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All items for April, 2014


President Obama Tries To Shut Up Media

Stanley Feld M.D.,FACP,MACE

On April 16th President Obama tried to shut up the media’s criticism of Obamacare with his announcement that 8 million people have enrolled in Obamacare. The administrations had reached its goal. Obamacare is a success

Mr. Obama pointed to the number to declare the law a success and that Republicans should stop trying to overturn it.

"The point is, the repeal debate is and should be over," the president said. "The Affordable Care Act is working and I know the American people don't want us spending the next 2½ years refighting the settled political battles of the last five years."

One month earlier we heard from the same administration that the 6.6 million people who had lost their healthcare insurance because of Obamacare was an insignificant sliver of the population.

President Obama’s announcement contained few new details about enrollment. 

The entire point of Obamacare was supposed to be to insure people who were uninsured previously.

It turns out (from insurance company data) that as many as 80% of the 8 million enrollees were replacing extremely expensive healthcare insurance policies with Obamacare healthcare policies.

Individual healthcare insurance for older people with a pre-existing disease is unobtainable or extremely expensive.

These people were in the individual healthcare market only. Many had pre-existing diseases and chronic diseases.

Their risk is much higher than low risk patients. Many of these people received government subsidies because they made less than $50,000 dollars a year.

The administration has still not published the number of people who did not have insurance before Obamacare went into effect and have signed up and paid their premium.

President Obama claims he does not know that number. If the healthcare insurance companies know the exact number the Obama administration has to know that number.

President Obama’s declaration of success is ludicrous.

Patients who enrolled and paid their premium are going to realize the negative impact it will have on their medical care shortly.

There is no class of American professionals who will be more negatively impacted by Obamacare than physicians.

Obamacare reinforces the worst features of third-party payment arrangements for payment of medical care. The third party payment system of healthcare insurance has already compromised the independence and integrity of the medical profession.

With Obamacare physicians will be subject to more government regulation and oversight, and will be increasingly dependent on unreliable government reimbursement for medical services. “

These are some of the difficulties physicians will face with Obamacare.

 The Medicare Payment Formula is flawed. Physicians continue to face the threat of deep payment cuts under Medicare’s sustainable growth rate (SGR) formula.

The SGR governs the annual growth of Medicare physician payments. Congress has kicked the can down the road since 2003. Physicians have incurred a potential reduction of 30% from the present payments if congress does not provide a permanent fix.

Medicaid will be expanded in states that agree to do so to cover any individual earning up to 138 percent of the federal poverty level—$15,856 for an individual in 2013. Many states have refused to expand Medicaid.

The Congressional Budget Office (CBO) projects that this expansion will add 12 million individuals to Medicaid by 2015.

The physician reimbursement rates for Medicaid patients is 58% lower than the reimbursement physicians receive in the private sector.

 Thirty three percent of physicians do not participate in Medicaid. Patients’ access to physicians is decreased. The result is Emergency room overcrowding. ER overcrowding was the very thing the President Obama’s healthcare policy wizards wanted to decrease.

Obamacare is imposing more bureaucracy, rules, regulations, and restrictions on physicians.

Since 2010, with few exceptions, the law prohibited physicians from referring Medicare patients to hospitals in which they have ownership.

  1. Thus, a whole class of physician-owned, specialty hospitals has been removed from competition, even though they enjoyed an undisputed record of providing high-quality patient care.
  2. This regulation has driven a large number of physicians to stop accepting Medicare even thought their service is of high quality and less expensive than hospital systems.
  3. There have been mountains of new regulations that are impossible to keep up with. These regulations have driven physicians away from accepting Medicare reimbursement.
  4. Obamacare has created multiple federal agencies, boards and commissions to regulate the practice of medicine.
  5. These creations are partly the fault of physician groups not effectively regulating their peers.

               a. Obamacare created a “nonprofit” Patient-Centered Outcomes Research Institute.  The institute will determine clinical effectiveness of medical treatments, procedures, drugs, and medical devices.

The result will be an administrative implementation nightmare. All medicine is local. Only financial incentive can work. Penalties and regulatory requirements will not work. It will simply generate an atmosphere of mistrust and non-cooperation.

