We Can Have a Reformed Healthcare System – Do we want one?

FreshLook1

Health Reform 2.0

 

Beyond partisan divide lies pragmatic solutions.

(I have been engaged in a significant effort for the past year or so and not able to publish my work – that process has completed. My work on a reformed healthcare system has not abated, in fact there are others now adopting many of the concepts described here.  If you find these ideas valid, please refer to others. We can reform our healthcare system. We can do so much more easily if we do it from within.)

Introduction

How do we ever expect to gain an effective, efficient and affordable healthcare system when every discussion of healthcare becomes instantly divisive? Calling the recent health reform law the ACA or the Affordable Care Act alienates some on the right that feel this affords legitimacy to legislation that should not exist. Alternately, referring to the law as ObamaCare removes any hope of consideration of the ideas that follow by some on the left as the illegitimate ranting of greedy right-wing conservatives who are only out to exploit and hurt the poor.

In the end, it is clear that whether you call it the ACA, the Affordable Care Act or Obamacare, this law itself is neither fixing nor breaking our healthcare system. The issues the act does address are too many steps removed from the root causes of the problems to effectively fix anything. In fact, we work from the premise that we are trying to correct a system that is not, nor has it ever been, a “system.”

Why we still need more reform

There are numerous systemic flaws in what we call our healthcare system. Yet perhaps the biggest issue we have with achieving a goal of effective, efficient and affordable care for all Americans lies within ourselves. Benjamin Franklin advocated for a style of “compromise through tolerance.” We no longer value this form of solution. Today almost all of our debate is mired in an all-or-nothing outcome based approach. This “I win – you lose” desire is epitomized in the latest healthcare legislation and the ongoing and unproductive debate. Further, what we consumers actually expect from our healthcare system is so far from the reality of what it can deliver to be almost unbelievable in its naiveté.

The debate continues to rage with selected arguments used to support some positions with what appears to be a purposeful ignorance of other issues. Yes, parts of the law are working for the benefit of individuals. Yes, parts of the law are failing because the overall costs are rising. We have problems with the composition of networks, the beginning of restrictions on both access and extent of care and a realization that the cost projections, like Medicare and Medicaid in 1964, are woefully underestimated. The problem with both sides of the arguments for the laws success or failure is that nothing in the law was meant to address the systems fundamental problems. Rightly or wrongly, the law was written for the most part to gain control over, and drive profit out of, the healthcare system. And none of this is actually helping us get what we need or what we want.

A new approach is needed

It is now crystal clear that the methods, some would say madness, that we have promulgated over the past 225 years to define the mechanisms we needed in order to provide healthcare to Americans have worked both spectacularly, and miserably, depending on your perspective and measures. America’s healthcare system has become a collection of practices, methods, and mechanisms that neither integrate nor properly manage the efficient, effective and appropriate level of care that citizens need nor does it provide an appropriate method to deliver the care we want.

How we got to this point

It is thus compromise on the basis of tolerance for others’ opinions that lead us to good solutions . . . – Benjamin Franklin

During the same 225 years, our overall understanding of America and our expectations of services have materially shifted. We now expect significantly more from our country – and by extension, its governmental structures: federal, states and commonwealths – than we did at its founding. We no longer value the role of tolerance in compromise as we once did. This has led to a frozen governmental structure where we are trapped between two ideological extremes. Everything we now attempt to do becomes locked in an all or nothing outcome based approach. The latest healthcare legislation, and more recent proposals, can be seen as the culmination of this dysfunctional approach.

For a variety of historical reasons, all seemingly reasonable and appropriate at the time, we have adopted a series of changes, often in the form of rules and laws, to try to affect corrections to one part of this non-system or another. All of these approaches, in the parlance of medicine, have affected the symptoms of the disease but they have not cured the underlying fundamental problems.

We must identify and agree on the fundamental problems

In order to correctly define an effective, cost efficient, and appropriate healthcare system for all Americans, we must first address the fundamental issues, disconnects, and problems of our historical non-system. In order to begin to actually address the needed fundamental fixes – therefore deal with the disease not the symptoms – we need to first identify and agree on what the fundamental problems are.

We have many beliefs about healthcare, and its underlying core of modern medicine, that have caused us to establish a set of unrealistic and unobtainable expectations when it comes to the care we receive. Much of what we believe about healthcare and the practice of medicine is wrong. We have ingrained these myths into the basic discussion of care so tightly that what we say is often obviously disconnected from what we actually mean. We speak of single payer systems, and specific cures for diseases. We routinely confuse popular beliefs or historical methods with actual scientifically backed best practice. We misunderstand the true extent of medicines capabilities, effectiveness and the cost of their increasing side effects. We conflate our heath needs with our health wants and ascribe equal weight and priority to both. We have so disconnected ourselves as consumers of care that we do not truly understand the real effect of the care we receive. More often than not it is our body’s natural ability to heal that is the cause of our perceived benefit, not what modern medicine can reliably deliver.

We have such fundamental flaws in our care system that the simple process of seeking care is now statistically one of the most dangerous activities we can do in our lives. 264 people per 100,000 die each year as a result of seeking healthcare. The next deadliest activity is that of being a commercial fisherman – think Deadliest Catch – where only 200 per 100,000 who practice this line of work dies.

Clearly, America is caught in this crossroads. Since we are now trapped between two ideological positions. It is because it is so often that neither party can find ground for compromise due to intolerance that we often say, “The only thing that we tolerate today is intolerance!” The principal of tolerance was a key characteristic that made America the leader of the free world it became. Specifically in the pursuit of efficient, effective and affordable healthcare we will need to regain this principal.

The Plague of Myths

  • We believe we have a healthcare system
  • We believe that we already have, or are near to having, cures for everything
  • We believe what is good for us as individuals is good for the human species
  • When it comes to healthcare we think that what we want is the same as what we need
  • We either believe only government should have the role of providing care or we believe that government should have no role at all
  • We believe that America can afford it – whatever it is
  • We believe that Employer Sponsored Insurance has been a good thing
  • We believe Co-Pays and Deductibles have helped lower costs and reduce consumption, and
  • We also believe that American Healthcare costs too much.
  • We believe many, many other myths as well.

It is in the codification of these myths that we have defined a healthcare system that can never meet our expectations. In summary, this thing that we call a healthcare system is really a collection of self-predatory practices and methods that promulgate massive increases in costs, erosion of effective checks and balances, little accountability and responsibility, and exponential unintended consequences to patients, providers, facilitators and program sponsors. Luckily, we have discovered a solution!

There is a solution

The solution to our healthcare systemic conundrum will require quite a bit of work, much debate and a healthy dose of tolerance. In the end, we believe we can find a compromise that will yield a much simpler, stronger, efficient and affordable system for Americans to get the care they need in crisis and also the care they want by choice. It is in the assured concept of an effective safety net for all, integrated with American’s need for choice that holds the key. Both parts of the system simply cannot exist without full integration as they will become predatory and consuming of each other. They must exist in a manner that systemically provides certain controls, checks and balances. Price certainty, transparency, portability and effectiveness need to be codified as requirements of any solution. At the same time, effective allocation of appropriate regulation, oversight and responsibility at the federal, state and individual level also need to be integrated into any system. Any solution must provide an effective safety net for all the helpless while filtering out the clueless – who inadvertently significantly increase costs and utilization of scarce resources – and the fraudsters – who purposely defraud the system in order to inappropriately receive disproportionate and unnecessary gain while also consuming available resources from those who desperately need them. Finally, the solution shall at its safety net, basic care level, provide the same access, scope and treatment options for all regardless of income or means with no additional hidden costs, taxes, fees or shifting of costs from one side of the system to the other.

We Need a Bifurcated System

Life Care – Market

  • A solution that converts “Patients” from inactive recipients of ineffective health services, to active Participants in the selection, management, delivery and prevention of care.
  • Assures price certainty, cost transparency, and full care portability. Assures coverage regardless of pre-existing condition or disease state. Provides full cost disclosure for all parts of healthcare, no hidden reimbursement systems, no rebates and no self-propagating cycles that obscure full and true cost
  • Requires no Deductibles, no Co-Pays, no hidden fees – all costs easily defined, certain and accountable
  • Allows no government “Death Panels” instead provides a representative citizen group, appointed by the states, of participants, facilitators, providers and sponsors that are empaneled to determine what constitutes basic health needs, treatments and therapies and establishes effective payment rates for providers under basic LifeCare Plans
  • Assures appropriate, effective, and efficient delivery of basic health needs. Delivers the ability to seek the provider(s) of their choice – No Networks
  • Effectively balances care outcomes expectations to healthcare’s ability to deliver effective services. And, Improves Participant outcomes
  • Transforms employers from the provider of healthcare to facilitators of wellness and prevention.
  • Incentivize employers to provide stipends to employees to help afford basic health needs, LifeCare plans and effectively plan and save for Quality of Life Advantage services.

Life Care – Plans

  • All companies wanting to sell health insurance should be required to sell basic LifeCare plans
  • All LifeCare plans from all insurers should be identical in scope, breadth and extent of treatment.
  • Treatments should be to standard best practice protocols for the care that people need to survive, be productive and maintain viability – but doctors should not be bound to the published protocols, preserving their, and their patients, choice.
  • Reimbursements for services should be fixed, based on the best practice protocol. LifeCare plan services and Quality of Life care services can be mixed by providers adding choice to basic offerings.
  • All LifeCare plans can be purchased from any insurer in any state regardless of where people live
  • Premium pricing should be based on the initial age and sex of the plan purchaser, and should stay the same, subject to COLA, for the rest of their life as long as coverage is uninterrupted
  • All licensed providers in America should be eligible to accept reimbursements under any LifeCare plan – Eliminating the need for networks
  • An in-force LifeCare plan becomes the basis for any healthcare coverage through the LifeCare market.

