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The Failure Of The Republican Establishment To Repeal and Replace Obamacare

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The Republican Establishment’s Failure

Stanley Feld M.D.,FACP, MACE

I am coming to the conclusion that the Republican establishment does not want to Repair the Healthcare System.

The Republican establishment has the same goal as the Democratic establishment.

Recently the mainstream media is saying that a single party payer system is looking good.

Neither party has any interest is having consumers control their healthcare dollars. It looks as if both parties want the government to control the consumer’s healthcare dollars.

All the politicians ignore the fact that government control is unaffordable. It also ends up not working.

The best example is the bureaucratic VA Hospital System and its system wide corruption.

A reader wrote:

I have read your last blog post carefully and agree with many of the points put forward but there is a glaring omission.” 

 “How are patients supposed to be responsible for their healthcare dollars when there is absolutely no transparency and no consistency in pricing.”

The lack of transparency is a major defect in our present healthcare system.

Only 20% of consumers use the healthcare system at any one time. Eighty percent of the consumers have not run into the lack of transparency problem in the healthcare system.

Most consumers do not care about transparency because they have first dollar coverage provided by their employer. They think their medical care is free. They believe they have excellent healthcare insurance.

President Obama took care of that notion with Obamacare. The defective structure of Obamacare caused healthcare insurance premiums and deductibles to skyrocket. First dollar healthcare insurance became too expensive for most employers.

Employers stopped providing first dollar coverage. Middle class employees are now noticing that out of pocket expenses have made their healthcare insurance unaffordable. Consumers have tried to compare prices of competitive providers. They have discovered that it is impossible!

Consumers are becoming aware of the lack of transparency. They have been astonished by this lack of transparency.

There is nothing in the new Republican bill that addresses Republican politicians’ awareness that the lack of transparency is a major defect in the healthcare system.

The lack of transparency is only one of the major defects in our healthcare system.

There is nothing in the Republican bill that speaks to the consumers’ responsibility for their health and healthcare dollars. Consumer driven healthcare is completely ignored.

There is nothing in the bill that addresses effective tort reform. The Massachusetts Medical Society survey showed that defensive testing to avoid lawsuits costs the healthcare system between $250 billion to $700 billion dollars a year.

The lack of the development of systems of care for chronic diseases cost another $700 billion dollars a year that our healthcare system does not address. There is nothing in the bill that emphasizes this very important defect in the healthcare system.

The Republican establishment thinks consumers are too stupid to take care of themselves.

The mainstream media likes to tell us that people love entitlements. The public does not want to give up these entitlements.

My question is how come less than 9 million people signed up for Obamacare’s individual healthcare plans last year if they love entitlements?

It is because they cannot afford to buy the health exchange insurance even though 85% of the premiums of those 9 million consumers are subsided by the government. Their high deductibles are not subsidized.

The Republicans are going claim they are promoting health savings accounts. The public is not told the amount of money they can put into a health savings account or whether it will provide first dollar coverage over that amount if they get sick.

There is no financial incentive for consumers to be responsible for their healthcare or their healthcare dollars.

My Ideal Medical Saving Account is a much better idea.

These are only a few of the major defects in the Republican establishment’s concept to fix the healthcare system.

President Obama did some of the awful things to Obamacare through rules and regulations after certain vested interests complained about the law. Obamacare’s rules and regulations have to be eliminated

There were crony waivers that would make one’s blood boil. In fact, elected congressional members got the best exemptions.

It is becoming apparent that congress doesn’t want to fix the healthcare system for the majority of Americans. The congressional establishment wants to control consumers.

Socialism does not work!

Socialsim for blog

Our political establishment does not tell us about the economic result in other countrys’ single party payer universal healthcare systems.

We don’t have to go to other countries. We only have to go to the indigent areas in California were everyone is covered by Medicaid.

The Republican establishment needs to get off the stick before all of them are kicked out of congress.

Just imagine the healthcare systems savings if every consumer were empowered to shop for the best healthcare at the best price.

The result would be a free market healthcare system in which competition would cleanse the system and make it affordable to everyone.

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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Medicaid’s Reimbursement Problems Increase As It Expands

Stanley Feld M.D., FACP,MACE

In order to attract more physician participation in Medicaid the Obama administration increased the level of Medicaid reimbursement to Medicare levels in 2013.

The Obama administration anticipated an increase in Medicaid recipients once Obamacare started in 2014.

In 2012 there was not enough physician participation in Medicaid to service the number of patients enrolled at that time. Appointment wait time was long. Access to care was rationed.

To prepare the primary care workforce for the influx of new Medicaid eligible patients established through the Affordable Care Act (ACA, Obamacare), this provision increases payment rates for certain primary care services to at least the level of Medicare in 2013 and 2014.

