Category Archives: Health Care

Trustees Report Warns Medicare Finances Worsening and Bernie Sanders is So Adamant in Medicare for All as the Answer to All Our Problems

 

22141171_1319583611504628_6195948361907076306_nPeter Sullivan reported that House Democratic Leader Nancy Pelosi(Calif.) said Thursday that “Medicare for All” proposals should be “evaluated” if Democrats win back the House this year, adding “it’s all on the table.”

Pelosi has long backed a public option for health insurance, but has not supported going further — as many Democrats want — and setting up government-run, universal health insurance.

The Democratic leader did not explicitly endorse the idea of Medicare for All during a press conference Wednesday, but she also did not rule out the proposal.

“I’ve always been for a public option so I’m always eager to talk about that,” Pelosi said when asked if Democrats would advance a public option or Medicare for All legislation if they win the House.

“Some of the other issues that have been proposed have to be evaluated in terms of the access that they give, the affordability of it and how we would pay for it, but again it’s all on the table,” she added.

Last year, Pelosi pushed back on the idea of Medicare for All, saying, “the comfort level with a broader base of the American people is not there yet.”

Medicare for All has been gaining traction among Democrats in recent years. The idea, championed by Sen. Bernie Sanders (I-Vt.), is now favored by many potential 2020 Democratic presidential contenders.

Many Democratic House candidates in battleground districts support the idea as well, which Republicans think will be a liability for them.

“When they come to Congress, any of those subjects can be on the table,” Pelosi said.

She defended the current Affordable Care Act as well.

“We believe in the Affordable Care Act, that it has the structure to take us forward in many different ways,” she said.

On CNN Thursday night, Chris Cuomo and Sen. Bernie Sanders (I-Vt.) spent a good 15 minutes talking health-care policy, but Cuomo started off with politics, noting that President Trump’s poll numbers are improving. “Don’t you think that President Trump deservedly gets credit for this strong economy, that it’s not just a byproduct of what’s going on globally?” Cuomo asked.

Sanders did not agree, saying Trump has to explain why Germany, Japan, Mexico, and the U.K. also have historically low unemployment. “Our economy is doing well in terms of unemployment,” he said. “But we are not doing well in terms of raising wages for working families,” and policy-wise, Trump “is going to war against working people. He is a tool of the wealthiest people in this country, and I think the American people understand that.”

Cuomo walked over to a whiteboard, saying he had done his homework and Sanders had to explain three things about his Medicare-for-all plan, starting with the idea that “socialized medicine,” and thus socialism, “smacks of the end of capitalism.” Sanders said Cuomo “is going to have to do some more homework,” pointing out that every other capitalist society has single-payer health care, and Americans love Medicare.

Cuomo noted that Americans hate change, and one in nine Americans works in healthcare, so Sanders’ plan endangers their jobs. “We will create more jobs under a rational Medicare-for-all system than currently exists,” Sanders replied. “There will be a transition, just in the same way, Chris, as we have to transform our energy system away from fossil fuel. We create more jobs, but there will be pain and you gotta deal with that pain.” “Right, but dealing with pain is not something that is done well in politics,” Cuomo noted, and they sparred about the political viability of raising taxes versus eliminating private health insurance costs — and also, more personally, family dynasties.

I couldn’t stand listening to Sanders anymore because he is such a Socialist and really doesn’t have a handle on the finances. Basically, he is an idiot and there are people who think that he has a good chance in the 2020 presidential election. Please, don’t let this man get any farther and put him in a retirement facility where he belongs.

Just read the predictions regarding the financial stability of Medicare.                       Ricardo Alonso-Zaldivar wrote that Medicare will run out of money sooner than expected, and Social Security’s financial problems can’t be ignored either, the government said Tuesday in a sobering checkup on programs vital to the middle class.

The report from program trustees says Medicare will become insolvent in 2026 — three years earlier than previously forecast. Its giant trust fund for inpatient care won’t be able to fully cover projected medical bills starting at that point.

The report says Social Security will become insolvent in 2034 — no change from the projection last year.

The warning serves as a reminder of major issues still languishing while Washington plunges deeper into partisan strife. Because of the deterioration in Medicare’s finances, officials said the Trump administration will be required by law to send Congress a plan next year to address the problems after the president’s budget is submitted.

Treasury Secretary Steven Mnuchin said in a statement that there’s time to fix the problems. “The programs remain secure,” Mnuchin said. Medicare “is on track to meet its obligations to beneficiaries well into the next decade.”

“However, certain long-term issues persist,” the statement added. “Lack-luster economic growth in previous years, coupled with an aging population, has contributed to the projected shortages for both Social Security and Medicare.”

Social Security recipients are likely to see a cost of living increase of about 2.4 percent next year, said government number crunchers that produced the report. That works out to about $31 a month.

At the same time, the monthly Medicare “Part B” premium for outpatient care paid by most beneficiaries is projected to rise by about $1.50, to $135.50.

Both the cost-of-living increase and the Medicare outpatient premium are not officially determined until later in the year, and the initial projections can change.

More than 62 million retirees, disabled workers, spouses and surviving children receive Social Security benefits. The average monthly payment is $1,294 for all beneficiaries. Medicare provides health insurance for about 60 million people, most of whom are age 65 or older.

Together the two programs have been credited with dramatically reducing poverty among older people and extending life expectancy for Americans. Financed with payroll taxes collected from workers and employers, Social Security and Medicare account for about 40 percent of government spending, excluding interest on the federal debt.

But demands on both programs are increasing as America ages.

Unless lawmakers act, both programs face the prospect of being unable to cover the full cost of promised benefits. With Social Security that could mean sharply reduced payments for retirees, many of whom are already on tight budgets. The report said the total annual cost of Social Security is projected to exceed total annual income in 2018 for the first time since the Reagan era, meaning the program will have to tap into reserves.

For Medicare, insolvency would mean that hospitals, nursing homes and other providers of medical care would be paid only part of their agreed-upon fees.

Medicare is widely seen as a more difficult problem that goes beyond the growing number of baby boomers retiring. It’s also the unpredictability of health care costs, which can be jolted by high-priced breakthrough cures, and which regularly outpace the overall rate of economic growth.

