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Obamacare 101!

Stanley Feld M.D.,FACP, MACE

I hope it is common knowledge that President Obama and his administration lie about the success of Obamacare.

The traditional media and especially the New York

Times simply regurgitates these absurd lies as published in the Obama administration’s press releases.

I have many smart, sophisticated friends who are physicians, lawyers, engineers and business professionals whose only source of the news is the New York Times.

They honestly believe that FOX news and the Wall Street Journal are entertainment vehicles of right wing conservatives. They think these organizations do not publish real news.

It is what the Obama administration and the New York Times told them.

FOX news and the Wall Street Journal get closer to the truth than the New York Times. They cover important stories of the day while many of the stories are not even mentioned in the traditional media.

The New York Times used to be my only source of news.  One day I realized the bias in almost every story in both the news and on the editorial pages.

I have been a critic of Obamacare from the beginning. It has been my opinion that Obamacare could not work. I have even suspected that President Obama wants to destroy medical care in America with Obamacare.

The construction of a massive bureaucracy to redistribute wealth for the benefit of the poor has not worked in the past because corruption, inefficiency and errors are usually built into the development of massive government bureaucracies.

Our federal government has never produced a well-oiled business devoid of inefficiency and corruption. Two recent examples are the TSA and the VA.

As medical care becomes more complex and as President Obama tries to control medical care the ability to develop a well-oiled machine becomes more elusive.

He does not understand that you cannot legislate morality especially by executive order. The bureaucracy and regulations make no sense to people he is trying to force to comply.

Government should be for the people and by the people. You have to provide incentive for people to enthusiastically operate within the systems created and encourage them to improve and take responsibility to improve the systems.

I have also presented my views on the value of the constitution and the freedoms we as Americans have under the constitution.

No one should be immune the law or the values of our constitution. President Obama and his administration are trying to force his ideology on the American people and trying to control our thinking by restricting our freedoms.

Many Americans do not pay attention to what is happening until it starts happening to them. Sometimes it is too late to change horrible laws and regulations.

Last week I received a note from a reader. The subject of the email said MANDATORY!

It is a simple explanation of the mechanics of the system imposed on us by Obamacare for everyone to understand.

Maybe some of my sophisticated friends and colleagues will start understanding the danger of Obamacare and why it cannot work.

President Obama’s Personal Experience: Obamacare 101!

Only weeks after leaving office on January 20, 2017, former President Barack Obama discovers a leak under his sink, so he calls Troy the Plumber to come out and fix it.

Troy drives to President Obama’s new house, which is located in a very exclusive, gated community near Chicago where all the residents have a net income of way more than $250,000 per year.

Troy arrives and takes his tools into the house.  He is led to the guest bathroom that contains the leaky pipe under the sink.  Troy assesses the problem and tells President Obama that it’s an easy repair that will take less than 10 minutes.  President Obama asks Troy how much it will cost.  Troy checks his rate chart and says, “$9,500.”

“What?  $9,500?” Obama asks, stunned, “But you said it’s an easy repair.  Michelle will whip me if I pay a plumber that much!”

Troy says, “Yes, but what I do is charge those who make more than $250,000 per year a much higher amount so I can fix the plumbing of poorer people for free.  This has always been my philosophy.  As a matter of fact, I lobbied the Democrat Congress, who passed this philosophy into law. Now all plumbers must do business this way.  It’s known as the ‘Affordable Plumbing Act of 2014’.  I’m surprised you haven’t heard of it.”

In spite of that, Obama tells Troy there’s no way he’s paying that much for a small plumbing repair, so Troy leaves.  Obama spends the next hour flipping through the phone book calling for another plumber, but he finds that all other plumbing businesses in the area have gone out of business. Not wanting to pay Troy ‘s price, Obama does nothing and the leak goes un-repaired for several more days.  A week later the leak is so bad President Obama has had to put a bucket under the sink. Michelle is not happy as she has Oprah and guests arriving the next morning.  The bucket fills up quickly and has to be emptied every hour, and there’s a risk the room will flood, so Obama calls Troy and pleads with him to return.

Troy goes back to President Obama’s house, looks at the leaky pipe, checks his new rate chart and says, “Let’s see, this will now cost you $21,000.”

President Obama quickly fires back, “What? A few days ago you told me it would cost $9,500!”

Troy explains, “Well, because of the ‘Affordable Plumbing Act,’ a lot of wealthier people are learning how to maintain and take care of their own plumbing, so there are fewer payers in the plumbing exchanges.  As a result, the price I have to charge wealthy people like you keeps rising. Not only that, but for some reason the demand for plumbing work by those who get it for free has skyrocketed!  There’s a long waiting list of those who need repairs, but the amount we get doesn’t cover our costs, especially paperwork and record keeping. This unfortunately has put a lot of my fellow plumbers out of business, they’re not being replaced, and nobody is going into the plumbing business because they know they can’t make any money at it. 

 I’m hurting too, all thanks to greedy rich people like you who won’t pay their ‘fair share’.  On the other hand, why didn’t you buy plumbing insurance last December?  If you had bought plumbing insurance available under the ‘Affordable Plumbing Act,’ all this would have been covered by your policy.”

“You mean I wouldn’t have to pay anything to have you fix my plumbing problem?” asks Obama.

“Well, not exactly,” replies Troy. “You would have had to buy the insurance before the deadline, which has passed now. And, because you’re rich, you would have had to pay $34,000 in premiums, which would have given you a ‘silver’ plan, and then, since this would have been your first repair, you would have to pay up to the $21,000 deductible, and anything over that would have a $7,500 co-pay, and then there’s the mandatory maintenance program, which is covered up to 17.5%, so there are some costs involved.  Nothing is for free.”

“WHAT?” exclaims Obama.  “Why so much for a puny sink leak?”

With a bland look, Troy replies, “Well, paperwork, mostly, like I said.  And the internal cost of the program itself.  You don’t think a program of this complexity and scope can run itself, do you?  Besides, there are millions of folks with lower incomes than you, even many in the ‘middle class’, who qualify for subsidies that people like you must support.  That’s why they call it the ‘Affordable Plumbing Act’!  Only people who don’t make much money can afford it.  If you want affordable plumbing, you’ll have to give away most of what you have accumulated and cut your and Michelle’s income by about 90%.  Then you can qualify to GET your ‘Fair Share’ instead of GIVING it.”