 At that time CMS (2012) promised states it would pay 100% of Medicaid reimbursement. Therefore the increase did not threaten individual state budgets because the federal government was paying 100% of the bill until 2015.

Many but not all Primary Care Physicians fell for this Obamacare ploy. Many physicians still did not sign up to accept Medicaid patients.

 “According to a survey conducted by The Physician’s Foundation in 2012, declining reimbursement rates are the most “significant impediment to patient care delivery in today’s practice environment by a large margin.

In 2012 a major administrative service provider for Medicaid said,

 “Enhanced payment rates may induce more physicians to participate in Medicaid. According to a survey conducted by United Healthcare, half of primary care physicians would increase their Medicaid case load if Medicaid payment rates were increased to the level of Medicare pay rates.”

There were long waiting times for appointments and decreased access to care in 2012. The Obama administration figured these issues would be cured with the change in reimbursement.

The new increase Medicaid enrollment figures have been an intentional mystery to the public. 

The Obama administration has provided convoluted enrollment figures to the public. These figures have confused everyone including those who are interested in them. I believe it has even confused the Obama administration itself. The non-transparency has prevented everyone from facing the reality of the Obamacare mess.

This analysis of the numbers must be read carefully. Physicians have been faked out once more.

“In the third quarter 2014 health insurance enrollment data show continuation of two trends during the first and second quarters—increasing Medicaid enrollment and declining enrollment in employer plans.

" However, while individual-market enrollment increased substantially in both the first and second quarters, it declined by 357,000 during the third quarter. The net result was 160,000 fewer Americans with health insurance."

These numbers are nowhere near the numbers the Obama administration reported to the traditional media and in turn to the public.

 All the traditional media did was celebrate President Obama’s victory lap. The public was deceived by the victory lap.

  “For the first nine months of 2014, individual-market enrollment grew by 5.83 million, but 4.93 million individuals lost employer coverage—offsetting 85 percent of the individual-market gain.”


 This was not been made clear by the Obama administration. The uninsured number still remains unclear. This analysis points to Obamacare being a total failure.

 Thus, the net increase in private health insurance for 2014 is so far 893,000 individuals. During the same period, Medicaid enrollment grew by almost 7.49 million. Taken together, the number of Americans with health insurance increased by 8.38 million during the first nine months of 2014, but growth in Medicaid accounted for 89 percent of that gain.

The situation has not gotten better now that the Affordable Care Act's bump in Medicaid pay to Medicare levels has expired.

Just seven states kept the higher rates in place for 2015, while the rest reverted to the previous low rates.

 Medicaid rates in virtually every state are a fraction of what will be paid by Medicare and private insurance companies.

 There are only so many hours in a day. How many physician practices could afford to devote their time to serving its lowest-paying patients?

A 2013 physician survey found 33% of physicians refused to see new Medicaid patients while 17% refused to see new Medicare patients. The obvious reason is Medicare pays better than Medicaid.

 With the expiration of higher primary care physician reimbursement it can be expected there will be less physician participation and decreased access to care for the expanding Medicaid enrollment.

The Obama administration anticipates this problem. It has introduced new regulations that it thinks will solve the problem.

It might, or at least help a little, except for the fact that it is going to cost the government more and help make healthcare insurance companies richer.

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

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Obamacare: Its Failure Increases

Stanley Feld M.D.,FACP,MACE


C-Span has provided the public with important lessons on how our government is really run by televising various congressional committee meetings.

The traditional mainstream media provides us with little of the important information that comes out of these committee meetings.

C-Span’s coverage has revealed how inefficient, political and bureaucratic our government is.

Americans should elect representatives to be our spokesmen. Our representatives should do what is right for us and not for the vested interests of various special interest groups.

The latest information about Obamacare has not been reported in the media but came out in committee.

The Obama administration had announced publicly to a subcommittee in April 2014 that its "risk corridor" plan would be revenue neutral.

In English, it means that there would be no extra taxpayer dollars available to cover the losses of the healthcare insurance companies. Those healthcare insurance companies insure enrollees through the government’s healthcare insurance exchanges.

Chet Burrell, head of Maryland insurer CareFirst told Valarie Jarrett this plan would result in premium increases of 20% or more later this year as Obamacare policies come up for renewal. 

He warned it would be "an unwelcome surprise" to the Democratic Party and Democrats running for reelection in November.

The Obama administration was very concerned about a 20% premium increase for enrollees in Obamacare. After a while, Ms. Jarrett assured Mr. Burrell the insurance industry would get 80% of the subsidy (bailout) they sought.

The 80% was granted by executive order without congressional approval. A few weeks later the healthcare insurance industry bailout was changed to almost 100% of the request with little notice from anyone.

The government guarantee affects all of the enrollees in Obamacare. It also permits the increase in private insurance plans.

