Medicine: Healthcare System

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Medical Care Must Not Be Converted To A Commodity

April 19, 2015

inConsumer Driven Health Care, Disinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

This blog post is a follow up to my last blog "Restricting Access To Care." I published this blog on May 10 2010. The Obama administration has ignored every word. As consumers and physicians might have notice the quality of medical care and the patient/physician relationships have deteriorated as I predicted because Obamacare.

Medical care is not patient centric. Healthcare reform (Obamacare) has been focused on process and not patients. This focus has distorted the effectiveness of medical care even more that it was pre Obamacare.

President Obama has increased the complexity of healthcare in an attempt to make medical care a commodity. His scheme is failing at the expense of consumers.

President Obama keeps on telling the same lie. “Obamacare is a success.” Consumers are not that stupid.

The public must start understanding what is happening now and not complain about why medical care has been destroyed later.

Once the public understands what is happening, individuals must write their congressperson and protest.

Consumers must not believe every lie thrown at them by the traditional media especially when the lie is counter to their every day experience.

I am republishing a previous blog that explains the attempt of turning medical care into a commodity.

Medical Care Must Not Be Converted To A Commodity

Stanley Feld M.D.,FACP,MACE

" President Obama is creating a new bureaucratic agency. It is called the Independent Payment Advisory Board. The Independent Payment Advisory Board will not be measuring clinical judgment or patient compliance when judging the effectiveness of treatment. Its measurement will be physician compliance with evidence based medicine. President Obama, please reexamine your premises.

I am in favor of clinical practice guidelines and evidence based medicine. However, both should be used as an educational tool for physicians and not as a punitive tool to judge payment.

The USPHTF will determine the evidence based medicine to be used. I have pointed out the deficiencies in the USPHTF in the past.

This bureaucracy is an attempt by the government to commoditize medical care. Once medical care is commoditized the cost for medical care is suppose to decrease.

Intensive control of the blood sugar for Type 2 Diabetes Mellitus can be expensive in the short run. If intensive control decreases the complications of Type 2 Diabetes Mellitus it can decrease costs in the long term.

The conclusion of the ACCORD study was intensive control was not worth the cost of medical care in the short term or long term. After the data was reexamined it turned out that the ACCORD conclusions were incorrect.

“It was not hypoglycemia from intensive control or intensive control itself that caused the increased deaths in the ACCORD study.”

Unfortunately, this information was not being reported on every TV station as the original study results were. The original study results set back universal use of intensive control of Type 2 Diabetes at least a decade.

“ It was important to say that in the intensive group it really was not the people with lower A_1c who had problems, it actually was those who had the higher A_1c who, despite intense efforts, we couldn't get under control."

This means patients did not comply with their responsibility to intensively control their chronic disease or their physicians did not teach them to control their blood sugar adequately.

"This reexamination gives a stronger momentum to the idea that we need to be thinking that one size doesn't fit all, we need to have different targets for different groups of people and perhaps different treatment strategies to reach those different targets as well. That's troubling both clinically and to the trialist.”

"This is something of a new idea, because previously there has been a strong impetus to having standardized guidelines for doctors and people with diabetes, but it's probably not the right thing to do.”

The reader can sense the discomfort of the academic physicians. They are realizing they cannot commoditize medical treatment. Ask any experienced practicing physician about their patients. Patients have different attitudes about their disease and treatment.

Each patient has to be related to differently. This is clinical judgment. Physicians communicating with their patients is called the physician patient relationships. Patients should be responsible for their outcomes along with physicians. This is the art of medicine. Neither patient nor physician can be treated as a commodity.

President Obama, I hope you are listening. Medical care is difficult to commoditize.

The ACCORD study originally suggested that the goal to normalize the HbA1c resulted in an increase in cardiovascular deaths. It turned out not to be true.

On the other hand an observational study was just published concluding that the lower the HbA1c the lower the complication risk.

