American. Black. Doctor: Uncensored
Let’s stop with the COVID-19 madness, shall we? Let’s stop the shutdowns; quit with the face masks. Dr. Marilyn Singleton — yes, that’s “Doctor” — says the numbers being reported don’t justify the political actions being taken. This “new normal” is a defeatist way of thinking.
By Marilyn M. Singleton, MD, JD
What if purchasing medical products and services were like buying peanut butter? Grocery stores have several brands and varieties: smooth, chunky, old-fashioned, natural, organic, no added sugar, reduced fat, no-stir, and pre-mixed with jelly with clearly marked prices ranging from $1.75 for the store’s generic brand to $7 for the over-priced Yuppie brand. After carefully examining the labels, our shopper chose a 16-ounce, $5 jar of no-added-sugar peanut butter. She paid the cashier $5 for the peanut butter and went home.
If our shoppers were transported to the universe of medical billing with the $5 jar of peanut butter, the shopper with Medicare would pay $1.00 but her grandchild will be presented with a bill for $4. When the shopper with private health insurance attempts to pay, the cashier becomes unglued. The shopper cannot say whether she met her deductible or has a co-payment, and whether the brand of peanut butter is approved by the network. She really wants the peanut butter so she grabs the generic from the shelf and pays the $1.75. Our privately insured shopper was pleasantly surprised at the generic’s good taste and healthful ingredients, her wallet was happy for the cost savings, and she was glad not to have the middleman hassle.
Comparison shopping is one pillar of bringing sanity to the high cost of medical care, but the opacity of the pricing system for medical costs limits the value of posting list prices to encourage lower costs through shaming, competition, and choice. In addition to research and development, manufacturing, and distribution costs, drug costs are affected by additional layers of middlemen: pharmacy benefit managers (PBMs) and insurers. Using a “trade secret” process, PBMs negotiate discounts and rebates for private and government insurers. The money saved is supposed to go back to the government (taxpayers) or to insurers to lower premiums or otherwise benefit patients. PBMs typically are paid by a percentage of the rebate or discount off the list price. The higher the price, the bigger the rebate. Thus, the rebate system gives an incentive to raise list prices rather than placing the lowest-priced drug on the insurer’s formulary. (This same system is used by Group Purchasing Organizations (GPOs) for hospital product purchases.)
An analysis of the effect of California’s 2-year old drug price transparency law illustrates the complexity of pricing. Despite being compelled to post list prices, pharmaceutical companies raised the list price for wholesalers by a median of 25.8 percent but the data did not indicate the “price” that consumers actually paid. Moreover, with medical services and products the simple What the Market Will Bear (WTMWB) pricing method works because either the medication is essential (e.g., Epi-Pen®), has no alternative, is in short supply, or the medical consumer is not paying directly for the services.
Similarly, publishing hospital the charge description master (“chargemaster”). i.e., the standard industry price does not give consumers enough information to make a rational choice regarding elective medical services. The data necessary to make price comparisons depends on an individual’s circumstances. More relevant than the chargemaster price, a self-pay patient needs to know the lowest possible cash price. A patient with health insurance must know (1) whether the hospital is in the insurance network, (2) the price negotiated between the health care provider and insurer (including Medicare), (3) the amount and method of calculating cost-sharing, (4) the amount Medicare or other insurer will pay for services performed in a physician’s office in contrast to the hospital which tags on a “facility fee.”
Transparency is one tool for lowering costs through choice. As one of many studies on hospital consolidation noted, “The Sky’s the Limit” on prices where there is lack of competition. But the difficulties of achieving useful price transparency must not be a cue for the government to initiate bureaucratic band-aids. As we have seen with Obamacare, forcing insurers to pay more of the costs leads to higher premiums, deductibles, and/or co-pays.
Nor should the government impose price caps. President Nixon’s 1971 wage and price freeze brought product shortages—which we are already facing with certain drugs, including anesthetics and chemotherapy agents. If the government sticks to enforcing anti-trust laws, a competitive market will thrive. The court house door anti-trust settlement by Northern California’s Sutter Health sends a message to big hospital chains to stop using their market share to inflate prices or require insurers to join their networks on an all-or-nothing basis to prevent insurers from negotiating lower prices at individual hospitals.
If we can get to the point of direct exchange of money for goods and services and reserve health insurance for major expenses, we can see costs decrease just as we have seen with the Surgery Center of Oklahoma over the last 10 years.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
By Marilyn M. Singleton, MD, JD
Buying and selling is in the news lately with President “at some point you’ve made enough money,” “climate change is urgent and growing” Obama’s well-publicized imminent purchase of a 7,000 square foot, $14.85 million estate in Edgartown, Martha’s Vineyard, the playground of the rich and famous, guaranteed to survive the rising seas. Our current politicians are also on the hunt for buyers.
