Reported experiences with the Oct 1 opening of the Obama health insurance Exchanges remind me of the critical error message in the primitive DOS computer operating system, white letters on the blue screen, often cited as an example of poor design of computer interfaces: “Abort, Retry, Fail?”
AAPS Washington representative Charles Sauer (@MarketInstitute on Twitter) tells The Daily Ledger about his experience trying to sign up for a plan after his family’s policy was cancelled: http://youtu.be/1i15QW2t3uU.
The Miami Herald reported on Oct 13 that persons who had successfully used the choked-up website to enroll in a subsidized plan “have reached a status akin to an urban legend: Everyone has heard of them, but very few people have actually met one.”
The federal government declines to release the number of actual enrollees, though the Department of Health and Human Services (HHS) reported that HealthCare.gov had received 14.6 million unique hits in the first 10 days.
It is claimed that zero Americans signed up in Hawaii or Tennessee and only five in Iowa. An anonymous insurance company official told the Washington Post that very few had enrolled in federal exchanges: “We’re talking single digits” (Forbes 10/3/13).
As many as 99% of applications can’t be processed because of inadequate information. And many who sign up for a plan and think they are covered may find out in January, when automatic bank account withdrawals start—or when they have an occasion to seek medical care, that they really aren’t.
What Is the Exchange Really About?
A $634 million website ought to be able to handle the volume of traffic. The technical problems are not simply from inadequate capacity, but are rooted in the basic architecture—which is related to the purpose of the Exchanges.
Unlike eHealthInsurance.com, where you can immediately learn about benefits and costs simply by entering your ZIP code, the Exchange is not just for providing customers with information and enrolling them in health insurance. You cannot see any actual plan information until you enter a lot of personal information, including your Social Security number, even if you are not interested in or qualified for a subsidy.
Hitting “apply” on Healthcare.gov causes 92 separate files, plug-ins, and other mammoth swarms of data to stream between the user’s computer and servers (http://tinyurl.com/kg7kzyz).
Once an account is set up, the user must consent to auditing and monitoring of network traffic, and it is not clear whether that includes one’s personal network, writes David McKalip, M.D.
What the Exchanges are really selling is dependency, writes Greg Scandlen. “As so many ObamaCare opponents consider it a major milestone on the Road to Serfdom,” writes Linda Gorman, “some grim amusement is provided by the fact that Leavitt Partners saw fit to call part of the Communication Interface “Serff Plan Management” in a diagram of exchange functions.
ObamaCare demands that people buy qualified insurance—but so far has made it impossible for most of them to do so. The historical precedents for governments powerful enough to control access to necessities are chilling. “History rhymes,” writes Ann Barnhardt. Stalin denied Ukrainian farmers seed at planting time, then later demanded the nonexistent harvest and accused the farmers of hoarding it. More than 3 million Ukrainians died in the resulting Holodomor.
Medical care, of course, is not as essential as food. Henry Kissinger said that “to control the people you must control the food.” Governments are still doing that today: “We won’t allow them to be nourished,” said a Syrian paramilitary about a population of a suburb of Damascus, where some rebel forces are located in the midst of 12,000 civilians (WSJ 10/3/13).
As Exchange computers were crashing, so was the system that processes food-stamp debit cards in 17 states, causing panic among dependents of the Electronic Benefits Transfer (EBT) program. While many blamed the government shutdown, a Xerox Corp. system failure was responsible—this time.
They Thought It Was Free
Many of the complaints that riddled the official ObamaCare Facebook page concerned “very scary” premium prices. While some people might have to pay only $11/mon, even the lowest-priced “Bronze” plans will double the cost many young people have been paying.
Said one ardent Obama supporter, whose premium increased by $1,800, “Of course I want people to have health care. I just didn’t realize I would be the one who was going to pay for it personally.”
In its first 10 years ObamaCare will increase American health spending by $621 billion above the amount it would have been otherwise —$7,450 per family.
Is There an Alternative?
AAPS director G. Keith Smith, M.D., explained to Bernard Lo of CNBC-Asia how a resurgence of a true market with transparent prices could occur: http://video.cnbc.com/gallery/?video=3000203405.
Exchange Facts
- Pre- and Post-ACA Premiums: While HHS is dodging the question of whose rates are going up, the Manhattan Institute has posted an interactive map. Worst off is North Carolina, which will see individual-market rates triple for women, and quadruple for men. Most people will not receive enough in subsidies to counteract the degree to which Obamacare drives premiums upward (Avik Roy, Forbes 9/25/13).