The Cabinet secretaries for Treasury, Health and Human Services, and Labor usually participate in the annual release of the report, along with the Social Security commissioner, and take questions from reporters. None of those top officials was present Tuesday; an aide cited scheduling conflicts.

The four top officials serve as the Social Security and Medicare trustees, along with two independent trustees who are supposed to represent the public. The public trustees are usually more candid, but those posts remain unfilled.

President Donald Trump campaigned on a promise not to cut Social Security or Medicare, but he hasn’t offered a blueprint for either program.

Democrats, meanwhile, want to extend the social safety net by spending more on health care and education. Advocates for the elderly said Tuesday there should be no cuts to Social Security benefits.

But federal deficits keep rising, and the recent Republican tax-cut bill is expected to add to the debt.

Last year’s tax law, which cut taxes on Social Security benefits, helped exacerbate the shortfall. So too did repeal of the individual mandate in so-called Obamacare, which promises to increase the number of people without health insurance and therefore Medicare payments for uncompensated medical care.

Higher deficits mean less maneuvering room for policymakers when the day of reckoning finally arrives for Social Security and Medicare.

In principle, the U.S. is supposed to be paying forward its Social Security and Medicare obligations by building up trust funds to cover future costs. That money is invested in special government securities, which also collect interest. But when the money is actually needed to pay for benefits, economists say a government deep in debt could be hard-pressed to make good.

Let’s get right to the point: Medicare is not going “broke” and recipients are in no danger of losing their benefits in 2026, but instead 2034. Now a more expanded breakdown of the problems.

Not broke, but not healthy                                                                                               However, that does not mean Medicare is healthy. Largely because of the inexorable aging of the Baby Boomers, program costs continue to grow. And, as the Trustee’s report forthrightly acknowledges, long-term costs could well increase even faster than the official predictions. The main risks: scheduled limits on payments to doctors and other providers may never be implemented and unknown future medical technologies are likely to increase all health costs, including for Medicare.

This will inevitably mean that either premium and/or taxes will rise; payments to doctors, hospitals, and other providers will grow more slowly; some benefits may be trimmed, or a combination of all three.

So what is the Trustee’s report, and what does it really say?

Hospital insurance                                                                                                                        The report is an annual exercise designed to review the health of the nation’s biggest health insurance program.  It looks in detail at each of Medicare’s pieces, including Part A inpatient hospital insurance; Part B coverage for outpatient hospital care, physician services, and the like; Part C Medicare Advantage plans; and Part D drug insurance.

Those “going broke” headlines are all about Part A Hospital Insurance (HI), which accounted for about 40 percent of the program’s $710 billion in spending in 2017. HI mostly is funded by the Medicare tax that is withheld from worker paychecks and paid by the self-employed.  And that tax—as well as other smaller sources of revenue– is not sufficient to pay the bills. It hasn’t been for years.

Because it anticipated the aging Boomers, Medicare built up a trust fund while its costs were relatively low. But that reserve is rapidly being drained, and, in 2026, will be out the money. That is the source of all those “going broke” headlines.

What will Congress do?

It doesn’t mean Medicare will stop paying hospital insurance benefits in eight years. We don’t know what Congress will do—though the answer is probably nothing until the last minute. Lawmakers could raise the payroll tax. But my bet is they’ll use general revenue to support the HI program, which is another way to say they’ll borrow the money and further raise the national debt.

Medicare Parts B and D are funded very differently, and are at no risk of “going broke.”  Unlike Part A, there is no dedicated tax for these programs. Rather, they are funded through a combination of enrollee premiums (which support only about one-quarter of their costs) and general revenues—another way of saying the government borrows most of the money it needs to pay for Medicare.

The coming political debate

As more Boomers age and health care prices increase, Medicare costs will continue to rise. Under the current system, that means premiums will continue to increase and so will government borrowing. The big political debate in coming years will be over how to divvy up those future costs. Will more of the burden fall on beneficiaries or will it fall on taxpayers at large who, eventually, will have to pay off the burgeoning government debt?

Because Medicare costs (like all health care costs) are rising faster than the overall economy is growing, the program will eat up more of the nation’s total economic output. And here is where the news really is scary.

Today, Medicare expenses are approaching about 4 percent of Gross Domestic Product. Under current law, the Trustees project it will increase to about 6 percent in two decades, then level off.

Unlikely assumptions                                                                                                                    But that forecast is built on several key assumptions that are unlikely to occur. In the 2010 Affordable Care Act, Congress adopted a package of cost-cutting measures. In 2015, in a law called the Medicare Access and CHIP Reauthorization Act (MACRA), it began to change the way Medicare pays physicians, shifting from a system that pays by volume to one that is intended to pay for quality. As part of the transition, MACRA increased payments to doctors until 2025.

But what if key ACA cost-cutting measures never take effect, the transition to the new physician payment system is delayed, and the temporary doctor payments continue indefinitely? In that case, the trustees forecast Medicare costs will not flatten out in the mid-2030s, and instead, keep rising—to 8 percent of GDP by 2070 and 9 percent of the entire economy by 2090.

That’s a long way away, you may say, and a lot can happen in the next 75 years. That’s true, but remember that whenever new medical technologies are adopted, overall health care costs tend to rise. So we face what the economists like to call an asymmetric risk: It is possible that future Medicare costs will grow more slowly than predicted, but it is more likely that they’ll be significantly higher than the trustees forecast.

The question is: What are we going to do about it?

Remember, this idea arose with Sen. Bernie Sanders (I-Vt.) during his 2016 campaign for president. Sanders knew that the term “nationalized medicine” would be seen as pejorative by a majority of Americans, so he renamed the concept.

Nationalized healthcare became “Medicare for All.” It was very creative on Sanders’s part. This has become the essence of the left’s proposals for how to pursue medical reform, now that ObamaCare has become too heavy a political burden to bear and is essentially non-functioning.

Even Democrats who presented themselves as being more moderate than the socialist Sanders — such as the two senators representing my home state of New Hampshire, Sens. Jeanne Shaheen and Maggie Hassan — have globed onto Medicare for All as the most convenient way to demonstrate their support for dramatic improvement in our nation’s healthcare system.

It is a spurious claim. It does not pass the smell test of political opportunism.

To assert that Medicare For All — or to use its more honest label, nationalization — would actually produce a better, more effective healthcare system for Americans is a hard sell when one looks at the facts.

