Tuesday, December 30, 2014

In 2015 The IRS Will Collect ObamaCare Penalties

Once they have their hand on your wallet, your heart and mind will follow.


In 2015, the IRS will begin to collect $325 from Americans’ wallets if they did not have a health insurance plan. This penalty , of course, is the guts of the individual mandate, a chief source of ObamaCare funding.

How this mandatory funding will play out politically is very much in doubt. Over 90% of Americans are not even aware of the ObamaCare penalty, and even if they were, it would be just as unpopular as the law, which 57% oppose.

Most Americans will not be aware of the $325 penalty or 2% of their income until they fill out their tax returns or see sharply diminished tax refunds.

Because of budget cuts, the IRS may not the money or resources to collect penalties from health plan- negligents. The coming 2015 penalties will be first time all taxpayers will have to report to the IRS if they have health insurance the previous year, if their tax status or income has changed, or that they have to pay $325 or 2% of their income if they have been naughty by not being insured.

The unexpected penalties will surely be unpopular, just as the law has been. The GOP will seek to undermine the law and its bureaucratic mishmash. Who will be assessed for penalties resides in murky gray zones since the law offers 30 exemptions or waivers for those undergoing financial hardships. H&R Block says 4 million will eventually pay penalties and 26 million will qualify for exemptions. Some taxpayers may find whether they qualify by going to Turbo Tax and clicking on “Exceptions Check,” but most will be in dark.

Taxpayers must act before February 15, the end of the second health exchange enrollment period, to see if they are exempt from payment. But according to the Kaiser Foundation, only 5% are aware of this deadline.

“We could be looking at a real train wreck after February 15, says Stan Dorn, a policy expert at the non-partisan Urban Institute. " People will file their tax returns and they will learn they are subject for a much larger penalty in 2015, and they can do absolutely nothing about it. “ We shall soon see if the “train wreck” metaphor, first advanced by then Democratic Senator, Max Baucas of Montana, holds.

One ObamaCare critic tartly observed, “ Alas, there will be no way to save your ass by weaseling out of the bureaucratic morass."

Whether taxpayers will resign themselves to their fates, Obamacare will collapse of its own political weight, the GOP will repeal the health law, Democrats will delay implementation of the individual mandate, or the health law will prevail via a Presidential veto, no one can say with confidence. All taxpayers can do is to hold onto their wallets and pray that political compromise and what’s best for the country, and for the hearts and minds of their fellow countrymen, will prevail.

Monday, December 29, 2014

Hitting ObamaCare on the Head without Redundancies

If you have a nail to hit, hit it on the head.

David Lambuth, The Golden Book on Writing

I sent a prospective book to a book agent. He said the book was too full of redundancies to accept. Would I please say what I think about ObamaCare without repeating myself? And would I please do it without insulting anybody politically. As Mark Twain said, “Reader, suppose you were an idiot or a member of Congress, but I repeat myself.”

OK, here goes.

1. GOP will seek to defund, delay, reverse, or repeal the medical innovation tax and elements of individual and employer mandates.

2. The Supreme Court will rule that federal exchange subsidies are unconstitutional, and chaos will ensue.

3. GOP will present an alternative plan before the Supreme Court rules and will vote in boh Houses of Congress to repeal ObamaCare through the reconciliation process, which Obama will veto.

4. Middle class revolt is upon us, as shown by midterm results at all levels of federal, state, and local governments because of rising costs, plan cancellations, and loss of health plan choice along with desire for smaller government and lower taxes.

5. Fatal ObamaCare flaws include – broken promises on choice of doctors and plans, unilateral executive actions, one-size-fits-all mindset, clash with American free enterprise cultural values, anger secondary to health law passage without single GOP vote and aggravation of doctor shortages.

6. Bewildering complexity of law affecting different people differently at different times while promoting redistribution of income and equality of outcomes and uncertainties engendered by federal control at odds with states’ desires for flexibility will turn voters off.

7. Physicians will respond by retiring early, working for hospitals and large integrated systems, going into specialties, and entering direct pay concierge practices without 3rd party involvement and by not accepting or seeing fewer Medicare, Medicaid, and health exchange patients.

8. The public will respond by seeking alternative care, including alternative care practitioners. getting care at retail outlets and clinics, going without health plans, delay, delaying care, or treating themselves, or getting direct care with concierge physicians and surgeons.

Sunday, December 28, 2014

Medicaid: Whether Thou Goeth?

Whether thou goeth, I will go, and where thou lodgest, I will lodge, thou people shall be my people, and thou God my God.

Ruth 1:6

Where goeth Medicaid? That biblical verse sprang to mind when I read , “As Medicaid Rolls Swell, Cuts in Payments to Doctors Threaten Access to Care,” by Robert Pear, New York Times, December 28, 2014.

There’s something biblical about Medicaid, even in this secular world. Government, in the minds of some, is God, and he will protect his flock through Medicaid.

And he may be in the process of doing so. Medicaid enrollment exploded from October 2013 to October 2014 by 9.7 million to reach a total of 68.5 million. That’s a 17% surge. It doesn’t take a social scientist to realize that at that exponential rate, Medicaid will inherit the Earth and eat the national budget in just a few years. Medicaid already covers one of five Americans. It’s one down and four to go.

But there’s are three catches. A Republican Congress, a conservative public, both concerned about the national debt and the state of the economy; and shrinking numbers of doctors, reluctant to see and treat Medicaid patients at government rates.

ObamaCare provided an increase of Medicaid rates in 2013 and 2014, but the increase expired this week, and may not be renewed. Cuts will average 43% across the nation for primary care physicians, and by 50% or more in large states such as California, Florida, New York, and Pennsylvania.

George J. Petrucio, a family physician in Turnerville, N.J, says the cuts are a “bait and switch’ tactic. “Once the government attempted to entice physicians into Medicaid with higher rates, then lowers reimbursement once the doctors are involved.”

You can’t just abandon a patient once you have them on board. So you bite the bullet, extend waiting times to see you, and put Medicaid patients at the back of the line.

What else are doctors to do? A survey by the Ohio State Medical Association indicates that Ohio doctors will accept fewer Medicaid patients. You have no legal recourse. The Supreme Court has ruled doctors cannot sue the government to equalize Medicaid and Medicaid rates. Other options include going out of business, going to work for the hospital, hiring more mid-level providers, retiring early, resigning themselves to lower incomes and to accepting government cuts as inevitable, or entering direct pay practices outside the realm and reach of Medicaid.

Under federal law, Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid beneficiaries have at least as much access to care as the general population in their geographic area. To many doctors, this is just meaningless government rhetoric by the elite chattering classes.

Saturday, December 27, 2014

Blogs After Eighty

Essays, like poems and stories and novels, marry heaven and hell. Contradiction is the cellular structure of life. Sometimes north dominates, sometimes south – but if the essay doesn’t contain contradictions, however small they may be, the essay fails.

Donald Hall, Essays after Eighty, Houghton Mifflin Harcourt, 2014

A blog is essentially an essay, a problem or belief stated, a background supplied, and a solution offered.

Essayist E.B. White said in Elements of Style, “ All writing is communication. It is Self escaping out into the open. No writer remains long incognito.”

I ought to know, I have written over 3600 blogs, over 500 this year alone. At my age, 81, you say what you think.

I believe in America, small government, a bottom-up society, a competitive market place, and individualism.

I believe ObamaCare is deeply flawed. It has good intentions and good points, but it contains fatal contradictions with American society and will inevitably devolve into something better.

I believe the experience of aging has its virtues and limitations. We all interpret the same facts differently, and we are entitled to.

I believe we are all fallible and engage in behavior in our own self-interest. And I believe innovative entrepreneurs, pursuing their dreams, and creative artists, expressing their beliefs freely , are the lifeblood of America’s exceptionalism.

These are some of the reasons why I enjoyed so much former poet laureate Donald Hall’s 134 page book Essays After Eighty.

Donald Hall is 85 years old and he still productive. He is still getting in his last words and his last licks about the state of mankind.

Over his life, he has written 19 books of poetry and 17 books of prose. He was a co-founder of the Paris Review in the 1950s with George Plimpton. Peter Mathiesen and others. I am a life-time subscription to the Paris Review. It features well-wrought interviews with writers. Hall was Poet Laureate of the United States in 2006 and 2007. He no longer writes poems, but he is fond of writing irreverent, off-beat, self-effacing essays on the pleasures of smoking, “No Smoking,” and of non-exercising, Physical Malfitness,” both of which are contained among the fourteen essays in this book.

Last year I met and spend two hours in his company at his home at Eagle Pond Farm in New Hampshire. I was there courtesy of my son, Spencer Reece, a poet in his own right and a friend of Donald Hall. Hall was crusty, outspoken, and memorable.

Spencer thinks of Hall as a mentor and critic. He has praised Spencer of this poetry but says Spencer's prose badly needs reworking. Nothing wrong with that. Hall claims his essays go through thirty to eighty drafts, as he seeks just the right word, the right way to say something, and the right rhythm and cadence. Precision in these things is the name of the writing game. If you’ll pardon the play on words, these are the “hall marks” of a good writer.

Hall has no qualms or illusions about his inevitable death. Of death he says, “It is sensible of me to be aware I will die one of these days. I will not pass away. Every day millions of people pass away – in obituaries, death notices, cards of consolation, e-mails to the corpse’s friends. They rest in peace, quit the world, go the way of all flesh, depart, give up the ghost, breathe the last breath, join their dear ones in heaven, meet their Maker, ascend to a better place, succumb surrounded by family, return to the Lord, go home, cross over, or leave this world.”