“But who would pass a crazy act like the ‘Affordable Plumbing Act’?” exclaims the exasperated Obama.

After a sigh, Troy replies, “Congress… because they didn’t read it.”

       I hope this simple example helps all those sophisticated New York Times readers understand the dangers of Obamacare more clearly.

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

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Healthcare Insurance Industry Moves Against Obamacare

Stanley Feld M.D.,FACP,MACE

The 3 R’s are not working out well for the government, the patients or the healthcare insurance companies.

The temporary reinsurance portion of the 3R’s is about to expire. It was meant to support the healthcare insurance industry as enrollment in Health Insurance Exchanges grew.

Patient enrollment figures in State and Federal Exchanges have not grown significantly in the last two years. Enrollment ii exchanges has been from high risk and elderly patients.

High risk and comprehensive coverage has meant decreasing profit for the healthcare industry.

The numbers the Obama administration publishes are confusing and mostly false. State exchanges are failing. The State Health Insurance Exchanges are causing (in states that have State Health Insurance Exchanges) greater budget deficits.

The reinsurance program is not covering the healthcare industry’s expected profit because of the redistribution of wealth component in the 3R’s.

The significance of the redistribution of profit and wealth component of the 3R’s was not fully appreciated by the healthcare insurance industry as was the reinsurance subsidy was.

The industry’s first step to combat this barrier to profit was to increase next year’s insurance premiums by 20-30 percent in both the private sector and the State and Federal Health Insurance Exchanges.

This has created inflationary pressure on the private sector and unaffordable healthcare in both the private and public sectors for consumers and companies that provide healthcare coverage to their employees.

Its effect is the opposite of what President Obama promised. He promised to make healthcare insurance coverage affordable to all.

It is also forcing corporations to switch their healthcare coverage plans from defined benefit plans to defined contribution plans. The net effect is to increase employee out of pocket expenses.

We do not know how many more people have lost healthcare insurance because of Obamacare’s rules and regulations.

The public is also unaware of the exact number of people who have gained healthcare insurance through the Health Insurance Exchanges.

The real figures are not easily available.

The next step by the healthcare insurers is to merge.  A series of merger negotiations are occurring. In the last three weeks two merger negotiations have been completed.

Anthem Inc. agreed to buy Cigna Corp. for $48 billion, capping months of merger frenzy among top U.S. health insurers that is set to reshape the industry.

“The merged company is projected to have around $115 billion in annual revenue and cover about 53.2 million people.

The deal, which needs regulatory approval, would help reshape health insurance industry.”

Three weeks ago Aetna agreed to buy Humana for $34 billion. The two deals accelerated the rapid-fire reconfiguration of the U.S. health-insurance industries. The two deals would decrease the industry from five major companies to only three.

The traditional media has not discussed the reasons the healthcare insurance industry is merging or the details of the mergers.

I will try to connect the dots.

The healthcare insurance industry realizes that the Obama administration is trying to play one insurance company against another. The redistribution of profit from insurance companies that profit to those that make less profit must be irritating to the healthcare insurance industry.

Perhaps they did not appreciate the intricacies of the 3 Rs. Maybe there was a small window where the temporary reinsurance was profitable.

I would guess that the healthcare insurance industry would try to stop the redistribution of profit. These mergers will increase their individual profits.

The companies will be in a position to force the government to discontinue the redistribution of profit or lose a company that is an administrative service provider.

The losers will be taxpayers and non-subsidized insurance consumers. The increases in premiums to consumers that are subsidized will be passed on to taxpayers. Non-subsidized taxpayers will also be paying increased healthcare premiums.

This will create non-affordable insurance premiums for all as a result of the Affordable Healthcare Act (Obamacare).

The healthcare system will collapse. The government will move in with a single party payer system and a bloated and wasteful government bureaucracy.

Remember Senator Kerry and Representative Barney Frank saying the ACA would not work without a Public Option? Remember President Obama saying we don’t need a Public Option?

President Obama is backing healthcare insurers into a Public Option corner and a single party payer system.

The government will be forced to limit access to care and ration care. Americans will not have freedom of choice.

The problem is the government will still have to hire one of the three healthcare insurance carriers for its administrative services instead of one of five major carriers. The price to the taxpayer will probably be high along with all of the government’s bureaucratic inefficiencies.

Remember the VA? The VA scandal is continuing without any apparent improvement in VA services or in reforming the dysfunctional VA system.

Congress is simply giving the VA more money to continue its dysfunctional ways.

The latest step in the healthcare insurance industry’s attempt to protect itself is the hiring of Marilyn Tavenner as CEO of America’s Health Insurance Plans (AHIP) the lobbying group for the healthcare insurance industry.

Marilyn Tavenner is the former head and CEO of CMS overseeing Medicare, Medicaid and ACA (Obamacare) implementation.

Marilyn Tavenner oversaw the botched rollout of the federal insurance exchange and the ACA-mandated cuts in payment rates to Medicare Advantage in additional to a myriad of new Obamacare generated Medicare and Medicaid regulations.

Some of these regulations are unconstitutional according to lawmakers. However, the legislators have done nothing about these unconstitutional regulations.

They have not even attempted to make Americans aware of them.

Health Insurance Exchange plans and Medicare Advantage plans are two areas of tremendous profit and significant growth for private insurers. The Obama administration knows this and has tried to limit or eliminate this growth.  AHIP hopes Marilyn Travenner can help the industry continue this growth by pointing out the bureaucracy’s weaknesses to healthcare insurance company’s executives.

The healthcare industry (AHIP) hired her for her political connections inside the administration, inside the CMS bureaucracy and inside the congressional committees that regulate them,” said Tim LaPira, political science professor at James Madison University.”

 The mainstream media parroting the AHIP’s press release said, that the insurance industry has accepted Obamacare (the Affordable Care Act) as the new business environment. AHIP wants a CMS insider to help during the next phase of its market development.

According to the AHIP press release, “her government experience will be invaluable to AHIP given how rapidly the public sector is dominating the financial, market and regulatory facets of health plans”

It is obvious to me that AHIP did not hired Ms. Travenner in order to understand the new business environment better for an instant.

I believe AHIP hired her as CEO for her connections in,

1.   CMS,

2. The Obama administration,

3. The administration’s bureaucracy.

4. Congress

Along with her impressions of CMS’s weaknesses.

