Federal Involvement in Medical Care is Not the American Way
Obesity: America’s Self-inflicted Preexisting Condition
Consuming too many potato latkes and Christmas cookies has left its mark on our waistlines. Unfortunately for Americans and their medical care, the seasonal overeating seems to last all year. Indeed, the American Medical Association has declared that obesity is a disease.
It may be more accurate to describe obesity as a contributor to certain diseases. Obesity raises the risk of premature death, heart disease, high blood pressure, stroke, type 2 diabetes, gallbladder disease, breathing problems, certain cancers, and osteoarthritis. Certainly, obesity can result from certain uncommon diseases and hereditary factors, but most people become obese simply because they eat too many unhealthy foods and do not exercise.
At its last count, the Centers for Disease Control and Prevention (CDC) estimated that 40 percent of U.S. adults age 20 and over, 21 percent of teens, and 14 percent of preschoolers are obese. A December 2019 study that analyzed 26 years of body mass index (BMI [the relation of weight to height]) data concluded that half of U.S. adults will be obese (BMI>25) by 2030. Some 25 percent will be severely obese (BMI>35). Moreover, less than 5 percent of adults get the recommended 30 minutes a day of physical activity. And even when people living in “food deserts” were presented with healthy options, only 10 percent changed their evil eating ways.
According to the CDC’s last comprehensive analysis, the annual medical cost of obesity in the United States to Medicare, Medicaid, and private insurers was $147 billion in 2008. And the medical costs for obese people were $1,429 higher than those of healthier weights.
The saddest development is the cultural normalization of obesity with lingerie models, singers, and television shows celebrating fatness. Do we high-five people with other lifestyle related conditions such as alcoholism, emphysema, or coronary artery disease? Of course not.
The obese are easy targets for drug company peddlers of quick fixes or “providers” who want to extract money from third-party payors. U.S. pharmaceutical companies spent $6.1 billion on direct-to-consumer prescription drug advertising in 2017. Many ads feature chunky type 2 diabetics happily frolicking about, thanks to the drug company’s magic pill. The ads might as well say, “pass the chocolate cupcakes with statin sprinkles drizzled with insulin.” We all know the prescription of eating less and exercising more is free of charge.
Alas, we are losing the battle of the bulge. A recent study found that participants failed to lose weight despite reporting that they were exercising and watching their diet. The authors concluded that “many of [the participants] might not have actually implemented weight loss strategies or applied a minimal level of effort, which yielded unsatisfactory results.”
While politicians debate the merits of spending trillions of dollars on government-sponsored medical care, a correctable source of high medical costs is hiding in plain sight. Irrespective of who pays for medical care, rational economic decisions must be made. The Affordable Care Act (ACA) waved a magic wand and removed preexisting conditions from the underwriting equation when calculating premiums. A sick person and a healthy person of the same age could purchase insurance at the same price. Consequently, the ACA doubled the costs for people who made the effort to take care of themselves.
The ACA did allow a “tobacco surcharge” of up to 50 percent more for premiums. Why not an obesity surcharge? This would provide an incentive for consumers to take obesity seriously. Additionally, health-conscious persons would not have to pay for the bad habits of others through taxes to fund government health insurance programs or through higher private insurance premiums.
Those who are stricken with illnesses through no fault of their own need a path to affordable medical care. A good start for lowering costs would be eliminating costly middlemen by encouraging consumers to pay directly for day-to-day medical expenses. Expanding contribution limits and eligible uses of Health Savings Accounts would help pay for the more reasonably priced direct-pay surgery and other alternatives to insurance like direct primary care.
With regard to insurance, we need a revival of competition in the insurance market with multiple products and carriers. Once again, single men could opt to decline pregnancy coverage. We need to restore the pre-ACA availability of low-cost catastrophic (major medical) insurance policies to all ages. Even before mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the large majority of insurers offered guaranteed renewable policies. Here, assuming timely payment of premiums, at the end of the policy period the insurer must renew coverage regardless of the health of the insured. Naturally, this valuable feature costs more but provides consumers with a strong incentive not let the insurance lapse.
Let’s confront the elephant in the room. Healthcare policy should promote personal responsibility, rather than encourage free riders. In America we are free to overeat and under-exercise but we have no right to make innocent bystanders pay for the consequences.