Not Donald Hall, he will get in his last word. He will have his say. He will make his last pass. He will say it the way he sees it. And if he sees a pretty girl, he is likely to say, “Oh, to be eighty again.”

Friday, December 26, 2014

A Christmas and New Year’s Message about Obamacare’s Future

Now the question is, once again, whether ObamaCare will emerge intact from the Supreme Court. If the Court dramatically narrows the ACA’s scope, the political calculus will change substantially in 2015 and beyond, The law’s recent momentum will be reversed, the fight over ObamaCare will intensify, and the future of health reform will be highly uncertain.

Jonathon Oberlander, Ph.D, University of North Carolina, “Unraveling Obamacare – Can Congress and the Supreme Court Undo Health Care Reform?” New England Journal of Medicine, December 25, 2014

Occasionally a clear-eyed, crisp, and beautifully written summary of ObamaCare’s benefits and ills crops up. Such is the case with Jonathon Oberlander’s critique of ObamaCare in this week’s New England Journal of Medicine.

Oberlander says ACA’s fate rests with the Supreme Court, who will hear the case of the constitutionality of subsidies on April 4 and issue its decision in June.

But he says much more, namely.

• The GOP cannot repeal ObamaCare with Obama, with his veto power, as president.

• The GOP will likely focus on changing the individual mandate, the employer mandate, the tax on medical devices, and perhaps the Independent Payment Advisory Board.

• The Republican strategy will be to force Democrats to vote on bipartisan issues with a chance to pass, even if Obama vetoes them, thereby labeling the president as leader of the party of “No.”

• The GOP’s problem may not be it cannot repeal Obamacare while Obama is president but after his presidency ends “With each passing year, the ACA’s reach growls larger and iots roots become deeper- more Americans gain coverage, the health insurance marketplaces and Medicaid expansions become further entrenched, and medical providers become more dependent on ACA business."

• “The calendar, Oberlander concludes, cannot be turned back to 2009. The ACA has made some irreversible change in U.S. health care.”
Post-Christmas Thoughts of 2015 Individual Mandate Penalties

1. A penalty imposed for a violation of a law. 2.loss, forfeiture, suffering to which a person subjects himself by nonfullfillment of some obligation. 3. Something that is forfeited, as a sum of money.


I hate to be a spoilsport but the time has come to start thinking about penalties imposed by ObamaCare’s individual mandate, which imposes a $95 penalty on you in 2015 if you did not buy health insurance in 2014, or if you did not report a change in income, or if there was some change in your life or health status, or a death in the family, or if you did not faithfully or accurately fill out ObamaCare forms or follow ObamaCare procedures.

The what ifs , whys, whens, and wheres of the individual mandates may drive you crazy because your phone calls and web inquiries to the IRS , HHS, CMS, or healthcare.gov may not be answered, or may require hours of waiting on the phone.

Don’t worry. If you fail to act or cannot act, the IRS will deduct $95 this year or $395 next year from your tax refund, which this year averages about $3000 for the average American.

Fret not. The individual mandate is an act based on a high, idealistic motive that all Americans’ health care ought to be covered by some other American, and other Americans ought to be penalized for violating the law through loss of money, even if he or she does not understand the law or its bureaucratic details, and does not know where or how to go to find out those details.

The Devil may be in the details, but the Devil may be inaccessible.

Take solace in the fact that this sort of thing is inevitable in a top-down government bureaucracy.

As Peter Drucker (1909-2006), the conservative and pragmatic social historian commented,

“The best we get from government in the welfare states is competent mediocrity. What is impressive is the administrative incompetence. Every country reports the same confusion, the same lacok of performance, the same proliferation of agencies , or programs, or forms.”

Relax. Your government, with its mediocre and imcompetent programs, will take care of itself. In 2014, it imposed $500 billion in 20 new taxes, 2500 pages of new regulations, created 159 new federal health care agencies, is projected to spend $1.4 trillion or more in next ten years in its health law and to exceed $20 trillion dollars in national debt.

Government health insurance is in good hands with itself and will good care of itself.

Wednesday, December 24, 2014

Bottom- Up, America! It’s Christmas!

Despite the conceits of New York and Washington, almost nothing starts there. America is a bottom-up society

John Naisbitt(born 1929), America's best prognosticator, in Megatrends (1982)

Every tub must stand on its own bottom.

John Macklin (1697-1797), The Man of the World

Bottom-up, America!

Hold your glasses high! America is on a roll again! An economic boom is on the horizon.

The American economy grew 5.0% last quarter – the largest rate of growth since 2003.

Many things contributed - brisk consumer spending, lower levels of personal debt, a soaring stock market, and plunging gas prices - but the biggest single overarching factor was American innovation from our diverse, flexible, experimental bottom-up society.

In this case, the most single powerful thing may have been fracking, formally called hydraulic drilling and horizontal fracturing.

This approach, led by private entrepreneurs, has made America the largest single producer of oil and natural gas in the world in just a few years. It has turned the world’s economies upside down, with the big losers being Russia, Iran, and Venezuela. It has been primarily responsible for the fall of gasoline prices for 88 consecutive days. It has been the equivalent of a tax windfall for American consumers, for we are a nation that runs on gasoline, diesel fuel, and natural gas. And so does the rest of the world. The number of vehicles fueled this way are predicted to double in the next ten years. Inexpensive energy helps keep the world from groping in the dark, starving in underdeveloped countries, freezing in the North, and sweltering in the South. Fracking may contribute to climate change, but that is a technologically soluble problem, and there is no evidence so far of pollution of our water supplies.

Why did fracking originate in the U.S. and not elsewhere?

After all, the U.S. government opposes fracking and drilling on government lands and the XL Keystone Pipeline and other projects and industries that employ fossil fuels that may harm the environment and warm the climate.

Why did fracking happen in the U.S.?
Because we are a resilient, bottom-up society.

Here is how Bret Stephens explains it (“The Marvel of American Resilience,” WSJ, December 23, 2014).

“Fracking happened in the U.S because Americans, almost uniquely in the world, have property rights to the minerals beneath their yards. And because the federal government wasn’t really paying attention. And because federalism allows states to do do their own thing. And because against –the-grain-entrepreneurs like George Mitchell and Harold Hamm couldn’t be made to bow to the consensus of experts. And because our deep capital markets were willing to bet against those experts.”

It is no secret why America leads the world in big earth-shaking innovations – the Internet, social media, mobile apps, medical developments such as cancer immunotherapy, the decentralization of our health system. It is not our government that makes a difference. between us and the rest of the world. It is our people and our diverse decentralized society. Our success is based on the resilience of our people rather than our reliance on central government. Government can only administer, dictate, repress, regulate, and centralize. It cannot adapt. It is too big and sclerotic for adaptation.

What we are seeing this Christmas is the rise of our bottom-up society. We see it in the the rise of middle-class workers, the return of power to the electorate at local and state levels, the demand for commonsensical results rather than lofty, impractical rhetoric by experts.

As Bret Stephens says, “We are larger than our leaders. We are better than our politics, We are wiser than our culture. We are smarter than our ideas. Enjoy the holiday.”

The path to our success as a nation comes from the bottom-up, not the top-down. The path to compassion for all comes through prosperity for all. That's the bottom-line.
The Road to Hell Is Paved with Good Intentions: The Story of ObamaCare

First Book of a Tetralogy

$9.99 Kindle E-book, Amazon.com

Book Description

Publication Date: December 23, 2014

In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.
Product Details
• File Size: 1161 KB
• Print Length: 189 pages
• Simultaneous Device Usage: Unlimited
• Publisher: Alethos Press; 1 edition (December 23, 2014)
• Sold by: Amazon Digital Services, Inc.
• Language: English

Tuesday, December 23, 2014

Tenth Annual Physician of the Year Awards

For over ten years, I have been a member of the Castle Connolly Medical Ltd. medical advisory board. For the last ten years, the board has helped Castle Connolly select top physicians from nominations submitted by physicians and medical leaders from across the country for rewards for excellence. The awards include three Clinical Excellence Awards and two Life Achievement Awards. These various Awards are the equivalent of Hollywood’s Academy Awards. The Awards will be presented on March 23, 2015 in New York City to the distinguished recipients, who represent American academic medicine.

