1. Featured Article: The Affordable Care Act will not survive November 6, 2012

David Gibson, MD, Director, Clearway Health Solutions

Here are my observations for the balance of this year.
We are in the eye of a political hurricane as it relates to health care policy.
The flood gates will open (pardon my mixing metaphors) starting November 7.
The following is my prediction of what will happen on that date.

The following article chronicling a just released USA Today/Gallup poll demonstrates that ACA is in real political peril. Three-quarters of registered voters believe the law’s requirement that every American carry health insurance is unconstitutional, according to this new survey. Furthermore, a majority of voters -- those surveyed in battleground states and nationwide generally -- agreed in their dislike of the Affordable Care Act. Voters in battleground states are more likely to want it repealed, the poll showed.

I predict that ACA will not survive for any one or all of the following reasons: Read more . . .

1. The SCOTUS will hear the case and rule on the mandate before the election in October.

2. The states cannot sustain the increased Medicaid costs starting in 2014.

a. Medicaid enrollment will increases from 37.0 million to 50.1 million after ACA takes effect in less than two years.

b. As a result, 10.8 million people who were previously uninsured (CA’s uninsured rate is over 20%) will newly enroll in Medicaid.

c. Nowhere is this unrealistic financial burden more evident than here in CA. CA is failing to reduce payments and scope of benefits for Medi-Cal

i. The state has attempted to reduce the reimbursement to providers. It was overruled by the 9^th Circuit and appealed to the SCOTUS. The high court just returned the case to the Circuit.

ii. Governor Brown is now requesting a waiver from the feds to restrict the scope of coverage and increase beneficiary co-payments, which appears unlikely.

3. Finally, the political reality (which is more important to politicians than any of the above) will determine the outcome of the election in November (see below and attached).

This brings me to the point of this memo, the calm here in the eye of this political hurricane will soon end after the election. The implications will be profound starting on November 7 of this year. To summarize:

1. With the unconstitutional SCOTUS ruling, the repeal or the financial implosion of ACA, the collective question within the market will be what do we do now?

2. In reality, the answer is simple. There are only two options.

a. One is to implement single payer which is now and will be a political impossibility.

b. The other is to implement a market option which will be a defined contribution rather than the current prevailing defined benefit designed employee health benefit plan design. HSA and varients of HDHP options will become predominant in the private market.

3. For all government based health entitlement programs the implications will be just as if not more dramatic:

a. Medicaid will become a state based grant program. The feds have no option other than to cap their risk into the future.

b. Medicare will similarly become a minimal coverage program with the option of add on private based benefits.

c. Both of the above will fundamentally change the incentives within both of these programs.

i. For Medicaid the bureaucracy centric reward system which encourages program growth, insider crony contracting and ignoring fraud will cease to exist.

ii. For Medicare, the same market dynamics that will be unleashed within the private sector will effuse the program. CMS will lose its top-down decision making mandate and the market will drive the selection of winners and losers.

There, based on all of the above, I believe that the balance of this year will be the most consequential any of us will experience during our lifetimes. All we need to do is be ready to contribute to the coming health policy debate. Having a working market model for defined contribution will be the hottest area of interest in Washington, the state capitols and in every political subdivision across the country.

David J. Gibson, M.D. Director, Clearway Health Solutions
916.993.3162 v / 916.359.4267 f / davidjgibson@reflectivemedical.com

latimes.com/news/politics/la-pn-poll-most-voters-believe-individual-mandate-unconstitutional-20120227,0,145991.story
latimes.com | Poll: Most voters believe healthcare mandate is unconstitutional
By Kim Geiger | February 27, 2012 | Reporting from Washington

Nearly two years after President Obama signed his landmark healthcare package into law, three-quarters of registered voters believe the law’s requirement that every American carry health insurance is unconstitutional, according to a new survey. . .

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2. In the News: California will to become the first state where RNs make more than $100,000

Nursing pay already higher in California than anywhere else is rising fast.

Nurses flex their political muscle in Sacramento and across California

By Darrell Smith and Phillip Reese, Sacramento Bee

Rose Ann DeMoro is always ready for another fight.

And why not? During the past decade, the leader of the California Nurses Association has won so many of her battles.

Largely because of CNA efforts, California is poised to become the first state where registered nurses make an average salary above $100,000. Read more . . .

The union helped defeat gubernatorial candidate Meg Whitman in 2010 and has become a political force, throwing financial support behind candidates for offices ranging from Santa Rosa City Council to state attorney general.

And more recently, nurses flexed their muscles with a series of one-day walkouts in support of other hospital employees who are in tough contract negotiations.

"This is a significant career with responsibility for life and death," DeMoro said. Hospitals, she said, "are looking to make more money off the backs of nurses. That's not going to happen."

The health care industry bristles at CNA tactics, including last Tuesday's one-day nurse walkout at Kaiser Permanente hospitals alongside striking workers from the smaller National Union of Healthcare Workers. Hospital officials say the solidarity strikes put patients at risk.

"We don't see how taking 23,000 nurses out of hospitals and having them walk the picket line advances quality patient care," Jan Emerson-Shea, a vice president at the Sacramento-based California Hospital Association, said before a prior walkout in September.

"They're putting access to care at over 30 hospitals at risk. In this economy, when is enough enough?"

Much of the union's influence is due to a seeming contradiction: California has so many nurses, but not nearly enough.

About 240,000 registered nurses work in California, making it one of the most common professions among those with a college education. But Nevada is the only state with a lower rate of nurses per 1,000 residents, according to the federal Bureau of Labor Statistics.

Just to get to the national average, California would need to hire 80,000 nurses – 33 percent more than the state has now.

The shortage is expected to worsen, handing nurses more ability to dictate terms. Already struggling to meet demand, many higher education institutions that train nurses are losing funding. Meanwhile, baby boomers are getting older, requiring more health care services. . .

Nation's first staffing law

California's nurses have done plenty to increase demand and their own bargaining power.

In 1999, they persuaded the state Legislature to pass a first-in-the-nation law setting nurse-to-patient ratios: the maximum number of patients assigned to a licensed nurse at any one time.

The staffing ratios, implemented in 2004, range from one nurse for every patient in a trauma unit, to one nurse for every four patients in a specialty-care unit.

The ratios eased workloads while increasing the need for nurses, pushing wages higher, said medical labor expert Joanne Spetz, a professor at the Center for the Health Professions at the University of California, San Francisco.

"It's a huge cost for hospitals," Spetz said, estimating about one-sixth of a hospital's total budget goes toward compensation of registered nurses, licensed vocational nurses and nurses aides.

The win was a defining moment for the CNA, affirming its growing influence in the state Capitol.

"We waged a massive war that became a model for the nation," DeMoro said. "It raised nurses' economic standard, and they were able to care for the patient longer. It was a hard battle. We mobilized thousands of nurses and the public. We were relentless – relentless – through this."