Sales Pitch Number One: A medical care crisis is afoot and only the government can save you. Yes, there is a crisis of rising prices and premiums after the government started meddling in the medical care market. Once health insurance became popular, by 1963 906 insurance companies wrote health and accident insurance, with 42 offering exclusively health insurance. Now we have five companies that have cornered the health insurance market. Additionally, politically powerful hospitals continue to merge and gobble up physicians’ practices leading to up to 70 percent higher prices in geographic areas with minimal competition.
Premiums and out-of-pocket costs steeply rose after the passage of the Affordable Care Act and show no sign of going back down. In 2018, according to eHealth, the average cost of health insurance premiums was $440 for individuals and $1,168 for families – almost double the cost in 2014. The deductibles (the amount of money that you have to pay out-of-pocket before health insurance starts paying for your covered benefits) similarly rose to $4,328 for individuals and $8,352 for families.
Sales Pitch Number Two: The government-to-the rescue plan is fair and free. Now that we have had debates and the Iowa State Fair, we’ve heard enough to know that Medicare-for-All is neither free nor fair. There is a good political reason the House and Senate Medicare-for-All bills fail to provide a financing mechanism. We would have a collective national heart attack after seeing the price tag.
In 2016, the federal government spent more than $1.2 trillion on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Total national health expenditures by all government levels and private entities were $3.3 trillion. A 2018 Mercatus Center analysis concluded that Medicare-for-All conservatively would add $32.6 to $38.8 trillion to federal expenditures during its first 10 years. The government predicts that in 2026 the Medicare Hospital Insurance Trust fund will be depleted and total national health expenditures will be $5.7 trillion. The federal government collected about $100 billion in Medicare premiums and a total of $3.32 trillion in taxes last year. Given the projected expenditures and no cost-sharing or premiums, new ways to perform mass wallet biopsies on the populace will emerge. The simplest tool, as Senator Sanders has suggested, is to raise payroll taxes on everyone.
Moreover, with the elimination of private insurance, when the money runs out and care is rationed, only the wealthy will be able to pay for care outside of the government system. Is that fair?
Upping the ante, Senator Sanders wants to pay off some Americans’ current medical debt by taxing Americans with no medical debt. Under his proposal, only people unable to pay their medical debt would be granted relief. Those keeping up with their payments would have to continue to pay. What does “unable” mean? If they are living below the poverty level, they have Medicaid. Is it the working poor? Or is it people who failed to prioritize their medical bills over Starbucks and take-out food? Hardly fair.
Sales Pitch Number Three: If you like your doctor you can keep your doctor, Politifact’s lie of the year. Essentially, the promise was that government would not interfere in the practice of medicine. But both state and federal government wants the final say-so in our medical care. For example, the California assembly passed a bill requiring the state Department of Public Health to review and potentially reject medical vaccine exemptions written by doctors who have granted five or more in a year. No exceptions for doctors specializing in neurological or immunological diseases. In order for Medicare to pay claims, physicians will be required to complete a computerized algorithm and certify that they have done so before ordering certain imaging like MRIs and CT scans. A computer will now determine whether the order is “appropriate.” Medical care by government robots will supplant individualized care – the heart of the patient-physician relationship. Who cares if the patient has a missed or delayed diagnosis?
As the government tries to trap physicians and patients in its restrictive bubble, independent physicians are pursuing avenues for increased choice in medical care and insurance products. Above all, we will never put the needs of the state ahead of the needs of the patient.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is a Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
By Marilyn M. Singleton, MD, JD
June has been a month of reflection on life, death, our values, and the greater good. We commemorated the 75th anniversary of the 1944 Normandy invasion (D-Day), which began the liberation of France from German occupation and turned the tide of World War II. In what must have been a decision fraught with soul searching, generals sent young soldiers into what could be certain death on the shores of Normandy. Their bravery was an act of unquestionable honor.
Contrast that with a law school ethics class scenario. The leader of an invading horde tells the mayor of your town that if he lets him kill a child, he will spare the lives of the town’s residents. Does the mayor sacrifice one innocent child for the good of many? On a practical level, anyone who would wantonly kill a child is not to be trusted. Morally, is the life of an innocent child reduced to a numbers game? What justifications can the mayor offer to convince the townsfolk to act like mindless, soulless, cowardly creatures and decide not to fight for the sanctity of life?
