Stanley Feld M.D.,FACP,MACE

We have not heard much about the healthcare issue in the last three weeks. The 47 million uninsured have been ignored by both candidates. The upcoming 100 trillion dollar Medicare deficit has been ignored. I guess if politicians ignore a problem it goes away.

The present administration and congress is ignoring the middle class during this financial crisis. In Naomi Klein’s Shock Doctrine the basis premise is only a crisis actual or perceived produces a real changes. Klein credits the theory to Milton Friedman. This You Tube link is worth seeing.  She provides numerous examples of recent applications of the premise to advantage the rich at the expense of the middle class.

A crises permits unimagined change. It produces increased citizen dependency on government. The government officials can imposes policies to the advantage of the few in the guises of helping the many. These changes must be imposed before society recovers from the shock. The Republican administrations has declared goal is the elimination of entitlements and regulations. President Bush and potential President John McCain want to privatize Social Security and Medicare. The only way to do this is to create a crisis on Main street and shift the costs to Main Street for the advantage of a few. 

I believe this is what is happening right now with Secretary Paulsen’s proposal to bailout the financial system. His bailout package does not offer assistance  to people with mortgage problems that resulted from the banking systems irresponsible but profitable actions.

The financial community will get relief. The taxpayer will not get relief with his proposal. The taxpayer will foot the bill without any hope for payback or profit. This present crisis has not happened overnight. Yet neither Presidential candidate took the lead in exposing the problems. The problems have been common knowledge for a long time. Neither has either candidate taken the leadership to articulate the unfairness of the proposed bail out to the American people.

The healthcare systems problem have not happened over night either. The Shock Doctrine principles will rear its ugly head. When the healthcare system collapses the Shock Doctrine will result in a disaster in either direction. Either the new Republican administration will hand unregulated total control of the healthcare system to the healthcare insurance industry. or we will have socialized medicine with the Democratic administration.

Yet, “No one is speaking about healthcare any more. The economy, price of gas, war in Iraq have surpassed the uninsured and healthcare insurance premiums as top election issue for candidates”

“Public opinion polls have shown that among the top issues of concern to Americans, health care is languishing far behind the economy, the war and the price of gas. One CBS poll from July put voter interest in health care at just 3 percent. In August, it was at 8 percent.”

How can this happen? It can happen very easily. The media is the message. Only 20% of the population uses the healthcare system at any one time. Healthcare is not the concern of 80% of the population at any one time. The bigger issue of Repairing the Healthcare System so Americans can receive the best care on the planet is not a vital issue to either candidate when Americans are preoccupied with the present shock. Barack Obama has tried to generate a conversation about healthcare but John McCain has no new healthcare plan or the interest in a  discussion about healthcare. He knows the Shock Doctrine will prevail when the healthcare system collapses. He will then be able to eliminate the entitlement he hates.

American’s most precious asset is health. A functional healthcare system is vital to our health as a nation.

“For a lot of people who have health insurance, they are paying more for health care, but it may not show up as concretely as paying $70 to fill their gas tank,” said Anna Greenberg, a Democratic pollster.”

The candidates do not seem to have an interest in healthcare because the majority of Americans are not affected. When we have a severe economic downturn the majority of Americans will be affected. However it will be after the election. It will be too late to deal with the healthcare issue rationally. Also the candidates must realize how shallow and uninformed their concepts of the problems of the healthcare system are.

“There were no conference calls to talk about health care. There were no television ads about health care”

Barack Obama’s campaign claims healthcare is a top issue but does not force it to be a top issue. His solution to the healthcare system is not a viable solution.

“Obama’s spokesman, Bill Burton, said the problem is the press, not the campaign.” 

“The issue of health care may be getting less attention than it deserves from the media, but it’s still a top concern for voters and among the top issues that Sen. Obama talks about on the campaign trail,” said Burton.

Tucker Bounds, a spokesman for McCain, acknowledged that the issue has not been prominent so far but when pressed with why the conversation is not a priority he says,

“However,” he said, “There is a stark contrast in the way both candidates would address the issue. Because the views on providing affordability, accessibility and portability of health care are so divergent, it could hardly escape the conversation each candidate will have with voters.”

As usual Tucker Bounds  is making a  meaningless statement.

I believe more and more Americans are waking up to the existence of these  non-specific answers to specific problems. Americans will express themselves at the polls next month. The traditional politicians better wake up. They had better start expressing the will of Main Street and not the will of Wall Street or else they will be out of power.

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

Stanley Feld M.D.,FACP, MACE

From a distance everything Barack Obama says sounds great. The events of the last eight years have created cynicism and despair. We are a nation thirsty for hope to solve our many problems.

