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President Obama’s New Joke

Stanley Feld M.D.,FACP,MACE

President Obama announced Thursday that 8 million people have signed up for health insurance under the Affordable Care Act.

He called the feat a success story that Democrats should "forcefully defend and be proud of" in the face of Republican election-year attacks on the law.

 He told the press the impending failure of Obamacare is no longer a headline story that should be covered.

Obamacare is here to stay.

If anyone believes the information in this press conference, I have a bridge to sell you.

President Obama’s story, at the press conference, mirrors Paul Krugman’s article one week ago. It is the same talking points filled with half-truths and lies. He offers no evidence, statistics or demographics except his word.

His word has been proven to be shaky in the past.

The real story behind Obamacare is the redistribution of wealth. The socialistic idea has continued to crush economic growth in an economy yearning to grow as a result of all the money that has been printed by the Federal Reserve Bank.

In order to gain real insight into Obamacare and its effect on economic growth please watch this video.

    

http://www.liveleak.com/view?i=91d_1386194531

Democratic representatives and senators up for reelection are still running away from President Obama and Obamacare.  They realize that he (President Obama) gave another pep talk without substance.

He also belittled Republicans for being misguided, stupid and devoid of ideas.

This is obviously not true but why should President Obama care.

The media is the message.

The temptation is to answer back one point at a time.

There is no need for that rebuttal because Obamacare’s effect is on individual voters directly now. It is no longer an abstraction. It is not pretty.

Those signed up will have high deductibles and limited access to care. The CEO of Wellpoint predicts that health insurance plan premiums will double next year.

Indivduals are starting to see it and feel Obamacare’s effect on their standard of living. They are angry.

The only people who are happy are the people with a preexisting illness or chronic illness who could not buy healthcare insurance at a reasonable price prior to Obamacare. The healthcare industry did not want the risk.

Now they can buy healthcare through the health insurance exchanges and be subsidized by taxpayers. They will be surprised when their access to care is limited.

The problem America will have is that is going to take a little time and waste a lot of taxpayer dollars to repeal the law.

I believe most Americans have noticed that politicians and the traditional media lie.  They try to manipulate us into believing the lies.

The saying is if you tell a lie enough times it becomes the truth. The addendum to that cliché’ should be until it affects individuals directly. The then stop believing the lies.

Please watch the video. It is funny and sad.

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

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Spring Cleaning

Stanley Feld M.D., FACP,MACE

Last week Cecelia decided it was time to do a little Spring Cleaning. It is true that I had promised her two years ago I would get up in the attic and get rid of the things I do not want.

I was amazed to discover what we have accumulated over a 44 year time period. Some of my friends have told me it is imperative that families move to another house every 10 years to get rid of all the junk you save.

Once you sell the house you have to empty the attic. That’s when you throw away all the junk you accumulated over the ten-year period.

I tried to do just that after we built our house and lived in it for five years. Brad was 11 and Daniel was 7 at that time.

Cecelia and I had custom designed a wonderful contemporary house. It has multiple great spaces and large glass windows in the front and the back. There were not many contemporary houses in Dallas at that time.

Contemporary houses are less rare now.

When we told Brad and Daniel of our plan to sell the house they said this is our house. "You cannot sell it. We have our initials in the driveway!'

"They said we love the neighborhood. We do not want to leave our friends or our schools."

 Actually, I was not unhappy about this reaction. A new house would mean either the stress of building or remodeling a house as well as a higher mortgage. A bigger house would mean we would have to move to a smaller property when the kids left for college and beyond.

My potential destiny would be to move into a condo. Condos were getting popular in Dallas Texas at that time.

So we stayed in “our house “ for the next 39 years. We are still going strong. I have no desire to move into a condo.

I was brought up in an apartment building in the Bronx. I remember the smells of many of our neighbors’ dinners. I remember the sounds of the music they played in their apartments.

A Columbia College classmate went on to become an architect as I went on to become a physician.

At dinner one night we had a discussion about New York City condos.

Cecelia and I were still thinking about settling in New York City.

His impression of condo living was that the condos were homes piled on top of one another.

He zoomed in on condos. He said if you think about them they are similar to shelves at a supermarket piled on top of one another. The people are like cans of food on a shelf.

The analogy has stuck with me since it fit how I felt living and growing up in the apartment in the Bronx.

Many years later one of my Dallas friends asked for my opinion about condo living.

Wrong question.

I did not even think that he had decided to downsize and buy a condo.

I told him about my classmate’s analogy to living as cans on a shelf in a supermarket. He was not pleased with that analogy. He had decided to buy a condo.

He has thrown it up to me at least 100 times over the years. I felt terrible I told him about this analogy. I have never used the analogy since.  