Weaknesses the AHIP can exploit.

Neither the Obama administration nor AHIP are working for the benefit of the American consumer of healthcare.

This behavior must be stopped somehow.

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What Are The 3R’s?

Stanley Feld M.D.FACP,MACE

The 3R’s are the Risk Adjustment, Reinsurance, and Risk Corridors program built into The Accountable Care Act (Obamacare). The 3R’s were meant to encourage the healthcare insurance industry to participate in providing insurance to participants in the State Health Insurance Exchanges. President Obama has extended the 3R’s to included Federal Health Insurance Exchanges.

The 3R’s were activated because of the poor enrollment in the State and Federal Healthcare Exchanges. It was billed to offer protection to the healthcare insurance industry against any losses incurred by participation in Health Insurance Exchanges.

The healthcare insurance industry’s participation in Obamacare’s Health Insurance Exchanges was negative at first.

The Health Insurance Exchanges were viewed as a trap set by the Obama administration to control the healthcare insurance industry. In the process the healthcare insurance industry would ultimately lose money.

The healthcare insurance industry did not participate widely in the health insurance exchanges at first.

 “These risk-sharing programs are often called the “3 Rs” because they are Risk Adjustment, Reinsurance, and Risk Corridor.” The three risk-sharing provisions were intended to protect insurers financially, especially in the first few years the Exchanges are in effect if activated.”

The ACA includes various mechanisms to accomplish this goal including requiring insurers to cover everyone who applies, prohibiting insurers from imposing preexisting conditions limitations, and severely limiting the factors insurers can consider in setting premiums.  Obviously, these mechanisms put insurers at financial risk, since their underwriters won’t have sufficient data to predict claims costs, such as the number of people likely to enroll, their health status or claims history, or other demographic information on enrollees.

The Obama administration included this safety net for healthcare insurers. It also set the traps for the healthcare insurance industry.

Purpose of Permanent Risk Adjustment

To combat overall adverse selection since health insurance is now guaranteed to anyone who applies. Healthcare insurance carriers cannot impose pre-existing conditions limitations. They cannot vary premiums based on individual’s health status.

The trap is that the government will redistribute money between insurance carriers. The Permanent Risk Adjustment scheme is supposed to redistribute profit from insurers with lower claims enrollees to those with higher claims enrollees and losses.

All non-grandfathered insured plans in the individual and small group market, in or out of the health insurance exchanges, are supposed to pay for this redistribution of money. This redistribution is to be monitored by the federal government. (Another bureaucracy)

Does anyone think this can work? I don’t.The second R is the Transitional Reinsurance Program. It is to run from 2014-2016 and then stop running.

The Transitional Reinsurance Program’s purpose is to stabilize premiums in the individual market during the first 3 years the exchanges operate, because higher-cost (sicker) individuals are more likely to enroll early.

This program’s purpose is to redistribute money from group health plans that make a profit to certain insurers with Qualified Health Plans on the individual State and Federal Exchanges that have high cost (claims) enrollees to prevent loses for those insurance companies. This is supposed to encourage insurance companies to join the exchanges.

All group health plans are required to pay for losses in 2014. There has been no reporting as yet to let anyone know how this has worked out in 2014. This provision further exposes President Obama’s lie that “if you like your plan you can keep your plan.” He knew no one could keep their healthcare plan as the bill was written.

A specific waiver was provided for 2015 & 2016. There are a few self-insured plans that self-administer their claims. Most corporations use healthcare insurance companies as third party payers. Therefore, the wavier is essentially eliminated.

The traditional reinsurance program is going to be very difficult to administer.

The Temporary Risk Corridor for 2014-2016 makes the 3R program even more complicated and more difficult to administer.

The goal of the temporary risk corridor is to limit insurer gains and losses in first 3 years of Obamacare and place all healthcare insurance company risks on a level playing field. The healthcare insurers have a limited amount of data on the risk of claims for Health Exchange enrollees. The healthcare companies have histories of claims for Qualified Health Insurance Plans and the expected enrollment. The health Insurance companies have to guess at their actuarial risk if they participate in Obamacare in order to set premiums.

Limiting the healthcare insurance industry’s risk will be complicated for the government.

Insurers who have actual claims more than expected claims will be paid the excess if funds from these insurers are not sufficient. HHS is directed to pay the excess.

The problem is Obamacare (ACA) did not provide for creation of a specified source of funds or a revolving fund for HHS to pay this excess.

In 2014, the first year of the exchanges insurers received $450 million dollars. The source of the government funds is unclear.

An important concept about insurance reimbursement is always ignored. Insurance claims have nothing to do with the actual insurance reimbursement. Reimbursement is usually 50% less than the claims.

Therefore, the amount of supposed payment is doubled using claims to calculate payment and probably future premiums.

The government is hoping that the entire scheme is budget neutral. It will collect and redistribute the profit made by one insurance company to the insurance company that loses money from the high-risk patients.

The government thinks it will have no out of pocket reimbursement obligation.

The government plans to compare insurers within a state based on the average financial risk of their enrolled population.

“ To more evenly spread the financial risk among insurers, government payments are made to insurers who cover a higher-risk population (e.g., people who are older, sicker or have more chronic conditions) from the profit of lower risk insurers. “

Theoretically, the insurers who make a profit from the lower risk population pay the insurers who make less from their older, sicker population with many chronic diseases.

This is called redistribution of profit and wealth. I have a tough time believing that profit making companies will sign up for that.

Below are the formulas that will be used in 2014 and 2015 for the redistribution of profit of healthcare insurance companies.

2014: Once an insurer has paid $45k in claims for an individual (the attachment point), the insurer is reimbursed for 80% of costs between $45k & $250k per person.  (Originally $45k was $60k)”

2015: $70k attachment point per insured, then insurer will be reimbursed for 50% of costs between $70k & $250k per person.  HHS publishes a Notice of Benefit & Payment Parameters each March, with the numbers for following year.”

“If actual claims are within 3% of expected claims, insurers in Exchanges keep the profits or bear the risks.  If claims are 3-8% more (or less) than expected, insurer pays the gov’t (or is reimbursed by the gov’t) 50% of the gains (losses) and keeps (or bears the loss of) the other 50%.” 

“If claims are at least or > 8% more (or less) than expected, insurer pays the gov’t (or is reimbursed by the gov’t) 80% of the gains (losses) and keeps (or bears the risk of) the other 20%.”