Lifetime Achievement

• M. Jeffrey Maisels, MD, Beaumont Hospital Royal Oak, Pediatrics

• John Cameron, MD, Professor, John Hopkins University Department of Surgery

• Michael E. Johns, MD, University of Michigan, Otolarygology

• William H. Donovan, MD, University of Texas Medical School, Physical Medicine and Rehabilitation

• Jerome Posner, MD, Memorial Sloan Kettering Cancer Center, Neurology

• Valantine Fuster, MD, Mount Sinai Hospital, Cardiovascular Disease

• Anthony Furlan, MD, Case Medical Center, Neurology

• Mark Siegler, MD, University of Chicago Medical Center, Internal Medicine

• James D, Crapo, MD, National Jewish Center, Pulmonary Disease

• David E. Schuller, MD, Ohio State University Otolaryngology

• John B. Mulliken, MD, Children’s Hospital, Boston, Plastic Surgery

• Joseph C, Maroon, MD, University of Pittsburgh Medical Center, Neurology

Clinical Excellence Nominees

• Fabrizio Michelassie, MD, Weill Medical College of Cornell University, Surgery

• Ricardo L. Carrau, MD, Ohio State University, Neurosurgery

• Kimberly A. Brown, MD, Henry Ford Health System, Gastroenterology

• John Villano, MD, Albert B. Chandler Hospital, Medical Oncology

• Christina M. Surwicz, MD, Harborview Washington Medical Center, Gastroenterology

• Alberto Esquenazi, MD, Albert Einstein Medical Center, Physicial Medicine and Rehabilitation

• Debra Somers Copit, MD Diagnostic Radiology

• Lawrence J. Brandt, MD, Montefiore Medical Center, Gastroenterology

• James R. Jett, MD, National Jewish Center, Pulmonary Disease

• Mark R. Katlic, MD, Sinai for Geriatric Surgery and Sinail Hospital, Geriatric Medicine

• Mani Menon, MD, Henry Ford Health System, Urology

• Louis Philipson, MD, University of Chicago, Endocrinology, Diabetes, and Metabolic Disease

• Kenneth Anderson, MD, Dana Farber Cancer Inztitutioe, Hematology

• Everett E. Vokes, MD, University of Chicago, Medical Oncology

• Henry Brem, MD, John Hopklnis Hospital, Neurosurgery

• Robert Spetzier, University of Pittsburgh, Neurosurgery

• Anthony Ata, Wake Forest Institute, Urology

Monday, December 22, 2014

Vermont Abandons Single-Payer

The work goes on, the cause endures, the hope still lives, and the dream lives on.

Senator Edward Kennedy (1932-2009), Speech at 1980 Democratic Convention

For each age is a dream that is dying,

Or one that is coming to birth.

Arthur O'Shaughnessy (1844-1881), The Music Makers

When I think of Vermont, I think of the movie “White Christmas.”

The movie’s setting was a Vermont country inn, although it was filmed in Connecticut.

I think of a quintessential liberal state with a homogenous generous people.

I think of cows and ice-cream made by Ben and Jerry. I think of its socialist senator, Bernie Sanders, who wears his compassionate heart on his sleeve.

I think of fellow New Englander, Senator Edward Kennedy, whose dream was single-payer.

I think of an April 6, 2014 blog in which I concluded, “Vermont is in the midst of implementing a single –payer, state-wide, health system. It believes it will save money and save its society.”

I think Peter Drucker (1909-2005), who wrote in the Age of Discontinuity, “There are, of course, never enough rich people to carry the burden of any general service. Indeed by the British Health Service and American Social Security (and generally in services of this kind), the rich are subsidized by the working and lower middle classes. In such a service everybody , as a rule, pays the same contribution through his taxes. In proportion to their wealth and income, the rich therefore pay less than lower income taxes.)

And I think of the liberal governor of Vermont, Peter Shumlin (D), who has just abandoned the dream of a single-payer system for Vermont. Shumlin says its abandonment is “the greatest disappointment in my political life.”

Shumlin faced reality. He almost lost his governorship in the midterms, and he admitted a single payer would impose “enormous new taxes,” requiring an 11.5% payroll tax on all Vermont businesses, an income tax of up to 9.5%, and it would cost the state $2.6 billion.

Taxes are the cost of a civilized society, but they become intolerable when paying them requires too much of your own money, not somebody else’s, money. And so the dream dies. This year single payer will not be under the Christmas tree for Vermonters. It is the year the dream died in Vermont.

Sunday, December 21, 2014

‘Tis the Season

For every thing, there is a season, and a time to every purpose under the heaven.


A time to be born, and a time to die. It’s a time to be born. Life expectancy has expanded by 6 years across the planet. Life for many in developed countries is now over 75, and the time to die for adults is now exceeding 80 and even 90 in many advanced nations.

It’s a time to plant, and time to pluck up that which is planted. We live in an age of genetically defined, longer lasting, healthier plants, like yellow rice, which is capable of limiting childhood blindness.

A tune to kill, as 5000 ISIS, Taliband, Jihad murders remind us.

A time to heal, a time to break down, and a time to build up, as the rapprochement with Cuba, the breaking down of the blockade, and calls for free trade worldwide remind us.

A time to weep and mourn, as the killing of blacks and white police officers attests.

A time to laugh, as the late night, afternoon, and comedians strive to do.

A time to dance, or at least to tango, as we hope the new Congress will learn.

A time to cast away stones, and at time to gather stones together; a time to embrace, and a time to refrain from embracing, in other words, a time to realize reality is inherently complicated and contentious.

A time to get, and a time to lose; a time to keep, and a time to cast way, a time to realize there will always be winners and losers, and a time to forget and move on.

A time to rend, a time to tear apart, a time to sew; a time to keep silent, and a time to speak, a time to know when silence is golden, and when silver-tongued speech is needed.

A time to love, and a time to hate; a time of war and a time of peace, and Christmas and Hanakukka is the time for love, peace, good will, and vain hope that good times will carry over into the New Year.

Saturday, December 20, 2014

In Data We Trust, All Others Use Their Minds

Big Brother is watching you.

George Orwell (1903-1950), 1984

If George Orwell are alive today, he would understand what Big Brother is doing to physicians and how he is seeking to monitor and control their activities.

As a physician you are under surveillance. The surveillance weapon is called an Electronic Medical Record. If you do not have it, if you do not prescribe with it, if you use it improperly, Big Brother Medicare will cut your fees and fine you and even exclude you from their Medicare.

Big Brother will cut your Medicare fees 1% next year if you don’t meet federal goals for EMRs, if you don’t prescribe electronically you will lose another 1%, if you don’t submit data on such measures as blood pressure, weight, andantibiotic use, you will face fines of 1.5% in 2015, climbing to 2.0% by 2019. Combined cuts and fines could cost doctors a total of 11% by 2017.

And none of this includes the $40,000 or so for installing an EMR, a like amount hiring and training staff to feed it and use it, the time and money spent searching for just the right ICD-10 code, and the 20% of our time away from patients dealing with related paperwork.

Pretty soon, we’re talking about real money, about real control, and about being a unpaid serf of government, unless, of course, you follow the arcane “meaningful use “ EMR guidelines, then you get a bonus for being an obedient government servant.

I understand the government’s EMR rationale. Every doctor has a computer, why not force them to use it? Computers interconnect and can be used to coordinate care. Everyone these days has some sort of computer device, and many devices are mobile, handheld, even wearable . Data can be stored on a cloud. It is impersonal . It is objective. It is clean. It is free of human biases and grievances. It does involve spiritual, emotional, and political issues like freedom to chose your care, or to negotiate with your doctor.

But alas, data is imperfect and full of gaps. It lends itself to glitches and hacks. It may allow massive fraud at the click of a mouse. It lacks the narrative touch. It does not tell a story. EMRs often do not talk to one another. And many doctors do not like them because EMRs get between them and the patient. Often you cannot dictate into them to tell your patient’ story.

And to top it all off, “Data is not information, information is knowledge, knowledge is not understanding, and understanding is not wisdom.” Clifford Stoll, American scientist and data skeptic. Furthermore, try as we may, life and disease are complicated things with never enough sufficient data to explain all. Government experts tend to possess more data than clinical judgment, which you can only gain by having enough time to talk, listen, observe and and examine the patient. Data requires interpretation and is useless without it.

Friday, December 19, 2014

Unaffordable Care Act

So let me get this straight. We have to pay higher premiums, higher deductibles, more out-of-pocket, and then bail out the insurance companies. That’s the unaffordable care act for you.

Urban Dictionary

Nearly 5 years (actually 4 years and 9 months) after the March 23, 2010 passage of the Patient Protection and Affordable Care Act, Americans are feeling less protected against health costs and finding health care less affordable.

According to a just released December 18, 2014. CBS News/New York Times poll of 1006 Americans.

• 52% say out-of-pocket costs have gone up, and 33% say they have gone up a lot.

• 28% say a collection agency has contacted them because of medial costs.

• 31% have gone without medical treatment because of cost.

• 25% have not filled a prescription or cut bills in half to save on costs.

• 6% have travelled outside the country or filled prescriptions from Canada.

• 78% are less likely to go a doctor because of cost.

• 69% are satisfied or somewhat satisfied with doctors, down from 78% 1 year after passage of health law.

• 55% disapprove of law, up from 53% just after passage.

• 59% approve of a government plan for all like Medicare, but only 43% favor a single-payer plan financed by taxes.

Welcome to the Affordable Care Act. It’s a good law if you can afford it.

Wednesday, December 17, 2014

Health Care Agents: Not Forgotten, Not Gone

Interview with David Racer, President and Founder of DGR Communications, St. Paul, Minnesota

Dave Racer is an old friend of mine from days gone by when he helped me produce the Reece Report, a newsletter that addressed physician and managed care issues. In recent years, besides writing, editing, and publishing 10 health related health care books, he has served as a friend, representative, facilitator and conciliator for health care agents, who form the bridge between patients, businesses, and health plans. He admires health agents, and they trust him to represent the valuable services they bring to the health system

1. What is your relationship with insurance agents?

I support licensed health insurance agents through research and writing, and providing ongoing education about their profession.

They view me as a resource to find answers to healthcare reform issues, and here in Minnesota, to resolve problems with MNsure , the Minnesota health exchange (I’ve developed a good working relationship with the MNsure CEO that often cuts through bureaucratic roadblocks and triggers quick action).

The many (ten so far) healthcare-related books I’ve authored, co-authored, edited, and/or published, have helped me bring a broader understanding of reform trends to agents.

2. What do you do for health agents?

During the past two years, I’ve conducted four major surveys of agents that have translated into communicating their concerns to lawmakers and to MNsure. The survey results have also generated goodwill to promote the role of agents.