I am still in my house. He did not grow up in an apartment building in the Bronx.

Let me continue with Spring Cleaning.

I am very fond of saving things from the past for historical reasons.

I started Brad on an excellent stamp collection. We had sheets and every end block of stamps issued in 1976 celebrating the 200th anniversary of the founding of the United States.

Brad has no interest in stamps now.

He has kept all the early computers we bought including the original Apple II, the first McIntosh computer and the first Compaq portable computer. He has them in his computer museum. I have about ten more to send him for his collection.

  Apple ii McIntosh Compaq
Apple II                         MacIntosh               Compaq portable (60 pounds

Cecelia and I gave the stamp collection to our granddaughter.

I taught Brad and Daniel how to collect baseball cards in the 1970s. Somewhere in the attic there are five shoeboxes full of 1970 cards that are preserved in mint condition. I will find them some day. They are probably very valuable to card collectors.

I couldn’t believe the things I found wrapped up and stored in the attic.

1. The Royal typewriter I used in college to type papers. It still works even though the ribbon is a little dry.

IMG_2267
 

2. My Zeiss medical school microscope along with the bill of sale. It was $300. Three hundred dollars was a fortune in 1959.  

  MPqd90p25PlRZdWDm6bSScg

3. A Pachinko machine. The family spent many hours playing with it.

  Pachinko

4. A Red IBM Selectric typewriter.

  Unknown-3

5. Almost every suitcase we ever owned.

6. A brass bed set I bought in anticipation of buying a ranch someday. I got them very cheap.

7. Boxes and boxes of checks, check statements and receipts from the 1970’s 1980s and 1990s.

I can go on forever. There were three finds in the attic that were extremely nostalgic.

The first was my appointment scheduling books from 1970,1971 and 1972. I used a Histicount system inclusive of billing and bookkeeping. The scheduling books represented my first three years practicing Clinical Endocrinology exclusively.

Those appointment books represented my building of a Clinical Endocrinology practice.  In the early 1970 there were few physicians in America practicing Clinical Endocrinology exclusively.

At that time over 70% of the nation did not know what a Clinical Endocrinologist was or what he did. Most could not pronounce Endocrinology.

In 1990 the formation of the American Association of Clinical Endocrinologists put Clinical Endocrinology on the medical specialist’s map.  

The appointment book was almost empty when I started in 1970.

At the end of 1972 the appointment book was completely filled.

M5756-1

2. Most of my friends will tell you I am a gadget guy. Mobile telephones intrigued me. I got most all the “hot telephones” and saved them for future historical reasons. What was I thinking?

  Phones_155648

20140413_wires

In recent years I stopped saving the phones. Cecelia convinced me that saving all this obsolete junk was ridiculous. I took this picture of them and their wires. It made me smile. Cecelia will find out how to appropriately dispose of them

3. Prior to the smart book and smart phones I used a date book to tell me where I was suppose to be and when I was suppose to be there. These date books are also going.

2014books_155038
 

There are three take home points to make here.

 1. Always listen to your wife. She knows best.

 2. If they are in the attic you never use them and you forget that you have them.

 3. The attic is less cluttered. The kids are only going to throw everything out when you are gone.

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

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Paul Krugman’s Inappropriate Victory Lap

Stanley Feld M.D.,FACP,MACE

Paul Krugman is one of President Obama’s henchmen. Mr. Krugman also won the Nobel Prize in Economics.

Last week he wrote a victory lap article for Obamacare. He continues to write articles without solid facts and a total disregard for basic economics. He works very hard to freeze and then belittle his opponents and the Republican Party.

“When it comes to health reform, Republicans suffer from delusions of disaster. They know, just know, that the Affordable Care Act is doomed to utter failure, so failure is what they see, never mind the facts on the ground.”

He attempted to freeze Mitch McConnell by ridiculing him.

“Thus, on Tuesday, Mitch McConnell, the Senate minority leader, dismissed the push for pay equity as an attempt to “change the subject from the nightmare of Obamacare.”

Mr. Krugman then pours out his non-facts as irrefutable facts by quoting the Rand survey that was just released in full.

“The same day, the nonpartisan RAND Corporation released a study estimating “a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014.”

The results of the Rand survey were published in the Rand Corps’ blog. The blog itself questions the significance of the 9.3 million numbers of enrollees through the Health Insurance Exchanges as implied in government statements.

Although a total of 3.9 million people enrolled in marketplace plans, only 1.4 million of these individuals were previously uninsured. 

The purpose of Obamacare was to insure the previously uninsured. The Obama administration has not published the actual number of uninsured that have been covered in the initial enrollment period.