“The Atherosclerosis Risk in Communities (ARIC) study is a community-based assessment of 11,092 middle-aged adults in four US communities with normal HbA1c were followed for up to 15 years (4 visits at about 3-year intervals) for onset of new diabetes, new CVD, stroke, and all-cause mortality.”

The higher the HbA1c the higher the average blood sugar and the greater the risk for chronic complications of Type 2 Diabetes Mellitus. HbA1c is a measure of the average blood sugar over the previous three months.

Table. HbA1c Levels and Corresponding Multivariate Hazard Ratios

HbA1c Level	Multivariate-Adjusted Hazard Ratio
< 5%	0.52 (0.40-0.69)
5% to < 5.5%	1.00 (reference)
5.5% to < 6%	1.86 (1.67-2.08)
6% to < 6.5%	4.48 (3.92-5.13)
≥ 6.5%	16.47 (14.22-19.08)

HbA1c = hemoglobin A1c

“The hazard ratios for stroke were similar, but for all-cause mortality, HbA1c displayed a J-shaped association curve. All associations remained significant after adjustment for the baseline FPG.”

The study found HbA1c values predicted Cardiovascular Disease (CVD) or death, whereas fasting plasma glucose (FPG) levels were not significant after adjustment for other risk factors.

“The recent ADVANCE [Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation], ACCORD [Action to Control Cardiovascular Risk in Diabetes], and VADT [Veterans Affairs Diabetes Trial] trials left us wondering about the value of tight glycemic control in reducing CVD risk.”

“One of the many shortcoming of each of these trials was that most participants had had diabetes for many years, and the designs could not account for the long-term accumulation of glycemic burden.”

The authors claim that the vascular damage from high HbA1c may have already occurred. Tight control during the trials might have had relatively little effect. This is probably not true.

There is evidence that normalizing the blood glucose can lead to regression of the vascular lesions that cause the complications of Diabetes.

The current ARIC analysis demonstrates that higher HbA1c levels, even in the normal range, increase CVD risk.

These results are not conclusive because it is an observational study as opposed to a double blind placebo controlled study. The USPHTF and President Obama’s Independent Payment Advisory Board would not give this study as much credit as the ACCORD study.

The ACCORD study was a placebo controlled double blind study. Its conclusions have more power than an observational study (ARIC). The problem is ACCORD measured the wrong endpoint. ACCORD has resulted in a great disservice to the standard of medical care of diabetes.

The results of The Atherosclerosis Risk in Communities (ARIC) study suggest that maintaining a HbA1c as near normal as possible even before the onset of diabetes may help prevent CVD.

As President Obama tries to quantify the standard of care he could be picking the wrong standard of care in order to reduce the cost of medical care. All medicine is local. Standards of care are always evolving. The standard of medical care should be determined by local medical leaders who are respected as teachers by local practitioners. It can also be enforced by local peer review with no monetary interest in the outcome.

President Obama’s effort to improve medical care at a reduced price will not succeed if it is interpreted as a punitive measure by a national bureaucracy.

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

May 30, 2010 "

A healthcare system that would work and be cost effective must be a consumer driven healthcare system. It must be patient centered and not stakeholder centered.

It must put consumers in a position of responsibility for their health and healthcare dollars and not in a position of dependence on the government.

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

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Medical Care Must Not Be Converted To A Commodity

April 19, 2015

inConsumer Driven Health Care, Disinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

President Obama has increased the complexity of healthcare in an attempt to make medical care a commodity. His scheme is failing at the expense of consumers.

President Obama keeps on telling the same lie. “Obamacare is a success.” Consumers are not that stupid.

The public must start understanding what is happening now and not complain about why medical care has been destroyed later.

Once the public understands what is happening, individuals must write their congressperson and protest.

Consumers must not believe every lie thrown at them by the traditional media especially when the lie is counter to their every day experience.

I am republishing a previous blog that explains the attempt of turning medical care into a commodity.

Medical Care Must Not Be Converted To A Commodity

Stanley Feld M.D.,FACP,MACE

I am in favor of clinical practice guidelines and evidence based medicine. However, both should be used as an educational tool for physicians and not as a punitive tool to judge payment.

