Election 2012: As Healthcare Goes, So Goes the Nation

Pivotal. Monumental. Constitutive. So much is at stake in the 2012 presidential elections that many have put its significance on par with the country’s first election, as well as the 1860 contest that spawned the American Civil War.  It is also a study in stark contrasts.

Perhaps nothing elucidates more sharply the axiological difference between the candidates than their approach to healthcare reform.

Without doubt, the Affordable Care Act will have a devastating impact on the economy and the sustainability of the U.S. healthcare industry. As a physician, I also have grave concerns about the very fundamental changes that ObamaCare, if not repealed, will inflict upon the American way of life. Rather than entrusting physicians to make informed clinical decisions and tailor care to individual patients, ObamaCare represents thousands of pages of new regulations that control office visits, operating rooms, consultations and treatment options. It ultimately prohibits the ability for doctors to provide the best possible care.

Few things are as sacrosanct as the relationship between patients and their doctors. We have laws that recognize the confidential nature of the alliance between people and their lawyers, and protect the “attorney-client privilege”.  We safeguard interactions between people and their pastors.  We hold dear the “spousal privilege” that protects the sanctity of conversation within a marriage. And historically, we have held the essence of the relationship between patients and their doctors in the same inviolable regard. 

As a country, we have always recognized that patients and their doctors are in the best position to make decisions about what is right for them and their families.  We have valued the very personal and private bond that occurs within the confines of the exam room.

For the first time in history, the Affordable Care Act threatens the very fiber of the patient-doctor relationship by inserting a host of government mandates and regulations that legislate what doctors can and cannot do. ObamaCare represents an egregious intrusion of the federal government into what was formerly hallowed ground.

Although the Affordable Care Act was passed in 2010 and is just now in the process of full implementation, the seeds of its philosophical transformation were sown from the beginning of the Obama administration.  Medical education itself has changed, as medical students and young physicians have been taught to rely on government issued “guidelines” and standards set by bureaucrats not trained in science. They have been inculcated with the concept that cost-of-care trumps quality, and that the government is better able to make decisions about treatment options than doctors and patients.  As a result, we are training an entire generation of doctors who are little more than reasonably competent “healthcare technicians”.  They have no understanding of how to assess and care for the whole patient, weigh treatment options, and make well-reasoned clinical decisions.

In what can be best described as linguistic subterfuge, ObamaCare’s architects and supporters have co-opted conservative terminology such as “personal responsibility” and “market competition”. They have hijacked these phrases in hopes of surreptitiously passing off their centrally planned and statist concepts. Forcing people to purchase a government-defined product -- and threatening them with a hefty tax penalty for failure to comply –is not “individual responsibility”. It’s extortion.  These requirements serve only to drive costs up and severely limit choice.  The healthcare law, and the new “insurance exchanges” that it mandates, are designed for overwhelming government control and income redistribution rather than for individual choice and free-market competition.  As with every other sector of the economy, liberals simply refuse to believe that the free-market can work in healthcare, and therefore, the government must intercede.

Despite President Obama’s claim that the insurance mandate will guarantee that everyone will now have access to care, “Insurance” is not “assurance” of anything; plummeting reimbursement and ObamaCare’s over-whelming intrusion into the treatment room will cause tens of thousands of highly-trained doctors to leave the practice of medicine, worsening an already critical physician shortage. The multitude of new taxes and entitlements included in the Affordable Care Act will devastate our economy and impoverish future generations.  Mandates and regulation will cripple medical innovation and technological advancement.  In short order, ObamaCare will lower the overall standard of living for Americans.

When the focus of healthcare delivery becomes standardization, and cost-containment, there is no option but for quality to suffer and rationing to ensue. How can physicians possibly render personalized treatment when they are restricted by mandates dictated by appointed bureaucrats like the Independent Payment Advisory Board (IPAB)? How can they provide the best care when they are being pressured by an auditor at an Accountable Care Organization (ACO) to keep costs down? Patients need a doctor who can be an advocate, as well as an expert to provide professional medical expertise. A physician should never be put in a position to choose between doing what is best for a patient and what has been mandated by the government. I took an oath to first and foremost, “do no harm”; ObamaCare will force me, and others in my profession, to violate that crucial first principle of medicine.

In speaking to medical students in 1908, famed poet Rudyard Kipling noted, “There are only two classes of mankind in the world – doctors and patients.” Americans no longer have the luxury of remaining apathetic or uninformed about the potential impact of this election.  It is incumbent upon all of us to vote and to encourage others to do so. If President Obama is re-elected, future historians will reflect on the period from 2008-2016 and conclude that he successfully forced the government take-over of American healthcare, and in so doing, sounded the death knell, both for democracy and for the greatest healthcare system on the planet.

Fighting for Our Lives: The Ten Worst Things About ObamaCare

The gauntlet has been laid down. With less than 50 days until the election, and what many agree will be the most significant political and philosophical decision point of our lifetimes, it’s time to take the gloves off. Not in terms of dirty politics, misleading television commercials or mud-slinging, but with regard to educating the American public about exactly what calamity will befall us if we do not vote President Obama out of the White House and repeal the Affordable Care Act (ACA). The clock has run out; the time is nigh. Failure to repeal this legislation before it is fully implemented will have nothing less than devastating consequences for our country and our lives. Americans need to fully engage in this battle.

