Politics

The Obama care runaway train.

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There is talk of repealing Obamacare if the Republicans take over Congress on November 2. Of course, that is unlikely with President Obama ready to veto any repeal legislation. “OK, we will defund it,” is the response. I doubt anyone realizes how fast this is moving and how difficult it will be to alter the course of this program.

A week ago, I posted on my blog a set of new rules that are being implemented for physician reimbursement. I review workers compensation cases as a part time job. The company that employs me has now come out with a new line of business to review cases for Obamacare. I have been asked if I would be willing to review cases on a 24 hour timeline. This includes weekends. I have spent 40 years reviewing cases for Medicare and the state medical boards for poor care. Now, I am being solicited to do concurrent review on a 24 hour basis for healthcare. I do some concurrent review for workers comp cases but the timeline is usually 3-5 days. Why weekends ? Does this mean that care cannot be provided without approval ?

The pace of change is breathtaking. Today, the Wall Street Journal explains.

A wave of consolidation is washing over the health markets, and the result is going to be higher costs.

The turn toward consolidation among insurance companies is not new, and neither is it among doctors, hospitals and other providers. Yet the health bill has accelerated these trends, as all sides race to anticipate and manage political risk and regulatory uncertainty. This dynamic is leading to much larger hospital systems and physician groups, and fewer insurers dominated by a handful of national conglomerates. ObamaCare was sold using the language of choice and competition, but it is actually reducing both.

The first surge will come among the 1,200 insurers doing business in the U.S., given that a major goal of ObamaCare is to convert these companies into de facto public utilities. Those regulations are now being written—and once they’re up and running some medium-sized carriers will collapse under the new mandates and higher overhead. State insurance commissioners warned the Administration this month that “improper or overly strident application . . . could threaten the solvency of insurers or significantly reduce competition in some insurance markets.” They also implied that bankruptcies are likely.

With these headwinds, investors and Wall Street analysts are now predicting a lost decade for health insurance stocks. But it may be more accurate to say that there will be a lot of losers and some very big winners. Mergers and acquisitions will increase dramatically once companies get a better look at the regulation and figure out the valuation of M&A targets. Larger carriers will swallow smaller ones quietly before they fail.

The pace of change is far more rapid than is appreciated.

Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as “accountable care organizations,” or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.

The Mayo Clinic has concluded that it cannot afford to treat Medicare patients. The Phoenix branch of the Clinic has already informed patients that they will accept no more Medicare. The model does not think it will work.

At the moment ACOs are only a gleam in some bureaucrat’s eye, and no one has a clue how they’ll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.

Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.

I spent a few minutes researching the doctors who appeared in white coats to support Obamacare last spring. Those who really were doctors were all hospital employees. Most of them had been hired right out of residency.

Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare’s Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.

This is an impossible situation and the Medicare patient will become indistinguishable from the Medicaid patient, a burden on the system to be treated by “physician extenders.”

The changes are coming like a runaway train and they will change American medicine irreversibly. Private medicine cannot afford to care for the discounted Medicare patients. Obamacare will convert private care to Medicare. Every one will be a charity case except for the gentry class that votes for Obama. University Hospital physicians may feel that they are immune to these changes but it has been known for 50 years that the value of salaried university physicians is directly related to the income of private physicians. In fact, the university physician has no overhead but they can always tell the administration that they can leave and earn as much, if not more, and this has given them a lot of power.

When I was in training, my surgical training program had three full time faculty members. Now, the same program has 90 full time members. In the same interval, their success in having graduates pass the American Board of Surgery has declined. That may or may not be significant but the culture of medicine is changing rapidly. Many physicians no longer recommend medicine as a career for their children. What this all means, I don’t know. What I do know is that it is coming very fast and few people realize it.

The left’s romance with terrorists.

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It is a bit peculiar how the left seems to be fond of terrorists. Bill Ayres and his wife, of course, are prime examples but not the only ones. Some of them have adoring books written about them. Naturally, Sarah Jane Olsen had become a “community activist” in her new identity.

Now we have a new example disclosed today by Andrew Breitbart. Bradblog is a left wing blog that has become very successful while attacking such people as James O’Keefe of the ACORN tapes, and it has spun numerous conspiracy theories about the right and election fraud, etc. It turns out that one half of the blog, which has received over $1.3 million in donations from such sources as Teresa Heinz’s Tides Foundation, is a convicted murderer and terrorist. His name is Brett Kimberlin although he was once known as the “Speedway bomber” as he terrorized a town in Indiana. He was also a drug smuggler and dealer and he eventually ended up with a 50 year prison sentence. He was paroled after only 13 years but, when he refused to make any payments to the widow of one of his victims who had won a civil suit against him, he went back to prison for four more years.

Today he is a prominent figure on the left and his story of how he went to prison, a total fabrication, has made him even more of a hero. It’s pretty interesting reading.

The Left and its delusions

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Cross posted at my own blog.

I skim the Washington Monthly blog as a window on the thinking of the far left. They are more civil (except in comments) than the DailyKos but the mentality is the same. Today is a reasonable example. The topic is taxes.