Data Mining, Artificial Intelligence, and Angels of Death
By Marilyn M. Singleton, MD, JD
Google is universally well known as a search and advertising company. Now Google is tapping into the $3.5 trillion healthcare market. To compete with the Apple Watch, Google acquired FitBit, the wearable exercise, heart rate, and sleep tracking device. Data is king.
Voluntarily worn fitness tracking devices are one thing, but Google has entered the realm of the brave new world.A government inquiry has brought to light Google’s “Nightingale Project” that collected private medical data from Ascension Health’s 2,600 sites of care across 20 states and D.C., unbeknownst to the patients. Dozens of Google employees had access to the data which included lab results, physician diagnoses, hospitalization records, and health histories, complete with patient names and dates of birth. Google claims that the project complies with the Health Insurance Portability And Accountability Act (HIPAA) because it is a qualified business associate of Ascension Health. And unlike the ads for socks that appear on your computer a nanosecond after you purchased some tennis shoes, Google promises that the data won’t be combined with consumer data. Fat chance.
Amazon, which already knows our every thought, was not satisfied with merely creating software that can read medical records. Now they’ve created Transcribe Medical, a system that transcribes confidential patient-doctor conversations and uploads them directly into the electronic health record. Doctors would relinquish all control over “private” patient records. Google also has been working on its own automatic speech recognition “digital scribe” to upload multiple speaker conversations.
Not only is there a problem with inaccuracies that could lead to a patient receiving the wrong treatment, but we all know the ubiquitous problem of hacking—even in the Department of Defense and the federal Office of Personnel Management.
Disturbingly, certain circles oohed and aahed over the revelation that Google, using electronic health records (EHR), created an artificial intelligence program that could predict death better than doctors. Fortunately for humanity, many others found the thought of leaving doctors out of the equation horrifying. The cheerleaders crowed that it would decrease work for the doctors; they wouldn’t have to waste their time going through those pesky medical records to arrive at a conclusion. Using an artificial neural network to predict the death of a human being is a far cry from having a computer interpret an inanimate x-ray who is not a daughter, mother, sister, wife, or grandmother.
If you put it all together, it adds up to a death panel of one. Google’s software would decide that there is not a high likelihood of walking out of the hospital, no treatment would be given. We are becoming witness to the devolution of humanity.
Moreover, the government is incentivizing workforce development in palliative care through the Palliative Care and Hospice Education and Training Act. Perhaps this is why the hospice team seems to greet the patient at the hospital door. Of note, once a person has signed on to the Medicare hospice program, Medicare will not pay for any curative treatment or medications. Medicare will not pay for an emergency room visit unless the hospice team arranged it or someone decides it is not related to the hospice diagnosis.
The number of hospice agencies participating in the Medicare program nearly doubled between 2000 and 2016, for a total of some 4,382 providers. In 2000, about 30 percent of hospice agencies were for-profit, compared to about 67 percent in 2016. In that same period, Medicare payments grew from $3 billion to $16.8 billion.
Hospice care is lucrative. The minimum Medicare payment is $196 per day regardless of the quantity or quality of services provided on that day. A July 2019 report from the Office of Inspector General for the Department of Health and Human Services found that more than 80 percent of end-of-life facilities in the United States had at least one deficiency, and nearly 20 percent were poor performers with serious problems that jeopardized patient health and safety. It seems the compassionate medical service to care for suffering patients has turned into a heartless cash cow.
Is this what we want for our loved ones and eventually, ourselves? Medicare for All promises every type of medical care under the sun, including long-term care. Long-term care is expensive and if done properly, labor intensive. What better way to save money than to promote a computer program that convinces doctors that the patient is going to die no matter what they do. So the hospital tells the family that treatment or home care will drain their finances. For what? I’ll tell you for what. My parents died at home only after they were tired of doctors and ready to go. They strolled into heaven. They were not shoved in with a giant government backhoe.
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.
Giving Medicare for All a Facelift: the Ugly Is Still There
By Marilyn M. Singleton, MD, JD
Medicare for All (M4A) retained its prominent place on the stage at the latest Democratic debate. In its purest Bernie Sanders form, concurrent with abolishing private health insurance, U.S. residents would be enrolled in “Medicare.” The program would pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health and substance abuse treatment, vision, dental, and hearing services, and long-term care with no out-of-pocket costs. Some supporters were scared off by the $32 trillion over 10 years price tag. Not to be outdone, Elizabeth Warren’s “I’m with Bernie” plan comes with a $52 trillion over 10 years price tag including up to $34 trillion in new government spending. Our country’s entire yearly budget is a mere $3.5 trillion. For perspective, if your salary is $40,000 per year it would take 25 million years to earn 1 trillion dollars. As M4A’s dark side emerged, the candidates distanced themselves from Bernie-care.
