Stanley Feld M.D.,FACP,MACE

President Obama and Ezekiel Emanuel set a trap in the Affordable Care Act (Obamacare) for all Americans including middle class and upper class wage earners. 

The administration has claimed that 7.1 million people have signed up on the exchanges as of March 31, 2014. It is now 10 days after his April 1^st claim.

I doubt that we are going to have a breakdown of the enrollees. I doubt that we are going to hear anything about the Rand Corp survey showing that only 875,000 people actually signed up for insurance that did not have insurance previously.

I have not heard any demands for those numbers from the traditional media or congress. It looks like President Obama got away with another one to the American people.

Ezekiel Emanuel M.D. is one of the main architects of Obamacare.

President Obama’s promised the American people that you can keep your doctor if you like your doctor and if you like your plan you can keep your plan. President Obama knew it was a lie before Obamacare was passed. Dr. Emanuel admitted as much in his multiple television interviews

Americans are starting to see another lie beginning to unfold. President Obama promised that his health insurance exchanges are a free market solution to promote competition.  It looks like he knew that this was not true before Obamacare was passed.

If you recall both John Kerry and Barney Frank said the Affordable Care Act would not work unless we have a single party payer system. They said the bill must contain a “Public Option.” 

http://youtu.be/-522hcm3woA

President Obama said, “don’t worry. We don’t have the votes. Also, we don’t need a “Public Option.”

He should have added, “We don’t need a “Public Option” the way the bill is written.”

The truth is a “Public Option” and a single party payer will happen by default as implementation of Obamacare proceeds.

In his recently published book, “Reinventing American Health Care” Ezekiel Emanuel predicted; by 2025, “fewer than 20 percent of workers in the private sector will receive traditional employer-sponsored health insurance.”  

With all the changes President Obama has made without congressional approval, it is obvious that each change will help Obamacare get to a single party payer system more quickly.

There must be a public outcry by the public to stop its loss of freedoms especially freedom of choice of physicians and choice of care.

All the stakeholders are confused about Obamacare at this point.

Many patients have lost insurance. If President Obama did not waive the corporate mandate and the small business mandate many more would be uninsured right now.

Many who think they are insured are not insured. Many physicians do not know if they are going to get paid. Insurance companies do not know if they are going to make money.

If the mandate were in place for all those that received waivers, there would have been a gigantic public outcry that would have sunk Obamacare immediately.

The mandate’s delay decreases the number of people directly affected all at once.

If a person is not directly affected by Obamacare, the long-term implications of the law are ignored. It is difficult to have a public outcry.

Dr. Emanuel’s book is subtitled; “How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System.”

All of the above are true. The healthcare system has been driven to this level of dysfunction because one action by one stakeholder leads to an unintended consequence which in turn leads to another untended consequence and another stakeholder’s reaction.

It is clear that government must set up concise rules that level the playing field for all the stakeholders.

All President Obama has to do is to discontinue the mandate for large corporations year after year. The large employers will drop its employer sponsored healthcare insurance for its employees. Having no other choice these employees will go to the health insurance exchanges to get the cheapest insurance.

“Dr. Emanuel argues that in the next two or three years, “a few big, blue-chip companies will announce their intention to stop providing health insurance.”

I believe this was the plan before the law was passed. It forces people into the “Public Option” without there being a “Public Option” in the law.

“Dr. Emanuel says that few small businesses will join the SHOP exchanges set up for them and that most of those that offer coverage now are even more likely than big companies to drop the coverage since those who employ fewer than 50 workers face no mandate.”

Enrollment in the health insurance exchanges to non-covered employees will increase if the price is right. The price has been right for the government subsidized people. The premiums are much higher for the employees that do not qualify for government subsidy.

“Dr. Emanuel thinks is fine.”

Many employees previously covered by the employer-sponsored plans will receive government subsidies.

The healthcare insurance furnished by the health insurance industry for both private insurance plans and government plans will still be price at non-subsidy prices for the government.

