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Doctors, Featured, Medicare, Medicine, Politics, Socialized Medicine, What's New

America Out Loud PULSE: How Uncle Sam Became Our Doctor

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From my America Out Loud Pulse podcast – https://www.americaoutloud.com/how-uncle-sam-became-our-doctor/

Don’t be fooled into thinking that all laws and regulations are passed for our benefit. I think we’ve figured out that some laws are just to put someone’s name in the newspaper or to reward some group for big campaign contributions. That’s marginally tolerable if someone has bought their name onto a local Post Office. But it is a different story when it comes to our health. Politically-motivated healthcare agendas do not always make for the best medical care.

Through a calculated narrative that seizes upon emotions, public attitudes about social welfare have shifted from Thomas Jefferson’s “that government is best which governs least” to Franklin Roosevelt’s “cradle-to-grave” social insurance philosophy. Consequently, the administrative state has taken over our medical care. We now have rigid rules and restrictive drug formularies based on consensus—leaving no room for individualized treatments. But patients want to be treated like a person, not a data point. Patients want physicians whom they can trust to be open, honest critical thinkers, not “providers” who are government puppets.

In this episode, we’ll see how the government intrusion into medical care began – and weaved its way into our minds. Whether due to good intentions or naked lust for power, the 29-page Social Security Act grew into an almost 4,000 page behemoth lording over our lives.

Take heart. There are warriors out there. A few years back, I was president of the Association of American Physicians and Surgeons.  This organization has done a public service to patients across the nation. AAPS has worked nonstop since 1943 to preserve of the private practice of medicine and the sanctity of the patient-physician relationship.

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. 

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. 

Health Policy, Healthcare Reform, Law, Medical Ethics, Medicine, Op-eds, Politics

Can We Trust the Government with Our Medical Care?

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By Marilyn M. Singleton, MD, JD

The short answer is No. And thinking that, we would be in good company. A new survey finds that Americans trust Amazon more than the federal government.[1] The most trusted entities were our military, Amazon, Google, local police, and universities. Congress came in as the least trusted, edging out political parties and the press.

Bureaucratic incompetence and cronyism are not the only reasons we should be wary of government involvement in our medical care. The federal government has a checkered history when it comes to medical judgments.

Forced Sterilizations

In light of state governments’ recent love affair with post-term abortions (aka infanticide), forced sterilizations are at the top of my list. Although other states had tried, Indiana became the first state in the country to successfully pass a forced sterilization law in 1907. The law applied only to the “feebleminded.” California and Washington jumped on board in 1909. By the 1920s, 33 states had forced sterilization laws. Heads of psychiatric institutions were free to sterilize anyone they considered social misfits. [2]

We now cringe at the words of the revered Supreme Court Justice Oliver Wendell Holmes in the 1927 case, Buck v Bell, upholding Virginia’s sterilization law for the  institutionalized “feeble-minded.”[3]

[Carrie Bell’s] welfare and that of society will be promoted by her sterilization. It is better for all the world if, instead of waiting to execute degenerate offspring for crime or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind…. Three generations of imbeciles are enough.

In fact, Carrie’s mother was a prostitute, but not feebleminded. After Carrie’s release, she maintained a job as a domestic worker and became an avid reader. Her “feebleminded” daughter was on her school’s honor roll.

With the third branch of the federal government on board, between 1909 and 1979 more than 20,000 government-funded forced sterilizations were performed. The last legal forced sterilization was in 1981. These went beyond the mentally challenged. Latinos and blacks were easy targets, particularly in the 1970s after Medicaid-funded family planning service offered sterilization. Some patients were bullied into consenting with threats of having their welfare benefits or medical care taken away. Sometimes patients were coerced into a tubal ligation immediately after their infant’s delivery. At other times, tubal ligations were done during Cesarean sections unbeknownst to the patients. These sterilizations were such an open practice in the South that that they became known as a “Mississippi appendectomy.”[4]

In North Carolina, an IQ of 70 or lower qualified a person for sterilization. Here, state social workers could file petitions for sterilization. One social worker sterilized her entire caseload.[5]

The Indian Health Service with its captive audience was worse. Between 1973 and 1976 some 3,400 Native American women— including minors—were sterilized without permission or with defective consent forms.[6]

