Stanley Feld M.D.,FACP,MACE

Bernie Sanders and the progressive Democrats are not interested in learning from other countries’ mistakes.

Their ideology blinds them to the fact that socialized medicine does not work. I vividly remember John Kerry and Barney Frank telling President Obama that the Affordable Care Act needs a Public Option. The Affordable Care Act would fail if it did not have a Public Option. With a Public Option included they said America would be well on its way to a single party payer system.

They said a single party payer system is the only healthcare system that would work

President Obama told them he had a clandestine “Public Option” built into Obamacare. However, he was never able to bring it about.  

Progressives believe deeply in their ideology. They do not consider past history, present reality or facts. 

Neither does the American College of Physicians. In a position paper it recommended Medicare for All. It was followed up with a letter published in the New York Times with 2,000 signatures out of the 159,000 members advocating Medicare for All.

“In a separate but related move to the ACP’s announcement, more than two thousand physicians on Monday announced an open letter to the American public, prescribing single-payer Medicare for All, in a full-page ad in The New York Times that will run in the print edition on Tuesday, January 21, 2020.”

https://www.nakedcapitalism.com/2020/01/in-historic-shift-second-largest-physicians-group-in-us-has-new-prescription-its-medicare-for-all.html

I wonder how many of these signatories have any idea of what the economic impact of “Medicare for All.” I really wonder how many members out of the 159,000 would support the position. I know I do not support the ACP’s position.  

All progressives have to do is look at what is happening to socialized medicine all over the developed western world and notice it is unsustainable and its citizens are dissatisfied with it.

Healthcare systems in the developed world are failing even as the ideologs believe it is succeeding.

America’s healthcare system is also having many problems. Americans are dissatisfied with our healthcare system. The healthcare system has gotten worse since Obamacare was passed. The government is responsible for making our healthcare system worse. It has not done the things I have suggested to repair our healthcare system.

 The Commonwealth Fund (a private progressive foundation) with a focus on healthcare is certain that a single party payer system is the only viable healthcare system.

The report ranked healthcare systems throughout the developed western world.  In its 2014 published ranking the National Health Service of Great Britain was considered the best medical system among the 11 of the world’s most advanced nations, including Canada, France, Germany, Switzerland and Sweden.

 The United States came in last.

 Few “experts” have the time or patience to read the complete report or pick out the defects in the report.

Most people read the summary. The summary in this report does not reflect the truth about the evidence present in the report.

The Commonwealth Fund’s rankings of countries is contradicted by objective data about access and medical-care quality in these countries in peer-reviewed academic journals.

The Commonwealth Fund’s methodology is defective. Its conclusions relied heavily on subjective surveys about “perceptions and experiences of patients and physicians.”

Kenneth Thorpe made an important point by examining differences in disease prevalence and treatment rates for ten of the most costly diseases between the United States and the ten European countries with a single payer system.

He used surveys of the non-institutionalized population age fifty and older. Disease prevalence and rates of medication and treatment are much higher in the United States than in these European countries.

Why would that be?

There are many reasons for this finding. The main one is the availability of care in the United States compared to the ten socialized western countries.

Another is lifestyle and incidence of obesity in the United States. Both lead to the onset of chronic disease and increased treatment.

 “Efforts to reduce the U.S. prevalence of chronic illness should remain a key policy goal.”

“Americans are diagnosed with and treated for several chronic illnesses more often than their European counterparts are.”

Americans diagnosed with heart disease receive treatment with medications and procedures more frequently than patients in Western Europe.

In the past local peer review was all that was needed along with confidence in the treating physician’s judgment. This confidence in physicians’ judgment has been destroyed by excessive media sensationalism. The real percentage of abuse is small and easily discoverable by peers and the use of social media.

Cancer treatment survival rates in America are far greater than the survival rates in Britain, and countries in western Europe.

The reasons for the higher cure rates is the availability of early detection and treatment.

Cancer treatment costs are high. The government should look into the reasons for this high cost and try to lower the cost.

The Commonwealth Fund’s report does not consider any of these factors.

“Over a quarter of a million British patients have been waiting more than six months to receive planned medical treatment from the National Health Service, according to a recent report from the Royal College of Surgeons. More than 36,000 have been in treatment queues for nine months or more.

Long waits for care are endemic to government-run, single-payer systems like the NHS. Yet some U.S. lawmakers want to import that model from across the pond. That would be a massive blunder.”

https://www.forbes.com/sites/sallypipes/2019/04/01/britains-version-of-medicare-for-all-is-collapsing/#d1df33b36b89

The NHS has a waiting list of 3.2 million people for admission to the hospital. In London alone over 500,000 patients are on a waiting list for diagnosis and treatment.