The government subsidy will result cause greater government deficits and/or an additional tax increase.

Employees who previous received healthcare coverage from employers received those benefits with pre-tax dollars.

Now they are going to pay for healthcare insurance with post tax dollars.

Employers received a tax deduction for the employer sponsored healthcare plan’s insurance payments.

Both employees and employers will be losing In Dr. Emanuel and President Obama’s system.

The winner is the government by collecting more taxes. The biggest loser is the consumer earning over $50,000 a year.

The next step is for government to stop calling the subsidized private insurance healthcare coverage.

“President Obama should call it something like it “Medicare G.” Obamacare will have achieved another entitlement without calling it a “Public Option.”

Why doesn’t the Obama administration concentrate on eliminating fraud, abuse, and waste in the healthcare system?

Why doesn’t it concentrate on making the healthcare system more efficient?

Why doesn’t it promote the patient/physician relationship?

Why doesn’t it concentrate on making the healthcare system more patient friendly?

Why doesn’t it put the patients in control of their healthcare dollars and promote patient responsibility for their health and healthcare?

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

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Stanley Feld M.D., FACP,MACE

Medical practice and healthcare policy are on a collision course. The politics of progressivism and socialism are dictating the course of medical practice.

Medical practice is a craft practiced between a physician and a patient. The physician patient relationship is the keystone to that craft.  Politicians and secondary stakeholders who influence on the healthcare system are destroying the craft.

Obamacare has accelerated the destruction of the physician patient relationship. Obamacare’s goal is to have the government make the decisions for consumers. The freedom of Americans to choice their physicians will disappear.

Why? The Obama administration’s view is that Americans do not have the ability to make the right medical choices.

The concern of healthcare policy makers has been about costs and not the relationship between physicians and patients. They are trying to cut costs.

The problem is they are cutting costs and increasing premiums and taxes on the wrong stakeholders, namely physicians and patients.

Obamacare’s focus is on providing subsidized healthcare insurance for the lowest 20% of the population while it is destroying medical coverage for the other 80% of the population.

At the same time Obamacare has been destroying the safety-net hospital systems throughout the country.

Safety net hospitals took care of that 20% of the population that is uninsured.

Many of these safety net hospitals were the best teaching hospitals in the country. Most of these hospitals are teaching hospitals serviced by medical schools.

President Obama has ignored improving the care and the facilities of these safety net hospitals.    

Americans are losing their healthcare insurance coverage because of Obamacare’s mandated requirements for healthcare coverage by the private healthcare insurance industry. He should be concentrating what is considered a direct medical care cost.

Employers are avoiding penalty for not providing Obamacare required coverage insurance by cutting full time employees to part-time employees working less than 30 hours a week. This has impacted the full time employment rate. It has also decreased purchasing power of part-time employees.

President Obama did not improve the situation when he unilaterally changed by executive order the law increasing the hours temporarily to 50 hours per week. This new executive order disappears in one year. The uncertainty in the future remains. Employers are still decreasing hiring to less than 30 hours per week.

President Obama has changed the law by direct executive orders 25 times. He has lost the trust of the American public with all his waivers to favored groups and to pressure groups.

The Obamacare waivers have created chaos and uncertainty for all the stakeholders. It is difficult to try to adjust to one set of rules and then find the rules have been indiscriminately changed the next month.

The Obama administration has increased the cost of care. He has not saved an American family $2500 a year as promised. He has cost them an additional $2500 a year. 

President Obama has asked Democrats to promise voters that he would fix the flaws in Obamacare.  I am convinced he doesn’t know what is basically wrong with Obamacare. He refuses to listen to others and labels them as destructive opponents.  He is making thing worse with waivers and uncertainty. These unilateral changes are probably unconstitutional. 

In order to talk his way out of the criticism he has been caught in a web of lies. These lies did not appear to the public as lies when he was running for reelection against Governor Romney. However, American citizens get it now.

Governor Romney said Russia is our number one enemy. President Obama and his spin machine ridiculed Romney without presenting any evidence to the contrary.

Now President Obama is telling Democrats to run on Obamacare because he will fix it. He has not presented the plan he will use to fix Obamacare.

How can Democrats running for re-election and voters trust President Obama again to fix the problems in Obamacare?

The effect Obamacare has had on taxes and economic growth has been devastating.

Obamacare is no longer an abstraction. Taxes, higher healthcare premiums and the lack of jobs and economic growth are now directly affecting the middle class and small businesses.

This effect had been predicted during the debate at the time of the bills passage.

President Obama’s taking points are the bill is doing so poorly because of Republican opposition. This is another attack on his opponents without any evidence. The problems with Obamacare are his doing and not the Republicans doing

His “best supporters” such as unions and Hispanics are realizing the devastating effects Obamacare is having on them directing. These groups are now opposing Obamacare.

Democrats in vulnerable states who are running for election are running away from President Obama and Obamacare. They believe President Obama and his talking points are toxic to their election.

The truth is Obamacare cannot be fixed. President Obama’s ideology is its biggest barrier.

We are beginning to see the direct affect on Americans of the next catastrophe resulting from Obamacare. The catastrophe is the impending effect on medical care in America.

Americans are going to experience medical care manpower shortages, medical care reimbursement problems, access to care problems and rationing of care problems.

Americans on the east coast and west coast will be directly affected. Most of them will start realizing they can no longer think about Obamacare in theoretical, abstract and intellectual terms.

Repairing the healthcare system and the medical care system must be thought about in realistic and pragmatic terms.

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

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Stanley Feld M.D., FACP, MACE

What is disintermediation?

Disintermediation is a process that provides a user or end consumer with direct access to a product, service or information that would otherwise require a mediator (middleman) such as a wholesaler, lawyer or salesperson.

In many cases the information available on the Internet has often eliminated the need for a middleman.

As commerce grew in the United States after WWII, there was a need for multiple middlemen to fulfill each commercial endeavor.

One of the strongest examples of early Internet disintermediation was Dell Computers. Consumers were able built custom computers by picking the components. They bought exactly what they wanted at a lower price. Michal Dell sold directly to the consumer and bypassed all the middlemen channels and normal retail outlets.

Amazon is another compelling example. It started with books and now includes almost everything. Amazon bypasses most of the channels and all of the expense of brick and mortar structures to lower the cost to the consumer.

Steve Jobs did it best with ITunes. Most people did not want the16 tunes on a CD. They might want one or two. Music publishers and all the middlemen in that industry fought him tooth and nail.

Steve Jobs won because he provided the consumer with what they wanted, the one song at 99 cents as opposed to 16 songs at $16 dollars.

The music publishing companies have now realized that they are doing better since ITunes with less middlemen and more product sales.

My son, Brad Feld, is going to disintermediate the book publishers. Brad authored 5 books for Wiley Press as part of the Start Up Revolution. Wiley Press and its bureaucracy treat him and other authors unfairly.

He and his partners at Foundry Group Venture Capital started FG Press.

“We treat authors like partners, not service providers. Instead of flat fees and unequal royalty assignments, we abandoned the old model and rebuilt it with the author as our top priority.”

I believe the FG Press results will be to disintermediate the entire book publishing industry.

Disintermediation though the Internet also happened in the travel industry, the airline industry, the stock broker industry and the banking industry.

Disintermediation cuts out the middleman.

“By using the Internet, companies and even manufacturers can deal directly with users or end consumers, which is a significant factor in decreasing the cost of servicing customers. The high market transparency often enables the buyers to pay less as they deal directly with the manufacturer, bypassing the wholesaler and the retailer. As another alternative, buyers can also buy directly from wholesalers.”

There is no reason disintermediation cannot be applied to healthcare. The goal in healthcare is to lower the cost, increase quality of care and increase access to care.