Elimination of private insurance? Whoa, Nellie! Over 156 million Americans —half the country—are covered by employer-sponsored health insurance plans and another 23 million have private individual policies. And most of these folks like that arrangement. Then there was pushback from some unions who had excellent health insurance policies for which they had bargained and given up other perks.
In the June debate the candidates raised their hands indicating they would abolish private health insurance. Now Mayor Buttigieg wants to “unify the American people around, creating a version of Medicare, making it available to anybody who wants it, but without the divisive step of ordering people onto it whether they want to or not.” Vice president Biden, noting his desire to keep patient choice stated, “we should build on Obamacare … adding a Medicare option in that plan, and not make people choose.” Of course, Obamacare caused a rise in premiums, a decrease in choice of insurance coverage, and like any large government-run program was prone to mismanagement and waste.
Possible financing mechanisms were screaming for a deep dive. One analysis concluded that most Americans would suffer financially if M4A were implemented as proposed. An analysis by a bipartisan think tank estimated a 32 per cent increase in payroll taxes would be needed to fund M4A. Everyone—even the working poor—would have more payroll taxes extracted from their paycheck. The analysis concluded that most households would pay more in new taxes than they would save by eliminating their current spending on private health insurance and out-of-pocket medical expenses.
Senator Warren tries to hide the ugly truth by railing about the evil rich who would be taxed down to their underwear. Take the deceptively worded “2-cent” annual tax for households with more than $50 million in assets. If you have $51 million in assets, most probably tied up in your business, you’d have to cough up (.02)($1,000,000) or $20,000, not 2 cents. The devil’s spawn, aka our 535 billionaires, would be subject to a 6 percent annual tax on their assets. Who will be the next target when the government has driven the assets to a sunny island in the Caribbean? Finally, raising the corporate income tax back up to 35 percent likely would result in businesses paying lower wages to current employees or cutting back on hiring to compensate for the increased tax burden.
During the latest debate, Senator Warren retreated from her “all-in” approach, asserting she would first provide Medicare at no cost to “everybody under the age of 18, everybody who has a family of four income less than $50,000”—about 135 million people. Second, she would lower the Medicare age to 50 and expand Medicare coverage to include vision, dental, and long-term care. In the third year, “when people have had a chance to feel it and taste it and live with it, we’re going to vote and we’re going to want Medicare for all.”
Senator Sanders owns that payroll taxes would be doubled or tripled and proposes a 4 percent surtax on families earning more than $29,000. So if you earn $60,000, you’d have to pay (.04)($31,000) or $1,240, enough for a whole year’s membership in a private Direct Primary Care plan. Senator Sanders, staying true to his principles, is sticking with unadulterated Medicare for All with its financial warts.
Even those who are numb to government over-spending can see the broader problem of inviting Uncle Sam into their lives in exchange for a Medicare card in their wallet. Any remaining privacy is erased. Our medical records would be furnished to the Department of Health and Human Services and the National Coordinator for Health Information Technology. Physicians and patients would be robbed of their autonomy and choice by medical care policies set by the government monopoly. Lack of competition leads to lower quality and fewer services. Coverage becomes an illusion.
Medicare for All’s beauty is only skin deep and its ugly goes to the bone.
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.
Halloween’s Over: Take off the Masks
At a graduation of a family friend, out of the blue, one in our group began lamenting that progressives tended to live in cities. She proposed that progressives should move to rural areas and “purge [such areas] of those awful conservatives.” Thus spake the tolerant Left. I was stunned. Given the festive occasion, I kindly reminded her that this is America and we are lucky that we have all kinds of people. I wanted to ask her what we should do with the conservatives. Re-education camps? Death by a continuous loop of Bernie Sanders speeches?
It is unfortunate that such unreasonableness isn’t isolated within the D.C. swamp containment zone.
These pied pipers who offer free college, free food, free medical care, and free money for simply having a pulse freely admit they have no idea how to pay for it. Oh, yes: tax the “rich” and corporations who will pass the tax on to consumers and employees in the form of higher prices and lower wages. And eventually the heretofore untouchable middle class will be taxed directly. Let’s not forget that free food and housing are components of slavery.
