Medicare and Medicaid have been called “America’s Crown Jewels.” The very phrase suggests the question of what kind of country has crown jewels: a republic, or a monarchy?
And what is ObamaCare? Michele Bachmann (R-MN) calls it the “crown jewel of socialism.” Those who understand the principles see that an attack on the Affordable Care Act (ACA) could also apply to Medicare and Medicaid.
Rep. Charles Rangel (D-NY) accuses Republicans of having fought Medicare since its inception. But one who successfully blocked it for years was Democrat Wilbur Mills, chairman of the House Ways and Means Committee for three decades. He warned that it would bankrupt Social Security, which he thought was unsustainable in any case. He calculated that if the hospital insurance was to remain sound, the taxable wage base would have to increase by $150 each year, three times as fast as the increase between 1959 and 1964.
But after Lyndon Johnson’s landslide victory, Mills shepherded the bill through Congress, rationalizing that it was good for his Party. In a recorded phone call, he told Johnson: “I think, we’ve got you something that we won’t only run on in ’66 but we’ll run on it from here after.”
While the law promised that the federal government would exercise no control over the practice of medicine or physician compensation (§1801, 1802, and 1803), Wilbur Cohen, secretary of the Dept. of Health, Education, and Welfare (HEW), told Johnson that doctors could not charge whatever they wanted. HEW would make an agreement with an intermediary, say Blue Shield, that would do the policing indirectly (ibid.).
The Greatest Generational Theft in World History
The modified community rating in ObamaCare forces the young and healthy to subsidize the older generation.
“Young Americans—especially the Millennial generation born between 1977 and 1995—are the biggest losers in this battle, but it will adversely affect their children and grandchildren to boot,” writes Chris Conover. “Obamacare simply represents the latest front in this war, which now rages from Social Security to Medicare to this deeply flawed law”.
The current fiscal imbalance calls for transferring an impossible $200 trillion from future to current generations (ibid.). Surely this qualifies as the greatest generational threat ever.
While today’s 65-year-olds are expected to receive $327,400 more in lifetime benefits than they paid in, children born now can expect to suffer $420,600 in net lifetime losses as they struggle to pay oldsters’ bills, writes Stanley Druckenmiller (WSJ 10/21/13). He rejects the “rat through the python” theory, which holds that entitlement costs will become bearable once the baby boomers die off. The debt accumulates, and by the 2040s, gargantuan interest payments will become a bigger problem than the entitlements.
“Obamacare is simply the cherry on top,” Avik Roy writes. “The government takeover of medicine occurred in 1965.” Enormous new ACA spending, exceeding $200 billion per year, is just a small fraction of total “legacy” federal spending on programs like Medicare and Medicaid (NRO 10/1/13).
If ObamaCare implodes, Democrats will likely push for “further bottom-up/top-down socialization, in which Medicare is offered to 55- to 65-year-olds and Medicaid is eventually expanded even more.”
Is There a Way Out?
“Irish democracy”—silent dogged resistance and withdrawal—could kill ObamaCare, writes Glenn Harlan Reynolds. Only 15% of the uninsured that were expected to sign up have done so (USA Today 1/26/14).
“Apparently many of the uninsured aren’t interested in prepaying for health insurance any more than they are interested in prepaying their credit cards” (Michael Barone, WSJ 2/2/14). And why should those with no assets to protect buy insurance?
The Massachusetts Exchange has placed 28,000 patients who might qualify for ACA subsidies into Medicaid (Forbes 1/29/14). Doctors are fleeing Medicaid, preferring to give true charity rather than bill Medicaid (Medical Tuesday XI(11)). But can patients decline the benefit and pay privately? AAPS is asking CMS administrator Marilyn Tavenner these questions: 1) Can patients signed up through an Exchange disenroll? 2) Is the risk of asset recovery disclosed, and can the rules change? 3) Can doctors be penalized for taking payment?
“Centerum censeo Carthaginem esse delendam”
Schoolboys used to have to memorize that line, with which Cato the Elder ended all his speeches in the Senate of the Roman Republic in the 2nd century B.C.: “Furthermore I say that Carthage must be destroyed.” His fellow senators chanted it along with him as a kind of ritual.
This reminds Christopher Manion of Rep. Robert Fleming Rich of Pennsylvania. As New Dealers introduced one spending bill after another, he would ask to be recognized, and roared, “Mr. Speaker, where are we going to get the money?” Other members would often join in jest, like a vaudeville chorus.
“History has a habit of rhyming, as Mark Twain observed.”
“Bumps in the Road”
To Obama, the death of Americans from a terrorist attack in Benghazi was a “bump in the road,” as is the high unemployment rate. In a debate on Larry King Live between AAPS president-elect Richard Amerling, M.D., and George S. Benjamin, M.D., executive director of the American Public Health Association, Dr. Benjamin brushed off ObamaCare’s creation of millions of new uninsured people: “Whenever you try something this big, there are always going to be some bumps in the road.”
The AMA says “the ACA roll-out may have its bumps, but we’re working toward a stronger future” (AMA Morning Rounds 2/5/14). Jan 1, 2014, the implementation date for ACA, “will stand out as transformational in the annals of US health care reform” despite an “arduous, confusing, and contentious road” (McDonough JE, Adashi EV, JAMA 2/12/14).
Dr. Amerling points out that the hard Left has a high tolerance for harming or killing millions of “bumps in the road” on the way to a socialist utopia.
More ObamaCare “bumps”:
- 2.5 Million to Leave the Work Force. According to the Congressional Budget Office (CBO), the equivalent of about 2.5 million full-time workers will be lost as people decide that their earnings from work would not be enough to offset loss of their ACA health benefits. This is not a middle-class tax increase, just a premium increase. Obama spokesman Jay Carney spins this as “freedom”—the new American Dream of not having to work.
- From Belarus with Love. “We are helping Obama complete his insurance reform,” said Valery Tsepkalo, director of the government-backed High-Technology Park in Minsk. Last year, programmers in Belarus were involved in an internet “hijacking” that diverted massive U.S. internet traffic to that Russian-allied dictatorship. Threats include cyber attacks, identity threat, and insertion of malicious code, writes Bill Gertz.
- It Only Hurts 3%. This claim was made to The New Yorker by Jonathan Gruber, who has received about $400,00 in consulting fees from HHS since 2009. He argues that “no law in the history of America makes everyone better off.” Chris Conover comes up with different numbers: 4.8 losers for every ACA winner, and 3.6 big losers for every big winner (Forbes 1/28/14).
- Spousal Coverage Dropped. To mitigate the costs of ACA, United Parcel Service has dropped more than 15,000 spouses from employer-sponsored plans. In 2014, 12% of such plans will not include spouses, three times more than in 2013 (Michael Cannon, Cato Policy Analysis No. 745, 1/27/14).
- Plans Dropped. Millions of plans in the individual markets lost their grandfathered status because of rigid HHS regulations. Also, some states forbade participation in Exchanges unless insurers canceled all non-grandfathered plans (ibid.)
♦ ♦ ♦
“It is unfortunately not too well understood that, just as the state has no money of its own, so it has no power of its own. All the power it has is what society gives it, plus what it confiscates…. [T]here is never, nor can be any strengthening of state power without a corresponding and roughly equivalent depletion of social power.” Albert Jay Nock, Our Enemy, the State
Medicare Destroys Charity
Joseph Scherzer, M.D., sends recollections from an acquaintance who was a medical records librarian in 1965:
“We had at that time free clinics all over the city. Every doctor in the city volunteered, and every worker on the staff was a volunteer. The buildings were donated by local businesses, who got a nice tax write-off. The then-president of the Virginia Medical Society,…William Eagles,…a neurosurgeon,…was solidly against Medicare. He said we didn’t need it in Virginia as there were free clinics all over the state…. The doctors said we could not afford Medicare and that the extra taxes to support it would be a hardship on most of America…. As soon as it was instated,… all of the free clinics disappeared. It wasn’t too long after that the government passed a law stating that hospitals had to accept patients who had no insurance…. I still feel to this day that we never should have begun Medicare.
“[After Medicare, the hospital] installed time clocks that we all had to punch. I would go up and punch the time clock at 5:00 and then go back to work because I couldn’t finish in 8 hours. We were all doing that because we loved our work and were used to overtime and knew the hospital couldn’t afford to pay us time and a half. It also caused hospital costs to rise dramatically to cover all the free patients. As the librarian, I had to create an entire new set of chart monitoring…. [W]orking in a hospital became a chore instead of fun. That’s why I didn’t stay in medicine. Even the money couldn’t keep me there. It caused a huge stir among the nurses who ended up having to work overtime most days…. [That’s when we got] nurse’s aides, tech aides, coders, etc., and costs went up even more. The whole thing was unnecessary and ridiculous. And now we have ObamaCare,…the icing on the cake of despair in medicine.”
Social Security Is Already Means-Tested
The tax on Social Security benefits, which kicks in above very modest income levels ($25,000 for a single person), is really a tax on saving for retirement—and marginal tax rates could exceed 100%, writes John Goodman. The increase in Part B premiums with income is an implicit marginal tax that can be steep.
Goodman thinks that many seniors would be willing to waive all future claims on Social Security (which includes Medicare), in return for a check for 75% of the present value of future benefits, which would be totally theirs, and part of their estate. As Medicare rationing becomes ever more severe, a way out will be increasingly desirable.
AAPS Calendar
March 30. National Doctors Day Meeting, Belleville, NJ
May 9-10. Thrive, Not Just Survive Workshop, board meeting, Minneapolis/St. Paul.
May 15. Dinner meeting in Manhattan.
Sept. 2-6. 71st annual meeting, Charleston, SC.
ACTION OF THE MONTH
Write to Marilyn Tavenner on Medicaid patients’ right to purchase private care, and encourage others to do so. See AAPS letter and press release.
Just a “Nuisance” Lawsuit
“Health care reform won a big victory in court on Jan 15,” writes Abbe L. Gluck, J.D., of Yale Law School, when a judge dismissed a challenge that “could have crippled the ACA by denying its generous tax subsidies to the more than 12.5 million Americans expected to use this financial assistance to buy their health insurance through a federally run exchange” (NEJM 2/5/14). Halbig v. Sebelius is based on clear wording in ACA that authorizes subsidies only for coverage on state-run Exchanges.
“It is a nuisance lawsuit that seizes on a sloppy but obvious drafting error to undermine the obvious intent of the new law,” writes Harold Pollack (Washington Post 2/3/14).
“Destroying the subsidies destroys the mandate, which in turn destroys the possibility of insurance market reforms.”
The vast majority of people who seek to buy insurance on Exchanges are expected to be eligible for subsidies, and 73% of Americans eligible for subsidies live in states with federally run Exchanges (Gluck, op. cit.).
Halbig is on appeal in the D.C. Circuit, and cases raising identical claims are pending in Indiana, Oklahoma, and Virginia.
So why not ask Congress to pass a technical correction?
Is the First Amendment Null and Void?
In its amicus brief supporting the challenge to ACA’s contraceptive coverage requirements (CCRs) brought by Hobby Lobby and Conestoga Wood Specialties, AAPS argues that the CCRs undermine everyone’s religious freedom in fundamental ways.
“The unqualified language of the Free Exercise Clause stands in striking contrast to the Fifth Amendment’s requirement that process only be ‘due,’ or the Fourth Amendment’s requirement that a search and seizure be ‘reasonable.’”
Free Exercise applies to external actions as well as internal beliefs, and to corporations as well as individuals, AAPS argues.
In addition, the admitted grammatical errors in Section 13(a)(4) render it incoherent, and the courts erred by interpreting the statute as they think it should be, rather than as it actually is. Drafters of the Constitution specifically rejected a “council of revision” allowing the executive to join the judiciary to rewrite a statute.
Moreover, when it enacted Section 13(a)(4), Congress had clearly not made any policy recommendations but left the difficult choices to the unelected Institute of Medicine (IOM) and the Health Resources and Services Administration (HRSA). The guidelines were not issued until 8 months after the expiration of the 111th Congress. Congress cannot delegate power it doesn’t possess, and it has no power to enact law after its term is over.
Finally, Section 13(a)(4) contains no marker or check to see whether HHS exceeded its authority. Under the construction suggested by the government, a clause giving it the power to regulate “at least” broccoli, ketchup, and hot dogs could be expanded to include an infinite number of other items, such as oranges.
As other amici, who are led by Eberle Communications Group, point out, the supposedly evidence-based recommendations of a 16-member IOM committee were “largely subject to the preferences of the committee’s composition.”
AAPS believes that the Constitution should be an impenetrable barrier to tyranny, not a mere “bump in the road.”
Tip of the Month: Photocopiers, including those at quick copy shops, have a hard drive that accumulates data from tax returns, bank records, police reports, and other confidential records. It is easy to buy a used copier that contains images of tens of thousands of documents, a bonanza for identity thieves. Software is available to wipe your copier’s hard drive; use it before disposing of your machine. http://youtu.be/B7-BcyFwQ7k
Medicare Appeals Suspended
Medicare beneficiaries are waiting 2 years for appeals of coverage denials to be heard, and 9 months for a decision. (By law, decisions are required within 90 days.) Because of the backlog of 375,000 cases, new requests for hearings by providers (90% of cases) will not be processed; the suspension is expected to last 2 years. Beneficiary appeals will still be processed.
The American Hospital Association has asked that audits by Recovery Audit Contractors (RACs) be suspended until the backlog is cleared; hospitals win 72% of appeals (Washington Post 1/19/14). Because RACs are paid on the basis of the number of claims they deny, they are incentivized to deny even correct claims. Legislation is proposed to require RACs to pay a fee whenever a denial is overturned on appeal (BNA’s HCFR 2/19/14).
Abortion Law Here and Abroad
Vladimir Putin signed a law banning abortion advertising; some members of the Duma are talking about banning the procedure itself—a turnabout in a country where the average woman had seven abortions in a lifetime. The early Bolsheviks invented the suction machine still used in abortion clinics. In 1920, Lenin signed a law legalizing unrestricted abortion, with the goal of destroying the family and getting women out of the home and into the workplace. There are still 1.7 abortions per live birth in Russia, but the rate is declining, and Russian population decline has apparently stopped (Steven Mosher, PRI 12/23/13).
The European Parliament rejected, on a vote of 334 to 327, the Estrela Report, with its goal of making unrestricted abortion available through public health systems—with no conscience protections for physicians (Life Issues Institute 12/14/13).
Americans who buy insurance in an ACA exchange will be paying at least $1/month to fund abortions. The House-passed No Taxpayer Funding for Abortion Act is blocked in the Senate (LifeNews.com 1/27/14).
A Patient’s View of ObamaCare
Henry Maybury writes that when he had an illness, the thought of seeing his primary care doctor was daunting. Though the doctor’s medical skills are good, “each visit to him has become torture, for him and us. Mostly he stares at the computer screen trying to follow the orders of the Obamacare computer gods…. His tension is heartbreaking to watch.” Maybury recognizes that the doctor doesn’t work for him any more. As his illness worsened, he got the idea of visiting a neighborhood walk-in clinic. There were few forms, and the doctor never looked at a computer. “It was like seeing a doctor back in the good old days (3 years ago).” For minor illnesses, “you might try seeing someone who has no records on you” (Early Warning Report, January 2014).
Correspondence
The SGR Deal. The government created a hated, unsustainable payment methodology, and now offers to rescue physicians by substituting a worse method. “The proposed system entails an unprecedented degree of healthcare micromanagement by the federal government,” writes David Howard, Ph.D., health policy professor at Emory University. “To be eligible for higher payments, providers will need to document and adhere to a number of different quality standards. Decisions about what constitutes high-quality care will become politicized. It is regulation via payment reform” (MedPage Today 2/6/14).
