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Culture & Society, Healthcare Reform, Medicare, Medicine, Op-eds, What's New

Obesity: America’s Self-inflicted Preexisting Condition

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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.

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. 

Culture & Society, Law, Medical Ethics, Medicine

The Soylent Green New Deal is Three Years Away

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By Marilyn M. Singleton, M.D., J.D.

In an effort to cut carbon emissions from burials and cremations, the state of Washington, led by staunch environmentalist Governor Jay Inslee, became the first U.S. state to legalize human composting. To think, people can be criminally prosecuted for disrespecting a human corpse, a symbol of a once-living person. But the religion of Mother Earth now supersedes all cultural decency.

We’ve already cemented the contempt for life at the front end. I thought we had evolved since the ancient Greek elders determined that only the strong newborns survived and the weak were left to die. Virginia’s Governor Ralph Northam made it clear that infants were once again throwaways at will. In explaining the procedure of an “abortion” of a child who was born alive, he said “the infant would be resuscitated if that’s what the mother and the family desired, and then a discussion would ensue between the physicians and the mother.”

Now we must be acutely aware of what is happening at the other end of life’s spectrum. In the U.S., elders are all too often considered expendable by society at large and sadly, by their own families. Such disregard in some 10 million cases escalates to abuse in many forms. Government-certified entities make a significant contribution to this contemptible crime.

In many states court-appointed guardians cravenly plunder their wards’ assets with no repercussions. A U.S. Government Accountability Office (GAO) report identified hundreds of allegations of abuse, neglect, and exploitation by guardians in 45 states and the District of Columbia between 1990 and 2010. An investigation of a small sampling of the allegations found that court-appointed guardians had stolen or otherwise improperly obtained $5.4 million from 158 incapacitated victims, mostly older adults. Moreover, such crimes were frequently overlooked by judges.

Soon after coming into office, President Trump signed into law the Elder Abuse Prevention and Prosecution Act that provided for 90 prosecutors and “elder justice coordinators” nationally to prosecute those committing elder abuse, including guardianship cases. Currently, a sleepy little bill in the wings, the Stamp Out Elder Abuse Act, will direct the proceeds of a new postage stamp to enforcing laws against elder abuse.

These new laws may be for naught with the advent of more physician-assisted suicide laws. New Jersey is the latest, complete with a cute acronym: MAID – Medical Aid in Dying. All the calls for government-controlled medicine are terrifying to those of us who remember a dystopian film where in 2022, with rampant food shortages and homelessness, the only food available is a high-energy wafer purportedly made from plankton. Alas, we witness humans entering a processing center for a happy death and emerging as the main ingredient of Soylent Green.

I contend that the trend of placing older people into hospice before the ink is dry on the hospital admission papers is a new form of elder abuse. Hospice has become the new Medicare cash cow for unscrupulous facility owners who abuse and neglect patients. One study found that 8 percent of the hospices studied did not provide a single skilled visit—from a nurse, doctor, social worker, or therapist—to any patients who were receiving routine home care in the last two days of life in 2014.

Recall that President Obama robbed Medicare of $716 billion to fund the Affordable Care Act, including $56 billion from hospitals serving poor people. Recall that an ethics advisor for ObamaCare, Ezekiel Emanuel, MD, advocates for the “Complete Lives System” of medical care where resources are directed to those with “future usefulness.” Dr. Emanuel proudly claims he wants to die at 75 years of age. Tell that to the countless lives Mother Teresa transformed when she was her 80s. Tell that to John Glenn, who went back into space for 9 days at 77, and to the 20 million other over-75 disposables—or should I say, recyclables.

Quite coincidentally, eliminating the over-75 crowd from the insurance pool would help fund government-sponsored insurance for this country’s remaining uninsured. In other words, hurry up and die before the Medicare program goes bankrupt.

My gratitude goes to those congresspersons who recognize that our elders need protection. Given that the federal trust fund that finances much of the Medicare program is projected to run out in 2026, let’s hope these compassionate people realize that the first losers of Medicare for All are our elders.