The Tuskegee Study

The “Tuskegee Study of Untreated Syphilis in the Negro Male” lasted from 1932 to 1972. The U.S. Public  Health  Service used 400 mainly poor, illiterate, black sharecroppers with  syphilis as lab animals. They were told they had “bad blood,” but not that they were actually suffering from a serious disease. That was the extent of the “informed consent.” In exchange for having their lives ruined, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years. The men were never given adequate treatment for their disease. Even when penicillin became the drug of choice for syphilis in 1947, researchers did not offer it to the subjects. Nor were the subjects given the choice of quitting the study. All subjects succumbed to untreated syphilis so our government could track the natural progression of the disease. Once the study became public in 1972, it took a nine-person panel appointed by the assistant secretary for health and scientific affairs to decide that the study was “ethically unjustified.”[7] A class-action lawsuit filed the next year resulted in a $10 million settlement for the victims and their families.

Germ Warfare

This one is personal. My first patient that died, whose name and face I still remember, was a drug addict with bacterial endocarditis due to Serratia marcescens. The medical resident was baffled. Drug addicts are more susceptible to unusual bacteria, but where did this Serratia come from? It came from our own government.

Throughout a week in September 1951 as part of the U.S. Navy’s “Operation Sea Spray,” a presumably harmless bacterium, Serratia marcescens, was sprayed over San Francisco in a biological warfare test.[8] The U.S. Army’s monitoring of 43 sites around the city determined that San Francisco had received enough of a dose for nearly all of its 800,000 residents to inhale millions of particles each day during the week of spraying. Consequently, cases of urinary tract infections and pneumonia in San Francisco also increased after Serratia marcescens was released.

During Senate subcommittee hearings in 1977, the army revealed that between 1949 and 1969 open-air tests of biological agents were conducted 239 times in populated civilian areas, including Minneapolis; St. Louis; Mechanicsburg, Pa.; the Washington, D.C., National Airport; and New York’s subway system.[9] Had President Nixon not terminated the program in 1969, how many more sprayings would we have had?

Experimental Vaccine

In 1989, a study sponsored by the Centers for Disease Control and Prevention (CDC) tested an experimental measles vaccine on 1,500 six-month old black and Hispanic babies in Los Angeles. The CDC director, Dr. David Satcher, admitted in 1996 that “a mistake was made” and “it shocked [him].”[10] The consent papers the parents signed said the children would receive one of two vaccines, but they were not told that one of the vaccines was experimental and unlicensed.

A deceptive brochure  was distributed with the consent form. The brochure advised: “This vaccine has been shown to be effective in younger children. Over 200 million children around the world have received this vaccine, but Los Angeles County is the first place in the United States where it is being offered.”It was not until a significant number of children in Africa and Haiti had died from the vaccine that the study was stopped in 1991.

The Veterans Health Administration

The Veterans Health Administration (VA) is the current model of a government-sponsored single-payer health system. Let the headlines do the talking. A 2014 report by Sen. Tom Coburn (R-Okla.) found that more than 1,000 veterans may have died in the last decade because of malpractice or lack of care from VA medical centers.[11]

Even after the long waits were revealed, “Deceased” notes on files were removed to make statistics look better: veterans would not be counted as having died while waiting for care at the Phoenix VA hospital.[12]

In January 2015 it was reported that more than 1,600 veterans waited between 60 and 90 days for appointments at facilities operated by the VA Greater Los Angeles Healthcare System. About 400 veterans waited 6 months for an appointment. The average wait time, according to documents dated Jan 15, 2015, was 48 days.[13]

By April 2015, despite major reforms, government data show that the number of patients facing long waits at VA facilities had not dropped at all. The number of medical appointments delayed 30 to 90 days has largely stayed flat. The number of appointments that take longer than 90 days to complete has nearly doubled. This was far from the government’s goal of 30 days.[14]

A 2018 report from the Department of Veterans Affairs inspector general found that  the  Washington, D.C., VA Medical Center has for years “suffered a series of systemic and programmatic failures to consistently deliver timely and quality patient care,” and heightened potential for waste, fraud and abuse of government resources.[15]

Finally, in May 2018, veterans saw relief with the VA’s Choice program, when the bipartisan bill passed and was signed by the President. Under the law, if the VA cannot provide the veterans with the level of care they need or the level of care they expected, or had long wait times, the veteran can seek care in the private sector.[16]

Q.E.D.

Conclusion

The noted 19th century statesman  and orator  Daniel Webster said, “Good intentions will always be pleaded, for every assumption of power; but they cannot justify it…. It is hardly too strong to say, that the Constitution was made to guard the people against the dangers of good intention, real or pretended.”[17] Given the government’s track record, even the most jaded bureaucrat cannot justify such betrayals of patients’ rights and the public trust.

