considered one of President Obama’s shovel ready projects. This project has lots of problems and was much less than shovel ready.

It was George W. Bush, not Obama, who started the project to digitize medical records. EMRs make sense if they are directed toward improving patient care.

President Obama funded the project with his shovel ready economic stimulus package in 2009. Physicians dislike the project. Patients find little value in the project.

It is estimated that in five years 50 times more health information will be generated and digitized than today. Diagnoses, treatments, DNA, medical images and vital signs already are being analyzed and stored.

One large problem is Americans don’t own their own healthcare information.

In its present form patients find little useful information in the EMRs. Many of the EMRs do not fit the Obama administration’s criteria of meaningful use EMRs. Medical practices will experience a penalty this year.

Government punishment hardly ever works. Government providing for innovative opportunities works.

The government and the insurance industry own the information.

The big data is derived from meaningful use EMRs. The government is only interested in evaluating the quality of physicians’ care. The government would like to decide on the reimbursement of that care.

The EMR has not added value to patient care because physicians have to spend too much time concentrating on filling in required documentation. Much of the information is worthless because they cut and paste template reports that are required documentation for the government to judge. The medical record is cluttered with information that is not useful.

The cost is physicians do not have time to relate to patients.

Michael F. Raab, M.D.Sanibel, Fla writes in the WSJ

 “I recently received 147 pages of EMR which took me 30 minutes to review. I only found three lines that added new information.”

HIPAA (Health Insurance Portability and Accountability Act) requires hospitals, physicians, labs, pharmacies and other “covered entities” as well as the health plans and their “business associates” (for example, an information-technology vendor) to protect how your data. This rule applies only to paper record. It does not apply to digital records.

Most EMRs aren’t covered by HIPAA at all, and providers and vendors can do whatever they want with your information.”

Digital records are vulnerable to hackers. Health records were stolen from nearly 80 million Anthem health-plan members. The façade of privacy has been exposed.

Electronic medical records companies, and hospitals and health systems that own physician practices own the patients’ digitized healthcare records.

These entities have withheld health information from patients in order to gain an edge over competitors. It becomes difficult for patients to switch to other healthcare plans or providers without their records.

Patients are entitled to their records but they must get past vendor delays.

There is great financial value of patients’ data beyond competitive advantages to these providers. The value is in marketing research for specific demographics. The revenue comes from using health information for drug research, targeted marketing and other efforts.

Many big data companies are investing heavily to own a piece of the multi-billion-dollar monetization of health information.

 “These companies know that whoever controls health information will dominate the health-care marketplace and its vast profit pool.”

Congress has been slow to fix these problems. It needs to update health-information policy and privacy rules.

These are the four most important rules that Dr.David Brailer (the former national health information technology coordinator in the Department of Health and Human Services (2004-06)has outlined.

"1. Individuals should have unqualified ownership of their health information. Every person should be able to access his information whenever he wants, without blocking or delay.

1a. Health information should automatically follow patients wherever they get treated, unless they don’t want that to happen.

1b. Patients should be able to control which people and organizations are allowed to see their information, and whether those organizations can retain that information.

2. Individuals should be able to designate an intermediary to manage their information on their behalf. Many people would not want to handle their health information, so an “infomediary” could assist them and ensure that their information is used to advance their health status.

2a. Intermediaries could be a spouse, a hospital, a health plan, a pharmacy or even a tech company like Google, SalesForce or Yahoo.

 3. Standards for security protection should be raised so that information is protected wherever it flows.

3a. A secure medical Internet—encrypted data lines that are walled off from hackers and other threats—is needed to protect the perpetual movement of information among hospitals, physicians and other legitimate data holders.

4. Every “covered entity” that touches health data, including every app, should follow the same rules."

Congress must act now!

The goal of the EMR was to have computers that could talk to each other for instant availability of patients’ medical information to enhance care and decrease retesting.

The availability of the $30 billion dollar Obama stimulus and the lack of consumer control has led to an evolving inefficient bureaucracy and rules and regulations that have created pain for the two most important stakeholders, patients and physicians.