Life is precious and fleeting. Once gone, you can’t get it back. This month the news has presented two ends of the spectrum: physician assisted suicide and abortion.
Years ago, people found Dr. Jack Kervorkian’s “death machine” ghoulish. He likely was well-meaning but was misguided. Now physician assisted suicide is culturally acceptable and legal in several states. New Jersey is the latest state to jump on thephysician-assisted suicide bandwagon that includes Colorado, the District of Columbia, Hawaii, Oregon, Vermont, Washington, and Montana. Maine’s bill has made it to the governor’s desk.
Physician-assisted suicide (aka aid in dying or death with dignity) now has an oft-used abbreviation (PAS) to mask a deed that runs counter to the command in the Oath of Hippocrates not to harm our patients. Some reasonably argue that it is harmful to refuse to follow a patient’s request to be irreversibly put out of her misery. But when does relieving pain—whether physical or emotional—transition into hastening death?
Some of these suicide laws have a requirement for counseling, but this can be merely one visit with a psychiatrist or psychologist. Moreover, the death may not be so dignified. A study in the New England Journal of Medicine of euthanasia and physician-assisted suicide in the Netherlands found complications in 7 percent of assisted suicide patients, including failure to remain unconscious, extreme gasping for air, vomiting, and muscle spasms. Physicians had to complete the procedure.
Did the cultural acceptance of physician-assisted suicide lead an Ohio critical care physician to take it upon himself to end some of his patients’ lives? His defense to the indictment on 25 counts of murder is that he was providing “comfort care” with massive amounts (up 10 to 40 times the therapeutic dose) of fentanyl. Merely because the patients were receiving palliative care did not mean they consented to lethal overdoses. Keep this in mind as we are steered toward hospice in our later years.
Simultaneously, several states passed or introduced laws prohibiting abortion after a fetal heartbeat is detected. Rep. Ilhan Omar decried the “horrifying” opposition to abortion as religious fundamentalists imposing their will on lawmakers. There are pro-life atheists who view abortion as an issue of respecting humanity. I am absolutely flummoxed by how the same ultrasound and anatomy can be described as a vibrating clump of cells or a baby on its way into the arms of a loving parent depending on the mindset of the mother.
Additionally, to “promote the dignity of human life from conception to natural death”, theDepartment of Health and Human Services (HHS) will stop funding research with fetal tissue from elective abortions. Private research is unaffected. Some researchersobjected, arguing that fetal tissue has aided in the advancement of medical science. Nazi experiments during World War II likewise provided novel medical information. Their experimental bone grafting, use of sulfa drugs, limb transplantation, and artificial insemination are now standard medical procedures. And the United States cannot justify its Tuskegee experiment in which black men were not given treatment for syphilis so doctors could see the natural progression of the disease. This experiment ended not during the 1940s in the wake of Nazi atrocities or penicillin being accepted as the treatment of choice for syphilis in 1945, but in 1972.
Does the end justify the means, if eventually the means will lead you down the road to perdition? I prefer to practice medicine in the mode of Dr. Mildred Jefferson, the first black woman accepted to Harvard Medical School: “I became a physician in order to help save lives. … I am not willing to stand aside and allow the concept of expendable human lives to turn this great land of ours into just another exclusive reservation where only the perfect, the privileged, and the planned have the right to live.”
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
by Marilyn M. Singleton, MD, JD
Now that it is the political season where divisiveness rules the day, the bevy of President wannabes’ interest in maternal health is suspect. After all, none of them have joined the many maternal health advocates who praised the President for signing into law the Preventing Maternal Deaths Act which gives grants to the states to help identify the causes of maternal mortality.
According to the Centers for Disease Control and Prevention, black and American Indian/Alaska Native women are about 3 times as likely to die from a pregnancy-related cause as white women. These politicians are neither epidemiologists nor medical personnel yet they have diagnosed differences in maternal outcomes of black women as a product of racism. Their racial pandering serves to foment disharmony rather than initiate an honest examination of the problem.
Of course, those vying for political real estate will not preface their theories with some medical facts: uterine leiomyomas (fibroids), a cause of post-partum hemorrhage, are present in three times as many black women as white women. Or that the higher rates of high blood pressure in black Americans may be due to a gene that makes them more salt sensitive. Perhaps this contributes to the 50 percent higher incidence of hypertension of pregnancy (pre-eclampsia/eclampsia) in black women than in any other racial or ethnic group. White and Hispanic women have substantially the same rate of the disease and Asian and Pacific Island women have the lowest rate of any ethnic group. As a noted black female obstetrician patient safety and risk management expert called the cause of pre-eclampsia a “mystery” and noted, “older schools of thought attempted to use socioeconomic status as a reason to explain the problem, but it doesn’t hold up under statistical analysis.”