The proposal is said to be legitimate because, after all, Medicare works fairly well for the older Americans who are insured by this national plan. So why would it not be just as good for everyone else?

As I have mentioned this seems like a reasonable view until it is submitted to rational analysis. Medicare works because the cost of the healthcare that is delivered to seniors is highly subsidized by those Americans who have private insurance.

It is estimated that the unreimbursed costs of hospital care under Medicare and Medicaid are approximately $58 billion a year. The vast majority of this cost is Medicare-driven. This means that the federal government when it so generously provides hospital coverage to people over 65, is only paying a limited amount of the real cost of the care.

The rest of the burden is borne by everyone else who has private insurance or by the hospitals eating the costs.

Thus if you go to a Medicare for All system, where everyone gets federally-paid health insurance — a nationalized system — the result will be billions and billions of dollars in unreimbursed costs.

Covering those costs becomes extremely problematic. If you look at the two major nationalized systems that presently are wrestling, unsuccessfully, with this problem, Canada, and the United Kingdom, it is evident that the quality and delivery of healthcare services are dramatically and negatively impacted.

Rationing, both overt and indirect, is one consistent outcome of a Medicare for All system as presently used in Canada and Britain. In Canada, the average total wait time to see a general practitioner, then a specialist, and then have a procedure is 20 weeks. This puts people at serious risk. It is one of the reasons that Canadians who can afford it come in droves to the United States for treatment.

In the UK, there is actually a board that determines whether or not a patient qualifies for a procedure. In part, it weighs the patient’s age against the costs and outcomes of the procedure. If you do not meet the criteria, you do not get the procedure.

These are only limited examples of the effects of rationing in these nationalized systems.

A significant reduction in the quality and number of people being attracted into the healthcare system is also a discernible result, as salaries are capped and costs related to quality are foregone.

The incentive to innovate and generate new medicines and procedures is also radically muted under nationalized systems.

The capital needed to pursue these expensive undertakings dries up due to the lack of adequate returns on the investment and the excess regulations of the government bureaucracy.

It takes about 12 years and $1 billion to bring a new, dynamic drug to the market. This type of investment simply cannot realize an adequate return in a nationalized system, and the development of breakthrough drugs and technology is therefore chilled.

Medicare for All, a.k.a. nationalization is one of those ideas that sounds good as a phrase in a stump speech. But if it were actually pursued, Americans would see a deterioration in their healthcare. All Americans would find that at some level their access to better care was rationed.

The track record of socialism in so many arenas is abysmal but it is especially so in healthcare. Yet this is the direction in which the left wants to take this country. The left calls out in full-throated hyperbole for a system they claim will give Americans Medicare for All. It is a failed and cruel policy but it has been sugar-coated in focus-group language.

My concern is and what the left should really be saying is that it wants Rationing for All. That would be a more honest statement of what would happen under the system of healthcare the leftists propose.

And remember, some of the States have taken steps to expand the Medicaid system, which counts on Federal funding as well as State funding. Where do you think that money will come from? Yes, we the tax-payers.

Health Care, Immigration Dominate California Governor Race. But Are We Sure We Want a Single Payer Healthcare System?

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California’s next governor faces a long list of challenges, from housing and health care to immigration. It seems like the upcoming mid-term elections that healthcare will be a dominant item in the debates. As Jonathan Cooper wrote, no topic has dominated California’s governor race like President Donald Trump including what he and the GOP are attempting to do with Obamacare. The Republicans want to be like him; the Democrats want to oppose him. But whoever wins will face a long list of challenges from housing and homelessness to health care. For example, all the Democrats say they support, at least in concept, “single-payer” health care — the idea that the government should pay for health coverage for everyone in the state, instead of the complex mix of employers, unions, individuals, Medicare and Medicaid that reigns today. But that didn’t stop it from being a major sticking point between them. Newsom was an enthusiastic supporter of a bill sponsored by the California Nurses Association that would implement a “single-payer” health care system. But it lacked key details, most notably a plan to cover the $400 billion cost. Chiang and Villaraigosa accuse Newsom of misleading voters with unattainable promises. Villaraigosa called it “snake oil.” For his part, Newsom calls his rivals “can’t-do Democrats” too fixated on the challenges of single-payer health care. Allen and Cox oppose single-payer health care.

Here are more of the specifics of the debates and is it really a single payer system or universal health care?

When Gavin Newsom campaigns on his support for a California single-payer healthcare system, he’s talking about more than the virtues of universal care. He’s trying to sell himself as a bold visionary.

When Antonio Villaraigosa warns of the financial calamity that awaits if the state adopts single payer, he’s trying to send a different message — that he’s a fiscally responsible realist who won’t make promises he can’t keep.

The debate over single payer in California’s race for governor reaches beyond how best to cure the inadequacies of health care in the state. It’s a political marker for the top Democratic candidates trying to woo different factions of their divided party and has emerged as the biggest policy flashpoint in the campaign.

“Single-payer health care has become a clear litmus test. If you support it, you’re a pure progressive. If you’re opposed to it, you’re a pragmatist,” UC San Diego political scientist Thad Kousser said. “It’s more of a declaration than a policy promise because this is never going to happen, certainly during the Trump presidency.”

But Newsom has promised to pursue a state-supported single-payer health care system if he’s elected in November. And fellow Democratic candidate Delaine Eastin, a former state superintendent of public instruction, also declared herself all-in on the concept. Both say California should lead the way but have been criticized by their rivals for failing to provide a concrete plan to fund such a program or overcome the many obstacles it would face.

Depending on who becomes the next governor, every Californian’s well being and bank account could potentially undergo a revolutionary change. With the June 5 primary just two months away, Newsom remains the clear front-runner.

Coverage of California politics:

“My opponents call it ‘snake oil,'” Newsom said at the California Democratic Party convention in February, a reference to Villaraigosa’s oft-used criticism of the lieutenant governor’s support for the plan. “I call it single payer. It’s about access. It’s about affordability. And it’s about time. If these can’t-do Democrats were in charge, we wouldn’t have had Social Security or Medicare.”

Villaraigosa dismisses Newsom’s campaign promise as a hollow attempt to entice the left. He said the system Newsom supports would require all Californians on Medicare to give it up in favor of a new, unproven state healthcare system — a declaration meant to rile up the 5.6 million residents covered by the popular federal program.