The USPHTF will determine the evidence based medicine to be used. I have pointed out the deficiencies in the USPHTF in the past.

This bureaucracy is an attempt by the government to commoditize medical care. Once medical care is commoditized the cost for medical care is suppose to decrease.

“It was not hypoglycemia from intensive control or intensive control itself that caused the increased deaths in the ACCORD study.”

This means patients did not comply with their responsibility to intensively control their chronic disease or their physicians did not teach them to control their blood sugar adequately.

President Obama, I hope you are listening. Medical care is difficult to commoditize.

The ACCORD study originally suggested that the goal to normalize the HbA1c resulted in an increase in cardiovascular deaths. It turned out not to be true.

On the other hand an observational study was just published concluding that the lower the HbA1c the lower the complication risk.

Table. HbA1c Levels and Corresponding Multivariate Hazard Ratios

HbA1c Level	Multivariate-Adjusted Hazard Ratio
< 5%	0.52 (0.40-0.69)
5% to < 5.5%	1.00 (reference)
5.5% to < 6%	1.86 (1.67-2.08)
6% to < 6.5%	4.48 (3.92-5.13)
≥ 6.5%	16.47 (14.22-19.08)

HbA1c = hemoglobin A1c

The study found HbA1c values predicted Cardiovascular Disease (CVD) or death, whereas fasting plasma glucose (FPG) levels were not significant after adjustment for other risk factors.

The authors claim that the vascular damage from high HbA1c may have already occurred. Tight control during the trials might have had relatively little effect. This is probably not true.

There is evidence that normalizing the blood glucose can lead to regression of the vascular lesions that cause the complications of Diabetes.

The current ARIC analysis demonstrates that higher HbA1c levels, even in the normal range, increase CVD risk.

The results of The Atherosclerosis Risk in Communities (ARIC) study suggest that maintaining a HbA1c as near normal as possible even before the onset of diabetes may help prevent CVD.

President Obama’s effort to improve medical care at a reduced price will not succeed if it is interpreted as a punitive measure by a national bureaucracy.

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

May 30, 2010 "

A healthcare system that would work and be cost effective must be a consumer driven healthcare system. It must be patient centered and not stakeholder centered.

It must put consumers in a position of responsibility for their health and healthcare dollars and not in a position of dependence on the government.

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

Please have a friend subscribe

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Restricting Access To Care

April 15, 2015

inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems, Physician's Problems, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP, MACE

As a retired Clinical Endocrinologist I don’t have a vested interest in generating income for myself from the healthcare system.

What I am trying to do is help consumers and healthcare policy makers understand the present healthcare system. I fear they have no interest in understanding what would work to repair the healthcare system.

I am also trying to explain to consumers that few politicians are interested in helping them. Politicians are interested in power. They are interested in making the people dependent on them.

Politicians and the central government are interested in controlling the healthcare system, the financial system, the Internet and the environment. Once politicians control these systems the people have lost their independence and freedom. Politicians will have the power they seek.

Many of our constitutional freedoms have been disappearing. American have been on the Road To Serfdom for many years.

President Obama has hastened the journey on the road to serfdom with his blatant disregard for the constitution and the bill of rights. To my chagrin he is succeeding.

President Obama is pretending to want to provide universal care. His goal is to destroy the healthcare system so that the people will beg for the central government to control the healthcare system. There are more uninsured people now than when he became President.

Paul Krugman is one of President Obama’s henchmen. He stated in a recent article that Obamacare is costing the government less money than the administration thought it would. He therefore calls Obamacare a success.

This administration and its henchmen in the traditional media flood us with half-truths.

Obamacare might be costing the government less than they expected. The Obama administration never told Americans what they expected to spend.

The Obama administration is the most non-transparent administration in my lifetime. Meanwhile, the Obama administration tells Americans it is the most transparent administration in history.

CGI is a Canadian company with offices in the U.S. It had the contract to develop the Obamacare website healthcare.gov. The website was a disaster. The development cost overruns were unbelievable.