The actual number of previously uninsured receiving healthcare insurance from the government’s Health Insurance Exchanges is closer to 895,000 people.

Paul Krugman’s fact that 9.3 million have been insured as a result of Obamacare is not a fact according to the Rand survey.

The headline of the RAND blog was “Survey Estimates Net Gain of 9.3 million American Adults With Health Insurance.”

"Our survey work can't say for certain, which of these shifts are due to the ACA and which are due to other factors, but we can draw some limited conclusions. A more detailed report describing the results summarized below can be found here."

http://www.rand.org/blog/2014/04/survey-estimates-net-gain-of-9-3-million-american-adults.html

Paul Krugman statement is a direct contradiction of the RAND survey’s statement

The RAND Corp, uses the number of uninsured as 40.7 million people in 2013. This could be a low number.

Many have used an estimate of 48 million were uninsured. It means the RAND number has a large margin of error. Estimates Net Gain of 9.3 Million American 

The RAND Corp., also states that 5.2 million lost healthcare insurance coverage in 2013 as a result of dropped healthcare insurance plans.

 It is estimated by many that 6.6 million lost their healthcare plans because the plans did not comply with Obamacare standards.

Let us use the RAND Corp’s numbers to understand the facts of enrollment through Obamacare. The RAND Corp survey labeled these numbers as estimates.

  • "Of the 40.7 million who were uninsured in 2013, 14.5 million gained coverage, but 5.2 million of the insured lost coverage, for a net gain in coverage of approximately 9.3 million.
  • This represents a drop in the share of the population that is uninsured from 20.5 percent to 15.8 percent.
  • The 9.3 million person increase in insurance is driven not only by enrollment in marketplace plans, but also by gains in employer-sponsored insurance (ESI) and Medicaid.
  • Enrollment in ESI increased by 8.2 million."

 Let us assume the 9.3 million estimate of the total increase in number of people insured is correct.

If 8.2 million people received healthcare insurance from employer sponsored healthcare insurance then only 1.1 million received healthcare care insurance from either private insurance plans or Medicaid on Obamacare’s Health Insurance Exchanges.

There is claimed to be an increase in 3.6 million people receiving Medicaid.  Of that 3.6 million increase in Medicaid enrollment, 1.4 million have signed up through a marketplace.

 The remainder gained Medicare coverage through other sources.

This means a net loss of three hundred thousand Americans having private insurance as a result of Obamacare and the Health Insurance Exchanges (1.1 million- 1.4 million = – 300,000)

Mr. Krugman builds on these non-facts and concludes with an undocumented conclusion. He states as a fact;

Obamacare is looking like anything but a nightmare. Let’s start with the good news about reform, which keeps coming in.

 First, there was the amazing come-from-behind surge in enrollments.”

He then criticizes his opponents in an attempt to make those who disagree with him and the Obama administration appear mean spirited and unwise. 

“Then there were a series of surveys — from Gallup, the Urban Institute, and RAND — all suggesting large gains in coverage.

Taken individually, any one of these indicators might be dismissed as an outlier, but taken together they paint an unmistakable picture of major progress."

 “There are indeed some nightmarish things happening on the health care front. For it turns out that there’s a startling ugliness of spirit abroad in modern America — and health reform has brought that ugliness out into the open.”

Paul Krugman attacks the Koch brothers and Mitch McConnell.

It’s worth noting that, so far, not one of the supposed horror stories touted in Koch-backed anti-reform advertisements has stood up to scrutiny, suggesting that real horror stories are rare.”

It is important to note that Mr. Krugman offers no documentation to his quote. There are many honor stories that are documented.

When he attacks Mitch McConnell he offers facts from Talking Points.com. http://talkingpointsmemo.com/livewire/obamacare-cuts-kentucky-uninsured-rate-by-40-percent

The talking point article contradicts the RAND survey numbers.

So, which is right?

It does not matter to Paul Krugman because the Media is the Message. Paul Krugman has gotten his message across in the New York Times.

“At the state level, however, Republican governors and legislators are still in a position to block the act’s expansion of Medicaid, denying health care to millions of vulnerable Americans.”

The concluding message is Republicans are bad. Democrats are good.

 Paul Krugman said the health economist Jonathan Gruber, one of the principal architects of health reform  recently summed it up:

The Medicaid-rejection states “are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.” Indeed.’

It is not true Democrats care for the poor according to Chicago Pastor James Meeks as he throws his support behind the Republican Gubernatorial candidate in Illinois.”

“The Democratic party just assume always that 97 percent of the African-American vote will go to the Democratic party. If that assumption is true, they never have to work for our vote,” Meeks said.

