Federal Involvement in Medical Care is Not the American Way
COVID-19 and the Universal Health Scare
Politicians are a strange lot. Not content with merely being Speaker of the House, Nancy Pelosi is moonlighting as Surgeon General, opining on what medications the President should be taking. Service to the public is a distant memory. The new charge is to invent catchy phrases, like the “new normal,” to quietly coax us into obeying dictates, while ignoring facts and science.
It is not normal to base lifting the lockdowns on the trend in positive novel coronavirus (aka SARS-CoV-2) tests. Predictably, positive tests (with many folks never becoming symptomatic) will continue to increase as more tests are done. Given that the stated goal of lockdowns was to lessen the strain on hospital resources, using hospitalization trends makes more sense.
It is not normal for New York and Minnesota governors to insist that COVID-19 patients be admitted to nursing homes, even after it became clear that nursing homes were a hotspot for infections and up to 81% of COVID-19 deaths.
It is not normal for healthy people to walk around wearing masks—particularly when it is not recommended by the sainted World Health Organization.
It is not normal to never see your parents, children, or grandparents. Older folks suffer from loneliness in the best of times.
It is not normal for children to stay home from school indefinitely. When children do go back to school, it is not normal to tell them they have to wear masks and might not be able to play or eat with one another. Meanwhile, the CDC’s latest report tells us that the infection fatality rate for those aged 0-49 years is 0.05%. The CDC’s latest numbers are what Stanford researchers predicted in April.
It is not normal to have cellphone apps that track your movements. I suppose helicopter parents and stalkers would make good use of them.
It is not normal to propose “immunity passes” enabling the holders to move about society unimpeded. Immunity passes make no scientific sense given that the serology tests are unreliable, the length of immunity to SARS-CoV-2 is unknown, and invites social stigmatization.
The real “new normal” is politicians being blatant with their old games. It is normal for California’s Governor Newsom to make a secret $1 billion deal with BYD, a Chinese-based electric bus maker, to manufacture N95 masks at $3.30 a piece. Kudos to his fellow Democrat legislators for seeking transparency about his pandemic spending spree. To his credit, Los Angeles Mayor Eric Garcetti purchased 24 million “Made in America” masks from Honeywell at 79 cents a mask.
COVID-19 is a handy justification for Congress to promote a political ideology rather than propose targeted measures to assist those struggling with the consequences of the virus. The HEROES Act, the fourth stimulus bill, presents a path to universal basic income by paying some workers more to stay home than they would receive by returning to work. The CARES Act suspended student loan payments, but the HEROES Act paves the way for free college tuition for all by forgiving up to $10,000 of student loans for every borrower.
Moreover, the HEROES Act contains a multitude of other agenda-driven programs like access to financial services and the marketplace for minority-owned cannabis-related businesses, diversity in banking, a Post Office bail-out, $50 million to the Environmental Protection Agency for environmental justice grants, economic impact payments to illegal immigrants, permanent voting by mail, and the clearly relevant requirement that the President inform Congress of the reasons for not filling a vacancy for an Inspector General position.
The proposed Medicare Crisis Program Act of 2020 would provide health insurance for those who lost their health insurance due to the COVID-19 lockdown and its consequences. We want to help those who lost their jobs, but why use a newly-minted premium-free Medicare program as the vehicle? Is it to get people accustomed to Medicare covering all age groups?
The CONTACT initiative requires the CDC to work with states to implement a national system for testing, contact tracing, surveillance, containment and mitigation of COVID-19. (Have we done this for the infectious and deadly flu?). The CDC regulations, instruct authorities to use the “least restrictive means” in implementing public health measures. However, “when an individual is identified as a threat to the health and welfare of others, such as refusing medical treatment at a healthcare facility and refusing to self-quarantine, the government may take the individual into custody.”
The government has been known to abuse its power—whether through cultivating fear, regulatory force, or by individual miscreants. Frederick Douglass warned, “Find out just what any people will quietly submit to and you have the exact measure of the injustice and wrong which will be imposed on them.” We cannot let a declaration of a public health emergency become the new gauge of what it takes to break our spirit of liberty.
Obesity: America’s Self-inflicted Preexisting Condition
Consuming too many potato latkes and Christmas cookies has left its mark on our waistlines. Unfortunately for Americans and their medical care, the seasonal overeating seems to last all year. Indeed, the American Medical Association has declared that obesity is a disease.
It may be more accurate to describe obesity as a contributor to certain diseases. Obesity raises the risk of premature death, heart disease, high blood pressure, stroke, type 2 diabetes, gallbladder disease, breathing problems, certain cancers, and osteoarthritis. Certainly, obesity can result from certain uncommon diseases and hereditary factors, but most people become obese simply because they eat too many unhealthy foods and do not exercise.
