Politicians who are reluctant to immediately go all the way to a complete government takeover of medicine propose the incremental strategy of a “buy-in” to a “public option.” Public programs predictably crowd out private ones. It is easy for government to drive out competition by imposing a regulatory load too costly for would-be market participants to bear.
How does one “buy” a “public” program that seems to be “free,” i.e. is paid for by taxes, primarily other people’s taxes? There’s some sleight of hand in the definition of terms.
Former Vice President Joe Biden’s proposal would “let people choose a government-run health system like Medicare if they aren’t happy with private insurance.” It would also shore up the Affordable Care Act (ACA) by getting rid of the income limit— 400% of the federal poverty level—used to determine who qualifies for tax credits that help pay insurance premiums. In states that did not expand Medicaid, it would let people who would otherwise qualify for assistance “buy” into the public option—without paying premiums. The estimated 10-year cost of $750 billion would supposedly be paid for by higher taxes on investment income of wealthy Americans (Wash Post 7/6/19).
While it formally rejected the proposed public option, ACA outlawed affordable private options that did not meet the “essential minimum benefits” mandates or guaranteed issue/community rating requirement. Up to 6 million people had their coverage cancelled and had to try to replace it with a far more expensive plan with a much higher deductible. Some saw a five-fold increase in premiums in 4 years for much worse coverage.
The Trump Administration’s efforts to liberalize Obama’s rules, allowing association plans and more short-term, limited duration insurance (SDLDI), are opposed by “liberals,” who file lawsuits or enact state mandates to replace the federal individual mandate that was zeroed out by the Tax Cuts and Jobs Act.
The highest penalty in ACA was $100 per day or $36,500 per year per employee, for employers caught giving employees pre-tax dollars to purchase their own coverage—showing the Obama Administration’s hostility toward private options. The Trump Administration has eliminated this penalty and is also allowing expanded use of Health Reimbursement Accounts (HRAs), writes John Goodman (Forbes 6/18/19).
The Wrong Metric
Freshman congressman Chip Roy (R-Tex.) believes that Republicans need to go on the offense on health issues, rather than simply attacking Obamacare and the Medicare for All Act.
“The problem Republicans have had for a long time is that we have accepted the premise that coverage is the metric by which we should gauge success,” Roy told the Washington Examiner. Instead, the goal should be access to high-quality care. He has introduced legislation that would expand health savings accounts, renamed “Health Freedom Accounts,” with employers and charitable organizations allowed to contribute. The plan would let people set aside up to $12,000 a year for an individual, up from $3,500, and have them use the funds to pay directly for drugs, catastrophic coverage, checkups, or other medical services. Patients, not third parties, would be in control.
Tellingly, the Republican leadership, in all its years of promising to repeal and replace ObamaCare, has done little to promote personal and portable insurance—or Goodman’s idea of health status insurance. Trump’s aggressive executive actions are taking on the special interests. Goodman notes that almost all the major players in health policy, especially large insurance companies, oppose these changes. And so far, Roy’s proposal has only one cosponsor, Rep. Andy Biggs (R-Ariz.).
Escaping the Public “Option”
Once you have enrolled in the public “option” of Medicare or Medicaid, then you have no right to be treated outside the constraints of the system—unless you can find a physician or facility that is not enrolled. Of course, all taxpayers have involuntarily “bought in” to Medicare and are constantly told that they have an “entitlement”—which is backed only by politicians’ promises, not by a legally enforceable contract.
One congressional candidate writes: “Government payments such as Social Security, Medicare, and veterans benefits should go as directly as possible to the people who depend on them. Funding for the special interests and bureaucrats, in and out of government, who now unnecessarily deplete those payments, should stop” (Art Robinson, Common Sense in 2012). John Goodman, during a dinner talk, once mentioned the idea of “buying out” Medicare beneficiaries. We should start a discussion on how this might work. A beneficiary might offer to forgo his future Medicare Part A entitlement in return for a monthly annuity of 50% of the actuarial value. He could buy insurance (if the ban on such insurance were repealed) or pledge the payment toward incurred medical bills. Half of his share of Medicare liabilities would vanish.
AAPS has proposed a 10-point plan to increase options, encourage competition, and unwind unsustainable spending, as well as a White Paper on “Freedom for All vs. Medicare for All.” The key points are: “Private” means patient-controlled. And the metric is care, not coverage.
Unwelcome “Surprises” in Proposed Bill
The Lowering Health Care Costs of 2019 Act, intended to “end surprise medical bills,” contains some nasty surprises itself, writes AAPS president Marilyn Singleton, M.D., J.D. Highlights of her analysis include:
Price Controls: Euphemistically called “benchmarks,” the price controls and bans on balance billing will lead to shortages and loss of patient access to independent physicians. Insurers are essentially handed near unilateral control over prices (§102 and 103).