There are 50 million people on Medicare, 65 million people on Medicaid, 9 million in the VA system, 7.3 million in Obamacare and an additional 149 million for employer-provided healthcare insurance.

It turns out that Obamacare is just another government subsidy program with the government throwing more money at the health care insurance industry while the healthcare insurance industry raises the premiums.

President Obama, by executive order, has created an unlimited Obamacare reinsurance program covering the healthcare insurance industry’s supposed losses.

According to some, the total subsidy to the healthcare insurance industry is $1.3 trillion dollars.

It’s no surprise that many more healthcare insurance companies are planning to participate in President Obama’s health insurance exchanges.

If a healthcare insurance company sells insurance without risk it is a great deal. Taxpayers are assuming the risk for the insurance companies. Some insurance companies are decreasing their rate to capture a larger market share. They will  cash in on the Obamacare subsidy.

This subsidy is a mistake. It adds little value in improving the nation’s health. President Obama does not seem to care about how much money he is wasting.

It is all about politics. 

The subsidy adds much political value to Obamacare because it postpones the 20% premium increase at this midterm election.

Bob Laszewski, a policy wonk and former insurance executive said,

 “The administration has succeeded in temporarily suppressing incipient Obamacare price hikes, contributing to an illusion of Obamacare sustainability.”

However, the healthcare insurance industry is finding it necessary to increase premiums an additional twenty percent despite the tremendous subsidies. This is the result of the enrollees who acquired insurance but did not pay the premiums and used the services and the terrible demographic distribution of enrollees who paid their premium.  Eighty-five percent of the people who paid premiums were high risk patients with pre-existing illnesses. 

The rules of Obamacare have turned out to be totally improvised. The Obama administration changes the contents of the law in order to keep it afloat without the approval of congress.

The plot thickens. A challenge is in the courts right now on whether the government health insurance exchanges are allowed to provide subsidies to enrollees.

The law specifically states that tax credits are only available through the state health insurance exchanges and not the federal health exchange.

Funny things are going on in the courts. One panel said yes, the subsidies may be provided by the federal health insurance exchanges. The D.C. panel of three judges said no.

Attorney General Holder appealed to the D.C. court of appeals. He wanted the judgment determined by the entire panel of 9 judges not a subpanel of 3 judges.  The 3 judges’ decision was overruled by the 9 judge panel.

I still do not understand how tax credits are given to people who do not earn enough to apply a tax credit to their income tax. Why do they receive a subsidy? They pay no federal income tax.

I hope Americans wake up soon to the fact that Obamacare is deeply flawed and cannot work. The only thing that will overturn it will be an overwhelming taxpayer protest.

This midterm election cycle is a good place for voters to start. A Republican majority of the senate might be able to stop Obamacare in its tracks.   

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

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Keeping Obamacare’s Failures Out Of The News

Stanley Feld M.D.,FACP, MACE

The Obama administration has tried its best to keep Obamacare’s failures away from the people. However, it has been almost as difficult as putting toothpaste back in the tube. The reasons are clear to me.

People are paying attention now because most are personally affected by the failures of Obamacare.

These failures along with President Obama’s other policy failures such as the IRS scandal, Benghazi scandal, Fast and Furious, border control failures, immigration failures, foreign policy failures, NSA privacy intrusions and his lying about those intrusions, attempts at Internet takeover, and unconstitutional unilateral changing of laws through executive orders have lead the American people to lose confidence and trust in whatever President Obama and the Obama administration say.

The traditional mass media has tried mightily to protect President Obama. They have tried to help him keep Obamacare’s failures out of the news.

They have been unsuccessful. If our only source for news was the traditional news media we could be fooled.

Americans must work to stay informed in order to maintain our freedoms.

I will list some of Obamacare’s failures of the last few months.

These failures have had little coverage in the traditional media.  Obamacare has continued to move forward to hobble and then destroy the medical care system in America.

President Obama’s goal is to prove that a free market healthcare system does not work. He has disregarded the fact that the healthcare system is not a free market system.

In a recent blog I presented the reasons for physicians’ discontent with Obamacare.

Survey of Physicians And Their Discontent

In July 2014 the “Physicians Foundation” published a survey sent to 660,000 physicians. Twenty thousand physicians completed the survey.

“Forty-six percent of doctors give President Obama's healthcare law a "D" or an "F," according to a new survey from the Physicians Foundation. In contrast, just 25 percent of those surveyed gave the law an "A" or a "B."

A large number of physicians complained about the vast new bureaucracy that has been added to the medical profession.

A physician comment read, "I'm a Canadian physician practicing in the United States. The politicians and policy makers need to understand that government involvement in healthcare never works."

The only newspaper that reported the survey to my knowledge was the Washington Examiner.

Enrollment Failures

President Obama and his administration are playing a numbers game with the enrollment figures. His March 31,2014 figures were inaccurate. The figures were grossly inflated.