The EMR project was not shovel ready as President Obama promised. It has turned out to be a waste of money. Instead of improving patient care it is hurting patient care.

An effective healthcare system would provide consumers with ownership of their healthcare data, their healthcare dollars and a desire to be responsible for their health.

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

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Medicaid Extortion


Stanley Feld M.D.,FACP,MACE

This topic is obscure. It is important because it is a defense of states rights opposed to federal control. The Obama administration wants to control states decisions through the use of subsidies 

I will try to make the issue as clear as possible.

The Obama administration has threatened to decrease funding of Medicaid in states (Florida, Texas and other states) that have declined to expand their Medicaid program.

The reason these states have declined to expand Medicaid is because at the end of two years these states would be stuck with increased costs they cannot afford to pay.

The Obama administration volunteered to pay all expenses for the first two years. When states that have expanded Medicaid under Obamacare are forced to raise taxes and increase their budget deficit, the people in those states will scream. The state will be hurt economically.

Obamacare and the state health insurance exchanges were designed to shift the financial responsibility for Medicaid from the federal government to the states. This action will drive the state budget deficits higher while slightly decreasing the federal deficit.

The federal government can print money. State governments cannot. State governments are required to have a balanced budget or an excess. A budget excess would result in lower state income taxes.

In June of 2012 the Supreme Court upheld the constitutionality of the Affordable Care Act by changing the “individual mandate” penalty for non-compliance to an individual tax.

I thought the court decision was wrong.

Americans must abide by the Supreme Court’s decision. This part of the decision captured the most media attention.

At the same time the Supreme Court struck down the Obamacare provision that let the federal government withhold Medicaid funding from any state that did not expand its Medicaid program or form a state insurance exchange as prescribed in the law.

 “This coercion of state governments—a “gun to the head,” as Chief Justice John Roberts put it—was a blatant violation of the constitutional principle of federalism.”

 The traditional mainstream media did not advertise this ruling widely. Many do not fully appreciate the significance of the ruling.

It is a decision in favor of states rights.

The traditional media has criticized the governors of Texas, Florida an eight other state governors that did not set up state health insurance exchanges. The criticism was that those states were wasting billions in federal funding.

In reality the ruling was a major blow to Obamacare. These governors know that Medicaid is a failed entitlement. All Obamacare did was expand Medicaid coverage to cover everyone earning less than 138% of the federal poverty level.

They knew they will be stuck with the cost overruns from a failed entitlement that did not fix the healthcare system. The ultimate result would raise taxes. These state were looking for a healthcare coverage program that would work and be budget neutral. Medicaid has not been budget neutral.

Everyone above 138% of the federal poverty level income threshold would get a subsidy to buy private coverage through the state health insurance exchanges.

The Supreme Court’s ruling has not bothered President Obama. He has a plan to get around that ruling. He has threatened to withhold more than $1 billion in Medicaid funds due the state of Florida under a waiver program first approved in 2005.

President Obama is threatening to cancel a five-year $29 billion dollar Medicaid waiver approved in 2011 for Texas.

Florida’s governor Rick Scott is suing the federal government for threatening to withhold that $1 billion. Greg Abbott Texas’ present governor will probably sue the federal government next. It will once more go to the Supreme Court.

The Obama administration is trying to get around the Supreme Court’s ruling .The scheme is called “cooperative federalism”.  Congress taxes a particular state’s residents. Congress then offers to give some of the revenue back to the state in exchange for that state adopting federal policies that the state had heretofore declined to adopt on its own.

President Obama is going to have a few problems. He needs a Democratic controlled Congress to pass the law to tax some states.

Medicaid payments are complex and vary from state to state. In Florida and Texas, Medicaid waivers allow these states to experiment with new forms of Medicaid coverage.

It is a smart move because Medicaid is a failed entitlement that needs a paradigm shift or a new system. States are supposed to be able to experiment with new ideas using these waivers..

 “States must get federal approval for their waivers, and although technically most are limited to five years, in practice they can be renewed or extended indefinitely. Some state waivers are decades old.”

Florida and Texas have waivers and get federal funding to pay for uncompensated care payment to hospitals treating Medicaid patients and the uninsured. 

