Dr. Gruber Video: Patients “Face Higher Cost Sharing” under ObamaCare

November 22, 2014

As you all know, Jonathan Gruber says he is not the architect of ObamaCare.  He only got paid millions to visit the White House about 20 times, and visit Congress, and drink coffee with the nice people – lol.  Here is a clip from my new Jonathan Gruber video:



This statement was made in response to a question at a medical symposium in 2011.  The question was basically “If we purposely raise patient costs to discourage overuse of healthcare, won’t patients get angry?”  The complete YouTube version of this video with explanatory captions is included later in this post.  But even from the short clip you can see that Dr. Gruber is fairly enthusiastic about the new “high deductible” insurance plans.  What he isn’t saying explicitly is that employers have been forced into these plans by ObamaCare.

The increased cost of the new beefed-up coverage now required for employees makes it impossible for employers to participate in the old, lower deductible, and lower co-pay plans.  The result is that patients will bear more of the cost of their own treatment, and as Dr. Gruber says, they won’t like it, but there’s really not much we can do about it.

The dirty little secret is that all this was planned – in the full video you will see the term “accountable patient” used by the questioner.  This refers to a patient who only uses the minimum amount of health care.  Patients are intentionally made accountable under ObamaCare by increasing their costs so they will make the decision not to overuse health care.

This intentional increase in patient costs runs contrary to what we were told by President Obama – i.e. that costs would fall by about $2500 per family – and reveals yet another  failure to tell the American people the truth of what they would face under  the new system.  Of course, now that we have Dr. Gruber saying that “lack of transparency was a huge advantage” in getting the law passed, these failures to tell the truth look more and more intentional.

By the way, in the December 9, 2014, House hearing, Dr. Gruber was asked whether any White House employee ever asked him to purposely make the language or process of the law confusing so that it would not be understood by legislators or the Public.  Dr. Gruber’s response surprised me.  Instead of saying categorically “No,” he thought about it for a few seconds, and then responded, twice, that he just couldn’t recall whether he had been asked to do that.  That sounds to me like a tacit admission.

Anyway here is the full YouTube clip of Dr. Gruber explaining how high patient costs are coming under ObamaCare.



Hope you enjoyed it.  I’ll be back soon with even more original video clips.  I’m not sure why the media haven’t picked these up – I’ve tried, but they just seem to want to protect this administration and it’s “signature” healthcare law.  You can see them all posted to my YouTube channel – JohnnyTucson- yes I’m from Tucson – which explains why I always say …


the sceptic


Dr. Gruber Admits “Patients are Going to Get Less” in new Video

November 19, 2014

The Sceptic has discovered a video of Dr. Jonathan Gruber at the 2011 Connected Health Symposium on Accountable Care Organizations (ACOs).  Under ObamaCare, ACOs provide “managed care” to some Medicare patients, and are basically a new version of the old HMOs (Health Maintenance Organizations) which fell out of Public favor due to delays and denials of service. In this video, Dr. Gruber admits that patients in ObamaCare ACOs will have a lower level of health care than what they used to receive.

This video shows what we already know – that patients under ObamaCare will experience a reduction in their level of care, but it also gives a glimpse into the Wonkacracy of the Grubers of the world.  Dr. Gruber lamely expresses his sincere “hope” that the reduced level of care will not affect the health of the patients, but, since his focus is cost reduction, that is not really his concern.  Wow, Dr. Gruber, you are such an objective professional.

Dr. Gruber believes devoutly in managed care systems like ObamaCare, so he takes great pains to explain that HMO’s didn’t really fail, and were actually quite beneficial, because they saved employers money on insurance premiums.  The real problem was that Americans were just … you guessed it … incapable of understanding that … duh … they were actually getting higher wages as the result of employer savings on health care – just too stupid, I guess.

Dr. Gruber is quite dismissive about the “patient backlash” against managed care, which he attributes to everyone “getting upset” about health care because of a Jack Nicholson movie.  I guess he means “One Flew over the Cuckoos Nest,” but that was made back in the 70’s.  Perhaps  he’s conflating the initial patient pushback on HMOs with the backlash against HillaryCare that occurred in the ’90’s.  But, anyway, the gist of his dismissal is his typical argument that the American Public acts in a nonsensical manner where health care is concerned.

Finally, Dr. Gruber opines that ObamaCare’s Accountable Care Organizations face the same challenge as managed care HMOs (i.e. patient rejection), unless the Government visits “pain” on the patient to force him/her to join an accountable care organization.  In fact, our Government has gone beyond mere incentivizing with pain…

This year, hundreds of thousands of Seniors (including a friend of mine) received notices that they had been involuntarily enrolled in an ACO because their doctor had joined one!  To find out more about ACOs, you can read my post on ‘ObamaCare’s Medical Walmarts’

By the way, “Accountable” is just health wonk code for reducing patient access to health care.  Why?  Because, left to their own devices, patients will use “more than their fair share” of health care, and traditional non-ACO providers will aid them in their wasteful practices.