In writing the majority opinion of the Supreme Court and upholding the constitutionality of the ACA, Chief Justice John Roberts stated:  

“Members of this Court … possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our nation’s elected leaders, who can be thrown out of office if the people disagree with them. It is not our job to protect the people from the consequences of their political choices.”

In so writing, Chief Justice Roberts challenged the American people to speak loudly and decisively with their votes on November 6^th. In the critical remaining days before this election, we need to be armed with the overwhelming and compelling facts about the travesty known as ObamaCare and we need to broadcast these truths from every pulpit:

1) ObamaCare will increase healthcare costs

Although one of the primary stated goals of ObamaCare was to bend the cost curve downward, the average price of a family policy has risen by $2,200 since passage of the law. Costs for families, individuals, doctors and hospitals are expected to rise further as additional components of the law are put in place. In addition to the direct impact on healthcare costs, ObamaCare will levy more than $569 billion in new taxes to offset its massive entitlement spending.  Many of these taxes have nothing to do with healthcare, including new taxes on bio-fuel, investment income, and tanning salons.

2) ObamaCare will increase the deficit

When the bill was passed in March 2010, leading House Democrats proclaimed that it would significantly reduce the deficit. Within less than 6 months of its passage, the CBO essentially doubled the cost estimates from $940 billion to $1.76 trillion and those same House Democrats were forced to admit that the bill was not even “budget neutral.” Current estimates put the cost of ObamaCare at over $2.6 trillion between 2014 and 2023. The reality of this bill’s monumental impact on increasing the deficit has become clear.

3) ObamaCare will limit patients’ healthcare choices

Despite President Obama’s promise that “you will be able to keep your health plan and your doctor” under the new system, that is far from likely; more and more physicians will refuse to accept Medicare and Medicaid patients as a result of inadequate reimbursement from these programs. A large percentage of businesses will drop their current healthcare insurance plans rather than try to meet onerous requirements and rising costs. Furthermore, the law prohibits Americans from paying out of pocket for services that are not covered by healthcare insurance and makes it unlawful for physicians to render those services. This hardly constitutes legislation that promotes choice or provides any element of control to patients and their families!

4) ObamaCare will decrease quality

Think of all the people that you know who fly to Canada, Cuba or the United Kingdom for their healthcare. Can’t think of any? That’s not a coincidence. Government run healthcare systems rely on a capitated budget. What that gets you is rationing of services, long wait times and limited access to the newest drugs and latest technologies. Significant increases in the number of insured, combined with a host of new entitlements promised in ObamaCare, will tax the supply of practitioners beyond capacity. More than 60 percent of physicians say that the increase in patient volume will hurt the level of care they can provide. There will be a leveling of quality amongst physicians because physicians will no longer have to compete for patient business, they will lose their autonomy regarding patient care decisions and their incomes will be capped. The vast majority of physicians will ultimately become government employees and Americans will get exactly the type of compassionate and personalized care that we currently receive at the U.S. Post Office and the Department of Motor Vehicles.

5) ObamaCare will control decisions made by doctors and other healthcare providers

Make no mistake: ObamaCare represents a clear and absolute government takeover of the healthcare system. Federal bureaucrats – not physicians – will determine what healthcare benefits and services are “essential.” Doctors and hospitals will face a tsunami of new regulations and reporting requirements to ensure that they are following the government’s definition of “quality care.” Hundreds of pages of new “guidelines” have already been produced, aimed at “educating” practitioners on ways to “manage finite resources” and “limit overuse of services.” Everything from preventive care and screening services to chronic disease treatment protocols are being rewritten by government appointees and bureaucrats – not based on new scientific studies, but based on actuarial reports that evaluate the cost of services rendered. These new guidelines are nothing less than a thinly veiled manifest for healthcare rationing.

6) ObamaCare will decrease access to care and increase the physician shortage

What good is an insurance card in your wallet if there aren’t any doctors to see you? The United States was already facing a significant shortage of physicians prior to the passage of the ACA; studies have estimated that there will be a deficit of more than 69,000 doctors by 2015. Adding an additional 30 million people to the rolls of the insured will make that shortage worse. More importantly, increased patient volumes and decreased reimbursement is driving physicians out of practice; 43 percent say that they are considering retiring within the next five years as a result of the new law.

7) ObamaCare slashes Medicare

Maintaining his usual distant but cordial relationship with the truth, former President Bill Clinton proclaimed at the Democratic National Convention that the new legislation “does not cut Medicare services.” While technically correct, it is irrefutable that the ACA cuts $716 billion from Medicare, and those cuts will come from drastic reductions in payments to doctors and hospitals. Medicare actuaries predict that 40 percent of physicians will either go bankrupt or stop seeing Medicare patients altogether as a result of these cuts. So while ObamaCare may theoretically extend the life of the Medicare trust fund, the reality is that there will be no Medicare providers to staff it and seniors will be left with a worthless insurance subscription.

8) ObamaCare negatively impacts job creation

Small business is the engine for job growth in America. As a result of the “employer mandate” – that portion of the legislation that requires employers with more than 50 employees to provide government-approved health insurance for their workers or face federal fines – many companies will limit hiring in order to stay below the 50 employee minimum. Furthermore, as many as 60 percent of employers intend to increase the portion of premiums that workers are required to pay. Recent surveys indicate that others – as many as 35-40 percent – will simply stop providing coverage for their workers and opt to pay the fine, forcing employees to purchase their own insurance from state exchanges. The most powerful job creation plan Congress could enact would be to repeal ObamaCare!