The Patient-Centered Outcomes Research Institute could be a teaching tool for physicians and patients.

However, the likelihood of the government dictating cookbook care guidelines and regulations, and interfering with physicians’ clinical judgment and the further destruction of the patient-physician relationship is high. The Institute will also retard clinical innovation in the delivery of care.

              b. President Obama’s Independent Payment Advisory Board (IPAB) is comprised of 15 unelected bureaucrats. It will be composed of non-practicing physicians, lawyer, laypersons and government bureaucrat.

The goal is to reduce the growth rate of Medicare spending and non-federal spending through health insurance exchanges.

 “IPAB’s recommendations would go into effect unless Congress enacts an alternative proposal of equivalent savings.”

The chance of congress presenting an alternative equivalent saving is small. President Obama has stated in the past that the IPAB has little power except to make recommendations. This is not true!

Former Vermont Democratic Governor Howard Dean (D) has said, 

"IPABs are essentially a health-care rationing body. By setting doctor reimbursement rates for Medicare and determining which procedures and drugs will be covered and at what price, the IPAB will be able to stop certain treatments its members do not favor by simply setting rates to levels where no doctor or hospital will perform them."

This is the only thing that Dr. Dean has ever said that I have ever been able to agree with.

The IPAB will control spending through reimbursement cuts. It can enable limited or no payment for selected services and medical procedures or for Medicare physician payment.

It looks as if it could drive physicians out of practice and hospital out of business. This is especially true in the absence of tort reform.

              c. Pay-for-performance programs are another terrible idea. Physicians can only control some of the outcomes. Patients’ compliance/adherence is the key to most outcomes.

Payment will be adjusted to reflect performance. The measurement will be based on data from the Physician Quality Reporting System and cost data from Medicare fee-for-service claims.

I have previously demonstrated the ineffectiveness of using claims data to make outcomes decisions.

These programs can be used to create powerful economic incentive by complying with standardized guidelines at the expense of individual patient care.

All you have to do is “check the box” to achieve a high and financially beneficial score as a condition of participating in the government’s health programs.

It is aa attempt created by bureaucrats that will not work in the real world.

Most physicians hate Obamacare. Forty-three percent of physicians are considering retiring in the face of the need for an additional 91,500 physicians by 2020.

“Obamacare neglects physicians’ most pressing concerns, such as tort reform, and significantly worsens the already painful problems that come with third-party payment and government red tape.”

Obamacare misses all the keys necessary for Repairing the Healthcare System. Obamacare steers out of the skid (wrong direction). It makes things worse.

Consumers must drive the healthcare system. The physician/patient relationship must be restored. Physicians must help patients make treatment decisions not government, insurance executives and other bureaucrats.

Repairing the Healthcare System will not be achieved until patients, not the government, control their health care dollars and decisions at the advice of their physicians in a viable physician patient relationship.

My Ideal Medial Savings accounts steer into the skid and repairs the healthcare system.

The Obamacare debate is hardly over as President Obama has declared.


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

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Different Views Of The Elephant

 Stanley Feld M.D.,FACP,MACE

There are many different ways of looking at a large elephant.  The cost of the healthcare system is similar to the large elephant in the room.

There are so many ways one could look at healthcare costs. A person can become crazy trying to solve the ever increasing cost through the prism of one’s  view.

The information available can be dizzying.  There are so many ways of looking at the problem. Much of the information is untrue or incomplete.

I have provided examples previously in which patients tried to find out fees from hospital systems for certain procedures. The fees have been totally opaque. Hospital systems should not be allowed to withhold fee information.

Price transparency is important because it has the potential to set up a system of competition.

The healthcare insurance companies could be a good source of this information because they are billed by the hospital systems. 

The big data they publish is essentially worthless because they pay only the contracted price the hospitals and physicians negotiate with each insurance company.

A few weeks ago an article in the Wall Street Journal published the billings from different hospital systems for certain diseases in the same location.

Hospital prices

Prices for the same diseases are differ all over the place in hospitals close to each other in California.

However these retail prices are meaningless. This is not price transparency.

