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Pharmaceutical Companies Shafting Healthcare Insurance Companies

February 20, 2011
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Quality medical care measures, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

 

The pharmaceutical companies are marketing kings. The large increase in generic sales has affected their bottom line. When they are up against the wall marketing gets innovative.

“EXECUTIVES of a small insurance company in Albany were mystified when, almost overnight, its payments for a certain class of antibiotics nearly doubled, threatening to add about a half-million dollars annually in costs.”

The drug benefits costs for this healthcare insurance company increased as it did for others because the drug company was innovative. It started giving out coupons to cover the patients’ co-pay. It did not cost the patient to pay for this new expensive medication. It cost the insurance company dearly because patients stopped using the generics since their co-pay was covered by the drug company. The effectiveness difference between the generic and the new antibiotic was questionable.

This is not the first time drug companies have given patients co-payment coupons. The coupons paid the branded drugs’ co-pay. This is another example of consumer driven power. Consumers will seek the best price and highest quality.

The use of such co-payment cards and coupons and other types of discounts has more than tripled since mid-2006, according to IMS Health, an information company that tracks the pharmaceutical industry.

Consumers are smart. They know when they are getting a good deal. Pfizer, the maker of Lipitor, introduced a new coupon card that reduces the co-pay for Lipitor to $4 a month. The co-pay for Lipitor is about $50 for a month’s supply. The coupon card saves consumers as much as $50 a month. The coupon gives Pfizer a chance to have Lipitor compete with generic Zocor at Wal-Mart and other chains.

The healthcare insurance industry pays much more for Lipitor than it does for generic Zocor. The clinical evidence for a difference in the medications is small. The marketing of the clinical evidence is a gimmick. The both work the same. Lipitor is twice as potent therefore, you need half the dose to achieve the same effect.

“Drug companies say the coupon plans help some patients afford medicines that they otherwise could not. “

The health insurance companies say the coupons are a marketing gimmick. In reality they are. The healthcare insurance industry is just going to pass the cost to its bottom line to consumers by raising the price of insurance premiums.

“The member is somewhat insulated from the cost of the prescription,” said Kevin Slavik, senior director of pharmacy at the Health Care Service Corporation, which runs Blue Cross and Blue Shield plans in Illinois and three other states. “In essence, it drives up the total cost of providing the prescription benefit.”

President Obama, where are you when the public needs you? The Food and Drug Administration has been ineffective.

“The Food and Drug Administration, meanwhile, is studying the effect of the discounts on consumer perceptions, concerned that the coupons will make consumers believe that a drug is safer or better than it really is.”

The differences in costs are astounding.

  1. Once a day Minocycline is $700 per month. The price of a twice a day generic Minocycline $40 per month
  2. In New York City in a union representing public employees, 59 percent of claims were brand-name statins whose co-pay was coupon supported. The claims cost the union $17.3 million. The other 41 percent of claims were for generic statins. It cost the union only $179,000. The union has eliminated the co-pay on generic statins to encourage their use.
  3. Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years. In order to cushion patients’ out of pocket cost, the company recently increased its co-pay assistance to as much as $1,200 a month.

“It seems the best strategy for a pharmaceutical company is to price their drug as high as they possibly can and offer that co-pay assistance broadly” to insulate consumers, said Joshua Schimmer,

Co-payment coupons are distributed by drug company sales representatives to physicians. Physicians are made to believe they are helping their patients. The coupons are also available directly to patients over the Internet. Patients present them at the drugstore when paying for their prescriptions and receive the discount.

Medicis, the company that sells Solodyn(Minocycline extended tablet), have told investors that the co-payment card is used by an “overwhelming majority” of patients, and is largely responsible for doubling use of the drug, to 26,000 prescriptions a week.

The use of once a day Minocycline vs. twice a day generic Minocycline results in a difference in cost of $2.6 billion dollars a year for this one drug.

There is something wrong. Physicians are not aware of the drug companies’ gimmicks. They think they are helping their patients. The pharmaceutical industry is indeed the king of marketing.

Pharmaceutical Companies Shafting Healthcare Insurance Companies. Healthcare Insurance Companies in turn will shaft patients by increasing their premiums.

President Obama’s healthcare reform act should be doing something about this if it wants to keep the cost of healthcare down. It is not doing anything about this problem.

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

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Healthcare Insurance Companies Shafting Patients

February 16, 2011
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP, MACE

Prescription drug consumption can demonstrate the power of the consumer. This can demonstrate the power of a consumer driven healthcare system. Since 2006 the use of generic drugs to reduce the cost of healthcare for patients and the healthcare insurance industry has escalated.

Consumers have demanded that physicians use generic drugs when possible. Insurance drug plans promote the demand for generic drugs by having higher patient deductibles for branded drugs as well as not covering some branded drugs. Some insurance drug plans have eliminated the patient deductible for patients using generic drugs.

Physicians are being forced by their patients to become more aware of the cost of medications. Patients (consumers) are demanding generic substitution. In the past pharmaceutical companies seduced physicians into trying their new drugs. They sold the new drug as better than the first generation drug. In some cases it was. In most cases the difference was marginal.

Pharmaceutical companies also started to manufacture many me too drugs as well as combinations of two older drugs in order to extend expiration of the drug patent. This prevented generic drug manufacturers from manufacturing blockbuster drugs at lower generic prices.

The marketing implications were that the new medications were “better” than the old medication. The Food and Drug Administration (FDA) approved many of the combination drugs.

As physicians became aware of the cost difference between branded and generic drugs they became irritated. They have switched patients to generics.

Brand name drug patents usually last 14 years from the initial studies for FDA approval. Generic medication manufacturing undergoes the same rigorous FDA quality control study as do brand name drugs.

Both the healthcare insurance industry and Medicare/Medicaid programs have drug benefit programs. Medicare and Medicaid drug benefits are outsourced to the healthcare insurance industry by the federal government. The healthcare industry buys drugs from a Pharmaceutical Benefit Organization (PBO). Many times a healthcare insurance company owns the PBO. The payment system is very complicated. There is no way of telling what the real wholesale price of a drug is. There are many conflicts of interests involved.

