Driving Your Doctor Out Of Business

It began almost as a footnote. 

Five months after Obamacare was passed, members of the Obama administration quietly published an article in The Annals of Internal Medicine describing the law’s planned impact on physicians.  

Shortly thereafter, the piece disappeared and was replaced with a more benign one, with the obvious cooperation of the journal. 

You won’t be able to find the original. It’s been wiped from the internet. 

(And no, not “like with a cloth or something.”)

What was so controversial about the article?

The admission that the law aimed to eliminate private medical practices — and drive physicians into the arms of hospital bureaucrats and huge medical groups. 

From the original:

“The economic forces put in motion by [the ACA] are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups … Physician practices that accept the challenge will be rewarded in the future payment system.”

The article’s authors were Nancy-Ann DeParle, JD, Office of Health Reform director, Robert Kocher, MD, formerly from the Obama National Economic Council — and the now rather infamous Ezekiel Emanuel, MD, Obamacare architect and a really special kind of bad guy.

What’s “vertical organization?”

In Medscape Medical News coverage of the piece, the writer likened “vertical organization” to the military and the federal government.

“This business catchphrase refers to enterprises
with a hierarchal structure and centralized management.
An integrated delivery system that owns hospitals,
medical practices, and other healthcare services is a prime example.”

Wow. Sure sounds like single payer, doesn’t it?

And the Obamacare masterminds have been largely successful in moving the medical community in this direction. Journalist Keith Speight observed in 2013 that:

“While the shift away from private practices was already under way prior to Obamacare, the legislation definitely threw gasoline on the fire.”

In its 2014 survey, the Physician’s Foundation found that “only 35% of physicians describe themselves as independent practice owners, down from 49% in 2012 and 62% in 2008.” In contrast, 53 percent of the survey respondents described themselves as hospital or medical group employees, increasing from 38 percent in 2008 and 44 percent in 2012.

Many of the physicians remaining in small practices have already been heroically laboring to comply with ACA and other federal requirements, spending evenings and weekends transmitting patient data through expensive electronic health record systems. 

The newest iteration of health reform,
MACRA (the Medicare Access and CHIP Reauthorization Act),
will break their backs.

MACRA (previously covered here) restructures physician pay by rewarding more patient data-gathering and obedience to government-dictated clinical and electronic activities.

The Centers for Medicare & Medicaid Services, the agency fleshing out the MACRA regulations, admits that its new rules will penalize 87 percent of solo practitioners  and 69.9 percent of practices with 2 to 9 doctors. Over time, many small practices will lose up to nine percent of their Medicare reimbursements. Meanwhile, only 18.7 percent of clinicians in groups of 100 or more will be penalized.

Tom LaGrelius, MD, president of the American College of Private Physicians, explains that “small organizations cannot possibly comply” with MACRA’s complex data-reporting requirements and will be unable to absorb the MACRA penalties. “Such practices are already running on very narrow margins with 70 percent-plus overheads.” 

The Physician’s Foundation reported that even pre-MACRA Medicare reimbursement has risen only 3.6 percent since 2001, while overhead expenses “have increased well over 20 percent.”

Orthopedic surgeon Tony Francis believes “compliance will be difficult or impossible” for small groups.

“Just reading a 962-page proposed rule would be daunting enough.
Comprehending the meaning of it is something else.
That would take a full team of lawyers and CPAs.
What small practice has that kind of resources?”

Why force independent physicians into hospital jobs? Physician and health policy expert Scott Gottlieb explains:

“It will be easier for Medicare to gain
more direct leverage over their clinical decisions.”

And you know what that means.

RATIONING

The inevitable results of the proposed MACRA regulations are these:

• We can expect an increase in the “silent exodus” of physicians from clinical care, either through retirement or career change. Even health IT whiz John Halamka, MD, finds the MACRA proposals to be “so overwhelmingly complex that no mere human will be able to understand them… as a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.”
• Some will no doubt surrender their positions as “the knuckle-draggers who just won’t get with the Managed Care 2.0 program,” and join corporate medicine, a move that didn’t turn out well in the 1990’s, and will certainly devalue the medical care Americans have enjoyed in the past. 
• Others will decide to opt out of the Medicare program and treat Medicare patients through private contracts.
• Wisely realizing that private insurance companies (the Aetnas and UnitedHealths of the world) will eventually make these very same data-collection demands, many physicians will terminate all insurance contracts, offering private individually-tailored care only through direct-pay or concierge arrangements.

