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Stakeholder Mistrust

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Obamacare Co-Op Folly

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The Obamacare Spin Goes On

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Social Engineering

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Obamacare Is Failing

Stanley Feld M.D.,FACP,MACE

The problems the Obama administration is having with Obamacare have not been in the news lately. They appear in government publications as minor policy changes or in press releases. They also appear in minor trade magazines. Little that is new has appeared in the mainstream media.

Readers of the New York Times are under the impression that Obamacare is working and is successful. The readers’ impression is that President Obama has done a great thing for the nation by getting Obamacare passed into law.

If a lie is told enough times it becomes the truth. The media is the message. All one has to do is lie to the media and the message gets through whether it is true or not.

The public’s perception of reality is not more complicated than the information fed to it whether it is true or false.

A key element in getting the message through is trust. It is my opinion, President Obama and his administration have lied to the public so much that there is a lack of trust in him and his judgment. The Republican and Democratic parties have lied to the public so much that there is a lack of trust in both parties.

It has been shown over and over again that Hillary Clinton as lied to the public. Yet, she is gathering millions of votes in her primary contests while others who have told the same lies have ended up in prison.

Black people are figuring out that the Democratic party has lied to them. The war on poverty started in 1965 and little progress has been made to eradicate poverty since then.

Why is there so much poverty and unemployment in the black community?

Why can’t black kids have a choice of public schools or charter schools in New York City? Why can’t education be a top priority?

As Leonard Cohen says, “the deck is rigged.”

I think the reason Donald Trump is running the table on votes in the Republican primaries is people do not trust politicians.

He promises to unrig the deck and make America great again. The politicians, pundits and traditional media are confused about why the public is listening to him.

The public does not trust or believe them. The public trusts Donald Trump and his promises without having objective reason.

Two significant events have occurred in the Obamacare world in recent weeks which are contributing to Obamacares further failure.

  1. President Obama caving in on the “Cadillac tax”

As part of the budget deal President Obama agreed to sign another delay in the Cadillac tax until 2020.

An Obamacare law provision levies a hefty 40 percent tax on the most expensive employer-provided insurance plans: those costing above $10,200 for individuals and $27,500 for families.

The Obama administration predicts it will generate $87 million per year in new taxes.

“If a plan cost $11,200, it would face a $400 tax — 40 percent of the amount above the threshold.”

The Cadillac insurance premium was a 100% tax-deductible expense to an employer providing a high cost healthcare insurance policy to employees.

High paid executives and some unions or union executives enjoy this high cost insurance. President Obama’s goal has been to provide a disincentive to employers from providing this type insurance.

The Kaiser Family Foundation estimates 26 percent of current plans could get hit with the tax in 2018; Towers Watson pegs it at 42 percent. This is the result of healthcare insurance rate increases.

I think it is a trick by President Obama to discourage corporation from providing healthcare insurance for their employees. The Obama administration would like to force corporate employees to buy healthcare insurance from the federal health exchanges. When the federal health exchanges fail the government could take over everyone’s healthcare insurance and dictate the terms of that insurance.

The “Cadillac tax” was suppose to go into effect in 2017 but has been previously delayed until 2018.

Lawmakers on both sides of the aisle agreed to delay Cadillac tax implementation even longer now until 2020. Some sort of political pressure has forced President Obama to sign the amendment to Obamacare. This new law will decrease the funding for Obamacare.

The traditional media has not emphasized this event leading to Obamacare’s demise.

  1. President Obama backs away from new Obamacare rules for 2017.

The execution of Obamacare by the Obama administration has not stabilized the healthcare insurance industry market as promised. In fact the federal exchange markets have become more chaotic. This is partly because of the inefficient bureaucratic structure and the lack of attraction to non-sick people, who would fund the federal health insurance plans. The healthcare insurance plans dictated by the federal government do not fit the needs of the people who would buy them. Instead, even though the health insurance plans are too expensive they attract people with pre-existing illnesses. These people have no choice.

The Obama administration’s typical response to fix unintended consequences is to create more rules and regulations. The new rules and regulations will lead to more unintended consequences.