President Obama said on March 31st, "this thing is working” successfully. President Obama claimed that 8 million enrolled in Obamacare.

“At a hearing Thursday September 18, 2014 at House Oversight and Government Reform Committee, Marilyn Tavenner, head of the Centers for Medicare and Medicaid Services, finally confessed that 7.3 million were enrolled in ObamaCare plans as of mid-August.”

The 7.3 million figure is also fiction. At least 115,000 additional enrollees have not validated their citizenship or legal status.  The validation must be completed by September 30,2014.

An additional 360,000 could lose their Obamacare subsidies because of discrepancies over their income. Eighty-five percent of the enrollees are receiving government subsides for healthcare coverage.

Most do not pay taxes because they make less than forty thousand dollars a year. They will not be able to afford the overpriced premiums.  

How many of the 8 million have not continued to pay the premiums? No one knows or is telling. Enrollees have a three-month grace period.

California reported in late August that an additional 100,000 of those who enrolled through its state-run exchange were at risk of losing their coverage over citizenship issues.

By my calculations less than three million of the forty-eight (48) million people who were uninsured pre Obamacare became insured. An additional 7 million people lost their healthcare insurance in the individual market.

President Obama provided the American public with a grossly overestimated enrollment figure.

Ms. Tavenner had to put a positive spin on this latest revelation of the fictional enrollment numbers by saying,

 "We are encouraged by the number of consumers who paid their premiums."

No one is buying this explanation.

She didn't provide answers to important details for these latest enrollment figures.

  • How many who dropped out were young and healthy?
  • How many have signed up through the so-called special enrollment process?
  • How many are keeping up with premiums?
  • How sturdy are the back-office computer programs in order to detect enrollment misinformation?
  • How will the government collect the money due to it from these non-paying enrollees?
  • Is the November 15th open enrollment period going to go smoothly?


Next Open Enrollment Disaster

It is easy to see that President Obama has delayed the open enrollment time from October 15th to November 15th for political reasons. He wants the potential disaster to occur after the mid-term elections.

 Kevin Counihan, the former chief executive of Access Health CT, Connecticut’s online marketplace, was just named head of the insurance marketplaces for the federal government.

 He said, “Part of me thinks that this year is going to make last year look like the good old days.”

 The front end of the web site looks like it will run smoothly. The back end of the web site still needs work. The government is still trying to see if the links to the IRS, the healthcare insurance industry and social security are functioning properly.

There were not enough healthy young subscribers to keep the insurance rates low. The premiums were too high for many young and healthy uninsured people.

This year the healthcare insurance premiums will be up at least 20%. Healthcare insurers fear it could be even more difficult to sign up young healthy people than it was last year.

Adding to the problem is that the sign up period for choosing a new policy this year will be shorter than last. It will be 3 months instead of six months.

President Obama will probably break the law again and extend the signup period an additional 3 months.

This year it should be more difficult to receive subsidies than last year.

People will drop out of the pool because of the increase in insurance rates. The renewal procedure has not been worked out yet.

Andrew Slavitt, principal deputy administrator for Medicare said they are working hard to make the process as easy as possible.

“We’re putting in place the simplest path for consumers this year to renew their coverage.” 

 This is another Obamacare smokescreen.

I predict it will be a price disaster.

Obamacare And Zeke Emanuel Setting Us Up For Rationing

One of the most bizarre articles imaginable was Zeke Emanuel’s article in the Atlantic Monthly  “Why I Hope to Die at 75”

Dr. Emanuel, one of Obamacare’s authors, gives all the reasons why he doesn’t want to live past 75 years old.

His argument is why should you live longer since you probably are not useful to society.

You have contributed all you are going to contribute. After 75 years old affliction will accumulate and disabilities will make life less pleasant.

It is apparent to me that he is setting us up for government rationing of healthcare for seniors.

The government controls Medicare. It is cheaper for the government not to pay for procedures such as hip replacements, knee replacements, for coronary artery surgery or cardiac pacemakers. All these procedures will extend the life of seniors over 75 years old who need them.

We have also heard rumors that this bureaucratic thinking is already in progress.

Don’t we live in a free country?

Isn’t it up to individuals to make their own life decisions? 

Should we leave these decisions up to the government and bureaucrats?

Should they decide our choose of treatment for us?

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

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Medicaid’s Problems And Obamacare

Stanley Feld M.D.,FACP. MACE

Some of my reader’s read my article about Moises and Medicaid on December 30, 2007. This was before President Obama was elected President.

At that time I was unsuccessful in my attempt to help Moises receive Medicaid healthcare coverage for his family of 4 in the state of Texas. I was successful in getting his kids covered in SCHIP.

We have all experienced the frustrations of government bureaucracy. The actual government policy might be praiseworthy. The execution of the policy hardly ever reflects the purpose of the policy.