There is another theme between the lines: offer the people free stuff and then use it as a cudgel to keep the recipients in line. The helpless, the poor, and Native Americans were easy targets. Now “Medicare for All” threatens to trap the rest of us in a system with no escape.

Marilyn Singleton, M.D., J.D., an anesthesiolologist, serves as president of AAPS. Contact: marilynmsingleton@gmail.com.

Download PDF of this article: https://jpands.org/vol24no2/singleton.pdf [originally published as “From the President” column in Summer 2019, JPandS.

REFERENCES

  1. Tiffany K. In Amazon We Trust—but Why?; Oct 25, 2018. Available at: https://www.vox.com/the-goods/2018/10/25/18022956/amazon-trust-survey-american-institutions-ranked-georgetown. Accessed April 2, 2019.
  2. Zhang S. A long-lost data trove uncovers California’s sterilization program. Atlantic, Jan 3, 2017. Available at: https://www.theatlantic.com/health/archive/2017/01/california-sterilization-records/511718/. Accessed April 3, 2019.
  3. Buck v Bell, 274 U.S. 200 (1927). Available at: https://supreme.justia.com/cases/federal/us/274/200/. Accessed April 3, 2019.
  4. Garcia S. 8 shocking facts about sterilization in U.S. history. Mic; Jul 10, 2013. Available at: https://mic.com/articles/53723/8-shocking-facts-about-sterilization-in-u-s-history. Accessed April 2, 2019.
  5. Schoen J. Reassessing eugenic sterilization: the  case  of  North Carolina. In: Lombardo PA, ed. A Century of Eugenics in America. Bloomington, Ind.: Indiana University Press; 2011:141-160.
  6. Government Accounting Office. Investigation of Allegations Concerning Indian Health Service HRD-77-3; Nov 4, 1976. Available at: https://www.gao.gov/products/HRD-77-3. Accessed April 3, 2019.
  7. Centers for Disease Control and Prevention. The U.S. Public Health Service Syphilis Study at Tuskegee; Dec 22, 2015. Available at: https://www.cdc.gov/tuskegee/timeline.htm. Accessed Apr 3, 2019.
  8. Subcommittee on Health and Scientific Research of the Committee on Human Resources, U.S. Senate, 95th Congress. Examination of Serious Deficiencies in the Defense Department’s Efforts to Protect the Human Subjects, of Drug Research. Hearings; Mar 8 and May 23, 1977. https://babel.hathitrust.org/cgi/pt?id=mdp.39015005321081;view=1up;seq=1
  9. Mahlen S. Serratia infections: from military experiments to current practice. Clin Microbiol Rev 2011;24(4): 755–791. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3194826/. Accessed Apr 4, 2019.
  10. Cimons M. CDC says it erred in measles study. Los Angeles Times, Jun 17, 1996. Available at: https://www.latimes.com/archives/la-xpm-1996-06-17-mn-15871-story.html . Accessed Apr 4, 2019.
  11. Devine C. Bad VA care may have killed more than 1,000  veterans,  senator’s report says. CNN; Jun 24, 2014. Available at: https://www.cnn.com/2014/06/24/us/senator-va-report/. Accessed Apr 4, 2019.
  12. Bronstein S, Griffin D, Black N, CNN Investigations. VA deaths covered up  to make statistics look better, whistle-blower says. CNN; Jun 24, 2014. Available at: https://www.cnn.com/2014/06/23/us/phoenix-va-deaths-new-allegations/. Accessed Apr 4, 2019.
  13. Bronstein S, Griffin D, Black N, Devine C. It’s not over: veterans waiting months for appointments. CNN; Mar 14, 2015. Available at: https://www.cnn.com/2015/03/13/us/va-investigation-los-angeles/. Accessed Apr 4, 2019.
  14. CBS News. “Livid” VA patients still facing long waits times for health care; Apr 9, 2015. Available at: https://www.cbsnews.com/news/va-patients-still-facing-long-waits-times-for-health-care/. Accessed Apr 4, 2019.
  15. Summers J. Systemic failures plague DC veterans hospital, inspector general finds. CNN; Mar 7, 2018. Available at: https://www.cnn.com/2018/03/07/politics/washington-dc-va-hospital-inspector-general/index.html. Accessed Apr 4, 2019.
  16. Summers J, Landers E. Senate passes proposal to expand private health care for veterans. CNN; May 23, 2018. Available at: https://www.cnn.com/2018/05/23/politics/veterans-health-care-senate-vote. Accessed Apr 4, 2019.
  17. AZquotes.com. Available at: https://www.azquotes.com/quote/1315991. Accessed Apr 3, 2019.