In the years since, the CNA has remained one of the most active players in state politics.

It spent $750,000 lobbying the Legislature during the 2009-10 session. Over the past three years, its political action committee gave more than $2 million to candidates and campaigns statewide.

In the last decade, the union went from "a doormat … to being someone that legislators rarely challenge," said Sacramento political operative Steve Maviglio.

CNA's scathing portrayal of gubernatorial candidate Meg Whitman as "Queen Meg" in the 2010 election was among the more memorable images from the campaign, and the union is credited with helping elect Gov. Jerry Brown.

"You softened her up," Brown told a group of nurses at a conference a few months later, "so there was almost nothing for me to do."

Highest nursing pay in U.S.

For many CNA members, there's a more potent measure of the union's success: Nursing pay, already higher in California than anywhere else, is rising fast.

The average salary for a California registered nurse grew from $57,855 in 2001 to $88,714 in 2011, according to the state Employment Development Department. Adjusted for inflation, that represents a 21 percent pay hike, compared with an 8 percent pay bump for other California workers during that span.

At the current pace, the average salary for a California registered nurse will eclipse six figures in three years. . .

But ongoing negotiations between Sutter Health and Bay Area nurses show that hospitals are determined to trim costs. Sutter is seeking a series of reductions in health and retirement benefits.

The CNA is refusing to accept any of the rollbacks, countering that the health care industry is doing well. Hospitals, they say, want to maximize profits instead of giving employees a fair shake. . .

Nurses repeatedly note that their raises often pale next to the bumps received by their bosses.

The chief executive officer of Sacramento-based Sutter Health, for example, made about $4.8 million in 2010, up from $1.1 million in 2001, tax records show. Kaiser Permanente's CEO made about $7.7 million in compensation and benefits in 2010, according to tax filings.

"Nurses finally achieve middle class and the industry is trying to vilify them? That's a war they don't want to have with us," DeMoro said. "This is one of the most profitable industries. I have not an ounce of sympathy for these employers. None."

Before they organized, she said, "we saw nurses making less than grocery clerks – and clerks actually had pensions." . . .

Read the entire article in the Sacramento Bee . . . .
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You suppose that Rose Ann DeMoro could help doctors as they approach $100,000 from the other direction than nurses? Maybe she could help reduce our Medicaid load to 10 hours a day.

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3. International Medicine: Traveling on medical mission to Nepal.

Sonoma Medicine | INTERNATIONAL MEDICINE

To Whom Much is Given …

Liana Meffert

Some lessons you can learn by walking out your front door. For others, you may have to travel a bit farther. During the summer of 2011, I chose the latter path, traveling with my father, Dr. Stephen Meffert, on a medical mission to Nepal. When people ask me about the trip, I have a hard time doing it justice. The statements I manage sound flat and clichéd: “It was quite an experience,” “I learned a lot,” and, my personal favorite, “It was unlike anything I have ever done before.” Few people get the full story, and even then it seems as if they are peeking through a keyhole. Read more . . .

I think it is fitting to begin my story with a quote from Mark Twain’s Innocents Abroad: “Travel is fatal to prejudice, bigotry and narrow-mindedness.”

There are always things we take for granted in our chaotic lives: things that go unspoken during Thanksgiving prayers and evade the expanse of our wandering thoughts while we languish in traffic. Personally, I’ve always taken my ability to communicate effectively with others for granted. While in Nepal, I was impressed to discover how location-specific my social skills are. At breakfast one morning, I was frustrated to find that the waiter shook his head “no” to every food I tried to order. We went back and forth for a while. I would order alternative options and he would reply with a shake of his head. Finally, I conceded that there would be no breakfast that morning and said “Okay.” He wrote something down and retreated to the kitchen. Ten minutes later he produced all that I had ordered. I took note in an email home that day: “I think I've read that in some places to shake your head means ‘yes’ and to nod means ‘no.’ Perhaps, I have arrived at that ‘some place.’”

I noticed with dismay that much of the subtle United States body language in which I was so well versed was rendered meaningless in Nepal. In Nepal, if I turned around too fast in crowded areas, my face would end up in the chest of whoever stood waiting behind me. My movements became much more concise and constricted, the result of a subconscious effort to maintain what little bit of “personal bubble” I had left.

At Lumbini Hospital, I met a resident physician whom I affectionately referred to as Bee for fear of butchering the pronunciation of her name on my American tongue. She took an interest in me early in our visit, standing close as we observed surgeries and helping me cinch up the XXL scrubs that drooped around my ankles. Our friendship was encouraged by two key components: she could speak nearly fluent English, and we were within four years of age.

Bee was fundamental in my interpretations of Nepalese culture. When people raised their voices to excitedly, I leaned over and asked her, “Are they mad at each other?” No, they were not. And when my dad and I realized that the respected greeting in Nepal was a slight bow of the head accompanied by “Namaste,” we both questioned if it was appropriate for us to make this gesture as well. “They would like that,” Bee said. Mainly though, I relied on the ubiquity of a smile.

The bindi was another source of cultural curiosity. The stunning red dollop of pigment, sometimes in the form of a sticker, was placed on the forehead of men and women alike. Bee explained that it was originally intended to signify that a woman was married, but that men wore it (higher up on their forehead than women) after visiting temples or on special occasions. More recently, the bindi has become decorative wear for both adults and children. At first I was annoyed by the inconsistency of its use, but then I glanced at my hands, realizing I was wearing a ring on my left-hand ring finger. At 18 and happily unmarried, I recanted my argument.

When I reviewed photos after the trip, the increasing ease at which I approached people for photographs was evident. Initially, I was concerned that they would react angrily or that it would just be awkward. Usually it was, but seconds of blank stares was a small price to pay for the moments I captured, and a friendly smile often won the participants over later. I realized that when people look at photographs, they open themselves to a view composed entirely at the photographer’s discretion. The world they see is the photographer’s world. In my vision of Nepal, I saw people whose lives were much different from mine, certainly much harder than mine, and if I could convey a tiny sense of that, then I had succeeded in my portrayal. For other sensory details, though, I was at a loss. The smell of warm rains during monsoon season, the sounds of schoolchildren singing outside the hotel window--those stay with the heart of the traveler.

In an email home, my growing respect for the Nepalese was apparent: “There are no appointments for the patients, so any patient that is not seen that day will return the next in the hopes that they will finally be seen. There is so much to say. I guess I will conclude with an observation that impressed Dad and myself: the patients are put under local anesthesia as opposed to general. They lie perfectly still and wide-awake for what can sometimes be three or four hours (as we discovered in the afternoon). Dad and I watched the patients’ hands for signs of movement, perhaps a slight fidget, but to no avail. One time, a patient began talking; we surmised he was experiencing some pain. The nurse applied a topical numbing gel and they continued. There was another boy seen in clinic, maybe nine or ten years old. The boy was complacent throughout the appointment; even holding still while the doctor treated his eye with the laser. These people are desperate for help--and very tough.” . . .

