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The Republican Establishment’s Failure

Stanley Feld M.D.,FACP, MACE

I am coming to the conclusion that the Republican establishment does not want to Repair the Healthcare System.

The Republican establishment has the same goal as the Democratic establishment.

Recently the mainstream media is saying that a single party payer system is looking good.

Neither party has any interest is having consumers control their healthcare dollars. It looks as if both parties want the government to control the consumer’s healthcare dollars.

All the politicians ignore the fact that government control is unaffordable. It also ends up not working.

The best example is the bureaucratic VA Hospital System and its system wide corruption.

A reader wrote:

I have read your last blog post carefully and agree with many of the points put forward but there is a glaring omission.” 

 “How are patients supposed to be responsible for their healthcare dollars when there is absolutely no transparency and no consistency in pricing.”

The lack of transparency is a major defect in our present healthcare system.

Only 20% of consumers use the healthcare system at any one time. Eighty percent of the consumers have not run into the lack of transparency problem in the healthcare system.

Most consumers do not care about transparency because they have first dollar coverage provided by their employer. They think their medical care is free. They believe they have excellent healthcare insurance.

President Obama took care of that notion with Obamacare. The defective structure of Obamacare caused healthcare insurance premiums and deductibles to skyrocket. First dollar healthcare insurance became too expensive for most employers.

Employers stopped providing first dollar coverage. Middle class employees are now noticing that out of pocket expenses have made their healthcare insurance unaffordable. Consumers have tried to compare prices of competitive providers. They have discovered that it is impossible!

Consumers are becoming aware of the lack of transparency. They have been astonished by this lack of transparency.

There is nothing in the new Republican bill that addresses Republican politicians’ awareness that the lack of transparency is a major defect in the healthcare system.

The lack of transparency is only one of the major defects in our healthcare system.

There is nothing in the Republican bill that speaks to the consumers’ responsibility for their health and healthcare dollars. Consumer driven healthcare is completely ignored.

There is nothing in the bill that addresses effective tort reform. The Massachusetts Medical Society survey showed that defensive testing to avoid lawsuits costs the healthcare system between $250 billion to $700 billion dollars a year.

The lack of the development of systems of care for chronic diseases cost another $700 billion dollars a year that our healthcare system does not address. There is nothing in the bill that emphasizes this very important defect in the healthcare system.

The Republican establishment thinks consumers are too stupid to take care of themselves.

The mainstream media likes to tell us that people love entitlements. The public does not want to give up these entitlements.

My question is how come less than 9 million people signed up for Obamacare’s individual healthcare plans last year if they love entitlements?

It is because they cannot afford to buy the health exchange insurance even though 85% of the premiums of those 9 million consumers are subsided by the government. Their high deductibles are not subsidized.

The Republicans are going claim they are promoting health savings accounts. The public is not told the amount of money they can put into a health savings account or whether it will provide first dollar coverage over that amount if they get sick.

There is no financial incentive for consumers to be responsible for their healthcare or their healthcare dollars.

My Ideal Medical Saving Account is a much better idea.

These are only a few of the major defects in the Republican establishment’s concept to fix the healthcare system.

President Obama did some of the awful things to Obamacare through rules and regulations after certain vested interests complained about the law. Obamacare’s rules and regulations have to be eliminated

There were crony waivers that would make one’s blood boil. In fact, elected congressional members got the best exemptions.

It is becoming apparent that congress doesn’t want to fix the healthcare system for the majority of Americans. The congressional establishment wants to control consumers.

Socialism does not work!

Socialsim for blog

Our political establishment does not tell us about the economic result in other countrys’ single party payer universal healthcare systems.

We don’t have to go to other countries. We only have to go to the indigent areas in California were everyone is covered by Medicaid.

The Republican establishment needs to get off the stick before all of them are kicked out of congress.

Just imagine the healthcare systems savings if every consumer were empowered to shop for the best healthcare at the best price.

The result would be a free market healthcare system in which competition would cleanse the system and make it affordable to everyone.

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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When Its Not Your Money

Stanley Feld M.D.,FACP,MACE

No one should be surprised at the money wasted by federal government programs. President Obama has been the biggest offender of wasting taxpayers’ money in my lifetime.

He increased the national debt from 10 trillion to 20 trillion dollars.

The volume of regulations, the creation of bureaucratic agencies, bureaucratic czars and the lack of enforcement of existing laws have served to create much of this waste.

However the public is unaware of the amount of taxpayers’ dollars spent because of the lack of government transparency. Congress ought to be standing on every mountain screaming about the waste.

I have observed the opposite. All we have to do is remember how congress marginalized Tom Coburn’s efforts to eliminate waste by eliminating duplication.