LifeCare is where Americans will receive fair and equal basic services and treatments that are geared to keeping us alive and productive. There must be a structure that provides efficiency, wide breadth but manageable effective extent of care, transparency, transportability, simple access through one point of administration, coverage certainty, improved outcomes, full access and affordability. We should eliminate extraneous constructs like care networks, co-pays and deductibles. This side of the care continuum will be focused on delivering the care that people need. This is the core of a national health safety net.

Life Care – Safety Net

  • The basic LifeCare plan becomes the core of any safety net offering.
  • The state and federal governments should no longer contract, or pay directly, for services. When necessary the government should step in and provide premium payment support.
  • Permanently Disabled – should receive monthly subsidies to pay for their LifeCare policy as long as they maintain eligibility
  • People in need of temporary support – displaced workers, catastrophic event or other support should be provided through premium loans. Once assistance is no longer appropriate, the amount advanced should be converted to loans amortized over the remainder of productive life (as an example to age 68).
  • Participants keep their providers and continue with coverage unabated in their community with no stigma nor interruption of coordination of care

We need a safety net. To have an effective safety net, everyone needs to have it. It needs to be incorporated into our overall system. It needs to use the same infrastructure and be seamless when needed. It should be immediately available upon eligibility

Quality of Life Care – Market

·         Quality of Life Care begins where the LifeCare plan ends

·         While the LifeCare system is predicated on high volume, highly efficient, pre-fixed low cost routine treatment modalities with some free market effects to lower cost, Quality of Life providers should evolve to be more market driven in nature.

·         Quality of Life Care should be where individuals get the additional care and treatment they desire based on their own individual priorities, responsibilities and choice.

·         Participants can choose to pay for Quality of Life Care services at the time of service through any means acceptable to the provider(s).

·         Participants can pay via cash, through tax free Life Health & Wellness Savings Accounts or they can purchase Quality of Life Advantage plans from any qualified health care insurer, or all three!

 

Because we are human, we strive to want and obtain more. We need a system to provide for choice without preying on others to get it. In fact, we need to have those who exercise choice participate in order to help increase the economies of scale for those who do not want, or can’t afford, choice. Quality of Life Care is the place where patient choice holds sway and value drives margin for providers.

We need two markets but one infrastructure and we need to enable people so they can self-actualize in order to have choice. If not effectively integrated, these two systems would prey on each other the same way our current structures have preyed on each other over the past 70 years.

If properly integrated, these disparate systems become mutually supportive systems and give us the best model to both pay for care for the helpless, minimize the cost of the clueless and the fraudsters and provide choice and increased margin to satisfy people’s wants.

Life Health & Wellness Savings Accounts

  • Like existing HSAs these accounts form the basis for healthcare payments via either the LifeCare or Quality of Life Care markets.
  • Not mandatory – Highly encouraged through significant tax incentives for both the individual and employer
  • While there should be limits to annual deductibility there are no lifetime caps
  • Unused balances remaining after death can be passed tax-free to beneficiaries
  • Means-tested larger contributions should be eligible based on certain catastrophic illnesses
  • Plans should be required for state or federally funded LifeCare premium support loans or permanent disability premium support.
  • Employers should get a tax deduction (up to a maximum amount) for monthly stipend to employees regardless of how employees use the funds
  • Employees should loose tax deductions on amount of funds not spent for eligible healthcare services and should also be subject to a penalty for funds ineligibly spent

We have HSAs today and HSAs but they are not effective and they do not clearly enable our access to an effective healthcare system. We can have effective HSAs and we can enable access to Quality of life care as we age and we can do so at less cost to the system and the country than the current system does.

Single Point of Administration Full Coordination of Care & Benefits System

  • Repurpose the current healthcare exchange infrastructure
  • One universal point of administration to locate, research, apply for and coordinate all care services.
  • True Participant Centered System coordinating Facilitators, Providers and Sponsors with the Participant (patient in the old system) as the center point for all care coordination. Through a virtual care group infrastructure, Participants, or their designated facilitators, maintain full control of all their information regardless of location.
  • Providers will now be aware at point of application and eligibility for all potential benefits from, federal and state programs to philanthropies, charities, institutionally sponsored programs, etc. reducing double claims, doubled services and double costs.

Regardless of how the system is constructed or evolves, we need to integrate the disparate parts to gain economies and efficiencies to provide for the care needs of participants in the low-cost economic LifeCare Side while providing a value based choice market for services people want in the Quality of Life side. We also can go a long way to reducing costs through the elimination of duplicated services, duplicate payments, fraud and abuse currently over half of every healthcare dollar spent.

National LifeCare Congress NLCC

We need a national regulatory body as a key part of any construct. It needs to be fully representative, it needs to cover all economic strata, all disease states, and all specialties, in the four legs of the healthcare stool:

  • Participants – include representatives from a fully representative economic, ethnic, geographic and disease-state sub-groups,
  • Facilitators – representatives from various sub-groups; faith-based, social workers, case workers, family/friends, guardian-ships, parole/probation, volunteer and public service, etc.,
  • Providers – representatives from physicians/doctors, nurses, nurse practitioners, pharmacists, therapists, etc. and representative subspecialties within these groups and
  • Sponsors – Federal, State, Municipal, Philanthropies, Corporate, Insurers, etc.

Other Key Points

  • NLCC is designed as a bi-partisan national governing body appointed by the various states composed of representatives from the four key healthcare constituent groups; Participants, Facilitators, Providers and Sponsors.
  • Representatives have a 3 year term – initial terms staggered
  • When a rep’s term is up the position should be randomly assigned to another state to appoint that rep position.

Summary

We have only scratched the surface as to the features and benefits of these solutions.  We have not touched on specific bipartisan agreed upon goals, nor have we spoken of the integrated objectives that need to be crafted into any solution. These are available on the Health Reform 2.0 Website at http://healthreform2dot0.org under Principals, Goals & Objectives.  We have not discussed in-depth the impact of our own myths and misunderstandings about what is really deliverable in terms of the scope and extent of care from medicine today. We also have not had the space to discuss how the solution provides for a true “Participant Centered” approach which is also key to lowering costs, lowering excess utilization and improving outcomes. These and many other topics are discussed in the draft Whitepaper, Summary Sheets and Articles on the Health Reform 2.0 website.

We believe that the solutions we proposed will fit neatly into a comprehensive approach that Americans will be able to embrace. We do not expect everyone to like every solution proposed in the system but, we do believe in the end these solutions are designed fit closely together to solve for a marketplace that will provide Americans with an affordable, cost-effective, efficient, fair and appropriate market, and safety net, required to get the Life Care they need; while preserving the options for a choice based system to get the additional Quality of Life Care they want. We do not want this to be seen as “The Solution,” but as a series of solutions that are interconnected. These ideas are not inviolate and must surely change. To achieve the goal that we seek, will require a Franklin style compromise, either from a renewed interest in bipartisan, bicameral solutions in Washington DC or from the real power-base of America – the American People.

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Why Ebola petrifies us: One reason is healthcare’s unobtainable expectations.

Ebolacare givers practice safe procedures

Ebola caregivers practice safe procedures

Petrified & Angry

We are petrified of Ebola. It is a deadly disease, but we are much more scared of this today than we were of Polio, and Tuberculosis years ago. Why?

In the 1940s and 50s, modern medicine was a bit less advanced than we are today.  We had many more diseases to be afraid of.  Polio was an epidemic. Outcomes from Polio were not particularly good. Tuberculosis (TB) was a significant issue as well.  People with TB were quarantined.

Travel in that period was not as easy and ubiquitous as it is today yet, we routinely restricted affected people’s movements. In some cases we incarcerated them in sanitariums to protect the public at large. Despite these actions and the lack of effective treatment for these, and many other, diseases, people were no where near as panicked then as we see them today with the current Ebola crisis.

People who grew up in this era will tell you that most Americans accepted the dangers these microbes presented as a regular part of life. Sure, they were afraid of the diseases but they recognized that they had little control over potential infection. If they became infected they understood that HealthCare did not have cures. While there may have been many things to help ease the symptoms, odds were usually not very good that they would see their symptoms eliminated. Continue reading

Breast Cancer and Environmental Causes: Links not as clear as we’ve hoped.

The latest research is finding that real links between environmental causes, genetics and occurrence of Breast Cancer continue to be elusive. Perhaps, it’s for a reason. Are we thinking of cancer in the wrong way?

Published in Aquila Style (click to read original article)

Published in Aquila Style
(click to read original article)

October is National Breast Cancer Awareness Month.

The above graphic is from an interesting article titled, Suprises in Hunt for Environmental Links to Breast Cancer, published by , 6:30 pm Monday, 11th November 2013 on http://www.aquila-style.com. The article is about one of the latest studies trying to find a definitive link to breast cancers’ origins. Many studies have tried to find links to environmental and genetic causes. So far the research has not been definitive to say the least. We do know that genetic mutations are present in many cancers, but we also know that they are sometimes not there in some – where we expect them, and are there in many – where do not see the cancer develop.

“We have still got 80 percent that has got to be environmental,” said Reinlib, who is part of the Breast Cancer and the Environment Research Program (BCERP) program that has received some $70 million in funds from the US government since 2003.

The above quote from the article seems to indicate that there is clear evidence that the causes simply have to be environmental because we have ruled out that family history is the main indicator. Yet, this may be a false premise as well.  Just because a white jelly bean is not vanilla flavored, does not mean it must therefore be coconut flavored. It can be any flavor at all or have none! Most of the research into environmental, family history and genetic mutation indicators have shown relatively slight correlation to the actual development of breast cancers.  These indicators may statistically increase the chances a few percent but they do not provide definitive guidance that one will, or will not, get cancer.