Do these politicians who label medical personnel as racists also tell you that 11 percent of obstetrician-gynecologists are black women (same as the general black population) and they were more likely than white or Asian ob-gyns to practice in federally funded underserved areas and areas with high poverty levels? Are these physicians racists?
Health problems are multifactorial and must be rigorously researched. While bias and social factors cannot be ignored, painting medical care personnel as racists will not advance the conversation.
Nor will depriving medical personnel of their religious rights eliminate discrimination in the delivery of medical care. Right of conscience laws have been on the books since the 1970s but the rules had been weakened and medical personnel began reporting workplace retaliation and harassment for their beliefs. Thus, the recently finalized Protecting Statutory Conscience Rights in Health Care rule ensures that medical personnel have the right to abstain from delivering certain medical services on the basis of religious beliefs or moral convictions.
The ink was barely dry on the final rule when San Francisco filed a lawsuit claiming it was “discriminatory.” The lawsuit alleges that the rule “prioritizes providers’ religious beliefs over the health and lives of women, lesbian, gay, bisexual, or transgender people, and other medically and socially vulnerable populations.”
First, as far as vulnerable populations, it appears black women have no trouble finding abortion providers: 49 percent of abortions are performed on white women and 40 percent on black women despite the fact that black women of childbearing age make up 14 percent of the population. Second, the lawsuit assumes that many physicians will wantonly begin to discriminate against LGBT patients. No one in the emergency room is asking the sexual history of a hemorrhaging patient.
Physicians who abide by the Oath of Hippocrates pledge to do no harm to their patients. Many physicians in their medical judgment do not believe that, for example, assisted suicide, sex-change surgery, and hormone blockers are harmless. Additionally, some surgeons simply have no desire to perform certain procedures just as breast cancer surgeons have no interest in bowel surgery.
The lawsuit contends that it is “the fundamental obligation of the medical profession and the right of patients to receive quality patient care.” The best care will come from physicians familiar and comfortable with the treatments sought. Certainly, in San Francisco with a major medical school and several large health systems, competent physicians who are well-versed in transgender surgery, sterilization, pregnancy termination, and euthanasia are available. The lawsuit is a political stunt.
No doubt some patients have experienced professionally unacceptable treatment. Fortunately, the universe filled with ethical professionals that this U.C. San Francisco-trained black female physician inhabits is more common than not. I have taken care of thousands of patients in public and private hospitals across the country. I’ve worked with hundreds of medical personnel, some of whom were not particularly warm and fuzzy with any of their patients. I cannot tell you what was in their hearts, but they always behaved professionally and competently.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
By Marilyn M. Singleton, MD, JD
May is Mental Health Month and it should inspire us to think about family, community relationships, and our growing disconnectedness. It is not an invitation for Congress and other troublemakers lose their collective minds.
While folks of all colors and lifestyles are quietly living and working together and building relationships, the professional malcontents are looking for offense around every corner. Take the sports teams shunning Presidential Medal of Freedom recipient Kate Smith for having performed some songs with racially offensive lyrics in the 1930s. One of the songs, thought to be satirical was also sung by black actor and well-known civil rights activist, Paul Robeson. Apparently, no one looked into Smith’s motives or other aspects of her life before shrouding her statue in black. How ironic that the very teams that excluded black players are “virtue signaling” at someone else’s expense.
Will the memorials to the progressive icons, Eleanor and Franklin Roosevelt suffer the same fate? Historians note that Mrs. Roosevelt called black folks “darkies” and “pickaninnies.” Yet she was instrumental in having black opera singer Marian Anderson perform in an integrated setting and flew in an aircraft piloted by a Tuskegee Airman, among other things.
The beloved President after whom many black American children were named, had a questionable racial record. He appointed Hugo Black, an ex-Klansman to the Supreme Court. He did not allow black reporters at his press conferences. And he did not support anti-lynching legislation for fear of losing Southern support. The Roosevelts’ personal lives were not exemplary: they both had continuing love affairs—not with each other.
And Harry S. Truman who as president desegregated the army, had made liberal use of the N-word. In a letter to future wife Beth, he wrote, “I think one man is just as good as another so long as he’s honest and decent and not a n***** or a Chinaman…” And as senator he called Mrs. Roosevelt’s wait-staff “an army of coons.” Should we topple his statues and remove his name from all buildings and universities?
People are complicated and must be judged as products of their times.