Roll Call noted this morning that the Senate is moving towards “an epic election-year battle over Bush-era tax cuts.” That sounds about right.

The dispute helps capture exactly what the two parties prioritize right now — Dems want to keep lower rates for the middle class, while reducing the deficit by letting the rich go back to the rates they paid when the economy was healthy. Republicans want to hold the Dem proposal hostage, fighting tooth and nail for breaks for millionaires and billionaires, and adding $680 billion to the deficit the GOP pretended to care about for a while.

The “middle class” is a very elastic concept for them with the top income range going all the way down to $150,000 per year. Secondly, the group with incomes of $250,000 or more, the target class, consists of mainly small business people who are not incorporated and who file all income with a personal return.

There is also no concept here of who pays the taxes. Shouldn’t “tax cuts” be distributed to those who pay taxes ? Otherwise, it is just one more government handout to those who are nonproductive. Here is a look. The top 1% of income pays 40% of the income taxes. Hmmm That’s also about $410,000 per year, not $2 million.

The top 5% pays 60.63% of the income taxes. The threshold for the top 5% is $160,000. Well, what do you know ?

Billionaires need little help from Republicans but they do invest and are the source of most new jobs. The concern for “the deficit” on the part of Democrats may be translated as the left side of the entire argument about spending versus taxing. Republicans want to talk about cutting spending, especially tea party Republicans. I even have a compromise: Let the tax rates go back to the Clinton administration rates but let’s also go back to the number of government employees of the Clinton period.

[W]here would this $680 billion go? Nearly all of it would go to the richest 1 percent of Americans, people with incomes of more than $500,000 a year. But that’s the least of it: the policy center’s estimates say that the majority of the tax cuts would go to the richest one-tenth of 1 percent. Take a group of 1,000 randomly selected Americans, and pick the one with the highest income; he’s going to get the majority of that group’s tax break. And the average tax break for those lucky few — the poorest members of the group have annual incomes of more than $2 million, and the average member makes more than $7 million a year — would be $3 million over the course of the next decade. […]

Notice how the “richest” become those with incomes over $2 million when we are talking about one aspect of the issue but, when it is time to actually impose the taxes, the incomes shrink back down to $250,000 or, in some cases, it shriveles all the way down to $150,000 per year.

Midwestern centrists such as Sens. Kent Conrad (D-N.D.) and Evan Bayh (D-Ind.) have called for an extension of all of Bush’s tax cuts, including those benefiting individuals earning more than $200,000 and families earning over $250,000 annually.

Other Democrats say they would consider raising taxes on individuals and families earning below those thresholds, despite President Obama’s promise that middle-class families would not see their taxes increase.

Some liberals balk at the notion that families earning $250,000 or more belong in the middle class.

“Two hundred and fifty thousand dollars? Is that the top 1 percent of Americans, or half a percent? Come on!” said Sen. Tom Harkin (D-Iowa).

Harkin said he would be willing to extend the tax cuts for families earning $150,000 or less annually.

See how elastic that number is ? Families with a combined income of $150,000 are “rich.” We went from $2 million per year to $150,000 per year just like that!

Or we’re told that it’s about helping the economy recover. But it’s hard to think of a less cost-effective way to help the economy than giving money to people who already have plenty, and aren’t likely to spend a windfall.

Did you notice that one ? Tax cuts “give” money to people who have “plenty.” Just keep repeating to yourself; it’s not your money. It’s the government’s money and they are “giving you some of it.” They used to call that “To each according to his needs.”

No, this has nothing to do with sound economic policy. Instead, as I said, it’s about a dysfunctional and corrupt political culture, in which Congress won’t take action to revive the economy, pleads poverty when it comes to protecting the jobs of schoolteachers and firefighters, but declares cost no object when it comes to sparing the already wealthy even the slightest financial inconvenience.

Once again, a translation. Schoolteachers “need” the money. Firefighters is just a cover. The “wealthy” (Those with over $150,000 per year income) don’t “need” the money.

Note, there is no concept of a private economy here. Nobody invests; nobody starts a business. The story of the 2001 tax cuts that Democrats want to repeal is here in more detail.

This is what socialism looks like in practice.

Who would be a Nazi ?

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This essay is dated but very pertinent today. Dorothy Thompson is just a name to most who are younger than I am but she had things to say that still speak to us 70 years later. Of course, Nazis are extinct, at least in the classical sense. They survive, however, as a type. This is as up to date as a guide to personality as it can be.

It is an interesting and somewhat macabre parlor game to play at a large gathering of one’s acquaintances: to speculate who in a showdown would go Nazi. By now, I think I know. I have gone through the experience many times–in Germany, in Austria, and in France. I have come to know the types: the born Nazis, the Nazis whom democracy itself has created, the certain-to-be fellow-travelers. And I also know those who never, under any conceivable circumstances, would become Nazis.

It is preposterous to think that they are divided by any racial characteristics. Germans may be more susceptible to Nazism than most people, but I doubt it. Jews are barred out, but it is an arbitrary ruling. I know lots of Jews who are born Nazis and many others who would heil Hitler tomorrow morning if given a chance. There are Jews who have repudiated their own ancestors in order to become “Honorary Aryans and Nazis”; there are full-blooded Jews who have enthusiastically entered Hitler’s secret service. Nazism has nothing to do with race and nationality. It appeals to a certain type of mind.

It is also, to an immense extent, the disease of a generation–the
generation which was either young or unborn at the end of the last war. This is as true of Englishmen, Frenchmen, and Americans as of Germans. It is the disease of the so-called “lost generation.”

This part of the essay is an anachronism since Nazism and Jews were two sides of an argument at the time. Let us, however, rename the two sides “leftist and Israeli.” Makes more sense doesn’t it ?

Sometimes I think there are direct biological factors at work–a type of education, feeding, and physical training which has produced a new kind of human being with an imbalance in his nature. He has been fed vitamins and filled with energies that are beyond the capacity of his intellect to discipline. He has been treated to forms of education which have released him from inhibitions. His body is vigorous. His mind is childish. His soul has been almost completely neglected.

At any rate, let us look round the room.

The gentleman standing beside the fireplace with an almost untouched glass of whiskey beside him on the mantelpiece is Mr. A, a descendant of one of the great American families. There has never been an American Blue Book without several persons of his surname in it. He is poor and earns his living as an editor. He has had a classical education, has a sound and cultivated taste in literature, painting, and music; has not a touch of snobbery in him; is full of humor, courtesy, and wit. He was a lieutenant in the World War, is a Republican in politics, but voted twice for Roosevelt, last time for Willkie. He is modest, not particularly brilliant, a staunch friend, and a man who greatly enjoys the company of pretty and witty women. His wife, whom he adored, is dead, and he will never remarry.

He has never attracted any attention because of outstanding bravery. But I will put my hand in the fire that nothing on earth could ever make him a Nazi. He would greatly dislike fighting them, but they could never convert him…. Why not?

Beside him stands Mr. B, a man of his own class, graduate of the same preparatory school and university, rich, a sportsman, owner of a famous racing stable, vice-president of a bank, married to a well-known society belle. He is a good fellow and extremely popular. But if America were going Nazi he would certainly join up, and early. Why?… Why the one and not the other?

Anybody think of John Kerry just then ?

Anyway, read the rest of it. It is startling and sobering to think how little has changed but the names. Credit for my finding it should go to The Anchoress

Another brief thought occurs, maybe this is a repeating theme in our history.

We think of ourselves as a meritocracy but we all know someone who wanted just a bit of a thumb on the scales. Maybe more than a thumb. I think my one complaint about Dorothy Thompson is that she might give more credit than is due to family and background. I think the blood of such families has gotten very thin the past 50 years. Many years ago, in Boston, I knew a few men who had used their family fortune to allow then to seek achievement in medicine and to ignore the necessity of earning a living that would support a lifestyle like that of John Kerry, although not so flamboyant. One such was J Gordon Scannell, chief of thoracic surgery at Massachusetts General Hospital in 1965. As Scannell Moving Company trucks passed outside, he spent his life in a taxing profession. Another, who became famous (although unknown as a real person) was Edgar Kahn, whose life was fictionalized by Lloyd C Douglas in his novel, Magnificent Obsession, in 1929.

I see the parallels today and wonder about human nature and how little it has changed.

What kind of delusion is this?

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Watched Charlie Rose last night. He and some of his guests were discussing President Obama’s political fortunes – post a Scott Brown victory – and what the President might do in order to reverse the downward trend. To give you a flavor of the conversation, I present the following excerpts from the transcript:

“CHARLIE ROSE: Joining me now, Jon Meacham, editor of “Newsweek”
magazine, in Washington, Tom DeFrank of the “New York Daily News,” and Anne
Kornblut of “The Washington Post.” I’m pleased to have all of them here as
we take a look at this week, which is important for the president, and a
state of the union which is very important to him.”….

JON MEACHAM: “Well, he has clearly found that history is a more
complicated matter than the speechifying and the glamour, really, of the
campaign…..

In politics, you don’t get credit for what didn’t happen. So I think
we should say that he did in concert with the outgoing administration and
with his own folks, he did keep us out of a more severe downturn in 2009.”….

To my mind, the real problem has been that he has a kind of
intellectual snobbishness about being simple and clear about what he wants
the country to be. What does he want it to look like when he leaves? And
it sounds odd to say that sound bites are important, but they are. Jesus
spoke in them, and his stuff has aged rather well.”….

THOMAS DEFRANK: “Why is he where he is today? I think it’s because they made a real
miscalculation on health care. They thought they could sell it. They
didn’t sell it. They lost control of the message. The critics have
controlled the message on health care for the last four or five months, and
it’s a negative message.”….

ANNE KORNBLUT: “I guess it’s confusing to me why it’s so difficult for
them to show what his emotions are. All of us who have been around him or
covered the campaign know he isn’t a robot. He actually does have emotions
and a family he cares about, and he’s extremely good at talking about the
feelings he felt growing up in extraordinary circumstances.” ….

Seriously, the entire transcript and conversation are like that: He’s misunderstood, he’s misrepresented, he’s under appreciated for all that he has done! What?