- Subsidies: Age-specific data from the 15 Exchanges that have released them show that more than 1 million 18-to-34-year-olds will not receive any subsidy, and nearly 4 million would save at least $500 by forgoing insurance and paying the fine (tax). “The subsidy structure…looks like a prime catalyst for a death spiral,” write David Hogberg and Sean Parnell (National Policy Analysis 9/13).
- Navigator Fraud: Consumers will not be able to verify whether a navigator or assister is legitimate—or is engaged in identity theft. Some are being paid by the number of persons they enroll, and are not required to disclose this conflict of interest. Some impersonators ask consumers for money (BNA’s HCFR 10/2/13). A history of number-fudging and whistleblower intimidation did not keep Seedco from getting multi-million dollar Navigator contracts (Michelle Malkin 10/2/13).
- Only the Beginning: Once they are up and running, Exchanges will be able to adopt policies to reshape the financing and delivery of care. They might require providers to apply research findings on comparative effectiveness. They may be able to contract selectively with particular insurers or care delivery organizations. They are “an instrument of enormous potential power” (Henry J. Aaron, Ph.D., and Kevin W. Lucia, J.D., M.P.H., NEJM 9/26/13).
The Nudge Squad
A late-20s former Wunderkind, Maya Shankar, was appointed senior policy advisor to the Obama White House Office of Science & Technology Policy. Her mandate is to organize a Nudge Squad to use insights from neuroscience to change behavior—related to matters ranging from energy efficiency to weight loss. Health insurance objectors and lapsed recyclers could become candidates for government intervention (David Martosko, Mail Online 7/30/13).
Breeding the Doctors We Need
Despite significant investments in medical education, the U.S. government asks very little of doctors, writes medical student Ben Gallagher. They are allowed to choose what specialty to practice, where to work, and how much to work. “If more students knew their government was making an expensive investment in them, they might strive to become the kind of doctors their country needs.” But since students are only human, government should consider policies to force more doctors to go into primary care, work in underserved communities, and work full-time. “These measures may sound punitive, but they are exactly what…Americans who can’t find a doctor need” (Atlantic 9/12).
A 5% Commitment?
Medicaid now covers more than 20% of the U.S. population, and with the Affordable Care Act (ACA) this will expand to millions more. Yet 30% of office-based physicians do not accept new Medicaid patients. This seems to be incompatible with the principle of professionalism and with the World Health Organization’s Declaration of Geneva, which many medical schools “ask” their students to accept, writes Lawrence P. Casalino, M.D., Ph.D.
“If all physicians cared for Medicaid patients, all would have a reason to care about the Medicaid program, so that more pressure could be brought to bear on the program to provide reasonable payment rates and reduce administrative burdens,” he states.
The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation, might ask physicians to voluntarily commit to accept a minimum of 5% of Medicaid patients into their practices (NEJM 10/9/13).
Why not instead provide liability coverage for the practices of physicians who serve the poor 4 hours per week without billing the taxpayers, as proposed by AAPS past president Alieta Eck, M.D.?
FDA v. Patients: Asking Permission to Live
The Oct 9 press conference at the National Press Club on FDA barriers to life-saving treatments, co-sponsored by AAPS and Americans for Free Choice in Medicine (AFCAM), can be viewed at http://FDAvPatients.com.
ABOG Certification Tied to Compliance
No matter how well-trained and knowledgeable, physicians may lose their certification by the American Board of Obstetrics and Gynecology (ABOG) if their practice is not consistent with ABOG’s definition of their specialty. At least 75% of their practice must be limited to areas of medicine within the examination topics listed in ABOG Bulletins. Treatment of men is prohibited except for a narrow range of circumstances such as government service, emergency call required by a hospital, infertility evaluation, expedited partner treatment for sexually transmitted diseases, administering immunizations, or management of transgender conditions (http://www.abog.org/definition.asp). Certification may be revoked for violation of ABOG’s ethical standards. Young prolife physicians may avoid ob/gyn training out of fear of facing a choice between abiding by their conscience or maintaining certification, should ACA’s “reproductive health” coverage demands be incorporated in ABOG’s ethics.
AAPS Calendar
Nov 1-2. Physician Summit: Prescription Freedom, Dallas, TX.
Jan 31-Feb 1, 2014. Workshop, board meeting, TBA.
Sept. 2-6, 2014. 71st annual meeting, Charleston, SC.