These Einsteins are scientists when it comes to global warming and evolution but think it’s medically acceptable to permanently sterilize 7-year olds to avoid appearing like a “transgender” bigot. Science lesson: there are 2 genders. Every human has 23 pairs of chromosomes. The X chromosomes and Ychromosomes determine sex. With rare exceptions of random abnormalities, female is XX and male is XY.
These self-described health care experts try to debunk innovative medical care delivery methods like direct pay and direct primary care subscription practices by claiming these are reserved for the rich. A mere $1,500 per year ensures that you and your doctor, make your medical decisions—not the government. These “experts” are the same people who prop up the medical-insurance-government industrial complex at the expense of private physicians, writing laws that favor big-box retail clinics staffed by non-physicians. These swamp creatures equate physicians with “mid-level” practitioners with one fifth the training and education as physicians—but likely demand the chairman of the department when they themselves need medical services.
These compassionate legislators are keen on the government taking over the “social determinants of health,” including loneliness. I anxiously await an army of a government operatives coming to our homes and telling us to be happy or else. Most people just want to control their own lives, even if their life does not fit the government blueprint. If you want your life to be your own, and your body to be your own, then you cannot let the government’s foot in the door.
These forward thinkers decided it was good public policy to ban children’s fathers from the home in order for the family to receive government funds. It became normalized for the federal government to be the daddy.
These elitists castigate the middle class for not wanting homeless people sleeping and defecating in front of their houses for which they worked two jobs, saved, and sacrificed for years. Their remedy is a tent city in a middle-class neighborhood that is nowhere near theirs. These people do not want to admit that the disintegration of the family and the moral decay leading to drug use and detachment from society is the first problem that must be addressed.
And the biggest hobgoblins of them all are the peddlers of faux racism. Americans do not wake up every morning hating on each other. They ponder their family’s safety and keeping a decent job to pay their bills. Something is seriously wrong, indeed demented, when a former First Lady—unchallenged—claimed that white Americans are “still running” from minority communities when they move to another neighborhood. Perhaps they are getting away from homeless encampments (with mostly white people) or poorly run government schools in Democrat-controlled cities. Get over yourself.
Everything is not about race. Get out in the real world and sit at a local bar or cafe in central Mississippi and watch blacks and whites eating and laughing together. Who is the hatemonger?
America has had a few tragic well-publicized racially motivated incidents. Undaunted, we continue to strive for liberty for all—despite the calculated enmity and scab-picking by rich and famous black people who ran away from minorities to live on a $15 million estate on Martha’s Vineyard (and not in Oak Bluffs) and who expect us to swallow their vitriol-laced baloney.
This insanity is patently sick and sickening. It is about power at any cost and not what can help move America forward.
Fraud and Anonymity: The Perils of Medical Care Bureaucracy
By Marilyn M. Singleton, MD, JD
The high cost of medical care is on the lips of every politician and draining the pocketbooks of most Americans. After creating the Medicare/Medicaid monster, the government’s expanded intervention into the medical care marketplace with the inaptly named Affordable Care Act doubled the premiums and deductibles for both employer-sponsored and individual insurance. Piling on more laws, regulations, and agencies is not the answer.
Anonymity, complexity, and opacity invite shady behavior. Individuals, companies, and patients who defraud the massive federal “health system” would never dream of lifting money from their patients’ wallets or stealing from their doctors’ cash drawer.
The government’s track record does not bode well for imposing more bureaucracy to remedy a problem created by the layers of third-party payer bureaucracy. Waste, fraud, and abuse are so rampant that the government has a Medicare Strike Force to root out and recover lost federal funds. Medicare fraud—about $60 billion in 2016 alone—is about 10 percent of Medicare’s total payments. By contrast the typical private business loses 5 percent of its revenues to fraud. Unfortunately, since its inception in March 2007, the Medicare Strike Force has recouped less than $2 billion per year in misappropriated funds.
Medicare’s $16.7 billion per year hospice program is fertile ground for the unscrupulous. Hospices are paid a fixed daily sum for each patient enrolled “regardless of the services provided.” One amoral scheme recruits patients who unknowingly forgo curative treatment options by joining hospice. A recent Office of Inspector General (OIG) report revealed that in 2012 hospices billed Medicare more than $250 million for services to patients in long-term care or assisted-living residences who did not require hospice care, costing four times more than the appropriate level of care. Even worse, the OIG found that the quality of care suffered in 31 percent of programs. The bureaucratic morass allows the perpetrators to pocket the fixed fee and skimp on the services.
