Stanley Feld M.D.,FACP,MACE

The truth about President Obama’s healthcare reform act is becoming obvious. The problem is the traditional media is not covering the true implications of President Obama’s healthcare reform act. The traditional media simply prints the administrations press releases. While the media covers some of the problems, it does not connect the dots to produce the true picture.

There are so many problems with President Obama’s healthcare reform act that the only way to fix it is to repeal it and start over again.

President Obama used tricky tactics to get the bill passed. They are now catching up with him. This week several problems became obvious. A significant problem as putting all the decision making power in the hands of the Department of Health and Human Services(HHS).

Kathleen Sibelius admitted to the House Energy and Commerce Health Subcommittee that the books were cooked in the passage of the healthcare reform act. Kathleen Sibelius and CMS made fools of themselves at an Energy and Commerce Health Subcommittee committee hearing admitting that President Obama cooked the books by double counting.

It was also clear that HHS did not have a handle on the potential unintended consequences of the healthcare reform act.

 Representative Marsha Blackburn (R-TN), asked Kathleen Sibelius to estimate the amount of money lost to Medicare and Medicaid fraud in those programs. She said, “We don’t know.” The Democratic congress and President Obama has put vast power in Kathleen Sibelius’ hands.”

She is in control of 18-25% of America’s gross domestic product, yet she did not know the answer to this basic question.

Do you think anything else could be overlooked?

Representatives of CMS admitted they did not know the extent or cost of Medicare and Medicaid fraud. Neither any of the CMS representatives nor Kathleen Sibelius knew the real estimate of the costs of healthcare reform.

It is becoming clear that President Obama’s “seminal accomplishment”, his healthcare reform act, will make medical care unaffordable, balloon the federal and state deficits even further, raise taxes and provide less care. The law will include healthcare insurance with less coverage and provide a decrease of access to care. The quality of care will not improve.

Last month, Judge Vinson’s opinion effectively put an injunction on the law. He expected the Justice Department to appeal immediately. President Obama and HHS ignored the judgment and continued to implement the law. The Justice Department has not filed an appeal after 30 days. Judge Vinson was annoyed at the administrations delaying tactics, and its attempt to ignore his ruling.

He is trying to force President Obama’s administration to file an appeal within one week.

The House passed a bill repealing the provision in “Obamacare” requiring everyone who pays more than $600 for a product or service to provide the vendor with a 1099 form. The purpose was to collect more taxes to pay for President Obama’s healthcare reform act.

The provision created a tremendous paperwork burden for small businesses for relatively small payments. The IRS estimated it would increase revenue by $17 billion dollars. Seventeen billion dollars is a long way from covering the $1.5 trillion dollar budget deficit this year. The cost to small business owners would be great enough to bankrupt some of them.

The provision would have increased the number of 1099 forms filed each year by something like two thousand percent. In the end, 70 percent of the House voted in favor of repeal, including 238 Republicans and 76 Democrats.

President Obama said he supported the repeal. His trick is he did not suggest a source for potential revenue replacement. Senate Democrats are balking repeal. They complain there is no revenue replacement. Repeal will increase the healthcare reform act’s deficit even further.

Harry Reid and the Democratic Senate do not want to pass the law. Mr. Reid is demanding a provision to fund the $17 billion dollar loss.

The weeds are getting higher each day for President Obama and his healthcare reform act. The truth of the high costs are coming out.

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

Stanley Feld M.D.,FACP,MACE

Once again, President Obama is being disingenuous. He told the nation’s governors he was willing to amend his healthcare reform act. He said he would give states the ability to opt out of its most controversial requirement the mandate for citizens to buy insurance in 2014.

Last week he started his speech by spinning his charm at the National Governors Association meeting by saying:

“I am aware that I have not convinced everybody here to be a member of the Affordable Care Act fan club,"

He said he understood that the majority of the public were not members of the Affordable Care Act fan club either.

He did promise “to give states the power to determine their own health-care solutions.” His qualifications to state power are the deal breaker.

President Obama’s qualifications to state power change in his healthcare reform act as it relates to Medicaid are:

1. The Administration retains the power to decide which states deserve a waiver.
2. The state would still need to cover the same number of uninsured.
3. Its coverage would still need to include the same comprehensive benefits.
4. It must be as "affordable" as determined by the Administration.
5. States could opt out of some consumer or employer mandates. This is a minor concession.
6. In reality, his conditions leaves no room for the states to innovate.
7. Innovations such as;
   1. Straight tax deduction or credit to purchase individual coverage.
   2. Alternative insurance designs such as;

              i. The high-deductible ideal medical savings accounts,

              ii. Plans that can be bought across state lines.

1. Even if the change was approved, it could be difficult for states to meet the federal requirements for the waivers.

Mr. Obama also asked the governors to come up with a bipartisan group to find ways to reduce Medicaid costs. There is no way to reduce Medicaid costs under the structure of President Obama’s healthcare reform act. The structure is defective.

President Obama must have stayed up all night trying to figure out ways to fake out the State Governors. President Obama is trying to reposition himself to the political center issues in the wake of the drubbing his party took in the November midterm elections. This proposal will not do it.