It is all very complicated. It will be impossible to enforce. This is another Obamacare trick to fake out the very profitable healthcare insurance industry.

I think the healthcare insurance industry knows all this. They are taking steps at this very moment to dodge the Obama administrations trap.

The losers will be the American people who will experience an increase in healthcare insurance premiums and higher taxes.

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CONGRESS DOES IT TO US, AGAIN

Stanley Feld M.D.,FACP,MACE

Americans have lived through scandal after scandal and lie after lie during the Obama administration.

None of the guilty parties have been penalized.

President Obama lied about Obamacare. “If you like your doctor you can keep your doctor.” “If you like your insurance plan you can keep your insurance plan.”

Yet Obamacare continues to destroy our healthcare system as well as our economy with unconstitutional changes in the law, lies, increased regulations and an expanded bureaucracy.

Notable scandals have included the Benghazi affair, clandestine weapons to Syria, red line foreign policy retreats, IRS scandals, the Clinton email scandal, and now the Iranian nontransparent nuclear agreement scandal. I can go on and on.

The traditional media does not report the details of the scandals. There is little complaining from the traditional media about these scandals that President Obama reports as insignificant.

The scandals last only a few news cycles. Most of the scandals are then ignored. There is hardly ever accountability from or punishment for the guilty parties.

Republicans just sit back and do nothing to expose the scandals.

The number of uninformed Americans amazes me. Government policies are mentioned but are deemed by progressives as being insignificant. There is hardly ever any correlation between the scandals and the effect on our budget deficit and our economy.

I think Americans are finally starting to get it. They are becoming fed up with the unbridled arrogance of President Obama and congress.

The government is shafting American taxpayers without anyone knowing it.

The most outrageous scandal in Washington has been kept under the radar and away from the press.

The House and Senate have both falsely certified themselves as small businesses in order to fund health insurance for themselves and their staff with taxpayer dollars, sidestepping provisions of Obamacare.

How did this happen? Why wasn’t this reported in the press?

When President Obama and the Democrats were rushing the health care law through Congress without even knowing what was in it, Chuck Grassley (R-IA) managed, with strong public support, to insert a provision in the law requiring members of Congress and their staff to purchase insurance through the new health care exchanges.

Senator Grassley’s goal was to have Congress and their congressional staffs have the same healthcare insurance experience that millions of Americans were going to have.

His hope was to create a strong incentive for Congress to make sure that President Obama’s new healthcare insurance system worked.

When congress and the congressional staff realized the cost of being in the healthcare exchanges and they needed to give up Medicare C, Congress’ special Medicare program, congressmen and their congressional staff bitterly complained to President Obama.

President Obama had the Office of Personnel Management (OPM) issue a rule in 2013 allowing Congress and congressional employees to once again have taxpayers continue pick up most of the cost of their premiums.

State and federal health insurance exchange rules do not permit employers of large organizations to pay the premiums for their employees.

Like many Americans being dumped into Obamacare exchanges, members of Congress and their staff stood to lose their employer contributions – in this case, the generous financing of their health benefits by taxpayers that they had before the law passed and took it away.”

The OPM ‘s rule makes clear that congressional members and staff  still can receive the contribution from the government even though they have purchased their insurance from their exchange.

Office of Personnel Management’s (OPM) changed the rule in 2013. The rule insulated these insiders from the premium increases of between $5,000 and $10,000 per person they would have otherwise faced if they were forced give up their taxpayer-subsidized policies and buy their insurance through the Obamacare exchanges.

This rule is illegal because it separates Congress and staff from the rest of the population. The only employers that can make contributions for their employees purchasing insurance through the exchanges are small businesses with less than 50 employees.

“There is no mechanism for employer contributions in the individual healthcare exchange market.”

Congress also filed false documents claiming the House and Senate each have less than 50 employees to qualify as “small businesses,” even though over 13,700 congressional employees have in fact signed up.”

 “ That’s fraud.”

Judicial Watch obtained these false documents in Freedom of Information Act litigation.

However, the documents were heavily redacted including the names of Senators and Representatives who signed these false documents under penalty of perjury.

The blatantly false documents stated that the Representatives and Senators each have only 45 employees. The congressional staff is not an individual Representative or Senator’s employee. They are government employees.

The employer, the federal government, has more than 49 employees and is not a small business.

“The House and Senate have both falsely certified themselves as small businesses in order to fund health insurance for themselves and their staffs with taxpayer dollars, sidestepping provisions of Obamacare.”

An important question the public has to know the answer to is which Senators and Representatives signed the false declaration.

Senator David Vitter (La.), chairman of the Senate Small Business Committee recently tried to subpoena the documents in which the false declarations were made, but he ran into strong bipartisan opposition.”

Senator Vitter wanted to know how the House and Senate, with thousands of government employees, came to be officially designated as small businesses. He wanted to know who signed the false documents and have his committee question these representatives.

Fourteen (14 of the 19) members of his committee objected to Senator Vitter proceeding with the subpoena of documents.

Democratic senators on Senator Vitter’s committee all voted in lockstep to keep the signed documents a secret from the American people.

They are: Jeanne Shaheen (N.H.), Maria Cantwell (Wash.), Ben Cardin (Md.), Heidi Heitkamp (N.D.), Ed Markey (Mass.), Cory Booker (N.J.), Chris Coons (Del.), Mazie Hirono (Hawaii), and Gary Peters (Mich.).

Republicans on the committee who voted to keep the documents secret from the people are Mike Enzi (Wyo.), Jim Risch (Idaho), Deb Fischer (Neb.), Kelly Ayotte (N.H.) and Rand Paul (Ky).

Republicans on the committee voted with Chairman Vitter to issue the subpoenas to those whose signed the false documents were Marco Rubio (Fla.), Tim Scott (S.C.), Cory Gardner (Colo.), Joni Ernst (Iowa).

These Republicans were the only ones that voted for the vested interest of the American people.

This is a very significant scandal.

The traditional mainstream media should be reporting this scandal. I think the Representatives and Senators who signed the false documents should be booted out of office.

It is a perfect example of Congress and the President making backroom deals for the benefit of Congressmen their congressional staff.

The congress is ripping off taxpayers while taxpayers not only are paying for their illegally subsidizing healthcare insurance.