And when did using salty language while angry become a capital offense? When President John F. Kennedy discovered that the Air Force spent $5,000 for a maternity suite for his wife, he ripped the bark off the general in charge, saying, “This is obviously a f***-up” politically. Presidential candidate John Kerry and Vice President Joe Biden famously added to the mix.
Instead of looking for reasons to tear us apart, our congresspersons should be focusing on proposals trying to move us in a positive direction. Who cares what side of the aisle originated the ideas? Communities and their legislators must find solutions for hypodermic needles and human feces on the streets, the homeless, and drug addiction to name a few. There are 130 people a day dying from opiate overdoses with no easy answer as to the root cause. The Department of Health and Human Services formed a Pain Management Best Practices Inter-Agency Task Force including physicians and other professionals involved in caring for patients with pain and addiction issues. The task force concluded what most physicians already know: patient care must be individualized.
Our congresspersons should be having town halls seeking input from their constituents about their concerns. They may discover that many patients are reluctant to seek treatment fearing loss of privacy. For example, in some states, law enforcement can access the Prescription Drug Monitoring Program (PDMP) database for opioids without a search warrant. Moreover, these privacy intrusions may not be worth it. A 2017 study found that “PDMPs were not associated with reductions in drug overdose mortality rates and may be related to increased mortality from illicit drugs and other, unspecified drugs.” These findings were confirmed in a June 2018 review.
The Centers for Disease Control and Prevention (CDC) has similarly found that the rapid rise in overdoses is due to street drugs. Preliminary research shows that patients who are weaned off long-term prescription opioids are twice as likely to seek out street drugs.
Disturbingly, many physicians are frightened into declining to prescribe opiates or to care for patients with pain by well-intentioned but draconian government programs. One such program is California’s “Death Certificate Project.” Here, Medical Board investigators mine prescription data and cross-reference with death certificates to improperly initiate discipline against physicians although their prescription was not necessarily the fatal dose.
Save for a few rotten apples, physicians are doing their best to care for patients with complex problems. Mental Health Month offers physicians the opportunity to reaffirm that we are not automatons and patients are individuals, not data points. Congresspersons should take this month to stop squabbling and jockeying for power and explore legislation that allows physicians and patients freedom to choose their own path to a healthy life.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
by Marilyn M. Singleton, MD, JD
New York’s Catholic Democratic Governor had the World Trade Center in lights to celebrate its abortion-on-demand-until-the-d
How can we tolerate this moral regression? Infanticide was the norm throughout ancient Athens and Sparta where the elders inspected the newborns to ensure that only the strong survived, and the weak were left to die. Early Roman law decreed that deformed children would be put to death. Fortunately, by the 4th century, European law, religion, and medicine rejected the intentional killing of an infant.
Americans have been sucked in before by pretty words that mask the brutal reality of “evolved” policies. There was a time when America’s best and brightest were teaching Dr. Josef Mengele a thing or two about eugenics, the “science” of improving the human gene pool for the preservation of society.
At the First International Eugenics Congress in 1912, a Carnegie Institute-supported paper, Preliminary Report of the Committee of the Eugenic Section of the American Breeder’s Association to Study and to Report on the Best Practical Means for Cutting Off the Defective Germ-Plasm in the Human Population (“Breeder’s Report”), analyzed the problem of the “unfit” and the need to find solution to “cut[ting] off the supply of defectives.”
Even black intellectuals jumped on board. The Harvard-educated professor and civil rights activist W.E.B. DuBois believed only fit blacks should procreate to “eradicate the race’s heritage of moral iniquity.” The NAACP promoted eugenics theory by hosting “Better Baby” contests.
The Model Eugenical Sterilization Law (1914) was the blueprint for the sterilization of the “socially inadequate” including the feebleminded, insane, criminalistic, epileptic, inebriate, diseased, blind, deaf, deformed, dependent, orphans, ne’er-do-wells, tramps, the homeless, and paupers. By the 1920s, thirty-three states had compulsory sterilization laws.
Margaret Sanger, the founder of Planned Parenthood, advocated for mandatory IQ testing for the lower classes and the issuance of government-approved parenthood permits as a prerequisite to having children. Sanger criticized philanthropy as tending to perpetuate “human waste.” She also proposed that “the whole dysgenic population would have its choice of segregation or sterilization.”
Compulsory sterilization of the “feebleminded” was etched in stone by the revered liberal Supreme Court Justice Oliver Wendell Holmes. Buck v. Bell (which has never been overruled) concluded that “the principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes.”