Further, the government cannot keep track of its program dollars. According to another OIG audit, in 2009, Medicare Prescription Drug program paid $33.6 million and hospice patients paid $3.8 million for medications that should have been included in the hospice daily fee. Even after discovering the snafu, the problem got exponentially worse. In 2016 the government paid $160.8 million for drugs that hospice organizations should have paid for from its fixed daily fee. Our tax dollars paid for the drugs twice.
Physicians know what patients want and are acting on it. Free from the restraints of government “healthcare” programs, the physician-led, price-transparent, direct-pay Surgery Center of Oklahoma performs some surgeries for less than the copays of some insurance policies. Direct Primary Care physicians provide 24/7 access and basic labs for as little as $50 per month with at-cost medications and low-priced x-rays.
The corporate private sector has learned a thing or two from innovative physicians. Care Accelerator is Sam’s Club’s version of “affordable [medical care] options with transparent pricing.” To offer relief from high out-of-pocket costs, $50 (individual) to $240 per year (families) buys access to lab screening for diabetes and heart disease, free generic drugs, telehealth, and up to a 30 percent discount on vision, dental, and other ancillary services. Additionally, Walmart is training its own employees for jobs in the health sector and ideally to staff Walmart’s own medical services. For their employees, Apple has “health care built around you” with its AC Wellness that offers office and home visits; Amazon launched its Amazon Care telemedicine services.
Given the outrageous price of drugs—largely due to the pharmacy benefit manager middlemen—Good Rx discount coupons are just what the doctor ordered. Good Rx is free to the consumer and makes money from advertisements on the website and referral fees. One typical victory is a Medicare patient whose neurologist prescribed a drug for his Parkinson’s disease symptoms. The government demanded testing that could not be done because of the patients debilitated condition. Despite a sympathetic ear and supporting research, the government arbiter could only parrot the party line: because the drug was not on the “list,” it was not covered by Medicare. In a fortunate twist of fate, with a Good Rx coupon the patient paid $34 per month cash instead of the drug’s $1,100 per month price with 20 percent patient co-pay that would have been charged through the Medicare Prescription Drug program.
Congress claims it plans a full-frontal attack on the high cost of medical care (with the same results as the war on poverty and drugs?). Frankly, we are better off with Congress engrossed in its impeachment clown show and keeping its nose out of our medical business.
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.
The Medical Care Wheel of Misfortune
By Marilyn M. Singleton, MD, JD
You finally get your dream and are selected to be a contestant on Wheel of Fortune. You get to see Pat Sajak and Vanna White! You win a vacation to some country that you don’t really want to see. You cannot get the cash equivalent. You have to take 10 days off of work to take the free vacation you did not want. You discover that you have to pay the tax on the free vacation.
Or you win a free car. You have a perfectly functioning 3-year-old car. The free car was not really the car you would have selected. You accepted it because it was free. Then you see that you have to pay tax on the list price of the free car. You also discover that the collision insurance and Department of Motor Vehicles registration for the free car are significantly higher than for the car you currently own.
These are examples of why nothing is “free.” This applies to medical care as well. You may have to see the “health care provider” the government program or private insurer makes available to you. You don’t particularly want to see a nurse, but that’s the way the cookie crumbles with free health care. Oh well, you convince yourself that it’s okay because, just like that car on the game show, it was free.
Here’s a new spin on “free.” Yes, your medical care should be free – free from the restraints of government control. Free from the government rules that have raised the price of insurance premiums. The Affordable Care Act mandated ten essential benefits that all insurance plans must include free of out-of-pocket charges to patients. Of course, this does not include the initial out-of-pocket charge: the insurance premium. Insurance premiums shot up over the post-ACA year because the insurance plan has to cover conditions that the insured persons may not even encounter in their own lives. A glaring example is obstetrics coverage in a menopausal female. Preventive and wellness visits are also labelled as free.
Moreover, a recent AMA study revealed that over the last four years the competition in the commercial insurance market has decreased. In over 50 percent of metropolitan areas, representing about 73 million persons, one insurer has half of the market. The more concentrated the market, the higher the premiums.