Bio: Dr. Singleton is a board-certified anesthesiologist. She is President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. 

Media & Press, Medical Ethics, Medicare, Medicine, Op-eds, Politics

Propaganda, Pandering, and Politics

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By Marilyn M. Singleton, MD, JD

For the next one and a half years we will have to endure the hyperbole, apocalyptic predictions, fake outrage, half-truths, and frank lies of politicians. Some kind soul should take pity on us and pass out beans to put in our ears.

Of course, we should expose ourselves to many opinions, but we have to be careful about propaganda. Propaganda, an ugly word, is viewed as more than mere opinion but information that is somehow manipulative, misleading, or not telling the whole truth.

Propaganda came to mind during a meeting I attended where well-heeled teenage girls sporting AOC for Congress T-shirts preached to the captive audience about how the government should pay for college tuition, books, and housing for everyone, while extolling the virtues of socialism. Had their parents heeded Vladimir Lenin’s “Give me four years to teach the children and the seed I have sown will never be uprooted”? Then some adults with vapid smiles admonished us that we should believe the young ladies, not because they provided statistics or pros and cons of the value of college for everyone, but because they are young and our future. This brings out one propaganda tool: it’s for the children.

Why would we willingly give up any of our freedoms and turn over our pocketbooks to the government because some nouveau socialists fed us propaganda? Because it works.

Look at the Social Security Act. No one would turn down the promise of financial security in old age, or as President Roosevelt said, a safeguard “against the hazards and vicissitudes of life.” I question if people think it is a good deal to pay more than 15 percent of your paycheck (including employer’s “contribution” and Medicare tax) to the government, thus taking your future savings out of your control. If you die young you get nothing; your savings go, not to your children, but into the government’s black hole.

Patients and doctors alike have been sucked in by statements of questionable accuracy. In promoting the Affordable Care Act, President Obama on multiple occasions assured us, “if you like your doctor you can keep your doctor, if you like your health plan you can keep your health plan.” The ACA likely would not have gotten traction if he had said, “We don’t know what the insurers will do after the ACA is passed, so good luck.”

Electronic Medical Records (EHRs) were part of the bumpy road to the ACA. President Obama, promised that EHRs would “cut red tape, prevent medical mistakes and help save billions of dollars each year.” The unwary believed the puffery versus the facts.

The promise: EHRs are efficient. Reality: Hundreds of different brands mean that the records cannot be exchanged between physicians, but they can be sent to the Office of the National Coordinator for Health Information Technology.

The promise: EHRs save time. Reality: Doctors spend half their time on the computer rather than talking with patients.

The promise: EHRs save lives. Reality: Software problems have memorialized incorrect information. One in 5 people surveyed by Kaiser Family Foundation has found a mistake in their records.

The promise: EHRs are private. Reality: There were more than 2,000 data breaches of 176.4 million patient records between 2010 and 2017.

It sounds so virtuous to insist that “healthcare is a right.” Thus, if you do not believe medical care should be free, you are not a moral person. This technique echoes Aldous Huxley’s view that “the propagandist’s purpose is to make one set of people forget that the other set is human.” (Of course, bearing arms is a constitutional right, but guns are not given away for free. Indeed, gunowners are thought by some to be horrible people). Free medical care for all is short, simple, and seductive.

The promise: Medical services are free. Reality: Government may deny the request for prior authorization for your treatment, or ration treatments for older folks, such as hip and knee replacements and cataract surgery. In the government health system 307,000 Veterans might have died waiting for medical care.

The promise: Drugs are free. Reality: The medication your physician thinks is best for you is not on the government’s formulary.

The promise: There are no without out-of-pocket costs. Reality: Private health insurance is abolished, leaving no consumer choice.

The promise: It’s free! Reality: Your taxes will be raised to heights unknown.