The job of the ACO, and, ultimately, all of ObamaCare is, in fact, to cut back on the use of health care resources by individual patients so it can be made available to society as deemed optimal by the bureaucrats. This means a reduction in the level of each individual patient’s access to care from what they received previously. So I will leave you with Jon Gruber’s question from the video – “Will patients be willing to do this?”

Personally, before I answer “yes” to that question, I need to hear a compelling argument that my reduction in care will actually be used to help others, and not be lost in the bureaucracy, and I need to hear what we never have – an honest admission that we are being asked to make sacrifices, and a heartfelt appeal to our better natures, rather than the deceitful propaganda that we have been fed about keeping our current level of care, getting lower consumer costs, saving $trillions,  etc.

Stay tuned … there is more to come from this same video regarding deductibles.

The Sceptic




ObamaCare Lies Were Actually Planned, Rehearsed

November 12, 2014

This week we have been treated to videos of Dr. Jonathan Gruber telling about how he and others had to mislead the Public (and Congress, by the way) in order to get them to accept some of the controversial aspects of ObamaCare.  Dr. Gruber should know since he was paid about $400K for his help in crafting the bill.

According to Gruber, the bill was worded in a  “tortured way” so that the Congressional Budget Office would not “score” the penalties for not having insurance (aka the “mandate”) as a tax, because that would “kill the bill” – i.e. it would not be cost-effective.  The same sort of deception was also used to try to hide the fact that the bill’s bloated minimum insurance requirements for young, healthy people was just a way to justify charging them higher premiums even though they would never use many aspects of the coverage.  These excess premiums were important to the bill because so many aspects of its operations and bureaucracy would definitely lose money.  Again, this was done in order for the CBO to “score” the bill as self-sustaining and cost-effective.

Dr. Gruber basically blames the “stupidity of the American voter” for the deception, which, I believe, does not really account for the deception of members of Congress, the CBO, and, perhaps, even some in the Administration.  This is truly fraud on a grand scale.  Dr. Gruber’s justification for the deceit is “I would rather have this bill than not” stated with the  self-righteous fervor of a zealot. This is an amazing statement, because there are millions of us who could say “I would rather NOT have this bill” with the same fervor.  Somehow Dr. Gruber thinks his voice and opinion outweighs ours.

Gruber has now attempted to walk back these comments, which were made in an arrogant, almost bragging manner – ‘what clever liars we are-‘  His explanation was that he made these remarks “off the cuff” and that they were not well thought out.  It now turns out that Dr. Gruber made similar remarks a several times and that they represent sort of a routine that he would trot out at appropriately obscure professional wonk venues.

The bigger story, though is how the President himself vehemently and repeatedly denied that the “mandate” was a tax in his 2009 interview with George Stephanopoulos. There is little doubt from this interview that the President had been rehearsed by his aides on how to refute any claim of taxation.  You can see the video here, although it is painful to watch at this point in time

Did the President know he was being less than truthful or is he just another victim of Gruber’s lies?  Certainly, from his unusually insistent manner in this interview he knew this was an important issue.  Advisors, including Gruber, had probably told him that bad things would happen to the bill if he didn’t sell the story that this was not a tax.  Did we know that we were being lied to?  I suspected it on many levels, and so did a lot of others, but we were painted as outlier conspiracy theorists – a merely routine dismissal from an Administration that fights its way thru the news cycle every day with almost the same level of false propaganda.

There is, however, one little silver lining for one person in Dr. Gruber’s rant – Chief Justice Roberts can now be given some measure of absolution for reaching the conclusion that the mandate was indeed a tax that the Feds could levy.  That was the way that Dr. Gruber and others fashioned the bill in the first place – so it would be understood as a “mandate” by the Public, economists, and the media, but would be understood by a lawyer as truly being a tax.  With this in mind, let’s recall the President’s background … yes, he was a lawyer … which makes the Stephanopoulos interview a little more damning.

Aren’t they so very clever? And aren’t you glad they are looking after you so carefully that they won’t let you know the truth when it wouldn’t be good for you to know it?


the Sceptic


UNMEER vs. US National Guard?

October 19, 2014

In view of events in West Africa, I will depart from our usual subject – the bureaucratic disaster of ObamaCare – and instead focus on Ebola and how to fight it.  This past week has been a blur with the U.S. muddying the waters by letting its secondary domestic infections become “The Big Story” – upstaging the true tragedy in West Africa.