Obamacare is no exception to immeasurable waste while it destroys the healthcare system.

Improper payments for Obamacare are soaring because of a defective law and government inefficiency and incompetence.

A study by HHS shows that the improper payment rate for Medicaid will be 11.5% for 2016. It means that more than one out of every 10 dollars spent is wasted on either fraud, errors in payment or accounting inaccuracy.

The pre-Obamacare improper payment rate was 5.8% or one in 20 dollars spent. In 2015 it was reported that the improper payment rate was 9.7%.

This is the waste rate for only 10 million people added to the Medicaid roles.

I would suspect all three reports are an underestimate of the real improper payment rates.

The actual dollar amounts of improper payment rates are increasing because Obamacare has expanded Medicaid enrollment.

As the number of Medicaid recipients increase the wasted dollars will increase.

With President Obama’s new executive order to expand the eligibility of illegal immigrants for Medicaid coverage, the rate and amount of dollars improperly deployed will skyrocket.

To my amazement a lot of intelligent people are ignoring this simple arithmetic.

Medicaid eligibility is increasing rapidly. In 2015 Medicaid enrollment increased by 13.8%. One in five Americans as well as all illegal immigrants are entitled to Medicaid coverage.

I guessed that HHS would blame physicians for the waste. I was correct.

Medicaid reimbursement is so low that physicians have figured out ways to see more patients per day. They are using physician extenders extensively.

These physicians are accused of running Medicaid mills. They are accused of Medicaid fraud.

Then these physicians are put through a costly audit and are penalized. Many get fined for fraud and abuse due to overbilling.

There are many other reasons for this waste. Most important is HHS’ lack of proper diligence in administering the program. It smacks of reasons similar to the VA Healthcare System scandals.

“There’s no particular reason the error rate should be spiraling upward other than overwhelming incompetence.”

On closer look, home health agencies are probably the biggest abuser along with an ineffective bureaucracy that becomes more ineffective as the program grows.

“In recent audits of Medicaid in Arizona, Florida, Michigan and New Jersey, the GAO uncovered 50 dead people who recouped at least $9.6 million in benefits after they died; 47 providers who registered foreign addresses as their location of service in places such as Saudi Arabia; and $448 million bestowed on 199,000 beneficiaries with fake Social Security numbers—12,500 of which had never been issued by the Social Security Administration.”

The problem is not discussed by the traditional mass media. The public has no idea this is occurring.

Medicaid is a single party payer system completely controlled by the government. Patients have no control over which doctors they will see for an illness.

Medicaid is another clear example of the lack of concern or incompetence by government agencies for spending other peoples’ money.

Even worse, the system does not work for patients or physicians. Patients are the most important stakeholders in the healthcare system. They are treated like a commodity.

Medicaid is inefficient and costly.

Twenty percent of our population is now in this system. There is limited access to care and rationing of care.

There is a better way. It is a consumer driven healthcare system using my ideal medical saving account.

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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If You Tell A Lie

Stanley Feld M.D., FACP, MACE

If you tell a lie enough times it becomes the truth. President Obama and Hillary and Bill Clinton keep telling the American public that there are 20 million new Obamacare enrollees.

Obamacare advocates believe that Obamacare provided healthcare insurance for 20 million people who did not have healthcare insurance before Obamacare.

These Obamacare advocates have little understanding of the details of this lie. They usually react negatively when I tell them the 20 million new enrollee figure is a lie.

Republicans do not pick this up and call Democrats out about this lie. Perhaps they have no understanding of what is going on.

The lie then becomes the truth.

I follow Charles Gabbe at Charles Gabbe is pro Obamacare. He publishes daily and weekly statistics as well as news in general about Obamacare’s progress and enrollment.

His numbers come from government sources. His numbers are very different than the numbers President Obama, Hillary and Bill Clinton are announcing.

The Obama administration continually manipulates the enrollment figures in order to give the impression that Obamacare has been successful.

President Obama continuously lies about the enrollment figures.

Obamacare has been a total failure because of its structure.

On December 9, 2015 published these enrollment numbers for 2016. publishes government release enrollment numbers weekly. These are the December 9th numbers.

Confirmed 2016 Exchange QHPs: 3,260,356 as of 12/09/15

Estimated 2016 Exchange QHPs: 4.73M as of 12/09/15 (3.60M via HCgov)

Projected Exchange QHPs: 5.76M by 12/12/15 (4.34M via HC.Gov)

Projected #OE3 QHP Selections: 14.70M nationally (11.23M via

Projected #OE3 QHP Selections by State

Maybe 9 million signed up for Obamacare last year. (2015)

What were the 12/09/14 enrollee numbers with 3 weeks to go until January 1, 2015?