A well-known quote has woven its way through generations of my family: “For those to whom much is given, much is expected.” I heard it driving to school as a child, and I am sure I will hear it again leaving for college this fall. Understanding what I have been given has empowered me with the ability to give back.

During my trip, I read Malcolm Gladwell’s Outliers. The book was a perfect supplement to what I witnessed every day and resounded whole-heartedly with the thoughts running through my head each time I stepped out into the streets. Why me? What right do I have to such a comfortable existence over all these other people? Recent estimates indicate that 1.7 billion people on this earth live without basic necessities. I will never be one of those 1.7 billion people.

Outliers confirmed that my chances of success exceed those of other people purely because of a series of predetermined factors: the nature of my heritage, my DNA, my ancestors, the extent of my parents’ education. Much of what I was “given” was the circumstance of my birth. What is “required” of me is nothing more and nothing less than to begin to bridge the gap between myself and the billions of people who did not grow up in a house full of books. To whom much is given, much is expected. Halfway around the world, I finally grasped the meaning of my great-grandmother’s words.

Ms. Meffert is a freshman at California Polytechnic State University.

Email: lmeffert@sonic.net

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4. Medicare: Ryan's Medicare Revolution

With little fanfare, the Wisconsin Republican congressman has persuaded presidential candidates and even some Democrats.

By FRED BARNES | OPINION | WSJ | March 1, 2012

Over the past year, an entitlement revolution has taken place on Capitol Hill. It has gotten relatively little attention from the media. Yet its implications for the budget deficit and the health care of senior citizens are enormous. Read more . . .

The revolution involves Medicare, the health-care program for the elderly and the single biggest cause of America's looming debt crisis. Reform of Medicare would be achieved by a policy known as "premium support." It would bring consumer choice and spending restraint to the beleaguered program.

You may not have heard of premium support. But thanks to the efforts of Paul Ryan, the Republican chairman of the House Budget Committee, it is now the leading alternative to current, fee-for-service Medicare. Indeed, it is the only credible alternative.

How would premium support work? Beginning in 2022, it would create a marketplace in which seniors have a fixed amount of money to buy health insurance. The amount of "support" would match the price of the insurance "premium." The poor would get additional support to offset out-of-pocket expenses. The better-off would get less. Payments would be "risk-adjusted" so the sick would be assured of full coverage.

Yes, it's a bit complicated. Insurers would compete for the business of seniors. There would be three options. One would be coverage at the support level. Another would offer less coverage at a lower price, with the difference rebated to the beneficiary. The third would provide broader coverage at a higher price, requiring the beneficiary to pay the amount above the support level.

That's the health-care part of premium support. The cost-saving part is simpler. Medicare in its current form is open-ended, its expenditures uncontrolled and unsustainable. With premium support, the cost of Medicare would be capped. Its payment would rise with the rate of inflation or GDP growth, or slightly above.

The salience of premium support doesn't depend on who wins the White House in November. It is bound to be a major part of budget negotiations. Without it, serious deficit reduction would be almost impossible. With it, a debt crisis like Europe faces today is avoidable.

True, Mr. Obama's health-care law has created an Independent Payment Advisory Board with the task of limiting Medicare spending, now rising at 6% a year, to the economic growth rate plus a half percentage point. Not only does the board lack the tools to achieve this, but even if it did, the cuts would drive away doctors by the thousands and force hospitals to close due to lack of funds.

How Mr. Ryan, a protégé of the late Republican reformer Jack Kemp, yanked premium support from obscurity is an amazing story. Discussed in policy circles for years, it was recommended by a bipartisan presidential commission in 1999. President Clinton ignored the advice, and President George W. Bush never embraced it.

It didn't get traction in Washington until last year, when Mr. Ryan drafted a budget for 2012 and included premium support. The Ryan budget passed the House before dying in the Democratic Senate, which refused to pass any budget.

But House passage alone was a milestone. When Mr. Ryan first proposed premium support in 2008, 14 House Republicans signed on as co-sponsors. But when his budget cleared the House in 2011—with Medicare reform its most controversial provision—only four of the 241 Republicans voted against it. Of the 87 GOP freshmen, only one voted no. In the Senate, all but five of the 47 Republicans declined to back Mr. Ryan's plan.

The story might have ended there. It's one thing for the congressional party to back premium support, another for the presidential wing to do so. Mr. Ryan personally talked to Rick Santorum, Mitt Romney and Newt Gingrich. He proved to be persuasive. (Mr. Gingrich retracted his charge that Mr. Ryan's plan was "right-wing social engineering.") Ron Paul hasn't taken a position on the policy.

The result? Premium support is now Republican orthodoxy. But absent a GOP landslide this fall, that's not sufficient to win congressional approval. Besides, entitlements are best enacted on a bipartisan basis. Otherwise, they may wind up like ObamaCare—unpopular, under legal challenge, and the target of endless partisan attacks. . .

John Gorman, a consultant who worked on health issues in the Clinton administration, says the "only thing that's going to save this program is structural reform." The Wyden-Ryan bill is "a reasonable compromise," he says, and "there's a lot of precedent for it." One is the Medicare prescription drug program, passed in 2003, under which commercial providers compete for the business of seniors. As a result, its cost to the taxpayers is 41% less than projected. Another is Medicare Advantage, selected by 20% of seniors. "The beneficiaries are happy," Mr. Gorman says.

Advocates of a single-payer health-care system are not happy. They like Medicare the way it is, a defined-benefit plan with no lid on costs and the government in full control. "Their vision of health care is the way Medicare is run today," says health-finance expert James Capretta. It points the way to a single-payer system.

Premium support doesn't. It is a defined-contribution plan, forcing insurers to be more efficient while making their product as attractive as possible. "It's the only way of saving Medicare without subjecting it to harsh rationing," Mr. Ryan says.

Mr. Ryan says the arrival of the large freshman class of House Republicans accelerated the drive for Medicare reform. But it's Mr. Ryan, 42, who deserves the bulk of the credit. He's the top Republican thinker on domestic issues. And he has a keen political sense. He's been on a roll since he took apart ObamaCare in front of Mr. Obama at the White House health-care summit in 2010.

Because of his tireless proselytizing, premium support has emerged as the most sensible way to reform Medicare.

Mr. Barnes is executive editor of the Weekly Standard and a commentator on Fox News Channel.

A version of this article appeared Mar. 1, 2012, on page A15 in some U.S. editions of The Wall Street Journal, with the headline: Ryan's Medicare Revolution

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Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5. Medical Gluttony: I can’t find the report. Can’t we just redo the untrasound?

