Stanley Feld M.D.,FACP,MACE

I predicted the bipartisan Romney universal healthcare plan for Massachusetts would fail. The reason is simple. The rules of the game were not changed for the insurance industry, the hospital systems and the physicians. The reason this important idea cannot work is because the program was superimposed on the rules of a broken healthcare system.

“The state’s new subsidized health insurance program will cost “significantly” more than the $869 million Governor Deval Patrick proposed in his 2009 budget just two months ago, the state’s top financial official said yesterday, after insurers were granted an increase of about 10 percent.”

As long as the insurance industry controls the pricing without price transparency the price is going to escalate. If hospitals and doctors are not competing in a price transparent market place, prices will escalate. As long as patients are not responsible for their healthcare dollar there will not be provider competition.

“Officials are scrambling for alternatives after the four healthcare insurance companies providing subsidized insurance under the state’s universal health care law offered bids for continued coverage that were far higher than expected.”

“To close the gap, the Patrick administration has asked insurers, hospitals, healthcare advocates, and business leaders to propose ways to cut costs and raise revenue.”

Notice the group missing from the discussions. Physicians are missing from the table. Physicians are the providers that control healthcare costs. Physicians should contribute to a discussion on how to control costs. Why has no one thought of asking physicians to contribute to the discussion? Perhaps physicians as the non contributing scapegoat is required?

“Leslie Kirwan, secretary of administration and finance, declined yesterday to discuss specifics of the proposals or the size of the budget gap, but said that without changes, the state doesn’t expect “to be able to live within” the proposed budget.”

You may recall that Leslie Kirwan, chairperson of the Commonwealth Health Insurance Connector, said 4 months ago’ “It’s too early to make any departure from the health reform plan,” “We will follow the trends and adjust, if needed.” http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2007/12/romneys-univers.html

“To partly offset the increased costs, the panel yesterday also voted to raise premiums by 10 percent for some of the 176,000 people enrolled in Commonwealth Care, and to increase copayments for many more. Starting July 1, the lowest premiums will range from $39 to $116 per month.”

If Massachusetts raises healthcare premiums and increases the healthcare copayment many more people will not be able to afford the mandated insurance. The state has already exempted 30,000 people from the mandate to date.

“The budget figure of $869 million already was significantly higher than projected by legislative architects of the plan because of the enrollment boom.”

The state budgeted $472 million in 2007 for the subsidized program, based on enrollment estimates made last winter. Commonwealth Care provides comprehensive insurance to people without access to work-based coverage who earn less than 300 percent of the federal poverty level, or about $31,000 for an individual. This represents an 84% increase and is not close to the insurance industry bids.

“In order to make up some of the difference Leslie Kirwan has shifted some of the money from the $448 million Health Care Safety Net Trust Fund, which pays for care at hospitals and health centers for uninsured patients.”

Officials at many so-called safety net hospitals said that as the new system – which requires all residents to buy health insurance – phases out payments for free care provided to the uninsured, hospitals are facing budget shortfalls and have been forced to cut back on investing in new equipment.

The Romney plan was suppose to be the new hope for a free market healthcare economy. Hillary Clinton’s healthcare plan is similar. However, I believe she knows her healthcare plan will fail. The nation would then be presented with her only alternative, a government run single party payer. In other words the politically incorrect term “socialized medicine” is the only remaining alternative.

No one has thought of giving patients responsibility for their care and ownership of their healthcare dollar. The ideal medical savings account can motivate people to be responsible for their health, their use of the healthcare system and be diligent in their use of their own healthcare dollar.

Stanley Feld M.D.,FACP,MACE

Ninety percent of the Medicare dollars are spent on the complications of chronic disease. Obesity is the cause of the onset of many chronic diseases such as Type 2 diabetes mellitus, and heart disease.
I have said there is a solution to the predicted $34 trillion dollar healthcare deficit. It is the prevention of the onset of chronic diseases. The government, corporate policies, patients, and physicians do little to prevent to onset of chronic disease or its complications.

In pursuit of the dollar Major League Baseball has outdone McDonald’s as an irresponsible corporate citizen. You will recall the relationship of McDonald’s super sized campaign and its relationship to elevating cholesterol and heart disease.

The public outcry caused McDonalds to retreat from its super sized campaign.

“Baseball and gluttony, two of America’s favorite pastimes, are merging in a controversial trend taking hold at Major League Baseball stadiums across the nation: all-you-can-eat seats.”