There are multiple wholesale prices for a drug. Every time the drug goes through another middleman overhead and profit are also built into the drug price. In fact, the healthcare industry earns 4.7 billion dollars from the federal government per year from Medicare Part D.

There is nothing transparent about the profits made by the secondary stakeholders.

Wal-Mart almost broke the healthcare insurance industry’s cash cow by selling many generic drugs for $4 per month. Wal-Mart has recently instituted a 3 month supply cost of the drug for $10. Interestingly enough the large pharmacies, the healthcare insurance industry and the PBOs have figured out how to rip off the consumers despite Wal-Mart’s initiative.

If patients use their drug benefit insurance policy for a generic prescription, they will be charged $4 or more. The total charge toward their Medicare donut might be $30. The price the pharmacy plan (Medicare Part D) supposedly paid for a one month prescription. If seniors pay Wal-Mart cash and do not use their drug benefit plan, the total cost of the transaction to seniors is $4 as opposed to the $30 charged to their donut.

Most seniors have not figured this out. They use Medicare Part D to pay for their medications. Seniors should buy their generic medications for cash. They should not charge it to their Medicare Part D drug benefit. Since the healthcare care insurance industry probably gets the generic from the pharmacy for $4, the healthcare insurance company’s out of pocket expense for the medication is zero. Seniors have paid for the drug with their deductible. If seniors hit their donut, they will have to pay retail to the pharmacy for additional medications.

President Obama’s healthcare reform act modified the donut insignificantly. Yet he is selling the $250 increase toward the donut as a great advance.

Why is it so complicated? We are dealing with lobbies from at least three industries. None of these lobbyists represents patients or physicians.

Does President Obama’s healthcare reform act do anything to solve the cost of medications seniors need to maintain health? No.

President Obama’s healthcare reform act has done very little and very ineffectively to fix the drug benefit problem. He has not protected seniors or others from the abuses of the healthcare insurance industry.

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

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Can Employers and Patients Trust Healthcare Insurance Companies? Part 2

September 3, 2007
inMedicine: Healthcare System
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Stanley Feld M.D., FACP, MACE

Michael O’Grady of Grosse Pointe Farms, MI expresses the mistrust between the employers and the healthcare insurance industry much better than I can. He also confirmed for me that people on the internet are not only thinking about the problem of healthcare and what I am saying but are upset about the terrible things that are going on in the healthcare industry.

“I must comment on two key components of the healthcare system I felt were blatantly missing from your blog. ”

“The first was in your list of stake holders. No where to be found are the employer groups who actually fund most of the health care in this country.”

At the time I received Michael’s comment he was correct. I was concentrating on how the 46.7 million uninsured can be insured. The key answer is for employers to be able to provide tax deductible funds to their employees in order for the employees to purchase their own healthcare insurance policy with their own money. If an employee chooses not to buy healthcare insurance he does not get the money.

This maneuver accomplishes three things. First, it gets the employer out of the healthcare insurance loop. Employers may stay in the loop if they think they can protect their employees. Second, the employee relieves the employer of the burden of negotiating a premium at a tremendous disadvantage. Employers have noticed that they have be less than effective in keeping premium cost down in recent years as expressed by EC previously. Third, it puts the patient in charge of his healthcare dollar. This creates a huge buyer pool and forces the healthcare insurance companies to develop innovative and cost effective products. If they do not become efficient, someone will come along and take away the business.

Unemployed or self employed consumers can buy healthcare insurance with pre-tax dollars. This level playing field does not exist today. A self employed or unemployed person must be able buy insurance with after tax dollars. Notice that this simple change in the tax law would weaken the healthcare insurance industries hold on healthcare and force them to compete for the healthcare insurance dollar.

President Bush has called for this tax reform. However, there has been no follow-up. It seems he has backed off. Congress has no interest in passing this logical law that could help cure the uninsured problem. It would be putting power in the hands of the consumer. It has been opposed by the healthcare insurance companies lobbying effort. The evaluation of the Congressional Budget Office seems to point to a positive outcome when read in detail.

“Although you appear to have many good ideas, and are a proponent of changing many of the necessary evils of the broken health care system, you are in fact a stake holder.”

Michael, I am presently a consumer stakeholder. I retired from an excellent practice of Clinical Endocrinology in order to devote adequate time to help repair the healthcare system for the benefit of the consumer and the survival of the patient physician relationship. I believe the patient physician relationship is a critical therapeutic element in the care of sick patients. Making medical care a commodity will destroy medical care in this country.

“The employers are the one in the end who actually foot the bill for most of the health spend in the U.S. The unfortunate circumstance is they are being led blindly down the path of excessive baggage by consultants and their partners, who we refer to as BUCA (Blues, United, CIGNA, and Aetna).”

Michael, you are correct. The large employers have human resource officers whose responsibility is to choose the correct healthcare insurance plan for its employees. The BUCA have learned to manipulate and confuse the human resource officers. It gets back to the old question: would you let your human resource officer, or insurance company purchase your food, your clothing or your car? You might let the HR person negotiate for you. However you are the owner of the purchase and would be responsible for the choice. Your unwillingness to let the HR person negotiate for you would increase if the purchases became more confusing and unsatisfactory. You would want control.

The seller (healthcare insurance company) is motivated in the present system to confuse the HR officers. The seller also has the advantage because the number of people in a single company is small compared to the total number of people in society as a whole. The key to repair is to motivate the seller to compete. In a real price transparent environment the healthcare insurance industry would be competing for customers. All the necessary changes would have to occur at the same time for it to be effective.

“The second piece I felt that was missing was the reimbursement methodology in place today prevents any fix of the health care system. The PPO discount system is a disaster and adds between four to six billion unnecessary dollars to the health care system each year. These are dollars employer groups are paying to the BUCA’s and PPO networks in access fees each year, to provide provider discounts. Twenty years ago there may have been a value to an employer group to receive discounts in exchange for steering patients. There may have been a value to a provider to provide discounts in exchange for steerage. These days are over, and retail is for suckers.”

Michael, you are right on target. No one pays retail unless they want to. The reason Sam Walton went from a bloomer salesman to the largest department store on the globe is because he learned how to provide the best price with a good quality product to the consumer . Consumers figured out which price and product was best for them.

