Archive for June, 2011

Top 10 Reasons to Repeal ObamaCare

June 22, 2011

It’s not easy to write a “Top 10” list for ObamaCare because this massive legislation is a Public Health Catastrophe on a lot more than 10 levels.  And in the current process of implementation, new nightmares are being discovered within it’s 2700 pages on an almost daily basis.  Among the many confusing details, one thing is clear – If we fail to roll back this disaster in the making, we will eventually have the citizens of this Nation on their knees to their Government, begging for what used to be seen as “self-evident” and Creator-endowed – the very right to live!    What an unseemly fate for a nation that was specifically created to empower its citizens with freedom, and the ability to determine their own lives with a minimum of Government intrusion!

DON’T LET IT HAPPEN!!!     HEAD OFF THE DISASTER!!!!   REPEAL OBAMACARE!!

Later, in an unhurried, open-minded,  and prudent manner, we will devise a system that puts the needs of patients and doctors first, then, secondly, addresses underlying cost factors in a gradual, measured, and reversible process of trial and error, and then, finally, relegates Government to its proper role in assuring that insurers, drug companies, hospital consortiums, test labs etc. play the game by the rules.

But first we need to – HEAD OFF THE DISASTER!!

Sticking to the “Top 10” tradition, here are the “Top 10 Reasons to Repeal ObamaCare.”   Each “reason” is directly linked to a discussion of that subject which occurs later in the post, and you may want to prioritize the “reasons” that interest you most and click on them first.  You can always return later to pick up the rest.

The roots of ObamaCare’s problems

10. ObamaCare Creates a Huge New Bureaucracy

9. The System Fails its Primary Stated Task: to Decrease Medical Costs.

8. ObamaCare Increases Premiums, Increases Costs to States, and Contributes to the Recession by Discouraging Employers From Hiring New Workers.

7. Patients Will Have Decreased Access to Health Care Under the New System, Especially Access to Specialized Care.

6. ObamaCare Pays for Unproven Programs by Slashing Medicare – Creating a “Medicare Ghetto” that Doctors Will be Reluctant to Serve .

5. ObamaCare Stifles Medical Progress  by Taxing Medical Devices, Regulating Drugs, and by Reducing the Number of Specialists

4. ObamaCare Will Introduce Systemic Rationing to Cut Expenditures.

3. ObamaCare Replaces the “Doctor – Patient Relationship” with the “Government Panel of  Experts – Doctor Relationship”

2. There Will Be a Shortage of Doctors Willing to Work in the New System.

1. Government Mandated Health Care Threatens our Freedoms and our Values.


The roots of ObamaCare’s problems.  The reason that it’s hard to write a top 10 list of the worst things about ObamaCare is that there are both hundreds of things wrong with it, and, basically,  just one thing wrong…  Anyone attempting to read the Patient Protection and Affordable Care Act will be struck – by the overreach in attempting to address every aspect from dialysis to vending machines –  by the arbitrary nature of the formulas for compensation – by the unfounded assumptions regarding usage and need – by the unrealistic timeframes and benchmarks – by the crazy quilt of separate, patched-together incentives/cuts originally identified as budget options by CBO (see http://www.cbo.gov/ftpdocs/99xx/doc9925/12-18-HealthOptions.pdf ), not to improve health care, but rather to reduce Government expenditures, (and for each one of which the CBO listed possible negative consequences for public health) – by the redistributionist political speak (the word “community” appears 448 times in the document) – by the uneven writing, and the uneven regulatory approach …  In brief, one is struck by the sheer impossibility that this thousand ton Rube Goldberg machine held together with duct tape will ever fly!!  (It will however use lots of fuel and create lots of noise and pollution!)

So the basic thing wrong with ObamaCare is – it can’t possibly work as proposed and written – not even close!!   Even more to the point, it is not really intended to “work,” at least not as a health care distribution system. The project is essentially a social experiment with a huge number of variables and no controls (we won’t even be able to tell which specific aspects are successful in terms of cost and quality vs which are not) – performed on 1/6th of our economy -with the American People and the Insurance Industry as the subjects of the experiment!!  It is the result of a rushed, headlong, frantic effort to just get something out there called “health care” that the Government will control – and the lack of forethought, cogency, and practicality behind this effort is, in fact,  the root of the problem with ObamaCare.

10. ObamaCare Empowers a Huge New Bureaucracy Of course, we have all heard about the additional 16,000 IRS agents authorized to be hired to fulfill the requirements of The Patient Protection and Affordable Care Act, but that is small potatoes compared to the real potential for Government growth created in this bill.  The Act itself is over 2700 pages long, but that is just a brief outline of the requirements which still need to be fleshed out in the implementing regulations currently being written at DHHS. That could amount to tens of thousands of pages of requirements in all, creating a whole new ecology of interrelated bureaucratic entities.

Indeed, according to the Congressional Research Service, it is not possible to determine how many new agencies, boards, etc. will be created  under this Act!    (see  http://www.politico.com/news/stories/0810/40561.html)

The estimates vary from around 50 to almost 160 new entities!   Each one of these entities will need to be staffed  and supported. The potential red tape is staggering, and so is the potential for interference with our exercise of free choice over our health care.

…within 5 years, our present system will be viewed nostalgically as a miracle of efficiency in delivering health care…

Some cynics among us would say that the real purpose of the rules and red tape is to hamstring the insurance industry and squeeze it out of business by creating expensive new requirements for the industry while reining in their profits, organization, and advertising and thus eliminating their ability to recoup costs.  Even if the game is not rigged in this way, there are still a legion of legitimate doubts about how efficiently these Government bureaucracies will interface with each other and the medical community, how effective they will be in implementing a system that is more complex and more ambitious in its scope than any centrally-planned health care delivery system ever attempted, and how the “frictional losses” in such an unwieldly system will compare with the much-maligned profits and overhead paradigm of the insurance companies.

I predict that, within 5 years, our present system will be viewed nostalgically as a miracle of efficiency in delivering health care to our demographically diverse and  geographically diffuse Nation compared to the new centrally planned system.


9. The System Fails its Primary Stated Task: to Decrease Medical Costs. The Skeptic is reluctant to beat this drum too loudly, because it would be easy to devise a system that cuts costs significantly, but provides horrible health care.  The dirty little secret about health care is that the primary driver of costs is not administrative costs and profits of insurance companies, but rather advances in medical technology and drugs.

