Category Archives: Affordable Care Act

Is Statewide Single-Payer Feasible, or Is It Just ‘California Dreamin’?

15826113_1072477266215265_6530794931196981565_nLast week we were treated to the future with the Democrats having the new candidate and even worse, a socialist getting involved in the future of our country and especially health care, immigration, and even more. Be careful! After her victory in Tuesday’s primary election, a lot of political commentators scrambled to figure out how a young socialist like Alexandria Ocasio-Cortez managed to unseat 10-year incumbent Joe Crowley. While there are some obvious explanations, like her campaign was strong and her ideas are good, the upset has also inspired dismissiveness and hand-wringing, with Nancy Pelosi brushing off the win as just “one district” and op-eds proclaiming that “Democrats can kiss swing voters goodbye with the progressive ballot.”

But Ocasio-Cortez is aware of those critiques—in fact, she had them in mind throughout her campaign.

This may be as good an electoral policy as the Democrats have had in a long time. For decades the Democratic playbook has been to try to peel off moderate Republican voters rather than energize a working class and left-wing base, and while that could, debatably, be a sound strategy in purple districts, it doesn’t make sense in a reliably blue territory. On top of that, the insistence on always playing to the middle while the Republican Party swings further into full-blown authoritarianism has produced a huge imagination deficit among the Democrats. There have been precious few big ideas coming out of the Democratic Party, particularly ideas that voters care about, and in that vacuum, the central policies of Ocasio-Cortez’s campaign, like Medicare for all and abolishing ICE, are concrete and exciting.

And on top of that, Ocasio-Cortez’s success has shown that her policies are popular. So popular that mainstream Democrats are quickly getting on board with things like abolishing ICE: this past week both Kamala Harris and Kirsten Gillibrand have publicly endorsed the position. It shouldn’t have taken a blowout election for establishment Democrats to come out against agencies literally throwing kids in cages, but it’s a big step forward from the previously most mainstream solution of throwing kids in cages along with their parents.

Ocasio-Cortez’s campaign is evidence that big solutions aren’t just fantasies. As long as Democrats are too afraid or just unwilling to take stands on the deepening crises happening on fronts across the country, they have little hope of regaining real political power and even less of actually accomplishing anything.

Rich Pedroncelli wrote that California’s leading progressives are currently debating — amicably, for the moment — when the right time will arrive to destroy the state’s healthcare system.

The frontrunner in the race for the governor’s mansion, current Lieutenant Governor Gavin Newsom, has long championed single-payer health care. But he recently softened his support. “[Single-payer] is not an act that would occur by the signature of the next governor,” he recently said. “There’s a lot of mythology about that.”

His most progressive allies — including the California Nurses Association, which has led the charge for single-payer — appear to be in more of a hurry. “To get there, state leaders must have the political will,” said Stephanie Roberson, a legislative advocate for the Association.

This debate — over when to implement single-payer — misses the point. Any single-payer system would be a disaster for California taxpayers and patients, whether it’s established tomorrow or in ten years.

California’s most recent dalliance with single-payer originated last June when the State Senate passed SB 562, the Healthy California Act. The bill would consolidate all public insurance programs — including Medicare and Medi-Cal — into a single state-run health plan. That plan would also gobble up uninsured Californians, those who buy insurance through Covered California, and the millions who currently have coverage through work.

Like most single-payer schemes, the proposed system would effectively outlaw private insurance. Public officials would determine which drugs, procedures, and services the one-size-fits-all system covers. Care would be free at the point of service. Californians would pay no premiums, deductibles, or co-pays, and referrals to specialists would not be necessary.

Assembly Speaker Anthony Rendon ultimately rejected SB 562 as “woefully incomplete,” since it included no funding mechanism. But to pacify progressives, he formed a special commission, grandly titled the “Assembly Select Committee on Health Care Delivery Systems and Universal Coverage,” to further study single-payer.

The Committee heard more than 30 hours of testimony before releasing a report authored by an independent healthcare consultant and professors from the University of California, San Francisco, and the University of California, San Diego. That report essentially concluded that implementing single-payer would be impossible in the short term.

Among the reasons? It’d cost about $400 billion. That’s more than double California’s entire annual budget.

In theory, the state could cover about half that total by poaching federal funding from existing public insurance programs, such as Medicare and Medi-Cal. But as the report points out, that would require a federal waiver — one the Trump administration almost certainly wouldn’t grant.

Even if Democrats retake the White House in 2020 and grant California a waiver, the state would still have to come up with $200 billion to fund the single-payer system. Senate leaders have floated a 15 percent payroll tax.

A study conducted by the University of Massachusetts, Amherst, economist Robert Pollin on behalf of the California Nurses Association claims that the state would only need to raise an additional $106 billion in revenue.

And even if those wildly optimistic projections are correct, California would still have to raise taxes significantly. The nurses’ study suggests an additional 2.3 percent sales tax — on top of the existing 7.25 percent levy — and an equivalent tax on business revenue.

Such enormous tax increases would drive businesses out of California. As the tax base continually shrinks, lawmakers would be forced to raise tax rates higher and higher to offset the lost revenue.

On the other side of the equation, single-payer advocates’ rosy revenue projections are predicated upon wresting significant savings out of the healthcare status quo. Practically, that means paying doctors and hospitals less — rates likely tied to Medicare or Medi-Cal, which are much lower than those paid by private insurers.

Many doctors would respond to such pay cuts by retiring early or moving to other states. Meanwhile, the best and brightest medical students would think twice about coming to California to practice. These twin outcomes would exacerbate the Golden State’s existing shortage of physicians, particularly in high-need areas.

Publicly funded health care for all sure sounds good. But the math behind single-payer doesn’t add up. And all the political will in the world can’t overcome that fact.

Canadians are one in a million — while waiting for medical treatment

Sally Pipes wrote that Canada’s single-payer healthcare system forced over 1 million patients to wait for necessary medical treatments last year. That’s an all-time record.

Those long wait times were more than just a nuisance; they cost patients $1.9 billion in lost wages, according to a new report by the Fraser Institute, a Vancouver-based think-tank.

Lengthy treatment delays are the norm in Canada and other single-payer nations, which ration care to keep costs down. Yet more and more Democratic leaders are pushing for a single-payer system — and more and more voters are clamoring for one.

Indeed, three in four Americans now support a national health plan — and a new NBC/Wall Street Journal poll finds that health care is the most important issue for voters in the coming election.

The leading proponent of transitioning the United States to a single-payer system is Sen. Bernie Sanders, Vermont’s firebrand independent. If Sanders and his allies succeed, Americans will face the same delays and low-quality care as their neighbors to the north.

By his own admission, Sen. Sanders’ “Medicare for All” bill is modeled on Canada’s healthcare system. On a fact-finding trip to Canada last fall, Sanders praised the country for “guaranteeing health care to all people,” noting that “there is so much to be learned” from the Canadian system.

