Current Events, Featured, Health Policy, Healthcare Reform, Politics, Socialized Medicine, What's New

More Red Tape Does Not Provide Better Health Care

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The Affordable Care Act’s hundreds of pages of mandates and thousands of pages of regulations could not provide what we Americans want: more choice, lower costs, and better care. The premiums and deductibles continue to rise. Patients are finding fewer “in network” doctors, leading to surprise medical bills. 

While some were busy pontificating about how much they care about patients, the President was busy working to make our medical care great again. There was a time when there were hundreds of insurers offering a variety of individual health insurance plans tailored to an individual’s needs. Just as we do with the variety of products that we buy every day, we can use our purchasing power to compare costs and value. This includes using our tax-free health savings accounts to pay to day-to-day medical care out of pocket. 

Back in 2017, the President started the road to put patients in charge of their own money and medical care. After ensuring that the ACA’s mandate tax was repealed, his administration increased insurance options that cost up to 60 percent less that the lowest price ACA plans. The President launched a rule to broaden the availability of association health plans for small businesses which are projected to cover up to 400,000 previously uninsured individuals for on average 30 percent less cost. He expanded health reimbursement arrangements that allow consumers to use tax-free dollars to pay for some medical costs. 

The President signed a law banning “gag clauses” that prevented pharmacists from telling customers when it would cost less to directly purchase a medication, rather than through their health insurance. He continues to make rules to lower prescription drug prices in federal programs.

Speaking of caring about real patients, the President expanded choice to our veterans by allowing them to seek care from private physicians. And after many years of work by advocates, the President signed the Right to Try Act so critically ill patients could have access to life-saving treatment. The President’s latest executive order promises that he will not sign any law that does not cover patients with pre-existing conditions.

Medical care is one of the most personal aspects of our lives. A government bureaucracy by its very nature is one size fits all—or more realistically, one size fits none. The ACA has shown us that more government control is not the answer. It’s time for the President’s plan rooted in patient control. 

Health Policy, Healthcare Reform, Medicare, Medicine, Op-eds, Socialized Medicine

Giving Medicare for All a Facelift: the Ugly Is Still There

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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. 

Health Policy, Healthcare Reform, Law, Medicine, Op-eds, Socialized Medicine

Fraud and Anonymity: The Perils of Medical Care Bureaucracy

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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. 

Culture & Society, Health Policy, Healthcare Reform, Medicare, Medicine, Socialized Medicine

The Medical Care Wheel of Misfortune

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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. 

Book Reviews, Health Policy, Medicine, Socialized Medicine

Book Review: China Rx: Exposing the Risks of America’s Dependence on China for Medicine

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by Rosemary Gibson and Janardan Prasad Singh, ISBN 9781633883819, Prometheus Books, 2018.

“Without firing a missile or hacking the electric grid, China can take America down by disrupting access to essential drugs,” write the authors of this important book.

This book is a fine piece of investigative journalism that educates the reader about the genesis of China’s grip on our supply of medications. China is now the largest global supplier of the active ingredients and chemical building blocks needed to make many vitamins, and prescription and over-the-counter drugs. These include antibiotics, steroids, and cancer drugs.

Until the mid-1990s, the U.S., Europe, and Japan manufactured 90 percent of the global supply of key ingredients for the world’s medications. Now more than half of the 4,000 active ingredients needed to make a make a pharmaceutical depend on China.

Our weakness for bargains has created a monster. The authors note that hospitals and retail pharmacies have become “like the big box stores, stocked with made- in-China items.” China’s winning formula is for a company—with the help of the government—to undercut the price of drugs or components; the  artificially   low price forces other companies out of the market; then the company is free to manipulate the price and supply at will.

But the authors warn that “cheaper drugs required a cheaper way to make them.” A light was shined on China’s poor manufacturing practices  of  ingestibles in 2007 with the well-publicized dog and cat-food recall. More than 4,000 pets died from renal failure due to contamination with melamine, an industrial chemical used in plastics manufacture.

The outrage over this “economically motivated contamination”  of pet food dissipated while in the next year  a far less-publicized drug contamination took human lives. Although “manufactured” by an American company (Baxter Healthcare Corporation), heparin was made in China under substandard conditions and was sold to unwitting hospitals with tragic consequences. One-third of the batches of heparin from China were contaminated. The book fully explores the heparin debacle, telling how it happened and what our government has done about protecting us in the future.

