AAPS News December 2018: Who Won in 2018?


The clearest winner in the 2018 midterms was Medicaid. Voters in Idaho, Utah, and Nebraska approved ballot initiatives to expand Medicaid, making 363,000 more people eligible for the program next year. With Democrats winning the governorship in Wisconsin and Kansas, these two states, which have resisted the expansion, may become more open to it. In Maine, the first state to approve the expansion by ballot initiative, Democrat governor-elect Janet Mills says she will make it her first priority. Gov. Paul LePage (R) has kept it tied up in court. “All told, about half a million more people could join the massive federal-state health insurance program for the low-income and disabled that covers more than 1 in 5 Americans” (WaPo 11/6/18).

As prospects for repealing the Affordable Care (ACA) got even dimmer, stocks of insurers that profit from Medicaid or ACA subsidies, such as Molina Healthcare, Centene, and WellCare Health Plans, hit record highs.

“Democratic Socialism” is in the ascendancy, certainly in the leadership of the Democratic Party. About 54% of overall likely voters—88% of Democrats and 21% of Republicans—believe that it is the responsibility of the federal government to make sure that all Americans have health coverage, write Robert Blendon, Sc.D., et al. (NEJM 11/1/18). They note that gun control and unrestricted abortion also gained support.

Democracy—what the Founders called “mob rule”—won, with the strategy of counting “every vote” (every ballot, that is) that materialized from unknown sources until the trailing Democrat crossed the finish line.

Avowed socialist Alexandria Ocasio-Cortez likens her upset victory to America’s historic moon landing.

Who Lost?

According to Nancy Pelosi, Republicans lost the House because of “health care.” Half the Democrats’ television ads—about $90 million worth—were on health care. The public largely shares the left-wing Democrats’ vision that “if you get sick you should get medical care and someone else should pay for it,” as John Goodman explains it. Nobody, including Republicans, seems to know what the Republican vision is, he states. Many provisions of ACA are quite popular, according to a Kaiser Family Foundation poll.

Establishment Republicans did not fare well. The Democrat majority may be slim, but now has control of all committees— and the agenda. Republicans may actually have ceded control through the retirement of more than 40 members, many because they were losing their committee chairmanships (and hence their significance) to term-limit rules. They are now likely trading their credentials for money on the other side of the “revolving door.”

Single payer, or Medicare for All (M4A) “lost big time,” according to Sally Pipes. “Not counting incumbents, 111 Democratic candidates gunning for the House backed Medicare for All. Of those, only 19 won their elections,” she writes. And Medicare-for-All supporters won only one in five House seats flipped by Democrats (Forbes 11/26/18).

Democratic National Committee (DNC) chairman CEO Seema Nanda was asked how Democrats would come up with $3 trillion per year, requiring that everyone’s taxes be doubled or tripled. “I don’t think we’re there yet” (tinyurl.com/yc449q7t).

Charles Blahous of Mercatus Center estimated a 10-year cost of $32.6 trillion—in addition to what the federal government already spends on healthcare programs and subsidies. That would be $38 trillion if the program didn’t cut providers’ payments by 40% (https://tinyurl.com/yd5zpplg).

Nancy Pelosi prefers improving the ACA, likely because of her support from the insurance industry. Her speakership is being challenged by hard-core progressives.

A really big loser was climate extremism, despite the backing of billionaire Tom Steyer. Ballot initiatives for a carbon tax in Washington and a 50% “renewable” energy mandate in Arizona were soundly defeated. The congressional Climate Solutions Caucus lost half its Republican members, and Andrew Gillum, recipient of $7 million from Steyer, lost his gubernatorial race in Florida (https://tinyurl.com/yb8p6aeh).

Our House Divided

The stark political division, as framed by Donald Trump in 2016, is between mutually exclusive regimes: multiculturalism vs. America. According to Thomas Klingenstein, chairman of the board of the Claremont Institute, the former includes identity politics and political correctness. The identity groups are “global citizens,” all somehow oppressed by white males. Multiculturalism opposes America’s “bourgeois culture,” which insists on one language and one set of laws, and which values, among other things, loyalty, self-reliance, and hard work. America’s most astounding success, writes Klingenstein, is assimilation of diverse groups into one people. The American understanding of justice is equality of individuals—not of identity groups.

“When there are two understandings of justice, as in the Civil War and now, law-abidingness breaks down.” Like non-negotiable opposition to slavery, the focus must be to oppose post-modern, anti-American, multicultural globalism.

What will win? Entitlement or empowerment? Oppression or liberty? Redistribution or creation? Globalist Marxism or America?

ACA Outcomes

Number of Insured: Despite more than $100 billion/year in subsidies, the percent of the population with private health insurance was less the last year of Obama’s presidency than when he took office. The number of people newly insured through the exchanges was largely offset by the reduction in employer-provided coverage. Subsidies encouraged substitution of inferior insurance for what would have been much better coverage (Goodman, op. cit.).

Costs: The pre-existings provision is the main reason for premiums doubling in the first 4 years, and necessitated most of the $1 trillion in new taxes, writes Michael Cannon. It also made coverage progressively worse, with narrower networks and skimpier drug coverage, despite  “risk adjustment” and “reinsurance” provisions (https://tinyurl.com/y88vqcfn).

Medicaid Expansion: Expanding Medicaid beyond its original purpose of caring for low-income pregnant women, children, the elderly, and the disabled is driving a nearly $300 million hole in the Kentucky state budget, writes Gov. Matt Bevin. Instead of the projected 188,000 enrollees, 439,000 signed up in the first two years. It became harder for Medicaid’s core users to get the care they needed.  Nationwide, the per-person cost of expanding Medicaid has exceeded projections by 76 percent. Enrollment has nearly doubled original estimates. From 2013 to 2016, Medicaid spending grew nearly twice as fast in states that expanded eligibility as in those that did not (https://tinyurl.com/y9bxtpc5).

Trump Repair-care

Association Plans: Under the new Trump administration rule, employer Land O’Lakes now offers workers comprehensive coverage at up to 35% less than exchange plans in the state. Several Nevada chambers of commerce and the National Restaurant Association have also formed association plans (tinyurl.com/y9a9rscs).

State Waivers: The Obama Administration’s “1332 waivers” or “innovation waivers,” have been re-named “state relief and empowerment waivers.” CMS administrator Seema Verma proposes allowing people to use subsidies to buy catastrophic, short-term, or association plans. One proposal would allow states to make cash contributions to accounts that could be used to pay premiums or out-of-pocket payments for medical services. States might also be allowed to set up high-risk pools (tinyurl.com/ycqm6ehq).

HRAs: The Trump Administration proposes to extend to all employees a rule that allows use of tax-free funds in a Health Reimbursement Arrangement (HRA) to pay premiums for individually owned (and hence portable) health coverage A provision in Section 18001 of the 21st Century Cures Act allows this freedom in companies with fewer than 50 FTEs (tinyurl.com/y9j7o7qv).

“Obama [recognized] that society does not necessarily require government ownership of the means of production to implement the egalitarian dream. As long as the government controls the economy and is able to replace the free-market capitalist economy with political economy, and subsequently control profits, the objectives of socialism can be achieved.  Obama also ascertained that in order to control the economy, the government needs to control only three major sectors – health care, finance, and energy.”

Alexander G. Markovsky, via American Thinker

Sign the Citizen Petition for Freedom to NOT CHOOSE
Medicare at http://www.cchfreedom.org/form.php/36. Spread the word to your contacts and by social media.

CCHF Petitions to Free Seniors from Medicare

The Citizens’ Council for Health Freedom is petitioning the Trump Administration to remove the instructions in the Social Security Administration’s Program Operations Manual System (POMS) that prohibit individuals from receiving Social Security benefits unless they enroll in Medicare Part A. These are neither a law nor a rule. Allowing seniors to opt out would allow the development of a private market for lifelong insurance and improve the financial stability of Medicare for those who remain. (http://www.cchfreedom.org/cchf.php/1483).