He worries about the gun violence, the poverty and the no-end-in-sight outlook. “Our schools are still broken and getting worse. We’re last in employment or business. Our neighborhoods are deplorable,” says Meeks. “And we still get the same promises from the Democratic party, but we don’t get any deliverable. I think it’s time we should look at another candidate.”

 Poster Meek summed it up saying: “The Democratic party just assume always that 97 percent of the African-American vote will go to the Democratic Party. If that assumption is true, they never have to work for our vote,” Meeks said.

Pastor Meek has 23,000 members in his church.

 The Democratic Party and Mr. Krugman’s methods of operation are to accuse, confuse and then conclude.

Obamacare is spending money like a drunken sailor. Obamacare has an outlandish bureaucracy that has produced little benefit. As this new entitlement grows it will bankrupt the country.

It is best for Democrats to blame the bankruptcy on the Republicans’ resistance.

Paul Krugman is an economist. He should heed the lessons of Economics 101. 

Mr. Krugman please watch this You Tube.

 

 

http://www.liveleak.com/view?i=91d_1386194531

 The pity of it all is Paul Krugman is spinning the Story Of Obamacare away from reality.

Fewer and fewer Americans are buying into Obamacare as they see how it is affecting them in daily life through increased taxes and false rhetoric.

Obamacare is not an abstraction anymore. It is an ugly reality for those affected.

There is a much better way to provide healthcare coverage for all.

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

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Another Trap From Ezekiel Emanuel and President Obama

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

 

 

http://youtu.be/-522hcm3woA

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

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

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

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

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

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

All the stakeholders are confused about Obamacare at this point.

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

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

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

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

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

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

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

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

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

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

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

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

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

“Dr. Emanuel thinks is fine.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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April Fools Day

Stanley Feld M.D.,FACP, MACE

On Tuesday April 1,2014 President Obama did a victory lap for Obamacare. April 1st is April Fools Day.

He stopped calling it the Affordable Care Act and once again called it “Obamacare”.

He announced that 7.1 million American have signed up for Obamacare on the Health Insurance Exchange web site healthcare.gov.

Since October the Obama administration has avoided providing the number of enrollees in Obamacare and its demographic makeup. The administration claimed they did not have the exact numbers.

The public viewed this as the administration’s avoidance of the number of enrollees who have purchased insurance because the numbers were so pitiful.

On April Fools Day one day after enrollment ended, President Obama announced the exact number that has signed up to the exact decimal point. It was 7.1 million.

Is that not strange?

I am publishing President Obama’s entire press conference. It is a must watch.

His words and body language is a site to behold. The audience's body language in also very telling.

   

 http://youtu.be/hmONeJ_j8EU

President Obama is extremely charming. The speech is littered with half-truths, misinformation and lies.

He calls all his critics liars just as Harry Reid did. The president doesn’t point out where they have lied just as Harry Reid did not.

This is a Saul Alinsky tactic.

He is so charming in his delivery that the audience wants to believe him despite the dysinformation.

He even threated the media. He warned them not to headline news of these glitches and problems just because there are some glitches and bad events ahead with Obamacare.

The most transparent half-truth was when he said “we haven’t seen any death panels yet as our opponents predicted.”

He right correct. He postponed initiating his “death panels”, the Independent Physicians Advisory Board (IPAB) himself until after the November 2014 elections.

His message is the Republicans are liars. The Democrats in vulnerable states can run on Obamacare because Obamacare is great for the people. He gave three examples to prove his point. Beware of the man with three cases.

He did not discuss the Congressional Budget Office’s view of Obamacare’s effect on the economy.

In Appendix C of the rather dense document, the CBO concludes that various provisions of Obamacare will “reduce the total number of hours worked,”  “will cause a reduction…in aggregate labor compensation,” and most dramatically will result in “a decline in the number of full-time equivalent workers of about 2.0 million in 2017, rising to about 2.5 million in 2024” as compared to employment growth in the absence of the Affordable Care Act.

The Obama administration called the CBO report a lie. It measured the wrong things.

The main cause of this trend is the work-discouraging combination of taxes and subsidies for lower-income Americans in Obamacare. In other words, the implied tax and subsidy penalties for success are so high that it won’t be worth a lower-income person’s effort to try to climb up the income ladder.

There goes the American dream. A dream that has driven America to the success it has achieved.

And while the CBO does suggest that demand for labor will not decline substantially due to the costs imposed by Obamacare, they do say that costs “will be borne primarily by workers in the form of reduced wages or other compensation.” So even the White House’s good news is bad news for working Americans.

Here is what he failed to discuss.

How many of those who signed up have actually paid the premium and purchased the healthcare insurance?

