Stanley Feld M.D.,FACP,MACE

Medicare is partially funded through payroll taxes of the workforce for the benefit of seniors. The unfunded liability of the government for seniors is enormous. It gets bigger each year. As baby boomers reach Medicare age the government unfunded liability is going to escalate more rapidly.

President Obama and the Democratic controlled congress are ignoring the Medicare trustee annual report of Medicare’s unfunded liabilities. They keep promising us the public option will provide the same insurance the congress receives under Medicare Part C. The only way to fix the unfunded liabilities is to decrease services or increase taxes or both. These reports are public information.

Medicare is funded by a combination of dedicated revenues (payroll taxes, beneficiary premiums, and state payments) and general revenues.

“Medicare’s Hospital Insurance (HI) trust fund, (Medicare Part A) financed by payroll taxes, is currently running a deficit and is projected to be exhausted by 2019” according to the 2005 Medicare trustee report.

“Conversely, the Supplementary Medical Insurance (SMI) trust funds’( Medicare Part B and Part D ) which cover outpatient services and prescription drugs, never face a deficit nor become exhausted, because annual adjustments are made each year—mainly drawing more from general revenues—to match expected costs.”

Nevertheless, with projected increases in demands on the Medicare program by retiring baby boomers and rising health costs, growth in program expenditures, which are already heavily reliant on general revenues, will soon require additional taxpayer funding.

The projection in unfunded liability in the next 75 years increased from $12.7 trillion in 2005 Medicare Trustee report to $34.2 trillion in 2007. The 2008 report estimated the unfunded liabilities will increase to $100 trillion in 75 years. These numbers are estimates for seniors only. If President Obama extends Americans covered under the public option the unfunded liability will be higher. The only way to cover these costs is to increase taxes, decrease coverage or both.

In 2006, total Medicare expenditures were $408 billion, or approximately 3.1 percent of GDP. But as a share of GDP, Medicare expenditures are projected to double to 6.5 percent by 2030 and nearly quadruple to 11.3 percent by 2081.

This was a 2007 estimate. In 2008 the estimate doubled. President Obama’s healthcare reform plan will knock the ball out of the park. $1 or $2 trillion dollars is a lot of money. $100 trillion dollars is unimaginable.

“The Medicare Trustees report shows that Medicare poses the single greatest challenge to taxpayers of all government programs.”

In 2005 Senator Judd Gregg R-NH, President Obama’s choice for Secretary of Commerce expressed the need for fiscal responsibility while the U.S. Comptroller General could not express the urgency in more graphic terms.

[W]e as a Congress has an obligation to try to fix [those entitlement programs] today so that they don’t end up bank­rupting our children and our children’s children tomorrow.

—Senator Judd Gregg (R–NH)[1]

There is no way we are going to deliver all the Medicare promises that have been made. No way.

—David M. Walker, U.S. Comptroller General[2]

Now we are hearing from President Obama that we cannot afford not to spend the money. The common invective about the Democratic Party is they are the tax and spend party. President Obama is turning the invective around. He plans to spend and then tax.

The administration is not testing reality. Government estimates are usually notoriously underestimated. In recent weeks the CBO estimated a $1 trillion dollar increase in the next ten years if the government adopts Ted Kennedy’s plan. $1trillion dollars is a big number. I believe the Congressional Budget Office is being kind to Ted Kennedy’s bill and the estimate of costs of the public option.

The Centers for Medicare and Medicaid Services (CMS), the agency that runs the Medicare program, gen­erated its own estimate in 2003 and has continued to do so every year since the bill’s enactment. Though not made public until 2004, the CMS’s 2003 estimate was $534 billion dollars in unfunded liabilities for the period 2004 to 2013. In CMS’s February 2005 estimate, the 10-year price tag of the drug provision is $724 billion dollars for the period 2006 to 2015.

Americans are being numbed by the numbers. A trillion here, several trillion dollars there and everything will be alright. Today the Medicare estimated unfunded liability will increase by $2 trillion in just one year without President Obama’s healthcare reform.