The Obama administration just backed off of two big new. The Obama administration proposed tight physician and hospital network adequacy provisions and new standardized health plan options provisions.

The previous Obamacare rules and regulations resulted in the healthcare insurance industry’s adjusting to their loss of income by creating narrower networks of physicians and hospitals. Many of the healthcare exchange plans use HMOs only and narrow networks of hospitals and doctors as a way to keep premiums lower.

The result was a decrease patients’ access to care. CMS basically backed off of the strict network options it wanted to dictate. The Obama administration once again proved that it depends on the healthcare insurance industry to function. The healthcare industry is dictating the rules.

The goal of the Obama administration to standardize options was to make it easier for consumers to compare the various levels of healthcare plans offered in the health exchanges. The Obama administration also felt it was necessary to define the levels of basic benefits to make shopping for the most affordable plan easier.

The winner is the healthcare insurance industry. The loser is the Obama administration. The biggest losers are patients both in Obamacare and those who have private insurance.

As time goes on it is becoming clearer to everyone that Obamacare is not the success that President Obama and Paul Krugman are talking about.

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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President Obama Somehow Finds The Money

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Thought You Could Win?

Stanley Feld M.D.,FACP,MACE

There are lots of healthcare systems that think they can win by supporting Obamacare.

It has always been clear to me that hospital systems cannot win by participating in the present rules of the Affordable Care Act.

Major hospital systems are finding that fact out slowly but surely.

“HealthSpan is the insurance arm of Catholic hospital system (Mercy Health).”

The Catholic Healthcare System is one of the top ten rapidly growing hospital systems with a network of 387 acute care hospitals.

The governance of the Catholic Healthcare System thought it could profit from Obamacare, its federal Health Insurance Exchanges and the formation of an Accountable Care Organization.

Mercy Health believed it could profit by setting up an insurance arm for its network and selling insurance in the Obamacare Health Insurance Exchanges.

In order to form an ACO it bought an existing integrated physicians group.

Mercy Health, a 23-hospital system, formerly known as Catholic Health Partners, bought Kaiser’s Ohio business in 2013.

Mercy Health tried hard to make the strategy work for its financially.

I have stated previously that it is very difficult to set up ACOs. The business model is destined to fail because of faulty premises and inadequate cultural and financial incentives.

Patients should be responsible for their healthcare dollars. Healthcare insurance companies should be responsible for financial risk and financial reward by providing the insurance coverage.

“HealthSpan, the insurance arm of Catholic Healthcare System Mercy Health, is getting rid of its medical group (Kaiser) and halting sales of Affordable Care Act policies just two years after acquiring Kaiser Permanente’s Ohio subsidiary.”

The move represents a failure of one health system trying to replicate the much-heralded Kaiser model of healthcare which integrates the payment and delivery sides.

HealthSpan has been a failure financially. Mercy Health’s managers realized that the two new programs became a financial disaster for the entire healthcare system.

The reality is in contrast to the optimistic statement made by CEO Michael Connelly two years ago. His announcement was not dissimilar for the many other statements by hospital systems that are on the road to failure. It almost sounds like they had the same consultant.

In announcing its agreement with Kaiser Permanente, Catholic Health Partners president and CEO Michael D. Connelly said in the joint release, “This opportunity interests us because it preserves a values-based, patient-centered care model that we can expand throughout the region. Additionally, it enables us to focus on enhancing quality, improving access to health care, and effectively managing costs.”

No one ever asks practicing physicians what system will work to Repairing the Healthcare System.

No one every talks about the patients’ responsibility in preventing chronic diseases or once a chronic disease occurs, what is their responsibility in managing the disease.

Until a healthcare system is built around patients’ responsibility along with ways to prevent insurance company, hospital system and physician abuse, a healthcare system will not be built that is cost efficient with increased quality of care.

 

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

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Here It Comes!

Stanley Feld M.D.,FACP, MACE

The mainstream media has been very quiet about Obamacare lately as the defects in its execution keep rolling along.