“So why should employers pay four to six billion a year for what really amounts to retail pricing? Transparency? Does it matter if a provider makes transparent their charge master? Each network or carrier has their own deal with each provider that is considered proprietary. What is being charged by the provider is irrelevant, thus making any HSA plan doomed to failure.”

Price transparency is bogus in healthcare lingo presently. The automobile industry is getting close to real price transparency. They are not there yet. The electronic industry is close with organizations like c/net.com and simonsays.com. The consumer is not stupid. When they are in control or their healthcare dollar they will force real price transparency. Actually, they are getting smarter each day.

“A new reimbursement methodology needs to be adopted. This new methodology needs to be developed in partnership with employer groups and providers. There is a necessity for administrative functions within the health care system. Third party payers and insurance carriers do provide a valuable service. Unfortunately, BUCA now is the majority stake holder in health care. Until this changes, and employers and providers begin to work together, BUCA and the consultants will continue to take advantage of this lack of connectivity and continue the path of absolute disaster.”

Bravo, Michael O’Grady. The easy way to accomplish your goal is to get the employer out of the picture. As EC pointed out the employer really wants to provide healthcare insurance to his employees. However, it is becoming an impossible and over costly task. Let it be between the patient and the physician. Reducing the physicians overhead by 20-30% will give the physician the ability to reduce his price. If he doesn’t he will suffer the consequence of the consumer walking with his feet and pocket book.

It does not have to be complicated. The primary stakeholders are the patients and the physicians. They should be the interface for the medical care transaction. If a hospital is too expensive, he would send his patients to another hospital. If patients had no choice of hospital the government should impose regulations on the hospitals to reduce the price. It can be done. It can also be profitable for everyone except the stakeholders that profit from the 150 billion dollars of administrative waste.

The healthcare insurance companies would once again be converted to a 6% broker and not the unconscionable owner of the healthcare system.

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Can Employers And Patients Trust Healthcare Insurance Companies Part 1

August 29, 2007
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Stanley Feld M.D.,FACP,MACE

I received several comments in recent weeks highlighting the hardships employers face trying to provide healthcare insurance to their employees. Employers, and individuals who want to buy individual insurance have been deceived by the healthcare insurance industry. Many associations subcontract healthcare insurance companies to provide healthcare insurance for the association membership. However, the healthcare insurance is expensive and deceptively limited. People think they are covered until they get sick and discover they are not.

The simple answer is the ideal medical savings accounts with high deductible insurance available to all after all the conditions for the ideal healthcare systems are met.

The healthcare insurance industry and congress have blocked the ideal medical savings account concept for years. Why has congress been so stubborn? MSAs were introduced by the Golden Rule insurance company at least a decade ago. Congress has been influenced by healthcare insurance industry lobbying to block the concept of individuals owning their healthcare dollar and also receive a pretax dollar tax exemption for buying their own healthcare insurance policy. I also do not believe that many of the members of congress want to understand the power and intelligence of the consumer.

In my naïve younger days, I simply could not understand why congress would be opposed to such a logical plan. It would eliminate 150 billion dollars of administrative waste in the healthcare system. My problem was I was not aware of the excessive influence the healthcare insurance industries lobbying groups have on congress.

Lobbying groups in general wield more influence than the will of the people in the daily activities of government simply because they have more money and are more focused than the individual. Previously, I spent a lot of time on TXU’s desired to pollute Texas even further with “Dirty Coal Plants”
and the subsequent acquisition of TXU by KKR with KKR’s promise to discontinue the pursuit of dirty coal plant permits.

This past week it was published that TXU and KKR spent $17 million dollars just to get its merger passed and work its way toward building dirty coal plants in Texas. Imagine how much the healthcare insurance industry pays lobbyists.

It is a true goliath against a weak and divided foe, namely patients (the consumer). Consumers do not get activated unless they are affected. Only then to they want to do something to solve the problem. The problem is only 20% of consumers are sick at any one time. We do not anticipate that we could be affected any day now.

It took the healthcare insurance industry four years and many millions of dollars to have firms like Cooper Lybrand and Price Waterhouse develop schemes that would counter the potential effectiveness of the Ideal Medical Savings Account. They developed the concept of the Health Savings Account. The HSA kept the premium dollar in the control of the healthcare insurance companies. The healthcare dollar does not belong to the patient. The healthcare insurance industry robbed patients, physicians and hospitals of incentives to be innovative in order to repair the healthcare system by being competitive.

United Healthcare bought the Golden Rule Insurance Company. It immediately destroyed Golden Rule’s medical saving account product. UnitedHealthcare has converted Golden Rule’s MSA to an HSA. I cannot understand why the health policy experts who advocated MSAs are satisfied for the now. Their argument is this is compromise. It is a step in the right direction.

To paraphrase the great German philosopher Fredrick Hegel “An ineffective step in the right direction is worse than no step at all. If the ineffective step fails then you will never created the correct concept.”

I will add, especially if the step in the right direction is a purposeful step in the wrong direction. HSAs are destined to fail, in my view, because they do not put the consumer in charge of his healthcare dollar.

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What Should Be Done to Repair the Healthcare System?

March 4, 2020
inConsumer Driven Health Care, Medicine: Healthcare System
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What Should Be Done to Repair the Healthcare System?

Stanley Feld M.D.,FACP, MACE

On March 10, 2020, Obamacare will be ten years old. Obamacare has had many failures. Obamacare’s biggest failure is the resulting distortion of the healthcare delivery system. The distortion is the result of all the stakeholders adjusting to Obamacare’s new rules and regulations.

All of the stakeholders had to adjust the way they delivered or priced healthcare to their individual advantage.

Primary care physicians started moving toward the model of Concierge Medicine. In order to have a primary care physician, consumers must pay primary care physicians between $2,000.00 and $38,000.00 annually to be in their panel.  The movement toward Concierge Medicine is the result of the Obamacare regulations, the healthcare insurance company’s reimbursement cuts, and the increase in malpractice insurance premiums.

Primary care physicians found that in order to make a living and pay their increasing overhead, they must become Concierge Physicians. This is to the disadvantage of consumers since they must continue to buy healthcare insurance.