A large percentage of patients triaged as urgent after being diagnosed with suspected cancer have a 62-day wait time to receive therapy.

Consider how long it takes to get care at the emergency room in Britain. Government data show that hospitals in England only saw 84.2% of patients within four hours in February. That’s well below the country’s goal of treating 95% of patients within four hours — a target the NHS hasn’t hit since 2015.

Now, instead of cutting wait times, the NHS is looking to scrap the goal.

Wait times for cancer treatment — where timeliness can be a matter of life and death — are also far too lengthy. According to January NHS England data, almost 25% of cancer patients didn’t start treatment on time despite an urgent referral by their primary care doctor. That’s the worst performance since records began in 2009.

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And keep in mind that “on time” for the NHS is already 62 days after referral.

Unsurprisingly, British cancer patients fare worse than those in the United States. Only 81% of breast cancer patients in the United Kingdom live at least five years after diagnosis, compared to 89% in the United States. Just 83% of patients in the United Kingdom live five years after a prostate cancer diagnosis, versus 97% here in America.

The British Health and Social Care Act 2012 authorized the use of the small private sector of healthcare to help the NHS with its problems.

The share of NHS-funded hip and knee replacements by private doctors increased to 19% in 2011-12, from a negligible amount in 2003-04. Each year there is an increase in NHS funded care by the private sector.

It sounds like the VA Healthcare System’s solution to its problems.

The NHS also routinely denies patients access to treatment. More than half of NHS Clinical Commissioning Groups, which plan and commission health services within their local regions, are rationing cataract surgery. They call it a procedure of “limited clinical value.”

It’s hard to see how a surgery that can prevent blindness is of limited clinical value. Delaying surgery can cause patients’ vision to worsen — and thus put them at risk of falls or being unable to conduct basic daily activities.

“It’s shocking that access to this life-changing surgery is being unnecessarily restricted,” said Helen Lee, a health policy manager at the Royal National Institute of Blind People.

Many Clinical Commissioning Groups are also rationing hip and knee replacements, glucose monitors for diabetes patients, and hernia surgery by placing the same “limited clinical value” label on them.

Patients face long wait times and rationing of care in part because the NHS can’t attract nearly enough medical professionals to meet demand. At the end of 2018, more than 39,000 nursing spots were unfilled. That’s a vacancy rate of more than 10%. Among medical staff, nearly 9,000 posts were unoccupied. Many physicians have left the NHS and have gone into private practice. Many do both NHS service and private practice.

These shortages could explode in the years to come. In 2018, the Royal College of General Practitioners found that more than 750 practices could close within the next five years, largely because heavy workloads are pushing older doctors to retire early.

English people who can afford private care and private healthcare insurance to avoid the NHS are switching to private insurance even though they have to pay $3,500 for each man, woman and child in a family into the NHS.

Physician shortages are the result of inadequate funding. The cost of the NHS with all these restrictions are unsustainable.

The single party payer system (NHS) is struggling with unsustainable costs even though we hear from progressives how great socialized medicine is in England.

The key ingredient missing in all these systems is patient responsibility for their health and their healthcare dollars. Both are powerful motivators for healthy living and detecting disease early.

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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.      

On November 11, 2007, I published the following blog: “Incentives and Mechanism Design.” The authors Leoid Hurwicz, Roger Meyerson and Eric Maskin were awarded the Nobel Prize in Economics for the concept in 2007.

 I suspect few politicians know about Mechanism Design in 2019. I am certain Bernie Sanders and the “Medicare for All” crowd do not know anything about Mechanical Design.

In my last blog, I described how politicians and the mainstream media use Confirmation Bias to try to put the government in control of healthcare against the will and welfare of the public.  

I think Donald Trump either studied the use of Mechanism Design and its mechanics or he intuitively uses its principles in his thinking.

Mechanism Design is a concept that tries to put science into social science. It mathematically evaluates vested interests of stakeholders in order to eliminate confirmation bias and line up all the stakeholders’ vested interests for the greatest good. It assumes all the stakeholders have expressed their vested interests truthfully.

The Democrats want to hold onto (fix) Obamacare. However, the Democrats understand Obamacare is not viable in its present form. I believe “Medicare for All” with central government control of healthcare will be a disaster as it has been in most single party payer systems.

I do not believe Obamacare is fixable. I believe President Obama and the Democrats believed that Obamacare would fail. Then the nation would beg either his public option or Medicare for All.

I think President Obama believes “Medicare for All” and the total government control of healthcare is the ideological solution to the problems in our healthcare system.

His confirmation bias overrules all of the examples of “Medicare for All” failed examples at home (Vermont California and Colorado), as well as Denmark, Sweden, England, and France.  