Although I am not a licensed insurance agent, I am a member of the National Association of Health Underwriters (NAHU) and serve as the Minnesota Legislative Committee Resource Director. I’ve spoken at NAHU events in more than 25 states as a keynoter and providing continuing education.

3. What is the role of health insurance agents in the American health system?

Agents are problem-solvers who provide counsel to individuals and employers seeking ways to mitigate the cost of medical care. While some are captive – able only to write coverage for a single company – many agents represent several insurance carriers. This means they are able to help a client make an informed choice about which health insurance best meets their needs, and budgets.

Agents earn commission from sales, and only get paid when they sell an insurance policy. Their compensation comes from the insurance company, not the individual. Insurance companies do not discount the premium if a person chooses to forgo working with an agent.

One of the greatest and most important benefits agents bring to the table is contributing to the formulation of public policy. What distinguishes agents is the same characteristic that distinguishes practicing physicians from others – they do their work in the context of reality, not theory. They are experts at judging human behavior and response to positive and negative incentives, and how individuals take advantage of the medical system. Lawmakers are wise to listen to agents’ counsel.

4. How do health insurance agents regard ObamaCare? Positively, negatively, or neutral.

Agents are ferociously independent people . Their opinions about ObamaCare vary widely.

A large faction understand that as it concerns individuals and employers who are already engaged in the commercial insurance marketplace, ObamaCare has fouled the waters – unnecessarily inflating insurance premiums. They see a chaotic marketplace driven by politics, not economics or even common sense.

Generally, agents seem to adapting to the new marketplace. Some look at it as an opportunity – mandated coverage and guarantee issue insurance having created a new revenue stream. Others are fighting for survival, and reluctantly play in the new market. But a good number are creating new models, like my friends at http://INSUREasy.net – a private insurance exchange that actually works.

5. I have the impression that agents feel neglected, even ignored, in the discussions surrounding the health exchanges. I also have the feeling that most agents believe the so-called health care navigators are not qualified to advise health plan prospects or small businesses about selecting the proper plan? Am I correct?

Think about it: Agents are insurance exchanges. They represent several companies and help clients find best value. Government insurance exchanges are competitors, not partners. Even though agent associations may say otherwise, government policymakers eschewed any real input from agents, instead paying lip service to their wise advice.

In my most recent survey of Certified MNsure agents, 56 percent said they would do all they could to keep clients away from MNsure, while an additional 26 percent said they would not re-certify. It’s turned out that fewer than 540 Minnesota agents are MNsure certified, compared with about 2,200 last January.

Agents are not opposed to working with navigators when it comes to helping low-income people find options. If ObamaCare worked correctly, navigators and agents would hand off clients to each other – working together to enroll people in appropriate plans.

But agents absolutely are opposed to unlicensed, inexperienced navigators making any recommendations to clients about commercial insurance. This is especially true in the far-more complex world of small business insurance.

6.I have read that most businesses rely on health agents before making changes in coverage for employees. Indeed, I have heard many business owners trust their health agents more than their wives.

As MNsure moved toward its launch, it spent millions on market research. Much to MNsure’s surprise – and dismay – 86 percent of Minnesota’s employers said they would not make a decision about health insurance without consulting their agent. And a similar number said they trusted their agent more than their spouses.

7. Many of the health agents in Minnesota and elsewhere are big promoters of health savings accounts, not only because they lower premiums but because workers like the ability to make their own choices and to set aside money for retirement. Do I have that right?

Minnesota has the highest rate of individuals enrolled in HSAs in the nation. Agents gave HSAs a quick and positive welcome from the start for at least two reasons:

1) They saw it as a way to save employers and employees a good deal of money by putting them in control of their healthcare purchases.

2) HSAs, combined with high deductible health plans (HDHPs), mitigated the ever-increasing premiums of HMO and PPO plans. Overall, agents embraced the idea of healthcare consumerism, placing individuals in charge of more of their healthcare decisions.

Minnesotans, however, had an advantage in that the differential between HDHP premiums and those of HMO/PPO plans was 20-60 percent or more. This reduced cost make it more possible for employers to subsidize HSAs. That premium gap has shrunk over the years, unfortunately.

8. What has been the experience in Minnesota with MNSure, a state run health exchange? Is it true that the best-selling health plan at MNsure recently had to dramatically raise premiums because they were going broke?

PreferredOne, an insurance carrier owned by three huge provider systems, sold more than 60 percent of MNsure health plans during the 2014 enrollment period. Politicians trumpeted their low premiums, “the lowest in the nation.”

Turns out, PreferredOne’s rates were far too low, and their loss ratio far too great. They dropped off MNsure for 2015, and then announced premium increases averaging 63 percent. Agents certainly hope that PreferredOne can weather this storm, but blame Minnesota’s regulators for pressuring the company to reduce its 2014 rates to dangerously cheap levels.

9. How popular is ObamaCare in Minnesota, a bastion of Democrat liberalism? What is the percent of the uninsured in Minnesota, which prides itself on its progressive politics? Is the legislature Republican or Democratic? Do you see changes in the offing?

Minnesotans elected a GOP House majority during the 2014 election. They also sent all five Democratic incumbents back to Congress, and reelected Democratic Gov. Mark Dayton and other Democrats in statewide races. Oh, they also sent Sen. Al Franken back to Congress, and he was the 60th vote that allowed ObamaCare to move forward.

As much as I wish it, I’m not sure ObamaCare played much of a role in the 2014 election in Minnesota.

Our uninsured rate had hovered around nine percent for the past several years, and before that, settled in around seven percent. But the most critical factor in this is that 60 percent of the previously uninsured already qualified for government health plans (Medicaid or MinnesotaCare) but didn’t sign up.

By the summer of 2014, MNsure boasted that “they” had reduced our uninsured rate to less than five percent. Nearly 96 percent are now covered by a health plan. Considering that 86 percent of MNsure’s enrollees were now in Medicaid or MinnesotaCare plans, we can make this conclusion: After spending $155 million in tax dollars, we finally figured out how to convince low-income people to sign up – send out an army of navigators to convince them to do so.

10. How is Minnesota different from Wisconsin, the adjoining state, which seems to have embraced the policies of Governor Scott Walker by making him the winner in three recent elections?

We had a popular two-term GOP governor in Tim Pawlenty. But Pawlenty walked a safe and fine line, careful not to disrupt Minnesotans too much. In many ways, Pawlenty slowed down Minnesota’s persistent march toward socialism, but we stayed committed to an activist government.

Walker, by contrast, took aggressive action to change Wisconsin’s direction in so many ways. We feel warm toward Pawlenty, but Walker has heated up our passion and hope that even progressive states can grow up and make mature changes.

11. What is the self-image of health care agents? How do they see their future? What changes do they advocate in the health system?

Imagine walking into an employer meeting to announce that this year’s premium increase is “only 37 percent.” Agents have delivered that kind of news for many years. For 2015, in some parts of the state, agents have had to deliver group insurance premium increases greater than 100 percent.

It’s humbling to deliver news of premium increases, but incredibly fulfilling to find solutions for employers that at least mitigate some of the worst.

So agents have often felt a bit like the cousin who shows up for a family event to which he’s not been invited. Loved? Sort of. Appreciate? Marginally.

Agents have nothing to apologize for, and in fact, need to hold their heads high for finding some point of refuge for clients. I remind them that they deliver more than $900 billion a year in payments for medical care to Americans. Without agents and the private insurance industry they represent, America would have nowhere near the high quality care we used to enjoy – before ObamaCare began dissembling it.
Agents generally see the private marketplace as the right way to resolve our medical cost problem; they prefer state solutions to federal solutions; consumerism to communism.

They want to be listened to, and ought to be. No other profession understands human behavior toward healthcare and spending like agents, save physicians. Hey, why not urge them to talk with each other to find solutions that work.
Sorting Out Healthcare. Gov Deadlines

People who like this sort of thing will find this sort of thing they like.

Abraham Lincoln (1809-1865)

I’ve been sorting through all sorts of news on what sort of people are enrolling in health exchanges in this 2nd launch (November 15 to February 15).

It’s all sort of confusing, which is sort of expected, since the time of 2nd enrollment is only 3 months , occurs at the peak of the holiday season, and takes place in the midst of changing over to a new Republican dominated Congress.

The deadline for re-enrollment was supposed to be December 15, but by December 5, only 720,000 had enrolled. Due to that slow start and the sudden surge just before December 15, a number of states – Idaho, New York, Maryland, Massachusetts , Minnesota, Rhode Island , and Washington – have delayed the December 15 deadline to December 19 to December 23.

The federal and state governments and the insurance industry agree on the delays for different reasons. The federal and state exchanges want to maximize credibility to offset GOP attacks on ObamaCare, and the insurers want to gain the greatest market share of the new exchange plans. So a new found symbiosis is taking place between government and private sectors.

The government is saying things are going swimmingly with 2.5 million enrollments, well on the path to expand the enrollment base from 6.7 million to 9.1 million. But critics say government is ill-prepared for the enrollment surge, as consumers endure longer waiting times as they try to unlock last year’s accounts , reset passwords, and prove their eligibility, both for exchange plans and Medicaid.

It’s all sort of confounding, with different key strokes for different folks and different sorts of information flowing from federal and state exchanges. About half those signing up are new customers. The other half are renewing customers. The old customers who miss old or new deadlines will automatically be enrolled by the January 1 deadline, and open enrollment will continue until the February 15 deadline.

Meanwhile depending on your state of enrollment, there will be soft and hard deadlines. But not to worry. You can always trust the government – sort of.