9) ObamaCare violates religious freedom

Despite its many promises to the contrary, the Obama administration has refused to respect religious liberty in implementing the Affordable Care Act. The new law guarantees women access to “free” sterilization procedures and contraceptives, including drugs that are intended to induce abortions. At issue is the requirement that faith-based institutions such as Catholic universities and hospitals either violate fundamental tenets of their faith by providing the offending drugs and services in their employee healthcare plans or face the federal fines for failing to meet the employer mandate. Although HHS has promised to issue some type of “accommodation” following the election, it is unlikely that it will truly allow religious organizations and individuals to freely follow the teachings of their faith without government intrusion.

10) ObamaCare violates personal freedom

In a breathtaking assertion of congressional authority, for the first time in history, the federal government will force citizens to use their own money to purchase a product – healthcare insurance. The fact that the Supreme Court ruled that the penalty for not complying is a “tax” does not attenuate this stunning conscription. Not only does it mean that Americans are compelled to purchase a product every month for the rest of their lives, but it reflects an intrusion of the government into our private lives in a way that was heretofore unimaginable.

Americans are just beginning to understand the misadventure that is ObamaCare. It is time that we accept Chief Justice Roberts’ challenge to protect ourselves from the consequences of our political choices. We must educate others on the facts about ObamaCare and the egregious assault it will levy on our personal liberties and healthcare as we know it. We must vote for the candidate who has vowed to repeal this abomination. Fight as if your life depends on it, because it does.

Entitlement Programs: Government Sanctioned Bondage

Responding to recent calls for entitlement program reform, Democratic Congressman, Henry Waxman proclaimed, “Republicans want to repeal the twentieth century.” In so doing, he further propagated the familiar liberal refrain that conservatives’ heartless approach to fiscal responsibility will somehow result in America “reverting back to” the dark and dangerous place that it was before the New Deal and the Great Society – You remember, when hordes of children were starving in the streets, and the elderly were left to die in the gutters?

As compelling as this revisionist history seems to be to liberals, the factual reality is that taking from others has never been a necessity of survival in this country.  The personal responsibility, hard work and independence that existed before the birth of the entitlement state resulted in a self-sufficient society where individuals took care of themselves.  Confidence and pride in this capability is what fueled America’s bitter battle for our independence from British sovereignty.  Prior to the birth of the welfare state, the vast majority of Americans were able to support themselves through productive work.  Those who fell on hard times relied on family, neighbors, church groups, local ethnic groups, and trade unions, rather than the government.  They exhausted personal savings, pursued private and commercial credit, and sacrificed on all but the bare necessities.  Today, most families living at or below the poverty line have cars, color televisions, and cell phones with data plans – none of which were provided by government entitlement programs.

Much has been written about the crippling cost of burgeoning entitlement programs – Medicaid, healthcare reform, welfare, housing and education subsidies, corporate bailouts -- and the inability of our local, state and federal governments to bear the growing financial burden.  These programs are clearly at the heart of our current financial crisis. But what of their unspoken costs; the insidious undermining of ingenuity, motivation, tenacity and drive –the very qualities that made America great?

There is a not-so-subtle numbing and demotivating effect that comes with the “free-lunch”.  Why sweat, struggle and persevere when an outstretched hand will garner the same reward?  Furthermore, repeated acceptance of handouts creates an on-going dependency – and growing commitment to – the giver, and a slow, steady abdication of freedom.  Even mother birds eventually, and predictably, push their young out of the nest.  That’s how they learn to fly.

Given Democrats’ recent consternation about Mitt Romney’s support of “unshackling” the private sector from onerous, job-killing regulations,--and the Vice President’s irresponsible retort that Republicans intend to “put ya’ll back in chains!” -- where is the moral outrage that our current entitlement policies are not only bringing us to our knees economically, but are functioning to enslave millions of Americans – Black, white, male, female, young and old?  An entire generation has forfeited any hope of self-sufficiency or independence in exchange for government freebies.  This time around, however, no one has been forced into involuntary servitude; instead, they have been lured, by the millions, into the lair of dependency, with the tantalizing promise of security and the chimera of “something for nothing”.  In the process, they have unwittingly traded personal freedom for the latest party favor.

Supporters of the welfare state will cry that any comparisons of entitlement programs to bondage are apocryphal and intentionally incendiary.  But make no mistake: Once the government controls and provides your food, your housing, your education and your healthcare, they own you.  They own you every bit as much as if you were picking cotton in their fields.  Physical chains have been replaced by economic and psychological ones, but the impact on the individual is the same. Ultimately, what allows men to be free is self-sufficiency -- the ability to choose and control where to live, what school to attend and what doctor to see.  Once an individual becomes reliant on the government for these services, and once the entitlement becomes ingrained in the culture, financial and emotional enslavement ensues. In each case, the recipient trades independence and free choice for the handout.

Liberal politicians always want us to believe that they have launched a “free-lunch” program that is intended to address some gaping chasm that will otherwise swallow leagues of under-privileged and downtrodden citizens.  But surely no one truly believes there is such a thing as a “free lunch”. Politicians, and the government institutions they control, always want something in return. Ultimately, their goal is not to provide improved nutrition or to keep the poor from starving, but to create dependency. Dependency on entitlement programs translates into votes, political support and control. Empowerment and self-sufficiency make for a healthier and more resilient society, but dependency is what gets politicians elected.