The insurance industry has adjusted to Obamacare’s regulations by lowering reimbursement to physicians and hospitals while raising premiums. Insurance companies and Medicare Advantage programs have restricted enrollees to only certain physicians in their network and restricted certain treatments and access to certain specialists and groups.

It all goes back to President Obama’s statement, “If you like your doctor you can keep your doctor. If you like your hospital you can keep your hospital.” To my disappointment the AMA accepted President Obama’s obvious lie in 2010.

As the the government and the insurance industry decreased reimbursement physicians have had to increase the number of patients they see in one day in order to make up for their decreased revenue.

Malpractice claims and malpractice payments for claims have increased in most parts of the country. This resulted from a lack of tort reform by congress and the Obama administration. Physicians then increased diagnostic testing in order to cover all possible illnesses.  The increase in testing led to an increase in healthcare cost.

Obamacare has also increased the cost of insurance by requiring payment for additional coverages. The first dollar insurance coverage after deductibles are met has resulted in the overuse of the healthcare system. The government and the insurance industry are trying to decrease the overuse of the system by increasing deductibles.

In fact, some Obamacare insurance plan deductibles are so high that insurance payment never kicks in. People who buy Obamacare insurance plans cannot afford the deductibles and do not use the insurance until they are so sick, they cannot avoid being hospitalized.

It is impossible to figure out how health insurance premiums increases are calculated by the private healthcare insurance sector or the government healthcare insurance sector. It is impossible to figure out how the multimillion-dollar salaries for insurance and hospital executives are calculated. These expenses are part of why insurance premiums are rising.

It is also impossible to determine how hospital systems price their care. The government also pays hospital systems a premium for outpatient hospital care in an outpatient setting. The fees are at least 20% higher than in a free-standing private practice office.  

Hospital systems are figuring out how to manipulate their reimbursement systems to have an advantage over their competitor.  In New York City, Columbia Presbyterian Hospital System has accumulated ownership of many hospitals inside the city and its suburbs. With that ownership, they have acquired many in-patient and out-patient hospital salaried physicians. The hospital system is now demanding increased payment from healthcare insurance companies and the government in order for patients to use their system. The hospital system has hired many of the physicians’ patients desire to see. Columbia Presbyterian has gained control of the reimbursement levels in those markets.

There is an encouraging trend that was started by Keith Smith M.D. in Oklahoma City. Dr. Smith started a cash-only outpatient surgical clinic several years ago. He charges less for procedures than a patient’s deductible from some insurance companies.

This gives us some insight into how much fat is in the healthcare system expenditures.  Dr. Smith and physicians working in his outpatient clinics are happier and are making more money than they were working for local high-cost hospital systems in town. The patients are happier because there are no hidden or surprise costs.

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Dr. Smith’s clinic is drawing patients from all over the United States. He has also inspired the formation of many similar clinics in the U.S.

This is not new. Specialists such as gastroenterologists have opened freestanding centers. They charge less for colonoscopy and endoscopy than the hospital systems. Radiology clinics have done this for many years. The hospital systems have, somehow, worked out payment for their higher costs with the insurance industry and the government.

Dermatology is a specialty that does not need a hospital system. Large physician-owned

dermatology clinics have opened. They charge less than the dominant local hospital system.  

Many of these large specialty centers have sold their clinics to venture capital firms.  

How the venture capital firms are going to leverage their investment is unclear to me.   

Emergency rooms all over the country are overcrowded because primary physicians cannot see all of the patients in their offices in a timely manner. Hospital system emergency rooms are inefficient and overpriced. The ER is an unpleasant experience for many patients.

Venture capital firms have opened free-standing Urgent Care and Emergent Care centers all over the country. (Doc-In The Box). Many of these centers are covered by nurses, nurse practitioners, and physician assistants. All physicians have to do is co-sign with the provider to get reimbursement by the government and the healthcare insurance industry.

This is not my idea of developing patient-physician relationships.    

If a patient has to be admitted to a hospital his primary care physician is not permitted take care of him in many hospital systems. Hospital systems have hired hospitalists to care for patients. A patient might see a different hospitalist each day of the admission.

What happened to the therapeutically valuable physician-patient relationship? This relationship is critical for curing much morbidity from chronic illness. 

 I have covered the Repair of the Healthcare System in great detail in the past.

 I have also covered the errors in the structure of Obamacare leading to the distortions in the delivery of healthcare and the increased costs of the healthcare system.

The stakeholders are physicians, patients, hospital systems, insurance companies, pharmaceutical companies, and the government.

All patients want is to get the best medical care when they get sick. The interest in disease prevention is slowing growing events though many millions of dollars have been spent on programs that could help prevent chronic disease.

All hospital systems, insurance companies, pharmaceutical companies are interested in are maximizing profits and minimizing expenses.

All physicians are interested in is delivering the best care possible.

Patients and physicians are the most important stakeholders in the system.

The government wants to spend the least amount of money possible to enable the best care at the lowest price.

There has been little attempt by congress, the bureaucracy or previous administrations to remedy the defects I have pointed out.

 I have not seen any attempt by Congress to lower the price by decreasing the bureaucratic impact on the price of healthcare. Nor have I seen the exposure of the clandestine deals hospital systems make with insurance companies or the government.

I have not seen any movement toward decreasing the malpractice crisis in America. Tort reform has been vitally necessary for the last thirty years. It has been totally ignored by government officials.

These are some of the basic reforms necessary to start repairing the healthcare system. All our politicians do is kick the can down the road to the advantage of the secondary stakeholders and not the consumers.

These are some of the main reasons the system has to convert to a consumer-driven system that I have outlined previously.

Consumers must control their health and their healthcare dollars. They must be provided with an education that will help them control costs. They must be provided with financial incentives to control costs.

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



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Canada Has Big Single Party Healthcare System Problems

February 20, 2020
inMedicaid, Medicare, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D., FACP, MACE

There are big problems in Canada that have been undisclosed by Democrats to the public in the United States.

There were two articles in American newspapers in 2011 that applaud the Canadian system.