It’s not so much that I favor a travel ban, it’s just that I feel strongly that CDC must quickly control the message and stay on point, rather than playing Keystone Kops on the world stage and blaming nurses and false protocols for secondary U.S. cases.  If they can control new cases with their illusory temperature scans (that have about a 15% chance of finding infected patients) – fine; with Ouija boards –  fine; with a travel ban – fine.  One way or another, the U.S. needs to get off center stage so that the World can focus on West Africa and what is needed to be done there.  That is the only place that Ebola can be defeated.

This week, I heard a voice that seem to strike just the right tone between desperation and hope – Anthony Banbury, the head of the United Nations Mission for Emergency Ebola Response – UNMEER.  Unfortunately, I heard only a short video clip such as that used by our media.   As I read more about this little publicized organization, I discovered that it has been effectively in charge of coordinating the international Ebola effort in Liberia, Guinea, and Sierra Leone since September 19 of this year.  Also, that it is the very first UN emergency medical mission to ever be commissioned to combat a specific disease, which says something about the depth of this crisis.  UNMEER appears to have what our National Guard and Army do not have – a working relationship with the Governments involved – intimate knowledge of the situation on the ground – effective logistical support for the not-for-profits like Doctors Without Borders, which are doing a lot of the heavy lifting, and, most importantly, … a plan!

In his October 14, report to the Security Council, Banbury proposed a number of specific goals and targets to be reached by December 1, 2014 – adding 3000 hospital beds – adding 15 new labs each capable of analyzing bloodwork from 100 patients per day – increasing the payment to burial details, and increasing their numbers tenfold – maximizing utilization of resources using computers etc. etc.   You can see Mr. Banbury’s complete report to the Security Council here  –


Unlike our sorry bureaucracy, which never wants to set short term goals that it might fail to meet, UNMEER understands that if they don’t get a handle on Ebola in the short term, and inspire further support, the resulting spike in cases, and demoralization of the West African populace at the end of this year could truly cause this epidemic to spiral out of control.  I think both the specificity and the urgency of Mr. Banbury’s presentation are something that resonate with Americans and make us want to say “Let’s solve this problem!  We can do this!”  If our Administration had a brain in their heads, they would latch on to the work being done by UNMEER and start writing some checks, and promote any successes as their own.

It does seem that CDC is aware of UNMEER since they have had representatives at recent UNMEER meetings.  The same is true of the International Monetary Fund.  But everyone seems to be just sitting on their money and waiting.  For what?  An additional 4000 dead?

Unfortunately, in return for its money, I foresee the U.S. will want a new bureaucracy under its control that will duplicate much of what is already in place, and I foresee that if not carefully coordinated,  President Obama’s promised military operations could actually impede efforts by UN aid workers and the local governments.  I sincerely hope that the U.S. will not just insert itself haphazardly into the mix, but will work in the background to assist what is already being done.  The Ebola epidemic in West Africa is certainly the place where we ought to “Lead from behind,” at least until we prove we can stop tripping over our own feet.

The Skeptic



Unheard Words: “What an Honest President would say about Health Care…”

March 19, 2014

The Administration is feverishly trying to recruit young people to sign up for ObamaCare before the end of March deadline, using an ad campaign designed to please viewers of “The Daily Show.”  However, they would probably want to bury the following words of truth spoken by Robert Reich, Bill Clinton’s Secretary of Labor, especially regarding his points about insurance for younger people.

Although Mr. Reich did not play a key role in creating ObamaCare, nevertheless his views are shared by many of those who did.  The only difference is, he has the guts to say what they truly intend this health care system to be, and implies the rest are just lying to you.  Check this video out, and remember it the next time you see an ObamaCare sales pitch.  (Hat tip to Morgenr for posting this)

I don’t necessarily agree with him that the current system avoids sick people.  Rather, the system may not provide insurance for some sick patients, but instead provides care in a very expensive way – at the emergency room.  About the new system though, Mr. Reich has it basically correct.

This clip has been around for a long time, but was ignored.  No one wanted to believe that our President would purposely misrepresent his health care system.  Most wanted to believe that he intends us only good.  Of course he does! – that’s why, in his own words, he had to break his (declared) promises so he  wouldn’t break “… an even more important (undeclared) promise.”  That would be the secret promise of all Progressives  – to move us toward their version of Utopia, with truth or with lies,  whether or not we want to go.

Hope you like our ObamaCare Utopia!   If not, no worries!  We can tweak it and tweak it to obtain even more  Progress until, a hundred years from now, Government-mandated health care will be, perhaps, half as good as what we originally had.

Of course, we may lose a few patients along the way, but it will be for a noble cause: Fairness – “Lousy Health Care for All!” (except for our Political Class and our one-percenters, who will skate above the requirements that the rest of us will live and die by).