With Congress steamrolling exclusively government-controlled medical care with Medicare-for-All, we must reflect on our past as well as the present policies of our civilized neighbors. What happens when the government runs out of money to pay for everything our politicians promised?
The Model Sterilization law’s selling point was that sterilization of those maintained wholly or in part by public expense was cost-effective: segregation for life cost $25,000 and sterilization a mere $150.
In Belgium, a nine and an eleven-year-old were euthanized for conditions that we in the United States vigorously treat: cystic fibrosis and muscular dystrophy. Canada is considering allowing such barbarism-aka medical assistance in dying—to be perpetrated upon its children.
Iceland has virtually eliminated Down’s syndrome through abortion. Coincidentally the Ministry of Health lists Down’s syndrome as the most expensive disease for the state-funded health care program.
The British National Health Service’s Institute for Health and Care Excellence supports the use of “quality-adjusted life years” (QALY) to measure the quality and quantity of life added due to a particular medical treatment. If the cost per QALY gained exceeds a predetermined amount, the government denies payment for that treatment. ObamaCare architect Ezekiel Emanuel’s “Complete Lives System” prioritizes adolescents and persons with “instrumental value,” i.e., individuals with “future usefulness.” With current nursing home costs averaging $7,500 per month, hospice care could be the default medically necessary treatment for the disabled.
It was not too long ago that the top Democrat official, Nancy Pelosi said “[Republicans] pray in church on Sunday and they prey on people the rest of the week. And while we’re doing the Lord’s work, ministering to the needs of God’s creation, they are ignoring those needs which is to dishonor the God who made them.” I don’t know whose “lord” she is talking about—perhaps the overlords who aim to take over mankind in sci-fi stories or the “Lord of the Flies.”
The day erecting a barrier to stop drug and human trafficking is considered immoral and killing viable live babies is celebrated is the day some Americans tossed morality into the abyss.
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
Despite being told, “they don’t take Negroes at Stanford”, she graduated from Stanford and earned her MD at UCSF Medical School.
Dr. Marilyn Singleton then completed two years of surgery residency at UCSF, followed by an anesthesia residency at Harvard’s Beth Israel Hospital.
Dr. Marilyn Singleton was first an instructor, then Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in Baltimore, Maryland before she returned to private practice in California.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
Dr. Marilyn Singleton has conducted make-shift medical clinics in two rural villages in El Salvador.
Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012. (Audio version of the speech to AAPS doctors by Dr. Marilyn Singleton.)
by Marilyn M. Singleton, MD, JD
Our legislators have been at their worst over the Supreme Court confirmation of Judge Brett Kavanaugh. What a shameful display: condescending, arrogant show-boating senators questioning him in a manner reminiscent of the Grand Inquisitor. The only things missing from this B-grade movie were the rubber hoses and interrogation lights. Some of us remember that you could count on one hand the “nay” votes for the confirmations of ACLU attorney Ruth Bader Ginsberg and known conservative Antonin Scalia.
This last-ditch effort to derail Judge Kavanaugh’s confirmation is more than mere political theater; the interrogators are immoral and beyond hypocritical. The “Lion of the Senate,” Ted Kennedy, killed a woman and former Senate majority leader Robert Byrd was an Exalted Cyclops in the Ku Klux Klan, and we all know about President Clinton. But that’s okay; their lapses in judgment were somehow worth our compassion and forgiveness.
Imagine if these political hacks were in charge of your medical care. Medicare-for-All as planned is the exclusive purveyor of medical “benefits.” If you want a medical service they do not want you to have, you are on your own.
The government is already shaping the way we use medical services. The Palliative Care and Hospice Education Training Act (PCHETA), S. 693 and the companion bill H.R. 1676 passed by the House and is now before the Senate Health, Education, Labor, and Pensions (HELP) Committee. This bill dedicates $100 million in additional taxpayer dollars to persuade patients to forgo treatment that might prolong life in exchange for a steady stream of increasing doses of narcotics. Perhaps knowing that many physicians still adhere to the Oath of Hippocrates, the legislators included multiple non-physicians and non-medical personnel as recipients of these funds.
Including outsiders in decision-making must be undertaken with caution. Hospice/palliative care has become the new growth industry in our “health system.” Compared to home health care, hospice had significant growth in 2017 – increasing 6.5 percent in one year. Further, according to the Medicare Payment Advisory Commission the “Increase in hospice is driven by for-profit providers” which made up two-thirds of the 4,400 hospices in 2016.