Taxpayers have to pay the increased premiums for their own insurance while they are paying for congress’ healthcare insurance by on illegal congressional maneuver.

This corruption should make the American people madder than hell if they knew this was going on.

However the media is the message. The media is keeping us stupid. This scandal like others will fade away as being insignificant.

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I Still Don’t Understand The Supreme Court’s Decision

Stanley Feld M.D.,FACP,MACE

I still do not understand the logic of the Supreme Courts decision in King vs. Burwell.

The solution to the healthcare insurance exchange subsidies is simple. Congress needs to change the law to include subsides for people buy healthcare insurance in federal exchanges. It is not the Supremes courts job.

The Supreme Court changed the law because it believes that federal health insurance subsidies were implied in the law when there is evidence that federal insurance subsidies were specifically restricted.

Chief Justice Roberts wrote, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,”

“If at all possible, we must interpret the act in a way that is consistent with the former, and avoids the latter,” he continued, echoing language he used in 2012 to uphold another centerpiece of the law, the requirement that most Americans carry health coverage or pay a penalty. In that ruling he defined the penalty for noncompliance as a tax.”

Obamacare is a partisan law that is destroying the health insurance markets not improving them. A vote to repeal it now might be bipartisan even though President Obama would veto it.

Obamacare has been more destructive than helpful to the healthcare system. There is a better way to “improve the health insurance markets.”

Chief Justice Roberts took the opposite view in dissenting against gay marriage (Obergefell).

“Roberts’s Obergefell dissent is, at its heart, an attack on the method Justice Anthony Kennedy used to reach the majority’s conclusion that the Constitution forbids states from denying equal marriage rights to same-sex couples. Kennedy held that marriage is a fundamental right, and that this right extends to same-sex couples.”

Roberts offers a harsh response:

“Stripped of its shiny rhetorical gloss, the majority’s argument is that the Due Process Clause gives same-sex couples a fundamental right to marry because it will be good for them and for society. If I were a legislator, I would certainly consider that view as a matter of social policy. But as a judge, I find the majority’s position indefensible as a matter of constitutional law.”

As Roberts explains, “the Obergefell plaintiffs’ “‘fundamental right’ claim falls into the most sensitive category of constitutional adjudication.”

 This claim does not rest upon a right that is specifically mentioned in the Constitution. Rather, the plaintiffs argued that marriage discrimination violates “a right implied” by the Fourteenth Amendment’s requirement that ‘liberty’ may not be deprived without ‘due process of law.”

A right implied is called “substantive due process.”

Chief Justice Roberts argued that federal health insurance exchanges’ subsidies were implied in Obamacare in his support in the King vs. Burwell case.

He rejected what is implied in the Obergefell gay marriage case.

Article 1, Section 7 is the part of the Constitution that gives us the process for creating laws in this country. This is the only method the Constitution permits for changing laws in this country.

  1. Both the House of Representatives and the Senate must pass a bill.
  2. Once a bill has passed both houses of Congress, the president can either sign it into law or veto it and send it back to Congress.
  3. If the bill is vetoed, Congress can over-ride the president’s veto and enact it into law with a 2/3 vote.

 

The Supreme Court has absolutely no role to play in creating or amending our laws according to the constitution.

The Supreme Court only has the power to make a judgments on the constitutionality of the laws enacted. It should not have the power to change the meaning of the written law.

This is especially true since a crafter of the law (Jon Gruber)  clearly stated the reason it was written that way.

“One of the architects of this law, Jon Gruber, has made it very obvious that this phrase was intended to mean exactly what it says.

Gruber has also emphasized that it was designed this way deliberately in hopes that it would pressure states to create their own exchanges

Chief Justice Roberts used the role of the courts argument in his dissent of the Obergefell gay marriage case. His reasoning is contradictory in both cases.

The Supreme Court decided that this law does not mean what Congress intended it to mean.

Applying this law as it was written would have some unpleasant consequences. Six of the nine justices on the Supreme Court have taken it upon themselves to re-write Obamacare to spare 6 million people loss of insurance.

The Obamacare cost to taxpaying Americans is $50,000 to $80,000 per person insured. There is a cheaper way to insure these 6 million people.

He did consider the cost of the EPA regulation to eliminate mercury from the air in the court’s decision to eliminate the regulation.

Did Chief Justice Roberts consider Obamacare costs to individual and group insurance plans? Individual and group plans are scheduled to increase by as much as 47% in Oregon. The Obamacare mandated penalty for not purchasing insurance in 2016 will be increased to $695 per person or 2% of the household’s income, whichever is greater.

The maintenance of the separation of power is a critical principal of the constitution and the Republic.

“It isn’t the Court’s job to save Congress from itself. If our politicians pass a boneheaded law that will have terrible effects on this country, it’s not the Court’s job to clean up the mess.

It is the role of Congress to figure out how to fix their own mess. If Americans recognize the mess Congress will face the consequences at the ballot box.”

President Barack Obama has consistently and unilaterally changed several of the deadlines.

He has constantly provided waivers from the law for people of consequence and labor unions who have protested. He has even given waivers from Obamacare to congress. 

Article 1. Section 7 of the constitution doesn’t allow the Supreme Court or the executive branch to make changes in the law without the consent of congress.

Few in congress have questioned whether President Obama has exceeded his authority with his numerous controversial executive orders. When some congressperson does he/she have been immediately marginalized by the President, his administration, and the traditional media.

The media is the message.  Millions of people repeat the same nonsense.

If you repeat a lie enough times it becomes the truth.

Even if you are someone who loves Obamacare, you should still hate this decision. The process of how you enact a policy is every bit as important as what policy is enacted.”

“And the way Obamacare has been manipulated demonstrates that our politicians are no longer restrained by the Constitution in any way.”

Everyone should be upset with the Supreme Court’s decision. It shows how irrelevant the Constitution and the rule of law have become in this country.

It demonstrates how close to tyranny our country is coming.

It’s our country’s 239th birthday.

Wake up America!

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King vs. Burwell and The Supreme Court

Stanley Feld M.D.,FACP,MACE

I have received a couple of emails asking me why I have not responded to the Supreme Court’s ruling in King vs. Burwell.

A ruling in King’s favor seemed so clear to me. I thought the case would be decided in favor of the letter of the law. This seemed obvious since Jonathan Gruber, the author of Obamacare, admitted the words “state health exchanges are the only exchanges that could provide subsidies” were intentional.