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

Judge Kavanaugh’s Character Assassins Could Be Controlling Your Medical Care

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by Marilyn M. Singleton, MD, JD

Our legislators have been at their worst over the Supreme Court confirmation of Judge Brett Kavanaugh. What a shameful display: condescending, arrogant show-boating senators questioning him in a manner reminiscent of the Grand Inquisitor. The only things missing from this B-grade movie were the rubber hoses and interrogation lights. Some of us remember that you could count on one hand the “nay” votes for the confirmations of ACLU attorney Ruth Bader Ginsberg and known conservative Antonin Scalia.

This last-ditch effort to derail Judge Kavanaugh’s confirmation is more than mere political theater; the interrogators are immoral and beyond hypocritical. The “Lion of the Senate,” Ted Kennedy, killed a woman and former Senate majority leader Robert Byrd was an Exalted Cyclops in the Ku Klux Klan, and we all know about President Clinton. But that’s okay; their lapses in judgment were somehow worth our compassion and forgiveness.

Imagine if these political hacks were in charge of your medical care. Medicare-for-All as planned is the exclusive purveyor of medical “benefits.” If you want a medical service they do not want you to have, you are on your own.

The government is already shaping the way we use medical services. The Palliative Care and Hospice Education Training Act (PCHETA), S. 693 and the companion bill H.R. 1676 passed by the House and is now before the Senate Health, Education, Labor, and Pensions (HELP) Committee. This bill dedicates $100 million in additional taxpayer dollars to persuade patients to forgo treatment that might prolong life in exchange for a steady stream of increasing doses of narcotics. Perhaps knowing that many physicians still adhere to the Oath of Hippocrates, the legislators included multiple non-physicians and non-medical personnel as recipients of these funds.

Including outsiders in decision-making must be undertaken with caution. Hospice/palliative care has become the new growth industry in our “health system.” Compared to home health care, hospice had significant growth in 2017 – increasing 6.5 percent in one year. Further, according to the Medicare Payment Advisory Commission the “Increase in hospice is driven by for-profit providers” which made up two-thirds of the 4,400 hospices in 2016.

Why direct $100 million for a new medical specialty in relieving pain and suffering, a skill all physicians should embrace as part of a comprehensive treatment plan? The focus on palliative care may be one more bipartisan incremental under-the-radar step along the road to government control of our medical care. Subtly devaluing life softens us up and primes the pump for rationing – without having to pass a sweeping single payer bill that is bound to draw attention and criticism.

Ironically, within days of passing the Palliative Care bill, the Senate passed a huge package of some 70 bills designed to reduce opiate abuse. Unafraid to practice medicine without a license, the Senate legislated prescribing mandates and penalties for failure to comply. And the government is developing a “system of care” where all people will receive “appropriate” and “evidence-based” care for pain.

So now physicians may be under pressure to relinquish their patient to a palliative care specialist and prescribe medications according to government dictates. This is wrong. Our patients must never have any doubts that every treatment their physician administers is in their best interests.

We must not allow the whims of politicians to direct our medical care. Physicians must refuse to be tools of the government. Patients must decide whether they want their tax dollars spent on developing cures and life-saving treatment – or programs that steer them toward the least costly alternatives.

Can we trust our medical care to legislators who are willing to sacrifice their integrity on the altar of partisan politics — legislators who are willing to destroy a man’s life in their naked quest for power? Can we trust that doctors who oppose their agenda will not be treated like Judge Kavanaugh by medical boards, hospitals, and courts?

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

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

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

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

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, Healthcare Reform, Law, Medicare, Socialized Medicine, Uncategorized

Mission Possible: Saving Freedom in Medical Care

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by Marilyn M. Singleton, MD, JD

In the original Mission: Impossible series, against all odds, through brilliant strategizing the good guys thwart stealth communist plots to undermine democracies. In trying to provide affordable, quality, personalized medical care, independent physicians face seemingly insurmountable obstacles: digging out from under piles of electronic paperwork, breaking free of third-party red tape, dodging hospital buyouts, and shielding patients from data mining and privacy intrusions.