In 2017, the Republicans with a slim majority in the Senate refused to repeal Obamacare. Whether the Republican failure to repeal Obamacare was because of intramural revenge or ideology is best to question is which system is best for the common good.

If our politicians understood the principles of Mechanism Design and were diligently working for the people who elected them benefit, America would be on the way to “Repairing the Healthcare System.”

Against this backdrop of a hostile Democratic Party, in control of the House of Representatives, Donald Trump and his administration is slowing working its way to “Repairing the Healthcare System” using the principals of Mechanism Design.

In November 2007, pre the Obama administration, I wrote:

Last month the Nobel Prize in economics was awarded to Leoid Hurwicz, Roger Meyerson and Eric Maskin. They were awarded the Nobel Prize for developing the economic theory of “Mechanism Design.” My first reaction was “what is that?”

After some research, I discovered the power of Mechanism Design. It is a brilliant economic theory that could solve many economic problems. Mechanism Design applied to our healthcare system could solve the healthcare systems problems.

What is it? “In economics, mechanism design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested. This is done by setting up a structure in which each player has an incentive to behave as the designer intends. The game is then said to implement the desired outcome. The strength of such a result depends on the solution concept used in the game. It is related to metagame theory, which is the theory of games the play of which consists of developing the rules of another game.

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare. However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers [1], thus significant research in mechanism design involves making trade-offs between these qualities. Other desirable criteria that may be achieved include fairness (minimizing variance between participants’ utilities), maximizing the auction holder’s revenue, and Pareto efficiency. More advanced mechanisms sometimes attempt to resist harmful coalitions of players.”

Lodi Hurwitz contributed to the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design a mechanism in which everyone does best for themselves. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

If everyone’s incentives are aligned, you have a much more efficient economic system. An example is defense contracting. If you agree to pay on a cost-plus basis you have created an incentive for the contractor to be inefficient. If you agree to pay a fixed price you can come close to an efficient price if you have all the truthful information. If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information. If the rules of the game require truthful information you can get close to an efficient market-driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off. Therefore, the incentive is to maintain your dominance by not being truthful at the expense of others. Hurwicz observed as others had that the dispersion of information was at the heart of the failure of a planned economy. He observed that there was a lack of incentive for people to share their information with the government truthfully. The free market mechanism was far less afflicted than central planning bureaucracy by such incentive problems. The free market economy was by no means immune to this defect. He observed that the free market economy can get us closer than central planning to incentive compatibility because the end consumer can drive the discovery of truthful information.

The customer creating rules of engagement in a market-driven economy can get you closer to the ideal of Mechanism Design. Since the customer determines success of an enterprise by creating demand in a transparent environment, they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

Roger Meyerson contributed the revelation principle, a mathematical model that simplifies the calculation to create the most efficient rules of the game. The mathematical model gets people to reveal their truthful private information leading to aligned incentives.

Eric Maskin’s breakthrough was in perfecting Mechanism Design with his “implementation theory.” His theory clarifies how to design mechanisms that heighten incentive alignment and efficiency.

How does Mechanism Design relate to the Repair of The Healthcare System? We have to set the rules of the games so that we align all the stakeholders’ incentives without one stakeholder takes advantage of another. The insurance industry is taking advantage of the patients, doctors and hospital systems. The hospital systems are taking advantage of the patients, doctors and insurance companies. Doctors are taking advantage of the insurance companies, hospital systems, patients and the government. The government is taking advantage of the hospital systems, the doctors and the patients. Employers who pay the insurance bills for their employees are taken advantage of by the insurance companies. The drug companies are taking advantage of patients and unduly influencing physicians.

In our healthcare system, everyone is pursuing his vested interest in a game that has rules that do not lead to “incentive compatibility.”

Some politicians think central planning will straighten out the rules. Historically, central planning has not worked. The winners of this year’s Nobel Prize in economics have proven this fact.

I believe consumers can fix the rules of the game so that all the incentives are compatible. Consumers have to have incentives to force politicians to fix the rules of the healthcare game. Consumer-driven healthcare system will achieve the alignment (incentive compatibility) using the ideal medical saving account.

Twelve years have passed since 2007. America has not gotten closer to the solution to Repair the Healthcare System even though the solution is staring us in our eyes.

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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

Nothing is free despite Bernie Sanders and other socialists’ promises. “Medicare for All”is proposed to replace private insurance with government insurance as the single party payer.

The government controls of several parts of our healthcare system. All these parts, Medicare, Medicaid and the VA Healthcare System, are financially unsustainable. All, except Medicare for seniors, are unsatisfying for patients.

Each year the Medicare premiums and deductibles for seniors have been increased, services have decreased and reimbursement to providers have decreased. It is past the point of being unaffordable for many patients although it has been invaluable for sick patients who could not possibly afford the cost of care without Medicare.