It was clear that the author of the law (Jonathan Gruber) and President Obama wanted to encourage states to create State Health Insurance Exchanges.

The carrot was money. If the states did not create State Health Insurance Exchanges they would lose their government grants.

The legislators of the states that refused the Obamacare trap would experience angry voters and get kicked out of office.

Dr. Gruber also admitted that if there was transparency during the law’s creation it would never have been passed. Jon Gruber called Americans stupid.

This comment motivated President Obama to distance himself from Jonathan Gruber. He said Dr. Gruber was not a major player in the creation of Obamacare. President Obama claimed that he barely knew him.  He claim Jonathan Gruber had only been to the White House a couple of times.

President Obama’s statement has been proven to be a lie.

 http://www.foxnews.com/politics/2015/06/24/editor-says-owes-gop-sources-apology-after-new-gruber-emails/?intcmp=ob_article_sidebar_video&intcmp=obinsite

 The Supreme Court’s decision has been a mind blower to me. I still have not figured out how to respond.

I thought the Supreme Court Justices’ job was to interpret laws within the context of the constitution. They should not create new laws or create new meanings for laws.

They also should not allow themselves to be bullied by the executive or legislative branch of government.

President Obama has been doing heavy duty bullying of the Supreme Court to rule in his favor in the last four months. President Obama’s goal is to not let anyone stand in his way on the road to control the entire healthcare system.

The justices live in our society. They are aware of the media and have access to the same information as everyone else.

It should be obvious to them that all the stakeholders dislike Obamacare now that they “know what is in it.”

Obamacare is a terrible law. President Obama told many lies and has taken many unlawful steps to hide the law’s failures.

The justices should have recognized that Obamacare is not a bipartisan law. Only Democrats voted for the bill even though many have admitted they did not read it.

It hardly represents the will of the people as they are now recognizing all its faults and deficiencies.

The Supreme Court’s codifying the law seems bizarre to me.

I also thought that the Supreme Court’s decisions had to be made in the context and spirit of the law and the meaning of the constitution. 

I am especially disappointed in Chief Justice John Roberts. His reasoning for ruling on King vs. Burwell was just the opposite of his reasoning for his ruling on gay marriage.

It is as if he has been influenced by outside sources in each ruling. 

I know the ruling has stunned many people. Congress made the law. Congress should change the law to mean what the Supreme Court said it meant.

I have not figured out what an appropriately reasoned response should be.

I believe the will of the people will prevail once people understand the harmful effects of this law. Its affect on the economy is becoming obvious. Its affect on Americans individually is also becoming obvious.

Obamacare will eventually die under its own weight. The Democratic Party will never be able to get rid of the label “tax and spend party.”

The Democratic Party and President Obama are putting America into greater debt.

I believe the lower socioeconomic groups, who President Obama claims to help, are realizing President Obama is doing them more harm than good.

His goal is to make Americans more dependent on the central government.

I do not think President Obama or the Democrats are going to be able to survive the coming tsunami of a plebiscite against Obamacare.  

In the end Americans are not fans of socialism. They know it doesn’t work.

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

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The New Medicaid

Stanley Feld M.D.,FACP, MACE

President Obama let the regulation to increase Medicaid reimbursements to the level of Medicare reimbursement expire because it failed to accomplish its goal. The goal was to get more physicians to accept Medicaid.

The Obama administration has proposed new federal regulations for Medicaid managed-care plans.

These regulations pledge the program's beneficiaries will have adequate access to a doctor. The pilot programs for these new regulations have been completed.

Two years ago six states made a deal with the Obama administration. Arkansas, Indiana, Iowa, Michigan, New Hampshire and Pennsylvania were willing to cover families earning up to 138% of the federal poverty level as long as it was on the states' terms.

Each state relies on private insurers, which are required to come up with qualified health plansthat meet the standards of Obamacare.

While Medicaid plan “purchasers” are almost totally subsidized, five of six states require some of these very low-income beneficiaries to make financial contributions that range as high as 2% of their income.

The idea is that everyone has some skin in the game. The plans also focus on setting up health savings accounts for beneficiaries and establishing wellness programs.

“While these are common features in many of today's corporate-sponsored plans (with only limited evidence to support claims that “more skin in the game” and wellness incentives hold down costs), these elements discourage enrollment by people who are scrambling to keep food on the table and a roof over their heads.”

I think the Obama administration is making another complicated mistake. There is not enough incentive in the program for Medicaid patients to try to save money for the government.

There is not enough incentive for physicians to sign up to accept Medicaid.

The Obama administration is using surveys of Medicaid beneficiaries.

Their response is not much different from the perceptions of Medicare beneficiaries and the privately insured.”

“But closer examination, experts say, reveals that beneficiaries' satisfaction is boosted by the additional access that comes from visiting hospital emergency departments and government-subsidized community health centers.”

 The Obama administration now proposes to hold Medicaid managed-care plans to the network adequacy of Medicare Advantage and Exchange Plans.

The six states, Arkansas, Indiana, Iowa, Michigan, New Hampshire and Pennsylvania, have been doing this along with offering higher-than-Medicaid rates to primary-care physicians to attract more of them to their networks.

A reduction in cost starts by managing patients in ways that encourage them to visit the doctor's office instead of the Emergency Department.

It does not have an element of encouraging patient responsibility or providing indigent patients with financial incentives to be financially responsible for their health or health care.

The same mistake is made over and over again. It is focused on providing patients healthcare coverage. The Medicaid Advantage healthcare coverage plans make Medicaid patients dependent on the government. It does not provide incentives for Medicaid patients to be responsible for themselves.

The healthcare insurance companies are planning to have a field day at the expense of the Obama administration. It seems like the Obama administration does not care how much the new plan costs.

The Obama administration is overlooking the important point. Healthcare coverage cannot work as long as patients are dependent on the government. Patients must be given financial incentives to be responsible for themselves.

All of the healthcare insurance companies that participate in the government supported medical insurance plans are aware of the impending changes in Medicaid.

These insurance companies bid for the administrative services contracts in each state.

The government makes the rules for engagement but the individual healthcare insurance companies bid for the contract.

It is totally logical for all the healthcare insurance companies attempted to merge. If these insurance companies were permitted to merge it would make Medicaid, Medicare and private insurance unaffordable to all.