The hospital is only going to receive the contracted price from that particular insurance company.

The variation in “retail price” only reflects a variation of service that hospital system performed in each particular disease category.

How much of that service needed to be done for the hospitals population is an important question. The comparison is not necessarily apples to apples.

What was the hopital system’s actual cost for that services?

How did they arrive at its billing?

How much is waste and bloated administration costs and how much is actual medical care?

How did that hospital system calculate the profit for that service?

If this was real price transparency we should be told how much the hospital system paid was for that actual service.

The WSJ article states “It's a simple idea, but a radical one. Let people know in advance how much health care will cost them—and whether they can find a better deal somewhere else.”

This is almost as foolish a question as the chart of the varying hospital prices for various diseases.

If consumers have sudden onset of chest pain they need medical care immediately. The consumer does not have the luxury of shopping for the best price in the area. Those consumers need to be treated at the closest hospital.

Medical bills are outrageous. They are also incomprehensible. In many cases the negotiated reimbursement varies within various healthcare insurance companies.

Hospital systems submit these high prices simply to get the most money from the various negotiated reimbursement deals they have accepted. They do not individualize the prices negotiated with each insurance company because their computer systems can’t handle it.

Physicians do the same thing. They accept the negotiated price for reimbursement by the various insurance companies even though their retail prices are higher.

Occasionally they bill an uninsured consumer. Then the hospital system and physician can collect their retail fee from an uninsured consumer. There is seldom any negotiating to benefit the consumer.

This is absurd but true.

Unlike other industries, prices for health care can vary dramatically depending on who's paying. The list prices for hospital stays and doctor visits are often just opening bids that insurers negotiate down.”

“ The deals insurers and providers strike are often proprietary, making comparisons difficult. Even doctors are generally clueless about what the tests, drugs and specialists they recommend will cost patients.”

The primary stakeholders in the healthcare system are consumers and their physicians. If consumers and physicians cannot get the prices of the services they are about to use they should demand them or use another vendor.

The declaration of proprietary prices sounds very official and mysterious.

Price transparency is common in most industries. Price transparency stimulates competition with lower cost and better quality.

Price transparency is rare in health care. The  "charges," "prices," "rates" and "payments" are all opaque. They bear little relation to actual costs.

It is essential that consumers drive the requirement of providers to publish their prices in order to get customers. The government has no interest in doing it.

If consumers were spending their own money, most consumers would demand price transparency.

If a third party is paying the bill for healthcare, consumers would have no interest in the price of care or controlling the price of care.

Last year, 38% of Americans with employer-sponsored insurance had a deductible of $1,000 or more—up from 10% in 2006, according to the Kaiser Family Foundation.”

Obamacare is expanding the services required for insurance policies. The services include unnecessary coverage for a lot of potential participants. Both health insurance premiums and private insurance require coverage of unnecessary services. President Obama is also taxing the insurance companies for every insurance policy they sell.

These additional costs are passed on to consumers without consumers’ knowledge in this price opaque world of healthcare.

Premium prices are skyrocketing; deductibles and copays are also increasing.

Obamacare mandates people to buy these healthcare insurance policies.

At the same time the silver and bronze plans created by the Obamacare (Affordable Care Act) carry average family deductibles of $6,000 and $10,386 respectively as opposed to $1,000 pre Obamacare.

More than half of bronze plans also require patients to pay 30% of doctors' fees, according to health-information site

Obamacare and all its regulations are not so affordable to anyone making over $50,000.

Everyone earning under $50,000 receives a subsidy from the government. Over 50% of the people earn under $50,000 dollars. These consumers do not have incentive to shop for cheaper medical care.

People making over $50,000 are trapped. The middle classes’ discretionary income is being reduced by the very program President Obama  (Obamacare) promised to protect.

My ideal Medical Savings Account solves all of these problems.

President Obama doesn’t want a solution to the healthcare system. He wants control of the healthcare system. He wants the government to be in control of the entire system.

Only then can he tell consumers what medical care they can and cannot have.

When the present Obamacare system implodes people will beg the government (payer of last resort) to bail them out even at the price of freedom and independence.