The Sceptic

Merry ObamaCare Christmas from the Sceptic

December 29, 2013

A 10c response to a $million ad campaign by the Administration and its allies to urge families to use holiday get-togethers to persuade their younger members to enroll in ObamaCare. Truly calculated and nonauthentic emotional appeal  – I think our 10c stands up pretty well to this old skool politik


“You can Keep Your Insurance:” An ObamaCare Lie Since 2010?

November 2, 2013

Many of the details of ObamaCare are buried in the implementing regulations.  Recently, critics, like myself, decided to tackle the chore of scrutinizing these almost unreadable compilations of bureaucratic jargon.  We were rewarded by discovering “the smoking gun” as to “what the Obama Administration knew” about Americans losing their insurance plans, and “when they knew it.”

In the preamble to the interim final ObamaCare regulations dated June 17, 2010, is the required Economic Impact statement that all Federal agencies must provide when promulgating new regulations.  This impact statement reveals that Administration officials believed that, as a result of the new ObamaCare rules, 40% to 67% of INDIVIDUAL policies per year would lose their so-called “grandfathered” status and require the policy holders to get other insurance.  That is to say,  they would “lose the insurance that they like.”

But, contrary to Jay Carney’s downplaying assertions that less than 5% of Americans in a few individual plans will be affected, this is just the tip of the iceberg.  In the same impact statement, there is an assessment of “EMPLOYER Plans Relinquishing their Grandfathered Status.” A range of scenarios is presented in table form with the percent of dropped employer plans expected to be at least 39%, but possibly going as high as 69% after just three years!  Here is the table provided by the Administration in their June 17, 2010 regulation.  [click to clarify/enlarge the image]

  •  75frtable

Now we haven’t reached these “2013” levels yet, due to changes, delays, and future effective dates, but a deluge of cancelled employer-based plans and required rate hikes for new plans may still loom in our near future.  This is especially true in the small group health market (less than 50 employees). Oddly, whether this deluge is actually as bad as predicted may be less important than the fact that it WAS predicted. The Administration BELIEVED that this massive loss of insurance  could happen, reported it in the Federal Register, and then proceeded to implement regardless of the consequences to tens of millions of Americans who they expected to be caught in this crunch!

And, beyond that, just one more thing – over the last three years the has President lied repeatedly, in speech after speech, to cover up his DHHS’s estimate, and deny that this would happen.  Why did he do this?  Out of ignorance? To win an election? To gain time for the system to be irreversibly implemented against the Public will?

This is a very, very serious story – not just a little blog post.  To read a good account of it go to this Forbes article that challenges Jay Carney’s excuses about only a 5% impact, and, instead, estimates that 93 million Americans could lose their coverage


My own estimate of the impact is somewhat less, because ObamaCare does not require the large group market plans to meet the costly “essential health benefits” (EHB) requirements after they lose their grandfathered status.  Small businesses of less than 50 employees, however, must comply with these EHB requirements, and when their current plans lose their grandfather status, it will take a toll.

I estimate that about 66% of small group health plans (the Administration’s mid-range estimate in the above chart) will lose their grandfathered status and need to comply with “EHBs”  About 30 million Americans are employed by such small businesses.  Only about 15 million of these employees choose to participate In their employer’s plan, but, if we assume, on average, each participant carries coverage for two individuals in their family,  I estimate that as many as 20 million small business employees and their family members could lose their coverage in the near future.  Add to this the number of individual plans that are already acknowledged to be lost, and we are talking about 35 million Americans potentially losing their insurance.

Since I made this calculation, McClatchy Newspapers has echoed this estimate.  In fact, McClatchy estimates that from 34 million to 52 million Americans may lose their current plans. They also echo my explanation that the majority of the impact comes not from the 5% of individually insured Americans, as the President mistakenly portrays, but rather from another 10 to 15% of Americans with employer-based plans.  Incidentally, McClatchy is generally viewed as an independent, non-ideological source.  Their story is here – http://www.mcclatchydc.com/2013/11/07/207909/analysis-tens-of-millions-could.html

Of course, even the large group plans will be affected by losing their grandfathered status.  Forbes estimates a 15% rise in premiums and copays and I estimate a much more significant rise in deductibles as the additional impact of no “maximimum lifetime benefits” starts to be felt.  These increases will be on top of whatever normal inflationary increases there may be.

I urge you to read the Forbes and McClatchy articles,  and then tell your friends and families what is coming if we don’t stop this disaster.

I will return to this subject in the near future with more background about how the regulations trumped the intent of the Act, and how the delay in the employer mandate could make this cancellation nightmare even worse.

the Skeptic

Does ObamaCare let you “Keep Your Insurance,” and is it the Insurance Companies who are Taking it Away?