Christmas to New Years consumes one week of enrollment. Holiday shopping will consume the other two weeks.

Why did the government reduce the expected enrollment to 5 million when enrollment was 9 million last year (2016)?

Does the Obama administration expect 4 million people to drop out of Obamacare because it is too expensive?

How did the Obama administration’s data given to the CBO cause the CBO to predict an enrollment of 21 million enrollees for 2016?

The 2016 Obamacare enrollment figures barely touch 10 million, not 20 million.

What is enrollment going to be when most of the major insurance companies have dropped out of the health insurance exchanges?

What is enrollment going to be when 18 of the 22 Obama administration created State Co-Ops have gone bankrupt?

President Obama and his administration have mislead Americans about the exact number of enrollees since the very beginning of the first enrollment period starting October 1, 2013. The first enrollment was delayed until November 1, 2013 and extended 6 months.

The American public has been mislead about:

  • The disastrous website development, reason for website crashes and cost of website development.
  • The exact number of enrollees the first year. (9.5 million corrected to 8 million and then re-corrected to 6.8 million)
  • An additional correction that resulted in another decrease of an additional 800,000 enrollees losing Obamacare insurance. The government belatedly discovered these 800,000 were ineligible for subsidies.
  • Decreasing the original predicted enrollees for 2015 from 13.5 million to 9.5 million.
  • The change in the start of enrollment from October 1, 2014 to November 15th to avoid discussion of enrollment around the time of the November 2014 elections.
  • Extending the 2014 enrollment 6 months.
  • Extending enrollment for 2015 for one to three months.
  • Finally, in 2015 announcing the back end of the website’s ability to send information to the IRS was still not complete.
  • Rehiring CGI, the same Canadian company that built the disastrous, to fix the back end of the website. A company’s employee is a friend of Michelle Obama.
  • Discovering that 1.2 million enrollees were counted that should not have been because they got dental insurance instead of healthcare insurance bringing the number of enrollees down from a recalculated 8 million to 6.8 million enrollees for 2014.
  • Announcing that 11.5 million people have enrolled for 2015 (these numbers seemed shaking at the time of enrollment. It seemed to be closer to 9.5 million or less.)
  • Announcing that the group market Obamacare insurance enrollment is being delayed a year or two while the mandate penalty for employers was to start January 1,2015.

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

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

However, we are told only ten million enrollees had Obamacare insurance in 2016.

Eighty five percent of those on Obamacare are receiving subsidies so the premiums are affordable. These subsidized recipients still cannot afford the deductibles.

The remaining 15% enrollees have a pre-existing illness. They cannot find private insurance to buy.

What about the 330 million people who might have subpar healthcare insurance? How many employers might discontinue employee insurance?

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

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

14 million people in the individual market lost their healthcare insurance pre Obamacare.

10 million gained insurance on the healthcare insurance exchanges in 2016. There is a net decrease of 4 million individuals that is not discussed by the Obama administration or the traditional mass media.

Many of the state healthcare insurance exchanges have failed.

Eighteen of the 22 state insurance co-ops have failed so far.

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

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

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

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

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

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

The discussion should be about the success of the healthcare insurance exchanges not the increase in Medicaid coverage.

The 2014 enrollment figures as of March 18, 2015 were also inflated. It is noteworthy than the Medicaid/CHIP estimate was 14.1 M. It is down to 10 million in 2016.

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

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

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

Written into the law is that only state healthcare exchanges can provide subsidies not the federal health exchanges.

President Obama has not asked congress to rewrite the law’s provision.

This was another example of executive overreach of power by President Obama.

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

Republicans have not pointed out all this manipulation to the voting public.

I believe the public has figured out the manipulation.

Hillary Clinton has promised she will expand Obamacare. Why expand a failed program?

Her unspoken goal is to institute a single party payer system. A single party payer system will also be unsustainable.

There is a better way!

It is a consumer driven healthcare system with my ideal medical saving account.

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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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


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%.


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 Extortion


Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

I thought the court decision was wrong.

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

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

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

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

It is a decision in favor of states rights.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Simple, Viable Republican Alternatives To Obamacare

Stanley Feld M.D., FACP, MACE

There are many simple and viable alternatives to Obamacare which Republicans should start considering.

Republicans should seriously consider My Ideal Medical Savings Account as an alterative to Obamacare. It is logical, simple, does not require a large complicated infrastructure and aligns all the stakeholders’ incentives.

It is easy for consumers to understand.