If the MACRA regulations are finalized, not only will independent practices suffer, but so will Medicare beneficiaries. Small physician-owned practices are already known to result in fewer preventable hospital admissions than hospital-owned practices. As the Physicians Foundation points out, while mega-health systems “can handle government rules and regulations,” they simply cannot provide “the personalized care found in the offices of private practices.”

Patients, physicians, and other stakeholders can voice their opinions about the destruction of our physicians’ small businesses at http://bit.ly/macracomment.

Your opportunity to comment will close on June 27, 2016.

Obamacare’s Biggest Legacy? More Welfare Beneficiaries.

Once upon a time, in the darkest, most putrid bowels of the White House, the diabolical creators of the worst piece of health legislation in American history connived to completely uproot one-sixth of the economy by convincing the populace this was first, necessary, and second, a boon to the country.

The Obamacare architects knew that there weren’t that many Americans truly locked out of health insurance, and certainly not in the numbers that would justify such a massive overhaul. Yet they, with the help of the lapdog media, touted completely bogus numbers of 45 MILLION!, 47 MILLION!, and 50 MILLION! (depending on the source) to get your attention.

It worked, didn’t it? And we all felt bad to learn this, didn’t we? Half of the country was covered by company plans and we thought it was unconscionable that people hoping to purchase their own health insurance couldn’t afford to.

We were told in 2010, by Jonathan Gruber’s CBO, that the Obamacare insurance exchanges would cover 22 million more Americans by this year (which is, you’ll note, less than half of the purported 50 million uninsured. Some “universal coverage” plan!).

We were also told that insuring these long-suffering individuals would actually save us money!

“$2500 per family per year!”

Employers “would see premiums fall by as much as three-thousand percent, which means they could give you a raise!”

Eureka, Big Daddy Government will deliver us from ever-increasing health care costs!!! We’re on board!

Now, of course, we realize that the middle-class is taking this law directly on the chin. Workers with health insurance benefits are seeing their out-of-pocket costs skyrocket — while many in the individual market have decided to take their chances as they abandon expensive Obamacare policies with unreachable deductibles. 

Meanwhile, as the Congressional Budget Office churns its new Obamacare numbers, we find that the 2009-2010 CBO — Jonathan Gruber’s CBO — was remarkably off-base in its projections. In short, this year’s CBO report shows that the enrollment numbers are roughly half the 21-22 million 2016 exchange customers CBO had consistently forecast in years past, even as recently as March 2015. 

 

Get this: For all the sacrifice
the American people are making,
only 10 million people
are expected to be enrolled
in the exchanges by year’s end.

 

So what happened? 

Well, what happened was that an unexpectedly large number of Americans were folded into Medicaid, the worst coverage in the entire country, instead of signing up for Obamacare plans.

As the Weekly Standard’s Jeffrey Anderson points out, “In 2013, the CBO projected that, in the absence of Obamacare … 34 million people would have been on Medicaid or CHIP” in 2016.

What are the Medicaid/CHIP numbers now? 

Sixty-eight million. 

That’s right. Sixty-eight million American human beings are now on (lousy) Medicaid. Let that sink in.

Even better news for Progressives: CBO also believes that slower wage growth in the future will qualify even more Americans for the welfare programs.

What’s ironic for Obamacare proponents is that increased Medicaid enrollment also poses an existential threat to the exchanges. Take it from CBO itself, which projects that “as more people become eligible for Medicaid coverage, enrollment in coverage through the marketplaces will decline.”

Dentons, a global legal firm, maintains that this is already happening:

“Medicaid and the Children’s Health Insurance Program (CHIP) cover 17 million more people in 2016 than projected, while private insurance through the non-group market, including exchanges … covers 10 million fewer people. Millions of young, healthy people are enrolled in Medicaid and CHIP, rather than in private insurance offered through the exchanges.”

Before a 2012 Supreme Court ruling made Medicaid expansion optional for the states, CBO assumed all Americans with incomes at or below 138 percent of the federal poverty level (FPL) would receive Medicaid. Nineteen states are currently opting not to expand, so a smaller pool of Americans are Medicaid-eligible.

Still, as Dentons notes, “in the past six years Medicaid and CHIP enrollment has nearly doubled from the 2010 baseline.”

We’ve repeatedly been told that state legislatures opting not to expand their Medicaid programs are “greedy, selfish and uncaring.” Yet it is in Medicaid expansion states that Obamacare enrollment and risk pools suffer the most.