CGI received the contract through an Obama crony capital award and a non-competitive bid.

CGI receive another contract to complete the backend of healthcare.gov.

The Affordable Care Act (Obamacare) is supposed to be affordable for consumers. Consumers are experiencing higher premiums and out of pocket expenses for medical services.

1. Obamacare has been under subscribed. Only 10 million people are verified premium paying subscribers. The Obama administration projected 30 million subscribers by 2015 when Obamacare was passed in 2010.

2. The deductibles are unaffordable. Obamacare is even unaffordable to those people who receive subsidies.

The subsidized people have avoided seeing physicians in a timely manner. The result is government costs are less in the short run but will be more in the long run as people get very ill.

3. The Obama administration is keeping the expenses for infrastructure and bureaucratic structure non transparent.

4. Obamacare’s rules and regulations are resulting in restricting access to care.

5. Paul Krugman and the Obama administration spin the truth by ignoring consumer out of pocket expenses.

There has been an explosive increase in premiums and higher deductibles though the health insurance exchanges as well as private insurance.

The Obama administration has been silent about this reality.

The Affordable Care Act is not affordable. It has not increased the “quality of care.”

Paul Krugman does not publish the real truth in his New York Times articles. Those who still read the New York Times take his words literally. They are deceiving themselves.

One of the ways the Obama administration is restricting access to care to lower its costs is through the U.S. Preventive Services Task Force’s (USPSTF) recommendations.

I have criticized the USPSTF methodology in the past for its conclusions about many clinical practices.

The task force is composed of a group of physicians that do not have clinical expertise in the medical or surgical topic they are evaluating.

The group simply reads the medical papers assigned to them to evaluate. The committee decides the efficacy of treatment on the quality of the literature they are given to evaluate. Clinical judgment is not included in their evaluation.

A positive decision is made if the literature contains a double blind controlled study yielding positive results.

Last month the U.S. Preventive Services Task Force (USPSTF) issued its final recommendation statement on Screening for Thyroid Dysfunction. The USPSTF studied this topic in 2004 with the same final opinion.

This time Obamacare will probably take action and restrict the evaluation on the basis of this recommendation

“ In its statement, the task force said that without more data from randomized clinical trials it could not assess the balance of benefits and harms from pre-clinical thyroid disease treatment and, thus, could not recommend that asymptomatic, non-pregnant adults be screened for thyroid dysfunction.”

The Annals of Internal Medicine (AIM), a journal of the American Medical Association published the USPSTF recommendation without expert clinical endocrinology comment or critique.

R. Mack Harrell, MD, FACP, FACE, ECNU current President of the American Association of Clinical Endocrinologists (AACE) is having the AACE Thyroid Scientific Committee submit a note to the Annals of Internal Medical addressing AACE’s concerns with the USPSTF’s paper.

AACE has studied and written many guidelines on the evaluation and treatment of thyroid disease. Its members have vast experience as practicing clinicians in the treatment of thyroid disease. Its input should be sought by the Obama administration not ignored in favor of a default decision that saves Obamacare money and puts the financial burden of care on consumers.

The following is Dr. Mack Harrell’s comment to AACE’s membership.

In my opinion Dr. Harrell’s’ comments are totally correct and should be heeded by the Obama administration.

“While agreeing with the USPSTF’s call for new, controlled thyroid screening studies, AACE issued a press release outlining its position on aggressive case finding suggesting: that this approach is an appropriate alternative to screening in patient groups where thyroid risk factors are present.

More specifically, AACE stressed that testing and treatment are indicated in those patients who are at highest risk for developing life-altering, overt thyroid disease, including:

Patients over 60, in whom symptoms of hypothyroidism are often minimal, absent or atypical

Newborns (continued mandatory screening for congenital hypothyroidism recommended)
Those with autoimmune diseases often associated with thyroid disease, such as type 1 diabetes and pernicious anemia
Patients with a prior history of thyroid disease or thyroid surgery, an abnormal thyroid exam, or taking drugs known to affect the thyroid
Patients with a family history of thyroid illness

AACE further emphasized that careful consideration should be given to thyroid testing in women who are planning pregnancy or are already pregnant given the clear-cut detrimental effects of thyroid hormone lack on fetal development in the early phases of pregnancy.