How many of those 7.1 million included the 6.6 million who lost insurance because of Obamacare?

How many were young adults signed up?

How many of the young and uninsured enrolled and paid their first premium?

How many of the older adults signing up had preexisting illness?

What is going to happen to the additional millions who are going to lose their healthcare insurance when their work hours are reduced below 30 hours per week?

How will they afford Obamacare insurance?

How will the McDonald waiver insurance workers afford insurance when the waivers expire?

What will happen to unions when the workers realize they are losing $5 dollar an hour in pay because of Obamacare? 

If 7.1 billion people now have healthcare insurance what does it cover?

The are hundreds of examples of cancer patients losing their doctors, buying health insurance care insurance and discovering that their cancer therapy is not covered?

How many of the previously 48 million uninsured now have become insured?

The entire idea of Obamacare is to insure the uninsured.

The Rand Corporation has completed a secretive survey for the Obama administration. The goal was to estimate how many uninsured received healthcare insurance.

Numbers from a RAND Corporation study that has been kept under wraps suggest that barely 858,000 previously uninsured Americans – nowhere near 7.1 million – have paid for new policies and joined the ranks of the insured by Monday night March 31,2014.

Isn’t the price America has paid so far for overturning, uprooting, and revolutionizing 18% of the economy and the medical care ecosystem staggering for only insuring 875,000 of the previously uninsured.

Someone should add up the cost in newly levied taxes, the effect on middle class income and standard of living, the cost of the massive bureaucracy, and the cost regulations as well as the cost of economic growth that Obamacare has had on the American economy.

The bizarre thing is Obamacare does not solve the issue of the dysfunction in the healthcare system. The ever increasing price of healthcare is the result of the misalignment of all the stakeholders' incentives.

The misalignment has increased with Obamacare.

A new business plan that aligns all the stakeholders incentives which is focused on consumers must be developed.

Obamacare does not bend the cost curve no matter how President Obama has lies about it.

President Obama has had no interest in the cost of Obamacare to America. His goal is complete central control over the healthcare system.

His April Fools Day press conference is no joke!

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

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Risk

Stanley Feld M.D.,FACP,MACE

The purpose of insurance is to cover risk. For many years the government has protected the healthcare insurance industry’s profit through laws and administrative regulations.

The state insurance regulators are supposed to protect consumers again abuses by the healthcare insurance companies. Many State Boards of Insurance have not administered their responsibility effectively.   

The federal government put out for bid the administration of the federal programs such as Medicare, Medicaid and the VA systems. It has not done this job very effectively. There has been much fraud and abuse in this system.

Somehow the healthcare insurance industry has talked these regulators into permitting the insurance industry to take 40% of the healthcare premiums off the top.

Obamacare mandated a Medical Loss ratio of 80/20. Eighty percent of the premium dollars are to be spent on direct patient care and 20% can be held back for expenses and profit.

However, the regulatory agencies have permitted an additional 20% of expenses to be written off as direct patient care.

The details of these expenses are so complex that few can understand the direct patient care expenses.

Recently, we have heard that if the insurance demographic mix is inappropriate, provisions are written into Obamacare that permit the healthcare insurance industry to achieve a profit.

If it does not reach its profit goal, Obamacare will bail out the healthcare industry. The traditional media has not paid much attention to this provision.

High deductible healthcare plans are very attractive to people who are at low risk for disease. If an unforeseen illness occurs they could buy an inexpensive first dollar coverage plan.

Obamacare is slowly eliminating those plans.

President Obama is trying to drive everyone into a health insurance exchange plan in the name of creating competition among insurance companies. His administration is also picking preferred insurance companies to sell these plans state by state.

President Obama is also choosing hospitals to participate in the state insurance plans’ networks. In some states the insurance company choices are thin to nonexistent. An example is New Hampshire with one healthcare insurance vendor. The same state has eliminated two thirds of hospitals and physicians eligible to participate in the health insurance exchanges.

Some of the best hospitals and clinics are not participating in the exchanges. In some cases reimbursement is too low.

Obamacare’s excuse is this will eliminate the facilities that overcharge and eliminate the risk of cost overruns.

All this keeps the healthcare insurance industry in charge of the risk. In order to reduce costs patients have to be motivated to avoid illness and be responsible for their own health and healthcare dollars.

This concept is not embodied in Obamacare. The government and the healthcare insurance industry will make the healthcare decisions for consumers. 

Another big idea included in Obamacare is the concept of shifting risk from the government and the healthcare insurance industry to physicians and consumers.

Accountable Care Organizations (ACOs) are supposed to be set up to integrate care. If an organization does better than average or better than the year before it gets to share the cost savings with the government. If it does worse it receives less money.