These cheap seats were difficult to sell. Now these seats are more expensive. They are advertised as party time with all you can eat food and drink. When people go to a ballgame they want to have fun. The message is fun equals baseball, hot dogs, nachos and soda pop. In a world where the” media is the message”

Major League Baseball is playing on the emotional message of fun while promoting the Obesity Epidemic.

“Fans in these diet-busting sections, for a fixed price usually ranging from $30 to $55, are able to gorge on as many hot dogs, nachos, peanuts and soft drinks as they can stomach. Some teams charge extra for beer, desserts and candy.”

I predict all thirty major league teams will have all-you- can–eat-seats in 2009. Where are the Presidential candidates on the issue of the obesity epidemic? Can the government do anything to protect us? Can people do anything to protect themselves? Can major league baseball do anything to stop this madness?

“At least 13 of the 30 major league teams are offering all-you-can-eat seats for all or part of the 2008 season, up from six last year. Some of the teams that offered them last season are expanding their all-you-can-eat sections this season.”

I have been saying for the past 2 years that citizens have to be responsible for themselves. The corporate interest is to make as much money as it can.

No one is going to step forward and protect us from ourselves unless public outrage occurs and we have a culture change toward overeating. “People Power’ expresses itself through public outcry.

“All-you-can-eat seats, usually in distant bleacher or upper-deck sections, are allowing teams to squeeze revenue out of parts of ballparks that used to sit empty game after game, team officials say.”

It is clearly all about money. All you can eat seats is an erroneous policy decision to increase revenue. The baseball executives always have lame excuses for bad policies.

“We’re getting rid of (tickets) and making the public happy” by offering them a way to save money, says Andrew Silverman, executive vice president of sales and marketing for the Texas Rangers. The Rangers saw sales of 616 seats in their stadium’s left-field corner take off last year after the seats were designated as all-you-can-eat areas.”

The public relations ploy is to put the blame on the fans and not their baseball franchise.

Mark Tilson, vice president of sales and marketing for the Kansas City Royals, says it’s up to fans to eat responsibly.
“We’re not making anybody purchase these seats, or eat seven hot dogs,” says Tilson.

Mark Tilson is correct. This is a strong reason for Americans to be responsible to themselves. If they owned their healthcare dollar they might not choose to abuse themselves especially if there was a financial incentive to take good care of their body. If they abuse their body they should be responsible financially as well as emotionally.

“What attracted me was eating as much as I could,” says Toney Fernandez, 20, of Harbor City, Calif., but “then I got hooked by the whole atmosphere:

The Dodgers began offering 3,300 right-field bleacher seats with unlimited Dodger Dogs, nachos, peanuts, popcorn, soft drinks and water. The section averaged 2,200 fans a game last season — and sold out for one-third of the team’s home games.

“Before the unlimited food and drink, such seats sold for $6 or $8, if they sold at all. Now, they go for $35 in advance and $40 for game-day tickets.”

The teams are doing it for money and not the health of their fans. The fans have eating contests.

” At the Braves’ Turner Field, some fans had hot dog eating contests, says Derek Schiller, executive vice president of sales and marketing.”

“The Royals tout their section with the slogan “Eat, drink and be merry!” At one game, a teenage boy scarfed down a dozen hot dogs, nachos and a couple of bags of peanuts.”

Ron Ranieri, general manager of concessionaire Aramark at Atlanta’s Turner Field, calculates that a typical all-you-can-eat customer downed: 3.35 hot dogs; one 20-ounce soda; one 7.9-ounce bag of peanuts; one 3-ounce order of nachos and 32 ounces of popcorn.

This translates to a caloric intake of about 4500 calories or about three times the recommended daily food intake. What is worse is that it also represents about 4 times the recommended saturated fat intake. This excessive intake increases the risk for heart disease, diabetes, stroke, and cancer and in turn the cost of healthcare. The question is who should be responsible for this excessive food intake. Should it be the government, society or the patient? In a free country it should be the patient’s responsibly for the excessive intake.

Should the government pay for care as a result of this abuse? Should the patient be responsible for the abuse? Should a system be created so that the patient acts responsibly and not abuse to his body? My answer is yes. The system be be able to accomplish this goal is not universal healthcare coverage with a single party payer.

Stanley Feld M.D.,FACP,MACE

It is easy for the presidential candidates to promise healthcare for all during a presidential election year. However this promise is made without testing reality. The reality is America can not afford to deliver healthcare to all. The country is having difficulty keeping its public hospitals open. These public hospitals are centers for last resort care.