“Newsom calls any attempt to demand details of his $200-billion tax increase and plan to force seniors off of Medicare as ‘defeatist,'” Villaraigosa said recently. “I call refusing to say how you will successfully persuade Californians to more than double their taxes while taking away their Medicare simply deceptive.”

State Treasurer John Chiang, the other major Democrat in the running, has also urged caution. Instead of transforming healthcare in California in one fell swoop, the state should implement single payer bit-by-bit to ensure that it’s affordable and effective, he said.

“I support single-payer, but we have to be truthful here,” Chaing said during a fall Democratic debate in San Francisco. “How many of you want to pay an additional 90% in taxes? … Let’s scale up, see what revenues we have because we can’t cover everything.”

In Washington, former presidential candidate Sen. Bernie Sanders (I-Vt.) is leading a push for a plan that would, in essence, expand Medicare to provide healthcare to all Americans., For now, it’s little more than a political mirage — the Trump administration and congressional Republicans have been trying to repeal, not expand, government healthcare coverage provided under the Affordable Care Act.

With federal action unlikely, the California Legislature debated in 2017 whether to implement a state-sponsored single-payer system. The legislation, Senate Bill 562, was shelved in the Assembly over concerns about the cost and the lack of a comprehensive plan of how to pay for and implement such a massive new government program. A legislative analysis estimated the cost to be $400 billion per year. Half of the money for the system would come from existing state funds currently spent on healthcare, with the other half from new revenues such as a payroll tax, according to the analysis.

Newsom’s support of SB 562 has been nuanced. When he spoke at a convention of the California Nurses Assn., which endorsed Newsom and is the most vocal backer of the bill, he told the enthusiastic crowd, “It’s time to move 562.” But later, when talking with reporters, Newsom said he was referring to moving the bill through the legislative process, and acknowledged some “open-ended” issues still needed work.

When a coalition of labor unions, community health organizations and immigrant-rights groups tried to steer the health care debate away from SB 562 in March, proposing a series of measures to make healthcare in California more affordable and accessible, Newsom praised it as a “step in the right direction.” He said it had the potential to move California closer to universal coverage.

Villaraigosa and Chiang have accused Newsom of shifting his message on SB 562 to appease different audiences.

But Newsom has taken shots at them for playing both sides as well. Villaraigosa and Chiang say they support the concept of single payer — ideally at the national level — yet call Newsom fiscally reckless for supporting a California program. Newsom has insinuated that they lack the political courage to make it happen.

He also said the hand-wringing over the cost of single payer is an argument. “Most of the money needed to support a single-payer system already is being spent on the plans that it would replace, he said: government-run exchanges and private healthcare plans.

“I think we can achieve it. Let me tell you why: We’re already spending $367 billion a year on health insurance in the state of California,” Newsom said at a San Diego debate in February. “In every developed nation in the world that has a single-payer financing system, one thing is absolutely true: It costs less money than multi-player.”

U.S. healthcare tab to keep rising, led by higher costs for drugs and services, a government report says. Driven by rising prices for drugs and medical services, the nation’s healthcare tab will continue to outpace economic growth over the next decade, according to a new government report.

And by 2026, healthcare spending will account for almost one-fifth of the U.S. economy, an all-time record. The $367-billion figure Newsom used comes from a 2016 study done in part by Gerald Kominski, a professor of health policy at UCLA. Kominski agrees that, in theory, additional revenue might not be necessary if all of that money spent on healthcare in California can be funneled to a single state healthcare agency. Still, that would require permission from the Trump administration and Republican-led Congress — both hostile to Democratic leaders in California — to take control of Medicare and Medi-Cal funding Washington sends to the state, as well as convincing all Californians to switch to state-run healthcare coverage.

“There are still some significant barriers,” Kominski said. Micah Weinberg, president of the Bay Area Council Economic Institute, said Newsom fails to account for the increased costs of the comprehensive coverage being promised under a state single-payer system. Those costs include covering an estimated 1.8 million immigrant adults in California who are in the U.S. without authorization and covering long-term care not covered by Medicare, as well as eliminating all deductibles and other out-of-pocket expenses for Californians, he said.

“We’re being misled into believing that if you provide free universal care, it’s going to cost less,” Weinberg said.

Eastin, the only candidate of the four to throw her unequivocal support behind SB 562, has said implementing single payer is essential because “people are dying” for lack of proper healthcare. She has also acknowledged that it won’t be simple.

“What we have to do is have a conversation, an adult conversation, with real leaders at the table talking about how we’re going to close the gap and get additional money,” Eastin said at one of the Democratic debates, adding that she’s open to exploring different revenue sources, including a gross receipts tax.

The two top Republicans in the race, Rancho Santa Fe businessman John Cox, and Huntington Beach Assemblyman Travis Allen, have both ripped single payer as a government boondoggle.

Cox mockingly suggested that the state could also provide “single-payer food and single-payer housing” for everyone. Allen said it would be as efficient and customer-friendly as the DMV and bankrupt the state.

A 2017 poll by the nonpartisan Public Policy Institute of California found that 65% of adults in California favored the creation of a state single-payer healthcare program, but that support dropped to 42% when asked about paying higher taxes to fund it.

“You have to wonder, over time, whether this is an issue that candidates want to own,” PPIC President Mark Baldassare said.

Other states are having similar discussions regarding the single-payer system, whether it is Medicare for All or Medicaid for all or some other variety of a government-run system. But is the single-payer system the correct approach as I started reviewing last week?

“Medicare for all” is a popular idea, but for Americans, transitioning to such a system would be difficult, to say the least. Olga Khazan last year wrote that French women supposedly don’t get fat, and in the minds of many Americans, they also don’t get stuck with très gros medical bills. There’s long been a dream among some American progressives to truly live as the “Europeans1” do and have single-payer health care.

Republicans’ failure—so far—to repeal and replace Obamacare has breathed new life into the single-payer dream. In June, the majority of Americans told Pew that the government has the responsibility to ensure health coverage for everyone, and 33 percent say this should take the form of a single government program. The majority of Democrats, in that poll, supported single payer. A June poll from the Kaiser Family Foundation even found that a slim majority of all Americans favor single payer.