We also intend to submit to AIM a formal statement from the AACE Thyroid Scientific Committee to address concerns that the task force’s “lack of data” argument could be incorrectly interpreted as a “lack of clinical need” to find and treat thyroid disease.

For years, members of AACE and the American College of Endocrinology have worked diligently to provide up-to-date, useful clinical guidelines and recommendations regarding decision-making about thyroid function testing for physicians. We will continue to keep our members and the medical community apprised as we communicate our position regarding thyroid disease testing.

Best regards,

R. Mack Harrell, MD, FACP, FACE, ECNU

The Obama administration has made many mistakes in writing Obamacare. Most of them have not been in favor of the consumers it professed to help.

About 50% of women over the age of 60% might have subclinical hypothyroidism. Overt clinical hypothyroidism can take several years to declare itself. During the time of subclinical hypothyroidism evolves to overt hypothyroidism patients can suffer mild to moderate symptoms that would decrease their quality of life on many levels.

I believe President Obama should show compassion and responsibility toward the millions of who people would suffer from subclinical hypothyroidism. President Obama is setting up the healthcare system to restrict access to care for these people.

I do not think he should rely on a committee that does not have the expertise in the field of clinical thyroidology.

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

April 12, 2015

inChronic Disese Management, Consumer Driven Health Care, Disinformation and the healthcare system, Health Savings Accounts vs Medical Savings Accounts, Healthcare Insurance Industry, Medicaid, Medicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust, Universal Healthcare

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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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The Republican Alternative to Obamacare

April 7, 2015

inHealthcare Insurance Industry, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D. FACP MACE

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

The Obama administration insists that the Republicans do not have a viable alternative. I doubt that anyone in the administration has read the alternatives.

President Obama’s tactic is to marginalize any opposition even if he has not reviewed it.

The Republicans have some good ideas. However, they do not address the basic problems in our healthcare system.

The implementation of their ideas will not repair our healthcare system.

“Republicans have now really muddied the waters with a huge take it or leave it alternative that will have plenty of its own reasons to give voters pause.”

Obamacare has so many parts. Most of Obamacare’s parts could have been predicted to fail. It is clear that congress did not understand this destiny before passage.

Obamacare was destined to fail from the start. It is on the way toward failure today. It will also destroy the entire healthcare system.

The Republican alternative is called, "The Patient Choice, Affordability, Responsibility, and Empowerment Act."

It's key provisions include:

A Full Repeal and Replacement of Obamacare

Eliminate Individual Mandate to Buy Health Insurance or an Employer Mandate to Offer Coverage

Consumer Protections – Republicans want to retain the popular consumer protections in Obamacare including no lifetime limits, coverage for children to age 26 on their parent's plan, and guaranteed renewability of coverage.

However, they propose to decrease the costs of healthcare insurance for younger consumers but want to increase the cost of healthcare insurance for older buyers.

The Republicans would create a new set of losers (older buyers) while increasing the incentive for younger people to buy insurance.

Republicans should be providing financial incentives for consumers to be responsible for their health and their own healthcare dollars. Consumers with chronic diseases should also be responsible for the control of their chronic disease.

A Return to Pre-Existing Condition Limits. This is a ridiculous provision. It guarantees the biggest villain in the healthcare system (the healthcare insurance industry) its control of premiums and profitability.

Default Enrollments – Republicans would allow states to create a default enrollment system for those eligible for tax credits as a means to reduce the number who would otherwise remain uninsured.

A complex agency would be needed to administer a complicated process.

High Risk Pools for the Uninsured – High-risk insurance pools did not work previously because of healthcare insurance companys’ control of the premiums for the sickest people and their high risk of disease.