Actually, this fact is well known to Congress and is only kept a secret from the Public because it does not fit the media storyline.  For example, in 2008, in his role as CBO Director (before he became President Obama’s OMB Director) Democrat Peter Orszag provided testimony to Congress regarding rising medical costs.  All of the studies included in his testimony indicated that advances in medical technology were responsible for from one-half to two-thirds of the cost increases from the 1940’s to the 1990’s, while administrative cost increases only amounted to around 10 to 20 percent! This testimony is available at http://budget.senate.gov/democratic/testimony/2008/Orszag013108HealthTestimony.pdf

So, while reining in expenditures will undoubtedly erode progress in medical technology more than it reduces overhead costs, and might not always be wise, the proponents of ObamaCare have allowed for no such nuance, but rather have promoted their plan as providing huge cost savings ( large enough to perhaps even balance the budget!! ). In view of these absurd claims, ObamaCare’s absolute failure to cut costs earns this item a place on our list.

The Congressional Budget Office first pointed out that the Act just doesn’t do enough to “bend the cost curve”  downward in a 2009 statement (http://www.kaiserhealthnews.org/Daily-Reports/2009/July/17/CBO.aspx).  Recently, the Director of the CBO, Dr. Douglas Elmendorf, has reiterated this observation for the revised health care bill (http://hotair.com/archives/2010/06/02/cbo-obamacare-bends-the-cost-curve-upward/).   Interestingly, in this last piece Dr. Elmendorf points out  that while the Administration’s efforts to control costs via the present legislation are ineffective, that more drastic, potentially more effective  “… efforts to reduce costs substantially would increase the risk that people would not get some health care they need…” thus confirming the concerns I have already raised regarding cost cutting.

Instead of focusing on lowering medical costs, ObamaCare seeks to cap prices – limiting what Government will have to pay out – especially for Medicare and Medicaid.   This will lead to a situation where  unrestrained costs bump their head on the Government price caps, and doctors and institutions are asked to “eat” the shortfall or find ways to reduce costs themselves (such as reuse of medical devices).  This will not be good for patients seeking quality medical care.  And, of course, because ObamaCare fails to address cost factors, the problem of rising costs will be back seeking solutions, and more massive legislation,  in only a couple of years (more on this later).

So, what happens, you may ask yourself, to medical R&D?  to doctors’ and nurses’ salaries? to the quality of health care provided? to delays in receiving care?

A good example of ObamaCare cutting expenditures at the risk of actually increasing costs are its drastic cuts to the Medicare Advantage programs.  These plans, which provide improved benefits for low to moderate income seniors, were targeted by supporters of ObamaCare because the Government expends about 13% more for enrollees in these plans than it does on conventional Medicare participants.  However, according to John Goodman, (http://www.john-goodman-blog.com/the-puzzling-war-on-the-elderly/), Seniors in Advantage  programs:       ” … had 18% fewer hospital days and 10% fewer hospital admissions.  More importantly, MA enrollees had 27% fewer emergency room visits, 13% fewer avoidable admissions and 42% fewer readmissions.”  These reductions in hospital visits and readmissions are the target of several sections of the Act and, supposedly, are a major goal of the Administration’s health policy, yet, when faced with the choice of making the 13% investment to reduce costs or taking the immediate  reduced expenditures, the Obama Congress unhesitatingly opted for the short-term illusory “savings” since these were needed to cook the books and bring ObamaCare in under target.

This is symptomatic of the utter lack of vision and creative thinking which pervades ObamaCare.  Another way the Administration might have  reduced costs substantially without harming quality would have been malpractice reform targeted to reduce the motivation behind the scores of billions worth of unnecessary tests and procedures performed by doctors each year solely to avoid malpractice suits.   Every major Socialist medical system in the world limits the financial impact of malpractice suits – some by capping the claims, and others by simply making the Doctors into employees of The State who cannot be sued!  (I favor a more targeted reform that would provide a “safe harbor” for doctors who perform diagnostic testing in conformance with minimum voluntary standards that would be developed for major pathologies by the Federal agencies together with experts from existing standards groups in consultation with diagnosticians).

But the special interest-focused Obama Administration decided not to “rock the boat” for its lawyer constituency and downplayed the savings that would be realized by tort reform.  The actual cost of defensive medicine is the subject of a heated dispute between advocacy organizations for lawyers on the one hand and doctors on the other.    A recent article that tries to aim down the center with fairly new data can be found at http://www.bnet.com/blog/healthcare-business/defensive-medicine-costs-less-than-doctors-think-but-still-influences-their-decisions/1727 .  This article reveals that while the cost of defensive medicine may be less than originally feared, it is still estimated at between $45 billion and $125 billion per year – far too great a potential saving to be  dismissed for mere political reasons, as it has been thus far.

When, in the next few years, it becomes clear that ObamaCare  has failed to control costs and that further regulations/legislation  are needed, these future regulations will probably still focus on the Government’s main concern – expenditures –  and avoid underlying cost issues.  Around the globe, Government-run health care systems generally avoid cost-saving measures as too complex and indirect, and instead use rationing to limit patient access to their systems’ more expensive areas. Many of the architects of the world’s Government-mandated health care systems believe that only around 10% of a country’s GNP should be expended on health care, and so they devise appropriate rationing schemes so their countries can achieve that target without a lot of concern regarding quality.  Let’s face it folks, our Government has much better uses for our resources (redistribution, Cap and Trade, etc.)  than to squander them on the Health of Americans!!  There is literally no incentive for Government to lengthen the lives of its citizens.

So, if the architects of ObamaCare get their wish, the share of GNP we spend on health care will shrink down from the current 17% to a figure closer to 10% while underlying cost factors will remain untouched.  Combine this decreased universe of resources with a demand increased by 32 million more enrollees, and with continued high costs per unit of delivered care, and we could face a “perfect storm” leading to severe shortage of per capita medical resources. So, what happens, you may ask yourself, to medical R&D?  to doctors’ and nurses’ salaries? to the quality of health care provided?  To the delays in receiving care? If you dare ask any of these questions out loud, you will be branded as an extremist- a fearmonger – a tool of the insurance industry – and because the President fronting for the powers behind this mess happens to be an African-American, you may also be accused of racism. Welcome to the great American health care debate!