Remember that free car? We all know and readily accept that car insurance does not pay for the gas and basic maintenance. So why should maintenance medical care be covered by insurance? Car insurance would be unaffordable for most car owners if it paid for gas, oil changes, new mufflers, radios, and batteries. Most states require drivers to have car insurance. If people can’t afford the insurance, they lose the benefit of owning a car.
Similarly, if you lose your health due to long waits or delayed diagnosis because the CT scan was not authorized or poor medication response because you had to take the formulary drug that was not the doctor’s first drug choice for you, the care is not free, but very costly.
The underlying message of free “health care” is disempowering. The message is that we are incapable of taking care of ourselves. Empowerment is having control over our own lives. First, we take charge of our own health by thinking about the choices we make. We choose to not smoke, overindulge in food or drink, or engage in foolhardy behaviors. Second, we decide what is important for our own health. If you do not want insurance coverage for obstetrics or fertility treatment because you are 50 years old and do not want children, there should be a less expensive insurance product available to you. Third, we need to be free to choose our own doctor as well as the treatment the doctor—not the invisible third-party payer—recommends.
The promised free health care would increase the payroll taxes on all workers, even if that worker does not want that particular brand of free medical care. The next time you hear that medical care is free, just think about that “free” car that is the wrong color, is too small, has uncomfortable seats, inadequate headroom, and overall is not what you really want.
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.
Don’t Buy What They Are Selling
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.
The Morality of Life and Death and Doctors
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.
Can We Trust the Government with Our Medical Care?
By Marilyn M. Singleton, MD, JD
The short answer is No. And thinking that, we would be in good company. A new survey finds that Americans trust Amazon more than the federal government.[1] The most trusted entities were our military, Amazon, Google, local police, and universities. Congress came in as the least trusted, edging out political parties and the press.
Bureaucratic incompetence and cronyism are not the only reasons we should be wary of government involvement in our medical care. The federal government has a checkered history when it comes to medical judgments.
Forced Sterilizations
In light of state governments’ recent love affair with post-term abortions (aka infanticide), forced sterilizations are at the top of my list. Although other states had tried, Indiana became the first state in the country to successfully pass a forced sterilization law in 1907. The law applied only to the “feebleminded.” California and Washington jumped on board in 1909. By the 1920s, 33 states had forced sterilization laws. Heads of psychiatric institutions were free to sterilize anyone they considered social misfits. [2]
We now cringe at the words of the revered Supreme Court Justice Oliver Wendell Holmes in the 1927 case, Buck v Bell, upholding Virginia’s sterilization law for the institutionalized “feeble-minded.”[3]
[Carrie Bell’s] welfare and that of society will be promoted by her sterilization. It is better for all the world if, instead of waiting to execute degenerate offspring for crime or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind…. Three generations of imbeciles are enough.
In fact, Carrie’s mother was a prostitute, but not feebleminded. After Carrie’s release, she maintained a job as a domestic worker and became an avid reader. Her “feebleminded” daughter was on her school’s honor roll.
With the third branch of the federal government on board, between 1909 and 1979 more than 20,000 government-funded forced sterilizations were performed. The last legal forced sterilization was in 1981. These went beyond the mentally challenged. Latinos and blacks were easy targets, particularly in the 1970s after Medicaid-funded family planning service offered sterilization. Some patients were bullied into consenting with threats of having their welfare benefits or medical care taken away. Sometimes patients were coerced into a tubal ligation immediately after their infant’s delivery. At other times, tubal ligations were done during Cesarean sections unbeknownst to the patients. These sterilizations were such an open practice in the South that that they became known as a “Mississippi appendectomy.”[4]
In North Carolina, an IQ of 70 or lower qualified a person for sterilization. Here, state social workers could file petitions for sterilization. One social worker sterilized her entire caseload.[5]
The Indian Health Service with its captive audience was worse. Between 1973 and 1976 some 3,400 Native American women— including minors—were sterilized without permission or with defective consent forms.[6]
The Tuskegee Study
The “Tuskegee Study of Untreated Syphilis in the Negro Male” lasted from 1932 to 1972. The U.S. Public Health Service used 400 mainly poor, illiterate, black sharecroppers with syphilis as lab animals. They were told they had “bad blood,” but not that they were actually suffering from a serious disease. That was the extent of the “informed consent.” In exchange for having their lives ruined, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years. The men were never given adequate treatment for their disease. Even when penicillin became the drug of choice for syphilis in 1947, researchers did not offer it to the subjects. Nor were the subjects given the choice of quitting the study. All subjects succumbed to untreated syphilis so our government could track the natural progression of the disease. Once the study became public in 1972, it took a nine-person panel appointed by the assistant secretary for health and scientific affairs to decide that the study was “ethically unjustified.”[7] A class-action lawsuit filed the next year resulted in a $10 million settlement for the victims and their families.