The healthcare insurance industry sets the prices for administrative services.

The price increases would lead to citizen protest. It would lead to total government takeover of the healthcare system and a single party payer system.

Insurance merge

 

http://money.cnn.com/2015/06/22/investing/health-insurers-mergers-cigna-anthem/

 

The CMS has released a sweeping proposed rule (PDF) intended to modernize the regulation of Medicaid managed-care plans.

 CMS plans call for health plans to dedicate a minimum portion of the rates they receive toward medical services, a threshold known as a medical loss ratio.

At the very last minute the Obama administration is proposing an 85% threshold for Medicaid managed-care plans, the same as the government’s regulations for large group plans in the private market. 

The formula is MLR= incurred expenses /premiums earned.

Private insurance and Medicare are subject to an 85% MLR. It means that 85% of the premiums earned must go to direct medical care. Seventy five percent means only 75% must go to direct medical care and 25% can go to expenses as opposed to 15%.

  MLRatio

The healthcare insurance industry also defines direct medial care expenses such as network formation, insurance salesmen’s commissions and other into the direct medical care column. 
 
As of 2015, plans doing business with Medicaid and the Children's Health Insurance Program are the only health plans that aren't subject to an MLR.

The Medical/Loss ratio is one large source of profit to the healthcare insurance industry for two reasons.

Each expense allowed goes into the incurred claims column. The insurance industry builds a cost plus profit into each expense.

  1. The more required services (Obamacare requirements) rendered by that insurance company the more fee for those services which include profit goes into the incurred claims column.
  2. Each expense allowed goes into the incurred claims column. The insurance industry builds a cost plus profit into each expense.
  3. The more premiums collected the more goes into expenses in the incurred claims column.
  4. The lower the percentage (85% to 75%) of the Medical/ Loss Ratio profit to the healthcare insurance company.

 An arbitrary cap on health plans' administrative costs could undermine many of the critical services—beyond medical care—that make a difference in improving health outcomes for beneficiaries, such as transportation to and from appointments, social services, and more,” interim AHIP CEO Dan Durham said in a statement."


The MLR that the CMS has proposed for Medicaid plans is a suggestion rather than an enforceable mandate.

Medicaid managed-care enrollment has soared by 48% to 46 million beneficiaries over the past four years, according to consulting firm Avalere Health. By the end of this year, Avalere estimates that 73% of Medicaid beneficiaries will receive services through managed-care plans.

"This proposal will better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans, to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage.”

America's Health Insurance Plans immediately said applying an MLR to Medicaid managed care fails to reflect much of what these managed care plans do to hold down costs.

 In essence the new Medicaid proposal will also fail if the healthcare insurance industry merges and the impending fight over the MLR continues.

 The cost of healthcare insurance will increase for the private sector, Medicare and Medicaid.

The fault lies in President Obama's lack of understanding in who should drive the healthcare system. Consumers should drive the healthcare system not the government.

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

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Medicaid’s Reimbursement Problems Increase As It Expands

Stanley Feld M.D., FACP,MACE

In order to attract more physician participation in Medicaid the Obama administration increased the level of Medicaid reimbursement to Medicare levels in 2013.

The Obama administration anticipated an increase in Medicaid recipients once Obamacare started in 2014.

In 2012 there was not enough physician participation in Medicaid to service the number of patients enrolled at that time. Appointment wait time was long. Access to care was rationed.

To prepare the primary care workforce for the influx of new Medicaid eligible patients established through the Affordable Care Act (ACA, Obamacare), this provision increases payment rates for certain primary care services to at least the level of Medicare in 2013 and 2014.

 At that time CMS (2012) promised states it would pay 100% of Medicaid reimbursement. Therefore the increase did not threaten individual state budgets because the federal government was paying 100% of the bill until 2015.

Many but not all Primary Care Physicians fell for this Obamacare ploy. Many physicians still did not sign up to accept Medicaid patients.

 “According to a survey conducted by The Physician’s Foundation in 2012, declining reimbursement rates are the most “significant impediment to patient care delivery in today’s practice environment by a large margin.

In 2012 a major administrative service provider for Medicaid said,

 “Enhanced payment rates may induce more physicians to participate in Medicaid. According to a survey conducted by United Healthcare, half of primary care physicians would increase their Medicaid case load if Medicaid payment rates were increased to the level of Medicare pay rates.”

There were long waiting times for appointments and decreased access to care in 2012. The Obama administration figured these issues would be cured with the change in reimbursement.

The new increase Medicaid enrollment figures have been an intentional mystery to the public. 

The Obama administration has provided convoluted enrollment figures to the public. These figures have confused everyone including those who are interested in them. I believe it has even confused the Obama administration itself. The non-transparency has prevented everyone from facing the reality of the Obamacare mess.

This analysis of the numbers must be read carefully. Physicians have been faked out once more.

“In the third quarter 2014 health insurance enrollment data show continuation of two trends during the first and second quarters—increasing Medicaid enrollment and declining enrollment in employer plans.

" However, while individual-market enrollment increased substantially in both the first and second quarters, it declined by 357,000 during the third quarter. The net result was 160,000 fewer Americans with health insurance."

These numbers are nowhere near the numbers the Obama administration reported to the traditional media and in turn to the public.

 All the traditional media did was celebrate President Obama’s victory lap. The public was deceived by the victory lap.

  “For the first nine months of 2014, individual-market enrollment grew by 5.83 million, but 4.93 million individuals lost employer coverage—offsetting 85 percent of the individual-market gain.”

 

 This was not been made clear by the Obama administration. The uninsured number still remains unclear. This analysis points to Obamacare being a total failure.

 Thus, the net increase in private health insurance for 2014 is so far 893,000 individuals. During the same period, Medicaid enrollment grew by almost 7.49 million. Taken together, the number of Americans with health insurance increased by 8.38 million during the first nine months of 2014, but growth in Medicaid accounted for 89 percent of that gain.

The situation has not gotten better now that the Affordable Care Act's bump in Medicaid pay to Medicare levels has expired.

Just seven states kept the higher rates in place for 2015, while the rest reverted to the previous low rates.

 Medicaid rates in virtually every state are a fraction of what will be paid by Medicare and private insurance companies.

 There are only so many hours in a day. How many physician practices could afford to devote their time to serving its lowest-paying patients?