You may recall President Obama telling Senator John Kerry and Representative Barney Frank not to worry about including a Public Option in the bill. He told them they would not have to include the Public Option in the Affordable Care Act.

Barney Frank said we would never get a single party payer system unless we have a Public Option in the bill.

President Obama was right. He didn’t need a Public Option because the single party payer system was already embedded in the bill without anyone knowing it.

Medi-Cal is California’s name for its Medicaid program. California is one of the states that have expanded the Medicaid program under Obamacare.

Twenty states have not expanded their Medicaid program for fear of the federal government impinging on states rights while sticking their state with the bill.

The states also feared increases in their budget deficit. States are required to balance their budget. The result would be an increase in state taxes.

The increase in state taxes would render the state unattractive to companies and their business. Less company growth would mean an increase in unemployment and a decrease in state tax revenue. A decrease in tax revenue would result in a decrease in state services.

President Obama said, “Don’t worry.” He promised to fund Medicaid expansion fully for the first 3 years. Federal funding would decrease after the first three years to 50%. The funding percent has changed a few times since that promise. One could not know the present decrease unless one read the Federal Register daily.

Expanding Medicaid was a key part of the Affordable Care Act (Obamacare). It was also a hidden trap set by President Obama to slip the healthcare system into a single party payer system by default. That is why President Obama insisted we did not need a Public Option.

Obamacare required nearly all Americans, under penalty of law, to have insurance starting in 2014.

Though a surprise, the high Medi-Cal enrollment is generally hailed as a success. California’s uninsured population has been cut in half since Obamacare, in large part because so many Californians signed up for Medi-Cal, which is free for beneficiaries.

Medi-Cal was opened to all low-income Californians starting two years ago, with the federal government paying for those new enrollments.”

In 2016 one third (1 in 3) or 12.7 million Californians are covered by Medi-Cal.

The total cost of the Medi-Cal explosion is $91 billion dollars, up from $54 billion dollars in 2012. California is responsible for $12 billion dollars. It will increase California’s budget deficit and may result in another tax increase.

The cost per insured is $7,165.35.

“The Medi-Cal program continues to grow at a very substantial rate, which is great. We are very happy that we’re able to provide healthcare to getting close to 13 million Californians,” said Mari Cantwell, chief deputy director at the state Department of Health Care Services, at a hearing in downtown L.A. this month. But, Cantwell added: “Obviously with that comes cost.”

The Medi-Cal is viewed by many state officials as being underfunded.

Medi-Cal patients are struggling to find doctors.

Many patients are receiving low quality of care by government standards.

A psychiatrist in Los Angeles told me that all the private practice internists in L.A. require an upfront concierge fee of at least $2,000 a year at the beginning of the year to be in their panel. If this is true, Internists in L.A. are insulating themselves against the low reimbursement of Medi-Cal. This concierge fee increases the California physician shortage.

The result has been that groups of activists have filed a federal civil rights complaint alleging that Latinos are being denied access to healthcare because the program does not pay doctors enough.

The Affordable Care Act allowed states to open up Medicaid to anyone making less than 138% of the federal poverty level.”

Twenty states did not sign up for the expanded Medicaid because of the fear of federal takeover and the further impingement of state rights.

Pre-Obamacare, states were required to pay 43% of Medicaid’s cost and the federal government paid 57% of the costs. States ran the program and determined reimbursement.

As costs increased reimbursement was decreased and physician participation decreased because of the decreased reimbursement.

As a result of the 20 states resisting Medicaid expansion the federal government will pay 100% of the cost of new expansion enrollees and 93 percent off the cost of expanding Medicaid over the next nine (9) years instead of the next two (2) years.

The present rule looks like a great deal for the states. However with the federal government paying most of the Medicaid bill for the next nine (9) years the federal government will want to control Medicare.

Who needs a Public Option to get to a single party payer?

Who is going to stop the federal government from changing the eligibility for Medicaid to 200 or 400% of the poverty level?

Who is going to force doctors to participate in Medicaid if they want to practice medicine with a federal license?

Where is the government going to get the money without having skyrocketing increases in taxes?