The only thing Canadian patients are “guaranteed” is a spot on a waitlist. As the Fraser report notes, in 2017, more than 173,000 patients waited for an ophthalmology procedure. Another 91,000 lined up for some form of general surgery, while more than 40,000 waited for a urology procedure.

All told, nearly 3 percent of Canada’s population was waiting for some kind of medical care at the end of last year.

Those delays were excruciatingly long. After receiving a referral from a general practitioner, the typical patient waited more than 21 weeks to receive treatment from a specialist. That was the longest average waiting period on record — and more than double the median wait in 1993.

Rural patients faced even longer delays. For instance, the average Canadian in need of orthopedic surgery waited almost 24 weeks for treatment — but the typical patient in rural Nova Scotia waited nearly 39 weeks for the same procedure.

One Ontario woman, Judy Congdon, learned that she needed a hip replacement in 2016, according to the Toronto Sun. Doctors initially scheduled the procedure for September 2017 — almost a year later. The surgery never happened on schedule. The hospital ran over budget, forcing physicians to postpone the operation for another year.

In the United States, suffering for a year or more before receiving a joint replacement is unheard of. In Canada, it’s normal.

Canadians lose a lot of money waiting for their “free” socialized medicine. On average, patients forfeit over $1,800 in lost wages. And that’s only counting the working hours they miss due to pain and immobility.

The Fraser Institute researchers also calculated the value of all the waking hours that patients lost because they couldn’t fully function. The toll was staggering — almost $5,600 per patient, totaling $5.8 billion nationally. And those calculations ignore the value of uncompensated care provided by family members, who often take time off work or quit their jobs to help ill loved ones.

Canada isn’t an anomaly. Every nation that offers government-funded, universal coverage features long wait times. When the government makes health care “free,” consumers’ demand for medical services surges. Patients have no incentive to limit their doctor visits or choose more cost-efficient providers.

To prevent expenses from ballooning, the government sets strict budget caps that only enable hospitals to hire a limited number of staff and purchase a meager amount of equipment. Demand inevitably outstrips supply. Shortages result.

Just look at the United Kingdom’s government enterprise, the National Health Service, which turns 70 this July. Today, British hospitals are so overcrowded that doctors regularly treat patients in hallways. The agency recently canceled tens of thousands of surgeries, including urgent cancer procedures, because of severe resource shortages. And this winter, nearly 17,000 patients waited in the backs of their ambulances — many for an hour or more — before hospital staff could clear space for them in the emergency room.

Most Americans would look at these conditions in horror. Yet Sen. Sanders and his fellow travelers continue to treat the healthcare systems in Canada and the UK as paragons to which America should aspire.

Sen. Sanders’s “Medicare for All” proposal would effectively ban private insurance and force all Americans into a single, government-funded healthcare plan. According to Sen. Sanders, this new insurance scheme would cover everything from regular check-ups to prescription drugs and specialty care, no referral needed — all at no charge to patients.

Americans shouldn’t fall for these rosy promises. As Canadians know all too well, when the government foots the bill for healthcare, patients are the ones who pay the biggest price.

Most Californians support single-payer unless they have to pay for it

Maybe Californians really are tired of paying so much in taxes. But Sal Rodriquez found that according to a recent survey from the Public Policy Institute of California, 53 percent of likely voters support the idea of a single-payer health care system in California, but support falls to just 41 percent if single-payer would require new taxes, which it will.

About two-thirds of Democrats support the idea of a single-payer system even if it means higher taxes – because to be a Democrat in California is apparently to firmly believe that the inept government in Sacramento deserves more of everyone’s hard-earned money.

Only 11 percent of (very confused) Republicans 31 percent of independents share that view.

According to the survey, the Bay Area is the only region in the state where a majority of likely voters support a single-payer system even if it means higher taxes, but even then it’s just 55 percent of them. Majorities of likely voters in the Central Valley and Orange/San Diego Counties outright oppose a single-payer plan, and almost half (47 percent) of Inland Empire likely voters also oppose the idea.

It should be absolutely clear that a single-payer plan will necessarily entail higher taxes and there’s no way around it.

A California Senate Rules Committee analysis of SB562, a single-payer bill which remarkably passed the state Senate despite not actually offering an actual plan, noted that “about $200 billion in additional tax revenues would be needed to pay for the remainder of the total program cost.”

For context, total estimated general fund revenues for 2018-19 for state government is just over $140 billion.

So, yeah, single-payer will require enormous tax hikes. Considering that most Californians already believe they pay more in taxes than they should and that the state can barely manage everything it does now, single-payer is a fanciful idea that shouldn’t be seriously contemplated at this time.

Bernie Sanders: Starbucks CEO ‘dead wrong’ on government-run health care

Kimberly Leonard of the Washington Examiner reported that outgoing Starbucks CEO Howard Schultz has been criticized by Sen. Bernie Sanders, I-Vt., over his comments on a healthcare system fully funded by the government.  (Reuters)

Liberal Sen. Bernie Sanders says outgoing Starbucks CEO Howard Schultz is “dead wrong” for saying that moving to a health care system fully funded by the government isn’t realistic.

The Vermont independent, who has been pressing for the U.S. to move toward socialized medicine, was asked to respond to comments Schultz made about the plan in another interview.

Schultz recently announced that he would be leaving Starbucks and said he was considering “public service.” He said on CNBC he was concerned about the way “so many voices within the Democratic Party are going so far to the left.”

Sen. Bernie Sanders said Medicare-for-all is a “cost-effective” program.  (AP)

“And I ask myself, how are we going to pay for all these things? In terms of things like single-payer or people espousing the fact that the government is going to give everyone a job, I don’t think that’s realistic,” he said.

CNN’s Chris Cuomo asked Sanders about the possibility of Schultz running as “the Left’s Trump” who may go up against the current president in 2020.

Sanders said he didn’t know Schultz but his comment was “dead wrong.”

“You have a guy who thinks that the United States apparently should remain the only major country on earth not to guarantee health care to all people,” Sanders said. “The truth of the matter is that I think study after study has indicated that Medicare for All is a much more cost-effective approach toward health care than our current, dysfunctional health care system, which is far and away the most expensive system per capita than any system on Earth.”

I think the Bernie is a nut socialist but he may be correct in this situation. However, Medicare for All is also questionable and I can’t believe these candidates suggesting that they as governors can change a federal law or system. And also remember what free borders for illegal immigrants mean to a health care system. Who is going to pay for all those illegal immigrants needing health care? Be careful what you wish for!!

And finally on to the discussion of Medicare for All!!

Politics are Ruining Our Future and Will Keep Us in Purgatory!! Obamacare Is A Political Nightmare That’s Not Going Anywhere. Is there A Solution?

35628362_1581684245294562_5252791796676689920_n

Some conservatives are unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back the Obamacare regime.

I was disgusted last week speaking with a friend who is a very powerful strategist in the Democratic Party. She agreed with me when I suggested to her that the Democrats would Never sign off on either an immigration or health care plan until after the midterm election. I sensed this after the President signed an Executive Order reversing the separation of illegal immigrant children from their illegal parents as the Democrats, especially Ms. Pelosi and Mr. Schummer asked him to “pen”.