The Obama administration informed Florida and Texas that expansion of Medicaid “would reduce the need for uncompensated care in the state and therefore he would link the waiver to expansion of Medicaid. If a state did not accept Medicaid expansion it might endanger the renewal of its waiver.

This sounds like extortion to me. I think Governors Scott and Abbott believe it sounds like too.

Chief Justice Roberts noted in the court’s ruling that Medicaid expansion under Obamacare “accomplishes a shift in kind, not merely degree.

“ Medicaid “is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage run by the federal government. ”

The Supreme Court found the conditions on federal funding of Medicaid to be coercive . 

When federal funds with conditions attached comprise such a large portion of a state’s budget, states do not really have any choice but to comply to the federal government’s wishes.

 States will find themselves unprotected from coercion by the federal government once they enter into the cooperative federalism scheme that President Obama and his administration concocted to bypass the Supreme Court’s ruling.

This example represents another trick play by President Obama and his administration in order to control and limit states’ rights.

I believe Chief Justice John Roberts understands this and the court will rule against the Obama administration.

However, the Obama administration’s threat will result in a huge waste of taxpayers’ dollars at both the state and federal level.

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

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Trust Is An Important Word

Stanley Feld M.D.,FACP, MACE

Trust is confidence in the honesty or integrity of a person or thing. An example of trust is the belief that someone is being truthful.

 The world is complex. As individuals we cannot know and do everything. We must assign surrogates to express and carry out our will.                                                           

We must trust those surrogates. When those surrogate seem to deceive us we distrust them.

In the past six years Americans’ trust in their leaders has been eroded.

It seems that our government surrogates have tried to deceive us over and over again. I have discussed almost all the instances the Obama administration has deceived the American people with respect to Obamacare i.e If you like your doctor you can keep you doctor” to name one.

The State Department has deceived us about Benghasi and with the outlines of the nuclear agreement. The Clintons have deceived us with their Clinton Foundation donations and the perception of undu pedaling of influence.

The result is public distrust of our institutions and each other. They have promoted distrust and  media is the message.

Atul Gawande M.D., a surgeon and public-health researcher, became a New Yorker staff writer in 1998. He contributed greatly in the public healthcare arena in 2007 making surgery safer by creating a pre-op, inter-op and post-op surgical checklist.

He has also created a checklist for delivery of babies in under-developed countries. These checklists have decreased morbidity and mortality.

I am a Gawande fan. He is a good thinker. However, in my view, he has a few blind spots. These blind spots showed up in his most recent article “Overkill.”  

Dr. Gawande’s problem is that even if his observations are somewhat correct they are not universally valid. He proves that his observations are not totally correct as he describes his approach to clinical practice.

His approach to clinical practice is to do less, not more. However, he does not consider the potential unintended consequences of doing less.

Most of his writings in the New Yorker criticize physicians and their practice of medicine.

 The articles could be interpreted as an attack of practicing physicians’ care. It could erode consumers’ confidence in their physicians causing them to mistrust all physicians and their clinical judgment and advice.

 Dr. Gawande should reexamine some of his premises. He should focus on educating both consumers and physicians as he did with his surgical checklist.

 Yellow journalism does not solve the healthcare system’s problems. It creates greater problems.

 In this New Yorker article his blind spot is well illustrated. He initially quotes Kenneth Arrow an economist who in 1963 won a Noble Prize in Economics for describing a vital problem economic call information asymmetry.”

“There is a severe disadvantages that buyers have when they know less about a good than the seller does.”

Kenneth Arrow pointed out that the prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting.”

Kenneth Arrow is absolutely right. Since 1963 many industries have worked to solve this problem of information asymmetry using the Internet to make consumers Prosumers.

Physician leaders knew Arrow was absolutely correct. Some have tried to correct the situation through patient education and the developed System of Care through the use of Chronic Disease Treatment Teams.

To me this represents a constructive approach to information asymmetry in the healthcare system rather than the approach of stimulating consumers to mistrust their physicians.

There is a simple solution. Patients must be empowered to understand their disease and the options they have for treatment. They must also take responsibility for their care.