Tuesday, December 16, 2014

Middle Class Families Squeezed

It is important to note that health-care cost increases of 24.2% and 42.1% for health insurance from 2007-2013 overlap the Affordable Care Act’s passage and performance since 2010. The law, as we all know, promised to have the opposite effect on health costs and health insurance.

Richard L. Reece, MD, Old Saybrook, Conn, Letter to the Editor, December 16, Wall Street Journal

As you can see, I made it to the Letters to the Editor section of the Wall Street Journal, America’s most widely daily circulated newspaper at 2.3 million, followed by the New York Times at 2.2 million, and USA Today at 1.2 million.

I read all 3, but I concentrate on the Wall Street Journal because it concentrates on the effect of ObamaCare on the economy, which it believes to be negative. The Times is more ideological. It focuses on how ObamaCare helps the uninsured. USAToday treads more neutral middle ground.

Since 2009, under the Obama administration the economy has grown an average of 2%, versus 4 to 5% in previous recession recoveries under Presidents Reagan and Clinton.

When Obama assumed office, 85% of Americans were satisfied with the health system. Today that percentage is much lower. At least 59% oppose ObamaCare and 54% support its repeal. Opposition of ObamaCare and dissatisfaction with the economy both contributed to the recent midterm election results.

Election results reflected a middle class revolt, largely of the working class, hungry for jobs and opportunity, against Obama economic policies.

Republicans will have to prove they can put together bipartisan policies that grow the economy while containing health costs for the middle class and expanding access to care for all.

President Obama has misread American culture. The majority believe government is best that governs least , that provides equal opportunity but not necessarily equal results for all, and that delivers on its promises of lower health costs for families while allowing them to pick their health plans while keeping their doctors and hospitals. You can only squeeze the middle class health care and economic lemon so much before it runs dry. When you're in a political bind, sometimes you throw out the covering rind.
Can GOP Fix ObamaCare?

What’s done is done and cannot be undone.


I belong to the school that says things will never be the same after ObamaCare.

What’s done is done and cannot be undone completely. No, but it can be partially redone.

As the New Year approaches and the GOP takes control of Congress, there’s a lot of talk of how Republicans might undo ObamaCare.

Much of this talk centers around the Supreme Court decision due in June on whether the health law’s wording allowed the Obama administration to offer subsidies through 36 federal health exchanges. What happens if the Court negates these federal subsidies?
What happens if these subsidies continue in state exchanges?

One, the federal government could talk back subsidies from some 7 million people (the exact number will not be known until after the February 15, 2015 deadline of the second launch ends). This seems political untenable, unstable, and unsustainable) since it would result in skyrocketing premiums, the death spiral of health insurance markets, and a deafening political uproar about unfairness between liberal and conservative states. Blue states – like California, New York, Maryland, and Connecticut – which have their own exchanges could continue to offer subsidies.

Two, the Court could simply edit the law to include all states offering exchanges, whether federal or state run, causing the law to remain essentially intact.

Three, the GOP could pass alternative legislature that would repeal ObamaCare and end subsidies for all and replace the subsidies with tax credits for all and allowing buying of plans across state lines, presumably lowering premiums through competition, or lowering costs by permitting patients the freedom to choose their own plans, free of comprehensive cost-raising regulations, coupled with such market-based changes as health savings accounts and catastrophic ceilings on costs.

Four, the GOP could repeal ObamaCare, make changes such as changing the definition of full time work from 30 to 40 hours, ending the excise tax on medical innovation companies, and ending penalties associated with the individual and employer mandate.

Whatever happens, the GOP must get its act together and put together a coherent, unified, pragmatic alternative to ObamaCare that makes sense to the American people and does not destabilize or cancel existing health plans, while at the same time, lowering premiums, deductibles and co-payments; decreasing the number of uninsured. And Republicans must do so with the knowledge they cannot redo the entire system and undo what has already been done. They can redo without completely undoing.

Monday, December 15, 2014

Private Health Partnership and Concierge Medicine

For over ten years, I have served on the medical advisory board of Castle Connolly Ltd, a medical company devoted to identifying America’s top doctors and to empowering, protecting, and optimizing the physician/doctor relationship.

Castle Connolly is now expanding its business by entering the arena of concierge medicine, both in the United States and abroad. There is a yearning here and elsewhere for private physician-patient relationships outside the realm of government.

For more information on how to join the concierge movement, visit ccphp.net or call 1-212-367-1950.

Here is the concierge private health partnership as envisioned by Castle-Connolly.

The CCPHP program offers a strong value proposition for both physician practices and patients. Key benefits include:

-- Conversion sales & marketing expertise with demonstrated success in both retaining patients and improving their satisfaction

--Increased emphasis on important aspects of patient care such as prevention, wellness, and chronic disease management

-- Longer and unhurried patient visits

-- Outstanding patient experience of care

-- Expanded collaboration between physicians and patients

Access to a proprietary health coaching model that provides staff with training, content, and ongoing support from national experts

These features lead to stronger physician-patient relationships and more desirable healthcare outcomes - a true win/win for patients and physicians.

Increased emphasis on important aspects of patient care such as prevention, wellness, and chronic disease management

-- Longer and unhurried patient visits

-- Outstanding patient experience of care

-- Expanded collaboration between physicians and patients

--Access to a proprietary health coaching model that provides staff with training, content, and ongoing support from national experts

These features lead to stronger physician-patient relationships and more desirable healthcare outcomes - a true win/win for patients and physicians.
Interview with Health Care Swami

Take up one idea. Make that idea your life - think of it, dream of it, and live on that idea.

Swami Vivekandanda

What do you see almighty swami?

I see a new health care economy,

I see sliced institute salami,

I see institutes of joints and knees,

I see institutes for cash only fees,

I see institutes for cancer only,

I see institutes for heart mainly,

I see institutes for arteriosclerosis,

I see institutes for cerebral thrombosis,

I see institutes for walk-in surgery,

I see institutes for neurosurgery,

I see institutes for ophthalmology,

I see institutes for oncology,

I see institutes for diabetes,

I see institutes for obesity,

I see institutes for the spinal,

I see institutes for the renal,

I see institutes for the fertile,

I see institutes for the infertile.

I see institutes for chemically addicted,

I see institutes for genetically afflicted,

I see institutes for primary care,

I see institutes for diseases rare,

I see institutes for quiet meditation,

I see institutes for bad medications,

Everywhere my eye can see and look

I see an institute for another nook.

Everywhere I look across the health care landscape

I see an institute with a special mission and mandate.

Sunday, December 14, 2014

Our Bipolar Health Care Future

The future ain’t what it used to be.

Yogi Berra (born 1924)

The mail this week brought the December issue of the Harvard Business Review’s Alumni Bulletin and a review of A Year with Peter Drucker, HarperBusiness, $29.99) by Joseph Maciariello, professor of Claremont Graduate University and longtime collaborator of Drucker.

The HBS Alumni Bulletin contains this forecasting quote from Robert Wah, MD, President, American Medical Association.

“We’re entering the third phase of medical information technology. The first phase was to get off paper and onto a digital platform. Then we networked that digital information together. And now we can analyze that information in new and powerful ways. That’s really going to the big payoff from the feeding of the electronic health records process. Because right now it is a feed process; we have to put the information in. And once it is in there, it is my belief that it will give back to the health system. Patients, doctors, hospitals, government, insurance companies, and researchers will all make better decisions in health care with better information.”

Matthew Rees, senior fellow at Dartmouth’s Tuck School of Business, weighs in with these observations on the Drucker book.

“While he (Drucker) is best known for this study of management, his writings also explored leadership, social transition, education, demographics, civil society, and religion.. Management seeks to overcome natural , ever-present entrophic forces towards bureaucracy, deterioration, and decay..Many of the ideas for which Drucker become famous –privitazation, decentralization, the knowledge worker of the information age, management by objectives – seem anodyne today but they were well outside the main stream when he advanced them… private enterprise cannot be justified as being good for business. It can be justified as being good for society.”

Doctor Wah may be right. The digital age may make health care better. And so too do many of Drucker’s view disciplined management approaches.

The future will be bipolar.

On the one pole, hospitals and other large organizations will rule the health care roost with a combination of being the most visible central figures of the system with marketing, skills for dealing with bureaucracy, access to capital, the capacity to bring technologies and specialties together, and the tools to drive data-driven diagnosis and treatment.

On the other pole, consumers will seek more personalized, quicker, more decentralized access to individual doctors outside the hospital and government mainstreams. This access will manifest itself in several forms - specialized facilities, which Regina Herzlinger, HBS professor, has dubbed “focused factories,” and concierge medical and surgical practices, where the consumer’s and doctor’s desires and needs reign supreme, and where consumers spend more of their own money, with less intervention by government and insurance companies.

Saturday, December 13, 2014

The Undeclared War on Private Practice

War is nothing more than the continuation of politics by another name.

Karl von Clauswitz (1780-1831), On War

Obama and his legions have declared war on private practice. It is an undeclared war.

It is a political war, waged in the name of humanity. It is like the war on cancer, the war on poverty, the war on women, the war of racism, waged in the name of greater causes for the common good.

By using the name “war,” you are showing your dedication and determination to wipe out the inequities plaguing humankind, or so you say.

You never officially declared a war. Your war is insidious, and it is political.

Many doctors, who cherish their autonomy and their freedom to exercise their clinical judgment, independent of government, see it as a war. If you doubt me, view Dick Morris’ video, “Obama’s War on Doctors,” sponsored by Money.