“Free” is America’s new verbal Potemkin village of health care, where Susie gets a free birth if she survives her abortion, free medical care for life, and even free food. All Susie has to do for herself is breathe. This is a panderer’s view of America. In fact, we are a country of individuals who want to govern their own lives and of physicians who want the freedom to properly care for their patients.

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

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

Culture & Society, Elections, Law, Medicine, Op-eds, Politics

The Real Loser in the Midterms: Individuality

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by Marilyn M. Singleton, MD, JD

After the election, sappy statements on social media exhort us to bow down in praise that the first minority this or the first woman that was elected and how this means we have catapulted our nation out of the Neanderthal era. Funny how no one mentions Young Kim’s victory – but she is not a Democrat so it does not count. It’s funny how no one cheered women of color when Condoleeza Rice was secretary of state. Instead she was called an Aunt Jemima and a house nigga’ in a nationally syndicated cartoon.

Now it is acceptable to call young conservative black students enjoying their visit with President Trump “N-words in Maggot hats” and ridicule them as “props.”  What racist insults! Undoubtedly, the prominently positioned little black boy at the Affordable Care Act signing just happened to be strolling outside the White House East Room.

These “first” types would rather we forget that we had a black Senator from Mississippi, Hiram Revels in 1870. Or that by 1920 the first black female millionaire, Madame C.J. Walker employed up to 40,000 women and lived in the same neighborhood as John D. Rockefeller.

Yes, the road to acceptance was long and paved by female businesspersons, physicists, pilots, and physicians, among many others. The road is littered with boorish people and men who targeted women for abuse.

There was a time when minorities and women advanced because they were accomplished, assertive, and strong. When Madame Walker was denied a speaking slot at the National Negro Business League convention, she admonished, “Surely you are not going to shut the door in my face. I am a woman that came from the cotton fields of the South.” The next year, she was the keynote speaker. Although only 10 percent of my medical school classmates were women (and a handful of minorities, including myself), the top two students were women. Sure it was a slog, but competence won the day.

Then something politically expedient happened. We lost the grit and pluck that propelled Madame Walker to success. Women became victims who feel they are always being stepped on by others, ignored or abused. And only women could rescue them from their evil white male oppressors. Now being a minority or a woman has become a shield against legitimate criticisms, setting back the struggle to simply be judged by the content of our character. One wonders how the press would report the botched Broward County ballots if Elections Supervisor Brenda Snipes were a white male.

Sadly, the focus on victimization has expanded to all Americans. The key to getting votes was to let people know how miserably unfair their lives are. Just like in George Orwell’s Animal Farm, the beleaguered seek to improve their lot through rigid exclusionary rules: “Whatever goes upon two legs is an enemy.” The newly minted pathetic wretches are exhorted to join the morally superior tribe who will protect them from those who disagree with their point of view. After all, they are likely racist sexist homophobes.

The “longshoreman philosopher” Eric Hoffer pointed out in his classic, The True Believer, “people whose lives are barren and insecure seem to show a greater willingness to obey than people who are self-sufficient and self-confident.” Such persons tend to value equality and fraternity more than freedom. Such persons will also more readily accept in their medical care government control, rationing, and paint-by-the numbers treatments (or non-treatments).

Before getting excited about the midterm election results, chew on this. Lying during a political campaign is protected by the First Amendment. Animal Farm’s core commandment, “All animals are equal” devolved into “All animals are equal, but some animals are more equal than others.” Analyze why the uber-rich with $42 million private jets financed the campaigns of the socialist-leaning candidates. Are they thinking, I’ve made it to the top thanks to the capitalistic system of hard work and rewards, but you can take the crumbs and sit on your lazy butts watching me pontificate on TV? How will the Bernie Bros and Single-payer sisters who voted to expand government health insurance with their $1000 iPhones feel when their toys are taxed out of existence? And our modern-day feminists who define themselves by their gender rather than competence have no right to be insulted if a patient says, “I prefer not to have a woman doctor.”