A patient from the Ukraine came in stating he wanted three stones removed from his abdomen. He had been having some discomfort in his right upper abdomen. He had an ultrasound done in an office in Auburn. He had lost the report. When asked if he could acquire the report, he stated, “Can’t we just do the test again?” In his country, cost was never a deterrent or a reason not to do. Read more . . .

This was a very interesting patient. Despite the language barrier he was finally able to separate three abdominal pains. It turns out that in addition to his gall stones, he had gastro-esophageal reflux disease which only became apparent after he ran out to his car and brought back a roll of Roll Aids which he always had with him. He also had pain along the right side of his abdomen associated with diarrhea of some year’s duration.

Gall bladder surgery was not the first step in his diagnostic evaluation. If he had health insurance with his previous physician, he would have already had the gall bladder surgery. It was only because he now has a slight financial responsibility that he consented to liver and gall bladder tests before we would refer him to a surgeon.

It’s the co-payment that brings financial reality to all of health care and dramatically reduces health care costs.

Much of popular health care reform wants to eliminate any financial responsibility including co-payments. This would dramatically increase health care costs by 50 percent or more unless we had an entire army of health care cops policing every physician order for lab tests, x-rays and other procedures.

Unless we reverse Obama Care, we will be practicing in an Army regimented battle field environment. Much of Medicaid is already dependent on the doctor acting as a cop to prevent excessive care. Doctors cannot be both a patient advocate and policeman. In any other field that would be a conflict of interest.

Why are we marching to a regimented battle field in health care practice?

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Medical Gluttony thrives in Government and Health Insurance Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6. Myths: The Results of the major economic planks of the "progressive" platform?

Imagine a city where all the major economic planks of the statist or "progressive" platform have been enacted:

A "living wage" ordinance, far above the federal minimum wage, for all public employees and private contractors. A school system that spends significantly more per pupil than the national average. A powerful school employee union that militantly defends the exceptional pay, benefits and job security it has won for its members. Other government employee unions that do the same for their members. A tax system that aggressively redistributes income from businesses and the wealthy to the poor and to government bureaucracies.

Would this be a shining city on a hill, exciting the admiration of all? Read more . . . We don't have to guess, because there is such a city right here in our state: Detroit.

Detroit has been dubbed "the most liberal city in America" and each of these "progressive" policies is alive and well there. How have they worked out?

In 1950, Detroit was the wealthiest city in America on a per capita income basis. Today, the Census Bureau reports that it is the nation's 2nd poorest major city, just "edging out" Cleveland.

Could it be pure coincidence that the decline occurred over the same period in which union power, the city government bureaucracy, taxes and business regulations all multiplied? While correlation is not causation, it is striking that the decline in per capita income is exactly what classical economists predict would occur when wage controls are imposed and taxes are increased.

http://online.wsj.com/article/SB10001424052970204880404577225200495554604.html?mod=ITP_opinion_0
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The reality of the Socialists Myths: Poverty

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7. Overheard in the Medical Staff Lounge: Can Mitt Romney beat Barrack Obama?

Dr. Rosen: It looks like most political pundits are giving the Republican candidacy to Mitt Romney? Do we agree with that opinion and then the prevailing question is, can he beat Obama?

Dr. Edwards: I’m not sure the pundits are correct. Hopefully Americans will awaken to the fact that if Mitt Romney runs, he will lose after the first debate. Read more . . .

Dr. Ruth: You mean the entire political process for the past year will have been useless?

Dr. Edwards: Barrack Obama can just lead off in the first debate thanking Romney profusely for giving his plan a trial run in Massachusetts, calling it a rousing success story, and that he will be happy, should he lose, that the Obama health care plan will be in his good hands.

Dr. Ruth: What if Romney makes it successful because he’s had a change in heart?

Dr. Rosen: There is nothing that Romney has said in the past year that even alludes to a change of heart.

Dr. Milton: The Obama health plan is so massive and complicated that no one really understands it. Even Pelosi admitted before the vote, she didn’t think that anyone understood it and she herself was waiting until after passage to try to understand it.

Dr. Dave: Isn’t that a pristine example of lawmakers having gone amok? Political agenda is more important than debate and substance?

Dr. Edwards: What if you found out after debates, there was no substance to the agenda, wouldn’t that change your vote?

Dr. Rosen: Not if you’re an avowed Socialist. Facts wouldn’t matter.

Dr. Edwards: Obama will be around chirping from the sidelines about any bumps in the road that no one would feel if he were still in charge.

Dr. Rosen: So the answer to our initial question is: No, Romney cannot beat Obama.

Dr. Paul: You got that right.

Dr. Edwards: The only bright spot may be the resurgence of Rick Santorum. As voters think the issues through, a man of strong moral character, even if not in agreement to the socialists, may be the only candidate that can not only beat Obama, but set this country on a strong ethical course again and really lead the world in the twenty-first century.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8. Voices of Medicine: Dr. Robert Hertzka in the San Diego Physician—February 2011

Dr. Robert E. Hertzka, who has a long history of working in the area of healthcare access, including being the chair of San Diegans for Health Care Coverage for the past 11 years (California’s largest bipartisan coalition supporting increased healthcare access), has been closely following the process that led to the passage and now initial implementation of the Patient Protection and Affordable Care Act, or PPACA.

As a follow-up to his February 2011 interview with San Diego Physician, Dr. Hertzka sat down with us to discuss PPACA — the following is the transcript of that discussion. The opinions expressed by Dr. Hertzka do not represent the opinions of the San Diego County Medical Society or of the California Medical Association. We invite physicians to participate in this discussion by submitting their comments to Editor@SDCMS.org for possible publication in a future issue of San Diego Physician.

San Diego Physician (SDP): When we last talked a year ago about the Patient Protection and Affordable Care Act (PPACA), it seemed clear that like any comprehensive piece of legislation, there were provisions that seemed positive and provisions that raised some concerns. What we want to do today is revisit some of those issues and concerns and see how we are doing.

We want to first focus on the two major provisions of PPACA, i.e., the expansion of Medicaid and the creation of health insurance exchanges (HIEs), each of which is projected to cover approximately 16 million previously uninsured people. While they will not roll out until Jan. 1, 2014, they do represent — by far — the most consequential parts of the bill. Any indication of how they are turning out?

Robert E. Hertzka, MD: Let’s start first with the Medicaid expansion. As you probably recall, it provides eligibility to all adults — children are already covered — at or below 138% of the federal poverty line (FPL), which is currently about $11,000 for an individual and $22,000 for a family of four. Most people do not realize that childless adults in most states have no Medicaid eligibility even if they earn $0, so we’re talking quite literally about coverage for 16 million of the most impoverished adults in the nation.

But demographics aside, so far there are at least four major, well-documented problems with the Medicaid expansion, and all four of these problems are unfortunately getting worse, not better, as 2014 approaches: Read more . . .