If the government really wanted to reform the healthcare system, be able to afford universal care and increase the quality of care to increase the health of the nation he would focus on the real problems in the healthcare system as I have outlined them.

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

Stanley Feld M.D.,FACP,MACE

Many people believe Medicare works well. Many people have said all we need to do to repair the healthcare system is lower the eligibility age from 65 to newborns.

America would then achieve a. universal care, b. affordable costs c. improved quality care. The healthcare system would be fixed. The statement is simplistic but popular.

Medicare coverage does work well for seniors if they have both adequate supplemental coverage and Medicare Part D to cover the Medicare gaps in coverage and drugs.

Medicare Part D( drug coverage) was poorly constructed. It was built to the advantage of the healthcare insurance industry not seniors. If seniors do not have supplemental Medicare insurance (Medigap) they could be bankrupted because of the Medicare deductibles and co-pays. .

Medicare does protect the senior from the retail price of medical care. It does guarantee insurability at a price not determined by pre-existing illness. It does permit choice of provider providing the provider sees Medicare patients.

Fewer and fewer physicians are accepting Medicare patients. Medicare reimbursement and coverage decline with each passing year. In many cases physician reimbursement is lower than the physician’s cost to provide the service.

This has been a constant battle for physicians since the government cost savings program was mandated in the 1980’s. Another 20% reduction in reimbursement is scheduled for 2010.

Seniors can still go to physicians who do not accept Medicare. However, seniors will be responsible to pay the retail price for the service. Seniors will collect directly from Medicare 80% of Medicare’s acceptable fee after they submit the bill to Medicare.

For example, if a medical bill is $200 and Medicare’s allowable fee is $80, Medicare will pay you 80% of the allowable fee or $64. The senior has already paid the physician $200. The senior’s out of pocket expense is $135 . If the physician honors Medicare $120 of his $200 fee is disallowed.

Medicare will pay the physician $64. The senior is liable for $16. If the senior has supplemental insurance (Medigap) the supplemental insurance will pay the remaining $16. .

The Medicare premium paid by seniors monthly is not cheap. The base assessment is $99 per month per senior. This assessment might not be affordable to many who are on a fixed income.

The Medicare Part D helped pay for prescription drugs. Many seniors cannot afford to buy the medication they need. Medication needed to stay well and out of the hospital.

1. Medicare has recently imposed an added assessment to the basic Medicare premium. It is called the Modified Adjusted Income Calculation. The IRS supplies Medicare with a senior’s previous year income tax returns. Capital gains, dividends, tax free dividends, and salaries are including in the Modified Adjusted Income calculation.

2. A married couple with a joint return and income from all sources is going to have an additional assessment of between $51.60 and $284 dollars per person per month depending on their combined Modified Adjusted Income calculation assessment.

3. The assessment starts at $160,000/yr and ends at $410,000 per year. A widow with dividends, capital gains, an annuity and rental income of $164,000 per year is assessed an additional $103.30 per month or $1239.60 per year.

4. This assessment is paid with pre tax dollars. It gets deducted from the Social Security payment. If a person has earned income in addition to passive income the person is also paying additional tax on his Social Security check.

5. The deductible of 20% of the allowable fee and the initial $992.00 deductible for a hospital admission becomes expensive quickly.

6. In order for the Medicare recipient to have full coverage for the deductibles they have to buy Medigap insurance. There are seven Medigap insurance policies. The best and most complete is the Medigap Part F. Several private healthcare insurance companies sell this coverage. For persons under 70 years the cost of the policy is $140 dollars per person per month in after tax dollars. The effective post tax cost per month is $200 per person or $400 per couple. The yearly after tax dollar cost is $4800 per year.

7. If you add Medicare Part D for prescription drug coverage, it adds another $24 per person or $34.28 dollars in after tax dollars per month per person or $822 dollars per couple per year. This cost does not consider the extra cost of the infamous doughnut hole.