My congratulations go to all the women and men — voters and candidates — who are independent critical thinkers, who display the grit of Madame C.J. Walker, and who follow the words of the abolitionist, William Ellery Channing: “No power in society, no hardship in your condition can depress you, keep you down, in knowledge, power, virtue, influence but your own consent.”

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, Medicare, Medicine, Op-eds, Socialized Medicine

Expanded and Improved Medicare for All: Beware of Greeks Bearing Broccoli

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By Marilyn M. Singleton, MD, JD

During the Supreme Court oral arguments in the challenge to the Affordable Care Act’s mandate to purchase health insurance, people laughed when the late Justice Scalia asked whether the government could make you buy broccoli. Never happen? The laughable has become reality. A California bill awaiting the governor’s signature forbids restaurants from serving any beverage other than water or unflavored milk with kiddie meals. As of yet, the meal’s purchasers, unlike the restaurant, won’t be fined for ordering another beverage for their child.

Shrugging off assertions that the ACA was about control, not care, President Obama quipped that his opponents acted like the ACA “was a Bolshevik plot.” That supposedly ludicrous plot is embodied in a too-good-to-be-true congressional bill, H.R. 676, the “Expanded & Improved Medicare For All”. With no dollar amounts in sight, the bill gives the government a blank check to exert total control over our medical care.

H.R. 676 provides that all individuals residing in the United States showing up at the doctor’s office are “presumed to be eligible” for benefits. The federal government will pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health, substance abuse, vision, dental, hearing, and long-term care — with no deductibles or other cost-sharing. Unless a patient opts out, all interactions will be memorialized in a “standardized, confidential electronic patient record system.” Yes, those same electronic records that have been hacked and are contributing to physician burnout.

Overseen by regional offices and the Presidentially appointed 15-member National Board of Universal Quality and Access, participating institutions will receive separate monthly fixed sums for capital expenses (e.g., buildings, improvements) and for operating expenses (including physician salaries). Non-salaried physicians can be paid based on a national fee schedule that is “fair and optimal” as decided by the government. Finally, each geographic region would receive a single allotment to cover long-term care.

There are some restrictions. Only public or not-for profit institutions may participate. Private physicians and clinics can exist but cannot be investor-owned. And to keep the patients on the reservation, private health insurers are prohibited from selling health insurance coverage that duplicates the government-sponsored benefits.

Ever magnanimous, the government will pay for “reasonable financial losses” resulting from the conversion from for-profit to nonprofit status through the sale of U.S. Treasury bonds, assuming we choose to buy them. Additionally, the government will compensate insurance and other relevant clerical, administrative, and billing personnel up to $200,000 per person for losing their jobs.

Patients would have “free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities.” But under the business restrictions and capped payments, the better institutions and clinicians may choose not to participate, thus decreasing access.

There is a big bad wolf in this fairy tale. In 2016, the feds 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.

H.R. 676 provides funding from appropriations for federal public health care programs, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP); an unspecified increase on personal income taxes on the top 5 percent of income earners; a “modest and progressive” excise tax on payroll and self-employment income; a “modest” tax on unearned income, and a “small” tax on stock and bond transactions.

Fast forward to 2026, when the government predicts that 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 costs, no cost-sharing, and the $2.4 trillion shortfall, the bill’s “modest” tax increases will soon be obscene.

Not only will the benefits decrease as the money runs out, patients will see real world consequences of total control. For example, Oregon’s Medicaid program wants to limit coverage for opiates for some chronic pain conditions and taper off patients who have been taking opioids long-term — even if they have no signs of addiction. Long-term care will be an easy target; the ACA’s long-term care program was scuttled due to cost concerns. With current nursing home costs averaging $7,500 per month, inevitably when the monthly allotment is depleted, hospice care becomes the medically necessary treatment.

Tell the sponsors of H.R. 676 that it’s your money, your health, your privacy, your life. The government is neither our parent nor our benefactor. The government is not the middleman you want between you and your doctor. At a time when the movement toward innovative and personalized care is moving forward, care via government control is taking us backwards.