“The prospects that Grady Memorial could close, and that Atlanta’s health infrastructure could crumble, have forced a civic re-examination of the region’s commitment to its least fortunate, a reckoning that has revived old antagonisms over race, power and class.”

“Some have suggested that Grady must compete for paying customers in Atlanta’s fierce medical marketplace, while others say that taxpayers should contribute more to continue its mission. Will Grady outsource, or simply downsize? And if it must downsize, which patients should be turned away?”

None of the presidential candidates have suggested viable solutions to the healthcare system’s problems. I think the Democratic Party wants its declared initiatives to fail. After the initiatives fail they will claim there is no other choice but universal healthcare system with the government as the single party payer. The failure of the proposed insurance paradigm is a back door entry to a single party payer system.

A recent Fortune magazine article said: “Medicare is poised to wreak havoc on the economy. And our presidential candidates are avoiding the issue.”

Alan Greenspan has been quoted as saying “the biggest threat to the American economy is Medicare. You’d think that the greatest threat to America’s economy would be Topic A for the presidential candidates. But it’s actually a topic they hate to touch.”

Instead, the great debate between Hillary Clinton and Barach Obama is to mandate universal coverage or not. If you require people to buy healthcare insurance using a defective healthcare insurance model all you will be doing is providing more customers for the healthcare insurance industry.

“An analysis of their speeches shows that last year Senators Hillary Clinton, John McCain, and Barack Obama would occasionally mention the Medicare mess. But recently, with the economy slowing and voters feeling insecure, all three candidates have turned more populist: Their economic talking points are about feel-good reassurances, not about facing hard realities.”

Americans should be suspicious of Sen. Clinton’s promises. I mention her because she has been the most vocal in diverting us from the reality of the government run healthcare systems mess.

“Unfortunately the day of reckoning is imminent. Sometime in the next President’s first term, Medicare Part A (hospital insurance) will go cash-flow-negative, and it’s all downhill from there.”

“Medicare services more than 40 million old and disabled Americans. As the country ages, Medicare and Medicaid will devour growing chunks of U.S. economic output.”

This is especially true if our obesity epidemic continues. Obese people are more prone to chronic diseases such as diabetes mellitus, hypertension and coronary artery disease.

If we institute universal coverage and single party payer the estimate of healthcare costs consuming 18% of our GNP will jump to 40% of our GNP by 2020.

“In 2070, when today’s kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget, with Medicare taking by far the largest share. No Army, no Navy, no Education Department – just those three programs.”

“Those estimates, reported in the latest Financial Report of the U.S. Government, assume that Medicare payments to doctors will be slashed drastically, by some 41% over the next nine years, as required by current law. It won’t happen. Every year for the past five years, Congress has overridden the mandatory cuts.”

It is obvious something has to change. The estimate of healthcare costs is base on a defect financial reporting by the US Government. The financial report admits these defects.

“As for future cuts, the Financial Report says drily, “Reductions of this magnitude are not feasible and are very unlikely to occur fully in practice.” So in reality, Medicare will go into the hole even faster than official projections reflect. And they show that if Medicare had to be accounted for like a company pension fund, it would be underfunded by $34 trillion.”

The Congress has been correct in its override of proposed Medicare cuts yearly. However, they have done it for the wrong reasons. I have been against the Medicare cuts to cognitive physicians. Medicare cuts do not solve the basic structural healthcare problems.

There are many other constructive solutions. These solutions include a War on Obesity, effective malpractice reform, encouragement of effective disease management and incentives for both patients and physicians to practice effective disease prevention and disease management to decrease the onset of complications of chronic diseases. The solution can only be accomplished with real price transparency by all the stakeholders, an ideal medical saving account, an ideal electronic medical record, and the creation of a system of competition so that the patients own their healthcare dollars and all the other stakeholders compete for their healthcare dollar. These elements of the solution can not be done piece meal. They have to be introduced and enacted as a complete package in order to be effective.

The solution proposed will probably never be enacted. The people (“People Power”) have to make the demand for effective change. There are too many powerful stakeholders who will lose and will not let effective change occur.

Physicians do an excellent job of fixing things that are broken. The government, corporate policies, patients, the healthcare insurance industry and physicians do little to prevent our bodies from becoming broken.
If Mr. Greenspan is correct and the healthcare crisis is “ the greatest threat to the U.S. economy and the candidates haven’t told us what they’d do about it, they haven’t told us a thing.”
The candidates should develop an understanding of the problems and viable solutions to the problems. However, they are avoiding them.

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

Stanley Feld M.D.,FACP,.MACE

Neither the Democrats nor the Republicans are discussing the real causes of the escalating costs of healthcare.