At its last count, the Centers for Disease Control and Prevention (CDC) estimated that 40 percent of U.S. adults age 20 and over, 21 percent of teens, and 14 percent of preschoolers are obese. A December 2019 study that analyzed 26 years of body mass index (BMI [the relation of weight to height]) data concluded that half of U.S. adults will be obese (BMI>25) by 2030. Some 25 percent will be severely obese (BMI>35). Moreover, less than 5 percent of adults get the recommended 30 minutes a day of physical activity. And even when people living in “food deserts” were presented with healthy options, only 10 percent changed their evil eating ways.
According to the CDC’s last comprehensive analysis, the annual medical cost of obesity in the United States to Medicare, Medicaid, and private insurers was $147 billion in 2008. And the medical costs for obese people were $1,429 higher than those of healthier weights.
The saddest development is the cultural normalization of obesity with lingerie models, singers, and television shows celebrating fatness. Do we high-five people with other lifestyle related conditions such as alcoholism, emphysema, or coronary artery disease? Of course not.
The obese are easy targets for drug company peddlers of quick fixes or “providers” who want to extract money from third-party payors. U.S. pharmaceutical companies spent $6.1 billion on direct-to-consumer prescription drug advertising in 2017. Many ads feature chunky type 2 diabetics happily frolicking about, thanks to the drug company’s magic pill. The ads might as well say, “pass the chocolate cupcakes with statin sprinkles drizzled with insulin.” We all know the prescription of eating less and exercising more is free of charge.
Alas, we are losing the battle of the bulge. A recent study found that participants failed to lose weight despite reporting that they were exercising and watching their diet. The authors concluded that “many of [the participants] might not have actually implemented weight loss strategies or applied a minimal level of effort, which yielded unsatisfactory results.”
While politicians debate the merits of spending trillions of dollars on government-sponsored medical care, a correctable source of high medical costs is hiding in plain sight. Irrespective of who pays for medical care, rational economic decisions must be made. The Affordable Care Act (ACA) waved a magic wand and removed preexisting conditions from the underwriting equation when calculating premiums. A sick person and a healthy person of the same age could purchase insurance at the same price. Consequently, the ACA doubled the costs for people who made the effort to take care of themselves.
The ACA did allow a “tobacco surcharge” of up to 50 percent more for premiums. Why not an obesity surcharge? This would provide an incentive for consumers to take obesity seriously. Additionally, health-conscious persons would not have to pay for the bad habits of others through taxes to fund government health insurance programs or through higher private insurance premiums.
Those who are stricken with illnesses through no fault of their own need a path to affordable medical care. A good start for lowering costs would be eliminating costly middlemen by encouraging consumers to pay directly for day-to-day medical expenses. Expanding contribution limits and eligible uses of Health Savings Accounts would help pay for the more reasonably priced direct-pay surgery and other alternatives to insurance like direct primary care.
With regard to insurance, we need a revival of competition in the insurance market with multiple products and carriers. Once again, single men could opt to decline pregnancy coverage. We need to restore the pre-ACA availability of low-cost catastrophic (major medical) insurance policies to all ages. Even before mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the large majority of insurers offered guaranteed renewable policies. Here, assuming timely payment of premiums, at the end of the policy period the insurer must renew coverage regardless of the health of the insured. Naturally, this valuable feature costs more but provides consumers with a strong incentive not let the insurance lapse.
Let’s confront the elephant in the room. Healthcare policy should promote personal responsibility, rather than encourage free riders. In America we are free to overeat and under-exercise but we have no right to make innocent bystanders pay for the consequences.
Data Mining, Artificial Intelligence, and Angels of Death
By Marilyn M. Singleton, MD, JD
Google is universally well known as a search and advertising company. Now Google is tapping into the $3.5 trillion healthcare market. To compete with the Apple Watch, Google acquired FitBit, the wearable exercise, heart rate, and sleep tracking device. Data is king.
Voluntarily worn fitness tracking devices are one thing, but Google has entered the realm of the brave new world.A government inquiry has brought to light Google’s “Nightingale Project” that collected private medical data from Ascension Health’s 2,600 sites of care across 20 states and D.C., unbeknownst to the patients. Dozens of Google employees had access to the data which included lab results, physician diagnoses, hospitalization records, and health histories, complete with patient names and dates of birth. Google claims that the project complies with the Health Insurance Portability And Accountability Act (HIPAA) because it is a qualified business associate of Ascension Health. And unlike the ads for socks that appear on your computer a nanosecond after you purchased some tennis shoes, Google promises that the data won’t be combined with consumer data. Fat chance.
Amazon, which already knows our every thought, was not satisfied with merely creating software that can read medical records. Now they’ve created Transcribe Medical, a system that transcribes confidential patient-doctor conversations and uploads them directly into the electronic health record. Doctors would relinquish all control over “private” patient records. Google also has been working on its own automatic speech recognition “digital scribe” to upload multiple speaker conversations.
Not only is there a problem with inaccuracies that could lead to a patient receiving the wrong treatment, but we all know the ubiquitous problem of hacking—even in the Department of Defense and the federal Office of Personnel Management.