1. The number of new Medicaid enrollees that will arise from PPACA appears to have been significantly underestimated. I say this with confidence based on the experience of several states, most notably Colorado, which decided to ramp up early for PPACA’s implementation by expanding eligibility in 2010 to childless adults at or below 100% FPL. Well intentioned, but after just a few months, they had to pull the plug on their program because it turned out that the number of people eligible for coverage was nearly three times as high and the cost of insuring them was almost nine times as high as what had been predicted.

And it turns out that they are not alone. A similar program in Wisconsin designed to enroll 22,000 people in its first year had 137,000 sign up in the first four months. And earlier pre-PPACA Medicaid expansion efforts in both Indiana and Oregon also turned out to have far more people eligible than expected.

This should really come as no surprise. Tens of millions of people in this country work at any number of jobs that pay them cash, and many of them do not bother to file tax returns. But with programs such as the ones in Colorado and Wisconsin, and as of 2014 in the entire country, everyone who submits a tax return listing — in the case of PPACA — $14,500 or less in income gets a free Medicaid card. The party line from PPACA proponents is that we will “only” see about 16 million new adult Medicaid patients. I think not. Try 30 million, maybe more, with at least 3 million of them right here in California.

2. The abysmal payment rates for physicians, particularly in California. While PPACA provides enhanced primary care reimbursement in 2014, after one year all physician payment rates revert to baseline levels, which in California have just been reduced an additional 10% from what were already ridiculously low levels. And by the way, to add insult to injury, those 10% rate reductions in California were, in the end, actually supported by the Obama administration. Looking to 2015 and beyond, the national outlook for physician payment in Medicaid is that it is unlikely to get any better and will probably even get worse.

3. The abysmal access to physicians, particularly specialists, due in large part again to those abysmal payment rates. Last June, The New England Journal of Medicine published a survey of access to specialty care in Chicago for children with Medicaid and found it to be dismal, yet Medicaid access in pediatrics is actually much better than for adults. Looking to 2015 and beyond, the outlook for physician access for Medicaid patients is that it will definitely get worse, and with the specter of ever-decreasing reimbursement levels, no one seems to have much of a clue about how to provide meaningful access to these new adult patients.

4. The culmination of 1–3, which looks to be that these tens of millions of new Medicaid patients will cause a massive flooding of our emergency rooms, which will actually end up driving up the wait times for services for all patients. We already know from every single study of emergency room usage in recent years that there is a disproportionate use of emergency rooms by Medicaid patients, far in excess of the utilization rates of the uninsured. How big an impact will this have post-PPACA? Well, one analysis by a former Congressional Budget Office director using RAND data concluded that PPACA’s Medicaid expansion would result in 13 million additional ER visits per year at a total annual cost of $7 billion. Another analysis from the National Center for Policy Analysis, a libertarian think tank, went one better, concluding that PPACA’s Medicaid expansion would result in 40 million additional ER visits per year.

In California, where we are always teetering on the edge of an on-call emergency room crisis, this may well put us over; look for massive increases in costs for on-call stipends and strains on Emergency Associates (EA) program funds, assuming that all of our ERs even survive. And mind you, on a national level, we will be implementing a law that seems guaranteed to spike emergency visits — for many years if not forever — in an environment that has seen 27% of the nation’s emergency rooms close during the past 20 years.

SDP: You are not painting a pretty picture.

Dr. Hertzka: There is nothing pretty about this. In fact, to many people, this massive Medicaid expansion, with only token efforts at providing new dollars or any increase in physician access, is enough reason to support repeal of the entire law, no matter how well the rest of it may work.

SDP: Well, how about the rest of the law? How about the state-based Health Insurance Exchanges (HIEs) and the whole effort to expand private coverage? Still a good idea?

Dr. Hertzka: HIEs are still a great idea. Letting small employers and individuals coalesce into a large purchasing pool and having health insurers offer them products is a fine concept; it certainly works well for 8 million federal employees. And providing subsidies to help lower-income workers buy insurance is very popular, and was a cornerstone of the health reform plan developed at CMA when I was its president.

But as 2014 looms, there is an amazing amount of confusion out there; no one really knows how PPACA’s HIEs will turn out. There has probably never been anything this big done by the federal government with so much uncertainty.

SDP: What are some of the issues?

Dr. Hertzka: First of all, even more dramatically than with the Medicaid expansion, we really have no idea how many people will be getting their private health insurance through these new HIEs. The original administration estimate was that it would be 19 million, while the nonpartisan Medicare Actuary originally projected 32 million. But on closer inspection, it now appears that both employers — and in some cases employees — will have substantial financial incentives to drop their existing health insurance arrangements in lieu of their state HIE. More recent surveys from management consultants such as McKinsey, Lockton and others suggest that as many as 55 or 60 million people will seek to utilize the HIEs, a number bigger than either Medicare or Medicaid, and all signed up virtually overnight in late 2013.

This is not only a potential administrative nightmare, but it could also be very costly. If 50 million rather than 20 million people use the exchanges for their private coverage, the additional subsidies required by PPACA could add more than $1 trillion to the cost of the bill by 2019.

SDP: Sounds daunting. Are the states ready for this?

Dr. Hertzka: That would be nice. But it turns out that for a variety of political and policy reasons, many states have not even started setting up an HIE. The Obama administration may need to step in at the last minute in mid-2013 and set up an exchange in as many as 32 states; and, to date, they have been silent on just how they plan to do this, even refusing to comment when asked in a recent high-profile Washington Post article on this subject.

And it gets worse. These exchanges need to be able to determine whether someone is eligible for Medicaid as opposed to a private plan, as well as the amount of subsidy that each person is qualified to receive. And health insurance companies have to design products to comply with the new requirements of either a state or federal government HIE, or both. All this requires sophisticated personnel and sophisticated IT, neither of which is what we tend to see with governmental health departments.

Finally, a key challenge that the federal government was supposed to solve for states was the determination of a standard “essential benefits” package so that there would not be major variance in benefits between states; imagine if Medicare benefits varied widely from state to state, making some states a magnet for seniors. But, for reasons that seem to be political, the administration kicked that decision down to the states, adding a huge burden to the 18 states that are actually trying to set up an HIE. In fact, the director of the new Oregon HIE said in a public hearing that when he learned that he was now responsible for establishing his state’s essential benefits package, he felt like he had just been handed a “live grenade.”

SDP: Why do you say that leaving the “essential benefits” decision to the states was political?

Dr. Hertzka: Not my words but that of award-winning columnist and author Robert Samuelson, who recently wrote in his Washington Post column that by making the “decision to delegate to states the final decision on defining essential health benefits,” Health and Human Services Secretary Kathleen Sebelius will have a “special place in the history of the 2012 campaign” for having done her best “to make the Affordable Care Act disappear as a political liability for the president.” What he meant was that any federal determination on benefits would have been controversial and would have left the administration, and the president, open to criticism. So kicking the decision down to the states, which to most observers is bad policy, is actually, again per Robert Samuelson, a political “masterstroke.”