Consumers want to have choices. The dysfunction of our healthcare system has gotten to the point where most consumers don’t have a choice. Consumers simply do not know they lost their freedom of choice and access to care until they get sick.

Consumers think they have adequate healthcare coverage until they get sick. Only 20% of the population gets sick.

The other 80% of the population refuses to think about the problem.

When they do experience illness, the dysfunction in the healthcare system makes them furious. They want to blame someone. Physicians are usually the targets of their frustration.  

Most physicians are trapped in a situation that causes them to fight for their own survival for all the reasons I have previously enumerated. This creates a more dysfunctional healthcare system.

All the stakeholders fight for their own vested interests. These vested interests have become misaligned. The vested interest of the government is to control of the system and decrease its costs.  

Costs cannot be controlled by regulations without consumer involvement.   Consumers of healthcare must understand the effectiveness of their care is dependent on their involvement in their own medical care.

Consumers’ adherence to treatment is a key component in the effectiveness of medical care.

Medical costs cannot be controlled by government price fixing.

Medical costs cannot be controlled by government restrictions to access of care. Consumers will become sicker resulting in a higher cost illness.

Consumers must be empowered to be intelligent, motivated and responsible consumers of medical care. Only then can healthcare costs be controlled.

A functional healthcare system must provide financial incentives to consumers in order for them to want to be empowered to control costs. Consumers should not be dependent on the government to control costs.

The government must repair the actuary and accounting rules of the healthcare insurance industry. Insurance reserves should not be scored as a loss to justify premium increases.

The healthcare insurance industry takes 40 cents off the top of every insurance dollar that is spent. Consumers with both private insurance and government insurance are only getting 60 cents value for every healthcare dollar spent. The healthcare industry is allowed to do some strange accounting with their required reserves.

If this accounting method were repaired, premium costs would decrease.

Effective malpractice reform would result in a significant decrease in healthcare costs. The Obama administration refuses to believe tort reform is needed.  

Many of the rules written into Obamacare, Medicare, and Medicaid are so screwy they defy common sense and penalize consumers. One glaring rule is Medicare permitting hospitals to admit Medicare patients to the hospital for observation for 48 hours.

Medicare does not pay for Observation admissions. Patients have to pay out of pocket for these admissions.

Consumers must become aware of these screwy rules and protest them. These rules have been written by the Obama administration to save the government money. These rules penalize patients the government professes to help.

Consumers are the only stakeholders that can motivate President Obama and congress to fix the significant points of waste in the healthcare system. Consumers have the power to vote.

I do not believe that President Obama has an interest in repairing the healthcare system. All of his actions signify that he wants the healthcare system to fail. After it fails people will beg the government to completely take over and have a single party payer.

Does anyone trust the government to take over our most valuable asset, our healthcare?

The government take over will also fail because dependent consumers will figure out how to game the system just as food stamp recipient have figured out how to game that inefficient system.

The goal of a sincere administration and congress is to figure out how to motivate consumers to be “PROSUMERS” (productive consumer) with an economic interest in the healthcare system.

Airlines, banks, bookstores, entertainment venues have all figured it out. Why can’t the government help consumers figure it out?

My blog entitled “My Ideal Medical Saving Account Is Democratic” presents a consumer driven healthcare formula. It gives every socioeconomic group the opportunity to be an effective “Prosumer”.

It gives all Prosumers the incentive to be responsible for their health and healthcare dollars.

Below is the blog My Ideal Medical Savings Account Is Democratic!

My Ideal Medical Savings Account Is Democratic!

Stanley Feld M.D.,FACP,MACE

A reader sent this comment; “My Ideal Medical Savings Account (MSA) “was not democratic and leads to restriction of medical care for the less fortunate.'

This comment is totally incorrect. I suspect the comment came from a person who has “an entitlements are good mentality.”

I believe that incentives are good. They lead to innovation. Innovation leads to better ideas.

Healthcare entitlement leads to ever increasing costs, stagnation, restrict freedom of choice and decrease in access to care.

The excellent example of increasing costs, decreasing choice, and decreasing access to care is Medicaid.

The fact that someone is covered by healthcare coverage does not mean they have access to medical care.

 I have written extensively about the virtues of My Ideal Medical Savings Accounts (MSAs). They are different than Health Savings Accounts (HSAs).

HSAs put money not spent in a trust for future healthcare expenses. MSAs take the money out of play for healthcare expenses. MSAs provide a trust fund for the consumer’s retirement.

MSAs provide added incentives over HSAs to obtain and maintain good health.  Obesity is a major factor in the onset of chronic diseases. Consumers must be motivated to avoid obesity to maintain good health. MSAs can provide that incentive.