Dr. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and President-elect 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, Doctors, Health Policy, Media & Press, Medical Ethics, Medicine, Op-eds, Politics

The Courage to Trust Medical Care to Patients and Physicians

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by Marilyn M. Singleton, MD, JD

The days of trusting your legislators to have your best interests at heart are in the rear view mirror. Apparently, their main interest is parroting the buzzwords of the moment to get elected and then being too busy banking lobbying money to listen to the voters. Our legislators have become spectators who wait for the perfect moment to pounce on their political “enemy” and then go on cable news shows to boast about it.

The “us against them” attitude, punctuated by hyperbolic, apocalyptic rhetoric closes the door to finding solutions. Our interests would be better served by having town hall meetings where voters could state their concerns, air their differences, and learn what legislators are doing about their issues. Caution: meetings at 9 a.m. on Wednesday when paid activists are guaranteed to outflank the working general public are prohibited.

There are strong differences of opinion on how to attain a healthy citizenry. Educating potential patients about what drives up medical care expenditures can start the conversation. Well-informed patients would demand solutions based not on corporate interests or government or political agendas, but on a fair, competitive market that maximizes choices and achieves lower costs.

Eight years of the Affordable Care Act have borne out Congressional Budget Office predictions that abandoning basic principles of insurance—which compensates only for events beyond the insured’s control and is priced according to the degree of risk—would lead to higher and higher premiums, fewer participating insurers, and unsustainable government expenditures to subsidize insurance premiums. The data in three recent Centers for Medicare and Medicaid reports on ACA exchanges show “individual market erosion and increasing taxpayer liability.” The average monthly premium for coverage purchased through the exchanges rose 27 percent in 2018, and federal premium subsidies increased 39 percent from 2017 to 2018.

A less frequently discussed cost driver is the disturbing trend of private doctors’ offices being scooped up by hospitals, health insurance companies, and venture capital groups. Prices tend to rise when health systems merge, because of decreased competition. And not only do hospitals and health systems generally charge more than private physicians’ offices, the government compounds this problem by paying more to hospitals than independent offices for the same service. A review of 2015 Medicare payments showed that Medicare paid $1.6 billion more for basic visits at hospital outpatient clinics than for visits to private offices. Patients are the biggest losers: they paid $400 million more out of pocket and had their tax dollars wasted. The study also found hospital-employed physicians’ practice patterns in cardiology, orthopedic, and gastroenterology services led to a 27 percent increase in Medicare costs. This translated to a 21 percent increase in out-of-pocket costs for patients.

Similarly, a U.C. Berkeley School of Public Health study of consolidation of California’s hospital, physician, and insurance markets from 2010 to 2016 concluded “highly concentrated markets are associated with higher prices for a number of hospital and physician services and Affordable Care Act (ACA) premiums.” In consolidated markets (defined by the Federal Trade Commission’s Horizontal Merger Guidelines), prices for inpatient procedures were 79 percent higher and outpatient physician prices ranged from 35 percent to 63 percent higher (depending on the physician specialty) than less concentrated markets.

Big medicine and third-party financing are taking the cost curve in the wrong direction. This speaks to the urgency of encouraging cash friendly practices that bypass insurance and direct primary care (DPC) practices. With DPC, all primary care services and access to low-priced commonly used medications are included in an affordable upfront price. Importantly, DPC’s time-intensive and individualized management of chronic diseases decreases hospital admissions, paring down Medicare’s $17 billion spent on avoidable readmissions.

Why corporations want to marginalize private practice seems clear; the government’s motive is open to debate. Surveys consistently find that patients overwhelmingly want “personalized provider interactions.” Thus, herding patients into government-directed programs is not the solution. One core problem with government systems is their reliance on the goodwill of politicians. As President Ford said, “a government big enough to give you everything you want is a government big enough to take everything you have.”

It’s time for Congress to scrutinize anti-competitive health system mergers. It’s time to bring to the floor over a dozen bills to expand and improve Health Savings Accounts (HSAs) to give patients more control over all facets of their medical care.

