AAPS News October 2019 – Medicare for Nobody

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Volume 75, no. 10  October 2019

In proposing “Medicare for All,” Bernie Sanders and his followers suggest that all Americans will be brought into a popular, successful, functioning program that provides well for seniors. In fact, the bill that Sanders claims to have written abolishes the current Medicare program, forces everyone into a very different program that deceptively uses the Medicare name, and incidentally repeals and replaces the Affordable Care Act (ACA).

As Chris Jacobs points out in his book, The Case against Single Payer, the Sanders proposal provides, in Section 901 (a)(1)(A), that: “no benefits shall be available under title XVIII of the Social Security Act [Medicare] for any item or service furnished beginning on [the effective date of the new program].”

Further: “(d) TRANSFER OF FUNDS.—Any amounts remaining in the Federal Hospital Insurance Trust Fund…or the Federal Supplementary Medical Insurance Trust…shall be transferred into the Universal Medicare Trust Fund.”

Over the next 10-15 years, counting the Trust Funds as assets rather than taxpayer liabilities, the Medicare program is 71% funded under trustees’ unfavorable assumptions, and 91% under favorable assumptions. The Mercatus Center estimates that the proposed program would be only 40% funded using existing resources—Medicare, Medicaid, ACA subsidies, and tax subsidies for employer-owned insurance.  Jacobs points out that this would transfer seniors into a program with even less security.

Restrictions on opting out would be extended to the entire population. “Patients who want private care must find a doctor who treats private patients only.” This is far more restrictive than the British system, which permits National Health Service physicians to have a private practice as well. Jacobs asks: “If single payer will produce the socialist paradise…supporters claim, why do they impose so many restrictions on people who wish to opt out?”

Communist East Germans called the Berlin Wall the “Anti-Fascist Protection Rampart,” ostensibly not for imprisoning its citizens but to keep others out of its paradise.

New Taxes

While Elizabeth Warren artfully dodges the question about middle-class tax hikes, Sanders admits to the need for them. Total federal revenue over the past decade has amounted to $28 trillion, much less than the estimated cost of $30 trillion to $40 trillion for the Sanders plan.  (Recall that ACA was supposed to add “only” $1 trillion to costs.) A 7.5% payroll tax on employers might raise $3.9 trillion over 10 years, and increasing income tax rates on incomes exceeding $250,000 another $1.8 trillion. How about a 4% income-based premium on those earning more than $29,000?Another tax on the top 1% of wage earners? (The bottom 90% earn 60% of the wages.) With these increases, revenue would still fall $16.6 trillion short of the cost of the plan, according to Urban Institute researchers.

Elizabeth Warren’s “Ultra Millionaire Tax” would supposedly solve the inequality crisis of the growing concentration of wealth in America. Anyone with more than $50 million in assets would be taxed annually for 2% of that value, and anyone with more than $1 billion in assets at 3%. The IRS would appraise the value of the property, and a mandatory annual audit would make sure everyone pays. For persons renouncing their citizenship there would be a 40% exit tax (not a Berlin Wall). The economists who wrote this plan estimate that 75,000 households would pay the tax, generating $2.75 trillion over 10 years. 

When the 16th Amendment to the U.S. Constitution was passed, the income tax was only supposed to apply to the very wealthy and to top out at 2%.

The wealth tax has a lackluster history.  In 1990, 12 member countries of the Organization for Economic Cooperation and Development had imposed some form of a wealth tax on their citizens. By 2017, that number declined to only four member countries. Millionaires have been leaving France, where wealth taxes still exist, by the tens of thousands. Hence, the proposed exit tax.

Some Democrats urge Warren to own up to the [certain] tax increases but say there will be a [promised] larger savings [for some] by eliminating premiums.

Trapped in a False Either-Or Dilemma

Warren said, and physician single-payer advocates now repeat, “I’ve actually never met anybody who likes their health insurance company.” But do people like the Internal Revenue Service or the Dept. of Motor Vehicles better? Why not advocate for getting the insurer out of most medical transactions, and for allowing competition from hospitals that do not have a whole wing devoted to Medicare/Medicaid compliance?

The Long Game

All In for Medicare for All” is Physicians for a National Health Program (PNHP), which commemorates the 2016 death of Quentin Young: “Quentin lives on in those of us who picked up his banner of health care justice and carried it forward.” Young joined the Young Communist League in the 1930s and was active in many radical groups. He was Barack Obama’s personal physician and mentor.

Is it the end game for American medicine, with medical care for nobody except as determined by government?


Flashback: Incidental Benefit of Income Taxation

On Jun 16, 1909, in a “Message Concerning Tax on Net Income of Corporations,” President William Howard Taft wrote:

If now, by a perfectly legitimate and effective system of taxation, we are incidentally able to possess the Government and the stockholders and the public of the knowledge of the real business and the gains and profits of every corporation in the country, we have made a  long step toward that supervisory control of corporations which may prevent a further abuse of power.