Medical Costs in Perspective

A CT scan of the foot takes 48 seconds on a device about the size of an office copier. The per unit time cost of renting this device is twice the cost of renting an oil-drilling rig in the Gulf of Mexico. An operation that takes 2 hours of a surgeon’s time was billed at $50,000. The surgeon probably earned 1% of the amount billed to the patient. Does medical care in the U.S. cost 5 times as much as it should—or 10 times? (Access to Energy, July 2018).

The Epic Upgrade

Boston surgeon Atul Gawande, M.D., reports on the Epic software upgrade that Partners Healthcare forced on 70,000 employees (New Yorker 11/12/18). Surgeons were forced to endure 16 hours of mandatory computer training. The cost was $1.6 billion: $100 million for the software, the rest for lost patient revenue and the tech-support people needed during the implementation. Physicians spend 2 hours doing computer work for every hour with a  patient. Scribes are one solution, but they are minimally trained, usually turn over within months, and have error rates of up to 50% in recording key data according to one study. They are said to pay for themselves by increasing the number of patients seen and the amount billed per patient.

Google Absorbs DeepMind’s Health Division

Google, which acquired London-based artificial intelligence lab DeepMind in 2014, announced that the DeepMind Health brand, which uses National Health Service patient data, will cease to exist and the team behind its medical app Streams will join Google as part of Google Health. DeepMind has long promised never to connect its health data with Google. Privacy advocates have accused it of brazen deception. “The latest developments (with Google, Facebook, and others) suggest that we cannot trust tech companies’ promises”  (Telegraph 11/13/18, tinyurl.com/yccqsyvd).

AAPS Calendar

Feb 22-23, 2019. Thrive, Not Just Survive; Board meeting, Dallas.

Sep 18-21, 2019. 76th Annual Meeting, Redondo Beach, CA.

AAPS Supports Indiana Anti-Discrimination Law

AAPS became the first group and only medical group to file  an amicus brief supporting Indiana’s Petition for Writ of Certiorari in Box v. Planned Parenthood of Indiana and Kentucky. The case seeks to reverse the Seventh Circuit Court of Appeals decision to invalidate the “Sex Selective and Disability Abortion Ban,” Ind. Code §16-34-4 (2016), which prohibits abortion solely for discriminatory reasons, such as gender selection. The Court also struck down a requirement, upheld in Minnesota nearly 30 years ago, that requires that abortive remains be disposed of in the same manner as other human remains. Planned Parenthood’s objection to the law is apparently based on its symbolic significance rather than on any actual interference with a woman’s access to abortion, AAPS argues (https://tinyurl.com/y7r3p4z7).

HHS Issues Conscience-Protecting Rules

Rules issued by the Trump Administration would protect employers from being forced to facilitate access to abortifacient contraceptives through their company health insurance plans. The “accommodations” introduced by the Obama Administration after Hobby Lobby and Zubik still required employers to cooperate with government to assure coverage. The new regulations were immediately challenged in three separate lawsuits.

A separate proposed rule requires insurers to issue separate invoices for any charges related to abortion coverage. While ACA does require separate payments, the Obama Administration allowed the use of one invoice as long as charges were itemized separately, but even that was not enforced  (tinyurl.com/ycendemp).

Charges against Pain Doctor Dropped

In a rare move, federal prosecutors filed a motion to dismiss pending healthcare fraud charges against West Virginia pain management physician Roland Chalifoux, D.O. The 3.5 year investigation was triggered by allegations from an employee who had been terminated for diversion. A 32-count indictment had been filed in July 2017; many counts were dismissed, and trial was scheduled on 11. Dr. Chalifoux’s attorneys stated that “the prosecution’s position was deeply flawed and based on a misunderstanding of health care regulations” (https://tinyurl.com/yc25tsd2).