Despite the country’s dire financial situation, the current administration has upped the ante even further: They have expanded their approach from ensuring that entitlement programs are available, to actively recruiting people to sign up for them.  A recent set of radio ads features two women out on a shopping excursion when one exclaims to the other “My, but you sure do look good these days!”  Her friend explains that her new, attractive figure is a result of improved nutrition since she has signed up for food stamps.  She goes on to encourage her friend to do the same: “It’s easy -- You can sign up too!” Democrats are actively pursuing new members to join the dole!  What was once perceived as shameful and a resource of last resort has been elevated to high-fashion status.

In retail, every season has its sales theme that directs consumer marketing; we have “White Sales” in the spring, “Father’s Day Sales” in June, “Labor Day Sales” in September, and we will have non-stop “Free Lunch Sales” between now and the November election.  Liberal politicians will work desperately to garner votes by promising to both protect current handouts and to expand entitlement programs even further. 

Promulgators of entitlement programs would have us believe that anything not provided by the government will directly result in deprivation of the populace: if you cut school lunch subsidies, children will starve, and if we fail to provide free healthcare, people will die on the streets. And the entitlement mentality that has become so prolific in this country will lull the masses into further submission and dependency. Liberals will continue to tell their tale of impending misery if program cutbacks are allowed to occur, while conservative politicians will be buried in a heap of opprobrium for simply attempting to rein in spending and balance the budget. In the words of Rep. Allen West (R-Fla.) "We [conservatives] reject the idea of the safety net becoming a hammock."

In a recent prayer for our nation, American Christian Evangelist, Billy Graham, offered “Your Word says 'Woe to those who call evil good,' but that is exactly what we have done. We have lost our spiritual equilibrium and reversed our values. We have exploited the poor and called it the lottery. We have rewarded laziness and called it welfare… We have neglected to discipline our children and called it building self-esteem. We have abused power and called it politics… We have ridiculed the time-honored values of our forefathers and called it enlightenment.”

And we have allowed politicians to disguise control as a “free lunch program” and called it entitlement.

America cannot and will not return to greatness until we break free from our current entitlement mentality, and elevate self-reliance, tenacity and personal responsibility to their former iconic status.

Of Medicaid, State Budgets and Government Coercion

On June 28, 2012, the Affordable Care Act received a highly controversial stay of execution from the Supreme Court; in a 5:4 decision, the Justices ruled that the individual mandate does not represent a constitutional over-reach, and that the entire bill should fundamentally remain intact.

This historic decision will reshape the American healthcare system, perhaps irreversibly, and going forward, will serve as legal precedent for the highly manipulative use of taxation to further facilitate usurpation of our rights.

Regardless of the recent High Court ruling however, individual states would have been left to contend with escalating healthcare costs and burgeoning uninsured populations – A fact that even relegating ObamaCare to the gallows would not adequately address.  The fact is that current Medicaid spending for low-income American consumes twice the percentage of most states’ budgets than it did just 25 years ago, and this spending is simply not sustainable.

Across the United States, 20% of the total population is enrolled in Medicaid, with Utah setting the lowest percentage at 11%, and California marking the high at 30%. Total Medicaid spending in 2010 was $390B, $126B of which was borne by the states themselves.

ObamaCare was designed to include a significant expansion of Medicaid eligibility, ultimately intending to bring an additional 17 million low-income Americans into its fold.  Although the Federal government is slated to cover the costs of the expansion initially, subsequent increased costs will be on the States’ tabs.  Even had the “Affordable Care Act” been struck down in its entirety, however, the flailing economy and weak jobs market has caused Medicaid rosters to explode.  Most states are feeling the crushing impact of their growing Medicaid populations: The number of Texas residents who qualified for the program doubled from 2000 to 2011. State officials say the new federal law will no doubt deal Texas another financial blow as they struggle to cover an additional 1.8 million low-income residents, but the problem was already well established.  Likewise, Medicaid enrollment in Colorado increased nearly 58% between January 2007 and December 2011 as a result of the economic downturn and the State’s own program eligibility expansion. Add to that another half-million or so new Colorado Medicaid enrollees courtesy of ObamaCare, and one begins to understand the magnitude of the problem. States can afford just so many lining up at the trough.

The burden of providing health insurance to low-income residents has become so onerous that a number of states are now working to craft their own solutions to rising costs and the uninsured. Vermont, for example, has a plan to replace its traditional insurance model with a single-payer system. In their plan, the state would act as a publically funded and managed insurer, setting reimbursement rates and paying healthcare providers itself, much like the Canadian system. Once again, however, the devil is in the details; no one has yet figured out how to pay for such a plan.  It is not a blind leap to suspect that hefty new taxes and serious restrictions on healthcare choices will have to be part any large-scale state-administered insurance program. 

As the States struggle to deal with the growing Medicaid liability, it is worth noting that while Obama’s reform plan remains wildly unpopular, the GOP has yet to launch a credible alternative that has garnered the support of the populace either.  Congressman Paul Ryan’s plan to overhaul Medicare was not widely embraced, and other “plans” suggested by conservatives have been long on rhetoric and short on detail. 