October 30, 2013

The answer to this apparently simple question is pretty hard to find, especially for folks who are not familiar with navigating the Federal laws and regulations surrounding health care.  It looks like the Obama Administration is  taking advantage of the complexity of these regulations to try to mask the impact that ObamaCare actually has on insurers so they can politick the issue.

But any fair examination of the ACA and the insurance industry response reveals a “cause and effect” relationship.  To blame the insurers for their current actions is to ignore the cause of those actions – ObamaCare and its regulations.  Betsey McCaughey has published a good piece on this subject at Investor’s Business Daily (http://news.investors.com/ibd-editorials-on-the-right/102913-677113-americans-duped-by-obamacare-promises.htm)

Looking at the Affordable Care Act (ObamaCare), the Preservation of Coverage Section [1251(a)(2)] states that

“With respect to a group health plan or health insurance coverage in which an individual was enrolled on the date of enactment of this Act, this subtitle and subtitle A … shall not apply to such plan or coverage,”

So we might think that these existing (“grandfathered”) individual and employer plans would not be affected by the new ObamaCare requirements, as the President has repeatedly stated.  Unfortunately, there are many other requirements in subtitles other than “A,” and their applicability to existing “grandfathered” plans is not at all clear in the Act.

One area that has been clarified by regulation, is the requirement for no cap on maximum lifetime benefits.  Since this requirement is contained in “subtitle A” of ObamaCare, we might think that “grandfathered” plans are exempt, as stated in the Preservation of Coverage clause quoted above.  That would be WRONG!  The regulations published on June 28, 2010, only five months after the Act was signed, contradict that section of the Act!

“The statute and these interim final regulations relating to the prohibition on lifetime limits generally apply to all group health plans and health insurance issuers offering group or individual health insurance coverage, whether or not the plan qualifies as a grandfathered health plan...”

So how much impact could this change have?  Right in the June 28, 2010 Federal Register is the following estimate for 2009:

“Sixty-three percent of large employers had lifetime limits; 52 percent of small employers had lifetime limits and 89 percent of individual market plans had lifetime limits.”

So it’s easy to see, as long ago as June, 2010, that, going forward,  tens of millions of people might be affected.  In general terms, eliminating these lifetime limits would be expected to cause increases in  premiums, copays, and deductibles to offset the risk, and these are exactly the kinds of changes to coverage that we are now seeing throughout the Country.

I find it hard to believe that even this sloppy Administration is ignorant of the information published in its own Federal Register notices. I think they are misleading the Public by claiming they didn’t realize the current increases would occur, and they are in bad faith by blaming the insurance companies, when those companies are just reacting as predicted by the Administration.

Additionally, any corporation counsel worth half his salary, would be alarmed by the fact that when the regulations are published they can conflict with the Act as to what is actually required of “grandfathered” plans.   This casts a shadow over the true, unwritten, legal intent of many of the other ObamaCare requirements.  How do insurers know that they will not be in violation next week or next month as new regulations and interpretations are issued?

In my opinion, this uncertainty is a big factor in the insurance companies’ decisions to just give up offering the old policies.

When is America finally going to wake up and figure out that beating up on the insurance companies is pure propaganda to cover up the intentions and impact of a bad law on a good health care system?

Come back and I will try truthin’ you again.  Maybe some of it will eventually stick.

The Sceptic

Accountable Care Organizations: ObamaCare’s Medicare Walmarts?

October 17, 2013


Walmart employs a business model which is widely regarded as greedy and evil by well-meaning liberals.  These same folks also support ObamaCare unquestioningly,  However, many ObamaCare programs, such as the Accountable Care Organization payment program, are just as focused as Walmart on their primary goal of cutting corners to lower expenses and help the bottom line.  The sad truth is that compared to ObamaCare, Walmart is harmless, because, while no one is forcing you to shop at Walmart, many Seniors may be unable to avoid ACOs for Medicare treatment.  In fact, unless the Affordable Care Act (ObamaCare) is overhauled, ACOs may become your best bet to find a doctor who will still take Medicare patients in the future.  More about this later.

To someone who understands just a little of Government double-speak, even the term “Accountable Care Organization” seems ominous – reminiscent of the “Ministry of Truth” – words fashioned to dupe the Citizen into thinking  that these new ObamaCare organizations might now operate under some increased “accountability”  to patients for patient outcomes.  Of course, that would be incorrect, because ACOs are actually “accountable” to DHHS under a contract that allows the ACO to be paid a bonus for reducing per patient expenditures, and calls for penalties after two years, if that goal is not met.  I wish I were kidding, but I’m not.