If it improves one year there is little room for improvement the next year. Its share will be less. It is self-defeating motivation.

A major problem is physicians can only control certain risks. Many risks depend on patients’ ability or willingness to adhere to the care recommended. Eighty percent of the healthcare dollars for any chronic disease is spent on treating the complications of the chronic diseases.

There are no provisions for risk weighting payments to physicians for disease complications resulting from patients’ lack of adherence to treatment. The more complications of a chronic disease patients have the greater the risk of higher costs that cannot be controlled.

Severe complications and decreased adherence increases the risk of higher medical costs.

ACO’s bundle payments for disease entities. One size does not fix all.

ICM-10 increases the number of diagnostic and treatment codes from 18,00 to 68,000 codes. This increases the complexity of coding. It is an opening for fraudulent coding. It also can result in the possibility of over or under coding as well as miscoding.  It will take years to learn and years to get right.

If physicians miscode those physicians will not get paid by the government or the insurance industry.

This brings us to the next barrier to the success of Obamacare. There is a constant threat of penalty to consumers and physicians. There should be a constant incentive to receive a monetary reward.

Consumers have higher deductible and higher premiums with Obamacare. Many middle class people cannot afford the higher premiums and higher deductibles. The government subsidizes the healthcare insurance for the poor.

The funding for these subsidies is unclear. It will probably result in yet another tax increase for the middle class. The poor are exempt from income tax payments.

Is this redistribution of wealth?

There are no incentives for anyone to stay healthy and avoid unnecessary and expensive physician visits and diagnostic testing.

There is no tort reform in Obamacare. The lack of tort reform increases the need for excess testing in order to avoid lawsuits for physicians not doing a complete workup.

Physicians and hospital systems have never figured out how to calculate Health Maintenance Organizations’ reimbursement. Physicians and hospitals lost a great deal of money trying to price HMOs bundled payments.

Physicians and hospital systems know less about pricing bundled payments for ACOs. They have no control over consumer usage even though they are being asked to cover the risk. They are hesitant to assume risk.

This is part of the reason ACO participation has been so poor as I pointed out in my last blog.

 It is Insurance coverage (public or private) that should cover and assume the risk. This is the definition of insurance. It is not in the physicians power to control risk nor should it be his responsibility.

It is the responsibility of the State Insurance Boards to price that risk for the healthcare insurance industry wisely. These boards should provide a wide range of products to fit consumers needs. The consumer should have the freedom to choose.

Federal and State officials should not accept the insurance industry’s word.

It is unacceptable.    

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

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Bigger Problems Ahead For Obamacare

Stanley Feld M.D.,FACP, MACE

Accountable Care Organization are supposed to be the organizations that reduce Obamacare’s healthcare costs.

Accountable Care Organizations (ACOs) were supposed to be operational in 2012 throughout the United States.

ACOs are supposed to provide financial incentives to health care organizations in order to reduce costs and improve quality of medical care. There are too many defects in the ACOs’ infrastructure to improve the financial and medical outcomes.

At a conceptual level, the incentive for ACOs is to increase efficiency and avoid overuse and duplication of services, resources, and facilities. In this model, ACO members (physicians and hospital systems) would share the savings resulting from the coordination and integration of care.

Accountable Care Organizations (ACOs) are not designed to decrease the waste in the healthcare system.

Waste occurs because of:

1. Excessive administrative service expenses by the healthcare insurance industry that provides administrative services for private insurance and Medicare and Medicaid. A committee is writing the final regulations covering Medical Loss ratios for President Obama’s healthcare reform act. The insurance industry regulations are far from curative.

2. The excessive administrative waste in hospitals and hospital systems leading to outrageous nontransparent hospital fees.

3. The lack of patient responsibility in preventing the onset of chronic disease. The obesity epidemic is an example.

4. The lack of patient education to prevent the onset of complications of chronic diseases. Effective systems of chronic disease self- management must be developed.

5.The use of defensive medicine resulting in over testing. Defensive medicine can be reduced by effective malpractice reform.

ACOs are not a market-based system. They do not put patients at the center of their medical care or permit patients to choose their medical care.

The government assigns patients to certain ACOs. The government controls the healthcare dollars and is at the center of patients’ medical care decisions directly and indirectly.

Consumers/patients are the only stakeholders in the healthcare system that can demand that this waste be eliminated. “They with walk will their feet” if given the chance.

Keith Smith M.D. and the Surgery Center of Oklahoma have proven that consumers desire choice and making their own medical care decisions with the Surgery Center’s transparent prices and their light administrative costs.

Patients must control their healthcare dollars and be responsible for their care in order to Repair The Healthcare System.  Consumers/patients will make sure prices become competitive. Patients in control of their healthcare dollars will not allow duplication of services.