SDP: You do not seem to have a lot of confidence that this administration can make PPACA work? Aren’t you being a little too cynical?

Dr. Hertzka: I don’t really think so. PPACA, particularly when it comes to something like having 50 state HIEs fully up and running in less than two years, is truly trying to design something that is just unprecedentedly huge from both a bureaucratic and a policy basis. What would give me confidence would be if the smaller and much simpler programs in PPACA were being implemented as projected. And there are in fact three much-praised and much less controversial programs to look at, all of which began in June of 2010: the high-risk pools, the small business tax credit, and the Early Retiree Reinsurance Program (ERRP).

SDP: How are those three smaller programs working out?

Dr. Hertzka: I believe that I mentioned the high-risk pools last year, projected to enroll 375,000 people by the end of 2010, and many more in 2011, but only 8,000 signed up by the end of 2010. Following some fairly massive additional premium subsidies, the program is up to 33,000 participants (6,000 in California), but has only spent 2% of its budget, despite offering what are now deeply discounted policies.

Same with the small business tax credit. Touted routinely by PPACA proponents, as in “don’t repeal PPACA because you will take away a major new small-business benefit,” it now turns out that in 2011 only 309,000 individuals claimed the credit (only 7% of the administration projection of 4.4 million).

The opposite, though, happened with the ERRP. Touted as a subsidy that would encourage employers who provide healthcare benefits to early retirees (ages 55–64), the $5 billion allocated is already all gone. No surprise, I suppose; the program was tailored to match existing union retiree benefit programs, which had no hesitation in accepting no-strings-attached federal dollars.

Let me put this in perspective with a little analogy. Say that you are a city government with a large parcel of land that you would like to see turned into a housing development with hundreds of homes, some schools, a park, etc. You ask a prospective developer to build you three 2,000-squarefoot sample homes, but what actually gets built are two 200-square-foot huts and a 6,000-square-foot mansion, and the mansion has no plumbing and no roof. Would you let that crew go ahead and build the rest of the development? Probably not, but that is what we are doing in PPACA by trusting the same governmental bureaucrats who misfired so badly on three simple programs to go out and create a massive HIE system that will almost overnight be responsible for providing health insurance to literally tens of millions of people.

SDP: How about California? Our state government seems 100% committed to making PPACA a success, including passing the first-in-the-nation Health Insurance Exchange bill 16 months ago. Certainly things will work out here, yes?

Dr. Hertzka: One would hope so, but I have my doubts. As I indicated earlier, with our worst-in-the-nation Medicaid reimbursements, we will probably be the state with one of the most problematic of the Medicaid expansions.

And on the HIE side, yes, we now have an HIE created by state law. It has a five-member board and staff, and, yes, they collectively have some experience with both public and private insurance, but it will be quite daunting over the next year and a half to set up all the required insurance options, including Medicaid options, for as many as 8 or 9 million people.

And our Legislature put some problematic caveats into our HIE. It will have unchecked power to allow insurers in or out of the HIE and to regulate their rates, which sounds good but can be dangerous. The experience in states where regulators can keep a tight hold on insurance premium rates is that in the end the insurers just squeeze the physicians and hospitals even more.

And mind you, with the Sebelius decision on essential benefits, we will likely be combining California’s generous health benefits (thanks to dozens of legislatively mandated benefits) with a politically appointed HIE board that will be capable of holding insurance rates artificially low. The only solution to that is to drive down physician and hospital payment levels even more, possibly to rates that will be near Medi-Cal levels.

Finally, and perhaps most problematic, our state HIE law forbids insurers from offering lower rates to people outside of the exchange, even though there is a strong consensus that the people in the exchange, many of whom will have been uninsured and/or have some preexisting medical problem, will be sicker than those outside the exchange. Many believe that this is unworkable, and it has led to a situation where none of the state’s major insurers are 100% committed to participating in our state HIE. In fact, the entire 50-state HIE process is looking so problematic that many commercial health plans are now setting up private HIEs outside of PPACA that will be directly competing with the fledgling government-backed HIEs.

SDP: Last year you suggested that PPACA “may end up being a brick that is just smothered with tasty frosting, but the American people are being told that it is cake.” How do you feel about that analogy today?

Dr. Hertzka: Last year I just suggested it, but now it seems to be the reality. Yes, there are more than a million otherwise uninsured kids ages 22–26 who are now on their parents’ policies, and we have banned rescissions and other abusive insurance company practices (which many states had already done). We have 33,000 people with preexisting conditions who now have good coverage, and a few dozen entities are splitting up $5 billion in “early retiree assistance” money. That’s the “tasty frosting.” But the core of PPACA, which is a combination of the Medicaid expansion and the pending HIEs, looks more and more like a brick to me every day. I am not looking forward to 2014.

SDP: What about the Supreme Court? They will be hearing arguments for and against PPACA in March and may rule it unconstitutional. Your thoughts?

Dr. Hertzka: I can recite the legal arguments on both sides of the issue, but deciphering the Supreme Court is not my expertise. Frankly, as problematic as PPACA is, having the Supreme Court uphold it means that we will have to fix it and get it right, whether that means significant amendments or, in the parlance of the day, “repeal and replace.”

If it is thrown out, that would probably be good short-term, but in the long run it might just empower those who do not want to see any meaningful healthcare reform. That is what happened after the Clinton health plan debacle of 1994: Health reform as an issue was largely buried for 14 years even as many of the problems in the system got worse.

SDP: But isn’t the individual mandate the key to holding the bill together?

Dr. Hertzka: Certainly in theory it is, and if the Supreme Court rules that part unconstitutional, it will probably be a fatal blow to the entire bill.

But you may remember from our discussion last year, the mandate in PPACA is so weak that it probably will not drive much behavior anyway. Since we spoke last year, and after a more detailed review from some of the medical students in my UCSD SOM health policy class, it now appears that only those earning between 133% and 250% FPL (roughly $14,500–$27,000) will even be at risk for the penalty, which in the first year would only be 1% of income ($145–$270). Compare that with what the cost of the policy will be, and the fact that a policy can be obtained as soon as any medical problem is identified, and it appears these penalties will probably have little effect.

SDP: How does PPACA’s polling look these days?

Dr. Hertzka: Private physicians, that is to say physicians who are actually aware of the cash-in, cash-out part of their practice environment, have been majority opposed all along, and that has shown in every survey taken. Physicians, particularly those who do any emergency work, know that the Medicaid expansion is a disaster-in-waiting. And given that the government has underfunded every physician access expansion for the past 50 years, there is scant optimism that PPACA will end up being good for physician practices.