Germ Warfare
This one is personal. My first patient that died, whose name and face I still remember, was a drug addict with bacterial endocarditis due to Serratia marcescens. The medical resident was baffled. Drug addicts are more susceptible to unusual bacteria, but where did this Serratia come from? It came from our own government.
Throughout a week in September 1951 as part of the U.S. Navy’s “Operation Sea Spray,” a presumably harmless bacterium, Serratia marcescens, was sprayed over San Francisco in a biological warfare test.[8] The U.S. Army’s monitoring of 43 sites around the city determined that San Francisco had received enough of a dose for nearly all of its 800,000 residents to inhale millions of particles each day during the week of spraying. Consequently, cases of urinary tract infections and pneumonia in San Francisco also increased after Serratia marcescens was released.
During Senate subcommittee hearings in 1977, the army revealed that between 1949 and 1969 open-air tests of biological agents were conducted 239 times in populated civilian areas, including Minneapolis; St. Louis; Mechanicsburg, Pa.; the Washington, D.C., National Airport; and New York’s subway system.[9] Had President Nixon not terminated the program in 1969, how many more sprayings would we have had?
Experimental Vaccine
In 1989, a study sponsored by the Centers for Disease Control and Prevention (CDC) tested an experimental measles vaccine on 1,500 six-month old black and Hispanic babies in Los Angeles. The CDC director, Dr. David Satcher, admitted in 1996 that “a mistake was made” and “it shocked [him].”[10] The consent papers the parents signed said the children would receive one of two vaccines, but they were not told that one of the vaccines was experimental and unlicensed.
A deceptive brochure was distributed with the consent form. The brochure advised: “This vaccine has been shown to be effective in younger children. Over 200 million children around the world have received this vaccine, but Los Angeles County is the first place in the United States where it is being offered.”It was not until a significant number of children in Africa and Haiti had died from the vaccine that the study was stopped in 1991.
The Veterans Health Administration
The Veterans Health Administration (VA) is the current model of a government-sponsored single-payer health system. Let the headlines do the talking. A 2014 report by Sen. Tom Coburn (R-Okla.) found that more than 1,000 veterans may have died in the last decade because of malpractice or lack of care from VA medical centers.[11]
Even after the long waits were revealed, “Deceased” notes on files were removed to make statistics look better: veterans would not be counted as having died while waiting for care at the Phoenix VA hospital.[12]
In January 2015 it was reported that more than 1,600 veterans waited between 60 and 90 days for appointments at facilities operated by the VA Greater Los Angeles Healthcare System. About 400 veterans waited 6 months for an appointment. The average wait time, according to documents dated Jan 15, 2015, was 48 days.[13]
By April 2015, despite major reforms, government data show that the number of patients facing long waits at VA facilities had not dropped at all. The number of medical appointments delayed 30 to 90 days has largely stayed flat. The number of appointments that take longer than 90 days to complete has nearly doubled. This was far from the government’s goal of 30 days.[14]
A 2018 report from the Department of Veterans Affairs inspector general found that the Washington, D.C., VA Medical Center has for years “suffered a series of systemic and programmatic failures to consistently deliver timely and quality patient care,” and heightened potential for waste, fraud and abuse of government resources.[15]
Finally, in May 2018, veterans saw relief with the VA’s Choice program, when the bipartisan bill passed and was signed by the President. Under the law, if the VA cannot provide the veterans with the level of care they need or the level of care they expected, or had long wait times, the veteran can seek care in the private sector.[16]
Q.E.D.
Conclusion
The noted 19th century statesman and orator Daniel Webster said, “Good intentions will always be pleaded, for every assumption of power; but they cannot justify it…. It is hardly too strong to say, that the Constitution was made to guard the people against the dangers of good intention, real or pretended.”[17] Given the government’s track record, even the most jaded bureaucrat cannot justify such betrayals of patients’ rights and the public trust.
There is another theme between the lines: offer the people free stuff and then use it as a cudgel to keep the recipients in line. The helpless, the poor, and Native Americans were easy targets. Now “Medicare for All” threatens to trap the rest of us in a system with no escape.
