Thursday, September 3, 2015


Skinning the ObamaCare Cat with High Deductibles, HSAs, and Self-Insurance


There's more than one way to skin a cat.

English Proverb, of uncertain origin

Employers, faced with increased health costs, secondary to the ObamaCare employer mandate, are seeking ways to empower workers by lowering their health premiums, introducing health savings accounts, and self-insuring. Despite ObamaCare restrictions, high deductible, HSAs, and employer self-insurance plans are growing and are reducing employer health costs by 15% or so.

As many as 100 million Americans are now covered by self-insuring companies, who pay health claims directly and can contract directly with providers. And HSAs, generally paired with high deductibles, increased by 29% in 2014, reaching a record high of 14.5 million. Nearly one third (31%) employers now offer HSAs, up from 4% in 2005.

These new approaches reduce employer spending by 15% or more, and empower consumers by lowering their premiums by as much as 25% to 50% and allow individuals to set aside tax-free money for out-of-pocket expenses and encourages them to set aside money for retirement. Individuals own their HSAs and do not depend on their place of employment. HSAs encourage workers to shop for care since they are using their own money to pay for services up to the level of the deductible. Self-insured employers can contract directly with providers without going through the trouble and expense of going through insurers, often dramatically decreasing employer expenses in the process. Some concierge practices and direct-cash ambulatory care surgery centers now hire middleman to directly contract with employers.

These new approaches are not a panacea for lowering health costs by according to Scott Atlas, MD, and John Cogan, senior fellows at Stanford University’s Hoover Institution, and Mike Ferguson, CEO of the Self-Insurance Institute of America, these approaches lower costs while empowering employers and their workers (“Two Essential Tools for Repairing the ObamaCare Damage,” Sept.2, WSJ, and “Remaking Companies of ObamaCare, “ Sept. 3, WSJ).

I have written 20 blogs on High Deductibles, HSAs, and self-funding or self-insurance. You may read them by going to Medinnovation and Health Reform and typing in High Deductibles, HSAs, and self-insurance into the search box. These concepts are not new, but they are not popular with ObamaCare advocates of employer mandates and ObamaCare health exchange plans.

One hundred million Americans work for companies that self-insure. ObamaCare fans are unhappy about it. It places control in hands of employers and workers.

Wednesday, September 2, 2015

The New Math

In mathematics two plus two makes four.
But in politics two plus two means much more.

In our so-called checks and balances system,
Balance was supposed to prevent mayhem,

Congress was to advise and consent.
too much Presidential power to prevent.

As a backup people could always vote,
Should either side try to jump the moat.

To keep things honest and on an even keel,
A president veto could bring Congress to heel.

But that was before Obama’s presidency,
And his unilateral actions without precedency.

Voters and Congress he has learned to circumvent
With executive action, he has avoided the malcontents.

has learned to create the new political math,
To get his way without taking a political bath.

Only 40% of voters approve the Affordable Care Act,
Yet it passed without a single GOP vote, that’s a fact.

Only 34 of 100 Senators approve the Iran Deal,
Yet even without his veto, the deal will become real.

His disregard for voters and their representatives,
Is astonishing: no one has come up with preventatives.

Since when does two-thirds disapproval,
become equal to two-thirds approval/

It must come down to executive unilateralism,
and the power of presidential supernaturalism.

The mathematician may say two and two makes four.
But in politics sum are calculated at the back door.
Ben Carson, MD, Transcends Black Lives Matter Debate

A debate is raging over the Black Lives Matter (BLM) organization. Does BLM foster hate over police tactics in suppressing black crime? Does BLM rhetoric result in more police killings, such as the “assassination” of a Houston deputy or the murder of a policeman in suburban Chicago. Should President Obama condemn the Black Lives Matter rhetoric of “Pigs in a Blanket” or “ Let the Bacon Fry,” the language used after the killing of two New York City policeman in their car.

No one can say for sure. Of course, as a matter of simple humanity, all lives matter, and no one has said this more eloquently than Ben Carson, the retired John Hopkins neurosurgeon who has risen to second or third in many polls.