Disturbingly, certain circles oohed and aahed over the revelation that Google, using electronic health records (EHR), created an artificial intelligence program that could predict death better than doctors. Fortunately for humanity, many others found the thought of leaving doctors out of the equation horrifying. The cheerleaders crowed that it would decrease work for the doctors; they wouldn’t have to waste their time going through those pesky medical records to arrive at a conclusion. Using an artificial neural network to predict the death of a human being is a far cry from having a computer interpret an inanimate x-ray who is not a daughter, mother, sister, wife, or grandmother.
If you put it all together, it adds up to a death panel of one. Google’s software would decide that there is not a high likelihood of walking out of the hospital, no treatment would be given. We are becoming witness to the devolution of humanity.
Moreover, the government is incentivizing workforce development in palliative care through the Palliative Care and Hospice Education and Training Act. Perhaps this is why the hospice team seems to greet the patient at the hospital door. Of note, once a person has signed on to the Medicare hospice program, Medicare will not pay for any curative treatment or medications. Medicare will not pay for an emergency room visit unless the hospice team arranged it or someone decides it is not related to the hospice diagnosis.
The number of hospice agencies participating in the Medicare program nearly doubled between 2000 and 2016, for a total of some 4,382 providers. In 2000, about 30 percent of hospice agencies were for-profit, compared to about 67 percent in 2016. In that same period, Medicare payments grew from $3 billion to $16.8 billion.
Hospice care is lucrative. The minimum Medicare payment is $196 per day regardless of the quantity or quality of services provided on that day. A July 2019 report from the Office of Inspector General for the Department of Health and Human Services found that more than 80 percent of end-of-life facilities in the United States had at least one deficiency, and nearly 20 percent were poor performers with serious problems that jeopardized patient health and safety. It seems the compassionate medical service to care for suffering patients has turned into a heartless cash cow.
Is this what we want for our loved ones and eventually, ourselves? Medicare for All promises every type of medical care under the sun, including long-term care. Long-term care is expensive and if done properly, labor intensive. What better way to save money than to promote a computer program that convinces doctors that the patient is going to die no matter what they do. So the hospital tells the family that treatment or home care will drain their finances. For what? I’ll tell you for what. My parents died at home only after they were tired of doctors and ready to go. They strolled into heaven. They were not shoved in with a giant government backhoe.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
Giving Medicare for All a Facelift: the Ugly Is Still There
By Marilyn M. Singleton, MD, JD
Medicare for All (M4A) retained its prominent place on the stage at the latest Democratic debate. In its purest Bernie Sanders form, concurrent with abolishing private health insurance, U.S. residents would be enrolled in “Medicare.” The program would pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health and substance abuse treatment, vision, dental, and hearing services, and long-term care with no out-of-pocket costs. Some supporters were scared off by the $32 trillion over 10 years price tag. Not to be outdone, Elizabeth Warren’s “I’m with Bernie” plan comes with a $52 trillion over 10 years price tag including up to $34 trillion in new government spending. Our country’s entire yearly budget is a mere $3.5 trillion. For perspective, if your salary is $40,000 per year it would take 25 million years to earn 1 trillion dollars. As M4A’s dark side emerged, the candidates distanced themselves from Bernie-care.
Elimination of private insurance? Whoa, Nellie! Over 156 million Americans —half the country—are covered by employer-sponsored health insurance plans and another 23 million have private individual policies. And most of these folks like that arrangement. Then there was pushback from some unions who had excellent health insurance policies for which they had bargained and given up other perks.
In the June debate the candidates raised their hands indicating they would abolish private health insurance. Now Mayor Buttigieg wants to “unify the American people around, creating a version of Medicare, making it available to anybody who wants it, but without the divisive step of ordering people onto it whether they want to or not.” Vice president Biden, noting his desire to keep patient choice stated, “we should build on Obamacare … adding a Medicare option in that plan, and not make people choose.” Of course, Obamacare caused a rise in premiums, a decrease in choice of insurance coverage, and like any large government-run program was prone to mismanagement and waste.
Possible financing mechanisms were screaming for a deep dive. One analysis concluded that most Americans would suffer financially if M4A were implemented as proposed. An analysis by a bipartisan think tank estimated a 32 per cent increase in payroll taxes would be needed to fund M4A. Everyone—even the working poor—would have more payroll taxes extracted from their paycheck. The analysis concluded that most households would pay more in new taxes than they would save by eliminating their current spending on private health insurance and out-of-pocket medical expenses.
Senator Warren tries to hide the ugly truth by railing about the evil rich who would be taxed down to their underwear. Take the deceptively worded “2-cent” annual tax for households with more than $50 million in assets. If you have $51 million in assets, most probably tied up in your business, you’d have to cough up (.02)($1,000,000) or $20,000, not 2 cents. The devil’s spawn, aka our 535 billionaires, would be subject to a 6 percent annual tax on their assets. Who will be the next target when the government has driven the assets to a sunny island in the Caribbean? Finally, raising the corporate income tax back up to 35 percent likely would result in businesses paying lower wages to current employees or cutting back on hiring to compensate for the increased tax burden.