Moises and Medicaid is an example of a failure to implement a policy designed to help the poor circa 2007. The consequences of not getting Medicaid coverage were potentially grave to Moises and his family. It is no different in 2013.

Moises is a hard working law abiding American citizen born in El Salvador. He is presently going through a government certified navigator to optain Medicaid coverage or Obamacare coverage..

He application is stuck. He does not know what his final income will be in 2013. I told him I thought they meant his income on his April 2013 tax return.

He started this application two weeks ago. It will not be completed by the December 23th deadline for January 1 coverage.

The Obama administration’s policy is to provide healthcare coverage for all.  

The poverty level income number is outdated. It was written in 1955. The income levels are supposed to be defined by the states. There have been slight increases in income levels to qualify for assistance each year. Medicaid eligibility is based on the poverty level in each state.

The federal government defines Medicaid eligibility in 2013 as earning an income of 133% above the poverty level. The poverty level is $23,550 for a family of four. One hundred and thirty three percent of that is $31,321.50 per year or approximately $15 per hour in a forty-hour work week.

"For many eligibility groups, income is calculated in relation to a percentage of the Federal Poverty Level (FPL). For example, 100% of the FPL for a family of four is $23,550 in 2013. The Federal Poverty Level is updated annually."

In 2007 President Bush did not permit a realistic change in the definition of poverty. The title of the New York Times article was “U.S. Curtailing Bids to Expand Medicaid Rolls.”

An hourly rate of $8.75 equates to a weekly pay of $350, monthly pay of $1,517, and an annual salary of $18,200. An hourly rate of $15.00 equates to a weekly pay of $600, monthly pay of $2,600, and an annual salary of $31,200.

 On Dec. 20,2007 the Bush administration rejected a proposal by Ohio to expand its Medicaid program to cover 35,000 more children. Ohio now offers Medicaid to children with family incomes up to twice the poverty level, or about $41,000 a year for a family of four. The state had proposed increasing the limit to three times the poverty level, to about $62,000.”

Is it better not to work?  

The average national unemployment insurance benefit was about $300 per week in 2010, 2011, and 2012.  However, individual benefit levels vary greatly depending on the state and the worker’s previous earnings.  In addition, in several states, workers receive higher benefits if they have dependents. 

 The maximum state-provided benefit in 2012 ranged from $133 in Puerto Rico and $235 in Mississippi (the lowest for a state) to $653 ($979 with dependents) in Massachusetts.[11]  

A hard working laborer is probably better off on unemployment insurance than working especially if unemployment insurance is extended to 99 weeks.

The average national unemployment insurance benefit is equal to a little under $15 an hour.

Unemployment coverage is 99 weeks. These people are also eligible for Medicaid. If you earn one dollar over $15 an hour you are not eligible for Medicaid.

Do these numbers encourage people to work and be independent or dependent on government largess?

This is a disincentive for someone to be a productive worker and advance in an earning position.

Obamacare creates a disincentive to be independent and make more than $31,321.50 annually.

 The healthcare insurance subsidy is not readily available.  

Obamacare subsidies might be a good deal for the poor who work hard to increase their income. So far it looks like the premiums and the $5,000 dollar deductibles are unaffordable for working families.

The key to successful healthcare reform is to encourage consumers to take responsibility for their care through incentives. Healthcare reform must encourage independence, self-responsibility and not to be dependent on the government.

Medicaid has big problems.

Medicaid does not insure all eligible consumers.

Physician reimbursement is horrible.

Most physicians do not participate in Medicaid.

Why don’t eligible patients participate?

The Medicaid application is too complicated.

Many of these citizens are laborers with meager education and cannot understand the application.

Many come from countries where medical care is free. They feel intimidated by the lengthy application.

They are afraid of government questions because they have experienced government oppression in the past. They want to be independent of government.

They believe it is too difficult to see a doctor. They only go to doctors when they absolutely need to go to the doctor.

Obamacare does not deal with any of these issues.

 I became aware of another horrible truth about Medicaid this week.

 "MEDICAID COMMUNICATION NO. 10-08", PDF  on November 24, 2010 from the state of New Jersey updated guidelines that were issued in Medicaid Communication No. 00-16, dated August 10, 2000, governing the recovery of correctly paid Medicaid benefits from the estates of deceased Medicaid clients or former Medicaid clients.

 “Medicaid benefits received on or after age 55 are subject to estate recovery.

This is specifically stated and acknowledged on the authorization page of the

PA-1G Medicaid Application Form.”

“Estate recovery in New Jersey includes payments for ALL services, not merely

services for institutionalized clients. There is no limitation on the type of

service for which DMAHS can recover its payments from estates including managed care (HMO) capitation fees.”

Many other states are looking into enforcing the Medicaid mandate now that many sick older (greater than 55 years old) consumers are applying for Medicaid.