Recently, some researchers are starting to discuss cancer, less as a disease — even though the outcome is devastating on the individuals and the family — but more of a naturally occurring process — perhaps necessary in the species. Perhaps this same process that sometimes evidences as cancer, is a natural part of the core engine that drives natural selection to improve the species. Changing how we think about and classify cancer may have more of an effect on how we learn to adapt to it than “cure it” as time goes on.

We have found many genetic markers in the past decade or so that we felt were the main drivers of disease, like the BRACA genes for breast cancer, only to find that they turned out to not be specific. BRACAs were considered a key indicator specifically for breast cancer but recently has been shown to exist for prostate — not much of a surprise as prostate and breast tissues are histologically very similar — lung and now many other cancers as well. BRACAs are more likely broad based cancer markers as time will likely tell.  Most genetic markers are likely relatively nonspecific. In fact, our genes may be good blueprints for building the body and its systems but may not be the control point for what happens with these things when they are built.

Further, genetic markers themselves have been know to not be definitive for the occurrence of a cancer. You can have the markers and not get the cancer, and you can sometimes have the cancer and not have the markers. Some other researchers now believe there is a different biochemical system at work. Undiscovered, this other system has been dubbed epi-genetic — meaning above the gene. Numerous studies over the past 15 years have indicated the presence of some other control point. Don’t forget that it took many decades for actual chemistry of DNA to be identified and proven; even though we understood the theory of its presence for many years.

It is likely in the years to come we will find more answers to these new questions and new theories will fundamentally change how we think of cancer and reset our expectations on its treatment and occurrence.

Please remember all those who have died due to this horrible disease!

Continue reading

Doctors NOT taking insurance may actually be a good thing for healthcare!

man_question_mark

Questioning Our Preconception of HealthCare

In an Aug. 23, 2014 Reuter’s article called, “‘I don’t take insurance’ not always a doctor deal breaker,” author Beth Pinker, explains how this typically plays out for a person seeking care.

As more and more people realize the extent of the funds they will need to spend before they gain access to insurance coverage — the average deductible is now $5000 — Physicians are waking up the fact that insurance and government reimbursements are too low for their “business” of medicine to survive. Recent numbers indicate that 40 to 50% — in some cases more — have already decided to opt out of insurance and move to so called concierge, i.e. retail, medicine.

The attraction for the physician is faster payment, and in most cases, a higher margin on the services performed. One of the big drivers is the total size of the pot of deductibles that will need to be spent for full insurance to kick in for the insured.

Some argue that the average deductible is not really $5000, that it is closer to $3000 per year. Still, with over 186 million insurance policies in the U.S. this lower estimate yields a total available market — called TAM by marketers —  of $500 billion that must be spent before insurance coverage kicks in. Any marketer will tell you, this Continue reading

When Mammograms Lie: An article by Sharon Kirkey published on Canada.Com

When Mammograms Lie: How cancer can sneak past our greatest screening techniques

Just because the results of your mammogram are negative, doesn’t mean you don’t have cancer

By Sharon Kirkey, Postmedia News May 23, 2014 (CLICK THE LINK TO READ THE ARTICLE)

“Four months after her mammogram came back “normal,” Susan Quinn-Mullins discovered the lump herself, a smooth, hard mass on her left breast the size of a big marble. An ultrasound revealed a tumour nestled deep in dense breast tissue. It was stage 3 — aggressive, invasive breast cancer that was spreading to the surrounding lymph nodes…”

Breast Density Types

Breast Density Types

This interesting article not only chronicles the story of people who initially relied on mammography to check the health of their breasts but also serves as an incitement over the undue reliance on this as the sole modality. It also brings in some contra posing views on the debate over dense breast notification laws.

Breast Cancer is the number two killer of women in America, lung cancer is number one at the moment. The issue of dense breast related problems in imaging has been long known but for the most part hidden. It is a sordid tale Continue reading

Article 4 – The Plague of Myths – Myth 3: We Can, and We Should, Live Forever!

We don't really have a healthcare system and its killing any reform.

We don’t really have a healthcare system and its killing any reform.

This is the fourth of a series of articles that are being published over the coming days and weeks. The series of articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”

List of Articles:

  1. Introduction to Healthcare reform: What’s next
  2. Article 1 – Introduction to the Real HealthCare System
  3. Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much
  4. Article 3 – The Plague of Myths: Myth 2 Healthcare, It’s Good for What Ails You!

We all want to live longer

It is clearly an historical ideal to live longer. We all, for the most part, desire not to die anytime soon. I am sure that for most of us it is a completely natural instinct to continue to live. We often find it morally abhorrent to want to die prematurely – like from suicide. It would be completely counter intuitive from what we know about the survival instinct, and the laws of natural selection to decide to become premature feedstock for the organisms that prey on us. Our individual desire to survive is primitive and persistent for most of our lives. And it is safe to say we have been built this way! Continue reading

Article 3 – The Plague of Myths – Myth 2: Healthcare, It’s Good for What Ails You!

We don't really have a healthcare system and its killing any reform.

We don’t really have a healthcare system and its killing any reform.

“This is the third of a series of articles that will be published over the coming days and weeks. The series of articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”

List of Articles:

  1. Introduction to Healthcare reform: What’s next
  2. Article 1 – Introduction to the Real HealthCare System
  3. Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much
  4. Article 3 – The Plague of Myths: Myth 2 Healthcare, It’s Good for What Ails You!
  5. Article 4 – The Plague of Myths: Myth 3 We Can, and We Should, Live Forever!

Do our expectations of Healthcare match reality?

We have a large number of myths that govern our beliefs about our current Healthcare system – or non-system to be more accurate.  One of the larger set of myths that drive our perceptions of both the positives and negatives of our healthcare system are our beliefs and expectations as to what we should get from healthcare and the underlying medicine.  We believe, that modern medicine has cures for almost anything we face.  We believe that the continual research and discovery that has occupied much of the past 164 years has led to a firm and almost complete understanding of the science of disease, injury, and treatment.  We believe that there is little difference in cost between the things we need for survival and the things that we want to improve our lives.  We believe that the current methods of treatment and the discoveries we have made over the past 80 years are making us a stronger more robust species.  We believe that the doctor is typically the best and most qualified person to deliver the care we need. And we believe that in most cases going to the doctor is safe and leads to improvements in our health. These are just a few of the myths and misconceptions we have about the current state of medicine and what we should expect from our healthcare system. Continue reading

4 Straight Years of Slowing Health Care Costs: Really?

man_question_mark

U.S. Marks 4 Straight Years of Slowing Health Costs(click to read the article) so blasts the headline from ABC News today, January 7, 2013. Like so much of the debate over Healthcare reform, many that read the article will walk away believing that things relating to healthcare costs are really improving—along with the economy. After all the article proudly says that the percentage that healthcare costs make upon of the Gross Domestic Product (GDP) has declined for the fourth straight year. This must be a good thing—one would think! But, like so much of the reporting Continue reading

Value Based Insurance: it sounds so – “valuable”

Value based insurance, sounds so - valuable!

Value based insurance, sounds so – valuable!

Value Base Insurance Coverage, it sounds so — valuable. But is it really valuable? Is Value Based Insurance Coverage (VBIC) what you really want — what you may need? Well, perhaps, that simply remains to be seen. As we move through the implementation of the Affordable Care Act, ObamaCare, VBIC will become the next big thing we need to pay close attention to. You can be sure that soon this item will be getting quite a bit of ink as the potential ramifications become apparent.

Like so many things in life, the reality of this “value” based system may be fraught with unintended consequences for the individual and massive values and benefits for Continue reading

The ACA Exchange Poster Child – Covered California: Works for some, not for others

CoveredCaCalifornia, has long had the reputation as being one of the most progressive, or liberal, states in the nation. Often in a neck and neck battle with New York over who gives more free-stuff to its people at any given time, California long ago adopted the philosophy that what is good for some should also be good for all. The concept of income redistribution though higher taxes is not a new one for California residents.  Yet this state, nicknamed “the Golden State,” and home to Hollywood, Biotech, Oil and Silicon Valley fortunes often confounds because there are also strong anti-tax forces that from time to time rise up and limits California’s spending power through measures like Proposition 13. Continue reading

Obamacare Insurance Cancellation: Welcome to the #ObamaNation

Welcome to the ObamaNation where we know better than you!

Welcome to the ObamaNation where we know better than you!

The cancellation letters people are now receiving for their earlier choice based plans– you know the ones that President Obama said they could keep, PERIOD–out of courtesy and perfect declaration should open with this line,

“Welcome to the #ObamaNation where we know better than you!”

Those of us who have warned of these effects under the law, and a number of other predictable negative outcomes that are only beginning to show up, have been called fear mongers, and haters. The shouted counter argument becomes a diatribe of how this law is going to be so great. How it will provide insurance for so much less cost. How it will lower the cost to the nation and the individuals. How you will get whatever you want and have to pay almost nothing for it! Continue reading

ObamaCare becomes DemoCare: Demolishes Middle Class!

DemoCare demolishes  America's Middle Class

DemoCare demolishes America’s Middle Class

The Affordable Care Act is often called ObamaCare but I think from now on it should be called “DemoCare” because it’s going to demolish care in America and along with that demolish America’s Middle Class.

There are quite a lot of things about the way this law works that make it undesirable.  Mostly, the causes are not in the debate that we hear so much about nor are they in the parade of facts that we are about to be inundated with over the next 90 days from those selling the benefits or arguing against them.  Like most debates the truth in the rhetoric is somewhere between the extremes. Continue reading

Dan Brown’s Inferno: A Coming Global Crisis?