During the latest debate, Senator Warren retreated from her “all-in” approach, asserting she would first provide Medicare at no cost to “everybody under the age of 18, everybody who has a family of four income less than $50,000”—about 135 million people. Second, she would lower the Medicare age to 50 and expand Medicare coverage to include vision, dental, and long-term care. In the third year, “when people have had a chance to feel it and taste it and live with it, we’re going to vote and we’re going to want Medicare for all.”
Senator Sanders owns that payroll taxes would be doubled or tripled and proposes a 4 percent surtax on families earning more than $29,000. So if you earn $60,000, you’d have to pay (.04)($31,000) or $1,240, enough for a whole year’s membership in a private Direct Primary Care plan. Senator Sanders, staying true to his principles, is sticking with unadulterated Medicare for All with its financial warts.
Even those who are numb to government over-spending can see the broader problem of inviting Uncle Sam into their lives in exchange for a Medicare card in their wallet. Any remaining privacy is erased. Our medical records would be furnished to the Department of Health and Human Services and the National Coordinator for Health Information Technology. Physicians and patients would be robbed of their autonomy and choice by medical care policies set by the government monopoly. Lack of competition leads to lower quality and fewer services. Coverage becomes an illusion.
Medicare for All’s beauty is only skin deep and its ugly goes to the bone.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
Medical Costs Transparency: As Clear as Peanut Butter
By Marilyn M. Singleton, MD, JD
What if purchasing medical products and services were like buying peanut butter? Grocery stores have several brands and varieties: smooth, chunky, old-fashioned, natural, organic, no added sugar, reduced fat, no-stir, and pre-mixed with jelly with clearly marked prices ranging from $1.75 for the store’s generic brand to $7 for the over-priced Yuppie brand. After carefully examining the labels, our shopper chose a 16-ounce, $5 jar of no-added-sugar peanut butter. She paid the cashier $5 for the peanut butter and went home.
If our shoppers were transported to the universe of medical billing with the $5 jar of peanut butter, the shopper with Medicare would pay $1.00 but her grandchild will be presented with a bill for $4. When the shopper with private health insurance attempts to pay, the cashier becomes unglued. The shopper cannot say whether she met her deductible or has a co-payment, and whether the brand of peanut butter is approved by the network. She really wants the peanut butter so she grabs the generic from the shelf and pays the $1.75. Our privately insured shopper was pleasantly surprised at the generic’s good taste and healthful ingredients, her wallet was happy for the cost savings, and she was glad not to have the middleman hassle.
Comparison shopping is one pillar of bringing sanity to the high cost of medical care, but the opacity of the pricing system for medical costs limits the value of posting list prices to encourage lower costs through shaming, competition, and choice. In addition to research and development, manufacturing, and distribution costs, drug costs are affected by additional layers of middlemen: pharmacy benefit managers (PBMs) and insurers. Using a “trade secret” process, PBMs negotiate discounts and rebates for private and government insurers. The money saved is supposed to go back to the government (taxpayers) or to insurers to lower premiums or otherwise benefit patients. PBMs typically are paid by a percentage of the rebate or discount off the list price. The higher the price, the bigger the rebate. Thus, the rebate system gives an incentive to raise list prices rather than placing the lowest-priced drug on the insurer’s formulary. (This same system is used by Group Purchasing Organizations (GPOs) for hospital product purchases.)
An analysis of the effect of California’s 2-year old drug price transparency law illustrates the complexity of pricing. Despite being compelled to post list prices, pharmaceutical companies raised the list price for wholesalers by a median of 25.8 percent but the data did not indicate the “price” that consumers actually paid. Moreover, with medical services and products the simple What the Market Will Bear (WTMWB) pricing method works because either the medication is essential (e.g., Epi-Pen®), has no alternative, is in short supply, or the medical consumer is not paying directly for the services.
Similarly, publishing hospital the charge description master (“chargemaster”). i.e., the standard industry price does not give consumers enough information to make a rational choice regarding elective medical services. The data necessary to make price comparisons depends on an individual’s circumstances. More relevant than the chargemaster price, a self-pay patient needs to know the lowest possible cash price. A patient with health insurance must know (1) whether the hospital is in the insurance network, (2) the price negotiated between the health care provider and insurer (including Medicare), (3) the amount and method of calculating cost-sharing, (4) the amount Medicare or other insurer will pay for services performed in a physician’s office in contrast to the hospital which tags on a “facility fee.”
Transparency is one tool for lowering costs through choice. As one of many studies on hospital consolidation noted, “The Sky’s the Limit” on prices where there is lack of competition. But the difficulties of achieving useful price transparency must not be a cue for the government to initiate bureaucratic band-aids. As we have seen with Obamacare, forcing insurers to pay more of the costs leads to higher premiums, deductibles, and/or co-pays.
Nor should the government impose price caps. President Nixon’s 1971 wage and price freeze brought product shortages—which we are already facing with certain drugs, including anesthetics and chemotherapy agents. If the government sticks to enforcing anti-trust laws, a competitive market will thrive. The court house door anti-trust settlement by Northern California’s Sutter Health sends a message to big hospital chains to stop using their market share to inflate prices or require insurers to join their networks on an all-or-nothing basis to prevent insurers from negotiating lower prices at individual hospitals.
