Consolidation of healthcare is not an island unto itself

Since 2005 I’ve written hundreds of thousands of words about healthcare. This includes 14 books I’ve authored, co-authored, and/or published. Never once, however, did I mention how the consolidation of healthcare into ever-larger organizations patterns what is happening all across America.

The GOP presidential debate included mention of the Dodd-Frank legislation that affects the banking industry. Candidate Jeb Bush told the story of a small community bank located in Washington, Iowa. The bank, with its $125 million in assets, struggles to stay in business because of Dodd-Frank. Why? Because of thousands of pages of regulations and an onerous compliance cost that grew from $100,000 a year to more than $600,000 per year.

It is likely that the community bank to which Bush referred will eventually be absorbed by a large banking system, which in turn, will be absorbed into a national or even international bank. Will the local communities that rely on these small banks be better served by $2.5 trillion behemoths like J.P. Morgan bank? U.S. Bank? Wells Fargo Bank?

When Congress passed The Health Insurance Portability and Accountability Act of 1996 (HIPAA) it added volumes of compliance requirements on medical providers, insurance plans, and related support industries. “Ma and Pa” pharmacies too often could not afford to upgrade to meet the compliance costs, and either went out of business or sold to larger chains of stores.

The Affordable Care Act of 2010 (aka ObamaCare) is having the same effect on medical practices. True enough, the consolidation trend predated ObamaCare as a response to managed care, HMOs, and the like, but the ACA exacerbated this problem. Now we are told that Bigger is Best and we will get better, more affordable care from huge health systems.

We will be coming to know these new health systems over the next few years. Accountable Care Organizations, hospital-owned practice groups, insurance-company owned practice groups, and the like, will provide the bulk of healthcare services to individuals. Healthcare management is moving away from the beside, between a doctor and the patient, to the backrooms where actuaries and accountants decide how to divvy up healthcare dollars. This is the trend.

Today, most patients do not hire doctors to provide their medical care – they “hire” an ACO, HMO, PPO, or in many ways, an Electronic Health Record, to provide care. Whether this proves to be more effective or efficient can only be evaluated over time and in terms of reduced quality healthcare. But for many, a reduction in quality means an increase in pain and suffering, and premature death.

Here’s the rub: Consolidation of banking, health data, healthcare services, and such, exposes new flaws and failures. When this happens, Congress and the regulators step in to further consolidate the failed consolidation. Seldom, if ever, will decentralization result. Too bad. For us.

Some patients, like me, still do hire their doctors. I hired a St. Paul internist to provide my primary care. Mr doctor does not accept insurance or government health plan reimbursements. He is in a Direct Pay Independent Practice model. His electronic health record serves my needs, not the needs of mega-health providers or government agencies. Did I mention that on December 24, 2012, he saved my life?

Should you trust a politican that lies about your health insurance?

Gov. Mark Dayton, through his Commerce Commissioner Michael Rothman, mislead the public about health insurance rate increases. Rothman stated on October 1, to a room packed with reporters – and me – that insurance premiums were going up 4.5% at MNsure this year. He said that Minnesota still would have the lowest rates in the nation. Rothman, by the way, refused to even discuss the bulk of health insurance sales in our state, those that occur outside of MNsure.

Gov. Dayton has since repeated Rothman’s claim about the 4.5% increase. Everyday Minnesotans clearly recognize Dayton is repeating Rothman’s spin (lie sounds so crude). Does this matter in the larger scheme of life? If a governor misleads you on so critical an issue as this, what does it say about his other claims?

The 4.5% is the average increase among insurance carriers that will sell products on MNsure this year to Twin Cities’ residents. These five companies – HealthPartners, Medica, BlueCross-BlueShield, UCare, and Blue Plus – will offer insurance in the Twin Cities. However, in other areas of the state, only one or two plans will be offered – UCare is sold in only a few areas of the state..

Since UCare dropped its prices by 9% in the Twin Cities, Rothman saw this as proof that prices only went up 4.5% ignoring the fact that UCare sold less than 600 policies on MNsure in 2014, while BlueCross-BlueShield sold more like 10,000, and their rates went up 17%. Everyone else went up by double digits, too.

The average rates in areas other than the Twin Cities also spiked upwards by double-digit amounts. But the 2,000 Pound Gorilla is the specific issue Rothman ignored, even though I called him on it.