Light summer reading

    Population Graph from "Inferno" by Dan Brown

Population Graph from “Inferno” by Dan Brown

In his latest book, Inferno, author Dan Brown explores a world where past symbols and artifacts from Dante Alighieri’s Italy, and his famous work The Divine Comedy, become the vehicle to unravel a diabolical and deadly plot of a modern day bio-terrorist. I originally grabbed this book because we were coming to the close of summer and I just finished working on a series of articles about the current issues of our healthcare system that will be appearing later this fall. Frankly, I was looking for a diversion from the complicated world of healthcare reform and Obamacare. I wanted a respite, a brief mindless romp in Dan Brown’s always entertaining world. Having read much of his prior work, I was confident that Mr. Brown would not let me down.

I found this work characteristically suspenseful, interesting, thought provoking and fun to read till I got to the following section which, in the story, lays the groundwork for the epic conflict between the antagonist, Bertrand Zobrist , a world renowned biochemist and leading geneticist and the protagonist, Elizabeth Sinskey, M.D. Continue reading

President Trumpets Obamacare Rebates as Deadline Approaches: Beware of Greeks Bearing Gifts!

President Trumpets Obamacare Rebates as Deadline Approaches - Time Swampland

President Trumpets Obamacare Rebates as Deadline Approaches – Time Swampland

Nought from the Greeks towards me hath sped well. So now I find that ancient proverb true, Foes’ gifts are no gifts: profit bring they none.” So observed the great philosopher and teacher Sophocles about 430 BCE.  Today we loosely translate this as, “Beware of Greeks bearing gifts!

No quote could be more apropos in regard to the supposed $500 million in insurance rebates being sent to 8 million Americans under #Obamacare. Like most ponzi schemes, at first blush this appears to be a great deal for America and Americans. Continue reading

Tax Code Driving ObamaCare Implementation: California’s ACA Odyssey Preview

Click to access the Original Article by John Gonzales

John M. Gonzales reporting for the California Healthcare Foundation Center for Health Reporting wrote a must read article called, How the U.S. tax code will drive Obamacare implementation, starting April 15. I strongly suggest all read it.

The negative effects of Obamacare on costs and care were immediate, and the ongoing negative effects are just starting to be disclosed and to build. Yesterday, I participated at a Health Care Summit put on by Continue reading

Steve Brills Article, “Why Medical Bills are Killing Us:” is a lesson of right and wrong at the same time!

Steve Brill's Time Cover Story (Click to read)

Steve Brill’s Time Cover Story (Click to read)

Time Magazine contributor Steven Brill has created a bit of a sensation due to his recent, February 20, 2013, article and Time Magazine cover story entitled, Bitter Pill: Why Medical Bills Are Killing Us: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/#ixzz2LkTuy5lv.  Mr. Brill caused controversy both due to the length of the article, 26,000 words, and his revelations about the high prices and seemingly arbitrary pricing methods in our so called healthcare system.  His article has prompted a number of other reporters to pick up the themes and provide both points Continue reading

The problem with “The Chart”

This morning as I did my news walk, I came across this article talking about the most important chart in American politics.  And as you can imagine it caught my eye. I find charts and graphs to be either extremely informative or extremely deceptive. Seldom is there a middle-ground.  Often the deceptive charts are constructed specifically for that purpose. It is seldom a surprise to find such charts in an article about politics.

This chart was one of the exceptions that prove the rule.  But not in the way you might imagine.  “The Chart” is deceptive, but I do not believe it is purposeful in its deceit.  Why not, you may ask?  Because the story it is trying to communicate would be stronger if the authors actually new the truth behind the problem.  But, like so much today, the surface suffices to make an argument.  The other details make the argument more difficult to communicate as the story can get Continue reading

Coca Cola Superbowl Ad stirs cries of racism

Coke ad stirs controversy, but this article takes the argument from the sublime to the rediculous

Coke ad stirs controversy, but this article takes it from sublime to ridiculous (click to read article)

Having heard of the controversy over the Super Bowl ad by Coca Cola the past few days, this morning I was captured by the above article.  I expected it to be along a similar vein of remarks showing how Coke was insensitive to Arabs and painting them in a bad light.  When I first heard this argument on the TV news, I was looking for the Association of Los Vegas Showgirls to show up any minute and complain, followed by the African American Cowboy Association, National Hispanic Cowboys,  etc…

What stopped me in my tracks was not the casual assertion of racism due to insensitive stereotyping in the pursuit of parody that I was Continue reading

On Football, Smoking, Soda and Obamacare: There is a spending problem!

Yes Football is a violent sport!

Yes Football is a violent sport!

After reading a recent spate of articles on how the president should, could or would ban or regulate football, I started to wonder what my father or grandfather might say? Then I wondered, how we got to this place where things that others choose to do to themselves is now our responsibility to monitor, manage, restrict and pay for?

50 years ago if we  spoke to our parents about the federal government making laws regulating football, or restricting peoples access to cigarettes and punitively taxing soda, they would think we had lost our minds.  Cleary, Continue reading

More Challenges to the ACA (Obamacare)

No Taxation Without Representation!

No Taxation Without Representation!

From Boston Massachusetts

By now, we all know that the Supreme Court upheld the insurance mandate of the Affordable Care Act (ACA) also known as Obamacare.  To recap, 26 states brought action to have the mandate, declared as an unconstitutional expansion of federal power under the commerce clause, the necessary and proper clause, and as a minor point its taxing authority.  The Supreme Court agreed with the states and found the mandate unconstitutional under the commerce clause, and the necessary and proper clause. However, in what many felt was a stunning decision by Justice Roberts­—and judicial over reach, the court upheld the mandate as a Continue reading

Treatment-resistant bacteria threat rises: What are the options?

Treatment-resistant gonorrhea threat rises in North America

Treatment-resistant gonorrhea threat rises in North America
By Julie Steenhuysen – Reuters.Com Jan. 8, 2013

Treatment-resistant gonorrhea threat rises in North America | Reuters.

A Reuter’s article today again illustrates the disturbing trend in our biochemical battle with other species, like the bacteria mentioned in this article–we are losing this war!  In the last few weeks, we have seen a number of articles outlining the discovery, or at least public disclosure, of new superbugs. Here is just a recent listing of articles on some superbugs: Continue reading

Eye of the Beholder: Me and my Arrow!

Eye of the Beholder

Eye of the Beholder

It was Lew Wallace (1827-1905) who said, “Beauty is altogether in the eye of the beholder.”

Since I began getting involved in Washington, DC with the debate over healthcare reform a number of years ago, I have wondered more and more about how we have arrived at such a place that every issue, every decision, every need is met with such partisan, fractional, divisive and inflammatory rhetoric. Today it seems that there are no discussions on any issue that doesn’t revert to, “they said this, and what they really mean, is that.”  Or, you can hear a statement from one side or the other to the effect that, “It’s clear that their agenda is to do X, Y or Z to harm us.” Any, and all, of these statements amount to “doodly squat” as Granny Hawkins would say! – a prize to anyone who knows this reference — without using the internet!

Spin is not a new concept

Nothing related to any issue facing our national interest today is devoid of some spin to gain advantage on some other tangential issue–related or not.  Not to pick on any one side, or the other, but how often do we now hear the phrase, unfortunately most recently attributed to Rahm Emmanuel, “never let a serious crisis go to waste.”  Or to be fair, the statement by Senator McConnell that the prime goal of republicans is to defeat the president. If you think Mr. Emmanuel or Mr. McConnell are the first to utter these kinds of ideas, that they meant them completely literally, or that it is not a practice by each side of the political aisle, I have a bridge in Brooklyn I am willing to sell you; if you can convince me you deserve it!

If you think hyper-partisanship and gridlock are new I again encourage readers to go to Google Books and look up some of the old papers from the late 1800s and early 1900s and read what was going on then. There are surprising similarities.

Agenda based legislation now the norm

During the drive for healthcare reform there were a series of changes to the goals of the legislation that occurred as the process spread to one committee after another.  Senator Kennedy began the current process of healthcare reform in the wake of the disastrous attempt during the Clinton administration.  The bill that he authored just prior to his death was the result of his long-term attempt to find some legislation that would be acceptable to people on both sides and improve the healthcare system.  The HELP bill, while clearly not likely to have conservatives jump up and proclaim it a triumph of modern legislation, was still a bill that he clearly had worked hard on to find areas of support from his political opponents and an honest attempt  to find methods to improve the healthcare system. Continue reading

The Truth About Medicare/Medicaid and Social Security: Ok What Do We Do Now?

President Roosevelt signs the Social Security Act of 1935

“We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life, but we have tried to frame a law which gives some measure of protection to the average citizen and his family against the loss of a job and against poverty-ridden old age.”

President Franklin Delano Roosevelt said as he signed the Social Security Act into law August 14, 1935.

“Care for the sick. Serenity for the fearful”

were the words Lyndon Johnson expressed some thirty years later Continue reading

The Supreme Court Decision: It hurts to be wrong-but it hurts more to be right and still wrong!

Now that we have all heard the decision by the Supreme Court on the Patient Protection and Affordable Care Act (Obamacare), perhaps it is time for some reflection.  I know as I read the decision Thursday morning, while I was waiting in the queue preparing for a radio interview on the issue, I felt both vindicated in my initial analysis, but also left wanting and inadequate for not seeing the sideways tax justification for its declared constitutionality.

First a recap

There were four questions heard by the Supreme Court in this case. Continue reading

Obamacare Supreme Court Ruling Likely Tomorrow: What will it mean to me?

If the discussion around water-coolers across the nation, or if the intensity of the discussion I have been having at meetings, discussions, or speeches I have given lately is any indication; then regardless of the decision from the Supreme Court tomorrow on the Affordable Care Act, or Obamacare if you prefer, the nation will once again find itself in a vitriolic and unnecessary national argument.