How has Ben Carson, a black doctor born into poverty in Detroit accomplished this feat?

By personal example.

graduated from Yale in 1971, married a black Yale fellow student, received his MD at the University of Michigan medical school, rose to the top of his profession at John Hopkins, raised three successful sons, and with his wife, wrote a book praising America, America the Beautiful. He and his wife created the Carson Scholars Fund, which has given 6,700 scholarships for student s in grades 4-11, towards their college education.

Along the way, he has spoken in a calm, reasoned, non-racist voice. He has taken generally conservative views and humbly admitted he has a lot to learn about foreign policy. All intelligent leaders, trained to make decisions based on facts and empirical data, he says, are capable of learning.

He has opposed ObamaCare, but said he would preserve its policy of prohibiting health coverage to those with pre-existing conditions. He dislikes the concept of for-profit insurers and would give every citizen catastrophic coverage, medical record, and a health care savings account. He had said the Affordable Care Act is “the worst thing that has happened in country since slavery because it makes all of us subservient to government.” Although this may sound harsh, Carson has expressed his views quietly without rancor. Among Iowa voters, he has an unprecedented 81 % likability or favorability rating, which may mean it’s not what you say but how you say it and whether you think all lives matter.

Sunday, August 30, 2015

Is America’s Diverse Culture Ending?b>

If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so weave a less arbitrary social fabric, one in which diverse human gifts will find fitting place.

Margaret Mead (1901-1978), Sex and Temperament in Three Primitive Societies

America is a diverse society, a culture that works best when immigrants assimilate, learn the language, and obey the laws. This is easy to forget when gun violence explodes, partisanship prevails, and accusations fly of the GOP as a terrorist organization exploiting women.

In my view, at our best, we are a fair, non-racist society, and non-ideological society. We twice elected a black president. Today the New York Times Magazine celebrated Serena Williams as “Her Excellency.” Ben Carson, a black neurosurgeon, rose to second place in Republican primary polls. Bernie Sanders, an avowed socialist, was leading Hillary Clinton in New Hampshire, and closing in on her in Iowa.

We are also a center-right society that fears big government will hamper personal freedoms and retard the opportunity for all citizens to rise, based on their skills, not on their race or gender. This belief produces social inequities. But we are a society that believes in diversity and choice and entrepreneurial skills as opposed to uniformity and equal outcomes for all.

This belief system may produce a political counter revolution that says the system is rigged for those with skills and money and oppresses minorities. And center-right thinking may lead to nation that regards itself as the first among nations rather than just a nation among equals and thinks of itself as superior to nations will less wealth and resources.

Former vice-president and his daughter, Liz, herself a former government official, expressed this view with these words in an August 29-30 Wall Street Journal Op-Ed with this argument.

“Our children need to know that they are citizens of the most powerful, good and honorable nation in the history of mankind – the exceptional nation. They must know that they are the inheritors of a great legacy and a great duty. Ordinary Americans have done heroic things to guarantee freedom’s survival . Now it is up to us.” (“Restoring American Exceptionalism, ” WSJ, August 29-30, 2015).

The Cheneys end by quoting President Reagan on the 40th anniversary of the D-Day landings, “ We will always remember. We will always be proud. We will always be prepared, so we may always be free.”

The proud words of the Cheneys were designed to mobilize opposition again the Iran nuclear deal.

Opponents will surely retort by saying that Pride always goeth before the Fall, that diplomacy must always replace confrontation , that you must always trust rather than vilify, and that unity must always supersede diversity when negotiating with foreign powers.

It is difficult to change a diverse culture that holds two opposed ideas equally in mind at the same time - government care and private care, second amendment gun rights and strict gun control . But we must. As President John Kennedy remarked in a 1963 address at American University, “If we cannot end now our differences, at least we can help make the world safe for diversity.”