In non-expansion states, low-income, young, able-bodied Americans can purchase highly-subsidized exchange policies and help to balance out the costs of older, sicker enrollees. In expansion states, those same young, able-bodied Americans at or below 138 percent FPL are FORCED into Medicaid — as in:

“Sorry, you can’t have a real insurance policy.
You’re too poor.”

In the nation as a whole, insurers need about 40 percent of Obamacare enrollees to be 18- to 34-year-olds. Meanwhile, over at healthcare.gov, only “26 percent of the individuals who selected, or were automatically reenrolled in, a 2016 Marketplace plan are ages 18 to 34.” 

Where’d they go?
Medicaid, anyone??

The Wall Street Journal reports the reason the young and healthy are needed in the exchanges: to “hold down premium rates by balancing out the greater medical spending of older enrollees.” Insurers are already dismayed over the greater-than-expected costs of their current Obamacare populations and are threatening to raise 2017 premiums by double digits. As a result, reports of adverse risk selection and death spirals are proliferating.

It wasn’t enough that Progressives like Harry Reid, Chuck Schumer, and Nancy Pelosi put the exchanges at risk by insisting on a Cadillac Tax delay — which thus postpones the incentive for employers to dump workers in the Obamacare “exchanges, whether they like it or not.”

Now we see that their failed Medicaid policies have doubled down on the damage.

The Obamacare exchanges are doomed,
and Progressives have only themselves to blame.

Ezra Klein, Please Don’t Fire Sarah Kliff

For months, Vox’s Sarah Kliff has complained about the declining value of workers’ health insurance coverage and in particular rising deductibles. 

Kliff has also written about Obamacare’s Cadillac Tax.

And we called her out on her failure to connect the two. Twice. 

“Three articles on increased worker cost-sharing 
and yet NO mention of the Cadillac Tax?” 

So did The Tax Foundation.

It appears that Sarah has now awakened to the fact that the Cadillac Tax is driving down the value of company plans — and increasing employee costs — and her discovery has not made her happy.

https://twitter.com/sarahkliff/status/661202808738357248

NOW she’s skeptical. NOW she wonders if workers will really experience pay hikes as their health plans lose value. It took a long time and some hard cogitating to get Kliff to this point, but we congratulate her for discovering what we revealed in June.

One may wonder how her enlightenment is sitting with Vox boss and alleged wunderkind and intellectual giant Ezra Klein. Klein was a HUGE fan of the Cadillac Tax when disgraced Obamacare architect Jonathan Gruber promoted it in 2009 and 2010. In fact, Klein and Gruber had a mutual Cadillac Tax love-fest, and Klein frequently wrote in support of the tax and its wage growth promise.

In 2009:

Earlier in the day, I’d been talking to MIT economist Jon Gruber about this issue. “There are a few things economists believe in our souls so strongly that we have a hard time actually explaining them,” he said. “One is that free trade is good and another is that health-care costs come out of wages.” To put it another way: Economists are pretty united on this point. A firm’s compensation for its workers is pretty static, and if relatively more goes to health-care costs, relatively less will go to wages, and vice-versa. But this isn’t just a matter of theory. 

In 2010:

Unions will respond by “rebalancing compensation away from expensive insurance plans and towards higher wages, which is exactly what the tax is supposed to.”

And again:

[T]he excise tax is small change. It won’t hurt many people. It won’t hurt folks badly. 

But should workers suffer, Klein was all in:

When a policy bumps up against the tax, a couple of different things could happen. One is that the employer just passes along the tax, either increasing premiums for the employee or taking it out of wages. The other is that the employer chooses a plan that’s beneath the threshold. That plan might have a higher deductible, or more co-pays, or tighter networks, or less coverage for brand-name drugs. It will, in other words, be more like the managed care of the 1990s, which brought down spending and didn’t hurt health outcomes, but which people really didn’t like. “Managed care worked,” says Gruber, “but workers didn’t know it. They didn’t see the benefit. We’ve got to make them feel the pain of not reforming and enjoy the benefits of reforming.” In this case, the pain will be the excise tax.

In what can only be called economic incest, Gruber used a chart Klein created from Gruber’s numbers as evidence that his premises were valid. 

The available evidence clearly illustrates that there is essentially a one to one offset between employer insurance spending and wages. There are a number of economics studies that support this conclusion. But it is perhaps most vividly illustrated by simply comparing the growth rate of health insurance costs to the growth rate of wages, a task recently undertaken by Ezra Klein…when health care costs moderate, wages rise.” 