SDP: How about the public? They were originally quite negative. How do they feel today now that all the “frosting,” as you put it, is out there?

Dr. Hertzka: “Frosting” notwithstanding, the public remains opposed to PPACA with amazing consistency. In the last 10 months there have been some 45 major national polls by Gallup, CBS, The New York Times, etc. When asked if PPACA was either a good thing or a bad thing, or something to be retained or repealed, all 45 polls said that it was a bad thing and/or needed to be repealed, and 40 of those 45 had at least a 10-point margin, and eight had a 20-point margin.

Frankly, this is amazing, given that the vast majority of people want to see more health insurance company regulation and embrace ideas like 26-year-olds on their parents’ policies. The public, most of whom are insured, certainly does not understand what Medicaid is, let alone the magnitude of the proposed expansion and the likelihood of increased emergency room wait times. And they certainly remain largely clueless about the HIEs. Yet even though the public really has only heard about the “frosting” and knows next to nothing about the “brick,” only about 38% favor PPACA, and they seem to do so mostly because they are partisan Democrats who seem to support the president unconditionally.

I would note that there is one exception to this polling trend, and that would be seniors, who have been and remain much more adamantly opposed, in the range of 70% opposed vs. 30% in favor. Seniors know that you cannot cut $530 billion out of Medicare without having some kind of negative impact on their care.

SDP: Let’s finish up with a little politics. 2012 is turning out to be quite the election year, and it appears that you were correct when you said that the presidential election may turn out to be a referendum on PPACA. But that said, won’t it be a problem for Republicans if they were to nominate someone like Mitt Romney, who promoted something very similar to PPACA when he was the governor of Massachusetts?

Dr. Hertzka: Actually not, but that will not stop his current primary competitors or President Obama in a general election from saying it. . .

SDP: Any last thoughts?

Dr. Hertzka: We have raised some important issues, but at the risk of piling on, I have to note that we have only scratched the surface . . .

SDP: What can any one individual physician do about what looms with PPACA?

Dr. Hertzka: The most important thing is to stay informed and to stay abreast of developments. . .

Finally, if you have ever thought about getting involved politically, 2012 would be a great time to start. If you are a Democrat, take the time to educate the legislators you know and support about how problematic PPACA is and how much it needs to be significantly adjusted. And if you are a Republican, you should look into supporting some out-of-state Senate candidates (no real Senate race in California in 2012), as well as a presidential candidate who understands healthcare and can win. Much is at stake in the 2012 elections, but perhaps nothing as much as the future of our healthcare system.

http://www.sdcms.org/article/patient-protection-and-affordable-care-act-interview

VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about

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9. Book Review: Pharmaceutical Warfare by Deborah Donlon, MD, Sonoma Medicine

Blood Feud: The Man Who Blew the Whistle on One of the Deadliest Prescription Drugs Ever

By Kathleen Sharp, 432 pages, Dutton (2011).

When the structure of erythropoietin was first isolated, the drug showed promise for treating and preventing anemia in chronically ill patients. Improved quality of life for those patients seemed certain to follow. According to journalist Kathleen Sharp, however, the pharmaceutical companies that marketed erythropoietin employed shady techniques to gain market share and profit, often at the expense of patient safety and well-being. Her nonfiction book Blood Feud focuses on two companies that marketed brand-name versions of erythropoietin: Johnson and Johnson (Procrit) and Amgen (Epogen). Read more . . .

We first meet Mark Duxbury, a novice sales rep hired to sell Procrit for Ortho, a division of Johnson and Johnson. His competition: a cadre of sales reps selling Epogen for Amgen. Early in their relationship, these companies sign an agreement to divide their target markets into dialysis and non-dialysis patients. Quickly, the race to reach sales targets leads to overt stealing of business between the two companies, and lawsuits follow. Adding intrigue to the story is the erythropoietin doping that sweeps the international cycling community, leading to untimely deaths and irreversible injuries.

Duxbury makes a compelling protagonist. He begins as an optimistic young salesman with an enthusiastic belief in Procrit, certain it will help patients live better lives. He is primed to steal Amgen’s business while his bosses plead ignorance to the practice. He experiences “gaslighting,” in which company ploys make him believe he is insane, and creepy guys peer in his home’s windows once he becomes a whistleblower. His health and personal relationships suffer. It’s easy to feel sympathy for the lonely salesman who spends untold hours on the road, earning millions for the company, yet can barely afford his mortgage and child support.

Even more compelling for a physician audience, however, are the themes brought to light by Sharp:

• Some drugs (such as Epogen and Procrit) are awarded FDA approval, and are promptly sold and administered to patients, even though the companies that produce them never complete the required safety studies. There is a lapse in FDA oversight, and patients are harmed.

• Sales reps are frequently offered access to patient charts to determine eligibility in studies, which violates HIPAA and patient confidentiality laws. The doctor and office staff are often too busy to perform the chart review function themselves.

• Pharmaceutical companies are not the only parties reaping financial gain from the sales of their drugs. Physicians, hospitals, and dialysis and oncology centers are sold drugs such as Procrit at a discount (or given a free “trial” supply) and then bill insurance and Medicare at full price. The Department of Justice provides insufficient oversight against this type of fraud.

• The marketing of a drug’s use for an off-label indication to physicians is illegal, yet common.

• Once a drug has FDA approval, it is fairly easy to get a higher dosage of the drug approved, despite lack of safety data to back up the dosage increase. These higher doses result in greater profits for pharmaceutical companies and may contribute to patient morbidity and mortality.

Sharp is an award-winning investigative journalist who has completed a health care fellowship. After reading her previous work, Duxbury approached her in 2004 and asked her write an article telling his story. After a time she agreed, and spent four years conducting over 100 interviews across the country. Of note, executives at Johnson and Johnson repeatedly declined to be interviewed for the book. Aside from some overly dramatic foreshadowing, Sharp is a good writer and presents her case well. . .

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The Book Review Section Is an Insider’s View of What Doctors are Reading about.

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10. Hippocrates & His Kin: Spending $100,000 Medicare Money last day of life.

Notable & Quotable | WSJ | FEBRUARY 16, 2012

Jarrett Skorup on Detroit, a model of progressive urban policy.

Imagine a city where all the major economic planks of the statist or "progressive" platform have been enacted:

A "living wage" ordinance, far above the federal minimum wage, for all public employees and private contractors, A school system that spends significantly more per pupil than the national average. A powerful school employee union that militantly defends the exceptional pay, benefits and job security it has won for its members. Other government employee unions that do the same for their members. A tax system that aggressively redistributes income from businesses and the wealthy to the poor and to government bureaucracies. Read more . . .

Would this be a shining city on a hill, exciting the admiration of all? We don't have to guess, because there is such a city right here in our state: Detroit.

Detroit has been dubbed "the most liberal city in America" and each of these "progressive" policies is alive and well there. How have they worked out?