The American Association of Clinical Endocrinologists initiated the team approach for the treatment of Diabetes Mellitus in the 1990’s. It was called “A System of Intensive Self-Management of Type II Diabetes Mellitus.”

Teaching patients to intensively control their own blood sugars and helping patients become the “professor of their disease” can decrease the complication rate by at least 50%.

The complications of diabetes result in 80% of the cost of diabetes to the healthcare system. Managing Diabetes Mellitus correctly also decreases the pain and suffering resulting from this devastating disease.

It took twenty years for the government and the healthcare insurance industry to support this notion of chronic disease management.

AACE wrote guidelines outlining the development of Diabetes Education Centers wherein patients with diabetes were the center of the Diabetes team with physicians being the coach of the team and nurse educators, dieticians, exercise therapists, psychiatrists or psychologists being the assistant coaches and an extension of the physician’s care. 

“A System of Intensive Self-Management of Type II Diabetes Mellitus.”

It is critical patients take responsibility for their diabetes care.  They must not be passive about their treatment. They must judge the quality of their treatment. If it is not excellent they need to move on. The problem might be that the patients’ healthcare plan will not permit the patient to choose those physicians and care provders in Obamacare.

Consumers have abrogated their responsibility for their treatment and the cost of their treatment to a third party. This problem originated when they were able to buy first dollar healthcare insurance coverage. Consumers were not and are still not at financial risk even though their health is at risk.

This system of disease management demands that patients become responsible for the management of their disease.

Our health is our most valuable asset. We must be responsible for our health.

Obamacare’s health insurance exchanges continue promote the same defect in our healthcare system.  It does not encourage patients to be careful about healthcare dollars or the responsibility for their healthcare.

“Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”

Please note that Gawande indicts physicians in his second sentence for recommending care of little or no value because it enhances income.

In fact ordering a CAT scan, MRI or lab work does not enhance physicians’ income unless the physicians own the machinery. Hospitals and independent testing centers own the machinery to do these tests and make the profit. Therefore his reason for “Overkill” is not primary.

Dr. Gawande goes on to expand Professor Arrow’s argument about over-testing in a system of information asymmetry.”

“Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body.”

“The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests.”

New technologies have ben a boom to the practice of good medical care. It could be argued that someone getting hit in the head and developing a long lasting headache should get a CAT scan or MRI of the brain rather than pre MRI, CAT scan era, a skull x-ray that would tell us almost nothing.

Perhaps the unnecessary care is not so unnecessary. Perhaps it is important to know the baseline study results of tests to understand the progression of an illness and controlthrough blood testing.  

There does seem to be too much testing. What might be the cause?

Dr. Gawande overlooks a very important cause of over-testing.

It is defensive medicine. Physicians are afraid of getting sued in our litigious society if they miss something. The Massachusetts Medical Society study brought out this very important point. Physicians by their own admission over-test to avoid missing an underlying disease.

A rough estimate of the cost of over-testing in America is between $200 billion to $750 billion dollars a year as a result of defensive medicine.

Dr. Ezekiel Emanual, an advisor to President Obama, has stated that the healthcare system does not need malpractice reform because defensive medicine only cost the system $25 billion dollars a year. The cost is insignificant. He is dead wrong. He is also immune to law suits because of institutional protection. He does not appreciate the wear and tear on the physicians being sued.

As Obamacare makes the healthcare system more dysfunctional consumers have less responsibility for their healthcare. A system of socialized medicine is evolving as a result of Obamacare. The government takes care of us. We all know that Medicare is unsustainable. Intelligent well-respected folks like Antul Gawade use questionable logic to unintentionally erode peoples’ trust in physicians and their judgment.

Meanwhile taxes continue to rise and America is digging itself into a deeper financial hole.

The question should be how do we do things in a constructive  rather than a destructive way.

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

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Big Pharma’s Interactions With Obamacare

Stanley Feld M.D.,FACP,MACE

President Obama strategy is to provide favors to potential enemies and then throw them under the bus when he has gotten what he needed from them.