“Steerage”: Insurers get more leverage to steer patients to “preferred providers” (§302).
Privacy: The collection and sharing of medical claims data without patient consent is enabled in §303.
Penalties: Physicians could be fined up to $10,000 (for each violation) for failure to provide or verify correct insurer directory information every 90 days, or to timely submit adjudicated bills to patients (§304 and 305).
According to Doug Badger, the bill would “bind doctors and hospitals to the terms of contracts they haven’t signed” and “tilt the system in favor of insurers by compelling doctors and other providers to accept payment rates that the insurer was unsuccessful in negotiating with them.”
A former solicitor general, Paul Clement, writes that the proposed bill would take property from physicians and medical facilities without just compensation in violation of the Fifth Amendment’s Takings Clause, and also violate the First Amendment right to freely associate. If accepted, such claims “would threaten the constitutionality of any kind of legislative price controls,” said Nicholas Bagley, a health law professor at University of Michigan.
News Briefs from Utopian Models
Canada Ranks Low: Compared with other “universal” systems, Canada’s completely “free” government monopoly performs poorly. Although among the top spenders, it ranks near the bottom for medical resources and has the largest percentage of patients waiting more than 4 weeks for a specialist appointment. Other countries allow private-sector competition, which can access private capital to fund medical innovations (WSJ 4/18/19).
Private Plans Grow: Employers in Denmark, Sweden, and Norway are increasingly offering private insurance to their top talent. Between 2006 and 2016, private coverage tripled in Sweden and more than quadrupled in Norway.
British Doctors Quit: Nearly 2 million patients are affected by the closure of 585 surgical practices in 6 years. Hefty pension taxes mean that some doctors must pay the NHS to work. Tax reform benefiting the “rich” is impossible.
“They…rake into the histories of former ages…for every instance of oppression and persecution which has been made by that body or in its favor in order to justify…their own persecutions…. After destroying all other genealogies and family distinctions, they invent a sort of pedigree of crimes. It is not very just to chastise men for the offenses of their natural ancestors, but to take the fiction of ancestry in a corporate succession as a ground for punishing men who have no relation to guilty acts…is a sort of refinement in injustice.”
Edmund Burke, Reflections on the Revolution in France, 1790
Public “Option”—or Else
A public option, like Medicare for All, “would expand the government’s control over the health system, albeit less visibly and more gradually,” write Joseph Antos and Joseph Capretta. “The rub: to work, physicians and hospitals must accept the government’s terms or face financial ruin.”
Under the Medicare Exchange Health Plan (or Medicare-X) proposed by Sen. Michael Bennet (D-Colo.), federally approved plans would be offered alongside private insurers through ACA exchanges. Because ACA requires uniform benefits, plans compete by offering lower premiums or wider networks of providers. The competition wouldn’t be fair because Medicare-X would use Medicare’s power to impose regulated prices on an expansive network of providers. Private insurers don’t have the power to dictate prices [yet]. The law would require all who accept Medicare or Medicaid to accept Medicare-X patients as well.
If Medicare-X is enacted, “private insurance would wither, competition would decline, innovation would slow, and the costs of health coverage would be hidden inside ever-rising tax bills,” they conclude.
HRAs Help with Pre-existings Problem
The problem of pre-existing conditions is largely a symptom of the disease of lack of portable coverage, writes Chris Jacobs. “Democrats don’t talk about solving the portability problem because they don’t want to solve it. They want the government to control everything through a single-payer health care system.”
The final rule on health reimbursement accounts released in June enhances portability by allowing employers to give their workers a (tax-free) contribution to an HRA, so employees can buy the plan that works best for them. If there’s any difference between the employer’s contribution and the total premium, the worker can pay the difference on a pre-tax basis if he purchases the plan outside of the ACA exchanges. Because employees own the plans and not the employer, they can keep their coverage when they change jobs.
The rule also improves affordability by permitting workers to forgo benefits they do not value. Currently, employees must forfeit the employer’s subsidy if they buy an alternative to the plan the employer offers, Jacobs explains. The change is a “win-win”: Workers get portable insurance of their own choosing, while businesses can avoid the paperwork and bureaucracy that comes with running a health plan for their employees. Those who favor individuals’ freedoms to make their own medical decisions should cite this rule in response to political attacks over the issue of pre-existing conditions.
AAPS Calendar
Sep 18-21, 2019. 76th Annual Meeting, Redondo Beach, CA
Sep 30-Oct 3, 2020. 77th Annual Meeting, San Antonio, TX
9th Circuit Removes Block on Title X Abortion Rule
In a 7-4 vote, the U.S. Circuit Court of Appeals for the Ninth Circuit let a June 20 decision stand, lifting an injunction against the Trump administration’s rule that strips federal funding of clinics that fail to separate facilities that perform or refer for abortions from those that receive Title X family planning funds, while the case against the rule is litigated. Former Planned Parenthood president Leana Wen complained that the rule would be “devastating” to abortion providers.
EHR Vendor Fined for Being Hacked
Medical Informatics Engineering (MIE), the victim of a cyberattack beginning in 2015 that exposed protected health information of 3.5 million patients, will have to pay $100,000 for a HIPAA violation, despite timely reporting a breach, because it had not conducted a comprehensive risk analysis before the breach occurred (Medical Practice Compliance Alert, July 2019). MIE will also have to pay $900,000 to various states and implement a corrective action plan. The cybercriminals apparently were not caught, and the damage to the patients whose records were compromised is not known.
Conscience Protection Rule Final
According to an HHS fact sheet, the rule “ensures that… healthcare professionals will not feel compelled to leave the practice of medicine because they decline to participate in actions that violate their conscience such as abortion, sterilization, or assisted suicide. It also protects the right of diverse faith-based health care institutions to retain their religious beliefs and identity as part of their mission of serving others.”
Regarding vaccines, the rule states: “none of the statutes that this rule implements create across‐the‐board exemptions on the basis of religious beliefs or moral convictions to vaccination requirements,” and defers to state law.
Some critics worry that the rule “privileges” providers’ conscience rights over care of their patients. Scout, Ph.D., of the National LGBT Cancer Network, said that “bigoted providers” might use the rule to hide their “refusal to appropriately treat trans people” under the misnomer of being “conscientious.” Kevin Diaz of Compassion and Choices fears that the rule might allow physicians to “leave patients in the dark” about options such as assisted suicide “until it’s too late” (MPCA July 2019).
Tip of the Month: Beware of the medical marijuana certification trap! States are encouraging physicians to obtain certificates to prescribe medical marijuana, but then refusing to cooperate if a physician wants to surrender the certification. Termination may become desirable by physicians in some areas where financial institutions are refusing to continue banking accounts with physicians who prescribe medical marijuana. When one state medical board was contacted with a request by a physician to surrender the certification, the board demanded that the physician release the medical board from all liability, and said it could report the termination to other entities including the National Practitioner Data Bank! “You can check out any time you like / But you can never leave!”– Eagles, Hotel California (1976).
Ontario Court: Doctors Must Refer for Euthanasia
On May 15, 2019, the Court of Appeal for Ontario confirmed a lower court ruling defending the requirement of the College of Physicians and Surgeons of Ontario (CPSO) that dissenting physicians make “effective referrals” for euthanasia (Medical Aid in Dying or “MAiD”). It stated that CPSO policies “strike a reasonable balance between patients’ interests and physicians’ Charter-protected religious freedom.”
Dr. Catherine Ferrier, president of the Physicians Alliance Against Euthanasia, writes: “In our view, the reason these doctors exercise their charter rights is to protect the interests of their patients.” Most patients do not want to die and refuse euthanasia if offered. Constantly informing seriously ill patients of their “right to die” could “exert undue pressure or cause subtle/overt coercion” and is “nothing less than universal suicidal suggestion imposed upon this vulnerable group.”
Since legalization in June 2016, there have been 3,302 euthanasia deaths in Ontario. Between 2017 and 2018, assisted deaths in Canada increased by more than 50%.
Father and Fetus Sue for Wrongful Death
In Alabama, Madison County Probate Judge Frank Barger is allowing a wrongful death case brought by Ryan Magers and his aborted fetus to go forward. Magers is suing the manufacturer of an abortion pill and the clinic that provided it to end the 6-week pregnancy of his then-girlfriend, despite his repeated pleas to carry the child. This decision, which confers personhood status on a fetus, could provide at least indirect support for all manner of abortion restrictions, write Dov Fox, J.D., et al.
The claim by the “other party in the case,” Ryan Magers, “also gives cause for concern and directly contravenes judicial precedent. In the 1976 case of Planned Parenthood v. Danforth, the Supreme Court affirmed a woman’s right to have an abortion over her partner’s objection, explaining that, as the one ‘who physically bears the child,’ she ‘is the more directly and immediately affected by the pregnancy’ ” (JAMA 7/2/19).
Men do have “important reproductive interests,” the authors state, such as a “man’s interest in not being a genetic parent” in cases involving the destruction of frozen embryos.
Expansion of Non-ACA Plans Upheld
D.C. District Judge Richard Leon upheld Trump’s rule that allows consumers to keep short-term, limited-duration health insurance for up to 3 years. “Lawmakers were not rigidly pursuing the ACA-compliant market at all costs, e.g., at the risk of individuals going without insurance altogether,” Judge Leon wrote. “While Congress certainly sought to foster a robust ACA-compliant market, its chosen methods for doing so were embodied by the individual mandate and tax penalty, not the definition of STLDI!”