If we can get to the point of direct exchange of money for goods and services and reserve health insurance for major expenses, we can see costs decrease just as we have seen with the Surgery Center of Oklahoma over the last 10 years.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
Fraud and Anonymity: The Perils of Medical Care Bureaucracy
By Marilyn M. Singleton, MD, JD
The high cost of medical care is on the lips of every politician and draining the pocketbooks of most Americans. After creating the Medicare/Medicaid monster, the government’s expanded intervention into the medical care marketplace with the inaptly named Affordable Care Act doubled the premiums and deductibles for both employer-sponsored and individual insurance. Piling on more laws, regulations, and agencies is not the answer.
Anonymity, complexity, and opacity invite shady behavior. Individuals, companies, and patients who defraud the massive federal “health system” would never dream of lifting money from their patients’ wallets or stealing from their doctors’ cash drawer.
The government’s track record does not bode well for imposing more bureaucracy to remedy a problem created by the layers of third-party payer bureaucracy. Waste, fraud, and abuse are so rampant that the government has a Medicare Strike Force to root out and recover lost federal funds. Medicare fraud—about $60 billion in 2016 alone—is about 10 percent of Medicare’s total payments. By contrast the typical private business loses 5 percent of its revenues to fraud. Unfortunately, since its inception in March 2007, the Medicare Strike Force has recouped less than $2 billion per year in misappropriated funds.
Medicare’s $16.7 billion per year hospice program is fertile ground for the unscrupulous. Hospices are paid a fixed daily sum for each patient enrolled “regardless of the services provided.” One amoral scheme recruits patients who unknowingly forgo curative treatment options by joining hospice. A recent Office of Inspector General (OIG) report revealed that in 2012 hospices billed Medicare more than $250 million for services to patients in long-term care or assisted-living residences who did not require hospice care, costing four times more than the appropriate level of care. Even worse, the OIG found that the quality of care suffered in 31 percent of programs. The bureaucratic morass allows the perpetrators to pocket the fixed fee and skimp on the services.
Further, the government cannot keep track of its program dollars. According to another OIG audit, in 2009, Medicare Prescription Drug program paid $33.6 million and hospice patients paid $3.8 million for medications that should have been included in the hospice daily fee. Even after discovering the snafu, the problem got exponentially worse. In 2016 the government paid $160.8 million for drugs that hospice organizations should have paid for from its fixed daily fee. Our tax dollars paid for the drugs twice.
Physicians know what patients want and are acting on it. Free from the restraints of government “healthcare” programs, the physician-led, price-transparent, direct-pay Surgery Center of Oklahoma performs some surgeries for less than the copays of some insurance policies. Direct Primary Care physicians provide 24/7 access and basic labs for as little as $50 per month with at-cost medications and low-priced x-rays.
The corporate private sector has learned a thing or two from innovative physicians. Care Accelerator is Sam’s Club’s version of “affordable [medical care] options with transparent pricing.” To offer relief from high out-of-pocket costs, $50 (individual) to $240 per year (families) buys access to lab screening for diabetes and heart disease, free generic drugs, telehealth, and up to a 30 percent discount on vision, dental, and other ancillary services. Additionally, Walmart is training its own employees for jobs in the health sector and ideally to staff Walmart’s own medical services. For their employees, Apple has “health care built around you” with its AC Wellness that offers office and home visits; Amazon launched its Amazon Care telemedicine services.
Given the outrageous price of drugs—largely due to the pharmacy benefit manager middlemen—Good Rx discount coupons are just what the doctor ordered. Good Rx is free to the consumer and makes money from advertisements on the website and referral fees. One typical victory is a Medicare patient whose neurologist prescribed a drug for his Parkinson’s disease symptoms. The government demanded testing that could not be done because of the patients debilitated condition. Despite a sympathetic ear and supporting research, the government arbiter could only parrot the party line: because the drug was not on the “list,” it was not covered by Medicare. In a fortunate twist of fate, with a Good Rx coupon the patient paid $34 per month cash instead of the drug’s $1,100 per month price with 20 percent patient co-pay that would have been charged through the Medicare Prescription Drug program.
Congress claims it plans a full-frontal attack on the high cost of medical care (with the same results as the war on poverty and drugs?). Frankly, we are better off with Congress engrossed in its impeachment clown show and keeping its nose out of our medical business.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
The Soylent Green New Deal is Three Years Away
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.
Can We Trust the Government with Our Medical Care?
By Marilyn M. Singleton, MD, JD
The short answer is No. And thinking that, we would be in good company. A new survey finds that Americans trust Amazon more than the federal government.[1] The most trusted entities were our military, Amazon, Google, local police, and universities. Congress came in as the least trusted, edging out political parties and the press.
Bureaucratic incompetence and cronyism are not the only reasons we should be wary of government involvement in our medical care. The federal government has a checkered history when it comes to medical judgments.