How can we make any progress at all when there is no cooperation between the parties and the administration? I am truly frustrated and wonder when we all are going to wake up and make these Senators and Representatives to “do their job”! They all only care about their own reelection models…. and impeaching the President. How have we sunk so low, so far??

Congress is still wading through the swampy waters of Obamacare. Congressional Republicans, who ran against Obamacare through four election cycles, have spent most of the past year running away from it. But they are finding the law hard to escape.

Democrats who once shied away from Obamacare now can’t stop talking about it. They are blaming Republicans for the next round of premium increases that will become finalized in the weeks leading up to the November elections.

Republicans will justifiably respond that Obamacare is a mess they didn’t make. Voters may nevertheless hold them accountable for not cleaning up that mess, despite years of campaign promises.

Congress should keep those promises, according to a group of conservative policy analysts, state-based think tanks, grassroots organizations, and GOP governors and state legislators. Tuesday, a group of them announced support for the Health Care Choices Act, a proposal that would repeal Obamacare entitlements and replace them with grants to states to finance consumer-centered reform.

The plan is innovative and bold. The ill-fated bills Congress considered last year kept the federal structure of Obamacare with relatively minor modifications. For example, those proposals modified the federal tax credits that are at Obamacare’s core; the Health Care Choices Act would repeal them. And while last year’s bills would have reduced federal spending on Medicaid coverage of able-bodied adults, the Health Care Choices Act would scuttle the Medicaid expansion policy entirely.

The proposal resembles the successful welfare reform of the 1990s, which repealed the individual entitlement to cash benefits and replaced it with grants to states to assist the needy. The Health Care Choices Act does the same thing with health care, but on a much grander scale. It would repeal an open-ended federal entitlement program expected to cost $1.6 trillion over the next decade and replace it with a block grant. It is welfare reform on steroids.

Block grants are not blank checks. Like welfare reform, which required states to implement policies to encourage work and reduce dependency, the Health Care Choices Act would require states to pursue two important goals: reducing costs and increasing health care choices.

States would be required to spend a portion of their federal allotments on meeting the medical needs of the sick without saddling the healthy with exorbitant premiums. Other stipulations would prevent states from using the money to expand Medicaid or to warehouse the poor in state-contracted managed care plans. States would have to provide low-income people assisted through the through the block grant, as well as Medicaid and State Child Health Insurance (CHIP) recipients, the option of applying the value of their assistance to the plan of their choice. Think of it as school choice for health care.

The new money would be provided through the CHIP statute, which, unlike Obamacare, includes permanent restrictions on the use of funds for abortion. Within those broad guidelines, states would design their own programs, determining who is eligible for assistance and what they’re eligible for. They would be released from Obamacare regulations on essential health benefits, age-related premium variation, and the requirement that insurers enroll the sick and healthy in the same insurance pools. Repealing these regulations would allow states to repair or ameliorate much of the market dislocation Obamacare produced.

In short, the Health Care Choices Act would dismantle two of Obamacare’s pillars and weaken the third: Obamacare’s individual entitlement would be abolished, the employer mandate (like the individual mandate) would be repealed, and federal insurance rules would be diluted.

Some conservatives look at the proposal’s health care reform donut and complain about the hole. They have particularly faulted the plan for not repealing Obamacare’s pre-existing condition rules.

A Republican reaction to last week’s Justice Department motion in a lawsuit that seeks to invalidate these rules is instructive. Democrats attacked the Trump administration – and Congressional Republicans – for opposing pre-existing condition protections.

To stanch the political bleeding, Senate Majority Leader Mitch McConnell declared, “Everybody I know in the Senate – everybody – is in favor of maintaining coverage for pre-existing conditions.”

McConnell’s colleagues pointedly did not race to the microphones to distance themselves from their leader. Nor are scores of House and Senate conservative incumbents campaigning on a promise to repeal the popular pre-existing condition requirements.

The message is clear: repealing that requirement does not enjoy anything like majority support even in a GOP Congress. For some conservatives, that is reason enough to leave Obamacare in place. If Congress can’t pass a perfect bill, they argue, then it shouldn’t pass anything at all.

A growing cadre of conservatives is unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back an Obamacare regime that continues to raise costs and constrict health care choices.

They view the Health Care Choices Act’s repeal of Obamacare’s entitlements and devolution of power from Washington to the states not as the final word on health care reform, but as an essential component of a broader effort. Expanding health savings accounts is part of that effort. Promoting innovative approaches like health-sharing ministries and direct primary care is another. Trump administration regulatory proposals to allow small businesses and independent contractors form health insurance purchasing groups across state lines also are part of it, as is its plan to expand the sale and renewal of short-term, limited duration policies.

Conservatives who back the Health Care Choices Act prefer real progress to theoretical perfection and the inaction it induces.  They also argue that it is politically better for Republicans to confront Obamacare than to be blamed for its failures.

Republicans are stuck in a Nash equilibrium on Obamacare repeal. Conservative firebrands, Republican moderates, and congressional leadership – each for very different reasons – are content to make Obamacare repeal the new balanced budget, something they talk about to mine money and votes from their base, but never seriously pursue.

The millions of families and thousands of small businesses suffering under Obamacare deserve better.

Obamacare Faces New Life-threatening Conditions

Opponents of the Affordable Care Act have been busy. In the midst of several headline-making events on other issues, the Trump administration has instigated two major efforts to effectively do what Congress could not do earlier this year — repeal Obamacare.

The result is a laundry list of warnings for all health care consumers, not just those who buy insurance on the ACA exchanges. Here’s a closer look at the latest changes to the health insurance marketplace:

Expanding association health plans

The administration issued new rules on Tuesday that expand the use of what’s known as association health plans. They allow small businesses and self-employed individuals to buy health insurance collectively through what’s loosely defined as an industry association. By pooling together, members can buy insurance for less expensive group rates, the way employees of large corporations do.

Association plans have been around for a long time, but under the ACA they were restricted. The new rules loosen some of these restrictions and expand the reach of these plans. At the same time, these plans are exempt from many of the protections under the ACA, including coverage of the 10 essential health benefits such as maternity and mental health services, hospitalization and prescription drugs.

In addition, the new rules allow association plans to sell insurance across state lines. States regulate health insurers, and for the most part, insurers must adhere to each state’s regulations for the consumers they serve in those states. But under the new rules, association plans can choose which state they want as their regulatory jurisdiction. That means they could conceivably choose a loosely regulated state as their home base.

Association plans have seen their share of scandals in the past, largely due to this state regulatory confusion.

The new rules aren’t a surprise. The Trump administration has been calling for the expansion of association health plans as a way of offering more options outside of Obamacare and a way for small businesses and individuals to have access to more affordable group insurance.