The MSA’s can replace every form of health insurance at a reduced cost. It limits the risk to the healthcare insurance industry while providing consumers with choice.

This would result in competition among healthcare providers. Competition would bring down the cost of healthcare.

Some people might not like MSA’s because they are liberating. They provide consumers of healthcare with freedom of choice. They also give consumers the opportunity to be responsible for their healthcare dollars while providing them with incentives to take care of their health.

MSAs could be used for private insurance purchasers, group insurance plans, employer self- insurance plans, State Funded self-insurance plans and Medicare and Medicaid.

In each case the funding source is different. The cost of the high deductible insurance is low because the risk is low. 

If it were a $6,000 deductible MSA, the first $6,000 would be placed in a trust for the consumer. Whatever they did not spend would go into a retirement trust.  If they spent over $6,000 they would receive first dollar healthcare insurance coverage. Their trust would obviously receive no money that year.

The incentive would be for consumers to take care of their health so they do not get sick and end up in an expensive emergency room.

If a person had a chronic illness such as asthma, Diabetes Mellitus, or heart disease with a tendency to congestive heart failure and ended up in the emergency room they would use up their $6,000.

If they took care of themselves by spending $3,000 of their $6,000 trust their funding source could afford to give their trust a $1500 reward. The benefit to the funding source is it saved money by the consumer not being admitted to the hospital. The patient stayed healthy and was more productive.

President Obama does not want to try this out. He wants consumers and businesses to be dependent of the central government for everything.

MSAs would lead to consumer independence from central government control of our healthcare. MSAs would put all consumers at whatever socioeconomic level in charge of their own destiny.

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

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Republicans who really want to repair the healthcare system should take notice of these suggestions. They should stop proposing complicated alternatives to Obamacare that will not work.

Republicans should start trying to understand the real problems in the healthcare system.

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

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View Of A Young Doctor: Dr. Starner Jones

Stanley Feld M.D.,FACP,MACE

 A reader sent this note to me with a request to pass it on. The note hits the nail on the head.

 Dr. Starner Jones is an intern in a large community hospital.

 As a young physician he understands the folly of America’s entitlement society.

His short two-paragraph letter to President Obama accurately puts the blame for America’s dysfunctional healthcare system and its accelerated unsustainability on our  "Culture Crisis." Our country has a "Health Care Crisis" as a result of its "Cultural Crisis".

He presents the crisis, its diagnosis, prognosis and cure in just three (3) short paragraphs.

If you doubt any part of what Dr. Jones says, go visit your local hospital emergency room as an observer for an hour or so some Friday or Saturday night. Then see how many responsible people you can send his solution to for them to send it on. 

 “Dear Mr. President:

During my shift in the Emergency Room last night, I had the pleasure of evaluating a patient whose smile revealed an expensive shiny gold tooth, whose body was adorned with a wide assortment of elaborate and costly tattoos, who wore a very expensive brand of tennis shoes and who chatted on a new cellular telephone equipped with a popular R&B ring tone.

While glancing over her patient chart, I happened to notice that her payer status was listed as "Medicaid"! (A Completely Free Healthcare Program provided by our Government) During my examination of her, the patient informed me that she smokes more than one costly pack of cigarettes every day and somehow still has money to buy pretzels and beer.

And you and our Congress expect me to pay for this woman's health care?

 I contend that our nation's "health care crisis" is not the result of a shortage of quality hospitals, doctors or nurses. Rather, it is the result of a "crisis of culture", a culture in which it is perfectly acceptable to spend money on luxuries and vices while refusing to take care of one's self or, heaven forbid, purchase health insurance. It is a culture based on the irresponsible credo that "I can do whatever I want to because someone else will always take care of me."

Once you fix this "culture crisis" that rewards irresponsibility and dependency, you'll be amazed at how quickly our nation's health care difficulties will disappear.


 If you agree…pass it on to responsible friends. 

There are additional reasons for America’s “healthcare crisis.” However, as long as we elect local, state and federal politicians who believe that all of society must be responsible for the welfare of the irresponsible members of society, America’s unsustainable economic situation will become worse.

Someone told me America is the greatest economic machine in the world “only because we print more money and suck less.”

 The more people receiving the benefits of the inefficient redistribution of wealth through entitlement programs the harder it will become to reinvigorate the American dream.

America is working its way toward a totally socialist society where the government supports us and tells us what to do and where and when to do it.

We will wake up one day and ask what happened to the freedoms guaranteed by the Constitution and Bill of Rights.

The answer is we gave them away to power hungry politicians who want to control us.

France just dropped its 75% tax rate because its society was economically unsustainable no matter how high its tax rate and the economy is collapsing.