AAPS Files Amicus in Liberty Univ. v. Lew
On Oct 9, AAPS filed a brief amici curiae in the U.S. Supreme Court supporting the petition for writ of certiorari by Liberty University. Although the courts below held that the issues of violating the Origination Clause and Presentment Clause had been waived, AAPS argues that the Court should address them sua sponte (on its own accord).
Chambers of Congress may not reallocate their own powers. The Constitution would never have been ratified without the Origination Clause. In 1872, Rep. James A. Garfield wrote: “Twice during the constitutional Convention of 1787, the whole system hinged upon the exclusive right of the House to originate revenue bills.” Large states would otherwise never have agreed to allow smaller states an equal voice with themselves in the Senate.
Amici believe the Senate’s power to “amend” a House-originated Revenue bill cannot be construed so broadly that the Senate is permitted to strike the entirety of the bill’s language and title without running afoul of the Origination Clause. Such a broad construction creates a loophole so large that it, in effect, eliminates the Origination Clause.
In considering the ACA, the Senate removed every vestige of the House bill except for the number. “One cannot conclude that ACA originated in the House without stretching the meaning of the word ‘originate’ well beyond recognition.”
The Presentment Clause requires that the House and Senate pass identical versions of a bill, which must then be signed or vetoed by the President in its entirety. A bill cannot be passed and amended simultaneously. But both the employer mandate and the individual mandate contain provisions that cross-nullify each other; i.e. they cannot be presented to the President in the same bill. Thus, it is appropriate for the Court to determine whether the mandates exist.
The Court has heard only eight Origination Clause cases in its history, writes Chris Conover, and follows a procedural rule whereby it simply accepts Congress’s statement of enrollment as the proper origination of the bill. It is, however, conceivable that the Court could put a stop to Congress’s steady erosion of the intent and letter of the Origination Clause, just as it set a limit on the constant expansion of the Commerce Clause.
The ACA and its tens of thousands of pages of regulations have spawned nearly 100 lawsuits, more than half of them concerning the preventive services contraception requirement, and a few still have a prospect of overturning the entire law, Conover states (Forbes 9/13/13).
More than 20,000 Pages of Regulations
Confusion and conflict mount as implementation proceeds. Some rules contradict others. To understand the penalties related to the employer mandate requires a flow chart. As a result, 77% of the job growth in the past few months has been part-time employment. (The Obama Administration denies this despite Bureau of Labor Statistics reports.) To compute the number of pages, Sen. McConnell searched the Federal Register website on “Affordable Care Act” and used the option to download the documents to an Excel spreadsheet. The “sum” feature counted 20,202 pages, but there may be 40,000 (http://tinyurl.com/kau9sv4).
HIPAA Non-covered Entities
There is a rumor that the window for the “country doctor exemption” established by AAPS in litigation against the “Privacy” Rule in the Health Insurance Portability and Accountability Act has closed, and that the law no longer allows one to become HIPAA-exempt. We have seen nothing to support this rumor (at least in federal law). One of our members writes:
“I promote HIPAA exemption, keeping employee FTEs below 10 per year, and filing only paper claims, never sending personal health information by electronic means.
“I used to think my HIPAA exemption was like virginity: once it was lost there was no reclaiming it. Then I researched it some years ago and concluded that it could be reclaimed. Either one could convert the practice by retooling claims and declaring exemption, or one could move to another corporation and start “anew” as an exempt [noncovered] entity.”
There has long been a gray area concerning how long one must be out of the system to revert to country doctor status. There is no clear demarcation. It is impossible to prove a negative—the nonexistence of some new federal rule, but our member’s explanation is as good as any we have seen.
Claims by Patients of Nonenrolled Physicians
From a Sept 9 letter to Sen. Ted Cruz by Richard Swint, M.D, of Paris, TX, re: “wrong information from your personnel” and “refusal of Medicare to pay claims”:
“One of my patients received a statement from Novitas that Medicare would not pay his claims, ‘submitted by him,’ on form CMS 1490S, for examination at my office.
“Medicare Congressional law guarantees patients free choice of a doctor. Congressional law supersedes rulings by the Secretary of Health. Congressional law does not require that patients can only be treated by Medicare enrolled doctors.. This patient has paid Medicare Part B premiums…. People paying Medicare Part B premiums do not forfeit their right to choose their doctor.
“As a physician, I made the decision to not renew my Medicare number, and therefore I am not enrolled in Medicare. I do not file Medicare claims, and my office does not take any payments from Medicare.
“I did not opt out, there is a difference, and my patients should be reimbursed for their medical treatment according to Congressional law. Enclosed is a copy of a letter from [CMS] which states that I am not required to file Medicare claims because I am not enrolled in Medicare [AAPS News, May 2011].