In healthcare the basic problem is not how we are going to pay for healthcare for all of our citizens but how to change the healthcare delivery system to create a healthier society and less chronic disease. Eighty percent of our healthcare dollars are spent on the treatment of chronic disease.

Barack Obama’s National Health Insurance Exchange does not address the basic problem in a meaningful way. It creates another bureaucracy that will drive competition out of the market place. It will result in socialized medicine with all of its bureaucratic and monetary problems.

“National Health Insurance Exchange:

The Obama plan will create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible.

I believe his National Health Insurance Exchange will drive the private insurance companies out of the healthcare insurance business. This might not be a half bad idea since the healthcare insurance industry controls healthcare cost and earns a grotesque amount of money. Also the government outsources and will continue to outsource its Medicare administrative services to the healthcare insurance industry at an equally large profit.

“ Insurers would have to issue every applicant a policy, and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and have the same standards for quality and efficiency. The Exchange would evaluate plans and make the differences among the plans, including cost of services, public.”

The only option remaining would be the new public plan similar to Medicare Part C the coverage that Senator Kennedy has. In recent years Medicare Part B has experienced increasing deficits. The increasing deficits have resulted in increasing costs to seniors and decreasing healthcare benefits. Increasing costs and deficits are inevitable in a single party payer system if the basic problems in the healthcare system are not addressed.

I believe the goal of the Democratic Party is to convert our healthcare system to a system of universal care with a single party payer. Hillary Clinton tried it in 1993 and Barack Obama will try in 2009 if elected.

It has been said that democratic countries in the west with single party payers do just fine. Canada and England have healthcare systems with universal care with a single party payer. All one has to do is look online at newspapers in Canada (National Post) and London ( Evening Star) to see how well these systems are really doing for their citizen. The following articles appeared in the National Post in Canada

1. Millions of Canadians lack family doctor

MD uses lottery to cull patients Not first such case as lack of doctors causes huge caseloads. In the latest jarring illustration of the country’s doctor shortage, a family physician in Northern Ontario has used a lottery to determine which patients would be ejected from his overloaded practice.

2. Let private sector into health care: CMA president Day

“We must not deny any patient access to essential health care based on ability to pay; nor should we deny access based on a shortage of doctors, hospital beds or operating time.

“Competition, consumer choice and market principles barely exist in our health system. The CMA President is asking for the basic principles that stimulate organizations to work properly

“Let’s note that three of the main Olympic values — excellence, universality, sustainability — are similar to our values and aspirations for a truly great health system. “And, of course, an integral part of the Olympics is competition. Without competition we cannot expect improvement, let alone excellence. “I believe that if we are to preserve universal health care for the next generation, we need to embrace similar principles.”

He clearly pointed out the problems with the Canadian system.

“And he bemoaned the fact that more than one million Canadians were on waiting lists for health care and that five million people did not have access to a family doctor. Yet neither the governing Conservatives nor the Liberal opposition seemed to care, he charged.”

This is what I worry about with Barack Obama’s healthcare plan.

“Individually, most [politicians] have a deep understanding of the plight of our health-care system.”Collectively, especially at the federal level, they are reluctant — even afraid — of engaging in a meaningful public policy discussion on health.

Claude Castonguay, a former health minister in Quebec summarized the findings of a report he submitted to the provincial government. He said that public health care system, as it now stood, was not financially sustainable.

The following articles appeared in the London Evening Star

1. Doctors call for ‘rationing’ of NHS services

“Rationing of services in the NHS is a ‘fact of life’, doctors insisted. The British Medical Association said a postcode lottery operates nationwide with some treatments denied to patients simply because of where they live.

It called for a charter that would tell patients exactly what ‘core’ services they are entitled to receive in England.

But in order to make the NHS work successfully, the BMA says the day-to-day running of the service must be wrested from politicians.

James Johnson, chairman of the BMA’s council, said there had to be an end to the ‘constant political dabbling’ and ‘micro-management’. “

2. London’s healthcare is lagging

3. Third of broken hip victims have to wait two days for surgery

“Thousands of elderly people with broken bones caused by falls are being betrayed by a postcode lottery in NHS care. A report says around one in three broken hip victims had to wait more than 48 hours for surgery – a delay that could have put their lives in danger. “

Enough said about the glories of socialized medicine in Canada or England. Is this what the American people want? Some say most people are satisfied with the healthcare service they receive in Canada and England. Only 20% of the population is sick at any one time. Therefore (most) have no idea what is going on in the healthcare system. It is easy to say they are satisfied with the system when they are not sick.

Rather than our next President creating another ineffective bureaucracy and costly entitlement program all he would have to do is

1. level the tax playing field for the self employed to be able buy insurance with pre tax dollars
2. permit the purchase of insurance across state lines
3. produce purchasing power and negotiating power for consumers with hospitals and physicians and insurance companies in a real price transparent environment
4. impose community rating with universal coverage regardless of pre-existing illness

5. provide ownership of the first $6000 to the consumer

I would bet consumers would use their healthcare dollar wisely.