France has had a "Culture Crisis "that is causing its social and economic collapse. The country finally realizes the people must have incentives to be creative. Progress does not happen as a result of entitlement and the redistribution of wealth.

The British National Health Service is in grave financial difficulty. 

 The NHS is in danger of being shut down.

"It’s a period of unprecedented pressure, of undue pressure. the NHS is facing very difficult times, yes. The word "crisis" implies that you can’t deal with it."

"A Department of Health spokesman said: "In common with healthcare systems around the world, the NHS is facing unprecedented demand, but undermining the principle of services being free at the point of use is not the answer."

I think rather than repeating the same mistakes over and over again, someone would learn something about fixing the “Culture Crisis”.

 As other countries are trying to fix their “Culture Crisis”, President Obama is going in the other direction and accelerating the road to economic failure.

Jack P, Athens wrote the following comment in,  

“Socialism always brings a good laugh when it collapses as the politicians raise taxes to cover their mistakes.”

President Obama is destroying the healthcare system with Obamacare.

I would try to fix America’s “Culture (entitlement) Crisis” by helping people become responsible and act independently. I would not increase policies that promote individual dependency on the government.

Somehow Americans have to wake up as a people and try to stop the government from following this path.

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

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Things Happen When No One is Looking

Stanley Feld M.D.,FACP,MACE

I wish you all a Happy and Healthy New Yew Year.

I have not written blogs during the holiday season because I figured no one would pay attention to what is happing in healthcare.

President Obama figured the same and snuck in a few things to continue to destroy the healthcare system.

Obamacare “innovative programs” seem to be going nowhere. The Obama administration continues to insist that all is going well.

The money spent is being wasted. The taxes for the funding of Obamacare’s 6.7 million enrollees is increasing as it attempts to increase enrollment to 9 million down from the original enrollment goal of 12 million.

I received a note from a reader who said Obamacare is here to stay. It is what it is. We should try to repair Obamacare rather than repeal it and replace it.

In my view Obamacare cannot be repaired. It was created to destroy the healthcare system. President Obama’s goal is to replace Obamacare with a government controlled single party payer system.

 The result will be to control and restrict access to care and ration care. It is a step on the way to restrict citizens’ freedoms.

Every week indications of Obamacare’s failures appear but are kept under the public’s radar.  The Obama administration spins the facts and the mainstream media’s regurgitates that spin.

 The Obamacare signup figures as complied by as of 12/30 2014 are very different that the administration’s spin to the media that the open enrollment period is going great.

Obamacare’s enrollment is still 1 million below estimate at this point

Confirmed 2015 QHPs: 7,403,558 as of 12/29/14
Estimated 2015 QHPs (Cumulative):
11/21: 610K (462K HCgov) • 11/28: 1.02M (765K HCgov) • 12/05: 1.80M (1.35M HCgov)
12/12: 3.26M (2.46M HCgov) • 12/15: 4.70M (3.52M HCgov) • 12/19: 8.52M (6.40M HCgov)
12/23: 8.65M (6.50M HCgov) • 12/30: 8.84M (6.54M HCgov)

state-level projections

 HHS finally announced that approximately 87% of Americans who selected 2015 health insurance plans through in the first month of open enrollment are receiving financial assistance to lower their monthly premiums. This percentage of subsidy awards is higher than in the same period last year.

The number is significant because, should the U.S. Supreme Court decide against the Obama administration in the King v. Burwell case it is scheduled to hear in March, consumers living in the 37 states relying on the subsidies from could lose their premium subsidies.

Another problem is even with the subsidy the people who received them cannot afford the insurance deductible. They do not seek medical care.

HHS has yet to disclose if it has a contingency plan should a ruling come down that only those who buy Obamacare insurance through state exchanges are eligible for coverage subsidies.

The CMS Innovation Center was established by section 3021 of the Affordable Care Act (Obamacare) for the purpose of testing “innovative payment” and service delivery models to reduce healthcare expenditures while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits.

To date the CMS Innovation Center has awarded $2.6 billion through September 2014 to hospitals, doctors and others through nearly two dozen programs that tested new ways to deliver healthcare and pay for it.

“Results of those programs some underway since 2011including more than 60,000 providers and 2.5 million patients in Medicare, Medicaid and the Children's Health Insurance Program, are largely not yet available, the Innovation Center said in its second report to Congress.”

The ICD-10 diagnostic and procedure codes were to be implemented two years ago. It appears to be going nowhere because it is too complicated. President Obama will probably delay it again.