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Liberal politicians are hearing them loud and clear. Vermont Senator Bernie Sanders reportedly plans to introduce a single-payer bill once Congress comes back from recess—even though no Senate Democrats voted for a single-payer amendment last month. Massachusetts Senator Elizabeth Warren has also said “the next step is single payer” when it comes to the Democrats’ health-care ambitions.

But should it be? It’s true that the current American health-care system suffers from serious problems. It’s too expensive, millions are still uninsured, and even insured people sometimes can’t afford to go to the doctor.

Single payer might be one way to fix that. But it could also bring with it some downsides—especially in the early years—that Americans who support the idea might not be fully aware of. And they are potentially big downsides.

First, it’s important to define what we mean by “single payer.” It could mean total socialized medicine, in that medical care is financed by—and doctors work for—the federal government. But there are also shades of gray, like a “Medicaid for all” system, where a single, national insurance program is available to all Americans, but care is rationed somewhat—not every drug and device is covered, and you have to jump through hoops to get experimental or pricier treatments. Or it could be “Medicare for all,” in which there’s still a single, national plan, but it’s more like an all-you-can-eat buffet. Like Medicare, this type of single-payer system would strain the federal budget, but it wouldn’t restrict the treatments people can get. Because it’s the term most often used in single-payer discussions, I’ll use that here.

The biggest problem with Medicare for all, according to Bob Laszewski, an insurance-industry analyst, is that Medicare pays doctors and hospitals substantially less than employer-based plans do.

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“Now, call a hospital administrator and tell him that his reimbursement for all the employer-based insurance he gets now is going to be cut by 50 percent, and ask him what’s going to happen,” he said. “I think you can imagine—he’d go broke.” (As it happens, the American Hospital Association did not return a request for comment.)

The reason other countries have functional single-payer systems and we don’t, he says, is that they created them decades ago. Strict government controls have kept their health-care costs low since then, while we’ve allowed generous private insurance plans to drive up our health-care costs. The United Kingdom can insure everyone for relatively cheap because British providers just don’t charge as much for drugs and procedures.

Laszewski compares trying to rein in health-care costs by dramatically cutting payment rates to seeing a truck going 75 miles an hour suddenly slam on the brakes. The first 10 to 20 years after single payer, he predicts, “would be ugly as hell.” Hospitals would shut down, and waits for major procedures would extend from a few weeks to several months.

Craig Garthwaite, a professor at the Kellogg School of Management at Northwestern University, says “we would see a degradation in the customer-service side of health care.” People might have to wait longer to see a specialist, for example. He describes the luxurious-sounding hospital where his kids were born, a beautiful place with art in the lobby and private rooms. “That’s not what a single-payer hospital is going to look like,” he said. “But I think my kid could have been just as healthily born without wood paneling, probably.”

He cautions people to think about both the costs and benefits of single payer; it’s not a panacea. “There aren’t going to be free $100 bills on the sidewalk if we move to single payer,” he said.

He also predicts that, if single payer did bring drug costs down, there might be less venture-capital money chasing drug development, which might mean fewer blockbuster cures down the line. And yes, he added, “you would lose some hospitals for sure.”

Amitabh Chandra, the director of health policy research at Harvard University, doesn’t think it would be so bad if hospitals shut down—as long as they’re little-used, underperforming hospitals. Things like telemedicine or ambulatory surgical centers might replace hospital stays, he suspects. And longer waits might not, from an economist’s perspective, be the worst thing, either. That would be a way of rationing care, and we’re going to desperately need some sort of rationing. Otherwise “Medicare for all” would be very expensive and would probably necessitate a large tax increase. (A few years ago, Vermont’s plan for single payer fell apart because it was too costly.) Also, we have to go back even farther to see the experience in the great State of Massachusetts and their experience.

If the United States decided not to go that route, Chandra says, we would be looking at something more like “Medicaid for all.” Medicaid, the health-insurance program for the poor, is a much leaner program than Medicare. Not all doctors take it, and it limits the drugs and treatments its beneficiaries can get. This could work, in Chandra’s view, but many Americans would find it stingy compared to their employers’ ultra-luxe PPO plans. “Americans would say, ‘I like my super-generous, employer-provided insurance. Why did you take it away from me?’” he said.

Indeed, that’s the real hurdle to setting up single payer, says Tim Jost, emeritus professor at the Washington and Lee University School of Law. Between “80 to 85 percent of Americans are already covered by health insurance, and most of them are happy with what they’ve got.” It’s true that single payer would help extend coverage to those who are currently uninsured. But policymakers could already do that by simply expanding Medicaid or providing larger subsidies to low-income Americans.

Under single payer, employers would stop covering part of their employees’ insurance premiums, as they do now, and people would likely see their taxes rise. “As people started to see it, they would get scared,” Jost said. And that’s before you factor in how negatively Republican groups would likely paint single payer in TV ads and Congressional hearings. (Remember death panels?) It would just be a very hard sell to the American public.

“As someone who is very supportive of the Democratic Party,” Jost said, “I hope the Democrats don’t decide to jump off the cliff of embracing single payer.”

Common misconception: Not all European countries have single payer. But we all know that this is not true!! Those that have money can pay for private healthcare or travel to the U.S.A. for treatment.

More next week.

Remember, Father’s Day is coming up and our book is a great gift!!

“The Search for Excellence in Clinical Practice-A Handbook on Clinical Process Improvement for Providers” by Orsini and Gurny, published by Sentia Publishers.

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.

 

Uber, Walmart, Amazon and Berkshire Hathaway Get into Healthcare; And Now Uber Launches Service To Get People To The Doctor’s Office!

 

 

28059229_1452381504891504_6986021347674518630_nUber wants to get you from your home to your doctor’s office — and you won’t even need to open the Uber app. The company announced Thursday that it’s teaming up with healthcare organizations to provide transportation for patients going to and from medical appointments.

Receptionists or other staffers can schedule the rides for patients through doctor’s offices. And they can be booked for immediate pickup or up to 30 days in advance. That means patients without a smartphone — who wouldn’t be able to use Uber otherwise — can become Uber customers.

Instead of operating through an app, Uber Health will send its passengers’ ride information through an SMS text message. The company also plans to introduce the option for passengers to receive a call with trip details to their landline instead. Drivers will still use the Uber smartphone app to pick up these passengers.