A 2013 physician survey found 33% of physicians refused to see new Medicaid patients while 17% refused to see new Medicare patients. The obvious reason is Medicare pays better than Medicaid.

 With the expiration of higher primary care physician reimbursement it can be expected there will be less physician participation and decreased access to care for the expanding Medicaid enrollment.

The Obama administration anticipates this problem. It has introduced new regulations that it thinks will solve the problem.

It might, or at least help a little, except for the fact that it is going to cost the government more and help make healthcare insurance companies richer.

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

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The Defects In Obamacare

Stanley Feld M.D., FACP, MACE

We live in an era of sound bites driving opinions rather than details driving opinions. The devil is always in the details.

The defects in Obamacare are too numerous to count. President Obama provides the traditional mass media with sounds bites leading to false conclusions.

The sound bites are misleading. Many of the sound bites are lies. One such sound bite is Obamacare is working and therefore does not need changing.

He and the Democrats keep the discussion on the sound bites level and do not dig into the real issue. President Obama even keeps the details away from congress the very people he is dependent on to pass the bill.

President Obama kept the facts and details about Obamacare away from the congress and the people. He is now doing it with the Trans-Pacific Partnership (TPP).

The Trans-Pacific Partnership (TPP) is a proposed regional regulatory and investment pact. Just as with Obamacare, President Obama expects congress to vote in favor of a pact they have not debated and have not had an opportunity to read the details in the final bill.

It is another one of those bills where the administration is telling the congress and the American people you have to pass the bill in order to see what is in it.

Americans are tired of his lack of transparency and lies. They do not trust President Obama anymore.

Congress should never make the same mistake they made with Obamacare. If they do all Americans should rally to throw all the bums out.

The devil is always in the details.

United States Senator Ron Wyden (D-OR) said,

   “Congress is being kept in the dark as to the substance of the TPP negotiations, while representatives of U.S. corporations—like Halliburton, Chevron, PHRMA, Comcast, and the Motion Picture Association of America—are being consulted and made privy to details of the agreement. […]

More than two months after receiving the proper security credentials, my staff is still barred from viewing the details of the proposals that USTR is advancing. We hear that the process by which TPP is being negotiated has been a model of transparency. I disagree with that statement.[98]

President Obama and the speaker have told us it is good pact for the country’s economy. Senator Cruz is right. “Don’t vote for something whose details you do not know.”

There are many defects in Obamacare. One major defect is that it is not affordable to consumers, the federal government or state governments. When fully implemented the cost of healthcare to the federal government will be at least 50% of our GNP not the 23% of GNP predicted. Twenty three percent is bad enough.

Federal and State taxes will have to be increased to cover all medical care entitlement costs.

President Obama keeps telling us that Obamacare is working. He says it is here to stay.

The reality is Obamacare is an unworkable and costly failure in multiple areas including the health insurance exchanges, healthcare.gov, insurance premiums and deductible costs, the development of Accountable Care Organizations, maintenance of employer insurance and more.

Americans deserve a better system than Obamacare.

It is impossible to cover all of the harmful details of every category in one blog. 

It is disingenuous for President Obama to claim, in his repeated sound bites, that there is no need to change anything in Obamacare because Obamacare is working fine.

The real cost of Obamacare to consumers (especially taxpayers), the federal and state governments and the economy have not been disclosed nor are they transparent.

The real costs start to leak out with stories about how the costs affect consumers and their lifestyle.

This usually leads to the sound bites that it will be better to have a government single party payer system.

The underlying defect is that this system leads to consumers being dependent on government and not responsible for themselves. Government changes rules on a whim. Consumers do not have options. This is a road to serfdom.

After the Affordable Care Act kicked in, a 52-year-old sales and marketing entrepreneur reported his monthly health-insurance premium to cover himself and his family grew to $848 from $513. Like others, he wasn’t happy about it. “It’s taking a lot out of pocket,” he said.”

He is one of millions of Americans who earn too much to qualify for government subsidies on policies purchased through the federal insurance exchange. He was in favor of Obamacare before he realized Obamacare’s effect on reality.

 Obamacare requires insurance companies to offer insurance policies with broad coverage and greater protection against catastrophic medical costs. It also requires coverage on illnesses and conditions such as pregnancy and birth control coverage for people who do not need this coverage.

Obamacare was supposed to save every family $2,500 a year. It costs families more than $2,500 dollars a year. It was not supposed to affect anyone making less than $250,000 per year.

It is true that many of the above a not taxes. However it is a cost burden on consumers making less than $250,000 a year.

Others, making less than $50,000 a year, receive complete or partial government subsidies. This is what is meant by redistribution of wealth. It is a significant cost burden on consumers making $50,000 to $250,000 dollars a year.

Everyone remembers President Obama promising that Obamacare will not cost families making less that $250,000 one dime.

Obamacare premiums have become unaffordable to people earning less than $50,000 per year as well.

Obamacare’s goal was to cover everyone with broad insurance coverage and greater protection against catastrophic medical costs.

Yet, only 10 million out of 330 million are covered by the exchanges. Each enrollee in the exchanges also has high deductibles. These deductibles can be as high as $6,000 a year.

Many of the insurance companies claim they will be losing money after the government’s health insurance industry subsidies disappear in 2016.

These companies will leave the Obamacare federal health exchanges reducing competition. This in turn will increase premiums further and make premiums more unaffordable.

Another detail overlooked is enrollees are poorer, sicker and older. The pool is not diluted by younger, healthier and richer. The result is more expensive insurance rates.

“ HHS was saying that it needed about 40 percent of the exchange policies to be purchased by people age 18-35 to keep the exchanges financially stable. It was 28 percent in both 2014 and 2015, according to HHS data. The CBO had projected about 85 percent of exchange enrollees to be subsidized, falling toward 80 percent as enrollment grew; instead, that number is 87 percent and actually rose slightly from 2014.”

According to a study last year by the National Bureau of Economic Research, people who bought silver and bronze plans on the federal and state health insurance exchanges saw total premiums and out-of-pocket payments rise an estimated 14% to 28% higher than pre- Obamacare premiums and out of pocket expenses.

Obamacare is not fulfilling any of President Obama’s sound-bite promises.

His claim that Obamacare is working well and does not have to change makes absolutely no sense.

If one tells a lie enough times it becomes eventually becomes the truth.

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

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