“Medicare should have the original claims that my patients have submitted. Please ask Medicare to review these claims and to send reimbursement directly to the patients.”
Correspondence
Opt-Out Renewal Refused. In the past several years, the number of opted-out physicians has more than tripled. In an apparent attempt to slow the trend of physicians opting out of Medicare, some Medicare contractors are making up guidelines and regulations so as to make it more difficult for physicians to opt out. I have routinely sent my opt-out renewal 6 months early because of the well-known inability of carriers to process things in a timely fashion. This time, our Medicare contractor, NGS, has refused to process my valid opt-out renewal multiple times simply because it was received more than 30 days in advance of the renewal date. In a phone conversation with “Suzanne” from NGS, I was first told that the CMS guidelines prohibited NGS from processing an opt out more than 30 days in advance, and later in the same phone conversation she said NGS could process an opt out 60 days in advance. She could not provide the statutory authority that allows a contractor to refuse to process a valid opt out when it is received more than 30 days in advance–likely because no such guideline exists. Each time the carrier refuses to process my application, I file a complaint against NGS with the HHS Secretary, CMS headquarters, and the Region II office.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Not So Glorious NHS. The Feb 5, 2013, Report of the Mid Staffordshire NHS Foundation Public Inquiry to the Secretary of State showed that the most basic elements of patient care were often neglected in British National Health Service hospitals. Patients were left in soiled sheets or sitting on commodes for hours. Patients were left unwashed for up to a month. Staff failed to make basic observations, and pain relief was provided late or in some cases not at all. Food and drinks were left out of patients’ reach. Hygiene standards were at times so appalling that family members cleaned toilets or disposed of soiled dressings. There was an “insidious negative culture involving a tolerance of poor standards.” In part, failure resulted from putting collection of statistics and reaching national access targets ahead of patient care.
Stanley Feld, M.D., Dallas, TX
Donald Berwick Responds. Until recently head of the U.S. Centers for Medicare and Medicaid Services (CMS), Donald Berwick, M.D., was called in to chair the National Advisory Group on the Safety of Patients in England (http://tinyurl.com/q3k7vyg). In a letter to senior NHS officials concerning the Mid Staffordshire inquiry, he writes: “You are stewards of a globally important treasure: the NHS. In its form and mission, guided by the unwavering charter of universal care, accessible to all, and free at the point of service, the NHS is a unique example for all to learn from and emulate. Faults are to be expected in any enterprise of such size and ambition.” The solution to problems: “The system must…abandon blame as a tool and trust the goodwill and good intentions of the staff.” Though patients suffered indignities, and many probably died from avoidable causes, no one is accountable.
Greg Scandlen, Consumers for Health Care Choices
The Real Don Berwick. Like most charlatans and mountebanks, Berwick has a moral high-ground position speech that sounds good. But once you change your priorities from the dignity of one human being to the collective welfare, killing is approved. Those who think Berwick is motivated by good intentions are like the leftists who were willing to be complicit with Communist killer elites. When socialists developed an ideology focused on “society,” they extinguished the traditions and mores of civilization. Why not allow the disabled to die—how can they contribute to the collective? After all the cant, it’s still about morality, isn’t it?
John Dale Dunn, M.D., J.D., Brownwood, TX
What Is the Goal? Chaos, havoc, and outright destruction of the existing medical profession are likely to be the result of ObamaCare, if not its goal. Doctors who think for themselves and advocate for their patients above all else are poison to its impossible utopian dream. ObamaCare requires compliant cogs who will push the limited buttons available to them and ration care on behalf of the government and third parties. Doctors will be a convenient scapegoat. Our intellectual property will be used to train our replacements, cogs with no history of ethics.
David McKalip, M.D., St. Petersburg, FL
What Is the Result? There is no evidence that socialized medicine has ever improved people’s health. There is massive evidence that medical care, once politicized, becomes a vicious game, where one’s worth to the “state” may determine whether one lives or dies. As long as government has a role in medicine, market distortions caused by bureaucrats (well-meaning or not) will result in shortages or surpluses, often resulting in misery or death.
G. Keith Smith, M.D., Oklahoma City, OK
Ethics and Economics. In the Soviet Union, every price encountered by producers or consumers was wrong. So everyone constantly had a perverse economic incentive to do the wrong thing. Ultimately, society needs to have individuals guided by ethical standards. So why not have a free market in medicine in which economic and ethical standards are aligned rather than at odds?
John Goodman, Ph.D., National Center for Policy Analysis