From the start, the authors received robotic, scripted, unhelpful replies to the straightforward question: where was this drug made? Searching for the answer, the authors delve into the loopholes in treaties and Food and Drug Administration (FDA) regulations that have allowed shoddily manufactured drugs for human consumption to be used in the U.S. Moreover, politics was interjected. The Transparency in Drug Labeling Act was introduced in 2008 to force drug labels to disclose where the drug was produced, not merely the location of the parent company. The law went nowhere, and it appears that the power of the drug company lobbyists prevailed over safety. Did this signal to China that the U.S. could be influenced by special interests, sometimes to the detriment of its populace?

China’s latest Five-year Plan for National and Social Development includes entering (and cornering?) the market on medical devices. The centralization of global supply in China leaves the world vulnerable. Not only can they  disrupt  the supply chain and cause shortages  but purposefully create shortages or adulterate drugs. Keep in mind, the active ingredient for ciprofloxin to treat anthrax is in China’s hands.

This  meticulously  researched  book is disturbing, but it is required reading for anyone who takes or prescribes medications. It is a real page-turner that reads like a novel and includes real-world scenarios. The authors included a detailed index, making the information readily accessible for repeated reading.

The Chinese think ahead with their well-known “five-year plans.”This book is a wake-up call for America to start planning for our future as well.

Review by Marilyn M. Singleton, M.D., J.D., Redondo Beach, Calif.

Purchase Book at: https://amzn.to/2IygpYD

Culture & Society, Health Policy, Medical Ethics, Medicare, Medicine, Op-eds, Socialized Medicine

Free Medical Care: a Deal with the Devil?

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By Marilyn M. Singleton, MD, JD

Listening to the campaign promises spewed out by the bevy of folks running for president brings the old but enduring story of Faust to mind. Despite being successful, Faust wanted more knowledge and possessions. To that end, he made a deal with Mephistopheles (aka the Devil) who promised to give him everything he wanted in exchange for his soul.

Who isn’t tempted by a bargain or better yet, something for nothing? Free income, free college, and free medical care. What do we have to lose? Self-respect, the opportunity to succeed at a career suited to one’s talents, your privacy and control over your own body.

Intended to ameliorate poverty, universal basic income can be counterproductive. Some promise income for merely having a pulse and others envision the government equivalent of a mama bird regurgitating food into the open mouths of her chicks. Neither option gives a sense of pride and accomplishment or the foundation for character development.

The high cost of college is the justification for free tuition. One key reason for the continually escalating tuition is readily available student loans: no matter the cost, the student can continue to borrow. Endless direct-from-the-government money would likely cause further increases. Further, one-third of college students drop out. The majority of these students were poorly prepared for, and not fully committed or suited to college. It is a bad idea to remove an incentive for perseverance, allow uncommitted students to waste their time on the government dime, or worse be stigmatized as a failure. Finally, as Senator Amy Klobuchar bravely pointed out, the taxpayers cannot afford it.

With regard to medical care, all “medically necessary” health services, including dental, vision, hearing, mental health, long-term care, home and community-based services, physical therapy, prescription drugs with no premiums, deductibles or co-pays from cradle to grave sound pretty good. Sold! Frankly, given the direction so-called reproductive health is going, you may never make it to the cradle. And with the current laser-focus on hospice for all, you may get to your grave a little faster.

Will free medical care halt one of the biggest drivers of poor health and medical costs? According to the Centers for Disease Control and Prevention (CDC), 40 percent of people in the United States are obese. And 47 percent of our $3.5 trillion per year of healthcare spending goes to treat the effects of obesity, with another 8.7 percent attributable to cigarette smoking. People have known for years that eating too much makes you fat and smoking contributes to heart and lung disease. Free care would worsen the problem because patients will expect more pills and procedures to cure their lifestyle-created illnesses rather than taking care of themselves.

Not only is the promise of free stuff an attempt to buy votes, but the politicians themselves have sold their souls to special interests. And we never know whether they are working for the metaphorical Devil or for you, the voters.

