Volume 74, no. 3 March 2018
The Center for American Progress is proposing the next step toward the total government takeover of medicine: “Medicare Extra for All.” It calls the Affordable Care Act (ACA) “an historic accomplishment,” which is “remarkably resilient,” with steady enrollment “despite repeated acts of overt sabotage by the Trump Administration” and repeated attempts to repeal the law. Yet costs and deductibles “remain too high.” There are 41 million underinsured (out-of-pocket costs exceed 10% of income) and still 28.8 million uninsured, according to the CAP Health Policy Team, 2/22/18, https://tinyurl.com/ycd8mspb).
The Center for American Progress, founded by John Podesta, was one of the key architects of ACA. The execution of ACA, writes Katherine Tillman, R.N., “is in the hands of powerful, interlocking individuals and organizations, many having been involved in designing ‘healthcare reform’ since the Clinton Administration. A central part of the transformation is compiling and tracking our most sensitive data, from health records and tax returns, which can now be used in making coercive decisions about our medical care, to help achieve the ‘progressive’ social goals of this elite, powerful group” (jpands.org/vol20no4/tillman.pdf).
Tillman provides background on key ACA players, including Optum, UnitedHealth Group, Lois Quam, Andy Slavitt, Ezekiel Emanuel, Sylvia Burwell, and Kathleen Sebelius (ibid.).
The new proposal is not quite Medicare for All because it would preserve privately financed employer-sponsored coverage for as long as employers wanted to stay in. It would soon become Medicare for Most because newborns, persons reaching age 65, everyone buying insurance in the individual market, and all uninsured persons including legally resident noncitizens would be automatically enrolled. Medicaid and CHIP would eventually be folded in (LA Times 2/27/18, https://tinyurl.com/yc4x562q).
Dental care, hearing aids, vision services, mental health, and substance abuse treatment would all be covered. Premiums, deductibles (if any), actuarial value (out-of-pocket limit), and copays would be on a sliding scale—the higher your income, the more you would have to pay for insurance and care. Premiums would be collected through the tax system.
The precedent for charging the “wealthy” more for their coverage has already been set in Medicare. Since Jan 1, Medicare beneficiaries with incomes of $133,501 to $160,000 (or $267,001 to $320,000 for couples) must pay 65% of the cost of their parts B and D benefits, up from 50%. And beneficiaries with incomes between $160,001 and $214,000 (or $320,001 and $428,000 for couples) were shifted from a 65% surcharge into the highest income group that currently pays 80% of the cost of their benefits. (In contrast, Medicare beneficiaries with incomes of $85,000 or less—or $170,000 or less for couples—pay only 25% of the cost of their benefits.) In 2019, thanks to the recently signed two-year budget deal, individuals with incomes of $500,000 or more and couples earning $750,000 or more will be broken out of the current top bracket and required to pay 85% of the cost of their Medicare parts B and D benefits. Thresholds will be adjusted for inflation starting in 2020 (WSJ 2/22/18).
As Baby Boomers retire at a rate of 10,000/day, more drastic measures are to be expected. A classic Huntoon Lampoon, by AAPS director Lawrence Huntoon, M.D., Ph.D., showed Medicare as PAC-Man, devouring more and more of the federal budget. Now Medicare spending is 15% of federal outlays, projected to reach 21% by 2042 (https://tinyurl.com/yddekwk7). What will happen to current beneficiaries and the federal budget if “Medicare-Man” grows to replace virtually all health insurance?
With the exception of employer-sponsored coverage, private insurance would be forbidden to duplicate Medicare Extra benefits. Complementary insurance could not base premiums on risk, exclude pre-existing conditions, or pay fees to brokers.
Administration would be by a new bureaucracy, immune to partisan political influence; the statute would leave little or no discretion to the executive branch on policy decisions.
The assumed cost savings would come from price controls. Out-of-network providers for employer-owned insurers would be prohibited from charging more than Medicare Extra rates. Administrative efficiencies would supposedly come from electronic transmission of claims information and payment. Electronic health records would automatically convert clinical entries into claims information. Savings and the “careful leveraging” of existing financing would keep the program from consuming all potential sources of tax revenue, it is claimed (CAP, op. cit.)
But just in case, funding options include rolling back recent tax cuts; increasing healthcare taxes; curtailing healthcare tax breaks; increased taxes on tobacco and sugary soft drinks; and eliminating the ability of heirs to step-up the basis of assets to diminish capital gains taxes [so government can tax fictitious gains from the depreciation of the currency].
As The Federalist notes, the plan would punish states that exercised their choice not to expand Medicaid (tinyurl.com/y7pomj8e).
No promise is made that “if you like your plan, you can keep your plan.” Obviously, you couldn’t. CAP’s overview is: “This proposal guarantees the right of all Americans to enroll in the same high-quality plan modeled after the Medicare program [emphasis added].” There is nothing about the patient’s or the doctor’s right not to enroll, or to engage in direct, private transactions, or to seek alternate financing as through sharing ministries.
ACP on Single Payer
There’s a boomlet for single payer in American public opinion, writes Bob Doherty of the American College of Physicians, citing a June 2017 Pew Research Center poll that shows 33% in favor of this approach, up 5 percentage points since January 2017 and 12 since 2014. And 58% said that “the government has a responsibility to ensure health for all.” The Kaiser Family Foundation’s June poll showed 54% for single payer and 43% opposed, but that public opinion was “malleable.”
In presenting questions that might be asked, e.g. about taxes, cost controls, delays, and limited access, Doherty writes: “This may seem like I’m arguing against single payer; I’m not” (MedScape 3/3/18, https://tinyurl.com/yaqlvldt).
13,000 Nurses Can Now Practice Medicine
In September, Illinois Gov. Bruce Rauner signed into law a measure that would permit about 13,000 advanced practice nurses (APRNs) to diagnose and treat illnesses without entering into a written collaborative agreement with a physician. The bill passed the Illinois senate 55–0 and the assembly 99–0 (https://tinyurl.com/y9yvw6hn).
The New Quality Physician
“Does Medicine Overemphasize IQ?” ask Ezekiel Emanuel, M.D., Ph.D., and Emily Gudbranson, B.A., of the Dept. of Medical Ethics and Health Policy at the Univ. of Pennsylvania. While an “adequate” IQ is needed, effective physicians also need a high emotional IQ (EQ), they write. A high IQ might help in diagnosing and treating heart failure, but is no guarantee that a physician can “lead a multidisciplinary health team or effectively help patients change their behavior in ways that tangibly improve their health outcomes.” They advocate eliminating “the irrelevant premed requirements of organic chemistry, physics, and calculus, while requiring training in psychology and leadership.” A model negotiating session might be included in the interview process. Of course, the physician must be able to “sensitively discuss end-of-life care preferences” (JAMA 2/20/18).
ACTION OF THE MONTH
Spread the word about the AAPS 75th annual meeting scholarship essay contest for medical students and residents: top prize $500. See http://aapsonline.org/essaycontest.
Administrative costs are estimated to represent 25%-31% of total U.S. health-care expenditures. In an academic center in North Carolina, processing time and total cost for billing and insurance-related activities were estimated to be 13 minutes and $20.49 for a primary-care visit, and 42 minutes and $61.54 for a discharged emergency-department visit. Amortizing the cost of the certified electronic record increased costs to $32.52 for a primary-care visit (JAMA 2/20/18).
“…[N]othing [is] more difficult to carry out nor more doubtful of success nor more dangerous to handle than to initiate a new order of things; for the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from the incredulity of mankind who does not truly believe in anything new until they actually have experience of it.”
Nicolo Machiavelli (1469-1527)
Vickie Yates Brown Glisson Runs for Congress
Formerly a member of the AAPS legal team, Vickie Yates Brown Glisson has announced that she is running for the U.S. House of Representatives in Kentucky district 3. Until filing her candidacy, she was Secretary of the Kentucky Cabinet for Health and Family Services. “I’ve seen too much federal government overreach and its burden on our communities,” she writes. She has spoken at many AAPS meetings, most recently at our 2017 Thrive Not Just Survive workshop in Cincinnati. Her campaign website is https://glissonforlouisville.com. The incumbent, Democrat John Yarmuth, is an avid supporter of ACA.
The Meaning of GDP
The gross domestic product is the federal government’s measure of annual production of all goods and services, now estimated to be $19.7 trillion/yr. The numbers are compiled from sales statistics, and are not “value-based.” If a vandal throws a brick through your car window, the cost of $200 to replace it adds $200 to GDP. If taxpayers pay a hospital $100,000 to save a drug addict’s life, the GDP gains $100,000. So, if Medicare Extra added 22% to medical spending, as some predict, it would boost GDP by hundreds of billions of dollars. “The more corruption, chaos and nonsense, the higher the GDP, writes Richard Maybury (Early Warning Report, March-April 2018).
The Oracle in the Federal Government
The priestess at Delphi in ancient Greece, who was called the Oracle, got high by inhaling petrochemicals from cracks in the earth and made predictions on economics and other matters. The guru of today’s top economists, John Maynard Keynes, who developed the socialist central planning model, was a heavy user of mind-altering drugs. After making and losing two fortunes in speculative investments, Keynes shifted to a buy-and-hold strategy, which did well. However, his math-addicted apostles now bet our futures on their ability to predict economic behavior (ibid.).
Recommended by AAPS president-elect Marilyn Singleton, M.D, thepeoplescube.com features scintillating articles such as “13 Russians and 63 million Trump voters indicted,” “Eva Braun stuns, fascinates at Berlin Olympics,” and “The Valentine Guide to Dating Dictators.” From “Life behind the Irony Curtain”: “Are you shovel-ready, Comrade? Re-educate Yourself!”
State AGs Sue to Overturn ACA
Twenty Republican state attorneys general, led by Ken Paxton of Texas, have filed suit challenging the constitutionality of ACA in federal court in the Northern District of Texas. The removal of the individual mandate tax penalty, as of 2019, removes the basis for ACA’s constitutionality, which is Congress’s taxing power, according to the U.S. Supreme Court in National Federation of Independent Business v. Sebelius (AAPS News, August 2012). Since ACA lacks a severability clause, voiding one provision would void the whole law.
“It’s basically a nuisance lawsuit,” stated Timothy Jost, emeritus professor of law at the Washington and Lee University School of Law (WSJ, 2/27/18).
“The Constitution is such a nuisance for the leftist agenda,” states AAPS executive director Jane M. Orient, M.D.
CMS Offensive against Direct Primary Care
The Centers for Medicare and Medicaid Services has been holding “listening sessions” in Boston, Dallas, Denver, and Seattle with groups of fee-for-service and direct primary care (DPC) physicians. There are more than 770 DPC practices across the country, with more opening every week. Now that they have formed the DPC Coalition (DPCC), CMS is taking heed. Representatives of both DPCC and the American Academy of Family Physicians (AAFP) were secretly present at CMS sessions without informing their members. Before unveiling its Direct Primary Care Prototype pilot project, CMS insinuated itself into the leadership of organizations supporting DPC, writes Niran Al-Agba, M.D. CMS is focusing on “physician capture, control, and capitulation.” Its prototype requires re-enrollment in Medicare, acceptance of pre-determined payments of $90-$120 monthly based on patient age and complexity, and submission of patient data to receive payment. “What appears to be a DPC-friendly endeavor will destroy the system from the inside” (https://tinyurl.com/y76gbmj6).
Kentucky Sues to Protect Medicaid Waiver
In January, CMS approved a waiver allowing Kentucky to impose work requirements on some Medicaid beneficiaries and charge monthly premiums. An activist group filed suit in Washington, D.C., against the federal government for approving the waiver. Gov. Matt Bevin is countersuing in federal court in Kentucky. Bevin’s general counsel Steve Pitt said, “We have complete confidence that Kentucky HEALTH will be upheld and will serve as a successful national model.” Bevin has threatened to end the state’s Medicaid expansion if a court invalidates the waiver, stating that the cost of covering so many new individuals is not fiscally sustainable without the waiver (https://tinyurl.com/yascxek3).