The change toICD-10 from ICD-9 has been pushed forward at least three times. It is too complicated. It is designed to commoditized medical treatment and eliminate physician judgment. Codes have been increase from 18,000 (complicated enough) to 68,000. Neither physicians nor their unsophisticated computer systems can comply correctly.

The Obama administration is still pushing for its execution and wasting money yearly. Physicians cannot and will not comply with this government regulation.

 It is destined to fail at a tremendous waste of taxpayers’ dollars.

President Obama promised the AMA he would fix the defective Medicare Sustainable Growth Rate formula( GRF) for calculating Medicare reimbursement to physicians. As a result of that promise the AMA supported President Obama’s healthcare reform bill.” 

The GRF is not fixed yet. Congress delays the reductions in reimbursement due to this defective bureaucratic formula  each year and adds the percentage reduction in physician reimbursement to next year’s reimbursement reduction.

This year physicians can expect another 4% reduction for a total of 32% since 2002.  We will see if congress fixes this defective formula this year.  

On January 1, 2015 physicians are going to experience a series of pay cuts from CMS.  If functional electronic medical records are not implemented physicians will experience additional reimbursement reductions from Medicare and Medicaid.

Physicians are struggling to deal with new measurements to improve quality and deal with a myriad of new changes in Medicare and Medicaid rules and regulations.

Two years ago in order to attract more physicians to accept Medicaid to care for the growing number of enrollees in Medicaid, Obamacare increased Medicaid reimbursement by 40%. The increase in reimbursement was to last only until January1, 2015 and then revert to the 2012 reimbursement schedule.

Those pediatricians, family practitioners and internists were faked out once more by Obamacare and President Obama’s promises.

The biggest pay surprise to physicians will come when the old reimbursement returns. Poor Americans on Medicaid will suffer when they cannot find a physician.  

No other segment of the health care industry faces penalties as steep as these and no other segment faces such challenging implementation logistics,” Dr. James Madara, the AMA’s CEO wrote to the Obama administration.  “The tsunami of rules and policies surrounding the penalties are in a constant state of flux due to scheduled phase-ins and annual changes in regulatory requirements.”

 The cascade of rules and regulations will affect every specialty of medicine. The only thing left is for physicians to quit participating in government programs.

Then government can force medical license renewal to be tied to participation in government healthcare programs.

Where is physicians’ choice and freedom? There is currently a physician shortage. If physicians quit medicine and surgery what will happen to patient care?

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

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The Significance Of The Jonathan Gruber Controversy

Stanley Feld M.D.,FACP,MACE

Jonathan Gruber, a professor of Economics at MIT and one of the authors of Obamacare, made comments in 2013 about the trick plays the Obama administration used to pass the Affordable Care Act.

Jonathan Gruber’s comments serve to help Americans understand the mechanics of the passage of Obamacare. Hopefully it will serve as a wakeup call for the entire electorate.

Jonathon Gruber’s comments reflect the attitude of President Obama and his entire administration toward the electorate.

The cover-up always makes it worse.

Mr. Gruber admits what many of us have understood throughout President Obama’s years in office. President Obama’s attitude is reflected in all the trick plays he has pulled on congress and the American people during the passage and implementation of Obamacare.

Please look at all the articles covering President Obama’s trick plays since 2008 by clicking here.

The mainstream media has done President Obama’s bidding. It has not covered the meaning of Jonathan Gruber’s comments and the disrespect he and others have for the intelligence of the American public.

A reader sent me this comment before Jonathan Gruber’s comments were discovered.

“Dr. Feld,

There is some science behind the Progressive methodology that non-progressives need to learn.  The Progressive movement talks directly to the limbic portion of the brain while non-progressives tend to sort through facts in the neocortex.

Decisions are made in the emotional limbic portion of the brain, hence the reason and way marketers appeal to emotions versus your facts. 

The bottom line is this, non-progressives need to turn their facts into stories that are emotional or conservatives will always be out sold by those who’s arguments are devoid of facts (or outright lies) but full of emotion.

Have an awesome day.”

The Gruber controversy has given Americans a story that stimulates an emotional response. Americans are offended by being called stupid.

Jonathan Gruber did not make these statements in a void. It had to reflect the thinking of Obama administration. Even John Kerry gave him some help.



Published on Nov 12, 2014

Gruber explains how Senator John Kerry helped him fool stupid voters into accepting a tax hike.

 Mr. Gruber could not have made the decisions on his own to take the policy actions he described.

He never should have described the actions of those involved in public.

 The Obama administration also provided the Congressional Budget Office (CBO) with wrong information. The information led to wrong CBO’s conclusions regarding Obamacare’s real costs. The CBO crunches numbers fed to it by the Obama administration.

 The Obama administration used CBO’s false scoring to sell the CBO’s economic conclusions to the public through the mainstream media.  