I believe in helping the less fortunate. I am not for increasing government waste and bureaucracy. I am not for the state taking away assets of the unfortunate family just because these consumers used Medicaid.

Who should you trust? Is it the government or yourself? The government’s job should be to level playing field for all the stakeholders. It is not to control the consumers and make them dependent on the government.

There are many things wrong with the Medicaid system. Rather than adding on to the complexity of the system and making it more inefficient, the Medicaid system must be revamped to encourage freedoms, independence, self responsibility, and incentives so that consumers can learn to become healthy, maintain their health and ultimately decrease the cost of healthcare.

A healthcare system that drives consumers into dependence on the state will diminish freedom, self-responsibility and incentives to stay healthy and diminish healthcare costs.  

It will ultimately fail.

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

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Obama Administration Continuously Declines To Renew Indiana’s Medicaid Waiver

 Stanley Feld M.D.,FACP,MACE

In light of the recent alleged IRS
scandel targeting certain groups, I am reminded of the Medicaid incident in
Indiana. I believe the incident is resolved now with the Obama administration
granting a waiver to Indiana after two years of bureaucratic haggling.

In 2007 Governor Mitch Daniels (R.) was
successful in getting the Indiana state legislature to pass a Medicaid reform
plan called the Healthy Indiana Plan. It is an expansion of Medicaid. It uses a consumer-driven
health plan to encourage low-income beneficiaries to take control of their
health and healthcare dollars.

This healthcare plan is a variant of my
ideal medical saving account.

 The Healthy Indiana Plan has been very successful.

Healthy Indiana Plan has been the most
innovative and successful reform of Medicaid in the history of the Medicaid

The federal government’s waiver for the
plan was given in 2007 and set to expire on December 31, 2012. Indiana applied
for an extension of the Medicaid wavier in early 2011. In November 2011 the
Obama Administration rejected the state’s request to extend its federal waiver.

Over 45,000 poor Hoosiers on Medicaid
were scheduled to lose this innovative Medicaid coverage in 2013.

Medicaid is theoretically run by the
states in cooperation with the federal government.  In reality, any time a state wants to make
the tiniest changes in its
Medicaid program, it has to go hat-in-hand to the U.S. Department of Health and
Human Services with a formal request for a waiver and these waivers are usually

 This federal control has been part of the
disagreement states have with the federal government over health insurance
exchanges. The central government wants to shift the financial burden on the
states while controlling the states’ decisions.

Indiana succeeded in gaining a waiver in 2007
because it was seeking to expand Medicaid to
a group of people who weren’t then eligible for the program and because the
state’s effort required no additional outlays from the federal government.  Governor
Mitch Daniels paid for the
Medicaid expansion by increasing the state’s cigarette tax by 44 cents. It made
sense to everyone except the people that smoked. 

Patients had skin in the game because
they had to pay 2 -5% of their income for their insurance coverage. The plan
provided financial as well as wellness incentives.

We did a lot of reading on
criticism of health savings accounts,” says Seema Verma, who was the
architect of the Indiana
program. “One of the criticisms was that people didn’t have enough money to pay
for preventive care. So we took preventive care out, made that first-dollar

“ Also, people said that people didn’t have enough for the
deductible, so we fully funded it. Then, you have to make your contribution
every month, with a 60-day grace period. If you don’t make the contribution,
you’re out of the program for 12 months. It’s a strong personal responsibility

 I described the Healthy Indiana plan in
detail in January 2008 pre President Obama

Medicaid patients get a specified amount
of preventive care for free.  Included
are free annual physical exams, pap smears and mammograms for women,
cholesterol tests, flu shots, blood glucose screenings, and tetanus-diphtheria

Medicaid beneficiaries have no
cost-sharing requirements (co-pays, deductibles, etc.) except for non-urgent
use of emergency rooms.

The money remaining in the Medicaid
patients’ POWER accounts at the end of the year can be applied to the following
year’s contribution only if they obtain the required free preventive disease

“The program has been, by many measures, a smashing success. “What
we’re finding out is that, first of all, low-income people are just as capable
as anybody else of making wise decisions when it’s their own money that they’re
spending,” Mitch Daniels explains in a Heritage Foundation video.”

“And they’re also acting more like good consumers. They’re
visiting emergency rooms less, they’re using more generic drugs, they’re asking
for second opinions. And some real money is starting to accumulate in their
[health savings] accounts.”

The program has been
very popular. Ninety (90) percent of enrollees are
making their required monthly contributions. Employers didn’t dump their
workers onto the program, crowding others out, because you needed to be
uninsured for six months in order to be eligible for it.

 “The program’s level of
satisfaction is at an unheard-of 98 percent approval rating,” Verma told 
Kenneth Artz.

Lower income families are not too stupid
to be wise healthcare consumers despite popular belief.