8. ObamaCare Increases Premiums, Increases Costs to States, and Contributes to the Recession by Discouraging Employers From Hiring New Workers. President Obama promised that under the new health care system we “would see premiums fall by as much as 3000 percent”  lol.  Of course, our math-challenged President really meant “$3000.”  But now under the initial phase of ObamaCare, premiums have actually started to rise!    So far, only minor parts of the Program have started to take effect – like dependent coverage until 26, and some of the “no preexisting” stuff – but these still need to be paid for.  The average premium increase this year is expected to be in the 10 to 20 percent range.  Additionally, the Congressional Budget Office has now predicted a total annual increase in premiums due to ObamaCare of $2100 per family!  (see http://www.humanevents.com/article.php?id=36651 )

That is $5100 per year higher than what Mr. Obama promised us!  In truth, it is probably a low estimate, especially if we count all the increased taxes to support the infrastructure (see item #10) and the larger co-pays being built in to discourage overuse.

“We didn’t think that we were going to cover 30 million people for free.”  President Obama, September 10, 2010

Additionally, under the new system, States are saddled with an expanded Medicaid Program, including individuals who did not previously qualify for Medicare.  This expansion consists of previously unqualified individuals with incomes up to 133% of the poverty line, and able-bodied individuals without children.  Additionally, there may be many “refugees” seeking coverage under the program including low income employees of businesses with fewer than 25 employees (exempted from providing mandatory coverage) and low income Seniors trying to escape from a Medicare system which will see physician fees drop below the Medicaid compensation levels by 2020!!  (These individuals may have difficulty finding doctors who will treat Medicare patients – see more under Reason #6 below).

The Federal Government has agreed to absorb these cost increases during the first 2 years, but then States will need to shoulder a portion of the increased payments as well as a large share of the administrative costs.  In the first 5 years of implementation, States may realize an increase in Medicaid costs of about $34 billion. (see ttp://www.heritage.org/research/reports/2010/07/obamacare-impact-on-states).

It may be useful to look to Massachusetts’ experience with “Commonwealth Care” to predict what may occur in the long term under ObamaCare.  The National Journal reports that the average government payment for low-income patients fell from 77% to only 60% after Commonwealth Care was implemented – that is a 22% reduction in funding of the total cost.  In the long term, we can probably expect a similar reduction of the Government share of Medicaid payments under ObamaCare, with the States left holding the bag.

Finally, some employers may be discouraged from hiring employees by the provisions of the Act.   On October 22, 2010, the Director of the CBO, Dr. Elmendorf, gave a remarkably unbiased presentation which admitted that employer demand for certain workers may be influenced by the provisions of ObamaCare. (see http://cbo.gov/ftpdocs/119xx/doc11945/USC10-22-10.pdf)   When added to the disincentive to some employees to work in order to obtain benefits now available under Medicaid, Dr. Elmendorf estimated a loss of jobs of about 0.5%.  This amounts to around 700,000 jobs accounting for $25 billion in revenue.

The actual initial impact on jobs may be even greater due to uncertainty about health care costs and requirements for employers resulting from the final regulations, which are not yet written.   Also, if premium increases are greater than expected (which appears to be the case), employer costs could rise considerably and they will have to choose how much to absorb themselves (resulting in fewer employees) or how much they choose to pass on to the workers (resulting in higher deductibles or lower salaries).   These effects could further increase unemployment.

Bottom line?  ObamaCare is costing a lot more than the American Public thought it would in taxes, premiums, deductibles, etc. that are pushed off onto users, employers, and States.

This “new reality” was reluctantly acknowledged by our new, young President on September 10, 2010  when he bristled in response to questions about increased insurance prices – “We didn’t think that we were going to cover 30 million people for free.”  The way this statement was delivered, the President seemed to be saying  “You idiots didn’t think we could cover 30 million people for free, did you?” It was both jarringly out of keeping with all of his other statements on this subject,  and argumentative – almost  insulting. Not only is this statement misleading regarding the current price rise (because those 30 million folks aren’t yet covered by the new system), but when critics said basically the same thing in 2009, Mr. Obama claimed this was misinformation spread by insurance companies to mislead the American Public!!    Once again, President Obama demonstrated, in this statement, not only his reluctance to admit to his own misleading (“3000 percent”) rhetoric that he used to sell us on ObamaCare, but also his basic inability to empathize with the real-world  concerns of American families as they now face increased health care costs under his new system.

7. Patients Will Have Decreased Access to Health Care Under the New System, Especially Access to Specialized Care. In short, while most people under ObamaCare will technically have “coverage,” no one will be able to get prompt care. The Massachusetts experience is a preview of how this will go. Far from decreasing emergency room usage, the new Commonwealth Care system has INCREASED emergency room loads. Why? Under Commonwealth Care, Massachusetts now has the longest delay in the Nation for obtaining routine medical care. Frustrated by delays in obtaining appointments and diagnostic procedures, folks try to shortcut the system and get care at the emergency room.

…delay and obstacles to access on the front end are a key part of the cost-savings in most Government-mandated health care systems …

One of the fictions that supporters of Government-run health care always trot out is that these delays in gaining access to care are just temporary and can be fixed down the road as the system is perfected.  Not true – delay and obstacles to access on the front end are a key part of the cost-savings in most Government-mandated health care systems.  Simply put, the chances are that some folks will get better and some will die before any further expenditure is necessary – delay is key to this sort of system – get used to it.

And this is just for routine medical care.  In addition, ObamaCare also proposes further hurdles for those needing access to specialized care.  Some of the payment pilot studies (which have a fast track to becoming regulations) would penalize doctors that make referrals to specialists.  Others would penalize specialists who charge more.  Also, specific Medicare cuts have been made (and more are scheduled) in  the main specialty areas of cardiology and oncology.   Radiology procedures are also discouraged by the payment formulas in the Act.

These are partially offset by increased funding of prescription medicines and a pilot of outreach programs to check whether people are taking their medicine properly.  Clearly, the architects of ObamaCare want to increase the use of “pill medicine” and decrease the more expensive “interventions” or “procedures” that rely on specialists’ expertise.  One can even detect a certain class hatred toward the specialists (check Bill Gates’ recent diatribe linked below in Reason #5) because … they simply know more, and charge more, and are more difficult for the Government to push around.