If you want to find out about the background of the core issue, you can read my Health Care Mandate and the Commerce Clause Articles or you can read, Supreme Court to hear arguments on Obamacare: An enigma, based on a canard, wrapped in a conundrum and read how the decisions could come down.

Regardless of the decision, it is clear that we will again have a major upheaval over any decision.  Passions are still running extremely high, and everyone seems to think this is the “be all and end all” of our future life, liberty and pursuit of happiness.  And all of us are wrong!

The decision, regardless of how it comes down, will neither further harm our healthcare system, nor will it improve our healthcare system because we just do not have a system in the first place.  What we have is clearly not a system.  In my recent book, The History and Evolution of Healthcare in America: The untold backstory of where we’ve been, where we are, and why healthcare needs more reform!, available at Barnes and Noble and  Amazon, and other fine bookstores, I discuss how we got to what we have today, how the practice of healthcare has evolved over the years – sometimes not for the benefit of patients – how we arrived at the point where what we believe and expect from healthcare is more mythical than reality, and some ideas on what we need to do to make available both choice and effective care for all.  It is a result of our collective mythical vision of healthcare and inaccurate focus on the symptoms, not the problems of our healthcare system, in the current bill, that we find ourselves with a collective national angst that will in the end just yield political discord not fix the fundamental problems.

As I write this, I am listening to the debate on the Eric Holder contempt of congress issue, also pending determination tomorrow.  Again we are in the middle of a huge national division and if one is cynical enough, we may come to the conclusion that this is all part of some diabolical plan. Since we have come to the place where instead of citizen politicians, we now have a professional political class whose job is to sell us free stuff and fulfill our wants, more than our needs, in exchange for our votes, and thereby significant power and riches; perhaps this is why we seem to have become a nation of thirds who argue everything, and find our leaders unable, or more likely unwilling, to fix the problems.

We are now composed of about 1/3 hard left progressive, 1/3 hard right conservative, and about 1/3 of the nation seem caught in the middle.  You should wonder, what would politicians have to get reelected on if they stop giving us free stuff; and how, on earth, would they get us to give them money so they can afford campaigns, if we are not mostly extremely irritated over something?  I am starting to think it is not our integrity and character that gets us engaged in critical issues anymore, but more likely it is just our passions.

There are some who declare that “Fast and Furious,” was a planned effort to create a national outrage in order to continue to clamp down on gun rights and perhaps severely restrict the second amendment.  Some label this actual fact, and some call this nothing more than wild conspiracy theory.  We all participate in this to some extent because we now habitually believe there can only be one extreme or another, not some logical blend in the middle.  The problem for those of us who are not trying to find conspiracy at every corner, is that we are at a nexus of a number of events created by the actions of the current and prior administrations that all seem to have at least some conspiracy elements in the actions.

In addition to “Fast and Furious,” you have the the actions and events over immigration reform, and the President’s recent unilateral action to implement some form of a dream act. You have the Supreme Court’s ruling on the Arizona Law and the administrations action to shut down the rulings effect by suspending the cooperation between ICE and Arizona’s police departments, and if you look back at the Affordable Care Act debate in congress. You have on the record, statements from people like Barney Frank and Charlie Rangle, and some others, who stated that the health care bill would be the path to a National Single Payer Healthcare system.  While you can look at each item discretely, and argue there is no Machiavellian agenda, when you look across the entire spectrum one needs to wonder if there is some agenda at work after all. And of course, the answer becomes; Yes –  there is an agenda.

Of course there is an agenda, and hopefully it is because those pursuing it truly believe what they are doing is right for America and Americans.  But being right for America and right for Americans may not always yield the same decision.  If may seem right for Americans to have congress conflate the promise given by the Constitution to all for Life, Liberty and the Pursuit of Happiness into an extrapolated promise of free heath care for everybody paid for by the government.  Conversely, at the same time it may not be right economically for the viability of America, to assume what historically was a personal responsibility if the assumption of these costs would bankrupt the nation.  Both decisions, in the narrow view, are good and reasonable decisions.

One path to a decision, has the benefit of giving something to political constituents that will help endear politicians to their electorate and gain reelection.  The other, could change the last fifty years of building the expectation that it is the government, not the individual, that needs to be responsibility for their own heath.  Regardless, this is just not a good situation for any of us, and it is partly why the bill that passed to become the law that is Obamacare is not really liked by either side or the middle.

While the 1964 extension of Social Security Act to include Medicare and Medicaid, was sold as a safety net, the reason for the passage was political gain, clearly on display if you listen to the Johnson tapes available today on-line.  And, subsequent to passage, regardless of whether or not there really was a Machiavellian plan, we have continued to want, and/or allow, Congress to convert the “safety net” into a national entitlement.  The end point is the same.

This is the reason that as we await the decision from the Supreme Court tomorrow, I do not think it will matter one iota in actually addressing the problems that we need to solve or developing a real system to make available both choice and effective healthcare for everyone.

The wheels of justice not only turn slowly they often confuse the common man

If you want to listen to the lengths modern law and its practitioners, lawyers, go to spin reality and obscure common sense to convince courts that which otherwise normal people would deem ludicrous, just go to and listen to yesterday’s oral arguments on the Tax Anti-Injunction Act part of the Affordable Care Act (Obamacare) Supreme Court review of its constitutionality.

It is interesting to note that the Solicitor General, representing the government, seems to be schizophrenic as he attempts to argue for the Obama administration’s position that the court cant here the case because of the act—as the President does not want the decision to come till after the election—and on the other hand in representing the position of the government (the people in general) he tells the court that he thinks the court should hear the case.

Another point to note as it has very particular relevance is that in his argument yesterday, he describes the assessed fee for not purchasing insurance, under the mandate clause of the act, is a tax.  Tomorrow he will be arguing that it is in fact a tax.  This schizophrenic position has been confounding the government’s position since they debated the law and passed it in the first place.  In arguing why the case can be heard, Solicitor General, Donald Verrilli, argues that the penalty is not a tax for the purpose of the Tax Anti-Injunction Act.  Tomorrow he will argue that the “penalty” is in fact a tax to justify the federal government’s position that it can levee it and therefore it is not violating state’s rights.

It is very important to note that like congress and the president, the power of the judicial branch, including the Supreme Court is granted, loaned if you will, from We, the people of the United States.  As such, if the decisions rendered make no sense to We, the people, then it is either because they are wrong or not crafted to reflect well on our intentions as a people.

We need to begin to exercise our responsibility as the grantors of these very important and solemn powers and demand that all decisions and arguments be rendered with a standard of language that we can all understand and does not obscure whether or not our constitutional rights are being upheld.

I encourage everyone to take the time to listen to the arguments in the first person, not as reported by others.  Yes they will take a combined six to nine hours but to allow others to police our rights is to grant them the power to help obscure the elimination, or neutering, of our rights.

To quote and old friends mother, “Pay attention, you can learn something from a fool!”  I worry that in the end the fool will be us!

Stupidity or Duplicity: WE pay anyway!

Click to link to original ABC News Article

Do you think they just don’t get it? In a supposed attempt to find some “middle-ground” in order to make the “middle-men” whole as to the cost of birth control, the administration is acting like we are in the “middle-ages”—all poor and uneducated. First, the administration’s talking heads took the position that the cost of free birth control would be a savings for employers, now forced to pay for it because, pregnancies and abortions are much more expensive. The employers now have to pay for a product, to prevent a cost that their health plan is paying. The premise is that paying the lower cost birth control will lower the plan’s coverage cost and the health plan will then, in turn, lower the premium cost to the employers—not hardly!

Also, there is a big assumption that the rate of single mother and unwanted pregnancies will decrease because of improved access to birth control. I am not sure I agree with this either. Free or subsidized birth control is widely available, it just is not conveniently available everywhere. I am not attacking a woman’s right to have access to birth control. We have a very strong habit, of late, of confusing the discussion of access with no-cost access. It is the no-cost access I have the most problem with. The cost is not free, we all end up paying for it anyway, and the system that is based on mandates, despite the method of the mandate naturally inject inefficiencies and vagaries of control, so that a significantly reduced percentage of dollars spent actually go to pay for the good or service. Look at the healthcare debate numbers from the president’s round table at Blair House with republicans in 2010. By numerous authorities, from both sides of the aisle, only about 35 – 45 cents on the dollar ever make it to real care. So why do we do it this way?

The government now classifies birth control as preventative care, because the ACA or Obamacare requires health plans to cover prevention at no cost. Exercise prevents heart disease, so this should be classified as prevention, as well. Health plans really should cover gym membership at no cost. And, you know having fresh fruit prevents scurvy, health plans need to cover free fruit. Listening to peaceful music lowers stress levels, and therefor prevents high blood pressure and the risk of stroke so good music systems are preventative and should also be covered for free. And of course a warm, comfortable home is clearly preventative to lots and lots of health related problems so I guess “health plans” should provide this as well. This is the same issue I have with the insurance purchase mandate and the rationalization of its constitutionality by the extension of federal power justified by pointing to prior extensions of federal power under the commerce clause.

It is not the idea of helping people; women in this case, get access to care that is the issue. It is the duplicitousness of the need for access by extension to now mean everybody else needs to pay for it, and the effort to obscure the nature of the extension logic that I am finding most troubling. The argument that is being used, now over and over again, goes like this . . . Someone, or some group, needs access to something—or for political gain, we can convince them that they are being discriminated against because they do not have this access and we want to give them access so they will see us as looking out for them, what we are providing is now considered preventative, we passed the law that says if its preventative it must be provided at no cost, ipso facto, you have to pay for this group to get it because it’s the law.