The Red Decade, Redux

The best book that will ever be written about today’s progressive mind-set may have been published in 1941, writes Harry Stein. The Red Decade by Eugene Lyons, republished in 2001, recounts “the spell cast by Stalinist-tinged social-justice activism over that day’s purported best and brightest.” The  story would be “jaw-dropping if it weren’t so eerily familiar.” He writes that  the power wielded by today’s progressives is “even more malign, for its heavy hand is all but unconstrained by countervailing forces” such as industry and organized religion.

American youth groups at the time of the New Deal were dominated by the Young Communist League. What the Administration and congressional committees treated as the voice of young America was really the voice of old Moscow. Frequently changing policies were dictated by Stalin. Lyons writes that the ease with which Communists put it over on the “Innocents’ Clubs” lay less in their own talents than in the “eager gullibility of the victims.” Stein comments on how little we have learned.


Fiscal Tremors

Global Debt: At the supposed peak of the biggest credit orgy of all time—2007—total global indebtedness was $112 trillion or 1.5 times the global economy. It is now $250 trillion or 3 times the economy, increasing at 7 times income growth. In the most recent fiscal year, U.S government spending surged 30%, while revenues fell 3%. (James Cook Market Update, early September 2019).

Inflation Understated: Using the new method of estimating inflation by a “constant level of satisfaction” has reduced the  reported rate of annual CPI inflation since 1980 by seven percentage points. Without this change, Social Security checks would be more than double what they are today (ibid.).

Peak Household Debt: During Q2 1971, the leverage ratio of “consumer” debt against wage and salary income stood at just 23.8%. It then rose slowly to 29.4% by Q2 1987. After Alan Greenspan became Federal Reserve Chairman, it took off. By Q4 2007 consumer debt reached $2.6 trillion, representing 39.8% of wage and salary income, and it peaked at 43.3% in Q2 2015. The household sector can now consume only what it produces and earns—no more Keynesian stimulus. “Risen leverage ratios are a one-time trick and that trick is now all done,” writes David Stockman (Contra Corner 9/24/19).


“A politician divides mankind into two classes: tools and enemies.”

Friedrich Nietzsche


ACTION OF THE MONTH

Do you believe it’s “everything for the patient” (omnia pro aegroto), rather than for the system? Can you spare $10/month to support AAPS?  https://aapsonline.org/monthly


76th Annual Meeting

At our meeting in Redondo Beach, CA, Kristin S. Held, M.D., of San Antonio, TX, was installed as president, and the following were elected:

President-elect: Paul M. Kempen, M.D., Ph.D., Weirton, WV

Secretary: Charles McDowell, Jr., M.D., of Johns Creek, GA

Treasurer: W. Daniel Jordan, M.D., of Atlanta, GA

Directors: Robert Emmons, M.D., Burlington, Vt.; Philip Eskew, D.O., J.D., M.B.A., Torrington, WY; Albert L. Fisher, M.D., Oshkosh, WI; Thomas Kendall, M.D., Greenville, SC.

Jane Lindell Hughes, M.D., of San Antonio, TX, was elected by the Board to fill Dr. Kempen’s unexpired term.

In the student essay contest, Tyson Amundson and Elisabeth Miller tied for first place on this question: “Every society grapples with establishing the relative importance of key values. What is the best way to balance the requirements of individual autonomy (freedom), justice and equality? Define your terms and apply them to the provision of medical care.” Parker Foster won first place on this question: “All proposals for providing medical care will have strengths, weaknesses and trade-offs. Identify and address weaknesses and potential negative trade-offs which arise within a free market.” All winners received $500. Winning essays will be published in the Journal.

The Resolution Regarding Mandatory Psychological Fitness for Duty Evaluation (PFFDE) and Treatment for Physicians Facing Allegations of Workplace Impairment was passed without dissent (full text and list of past resolutions).

The Principles of Medical Ethics were amended to delete the first sentence of principle #11: “The physician should not solicit patients. Professional reputation is the major source of patient referral. The physician should be circumspect and restrained in dealing with the communication media, always avoiding self-aggrandizement.” Use of modern methods such as websites to inform patients about services should not be considered unethical.


AMA: You Need to be a Systems Thinker

The Accreditation Council for Graduate Medical Education’s (ACGME) core-competency requirements include patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. The sixth—medical knowledge—is “typically addressed during clinical education,” and modules from the AMA Ed Hub, which is closely tied to Maintenance of Certification (MOC), address the rest.