Barack Obama’s National Health Insurance Exchange is a bad idea. It will not work if passed. The fact is the plan is not hopeful. It is the opposite of Barack Obama’s message of hope. A message America dearly needs.

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

Stanley Feld M.D.,FACP,MACE

I continue to look at Barack Obama’s statement puny statement on subsidies.

Subsidies.

“Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.”

Is this a false hope? Another example of a deficient subsidy is Medicare Part D. Again, the intention was good but the construction of the subsidy resulted in subsidizing the healthcare insurance industry.

UnitedHealthcare paid AARP $4 billion dollars to be the only provider of AARP’s Medicare Part D plan. Would UnitedHealthcare do this if they thought they would lose money? No! Part D is supposed to be a plan subsiding drug benefits for seniors. The government is supposed to fix the premium for all seniors regardless of health risk.

Last year UnitedHealthcare’s net income from Medicare Part D was over $1 billion dollars. UnitedHealthcare expects this net income to increase in the future as more baby boomers qualify for coverage. Despite all the profit from Medicare Part D next year the premium for seniors is going to increase from $25 to $28 per month per senior in post tax dollars.

The government does not negotiate directly with the pharmaceutical companies for drug prices as it does in the VA and Military healthcare systems. The healthcare insurance industry does the negotiating. The prices set are non transparent.

If the government wanted to be effective it would do its own negotiating. However, this does not seem to be the bureaucracy’s way. This is one of the reasons the government should not be a single party payer.

“Medicare’s drug plans will cost beneficiaries an average of $28 a month in 2009, about $3 more monthly than this year, according to the U.S. health-care program for the elderly.”

This increase represents an 11.5% increase from the previous year monthly cost of $25. It brings up the question again as to whether we can trust our politicians to look after our welfare and not the welfare of a secondary stakeholder?

“Premiums paid by beneficiaries for basic prescription plans cover about one-fourth of the program’s cost, with the government paying the remainder, according to Medicare. Medicare will spend about $36 billion this year to subsidize drug coverage.”

This is ridiculous. A generic drug estradiol cost $4 a month in Wal-Mart outside the Medicare Part D system. Inside the Medicare Part D system the patients benefit (“Doughnut”) is charged $20. The patient’s co-pay is $4 for the generic estradiol. Does anyone think Wal-Mart charged the healthcare insurance company $18 for this prescription? Does anyone think the Healthcare insurance company didn’t charge CMS (Medicare) $18 plus an additional administrative fee for this prescription? All we are told is Medicare will spend about $36 million this year to subsidize drug coverage.  

Who is benefiting from all this money? In reality the government is subsidizing the healthcare insurance industry at a sizable profit. One can blame it on the Republicans. However it was a bipartisan bill with politicians being influenced by the vested interests of the healthcare insurance industry.

I have received many complaints about Medicare Part D. An outstanding complaint of a patient reaching the $2500 drug subsidy limit was a patient with glaucoma. The drops the patient was prescribed was not generic. The patient had a $65 co-pay. She paid this amount without noting the amount charged to her. After she paid $65 a month for 5 months she was out of drug coverage and into her Medicare Part D doughnut hole. She was charged $500 for her sixth month prescription. This was an out of pocket expense.

She complained to her ophthalmologist. Her ophthalmologist discovered that the retail price on the glucoma eyes drops was $90 for a one month supply bottle rather than $500 charged Medicare by the pharmacy. Her Medicare Part D account was charged $500 each month. She tried to complain but got nowhere. She did not receive a response from the healthcare insurance carrier or the government. The pharmacy said this was the price. They could not tell her how much the healthcare insurance company paid the pharmacy.

“The new estimates for Medicare Part D were based on bids submitted by companies that receive government subsidies to offer the plans.” “About 25.4 million Americans have drug coverage through Medicare, 17.7 million of them in standalone plans and 7.7 million in Medicare Advantage plans that provide health care through private insurers.”

My guess is the healthcare insurance companies make a greater net profit from Medicare Advantage than Medicare Part D because the subsidy is greater.

The point of these examples is the government will overpay the healthcare insurance companies and undercover patients for care. It continuously cuts the reimbursement to physicians while a facilitator stakeholder increases its profit.

George Bush recently proposed consumers pay for Medicare Part D on a means tested bases. He did not demand price transparency or cut the profit from the subsidy to the healthcare insurance industry.

“Republican President George W. Bush proposed raising the premiums paid by individuals earning more than $82,000 a year and married couples making more than $164,000. Democrats in Congress have said the government should have to power to negotiate directly with drug makers to hold down prices.”