Forced Sterilizations
In light of state governments’ recent love affair with post-term abortions (aka infanticide), forced sterilizations are at the top of my list. Although other states had tried, Indiana became the first state in the country to successfully pass a forced sterilization law in 1907. The law applied only to the “feebleminded.” California and Washington jumped on board in 1909. By the 1920s, 33 states had forced sterilization laws. Heads of psychiatric institutions were free to sterilize anyone they considered social misfits. [2]
We now cringe at the words of the revered Supreme Court Justice Oliver Wendell Holmes in the 1927 case, Buck v Bell, upholding Virginia’s sterilization law for the institutionalized “feeble-minded.”[3]
[Carrie Bell’s] welfare and that of society will be promoted by her sterilization. It is better for all the world if, instead of waiting to execute degenerate offspring for crime or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind…. Three generations of imbeciles are enough.
In fact, Carrie’s mother was a prostitute, but not feebleminded. After Carrie’s release, she maintained a job as a domestic worker and became an avid reader. Her “feebleminded” daughter was on her school’s honor roll.
With the third branch of the federal government on board, between 1909 and 1979 more than 20,000 government-funded forced sterilizations were performed. The last legal forced sterilization was in 1981. These went beyond the mentally challenged. Latinos and blacks were easy targets, particularly in the 1970s after Medicaid-funded family planning service offered sterilization. Some patients were bullied into consenting with threats of having their welfare benefits or medical care taken away. Sometimes patients were coerced into a tubal ligation immediately after their infant’s delivery. At other times, tubal ligations were done during Cesarean sections unbeknownst to the patients. These sterilizations were such an open practice in the South that that they became known as a “Mississippi appendectomy.”[4]
In North Carolina, an IQ of 70 or lower qualified a person for sterilization. Here, state social workers could file petitions for sterilization. One social worker sterilized her entire caseload.[5]
The Indian Health Service with its captive audience was worse. Between 1973 and 1976 some 3,400 Native American women— including minors—were sterilized without permission or with defective consent forms.[6]
The Tuskegee Study
The “Tuskegee Study of Untreated Syphilis in the Negro Male” lasted from 1932 to 1972. The U.S. Public Health Service used 400 mainly poor, illiterate, black sharecroppers with syphilis as lab animals. They were told they had “bad blood,” but not that they were actually suffering from a serious disease. That was the extent of the “informed consent.” In exchange for having their lives ruined, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years. The men were never given adequate treatment for their disease. Even when penicillin became the drug of choice for syphilis in 1947, researchers did not offer it to the subjects. Nor were the subjects given the choice of quitting the study. All subjects succumbed to untreated syphilis so our government could track the natural progression of the disease. Once the study became public in 1972, it took a nine-person panel appointed by the assistant secretary for health and scientific affairs to decide that the study was “ethically unjustified.”[7] A class-action lawsuit filed the next year resulted in a $10 million settlement for the victims and their families.
Germ Warfare
This one is personal. My first patient that died, whose name and face I still remember, was a drug addict with bacterial endocarditis due to Serratia marcescens. The medical resident was baffled. Drug addicts are more susceptible to unusual bacteria, but where did this Serratia come from? It came from our own government.
Throughout a week in September 1951 as part of the U.S. Navy’s “Operation Sea Spray,” a presumably harmless bacterium, Serratia marcescens, was sprayed over San Francisco in a biological warfare test.[8] The U.S. Army’s monitoring of 43 sites around the city determined that San Francisco had received enough of a dose for nearly all of its 800,000 residents to inhale millions of particles each day during the week of spraying. Consequently, cases of urinary tract infections and pneumonia in San Francisco also increased after Serratia marcescens was released.
During Senate subcommittee hearings in 1977, the army revealed that between 1949 and 1969 open-air tests of biological agents were conducted 239 times in populated civilian areas, including Minneapolis; St. Louis; Mechanicsburg, Pa.; the Washington, D.C., National Airport; and New York’s subway system.[9] Had President Nixon not terminated the program in 1969, how many more sprayings would we have had?
Experimental Vaccine
In 1989, a study sponsored by the Centers for Disease Control and Prevention (CDC) tested an experimental measles vaccine on 1,500 six-month old black and Hispanic babies in Los Angeles. The CDC director, Dr. David Satcher, admitted in 1996 that “a mistake was made” and “it shocked [him].”[10] The consent papers the parents signed said the children would receive one of two vaccines, but they were not told that one of the vaccines was experimental and unlicensed.
A deceptive brochure was distributed with the consent form. The brochure advised: “This vaccine has been shown to be effective in younger children. Over 200 million children around the world have received this vaccine, but Los Angeles County is the first place in the United States where it is being offered.”It was not until a significant number of children in Africa and Haiti had died from the vaccine that the study was stopped in 1991.