In order to truly Repair The Healthcare System a system of incentives for patients and physicians must be created.

 “In theory, ACOs provide financial incentives to health care organizations to reduce costs and improve quality. In reality, given the complexity of the existing system, ACOs will not only fail; they will most likely exacerbate the very problems they set out to fix.”  

ACOs shift the risk of patient care away from the healthcare insurance industry  to physicians and hospital systems.

Most physicians are reluctant to assume accountability for patient outcomes.  Physicians recognize that much of the outcome is directly under the patients’ behavior and adherence to recommended therapy.

ACOs remove the consumer/ patient from being responsible or accountable for their medical care. ACOs undermine any attempt to create a truly accountable healthcare system that can drive down costs.

There are also grave uncertainties and practical issues in distributing savings between the hospital system and physicians. There is a long history of hospital systems taking advantage of physicians’ skills and intellectual property.

Many physicians and hospital systems are concerned about the shifting of risk and the lack of control over this risk.

 “The Mayo Clinic says it will not be part of a critical piece of national health care reform under the government's proposed rules.”

“ The Mayo Clinic announced that the proposed regulations “conflict with the way it runs its Medicare operations.” Mayo treats about 400,000 Medicare patients a year. The bottom line is that Mayo figured out that they would assume too much risk, lose too much money and relinquish too much control over its processes to the federal government.”

ACOs are really HMOs on steroids. There is too much risk that neither physicians nor hospitals can control. Neither consumers or physicians nor hospital system liked HMOs.

 This same sentiment is reflected in statistics released the Leavitt Partners Center for Accountable Care Intelligence. Centers for Medicare and Medicaid Services (CMS) and the Obama administration are spinning these numbers the same way they are spinning the figures for Obamacare enrollment.

Chart 4: Accountable Care Organizations by State; Source: Leavitt Partners Center for Accountable Care Intelligence

Aco by state-Chart-4

 California leads all states with 58 ACOs followed by Florida with 55 and Texas with 44.  ACOs are primarily local organizations, with 538 having facilities in only one state.

 

Chart 5: Accountable Care Organizations by Hospital Referral Region; Source: Leavitt Partners Center for Accountable Care Intelligence

Aco by region-Chart-5

 The number of ACOs, again, is of secondary importance to the number of covered lives.  Nationally, approximately 6 percent of the population is estimated to be enrolled in an ACO.

Chart 6: Estimated Accountable Care Organization Covered Lives by State; Source: Leavitt Partners Center for Accountable Care Intelligence

Aco covered lives-Chart-6

Chart 7: Estimated Accountable Care Organization Covered Lives by Hospital Referral Region; Source: Leavitt Partners Center for Accountable Care Intelligence

Aco covered lives by region-Chart-7

President Obama and his administration must be living in some fantasy world. It does not matter what the Obama administration is saying adoption of ACOs by physician groups and hospital systems is poor.

The call for forming ACOs started in 2010. The government tried to stimulate the formation of ACOs with sizable grants. It has not worked very well.

Many of the formed ACOs are not functioning in a cost effective manner. In ACOs that are sharing cost saving with the government the fighting between the hospital systems and physicians is just beginning.

Patients in ACOs are starting to feel the dysfunction.

The delivery of medical care under Obamacare and the ACOs are in big trouble.

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

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The Next Obamacare Tragedy

Stanley Feld M.D.,FACP, MACE

Late in the afternoon March 25th  the Department of Health and Human Services announced that it is extending the enrollment period for Obamacare to April 15th from March 31st.

“The Obama administration has decided to give extra time to Americans who say that they are unable to enroll in health plans through the federal insurance marketplace by the March 31 deadline.”

Those who are going to apply have enough time to apply in seven days if the website and the navigators are working correctly.

It sounds as if enrollment figures are not good.

“Under the new rules, people will be able to qualify for an extension by checking a blue box on HealthCare.gov to indicate that they tried to enroll before the deadline. This method will rely on an honor system.”

“The government will not try to determine whether the person is telling the truth.”

This is not a very good way to run a business.

The next tragedy in the implementation of Obamacare is providers’ participation in the Affordable Care Act. There is so much uncertainty in the Obamacare that many physicians and physician groups have opted out of participation in Obamacare.

In California, independent insurance brokers who work with both insurance companies and doctor networks estimate that about 70 percent of California's 104,000 licensed doctors are boycotting Covered California, the state health exchange.

Dr. Richard Thorp, president of the California Medical Association said,  “It doesn't surprise me that there's a high rate of nonparticipation,” 

The CMA represents 38,000 of the roughly 104,000 doctors or 20% of the physicians in California. Dr. Thorp said nothing about the California Medical Association doing a study to determine the percentage of physicians who are not participating in Obamacare.