“Transportation barriers are the greatest for vulnerable populations,” says Chris Weber, the general manager of Uber Health. “This service will provide reliable, comfortable transportation for patients.”

Transportation is, indeed, a barrier to good health care. Affordable access to a vehicle is consistently associated with increased access to medical care, according to a study. Around 3.6 million Americans miss doctor’s appointments or delay medical care due to a lack of transportation every year, according to the National Conference of State Legislatures.

To meet the medical privacy standards outlined in the federal HIPAA law, drivers won’t know which of their passengers are using Uber Health. Like a typical Uber ride, only a passenger’s name, pickup and drop-off addresses will be given to the driver. So Uber drivers won’t be able to opt into the health service the same way that they opt into Uber Eats, a food delivery service.

Peter Whorley, who drives a Honda Odyssey minivan for Uber in Fort Lauderdale, Fla., often picks up passengers who need the extra space, including patients traveling to and from doctor’s offices.

“I just picked up someone with back surgery the other day,” he says. “I like to help people, if they need extra assistance, I personally don’t have that problem. But some people might be squeamish, and not want to.”

Whorley, who has been driving for Uber for more than two years, is more skeptical about picking up people without smartphones. He thinks location tracking on smartphones is vital to the efficiency of the ride-hailing service. “When you’re a good passenger, you should be able to have your phone out to communicate with your driver,” he says.

Uber’s Weber says that because health care providers will use their best discretion in scheduling the rides, they won’t call Ubers for people in need of urgent medical attention. “It’s not a replacement for ambulances,” he says, but a reliable means of transportation to non-urgent medical services that he hopes will curb missed appointments.

One hundred healthcare organizations in the U.S., including hospitals, clinics, rehab centers, senior care facilities, home care centers, and physical therapy centers have already used Uber Health’s test program. The service will be rolled out to healthcare organizations gradually. The only part of this program is that they plan on billing the physicians and their organizations. I can’t agree with this concept, especially with the discounted insurance reimbursements.

And Here Comes The Uber Of Healthcare. CONCIERGE KEY Health is the first mobile app to provide healthcare consumers with on-demand access to elite physician specialists, urgent care clinics, and hospitals. Founder Robert Grant thinks that app-based healthcare is about to take off, digital journal.

The aim of CONCIERGE KEY Health is to eliminate excessive appointment and in-office wait times in the U.S. health system, through a consumer subscription-based membership. The app is based on concierge medicine model and it includes elite providers in all fields, from general practitioners to dentists.

The model enables patients to expedite the process of connecting to and consulting with elite top-tier doctors across the healthcare spectrum. Speed, convenience, and connecting with elite medical providers are the basis of the business model.

To find out more about this different approach to securing medical services, Digital Journal spoke with the founder, Robert Grant. Grant has previously had tenures at the ALPHAEON Corporation, Bausch+Lomb Surgical, and Allergan Medical.

We began by asking about the state of U.S. healthcare.

Digital Journal: What are the major challenges facing healthcare?

Robert Grant: “Healthcare has been upside down for a long time now because it has forgotten who the ultimate customer is: the patient.

“The overly complex and highly opaque healthcare third-party based ecosystem of today prioritize in the following order: payors (insurance companies), pharma, physicians, and finally, patients. This is due in part to the well-organized lobby and narrative of the industrial complex of healthcare, which is made up largely of payors and pharma corporations.

“We believe the healthcare ecosystem should be prioritized in exactly the opposite way of how it is structured today: first, patients; second, physicians providing care; third, products and finally payors.

“Because today’s industrial complex prioritizes the benefit of payors and pharma above physicians and patients, the entire analysis begins and ends with the ‘see-saw’ and the purported zero-sum game of cost versus quality of care. Forgetting that the ultimate customer of healthcare is the patient, today’s ecosystem is not focused on the patients/customer experience.

DJ: Why has health care become so bureaucratic?

Grant: “Because it is not clear who the customer is. When your doctor writes a prescription for medication to you, who exactly is the customer of that pharmaceutical product? Is it the pharmacy that inventories it? Or, is it the patient that picks it up from the pharmacy? Or, is it actually the third-party payor (insurance company) that pays for it? Or, is it really the doctor who wrote the prescription in the first place? Or, is it actually the patient who pays the premiums to the payors in the first place?

“It is an extraordinarily complex and opaque ecosystem, with all parties self-interested to maximize returns, and it isn’t clear that the patient is actually the customer. That way there is so much dissatisfaction in healthcare among patients.”

DJ: How can digital technology and automation help?

Grant: “Technology empowers consumers and further clarifies and magnifies the link and balance between vendors and customer. Vendors must serve the needs and demands of their customers.

“In virtually every other non-monopolized industry, vendors who fail to adequately serve their customers cease to exist. Cost and quality are not the only measures of performance. Customer experience and satisfaction play a major role in the so-called ‘Experience-Economy,’ which has penetrated every industry with widespread adoption by vendors and customers alike. Healthy competition sustains this balance between vendor and customer. Healthcare has been and continues to be the exception thus far.”

DJ: Please explain your new app and how it aids the patient.

Grant: “The CONCIERGE KEY Health app upgrades the healthcare experience for consumers. It provides personalized and on-demand access to the world’s elite physicians, including specialists, urgent care facilities and hospitals.”

DJ: What are the advantages with the app for healthcare institutions?

Grant: “Institutions will benefit from the CONCIERGE KEY Health app as it will reduce their financial dependence on payors and improve the healthcare experience for their customers, the patients. It will also provide a new service and revenue source that consumers want and are willing to pay for.”

DJ: What has the interest been from the medical community?

Grant: “The interest for CONCIERGE KEY’s “on-demand” service has been very high from the medical community. It appeals equally to patients and doctors alike. Longer doctor wait times, a better process to inform doctor selection than paid advertising and Yelp provide and the desire for a distinctive and personalized health experience are the major drivers of consumer demand.”

DJ: Which demographic groups do you think the app will appeal to most?

Grant: “Recent third-party surveys of approximately 900 consumers across 11 metro areas nationwide revealed a very high demand among 25 to 50-year-old consumers. There is a strong bias in the data toward family participation in CONCIERGE KEY.”

DJ: How have you addressed data security concerns?

Grant: “Our CONCIERGE KEY on-demand app includes state-of-the-art security protections and is HIPAA compliant.”