But advocates worry that the move is a return to the bad old days before insurers had to adhere to standard regulations that protected consumers from paying insurance premiums, only to find coverage wasn’t there when they needed it.

“The new rule will allow groups of businesses to band together to buy insurance across state lines, which will be bad for small firms and their employees because it will lead to higher premiums, unbalanced risk pools and lower-quality insurance,” said John Arensmeyer, founder, and CEO of Small Business Majority.

In addition, the provision may encourage a new batch of healthier people who can get by with skimpier coverage to sign up for association plans instead of the ACA exchange plans. That could leave more sick people in the exchanges without the benefit of younger, healthier people balancing the risk pool. According to the Congressional Budget Office, 6 million people are expected to enroll in expanded association health plans.

If you’re considering one of these plans, many of which are expected to be available in September just before the 2019 ACA open-enrollment period, be sure to read everything you can get your hands about the plan as carefully as you can. You’ll want to be sure you understand any limitations in coverage so you can determine if the plan is right for you.

A threat to preexisting condition coverage — and more

Tuesday’s announcement comes on the heels of another potentially devastating blow to the ACA. Earlier this month the Justice Department announced it would not defend the law against a lawsuit brought by the attorneys general of Texas and 19 other states.

The suit claims that because the newly enacted tax law eliminates penalties associated with the individual mandate, the ACA requirement that most Americans carry health insurance is no longer constitutional. In addition, the suit contends that consumer insurance protections under the law also aren’t valid.

Since then an outcry has been heard from health care advocates, insurers, congressional Republicans and most recently a group of bipartisan governors from nine states. The protest is focused on the provision in the ACA that requires insurers to provide equal coverage and the same premium rates to people with pre-existing conditions as they provide to people without previous health problems.

The requirement applies to all insurers, not just those in the exchanges, and polls show most Americans — including many who don’t support Obamacare overall — want to preserve it. Even Senate Majority leader Mitch McConnell famously said, “Everybody I know in the Senate, everybody, is in favor of maintaining coverage for preexisting conditions.”

Still, the Texas court case would potentially eliminate many more ACA provisions, including the premium subsidies so many exchange customers rely on, essential health benefits and Medicaid expansion, said Eliot Fishman, senior director of health policy at Families USA. That said, Fishman believes the court case will take time, so consumers who are planning on signing up for exchange coverage for 2019 at the end of this year should not be dissuaded from doing so.

Health warning-Obamacare is in legal peril once again! Many legal scholars are dismissing a new case. Don’t listen to them.

Noah Feldman wrote that one shouldn’t turn your back.  Could key portions of the Affordable Care Act be declared unconstitutional – years after the Supreme Court upheld them? The Trump administration’s Department of Justice has just filed a brief saying so in a suit by several states that aims to take down the whole program.

Most mainstream legal commentators think the government’s arguments are unconvincing. But it’s crucial to remember that this was exactly the reaction of the same set of people in 2010 when the original argument was made against the individual mandate by libertarian law professor Randy Barnett. Just two years later, five justices of the Supreme Court embraced Barnett’s argument.

Given the excitement for judicial activism building among conservatives, the Trump administration may have more than a 50 percent chance of success.

Just in case you haven’t thought much about the individual mandate and the Constitution in the last six years, let me provide an update and a brief refresher. The update is that, in 2017, Congress passed the Tax Cuts and Jobs Act. In the law, Congress repealed the tax penalty associated with the individual mandate that everyone has health insurance.

In other words, the ACA still says you have to have insurance. But if you don’t, nothing happens to you. You may remember that the Obama team was worried about the interaction between the individual mandate and the popular ACA provisions that say insurance companies can’t refuse to cover anybody because of pre-existing conditions and can’t charge you more if you are already sick.

The theory went something like this: If you aren’t compelled to buy insurance when you’re healthy, but you’re allowed to buy it when you find out you are sick, then only sick people would buy health insurance. That, in turn, would create a “death spiral” for insurance under the ACA, as insurance costs went up.

Crucially, President Barack Obama’s Department of Justice relied on this argument in trying to convince the Supreme Court to uphold the individual mandate. This death spiral doesn’t seem to have happened yet, however.

Now comes the new constitutional challenge to the ACA, filed by a group of states led by Texas. Their argument begins with the fact that, when the Supreme Court upheld the individual mandate, it did so in a very strange way. The five conservative justices all agreed that, under the commerce clause of the Constitution, Congress did not have the authority to make people buy insurance.

Their reasoning was borrowed from Prof. Barnett, who had proposed in his article that while the Congress has the power to regulate existing commercial activities, it can’t force people to undertake a commercial activity they are not already engaged in. This was the famous broccoli hypothetical: the conservatives argued that the commerce clause wouldn’t allow Congress to pass a law requiring everyone to buy and eat broccoli, even though Congress could lawfully regulate broccoli prices.

Despite this conclusion about the commerce clause, however, Chief Justice John Roberts joined the four liberals to uphold the individual mandate on the ground that it was a tax and therefore fell within Congress’s separate taxing power. The other four conservatives were clearly frustrated with Roberts, but his vote carried the day.

The states are now arguing that once Congress repealed the tax penalty for the individual mandate in the 2017 law, no more constitutional authority exists for Congress to keep the individual mandate in place. The Supreme Court already excludes the commerce clause, and now the tax rationale is gone. Trump’s Department of Justice has agreed with this claim.

The states say that without the individual mandate, the whole ACA should be struck down as unconstitutional. Trump’s Justice Department didn’t go quite that far. But it did say that the ACA provisions on pre-existing conditions are so linked to the individual mandate that it should now be struck down.

Legal observers are pretty upset about this — but not all for the reason you’d think. Some are focused on the strange circumstance that Justice is arguing that the law is unconstitutional. It’s not supposed to work that way. The executive branch is supposed to argue in favor of the constitutionality of laws currently on the books.

That’s bad, without a doubt. But it seems less worrisome than the possibility that courts, including the Supreme Court, might actually adopt the Trump administration’s view and strike down the ACA provisions on pre-existing conditions.

Legally, I don’t think that would be the right decision. I don’t think that the repeal of the penalty means that the no-penalty individual mandate is necessarily unconstitutional, since there is no sanction for violating it, so it isn’t really much of a law at all.

And even if the no-penalty mandate were unconstitutional, it doesn’t follow that the mandatory coverage provisions need to go. They are logically separate from the individual mandate. The mandate may have been thought been necessary to make those provisions work in practice, but it turns out that, so far at least, they are operating without it, and the death spiral hasn’t happened.

But it is entirely possible that five justices would follow the chain of formal logic laid out by the states and adopted by the Justice Department. The best argument in favor of that position is that the Obama Department of Justice told the Supreme Court years back that these provisions were interlinked – “inseverable” in legal jargon.

There is, therefore, a real and indeed significant chance that the most popular part of the ACA could be struck down. You may have thought that the whole ACA-and the-courts topic was over. But as it turns out, it keeps coming back, like a figure from a horror movie. Don’t turn your back.