 Article 1. Debunking Canadian health care myths – The Denver Post .

Article 2. Everything you ever wanted to know about Canadian health care in one post. Washington Post.

Both articles are opinion articles and lack concrete evidence. The articles contain both misinformation and disinformation.  The articles are in essence  fake news designed to mislead the American public into believing that a single party payer system is the answer to America’s healthcare systems problem.

The articles are precisely why the American public should not and does not trust politicians and the traditional mass media.

The Fraser Institute is a well-respected Canadian think tank. Its research is considered accurate, with a libertarian slant.

Its 2011 report contradicts the statistics in both the Washington Post’s and the Denver Post’s articles about the Canadian government healthcare costs.

 Article 1. “Ten percent of Canada’s GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada’s.”

Article 2.  “In 2009, Canada spent 11.4 percent of its Gross Domestic Product on health care, which puts it on the slightly higher end of OECD countries.”

This is not true according to the Fraser report. Six of ten Canadian provinces are on track to spend half of their revenues on health care, according to the Frazer Institute. To be specific, in 2011, health care spending consumed 50% GDP in Canada’s two largest provinces, Ontario and Quebec.

“Total federal, provincial and territorial government health spending has grown by 8.1 percent annually, while the national GDP in Canada rose by only 6.7 percent during the same period.”

 The provincial governments have raised taxes and rationed care, while increasing patient wait times.  

“Provincial drug plans have also more often refused to pay for most of the drugs that are certified as “safe and effective” by Health Canada.”

“Unsustainable rates of growth in health care spending crowd out the resources available for other purposes including education, public safety, and economic growth-enhancing tax relief.”

One has only to think about the Obama administration’s initial propaganda and the stunning reality we are facing presently. 

The VA is now asking for additional funding to clear up its disaster.

The problem is entitlements are too expensive for governments.  Entitlements do not work because governments cannot legislate behavior by directives. Individuals must be responsible for their health and healthcare dollars.

The other problem is government entitlement programs generate a large bureaucracy. The bureaucracy stimulates the development of inefficiencies and corruption. The new bureaucracy practically guarantees the failure of the entitlement.

The government never gets to the core problems that must be repaired when they try to construct a healthcare system that is efficient, cost effective and will benefit consumers. 

The primary stakeholders are consumers of healthcare. Physicians are a close second. Secondary stakeholders are hospital systems, healthcare insurance companies, drug companies, malpractice insurance companies, and the government.

In order to Repair America’s Healthcare System, the government must focus on the primary stakeholders’ (patients’) needs and ways to satisfy those needs. The key is to set up a system that provides the primary stakeholders (consumers of healthcare) with incentives to maintain their health and conserve their healthcare dollars. This applies to healthy consumers as well as patients with chronic diseases.

Patients with chronic diseases must become professors of their disease. They must understand the latest techniques and use the latest tools to prevent the progression of their disease.  

The healthcare system must help consumers be prosumers (productive consumers) of their own healthcare.

The Canadian system is not the answer to our healthcare system’s problems. The United States has a much larger population than Canada. The Canadian government cannot support its universal healthcare system.

 How will we? Bernie Sander’s state of Vermont has abandoned its “Medicare for All” program.

The only way the portion of our population in favor of Medicare for All is going to believe it is unsustainable and destined for failure is going to experience its failure. It seems Bernie and his followers have little interest in learning from previous experience.

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

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Slowly But Surely :Trump Is Quietly Reforming Healthcare

June 27, 2019
inUncategorized
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Stanley Feld M.D.,FACP, MACE

Since congress did not want to help President Trump repeal Obamacare and fix the healthcare system, he decided to quietly repair the healthcare system by himself. He has no choice. Obamacare will self-implode and disappear.

President Trump has kept his steps toward healthcare reform under the radar. It is all published and there for everyone to see.   

President Trump is hoping that after the 2020 election he will have a friendlier congress. A congress that wants to do something to help him help American consumers of healthcare obtain affordable healthcare.

Consumers need relief from the Obamacare disaster. Obamacare has caused increased dysfunction on top of an already dysfunctional healthcare system.

Obamacare has caused a previously unaffordable healthcare system to become more unaffordable.

I hate to say it. I predicted Obamacare would fail in 2010. Basically Obamacare did not align stakeholders’ incentives.

Will Obamacare Fail?

I explained why Obamacare was failing in each subsequent year of its passage.

http://stanfeld.com/?s=Obamacare+will+fail

 I also offered my concept of repair of the healthcare system with my ideal medical savings accounts.

My Ideal Medical Savings Account Is Democratic!

President Trump has taken important steps to repair the healthcare system. He has brought back the power of “Associations.”  Associations now have the ability to negotiate with healthcare insurance companies and sell healthcare insurance to its members.

The Trump Administration Makes Progress On Health Care

In addition, Associations now have the ability to offer its members healthcare insurance at pre-tax dollars. This is a very big deal. Previously individuals seeking individual insurance had to pay for that healthcare insurance with post-tax dollars.

https://www.modernhealthcare.com/article/20181110/NEWS/181109905/early-association-health-plans-defy-fears-offer-comprehensive-benefits

Instantly, healthcare premiums are effectively reduced to consumers by 20-40% using pre-tax dollars. This make present premiums more affordable.

Associations are growing very rapidly as final rules are being created to make their healthcare insurance available. The significance of Associations has been largely ignored by the mainstream media. 

Associations will create competitiveness among healthcare insurers and help individuals, small business and even giant corporations eliminate the need to negotiate and provide healthcare insurance to their employees. It might even help the government’s unsustainable programs such as Medicare, Medicaid and the VA rid itself of these unsustainable programs.

The traditional mainstream media has been busy publicizing the socialist concept of “Medicare for All.”

I have pointed out that “Medicare for All” doesn’t work. It has never worked in a financially sustainable way for many countries. In countries that have socialized medicine consumers are dissatisfied because there are long waiting times and a shortage of the access to medical and surgical care.

The Concept of “Medicare for All” is Misguided
Bernie Sanders’ Proposed Tax Hikes To Pay For “Medicare for All”

Our leftist politicians say socialist medicine has worked beautifully in countries like Sweden, Denmark, Canada, and England to name a few.