But the biggest obstacle to great medical care is the socialist brigade rallying around Medicare for All, the proposed federally financed program that boasts no premiums, deductibles or copays, and medical, dental, vision and hearing benefits. What could possibly go wrong? As they say, show me the money. The Congressional Budget Office estimates the federal government will spend about $1 trillion on healthcare programs in 2018. A detailed Mercatus Center analysis concluded that Medicare-for-All would add $32.6 trillion to federal expenditures during its first 10 years.

Currently, payroll taxes and income tax on Social Security benefits fund Medicare’s Part A Hospital Insurance Trust Fund. The Centers for Medicare and Medicaid (CMS) estimates this fund will be depleted in 2026. General tax revenues and beneficiary premiums fund medical services coverage (Part B). Medicare for All would be financed by current Medicare funds – minus the insurance premiums – and would be supplemented by the ever-popular “taxing the rich.” Beware: the definition of “the rich” will be ratcheted down to encompass more taxpayers.

Then there is the coercive nature of Medicare. A beneficiary’s opting out of Medicare Part A means forfeiting all past and future Social Security benefits. Medicare for All makes it clear that no straying from the herd is allowed: neither private insurers nor employers can offer insurance that competes with the government.

Fortunately, more choices are becoming available for potential patients. The House of Representatives recently passed two packages of expansions of Health Savings Accounts (HSAs) (H.R. 6199, H.R. 6311). To name a few benefits, the contribution limit for an HSA nearly doubled to $6,650 for individuals and to $13,300 for families. HSAs would be allowed to pay for direct primary care (DPC) monthly fees. Best yet, anyone would be able to purchase a lower-premium catastrophic plan — removing the ACA’s under age 30 restriction. And purchasers of “bronze” and catastrophic (“copper”) plans would be able to contribute to an HSA.

Improving HSAs is not a trivial goal. HSAs are portable. HSA contributions reduce taxable income, money in the account grows tax-free, and money can be withdrawn tax-free to cover qualified medical expenses. The Employee Benefits Institute estimates that a person saving in an HSA for 40 years, assuming a 2.5% return, could accumulate up to $360,000.

The Executive Branch acted on CMS’s report that lower-cost alternatives were necessary given the rising premiums responsible for the decline in the purchase of unsubsidized ACA plans. The Administration created new rules for short-term limited duration (STLD) insurance policies, which are not bound by the ACA’s restrictive mandates.

STLD plans, defined by the Obama administration as less than three-months duration, can be up to 12 months duration and can include an option for guaranteed renewal up to 36 months. Californians may be out of luck if the proposed consumer protection legislation prohibiting STLD policies makes it to the governor’s desk.

According to CMS, in the fourth quarter of 2016 the average monthly premium for individuals for a STLD policy was approximately $124, compared with $393 for an unsubsidized ACA-compliant plan with comparable $5,000 deductibles. That is an annual savings of $3,228. Even adding $50 per month for a direct primary care practice, an individual saves $2,628 a year. With DPC, all primary care services, including chronic disease management and access to low-priced commonly used medications are included in the upfront price.

The HSA bills and the new STLD rules are an antidote to the erosion of our freedom to contract under the guise of protecting us from “junk” insurance. Medicare-for-All is not the cure for health care ills. Once the central planners lure the masses into dependence on “free” stuff, abuse of power ensues. Voluntary participation by physicians becomes mandatory. When the money tree withers, the non-negotiable provider payments are slashed, and services to patients are rationed.

To mitigate the unacceptable, sometimes fatal wait times in the Veterans Administration health system a bipartisan Congress looked to the backbone of great medicine: private practice physicians. Independent medical practices will lead the way to achieving great affordable medical care through competition and consumer choice.

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

Platitudes and Glittering Generalities

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By Marilyn M. Singleton, MD, JD

We are living in strange times. Virtual money, virtual friends, virtual reality. And regrettably, we are currently burdened with virtual leaders and virtual health insurance coverage.

Last month’s Gallup poll revealed that by a huge margin the “most important problem facing the country today” was dissatisfaction with the government. Our representatives in Washington spend more time meeting with moneyed “stakeholders” than fashioning constitutional legislation based on what their constituents voted for. When our “representatives” occasionally take a break from sniping at the White House or one another, they offer platitudes and intangibles to distract us from their ineffectiveness. Sustainability, the rich, social (in)justice, the common good, a living wage, a better health care system are glittering generalities, known in some circles as propaganda.