Barack Obama plan will simply extend the charade. The only way to fix it is to have the consumer control their healthcare dollar and motivate him to use is healthcare dollar wisely.

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

Stanley Feld M.D.,FACP,MACE

Barack Obama’s healthcare policy calls for subsidies.

Subsidies

“Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.”

Barack Obama should do some arithmetic. A minimum wage worker without a healthcare insurance benefit does not qualify for Medicaid coverage in most states.

Presently in Texas a family can not earn more than $800 a month in order to receive Medicaid. A family of four can not live on $10,000 a year and think of buying health insurance. Moises has a very difficult time supporting his family earning $22,000 a year. He worries about getting sick every day of his life but can not spare a penny of his income for healthcare coverage. .

Poverty today is defined by a 1955 definition. It is not adequate. President Bush rejected the SCHIP program twice because he sees the deficit writing on the wall. Republicans want to eliminate entitlement programs not add them. An additional entitlement will bankrupt the country at a faster rate than our present Medicare and Medicaid programs.

Maybe we could help the needy with a healthcare insurance program that would create incentives to be responsible for their health (exercise, lack of obesity and adherence to medication), and medical care? Maybe we could create programs to stimulate corporate America to promote wellness and exercise social responsibility to combat obesity? This would be a worthwhile investment for our government. It might even be a better investment that protecting corporations in search of increasing markets in the name of globalization.

Obesity, addiction, non-compliance with recommended medical treatment is a huge cost to our system. It must be dealt with. Only the consumer can deal with these issues on a personal level.

Some states like Indiana and New Jersey have tried to increase the income level for the eligibility for Medicaid. The federal government has refused to fund these new definitions because it does not have the money to pay for it.

States that are in worse shape financially than the federal government need to fund the difference. The only way it can be done is by raising taxes.

Michael Bloomberg seems to be the only politician with constructive ideas.

The “bipartisan Romney plan” of universal healthcare coverage in Massachusetts is shaping up to be another disaster of fuzzy thinking. The intention was good. The cost overrun this year is in the range of over $400 million dollars. The present Massachusetts administrators are hailing their universal healthcare plan as a success because more people are insured. The problem is the administrators have left the pricing and control of the healthcare insurance coverage in the hands of the healthcare insurance companies. The plan has not eliminated any of the administrative inefficiencies of the healthcare insurance industry or encourages medical practice efficiencies. It does not encourage patient responsibility nor chronic disease management incentives.

The Massachusetts plan is certainly going to result in an increase in state tax is Massachusetts.

Barack Obama’s policy statement on Subsides is naive. It presents a false hope without a plan. All government subsides so far have gone to the wrong stakeholder. The result of a policy executed with this open ended philosophy will result in increased government cost. In effect the government is providing an entitlement for the healthcare insurance industry. They are leaving control of pricing and administration in the healthcare insurance industry’s hands. An increase in government spending will result in a decrease in healthcare coverage for the average person as well.

How can I say that? Recent past history has demonstrated it. As long as the healthcare insurance industry is in control of the pricing, government bureaucracy is suppose to oversee that pricing. Historically the price has increased and healthcare coverage has decreased.

To paraphrase Yogi Berra “it is the $600 toilet seats all over again”.

Stanley Feld M.D.,FACP,MACE

Every week the words used to describe Barack Obama’s healthcare policy change. I am going to review his healthcare platform as described during the week of August 5-11^th. Each platform revision has the same bottom line. The bottom line is universal coverage with the government being the single party payer.(socialized medicine with all its regulations and inefficiencies).

However, each week his words are refined to made them more palatable. It gets to the point where one could believe the words are something more significant than they are. Clearly Barack Obama’s platform is not a solution to our dysfunctional healthcare system. I will evaluate each of his heading separately.

Comprehensive benefits. “The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential medical services, including preventive, maternity and mental health care.”

This sounds perfect because 90% of the healthcare dollars is spent on the complications of chronic diseases. However, the restrictions to access to care and the availability of care have to be analyzed to be understood. Does anyone think Senator Kennedy suffered any of these restrictions for the treatment of his brain tumor?

When Senator Edward M. Kennedy disclosed on May 20 that he had brain cancer, three days after suffering a seizure, doctors did not list surgery as a possibility. A news release from Massachusetts General Hospital in Boston left the impression that radiation and chemotherapy were the main options for his pernicious type of cancer.

Precisely why Mr. Kennedy’s treatment course changed is not known; he and his doctors are not talking to reporters.

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

Is this what Senator Obama means by The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have.” Does anyone believe this policy would produce the care Senator Kennedy received? If it were true it would be great. However, this is an expansion of an entitlement America can not afford without improving the many inefficiencies and loopholes in the present healthcare system.