Tip of the Month: Beware of Medicaid enrollment conditions that require subjecting your practice to on-site audits. The Medicaid program in Pennsylvania and elsewhere expressly require this, as do many insurance plans. Such on-site audits are intimidating and disruptive, upsetting to physician and staff, and can be “fishing expeditions.” Watch out for interrogations that go beyond the scope of the audit. Rather than agreeing to an interview, it is better to require that any questions be submitted in writing.
Antitrust Case against AOA Can Proceed
A New Jersey court denied a motion to dismiss the class action antitrust lawsuit, Talone, et al. v. The American Osteopathic Association, Case No. 1:16-cv-04644 (D. N.J. Jun. 12, 2017). Plaintiffs state that since 2012, the AOA has required that all 32,000 board-certified osteopathic physicians must, in addition to the annual board certification maintenance fee, maintain membership in AOA. The court found that if this allegation is true, AOA ties together two distinct products—board certification and AOA membership, a “tying arrangement” that is illegal under antitrust law. This action substantially limits the ability of other professional organizations to compete for membership. In addition, AOA has allegedly violated New Jersey’s Consumer Fraud Act with its alleged pre-2002 promise that certification would never expire (National Law Review 4/6/18, https://tinyurl.com/y8h2g8r9).
Trump Restores ACA Escape Valve
Before 2016, individuals could buy short-term, limited-duration medical insurance (STLDI or STM) plans that are exempt from ACA regulations. Many healthy individuals were choosing to buy these plans and pay the individual mandate penalty rather than pay two to three times as much for an ACA-compliant plan. So the Obama Administration limited their duration to 90 days rather than 364 days. Trump administration has now proposed new rules under which these affordable STLD plans would once again be available to those who want them, for up to 364 days. “While in the past these plans were a bridge, now they can be a lifeline,” says CMS chief Seema Verma. CMS estimates that about 1% of the ACA exchange market will migrate to STLDI plans in response to the rule change (Avik Roy, Forbes 2/22/18, tinyurl.com/y9wejs89). Such plans will likely be still more desirable once the individual mandate penalty is gone—and if Trump decides to allow them to be guaranteed renewable.
Andy Slavitt, former acting administrator of CMS, tweeted: “Trump launched his biggest assault to the ACA, American families, and the law.” Sen. Bob Casey (D-Pa.) called STLDI plans “junk insurance” (Wash Post 2/21/18, tinyurl.com/y7brwoa8).
Progressives need “the forgotten man”—healthy middle-class families—to subsidize unaffordable insurance mandates.
Idaho Plans to Ignore ACA Rules
Before 2014, individual market or nongroup plans were regulated solely at the state level (Roy, op. cit.). But Idaho’s recent announcement that it intends to approve ACA-noncompliant plans has led to cries from progressives that if the Trump Administration “lets the state get away with it,” it could “set off a catastrophic chain reaction,” and “health care for millions could be at risk.” Nicholas Bagley calls Idaho the site of “an insurgency” that “just opened the latest front in the endless war against health reform.” (Vox 2/22/18, https://tinyurl.com/yafqowft).
Notably, Obama himself set a bad precedent for selective enforcement, allowing the sale of “grandmothered” plans that violate ACA rules. If the Administration doesn’t act, the courts might—or might not. Standing to sue might be a problem. Bagley suggests that HHS threaten to fine Blue Cross $100/day/enrollee.
Remember: “everybody in, nobody out.”