Why direct $100 million for a new medical specialty in relieving pain and suffering, a skill all physicians should embrace as part of a comprehensive treatment plan? The focus on palliative care may be one more bipartisan incremental under-the-radar step along the road to government control of our medical care. Subtly devaluing life softens us up and primes the pump for rationing – without having to pass a sweeping single payer bill that is bound to draw attention and criticism.
Ironically, within days of passing the Palliative Care bill, the Senate passed a huge package of some 70 bills designed to reduce opiate abuse. Unafraid to practice medicine without a license, the Senate legislated prescribing mandates and penalties for failure to comply. And the government is developing a “system of care” where all people will receive “appropriate” and “evidence-based” care for pain.
So now physicians may be under pressure to relinquish their patient to a palliative care specialist and prescribe medications according to government dictates. This is wrong. Our patients must never have any doubts that every treatment their physician administers is in their best interests.
We must not allow the whims of politicians to direct our medical care. Physicians must refuse to be tools of the government. Patients must decide whether they want their tax dollars spent on developing cures and life-saving treatment – or programs that steer them toward the least costly alternatives.
Can we trust our medical care to legislators who are willing to sacrifice their integrity on the altar of partisan politics — legislators who are willing to destroy a man’s life in their naked quest for power? Can we trust that doctors who oppose their agenda will not be treated like Judge Kavanaugh by medical boards, hospitals, and courts?
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
by Marilyn M. Singleton, MD, JD
The days of trusting your legislators to have your best interests at heart are in the rear view mirror. Apparently, their main interest is parroting the buzzwords of the moment to get elected and then being too busy banking lobbying money to listen to the voters. Our legislators have become spectators who wait for the perfect moment to pounce on their political “enemy” and then go on cable news shows to boast about it.
The “us against them” attitude, punctuated by hyperbolic, apocalyptic rhetoric closes the door to finding solutions. Our interests would be better served by having town hall meetings where voters could state their concerns, air their differences, and learn what legislators are doing about their issues. Caution: meetings at 9 a.m. on Wednesday when paid activists are guaranteed to outflank the working general public are prohibited.
There are strong differences of opinion on how to attain a healthy citizenry. Educating potential patients about what drives up medical care expenditures can start the conversation. Well-informed patients would demand solutions based not on corporate interests or government or political agendas, but on a fair, competitive market that maximizes choices and achieves lower costs.
Eight years of the Affordable Care Act have borne out Congressional Budget Office predictions that abandoning basic principles of insurance—which compensates only for events beyond the insured’s control and is priced according to the degree of risk—would lead to higher and higher premiums, fewer participating insurers, and unsustainable government expenditures to subsidize insurance premiums. The data in three recent Centers for Medicare and Medicaid reports on ACA exchanges show “individual market erosion and increasing taxpayer liability.” The average monthly premium for coverage purchased through the exchanges rose 27 percent in 2018, and federal premium subsidies increased 39 percent from 2017 to 2018.
A less frequently discussed cost driver is the disturbing trend of private doctors’ offices being scooped up by hospitals, health insurance companies, and venture capital groups. Prices tend to rise when health systems merge, because of decreased competition. And not only do hospitals and health systems generally charge more than private physicians’ offices, the government compounds this problem by paying more to hospitals than independent offices for the same service. A review of 2015 Medicare payments showed that Medicare paid $1.6 billion more for basic visits at hospital outpatient clinics than for visits to private offices. Patients are the biggest losers: they paid $400 million more out of pocket and had their tax dollars wasted. The study also found hospital-employed physicians’ practice patterns in cardiology, orthopedic, and gastroenterology services led to a 27 percent increase in Medicare costs. This translated to a 21 percent increase in out-of-pocket costs for patients.
Similarly, a U.C. Berkeley School of Public Health study of consolidation of California’s hospital, physician, and insurance markets from 2010 to 2016 concluded “highly concentrated markets are associated with higher prices for a number of hospital and physician services and Affordable Care Act (ACA) premiums.” In consolidated markets (defined by the Federal Trade Commission’s Horizontal Merger Guidelines), prices for inpatient procedures were 79 percent higher and outpatient physician prices ranged from 35 percent to 63 percent higher (depending on the physician specialty) than less concentrated markets.
Big medicine and third-party financing are taking the cost curve in the wrong direction. This speaks to the urgency of encouraging cash friendly practices that bypass insurance and direct primary care (DPC) practices. With DPC, all primary care services and access to low-priced commonly used medications are included in an affordable upfront price. Importantly, DPC’s time-intensive and individualized management of chronic diseases decreases hospital admissions, paring down Medicare’s $17 billion spent on avoidable readmissions.