Tax laws and lack of pro-growth tax reforms are inhibiting America’s economic growth.

America has been set up to have the future state of healthcare be a single party payer system. President Obama has done it in a clever way. He has had no regard for being fiscally responsible in the face of a 19 trillion dollar, and rising, debt.

Single party payer systems have failed in England and Canada.

Why should America create another failure?

Can Americans have a future state healthcare system that is not destined to fail?

Yes we can!

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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Premises Must Be Re-examined

Stanley Feld M.D.,FACP,MACE

A few weeks ago I had a terrific exchange with Steve Brachet M.D. who forwarded my blog to Steve Gregg.

“Stan,

I forwarded your recent blog featuring the five essential steps for HC reform to Stephen Gregg of Portland Oregon.

Steve Gregg is a former senior hospital executive, turned CEO of a managed care plan (successful in WA and OR), developer of alternative healthcare products, developer of patient care informatics, and thought leader in past 10 years on dimensions and confounding variables of health care in all its complexities.

He asked me to send the attached (very brief) piece recently published in the Oregon main media.

I don’t know if he expects a comment or two – but if you care to comment feel free to respond to Steve Gregg directly.

I take it that you are continuing to do your best to ‘right this HC ship’ that seems unlikely to improve on its own – nor with the help of the current Congress.

Steve Barchet M.D.”

I was fascinated with the article Steve Gregg wrote. I agree with many of the points he makes. I am publishing his article with Steve Gregg’s permission. I wrote back and said;

Dear Steve

I welcome your article.

My blog explains the elements needed to Repair the Healthcare System from a physician’s point of view.

As a result of the Internet and improved software, consumers have become king and are driving the consumer consumption market. Amazon and ebay have led the way. Opaque purchasing models have been replaced by price transparent purchasing.

Wal-Mart has been forced to close stores because of online purchasing to remain competitive.

A consumer driven transparent online purchasing model has replaced airline ticket purchasing through travel agencies.

Online banking is transforming banking services. Hardly anyone goes into banks anymore.

There is no reason that shopping for healthcare services cannot transform the healthcare industry with all its opacity.

Consumers must be put in a position to drive the healthcare system and be responsible for their health and healthcare dollars.

Our 2020 business model can transform the dysfunctional healthcare system that can align all the stakeholders’ vested interests by empowering consumers and letting them drive the system.

The result will be a decrease in cost. It will eliminate the entitlement mentality of healthcare consumers and create a competitive mentality for all stakeholders as it has done in the examples above.

All Obamacare is doing is trying to put a patch on a healthcare system whose demise has been accelerated since passage of the Affordable Care Act.

Your articles describe many essential premises that must be reexamined.

However, consumers must be involved and be the responsible party in the healthcare system. They have to be given financial incentive to be involved and responsible.

Thank you for letting me reprint your article.

 

Health Reform…What Next?

Steve Gregg

With the expensive collapse of Oregon’s Health Exchange, a New Year, and approaching changes at the Federal level, it is time to reconsider the formative assumptions driving health care reform.

Ten Game Changing Assumptions Shaping Health Reform:

 

  1. The ideologies of the left and right will not sustain a reform solution grounded in compromise and “deal making”.   The endless search for consensus confuses the problem, and is a recipe for failure.

 

  1. The State’s public bureaucracy is too conflicted with its own self interest to impartially govern health reform.

 3.The plethora of proposed actions to reduce demand will not reduce costs. “Supply” being a more important driver of costs than ”Demand”.

  1. Sustainable reform cannot tolerate the variation in provider pricing to patients with differing sources of payment. Perhaps less than 15% of the typical hospital’s patients pay what the hospital bills.

 

  1. It is wrong headed to view reform as a matter of amending the existing system.

 

  1. Financial goals stabilizing health care costs cannot be achieved without prospectively stated and independently measured metrics.

 

  1. Equal access is not a realistic expectation. Universal coverage must be.

 

  1. Genuine Altruism is a deceptive and widely abused value of our non- profit institutions and trade associations.

 

  1. The United States spends twice as much per capita on health care because our health care workers of all stripes (including insurance companies,hospital sytems, government and pharmaceutical companies) s(take out twice as much from the system.

 

  1. The health care structures of other countries, while instructive, are not transferrable to the United States.

 

Bonus:

 The Oregon Healthcare Project rationing experiment was a colossal hoax that channeled billions of new dollars to Oregon’s health care interests. Never measured, never critically evaluated. It was a severe case of the “Emperor Wears No Clothes”.

Conclusion: Think in terms of 2-3 alternative systems reflecting differing ideologies: Liberal / Conservative / Libertarian.

What would this suggest for process?

 

  • Form 3 small task forces assembled around three ideologies: Liberal, Conservative, and Libertarian to articulate assumptions, problem definition, and a broad solution compatible with each ideology.
  • At the end of the process examine what consolidation can occur and if not presume the development of 3 systems available to the free will of people to chose.

 

Liberal: Socially and fiscally liberal

Conservative: Fiscally and socially conservative

Libertarian: Socially liberal / Fiscally conservative

 Note: The prospect of 3 systems capturing U.S. Healthcare, sounds daunting but in reality we have more than that now: Employer, Medicare, Medicaid, TriCare, Municipal, Insured, Self funded etc.

 Alternative List of Assumptions:

 

  1. A sustainable health reform strategy cannot be achieved without the foundation of a well-conceived definition of the problem and formative assumptions.

 

  1. Subsidized or “free” health care is inflationary and will overwhelm administrative protocols for cost reduction.

 

  1. Genuine Altruism is rare and a widely abused cover for proprietary agendas.  Excessive profit is a measure of good management.

 

  1. The community’s health care pathology is infinite and those making a living and profits from health care will seek to capitalize on that.

 

  1. Our health care system in the main is a proprietary endeavor with millions of economic interests seeking to protect or increase revenues. Any initiative that threatens that cash flow will be vigorously resisted.

 

  1. Does the system tilt toward choice and self – determination or equalness, limited choice, and a central authority?

 

  1. “Nearly half of all care delivered produces no medical benefit” is in obvious conflict with a prevailing view of vast health manpower shortages.   Does increasing supply reduce prices and the costs of health care?

 

  1. If the national will demands universal coverage, the utility of competing traditional insurance companies should be called into question.

 

  1. The reformed system must promote individuals seeking care from the “best” provider of care as early as possible in the development of any adverse health care condition.   Forcing patients into an inferior food chain of care is unethical and probably more costly in the end.

 

  1. There is something wrong with a requirement to select a health plan, provider network, and insurance in advance of acquiring a dire condition, and then being locked out of access to the “best” provider.

 


Steve

I do not see consumers playing an active role in your assumptions to Repair the Healthcare System.

Obamacare is wasting money developing an entitlement system that cannot work. The only stakeholder that can develop a healthcare system that can work is a system driven by consumers.

Consumers can force the secondary stakeholders to be competitive and transparent, as they have done in other industries.

It would be cheaper for the government to invest in empowering all consumers using the revolution in information technology and providing financial incentives to all using My Ideal Medical Saving Accounts.

Everyone could be insured as I have described in my article The Ideal Medical Saving Account Is Democratic.

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

 All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

 

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Obamacare Is Increasing Health Savings Account Participation

Stanley Feld M.D.,FACP,MACE

Patients’ responsibility for their health and their healthcare dollars is one of the most important elements in a functioning and cost effective healthcare system.

Despite the fact that my ideal medical savings account (MSAs) would be more effective than health savings accounts (HSAs) in encouraging patient responsibility for their health and healthcare dollars, health savings accounts are flourishing because of Obamacare is costly and has taken freedom of choice away from individuals.

Devenir is a HSA Mutual Fund that accepts and invests HSA trust contributions and invests those contributions. Devenir just published a study that showed that:

1. As of June 30, 2015, the number of HSAs had climbed 23% from the previous year to 14.5 million.”

  “2. Account balances jumped 25% to approximately $28.4 billion over the same time period.”

In 2010 the year Obamacare was passed, there were 5.7 million HSAs with balances totaling $7.7 billion.