DJ: What else are you working on?

Grant: “We are laser-focused on perfecting our on-demand service. The market potential for this first patient-centric service is massive. Once we achieve our initial goals of widespread adoption of our on-demand service here and abroad, we see CONCIERGE KEY as an innovative platform for patient-centered and simple solutions to other healthcare needs, where we can help untangle unnecessary complexity and upgrade the overall healthcare experience for our subscription members.

DJ: How else do you envisage healthcare technology evolving?

Grant: “The entire healthcare debate has focused solely on the see-saw of cost versus quality of care. To us, these are simply the hygiene factors of healthcare. No company has embedded a truly keen focus and understanding of the patient experience. Healthcare is the largest industry in the United States, representing almost one of every five dollars spent by Americans every year. No other industry is so late to emphasize the motivators for consumers related to the customer experience as healthcare is.

“While new technologies to treat our various ailments emerge every year by gaining FDA approval, we believe the next leap of technology expansion will address the personalization and overall experience of patients within the healthcare economy and we intend to lead that effort.”

While CONCIERGE KEY Health is the first mobile app that provides on-demand access to specialists, urgent care clinics and hospitals for U.S. patients, it will be intriguing to see if an Uber-like model can develop in the healthcare space.

Uber Cofounder’s ‘Uber For Healthcare’ Startup Raises $14 Million.

While dozens of startups today look to Uber as a template for how to bring on-demand convenience to a long-standing market, one “Uber for healthcare” startup has an advantage. Its co-founder Oscar Salazar, who helped build the first Uber prototype, knows a thing or two about the $46 billion-plus valuation company first-hand.

Pager announced Tuesday it had raised $14 million from Ashton Kutcher’s Sound Ventures and New Enterprise Associates, with existing investors Goodwater Capital, Lux Capital, and Montage Ventures rejoining. The money’s aimed at expanding the New York City-focused service to new markets including San Francisco and Los Angeles and building out the product.

While services like ZocDoc and Doctors On Demand have made it possible for customers to find and book doctors more easily by computer or phone, Pager tries to take the process further by making your appointment instant and for a flat fee. A first-time urgent care visit is $50, and $200 after that. A physical is $100 and a phone consultation $25.

The parallels to Uber are peppered throughout Pager’s product. The service finds and verifies doctors for its network and bills you automatically over a linked credit card. There’s a $10 cancellation fee if you bail on an appointment after more than 5 minutes. And because the service is out of network, for now, it favors those for whom convenience can come at a premium to healthcare network costs.

That’s why it’s no surprise that Salazar is involved. Since building the prototype of the Uber app with billionaires Garrett Camp and Travis Kalanick, Salazar’s become something of an on-demand Uber exporter. He’s got a co-founder title with Ride, an app to bring Uber-like convenience to carpooling. Last month he linked up with another startup to work on an “Uber for trash.” Salazar doesn’t work full-time or daily at any of these startups.

“I don’t build companies, I help people build companies,” says Salazar. “It’s part of my strategy to work with companies like Uber because I can do my job faster and I want to have value to add.”

As Salazar helps with high-level product issues and builds out technical teams, it’s up to operators lesser known than Kalanick to execute at each one. At Pager, that’s the job of CEO Gaspard de Dreuzy. “Pager is focused on delivering a broader range of care options on demand” that exist today, de Dreuzy says. “It could be a tele-consult via phone or messaging, or an in-person visit in the home, or a referral to the right specialist. We like to think of ourselves as the Amazon for healthcare.”

Eventually, Pager will build partnerships with national providers to improve their own customer reach, says new investor and NEA partner Mohamed Makhzoumi. That’s where Pager’s vision may translate into large numbers of users, as its technology helps push the rest of the industry to improve its tech. Otherwise, Pager’s pricing and pitch could come off—as Uber once did—as a service of convenience for the well-heeled Donotpaginate

The influence of Salazar’s background helped with investors and with the product. It also helps Pager stand out among a dozen of startups striving for attention. But Salazar himself makes it plain that he’s not helping any of his startups score major Uber partnerships trading off his reputation at Uber HQ.

Salazar’s already got a new area where he’s looking for an “Uber for X”: education. “ They all share a narrative, Salazar says. “All the projects I’m involved in have a social impact. That’s where startups can change the world faster.”

Amazon, Berkshire Hathaway, And JPMorgan Chase Launch New Health Care Company. Health care costs are “a hungry tapeworm on the American economy,” Berkshire Hathaway Chairman and CEO Warren Buffett says, and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their U.S. employees at a lower cost.

The new company will be “free from profit-making incentives and constraints” as it tries to find ways to cut costs and boost satisfaction with the health care plan for employees of Amazon, Berkshire Hathaway, and JPMorgan Chase. The trio unveiled their new venture in a news release.

“The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost,” the companies said.

The enterprise unites three of the largest and most envied companies in their respective sectors — from retail to banking, and including Berkshire’s wide portfolio of companies such as Geico and Fruit of the Loom. And in Buffett, Amazon’s Jeff Bezos and JPMorgan’s Jamie Dimon, the companies also have veteran leaders who have shown an ability to solve vexing business problems.

According to recent annual reports, taken together the three companies employ more than 950,000 people worldwide. The three CEOs say they’re aware of the enormous challenges they face. “The health care system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” said Jeff Bezos, Amazon founder, and CEO. “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.”

Responding to the announcement Tuesday morning, White House economic adviser Gary Cohn told CNBC “we agree in that philosophy. We think that individual workers should have to pay less for health care.”

Still, the Trump administration already “created association health-care plans, which is the exact same thing that those companies did,” Cohn said, referring to an executive order last October that sought to make it easier for employers to combine efforts in offering insurance. That order also opened the possibility some groups could get coverage across state lines — “a move that Republicans have long advocated as a way to lower costs,” NPR’s Scott Horsley explained at the time.

“Smaller businesses could pool their employees together to get more purchasing power,” Cohn added Tuesday, “so they could save money on health care.” NPR’s Scott Hensley tells Morning Edition there is a precedent for the case of a non-health care company wading into the healthcare business — “in fact, it has happened repeatedly.”

“One of the most prominent examples is what is now Kaiser Permanente, a big provider of health care in this country. It started with the Kaiser shipyards and providing, first, workers comp kind of care and, later, more integrated health care for employees,” Scott explains. “So it is possible.”