According to the Center for Responsive Politics, in 2018, both sides of the Congressional aisle received a total of $134,590,142 in contributions from the health sector (health professionals, device and pharmaceutical manufacturers, hospitals and nursing homes). The health sector was the top spender of lobbying money – some $562,968,799 spread among 2,810 hired guns. Pharmaceuticals/Health Products topped the list with $281,872,969.

On the bright side, when given the full picture, people are not that easily bought. A recent Kaiser Family Foundation study found that 70 percent of those polled approved of Medicare for All when told the plan would eliminate insurance premiums (which are sky-high thanks to ObamaCare). But up to 70 percent opposed Medicare for All when told it would lead to treatment delays, tax increases, or loss of their option for private insurance.

Perhaps those polled read that private insurance is allowed in all but two countries with universal coverage, and patients in all countries have some out-of-pocket expenses. Perhaps they realized that when the citizen money tree has been picked clean, promised services must be reduced. Perhaps they realized that free stuff can be used as a cudgel to keep the recipients in line and trap them in a system with no escape. Perhaps they were of a certain age where they were warned that the tasty-looking Halloween candy might be laced with razor blades. Or more likely, those infamous words, “If you like your doctor, you can keep your doctor” were flashing before their eyes or echoing in their ears.            

Free stuff is an age-old snare, a temptation that can steal one’s critical thinking abilities. Despite the old saw that there is a sucker born every minute, there are always those who will not be fooled. Which will you be?

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. 

Culture & Society, Healthcare Reform, Medicare, Medicine, Op-eds, Socialized Medicine

Hoaxes, Scams, and Your Medical Care

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By Marilyn M. Singleton, MD, JD

Hoaxes and scams have been dominating the news lately. We have a marginally known actor faking a hate crime supposedly to raise his Hollywood profile. His attempt to claw his way to the middle could have resulted in race riots, injury, and death. His punishment? All charges dropped.

The scandal about Hollywood and other elites buying their children’s way into top-rated universities really hit home. I remember when I had tutored some recent Vietnamese immigrants for a debate contest to win a scholarship for college. I could only hope that their hard work was rewarded and not wiped away by special favors bestowed on the “haves.”

Now we continue to have a slew of healthcare hoaxes: corporate stakeholders, legislators, and government agencies promise everything and have no accountability for their failure to keep their promises.

Take the large health systems’ claim that hospital consolidation and buying up physician practices would benefit consumers with cheaper prices from coordinated services and other unspecified savings. A major study of California hospital mergers found just the opposite. The analysis showed that the price of an average hospital admission went up as much as 54 percent. When the large hospital systems bought doctors’ groups, the prices rose even more. There was as much as a 70 percent increase in prices of medical services in geographic areas with minimal competition. This finding seems obvious to any of us who has the choice of shopping at Walmart or Target or Costco.

Logic aside, some legislators believe that having the government take over medical care would solve our access and cost problems. Single payer means no competition whatsoever. The single payer plans (H.R. 1384 and S. 1804) that abolish private insurance leave patients with an empty choice. Patients can contract with a physician to pay cash for government medical services covered by the government. But if the physician contracts for such services he cannot be part of the government program for any patient for 2 years. Realistically, these single payer bills make it financially unfeasible for physicians to privately contract with patients. Thus, only well-heeled patients, along with independently wealthy doctors, can buy their way out of the system.

There are variations on the theme of government involvement that allow buy-ins to Medicare, Medicaid, or iterations of the Affordable Care Act marketplaces. All of these all have the same defect: expanding the government healthcare monopoly.

The opioid crisis is an example of the unintended consequences of intervention by oversight agencies not directly involved in patient care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now the Joint Commission, a nonprofit organization that accredits more than 20,000 healthcare organizations and programs in the U.S, is for all practical purposes a government surrogate. In 2001, JCAHO declared that pain was the “5th vital sign” that had to be addressed or face consequences. The Federation of American Medical Boards told physicians that “in the course of treatment,” large doses of opioids were just fine. Moreover, Medicare has a hospital payment formula that relies on patient satisfaction surveys. If the patients are satisfied, including being so zoned out on opiates that they can’t taste the bad food, the hospital is paid more. The hospital is penalized for a bad rating.