!Tip of the Month: Arbitration Agreements. Physicians can enter into helpful contracts with their patients to require the submission of disputes to arbitration. This safeguards against runaway jury verdicts and costly litigation. Appeals are usually not allowed, which improves finality and reduces costs further. Also, the forum is private rather than public. While praising the benefits of arbitration agreements, however, Medical Justice points out that in some states an arbitration agreement can allow a malpractice claim to bypass the statute of limitations to the detriment of the physician. (https://tinyurl.com/y85n5n2p). Medical Justice urges consideration of adding language to an arbitration agreement in order to obtain the protection of the statute of limitations. We suggest including language like this for patients to sign: “I agree that no claim may be brought under arbitration or otherwise after the statute of limitations applicable to such a claim in a court of law has run or expired.”

Anti-FGM Law Declared Unconstitutional

U.S. federal judge Bernard Friedman dismissed charges against two physicians who performed genital mutilations on nine girls in a Detroit clinic, as well as four women who tricked their minor daughters into going to the clinic. Dr. Jumana Nagarwala and others still face charges of obstruction and conspiracy to travel with intent to engage in illicit sexual conduct.

Judge Friedman argued that Congress had “overstepped its bounds by legislating to prohibit female genital mutilation.” He agreed that the practice is a criminal assault, but it has no demonstrable effect on interstate commerce, so it is up to states to regulate it. Michigan did not ban the practice until after Nagarwala’s arrest in 2017 (https://tinyurl.com/yabucq6s).

A Victory for Price Transparency

In In Re North Cypress Medical Center Operating Co., the Texas Supreme Court ruled that information regarding a hospital’s reimbursement rates and government payers was relevant to whether the amount it demanded from an uninsured patient was reasonable. The plaintiff argued that a lien placed by the hospital was invalid to the extent that it exceeded a reasonable and regular charge for services rendered (https://tinyurl.com/y848hdpg).

“Death Certificate Project” Nabs Calif. Doctors

In a controversial project launched 3 years ago, California’s medical licensure board reviews death certificates from 2012 and 2013 listing overdose of a prescription drug as a cause of death. The state agency then cross-checks California’s prescription drug database to identify which physicians prescribed controlled substances to those patients up to 3 years before their death.  About 450 allopathic physicians, 12 osteopathic physicians, and another 60 nurse practitioners and physician assistants have been targeted for a more detailed probe. In roughly half, the board has determined not to pursue charges, with the rest either pending or resulting in formal accusations. One specialist in palliative and hospice medicine complained that because of a false accusation, he had been “blacklisted from doing anything directly or indirectly with patients” (MedPage Today 11/6/18). 

State Mandates Could Face Legal Challenges

In May, New Jersey imposed a health-insurance mandate requiring all residents to buy insurance or pay a penalty. As the federal mandate’s penalty disappears Jan 1, and new Democrat majorities want to “protect” ACA, more states may follow suit.

 But how will they ensure compliance? Federal law generally prohibits the Internal Revenue Service from disclosing tax-return data. The coverage-reporting regimes enacted this year by New Jersey and the District of Columbia likely conflict with the Employee Retirement Income Security Act (ERISA), which explicitly pre-empts “any and all state laws insofar as they may now or hereafter relate to any employee benefit plan.” A legal challenge would be bolstered by  Gobeille v. Liberty Mutual, in which the U.S. Supreme Court struck down a Vermont law requiring employers to submit payment claims to a state database (WSJ 11/18/18).  AAPS filed an amicus brief in Gobeille.


Where’s the Advantage? On Oct 13, The New York Times published a truth-revealing article detailing how Medicare Advantage Plans wrongfully deny claims routinely so as to increase HMO profits. As I have been saying since the 1990s in my “Wedont Care HMO Card,” Medicare Advantage Plans dupe patients into signing up for additional “free benefits,” which come at the high cost of rationing care for those who develop severe illnesses requiring expensive treatment.  “Everything covered” often turns out to be a fraud. Medicare Advantage HMOs literally bank on senior citizens being unable to appeal wrongful denials of claims, or lacking the savvy to deal with the “delay and deny” HMO bureaucracies. According to the HHS Inspector General, “Relatively few people appeal the denial of claims, leaving insurers free to avoid payment.” Medicare Advantage plans also work to put as many obstacles as possible between the patient and access to appropriate medical care by their “onerous and often unnecessary prior authorization requirements.”

Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY

Who’s in Control? Blue Cross Blue Shield of North Carolina insures 3.89 million covered lives. North Carolina Medicaid, as of last year, insured an average of 2 million beneficiaries per month. The Secretary of NC Health and Human Services, Mandy Cohen, previously served as Chief Operating Officer and Chief of Staff at the Centers for Medicare & Medicaid Services (CMS) when Barack Obama was president. The CEO of NC BCBS is Patrick Conway. He previously served as CMS Deputy Administrator for Innovation and Quality, and Director of the Center for Medicare and Medicaid Innovation (CMMI) when Barack Obama was president. We therefore have two Obama administration graduates managing the health care coverage of more than 5 million North Carolina citizens. What could possibly go wrong?

Joseph Guarino, M.D., Reidsville, NC

BBC Supports Cultural Revolution. The tax-funded BBC is going to increase the number of LGBT people appearing in its programs and news output as part of new diversity reforms. This is one of the recommendations in a new report based on a survey of LGBT staff attitudes, which found that many perceived the corporation to have a “heteronormative culture.”

It has been pointed out that Nature is “heteronormative”—another name for Reality. It is only a short step before mandatory quotas of each favored group are required not only on TV, but in textbooks, classrooms, and so on.

William Briggs, Ph.D., http://wmbriggs.com/post/25599/

Ethical Double Whammy. (1) In Minnesota, most physicians are employees of large hospital-clinic organizations, and their scope of practice is dependent on decisions of administrators. (2) Clinical practice is universally dependent on computers. The “provider” must input data and satisfy the computer in order to be paid. I argue that the doctor-computer relationship has essentially replaced the patient-physician relationship.

Lee Beecher, M.D., Maple Grove, MN

The Biggest Privacy Breach. Anthem may have had to pay $16 million for a privacy breach, but the biggest breach of all is the permissive Health Insurance Portability and Accountability Act (HIPAA), and the push for physicians and hospitals to use government-designed electronic health records (EHRs). The government has authorized 700,000 medical facilities, insurers, and data processing companies, and their 1.5 million business associates, plus government agencies, to dig into Americans’ private lives.

Twila Brase, R.N., Citizens’ Council for Health Freedom

The Real Purpose of EHRs. EHR software was marketed by vendors to “sustain any audit” for the maximum service rendered in any encounter and to meet MIPS/MACRA reward requirements. The problem is not just the corporate practice of medicine but physicians crossing the line to justify actions based on unfair and unsustainable price cuts. The harsh reality is that the only way to save our profession is to cancel all commercial contracts, be non-par at minimum for Medicare, and do not comply with MIPS/MACRA. The loss from reduced payments is less than the cost of compliance.  Become out of network for all insurers!

Jane Hughes, M.D., San Antonio, TX

PA Medical Society Opposes MIPS. At its 2018 House of Delegates meeting, the Pa. Medical Society passed a resolution supporting the repeal of the Merit-based Incentive Payment System (MIPS). Also, “PAMED will petition the American Medical Association (AMA) to support the repeal and to oppose any federal efforts to implement pay-for-performance programs unless they do not add significant regulatory or paperwork burdens to the practice of medicine and have been shown by evidence-based research to improve quality of care” (tinyurl.com/ybm2tnme).

Kurt Miceli, M.D., Newtown Square, PA

Blood on Their Hands. People who see themselves as sensitive, caring, and hip, yet who consume illicit drugs, are supporting Mexican drug cartels and contributing to the carnage at home and abroad: 250,000 dead, 37,400 missing in Mexico (WSJ 1/14/18).

Craig Cantoni, Tucson, AZ