Operating under the cloak of munificence and on the premise (or pretense) that the financial and physical best interests of everyday people were at heart, the proponents of the unipartisan Affordable Care Act produced an unrecognizable version of insurance. Health insurance in the United States grew out of concerns for the high cost of serious injuries due to the wide use of machinery in the early 1900s. The ACA – to quote President Obama – “fundamentally changed” the American the health insurance market to forcibly insure individuals for every medical issue no matter how minor. Of course, the promised benefits were illusory since most patients would never meet the high deductible. The ACA robbed us of choice in the insurance market. No more inexpensive major medical insurance policies for those over the ripe old age of 30.

Predictably, nearly half of ACA marketplace enrollees polled in a Kaiser Family Foundation health reform survey report that their premiums, deductibles, and copays have been going up and will create a “financial burden.” And sixty percent of those with any kind of private insurance expect their premiums to go up “a lot.” Their perception is based in reality. In the 20 states where the information was available the 2018 premium increases range from 33 to 49 percent.

As for the negative effects on the other half of the patient-physician relationship, a recent Mayo Clinic study verified that the government-mandated electronic health records are contributing to increasing rates of physician burnout. A majority of those surveyed indicated their electronic medical record systems were causing a clinical burden, resulting in emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.

Moreover, the new complex metrics required under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA), have become a new source of frustration and increased clerical duties.

The ACA and its progeny must go. Responsive government is based on an exchange of ideas with the voters and accordingly, constitutional laws that advance the interests the citizenry. The ACA appeared to respond to the wishes of corporate lobbyists and social engineers, not the public at large.

Dissatisfied with the government? Reject the political pap and decide whether you would rather pay $600 per month and a $5,000 deductible for services that you do not want or need or have the ability to buy inexpensive major medical insurance and pay out- of-pocket for routine office visits. Keeping in mind the hacking of 143 million Equifax records, do you want your medical records housed and managed by the Office of the National Coordinator for Health Information Technology or in your doctor’s office? For many, the answer is clear. Support policies that put the sanctity of the patient-physician relationship first, last, and always.

Dr. Singleton is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) Board member. 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, Medicine, Op-eds, Politics

Warning: Government Can Be Harmful to Your Health

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By Marilyn M. Singleton, MD, JD.

Trust in our government was a mere 19 percent in 2013 according to Pew Research Center. Not surprisingly, 56 per cent of Americans think it is not the government’s responsibility to provide a healthcare system. Waivers, favors, off-the-cuff rule changes, and the bungled launch of the Affordable Care Act website validate that distrust.  Bureaucratic incompetence and cronyism are not the only reasons we should be wary of government involvement in our medical care.

The federal government has a checkered history when it comes to medical judgments. We now cringe at the words of the revered Supreme Court Justice Oliver Wendell Holmes in the 1927 case, Buck v Bell upholding Virginia’s sterilization law for the institutionalized “feeble-minded.” “[Carrie Bell’s] welfare and that of society will be promoted by her sterilization.

It is better for all the world if, instead of waiting to execute degenerate offspring for crime or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. . .Three generations of imbeciles are enough.” In fact, Carrie’s mother was a prostitute, but not feeble-minded. After Carrie’s release she maintained a job as a domestic worker and became an avid reader. Her “feeble-minded” daughter was on her school’s honor roll.

Let’s recall the appalling Tuskegee Syphilis Study lasting from 1932 to 1972.  The U.S. Public Health Service used 400 hundred mainly poor, illiterate black sharecroppers with syphilis as lab animals. They were told they had “bad blood,” but not that they were actually suffering from a serious but treatable disease. All subjects succumbed to untreated syphilis so our government could track the natural progression of the disease.

The U.S. Navy sprayed the presumably harmless bacterium, Serratia marcescens, over San Francisco in 1951 in a biological warfare test. Numerous residents contracted pneumonia-like illnesses resulting in at least one death. The experiments came to light in the 1977 Senate hearings on Health and Scientific Research. Two hundred thirty nine populated areas, including Minneapolis, St. Louis, Washington D.C.’s National Airport, and New York’s subway system, had been contaminated from 1949 to 1969 when President Nixon terminated the program.

In 1989, a Centers for Disease Control and Prevention (CDC)-sponsored study tested an experimental measles vaccine on 1,500 six-month old Black and Hispanic babies in Los Angeles. The CDC admitted in 1996 that parents were never informed that the vaccine was experimental.