In a recent opinion piece, political analyst, Scott Rasmussen, posited that lack of consumer involvement and control was ultimately responsible for our healthcare insurance crisis.  According to Rasmussen, “Both plans [Obama’s and Ryan’s] are unpopular because neither one puts consumers in charge of their own health care decisions. More than anything else, that lack of consumer control is the root cause of the health care problems facing our nation today.”  Even apart from consumers’ lack of personal and fiscal accountability regarding health and life-style decisions, Rasmussen has a point when it comes to the acquisition of health insurance.

First, Rasmussen’s argument gets to the proverbial “carrot vs. stick” dilemma: ObamaCare was designed for ultimate governmental control over the system, and it intends to employ a hefty stick, in the name of a tax, to levy on those who do not comply with the mandate to buy insurance. Second, is the more subtle and more insidious fact that people do not place the same value or appreciation to those things that are either chosen for them or forced upon them.  

A more palatable approach would be to align incentives such that consumers are motivated to purchase their own insurance, and to arm them with tools to make the most prudent and informed choices for themselves and their families.  This includes the multitude who are currently preparing to be embraced by the newly expanded Medicaid cloak, many of whom might be inclined to seek out private insurance rather than settle for the public option if they were appropriately enticed to do so.  Let’s face it: Does anyone really think that the public option will be a better one than private insurance?  Public housing with a fresh coat of paint is still public housing; and most people would far prefer another alternative.  Since most Americans recognize that it isn’t in the country’s best interest to have millions of uninsured citizens drawing resources from the system, the challenge becomes how to approximate “universal coverage” on a more voluntary basis.

For the 50% of the population that actually pays taxes, offering broader tax incentives would likely result in more people voluntarily buying insurance.

Rather than companies providing insurance for their employees, workers should be allowed to use employer designated monies, as pre-tax dollars, to pick their own insurance plans, supplementing with personal funds if the plan chosen costs more than the company has allocated, and perhaps keeping the surplus if they opt for a less expensive one.  Part and parcel with such an approach is to have a wide variety of competing insurance plans for employees to consider, including options with both high and low deductibles and corresponding premiums.

People should be able to buy insurance policies across state lines, and take their policies with them should they leave and choose other employment.

It is also high time to end the federal antitrust exemption currently granted to health insurance companies, eliminating price-fixing, bid rigging, and market allocations.

Lastly, and not insignificantly, healthcare insurance companies should be allowed to offer attractive discounts to subscribers who make proactive healthy life-style choices such as maintaining a normal BMI, exercising regularly and not smoking, in the same way that auto insurers reward safe driving records and homeowner’s insurers incentivize fire suppression systems.

All of this would result in increased free-market competition among insurance companies, and would likely do more to drive down costs than any amount of government interference or regulation.

Many of these same strategies could be instituted for the newest population of Americans who are heading to flood the Medicaid program.

Rather than further burdening the states to provide additional residents with subsidies in the form of Medicaid -- and rather than trying to strong-arm citizens to purchase insurance for fear of the tax hammer -- aligning incentives to drive consumer engagement and desired behaviors, and empowering people with information to make informed decisions about their healthcare is a far more worthwhile approach.

Healthcare or Otherwise: Is Government the Righteous Steward of Taxpayers’ Money?

Legend has it that when asked why he robbed banks, Willie Sutton replied, "Because that's where the money is."  If the original Slick Willie were still around and in business today, he'd likely be going after some bloated federal government program instead of banks.  He'd find it far more lucrative, and by all appearances thieves almost never get caught.   A brief examination of Medicare and Medicaid prove the point.

One of the more contentious issues in the healthcare reform bill has been the elimination of more than $500 billion in future Medicare spending in order to claim that the bill was paid for.  At the same time that these cuts (portrayed by the administration as “savings”) were announced, congressional democrats were assuring seniors that no decreases would be made in coverage or services.  And so it goes: The shell game accounting scam that has defined the Affordable Care Act continues. 

A better option to balancing the numbers might have been to stanch the hemorrhaging from the gaping hole in the program that results from rampant fraud and abuse – an approach that may well deliver the same amount of “savings”.  Moreover, the unfettered outpouring of fraudulent Medicare payments, and the government’s historical ineptitude in controlling this enormous problem, ultimately begs the credibility of the federal government as a competent steward of the people’s money

Although estimates vary somewhat, Republicans and Democrats alike acknowledge that Medicare fraud accounts for between 10 and 30 percent of the total program spending.

This is not a new revelation; In 2007, the Department of Justice and the Department of Health and Human Services formed the Medicare Fraud Strike Force, a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing.  Strike Force teams were established in seven cities believed to host significant fraudulent schemes: Miami, Los Angeles, Detroit, Houston, Brooklyn, Tampa and Baton Rouge.  Despite the Strike Force’s best efforts, fraud and abuse have continued to escalate.

In 2009, Tom Coburn opined that nearly 20% of Medicare’s $500-plus billion annual spending is for fraudulent claims.  The senator said, "If you look at Medicare and Medicaid, both vital programs today, they're highly inefficient. People claim that they're efficient. Medicare has at least $80 billion worth of fraud a year. That's a full 20 percent of every dollar that's spent on Medicare goes to fraud”.

With some minor variations, the Congressional Budget Office concurs. CBO actuaries reported that total Medicare spending was $528 billion in 2010, and that $47.9 billion was determined to be for “improper payments”, aka fraud.