And now to deal with the opiate issue, the government has issued guidelines that have been found to be harmful to some patients. One-size-fits-all restrictions have caused physicians to fear being flagged as over-prescribers by the medical board. Consequently, some physicians are tapering patients off opioids more quickly than they would ideally like. And in the public eye patients have been transformed from objects of compassion to criminal drug addicts.

Individualized medical care must not be reserved for the chosen few. Patients need physicians who are empathetic, thorough, and not married to a medical cookbook written by disinterested third parties. Perhaps this is why Mick Jagger of the Rolling Stones chose to have his heart surgery in the U.S. and not with his British homeland’s National Health Service.

Central control is not a good idea. Period. Do not believe the hoax perpetrated by the ruling class who will never have to live by their own rules. It is highly unlikely that Venezuela’s President Maduro is starving along with his people.

BDr. 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. She lives in Oakland, Ca.

Healthcare Reform, Law, Medicare, Op-eds, Socialized Medicine

Thought Police (Oops, Medicare) For All

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by Marilyn M. Singleton, MD, JD

The new Medicare for All bill (H.R. 1384) has come and hopefully will go the way of the pet rock. Everybody now knows the basics: the government will take care of all medical, dental, vision, pharmacy, and long-term care services with no out-of-pocket expenses. The bill prohibits parallel private insurance, and has the glaring absence of a financing mechanism.

But as usual, bills contain hidden gems. Section 104 of the bill tracks the Affordable Care Act’s “anti-discrimination” rule, making it clear that no person can be denied benefits, specifically including abortion and treatment of gender identity issues “by any participating provider.” The bill does not correspondingly reaffirm the federal laws protecting conscience and First Amendment religious freedom rights of medical personnel. Such protections relate to participation in abortion, sterilization, assisted suicide, and other ethical dilemmas.

Most sane individuals agree that we do not want our government to control any aspect of our individual lives—particularly not our religious beliefs and moral codes. When the Department of Health and Human Services (HHS) sought to clarify such conscience protections, thousands of commenters offered evidence of discrimination and coercion to violate the tenets of the Oath of Hippocrates and their own ethics. Some left their jobs or left the medical profession entirely when their conscientious objections were not honored.

Conscience protections are vital in this time of unabashed devaluing of life. Last year, the Palliative Care and Hospice Education Training Act (PCHETA), passed the House but died in the Senate. This bill would have dedicated $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. Already some families feel they are not merely offered hospice as a choice but are steered toward it when their older relatives fall ill, even when the medical prognosis is uncertain.

The focus on palliative care and lowering costs by reducing “aggressive” end-of-life treatment is one more incremental under-the-radar step along the road to government control over life and death. A culture of hastening death has gradually evolved, disguised as “death with dignity.” California, Colorado, Oregon, Washington, Montana, Vermont have legalized physician-assisted suicide with 20 other states considering implementing such laws.

Subtly devaluing life primes the pump for rationing of medical care at all stages by a government-run program that is the exclusive purveyor of medical “benefits.” Our western counterparts with single payer have discovered that offering fewer benefits is the simplest way to control costs. 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.”

This year, legislators were not so subtle. It is bad enough that our elderly are pushed into hospice, but now the compassionate legislators have set their sights on newborns. New York passed, and Virginia floated laws that permit the killing of babies after birth. The U.S. Senate garnered only 53 of the 60 votes needed to pass the Born Alive Survivors Protection Act which would mandate medical care and legal protections to infants born alive after an attempted abortion.

Starting in the 1970s, the federal government clearly saw a need to protect medical personnel from the tyranny of the government mandates that could violate religious or moral convictions. Personal liberty is an integral part of our democratic republic. While a physician’s calling is to render treatment to all patients, this is balanced with an individual physician’s moral beliefs. This is no more apparent than in legislation permitting physician assisted suicide and post-delivery “abortions.” Sadly, under threat of discrimination lawsuits, some physicians have acquiesced to patients’ requests for medications and surgical procedures that conflict with their moral code.

As anthropologist, Margaret Mead so brilliantly wrote, “One profession, the followers of [Hippocrates], were to be dedicated completely to life under all circumstances…This is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer—to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. … It is the duty of society to protect the physician from such requests.”

We must not let the government bury our conscience and beliefs under layers of bureaucracy. Medicare for All may mean independent thought for none.

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.