The plaintiffs, led by the Association for Community Affiliated Plans (ACAP), said they will appeal Leon’s decision. The Trump rule allows “junk insurance” to compete with comprehensive coverage, they complain.
HHS Secretary Alex Azar hailed the decision as “a clear victory for American patients who saw their costs rise and choices disappear” under ACA.
Correspondence
More Price Controls. Progressives are trying to ram through a bill in Congress that limits out-of-network payments for surprise bills to insurer-determined in-network rates. What we need is a law to outlaw “surprise involuntary insurance contracts”—i.e. physicians should not be forced by law to essentially agree to in-network fees for in-network contracts. As MSSNY president Art Fougner notes: “These proposals would further incentivize abusive contracting practices of multi-billion dollar [insurers].”
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Psychological Dependence on Communism. Older Romanians today are so damaged psychologically that they are nostalgic for communism, for Ceausescu’s brutal regime. They were satisfied with the meager communist welfare and rations because it was a dependable constant in an otherwise destitute life. My older cousin said, “We got a salary every month, whether we tried hard or not. We could bribe doctors with a chicken, a pat of butter, a liter of cooking oil or fresh milk, a bar of soap, extra rationing coupons, for fake medical excuses, and we stayed home to rest for weeks on bogus medical diagnoses. The salary kept coming, and we still had a job when we returned.” People can flee physical communism, but are they able to erase their psychological and welfare dependence created by communist indoctrinators?
Ileana Johnson, Ph.D., https://canadafreepress.com/article/psychological-dependence-on-communism
The Evolution of Socialism. Marx’s theory was killed by the rise of the middle class in capitalist societies and by the death of the labor theory of economics. Marxism was saved by the Evolutionary Socialism of Edward Bernstein, which calls for infiltration and cultural invasion, with social democracy as the indispensable instrument. By deceit and propaganda, America is now under attack by forces that aim to destroy Western civilization. We are at a critical point. Freedom of speech for conservatives is now nonexistent on America’s university campuses. They are in embryo the one-party state the Democratic Party is working overtime to achieve. To grasp the nature of this war, and to understand its goals, it is essential to recognize its origins in the war against Christians. The Christians who created America, writes David Horowitz, made religious liberty and freedom of conscience the foundation of all Americans’ other freedoms. “Christian beliefs in the sanctity of life, in free will (and hence individual accountability), and in the flawed nature of humanity are the principal bulwark against our descent into the barbarism that progressivism promises us.”
John Dale Dunn, M.D., J.D., Brownwood, TX
Free Market v. ACA. I joined Liberty HealthShare because the ACA cost for a plan was more than $1,800 a month with a $25K family deductible. That is criminal. More than a million people have joined health-care sharing ministries, up from 200,000 pre-ACA. Revenues at Christian Healthcare Ministries more than doubled between 2015 and 2017, when they exceeded $300 million. I have never had a patient complain about these plans in 5.5 years of direct primary care, but I have never had a patient not complain about an ACA plan. In some states, insurance regulators are trying to take down this idea. They couldn’t be in the pocket of the insurance industry, now could they?
Douglas Farrago, M.D., https://authenticmedicine.com/somebody-doesnt-like-the-health-sharing-companies/
Breaking the Bond. With the push for corporate branding over the personal relationship between patient and their doctor, patients are feeling like they are just a number. They are shifted around to other “providers” for convenience and I believe to strategically destroy the bond patients have with their physician and coerce their allegiance elsewhere. A patient who is part of a large health organizations is the patient of ACME Healthcare, not of a specific physician. Corporate medical institutions and insurers count on this. They love the ability to manipulate patients at their whim. They do not want patients to have an allegiance to their doctors, otherwise they lose all the control. The loss of the patient-physician relationship is an important cause of burnout.
Jaclyn Nadler, M.D., https://authenticmedicine.com/the-value-of-the-physician-patient-relationship/
Ransomware Kills a Practice. A huge patient data hack at Brookside ENT and Hearing caused two physicians to retire early and permanently close the clinic. When they refused to pay a $6,500 ransom, hackers wiped out all patient data.
When Congress mandated electronic records, it opened the door to hacking; nearly every patient’s data is at risk. Also there is a data-collecting, command-and-control surveillance system in every exam room. The watched are never free.
Twila Brase, R.N., Citizen’s Council on Health Freedom
The Root of the Problem. Insurance networks are the root of all evil in our industry. They hog-tie us to impossible rates and terms, and prevent balance billing. We need to push for a move against insurance networks. We need to return to real insurance with direct patient payment and balance billing with notice to patients—instead of prepaid services and profiteering. Eliminating the Medicare participation network would go a long way in reestablishing patient sovereignty and responsibility, and most importantly choice. Commercial payers would likely follow.
Craig Wax, D.O., Mullica Hill, NJ