According to the Department of Health and Human Services (HHS), lax oversight at the Stratton Veterans Affairs Medical Center in Albany, New York, allowed cancer research coordinator Paul Kornak from 1999 to 2003 to “dishonest[ly] handle research records and demonstrate a complete disregard for the well-being of vulnerable human subjects under his care.” Kornak pleaded guilty to criminally negligent homicide.

In another vein, the degree of political underpinnings in government health policies is unknown. Agencies such as the United States Preventive Services Task Force, self-described as an “independent panel of non-federal experts in prevention and evidence-based medicine,” submit recommendations to the HHS Secretary. Even assuming the recommendations are grounded in science, the Secretary is an arm of the executive branch, so in creeps politics.

This leads us to the question of whether we can always trust “evidence-based medicine.” Reporting bias is systemic in medical literature. A 2012 Cochrane independent review found that company-sponsored trials were more likely to report favorable efficacy results compared with non-industry sponsored studies.  Even in academic studies positive results are more likely to be published. A 2009 analysis of 18 surveys by multiple authors found 34 percent of researchers admitted to “questionable research practices.”

Recently, a large analysis of “secure” studies found the European guideline recommending liberal use of peri-operative beta-blockers for non-cardiac surgery in fact caused a 27 percent increase in mortality or some 800,000 deaths over 5 years. The guidelines were based on trials tainted by scientific misconduct by the principal investigator, Don Poldermans, who was also chairman of the committee that drafted the guideline.

Government intervention in medicine can be harmful to your health. Rigid rules and restrictive drug formularies are advanced based on consensus, leaving no room for individualized treatments. We want physicians whom we can trust to be open, honest critical thinkers, not “providers” who are government puppets.

Dr. Marilyn SingletonDr. 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

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

ObamaCare: Sold to the Highest Bidder

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By Marilyn M. Singleton, MD, JD.,

The Affordable Care Act is like the television show Storage Wars, where unclaimed items in storage lockers are auctioned off after a quick peek through the door. People bid top dollar and hope for the best. Some find a goldmine, but the unseasoned bidders usually receive a Pandora’s Box.

Let’s look at some of the winners. The Center for Public Policy, a non-partisan public interest think tank in Washington D.C., estimated that $120 million was spent lobbying for health reform. Pharmaceutical Researchers and Manufacturers of America (PhRMA) alone spent $26 million lobbying for Obamacare in 2009. And PhRMA has spent well over $100 million on ad campaigns promoting healthcare reform legislation.

Upon passage of the bill, the stocks of some of the largest health insurers, including Cigna, UnitedHealth Group, WellPoint,and Aetna stocks climbed. Major makers of electronic health records (EHR) systems lobbied hard, locking out smaller competitors.

Chicago-based Allscripts Healthcare Solutions former CEO Glen Tullman, who had served as health technology adviser to Obama’s presidential campaign in 2008, made more than $200,000 in contributions to the campaign, and was frequent guest at the White House during 2009.

With some nudging from the Stimulus mandate for EHRs, annual sales of Allscripts more than doubled from $548 million in 2009 to $1.44 billion in 2012. Cerner, another software purveyor, spent $400,000 lobbying for EHR. During the same three-year period, sales rose 60 percent.

Of course, AARP’s CEO, Barry Rand, wrote that the ACA was “vital” for the nation’s seniors. This makes no sense when the ACA in fact cut a half a billion dollars from the popular Medicare Advantage program. It seems the ACA’s passage was vital to AARP’s insurance Medi-gap insurance products – which people with Medicare Advantage do not need.

The presumptive owners of the mystery storage locker – Congress – can change the contents at will. Congress, in a moment of bipartisan backbone or populist pandering, voted that their staff would be on the Exchange. Under the ACA, if an employee purchases a health plan through the Exchange, the employee will lose the employer contribution (if any) to any health plan.

When the chips were down as the moment of truth neared, Congress made a little adjustment: their staffers will keep their employer contributions of $5,000 to $11,000 – far and above those of ordinary Americans.

For example, a single person in Washington, D.C., earning $35,000 per year (an average staffer’s salary) can find a Silver plan unsubsidized annual premium of $2,166. This everyday American is not eligible to receive a government tax credit subsidy, and can have up to $6,350 in co-pays and deductibles (not including the premium).

So we the proletariat get containers of empty promises. We all remember, “if you like your current health plan, you can keep it.” But the CBO estimates that up to 8 million people will lose their employer-sponsored insurance.