Why corporations want to marginalize private practice seems clear; the government’s motive is open to debate. Surveys consistently find that patients overwhelmingly want “personalized provider interactions.” Thus, herding patients into government-directed programs is not the solution. One core problem with government systems is their reliance on the goodwill of politicians. As President Ford said, “a government big enough to give you everything you want is a government big enough to take everything you have.”
It’s time for Congress to scrutinize anti-competitive health system mergers. It’s time to bring to the floor over a dozen bills to expand and improve Health Savings Accounts (HSAs) to give patients more control over all facets of their medical care.
Congress, the clock is ticking on this legislative session. Stand up for patients. Or did the dog eat your courage?
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
By Marilyn M. Singleton, M.D., J.D
April 16th begins a week of National Healthcare Decisions Day. Hopefully this week will encourage honest discussions not only about a so-called “good death” but the value of an individual’s life. I am not optimistic, given the trend toward consciously or unconsciously steering patients toward “death with dignity” rather than focusing on the dignity of life. Indeed, a recent documentary video of an Oregon couple’s dual physician-assisted suicide received positive reactions.
One Affordable Care Act program to promote “quality care” through financial incentives for attaining high performance scores (and penalties for low scores) contains a metric that is fraught with moral hazard. Hospitals with higher numbers of pneumonia, heart failure, or heart attack patients who die within 30 days of discharge receive a lower score. But if patients are designated for hospice (palliative) care during the first 24 hours of their hospital stay, and then die within 30 days of discharge, they are not counted against the hospital’s score. In order to improve its quality-of-care score, one Veterans Administration hospital disclosed that it used an “inappropriate admissions system” where sicker patients were turned away against the physicians’ recommendations.
As the Affordable Care Act continues its painful death, many are seduced by the promises of government-sponsored single payer healthcare. Given the federal government’s 2017 healthcare expenditures of $1.14 trillion, politicians and policymakers ponder how to pay for such a massive program. Patients wonder whether they will pay with their pocketbooks (taxes) or their lives (rationing).
The fallback solution of raising everyone’s taxes is unpalatable to most. Aware that providing fewer services saves money but fearing public outrage, politicians have shunned efforts to explicitly ration health. Thus, policymakers promote programs that reduce waste and inefficiency. For example, frugality is encouraged by reimbursing a set dollar amount for a course of treatment that includes all inpatient and outpatient care and physician fees (“bundling”). But once the waste and inefficiency are successfully addressed, what is the next step to rein in “overuse” of services?
The British National Health Service’s National Institute for Health and Care Excellence (NICE) supports the use of “quality-adjusted life years” (QALY) to measure the quality and quantity of life added due to a particular medical treatment. One QALY is one year of perfect health. Zero QALY is death. If the cost per QALY gained exceeds a predetermined amount, the government denies payment for that treatment. Touted as more ethical, the “Complete Lives System”—the brainchild of ObamaCare physician architect Ezekiel Emanuel—includes worrisome determinants of who should receive care. The system prioritizes adolescents and persons with “instrumental value,” i.e., individuals with “future usefulness.”
These rationing systems devalue the benefits the disabled, elderly, or others with a lower life expectancy could receive from a given treatment. A study of individuals with late-in-life disabilities found that overall quality-of-life assessments were often positive even as participants described things that made their lives uncomfortable or difficult. Dignity and a sense of control were most closely tied to overall quality of life.
Importantly, health care professionals are not immune to personal bias in presenting the treatment options to patients. And physicians sometimes forget that their notion of quality is not the same as the patient’s.
A nationwide multi-medical center study revealed the inadequacy of written living wills or the generic check-the-box Physician Orders for Life-Sustaining Treatment (POLST). Based solely on these documents, physicians reached a consensus (95 percent agreement) on code status and resuscitation decisions in only two out of nine clinical scenarios. Viewing a patient’s video statement produced statistically significant improvement in physician agreement in interpreting the patients’ wishes in seven scenarios. Moreover, in five of the seven scenarios, physicians were more likely to choose full aggressive treatment.
It seems the best way to be your own best advocate is jump into the 21st century and make a video. Ensure that in a critical moment you are seen as not merely a medical condition but a person. If you want no medical intervention, say so in your own unambiguous words. If you want the full court press, be clear and explicit. Tell your doctors to treat you as aggressively as 92 year-old Jimmy Carter was treated for his metastatic malignant melanoma. And NO, a former president is not more important than you are.
And to my fellow physicians: ask yourself what you would recommend to the parents of a 19 month old deaf and blind toddler who needed extensive intensive care. Helen Keller’s parents have the answer.
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.