The way to do it is by making consumers the most important stakeholder. Consumers must drive the healthcare system just as consumers are put at the head of the line in other disintermediated systems that work.

I have described the evolution of the healthcare business model of 1946 to the business model of 2014 and beyond.

In 1946 the healthcare business model was simple. The healthcare contract was between consumers/patients and physicians.

Consumers were responsible for their medical care. The only technology was physicians’ car his stethoscope and his doctors bag. Consumers were also cautious in their utilization of healthcare services. They did not want to waste their money. They were responsible for their health and their healthcare dollars.

Healthcare insurance destroyed this relationship. Healthcare insurance was attractive to sick people. It was attractive to employers to help their employees stay well. It also helped employer keep their valuable labor force.

Consumers became less cautious about spending their healthcare dollars as third parties were paying for healthcare costs.  

The use of technology boomed in medicine. The cost of healthcare escalated as more and more technology was used.

 In 1965 the government created Medicare. Medicare regulations distorted the free market healthcare system. The distortion increased further in the early 1980s.

 All of a sudden there were more and more middlemen. The middlemen added little value to the medical care of consumers/patients. However they did add increased costs to the healthcare system.

In 2008 the healthcare system became so complex and riddled with rules and regulations that enormous barriers existed between the consumers/patients and their physicians.

It looks like a giant hairball that cannot be digested.

Obamacare was invented to use technology and ideology to straighten this all out. It has made and is making healthcare more unsustainable.

Obamacare cannot work. It is government control. The majority of consumers and physicians are against it.

Obamacare destroys the patient physician relationship. Obamacare has resulted in more bureaucracy, large overhead, more middlemen and an increase in costs to the consumers in terms of higher taxes and higher healthcare insurance premiums. 

The major problems are there are too many middlemen and the bureaucracy is superimposed on a failed legacy healthcare system.

The healthcare insurance industry takes 40% off the top leaving 60% of the premium dollars working for the delivery of medical care.

Hospitals charges are outrageous. Hospital expenses are inflated.

The need for cost shifting puts a large burden on hospital systems.  

Government interference simply escalates costs.

An example is the cost of chemotherapy. In hospital chemotherapy cost is 2 to 3 time the cost of the chemotherapy done by the same doctor in that doctor’s office. The government does not pay for chemotherapy in the doctor’s office.

An example of disintermediation in the healthcare system is the Oklahoma Surgery Center.

“The Oklahoma Surgery Center demonstrates that it’s possible to offer high quality care at low prices. Surgeons can do twice as many surgeries in an outpatient surgery center than they can in a traditional hospital surgical suite.

Most industries try to improve efficiency. However, simple efficiencies have not occurred in most traditional hospitals. Surgeons spend half their time waiting for the patients to come to the operating room or for the availability of operating rooms and equipment.

The Surgery centers have solved these efficiency problems. They can service surgeons’ needs at less than half the cost without the wasted time.”

A key reason is there are not multiple administrators creating multiple regulations and collecting multiple $500,000 to $3 million dollar a year salaries. Surgical centers have one head nurse responsible for everything and zero administrators.

The cost of a “complex bilateral sinus procedure” at the Surgery Center was an all-inclusive $5,885. The traditional hospital bill totaled $33,505 without the surgeon’s and anesthesiologist’s bill included.”

Hospital systems in the area are lowering their prices and becoming more transparent.

Obamacare has made the healthcare insurance costs worse for the middle class. The middle class healthcare insurance premiums are not subsidized by the government.

Obamacare has made the premium cost better for the poor and sick. It has not necessarily lowered the deductible. It has not made access to care better for the poor.

Obamacare may make quality of care worse. It will restrict access to care. It will ration care. Obamacare will make medical care decisions for consumers.

The only way to repair the healthcare system is to make it a consumer driven healthcare system using my ideal medical saving accounts.

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

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