“Practicing medicine today is so much more than the interaction between you and the patient sitting before you. Physicians must understand all parts of the health care system,” writes Tanya Albert Henry for the AMA. This includes the “providers system,” the “health care system” as a whole, community organizations, administrative processes, and the patient’s family and contacts. All this is to be coordinated with the “team”—in 10 minutes or less. No time to examine the patient.


Doctors Targeted for Opioid Prescribing

The Death Certificate Project initiated by the Medical Board of California in 2015 has investigated 469 physicians for excessive prescribing because of patients’ overdose deaths in 2012 or 2013. Formal accusations of wrongdoing have been filed against 64 physicians, of which 43 are awaiting a final decisions. Patients, according to a death certificate, fatally overdosed in 2012 or 2013, as long as three years after the accused doctor had written a script, and not necessarily from the same drug the doctor prescribed.

Critics say that a “witch hunt” has disrupted practices by many physicians who, prior to 2014, were abiding by the now outdated mantra that patients’ pain complaints should be aggressively treated with whatever it takes. Representatives of organized physician groups say the project is now hurting patients in pain. Specialists’ waiting lists have backed up, and increasing numbers of primary care providers refuse to prescribe opioids. Others complain that the Board has been too lenient.

The Board will next scrutinize doctors whose patients fatally overdosed in 2016 and 2017. 


Organ Harvests

While his family was challenging a “brain death” opinion, 26-year-old Ruben Vati, who had suffered a drug overdose, had his organs removed by Arizona Donor Network. He was declared brain dead four days after being admitted to HonorHealth John C. Lincoln Medical Center in Phoenix. Vati had checked the organ-donor box on his driver’s license renewal, but later expressed regret, according to his family. The hospital did not comply with a court order to transfer the patient to another hospital, said Life Legal Defense Foundation, and the organ processing corporation sued to take possession of the organs. His father insisted that his son had shown signs of life, tearing up at the sound of his voice.

Fetal hearts are not transplanted, but they are used for research, and they must be harvested from a living donor. In a hearing concerning the undercover videos related to Planned Parenthood’s trafficking in body parts, Theresa Deisher, Ph.D., told the court that the heart must be removed while beating, then perfused with a potassium-containing solution to arrest it in a relaxed position. David Daleiden and Sandra Merritt are claiming a Section 633.5 defense against criminal allegations of illegal taping. This allows covert taping when investigating violent crimes.

“Those kids are actually killed through vivisection,” Daleiden said.


Tip of the Month: If you are still accepting payment from government programs, be aware that waiving copayments is in the government’s crosshairs. Waivers violate the False Claims Act by misstating the charge for services, and the Anti-Kickback Statute by encouraging patients to seek more services. Waivers may be issued on an occasional, case-by-case basis, if the practice has made a good-faith effort to determine that a patient cannot pay. But practices are required to waive copayments and deductibles for certain preventive services; be sure your lists are up to date.

See OIG Special Fraud Alert at http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html (Medical Practice Compliance Alert, September 2019).


AAPS Files Amicus to Fight BC Payment Denial

AAPS asks the Court to rule in favor of a neurosurgeon denied payment in the case of California Spine and Neurosurgery Institute v. Blue Cross of California  (Ninth Circuit Court of Appeals, Case No. 19-15192). Adebukola Onibokun, M.D., is an out-of-network physician in San Jose. He operated on a patient covered by an ERISA plan and took assignment of the patient’s rights. He obtained approval from the insurer, Blue Cross doing business as Anthem, which agreed to pay a reasonable fee. But then it paid him less than 5% of his charges. The plan has an anti-assignment clause, but arguably waives it by failure to assert it when the physician seeks approval for the treatment. The lower court dismissed Dr. Onibokun’s claim. The argument on appeal is that an ERISA plan should not be able to do a bait-and-switch by telling the physician to do the surgery based on an assignment of the claim, but not object based on the anti-assignment clause unless and until the physician sues. 

“Not even the United States, backed by a federal anti-assignment statute, is allowed to use ‘litigation defense’ as a basis for objecting to an assignment of a claim, when its prior conduct implied a waiver,” writes AAPS.  “It is difficult to see why an insurance company should have some kind of special right, greater than what the United States enjoys, in order to take a position in litigation which contradicts its prior waiver with respect to an anti-assignment provision.


Internet Snitching

One suggestion in “The Lazy Person’s Guide to Saving the World” by the UN is to “report online bullies. If you notice harassment on a message board or in a chat room, flag that person.” You should share, don’t just like, interesting social media posts about women’s rights or climate change—assuming the views are correct. Every person on earth can help achieve the UN’s Sustainable Development goals.


Medicare Genetic Testing Fraud

In “Operation Double Helix,” federal agents took down one of the largest alleged scams ever targeted, in which Medicare was billed $1.2 billion. Seniors were allegedly solicited in phone calls and at health fairs or conferences to give a mouth swab to check for cancer risk or for how their body handled their prescription drugs. The patients never got a bill—Medicare was billed as much as $33,000—and often no results either. The patient’s Medicare ID is now in the hands of fraudsters. Medicare might deny future testing because the record shows it was already done. Nine doctors, as well as owners of telemedicine companies and testing labs, have been charged.