In reality the government owns these healthcare services, but it does not run these healthcare services. The administrative services are outsourced to the healthcare insurance industry. The healthcare insurance industry, in turn, has figured out how to game the system and take advantage of the government and citizens involved in the system.

Additionally, the inefficiency of government bureaucracy intensifies waste and cost. The estimated cost of Bernie Sanders’ “Medicare for All” is thirty -trillion dollars of ten years. Many believe thirty-two trillion dollars over ten years is a low number. It is also over 90% of the United States’ total ten- year budget at present spending.  

 Bernie Sanders has released a set of tax hike options in order to get some of the money to pay for his fiasco.

“These tax hikes would hit American families at every income level and businesses large and small. The proposal increases taxes by $16.2 trillion over the next decade, according to an estimate of Americans for Tax Reform.”

This proposal will cover only half of the thirty-two trillion-dollar estimate.

1. A 4% increase in payroll tax to employees.

“According to Sen. Sanders’ estimates, this increases taxes on American families and individuals by $3.9 trillion over ten years.”

1. A new 7% increase in payroll tax for employers.

This tax will hinder business growth. It will decrease employment because it will decrease business spending on employees. It will also increase government spending for entitlements. This tax increase will only provide an estimated 3.5 trillion dollars over 10 years. It will probably result in less than 3.5 trillion because there will be less payroll tax to collect.

Please note Bernie’s numbers between employee and employer payroll taxes do not add up. It is pure fiction.

1. The proposal would ban employer-provided healthcare insurance and repeal the employer deductions for health care insurance. The net result will be increasing taxes on businesses by over $3 trillion over a decade.

     This adds up to an additional 3 trillion-dollar cost to business not necessarily a three trillion-dollar savings.

1. Bernie Sanders’ proposal would also repeal Health Savings Accounts, which are utilized by an estimated 25 million American families. Health Savings Accounts are a good deal for middle class families earning between $60,000 to $200,000 a year. Health Savings Accounts would even be more attractive if they were changed to Medical Savings Accounts.  

At present roughly half of the Health Savings Accounts are owned by middle class families.

A key element in a successful reform of the healthcare system is to provide health and financial incentives to citizens. Citizens must become responsible for their health and healthcare dollar in order for healthcare reform to succeed.

Bernie’s plan helps people be less responsible for themselves and more dependent on the government.

Isn’t this exactly what the socialists want? Historically socialism always fails.

1. The tax deduction for cafeteria plans and the medical expense deduction is also eliminated.
2. Eliminating Health Tax “Expenditures”

n all, Sanders estimates this will increase taxes on families and businesses by $4.2 trillion.

1. 70 percent Top Tax Bracket for Ordinary Income and Capital Gains Income

This would give America the highest income tax rate in the world.

“ According to the Tax Foundation, a top 70 percent rate for ordinary income and capital gains income above $10 million will raise $51.4 billion over a decade. After accounting for macroeconomic effects, the proposal would actually cost the government $63.5 billion because of the proposal suppresses investment and economic growth.” In reality the income and negative effect to the government are a small number and insignificant to paying for the cost of “Medicare for All.”

1. 77 Percent Death Tax

“Sanders proposes raising the death tax rate to 77 percent for inheritances.  

     Currently, the death tax applies to estates over $11 million or 22 million per couple. Over 22 million dollars is taxed at a rate of 40%.

      The death tax is, in reality, a double tax. People have paid tax on the money they have saved already. At the time of death, the government taxes them again on post-tax dollars. The tax should really be called a confiscation tax.

      Bernie Sander’s death tax proposal will increase taxes by $2.2 trillion over ten years. This is an insignificant amount compared to what “Medicare for All” will cost.

1. Wealth Tax
   “Bernie Sanders proposes an annual wealth tax of 1 percent kicking in above $21 million in assets. Sanders estimates the proposal will increase taxes by $1.3 trillion over ten years.”

      10. Bank Tax

         “ Sanders proposes a tax on financial institutions totaling $800 billion over ten years.”

      11.Broaden the Self Employment Tax
Sanders would require business owners to report more of their business income as salary, increasing the amount of self-employment tax owed. This would increase taxes by $247 billion over ten years.

The total increase in taxes would only result in a $16.5 trillion-dollar payment on a thirty-two trillion-dollar bill. Where will Bernie get the rest of the money? He probably figures the government could print the other $16 trillion dollars. If it does it will decrease the value of the tax increases and an overall cost will be higher than 32 trillion dollars.

There is something seriously wrong with socialistic thinking. I do not believe the majority of American will fall for this serious defect in thinking.

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



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