I have published the difficulties consumers have had in these socialized medicine countries.

Swedes Are Frustrated Over Their Socialized Healthcare System
Do Finland’s and Britain’s Healthcare System Work

Unfortunately, our leftist politicians are either ignoring the truth or do not know what they are talking about. The traditional mainstream media are simply acting as puppets for our leftist Democratic politicians who want to control the healthcare system.

Everyone knows the larger the bureaucracy the more inefficient the system. The VA healthcare system is a perfect example of this statement.     

Associations Are  Growing

“Last week, the executive order was initiated that will empower consumers in the individual healthcare insurance market and those consumers in the small corporations to purchase healthcare insurance through associations. It will allow the employers in small corporations to pay for their employees the healthcare insurance through the Associations with pre-tax dollars.”

“It will level the playing field to enable individuals in both groups to negotiate healthcare insurance premium prices through their associations with the same purchasing power that large corporations have.”

https://www.modernhealthcare.com/article/20181110/NEWS/181109905/early-association-health-plans-defy-fears-offer-comprehensive-benefits

It could also work for consumers working for large corporations. Those employees who are displeased with their corporate provided healthcare insurance coverage can change to association provided insurance.

The new rules can potentially get employers out of the healthcare insurance providing business.

These new regulation has had little coverage in the New York Times, network television or any other mainstream media.

The traditional main stream media have been pushing the Democratic Socialists’ idea of “Medicare for All.”  “Medicare for All” cannot work.

The Concept of “Medicare for All” is Misguided

“On Thursday June 20th 2019, the Department of Health and Human Services announced a final regulation that allows businesses to fund employees who buy health insurance on the individual market–something that until now has been illegal.”

 “The U.S. Departments of Health and Human Services, Labor, and the Treasury issued a new policy that will provide hundreds of thousands of employers, including small businesses, a better way to provide health insurance coverage, and millions of American workers more options for health insurance coverage.”

Since this new policy is a President Trump initiative, the elites in the media must have concluded that is a silly policy and it cannot work.

“ The Departments issued a final regulation that will expand the use of health reimbursement arrangements (HRAs). When employers have fully adjusted to the rule, it is estimated this expansion of HRAs will benefit approximately 800,000 employers, including small businesses, and more than 11 million employees and family members, including an estimated 800,000 Americans who were previously uninsured.”

A close study of Health Reimbursement Arrangements (Associations) will make it clear that these numbers are correct. In fact, these estimates might be a gross underestimation of increased number of consumers with healthcare coverage.“Under the rule, starting in January 2020, employers will be able to use what are referred to as individual coverage HRAs to provide their workers with tax-preferred funds to pay for the cost of health insurance coverage that workers purchase in the individual market, subject to certain conditions. … Individual coverage HRAs are designed to give working Americans and their families greater control over their healthcare by providing an additional way for employers to finance health insurance.”

https://www.modernhealthcare.com/article/20181110/NEWS/181109905/early-association-health-plans-defy-fears-offer-comprehensive-benefits

Associations allow everyone to be participants in the large corporation negotiating healthcare market. It allows consumers to avoid the trap of large, bureaucratic and by definition inefficient government control healthcare.

“The HRA rule also increases workers’ choice of coverage, increases the portability of coverage, and will generally improve worker economic well-being. This rule will also allow workers to shop for plans in the individual market and select coverage that best meets their needs. … [T]he final rule should spur a more competitive individual market that drives health insurers to deliver better coverage options to consumers.”

 The new policy empowers individual consumers to shop the market and select the healthcare coverage that best meets the needs of their family.

The insurance industry will not have to comply with the burdens of Obamacare’s regulations for healthcare coverage. They can create new products including medical savings accounts without restriction.

This will create an extremely competitive healthcare insurance environment.

“This is a good example of how the Trump administration is moving forward in practical ways on important issues, empowering consumers and freeing up markets. The Democrats don’t like it, of course. But the new HRA system will be popular with millions of Americans whose ability to access the individual market and exercise consumer choice will be enhanced.”

https://www.modernhealthcare.com/article/20181110/NEWS/181109905/early-association-health-plans-defy-fears-offer-comprehensive-benefits

The only big barrier is that it will make consumers become responsible for choosing their healthcare coverage and be responsible for their healthcare dollars.

I believe most Americans are up for the challenge.

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



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Mechanism Design and the Repairing the Healthcare System

May 15, 2019
inUncategorized
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Stanley Feld M.D., FACP, MACE.      

On November 11, 2007, I published the following blog: “Incentives and Mechanism Design.” The authors Leoid Hurwicz, Roger Meyerson and Eric Maskin were awarded the Nobel Prize in Economics for the concept in 2007.

http://stanfeld.com/?s=mechanism+design

 I suspect few politicians know about Mechanism Design in 2019. I am certain Bernie Sanders and the “Medicare for All” crowd do not know anything about Mechanical Design.

In my last blog, I described how politicians and the mainstream media use Confirmation Bias to try to put the government in control of healthcare against the will and welfare of the public.  

https://en.wikipedia.org/wiki/Confirmation_bias

I think Donald Trump either studied the use of Mechanism Design and its mechanics or he intuitively uses its principles in his thinking.

Mechanism Design is a concept that tries to put science into social science. It mathematically evaluates vested interests of stakeholders in order to eliminate confirmation bias and line up all the stakeholders’ vested interests for the greatest good. It assumes all the stakeholders have expressed their vested interests truthfully.

Please Read Between the Lines

The Democrats want to hold onto (fix) Obamacare. However, the Democrats understand Obamacare is not viable in its present form. I believe “Medicare for All” with central government control of healthcare will be a disaster as it has been in most single party payer systems.

I do not believe Obamacare is fixable. I believe President Obama and the Democrats believed that Obamacare would fail. Then the nation would beg either his public option or Medicare for All.

I think President Obama believes “Medicare for All” and the total government control of healthcare is the ideological solution to the problems in our healthcare system.

His confirmation bias overrules all of the examples of “Medicare for All” failed examples at home (Vermont California and Colorado), as well as Denmark, Sweden, England, and France.  