The straw that is breaking the back of many on this issue is now that this administration is saying well, since you are objecting to assuming this cost, we, the government, will find some way to make you whole here, you won’t have to shoulder the cost. Everything the government does cost the people of the United States money. No matter how they try to spin this, it costs us money. We are the government and we are the only source of money. So nothing they can do at the federal level is going to make anyone whole without laying it on the backs of all of us in the long run. Simply saying OK we will let you get a credit to reduce something you pay us over here, just reduces the income the federal government needs to pay what is already spent ten years ago. Do they really think we believe they will not increase fees somewhere else to get the money? If they lay it on the back of some other industry, they are going to increase prices that we all pay so once again it is out of our pockets. There is no escape from zero-sum economics. Even if they just print new money out of thin air, as they have been doing for forty years now, it reduces the buying power of our currency and prices go up, again we pay.

Finally, it is time we realize that we only have finite resources, and everything we do costs us in one way or another. Paying for birth control for everyone is just reducing the money we need to pay for everything else. People are now living much longer and as we crossed from average life expectancy at the mid-seventies to where we are not in the eighties, the average cost of care has rapidly increased. Now we demand that heal plans no longer just cover basic life-saving procedures, we expect they also cover quality of life items as well. The technologies we have developed to make this real gain in median life span is based on very expensive technologies adding to the costs, and the magic bio-chemical bullets we have developed to fight the war with the other species, like bacteria, and viruses, etc. are increasingly costing more and causing more side effects as these species have evolved to be resistant. All of this, with some other reasons as well, is causing the steadily increasing cost for our healthcare. Sometime soon we need to begin to discriminate at what point people are individually responsible for at least some of these costs.

So I wonder are the people coming up with these ideas really this stupid. If they are not stupid, then do they think we are this stupid? Or are they simply Machiavellian? My initial reaction is they are not smart enough to be this duplicitous, but perhaps I am mistaken!

Supreme Court to hear arguments on Obamacare: An enigma, based on a canard, wrapped in a conundrum.

Enigma, based on a canard, wrapped in a conundrum!

March 26, 27, and 28 2012, become the next significant dates in the future of the Affordable Care Act (ACA or Obamacare).  It is on these dates a little over two weeks from now that the Supreme Court will hear arguments both challenging the constitutionality of part of the legislation and arguments as to why the court should uphold the legislation. For most of us on both sides of the aisle, involved in the debate over healthcare reform, we see this as an enigma, for widely opposite reasons, as to how we have arrived today at this point.

For those of you that are interested in this current debate, you can find a number of places to read the arguments, or you can simply read someone else’s interpretation of the arguments.  Here, are some links:

My advice to you is, don’t rely on others interpretations, read the source documents for yourself.  Everyone, including me, are bringing their own bias to their review; some unintentionally, many intentionally.  This has become the partisan issue of this decade.  None of these arguments is a simple read for the non-lawyer.  I would argue that it is the view of a non-lawyer, the view of a common citizen that is now most required to be heard.  The lawyers now are so wrapped up in the history of all judicial actions, and their arguments are both driven by, and necessarily constrained by, the rulings that have preceded; the legal principle of stare decisis—Latin for stand by the decision—the obligation for the court to uphold what has gone before.  It is now, that someone, not a lawyer, needs truly to ask what is the right principle.

As James Madison wrote, “The powers delegated by the proposed Constitution to the federal government are few and defined. Those which are to remain in the State governments are numerous and indefinite.” This
constitutionally mandated division of authority was “adopted by the Framers to ensure protection of our fundamental liberties.”

I am not a lawyer, and I have my own biases.  I write this, not to tell you what to think, but to tell you how I have chosen to understand this issue.  I hope you will use this as a stimulus to plot your own quest for an answer.  We are at a point in our history that if we do not reengage as citizens, in an active role, in the formation of our governance, we will find that the government that we end up with, will be consumed by forces we do not want, nor can we afford.   The power of our “constitutional republican” form of government is based that the power comes from the people, is enacted by our representative people (the extension of us, not a special or elite class), and is for the benefit of us, the people. We are now at a critical juncture, where we, as a people, need to review the decisions we have allowed to be made and expanded like weeds in an uncultivated field, over the past seventy years.  We need to determine if what we now have accurately reflects what we intended; and if not, we need to no-longer allow the subtle expansion, and extension of federal powers, to continue indeterminately.

I am not arguing if we do, or we do not, agree with the constitutionality of the mandate in the Affordable Care Act.  That argument should come, but it needs to come after we determine if the precedent decisions, beginning with the pivotal case of Wickard v. Filburn reflect what we intended: and if it does not, then the pending arguments will continue to leave us sliding down the slope.  If it does, then we all must now accept the ramifications and understand the fundamental change to our current constitutional republican form of government that will fall out of these next actions.

For a review of the historical actions that have led to the current belief that the Federal Government can enact such a law, feel free to read my prior articles: Health Care Mandate and the Commerce Clause Articles, Entitlement vs. Safety Net: It’s not a matter of degree!, U.S. District Court of Appeals “Reaches” for the answer to the purchase mandate, and ACA, Politics, Mandates and the Commerce Clause.

The Arguments

As the Patient Protection and Affordable Care Act was passed, the controversy and the challenge began immediately.  Within hours of passage, states’ legislatures and attorneys-general began filing actions to block its implementation.  Some of these actions were new state laws that helped limit the laws effect.  But, the more effective challenges were the suits filed by the states to block the federal law’s implementation.

Numerous arguments were originally made to challenge the law.  Arguments that the act violated the constitutional right of privacy, violated the free exercise of religion, and even violated the thirteenth amendment prohibiting slavery, along with many others, were made.  As the cases have moved through the judicial system, the plethora of arguments has continually been pared down to a remaining few.  In a little over two weeks, the Supreme Court has agreed to hear a subset of the original arguments.

There are now two main questions pending from the original challenges and two additional questions posed by the court itself.

  • Remaining Questions
  1. Does the Individual Mandate clause exceed congress’s enumerated powers?
  2. Does the expansion of eligibility of Medicaid to include all legal citizens less than 65 years old and earning less than 135% of Federal Poverty Level (FPL)—approximately $37,500.00 per year—force the states to implement what is federal legislative power thereby violating the separation of powers principle?
  • Additional Questions
  1. Does the Tax Anti-Injunction Act bar the court from hearing the case?
  2. Is the mandated coverage constitutionality question severable from the remainder of the act?

Supreme Questions

In reading through the briefs and the summaries, available through the links above, I see the arguments breaking down this way. On the side to overturn the legislation, the arguments are framed as to whether, or not, the original intention of the commerce clause in the constitution, grants this right to the federal government, or does it remain as a right of the people i.e. the individual states.  The arguments for the act to be upheld seem to me based on legal tricks and gimmicks to justify the extension of the power based solely on the extensions that have gone before.  Perhaps this is not fair but I believe the fundamental question needs to supersede those decisions that have gone before, with which I think most Americans would also disagree.  I think it is mere trickery to cite one bad ruling as the basis for another if the root decision is in question.

Despite the tricks and histrionics on both sides, the basic argument comes down to, is it the federal government, or the state government, that have the authority to enact  legislation governing personal behavior.  The main argument for this federal right is the precedent cases, not the root argument of what the Commerce Clause actually means.  For me, it is this framing of the debate that is now the problem.  If the arguments are bound by the principle of stare decisis, then I believe the logical conclusion will be a 5 to 4 decision in favor of upholding the mandate in the ACA.  If the issues revert to the principal determination of whether, or not, the commerce clause was framed to grant any of the rights, now assumed by precedent, to the federal government, then I think we will have a 5 to 4 decision overturning at least the mandate portion of the law.  And, without the mandate, most believe that the ACA law becomes moot.

The secondary argument made by those in favor of the mandate follows the “everything now is interstate commerce” logic because if people do not conform to this mandated behavior then their actions become a fiscal drain on the rest of us, because either the industry, or the government now must go provide for their needs, and the cost will get passed back to the rest of us.  But, this argument is a canard.  The cost to us for lack of action by others is a real cost, but it is predicated by a government action of over forty years ago that mandates that we are going to provide the services in the second place when the individual fails to take appropriate steps to be responsible for their own needs in the first place.  By the way, I am not talking about eliminating a safety net.  We need a safety net!  Safety nets should be provided for the helpless.  What we have today is not a safety net, it is an entitlement, and while some helpless get benefit, predominantly it is providing support for the clueless and the worthless.

The recent Birth Control debate is a timely example.  Forget the religious argument; this is mere political theater at this point.  The argument goes like this.

Someone, employers or insurance companies, i.e. us due to cost shifting, must pay for birth control for women because it costs too much and they cannot afford it.  They will have sex and some will get pregnant.  They will then have babies because they cannot afford, or do not want, to get abortions. Then the government will have to pay to birth these children and support the mothers and their children causing a larger fiscal drain than the cost of birth control itself.

This is a canard because the requirement for the cost for the voluntary pleasurable act of sex, a biological drive, that may result in pregnancy and birth of a child, only places the cost of birth and support of the mother, and child, on us, because we have chosen to accept the responsibility of these costs in the first place.  I am not arguing whether or not we should do this.  I am simply saying we made a choice to do this, and to take the responsibility for the act off the participants and place it squarely in our collective laps.  To swallow the argument that one now begets the other is to believe that the requirement for us to absolve the participants of their personal responsibility and accept the burden of their actions is somehow inviolate and must remain so for all time.  This is simply false.

The humanistic, moral and ethical implications aside, we should be under no perpetual obligation not to revisit the original decision as to who is responsible for what in society.  There are many other cultures around the world that do not accept this responsibility at all, and often these acts result in poverty, pain and in some cases death to mothers and children.  We choose to be more humanistic, and believe ourselves more moral and ethical, and have chosen to believe that we are obligated to support those that will not support themselves.  Understand I am not arguing we should not do these things, I am just pointing out that this decision is both cause and effect on many others we now face.  It is political gamesmanship to present one side of a justification as fait a compli, this is routinely done in the body politic these days, and often fools us into limiting the debate and choices, yielding ineffectual results.