8. The total premium for adequate Medicare insurance is $2244 plus $4800 plus $822 or $7866 per year. This calculation excludes the modified adjusted gross income. The modified adjusted income can add $619.20 to $3408 per couple per year to the premium. The MAGI creates a means adjusted premium. The maximum means adjusted premium is $11,274. per year per couple in 2008.

It should be clear that Medicare has its benefits. However it also has limitations because despite these premiums and deductibles the government’s unfunded liabilities for Medicare is escalating to unsustainable levels.

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

Stanley Feld M.D.,FACP,MACE

Modernizing the Medicaid Benefit and Protecting Medicare Beneficiary Choice

The health security for low‐income families and American seniors is threatened by the outdated formulas and exploding costs of Medicaid and Medicare. These vital programs require significant reforms to better balance value for those beneficiaries in greatest need and protection for U.S. taxpayers. The Patients’ Choice Act would make important improvements to both programs without limiting eligibility or benefits by:

• Integrating low‐income families with dependent children into higher‐quality private plans through direct assistance

What is the definition of higher-quality private plans? Who is going to judge quality? How is government going to fund these “higher quality private plans?”

• Removing the stigma of Medicaid and providing access to the same coverage options available to all Americans

How will this be accomplished when Medicaid reimburses so poorly. There is a shortage of Medicaid physicians already. These physicians must do a volume business (Medicaid Mills) to make ends meet. These volume practices (Medicaid Mills) are being investigated for fraud.

• Realigning responsibility between federal and state governments in order to better coordinate benefits by requiring the Medicare program to assume Medicaid responsibility of premiums, cost‐sharing, and deductibles for low‐income seniors

The above is just words. It almost sounds as if the federal and state government are going to be responsible for increased funding for private enterprise.

• Rebalancing long‐term care services to ensure choice between institutionalized and home‐based care

• Empowering Medicare beneficiaries with more choices and more power by reforming Medicare Advantage

Medicare Advantage is recognized as an insurance product designed to rid the government of the Medicare entitlement . The government under the Republican administration paid an extra $3,000.00 per person to outsource the responsibility for Medicaid from the state to the healthcare insurance industry. The cost is unsustainable. Excess profits flow to the healthcare insurance industry.

• Allowing for the creation of Medicare Accountable Care Organizations that would improve payment to

physicians, hospitals, pharmacists, and nurses for demonstrable improvements in quality and patient satisfaction while reducing costs

This is a “pay for performance a system” that ultimately cannot work because of intrinsic defects in the pay for performance concept. Quality medical care has not been defined appropriately. Is it defined as medical outcomes, financial outcomes, number of test performed or disease discovery?

• Requiring wealthy Medicare beneficiaries to contribute a little more for their care under Medicare Part D

Medicare Part D is a poorly constructed in the present form. It is written to the advantage of the healthcare insurance industry, the pharmacies and the pharmachuetical companies. It is not a patient centric plan.

Ensuring Compensation for Injured Patients

Our current legal system does a poor job at compensating patients for medical mistakes in a fair and efficient manner. Instead of nurturing an environment where medical professionals can openly learn from their mistakes, our legal system often forces doctors and patients into contentious courtroom disputes. The Patients’ Choice Act would reform this broken system that helps drive health care costs out of control by:

• Encouraging states to adopt a number of legal alternatives entirely run by the state that would include the establishment of expert medical panels to resolve disputes, creation of health courts, or a combination of both

This is logical. How are they going to encourage states to adopt legal alternatives when the law makers are lawyers? When there aren’t specific legislative action points nothing gets done.

Establishing Transparency in Health Care Price and Quality

For a vibrant health care market to function properly, patients must know what services cost and who provides the best service. Uniform and reliable measures of reporting quality and price information should be designed by the stakeholders in health care rather than the heavy‐hand of government. The Patients’ Choice Act would bring this much needed transparency into the health care market by:

• Creating a Healthcare Services Commission that relies on a public/private partnership to enhance the quality, appropriateness and effectiveness of health care services through the publication and enforcement of quality and price information

• Empowering the private sector – rather than Washington bureaucrats – to set standards on price and quality with the input from all major stakeholders in health care, as well as the general public

• Ensuring that measures of effectiveness keep pace with innovation

This is the most logical proposal in the plan. It also contains specific action points. However it keeps the power in the healthcare insurance industry’s hands. It should put the power in the consumers’ hands. If the private sector (healthcare insurance industry) does not cooperate, it should be restricted from selling insurance by the state board of insurers.