The price of ObamaCare’s revenge on the specialists is that there will be far fewer interventions that actually resolve medical issues.  There will be an increase in the number of chronically ill individuals,  and an increase in the drug burden borne by our already over-medicated population.  Of course, big PhRMA loves the concept of selling thousands of pain pills to a Senior who cannot get a hip replacement!    This emphasis on “pill medicine,” plus the Administration’s promise to not use the market power of ObamaCare “exchanges” to negotiate drug prices downward for at least 10 years, was the deal that led to PhRMA’s endorsment the health care reform bill.  So now we have identified three big winners in the ObamaCare lottery:

– Bureaucrats

– Lawyers

– Drug Companies

If you are not in one of these categories, you are a loser!  And if you happen to be older than 65, you are a big loser.  This leads to the next reason …

6. ObamaCare Pays for Unproven Programs by Slashing Medicare, Creating a “Medicare Ghetto” that Doctors Will be Reluctant to Serve . For a long time we have been aware of the planned $400 billion to $500 billion in medicare cuts that were used to offset the purported $938 billion cost of ObamaCare over the next 10 years.  These were the figures that were used by the CBO when they originally “scored” the bill.

More recently, however, we have been told by the Center for Medicare Services (CMS) that estimated savings in the  bill were overestimated (or double counted) by approximately $1.1 trillion over 10 years!   This would make the true cost of the bill approximately $1,800 billion – not $938 billion as originally touted! (see article at http://blog.heritage.org/2010/09/13/). In line with this underestimate of the cost, so too have the cuts to Medicare also been underestimated.  The Wall Street Journal Reported in a September 9, 2010, column (“How ObamaCare Guts Medicaid” –http://online.wsj.com/article/SB100014240527487036):

“In his analysis accompanying the recently released Annual Report of the Medicare Board of Trustees, Richard Foster, Medicare’s chief actuary, noted that Medicare payment rates for doctors and hospitals serving seniors will be cut by 30% over the next three years … by 2019 Medicare payment rates will be lower than under Medicaid.”

So exactly how big are the Medicare cuts?  The Chief Actuary’s report indicates that if we count both Medicare Part A and Part B cuts, the total cuts will be over $1 trillion over the first 10 years and almost $5 trillion over the first 20 years!!

But that’s not all.  There are further cuts to be made by the Independent Payment Advisory Board created by the bill.  These cuts proceed per a schedule of budget targets, and the decisions of the Board in meeting these targets may not normally be overturned by Congress.  While this highly controversial section may not be Constitutional, if the cuts are allowed to continue as planned over the next 75 years, the Chief Actuary estimates that Medicare reimbursements would be only one-third those made by private insurers and only one-half  those paid by Medicaid!  This could create a “Medicare Ghetto” that doctors and institutions will become increasingly unwilling to serve.

In reality, Medicare would probably fail completely before reaching such a low relative reimbursement rate.   And it is highly likely that, in the future, Medicaid will also suffer similar cutbacks.  I do believe, however, that Medicare will be hardest hit because, clearly, the thinkers behind this system, including Dr. Berwick and Dr. Emanuel, believe that a rational health care system must spend less on older patients (see  “Obama’s Health Rationer in Chief” on the sidebar).  This logic is antithetical to most Americans, who understand that their grandfathers and grandmothers have more health challenges than younger citizens, and, therefore, might need more, rather than fewer health care resources.  But the central planners have other ideas.

We cannot reasonably expect that doctors and health care facilities will continue to care for Medicare patients while operating at loss due to inadequate reimbursement rates.

Indeed, there are signs that the Medicare “crunch” has already started.  It is estimated that about two-thirds of hospitals currently  lose money on their Medicare patients.  In a highly publicized case, the Mayo Arrowhead Clinic in Glendale, Arizona has stopped accepting any new  Medicare patients because they were losing about 50% of expenses on each patient. (details at  http://www.nationalcenter.org/NPA602.html ).  This case was notable because during his health care campaign, President Obama cited the Mayo Clinic as an excellent example of how high quality medical care could be provided at reasonable prices.

However, it seems that even reasonably priced medical care costs far more than what our Government intends to spend on Seniors.   The Mayo Clinic is now considering curtailing Medicare services at its other facilities in Arizona, Florida, and Minnesota, because they are losing over $800 million per year!  We cannot reasonably expect that doctors and health care facilities will continue to care for Medicare patients while operating at loss due to inadequate reimbursement rates.

How will this impact Seniors?  A recent survey conducted by the Medicare Payment Advisory Commission found that  30 percent of  Medicare patients reported some difficulties finding a primary care physician.  This is in line with other estimates by the Commission that only about 72% of primary care physicians are currently accepting new Medicare patients.

The situation will get much worse if ObamaCare is allowed to proceed with its Draconian cuts to Medicare reimbursement rates.  Eventually, even those doctors and hospitals that still accept Medicare patients will be forced to ration care to these patients so that they can keep their doors open.  Elderly Americans will simply be unable to get adequate care, with Doctors on the front line cutting corners, and Medicare bureaucrats in the rear denying approval for many procedures which today are commonplace.

The Obama Congress has lied repeatedly that ObamaCare will “strengthen Medicare.”  In fact, DHHS is now running “Public Service” announcements asserting that activities like Medicare fraud detection and “plugging the doughnut hole” are unique elements of ObamaCare that “strengthen Medicare.”  The idea that these goals could not be achieved without a comprehensive and intrusive system like ObamaCare is ridiculous.  It is also exceedingly misleading to try and convince Seniors who, according to one spot are a bit dotty and “need to keep up,” that the trinkets and beads offered them by ObamaCare somehow offset the $trillions that will be cut from real treatment and care for Seniors suffering from cancer and other life threatening diseases.   In fact, this goes beyond misleading into the category of a detestable con job intended to sway Seniors into doubting their own intuitive understanding of this complex bill.  The goal is to try and drum up support for this disastrous program and thus help protect it from repeal.