It is clear that President Obama and his administration believe they are smarter than the American people. President Obama believes that his administration knows what is best for Americans.

The only reason the American people have not connected the dots is because they believe the president is an honorable man. The president is not expected to lie to the public.  

The progressive press is trying to divert attention from Jonathan Gruber’s comments. It is trying to get the public to ignore Mr. Gruber.

An initial diversion came from Paul Krugman in his Victory Lap article about Obamacare.

Paul Krugman said the health economist Jonathan Gruber, one of the principal architects of health reform  recently summed it up:

The Medicaid-rejection states “are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.”

Paul Krugman did not provide any facts just an appeal to emotion.

 MSNBC used this emotional stimulation to get its followers to ignore Jonathan Gruber’s comments.

“Part of the problem with the Jonathan Gruber “stupid” story is that it’s a shiny object for the political world to stare at for a while. It offers more heat than light. It’s a bouncing ball for political insiders to chase after, despite its relative insignificance.”

“But since it’s likely to soon be the subject of congressional hearings, and since your crazy uncle who watches Fox News all day will be talking about nothing else at Thanksgiving, let’s grudgingly tackle this week’s Most Important Story Of All Time As Agreed Upon By Republicans And The Beltway Media.”

Please note the inference that Republicans and Fox News are stupid for making an issue out of Jon Gruber’s statements. The implication is MSNBC is smart.

Progressives need public support in order to maintain power.

The problem is the public is tired of progressives’ emotional appeals devoid of facts.

The progressive press including MSNBC and The New York Times need examine their premises. They are daily losing listeners and readers .

Nancy Pelosi is incredible.

She said,

“Let’s put Jonathan Gruber aside.”

 “House Minority Leader Nancy Pelosi responds to Jonathan Gruber’s comments on the Affordable Care Act, saying, “I don’t know who he is. He didn’t help write our bill. So with all due respect to your question, you had a person who wasn’t writing our bill commenting on what was going on when we were writing the bill who has withdrew some of the statements that he made. So let’s put him aside.”

It is almost as bad as "we will not know what is in the bill until we pass it."

President Obama and his administration are trying to prevent public understanding of his current tricks plays. He continues to try to divert American from the truth about Obamacare.

President Obama needs to explain the truth to regain his credibility with the American people.

He must address these unanswered issues if he wants to maintain his promise of transparency.

  1. Why the open enrollment period was delayed until November 15th.
  2. What is the actual number of valid enrollees in Obamacare in 2014? Is it 8 million, 7 million, 5.6 million or 3 million? I thought Obamacare and its mandate would be in effect for small businesses and corporations in 2015.
  3. Why has the estimate of total enrollment for 2015 been reduced from 13 million to 9 million? I thought 2015 Obamacare would be fully implemented and many more people would sign up as they lost employer sponsored insurance.
  4. How many people who received government subsidies last year lied on their application?
  5. Why weren’t the rules for subsidies enforce?
  6. How many people lost their subsidy?
  7. How are you going to collect the subsidy from people that lied?
  8. How many people have claimed they are not going to re-enroll in Obamacare this year and why are they not going to enroll?
  9. How does a person receive a tax credit when he has no taxable income to apply that tax credit to?  

     10. Explain the status of the open enrollment and the mandate for small businesses and large corporations.

      11. What is the status of waivers that companies and unions received from Obamacare for 2015?

      12. Why does the state of Massachusetts have a failed State Health Insurance Exchange that     required  $400 million dollars in federal  supplements each year if Romneycare is so successful?

      13. Why would the government subsidize healthcare insurance companies to participate in Obamacare?

     14. Why is the public being told that healthcare exchanges premiums are going down when in reality they are going up?

     15. What is happening with the Minimed Insurance policies that were supposed to expire in 2015?

     16. What does Obamacare cost the federal government? Is it budget neutral?

     17. What is the exact amount of increased taxes used to fund Obamacare?

     18. What percentage of the increased taxes are collected from each income group?

These are just a few of the questions President Obama and his administration have not provided the answer to.

 The answers to these questions would permit the public to understand Obamacare’s sustainability.

 The Jonathan Gruber incident has made it clear how President Obama and his administration operates as well as its lack of respect for the intelligence of the American public.

 Americans are not dumb. They want to believe their leaders. Their leaders have lied to them. Americans recognize that. President Obama and his administration have little credibility with the American public. President Obama promised a transparent government. There is not any transparency.

The midterm elections proved Americans are aware. It is a good first step.  Now we have to see what the Republicans will do with this leadership opportunity. 



An explanation of Obamacare.

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

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