There is the entire proposal. There is nothing new and no outline of action to accomplish any part of the proposal.

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

Stanley Feld M.D.,FACE,MACE

It is not fair to criticize the Republican Party’s healthcare proposal without providing the reader with the source material. The source material comes from Senator Tom Coburn’s web site. My negative comments should be judged in light of the original proposal. The executive summary follows.

Preventing Disease and Promoting Healthier Lifestyles

· Critical investments in public health and disease prevention will go a long way in restraining

health care costs and improving the quality of Americans’ lives. The Patient’s Choice Act of 2009 would:

• Encourage increased coordination of federal prevention efforts and bring long‐overdue accountability to these programs

• Require CDC to undertake a national campaign highlighting science‐based health promotion strategies

• Equip recipients of Supplemental Nutritional Benefits with easily understandable information about nutritious food options and target the use of food stamps to healthy food choices

• Invest $50 million annually for increased vaccine availability and bonus grants to states that achieve 90 percent or greater coverage of CDC‐recommended vaccines

• Provide incentives for states to reduce rates of chronic disease like heart disease and diabetes

All of the above proposals should be executed. How will they be implemented? The Republicans do not have a plan but not having a plan does not make the Democrat’s plan a good one.

Creating Affordable and Accessible Health Insurance Options

Our health care system should be easier to navigate and provide integrated care in a more equitable manner. A vibrant market for health insurance that is consistent and fair will allow all Americans access to health coverage.

How will Republicans make a vibrant market for healthcare insurance? How will people who cannot afford healthcare insurance pay for it? The tax credits might help a little. However, if you do not have the cash you cannot pay for the insurance.

The Patient’s Choice Act of 2009 would encourage states to establish rational and reasonable consumer protections, including the following:

• Creates State Health Insurance Exchanges to give Americans a one‐stop marketplace to compare different health insurance policies and select the one that meets their unique needs

• Gives Americans the same standard health benefits as Members of Congress, so all Americans have a wide range of choices

• Protects the most vulnerable Americans to ensure that no individual would be turned down by a participating Exchange insurers based on age or health

What will the premium be for those with preexisting illnesses? Will the premiums be higher for patients with preexisting illnesses? The high risk pool premiums have been very expensive.

• Creates a non‐profit, independent board to risk adjust among participating insurance companies to penalize companies that “cherry pick” health patients and reward insurers that encourage prevention/wellness and cover patients with pre‐existing conditions.

• Expands coverage through auto‐enrollment at state and medical points of service, for individuals who do not select a plan at the beginning of the year

This is an empty statement. How will this be administered? The devil is in the details and there are no details presented.

• Gives states the ability to band together in regional pooling arrangements, as well as the creation of robust high risk pools, reinsurance markets, or risk adjustment mechanisms to cover those deemed ‘uninsurable’

Risk pooling has been tried and has been unsuccessful. It has been an excuse to allow the insurance industry to spread the risk. The proposal also implies variable premiums.

Equalizes the Tax Treatment of Health Care, Empowering All Americans with Real Access to Coverage

Economic analysts across the political divide agree that the tax code is stacked in favor of the wealthy and those who get their health coverage through their employers, discriminating against the self‐employed, the unemployed, and small businesses. The Patients’ Choice Act of 2009 would restore fairness in the tax code and give every American, regardless of employment status, the ability to purchase health insurance by:

• Providing an advanceable and refundable tax credit of $2,300 per individual or $5,700 per family

• Improving the operation of Health Savings Accounts [HSAs] by allowing health insurance premiums to be paid with HSAs without a tax penalty

• Allowing preventative services to be covered by High Deductible Health Plans

• Increasing the amount of money an HSA owner may annually contribute to their account

Healthcare insurance premiums are $14,000.00 a year for a family. A $5,700.00 tax credit does not cover it. It also assumes the consumer has enough income to have a $5,700.00 be tax liability. Citizens are not subject to income tax if they make up to $38,000.00 year. HSA’s retain the healthcare dollar to be used for future spending on healthcare. The healthcare insurance industry retains control over the premium and the healthcare dollars. It is not a pro consumer proposal. It does not offer financial incentives to consumers .