He managed to seduce the American Medical Association, the American Hospital Association and the American Pharmaceutical Association (Big Pharma) to support Obamacare as it was being passed.

Recently he has thrown the American Pharmaceutical Association under the bus.

President Obama needed Big Pharma’s support in order to decrease the resistance to the passage of Obamacare in 2009.  In order to get Big Pharma’s support President Obama made many promises to Big Pharma and satisfied Big Pharma’s vested interests.

These promises included political protection against the left wing wish list to control drug prices. The wish list included weakening drug patents, decreasing intellectual property shelters for new drugs from 12 years to seven years and decrease payment rates for medications administered in the hospital (namely cancer drug therapies). 

Additionally, the White House agreed to spare the drug companies from central planning such as allowing the Health and Human Services Department to “negotiate” lower drug prices.

President Obama succeeded in getting Big Pharma to contribute $80 billion dollars via drug discounts that would affect Obamacare’s bottom line. Big Pharma did that largely by increasing the Medicaid’s drug discount from 15.1% to 23.1%.

Big Pharma also agreed to mark down prescriptions for seniors by 50% above a certain drug cost.

It might appear that President Obama got the better of the deal to obtain Big Pharma’s support for Obamacare.  

This was definitely not true. Big Pharma is making a killing from the government and from out of pocket payment from consumers.

A small part of the killing is explained in Dr. Dale Fuller’s article (that appear in the blog) about Oncology drugs "Is Pharmaceutical Pricing Weird, Or What?"

“Remember the business line, circa 2009, that if you weren’t at the Obamacare table you were on the menu (to be eaten)? Well, Big Pharma sat at the table, gave Mr. Obama what he wanted, and is now back on the menu as the cheese course. “

I believe President Obama’s agenda was to take all the favors away after Obamacare was passed and became law.  He tried to take Big Pharma’s favors away in the 2015 budget. He did not succeed.

He slowly worked to get most brand name drugs covered by eliminating the price fixing reprieve. Medicare Part D pays nothing or little for Brand Drugs. 

“ 2009 was then. The budget directors now claims to be “deeply concerned with the rapidly growing prices of specialty and brand name drugs” and, sure enough, it rescinds the price-fixing reprieve.”

President Obama is becoming more aggressive. He is using the mainstream media to create a furor over the price of specialty drugs. A well-publicized example is the price of the drug that cures hepatitis-C. The government will negotiate a lower price.

Drug prices had been escalating long before Obamacare. Obamacare simply let the genie out of the bottle with its favors to Big Pharma.

Big Pharma overplayed its favors and took advantage of the price reprieve inviting Big Government to step in.

I predict we are going to see all of the favors given to Big Pharma  rescinded before President Obama’s time in office is over.

The federal government will launch a price fixing offensive and choke Big Pharma’s profit making machinery completely.

This is the era of generic drugs. Big Pharma gave this away to the federal government to retain control of the new drug profit margin.  

Since government doesn’t pay for new drugs it can brag, 

“Taxpayer costs were $353 billion or 36% less than the Congressional Budget Office’s original projections for 2006-2013.”

"President Obama’s order to rescind his deal with Big Pharma will result in unintended consequences. Big Pharma will have not the incentive to develop new drugs.

President Obama’s with Big Pharmadeal should have never been  made in the first place.

Handing the $1.093 trillion HHS bureaucracy Soviet-style price fixing powers will undermine the pharmaceutical innovation that depends on large returns on the few medicines that succeed. Even the threat of price fixing could distort investment decisions

President Obama double-crossed Big Pharma.

“ In this double cross lies a warning for the next CEOs and lobbyists who are deluded enough to trust Washington liberals.   Everyone will get devoured eventually.”

“It’s tempting to say the drug makers deserve their fate, except that the ultimate costs of their folly will be born by Americans who won’t enjoy the longer lives, fewer hospitalizations and less suffering that new therapies can bring.”

 It is clear to me that a centrally controlled market rather than a free market leads to a distorted marketplace that is not self-correcting. Consumers, and not the government, must be in control of the healthcare system.

The government should protect consumers from being abused by other stakeholders in the system.