AMA’s 2020 CPT® and RVU Changes

Rates start at $1,150 for a workshop on the “insider’s view” of 394 changes in the 2020 code set, including new codes for digital visits and health monitoring. CPT® is “trusted since 1966 [Medicare enactment] as the health system’s common language”—and the AMA’s cash cow.


Correspondence

FBI Surveillance of “Potential” Mass Shooters. According to the Buffalo News, the FBI has been discreetly following and watching dozens of people in this area for the past 7 years. Neighbors are being encouraged to report neighbors. The FBI gathers information from school officials, mental health professionals, colleges and even “houses of worship.” The article quoted an FBI agent, who stated: “We’re doing a very deep dive…. What’s going on in the person’s professional life and their personal life? What’s going on in their love life?” The agent said that “deep-seated feelings of injustice” are often what qualifies one as a “potential mass shooter.” The surveillance effort is spear-headed by the FBI’s Behavioral Analysis Unit, and is said to be “part of a larger FBI response to mass shootings across the country.” According to the article, the effort is usually secretive enough that the person being watched doesn’t know it (tinyurl.com/y4t9ny7s). However, “usually” doesn’t mean always, and one wonders what type of psychopathology is created/caused/exacerbated by the FBI’s surveillance. Some people have been watched “for years.” Given the recently exposed strong partisan views of some in the FBI, one might ask whether one’s political views might be used in part to determine who should be subject to FBI surveillance.

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


The Cause of Surprise Billing. An offshoot of Medicare price-fixing in 1986, networks are the problem. Forcing out-of-network physicians to accept a price set by a third-party payer is not the way to restore sanity to medical pricing. Imagine that you asked the price of a gallon of milk and were told, “I don’t know. Which credit card will you be using?” (Wall St J 5/20/19).

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


“Lower Health Care Costs” Bill a Disastrous Charade. The bill introduced by Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.) to end “surprise medical bills” will impose price controls, put health plans like Aetna and Anthem in charge of what doctors get paid, cause doctors to retire early, reduce access to care, and create a massive federal database of private patient information. It won’t lower costs, but it will raise prices. This proposal would essentially socialize physicians to help patients out of the mess created by the health plan networks that Congress put in place and empowered. It would  eliminate a physician’s right to participate in a free market. It will protect insurers by forcing out-of-network physicians, by law, to accept a similar level of payment from patients as in-network physicians agree to by contract. 

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


Insurers Keep Doctors Out. A press release from the American College of Emergency Physicians (ACEP) notes that insurers benefit when they themselves “opt out” of bringing physicians into their network. Their high deductibles for out-of-network services shift more costs to patients. Patients are indeed surprised by how little their insurance covers.

Jeremy Snavely, Tucson, AZ

Caravans Explained. As the National Association of Former Border Patrol Officers (NAFBPO) has surmised, the failure to secure our borders, the caravans, and failure to stop fraudulent immigration claims stem from UN policy. The UN website still promotes a 2000 study on the need for “replacement migration” to countries of low fertility, including France, Germany, Great Britain, and the U.S.

Zack Taylor, Chairman, NAFBPO

A Mental Health Challenge. Kurt Vonnegut spoke of a prospective book to be titled SS Psychiatrist, about a physician who had been psychoanalyzed and was stationed at Auschwitz. His job was to treat the depression of staff members who did not like what they were doing. Vonnegut said the point was that mental health workers at various times find themselves asked to make healthy people happier in cultures and societies that have gone insane. Vonnegut, author of Slaughterhouse-Five, was a veteran of the Battle of the Bulge, a prisoner of war who survived the Dresden fire-bombing in a bunker five stories underground.

Tamzin Rosenwasser, M.D., Lafayette, IN


Mass Shootings. The number of  lives lost in mass shootings is dwarfed by the lives taken in daily urban crime. These killers lack conscience, morality that values human life, and ordinary self-restraint. What is happening to young men? The tide of illegal immigration and globalism has left them economically marginalized. Radical feminism has robbed them of their place in the natural order. Many are raised in single-parent households, in a culture of moral relativism. Oprah Winfrey, in an astonishing about-face, said we need more people in church and practicing their religion.

Joseph Guarino, M.D., Reidsville, NC


Socialist Youth. Pampered young people, steeped in moral relativism, have become paid angry activists trying to force us to accept their Marxist ideology. When their more rational, hard-working elders die off, the country will be under a totalitarian regime. The handouts will be withdrawn as readily as they were given. It will not be like Denmark.

Ileana Johnson, Ed.D.