In 2017, the Republicans with a slim majority in the Senate refused to repeal Obamacare. Whether the Republican failure to repeal Obamacare was because of intramural revenge or ideology is best to question is which system is best for the common good.

If our politicians understood the principles of Mechanism Design and were diligently working for the people who elected them benefit, America would be on the way to “Repairing the Healthcare System.”

Against this backdrop of a hostile Democratic Party, in control of the House of Representatives, Donald Trump and his administration is slowing working its way to “Repairing the Healthcare System” using the principals of Mechanism Design.

In November 2007, pre the Obama administration, I wrote:

Last month the Nobel Prize in economics was awarded to Leoid Hurwicz, Roger Meyerson and Eric Maskin. They were awarded the Nobel Prize for developing the economic theory of “Mechanism Design.” My first reaction was “what is that?”

https://en.wikipedia.org/wiki/Mechanism_design

After some research, I discovered the power of Mechanism Design. It is a brilliant economic theory that could solve many economic problems. Mechanism Design applied to our healthcare system could solve the healthcare systems problems.

What is it? “In economics, mechanism design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested. This is done by setting up a structure in which each player has an incentive to behave as the designer intends. The game is then said to implement the desired outcome. The strength of such a result depends on the solution concept used in the game. It is related to metagame theory, which is the theory of games the play of which consists of developing the rules of another game.

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare. However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers [1], thus significant research in mechanism design involves making trade-offs between these qualities. Other desirable criteria that may be achieved include fairness (minimizing variance between participants’ utilities), maximizing the auction holder’s revenue, and Pareto efficiency. More advanced mechanisms sometimes attempt to resist harmful coalitions of players.”

Lodi Hurwitz contributed to the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design a mechanism in which everyone does best for themselves. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

If everyone’s incentives are aligned, you have a much more efficient economic system. An example is defense contracting. If you agree to pay on a cost-plus basis you have created an incentive for the contractor to be inefficient. If you agree to pay a fixed price you can come close to an efficient price if you have all the truthful information. If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information. If the rules of the game require truthful information you can get close to an efficient market-driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off. Therefore, the incentive is to maintain your dominance by not being truthful at the expense of others. Hurwicz observed as others had that the dispersion of information was at the heart of the failure of a planned economy. He observed that there was a lack of incentive for people to share their information with the government truthfully. The free market mechanism was far less afflicted than central planning bureaucracy by such incentive problems. The free market economy was by no means immune to this defect. He observed that the free market economy can get us closer than central planning to incentive compatibility because the end consumer can drive the discovery of truthful information.

The customer creating rules of engagement in a market-driven economy can get you closer to the ideal of Mechanism Design. Since the customer determines success of an enterprise by creating demand in a transparent environment, they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

Roger Meyerson contributed the revelation principle, a mathematical model that simplifies the calculation to create the most efficient rules of the game. The mathematical model gets people to reveal their truthful private information leading to aligned incentives.

Eric Maskin’s breakthrough was in perfecting Mechanism Design with his “implementation theory.” His theory clarifies how to design mechanisms that heighten incentive alignment and efficiency.

How does Mechanism Design relate to the Repair of The Healthcare System? We have to set the rules of the games so that we align all the stakeholders’ incentives without one stakeholder takes advantage of another. The insurance industry is taking advantage of the patients, doctors and hospital systems. The hospital systems are taking advantage of the patients, doctors and insurance companies. Doctors are taking advantage of the insurance companies, hospital systems, patients and the government. The government is taking advantage of the hospital systems, the doctors and the patients. Employers who pay the insurance bills for their employees are taken advantage of by the insurance companies. The drug companies are taking advantage of patients and unduly influencing physicians.

In our healthcare system, everyone is pursuing his vested interest in a game that has rules that do not lead to “incentive compatibility.”

Some politicians think central planning will straighten out the rules. Historically, central planning has not worked. The winners of this year’s Nobel Prize in economics have proven this fact.

I believe consumers can fix the rules of the game so that all the incentives are compatible. Consumers have to have incentives to force politicians to fix the rules of the healthcare game. Consumer-driven healthcare system will achieve the alignment (incentive compatibility) using the ideal medical saving account.

Twelve years have passed since 2007. America has not gotten closer to the solution to Repair the Healthcare System even though the solution is staring us in our eyes.

www. stanfeld.com

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



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Did Obamacare Cause The Increase In Private Healthcare Insurance Premiums?

February 2, 2019
inMedicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP, MACE

A reader of my blog received this question from one of his friends.

The reader asked me his friend’s question  “I have a question and I don’t want it to be political (as I stay away from that for many reasons).                                                                                                                                 
Health insurance is so expensive and it does not cover hardly anything. We had to get the worst plan with the worst coverage. But it was not this way 6 years ago. We could afford good coverage.   

 The question is: Did Obamacare cause this change in healthcare insurance and these problems in access to care?

A reader asked:

Which of your blogs would be the best one to show him to answer his question?

The answer to the question is YES!! I will try to explain.

If I sent all the links to your friend would be overwhelmed. There are too many to count.  I will summarize some of the major reasons Obamacare is to blame for some of the increases in private healthcare insurance premiums and the decrease in the access to care. Obamacare has led us into a financial disaster. “Medicare for All” is not the answer.

I believe the goal of Obamacare was to create greater dysfunction in the healthcare system which would lead to huge premium increases for private healthcare coverage. The public would then beg the government to adopt a single party payer system with “Medicare for all.” This has been the progressives”  goal since 1935. Do you remember Barney Frank and John Kerry saying we cannot have a single party payer system yet because we do not have the votes?

https://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2018/10/the-main-reason-behind-rising-medical-costs.html

The government has not had a very successful single party payer systems record.  The VA Health Administration, the Indian Health Service, Medicare and Medicaid are all inefficient and financially unsustainable.

“Our federal government already runs three single-payer systems—Medicare, the Veterans Health Administration, and the Indian Health Service—each of which is in a shambles, noted for fraud, waste, and corruption.”