Is America’s cultural diversity ending ? Perhaps. Something is happening out there, 71% of Americans say the country is moving in the wrong direction.
The political tectonic plates are shifting. We seek something or somebody new, fresh, and different – something that will bring us together again and make us great again, something we seem to have lost.
Call it what you wish - anger, angst, or anxiety - Americans distrust everybody on both sides of the political establishment. Into this vacuum has moved non-politicians offering something better , a better America, better business deals, better government - anything but what we have now. We have new Wizards of Oz. The questions surrounding those behind these new curtains are these: Is there any there there? And if so what?

Friday, August 28, 2015

Political Word Games

This week the Quinnipiac national polling firm ran a poll asking 1563 people the first word that came to mind when thinking about 3 national political candidates.

For Hillary Clinton, the first word was “liar,’ for Bush “Bush,” and or Trump “blowhard.” These word associations partially explain why Clinton’s numbers are dropping, Bush’s are drooping, and Trump’s are booming.

Trump may be a blowhard, but he is lighting up the polls, and sucking up the oxygen from the other GOP political candidates.

Why is this?

Donald Trump is blatantly outrageous.

But his message is proving to be contagious.

On the campaign podiums he may be a blowhard

But at reading voters’ feelings he is a Mozart.

Critics say his promises are bombastic,

But he counters- my results are fantastic,

He claims all other candidates are stupid,

Only he has the God-given smarts to be lucid.

In debates he says he is the only adult,

And he has mastered the art of the insult.

He says he speaks for the silent majority,

And he speaks for them with authority.

People are mad as hell and won’t take it anymore,

This giving away of the U.S. company store.

In the bully pulpit, we will have a deal-maker,

Not a political puppet, but a mover and a shaker.

Voters as this stage love him on the stump,

Will they love him when their ballots they dump.


The Truth about Doctor Demand Dilemmas

As scarce as truth is, the supply has always been in excess of the demand.

Josh Billings (1818-1885)

As the physician shortage grows, technology advances, and government-subsidized care expands, the truths of the law of supply and demand become evident.

The demand side of the supply and demand equation states says that as the quantity of a good demanded falls, the price of the good rises.

Costs of care are rising, as premiums spike, often by 20% or more. Demand for physician services is growing. This demand stems from an aging population with more chronic diseases, technologies proven to alleviate those diseases, physician shortages across the board, expanding government programs - Medicare, Medicaid, and health exchange plans, more physicians not accepting those in government subsidized plans.

The truth is that the physician shortage is growing. It stands at 50,000 today and may exceed 100,000 by 2015. How could this be? Physicians are among the top 5 % in income, with top-earning specialists making $300,000 or more, and primary care doctors pulling down $150,000 or more. And physician recruiting firms report doctors finishing residencies get 100 or job offers, mostly from hospitals or large physician groups. These jobs generally come with health benefits , malpractice coverage, time off for vacations, and help paying off educational debt.

What’s not to like about becoming a physician? Well, as a recent “summit at the summit” meeting of physicians sponsored by United Physicians and Surgeons highlighted, there’s a lot not to like, including intervention into the patient-physician relationship, loss of physician autonomy, unreasonable credentialing requirements, unnecessary installation and use of dysfunctional electronic health records, time and effort spent searching for arcane IDD-10 codes to get paid, and second guessing at every step of the authorization of procedures and billing process.

The truth is that many, if not most physicians, are unhappy campers on the federal camping grounds. The truth is that health care has become a huge national business, consuming nearly 20% of GNP. The truth is that health care has consolidated into massive entities, with government, insurers, and large integrated health systems at the controls, rather than independent physicians in scattered practices. The truth is that costs of entitlement programs are becoming unsustainable, that something must be done to control costs, and that those controls begin with controlling physicians. The truth is that it is difficult, if not impossible for government, to dictate and monitor care from the top-down in a system involving billions of transactions at the bottom of the system.

The truth is that physicians are seeking ways through, out, and around the demands being placed upon them. These ways include becoming more efficient by using more physician assistants, nurse practitioners, and data scribes; opting out of the system by foregoing 3rd party participation and contracting directly with employers and patients; and going around hospitals and other competitors, by creating more focused, efficient, convenient physician-owned and directed facilities.
Where the physician Merry-Go-Round stops no one knows.