Government should not make under the table deals that hurt consumers.

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

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Obamacare Enrollment Deceptions Continues

Stanley Feld M.D.,FACP, MACE

I made a big deal out of the poor enrollment in Obamacare throughout the winter.

There are more than 330 million Americans who should have healthcare insurance. In 2014, 15 million people lost their healthcare insurance because of Obamacare regulations.

At the end of the healthcare enrollment period for 2014 the Obama administration claimed there were 9 million enrolled in health insurance exchanges. The number was modified to 6.7 million enrollees because of mistakes in counting dental plans and non-payment of the enrollees’ initial premium.

Never the less President Obama did a victory lap and declared Obamacare is working. Nothing could be further from the truth.

It is very difficult to keep track of all the false numbers thrown at the public.

The 2015 open enrollment period was delayed one month until after the mid-term elections for political reasons. President Obama and the Democrats wanted to keep the conversation about Obamacare out of the traditional media headlines.

The enrollment period of November 15th to December 31st was extended to February 15th 2015. On February 16th it was extended to March 1st 2015.

On February 16, 2015 Aaron Albright, as CMS spokesman announced,

 “Americans who couldn't enroll in federal Obamacare insurance plans over the weekend because of computer glitches or long waits will now have until next Sunday to sign up, federal officials announced early Monday.

"We are pleased that the vast majority of consumers were able to apply and pick a plan through or its call center without a problem,"  

"For those consumers who were unable to complete their enrollment because of longer than normal wait times at the call center in the last three days or because of a technical issue such as being unable to submit an application because their income could not be verified, we will provide them with a time-limited special enrollment period for March 1 coverage."

“The special enrollment period begins Monday and ends Feb. 22.”

 The extension was prompted by the Saturday outage of an Internal Revenue Service function for Obamacare enrollment, which could have prevented about 500,000 people from enrolling.

The enrollment period was extended to allow those predicted 500,000 to enroll.

The enrollment period was was extended from February 15th to February 22nd and the March 1st.

 On March 1st a special tax penalty enrollment extension was started to expire April 30th.

Only 98,000 enrolled during that 2 month extension. The predicted five hundred thousand (500,000) people did not enroll as was announced.

On December 15th  2014 these were the published enrollment figures.


Confirmed 2015 QHPs: 3,039,524 as of 12/15/14”

“Estimated 2015 QHPs (Cumulative):

11/21: 610K (462K HCgov) • 11/28: 1.02M (765K HCgov) • 12/05: 1.80M (1.35M HCgov) Thru 12/15:
4.70M (3.52M HCgov

Enrollment by state can be studied in the following link.

The Obama Administration bragged:

“The number of people enrolling or re-enrolling last week was considerably higher than in previous weeks. Week one saw 500,000 enrollees, week two had 300,000 and week three saw 600,000 sign up through”

Only 3.4 million sign ups were confirmed to receive healthcare coverage by January 1,2015.

This is only seventy percent (70%) of the expected enrollment through 12/15/14. The enrollment had been extended before New Year to February15, 2015.

“The government estimates a total 10.7 million will enroll by February 15,2015. On February 2,2015 there were 7.53 million qualified enrollees. The original estimate in 2010 was 17.5 million. The first 2015 estimate enrollment in 2014 was reduced 3 months ago to 13 million. The enrollment figure was modified.”

Somehow, the February 22 deadline was extended to April 30, 2015. The Obama administration continues to make up the rules as the go.

 On April 28th two days before the open enrollment period was supposed to close for 2015 publish these figures.


Confirmed Exchange QHPs: 11,897,180 as of 4/28/15
Estimated: 12.30M (9.38M via HCgov) as of 4/28/15

It is important to note that only 9.38 million people enrolled via HCgov in 2015. There is no change from the 2014 pre modification of the 2014 data.

It is not known how many enrollees paid their first premium.

None of these fact have been reported in the traditional media. Obamacare and the health insurance exchanges are not doing as well as President Obama says they are.

President Obama and his administrations continue to lie to Americans about enWhen is the American public going to demand a stop to the Obamacare deceptions?

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

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