Like Medicare, Medicaid has also been a target for egregious fraud and abuse. The Medicaid program is administered by the states, and fraud has become a major problem for all of them. New York State, for example, has a total budget of $116 billion, $50 billion of which was spent on Medicaid in 2011. According to actuaries, as much as $18 billion of that amount – more than one-third - is fraudulently claimed. 

Apparently, ripping off Medicare and Medicaid is so lucrative that a number of organized crime families in the U.S. and abroad have diverted efforts towards it in preference to more traditional and more dangerous organized crime pursuits.

The fact is that the Medicare program is a prime target for fraud because it is based on the "honor system" of billing. It was originally established to assist physicians who provided medical care to the needy. In an attempt to prove efficiency, there were few safeguards to identify and eliminate false claims. Claims are paid automatically and with minimal review in what is known as a “pay and chase” model, because the goal of Medicare is not to root out false claims, but to pay claims quickly and smoothly.

Now, to be fair, the Obama administration has not completely ignored the continued fraudulent siphoning of monies from the Medicare coffers.  The Affordable Care Act of 2009 provides an additional $350 million to pursue physicians who are involved in both intentional and unintentional Medicare fraud through inappropriate billing.

In 2011, Federal authorities were successful in recovering $4.1 billion from fraudulent Medicare activity, but they spent millions of dollars to recover it.  Likewise, states recovered $1.7 billion in fraudulent Medicaid payments in 2011; the bad news is that the government had to spend $208 million in the process.  Just last week the Government Accountability Office reported that the National Medicaid Audit Program spent $102 Million of taxpayers monies since 2008 in order to identify less than $20 Million in overpayments. With returns on investments like these, it’s no wonder that people are questioning whether the Center for Medicare and Medicaid Services (CMS) should really hold the keys to the till.

It’s a recurring theme: The additional anti-fraud provisions baked into the healthcare reform bill simply allow the government to spend significant sums of money in an attempt to recoup fraudulent payments that may well be less than what it costs to recoup them.  Furthermore, they still lack a clear process to assure that the problems are actually resolved. ObamaCare is spawning bureaucratic offshoots aimed at plugging holes in a highly riddled system.  In this case, layers of additional bureaucracy are being added to an already bloated system, in hopes that additional tax dollars and more government involvement will somehow render the system less prone to fraud.

Ultimately, the problem is that the government shouldn’t be running healthcare in America, because it simply can’t do it efficiently, cost effectively or with reasonable oversight.  Let’s face it; the types of losses regularly sustained by Medicare and Medicaid would never be tolerated by the private sector.  These types of losses are frowned upon in real businesses operating in the real world.

Conventional wisdom suggests that prior performance and a demonstrated history of responsible and successful appropriation of funds are worthy attributes in a potential management vehicle.  Few would feel comfortable giving carte blanche authority to a private entity to administrate a half trillion-dollar program if that entity routinely posted losses of 20 to 30 percent due to “improper payments”.

Pompous overconfidence that “government knows best” and stunning inability to control and manage spending have served as the leitmotif for this entire administration.  Perhaps the flagrant fraud and abuse in the Medicare system should provide the final evidence that the private sector, not the government, is best equipped to manage the people’s money.

                                                   story by Kelly Victory MD

More Blowback from Healthcare Reform: The Growing Physician Shortage

On March 21, 2010, the House of Representatives passed the Patient Protection and Affordable Care Act, and completed what then Senator Ted Kennedy called “the great unfinished business of our society”.  In so doing, congress purportedly ensured that every American would have access to quality, affordable health care, as a right and not a privilege.

While the 2700 pages of the bill include a vast array of new insurance and physician requirements, and hosts of new patient entitlements, perhaps nothing has gained more attention than the bill’s mandate for health insurance coverage.  In addition to controlling and driving down escalating healthcare costs, the final health insurance reform legislation had the highly publicized goal of care accessibility for all Americans.  Apparently, the bill’s architects believed that mandating healthcare insurance would somehow translate into assuring this access to care.  In the vernacular of the Left, “insurance coverage” has become synonymous with “care access”. Nancy Pelosi herself stood at the podium and announced, “This bill assures that millions of previously uninsured people are now covered, so that now all Americans have access to healthcare!”  Ah, the power of Liberal magic! 

Unfortunately, as seems to be the case with so many things that the Democrats control, someone forgot to do the math.  America was already facing a significant shortage of physicians prior to the passage of the reform bill.  Adding more than 30 million newly insured people into the system will make the deficit far worse.

The Association of American Medical Colleges’ Center for Workforce Studies released new estimates that show physician shortages will be 50 percent worse in 2015 than forecast.  "While previous projections showed a baseline shortage of 39,600 doctors in 2015, current estimates bring that number closer to 63,000, with a worsening of shortages through 2025," the group said in a statement.

In addition to the 30-plus million people newly insured as a result of the mandate, the federal government plans to expand Medicaid coverage to low-income adults and to subsidize purchases on the health insurance exchanges.  These potential new patient numbers are additive to an already aging population with a steady increase in the incidence of chronic disease.

Although there are some preliminary plans in the reform bill to increase the number of primary care physicians, none of the provisions will have any impact on the doctor shortage by 2014, the year that most of the insurance coverage mandates go into effect.  Unfortunately, a nicely laminated insurance card will not mean much to patients without providers to actually care for them.  Ultimately, what has been touted by the Democrats as a solution to lack of healthcare access is tantamount to addressing a hunger crisis by passing out gift certificates to Denny’s in a town that has no Denny’s!