We get corporatized medicine, more bureaucracy, less choice, more likelihood of seeing a mid-level practitioner rather than a physician, shorter office visits, markedly higher premiums for young men that pay for those “free” preventive services, no catastrophic/major medical plan option unless you are under 30 years old, more IRS snooping, work hours decreased to 29 hours a week to avoid the threshold requiring a business to provide health insurance, risk of exposure of private medical and financial information, unelected bureaucrats making unilateral decisions by non-medical personnel, unvetted government customer service navigators who are privy to our personal financial information, and predictions of increased emergency room use because of the increased number of Medicaid patients who historically use the ER more due to the shortage of primary care physicians.

Our esteemed public servants claim to be advancing good government but are instead engaging all the while in cronyism to our detriment. We are on a slow descent into tyranny and dependence on government. We still have our voices.

Insist that medical care be about you. Demand that medical care remain between you and your doctor – not the government’s highest bidder.

Dr. Marilyn SingletonDr. 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, Healthcare Reform, Medicine, Op-eds, Politics, Socialized Medicine

ObamaCare Is About Your Money, Not Your Health

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

“Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying all the wrong remedies.” Groucho Marx

The politics of selling the Affordable Care Act (ACA) focuses on promising health and wellness. Somehow, having “coverage” is supposed to get you to a primary care doctor, who will keep you healthy. And if he doesn’t, he will be held accountable by not being paid.

The fact is that “healthcare reform” is not going to cure America’s health problems.

Physicians, think tanks, and politicians are pointing out a myriad of problems with ACA. But most of them miss the main point, which starts with calling it “healthcare reform.” The term, and the conversation about it, conflates health care and medical care. But they are not the same thing. Individuals are in charge of their own health care. Physicians provide medical care to those who become sick.

Health reform begins with making it clear that individuals’ health is in their own hands. The relationship between personal behavior and health is clear. Almost all of the illnesses that we can prevent are related to smoking, over-eating, lack of exercise, alcohol or drug abuse, high-risk behavior, or too much sun exposure.

According to the CDC, 19 percent of all U.S. adults (43.8 million people) smoke tobacco. Almost one third of adults living below the poverty line smoke. Adverse effects include heart and vascular disease, stroke, emphysema, bronchitis, and cancer (lung, oral, esophageal, and likely bladder, kidney, and pancreas). Smoking tobacco is responsible for almost $200 billion in lost productivity and medical care expenditures per year.

Under ACA, doctors will check a box saying they asked about smoking and counseled people to quit. But the decision is up to the patient.

One third of American adults and 17 percent of children are obese. Consequences include fatty liver disease, type 2 diabetes, heart disease, high blood pressure, stroke, gallbladder disease, osteoarthritis, breathing problems, sleep apnea, pregnancy complications, and increased surgical risk. In 2011, the estimated annual medical care costs of obesity-related illness were nearly $200 billion, or 21 percent of annual medical spending in the United States.

Such costs are expected to rise if we allow today’s obese children to grow into obese adults. Obesity must not become the new normal. Indeed, a recent study concluded that since black women are more likely than white women to be satisfied with their weight and have less social pressure to lose weight, merely maintaining their current level of obesity was a success!

Prevention of obesity occurs at home: in the kitchen, at the dinner table, and while shopping. Not in the doctor’s office.

One-fourth of American adults don’t participate in any physical activities. Exercise can lower the risk of heart disease, stroke, dementia, colon cancer, breast cancer in post-menopausal women, and endometrial cancer.

More than half of all cancers related to lifestyle factors: 25-30 percent to tobacco, and 30-35 percent to obesity, physical inactivity, and poor nutrition. Certain cancers are related to sexually transmitted diseases such as hepatitis B, human papillomavirus infections (genital warts), or human immunodeficiency virus (HIV). Many skin cancers are caused by sun exposure.

We will have healthier people only if patients value their own health as much as good doctors do. And doctors must practice what they preach—who is going to listen to an obese doctor or nurse?

Some patients place a higher priority on enjoying risky behavior than on their health. ACA will not make them healthy. It only shields them somewhat from the consequences of their actions by forcing people who do take care of their health to share their costs.

Government cannot make us healthy, not even by trying to prohibit overindulgence or bad habits. Certainly, ACA’s massive new regulations, erosion of privacy, and higher taxes don’t bring health. But ACA’s subsidies compound our unhealthy reliance on government.

ACA redistributes the money flowing through the system. But your health care is still your responsibility. We can make others share the health plan premiums, but the pain and suffering are still the patients’ to endure.

Dr. Marilyn SingletonDr. 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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