The Veterans Health Administration
The Veterans Health Administration (VA) is the current model of a government-sponsored single-payer health system. Let the headlines do the talking. A 2014 report by Sen. Tom Coburn (R-Okla.) found that more than 1,000 veterans may have died in the last decade because of malpractice or lack of care from VA medical centers.[11]
Even after the long waits were revealed, “Deceased” notes on files were removed to make statistics look better: veterans would not be counted as having died while waiting for care at the Phoenix VA hospital.[12]
In January 2015 it was reported that more than 1,600 veterans waited between 60 and 90 days for appointments at facilities operated by the VA Greater Los Angeles Healthcare System. About 400 veterans waited 6 months for an appointment. The average wait time, according to documents dated Jan 15, 2015, was 48 days.[13]
By April 2015, despite major reforms, government data show that the number of patients facing long waits at VA facilities had not dropped at all. The number of medical appointments delayed 30 to 90 days has largely stayed flat. The number of appointments that take longer than 90 days to complete has nearly doubled. This was far from the government’s goal of 30 days.[14]
A 2018 report from the Department of Veterans Affairs inspector general found that the Washington, D.C., VA Medical Center has for years “suffered a series of systemic and programmatic failures to consistently deliver timely and quality patient care,” and heightened potential for waste, fraud and abuse of government resources.[15]
Finally, in May 2018, veterans saw relief with the VA’s Choice program, when the bipartisan bill passed and was signed by the President. Under the law, if the VA cannot provide the veterans with the level of care they need or the level of care they expected, or had long wait times, the veteran can seek care in the private sector.[16]
Q.E.D.
Conclusion
The noted 19th century statesman and orator Daniel Webster said, “Good intentions will always be pleaded, for every assumption of power; but they cannot justify it…. It is hardly too strong to say, that the Constitution was made to guard the people against the dangers of good intention, real or pretended.”[17] Given the government’s track record, even the most jaded bureaucrat cannot justify such betrayals of patients’ rights and the public trust.
There is another theme between the lines: offer the people free stuff and then use it as a cudgel to keep the recipients in line. The helpless, the poor, and Native Americans were easy targets. Now “Medicare for All” threatens to trap the rest of us in a system with no escape.
Marilyn Singleton, M.D., J.D., an anesthesiolologist, serves as president of AAPS. Contact: [email protected].
Download PDF of this article: https://jpands.org/vol24no2/singleton.pdf [originally published as “From the President” column in Summer 2019, JPandS.
REFERENCES
- Tiffany K. In Amazon We Trust—but Why?; Oct 25, 2018. Available at: https://www.vox.com/the-goods/2018/10/25/18022956/amazon-trust-survey-american-institutions-ranked-georgetown. Accessed April 2, 2019.
- Zhang S. A long-lost data trove uncovers California’s sterilization program. Atlantic, Jan 3, 2017. Available at: https://www.theatlantic.com/health/archive/2017/01/california-sterilization-records/511718/. Accessed April 3, 2019.
- Buck v Bell, 274 U.S. 200 (1927). Available at: https://supreme.justia.com/cases/federal/us/274/200/. Accessed April 3, 2019.
- Garcia S. 8 shocking facts about sterilization in U.S. history. Mic; Jul 10, 2013. Available at: https://mic.com/articles/53723/8-shocking-facts-about-sterilization-in-u-s-history. Accessed April 2, 2019.
- Schoen J. Reassessing eugenic sterilization: the case of North Carolina. In: Lombardo PA, ed. A Century of Eugenics in America. Bloomington, Ind.: Indiana University Press; 2011:141-160.
- Government Accounting Office. Investigation of Allegations Concerning Indian Health Service HRD-77-3; Nov 4, 1976. Available at: https://www.gao.gov/products/HRD-77-3. Accessed April 3, 2019.
- Centers for Disease Control and Prevention. The U.S. Public Health Service Syphilis Study at Tuskegee; Dec 22, 2015. Available at: https://www.cdc.gov/tuskegee/timeline.htm. Accessed Apr 3, 2019.
- Subcommittee on Health and Scientific Research of the Committee on Human Resources, U.S. Senate, 95th Congress. Examination of Serious Deficiencies in the Defense Department’s Efforts to Protect the Human Subjects, of Drug Research. Hearings; Mar 8 and May 23, 1977. https://babel.hathitrust.org/cgi/pt?id=mdp.39015005321081;view=1up;seq=1
- Mahlen S. Serratia infections: from military experiments to current practice. Clin Microbiol Rev 2011;24(4): 755–791. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3194826/. Accessed Apr 4, 2019.
- Cimons M. CDC says it erred in measles study. Los Angeles Times, Jun 17, 1996. Available at: https://www.latimes.com/archives/la-xpm-1996-06-17-mn-15871-story.html . Accessed Apr 4, 2019.
- Devine C. Bad VA care may have killed more than 1,000 veterans, senator’s report says. CNN; Jun 24, 2014. Available at: https://www.cnn.com/2014/06/24/us/senator-va-report/. Accessed Apr 4, 2019.
- Bronstein S, Griffin D, Black N, CNN Investigations. VA deaths covered up to make statistics look better, whistle-blower says. CNN; Jun 24, 2014. Available at: https://www.cnn.com/2014/06/23/us/phoenix-va-deaths-new-allegations/. Accessed Apr 4, 2019.