The Charge of the Leftist Brigade. The Oregon House of Representatives passed a bill, 35 to 25, that would enshrine in the state constitution “a right to health care” for every resident (WSJ 2/14/18). Opponents noted the lack of a funding source and the prospect of making the state vulnerable to lawsuits. Should the measure be placed on the ballot in November and pass, I predict that the faux knights waving their wooden swords and leading the charge to “free stuff for all” will go the way of their socialist playmates in Vermont, who discovered, after they won their much ballyhooed victory, that they did not have the funds to pay for single-payer medical care. Once you take out the “payer,” what is left? Depressed, disappointed socialist dreamers.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Physicians Losing Jobs. An endocrinologist working for a large hospital-based corporation got a 90-day without cause termination notice. Apparently, she is to train her APC (advanced practice clinician) to replace her in 90 days. The long-term corporate goal is to have 50% APCs as providers. Who is supporting this movement? Rutgers Robert Wood Johnson Medical School is incorporating medical students and other health-profession learners into care-coordination teams of the Robert Wood Johnson Partners Accountable Care Organization (ACO). This “transformative medical education project” was awarded a grant by the AMA (https://tinyurl.com/yd54olc8). Some fine people worked under organizations that once had luster, but we cannot ignore the tarnish that these organizations with their conflicts of interest have brought on our profession.
Marion Mass, M.D., Sellersville, PA
Fired for Speaking Out. A pediatrician with 35 years of service was fired by a federally qualified community health center because of a kind, gently worded op-ed he published on the difference between physicians and nurse practitioners (https://tinyurl.com/ycblcklm). At his surprise-termination interview, he was told that his article opposed the principles of the organization, specifically, the principle of mutual respect.
Paul Martin Kempen, M.D., Weirton, WV
The Medical System Needs Disruption. The mere specter of the disruptive potential of a non-profit company formed by Amazon.com, JP Morgan Chase, and Berkshire Hathaway is causing some investors to scurry away from UnitedHealth, Aetna, and Humana. These large “insurance” companies have been ripping off the medical system for decades. Their fortunes improved with ObamaCare. Now they are afraid they are going to lose their stronghold. Mitch McConnell has taken repeal off the 2018 agenda and passed the budget that will force the taxpayer to cover the tremendous shortfalls caused by the defective structure of ACA. The public needs to find out about ACA’s effect on the deficit. If Jeff Bezos, Warren Buffett, and Jamie Dimon understand the reason for the health system dysfunction, they might succeed.
Stanley Feld, M.D., Dallas, TX
No Medical Training Needed to Do Autopsies. In California, elected or appointed coroners with no medical training can even do forensic autopsies. Power politics can be used to influence collection of data to protect persons who have used their authority to cover up a homicide. SB 1303 would require that counties with population greater than 500,000 use bona fide medical examiners to conduct autopsies. It should be amended to require that the medical examiner be a physician licensed in California. In the past, insurers used doctors not accountable to the California Medical board to deny care to injured workers.
Robert Weinmann, M.D., politicsofhealthcare.com
Carrot, or a Different Stick? Secretary Azar says HHS may eliminate reporting requirements for MIPS (Merit-based Incentive Payment System) “value-based” care. Is HHS beginning to hear us? Or is something bad once again being replaced with something worse? Instead of requiring physicians to submit patient data, the proposal suggests having the government use claims data and patient surveys to grade doctors in the program. “We would be able to independently look at data ourselves to decide their compliance with the quality programs rather than their having to even report anything,” Azar said at a Senate Finance Committee hearing. At least we wouldn’t be in double jeopardy, having to pay a penalty after paying for the data collection.
Craig M. Wax, D.O., Mullica Hills, NJ, ip4pi.wordpress.com
Online MOC® vs. Privacy. The American Board of Internal Medicine (ABIM) advertises Maintenance of Certification® using 2-year assessments “in the privacy of your home or office.” The platform is wholly untested for the theft of identity, email content, patient information, etc. The former ABIM Director of Test Security, who departed last year, used an online alias that neither hinted at his past nor disclosed his relationship with the shady test security firm Caveon. This came to light only after ABIM’s lawsuit against [Dr. Jaime Salas Rushford] for alleged copyright infringement, which ABIM lost. Caveon’s system could be imaging our computer’s files or keystrokes for its own purposes.
Westby G. Fisher, M.D., http://drwes.blogspot.com/