2010 study by
Mathematica Policy Research found that in the program

71 percent met the preventive care
requirement and were able to roll the balances over to the following year.  Only 39% obtained preventive care in the
first six months. It proves financial incentives work.

The lack of physician access is the
biggest reason why health outcomes for Medicaid patients lag far behind those
of individuals with private insurance.

Healthy Indiana pays better than
traditional Medicaid. The physician access trend has been reversed. Preventive
care participation rates are higher than the
privately-insured population.

Why would the Obama administration, which
controls the states’ Medicaid programs, refuse to grant a waiver for Indiana’s successful

The first excuse HHS used was “ HSS  hadn’t written the regulations for Obamacare

According to Seema Verma  “the state will now have to file a much more
complex “State Plan Amendment” that may not get approved before the Healthy
Indiana program is set to expire.”

Before his term expired Gov. Daniels
had written to HHS Secretary
Kathleen Sebelius asking her for permission to use the Healthy Indiana Plan to
handle Obamacare’s mandatory expansion of Medicaid. He had not heard back.

The Obama Administration claims to be on
the side of the poor.  Why would it not
approve a waiver of a popular program for the poor that provides the poor with
superior health care?

Whatever the reason, tens of thousands of people will be
needlessly harmed.

burdens and “poison pills” have been thrown at the Indiana health plan. One
such poison pill is not allowing the state to include the $1100 Power account given to Medicaid patients to make
wise medical care choices.

the government pays the healthcare insurance industry for help desks and rent
for buildings where there are help desks as direct patient care instead of

It is
not only bewildering, it is obscene.

controversy continued throughout 2012 past the expiration date of the 2007
waiver into 2013.

Pence, the new governor, kept fighting off bureaucratic rules but got nowhere
through March of 2013.

The subtext of all of this is the
Obama administration wants a top down centrally controlled Medicaid system with
the financial burden on the states and Indiana wants to control its own destiny
with its successful plan.

like the following has been going on. Diane Gerrits, CMS' director of state
demonstrations and waivers, wrote in a Feb. 25 letter that the state will have
to resubmit its application because it had not yet held two public hearings
required by law.

CMS said as a result of the failure to comply with the transparency portion of
the proposal, the state must begin a 30-day state public comment and notice
period. The state must follow with an additional 30-day federal public comment.

has been going on since 2011

Mike Pence fired back,

 "The Feb. 25, 2013, letter from HHS does not
indicate in any way that the waiver application process has been
jeopardized," he wrote Thursday. "It does, however, speak to the
flawed bureaucratic process that has impeded progress on our successful Healthy
Indiana Plan."

Obama administration is trying to destroy all health savings accounts both
public and private. This is probably the reason for these artificial delays.

in mid April, under public pressure and possibly the impending IRS scandal Indiana’s
waiver request was approved.

is a happy ending to the Indiana saga and perhaps a model to get all the
Medicaid programs out of the deep ditch they are in.

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

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Evidence For Impending Healthcare System Failure

Stanley Feld M.D.,FACP,MACE

The following are the links that is the evidence for the impending failure of the healthcare system in its present form and in the form that Obamacare is adopting.

Obamacare is piling on more regulations and restrictions to the present healthcare system. The present system is a failed system.The regulation will be impossible to comply with and impossible to enforce. They will create more opportunity for secondary stakeholder to extract more funds from monies needed for direct patient care creating a greater decrease in access to care for all .

The links follow the slides I presented in my last blog. Those links could not be opened because they were jpegs.

My hope is the links serve as an excellent reference to Repair The Healthcare System presently or when it collapses under it unsubstainable costs and the present system's inability to be executed.

The Etiology of Accelerated


Medicare 1965-1980 Fee for

authorized HMO’s

Medicare Price Fixing Begins In 1980

Cost shifting Penalizes Private

HMO Fail Because Of Faulty Assumptions In 1990.

 Reasons for Hillarycare’s
Failure To Pass.

Distrust of Government

Healthcare Insurance Companies
Raise Premiums.

Birth of Managed  Care: Another Compicated Mistake  

Managed Cares Fails. 

Managed Care Pricing And
Premiums Remain

2009 Obamacare And The Threat
Of Government Takeover To Freedom, Liberty and Choice.

Rationing Of Healthcare

ACOs Are HMO's On Steroids Combined With Managed Care Is Obamacare's Complicated Mistake. 

ACOs Will Fail At Great Costs To Everyone.

 Tort Reform And Defensive Medicine Are Ignored By Obamacare.

Medical Cost Escalate Out Of
Control And Then The Healthcare System Will Collapse.

The other major slide in the last blog was the barriers to the
Physician/Patient Relationship. This relationship is critical to the
theraputic index. It is almost destroyed and will be totally dstroyed in
Obamacare. Both physicians and patients will become commodities in a
bureaucratic healthcare system. Patients will not win.