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

Stanley Feld M.D.,FACP.MACE

Republicans in Congress have introduced their health care reform plan. "The Patients’ Choice Act of 2009," has been introduced by U.S. Senators Tom Coburn, (R-OK) and Richard Burr (R-NC) and U.S. Representatives Paul Ryan (R-WI) and Devin Nunes (R-CA).

The proposal that relies heavily on private mechanisms does not contain an individual mandate to have healthcare insurance, It offers insufficient tax credits for families and individuals previously insured and not in a group insurance plan. It must be noted that people who make less than $38,000 per year pay no income tax. A tax credit is meaningless to them. These are the people who are uninsured.

Individuals not in a group insurance plan pay retail for healthcare insurance premiums with after tax dollars. Employers that have group healthcare insurance for employees, pay the insurance premiums with pretax dollars.

The new Republican healthcare plan would eliminate employers tax deductible benefit. This would discourage employers from providing healthcare insurance to employees. The plan is not dissimilar to the proposal championed by John McCain during the presidential campaign. His proposal was considered inadequate.

“The focus of the proposal is to push for a "guaranteed choice of coverage" in the private market through federal-state partnerships know as State Health Insurance Exchanges.

Individuals will have a "one-stop marketplace" to choose plans in the exchange, including the option of keeping their employer coverage and/or existing insurer.

The plan eliminates pre-tax dollar deduction for employers who provide health coverage to their employees. It provides a $5,710 tax credit to families and a $2,290 tax credit to individuals toward the purchase of health insurance coverage.

This is not enough of a tax credit to be effective for those who can afford to buy healthcare insurance. In reality it will save the government money. It would eliminate employer tax deduction. An unintended consequence will be an increase in thenumber of uninsured.

Healthcare insurance premiums average $14,000 per family and $7,000 per individual. The healthcare insurance industry cherry picks patients. It eliminates the sick and over 55 year olds with a high potential for illness. If its ability to cherry pick is eliminated the healthcare insurance premiums will be even higher.

The Republican healthcare plan does not state if the non insurable sick will be subject to the same or higher premiums.

"Participating insurers," meanwhile, would be required to "offer coverage to any individual — regardless of patient age or health history" though there is no mandate for an individual to purchase that insurance”.

Many things are wrong with the Republican party’s proposal. I am disappointed in Senator Tom Coburn. He is a “practicing M.D” he should know the real problems in the healthcare system..” The proposal has some good ideas but no suggestions on how to implement those ideas.

His plan ignores the real problems. The uninsured cannot afford to purchase healthcare insurance. Some young healthy people do not want spend the money for healthcare insurance. Many people are underinsured. Illegal immigrants are uninsured. They show up for care in our safety net hospitals. Our safety net hospitals are underfunded. The plan does not contain incentives for patients to work hard to remain healthy.

The reasons healthcare costs are so high are many. Price Waterhouse has calculated 1.1 trillion dollars is wasted dollars between defensive medicine and unnecessary administrative cost.

Medical care for the complications of chronic diseases absorbs 80% of the healthcare dollars. The complication rate can be reduced by at least 50% if patients became “professors of their disease” and they themselves prevented the complications. This can only be accomplished through education and financial incentives.

The proposal does not repair any of the abuses of the healthcare insurance industry, the government, the hospital systems or physicians.

The proposal gives employers a perfect excuse to drop insuring employees by the removal of their tax exemption for premiums. President Bush tried very hard to accomplish this and failed. .