Basically, ACOs are economic and legal entities made up of doctors or hospitals that group together in an attempt to make economies of scale in treating Medicare patients. The heart of the program is contained in the law:

  • “…a percent (as determined appropriate by the Secretary) of the difference between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, under the ACO and such benchmark for the ACO may be paid to the ACO as shared savings and the remainder of such difference shall be retained by the program under this title.”

Which means … the already paltry Medicare payment scheme will be pressured downwards for ACO’s, and they will be paid a per patient allotment plus a “shared savings” bonus both based on the ACO’s historically-based benchmark per capita annual expense (there are volumes on how the ACO should determine this). The further an ACO’s annual expenses fall below the benchmark amount, the more “shared savings” they will be allowed to keep, and the balance will be retained by the Centers for Medicare and Medicaid Services (CMS). In other words, the ACO and DHHS are partners in splitting the “savings” that are not spent on the patient, and the ACO actually has a contract with DHHS to fulfill their end of the deal.

“… Government, in its role as insurance company, has coopted your ACO doctors with financial incentives and turned them into instruments of Public Policy rather than advocates for your health care.”

There are a lot of caveats in the regulations that small practices will not be able to keep up – they will fail financially under this system. So DHHS is encouraging only large group ACO’s who can handle lots of patients quickly – think assembly line, pill-prescribing medicine. Besides, there are so many requirements for reporting, feedback, forms, financial and legal requirements etc. that only a large group could afford the non-medical support personnel it will take to sustain this system.

I am trying not to dismiss of the whole ACO concept – there may be parts of it that could be used – but overall, ACOs spell bad news for individual patients.  First of all, the ACO is basically encouraged to withhold access to care in order to stay below their DHHS-defined benchmark.  Thus the doctor-patient relationship is  superseded by the Government-ACO relationship – this is where all the “accountablility” lies, not to the patient.  Even when patient satisfaction and outcomes are a factor in this system, it is up to the Government to determine the acceptability criteria.  In the pilot program, although lip service was given to acceptable outcomes, and they were indeed measured, all of the decision-making regarding “shared savings” was solely based on whether the ACO could stay sufficiently below the benchmark.  The role of the quality metrics is not nearly as well-defined as for the financial metrics, and seems to be left to the discretion of the Secretary.  Essentially, the Government, in its role as insurance company, has coopted your ACO doctors with financial incentives, and turned them into instruments of Public Policy rather than advocates for your health care.

Most seniors won’t even know they have become part of an ACO until after the fact.  My friend, Manny, recently received a note from an ACO he had never heard of telling him that his primary care doctor had joined the ACO, and asking him to complete a  long questionnaire.  He finished about half of it before he gave up,   I checked the regulations for him and it’s true – if your primary care doctor joins an ACO, then you will be automatically assigned to that ACO by DHHS.   The famous line “if you like your doctor, you will be able to keep your doctor,” really pertains only to this “gateway,” primary provider.   Unless the specialists that you see also join the ACO, they will not be readily available to you, and you will need to use whatever specialists the ACO has on staff (the ACO will be penalized for referring you to an outside specialist).

ACO patients can expect to experience delays in scheduling appointments because the ACO receives some payment whether or not they “see” you, so there is reduced incentive for doing so in a timely fashion.  ACO patients can also expect delays in referrals to specialists since this drives up costs. For example, an ACO might be tempted to delay fourth quarter referrals to the next year to keep down the present year per capita cost . The quality of specialists may also  deteriorate as good specialists become discouraged by meager payments under this system, and abandon the ACO.  The amount of patient time spent with the doctors will necessarily shrink under the ACO system, because doctors will be required to see many more patients in order to maintain the ACO’s financial viability.

Additionally, there are incentives for ACOs to use technology to monitor patients remotely via telephone, computer, remote sensors etc. in order to keep patients far away from the doctors as much as possible. These remote technologies may be the only ones that are incentivized under the ACO system.  Studies indicate that ACO patients receive fewer diagnostic tests, especially imaging tests, and new technologies and medical devices tend to be avoided out of cost considerations.  No wonder economists have noted that automatic enrollment in ACOs is necessary because there is no reason why a patient would voluntarily join an ACO.

Of course, these reductions in access to health care are welcomed by ObamaCare proponents, who view what I have called “coopting” doctors away from being advocates for their patients, as absolutely essential for the good of Society (i.e. Government).  They will unblinkingly tell you that we must refrain from using too many resources on individual patients, regardless of their needs.  To put it in a form you may recognize: we must prevent patients from getting more than “their fair share” of health care.  In fact this concept undergirds almost all of ObamaCare’s many patchwork programs and initiatives.  For example, why on Earth would a rational program impose taxes on health insurance policies with higher premiums than a certain cap for individual and family plans?  Isn’t this adding insult to injury for folks that may be stretching to make those payments?  Not all those folks are millionaires who can easily afford such a tax  – many just happen to have good insurance through their union contracts. And besides, why do we care?  The reason for these penalties and the incentivized payment schemes, and all the rest is because those folks are viewed, through the ObamaCare optic, as getting more than their share of health care.