To exacerbate the issue further, despite being reassured repeatedly that we will love life in the new world order of healthcare reform, the majority of Americans have significant distrust for the bill, and most are concerned that it will ultimately increase the cost of care while lowering quality and extending wait times. 

Physicians, in particular, are unhappy with the bill – So unhappy that many feel that they will retire or look to other avenues for employment.  In a survey done in 2010, nearly one-third of all practicing physicians indicated that they would leave the medical profession if the healthcare reform legislation was signed into law. The survey was conducted by the Medicus Firm, a leading physician search and consulting firm, and was published in the New England Journal of Medicine. A majority of physicians interviewed said that healthcare reform would cause the quality of medical care in America to “deteriorate” and that it could well be what sends a sizeable number of doctors out of medicine altogether.

Nearly a third of the over 1,100 doctors who responded to the survey said that they personally would quit the profession or retire early if the bill became law.  A whopping 63 percent of physicians said they would not recommend the profession after healthcare reform passed.

In addition to many doctors abandoning their practices entirely, the healthcare reform legislation will likely have a significant impact on practice styles for those who remain in the game.  In response to a huge influx of new Medicaid patients and others covered by plans with low reimbursement, physicians will continue to migrate toward hospital-based practices and other employment models where reimbursement is less uncertain. Physicians will also likely reduce or entirely eliminate patients from certain insurance categories, including Medicaid and Medicare.  Interestingly, a study co-authored by the American Medical Association, the Association of American Medical Colleges (AAMC), and the Council on Graduate Medical Education (COGME) noted “a strong correlation between the decline in inflation-adjusted physician fees and the decline in average physician hours worked per week”, suggesting that physicians tend to work less the less they are rewarded. Wow.  Who knew?  While some doctors will simply work less, others will opt to open concierge-type practices in order to avoid third-party payers, and some will move to temporary, locum tenens or part-time work.  The cumulative effect however, is the same: They all result in the overall decrease in physician hours and a reduction in patient access to care.

Americans who live in areas that already have a shortage of physicians will likely experience escalating wait times for appointments as the ranks of newly insured patients increase. Those who move into a new community may well have difficulty finding a doctor who accepts new patients, especially if they are on Medicare or another government subsidized plan.

Healthcare was already a financially precarious industry.  Well prior to the passage of the reform bill, a large percentage of doctors felt that they would not be able maintain their practices if patient loads continued to increase while reimbursement decreased.  The average debt for a medical school graduate is $140,000, and many students rack up school loans approaching a quarter of a million dollars or more. By definition, cost savings on healthcare will not be achieved by limiting access to health insurance, as the insurance mandate does just the opposite. Proponents of the bill maintain that rationing of care is not their goal.  Savings, therefore, will have to come from reduced fees to doctors and other care providers. As a result, even if there are still some willing to make the onerous time and work commitment to medical education and training, being a doctor is becoming less and less financially feasible.

It appears that an unintended consequence of the healthcare reform legislation may be a very dramatic decrease in the physician workforce, coincident with an all time high on its demand.  This now limited workforce will be relied upon to care for our growing aging population, our escalating numbers of obese and chronically ill, and the tens of millions of patients newly insured through health reform.

Whether or not the Supreme Court overturns the recently passed legislation, no version of health care reform will succeed without an adequate supply of physicians.  It is therefore incumbent upon Congress to enact policies that increase the nation's primary care and specialty physician workforce.  The medical practice environment must also be changed to ensure a physician workforce that is motivated and robust. Improved and standardize reimbursement processes, serious tort reform, a reduction in medical educational debt, increased clinical autonomy, and reciprocity of state medical licensure are needed to attract new doctors to the profession and to encourage those already in it to remain.  If we fail to protect medicine as an honorable and sustainable career and to ensure a rewarding work environment, lack of physicians will be the new form of rationing.

                                                            written by Kelly Victory

Tragically, Repealing ObamaCare Will Not Be Enough; the Seeds of Healthcare Rationing have already been Sown

As of this writing, we are likely only weeks away from knowing how the Supreme Court will rule regarding the constitutionality of the Patient Protection and Affordable Care Act, otherwise known as ObamaCare. As egregious as the legislation is in its disregard for the constitution and the most basic of personal liberties, one would be misguided in believing that its over-turn by the nation’s highest court would guarantee the safety of our healthcare system from the socialist wiles of our current president.

Forging ahead without concern for the very recent Supreme Court hearings, the Obama administration has surreptitiously diverted nearly $500 million of the Department of Health and Human Services’ (HHS) $1 billion “implementation fund” to the IRS, which is responsible for over-seeing the individual mandate provision of the new law.  This money is only part of the IRS’s total planned spending for the implementation phase, and it is being provided outside the normal appropriations process.  It appears that HHS intends to spend the entire sum before the presidential elections this fall, and most of it before the Supreme Court renders its verdict in June.  Republican lawmakers have thus far been unsuccessful in freezing the slush fund until the Supreme Court rules on the legislation’s future.