The Republican plan would leave a greater number of Americans uninsured with no improvement in the health of the nation.

The Patients’ Choice Act contains many of the popular sound bites. It does not have a plan to achieve change. The only way change will occur is by leveling the playing field and providing incentives for patients. The plan keeps the healthcare insurance industry in control of the healthcare dollars.

It states; “ the Act transforms health care in America: strengthening the relationship between the

patient and the doctor; using the forces of choice and competition rather than rationing and restrictions to contain costs; and ensuring universal, affordable health care for all Americans.”

I am disappointed in the Republican proposal. It is a proposal of empty words. The public will not be fooled. The public wants change. I will publish the executive summary so readers can judge for themselves.

Under the Republican plan, instead of a competitive marketplace for healthcare coverage I can visualize a market place dominated by a few healthcare insurance companies. The result will be further increase in cost of premiums. The healthcare insurance industry would continue to own the healthcare dollar and be non transparent.

The healthcare insurance industry would continue to abuse patients, physicians, hospitals and the government.

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

Stanley Feld M.D.,FACP,MACE

The United States cannot afford to provide universal healthcare coverage under a single party payer. The country is in financial difficulty without expanding Medicare.

“Bernie Madoff is small-time compared to the federal government. Really. You want Ponzi schemes? The new Obama-Democrat budget deficit is $1.8 trillion, four times larger than it was only last year. The national public debt has increased by more than 10 percent since Inauguration Day.”

Social Security and Medicare are underfunded entitlement programs. Medicare for the entire country is not viable.

These are the published numbers for 2008.

• Social Security’s unfunded liabilities stood at $13.6 trillion.
• Medicare’s unfunded liabilities are more than $30 trillion.
• Medicaid, another severely underfunded and politically untouchable entitlement program, only adds to the total.
• The federal government’s current entitlement bill, including future obligations-based only on promises it has made in the past — is greater than $57 trillion.”

The first Baby Boomers started drawing early retirement benefits from Social Security last year.”

78 million people are going to stop working, stop paying taxes, stop paying into retirement programs and start drawing Social Security and Medicare benefits. The federal government has made explicit and implicit promises to millions of retiring citizens. It does not have the funds to keep those promises without a big hike in taxes.

“According to a recent forecast by the Congressional Budget Office shows that Medicare and Medicaid alone are going to crowd out everything else the federal government is doing by mid-century”

In order to get close to funding our current obligations it is estimated that the income tax rate will have to increase to 66%. With all the bailouts and economic stimulus packages the federal government’s debt can only get worse.

Yet the game of who can have better sound bites and who can win is the only thing that is important to President Obama, the healthcare insurance industry, and the Democratic congress.

Healthcare reform should not be about a National Healthcare Insurance Exchange or universal healthcare with a single party payer. This is not going to fix the healthcare system. It will make our financial problems worse. Our government officials should face reality. It should do what all physicians know needs to be done.

It should be passing legislation to create a less polluted environment. It should revise the Farm Bill. It should eliminate the use of corn syrup. It should fight obesity with public service educational campaigns. It should create an insurance product that provides consumers with financial incentives to stay healthy. It should eliminate the causes of administrative waste and defensive medicine. These should be the areas of discussion in order to repair the healthcare system. These bold topics threaten powerful vested interests and are politically explosive.

America should set up a healthcare insurance system that provides incentives consumers to demand better foodstuff and a healthier environment. Consumers should own their healthcare dollars and be able to save what they do not use. (ideal medical savings account).

The federal government should make the conversion to functional electronic medical records easier and less costly to physicians (ideal electronic medical record). We should have major tort reform to decrease the intolerable cost of defensive medical.

These are areas in which the healthcare reform debate should be focused. If the Republican Party wants to seize the initiative from the Democratic Party and excite the citizens of our country they need to act .

Instead, we have a silly debate pitting the new media (Democratic Party) against the old media (Republican Party) over systems we cannot afford. The new media will win. Americans lose no matter which side wins.

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