Marilyn Singleton, M.D., J.D., an anesthesiolologist, serves as president of AAPS. Contact: [email protected].
Download PDF of this article: https://jpands.org/vol24no2/singleton.pdf [originally published as “From the President” column in Summer 2019, JPandS.
REFERENCES
- Tiffany K. In Amazon We Trust—but Why?; Oct 25, 2018. Available at: https://www.vox.com/the-goods/2018/10/25/18022956/amazon-trust-survey-american-institutions-ranked-georgetown. Accessed April 2, 2019.
- Zhang S. A long-lost data trove uncovers California’s sterilization program. Atlantic, Jan 3, 2017. Available at: https://www.theatlantic.com/health/archive/2017/01/california-sterilization-records/511718/. Accessed April 3, 2019.
- Buck v Bell, 274 U.S. 200 (1927). Available at: https://supreme.justia.com/cases/federal/us/274/200/. Accessed April 3, 2019.
- Garcia S. 8 shocking facts about sterilization in U.S. history. Mic; Jul 10, 2013. Available at: https://mic.com/articles/53723/8-shocking-facts-about-sterilization-in-u-s-history. Accessed April 2, 2019.
- Schoen J. Reassessing eugenic sterilization: the case of North Carolina. In: Lombardo PA, ed. A Century of Eugenics in America. Bloomington, Ind.: Indiana University Press; 2011:141-160.
- Government Accounting Office. Investigation of Allegations Concerning Indian Health Service HRD-77-3; Nov 4, 1976. Available at: https://www.gao.gov/products/HRD-77-3. Accessed April 3, 2019.
- Centers for Disease Control and Prevention. The U.S. Public Health Service Syphilis Study at Tuskegee; Dec 22, 2015. Available at: https://www.cdc.gov/tuskegee/timeline.htm. Accessed Apr 3, 2019.
- Subcommittee on Health and Scientific Research of the Committee on Human Resources, U.S. Senate, 95th Congress. Examination of Serious Deficiencies in the Defense Department’s Efforts to Protect the Human Subjects, of Drug Research. Hearings; Mar 8 and May 23, 1977. https://babel.hathitrust.org/cgi/pt?id=mdp.39015005321081;view=1up;seq=1
- Mahlen S. Serratia infections: from military experiments to current practice. Clin Microbiol Rev 2011;24(4): 755–791. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3194826/. Accessed Apr 4, 2019.
- Cimons M. CDC says it erred in measles study. Los Angeles Times, Jun 17, 1996. Available at: https://www.latimes.com/archives/la-xpm-1996-06-17-mn-15871-story.html . Accessed Apr 4, 2019.
- Devine C. Bad VA care may have killed more than 1,000 veterans, senator’s report says. CNN; Jun 24, 2014. Available at: https://www.cnn.com/2014/06/24/us/senator-va-report/. Accessed Apr 4, 2019.
- Bronstein S, Griffin D, Black N, CNN Investigations. VA deaths covered up to make statistics look better, whistle-blower says. CNN; Jun 24, 2014. Available at: https://www.cnn.com/2014/06/23/us/phoenix-va-deaths-new-allegations/. Accessed Apr 4, 2019.
- Bronstein S, Griffin D, Black N, Devine C. It’s not over: veterans waiting months for appointments. CNN; Mar 14, 2015. Available at: https://www.cnn.com/2015/03/13/us/va-investigation-los-angeles/. Accessed Apr 4, 2019.
- CBS News. “Livid” VA patients still facing long waits times for health care; Apr 9, 2015. Available at: https://www.cbsnews.com/news/va-patients-still-facing-long-waits-times-for-health-care/. Accessed Apr 4, 2019.
- Summers J. Systemic failures plague DC veterans hospital, inspector general finds. CNN; Mar 7, 2018. Available at: https://www.cnn.com/2018/03/07/politics/washington-dc-va-hospital-inspector-general/index.html. Accessed Apr 4, 2019.
- Summers J, Landers E. Senate passes proposal to expand private health care for veterans. CNN; May 23, 2018. Available at: https://www.cnn.com/2018/05/23/politics/veterans-health-care-senate-vote. Accessed Apr 4, 2019.
- AZquotes.com. Available at: https://www.azquotes.com/quote/1315991. Accessed Apr 3, 2019.