The next step will be to control all of the freedoms that Americans have left.


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

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The Wrong View Of The Right Problem

Stanley Feld M.D.,FACP, MACE

Most of the stakeholders in the healthcare industry are not stupid. Most understand the issues very well.

The problem is they all look at the same problem from the prism of their own vested interest. Each government action causes these stakeholders to react in their vested interest.

Each reaction causes a compensatory reaction from the other stakeholders, which in turn causes another chain of reactions.

The healthcare system becomes further twisted into a tighter non-functioning hairball that is more expensive than previously.

Aetna CEO Mark Bertolini was the keynote speaker at HIMSS14. His analysis was correct He said,

“Antiquated systems and out-of-control healthcare costs in the United States are not sustainable.”

He went on to say the healthcare system is plagued by inefficiency and waste.

“ We can’t afford it. It’s unsustainable.”

Employees are now paying 41 percent of their healthcare dollars to the healthcare insurance industry. It includes premium costs, deductibles, and copays.

These costs consume much of employees’ disposable income.  Mark Bertolini predicts that employees will be paying 50% in 5 years as insurance premiums increase.

Mark Bertolini is really saying consumers will stop buying insurance soon. The result will be a decrease in Aetna’s profit.

Who is at fault?

All the stakeholders are at fault. Consumers are at fault for not taking care of themselves. The incidence of the onset of all chronic diseases increases with the incidence of obesity.

When there is an increase in chronic disease there is an increase in the complications of chronic diseases.

Eighty percent of the money spent on treating that chronic disease is spent on treating the complications of that chronic disease.

Patients must manage their chronic diseases under their physicians’ direction. The patient lives with that disease 24/7.

Patients must be taught to be the “Professor of Their Disease” so that they do not get a complication of that disease.

Patients must also be given financial incentives to become the manager of their disease. This incentive can be developed in many ways.

Reimbursement for education is not routine. There is little financial incentive for physicians to set up educational systems.

Hospitals at one time set up educational systems for chronic disease. They found them a financial burden and discontinued them.  The educational systems did not distinguish one hospital from another.

The educational systems were not set up correctly. They should have been set up as an extension of the patient’s physician’s care.

I believe the healthcare insurance industry really wants to lower costs while retaining the profit margins enjoyed in the pre and post Obamacare era.

Aetna’s Bertolini got it right. “We can’t afford it.”

“If we really want to take care of people, we should align incentives around keeping them healthy.”

He is right. His problem is he thinks he controls patients and patient care.

The government thinks it controls patients.

Physicians know they do not control their patients’ behavior.

Neither the healthcare industry and government nor physicians controls patients.

Patients control themselves.

Bertolini said. "Recent data compiled by Aetna found that the top 5 percent of Medicare patients consumed 43 percent of Medicare dollars. They spent on average $108,000 a year per person."

The demographics of these patients disease including past and present lifestyle are not discussed in the data mining survey. This information would be helpful to know the true meaning of this data.

He then concludes, “Let’s not keep sending these people around with 25 different prescription and all these different doctors and hospitals.

Who is the stakeholder sending patients to all the different hospitals and giving all the different prescriptions.

Physicians, of course!

Therefore, let us penalize physicians for spending all this money on our patients.

This is the wrong way to look at the problem.

If there was meaningful Tort Reform, physicians wouldn’t be doing so much unnecessary testing and treating to avoid missing something that could result in a malpractice suit.

If there were meaningful incentives for patients to be responsible for themselves people would stay healthy.

Patients should be responsible for their healthcare dollars not the government or the insurance industry.

People should also be rewarded if they stay healthy just as the auto insurance industry rewards drivers who do not have an accident.

If the government made a meaningful effort to change our eating habits through meaningful education much illness and medical costs would be reduced.

The center of the new healthcare system should be the patients. It should be a consumer driven system.

As soon as all the secondary stakeholders focus on that fact and start helping instead of penalizing patients and their physicians, the cost of the healthcare system will come down.

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

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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.

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.


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


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


4. A Red IBM Selectric typewriter.


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.


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?



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.


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."

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

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.

 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.”

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

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.

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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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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