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.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Health Policy, Healthcare Reform, Medicine, Op-eds, Politics, Socialized Medicine

Jumping Into Medicare For All With Eyes Wide Shut

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by Marilyn M. Singleton, MD, JD

The unveiling of the ballyhooed House of Representatives Medicare for All Act of 2019 bill will be met with chants of “equal healthcare for all!” While the country will be forced into a government-run program, the limousine liberals and champagne socialists will keep their array of medical care choices — whether on or off the record.

A key feature of the Medicare-for-All bills is the elimination of private health insurance that duplicates benefits offered by the government. Given the coercive nature of the existing Medicare program, we should be very concerned. Medicare Part A (hospital insurance) is mandatory for those eligible for Medicare who receive Social Security payments. If beneficiaries want to opt out of Part A, they must forfeit all of their Social Security payments — including paying back any Social Security benefits received up to the time Part A was declined. So a “beneficiary” is punished for saving federal dollars by declining to be on the government healthcare dole.

Enrollment in Medicare Part B (all physician and most outpatient services) is not mandatory but beneficiaries are financially coerced to enroll. The standard 2019 Part B premium amount is $135.50 per month, progressing to $460.50 based on income. But if a beneficiary doesn’t sign up for Part B when first eligible, he must pay a lifelong penalty of 10 percent for each full 12-month period that he could have had Part B. So if the beneficiary waited 3 years before signing up, he would pay a 30 percent higher premium throughout his lifetime.

Medicare Part D (prescription drugs) also imposes penalties on those who do not sign up when eligible unless they are in a Medicare Part C/Medicare Advantage HMO that covers drugs. The lifetime penalty is not trivial: one percent per month of the average monthly premium (currently about $33) for all the months they were not signed up.

Will we be somehow punished if we do not want to enroll in the new government program? Will there be an “individual mandate” penalty? Hopefully we’ll know before the bill is passed and we can find out what’s in it.

Another troubling aspect of a new government health program is the lack of an articulated budget or cost controls. According to the Medicare Board of Trustees 2018 Report, Medicare’s Part A trust fund will be depleted in 2026, three years earlier than the 2017 projection. Our 2017 healthcare costs were $3.5 trillion with $1.2 trillion attributed to Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Apparently, financing would depend on monies earmarked for existing federal health programs, heavily taxing “the rich” and an unspecified increase in everyone’s taxes.

In addition to notoriously underestimated cost projections, Medicare underpayments to hospitals must be addressed. Hospitals receive 88 cents on the dollar from Medicare and 90 cents on the dollar from Medicaid for their expenditures on these patients, translating to reimbursements of $41.6 billion and $16.2 billion, respectively, below actual costs. Currently, hospitals make up the shortfall with higher payments from private insurance — which will no longer exist. Slashing oft maligned CEO salaries would be a drop in the bucket. Hospital workers — unionized or otherwise would not accept pay cuts.

So how will the inevitable funding shortfall be addressed? Private practitioners may be enticed by the promise of a steady stream of patients and income or strong-armed into submitting to lower reimbursement or by new licensing requirements. Of course, many of us remember being paid with IOUs from the California Medicaid program.

The promise of completely “free” medical care of every sort imaginable gives one pause. What happens when the money runs out? Because Medicare defines what care is reimbursable as  “medically necessary,” the simple answer is to decrease covered services. But by then, the private health insurance industry would be decimated and our options limited.

Proponents of government-sponsored healthcare say people want it. But a 2019 Kaiser Family Foundation survey found that enthusiasm wanes when folks are told they would (1) lose their private insurance, and/or (2) pay more taxes and/or (3) have longer waits.

Direct pay independent physicians may be the salvation. Many Medicare patients are paying for direct primary care where a modest monthly fee direct to the physician guarantees full access to a physician, inexpensive medications and lab tests. Some specialists treating various chronic conditions such as diabetes also use this model to provide patients with timely individualized quality care.

The same people who clamor for a woman’s reproductive choice are strangely silent about everyone else’s freedom to choose the type of medical care they want. Patients and physicians should be free to pay for services and accept payment for services without being subject to penalties.

Medicare for All could be one of those concepts that “seemed like a good idea at the time” – just like diving head first off a cliff into an inviting but shallow pool of water.

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.

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.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton