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. 

Doctors, Health Policy, Healthcare Reform, Medicare, Medicine, Politics

Don’t Buy What They Are Selling

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By Marilyn M. Singleton, MD, JD

Buying and selling is in the news lately with President “at some point you’ve made enough money,” “climate change is urgent and growing” Obama’s well-publicized imminent purchase of a 7,000 square foot, $14.85 million estate in Edgartown, Martha’s Vineyard, the playground of the rich and famous, guaranteed to survive the rising seas. Our current politicians are also on the hunt for buyers.  

Sales Pitch Number One: A medical care crisis is afoot and only the government can save you. Yes, there is a crisis of rising prices and premiums after the government started meddling in the medical care market. Once health insurance became popular, by 1963 906 insurance companies wrote health and accident insurance, with 42 offering exclusively health insurance. Now we have five companies that have cornered the health insurance market. Additionally, politically powerful hospitals continue to merge and gobble up physicians’ practices leading to up to 70 percent higher prices in geographic areas with minimal competition.

Premiums and out-of-pocket costs steeply rose after the passage of the Affordable Care Act and show no sign of going back down. In 2018, according to eHealth, the average cost of health insurance premiums was $440 for individuals and $1,168 for families – almost double the cost in 2014. The deductibles (the amount of money that you have to pay out-of-pocket before health insurance starts paying for your covered benefits) similarly rose to $4,328 for individuals and $8,352 for families.

Sales Pitch Number Two: The government-to-the rescue plan is fair and free. Now that we have had debates and the Iowa State Fair, we’ve heard enough to know that Medicare-for-All is neither free nor fair. There is a good political reason the House and Senate Medicare-for-All bills fail to provide a financing mechanism. We would have a collective national heart attack after seeing the price tag.

In 2016, the federal government spent more than $1.2 trillion on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Total national health expenditures by all government levels and private entities were $3.3 trillion. A 2018 Mercatus Center analysis concluded that Medicare-for-All conservatively would add $32.6 to $38.8 trillion to federal expenditures during its first 10 years. The government predicts that in 2026 the Medicare Hospital Insurance Trust fund will be depleted and total national health expenditures will be $5.7 trillion. The federal government collected about $100 billion in Medicare premiums and a total of $3.32 trillion in taxes last year. Given the projected expenditures and no cost-sharing or premiums, new ways to perform mass wallet biopsies on the populace will emerge. The simplest tool, as Senator Sanders has suggested, is to raise payroll taxes on everyone.

Moreover, with the elimination of private insurance, when the money runs out and care is rationed, only the wealthy will be able to pay for care outside of the government system. Is that fair?

Upping the ante, Senator Sanders wants to pay off some Americans’ current medical debt by taxing Americans with no medical debt. Under his proposal, only people unable to pay their medical debt would be granted relief. Those keeping up with their payments would have to continue to pay. What does “unable” mean? If they are living below the poverty level, they have Medicaid. Is it the working poor? Or is it people who failed to prioritize their medical bills over Starbucks and take-out food? Hardly fair.

Sales Pitch Number Three: If you like your doctor you can keep your doctor, Politifact’s lie of the year. Essentially, the promise was that government would not interfere in the practice of medicine. But both state and federal government wants the final say-so in our medical care. For example, the California assembly passed a bill requiring the state Department of Public Health to review and potentially reject medical vaccine exemptions written by doctors who have granted five or more in a year. No exceptions for doctors specializing in neurological or immunological diseases. In order for Medicare to pay claims, physicians will be required to complete a computerized algorithm and certify that they have done so before ordering certain imaging like MRIs and CT scans. A computer will now determine whether the order is “appropriate.” Medical care by government robots will supplant individualized care – the heart of the patient-physician relationship. Who cares if the patient has a missed or delayed diagnosis?

As the government tries to trap physicians and patients in its restrictive bubble, independent physicians are pursuing avenues for increased choice in medical care and insurance products. Above all, we will never put the needs of the state ahead of the needs of the patient.

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

Culture & Society, Law, Medical Ethics, Medicine

The Soylent Green New Deal is Three Years Away

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

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

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

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

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

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

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

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

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

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

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

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

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

Doctor Robot for You, Real Doctor for Me

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by Marilyn M. Singleton, MD, JDl

A couple of years ago, computer programs, algorithms, and glorified Google searches were touted as the replacements for a physician’s analysis of a patient’s medical condition. Compressed medical research is quite useful for clinicians who are presented with novel situations and have no readily available colleagues with whom to discuss the case. However, the purpose of flow charts should not be to replace the brains of busy clinicians or, worse yet, be a cookbook for the practitioners at drugstore clinics.

Medical technological aids have now jumped the shark. An unbelievable, but—thanks to cell phone video—verifiably true newsreport detailed how a robot rolled into a patient’s Intensive Care Unit cubicle and a physician’s talking head appeared on the robot’s “face” and told the patient the sad news that he had a terminal illness. While remote medicine is reasonable in rural areas where access to medical care is limited, telling a patient he is going to die from a TV screen is a crime against all medical ethical principles.

We can certainly expect more medicine by proxy as larger corporations and the government take more control of our medical care. The patient becomes secondary to the goal of “value-based care” or some other medically meaningless metric developed by government bureaucrats to give the appearance of managing costs.

It is highly unlikely that the ruling class (aka legislators) or elitist wannabes (aka limousine liberals) would tolerate a robot doctor. And neither should we.

Thankfully, people are waking up to the incremental erosion of their freedoms. and they are using the free market to find ways around being treated like mindless cattle. In California, where there is a 3-month wait for an appointment at the Department of Motor Vehicles (DMV), for a modest fee a private company will get you an appointment in 2 weeks. For a little more moola, they’ll have a surrogate stand in line in your stead. Almost on cue, our fearless leaders put forth a bill to outlaw the service because it is “unfair.” What is unfair is a monopolistic government service that holds working people hostage to its incompetence.

DMV style medicine is gradually supplanting individualized care. Clinicians are sharing reports of chronic pain patients being harmed by government one-size-fits-all guidelines pulled together in an effort to stem the tide of opioid abuse. Health Professionals for Patients in Pain, a large group of prominent academic and private physicians, have urged action on this issue. In a letter to the Centers for Disease Control and Prevention (CDC) and relevant House and Senate Committees the group advised that “patients not only have endured unnecessary suffering, but some have turned to suicide or illicit substance use” or had their conditions deteriorate.

It would be disastrous to even more patients if this paint-by-the-numbers approach to our medical care were expanded. If—as the Medicare for All bills propose—all private insurance is outlawed and the government is the sole arbiter of our medical care, what are average people to do? Stay behind the electrified fence and chew their cud?

At a time when depression and suicide are increasing at an alarming rate, the personal touch is more crucial than ever. If you want to ensure that your doctor treats you like an individual, run – don’t walk to a direct-pay or a direct primary care (DPC) practice. For a monthly fee from $10 to $140 based on age, you can receive all basic medical services, lab tests and medications at amazingly low prices. Best of all, you will have an empathetic and humane doctor who has the time to be thorough and whose face is not buried in a computer screen full of metrics and centralized standards.

The patient-physician relationship is the most effective part of doctoring. National Doctors’ Day is coming up on March 30th. Let’s make it mean something: just say no to cattle prods and robots.

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

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

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

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

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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

Thought Police (Oops, Medicare) For All

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by Marilyn M. Singleton, MD, JD

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

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

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

Conscience protections are vital in this time of unabashed devaluing of life. Last year, the Palliative Care and Hospice Education Training Act (PCHETA), passed the House but died in the Senate. This bill would have dedicated $100 million in additional taxpayer dollars to persuade patients to forgo treatment that might prolong life in exchange for a steady stream of increasing doses of narcotics. Already some families feel they are not merely offered hospice as a choice but are steered toward it when their older relatives fall ill, even when the medical prognosis is uncertain.

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

Subtly devaluing life primes the pump for rationing of medical care at all stages by a government-run program that is the exclusive purveyor of medical “benefits.” Our western counterparts with single payer have discovered that offering fewer benefits is the simplest way to control costs. The “Complete Lives System”—the brainchild of ObamaCare physician architect Ezekiel Emanuel—includes worrisome determinants of who should receive care. The system prioritizes adolescents and persons with “instrumental value,” i.e., individuals with “future usefulness.”

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

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

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

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

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

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

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

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

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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

Jumping Into Medicare For All With Eyes Wide Shut

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by Marilyn M. Singleton, MD, JD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Culture & Society, Doctors, Health Policy, Law, Medical Ethics, Medicine, Op-eds, Politics

Eugenics, Euthanasia, Infanticide, and the Lord’s Work

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by Marilyn M. Singleton, MD, JD

New York’s Catholic Democratic Governor had the World Trade Center in lights to celebrate its abortion-on-demand-until-the-day-of-birth law. This law was framed as empowering women through guaranteeing “Reproductive Health.” Women in New York must be really powerful since New York’s abortion rate is twice the national average. This and eight other similar state laws were largely ignored as merely codifying Roe v Wade.But the state of Virginia’s pediatrician governor’s ghoulish advocacy for abortion until delivery of the infant was jaw-dropping as he explained that killing the infant after birth was allowed.

How can we tolerate this moral regression? Infanticide was the norm throughout ancient Athens and Sparta where the elders inspected the newborns to ensure that only the strong survived, and the weak were left to die. Early Roman law decreed that deformed children would be put to death. Fortunately, by the 4th century, European law, religion, and medicine rejected the intentional killing of an infant.

Americans have been sucked in before by pretty words that mask the brutal reality of “evolved” policies. There was a time when America’s best and brightest were teaching Dr. Josef Mengele a thing or two about eugenics, the “science” of improving the human gene pool for the preservation of society.

At the First International Eugenics Congress in 1912, a Carnegie Institute-supported paper, Preliminary Report of the Committee of the Eugenic Section of the American Breeder’s Association to Study and to Report on the Best Practical Means for Cutting Off the Defective Germ-Plasm in the Human Population (“Breeder’s Report”), analyzed the problem of the “unfit” and the need to find solution to “cut[ting] off the supply of defectives.”

Even black intellectuals jumped on board. The Harvard-educated professor and civil rights activist W.E.B. DuBois believed only fit blacks should procreate to “eradicate the race’s heritage of moral iniquity.” The NAACP promoted eugenics theory by hosting “Better Baby” contests.

The Model Eugenical Sterilization Law (1914) was the blueprint for the sterilization of the “socially inadequate” including the feebleminded, insane, criminalistic, epileptic, inebriate, diseased, blind, deaf, deformed, dependent, orphans, ne’er-do-wells, tramps, the homeless, and paupers. By the 1920s, thirty-three states had compulsory sterilization laws.

Margaret Sanger, the founder of Planned Parenthood, advocated for mandatory IQ testing for the lower classes and the issuance of government-approved parenthood permits as a prerequisite to having children. Sanger criticized philanthropy as tending to perpetuate “human waste.” She also proposed that “the whole dysgenic population would have its choice of segregation or sterilization.”

Compulsory sterilization of the “feebleminded” was etched in stone by the revered liberal Supreme Court Justice Oliver Wendell Holmes. Buck v. Bell (which has never been overruled) concluded that “the principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes.”

With Congress steamrolling exclusively government-controlled medical care with Medicare-for-All, we must reflect on our past as well as the present policies of our civilized neighbors. What happens when the government runs out of money to pay for everything our politicians promised?

The Model Sterilization law’s selling point was that sterilization of those maintained wholly or in part by public expense was cost-effective: segregation for life cost $25,000 and sterilization a mere $150.

In Belgium, a nine and an eleven-year-old were euthanized for conditions that we in the United States vigorously treat: cystic fibrosis and muscular dystrophy. Canada is considering allowing such barbarism-aka medical assistance in dying—to be perpetrated upon its children.

Iceland has virtually eliminated Down’s syndrome through abortion. Coincidentally the Ministry of Health lists Down’s syndrome as the most expensive disease for the state-funded health care program.

The British National Health Service’s Institute for Health and Care Excellence supports the use of “quality-adjusted life years” (QALY) to measure the quality and quantity of life added due to a particular medical treatment. If the cost per QALY gained exceeds a predetermined amount, the government denies payment for that treatment. ObamaCare architect Ezekiel Emanuel’s “Complete Lives System” prioritizes adolescents and persons with “instrumental value,” i.e., individuals with “future usefulness.” With current nursing home costs averaging $7,500 per month, hospice care could be the default medically necessary treatment for the disabled.

It was not too long ago that the top Democrat official, Nancy Pelosi said “[Republicans] pray in church on Sunday and they prey on people the rest of the week. And while we’re doing the Lord’s work, ministering to the needs of God’s creation, they are ignoring those needs which is to dishonor the God who made them.” I don’t know whose “lord” she is talking about—perhaps the overlords who aim to take over mankind in sci-fi stories or the “Lord of the Flies.”

The day erecting a barrier to stop drug and human trafficking is considered immoral and killing viable live babies is celebrated is the day some Americans tossed morality into the abyss.

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.

Despite being told, “they don’t take Negroes at Stanford”, she graduated from Stanford and earned her MD at UCSF Medical School.

Dr. Marilyn Singleton then completed two years of surgery residency at UCSF, followed by an anesthesia residency at Harvard’s Beth Israel Hospital.

Dr. Marilyn Singleton was first an instructor, then Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in Baltimore, Maryland before she returned to private practice in California.

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.

Dr. Marilyn Singleton has conducted make-shift medical clinics in two rural villages in El Salvador.

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. (Audio version of the speech to AAPS doctors by Dr. Marilyn Singleton.)

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

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

The Healthcare Revolution: More Choices, Not More Taxes

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By Marilyn M. Singleton, MD, JD

Paris is in flames over a fuel tax increase that would pile 30 cents onto the $7.06 per gallon price paid by citizens whose average monthly salary is $2,753.This burdensome “carbon tax” on the middle class is intended to help meet Europe’s commitment to reduce carbon dioxide emissions and thereby halt global warming or climate change. It appears that the 21st century French Revolution has begun. This time, Brussels is sending in tanks to protect the new elite and its agenda.

Back in the states, some well-heeled, presumably well-intentioned Medicare-for-All advocates from California, New York, and New Jersey are grousing about how “Trump took away my homeowners tax deduction!” The Tax Cuts and Jobs Act now caps the previously unlimited federal tax itemized deductions for the combined state, local and property taxes at $10,000. The portion of a mortgage on which interest can be deducted is limited to $750,000, down from the current limit of $1 million.

Folks with million-dollar homes who continue to vote for legislators who impose high state taxes to finance their pet social programs are less sympathetic than the French Yellow Vests—especially when these same elitists want to take away the “crumbs” from the 80 percent of taxpayers who are receiving some relief from the near doubling of the standard deduction.

But everyone will face still more taxes to fund Medicare-for-All. Bernie Sanders’s financing plan would “limit tax deductions for the wealthy,” defined as $250,000 per household. Sanders also proposes eliminating health savings accounts (HSAs), which allow patients to take charge of their own care. And it won’t stop there—or at the equivalent of 30 cents per gallon.

It’s not just the taxes: it’s the loss of the freedom to choose. The M4A bills prohibit virtually all private health insurance. M4A promises “free” access to “willing healthcare providers”—but robs us of choice. Even existing Medicare offers 11 supplemental insurance programs with options for different premium structures. Purchasers can decide to pay a little more now for a stable premium price as they age, or pay quite a bit less and anticipate the age-related increase over the years. But, you say there would be no premiums with M4A. Wrong. The “premiums” are increased taxes. And taxes are not optional. You must obey.

We should take a cue from the French (minus the fires and looting). We need a middle-class medical care revolt against the elitists and politicians who think more government through high taxes is The Answer while ignoring community solutions. For example, We Do Better, a humanitarian movement, seeks out solutions to social problems based not on a particular political ideology or lobbyist’s effort, but on what works. In Southern California eight Clinica Mi Pueblo (CMP) clinics accept only cash, have transparent pricing on their website, and their services cost less than half of the price set by third parties. Where the average charge for an X-ray is between $260 and $460, CMP charges only $80. Utah’s Maliheh Free Clinic (MFC) serves low income and uninsured residents who are ineligible for Medicare, Medicaid, or any government subsidized healthcare. The MFC provided free healthcare to more than 15,000 patients in 2016 at an average cost of only $56 per patient, and 95% of donations to MFC go to providing medical services. New Jersey’s Zarephath Health Center is a volunteer-run and funded facility for patients who cannot find care “in the system.” Here it costs $15 to see a patient, versus $160-$280 at the Federally Qualified Health Center down the street.

Another increasingly popular model is direct primary care (DPC). Here, patients pay a monthly subscription fee to the practice (between $40 and $100 depending on age and family size), which covers all primary care services, certain laboratory tests, and at-cost pharmaceuticals at as much as 15 times less than the price at the pharmacy. The personal relationship with a physician enhances the care to patients with chronic conditions, reducing costly hospitalizations. Catastrophic insurance can cover major medical expenses. St. Luke’s Family Practice in Modesto, California is a DPC non-profit organization. Here, “benefactors” pay the fees for the “recipients” – those who cannot afford the fees.

Then there are many health care sharing ministries where members engage in voluntary sharing of costs for its members’ health needs. One such model, the Christian Healthcare Ministries (CHM), has plans that cost half as much as ACA Marketplace plans. It has more than 279,000 members, and has covered more than $1 billion in medical bills since 1981.

Americans want authority over our own lives. Our innovative spirit and generosity have created and will continue to create ways to deliver medical care to the most people without sacrificing choice—and at a more affordable cost.

Dr. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and 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, Medicare, Medicine, Op-eds, Socialized Medicine

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

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By Marilyn M. Singleton, MD, JD

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

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

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

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

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

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

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

There is a big bad wolf in this fairy tale. In 2016, the feds spent more than $1.2 trillion on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Total national health expenditures by all government levels and private entities were $3.3 trillion.

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

Fast forward to 2026, when the government predicts that the Medicare Hospital Insurance Trust fund will be depleted and total national health expenditures will be $5.7 trillion. The federal government collected about $100 billion in Medicare premiums and a total of $3.32 trillion in taxes last year. Given the projected costs, no cost-sharing, and the $2.4 trillion shortfall, the bill’s “modest” tax increases will soon be obscene.

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

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

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

Culture & Society, 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