In his video, Morris, former adviser to President Clinton and no friend of Obama, invites doctors to describe the war.

Embattled bitter doctors, forced out of private practices, blast ObamaCare in vivid, often blasphemous language. They complain of low reimbursement from Medicare, Medicaid, and health exchange plans, of being compelled to install expensive electronic record systems, of having to hire extra staff to handle bureaucratic hassles and to feed data into computers, of being banned from setting up organizations of government preventing them from organizing their own competitive business organizations through self-referral and anti-kickback provisions.

Scott Gottlieb, MD, a practicing physician, scholar at the American Enterprise Institute, who has served in various capacities at the FDA and at CMS on medical technology issues, described the components of this undeclared war in a recent article in the WSJ “ObamaCare Threat to Private Practice.” Gottlieb said ObamaCare policies are forcing doctors to sell out to hospitals.

The ObamaCare strategy. claims Gottlieb, is simple and devastatingly effective, and it precedes him. Since 2003, when 70% of doctors were in private independent practice, today only 35% are, down from 49% in 2012 and 62% in 2008. The pace of physician-sell out to hospitals is accelerating.

How does the strategy to render private practice work?

1. It is a control not a cost issue. The government assume doctors on salary are easier to control than independent physicians, hence the ObamaCare strategy of placing doctors in Accountable Care Organizations on salary to coordinate care across the health care spectrum.

2. To prevent doctors from forming competitive organizations to compete with hospitals, you forbid them from gathering together in their own organizations, you stop them from referring to each other by saying you are preventing anti-kickback self-referrals.

3. You give doctors a lump-sum of money to care for patients in Medicaid, Medicare, and health exchange plans, which requires management and bureaucratic infrastructure to track and contol.

4. You allow hospitals to consolidate into larger and larger entities employing thousands and thousands of employees until hospitals and their systems become the dominant and largest employers in any given community, region, or state.

The hypocrisy is that in these large entities, self-referral within the system is a given. Salaried physicians within the system are obligated to refer to each other and to departments within the hospital.

Why is the large number of hospital employees so powerful politically? Because this employment base gives hospitals the leverage to negotiate with politicians. Hospitals argue that competing physician organization offering lower prices might cause them to downsize and lay off workers. This , of course, is anathema for politicians, whose job is to prevent unemployment. The incentive for hospitals is to buy more and more physician practices to further increase the number of employees, their market dominance, their leverage with politicians, and to decrease the threat of physician-market competition.

Because of regulations forbidding physician self- referrals with kick-backs and because hospitals can charge extra for “facility fees,” for visits or procedures done under the aegis of hospitals, physician fees are much higher for tasks done by salaried hospital physicians, e.g. heart scans ($749 versus $503), colonoscopies ($856 versus $402), and office visits $124 versus $70).

But never mind. Political control, not cost, is what counts in the undeclared war on physicians. It may also be one of the reasons why the original estimate of the cost of ObamaCare, $984 billion, is now $1.89 trillion, according to the latest CBO estimate.

Friday, December 12, 2014

Quotes to Note: from “Gruber on ObamaCare: 'I helped write it'”, by Jesse Byrnes, The Hill, December 110, 2014.

The following quotes are by the man himself, Johnathon Gruber, in a lecture videotaped to an MIT undergraduate economics class and in subsequent videos.

“ObamaCare is the single most important piece of government legislation perhaps since World War II."

“Full disclaimer: I'm going to describe it objectively, but I helped write it.”

“So I'll be objective – I'll try to be objective – but just full disclaimer I was involved in writing the legislation, so there is some bias involved here.”

“Yes, I want the public to be informed by an objective expert. But the thing is, I know more about this law than any other economist."

“Several of the architects of Massachusetts reform, including myself, worked closely with the Administration and Congress to translate the lessons from Massachusetts onto the national stage.”

The back cover of his 2011 comic book explaining healthcare reform says he was “a key architect of Massachusetts's ambitious health reform effort” who “consulted extensively with the Obama administration and Congress during the development of the Affordable Care Act.”

Of a visit to the White House in 2009 with a private chit-chat with the President:

“It was just a fun, intellectual conversation.”

Conclusion: Jonathon Gruber is a legend in his own mind and a liability to the Obama legacy.

Medicaid SNAFU

SNAFU – Situation Normal – All Fouled Up.

Army Saying – World War II

Federal investigators have issued a report that says, in essence:

• Half of doctors could not offer appointments to Medicaid patients.

• One-third of doctors could not be found at locations listed in Medicaid managed care plans.

• 8 % properly listed were not accepting Medicaid patients.

This news comes in fact of what everyone knew already: overall, less than half of doctors across the nation accept Medicaid patients.

The reasons why are obvious: due to doctors shortages, practices are overloaded: reimbursements are as low as 60% of private pay; Medicaid regulations are fraught with bureaucratic hassles; only one fourth of physician groups are accepting Medicaid patients from health exchanges.
Add to these problems that fact that is almost impossible to find specialists who care for diabetes, asthma, sickle cell disease, and other chronic diseases and that Medicaid is exploding in growth, with 9 million beneficiaries added in 2013, a 16% increase.

Medicaid faces a five pronged problem:

• One, explosive growth

• Two, doctor shortages

• Three, overloaded practices

• Four, doctors not accepting new Medicaid patients

• Five, inaccurate government records listing where Medicaid doctor are located.

Medicaid is like a faulty five-pronged dull government fork, with half the prongs missing.

Coverage is not necessarily the same thing as care. What good is government coverage without private doctors to provide the promised care?

The situation is a reminder of a Casey Stengel story when he was manager of the New York Mets. The Mets had a hapless first basement named Marv Thornberry, who was constantly dropping throws and infield fly balls.

Casey went into the outfield and had batters hit Stengel fungo fly balls.

When Casey dropped the first fungo, he yelled, “Thornberry, you’ve got this position so fouled up, nobody can play it.”

Thursday, December 11, 2014

Questions of Moral Equivalence

What is morality at any given time or place? It is what the majority then and there happen to like and immorality is what they dislike.

Alfred North Whitehead, Dialogues

These days we are wrestling with questions of moral equivalence.

Are the Obama administrations drone strikes, which kills terrorist leaders but also slaughters innocents as part of inevitable collateral damage, morally equivalent to enhanced interrogations, i.e. “torture”, of known terrorists after 9/11?

Is ObamaCare, which has covered and subsidized 10 million or so of America’s 30 million uninsured, morally equivalent to unknown millions of health plan cancellations and raising premiums, deductibles, and co-payments of the insured?

These are slippery questions.

As Ernest Hemingway said, “What is moral is what you feel good about after and what is immoral is what bad about after.”

The answers lie in the mind of the beholder, and in your political ideology, e.g. whether you are a “bleeding heart liberal”or a “a hard-heart conservative.”

Does the end justify the means, 13 years without a terrorist attack on the U.S.? Or does the end have anything to do with the means? Did the means thwart a terrorist attack on the homeland?

Do the means, passing ObamaCare through misleading obfuscation arguments, and false promises, justify its final results, covering 10 million previously uninsured?

You have to put the answers in context, something that is hard to do in these days of extreme partisanship.

But unfortunately, As Oscar Wilde trenchantly observed, “Moderation is a fatal thing. Nothing succeeds like excess.”

Or as Bret Hume of Fox News noted in a current video, " The Feinstein report is as one-sided as the Rolling Stone Report on UVA rapes.”

There appears to be no refuge for the moderate. No platform for those asking for reason, no quest for middle ground.

The attitude seems to be. If you have a point to make, make it strongly, or you won’t be heard about the roar. The other person is wrong, you are right. If you have a nail to hit, hit the other guy on the head. It's your side v their side, and never the twain shall meet.

And so, to get some context, some sense of reality, you have to turn to what the majority say in the polls.

Today’s polls indicate a 42% ObamaCare approval, a 58% disapproval of ObamaCare, and past Pew polls say 53% support enhanced interrogations of terrorists. So far, in an ongoing Fox poll, 78% of people think releasing the CIA report was a “bad thing.”

Bad thing? Right thing? Moral or immoral thing? Let the majority decide.

Wednesday, December 10, 2014

Gruber: People Losing Insurance Plans "Part of Calculation"

Our calculations have outrun conception. we have eaten more than we can digest.

Percy Shelley (1792-1822)

In the House Oversight Committee on Oversight and Government Reform , Representative Patrick McHenry (R) of North Carolina asked Jonathon Gruber about his computer model’s calculations and predictions about how many people would have their health plans cancelled when the plans did not comply with ObamaCare plan benefit requirements.

Said McHenry, “Of my constituents in North Carolina, according to the North Carolina Department of Insurance, 473,000 lost their health insurance because of ObamaCare. Did you think that there would be such a large number of folks that would lose their health insurance?”

Replied Gruber in an artful bureaucratic dodge to change the subject,” "What I was focused on was the net increase in newly insured we had under the law which has been quite substantial.”

"So it's not relevant to your calculation that there would be people that would lose their health insurance?" McHenry asked.

"That was part of the calculation," Gruber admitted. "I don't recall the exact numbers I modeled but we did model some individuals who would lose existing plans and move to new forms of coverage."

I don't know the exact number in North Carolina, but –“

McHenry: “Well, it is 473,000 according to the Department of Insurance and Raleigh News and Observer.”

In other words, Gruber was saying, “The number cancelled was not my concern. I was only concerned with the numbers of newly insured.”