He has once again used smoke and mirrors.

This is not a shift. The mandate in particular is under fierce attack in the courts, where federal judges have issued conflicting opinions on its constitutionality. The mandate is also a rallying cry for conservatives and Tea Party supporters, who regard it as a prime example of overreaching by the federal government.

President Obama will not allow states to cut Medicaid rolls to ease their fiscal distress.

President Obama said. “I am not open to refighting the battles of the last two years,” he said, “or undoing the progress that we’ve made.”

Gov. Rick Perry of Texas, chairman of the Republican Governors Association said. “Pretty much all he did was to reset the clock on what many of us consider a ticking time bomb that is absolutely going to crush our state budgets. The states need more than that.”

Indiana’s Mitch Daniels and 20 other Governors recently wrote to President Obama requesting a genuine relaxation of the waiver standards. He has also asked for states to have the ability to be innovative and control each individual Medicaid program.

"Healthy Indiana" the Medicaid reform Governor Daniels initiated in Indiana is run because of special federal permission. The program has been a huge success. Federal support for the program is about to disappear.

The Health and Human Services(HHS) department does not like the Healthy Indiana program because it features health savings-like accounts. Healthy Indiana decreases federal control over the Medicaid system in Indiana. The program puts the healthcare dollars under patients’ control.

‘The reality is that the liberals who wrote this bill really do think they have a monopoly on good ideas, and they do not include markets. Democrats are more than happy to give the states more freedom, as long as the states use it to impose comparable government control.’

That may be why we hear that White House health staffers Stephanie Cutter and Nancy-Ann DeParle have been privately telling liberal interest groups that this is a way to increase centralization—for instance with a state-based "public option" or even single payer.

President Obama’s “flexibility” is a shame. He is telling the states you can do anything you want. However, you must do what we want you to do. We will determine what we will approve.

The list is defined arbitrarily by unelected bureaucrats and a non- congressional approved head of CMS (Don Berwick) who refuses to answer any congressional questions directly.

I believe President Obama wants the healthcare reform act to fail. He wants the federal government to get complete control over the entire healthcare system.

He is stalling for time with his most recent tactic. It is essential to him to get all new 256 agencies up and running. Then it will be difficult to close down new agencies.

I hope the state governors are not faked out by his charade.

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

Stanley Feld M.D.,FACP, MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stanley Feld M.D.,FACP,MACE

President Obama is starting to believe. State Governors, both Democratic and Republican, are serious about trying to balance their budgets. He also understands that the proposed cuts in services and reimbursements for Medicaid eligible patients will torpedo his healthcare reform act.

President Obama cannot afford to lose state support for his Medicaid law.

Kathleen Sebelius , Secretary of Health and Human Services said in a letter to state governors that the administration understands the governors budgetary concerns. She also emphasized the administration’s understanding that states already has substantial discretion to alter benefits and establish or increase co-payments.

She went on to instruct governors on how to save money by selectively and judiciously reducing benefits, curbing overuse of costly prescription drugs and attacking fraud all at the states’ expense.

She refused to say whether President Obama would allow states to adopt stricter eligibility standards. President Obama understands that changing the eligibility requirements would, in effect, throw low-income people off the Medicaid rolls. It would destroy his objective of “universal coverage.” The states have realized that his objective of “universal coverage” was going to be at the states’ budgetary expense.

“The states are hamstrung by federal prohibitions against lowering Medicaid eligibility, governors from both parties are exercising their remaining options in proposing bone-deep cuts to the program during the fourth consecutive year of brutal economic conditions.”

“Please know that I understand fully the impacts of this rollback, and it is with a heavy heart that I make this request,”. Arizona governor Jane Brewer wrote this week in seeking a waiver, the first of its kind, from Kathleen Sebelius, the secretary of health and human services. “However, I am left with no other viable alternative.”

Gov. Nathan Deal, the new Republican leader of Georgia, proposed this month to end Medicaid coverage of dental, vision and podiatry treatments for adults.

A number of states, Texas and California among them, are considering further reductions of as much as 10 percent in payments to providers. Medicaid reimbursement is already so low that many physicians refuse to accept the coverage.

South Carolina is considering going a step further by also eliminating hospice care.

Rick Scott in Florida is proposing a 5 billion dollar budget cut for Medicaid.

Even with increase in federal payments for Medicaid aid to states from President Obama’s economic stimulus package, state budget deficits from Medicaid were so great that 39 states cut Medicaid payments to providers in 2010 according to the Kaiser Family Foundation. The economic stimulus package subsidy was unsuccessful and is scheduled to disappear in July 2011.

MITCH DANIELS ,governor of Indiana wrote a brilliant op-ed piece in the Wall Street Journal on February 3.

“Unless you’re in favor of a fully nationalized health-care system, the president’s health-care reform law is a massive mistake.

It will amplify all the big drivers of overconsumption and excessive pricing: "Why not, it’s free?" reimbursement; "The more I do, the more I get" provider payment; and all the defensive medicine the trial bar’s ingenuity can generate.”