And look at all of the campaign “idiots” who are experts on health care and declare that their State will have better healthcare by adopting Medicare for All. Don’t they know that Medicare is a Federal program that States can’t themselves change? And how are they going to pay for it if the prediction that Medicare and Social Security programs will be out of money by 2026-2034?

Let’s talk more about Medicare for All!

The Single Payer system/ Medicare for All and now Bernie Sanders seeks ‘citizen co-sponsors’ for a ​single-payer health care bill

26993261_1432436440219344_4607508862949775129_nNicole Gaudiano reported that Sen. Bernie Sanders is now seeking “citizen co-sponsors” for a “Medicare-for-all” health care bill he plans to introduce in a few weeks.

While pledging to fight GOP efforts to repeal Obamacare, the Vermont independent told supporters in a Wednesday email that the ultimate goal is a single-payer system, a federally administered program that would eliminate the role of private insurers in basic health care coverage. He suggested a Medicare for all system.

He asked supporters to sign on as citizen co-sponsors because — in a reprise of his 2016 presidential campaign’s clarion call — “getting there will require nothing short of a political revolution.”

“It is time to wage a moral and political war against a dysfunctional health care system in this country,” he wrote. “When I introduce the legislation, I want it to be clear that the American people believe health care should be a right in this country.”

Republicans say the single-payer approach to health care is a “government takeover” of insurance that will cost trillions and be financed on the backs of taxpayers. They point to an Urban Institute study of Sanders’ proposal during his presidential campaign that said it would increase federal expenditures by $32 trillion over 10 years, though a Sanders aide says the forthcoming bill will cost less than the campaign plan.

Sanders, in his email, said the system would save lives and “hundreds of billions” in annual health care costs.

“The savings for businesses would be astronomical and allow them to compete on equal footing with companies in Europe,” he wrote. “And for the millions of Americans who are currently in jobs they don’t like but must stay put because of health care access, they would be free to explore more productive opportunities as they desire.”

But is it really the answer and do we really want it?

Why Bernie’s Universal Healthcare System Would Be A Disaster

The Staff at TWD and Associates wrote that this past week, Senator Bernie Sanders of Vermont proclaimed in a New York Times op-ed that the time has come to create a program of “Medicare for all,” a government-run single-payer healthcare system that would over a four-year period displace all existing private healthcare plans, Newsweek writes.

His new program, rightly denounced as delusional, purports to provide to over 325 million Americans coverage that would be more extensive and costly than the rich benefits supplied to the 55 million Americans on Medicare—which itself teeters on the edge of insolvency.

Sanders proposes to fund his new plan with a variety of heavy taxes on productive labor and capital, without noting that his program will cut into the very tax revenues needed to support such a system. Incentives matter, even in la-la land.

None of this matters to Sanders, for whom noble aspirations cure all technical defects. He believes that the United States, like all other modern states, should “guarantee comprehensive healthcare to every person as a human right.”

In his view, the simplification of administrative costs should remove frustration from a beleaguered citizenry constantly at war with its insurance carriers, while simultaneously slashing the expense of running a healthcare system.

It is fortunate that the odds of getting this plan enacted soon are low, notwithstanding that his position is swiftly becoming mainstream in the Democratic Party. Of greater import is the catastrophic consequences that would follow its enactment.

Most fundamentally, Sanders and his many acolytes never ask hard questions about what the term “comprehensive” means. Many public healthcare plans, like that of Great Britain, wrestle with this challenge, knowing that aggregate demand for expensive medical services explodes whenever these are offered for free.

The extra services demanded cannot be supplied from existing personnel and facilities, so finding additional resources is expensive, given the inevitable diseconomies of scale. It is only possible to survive the onslaught by defining protected benefits relatively narrowly.

These systematic shortages are aggravated as the existing supply of medical goods and services shrinks, with the government imposing caps on salaries, drugs, and procedures. These shortages impose high costs as services are rationed by queuing, not money.

These queues spawn intrigue: the rich (who under the Sanders plan would be barred from paying private providers of goods and services) go either overseas or into the black market in order to obtain vital goods and services that less fortunate individuals cannot afford.

This grim picture is no idle abstraction. These incentive effects are so powerful that they will swamp any effort to improve national healthcare by government fiat.

It is conceptually indefensible and politically naïve to assume that healthcare is somehow “special” and therefore follows economic rules that don’t apply to other markets. In housing, it has been known for decades that rent control only aggravates shortages by creating massive distortions in housing markets.

In agriculture, ethanol subsidies for gasoline have wrecked the operation of both food and energy markets. In transportation, endless queues formed when price controls at the pump created systematic gasoline shortages. The lesson is that basic economic principles apply to all goods and services, no matter their elevated position in the social discourse.

We already have good evidence of the destructive effect of regulation on healthcare markets. The individual mandate of the Affordable Care Act (ACA) does in miniature exactly what the Sanders plan will do in the aggregate.

By mandating benefits and coverage formulas, it requires huge public subsidies to keep the program alive and then makes matters worse with its system of community rating. The combined effect of these initiatives is to contract severely the insurance market for individual healthcare policies.

The failure of central planning to work should lead people to shy away from universal healthcare, which will only magnify the same set of dangers. But instead, the constant refrain one hears today is that the public wants single-payer to ease the frustration and complications of the current healthcare system.

This common position makes the disease the cure. But there is another way: deregulation. Removing regulation can do two things that a national healthcare system cannot.

First, it reduces administrative costs by removing the role of government in decisions insurers should make about what goods to supply and what prices to charge.

Second, it increases the level of choice in the selection of healthcare coverage. There is no reason to think that every American needs exactly the same set of benefits regardless of age, health, sex, and income.

Choice is generally regarded as a virtue in markets that deal with food, transportation, housing, and other goods. It is a fatal conceit to think that healthcare is so unique that a central planner can decide at a low cost which of the thousands of permutations of goods and services belong in the one comprehensive nationwide healthcare plan, especially after dismantling the private sector—which would take away the essential information needed to best allocate scarce resources.

In contrast to central planning, markets tend to bring supply and demand into balance, as higher prices draw in more suppliers in case of shortages, while lower prices draw in more consumers in case of surpluses.

Price controls for healthcare services operate just like price controls everywhere else: the shortages they create ripple quickly through the entire economy. Delays in the provision of healthcare allow serious medical conditions to fester until emergency care becomes necessary, but prompt access to such treatment is far from certain.

Bernie Sanders misses the point because he lives in a Pollyannaish universe in which these fundamental structural principles somehow do not apply. Accordingly, he finds it all too easy to pin the breakdown in the current healthcare system on the villains of “the medical industrial complex.”

In so doing, he foolishly assumes that the high salaries paid to executives are unearned and should be plowed back into better services for the population at large. Wholly foreign to his way of thinking is that people who command these salaries function in a competitive market in which few players long prosper if they do not deliver to their customers benefits in excess of what they receive in exchange.