Another argument by the supporters of the ACA is based on the following quote,

“Opponents of the health care law say that if it is upheld, then government can force people to buy an American car or eat broccoli.  But, a person can opt not to drive a car or eat vegetables: no one realistically can opt out of health care.”

This argument follows, what is called in sales, “the Reverse Ben Franklin Close.”  In effect, this technique is geared to obscure the argument, by saying that you can be forced to buy a car and to eat broccoli if you are also forced to buy healthcare insurance, but unlike the others, you do need health care.  In effect, leaving the impression that they are not equivalent and therefore, the worry is not valid. The technique, not the argument, obscures the real issue.  Yes, you almost certainly will need healthcare as you live, and your need will grow proportionally to the length of time you live. But, the argument is that we have to pay for your healthcare not the fact that you need healthcare and don’t need broccoli or to drive.  We don’t pay for your car or vegetables.  That is ultimately the key question.  It is not the benefit of the ACA. The question is, at what point does a safety net come into play to serve the needs of the helpless.  How do we define the helpless?  And, how do we filter out the burden of the clueless and the worthless? Currently we have chosen to propound the philosophy that all people are now entitled to healthcare, regardless of their personal choices or life planning.  We do not as yet entitle people to a car of free vegetables.  The worry by some is that this is coming next.

Does the Individual Mandate exceed congress’s enumerated powers?

This question has become the key question and the key argument for, and against, the viability and continuance of this legislation.  Is the federal government authorized to require citizens to purchase health care and in effect penalize them in the form of a tax or a penalty if they do not buy insurance?  The crux of the argument, for this federal power, is a U.S. Supreme Court case that was argued in 1942, Wickard v. Filburn, 317 U.S. 111.  I have written about the case in my article, Health Care Mandate and the Commerce Clause. I will not rehash the case here but encourage you to go read the article and read the link to the case.

In reading this case, and the other cases that piggybacked on top of Wickard to justify the expansion of federal power, I have come to my own conclusions.  As you read those articles, you will find clearly what I believe.  The question is not what I believe, it is what you believe, and more importantly, what do we, the people, believe is the appropriate border line between where the state’s power begins and the federal power ends.

Does the expansion of eligibility of Medicaid to include all legal citizens less than 65 years old and earning less than 135% of Federal Poverty Level (FPL)—approximately $37,500.00 per year—force the states to implement what is federal legislative power thereby violating the separation of powers principle?

This issue in the end is a non-issue.  The crux of this argument hinges on one of the same tenants as the Mandate—where do the federal powers end and the state powers begin.  This argument began at the formation of the constitution in Philadelphia, and has continued to rage since the formation of the government, and the election of George Washington as the first president.  It was the main factor in the initial fractionalization of the founding coalition government in Washington’s first term, into one that had the federalists, headed by the strong central government vision of Alexander Hamilton, on one side, and the republicans, headed by the anti-monarchists, state’s rights principals of Madison and Jefferson, on the other side

Medicaid is a federal program.  In fact, Medicaid is an extension of Social Security, as is Medicare.  But, if you listen to the current administration they want it both ways.  On the one hand, the president calls Medicaid a state program, but, on the other hand, he wants the federal government to set the rules.  The state governors clearly and uniformly call Medicaid a federal program, and since it is breaking the banks of the states, would prefer to remove the expense from their books.  The conundrum is because in 1965, as President Johnson was framing the extension of the Social Security Act, the legislators know that they had to make Medicaid a “state” program or it would violate the separation of powers principles.

Does the Anti-Injunction Act bar the court from hearing the case?

This argument was raised in the case I discuss in U.S. District Court of Appeals “Reaches” for the answer to the purchase mandate.  In essence, there is an argument that the court should not be able to hear the case, because this act prohibits courts from preemptively enjoining any federal collection of tax revenue until after the revenue is collected.  The base argument is the court cannot enjoin the federal revenue stream until there is real harm.  I actually think the premise of this argument restricting courts below the Supreme Court is valid.  This act provides a check on the courts by eliminating a mechanism where lower courts could effectively shut down the federal government by strangling its cash flow.  I do not feel the same way at the level of the Supreme Court, in that, if it also binds the Supreme Court, the law would grant an unequal power to congress to prevent the Supreme Court from ruling on the constitutionality of some laws prior to harm being done. The Supreme Court is supposed to be the peoples effective check on the powers of congress to create bad law. I don’t think most of the justices are inclined to agree that Congress can pass a law that prohibits them from reviewing congressional actions.

Is the mandated coverage constitutionality question severable from the remainder of the act?

This is another interesting set of arguments and important to those arguing for and against the legislation.  When congress wrote this law they specifically excluded a clause that would allow for any section of the code that was found unlawful, or unconstitutional not to affect the other provisions.  So, on the face it would be argued that it was the intention of congress that all part of this law stands together, and if one part falls they all fall.  Of course, the counter argument is that since there is no statement that says that it all stands as one and it is not dividable on the merits then it must be severable.  I believe this argument is window dressing for the most part.  I believe the justices will rule with a significant majority that the law is severable.

In the end, the main piece is the Mandate. If the mandate falls, for the most part, the law falls.  If the mandate stands, than the law stands: another step in the additional extension of power to the federal government will occur and despite the contrite arguments from both sides, this new precedent will become the stage for another expansion later on.  If the mandate stands, Hamilton and his federalists would have been thrilled, and Madison,  Jefferson, and their republicans, would have been horrified.

The conundrum is that despite our best intentions, intelligence, humanity, economic analysis, and strong convictions, we have now created a major problem based on fundamental disagreement over what the founders intended and whether we are to stay true to this intention or if we should feel free to change it at will.  Frank Zappa once said, “The crux of the biscuit is the apostrophe!”  (There may be a few of you that actually know what this was in reference too, and for those that do, I apologize for the original context. If you know feel free to post in the comments area. I will post the explanation in a few days if others do not.)  I am using the statement to illustrate that the apostrophe of this conundrum is at the point that helping some people becomes detrimental to all people.  Spock said to Kirk, “Sometimes the needs of the many outweigh the needs of the few, or the one.”  This is a loaded statement, as the needs of the many may be affected in very dangerous and deleterious ways by catering to the needs of the many.  Sometimes, as in this case, society gets to the point where the definition of what is needed needs to be clear and it is imperative to prioritize the fundamental needs and eliminate the extraneous wants.

In the end, we are faced with an enigma, based on a canard, wrapped in a conundrum!  I hope we have the national and personal character to address the problems and find real resolutions.

 Note: I hope this article at least provides a process for you to seek your own answer.  I am sure once again we will be much divided, but perhaps the arguments can become fundamental and appropriate, and no longer tangential, and irrelevant. I ask you to come back and post your thoughts in the comment section.

California AB171 & AB254: And we wonder why healthcare costs in CA continue to increase?

One of the largest drains on every states budget is healthcare cost.  California has historically been in the top of state healthcare expenditures due largely to its past of providing one of the most generous sets of program benefits in the country.  Both Governor Brown and Secretary Dooley deserve a tremendous amount of credit for acknowledging the mounting problem of healthcare costs and taking steps to begin the process of addressing it.

Healthcare costs in the U.S. are estimated to top $3 trillion this year.  That is a significant increase from the estimated $2.4 trillion in 2009.  The Affordable Care Act (ACA), aka Obamacare, is supposed to be lowering the costs and improving efficiencies for healthcare.  While it can be argued, and it has vociferously, that it is early in the process and the projected savings will begin in the next four to five years, there are some significant indicators from the administration in Washington DC that more and more of the promised savings will not happen.  This will spell further disaster for states like California that already shoulder a disproportionate share of the healthcare burden of our population.

Before we can discuss AB154 and AB171, let’s review some broader recent decisions and data that have a direct impact on California’s projected healthcare costs.

Part of the plan to afford the care under the Affordable Care Act was to appropriate revenue from the purchase of healthcare and penalties for non-purchase of policies.  The governing method to assess the fees and assure collection was the IRS.  Within months of its passage the government had to admit that the idea of the IRS administering this program’s revenue would not work and that segment of the legislation was repealed.  This now begs the question how will this revenue be assured?

As we are all painfully aware, there is some disagreement over whether or not the Affordable Care Act’s mandate to purchase insurance is constitutional.  Scholars, pundits, and constitutional lawyers on both sides are already at polar opposites over the issue with each side quoting chapter and verse as to why, or why not, it will be upheld or declared unconstitutional. The reason for the gulf in the interpretation of the underlying law is its base on a prime case called Wickard v. Filburn from 1942 that started the justification for the federal government’s expansion into what had prior been clearly state jurisdiction.  Any non-lawyer’s reading of the case simply defies common sense—this will be a very sticky wicket indeed. If the Supreme Court declares the mandate unconstitutional then much of the insurance reform inherent in the bill falls apart. Another large segment of projected saving will revert to increased expenses ultimately burdening the state both directly and indirectly.

The U.S. Secretary of Health and Human Services, Kathleen Sebelius, has recently ruled that the CLASS Act—a segment of the bill that was designed to expand options for people who become functionally disabled and required long-term services and support—is not affordable by the definition under the act and therefore it has been suspended.  Where will these costs fall if the federal government stimulates the expectation but fails to provide the funding?

A major part of the projected savings was though the requirements of Accountable Care Organizations (ACO’s).  In the bill they were projected to provide a savings of approximately $333 million per year, or just about $1 billion over three years. The CBO recently announced the results of a 20 year study focused on disease management and value based payment methods that fundamentally negate most, if not all, of the assumption on which these projected savings were based. In fact the study indicates they will potentially increase costs.