Physician/ Patient Barriers to the Physicians/Patient Relationship



The Physician/Patient

physician/patient relationship

 The Magic  of the Patient Physician Relationship  

 Patient and
Physician responsibility contract

 Patient should be the leader of the team

 Barriers for physicians in the Physician/Patient


1. Tort
Reform/Defensive Medicine.

2. Restriction
of Physicians Clinical Judgment

3. Medicine
is a calling not a business

  4.  Constant
lowering physicians’ reimbursement

 5. Physicians
are driven to decrease time spent with patients

6. Government
rations care through panel of experts

7. Physician’s
treatments are driven by government regulations

8. The
traditional media undermining physician credibility

9. Government
is attempting to commoditize medical treatment


Patient Barriers To the Patient/Physicians Relationship

1. Patients are not in control of their own medical decisions.

2. Patients are not in control of their own healthcare

3. Patients
do not have to be responsible for their treatment because they

first dollar coverage.

4.  Education about chronic disease must be extension of
physician’s care

5.  Internet can undermine the Physician/Patient

6. Method of choosing a physician is random and must be
made clearer

7. Portability of information about previous treatment
is difficult

8. Patient must be responsible and in control of their
medical record.

9. Patient must endure poor communication by their

Government and the healthcare insurance industry limit choice with


11. Patients should be responsible for their treatment

America's healthcare system is at a critical turn in 2012.

Obamacare must be repeal.

Effective healthcare reform is essential. Both the primary and secondary stakeholders have abused a system. A system that is punitive.

Consumers must drive the system by being responsible to themselve and their healthcare dollars.

Obamacare is building a system of government dependency by all stakeholders (patients,physicians,hospital and healthcare insurance companies).

The healthcare system should be developed to create innovation and competions among stakeholders for the benefit of consumers and their indepent choice.

The government's inefficiency will create a healthcare system destined to doom at the expense of all of us taxpayers.

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

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State Medicaid Coverage -A Cash Cow For The Healthcare Insurance Industry

Stanley Feld M.D., FACP,MACE


The healthcare insurance industry is preparing to capitalize on a $40 billion opportunity to run Medicaid plans for states when President Obama’s healthcare reform act adds 16 million people to the Medicaid roles in 2014.

Do the math. $40,000,000,000 divided by 16,000,000 people is a net profit of $2,500 per patient after expenses.

“Medicaid, the state and federal program for the poor, has become a growth area for big insurers.”

Citigroup research group estimates that presently the overall healthcare insurance industry’s net profit is about $56.5 billion per year. The addition of 16 million enrollees will add $40 billion dollars in net profit to the healthcare insurance industry’s bottom line.

The positioning of both major healthcare insurance companies and smaller companies has been proceeding quietly, as they want to stay below the radar of public detection.

California will have 2 million new enrollees. Texas will have 1.9 million enrollees.

The healthcare insurance industry is preparing bids to provide administrative services for each state’s Medicaid program. Most states are experiencing budget crises and find it is cheaper to outsource the administrative services of their Medicaid programs.

The healthcare insurance industry manage coverage of 70% of Medicaid enrollees, or 33.4 million people, up from 56% in 1999, according to Sanford C. Bernstein.”

States let contracts lasting five years. The states want to contract with vendors now so they do not experience disruptions in 2014 when the Medicaid expansion occurs.

The healthcare insurance companies are trying to customize their plans to win their bids.

Medicaid is one of health insurers’ few bright spots, as their margins are pressed by regulatory crackdowns on premiums in their traditional policies. Gail Boudreaux, UnitedHealth’s executive vice president, told investors last month that: "The Medicaid space is a significant long-term growth opportunity for us. It’s a big market that’s getting even bigger." UnitedHealth pegs the value of new bids or expansions over the next three years at $40 billion.”

Many healthcare insurance companies are jumping in to capture the Medicaid business. UnitedHealth and WellPoint(Blue Cross/Blue Shield) are at the head of the class. Smaller companies such as Amerigroup, Centene and Molina claim their specialized focus gives them an advantage over the larger companies.

"Understanding the state as a customer is quite different than understanding what GE or IBM want as a purchaser," said John Littel, Amerigroup’s executive vice president of external relations.”

President Obama did not think out his plans for Medicaid very well. His healthcare reform act has done nothing to repair the problems in the Medicaid insurance system. In fact, the funding demanded of the states has resulted in a decrease in funding of vital safety net city and county hospitals.

What remains is an expansion of a system that has failed to provide adequate care over the last 40 years. The defective design of the Medicaid system is responsible for its failure. It makes no sense that by expanding the program by 16 million uninsured people it will produce a successful program. Expanding a failed system will not solve our universal healthcare goals. It will only expand our federal and state deficits and provide more profit for the healthcare insurance industry.

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