Unfortunately, Sanders starts from the Marxist premise that all contracts are forms of exploitation. He thus finds it hard to fathom the essential truth that markets work precisely because of the gains from trade that follow from voluntary exchange.

In 2016, Pfizer, for example, offered its CEO a compensation package of over $17 million, which is small potatoes against its nearly $53 billion in sales that year. On a daily basis, the CEO and his team have to make high-stakes decisions that go straight to the bottom line.

You pay top talent top dollar because complex businesses are exceptionally hard to run, especially in today’s regulatory environment. Perhaps Sanders thinks that every compensation committee in the land is afflicted with some deep confusion concerning the worth of its key officers.

Perhaps he also believes that institutional shareholders, to whom this information is disclosed in a myriad of ways, are duped just as easily.

Indeed, when he writes that the United States should negotiate down the prices of key drugs, he ignores the well-established point that a cut in prices will necessarily lead to a decline in pharmaceutical innovation. The large payments to drug companies would be a proper source of concern if they resulted from some improper use of monopoly power.

But under competitive conditions, these prices reflect both the high cost of getting drugs to market through the approval maze set up by the Food and Drug Administration, and, once some drugs run that gauntlet, the huge benefits they provide by stabilizing chronic conditions, responding to acute illnesses, and eliminating costly surgeries and other forms of intervention.

There is much that can be done to fix the American healthcare system. All sides of the debate agree that it costs too much to operate and supplies too few benefits. But there is no way that a system can control costs while catering to unlimited consumer demand. The law of unintended consequences applies to all social activities, healthcare included. It is this message that has to be hammered home in the upcoming debate over healthcare reform.

Maybe we should be getting away from the Medicare for all and consider other single payer ideas.

Democrats push ‘Medicare for All’ bills, but not all in the party are onboard and with the Mid Term elections almost upon us what should we expect?

Hunter Walker a correspondent for Yahoo wrote that Minnesota Rep. Keith Ellison, who is also a vice chair of the Democratic National Committee, became the lead sponsor of the House single-payer health care bill on Wednesday. The legislation has detractors among his fellow Democrats, but Ellison said he’s eager for a “debate” on the policy.

“Our movement is ascending, but the truth is that, for many years, people weren’t there,” Ellison said of the “Medicare for All” push in an interview with Yahoo News on Sirius XM’s politics channel, POTUS. “So more and more people are coming on every day, but not everyone is on. We have to convince them, we have to talk to them, we need to engage in a respectful, fact-based debate about which systems are the best.”

Ellison’s House colleagues voted unanimously to let him assume leadership of the bill, which is officially named “The Expanded & Improved Medicare for All Act” (H.R. 676). It was originally sponsored by Rep. John Conyers, D-Mich., who stepped down late last year amid allegations of sexual misconduct. The bill would establish a universal health care system akin to the Medicare program that currently exists for senior citizens and includes coverage for prescriptions, primary care, emergencies, and long-term care.

“Everybody would get a card, and you can get the care that you need, not unlike what they have in Canada right now. And truth be told, every major industrial country has a universal system; many of them have single-payer systems,” said Ellison.

Conyers first introduced the bill in 2003 with 25 co-sponsors. As of this writing, there are 121 co-sponsors of the bill, all of whom are Democrats. In the Senate, a separate Medicare for All bill has also been introduced by former Democratic presidential candidate Sen. Bernie Sanders, I-Vt.

No Republicans have signed on to the idea of Medicare for All, and the plan doesn’t enjoy universal support from Democrats. In the House, there are 72 Democrats who do not back the measure and 31 of the Senate Democrats don’t support Sanders’s bill in the upper chamber.

Polls show a growing number of people support a government-run health care system. The country is essentially split between those who want a public program and those who prefer private insurance.

Critics note Medicare for All would come with tax increases to pay for the trust fund that finances the program. “It would essentially be paid for through some taxes. One would be a 5 percent tax on high-net-worth individuals that just got a major tax cut a few weeks ago, so they got it,” Ellison said, adding, “There would be a financial transactions tax, and it would be a very small payroll tax to cover everybody.”

And overall, Ellison argued the program would “save a lot of money” by bringing down health care costs for individuals, including premiums, co-pays, deductibles and the price of medicine. “It would save the nation more than $500 billion a year, in large measure because of preventative care,” Ellison said.

Along with cutting down on expensive health emergencies due to lack of preventive treatment, Ellison claimed the bill would lower administrative costs associated with health care. Sanders has cited a similar $500 billion figure tied to those costs. Politifact called that claim “half-true” and said the number may be a high estimate, though there could still be “pretty substantial savings” of at least $300 billion.

Another sticking point for Medicare for All critics is the question of what might happen to people who currently have private insurance and are satisfied with their policies. Ellison did not answer directly when asked if he could make the infamous “if you like your plan you can keep it” promise that dogged President Obama following the implementation of the Affordable Care Act. However, he said there would be room for private insurance policies to exist under his plan.

“You would be able to take out private insurance policies for certain things,” Ellison said. “It’s not inconceivable that single-payer systems and private systems coexist. They certainly do in England right now, so it’s not really that big of a problem.”

While Ellison points to programs in Western Europe and Canada as exemplary models, some critics respond by noting that those programs are plagued by long lines and lower standards than the U.S. system. Ellison said health outcomes in this country have “lagged behind” other nations, a claim backed by some experts. He also pointed out Canadians are largely satisfied with their public health system and want to see it expand.

“I’ve never met a Canadian that wants to switch their system for ours,” Ellison said. “They like their system. Do they complain about it? Yes. Because guess what? People complain about stuff no matter where they live. … But I can tell you that people who live in Canada and benefit from that health care system, they like it.”

With all 435 House seats and 35 spots in the Senate up for election this year, Medicare for All has become a major question for Democrats on the campaign trail. The issue is in some ways emblematic of the divide that emerged in Sanders’s presidential primary race against Hillary Clinton and Ellison’s campaign for the DNC chairmanship, between the party’s progressive base and the establishment.

One Democratic candidate who has taken heat from progressives for not embracing Medicare for All is Talley Sergent, who is running to represent West Virginia’s second congressional district. Sergent also appeared on Yahoo News’ SiriusXM broadcast on Wednesday, and described Medicare for All as “an option.” We asked what she’d say if she won her race and Ellison called her up to ask her to sign on to his bill.

“Well, I’d appreciate the congressman calling me up, but I’m going to listen to the folks across West Virginia and make sure that it makes sense for people here,” Sergent said. “That’s who I care most about, and what they think and what they say.”

With his dual role as one of the top backers of Medicare for All and a leader of the DNC, Ellison is in a unique position. However, he said he doesn’t believe the party needs to take a side, and he thinks Democratic candidates can succeed regardless of their position on his bill.

“I think people can win for all kinds of things … all over the country. This is not a doctrinaire movement where we’re going to litmus-test people,” Ellison said.

Single payer: Yes! Well Maybe! but Medicare for all: No!