The Obamacare bronze plan is the least expensive federal health insurance exchange plan. Its coverage is poor and it has a high deductible that most people cannot afford.

The premium and deductible are only good for patients with pre-existing illnesses that have no other place to purchase insurance. That is the reason the demographic for enrollees from healthcare.gov is so poor.

The government is loosening the noose on HSAs even though it is still restrictive.

“For the 2016 tax year, you can make a deductible HSA contribution of as much as $3,350 if you have qualifying high-deductible self-only coverage or as much as $6,750 if you have qualifying high-deductible family coverage. If you are age 55 or older as of the end of 2016, the maximum deductible contribution goes up by $1,000.

For 2015, the contribution caps are the same, except the maximum deductible contribution for family coverage is $6,650. These amounts are increased by $1,000 if you were 55 or older as of December 31, 2015. You have until April 18, 2016, to make an HSA contribution for the 2015 tax year.”

You must have a qualifying high-deductible health insurance policy — and no other general health coverage — to be eligible for this HSA contribution privilege. For 2015 and 2016, a high-deductible policy is defined as one with a deductible of at least $1,300 for self-only coverage or $2,600 for family coverage.

For 2016, qualifying high-deductible policies can have out-of-pocket maximums of as much as $6,550 for self-only coverage and $13,100 for family coverage. For 2015, these amounts are $6,450 and $12,900, respectively.

If you are eligible to make an HSA contribution for a tax year, the deadline is April 15 of the following year (adjusted for weekends and holidays) to open an account and make a contribution for the earlier year.”

The government has increased the maximum deductible in 2015 and continues to increase in 2016.

For the 2016 tax year, you can make a deductible HSA contribution of as much as $3,350 if you have qualifying high-deductible self-only coverage or as much as $6,750 if you have qualifying high-deductible family coverage.

“ If you are age 55 or older as of the end of 2016, the maximum deductible contribution goes up by $1,000.”

More large companies are Increasingly offering workers high deductible health saving account. However, the employee is responsible for the high deductible and most of the plans are 70/30 coverage after the deductible is reached up to a maximum of $10,000.

Most large and small employers can afford to pay all or some of the high deductible and buy reinsurance for first dollar coverage beyond the deductible.

Both large employers and small employers are offering their employees health savings accounts. The full insurance premiums have become so high that employers are shifting the burden to employees by having the employee pay the deductible and the employer paying the reinsurance.

UnitedHealth has about 40 individual high deductible plans with 70/30 copays over the limit of the deductible. The maximum out of pocket cost is $10,000. The premium for a young married couple without kids is from $125 to $350 per month depending oo the deductible chosen. The premium increases with the number of children.

A great advantage to these plans now is that UnitedHealth has already negotiated the physicians’ and hospitals’ fees for you. The uninsured would pay retail price for the same services.

The cost to small to large companies is relatively difficult to find in an online search.

Most companies are self-insured and would not fall under the rigid coverage rules of Obamacare. The company can decide on the amount of the deductible they would pay for the employee.

The point of all this is health saving accounts are not as good as my ideal medical saving account. HSA’s do not provide enough incentive for employees or individuals to manage their health or healthcare dollars wisely as an MSA would.

A large defect in Obamacare is patients do not have incentive to be wise shoppers of their healthcare. They have restricted choice. They have little incentive to stay healthy because they have an entitlement program available that will take care of their expenses. There is no financial incentive for them to try and reduce the cost of healthcare.

If the consumers managed their health and healthcare dollars well the cost of healthcare would drop because the complications of chronic diseases would decrease to at least 50%.

If Republicans are looking for an alternative plan to the liberals’ and progressives’ inevitable march to a singe party payer system most of the infrastructure is already in place.

Only small modifications to the HSAs have to be made by the congress and the President and America would be on its way to a free market healthcare system.

This alternative healthcare system would align all of the stakeholders incentives including the government’s incentives, if the Obama administration did not want to increase its power by having more control over its people and its people’s freedom of choice.

My ideal Medical Saving Accounts would be democratic and cover everyone.

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

 All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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