If you read the links referenced in this section, you will see that the assertions that ObamaCare strengthen Medicare are merely absurd propaganda offered for political cover.  And now that Dr. Donald Berwick has been given a “recess appointment” as the head of the Centers for Medicare and Medicare Services without even a Senate hearing to expose his views and goals to the Public, we can expect the dismantling of Medicare to proceed in the dark corridors of Washington at a rapid pace. I am telling all the Seniors I know that they really need to take care of themselves, both physically and politically because their Government is no longer interested in their survival.

5. ObamaCare Stifles Medical Progress  by Taxing Medical Devices, Regulating Drugs, and by Reducing the Number of Specialists – Of all the “reasons” on this list, none better illustrates the contrast between the Central Planner and the Free Marketeer than this one. Our advance in medical capability (not the evil Insurance Industry) is  indeed the “500 pound gorilla” of health care – estimated by experts to account for from one-half to two-thirds of the cost increases experienced over the last 60 years (see “Table 1” of then CBO Director Peter Orszag’s January, 2008, Senate Testimony http://budget.senate.gov/democratic/testimony/2008/Orszag013108HealthTestimony.pdf).

To the free-marketeer who sees opportunities for high-paying, high technology jobs at which American workers excel, in addition to opportunities for improved health outcomes for American patients, the increased cost of medical technology is no threat.  To the grim collectivists who say  “there is only so much pie to go around,”  or “we can’t spend more than X% on medical care,”  advances in technology and drugs pose a severe threat to the common good, and must be sharply limited.

To just get a flavor for the ideological bent behind ObamaCare, first listen to this clip of Robert Reich (former Secretary of Labor) speaking at Berkeley’s School of Public Policy
http://www.youtube.com/watch?v=IT7Y0TOBuG4 Toward the end of this somewhat amazing clip, Dr. Reich reveals that in order to control costs we need to have “less innovation” and this means less medical research and fewer new drugs and device.   This dovetails nicely with the writings of Dr. Ezekiel Emanuel (who serves the Administration as both a Special Health Advisor and on the Council for Comparative Effectiveness Research). Dr. Emanuel has said that  the “major contributor” to rapid increases in health spending is “the constant introduction of new medical technologies, including new drugs, devices, and procedures. . . . With very few exceptions, both public and private insurers in the United States cover and pay for any beneficial new technology without considering its cost. . . .”

So, one of the principal objects of Government-mandated health care is to slow down medical progress.  This can be accomplished via the approval process for drugs and medical devices conducted at the Agency I worked for for 30 years – the FDA.  As you may be aware, the drug Avastin is currently undergoing review as to whether its original indications for use are appropriate – more specifically, the review questions whether it is appropriate to continue providing Avastin to women with breast cancer.  The FDA panel’s finding to date is that, while possibly effective, the drug was just too costly for this indication.  This finding, which is the first to ever be based on cost rather than safety and effectiveness, has raised concern among voters, so a new review has been promised … after the election, of course, lol.

An effective way to discourage innovation is to tax it.  Specifically, via an excise tax on medical devices (wheelchairs, MRI machines, pacemakers, stents etc.).  While this tax has been scaled back  from  the original proposal, it can still take a sizable chunk out of a manufacturer’s bottom line – about 5 to 10% is estimated.  The chances are that, for larger companies, this chunk will come directly out of research and development.  For smaller companies, the impact can be more devastating, and can threaten their financial existence.

Since, traditionally, most of the innovation in medical devices comes from such small firms, and since new medical devices are often associated with new types of “procedures,” this could have a significant impact on the rate of medical progress.  The potential impact is so severe, that these smaller firms are now lobbying to get an exemption for firms with less than $100 million in sales.  In view of Dr. Reich’s and Dr. Emanuel’s revealing comments, I think it is entirely the intention of ObamaCare to punish such progress, and I would estimate the likelihood of these firms getting their exemption is just about zero.

Another way to discourage progress in medicine is to reduce the number of specialists.  Most of the studies on new devices and medical procedures are not performed by academicians, because they generally lack the requisite skills for human studies, but rather by highly trained specialists.  Anyone who has ever attended a medical convention would quickly realize that virtually all the presentations and papers are by specialists.

…as ObamaCare proceeds in implementation, we will see specialized care become virtually the sole province of the ultra-wealthy.

I have already partially covered how ObamaCare works to discourage specialists in Reason #8 above, but let’s just put the exclamation point on how these folks think by listening to Bill Gates recently accuse specialists of essentially being enemies of the State – http://www.youtube.com/watch?v=UynOabdkKHQ&feature=related –  I know that some of you will cringe that I am using Michael Savage’s broadcast replay of Mr. Gates’ statement.   However, the interesting part, which  runs from around 1:00 to 2:40, is simply unavailable from any other source!!  I encounter this problem all the time – mainstream media simply do not report on the unpleasant facts about ObamaCare, and often one is constrained to cite conservative sources.

Anyway, I think this amazing statement and accusation towards specialists is entirely unfounded, and moreover, is simply made in bad faith.  The main reason specialists need to be villified is to discourage doctors from becoming specialists and to slow down the progress of medicine.  Another “benefit” of eliminating most specialists, of course, will be to greatly decrease the access of average Americans to expensive specialized care.  Indeed, as ObamaCare proceeds in implementation, we will see specialized care become virtually the sole province of the ultra-wealthy.  The rest of us will be taking pills, as Mr. Gates recommends.


4. ObamaCare Will Introduce Systemic Rationing to Cut Expenditures. This indisputable concept was repeatedly denied by Administration representatives in the political back-and-forth about “death panels” while ObamaCare was still seeking approval.  But now that ObamaCare has passed, the truth about rationing has begun to surface.  For example, ObamaCare apologists such as Bill Gates are now almost condescendingly explaining why such rationing is necessary – implying that those who oppose it are just naive, ignorant, or selfish.  Another example is Peter Orszag’s (former Obama OMB Director) highly relieved, somewhat surprised confession that the Administration was able to include in the bill a controversial Independent Payment Advisory Board with extraordinary powers to cut Medicare reimbursements (and treatments) even when the majority in Congress do not agree with the cuts!  – see http://hotair.com/archives/2010/04/27/video-orszag-explains-how-obamacare-imposes-rationing/

Another sign of the rationing to come is the recent FDA panel decision that, the drug, Avastin is not indicated for late stage breast cancer due to cost-benefit considerations, effectively rescinding previous approval for use by about 17,000 women .  This marks the first time that an FDA clearance is not based on efficacy and safety, but rather on cost.  While, in this case,  a reasonable argument can be made supporting the FDA decision (because of the very high cost and the relatively low extension of life expectancy) nevertheless, this creates a precedent for making other similar decisions where the criteria may less clearly support such a conclusion.  The disturbing fact is that what these future decisions will share with the Avastin decision is the clear interest of the Government in saving resources for use in sustaining the bureaucracy and for expenditure on other, more worthy, categories of patients.  That is, in a system where the Government is responsible for health care expenditures, the motivation to use its authority to deny access to care will always be present, regardless of what the science tells us.

To those who will argue that same motivation also exists within insurance companies, let me point out that insurance companies are not mandated by law to determine the safety and efficacy of drugs and medical devices for various treatments.   Let me also point out that when an insurance company decides not to cover a given treatment, that does not preclude other insurance companies from offering that same treatment in their policies.  However, when the Government disapproves a given drug or device for an indication, there is basically no appeal.  No company may legally market the drug or device for this use, and any doctor trying to use it in this fashion would be exposed to malpractice sanctions.

“The decision is not whether or not we will ration care. The decision is whether we will ration with our eyes open.”   Dr. Donald Berwick Head of CMMS

This leads us back to the concepts behind ObamaCare.  One of the lies that has been used to sell us on this plan is that the insurance companies are just not spending enough on their customers.  In truth, the designers of ObamaCare want to limit the total expenditures of all parties – Public and private – on health care.  In their mind, insurance companies have actually been far too willing to pay for treatments!  And they intend to rein in that spending by leveraging the Government subsidies for lower income patients provided by ObamaCare to force private insurers to conform to coverage and compensation norms mandated by the Government.    Once spending has been arbitrarily capped, rationing must ensue.  Eventually, if the thinkers behind ObamaCare get their way, we may be headed toward something that looks like the plan proposed by Dr. Ezekiel Emanuel in his January 31, 2009, Lancet article (see “Obama’s Health Rationer in Chief” on the sidebar):

[mccaughey]

Dr. Ezekiel’s plan describes the likelihood of receiving an “intervention” (i.e. specialized medical care including “operations”) for persons of all ages.   As you can see, this plan calls for “interventions” for a 60-year-old to be allowed at only about one-third the rate designated  for a 20-year-old, and at about one-half the rate designated for a 10-year-old. Let me be clear – these figures are not based on clinical considerations (older patients probably have a greater need for any given indicated “intervention” than younger patients) – rather they are a blueprint for the use of society’s resources based on an individual’s value as determined by age.

In order to fulfill Dr. Emanuel’s arbitrary probability curve, an equally arbitrary system of strict rationing by age must be imposed. This system has been devised and is well on its way to implementation (see Reason #6 above).  And that may be just the beginning – why not also value individuals by other criteria – based on the usefulness of their careers to society?  based on whether they are Government employees?  based on whether they are Union members?  based on their IQ?  based on whether they are in prison? etc.  Once we abandon the traditional landmarks provided by clinical relevance, and the doctor-patient paradigm, we are adrift, and virtually any rationing scheme can be justified!

Our new Director of the Centers for Medicare and Medicaid Services, Dr. Donald Berwick, agrees with Dr. Emanuel’s social utility paradigm, and sees the British National Health Service (NHS) model of “evidence- based” medicine and “comparative effectiveness” as the best way to get there.  Basically, this system uses cost-effectiveness to choose between possible treatment alternatives and allows the denial of access to more expensive treatments.  Effectiveness in resolving a medical condition, and quality of life concerns may or may not be relevant; rather a patient’s access to effective health interventions are likely determined by their ailment, their demographic (such as age), the time of (the budget) year and the degree of fulfillment of the quota for such interventions and, of course, cost.  In fact, many elderly Britons wait indefinitely for treatment that never comes, or that comes too late.

Dr. Berwick is unapologetic about his enthusiasm for a British-Style Government-mandated rationing system (“It’s such a seductress!”  he commented about the NHS).  In his 2009 interview with the journal, Biotechnology Healthcare, Dr. Berwick stated, “The decision is not whether or not we will ration care. The decision is whether we will ration with our eyes open.”

I think with all the recent confessions by former “death panel” deniers, the eyes of many Americans are indeed starting to be opened regarding the reality of rationing under ObamaCare.

3. ObamaCare Replaces the “Doctor – Patient Relationship” with the “Government Panel of  Experts – Doctor Relationship” –  What we can come to expect may have been hinted at by President Obama himself in a June 24, 2009  town hall meeting at the White House.   He was asked by Ms. Jane Sturm whether “any consideration” would have been allowed for her 100 year old mother’s “spirit” as she sought a pacemaker to address her arrhythmia problems ( a pacemaker which, under the present Medicare system, had indeed been implanted, giving the woman five more years of life to date).  His initial answer was basically “No” because

“…  the waste that exists in the system … that is loading up on additional tests or additional drugs that the evidence shows is not necessarily going to improve care, that at least we can let doctors know (emphasis mine), and your mom know, that you know what, maybe this isn’t going to help, maybe you’re better off not having the surgery, but taking the painkiller.”

But then Ms. Sturm added that her mother’s repeated hospitalizations prior to receiving the pacemaker may have cost Medicare more money than the pacemaker procedure itself.  To which Mr. Obama responded:

“Well, and that’s a good example of where if we’ve got experts who are looking at this and they are advising doctors (emphasis mine) across the board that the pacemaker may ultimately save money, then we potentially could have done that faster.”

In both answers, Mr. Obama clearly expects Government experts to inform doctors as to the appropriate course of treatment.  Importantly, this advice (most likely rendered in the form of a guideline since it is given “across the board” to all doctors treating patients with this condition) seems to be primarily based, not on clinical issues, but rather on improved efficiency (eliminating “waste”), and on “saving money!”  The well-being of the patient never seems to enter into the equation!  The doctor-patient relationship is missing – supplanted by the Government expert-doctor relationship, whose primary goal seems to be to reduce the resources expended on the patient!

A decision by the USPSTF, or other Government entity, which  under our current system is merely an arbitrary and ill-informed recommendation…  has the potential, under a Government-mandated system, to become a death sentence

An example of how a Government Panel of “experts” may act to dramatically worsen health care was the fiasco regarding mammograms for women under 50 years of age which occurred during the height of the health care debate.  This example illustrates two major points:

  1. How easily an isolated panel of “experts” can reach a ridiculous conclusion and
  2. How automatically and mindlessly a bureaucratic system like ObamaCare might implement such a conclusion, even to the detriment of Public Health.

On November 16, 2009, the United States Preventive Services Task Force (USPSTF), a Government-appointed panel advising DHHS on the practice of preventive medicine, declared that mammography for women under 50 years of age was rated as a class “C” procedure.   Astoundingly, this decision, which contradicts the recommendations from many other medical groups, was apparently made without a single oncologist on the panel!  Unfortunately, under ObamaCare, the USPSTF decision, no matter how arbitrary and unfounded, would trump other recommendations because USPSTF ratings are codified and linked to coverage in Section 2713 of the Act.

This meant that, under ObamaCare, insurers, both Public and Private, would not be required to pay for mammograms for women under 50 years of age, thus restricting access to mammography in the at-risk age range from 40 to 50.  The effect could be devastating. An alarmed Senator Mikulski observed that “Studies have found mammography screenings decrease breast cancer deaths among women in their 40s by over 40 percent.”  For this reason, an emergency amendment- the “Mikulski Amendment”- was quickly passed to put a band-aid over this unbelievable disaster built into ObamaCare.

So did this amendment add requirements that the USPSTF include experts with specific knowledge relevant to the pathology being “prevented?”  Did it include requirements for USPSTF to validate or benchmark its rulings to previous findings or to the recommendations  of other “outside” organizations of  experts? Did it provide a monitoring and review process for correcting USPSTF decisions subsequently discovered to have negative health impacts? In brief, did the amendment include ANY of the typical systems safeguards that might reduce risk of the implementation of future disastrous decisions by USPSTF?

No. Despite this virtual textbook case study in system failure,  Senator Mikulski and her fellow Senators failed to address the underlying systemic threat – i.e. a decision by the USPSTF, or other Government entity, which  under our current system is merely an arbitrary and ill-informed recommendation, which doctors and insurers may choose to regard as just bad advice, has the potential, under a Government-mandated system, to become a death sentence!   Instead of addressing the causes of the failure, section 2713 was only narrowly revised to specifically nullify the November 2009 ruling of the USPSTF regarding mammography!  This is the kind of stonewalling, refusal to address systemic problems and inability to admit to making mistakes that is the hallmark of the bureaucracy, and it shows us the inflexibility we can expect from this centrally-planned, heavy-handed system.

As a result of this stonewalling (Senator Mikulski actually had the chutzpah to try to spin this problem as the fault of the insurance industry!), and the total lack of root-cause thinking, the potential for unlimited future USPSTF timebombs remains in the Act,  lurking behind decisions still to be made on any number of preventive medicine procedures!  What happens under the new system when there is a similar arbitrary USPSTF decision regarding children, or old people, or people with a rare and unpopular disease?  In short, what happens when rationing is imposed on a group that is not a key interest group and that does not have Senators who are eager to stand up and fight for it?  Will there be a Senator with me in the Doctor’s office when my Doctor consults the Law, the Regs, and the USPSTF guidelines, and then informs me I am not eligible for some early detection diagnostic procedure that might save my life?

And this is just one panel of experts!  There are many such boards and panels created under the new Bureaucracy.  Some are specifically tasked with disseminating “best practice” information to physicians.  Others are tasked to develop “evidence-based” outcome information that will provided to doctors to encourage them to avoid expensive procedures or tests in favor of “pill medicine.”

Additionally, ObamaCare provides for the funding of targeted training for new doctors.  Part of this training will be in “evidence-based” medicine and in the “socially conscious” practice of medicine (see link to “Obama’s Health Rationer In Chief” on the side bar).  Doctors schooled in this way will be more likely to think of the cost of health care to society, and less likely to advocate for good care for their patients.  They will also be ready to accept without question the “recommendations” of the Expert Panels telling them how to practice medicine.  I think we can also expect that doctors willing to accept this level of regimentation will be less likely to “think outside the box,” or to take any initiative in developing novel treatment regimens.

This, of course, is exactly what the Government is seeking to achieve – less medical progress, less patient advocacy, lower aspirations on the part of both doctors and their patients.  Unfortunately for patients, there may not be enough qualified individuals who are interested in practicing medicine in such an environment.  This brings us to the next reason …

2. There Will Be  a Shortage of Doctors Willing to Work in the New System. In fact, the shortage has already begun, caused in part by existing policies which ObamaCare continues and exacerbates.    For example, since 1997, the Federal Government has been trying to control Medicare costs by capping the number of residencies that it will support.  This cap has created an artificial shortage of doctors relative to demand for medical care caused by the advance of the “Baby Boomers” to old age.   (see http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aMUUwixXaq_I).

Of course, the situation will be made worse by the addition of  over 30 million  new enrollees  with increased demand for care.  This is reflected in the estimate by the American Association of Medical Colleges that the shortage will amount to 63,000 doctors in 2015, shortly after ObamaCare takes effect, and could grow to over 200,000 doctors by 2025!
(see http://www.reuters.com/article/idUSTRE68T67120100930).

While an effort is being made to increase the number of students in medical schools, this effort is probably not going to solve the problem, partially due to the residency bottleneck mentioned above, but also partly due to the lack of incentives for doctors to continue working at the level that we have traditionally come to expect.   A recent study published in JAMA  indicates that doctors are now working shorter hours than in the 1990’s.  As cited in the VOA News (http://www.voanews.com/english/news/usa/Doctors-in-America-in-Short-Supply–85332477.html),

“Using data from the US Census bureau, the researchers found that doctor’s hours declined while at the same time their incomes dropped 25 percent between 1995 and 2006.  The loss in income was most likely the result of cuts in private and government insurance reimbursements, the authors said.  One doctor put it this way: the less you are paid, the less incentive there is to work harder.”

Of course, this kind of free-market reasoning is just gibberish to the ideologues behind ObamaCare, and they will, most likely, continue to “engineer” the availability of residencies, and to cap the reimbursement of services because it gives them the illusion of cost savings, and the illusion of control.

This “Titanic” illusion may be headed for a huge iceberg of which we have only seen the tip.  Some polls indicate that almost half of current Doctors are considering “early retirement” in order to avoid the stress and micromanagement of the new system (see http://www.investors.com/NewsAndAnalysis/Article.aspx?id=506199).

Additionally, students considering a medical career may be discouraged by the higher debt, lower salary, and fewer opportunities for advancement in this bureaucratically-run system relative to competing careers in the private sector, such as The Law.  Even President Obama has acknowledged the disincentive of debt relative to possible income for students considering medical careers. Unfortunately, ObamaCare does nothing to relieve this disincentive.

The impending doctor shortage is, perhaps, the most serious long-term effect of ObamaCare on the delivery system.   Add the possible increased demand by 30 million new enrollees on top of this shortage, and we have the potential for a true health care gridlock nightmare.

1. Government Mandated Health Care Threatens our Freedoms, and our Values Juxtaposing the immense power of  a Government-mandated health care system against the power of an individual patient is inherently dangerous, and violates all of the principles of individual freedom on which this Nation was based. Today’s  society seems to understand this sort of dangerous disparity in power (not to mention conflict of interests) when we talk about something like workplace sexual harassment – the power difference between the employer (or supervisor) and the employee means that even a trivial infringement of rights in the employer’s eyes can be a serious threat as viewed by the employee.  And the situation is 100 times worse when we have a Federal Government intent on reducing health care expenditures dictating life-and-death health care decisions to us!

It is actually less threatening to our Freedoms, and less morally reprehensible for an Insurance Company to deny access to health care than for our Government to do so …

Moreover, letting our Government decide which Citizens shall receive medically effective care and which shall receive palliative or lower level care inherently violates our basic contract with our Government, because it means that not all Citizens are treated equally – some will be denied access to effective care by the various rules that are devised.  Of course, apologists for Government-mandated health care always argue that this situation already exists currently with insurance companies making the decisions.

But they are missing the point – unlike a contract with an insurance company, the Citizen’s contract with his Government includes an implicit pledge of  allegiance!  It is essentially immoral for the Government to take advantage of the Citizens’  loyalty and adherence to the rule of law in order to impose a system that denies one Citizen access to effective health care so that another Citizen, deemed more worthy, can receive additional health care resources!  Basically, I can change my insurance company at any time – but I can’t change my Government.  Beyond that, the Government currently provides some patient protection by overseeing and regulating insurance companies, but under the new system, who will rein in a Government mandater that is effectively partnered with the insurance industry in their joint goal to reduce expenditures on patients?  Under such a system, who will be the honest broker to protect patients from abuses?

What abuses could possibly occur under the auspices of our totally virtuous Bureaucracy?  Because the rules for health care access will now be made by Government, Congress and those officials making the rules will be the object of vigorous  lobbying by various interest groups seeking increased access to health care for their special interest constituencies (e.g. demographic groups, labor unions, those with a specific ailment etc.).   Some may also seek to “opt out” of difficult requirements or seek less expensive means to meet them.   This means that over time there will be a great likelihood for corruption and politicization to creep into the system.   Already, the San Francisco Examiner reports that 915 exemptions have been given, mostly to labor unions and others friendly to the Administration http://www.sfexaminer.com/opinion/op-eds/2011/02/new-health-care-law-marred-obvious-political-exceptions

Revisiting the moral quagmire created by Government-mandated health care…

When we institutionalize immorality (such as slavery)  in the instrumentalities of the State, we all suffer moral degradation because those instrumentalities (bureaucracies) act in Our name – on Our behalf.  Indeed, how many times have we already heard the former Speaker and the Senate Leader tell us that they enacted this health care monstrosity “for the Good of the American People?”   So, incredibly, the Political Class is pinning responsibility for ObamaCare on the American People- the very People who emphatically opposed this system by a sizeable majority from the very beginning!   By their reasoning, the American People share the responsibility for the new health care system because individually (i.e. some Citizens in preferred demographic groups) and collectively (from a bean-counting perspective) we will benefit from the rationing priorities inherent in this system.  From their viewpoint, the American People are therefore, responsible for the fact that the new rationing priorities will necessarily deny many other Citizens (including most Medicare recipients) access to treatment!  The unbelievable, hypocritical irony in all this is that it is the Political Class which has been winning election after election by telling these same Citizens who will now be denied access to care that they needed to vote for them in order to maintain that access!  Simply unbelievable!!!

Of course, the American People are not truly responsible for these inherent inequities since  we had no say at all in the creation of this system, and most of us courageously opposed it.  Unfortunately,  if we now fail to continue our opposition, and, instead, try to abide by this system in the hope that it won’t affect us, we will be morally complicit in all the abuses that will flow from it from this point forward. This erosion of the Citizen’s moral standing and his co-option into the gray, amoral, bureaucratic health care agenda, with its emphasis on expediency and expenditure, is truly infernal, and, I believe, intentional, and poses a greater threat to our values than any abuses that may exist under the free-market system.

At particular risk is our tradition of upholding the importance of the individual and of protecting the individual’s rights from being trampled by the instumentalities of the governing majority.  ObamaCare turns this on its head and devalues the individual Citizen to the point where he(she) can be officially denied access to health care and makes us all a party to this injustice because we are all reaping some supposed collective benefit derived from conserving resources.  In short – It is actually less threatening to our Freedoms and less morally reprehensible for an Insurance Company to deny access to health care than for our Government to do so!!

Not enough has been made of this issue. People just close their eyes and talk about the evils of insurance companies. The fact is that no insurance company nullifies individual choice and poses the threat to freedom that a Government with this sort of immense leverage over its citizens poses. Those failing to understand this either haven’t really thought this through, or are simply choosing to ignore 10,000 years of human experience with “Government.” I guess we could call this blindness “hope,” but I fear this is destined to “change” … to despair… as the veil falls away and we finally see this collectivist system in all its grim reality.  This is the real “Hope and change” paradigm that we will learn so well, unless we …

HEAD OFF THE DISASTER!!  REPEAL OBAMACARE!!

The Skeptic


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