Shannon Tapia wrote last April that thankfully, the GOP did not pass Paul Ryan’s repeal and replace bill for Obamacare.  Immediately after, she saw a headline hopefully concluding, “Medicare for all may be next.”  In Medicare’s current form, this would be devastating for the health of America.  I am a young geriatrician; I know a heck of a lot about Medicare.  Most people don’t.  They just see it as a great perk of turning 65 in America and the social healthcare we offer to elderly and disabled.  I did too until I became a physician who only sees Medicare patients.

Medicare originated in 1966 in recognition that we needed to do a better job as a nation at caring for our aging and disabled who could not get employer-provided insurance.  In 1989 the Omnibus Budget Reconciliation Act established a fee schedule for Medicare payments.  This assigns “relative value units” or RVUs to everything we do for our patients in medicine.  The formula that determines RVUs disproportionately favors procedural care to time-based care.  Essentially, Medicare pays and incentivizes medical providers to do things to patients and actually disincentivizes physicians from taking their time with patients.

If you wonder why the doctor-patient relationship is not doing well right now, wonder no more.  Trust takes time.  Even family doctors who take Medicare have to turn their practice into a patient or low-risk procedure mill to make ends meet.  Medicare will pay a physician between $70 to $80 to freeze off a wart, a procedure that takes about 2 minutes to do, and 1 minute to document in an EMR.

In contrast, I can spend an hour with an elderly patient with multiple complicated issues, addressing their concerns, reviewing and adjusting their many medications, and coming up with a plan and then having to take 30 minutes later to document what happened and get paid essentially the same amount (about $80) had I just spent 3 minutes removing a wart and sending them out the door.  Is it any wonder that geriatrics is a dying field?

There was a time, however, when despite the RVU working against physicians who primarily use their time and knowledge to diagnose and care for patients, physicians still did it because they could make a decent living while being fulfilled in the solace they were helping.  But times have changed.  My father is a geriatrician.  He went to the equivalent of his state medical school from 1978 to 1982 for $5,000 a year in tuition.  No loans needed.  Had I gone to my state school (same as his) from 2006 to 2010, in-state tuition would have been $25,000 per year.  I came out of medical school with roughly $200,000 in debt at anywhere from 7 to 15 percent interest that accrues quarterly, and I’m lucky.

The physicians today in their fifties to seventies truly cannot comprehend the financial sacrifice new physicians make when committing to primary care today.  But, it’s not all about the money.  There is far more paperwork, tracking of useless data, non-patient care related work that we are forced to do that merely detracts from the already limited time we have to see patients and develop a relationship.  And we have to deal with this burden from day 1 of our practicing lives.  Many of the older docs have moved into administrative roles yet still remember clinical practice how they experienced it.  In turn, they create detrimental policies and regulations to feed metrics in the name of “quality” all while being clueless as to what it is like to actually treat patients in the modern era.

Some might argue that by expanding Medicare for all, it would cover less complicated patients so the current model shouldn’t be a problem.  I’d also beg to differ on that one.  Doing things to people, even prescribing medications, is dangerous and should not be taken for granted.  Medicare still incentivizes doing more invasive things for the least complicated patients.  Say we expand it to everyone, and a 22-year-old comes in with a cough she’s had for five days.  It’s viral.  Viruses are the worst.  There is no treatment other than time and support.  But convincing patients of this when they know I have the power to prescribe a Z-pak and they always get better on the Z-pak (20 percent of the effect of any treatment is placebo) takes a long empathetic conversation.

You know what is quick and easier?  You got it, just writing the darn script and moving on to the next person so I can get paid more.  And then we have massive bacterial resistance to azithromycin (the Z-pak) and C. diff is on the rise.

The numbers on all accounts point to the reality that Medicare’s RVU system of paying providers is causing worse outcomes, is unsustainable in cost and is not attracting young talented physicians to the most needed primary care fields.  I wonder how many of the new family docs will inevitably succumb to 10-minute visits with high procedures and more referrals to costly specialists or ultimately opt-out of Medicare and insurance for direct primary care?  Medicare spent 650 billion dollars in 2015.  An underestimate suggests 200 billion dollars (or 30 percent) was spent on beneficiaries in their final year of life.  That means we as a medical community, despite probably knowing the patients were dying, kept doing procedures and tests and more treatments to people because that is what we are paid to do.

American culture indoctrinates us that death is optional.  It’s really not.  But why would a physician take the time explain to a patient and family the reality of their situation, a conversation that is exhausting and challenging for everyone involved, when they are paid about 5x more to just offer another procedure or test and move on?  And then we spend billions of dollars doing things while ignoring the essentials that require time, and we get the worst outcomes.   The current Medicare, if expanded to all, will only exacerbate the costly failures of our current system.

A single-payer universal coverage system?  Maybe!  But, not Medicare as we know it.  Heed the geriatricians now and the patients covered by Medicare while you still can.  They are the most needed physician endangered species.

More on Single Payer Healthcare Systems to follow!

And the announcement- Our book is finally available from the Sentia Publishing Company: The Search for Excellence in Clinical Practice, A Handbook on Clinical Process Improvement for Providers. ISBN 978-0-997890-6-9.

 

Increased Burdens on the Healthcare System

!10475590_553091551487175_3290808461948566084_n

Initially I was going to continue our conversation from the last two weeks and discuss health care practice changes for the future. However, the fervor regarding the influx of undocumented illegal immigrants got me thinking about the numbers and the effect on other systems besides the legal issues.

According to the Texas Hospital Association, hospitals along the U.S.-Mexico border are reporting an influx of unaccompanied children. After children are detained by the border patrol, they are put under federal jurisdiction. Hospitals may request federal payment for the children’s care, you and I then pay the tolls; in the same way they’re already submitting payment requests for other undocumented patients. The whole situation may be incendiary and it seems that nobody wants to be responsible for saying something and ending up in an unflattering media spotlight. It seems that the journalists are being fed information to fit political messaging.

Go back to one of my earlier blogs when I discussed the numbers of uninsured people out there in the US. I mentioned the number of 11 million undocumented immigrants who didn’t have health care insurance. I also mentioned the fact that if the governing body had solved this issue of managing the undocumented aliens, by whatever means that we may want to consider, that the 11 million could eventually become tax paying, insurance purchasing part of the population, financially contributing to sustainability of the health care system.

I mainly discussed the California situation where the burden is felt throughout the health care provision system, in the form of non-reimbursed ER visits, hospital stays, physician visits, etc. The undocumented aliens will continue to stress the health care as well as the educational system.

I just had a patient in the office that, at the end of her Spring semester as a teacher had the principal bring 4 undocumented immigrants from Honduras who she, the teacher was supposed to integrate into her 6th grade class. Neither did she speak Spanish nor did the children speak English. The best is that although the students of Maryland are required to have the necessary vaccinations, none of these children had any of their vaccinations before being shunted into this teacher’s class. Best f all was that she had to provide the necessary school supplies from her own pocket, which she was not reimbursed. This now becomes a health care risk for the Honduran students as well as the rest of the class. Why, because they haven’t been immunized and that we are finding the undocumented immigrants coming across the border with chicken pox, scabies and tuberculosis.