I suspect cows would understand this tactic well. Drop a few bread crumbs (a 0.5% increase) on the path leading to the chute. Offer a small piece of carrot (a 5% increase) to induce the cows to enter the chute (that leads to the slaughterhouse).
The cost of repealing SGR was estimated to be $300 billion a year or two ago. How was this estimate cut in half?
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Spinning the Numbers. In its optimistic report on the ObamaCare enrollment numbers, the Administration has not answered these pertinent questions: How many of those who “selected a plan” have actually received an insurance card and paid their first month’s premium? How many had lost their previous insurance as a result of ACA requirements? How many enrollees have a pre-existing condition and are a high risk? Concerning the 79% who will receive a subsidy, what is the average amount of financial assistance they will receive? While the Administration is spending $600 million to persuade 18- to 34-year-olds to sign up through the Exchanges, so far only 24% of the risk pool are healthy young people, far short of the 40% needed to pay for the high-risk people who have already applied. Apparently, young Americans mistrust the government and feel they are being used.
Stanley Feld, M.D., Dallas, TX http://stanleyfeldmdmace.typepad.com/
What Will Happen When Employers’ Plans Are Cancelled? Some will likely try to self-insure, unless their states prohibit reinsurance. Will employees, who were used to having their employer see to the premiums and manage the coverage, undertake the hassles of dealing with the Exchanges, even if the process starts to work smoothly? Will they be willing to pay the premiums, report changes in income or living arrangements to the Exchange, or figure out what doctors or hospitals a Plan will allow them to use? My guess is that many, perhaps half, won’t do it. They don’t value their coverage that much.
Greg Scandlen, Consumers for Health Care Choices http://healthblog.ncpa.org/the-next-wave/
Inequality Happens—for a Reason. If you do these four things, it is almost impossible to remain poor: 1) Finish high school. 2) Get a job. 3) Get married. 4) Don’t have children until you get married. Those who do all these things have only a 2% chance of remaining in poverty, and a 75% probability of joining the middle class.
John Goodman, Ph.D., National Center for Policy Analysis
Centralized Healthcare. All centralized healthcare systems contain these four elements: 1) unlimited consumer demand; 2) limited tax resources; 3) government-mandated rationing by doctors; 4) epic failure, preventable suffering and death, doctor burnout.
Craig Wax, D.O., Mullica Hill, NJ http://ip4pi.wordpress.com/
Scribes. When I went to the doctor’s office recently, a physician assistant entered the exam room along with a young man in a tee-shirt pushing a computer on a rolling stand. I was introduced to the “scribe,” but no one asked my permission for him to be in the room and record everything I said. There are now 10,000 scribes working nationwide, being paid $20 to $25/hr.
Doctors should refuse the government’s rationing tool, the electronic medical record—and the third-party payment. And patients should follow them in droves.
Twila Brase, R.N., Citizens’ Council for Health Freedom
Medicare “Down Under.” In Australian Medicare, the government decides what it will pay for a procedure, and the doctor and the patient negotiate the “gap.” A recently retired CEO of a big company said he recently had a knee replacement. The leading expert wanted $5,000 for the gap, but the CEO chose an excellent younger orthopaedist who did it for $500. The government there encourages people to get off Medicare, and pays up to 30% of the cost of private insurance.
Donald D. Palmisano, M.D., J.D., http://intrepidresources.com
The “Pre-Existings” Lie. The President and his supporters keep pretending that before ACA, insurers could drop policyholders who became sick. Since 1996 (HIPAA), all individual plans have had to have guaranteed renewability, and group plans sold to businesses cannot exclude individuals with pre-existing conditions. According to a 2001 HHS survey, less than 1% of the under-65 population has ever been denied health insurance. To address a problem affecting this minute proportion of the population, Congress committed trillions of dollars to drop a nuclear bomb on the healthcare system. For a tiny fraction of the cost we could have health-status insurance or viable high-risk pools.
Jeffrey A. Singer, M.D., Phoenix, AZ