Another main point of the Affordable Care Act was to eliminate treatment disparity.  Who wants to argue for disparity? No one!  But even CA Secretary of Health and Human Services, Dianna Dooley, has said publically that “…we all need to get used to the idea that disparities will exist.”  I commend her for this statement because it is unequivocally true.  There is a basic law of diminishing returns that says that you will spend 80% of your money trying to arrest 20% of the problems.

Another key segment area of the ACA savings plan is Insurance Rebates. The act maintains that it has teeth to control the insurance industry profits because of its ability to mandate rebates for fees in excess of the medical loss ratio that the U.S. Secretary of HHS sets.  In the first place, the rebate amount is a mere trifle compared to the $3 trillion national expense.  More importantly, rebates have been mandated by the federal and state governments of Pharma for years.  Rebates do not lower costs at all.  Rebates in this bad play are methods to redirect money from the general consumers of the products, prescription drugs in this case, to other areas that the federal government, or the state, wants to spend them.  They do nothing but increase the cost in an arbitrary and specious way and obscure the real cost of care in America.  If monies flow in payments to the drug companies, and then flow back to the states, and the states, like California, can redirect these monies back to the programs or the general fund to fund more patients, it amounts to nothing more and a consumption tax.  A look at the California budget shows that about ½ of the drug spend for some programs comes through mandated rebates.  Sure this is a good thing for the participants in the programs, if like California the moneys flow back to services—not all states do this, some pay for other infrastructures—but it is not good for understanding the real impact of these programs economically as the myriad of convoluted funds flow become impossible to track or account effectively.  Frankly, the $3 trillion in health costs for the U.S. is not likely even close to $3 trillion because it is an unintelligible mix of both invoice pricing and actual reimbursement payments.  And for those who do not know, a healthcare provider typically is getting reimbursed from eleven cents on the dollar to twenty-two cents on the dollar for services they bill—and they seldom can predict the amount.

Yet another key segment of savings under ACA was the premise that hospital readmissions will reduce.  The plan is to select a series of specific disease states and for the government to begin to select measures that will allow for adjustment, read penalties, to hospitals that have higher than the selected measures for readmission.  Houston, we have a problem.  One of the biggest drivers of healthcare cost is age related illnesses.  Since 1964, when we created Medicare and Medicaid, the lifespan has increased from about 70 years old to almost 83 years old today.  The effect of this increased lifespan has been to significantly increase the cost of care in one’s life and shift the cost curve of lifetime health expenses to our last few years of existence. A recent Kaiser study now indicates that almost 85% of our lifetime expense for healthcare will be made in the last 5 years of life—and the trend is still increasing.  We are aging, our culture of how we manage our elderly relatives has shifted from family responsibility to outsourced solutions (nursing homes), and we now are more focused on quality of life than just life as the basis for our expectation of care.

Let’s stay on the topic of re-admissions for another moment because this is a big one.  One of the assumptions that drive the belief that we can reap savings by setting measures and penalties is that and assumption is that the reason for the readmission is that hospitals get more money for readmissions. As a result, they are not doing much, or enough, to improve the outcomes in the first place.  But this is a false assumption for many reasons.  To illustrate the issue, let’s discuss Hospital Acquired Infections.  The premise is that Hospitals are sloppy or slipping when it comes to hygiene and if they simply do a better job following antiseptic protocols to reduce infection, then these unnecessary costs will go down.  The people drawing this conclusion do so from the basis that healthcare is more of a cause and effect system, a static system, where we have fixed cures for most of what affects us.  This is one of the main cores of why we keep thinking we can make progress if we just keep doing X process more and better…. But the problem is, the practice of healthcare, after all, actually is largely a war with other species (bacteria, viruses, and other complex pathogens), a war with our environment, (accidents, violence, and pollution) and also a war with ourselves (diet, exercise, work habits, and sleep). From time to time, we can see gains for ourselves in these battles, but our mortality assures us that we will all eventually lose the war. Basic biology and the laws of nature have stacked the deck against us. Innovations in technology, science, and medication have helped many of us delay the day of our ultimate surrender, but these advances have also fostered the false belief that no price is too high to pay for an extra day or week of life. Related to infections, we are losing this war as our chemical and biological weapons have continued to become less and less effective. The protagonists, other species, have evolved resistance to our weapons and the remaining available chemistries’ at our disposal have become more toxic to us who take them. Hospital readmissions will likely continue to increase.

Lastly, ACA relies heavily on projected savings from the mandate of conversion to Electronic Health Records (EHR’s).  While EHRs are a good thing and will very likely improve patient outcomes, any projected savings, should they even materialize, will be negligible.  How can I predict this so definitively?  If you look at where the healthcare dollar is spent only about 12 cents is spent in administrative costs today as it is.  The percentage that may be gained in efficiency from conversion to electronic records will likely be 10% to 20% of that number which would yield about 1.2 cents, to 2.4 cents, for every healthcare dollar.  The current plan for EHRs does nothing to change the current HIPPA regulations and as such the sharing or coordination of care though the transportability of these records between providers and sponsors is very expensive and practically prohibitive.  The application of technology has always been made with the promise of increased productivity and lower costs but an honest assessment of the past 40 years shows that overall lower cost and significant gains in productivity are the exception not the rule.

The largest cost drivers, where EHRs could have a major influence, are in the areas of duplicated services, defensive medicine, fraud, and abuse.  By many estimates, on both sides of the political spectrum, only about 33 cents of the governmental healthcare dollar is realized in services—about 60 cents is lost in these areas.  There is little debate on this total number across the aisles.  There is large debate as to whether the costs are larger in the fraud and abuse area or in the duplicated services/defensive medicine areas.  This debate is moot as EHRs could have the potential to drastically reduce these aggregate costs if, and only if, they are coupled with mandated coordination of care and benefits across all available sources.  By the way, I don’t mean single payer.   Single payer is a great sound bite but the term likely does not really describe what people are seeking.  Do we really want all care to come from a governmental source—eliminating choice, volunteer treatment, faith based programs, non-profits, philanthropic sources, corporate sources, etc.?  When I have had this discussion with various legislators, both state and federal, the answer invariably has become; well no, of course not!  What most really seem to want, and what is necessary to make this all work, is a central point of administration with the ability to connect the providers around the patient as the center point in a kind of virtual care team.  This is relatively inexpensive, does not initially even require full HER implementation to achieve significant savings, and provides a great role for state government to play.

With this as a backdrop, we come to the last big issue facing why healthcare is continuously increasing in cost and the issues with AB154 and AB171 drastically put at risk California’s healthcare future.  AB154 is legislation recently approved by the Assembly that will require private insurers to cover diagnosis and treatment of mental illnesses (it appears all mental illnesses on the books).  AB171 requires coverage of developmental diseases such as autism.  The Assembly also approved legislation to cover oral chemotherapy and mammography regardless of age.  While I applaud the sentiment, these kinds of actions that constantly increase the overall coverage of anything, and everything, which can ever affect anyone as they perpetuate their long risky walk through life to older and older age, in conjunction with the items previously discussed, are setting California up for a perfect storm.  As the ACA projections continue to fall apart and as the federal cost for healthcare programs like Medicare and Medicaid continue to increase, states like California will be left in the crosshairs of larger expectations for treatment and less, perhaps no, federal money to pay for it. Already the president refers to Medicaid as a state program.  I guess he forgets that both Medicare and Medicaid are just parts of the federal Social Security Act of 1964.  Of course, the states consider this a federal program and due to the increasing drain on state budgets some are trying to figure out how they can again opt out of this federal program.

Our largest issues come down to the following things.  We no longer truly insure health care to preserve basic life.  More and more we are requiring insurance to cover “quality of life.”  We have extended though technological gains the amount of time we can spend on the planet to the point that we are now on average way beyond the period where our bodily systems effectively fight the healthcare war.  As we have gained the additional ten more years of life from the past forty years of technical and medical accomplishments, we have moved into a new reality that to preserve our quality of life during this extended period we are consuming consuming more and more of our resources.  Unfortunately, much of what programs like Medicare and Medicaid are now paying for are not the actual costs of care.  They are paying for the things we purchased during the former years to improve our quality of life way beyond the realm of healthcare.  These programs are really funding the earlier purchases of larger screen flat panel televisions, vacations, 2nd homes, new cars.  They fund the things that, prior to 1964, we typically did not purchase because we knew we needed the money for our elderly rainy day funds.  We were worried that we would need to pay for the catastrophic accidents and illnesses that fate dictated we would face as we aged. Today we are all free to make these lifestyle purchases because the threat of elder catastrophe is now covered by entitlement.

This is not an argument to go back to the way it was, not an argument to eliminate these programs, not an argument that we should die earlier.  I know of no one that wants to see people die younger, suffer more, or live in destitution.  The point of this article is to bring to the front the dilemma.  It is here we need to develop a better dialog and, as Ben Franklin said, “find compromise, through tolerance.”  It is here we also need to start to focus our hard decisions on where personal responsibility ends and our safety net begin.  Until we do this, California faces the coming perfect storm and like all other state will likely face it alone without federal help.  The decisions we make on items like AB154 & AB171 while laudable are significantly increasing expectations and hence our risk of future economic collapse.  Remember it was Albert Einstein who said, “Insanity is doing the same thing over and over again and expecting different results.”  Wait, is this why AB154 is being passed?

I commend the Governor and the Secretary for their effort to begin to address this dialog.  While there are many who want to lay blame for everything at their feet, I find in both inappropriate and counterproductive.  Both have had long records of public service.  Both began, perhaps, more on the side of idealism but they have each arrived at pragmatism based on hard one experience and dedication to effective solutions.  I can’t think of any I would rather have trying to help California move these issues forward.  That said it is time we all begin to recognize the depth and diversity of the problems, reset our expectations and all become responsible for the solutions!