Look to the European experience if you want to see what eventually happens with the influx of an abundance of non-tax paying illegal immigrants from the Middle East

They are a huge burden to the system, requiring increased funding of an already stressed system where waiting times are measured, not in minutes, hours or days. Instead there are waiting times of months for physician visits as well as for necessary surgical procedures. The British are already increasing their Value Added Tax from 17% to 27% and the patients will be paying co-payments, which their system has not had since 1948.

Not solving the continued poring of illegal immigrants over our borders will raise the numbers of uninsured, some uninsurable, to ballooning number of 12-15 million. What do we do then in a system that is already planning to solve the VA health care problem by shunting the Vets into the private and or ACA system?

Is anybody using their brain over there in Washington, D.C.? I think not or are they continually playing the game of politics?

The politicians, including the President as well as the idiots in the Senate and the House want to make the other party take the blame in order to boost their party’s mid-term election results.

The UN Secretary General made things even worse labeling this population of illegal aliens as refugees. They should be protected and integrated into our society. But I ask you, at what cost to the rest of the US population- educational, financial as well as the health care burden?

Nancy Pelosi, shut your mouth, come up with a constructive solution or bus/transport them all to your house, or at least your district! You then can bear the financial cost and health care burden.

This is a problem that has been brewing for years, but no one seems to want to solve the problem and possibly lose their seat in Congress, or worry about offending the “wrong” people.

Get over it and make some hard and constructive decisions! Otherwise the whole system will implode

Responsibilities of the Patient, the Doctor and the System/Skin in the game

Over the last many weeks we have discussed a number of pros and cons regarding the Affordable Care Act (ACA). Whether we want to argue the nature of free health care for all and the constitution, the fact is that health care for all is a great concept. Yes, our health care system is broken or sick and that it is considered to be the most costly with an extremely poor return on investment. Why?

The answer is simply yet complex. Our rights, our freedom, and desire to make money, allow us to make bad decisions and with no cost consequences. We demand expensive CT scans or MRI’s when we get headaches at no cost to each of us and “forcing” the health care worker and the health care system to provide these expensive tests to cover “their behinds” so that they won’t get sued or to reduce their liability.

Traditional medicine and our freedoms are making us sick. We as a notion lack self control and the results are that chronic diseases such as heart disease, stroke, cancer, diabetes, and arthritis are among the most common and preventable of all of the problems on the US.

I site the Mark Twain quote: “The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you druther not” That is, the four modifiable health risk behaviors that we just fail to improve are the lack of exercise or physical activity, poor nutrition, tobacco use and excess alcohol consumption. As Ron Graham further discusses in the Healthcare blog, these health risk behaviors are responsible for much of the high health care cost, illness, suffering and early death related to the chronic diseases that we discussed. Consider that the latest reported obesity rates is the US is 27.7%. Unbelievable!

How then can we improve the health care system if we “give” insurance coverage without consequence for bad behavior?

Also, we should think about the behavior of the health care worker.

Their behavior also has to change. But how do they do that if they are always worried about malpractice. The future of the health care system under the Affordable Care Act will depend on quality and quantity will not be paid and possibly be penalized. So, we need to make sure that physicians, nurse practitioners, physician assistants and others deliver the best health care efficiently and cost effectively without fear of lawsuits.

How will that be possible? Working on a book over the last 4 months on clinical process improvement, my co-author, Dr. Paul Gurny, and I realize the need for improving the clinical process through analysis, using strategic tools, benchmarking so that clinical protocols and critical pathways/ standards of care are established. Then as long as the care givers utilize these pathways/ protocols they are somewhat protected and the delivery systems are utilized to promote the best care for the patient, again, effectively, efficiently, cost effectively and resulting in the least number of errors and complications. Health care is in constant flux, but not all of the latest “improvements” are effective and some are so costly with minimal impact to good care to the most important factor in the equation, the patient.

How else do we promote great care and protect the health care worker, specifically the physician, who has the highest malpractice premium. Remember, this malpractice premium has to be paid before the physician can see even one patient or operate on any patient. Many physicians withdrew their memberships from the American Medical Association (AMA), because as physicians they were counting on the AMA to push for a number of important aspects of a new health care program including tort reform (malpractice reform), cost effective education for physicians and protection from continual discounting of their services. Consider the cost of the education of a physician. The average debt incurred by a physician in their education averages to about $325,000. Now consider that the payment for the services for the physician has been discounted continuously over the last 20+ years. Also, the new members if the insured under the ACA, were enrolled in the Medicaid system, a system that reimburses the physician at around 10 cents on the dollar. How then do they pay back their loans? How then do they pay their malpractice insurance premiums or the overhead of the offices including the new demands of an electronic medical record system (EMR), which on average costs the practice $30,000 per physician per practice? With the health care system if you don’t have an acceptable EMR the system will penalize the practice a minimum of 1% of each reimbursement.

The cost of medical education is out of site and we need to look at improving the system mirroring the European education system, which is supported partially or completely by the government. Also, the foreign education of the physician is often reduced from 8 years to 6 years. This alone makes the education of the physician more cost effective.

Tort reform, although not enacted has seen a crack in the malpractice legal armor. A number of states, currently 12, are in the process of working through “apology inadmissibility bills” where the physicians’ expressions of apology, sympathy or responsibility inadmissible in medical liability cases.

Idaho and five more states either have passed or are introducing standard of care protection acts, where the physicians will be protected from exposure to new causes of action based on whether the physician complied with quality and delivery improvement initiatives (remember Dr. Gurny and my book, clinical process improvement) outlined by the ACA.

These new laws as well as the proposed bills introduced in Congress would ensure physicians to excise their clinical judgment without the potential for medical liability claims based on quality reporting programs, performance metrics imposed by the ACA as well as those developed by strategic planning and process improvement.

In summary the ACA has a tremendous potential if modified to include improvement in a number of parts of the health care deliver equation. If patients don’t

Patients need to be involved with their care and need to see both benefits for good behavior as well as penalties for bad behavior to improve their health. The patients that ignore their health care providers and remain obese, continue smoking and eat without care letting their diabetes continue out of control need to pay more into the system. The healthy that “do the right things” to remain healthy, exercising, eating responsibly and never smoking or if they do smoking, involving in cessation programs, need to receive benefits with lower premiums, etc.

Doctors and other health care providers need to modify their behavior also to deliver cost effect quality care or suffer penalties for their bad behavior as well as bonuses for good behavior.

I believe the Republican Party has seen the light in trying to get the law thrown out and now sees the frailty in this strategy. Since it is law we all need to look to the future and make the future health care system effective and sustainable, delivering excellent care to all. Look to the Veterans Administration health care system to realize what can go wrong and build a better program.

Voters educate your selves and vote smartly, ignoring the media hype and lies! We are all part of the problem and all part of and responsible for our future.