The media, policy wonks and pundits are on another insignificant tangent about costs. I also believe our Presidential candidates are not interested in understanding the real problems in the healthcare system.

The solutions to the real problems challenge the vested interests of important and powerful secondary stakeholders. Secondary stakeholders finance the Presidential candidates’ campaigns.

America needs less costly political campaigns. Campaign finance reform would diminish the influence of secondary stakeholders in favor of the interests of the consumer. Candidates should be advocate for their most important constituent, the consumer.

Consumers have written to tell me the issues involved in healthcare reform are too complex to understand. I believe it is the consumers’ obligation to themselves and their families to understand the issues. It is the media’s obligation to truthfully present the issues. Politicians need to be shown the level of consumer concern or they will do nothing to reform the system.

The media is probably opposed to campaign finance reform. Its revenue would be severely decreased by campaign finance reform. None of the candidates would be able to afford advertisements on television or radio. Occassionally the media touches on a core issue that the politicians avoid. The issue is inequality in the tax code for healthcare.

“Democrats, and even a few Republicans, are in a populist mood, and fair enough. But if they really want the tax code to be more “progressive” — i.e., from each according to his means — they ought to forget the Bush tax cuts and address the way the government subsidizes health insurance. On the advice of our doctors, we’re not holding our breath.”

A progressive tax code is one core issue. Politicians are not dealing with the issue of the tax code and healthcare reform.

“According to the Democratic consensus, too many people lack health insurance, and the liberal remedy is to protect the status quo while expanding public programs for the uninsured.”

We know most public programs such as Medicare and Medicaid are on the verge of bankruptcy. Patients are constantly faced with diminished access to care and increasing out of pocket expenses for services not covered by these entitlements. Physicians are faced with ever decreasing reimbursement for services.

What makes anyone think that expanding public programs for the uninsured would lead to an increase in efficiency of care? How could expanding public programs decrease the cost of care and increase the quality of care or access to care?

“Not only does the current system cause unnecessary problems for the insured, but many of the gaps in coverage are the result of the way tax subsidies shortchange the uninsured, particularly working-class and middle-income families.”

This represents a perverse outcome to the Democratic Party’s declared mission to help working-class and middle income families.

“If such inequality and unfairness existed anywhere other than health care, the Democrats would be raising hell. Instead, they’re silent — which is politically telling.”

The Democrats are clever. They want to pass a healthcare policy that will fail. Then the only remaining option will be universal healthcare with a single party payer. The politicians’ goal is to keep consumers frighten and not in control of their own destiny. Frightened consumers lead to political power.

“The core problem is that people who get insurance through their employers pay no income or payroll taxes on the value of the benefit. The Treasury defines this as”tax expenditure,” meaning its revenue the government forgoes to encourage certain behavior. If these losses were converted to the equivalent of direct spending, the tax exemption would have cost more than $208 billion in 2006. The only federal programs that cost more are Social Security, Medicare and national defense.”

This deduction is in favor of employer and high income earners. The deduction is not reflected in the federal budget. The self insured do not enjoy an equal benefit.

“If the purpose of health-care reform is to decrease the ranks of the uninsured, these job-related tax breaks are poorly targeted, even regressive. The more generous the employer health plan, the more the subsidies increase. On average, lower-wage workers have more limited coverage as part of their compensation, usually from small- or medium-sized businesses. Estimates show that the subsidy is worth more than $3,000 for upper-income families (with higher marginal tax rates), and less than $1,000 for those on the lower income rungs.”

If the politicians really wanted to subsidize the poor, they would reverse structure of this subsidy. This is not a new insight. It is an insight that is simply ignored by politicians.

“So why the Democratic silence? Perhaps it’s because they think such a change would interfere with their main policy goal, which is slow but steady progress toward government control of the health-care market. Or possibly it’s because many of the most generous tax-subsidized health plans come from union-negotiated contracts. Or maybe Democrats simply don’t want to concede that President Bush has a point.”

All of the above are true. However, President Bush has not shown political will, nor does he have the political capital or courage to declare that all the reforms he suggested must occur simultaneously in order to be affective in repairing the healthcare system.

“If the Republican Party came to their senses, they would recognize an opportunity to poach a traditionally Democratic issue. Whatever the Democratic Party’s other ambitions, how can they stand by a system that offers the least assistance to the working class and nothing at all to the uninsured?”

Healthcare is a major national issue. Let us get on with the business of Repairing the Healthcare System. Consumers must understand the issues and demand reform.

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