In addition to spending the pot of implementation monies as quickly as possible, an article published earlier this month in the New York Times revealed some other insights into how the Obama administration plans to mitigate the impact of a potential Supreme Court ruling against the healthcare reform bill.  Perhaps in preparation for its defeat, in part or in toto, the “American Board of Internal Medicine Foundation” (ABIM Foundation) came out with new guidelines aimed at decreasing the performance of a number of common tests and procedures.  Representatives from the foundation claim that these new recommendations are simply an attempt to curb “unnecessary care and overuse of the system”.

The recently published recommendations are part of the ABIM Foundation’s “Choosing Wisely” initiative. According to the group’s website, this involved, amongst other things, physicians, patients and “other stake-holders” meeting to discuss various responsibilities of the healthcare community in “managing finite resources”.

While many of the Foundation’s recommendations are rife with complex medical terminology and explanations, even the average layperson can read others and understand the significant philosophical shift that is being suggested.

Here is one example from the recently released guidelines:

“Don’t perform Pap smears on women younger than 21.”

For decades, the standard of care has been for women to get Pap smears to screen for cervical cancer three years after becoming sexually active or at age 21, whichever came first.  Given that many females are sexually active in their mid-teens, this would mean initiating Pap testing at age 18 or 19, or perhaps younger.  These traditional guidelines also increased the likelihood that young, sexually active females were being seen by a clinician, screened for sexually transmitted diseases, and receiving counseling.  The Foundation’s explanation for this new delayed screening recommendation? 

“Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost.” 

But what about the abnormalities that don’t regress and are actually cancerous or precancerous? Sexually active women are at increased risk for cervical cancer, regardless of having reached their 21^st birthdays.  To suggest that we put a higher priority on “anxiety” and “cost” (the real issue) rather than on early detection is preposterous.  And this is from the folks who chastised Republicans for not caring about women’s health issues!

Here is an even more frightening new recommendation from the Foundation whose website positions them as focused on “medical professionalism”:

“Don’t perform routine cancer screening for dialysis patients with limited life expectancies.”5

Their reasoning?

“Due to high mortality among end-stage renal disease (ESRD) patients, routine cancer screening—including mammography, colonoscopy, prostate-specific antigen (PSA) and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost effective and does not improve survival. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis and increased stress.”

Apparently, the Foundation has determined that most patients who are on dialysis are no longer worth screening for cancer.  One assumes that these patients are already costing the system too much, and therefore diagnosing a malignancy in time to treat it would simply prolong their time draining the “finite resources” that the ABIM Foundation has set out to protect.

These are just two of an extensive list of new recommendations, aimed at decreasing a broad range of tests and procedures. 

There is no question that unnecessary testing and over-treatment are issues that contribute to the high cost of healthcare in this country.  Studies have indicated that as much as one-third of all medical spending in the United States is not medically necessary.  What has not been shown, however, is that this overage is a result of physicians attempting to “game the system” to make more money, or because previous medical guidelines have been too lax.  Rather, it is “defensive medicine” -- a direct result of serious concerns over medical liability, escalating malpractice awards, and an abject refusal by American trial lawyers to allow critical tort reform. In 2700 pages of new healthcare legislation, any mention of tort reform is glaringly absent.

So what explains the somewhat conspicuous timing of these new recommendations? The “American Board of Internal Medicine Foundation”, despite its very official sounding title, is a self-appointed group whose charter is aimed at “advancing medical professionalism”. 

Just a cursory review of the resumes of the board of the ABIM Foundation reveals some interesting backgrounds. Dr. Christine K. Cassel, president and chief executive officer of the Foundation, is one of 20 scientists chosen by President Obama to serve on the President’s Council of Advisors on Science and Technology (PCAST). She is also co-Chair and Physician Leader of a PCAST working group that makes recommendations to the President on issues relating to health information technology.

ABIM Foundation Chairman, Glenn Hackbarth, is a lawyer with no medical training whatsoever.  He is also the current Chairman of the Medicare Payment Advisory Commission in the Obama administration.

Coincidence?  Not likely.

Speaking of an “unelected group of people”, this group has made some rather radical recommendations for rationing healthcare and has slyly tucked them in under the banner of something called “medical professionalism”.  While it is true that the American Board of Internal Medicine Foundation has no legal authority to set policy, their recommendations certainly hold sway over Medicare, Medicaid and private insurance companies.  When panels of medical “experts” make broad sweeping recommendations that physician should eliminate certain tests, treatments and procedures, it becomes more and more likely that payers of all types will refuse to cover those same items.  These newly published guidelines are therefore likely to alter treatment standards in hospitals and doctors’ offices nationwide.  Furthermore, they will remain in place, even if the healthcare reform bill is repealed. 

It is this last fact of which Americans need to be most cognizant: the Obama administration has launched an all-out assault to dismantle U.S. healthcare as we know it.  The massive Patient Protection and Affordable Care Act is the body of Obama’s machine  – But there are tentacles and independent offshoots that can and will proliferate like malignant cancer cells left behind even if the larger tumor is removed.  

Should the Supreme Court justices makes the correct decision to over-turn the healthcare reform bill as unconstitutional, we will still need to deal with all of the new IRS agents already hired through the HHS “implementation fund”, as well as with these insidious panels of experts who have been working over-time to craft new guidelines clearly aimed at saving money at the cost of human lives.  This is truly sinister government; if Obama remains in office, repealing the healthcare reform bill will never be enough.

                                              blog founded by Kelly Victory MD
                                      story developed with Kelly Victory Steamboat Springs