Affordable Insurance Policies – This is also a pipe dream. America’s population is becoming more obese. Obesity generates more illness and higher risk. As long as the healthcare insurance industry is calculating and is in control of the actuary risk, healthcare insurance will not be affordable. The problem is how the insurance industry is allowed to do its accounting.

The Republicans are proposing the elimination of benefit mandates and downsizing guaranteed insurability with their "continuous coverage" provision.

This proposal is ridiculous. As long as consumers are not responsible for their health and their healthcare dollars and the healthcare insurance industry controls price, the healthcare system will be increasingly more expensive and dysfunctional.

Tax Credits to Buy Coverage – Tax credits are an unearned entitlement. Unearned entitlements do not work. Tax credits would be available for those in the individual health insurance market, those working for businesses with fewer than 100 employees, and those working for larger employers that do not offer coverage.

Tax Credits Only Up to 300% of Poverty – A system of tax credits leads to an agency that must be connected to another government agency, which leads to a larger government bureaucracy. In turn the bureaucracy leads to fraud and abuse

Flat Amount Tax Credits By Age – The goal of this proposal is to eliminate federal and state exchanges. Obamacare’s state and federal exchanges have not worked no matter how the administration spins the truth.

It would be easy to just give everyone a tax credit by age. A new bureaucracy would not be needed.

However, control of price and actuarial risk is still determined by the healthcare insurance industry. Consumers are not empowered. The healthcare insurance industry is empowered. Only at the time consumers are stimulated to control their health and healthcare dollars will the system work. Tax credits and price controls do not work.

No Limits on the Kind of Insurance Policies That Could Be Offered – This is not a bad idea.

Capping the Tax Exclusion on Employer-Provided Health Insurance – The entire tax benefit for the employer and the individual should be equalized. Benefits should not be exclusive. Healthcare insurance premiums should be paid for with pre-tax dollars by all. The individual market should not pay for premiums with after tax dollars and the group market pay for premiums with pre-tax dollars. The present system is a hidden tax on consumers buying insurance in the individual market.

Moving Toward Defined Contribution Health Insurance – This is a stab in the dark by Republicans. It would penalize consumers and it would benefit employers. Employer want to avoid providing the same level of healthcare coverage for all their employees

Medical Malpractice Reform – This is a sensible reform. It is estimated that is would lower healthcare cost between $300 and $750 billion dollars a year if all costs were included.

If malpractice reform took the right form to protect consumers and physicians, the abuse in the malpractice system by lawyers and the insurance industry would be eliminated.

Both the Democrats and the Republican have protected the lawyers and the insurance industry in the past. Past behavior is a predictor of future behavior.

Repealing the Medicaid Expansion – Medicaid should be eliminated and replaced by an all-inclusive healthcare system.

The poor should have the same insurance coverage as the rest of society. The immediate response is the nation couldn’t afford it. Yet President Obama is expanding Medicaid as access to care is being restricted. Therefore formulas that try to control costs fail because the development of severe illness is more expensive than consumers of healthcare learning how to control their disease. A consumer having healthcare insurance coverage does not make those consumers well.

Empower Poorer Consumers by Giving Them Mainstream Health Plans –

Republicans do not offer a plan of action within this category. It sounds good but feels as if it is an empty promise. Actually it is an important factor in repairing the healthcare system. I will explain in the next blog.

The solution to the healthcare system’s dysfunction must be a simple solution.

The Republican solutions are almost as complex as Obamacare. It does not decrease governmental bureaucracy nor does it avoid the potential for fraud and abuse.

The Republican solutions promote continued control over consumers and their freedoms.

The Republican solutions do not get to the main problem in the healthcare system.

The healthcare system must be set up so consumers are motivated to have incentive to be responsible for their own health and healthcare dollars.

The alternative to Obamacare should exclude the government from making consumers dependent on the government.

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

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The Republican Misguided Alternative to Obamacare

March 30, 2015

inDisinformation and the healthcare system, Medicine: Healthcare System

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Stanley Feld M.D., FACP, MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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King vs. Burwell

March 23, 2015

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP,MACP

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The issue before the Supreme Court is simple.