Unfortunately, for all its cost reduction measures, the ACO system could lose as much or more than the current system to fraud.  Without going into details, or giving folks ideas, ACOs who are able to meet their benchmark can misrepresent their actual per capita costs and game the system.  To prevent this, look for even more reporting and recordkeeping requirements that will further reduce the thin ACO margin, while succeeding only in “keeping the honest man honest.”

How do Medicare patients survive this crunch that they are faced with?  The Independent Advisory Payment Board (IPAB) is like the top-down “hammer” reducing Medicare payments to doctors in order to shape their behavior.   The ACOs, by contrast, are the bottom up “anvil” co-opting your doctor with financial bonuses to look after the Government’s cost-saving interest rather than your health.  Caught between this hammer and anvil what chance do you have?

Right now there is a bill under consideration in the House called H.R. 351 which would reduce the power of the IPAB and allow for reasonable payments to doctors for services rendered.   This bill would restore the power of your doctor to act in your best interest and still receive adequate compensation to keep you as a patient.  This bill has some bipartisan support, and I would urge you to call or write your congressional representatives and tell them to finally do the promised “Doctor Fix” and vote for this common sense approach to reigning in the power of a remote, detached, bean-counting bureaucracy that sees you as an expense, not as a Citizen-patient.

An UPDATE on 11/21/ 2014 because I am now linking to this post from the Gruber video: 

Honestly, I am so gullible – I actually believed this when I wrote it- even talked to my congressperson- but HR 351 was gutted of all solutions, except temporary deferrals etc., and the problem was kicked down the road to future doctors and future Congresses. I despair that politicians can ever face the consequences of their own actions and fix them.  At this point, the only thing they will hear is if we go back to a hardline demand for repeal.

Sad but true – the Sceptic

If this resolution, or one like it, does not pass, then the IPAB will proceed to cut Medicare payments to doctors to fulfill the spending reduction targets that are built into the ACA.  Understand, as written in current ACA, the decisions of this board as to where and how much to cut are virtually unchallengeable by Congress, and will change how Medicine is practiced. For example, if the IPAB sets the payment amount for a knee replacement to only a meager amount that doesn’t cover the cost, while at the same time coverage for pain killers and payments for peptalk visits ( “r u taking ur meds?”) are generous, then doctors will tend to stop the knee replacements.

The Medicare actuary has projected that, if the IPAB meets all the ObamaCare spending cut targets, then the payment to a doctor to treat a Medicare patient will fall below the payment to treat a similar Medicaid patient in the not too distant future.  At that point, and even now, many doctors may just refuse to accept Medicare patients.  Notable casualties already are the Mayo Clinic and the Cleveland Clinic.  I have nothing against Medicaid patients, but I do feel Medicare patients were made a solemn promise, and sacrificed heavily to pay into the system over their lifetimes for coverage that is now being quietly dismantled to redistribute the health care to other patients deemed more worthy.  That breach of trust is, quite simply, unacceptable, which is why many of us have been fighting this ObamaCare monstrosity from the beginning, understanding where it will lead.

If there is no H.R. 351 – no relief from the arbitrary power of the IPAB – then, as mentioned at the beginning of this post, your best strategy may well be to join an ACO.  At least these organizations may still honor your Medicare coverage and accept you for health care, and their lean-and-mean approach may give them a chance of surviving under the payment starvation strategy of the ObamaCare bureaucrats.

I will write more in another post.

The Sceptic

Media Matters Rips Fox on Story about Obamacare and Mammograms

October 2, 2013

In response to a September 25, 2013, Fox story on mammography, Media Matters has published a response and critique. Unfortunately it has a lot half-truths and wishful thinking to support their premise that Obamacare is infallible and benign. The tragedy here is that discussions of this subject which fail to categorically condemn the November 2009, decision by an ObamaCare board, the USPSTF (United States Preventive Services Task Force), can only lead to further confusion about mammograms among patients and doctors.

This confusion has already resulted in 54,000 fewer mammograms per year for women between the ages of 40 and 49 according to a Mayo Clinic study released in 2012. You can read about it at http://consumer.healthday.com/Article.asp?AID=666143″>http://consumer.healthday.com/Article.asp?AID=666143 or at the Mayo Clinic site http://www.advisory.com/Daily-Briefing/2012/07/05/Mammography-rate-dipped-following-USPSTF-guidelines

However, the Fox story is also incorrect. Let’s take on these claims and evaluate whether dumb Fox or evil Media Matters is more correct about mammograms under ObamaCare.