Congress, the clock is ticking on this legislative session. Stand up for patients. Or did the dog eat your courage?

Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

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

Culture & Society, Health Policy, Medicine

Create Your Own Healthcare “System”

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By Marilyn M. Singleton, MD, JD, @MSingletonMDJD

Kudos to the folks in D.C. who are advancing alternatives to the Affordable Care Act’s over-regulated and expensive health insurance policies. Small business association health plans and expanding health savings accounts (HSAs) are among several tools to increase health care choices. However, one element in the medical care cost analysis that is rarely addressed is personal responsibility for one’s health. Politicians are reluctant to “blame the victim” (patients) so they criticize the health care “system.” That misses the point: It is not the government’s job to keep us healthy.

Estimates of 2016 U.S. health care spending averages $10,345-per-person. Purchasing insurance makes up the bulk of the spending: $3,852 annual insurance premium, $4,358 to meet the deductible, for a total of $8,210. But most of the actual spending on medical care is for 5 percent of the population, mainly for chronic conditions.Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures (2010) were for people with chronic and mental health conditions.

It takes more than good luck to maintain good health. Up to 40 percent of lost years of life from each of five leading U.S. causes (heart disease, cancer, chronic lower respiratory diseases, stroke, and unintentional injuries) are preventable according to the Centers for Disease Control and Prevention (CDC). Sadly, opiate use disorder jumped from 52nd on the list in 1990 to 15th in 2016.

Research suggests that behaviors, such as smoking, poor diet and over-eating, and lack of exercise are the most important determinants of premature death. Over the last 25 years the percentage of Americans with healthy lifestyles (exercise, good diet, “normal” body fat, non-smoking) has dropped from 6.8 percent to 3 percent. More than two-thirds of all adults and nearly one-third of all children and youth in the United States are either overweight or obese. The CDC reports that 9.3 percent of Americans have diabetes. Will this problem be solved by expanding government “healthcare” programs? No. In 1965 when Medicare and Medicaid were established, 1.2 percent of Americans had diabetes. This number had doubled by 1975, even with more sources for medical care, and continued to rise at the same rate despite the implementation of the ACA.

The American Diabetes Association estimates that in 2017, diabetes and its related complications accounted for $237 billion in direct medical costs — a 26 percent increase from 2012. The price of poor lifestyle choices is staggering. For the years 2009–2012, the costs for direct medical care due to smoking was at least $170 billion. Medical costs linked to obesity were estimated to be from $147 billion to nearly $210 billion per year.

Let’s face it. Many Americans have been duped into ignoring responsibility for their own health. With the drug companies’ relentless ads, prescription drugs have become the equivalent of “As Seen on TV” products. These ads send the unstated message that the latest diabetes or lung disease medication will take care of you so you do not have to take care of yourself and possibly avoid these diseases in the first place. It’s no surprise that 70 percent of Americans take at least one prescription medication.

And the same government geniuses that permit food stamps to be used at fast food outlets mandates over-priced insurance products that include “free” preventive care. But, of course the high-priced cholesterol medication will cancel that out, right?

No sane person would wish a chronic condition on anyone, or deny treatment for such patients. But preventive health begins at home. Changing behaviors requires someone who connects with patients, will take time to listen and help identify personal motivators for change. This requires a physician who will spend time with you—not a storefront doc-in-the-box. Direct pay practices (DPC) offer quality time, service, and chronic disease management. These physicians are not constrained by insurance companies’ and the government’s paint-by-the-numbers treatments.

Health insurance is necessary for big ticket items like hospitalizations. But there is no need to pay thousands for services that will never be used. Pre-ObamaCare high-deductible plans and their out-of-pocket costs were generally offset by lower premiums and employer contributions to health savings accounts.

Shifting all our personal responsibilities to the government has not improved our nation’s health. Imagine if the $1,000 spent on designer coffee or manicures were spent on foods and a non-sedentary activities that improved health.

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

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