At the end of the October 1 press conference, I asked Rothman to comment on insurance sold outside of MNsure (MNsure, in reality, only sells a small percentage of individual and small group insurance plans). I wanted him to talk about PreferredOne, the company that wrote 60% of new coverage at MNsure in 2014 – and refused to sell on MNsure during 2015.

Rothman would not comment about PreferredOne, and for good reason. A few days after the press conference, PreferredOne released its individual rates for 2015. Their average increase across the state? 63%!!!

What does all this mean, and does it even matter?

It means that the Affordable Care Act will punish families and individuals by forcing them to buy very expensive health insurance in 2015. Even if you use MNsure and receive a tax subsidy to pay your insurance premium, your rates will go up by double digits for 2015.

What does it say about Gov. Dayton when he refuses to tell the whole truth about health insurance rates? “Politics as usual,” the cynic would answer. “They all do it,” you might say.

Not acceptable, and I’ll tell you why. The spikes in insurance premium are driven by a very bad law – the Affordable Care Act (also called ObamaCare). In Minnesota, we should call it DaytonCare, because the yarns he’s telling about it are just as false as those told by Pres. Obama.

DaytonCare will cost you far more than you can afford. If you fall into a lower-income bracket and are auto-enrolled into Medicaid or Minnesota Care, you should be able to afford the monthly cost (zero to $50). Try to find a doctor on short notice, or at all – that’ll be your problem. According to The Wall Street Journal, only 23% of Minnesota physicians will accept Medicaid patients.

Now that you have a few facts, you have to decide. If you like DaytonCare and ObamaCare, vote for the man who wouldn’t give you a straight answer on this critical issue. Then hope you can afford health insurance going forward.

If you don’t like being lied to about such a critical issue, then vote for someone else. GOP candidate Jeff Johnson didn’t lie about this, and neither did Independence Party Candidate Hannah Nicollet.

Gov. Dayton’s Refusal to Sign Obama Waiver Hurts Tens of Thousands of Employess & their Families

(A comprehensive paper on this issue is available by clicking here.)

This Thanksgiving and Christmas could be one of the saddest ever for many Minnesotans. Instead of Christmas presents, families will be scrambling to find new health insurance to replace their employer-provided health insurance.

Pres. Obama knew in November of 2013 that this was going to happen in 2014. At that time, and again in March 2014, Obama told each state governor they could protect their residents from these record rate increases. They could sign the opt-out waiver and allow employers to choose to keep their current health plans, instead of the new expensive Affordable Care Act health plans.

Thirty-nine (39) state governors signed the waiver – even California Gov. Jerry Brown. Signing the waiver protected millions of Americans from losing their group health insurance due to unaffordable rate increases. Although it is hard to believe, Gov. Dayton did not join with these other 39 governors to protect Minnesotans from record premium increases.

Employers and employees across the state began writing to Dayton in early summer, asking him to sign the waiver. On September 8, Dayton wrote to employers, claiming that it was now too late for him to act. He said that “…75 percent of businesses in Minnesota’s small group market have already complied with the law.” His excuse is unacceptable. His logic is that 75 percent have already endured the pain, with historic premium increases for many. So now he is implying it would be unfair to allow the other 25 percent to escape the pain. These are the employees whose new insurance will renew between October and December, 2014. This represents as many as 150,000 Minnesotans – 72,000 employees plus their children and spouses.

Dayton’s excuse also fails to mention how many thousands of Minnesotans have already lost their group insurance because he refused to sign the waiver.

Conveniently, many of those who have already lost their group insurance have been encouraged to go to MNsure to enroll. By the middle of September, over 275,000 individuals – more than 83 percent – of MNsure’s total enrollees are covered under government health plans: Medicaid or MinnesotaCare. It is certain that thousands of them previously were covered by employers. These employees had been relying on private health insurance, but now are dependent on government health plans – Medicaid and MinnesotaCare. And adding thousands more to government health plans means all of us are now forced to pick up the additional cost of coverage, when employers had been willing to pay this cost in the past.

As a result of Dayton’s refusal to sign the waiver, employers across Minnesota now face insurance premium rate increases of 30-90 percent. Thousands of Minnesota employees and their dependents still face the nightmare of losing their group insurance, and this reality will hit them during the holiday season. And we face hundreds of millions of dollars in new cost to support these individuals who are now enrolling in MNsure’s government health plans.

None of this had to happen, if Gov. Dayton would have signed the waiver.

Zeke Emanuel Wants You To Die At 75

Greg Scandlen wrote the following “must read” piece. I’ve talked about Dr. Ezekial Emanuel in nearly every presentation I’ve done about health care reform, because he played a key role in writing the Affordable Care Act. His philosophy of using raw statistical science, devoid of any traditional moral judgment, can be seen throughout ObamaCare. This is a very important article for you to read, and I hope you do.–

Emanuel cannot stand to think that, someday,he might not be as fabulous as he is now.

By Greg Scandlen – September 23, 2014

When Ezekiel Emanuel popped onto the national stage during the Obamacare deliberations, some of us had serious misgivings.

We were familiar with his previous work, such as his “complete lives system” of allocating health resources. This would have prioritized adolescents and young adults in receiving health care and put infants and the elderly at the end of the line. Samuel Kerstein of the University of Maryland and Greg Bogner of New York University wrote a dispassionate critique of the proposal, concluding that it lacked an “adequate moral foundation” and failed to “provide meaningful guidance on a range of central issues.”

Many Obamacare critics worried such an allocation system would be used sooner or later to ration services within the program. It was not an unreasonable fear. Virtually all the writing of the legislation took place behind closed doors, and one of the priorities was to lower costs. House Speaker Nancy Pelosi’s statement that we won’t know what is in the law until after it was passed certainly didn’t help sooth these anxieties.

Now Zeke is back with a major article in The Atlantic, in which he provides a rationale for death at age 75. In his opinion, people older than 75 are annoying. They aren’t as productive as they used to be, don’t “contribute to work, society, the world.” They are more likely to be disabled, “a state that may not be worse than death but is nonetheless deprived.” Plus, they are a pain in the ass: “they set expectations, render judgments, impose their opinions, interfere, and are generally a looming presence for even adult children.”

Zeke is only 57, but I would say he already qualifies on most of those measurements. I can’t see that he contributes much to society and the world, and he certainly “renders judgments, imposes his opinions, and interferes” where he isn’t wanted. And I would guess he isn’t as productive as he once was. Why wait until he is 75 years old?

You’re Just a Statistic

Zeke admits there are exceptions to all of this. Why, he even once worked with an 80-year-old economist who was quite useful. And the article includes a pull quote (so you know it’s important) that states, “The average age at which Nobel Prize winning physicists make their discovery is 48.” This is supposed to show (I guess) that older people aren’t all that clever. In fact, it doesn’t support that idea at all. If the average (median?) age is 48, then half are making their discovery after 48, possibly well into their 60s, or even (gasp) their 70s.

That may be Zeke’s biggest flaw—he is arbitrary.

And that may be Zeke’s biggest flaw—he is arbitrary. There is nothing magical about the age of 75. Some people have rich lives long beyond that. Other people become senile well before. But like most Progressives, Zeke sees only cookie-cutter people. In his mind, we are all the same, just a pile of numbers and statistics.

He has no idea how offensive this is. He genuinely seems to think that once someone is stamped with the label “Disabled,” they are less than human. He says, “We [Americans] are growing old, and our older years are not of high quality.” What an idiotic statement. What is “high quality?” Is it okay with him if my life is not “high” quality but still “pretty good” quality? Is his standard of high quality the same as mine? Are there no younger people with “low-quality” lives?

But he is also naïve. He cites a study of aging, and says “[t]he results show that as people age, there is a progressive erosion of physical functioning.” Good grief. He needed a study to know that? Everyone has known that since the dawn of man.

The man is 87 and has slowed down, but he is happy. Only Zeke Emanuel would see this as a problem.

He writes of his 87-year old father, who had a heart attack about ten years ago. “Since then he has not been the same. Once the prototype of a hyperactive Emanuel, suddenly his walking, his talking, his humor got slower. Today he can swim, read the newspaper, needle his kids on the phone, and still live with my mother in their own house. But everything seems sluggish.” He also quotes his father as saying, “ I have slowed down tremendously. That is a fact. I no longer make rounds at the hospital or teach.” Zeke adds, “Despite this, he also said he was happy.”

The man is 87 and has slowed down, but he is happy. Only Zeke Emanuel would see this as a problem. Apparently, in Zeke’s mind the failure to be hyperactive is worthy of death.

Emanuel Thinks He Can Quantify Your Worth

As it happens, I agree with him about my own life. I, too, have advance directives instructing caregivers not to prolong it artificially. I don’t see much value in squeezing out every extra day, especially if I am in pain. I’m 67, my hearing is shot, and my vision is getting worse. I don’t normally talk about these things because no one wants to hear it and I’m not looking for sympathy.

On the other hand, since I retired, I’ve been able to read some of the great classics I never had time for when I was working. I give back to my church and my community. I do what I can to nurture my children and grandchildren and can encourage younger colleagues in their work. And I’m writing a book about the history of health reform. Is that so very bad? Is it likely to stop in eight years when I turn 75?

Now, Zeke also takes a moment to consider the spiritual side of things:

“I also think my view conjures up spiritual and existential reasons for people to scorn and reject it. Many of us have suppressed, actively or passively, thinking about God, heaven and hell, and whether we return to the worms. We are agnostics or atheists, or just don’t think about whether there is a God and why she should care at all about mere mortals. We also avoid constantly thinking about the purpose of our lives and the mark we will leave. Is making money, chasing the dream, all worth it? Indeed, most of us have found a way to live our lives comfortably without acknowledging, much less answering, these big questions on a regular basis. We have gotten into a productive routine that helps us ignore them. And I don’t purport to have the answers.”

Here, Zeke reveals his narcissism. He has certain attitudes, and assumes the rest of the world is the same. But that may underlie his desire to die at 75, as well. He can’t stand the thought that someday he will not be as wonderful as he thinks he has always been.

He’s right about that. Aging is the ultimate cure for narcissism. And that is something Zeke Emanuel cannot abide.

Click here to read more of Greg Sandlen’s work.

Health of American Law at Stake in ObamaCare Decision

 

Supporters and dissenters are anxiously awaiting a decision this week from the D.C. Circuit Court in Halbig v. Burwell, one of the cases challenging the IRS’s authority to offer subsidies through the federally-established ObamaCare exchanges. – See more here.

Halbig is about the plain language of a statute. When Congress wrote the Affordable Care Act, it created health insurance exchanges. To entice (bribe) people to sign up for health care, the ACA offers taxpayer subsidies to qualifying individuals to reduce their personal cost of insurance.
Congress, however, wrote very plain language about the subsidies. The law very specifically limits paying tax subsidies only on insurance bought through state-based exchanges. Oops.

Thirty-four states refused to set up exchanges. Several state exchanges have since malfunctioned, but that’s a different story.

Since 34 states refused to set up exchanges, the federal government rushed to put them together. They are called Federally Facilitated Marketplaces and are run by the federal government, not states. In a handful of cases, states operate part of the exchange while the feds do most of the heavy lifting.

Here’s the rub: The ACA does not authorize a single dime in premium tax subsidies to be paid on coverage bought on a federal exchange. Zip. Nada. Zilch.
In contradiction to this clear language, Obama’s team went ahead and paid it anyway. Hence, the lawsuit.

If the plaintiffs prevail in the upcoming district court decision, then those millions who have purchased subsidized coverage in federal exchanges will suddenly be stuck with huge, humongous insurance premiums. Oops. As bad as that would be for Obama and his team of social planners, there is a far worse potential outcome awaiting the rest of us.

If the court decides that Congress meant to include the federal exchanges, but just got the words wrong, then the subsidies would continue. This would be a huge loss for those of us who believe in the rule of law, and the constitution.

If a law only says what the president says it says, then the president can say whatever he wants about a law and that’s that. Forget the process of laws, or binding down leaders with laws (the Founding Fathers’ idea).

I’m counting no the federal district court to do the right thing, but keep in mind that Pres. Obama has packed the court with his own appointees. In any case, this lawsuit will end up at the Supreme Court. Let’s hope that the current “conservative majority” stays put long enough to decide it.

Trusting your health to the paymasters will be hazardous to your health

The federal government has taken to trumpeting its “success” enrolling individuals into health plans. Likewise, the state insurance exchanges that at least worked well enough to sign some folks up are bragging about their results.

MNsure, for instance, is proud of the 250,000 individuals who’ve enrolled into coverage through its website. These “insured” people might better be called “voters,” because they will fight like crazy to keep their entitlement in place going forward.

MNsure admits that at least 80 percent of its 250,000 enrollees get their health care paid directly by government programs – Medicaid (called Medical Assistance) and MinnesotaCare. MNsure seems less willing to talk about the 20 percent that purchased commercial insurance on the website – half of which receive taxpayer subsidies to pay their premiums.

Fully 90 percent of enrollees at MNsure will have part or all of their health care paid for by taxpayers – and that’s a lot of voters.

There are more enrollees waiting to be slid into MNsure’s system later this summer. Some 600,000 individuals who were already enrolled in government health plans prior to MNsure’s rollout will be moved into MNsure’s care and keeping very soon – if MNsure’s software can be brought up to speed. Eventually MNsure projects 880,000 Minnesotans will receive health care paid nearly entirely by taxpayers – plus tens of thousands more getting federal tax credits.
Progressives see MNsure’s “success” as proof of the value of the Affordable Care Act, and vindication of its goal of reducing the number of uninsured individuals. Progressives don’t talk about the short and long term effects of their taxpayer largesse.

A recent survey of physicians shows that nearly 54 percent will no longer accept Medicaid patients. Physicians lose money caring for these patients, and though they are motivated to do well for everyone, doing too much care without adequate compensation drives them out of business. Having a government health plan does not mean an individual will get the quality and quantity of health care they need, want, or desire.

Longer term, individuals should consider the day, coming sooner than later, when federal and state governments can no longer afford all the care that individuals want to consume. When, not if, governments began forcing physicians to take patients as a matter of licensure, and when, not if, governments begin to ration care to those on Medicaid and MinnesotaCare, the “voters” enrolled in those plans will be outraged – but at conservatives who refuse to spend the country more quickly into bankruptcy. Progressives, on the other hand, will have a field day scaring the “voters” enrolled in these health plans to steal away their votes.

“Give me liberty, or give me death,” once said American founder Patrick Henry. Being indentured to a government health plan that bankrupts America will lead to slavery and poverty, not liberty. It is a bad solution to what ails us.

Hobby Lobby decision does not block contraception

ObamaCare is a political solution to an economic issue. It is not a health care law. Proof of this is obvious in the reaction of elements on all sides of today’s Supreme Court decision in the Hobby Lobby case.

The court gives the owners at Hobby Lobby, and to others who are similarly inspired and informed, the right to opt out of a government mandate. In this case, Hobby Lobby does not want to use its money to pay for contraceptive devices that kill unborn children in the womb – abortifacients.

Women who want to use contraceptive devices and formulations can still get them. If they work for Hobby Lobby, they have to pay for them out of their own pocket. Contraceptives are inexpensive. Go buy them.

Contraceptives should not be covered by health insurance as preventive care anyway. Although they do prevent pregnancies most of the time, if they are used correctly – or in the case of abortifacients, kill the little one soon after conception – there is no sound reason why health insurance should pay for them. In fact, there is no sound reason why health insurance should pay for most preventive health care procedures – they should be paid out of pocket by people who choose to use them.

Health insurance ought to be about paying the high cost of treating the effects of illness or injuries – these are the incidents that cost so much. Preventive care is, by comparison, cheap and inexpensive.

The Affordable Care Act (aka ObamaCare) specifies, by the way, that all medical services classified as preventive must be certified by the Preventive Health Care Services Task Force. The law should have tied the hands of former Health and Human Services Secretary, Kathleen Sebelius. Like all things relative to the political law known as ObamaCare, however, Sebelius took her advice from an agency other than the one prescribed by law. She turned to the Institute of Medicine, and you will not find their name anyway in the language of the law.

Now we will spend the rest of the summer listening to one side talk about religious freedom – an critical issue in the Supreme Court’s decision in favor of Hobby Lobby. The other side will insist this is a war against women, and try to link GOP candidates to it. This is baloney, but it won’t stop the pro-abortion crowd from crowing it everywhere.

One reason we no longer can have a sane discussion about critical public policy issues is that they are all cast in the shadow of the accumulation of power – politically manipulated solely for the purpose of creating victims who will turn out to vote in the next election.

Our politics are sick, and producing laws like ObamaCare that will end up choking the life out of our Republic.

Now, let me repeat it: If you want contraceptives, and your MD says it’s okay, go to the pharmacy and buy them. No one will stop you.