Fox: The USPSTF recommendations would delay the beginning of regular mammograms until age 50.

Inaccurate – that WOULD have happened except that Senator Mikulski and others amended ObamaCare to nullify the task force’s November 2009 recommendation.

Fox: The USPSTF recommendations would end mammograms at age 74.

Inaccurate – The USPSTF held off judgment on this issue for lack of data

Fox: Cancer patients take a greater reduction in services from ObamaCare than other patients.

True, but it’s not just from ObamaCare. Congress has reduced the budget share for cancer treatment compared to other health care areas several times even before ObamaCare was on the scene.

Fox: Hospitals and doctors are disincentivized from providing care to the elderly.

True – The payment schemes in Medicare will now punish doctors and hospitals exceeding a baseline average per patient expenditure deemed appropriate for their institution. Hospital readmissions will also result in penalties.

And now for Media Matters

Media Matters: ObamaCare Contains “Specific Repudiation” Of the Task Force Recommendation

Inaccurate – Although Media Matters faithfully presents the wording in the Act, the assertion that it is specific, or that it repudiates the USPSTF finding is unfounded – you be the judge. Here is the wording:

“…the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography and prevention shall be considered the most current other than those issued in or around November 2009,”

Is that clear to you? This awkward wording was added after the issuance of the recommendations to try and fix up the mess in the Act. I will translate – the “current” recommendation (of November 2009) is not the “most current.” Rather, the previous “current” recommendation of 2002 is now considered the “most current.” This wording, far from being specific, does not even mention any problem with the 2009 recommendation, and does not give any hint of disapproval or sanction.

Actually, the vagueness of the wording fulfills that age-old bureaucratic requirement of not admitting to error, and of not tying your hands for the future. The time-specific wording of the rescission also leaves open the possibility that USPSTF could revisit mammography at some time other than “November 2009” and make a similar recommendation. The USPSTF has never rescinded their recommendation, and, in fact, have defended it, so a future similar recommendation would not be surprising.

Media Matters: The task force’s recommendations are “not binding

Inaccurate – They are really reaching here – using only media references including a statement from a paid TV Doc (NBC’s Snyderman). But the law is another matter, and it is quite specific at sec 2713 – USPSTF is empowered to rate diagnostic procedures as “A”, “B”, or “C.” When it rates a procedure as “C,” co-pays can be required by the insurer. All I can guess is that Snyderman was thinking it is not binding on doctors, but, when “C” is decided, it’s pretty binding on patients because their insurers are not going to cover any such procedure for free. The result may be that many patients may elect not to pay for a Class C test that they would just as soon avoid in the first place.

But actually it’s worse than that. Media Matters also uses a statement from the NEA Health Network to point out that the recommendations are not binding, but also were only intended to protect women from unnecessary procedures. That rationale is indeed part of the USPSTF finding and one would have to be extremely dense to think that such a finding published by a Government board of supposed “experts” would not impact doctors’ decisions to prescribe the test. In fact, the Mayo Clinic study has shown that the USPSTF “recommendations” resulted in 54,000 fewer mammograms per year among women 40-49.

Media Matters: Task Force Did Not Recommend Blanket Ban On Mammograms For Women Under 50 AND

Task Force Encouraged Policymakers To Include Additional Considerations And “Individualize Decision Making To The Specific Patient Or Situation”

Misleading – These boiler-plate type disclaimers by USPSTF overestimate the power of both doctors and policymakers to act outside the recommended guidelines. Every guidance document I wrote at FDA prominently bore required statements that they constituted non-binding guidance. However, once issued, these documents were slavishly adhered to by industry, who are just looking for a ‘safe harbor’ where they will have reduced exposure to litigation. Doctors are in this same boat trying to avoid exposure to malpractice, and policymakers are just looking for an expert on whose opinion they can base their position – they are not going to go beyond what they are handed.

So who fared worse in this clash of titans? I would say that Fox made the more egregious factual error in failing to recognize that ObamaCare ultimately did include the Mikulski amendment rescinding the November 2009 recommendation. However, Media Matters’ omission of the desperate need for an 11th hour amendment to “fix” the mistake made by a board specifically empowered by ObamaCare, and the assertion there was no problem anyway because the recommendation was non-binding, puts a happy face on a systemic shortcoming that is far from fixed for every other diagnostic procedure, and maybe even for mammography. This board’s power is essentially unchecked and there are insufficient safeguards to make sure that their future errors are not as catastrophic as this one.

To the extent that Media Matters may have lulled their public to sleep and avoided the root issue that still exists at sec 2713, their errors of omission may have the more severe Public Health consequences.

The Sceptic

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