The number of plans cancellations could be "substantial" since 276 million Americans are covered by health plans, and 20 million of these are in the vulnerable individual market. It has been estimated that 40 million health plans may be subject to cancellation. But not to worry says the Obama administration. The cancellations will be delayed, and besides, in 2010 it was predicted only 66% of those in 40,000 small business plans would face cancellations.

According to HHS and CMS, 6.7 million uninsured people gained insurance through the health exchanges.

How many lost insurance is not known because the states are not obligated to report cancelled policies. The number of cancellations reported vary widely by state. Among the numbers reported are these: Florida 300,000, New Mexico 30,000, Virginia 250,000, Kentucky 14,000, Tennessee 20,000, Nevada 90,000, New Jersey 650,000. These cancelled plans could be the tip of an iceberg.

Let’s take McHenry’s 473,000 cancellation as truth. North Carolina had a population of 9.848 million in 2013. 473,000 of 9.848 million is 4.8% of the population. 4.8% of the current U.S. population would be 15.36 million. The numbers are nowhere near that, according to the New York Times, which says only 2 million have had their plans dropped because of noncompliance with ObamaCare. A small number of no concern , says the Times, unless of course your plan is the one being cancelled, and you are forced to switch to a health exchange plan, 39% of which have higher premiums, deductibles, and co-payments.

Whatever the exact figure, the number of cancellations is in the millions. Gruber knew this would happen back in 2010, as did other designers and writers of the health care law, including President Obama. These cancellations were not part of the adminitration's talking points, which were: ” If you like your doctor and your health plan, you can keep your doctor and your health plan. Period.” That Period should have been a Semicolon or a Colon or maybe even a dash - followed by the phrase, "if your plan meets ObamaCare requirements, in which case your premiums will be higher".

Tuesday, December 9, 2014

Book Notes

Just a brief note to let you know I have two E-Kindle books you might want to read and order on Amazon. Right now, with the newly elected Republican majority , the Gruber testimony before Congress, and the prospective of a possible negative Supreme Court decision denying subsidies on federal health exchanges, ObamaCare is undergoing a rough political patch.

1) Understanding ObamaCare (Westbow Press), an E-Kindle book (Amazon).
The book describes the virtues, faults, and vulnerabilities of ObamaCare and why it may end up being repealed, replaced, or significantly transformed to meet the wishes of the American people, who oppose it by a current margin of 57% to 39%.

1) Direct Pay Independent Practice – Medicine and Surgery (E-Kindle book), $9.77 Amazon
An explanation of why health consumers are turning to direct pay concierge practitioners and ambulatory surgery centers for more convenient, economical, personal , prompt, and understandable health care without insurance and bureaucratic obstacles to care, and why ObamaCare health exchanges, with their high premiums, deductibles, and co-payments make direct pay medicine and surgery offer a reasonable alternative to current health plans.
Reaction to Gruber’s Written Testimony Before Congress

It is what I am, not what I am not.


This morning, in his written testimony before Congress, Jonathon Gruber explained:

What he is.

“I am a professor of economics at MIT.”

What he did.

“I ran a microstimulation model to help those in state and federal branches to better access the likely outcomes and various policy options.”

What he is not.

“I am not a political advisor nor a politician. ..I did not draft Governor Romney’s health care plan, and I was not the “architect “ of president Obama’s health care plan..I am not an expert on politics . I am not an elected official, nor am I a political advisor.”

Well, what is he?

He collected upwards of $6 million for giving advice and counsel to the state and federal government. In the course of his consulting activities, Democrats, including Nancy Pelosi and President Obama, gave him credit for being "the man" on health reform. He made 19 visits to the White House, and he testified before Congressional committees.

In his written testimony, he apologizes for his gaffes, insults, negative comments, and lack of transparency and outright deceptions behind the implementation of ObamaCare and the “stupidity “ of American voters.

This approach, he said, was essential to get the health law passed.

Gruber poses as a Forrest Gump sort of expert, an idiot savant on computer algorithms, who was oblivious of what others thought or were impacted. He simply developed an microstimulation model of what would happen if one passed a health law remodeling a health system that effected one-sixth of the U.S. economy, that redistributed wealth among Americans, and that represented a one-side political agenda. He did nothing more,, nothing less.

Gruber is hoping and praying American voters will naively accept what he is, what he did, what he did not do, and that they will accept the notion that he innocently and accidentally happened to help weave a political web in which false political promises and a progressive ideology trapped, snarled, and entangled the American people into something that did not understand and would not have accepted had they understood.

Monday, December 8, 2014

Quote to Note: Scott Gottlieb, MD "ObamaCare’s Threat to Private Practice: The Payment System Is Forcing Doctors to Sell Out to Hospitals. The Trend, and the Law, Will Be Unstoppable Without Reform." Wall Street Journal, December 8, 2014

“Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.”
Technology Innovations - Energy Fracking and Genetic Cracking

Physics does not change the nature of the world it studies, and no science of behavior can change the essential nature of man, even though both sciences yield technologies with a vast power to manipulate their subject matters.

Burrhus Fredric Skinner (1904-1990), Walden Two (1948)

Two technological innovations are about the change the world Americans live in.

These innovations are:

One: Fracking (hydraulic fracturing and horizontal drilling).

This technique has spread rapidly in the U.S. and promises to make the U.S. energy dependent by 2020. As the result of fracking, the price of oil of a barrel of oil has dropped 30%, and price of gas has declined 51 cents to $2.74 in less than a year. According to Mark Papa, CEO of EOG Resources, a fracking leader, “There’s been a million frack jobs in the U.S. with zero documented case of damage to the drinking water table.” Papa claims we have enough natural gas and oil to last for over 50 years, and the advantages will be bursts in employment, business investment, growth in GDP, a tax revenue bonanza, and two to three fold competitive price advantage over Europe and Asia. There may be an even more important lesson: the power of entrepreneurial -devised technologies to surpass punitive government regulations. The fracking revolution occurred independent of and in spite of government regulations and without government subsidies. Decentralized human behavior works better and faster than centralized bureaucracies trying to impede and control that behavior.

Two: Cracking of Genetic Code ( conversion of cancer to chronic disease).

With more knowledge of genomic DNA and how the human immune system produces T-cells (specialized white cells known as lymphocytes), we are the verge of curing or converting solid tumors (melanomas, Hodgkin disease. lung cancer, kidney cancer, and maybe even so-called liquid tumors of blood and bone marrow) to chronic diseases. Studies from drug companies, such at Bristol-Myers and Merck and from cancer institutes, like Dana Farber and Sloane Kettering, indicate the PD-1 inhibtors, allow investigators to remove the natural brakes on T-cells, permitting the patient’s own immune system to attack its own tumor cells. Apparently some tumors, particularly melanoma and Hodgkin’s disease, have genetic abnormalities that produce a large amount of PD-1 vulnerable cells.

What the lesson here? Archimedes (286 B.C. -203 B.C.) said, “Give me where to stand, and I will move the world.” Archimedes, of course, was referring to the use of the lever and the principles of leverage. Technology is man’s lever and leverage for moving the world, and technology is something the U.S. and its entrepreneurs are extraordinarily good at creating and refining. Witness the Internet, Google, Twitter, Microsoft, and the fact that U.S. produce 80% of Nobel Prize winners in science and medicine. Technology, of course, is also a multi-headed monster – it may be dehumanizing, it may move too fast with negative social consequences, it may be uneven in its results, is the refuge of the skilled and educated, it rewards the rich, it is something that works best in capitalistic systems of government. But technology, with all its faults, is also something that gives convenience and benefits the masses and feeds the world. Technology creates leverage, progress, solutions, and prosperity.

Sunday, December 7, 2014

Republicans on a Roll, To Where?

You roll my log, and I will roll yours.

Seneca (4 BC – 65 AD)

Republicans are on a roll.

Bill Cassidy, MD (R) rolled over Mary Landrieu (D) in Louisiana along with 2 Republican House of Representative candidates in that state, giving Republicans a 54-46 Senate majority and a 246-188 majority in the House., the greatest House majority since 1946.

Republicans now have more state attorney generals than Democrats, and have united to try to reverse E.P.A. and ObamaCare policies across the United States.

To further encourage Republicans, the U.S. economy is on a roll, adding 321,000 jobs, GDP growing at 3.9%, and outpacing European and Asia economies.

In the Real Clear Politics poll roll call, more Americans now declare themselves Republicans (51.6%) than Democrats (45.5%).

Republicans are saying that failed Obama policies got them where they are today – in the majority as far as the eye can see – the Senate, the House, and the Statehouses across the land.

What to make of all of this?

I looked up “roll,” and there are 54 definitions, ranging from "drum roll", to" on a roll", to "bank rolled", to "being rolled".

The message is: Don’t get cocky. You’ve got a long way to go. Congress is even less popular than Obama. And you’re not going to be trusted until you do something. Polls of Americans indicate only 20% approve of Congress while 42% approve of president Obama.

As Peggy Noonan said in her regular “Declarations” column. “Can the GOP Find Unity and Purpose” (WSJ, December 6-7)."

“The president isn’t the story. That’s what Republicans need to know.”

“The story is what they make of their new power.”

“Early on they should take good, small bill, an economic measure that Republicans will and moderate Democrats can support. They should try very hard to do what the president didn’t do; show bipartisan respect, work with the other side, put out your hand. They should get that bill through the House and Senate. If the president vetoes it, they should attempt to override. If they succeed, they’ve made a good law, If they don’t, then try again.”

As President Obama used to say, before his deeds proved otherwise, “We’re all in this together.”

Be a party of the people, rather than the special interests. Be a party that represents working Americans and the middle class, rather than strictly a party for those on the upper and lower fringes.