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

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

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

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

http://www.nytimes.com/2015/02/25/upshot/health-secretary-says-theres-no-backup-plan-if-court-rules-against-health-law.html?abt=0002&abg=1

http://www.nytimes.com/2015/03/10/upshot/a-roadmap-for-how-many-people-could-lose-their-health-insurance.html?emc=edit_tnt_20150309&nlid=8639975&tntemail0=y

http://www.nytimes.com/interactive/2015/02/03/upshot/obamacare-back-at-the-supreme-court-frequently-asked-questions.html?abt=0002&abg=1#subsidies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This is a very important constitutional issue.

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

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

https://mail.google.com/mail/u/0/#inbox/14c3d6566f26ca10?projector=1

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

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Let’s Do The Numbers : Another Obama Trick

March 19, 2015

inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

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

The answer is no.

Are the increased taxes becoming painful yet?

The answer is yes.

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

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

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

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

Are all the Obamacare pronouncements confusing?

Yes. I believe they are intentionally confusing.

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

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

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

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

The American public was mislead about ,

The disastrous website development, reason for website crashes and cost of website development.
The exact number of enrollees the first year. (9.5 million correct to 8 million and then down to 6.8 million)
The resulting further correction by a decrease in 800,000 more people losing insurance because of discovered ineligibility 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 15^th to avoid discussion of enrollment around the time of the November 2014 elections.
Extending the 2014 enrollment three months.
Extending enrollment for 2015 for one to three months.
Finally in 2015 announcing the back end of the website sending information to the IRS was still not complete.
Rehiring CGI the same Canadian company that built the disastrous healthcare.gov to fix the back end of the website.
Discovering that 1.2 million were counted that should not have been because they got dental insurance bringing the number of enrollees down from a recalculated 8 million to 6.8 million enrollees for 2014.
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.)
Eight hundred thousand (800,000) enrollees lost their subsidy because they lied on their application
Announcing that the group market Obamacare enrollment is being delayed a year or two while the mandate penalty for employers was to start January 1,2015.

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

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

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

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

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

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

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

Several states healthcare insurance exchanges have failed.

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

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

The following is President Obama’s next trick play.

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

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

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

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

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

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

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

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

http://acasignups.net

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

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

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

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

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

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

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

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

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

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

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If You Tell A Lie | Stanley Feld M.D., FACP, MACE
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Obamacare Tax Hikes That Are Forgotten

March 15, 2015

inDisinformation and the healthcare system, Medicare, Medicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

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

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

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

https://youtu.be/eHlRY3kHhBk

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

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

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

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

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

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

http://youtu.be/56c1fSdTAWI

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

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

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

Mr. Norquist’s article appeared in 2012.

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

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

Taxes that took effect in 2010:

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

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

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

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

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

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

Taxes that took effect in 2011:

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

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

Taxes that took effect in 2012:

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

Taxes that take effect in 2013:

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

	Capital Gains	Dividends	Other*
2012	15%	15%	35%
2013+	23.8%	43.4%	43.4%

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

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

	First $200,000 ($250,000 Married) Employer/Employee	All Remaining Wages Employer/Employee
Current Law	1.45%/1.45% 2.9% self-employed	1.45%/1.45% 2.9% self-employed
Obamacare Tax Hike	1.45%/1.45% 2.9% self-employed	1.45%/2.35% 3.8% self-employed

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

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

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

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

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

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

Taxes that took effect in 2014:

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

	1 Adult	2 Adults	3+ Adults
2014	1% AGI/$95	1% AGI/$190	1% AGI/$285
2015	2% AGI/$325	2% AGI/$650	2% AGI/$975
2016 +	2.5% AGI/$695	2.5% AGI/$1390	2.5% AGI/$2085

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

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

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

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

Taxes that take effect in 2018:

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

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

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

$104.20 in 2012

$120.20 in 2013

And

$247.00 in 2014."

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

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

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

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

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

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

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

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

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