“Why would we want to turn over all of the American medicine to those who have proved themselves incompetent to run large parts of it?”

https://imprimis.hillsdale.edu/short-history-american-medical-insurance/

The federal government depends on healthcare insurance companies to do the administrative services for Medicare, Medicaid and Obamacare. Administrative services include negotiating payments to hospitals, nursing homes, physicians and providers on all levels.

The various healthcare insurance companies are supposed to bid for these service contracts. The insurance companies receive one global fee.  The healthcare insurance company with the contract must pay providers on a fee for service basis. The healthcare insurance companies do not have good enough data to make an accurate bid estimate.  Actuary science is not rocket science. The healthcare insurance company builds in a twenty percent cushion to the bid. If the bid was low and the healthcare insurance company that lost money Obamacare guaranteed through a complicated reinsurance formula reimbursement to the company for its loss.

Recently the government audit discovered an overpayment of $10 billion dollars to the healthcare insurance industry for Medicare Part D.

I believe there is much more overpayment in Medicare Part A, B and D because of the government bureaucracy. The government only had the money to pay 12% of the reinsurance claims of the healthcare insurance company one year. The insurance industry simply raised the premium in the private sector.

http://stanfeld.com/president-obama-somehow-finds-the-money/

http://stanfeld.com/accelerating-the-destruction-of-the-healthcare-system/

http://stanfeld.com/the-deception-and-disinformation-continues/

Nationwide, the Obama administration made $7.3 billion in reinsurance payments to health insurers. The reinsurance program, funded by taxes on health insurers and self-funded employer health plans, has been criticized by Republicans as a “bailout” for insurers.

https://www.ibj.com/blogs/12-the-dose-jk-wall/post/53906-obamacare-shovels-another-122m-to-indiana-insurers

The healthcare insurance industry then once again raised premiums on the private healthcare sector to make up for its losses. to

The government reinsurance payments weren’t enough in all cases. New York-based Assurant Inc. asked for a 26 percent hike in private premiums for 2016, due to high claims in Indiana, before that company decided to exit the Obamacare markets in all states.

This was typical price shifting.

http://stanfeld.com/?s=price+shifting

Healthcare insurance companies projected that Obamacare would result in them losing money because of adverse selection. Obamacare’s increase required benefits for both public and private insurance. Obamacare’s rules included coverage for oral contraceptives for all and coverage of pre-existing illnesses among others. A sixty-year-old male does not need an insurance policy the receives oral contraceptives.

The healthcare insurance industry asked for double-digit increases in private healthcare insurance in every state. The logic was that these enrollees would pay for the loses that would occur from the Obamacare enrollees.

http://stanfeld.com/managing-points-of-view-and-healthcare/

The government’s argument is all should pay for everyone ’s healthcare needs. These healthcare needs have increased as the population has gotten more obese and has had a rise in drug addiction. These increased healthcare risks resulted in increased actuary estimates of healthcare cost. It does not put a burden on consumers who do not act responsibly.

The increased healthcare premiums caused many employers to drop healthcare coverage for their employees. The decrease in healthcare insurance coverage added to the pressure of healthcare premium increases.

The healthcare insurance industry also plays games with the Medical Loss ratio. The result is an increase in healthcare premiums and deductibles while decreasing services. The Obamacare issued regulations that the insurance industry must dedicate 80% of the healthcare premium to direct medical care and 20 % can be used for administrative expenses for both the public government insurance and private insurance. It is the state insurance regulators responsibility to enforce the regulation.

The expenses the industry wanted to be included are;

Expenses to be included in direct medical care are:

  1. The cost of verifying the credentials of doctors in its networks.
  2. The cost of ferreting out fraud such as catching physicians over testing patients or doing unnecessary operations.
  3. The cost of programs that keep people who have diabetes out of emergency rooms.
  4. The sales commissions paid to insurance agents.
  5. Taxes paid on investments.
  6. Taxes paid on premium income.

All these expenses are administrative expenses in my view and not medical expenses. If these expenses are permitted as benefit expenses, premium money available for direct medical care would decrease. The eighty percent required for direct medical care would be markedly reduced. The result would be an increase in healthcare insurance premiums.

http://stanfeld.com/medical-loss-ratio-how-did-the-healthcare-insurance-industry-do/

http://stanfeld.com/what-is-the-medical-loss-ratio/

The calculation for direct medical care helps the healthcare insurance company prove it lost money. The insurance company then applies to state regulators for a premium increase. The state regulators permit the premium increases.  If the premium increase is refused by the regulators the insurance company threatens to leave the state. The other option the healthcare insurance company uses is to decrease the insurance services and/or increase the insurance deductibles.

Another problem has developed in the healthcare insurance industry that is causing it to raise premiums and reduce services and access to care as a result of Obamacare.

Hospital systems are buying out physicians’ practices. Obamacare has put many restrictions on physician practices. It has increased practices overhead. Obamacare has decreased the ability for physicians to use their medical or surgical judgment that they have become happy to sell their practices to hospital systems. The hospital systems now have to deal with the problems of medical practice. The cost of electronic medical records, which have not added to the quality of medical care, increased many physicians’ willingness to sell their practices to hospital systems. At the moment the percentages of hospital-owned practices are up to 65% from only 17% ten years ago.

http://stanfeld.com/physicians-barriers-to-practice-their-profession/

https://www.wsj.com/articles/SB10001424052748704122904575315213525018390

As premiums have gone up physicians have not experienced an increase in reimbursement. They have been forced to see more patients quickly to earn almost as much as before Obamacare. Obamacare has destroyed the patient-physician relationship which in my view is essential in medical care. Physicians simply do not have time to talk to patients.

Hospital systems have taken over physician populations in many communities. This gives the hospital leverage over the healthcare insurance industry. The hospital system can demand higher reimbursement because it provides all the physicians.

The large hospital systems can demand that the insurance company only use the physicians in its hospital system even if there are lower cost of care options in a community.

The result is an increase in healthcare premiums and decreased the quality of care.

All of this is the result of Obamacare. There are about ten more reasons why Obamacare has increased premiums and decreased access to care. I have left link exposed. You are encouraged to look at them to see the full explanation for some of the point I have made.

I hope this blog answers your friend’s question. :  Did Obamacare cause this change in healthcare insurance and these problems in access to care? 

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



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