His article represents the position of twenty-one governors representing more than 115 million Americans. They have written to Kathleen Sebelius asking for more flexibility on health-care reform.

President Obama’s healthcare reform act has provided Kathleen Sebelius massive power without the need for congressional consent.

“All the claims President Obama made for his healthcare reform act were false. It will add trillions to the federal deficit. It will lead to a de facto government takeover of health care faster than most people realize.”

“As millions of Americans are added to the Medicaid rolls and millions more employees (including, watch for this, workers of bankrupt state governments) are dumped into the new exchanges many trillions of dollars will be added to the federal deficit.”

The traditional media has not articulated this impending disaster. It will get worse. Governor Daniels has expressed his concerns gently. He also hit the nail on its head for the states.

“The law expects to conscript the states as its agents in its takeover of health care. It assumes that we will set up and operate its new insurance "exchanges" for it.

“The federal government want us to use our current welfare apparatuses to do the numbingly complex work of figuring out who is eligible for its subsidies, how much each person or family is eligible for and re-determining this eligibility regularly, and more.”

“Then, we are supposed to oversee all the insurance plans in the exchanges for compliance with Washington’s dictates about terms and prices.”

States do not have the infrastructure to accomplish most of this. The federal government does not have the apparatus to accomplish this. The point was proven recently by the federal fiasco when the states refused to participate in setting up high-risk pools.

“ As widely reported, it went poorly, with costs far above predictions and only a tiny fraction of the expected population signing up.”

“If the feds can’t manage this little project, what should we expect if they attempt it on a scale hundreds of times larger and more complex?”

Either we have a bunch of rookies in the White House who do not know what they are doing, or we have a bunch of geniuses who have choreographed the destruction of the healthcare care system in such a way that America will have no choice but to permit President Obama to install a completely socialized medicine system with the inefficiency inherent in government run bureaucracies.

Stanley Feld M.D.,FACP,MACE

Twenty-six states joined Florida’s legal challenge on the constitutionality of President Obama’s healthcare reform act. The sub-plots of the law suit are states’ rights vs. federal control, the constitutionality of a mandate to force individuals to purchase insurance and forcing states to create increases in budget deficits. President Obama’s healthcare reform act is going to cause fiscally responsible states to fund fiscally irresponsible states through increased federal taxes. The result will be an increase in state taxes.

President Obama’s mandate has greater significance than forcing everyone to have healthcare insurance. Federal Judge Roger Vinson struck down President Obama’s entire healthcare reform act last week on all counts. He essentially ordered President Obama to cease implementation of his healthcare reform act.

“A federal court issued a binding judgment voiding the law, with Judge Vinson noting that he trusted the Administration would obey the "long-standing presumption" that such a judgment is "the functional equivalent of an injunction."

The White House and Health and Human Services announced they’ll continue to implement “ObamaCare” as if nothing has changed.

This is disgraceful.

It tells us something about President Obama’s respect for the law of the land. If President Bush had said the judicial rulings against his policies on wiretapping and some civil liberties would be ignored the traditional media would have been all over him.

State governments have decided to obey Judge Vinson’s injunction and are suspending implementation of the new regulations and mandates.

"For Wisconsin, the federal health-care law is dead," Attorney General J.B. Van Hollen said in a statement, unless Judge Vinson’s decision is stayed by the 11th Circuit Court of Appeals.

Florida Governor Rick Scott said he had no intention of wasting "time and money" executing the for-now defunct law, and his insurance commissioner returned a $1 million federal assistance grant.

Idaho will also freeze implementation, and we hope the remaining 23 states will join the rejectionists.

President Obama’s healthcare reform act has previously demonstrated disrespect for the will of the people. Its passage also demonstrated a lack of respect for the congressional process. Now President Obama is demonstrating his disrespect for the judicial process. His web site dismissed the judgment as a decision by an activist judge.

President Obama’s arrogance is obvious. He knows best. He knows what the people need regardless of what they want.

I have pointed out continuously that President Obama’s goal to reform the healthcare system is admirable. He wants universal coverage, more affordable care and an increase in quality of care. His strategy to achieve his goal is wrong.

President Obama’s methodology is not practical. It will destroy America’s healthcare system. If permitted to proceed it will not only expand the federal deficit, it will decrease the quality of medical care as well as decrease access to care and result in rationing of care.

Attorney General Holder can file an appeal asking the 11th Circuit for a stay. The prediction is he will. When he does, President Obama will be admitting that his administration has ignored the rules of the judicial process.

The traditional media has failed to describe effectively the issues individual states face and the threat to individual freedom.

President Obama has made so many “deals” and granted so many waivers that his healthcare reform act is becoming a joke.

The legal and political challenges against President Obama’s healthcare reform act are becoming increasingly more complex daily. The American public is starting to understand the horrible process used to pass the bill and the actual meaning of terrible legislation. It is not going to Repair the Healthcare System.

The best way to fix “Obamacare” is to repeal it, provide an alternative that will express the will of the people and align all the stakeholders’ vested interests.

Most importantly, we must put Patients First.

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