- Bronstein S, Griffin D, Black N, Devine C. It’s not over: veterans waiting months for appointments. CNN; Mar 14, 2015. Available at: https://www.cnn.com/2015/03/13/us/va-investigation-los-angeles/. Accessed Apr 4, 2019.
- CBS News. “Livid” VA patients still facing long waits times for health care; Apr 9, 2015. Available at: https://www.cbsnews.com/news/va-patients-still-facing-long-waits-times-for-health-care/. Accessed Apr 4, 2019.
- Summers J. Systemic failures plague DC veterans hospital, inspector general finds. CNN; Mar 7, 2018. Available at: https://www.cnn.com/2018/03/07/politics/washington-dc-va-hospital-inspector-general/index.html. Accessed Apr 4, 2019.
- Summers J, Landers E. Senate passes proposal to expand private health care for veterans. CNN; May 23, 2018. Available at: https://www.cnn.com/2018/05/23/politics/veterans-health-care-senate-vote. Accessed Apr 4, 2019.
- AZquotes.com. Available at: https://www.azquotes.com/quote/1315991. Accessed Apr 3, 2019.
Free Medical Care: a Deal with the Devil?
By Marilyn M. Singleton, MD, JD
Listening to the campaign promises spewed out by the bevy of folks running for president brings the old but enduring story of Faust to mind. Despite being successful, Faust wanted more knowledge and possessions. To that end, he made a deal with Mephistopheles (aka the Devil) who promised to give him everything he wanted in exchange for his soul.
Who isn’t tempted by a bargain or better yet, something for nothing? Free income, free college, and free medical care. What do we have to lose? Self-respect, the opportunity to succeed at a career suited to one’s talents, your privacy and control over your own body.
Intended to ameliorate poverty, universal basic income can be counterproductive. Some promise income for merely having a pulse and others envision the government equivalent of a mama bird regurgitating food into the open mouths of her chicks. Neither option gives a sense of pride and accomplishment or the foundation for character development.
The high cost of college is the justification for free tuition. One key reason for the continually escalating tuition is readily available student loans: no matter the cost, the student can continue to borrow. Endless direct-from-the-government money would likely cause further increases. Further, one-third of college students drop out. The majority of these students were poorly prepared for, and not fully committed or suited to college. It is a bad idea to remove an incentive for perseverance, allow uncommitted students to waste their time on the government dime, or worse be stigmatized as a failure. Finally, as Senator Amy Klobuchar bravely pointed out, the taxpayers cannot afford it.
With regard to medical care, all “medically necessary” health services, including dental, vision, hearing, mental health, long-term care, home and community-based services, physical therapy, prescription drugs with no premiums, deductibles or co-pays from cradle to grave sound pretty good. Sold! Frankly, given the direction so-called reproductive health is going, you may never make it to the cradle. And with the current laser-focus on hospice for all, you may get to your grave a little faster.
Will free medical care halt one of the biggest drivers of poor health and medical costs? According to the Centers for Disease Control and Prevention (CDC), 40 percent of people in the United States are obese. And 47 percent of our $3.5 trillion per year of healthcare spending goes to treat the effects of obesity, with another 8.7 percent attributable to cigarette smoking. People have known for years that eating too much makes you fat and smoking contributes to heart and lung disease. Free care would worsen the problem because patients will expect more pills and procedures to cure their lifestyle-created illnesses rather than taking care of themselves.
Not only is the promise of free stuff an attempt to buy votes, but the politicians themselves have sold their souls to special interests. And we never know whether they are working for the metaphorical Devil or for you, the voters.
According to the Center for Responsive Politics, in 2018, both sides of the Congressional aisle received a total of $134,590,142 in contributions from the health sector (health professionals, device and pharmaceutical manufacturers, hospitals and nursing homes). The health sector was the top spender of lobbying money – some $562,968,799 spread among 2,810 hired guns. Pharmaceuticals/Health Products topped the list with $281,872,969.
On the bright side, when given the full picture, people are not that easily bought. A recent Kaiser Family Foundation study found that 70 percent of those polled approved of Medicare for All when told the plan would eliminate insurance premiums (which are sky-high thanks to ObamaCare). But up to 70 percent opposed Medicare for All when told it would lead to treatment delays, tax increases, or loss of their option for private insurance.
Perhaps those polled read that private insurance is allowed in all but two countries with universal coverage, and patients in all countries have some out-of-pocket expenses. Perhaps they realized that when the citizen money tree has been picked clean, promised services must be reduced. Perhaps they realized that free stuff can be used as a cudgel to keep the recipients in line and trap them in a system with no escape. Perhaps they were of a certain age where they were warned that the tasty-looking Halloween candy might be laced with razor blades. Or more likely, those infamous words, “If you like your doctor, you can keep your doctor” were flashing before their eyes or echoing in their ears.
Free stuff is an age-old snare, a temptation that can steal one’s critical thinking abilities. Despite the old saw that there is a sucker born every minute, there are always those who will not be fooled. Which will you be?
Dr. Singleton is a board-certified anesthesiologist. She is President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.