The particulars remain scarce at the moment, though. Details such as the company’s name, a base of operations and long-term leadership weren’t included in a joint news release about the new company that was sent out Tuesday morning.

At the start, the new company will be led by executives from each of the troika of giant firms: Marvelle Sullivan Berchtold, a managing director of JPMorgan Chase; Todd Combs, an investment officer of Berkshire Hathaway; and Beth Galetti, a senior vice president at Amazon.

JPMorgan’s Dimon said, “The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.”

Everyone seems to want to get the market for health care and thinks that they know what the solution is to the healthcare crisis. Remember that in 2014 Walmart decided to get into Primary care. Walmart’s New Primary Care Clinics Shake up Healthcare Market

Walmart has recently launched half a dozen primary care clinics across South Carolina and Texas, with plans to open six more before January. Staffed by nurse practitioners, in a partnership with QuadMed, these clinics are fully owned by the company and branded explicitly as one-stop shops for primary care.

Prior to this, Walmart’s 100-plus retail clinics were hosted through leases with local hospitals. With a walk-in visit price of a mere $40 (and $4 if you are a Walmart employee), Walmart’s goal for these clinics is to be a low-cost alternative to traditional options.  Additionally, the clinics will also stand out from competitors as they will be open for 12 hour days on the week and 8 hours (per day) on the weekend.

The rollout of clinics is beginning in rural areas, where doctors are scarce.  When comparing the number of hospitals in urban versus rural areas, Definitive Healthcare’s hospital database’s search accounts for 2,228 hospitals located in rural areas, but 3,871 hospitals located in an urban geographic location.

Previously, Walmart only offered what is known as “convenient-care-clinics” or “retail clinics,” which treat uncomplicated minor illnesses and provide preventative health care services.  Besides Walmart, CVS offers their Minute Clinic through this model, as well as Target’s Target Clinic.  With their new clinics, Walmart will be able to support a broader range of services such as chronic disease management.

The New York Times examines this news on Walmart, by also comparing their model to Walgreens.  In 2013 Walgreens also began offering primary care services in their 400 clinics across the country.  They were the first-ever chain retailer to become a direct provider of primary care services.  Walgreens, however, differs in that they are still reluctant to call their facilities primary care clinics, while Walmart put that label front and center.

Additionally, Walgreens differs because also last year, they became the first mover when they began partnerships with ACOs.  Their partnership with three providers, Advocare Walgreens Well Network (New Jersey), Diagnostic Clinic Walgreens Well Network (Florida), and Scott & White Healthcare Walgreens Well Network (Texas), was aimed at participation in the Medicare Shared Savings Program (MSSP).  This was the first retailer/provider partnership that will try and improve care and reduce costs of Medicare.

Definitive Healthcare’s healthcare database tracks intelligence on 600+ accountable care organizations (ACOs), including those affiliated with Walgreens. In addition to the three MSSP ACOs, Walgreen is also in collaboration with four other ACOs, such as Centura ACO Health of Colorado.  Definitive Healthcare’s database provides intelligence on 34 members of that ACO, as well as tracks their technology modules of HIE and EHR/EMR.

Instead of replacing one’s primary care physician, as what is intended with Walmart’s goal, Walgreens instead stresses that their collaboration will provide a comprehensive experience for the consumer.  They still want the majority of care coming from the patient’s physician group or health system, but Walgreens would just add distinct value to the ambulatory network, etc.

While it still is a bit too early to tell, The Advisory Board Company has already written on how the Walgreens’ ACO partnership is on the right track. As Walmart continues to roll out these physician centers, it will be interesting to track the success of these new clinics. Walmart’s clinics will accept Medicare but currently does not accept third-party insurance.  The timing of these new clinics could benefit greatly from the changes resulting from the Affordable Care Act.

And as another article reported Thomas M. Loarie Walmart To Put MRI Scanners In Stores and Will Charge $400/Scan. The US Healthcare System is Anti-Middle Class Says Healthcare Executive /  Middle-Class Friendly Walmart to Place MRI Units in its 3000 Stores by 2018. James Orlikoff, President of Orlikoff and Associates (Chicago), outlined the economic pressures related to healthcare that are going break the middle-class if we “do not break rather than bend the healthcare cost curve.” His comments were made during a pre-meeting workshop, “Something Disruptive This Way Comes: Preparing for Consumerism in Healthcare” at last week’s 23rd Annual Health Forum and American Hospital Association Leadership Summit in San Francisco.

“Rapidly increasing deductibles and co-pays along with means testing by Medicare are pushing healthcare financial risk to the patient.” And with a slow growth economy, personal income growth is being more than offset by healthcare expenses.

Orlikoff went on to say that despite the enactment of the Accountable Care Act (Obamacare), healthcare spending is forecasted to accelerate this year and continue for the foreseeable future.  The modest increase in healthcare spending over the last few years was due largely to the recession.

He went on to say “We have known this train wreck has been coming but we did nothing about it.” Its effects extend beyond healthcare to the general economy as healthcare continues to take a big bite out at 18% of GDP. We are at a significant competitive disadvantage with emerging economies where healthcare represents only 3-5% of GDP. He added that competitiveness is critical. Without it, we will be unable to create the jobs and income critical for the middle class that pays for healthcare.

“Even healthcare systems cannot afford to buy their own product for their employees.”

These economic factors are attracting consumer companies to the healthcare services market. CVS, Walgreens, Rite-Aid, Target, Walmart, Apple, and others eye the $30 trillion to be spent on healthcare over the next decade as an opportunity and see the consumer as the new decision-maker.  The retail pharmacies and rapidly growing urgent care centers are improving access, quality, and convenience while reducing cost.

As healthcare moves from wholesale to retail, cost-based pricing is being transformed to price-based costing. Walmart today offers a “truss” for those who have inguinal hernias in lieu of having surgery – $50 versus $5800-$10,000. Walmart has announced it will put MRI’s (diagnostic imaging) in all of its stores by 2018.Orlikoff said Walmart plans to price an MRI at $400.

Can they, the Walmarts, the Ubers, Amazon and Berkshire Hathaway know anything about healthcare or the solutions to health care?

Back to the discussion of a Single payer healthcare system!

Increased Burdens on the Healthcare System

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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.