In 1950, Detroit was the wealthiest city in America on a per capita income basis. Today, the Census Bureau reports that it is the nation's 2nd poorest major city, just "edging out" Cleveland.

The end result of socialistic policies. Will San Francisco be the next example?

Eighty-four-year –old spending taxpayer’s funds to his last day. –The Lutheran Laymen

Even in death, Harold O. Bunge, 84, of Monroe, Mich, made a strong witness to the Lord. Over the years he attended various LLL Conventions. As LHM Ambassador at Holy Ghost [Lutheran Church], Monroe, Harold re-enrolled in the new Ambassador program and made his LHM Sunday presentation on February 5. He entered the hospital the next day for heart valve replacement. Harold entered glory on February 7. . .

Wouldn’t it had been more glorious, if he had followed the example of Dr. Martin Luther, (who when he reached this stage in his life proclaimed: I have a desire to depart and be with my Lord, which is far better) than to spend what may have been $100,000 of Medicare Funds the last 24 hours of his life?

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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow

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11. Organizations Restoring Accountability in HealthCare, Government and Society:

• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports.

• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog.

• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government.

• To read the rest of this column, please go to www.medicaltuesday.net/org.asp.

• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels.

• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?.

• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education.

• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter.

• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis.

• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section.

• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions. We would also caution that should Mitt Romney ever run for National office again, he would be dangerous in the cause of freedom in health care. The WSJ paints him as being to the left of Barrack Hussein Obama. We would also advise Steve Forbes to disassociate himself from this institution.

• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

• CATO. The Cato Institute (www.cato.org) was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html.

• The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

• McLauren Institute MacLaurinCSF is a community of students, scholars, and thinkers working together to explore and understand the implications of the Christian faith for every field of study and every aspect of life.* Our Mission: MacLaurinCSF bridges church and university in the Twin Cities metropolitan area, bringing theological resources to the university and academic resources to the church. Our goal is to strengthen Christian intellectual life in this region by creating public space for leaders in the academy and church to address enduring human questions together. MacLaurinCSF is grounded in the Christian tradition as articulated in Scripture and summarized by the Apostles’ and Nicene creeds, and our conversations are open to all.

• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.

• Chapman University: Chapman University, founded in 1861, is one of the oldest, most prestigious private universities in California. Chapman's picturesque campus is located in the heart of Orange County – one of the nation's most exciting centers of arts, business, science and technology – and draws outstanding students from across the United States and around the world. Known for its blend of liberal arts and professional programs, Chapman University encompasses seven schools and colleges: The university's mission is to provide personalized education of distinction that leads to inquiring, ethical and productive lives as global citizens.

• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17^th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. Choose recent issues. The last ten years of Imprimis are archived.

* * * * *

Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

Words of Wisdom

"Wisdom is not a product of schooling but of the lifelong attempt to acquire it."

— Albert Einstein: was the father of modern physics

"The brain is like a muscle. When it is in use we feel very good. Understanding is joyous."

— Carl Sagan: was an American astronomer, astrophysicist, cosmologist and author

"In times of great stress or adversity, it's always best to keep busy, to plow your anger and your energy into something positive."

— Lee Iacocca: Businessman, author, former CEO of Chrysler Corporation

Some Recent Postings

In The Feb 28 Issue:

1. Featured Article: Rick Santorum and Secular Natural Law

2. In the News: A Church president responds to Obama’s restriction of religious liberty.

3. International Medicine: The Fight to stop the reform of the National Health Service

4. Medicare: Health Care's Coming Price Revolution

5. Medical Gluttony: Have a Clinic in several cities

6. Medical Myths: Politicians will fix the health care system.

7. Overheard in the Medical Staff Lounge: Musical Chairs Continue For Mitt and Newt

8. Voices of Medicine: Why Doctors Die Differently

9. The Bookshelf: The Story of a Family Who Would Never Give An Inch

10. Hippocrates & His Kin: The Cost of Dying

In Memoriam

Whitney Elizabeth Houston, pop singer, died on February 11th, aged 48

The Economist |from the print edition | Feb 18th 2012

THE year was 1985, the scene Whitney Houston’s second sellout concert in Carnegie Hall in New York. There were almost 3,000 in the audience, and from somewhere among them, as she launched into “I am Changing”, a voice rang out: “Sing it, Whitney honey! Sing us the truth!” Read more . . .

But what was the truth? Apparently it blazed before them, a huge, pure, beautiful voice from an impeccably poised young woman who had strode out in an evening gown, radiating self-confidence. She didn’t move much on stage: every ounce of power was reserved for filling the hall with spine-tingling ballads of longed-for love. Her fans could see that this was God-given, a gift hauled up from deep inside, as when the little girl in the New Hope gospel choir had closed her eyes tight and soloed “Guide me, O thou Great Jehovah” in church, and the Holy Spirit had rolled out over that congregation. Others, though, could see she was a product of careful packaging by Clive Davis of Arista Records, who had spotted her in a New York night club, signed her at 19 and then waited two years for the right string-lush ballads to come along; who had cut back the frizzy hair, lightened the make-up, changed the dress, and launched her on the world so perfect that by 1986 she was Billboard artist of the year, an instant sensation.

Like Cinderella, she said. And, like Cinderella, she claimed her ambitions were small. All she wanted was to go to the mall and find true love, like any other 21-year-old. But as a soul singer her heritage was already royal rather than rags: daughter of Cissy Houston of the Sweet Inspirations, cousin of Dionne Warwick, god-daughter of Aretha Franklin (“Auntie Ree”), all of whom she’d learned from when her braids still got in the way of the microphone. Hard-headed, she had chosen to build her career the way Mr Davis advised her: “Longevity, that’s what it’s all about.”

Besides, she enjoyed being a princess—possessor of multiple platinum discs, holder of six Grammys, earner of more money and seller of more records than any female star before her. . .

Read the entire obituary in The Economist – Subscription required . . .

On This Date in History – March 13

On this date in 1884, world standard time was established. We’ve only been able to look at our clocks and know exactly what time it is in Singapore, Moscow or Timbuktu since 1884 when an international conference on this date in Washington, D.C. established a world system of standard time, based on Greenwich Mean Time.

On this date in 1852, the first Uncle Sam Cartoon, the lanky Yankee in the star spangled outfit was born in the New York weekly called The Lantern. Uncle Sam is our favorite relative, and a figure of admiration or hate for most of the world. With variations to suit the times, Uncle Sam has been around ever since. We seem to be the only country whose national popular symbol is everybody’s relative.

After Leonard and Thelma Spinrad

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Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. We respect copyright as exemplified by George Helprin who is the author, most recently, of “Digital Barbarism,” just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

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Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, any single payer initiative, Social Security was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

We must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.

MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol X, No 23, Mar 13, 2012