Saturday, December 6, 2014

CMS Lays Its Codes on the Table

To lay cards on the table – to be very precise about one’s position

Critics like to say the U.S. has no national health system.

The critics are wrong. The CMS (Centers for Medicare and Medicaid) is our national system. CMS accounts for 35% of all health care spending, and along with the AMA’s Relative Value Update Committee (RUC) dictates what 57 specialists (Allergists to Vascular Surgeons) are paid. Health plans and speciality societies invariably follow the CMS lead.

CMS posts its pay codes in November on “Table 93", to which one can access on the Internet.

The total reimbursements listed there is supposedly based on 3 components – relative workload, practice expenses, and malpractice expenses – but I have a sneaking suspicious it rests on the Obama administration philosophy for containing costs. In the eyes of its critics, CMS codes tend to be arbitrary and capricious and malicious towards specialists spenders and soft and supportive of low generalist spenders.

In any event, this year's winners and losers on table 93 are:


1. Chiropractors, +14%

2. Psychiatrists, +8%

3. Geriatricians, +8%

In addition, the Obama administration says its will pay primary care physicians, general internists, and geriatricians 10% more.

Although not listed, other supposed winners are primary care physicians, who CMS says may be paid $42.60 for each Medicare patients in their panel with 2 or more chronic conditions, if these physicians have EHRs and have the resources to support extensive documentation.


1. -23% diagnostic testing facilities providers

2. -20% diagnostic laboratories
3. -17% radiation treatment centers

4. -13% pathologists

5. – 11% oncologists

6. - 7 % neurologists

Many of these changes are arbitrary and reflect the Obama administration thrust to upgrade those specialties which depend on talk and time spent on office visits with downgrading of specialties more reliant on testing, imaging, and interpretation of technological results.

In the background and not listed in table 93 are physicians’ resistance to the ICD-coding overhaul which introduces hundreds of new codes and complicates physicians’ life by requiring them to spending time searching out appropriate codes and hiring new staff to implement billing for the codes.

The ICD-10 overhaul is reminiscent of the healthcare.gov launch. The new coding systems have not been adequately pre-tested. The new codes snarl and confuse the billing process without knowledge on the federal level of the impact on health care practitioners.
Reality Check: Where the Nation’s Health Care Dollars Went in 2013

In 2013, the U.S. spent $2.9 trillion on health care, 17.4% of GDP. This was a 3.4% increase over 2012, the slowest growth in spending in a decade, probably the combined effects of the recession, consumers forgoing care because of high costs, and ObamaCare regulations.

Leading costs in 2013, in descending order, were:

1. Hospital care, 32%

2. Physicians and clinics, 20%

3. Other (personal, public health, medications), 14%

4. Prescriptions, 9%

5. Dental and other professionals, 7%

6. Government administration and health insurance, 7%

7. Investment (research, buildings, equipment), 6%

8. Nursing homes, retirement facilities, community clinics), 5%

Other pertinent facts included:

1. Medicare spending, $583 billion, up 3.4%, 20% of all health care spending.

2. Medicaid spending, $449 billion, up 6.1%, 15% of all health care spending.

3. 190 million Americans covered by private plans, 60% of all health care spending

4. Out-of-pocket spending, 12.5% of all spending.


The U.S. spends nearly one-third of health care dollars on hospitals and physicians (32%) and over one-third on Medicare and Medicaid (35%). Medicare and Medicaid are the fastest growing and biggest contributors to the national debt, now over $18 trillion.

Friday, December 5, 2014

Repealing and Replacing ObamaCare and Restoring Confidence in Health System

In War: Resolution. In Defeat: Defiance. In Victory: Magnanimity, In Peace: Good Will

Winston Churchill (1874-1965), The Second World War. The Gathering Storm (1948)

The last 4 years have been a political war over ObamaCare, which passed without a single Republican vote.

The GOP resolved to defeat it, were defiant in their opposition, and now have a clear path to repealing and replacing it, thanks to 4 Supreme Court Justices who may help form a majority that will stay 37 federal health exchanges violate the wording of the health law and effectively sink the law.

If the Court rules against ObamaCare, I hope victorious Republicans have the magnanimity and class to include Democrats in rewriting the replacement law. The GOP should not repeat the Democrats’ arrogance of excluding the opposing party from the process then engaging in parliamentary trickery and political bribes to get it that passed. These tactics were a tragic mistake, sowed distrust, and precipitated a bitterly divisive political civil war.

According to Randy Barnett, the repeal and replacement of ObamaCare and the writing of an alternative bill should go like this. The replacement bill should Make a fresh start with a clean skate by completely repealing the Affordable Care Act, then writing a replacement bill that would:

1. Restore private insurance markets using actuarially based insurance priced by risk.

2. Restore consumer choice to buy true private insurance limited to what they want to pay for, including policies insuring only against catastrophic health care costs, and medical savings accounts.

3.Allow state-regulated insurance to be sold across state lines so consumers can keep their policies when moving from one state to another.

4. Increase equity by extending the tax benefits now available only to employer-based insurance to all health insurance. Like car insurance, you should not have to change health insurance policies .

5. Be bipartisan , make sure contains a "refundable" tax credit for health insurance for all Americans, regardless of income — extending to everyone the very subsidies that the court will strike down, another magnanimous gesture towards Democrats.

6. Encourage Democrats to participate in the process, by doing so not only can they ensure that subsidies are included, but in their minds they also can claim victory.
Thanks to voters in November and the 4 justices who voted to hear the case, beginning in January, Republicans in Congress could conceivably craft a bipartisan market-based replacement.

The president, thanks to Democratic participation in the process, may be compelled by his fellow Democrats to sign in June when the court announces its decision without losing face.

Source: Randy Barnett, “ Supreme Court More Likely to Act if Republicans Have Alternative Bill Ready,” USAToday, December 5, 2014
No Rosy Scenarios if Supreme Court Decides Against Federal Health Subsidies

I don’t think there are any rosy scenarios! It’s a complete disaster.

Timothy Just, JD, Washington and Lee Law Professor, commenting on what would happen if Supreme Court Strikes Down Federal Health Subsidies

As everybody knows, we live in an age of doom and gloom, dark forebodings, and negative images. Racial discrimination is rampant, white police are killing blacks without cause, ISIS is beheading innocent Americans, and now the U.S. Supreme Court is on the verge of terminating subsidies to 4.6 million people who receive federal health exchanges in 37 states.

What happens if the Supreme Court invalidates these subsidies?

What are the consequences? Here are what legal scholars and pundits are predicting.

• The immediate impact would be the Internal Revenue Service would stop paying subsidies to those in federally run exchanges. In 2014, more than 4.6 million people were getting those subsidies but the number may grow to as many as 13.4 million by 2016,

• Most people can’t afford insurance without the tax credits, so many would have to go without insurance.

• The insurance industry, through its trade group America’s Health Insurance Plans, argued in a legal brief for a related case ending federal exchange subsidies could seriously undermine those markets, creating an insurance death spiral.

• Hospitals who are now receiving subsidized patients through the federal would take a hit , and many might to have to close or cut back on services.

• States could set up and run their own exchanges, which is improbable since many have already tried and failed, and the cost of doing so prohibitive.

• ObamaCare would unravel , or simply collapse or die because insurance-run market places are the backbone of the health law, as well as the essence of the individual and employer mandates.

• Congress could reopen or rewrite the law.

• Repeal would be unnecessary, and Republicans could create a more market-based law with retention of popular elements of the current law.

Perhaps, there will be a rosy-fingered dawn, For the moment, at least, it seems things couldn't get worse.

Thursday, December 4, 2014

Requiem for ObamaCare

That we would do, we should do, when we would, for this “would” changes.

Shakespeare (1564-1616), Hamlet

Shoulda, Coulda, Woulda

Title of popular song

After their devastating midterm losses, Democrats are holding a requiem for ObamaCare.

This requiem could be titled: Woulda, Coulda, Shouda, Gooda, meaning no use dwelling on what would, could, and should have been, and is.

The Woulda, Coulda, Shouda, Gooda theme goes like this:

On ObamaCare, we woulda have been better off not passing it and holding out for single payer or a public option; we coulda focused on the economy rather than health care, but we made a mistake and blew it; we shoulda not have listened to that Gruber guy and we didn’t , even though we did; we were big and bold and moved forward, for 9 to 10 million now insured and for the common gooda, even though it raised the price for s the middleclass, the seriously ill who needed special drugs, and those who had to pay higher deductibles causing millions to delay or put off care.

In short, What's done is done. Now we must move on.

In retrospect. was ObamaCare worth it?

You betcha, say Nancy Pelosi, Kathleen Sibelius, President Obama, and the 9 to 10 million uninsured signing up for subsidized health exchanges plans.

Not if we have to pay extra, said the middle class, those in unsubsidized health exchange plans, and voters, who could, would, and should not afford the new elevated deductibles, premiums, and co-payments.

Sources reporting on December 3 and 4

1. “Dems on O-Care: Was It Worth It?" The Hill

2. “Obama Author: Health Law Is ‘Really Complicated,” The Hill

3. "Kathleen Sibelius: Jonathon Gruber: Who?” USA Today

4. “Cancer Patients (and HIV, MS, and Patients with Certain Chronic Diseases Pay More for Care, “ Bloomberg Business World.

5. “ObamaCare Sign-Ups Top 765,000 in First Two Weeks, “ National Journal.

6. "Consumers Absorb More Health Costs, and Delay Care, Wall Street Journal