However the Daily Kos ranted about the Washington Examiner story not being true.

“The latest right-wing disinformation campaign, all over the far-right media is that 70 percent of California's doctors are boycotting Obamacare. Is it true? Of course not. Is anything the Washington Examiner, WND, or Breitart publishes true?”

However the Daily Kos did not offer any facts about what is true.

It is a typical Alinsky disinformation tactic. You must freeze your enemy and then criticize and discredit him.

The LA Times reported in December that the state exchange Covered California reported,

In fact, according to Covered California, the only source with verifiable numbers, some 58,000 doctors, or more than 80% of the state's practicing physicians, will be available to enrollees in the exchange's health plans.

First of all, 58,000 physicians are not over 80% of California practicing physicians, if the 58,000 number is true. It is 55.77% of practicing physicians.

“Covered California says that the doctors participating in its exchange plans include 100% of Kaiser Permanente's 14,000 California doctors, 43,000 taking HealthNet patients and 35,000 in Blue Shield's network. (There's probably some overlap between the latter two networks.)”

The twisting of the facts is the method of operation.

On February 7, 2014 the LA Times reported Covered California admitted there are many errors in their physician directory.

“Admitting Covered California gave some consumers bad information, California's health insurance exchange pulled its physician directory for having too many errors.”

It appears that Covered California was not a very good source for the LA Times and Daily Kos to quote. Both media outlets called the Washington Examiner story a right wing lie.

Covered California made the move late Thursday amid growing frustration among both consumers and doctors over inaccurate information about insurance networks in the state marketplace.”

California patients are discovering that their physicians are not participating in Covered California. Some have discovered that they are not covered by healthcare insurance coverage at all because of computer glitches.

The exchange previously yanked its online directory of medical providers in mid-October after acknowledging there were serious problems then with the data. It published an updated list in November.

The updated list at that time still had some serious problems. The list misled consumers into signing up on the exchange. Covered California is bragging about the number of people they have signed up.

California is supposed to be the star of the state exchanges. Yet they had to close down the exchange in February for repairs and updates. The federal government gave the state exchange an additional $155,000 million dollars to fix the exchange. This is not a small amount of money for a “superb exchange”.

Here are some facts from practicing physicians.

In September 2013 insurance companies disclosed that their rates would be pegged to California’s Medicaid plan, called Medi-Cal. This is contrary to the Daily Kos claim that the physician fees are negotiated.

Dr. Theodore M. Mazer, a San Diego ear, nose and throat doctor is quoted as saying, “In other states, Medicare pays doctors $76 for return-office visits. But in California, Medi-Cal's reimbursement is $24,.” “In other states, doctors receive between $500 to $700 to perform a tonsillectomy. In California, they get $160.

It is logical that physicians in California would say no to the state exchange, Covered California. No matter what lies the spin masters use the facts are the facts.

Physicians say, “We need some recognition that we’re doing a service to the community. But we can’t do it for free. And we can’t do it at a loss. No other business would do that,”

 

California physicians have protested that the Covered California's website lists many doctors as participants when they aren't. This is false advertising.

“Some physicians have been put in the network and they were included basically without their permission,” Lisa Folberg said. She is a CMA’s vice president of medical and regulatory Policy.

Donald Waters, executive director of the Alameda-Contra Costa Medical Association said. “They may be listed as actually participating, but not of their own volition”.  

Waters said. He called the exchange's doctors' list a “shell game” because “the vast majority” of his doctors are not participating.

 “This is a dirty little secret that is not really talked about as California promotes Covered California”.

Dr. Sherry Franklin, a pediatric endocrinologist at Rady’s Children’s Hospital, San Diego said, last summer she "got a letter in the mail letting me know if I wanted to participate with Blue Cross through the exchange, which is different from my regular Blue Cross practice, because they are paying les.s

 They did not tell me how much less. You had to agree or disagree. So, of course, I said no."

Covered California expects 85% of the physicians in California to participate. So far they have made these statements to the press but have not published any proof of participation.

 Covered California asks physicians to participate but does not disclose the reimbursement rates they will pay for participation in Obamacare.

Other state exchanges’ are also in trouble. Oregon and Connecticut are the most outstanding.

This is only the beginning of Obamacare’s provider problems. It is too bad that America is afflicted with this albatross at this time. Obamacare is destroying the healthcare system for consumers and physicians.

President Obama will not be able to charm his way out of the failure of Obamacare.

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

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Medical Care Is Serious Business

Stanley Feld M.D., FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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