In other words, Gruber fed Klein his numbers, Klein sold them to America, and Gruber quoted Klein as evidence for his wage growth hypothesis. 

So Kliff now concludes that “the evidence is thin” that Klein’s Cadillac Tax sales job was honorable.

Let’s hope he doesn’t punish her for actually thinking this through herself, even as it took her years.

UPDATE: Who could have anticipated this? Klein admits Gruber’s “wage growth” hypothesis was bogus all along.

@ezraklein you sold gruber crap to the country and NOW you print this?? Wow. Just wow.

— Rich Weinstein (@phillyrich1) November 3, 2015

You have some ‘splaining to do, Mr. Klein.

Sarah Kliff Unloads Yet Another Awful Voxplanation

Is “awful” too harsh an adjective for Vox.com, the faux-educational ‘splainer site run by alleged wunderkind and intellectual giant Ezra Klein? One Twitter user, after reading our last piece on health beat reporter Sarah Kliff, didn’t think so.

@sarahkliff is taken to the woodshed for more awful #Voxplanations: https://t.co/d6zsUKoAYU

— Small Truck Appreciator (@spongeworthy2) August 31, 2015

Vox has also been called “terrible” and “a joke.” The staff has been referred to as “complete idiots” and likened to “sleazy mob lawyers.”  David Harsanyi of The Federalist writes that “Vox makes us stupid.”

Let’s agree to call them awful. Because they really are. Say it like Donald Trump would. 

“Vox is awwwwwwful!”

In her latest awful health care ‘splainer, Kliff tells us “Why your health bills are getting higher, in one chart.” And Kliff, who is now rather famous for producing pieces that cover only part of the story, once again fails to disappoint her reader(s)!

Let’s be clear: she really doesn’t explain “Why your health bills are getting higher, in one chart.” She only informs the reader that one component — the deductible — is on the rise. As if we hadn’t noticed.

She must believe Americans open bills from their doctors or hospitals and think, “Whaa?? How did this happen to me? I sure hope Sarah Kliff can ‘splain this!”

But see, she doesn’t. She just calmly ’splains that “This is your new deductible. On steroids.”

Actually, middle-class Americans already realize that Obamacare has made everything related to health care — not just deductibles — awfully expensive. Copayments and coinsurance are rapidly increasing. So are pharmaceutical and medical device costs, narrow networks (“if you have a doctor you like, you will be able to keep your doctor”) and insurers’ “medical necessity” audits and preauthorization requirements.

Why, oh why, is this happening, dear Sarah?

She’ll never admit this, of course, but it’s by design, courtesy of Obamacare architects like Jonathan Gruber, Zeke Emanuel, John Kerry, and The Won. You’re supposed to embrace this financial pain. It’s supposed to be awfully good for you. It’ll force you to reconsider scheduling that physician visit (as if you relished such appointments before) and filling your prescription order.

Never mind that it’s causing people to avoid care. (Shush!)

And never mind that you weren’t told of this plan before you voted in 2010 and beyond.

Kliff would have you believe these cost increases are occurring because “bosses are mean and stingy.” That is her implication in this, the latest of three articles in which she’s complained about deductibles and NOT mentioned the source of this pain: Obamacare’s Cadillac Tax on company health plans. 

(You can read all about the forty percent excise tax here and here.)

Kliff is merely taking a page from her progressive elders’ script: blaming company owners — for rising health care expenses and dropped policies — was the plan all along. 

Emanuel advanced this move in an interview with FOX news anchor Chris Wallace:

The president — look, the law does not say “Sears, drop coverage.” Sears decides what’s good for Sears… When the private companies decide that they’re going to drop people or put them in the exchange, you blame President Obama. He is not responsible for that.

Yeah, that’s right. The Preezy didn’t write an executive order commanding Sears to trim or drop company plans. He and his fellow Obamacare masterminds just made it a whole lot harder for Sears to keep its doors open. Paying a forty percent excise tax on health policies would put many firms out of business; employers simply have no choice but to skimp on or terminate company insurance.

We’re not alone in noticing Kliff’s awful omissions. The Tax Foundation also offered commentary on her latest skewed article:

Vox today covered the issue of rising deductibles in the U.S. health care market. As with their past coverage of the issue, there is a curious omission from the piece: the Cadillac tax…A number of outlets have linked this industry trend of higher deductibles to the Cadillac Tax. If Vox is to live up to its tagline and “explain the news,” it should perhaps give some consideration to the possible explanation offered by reports from Kaiser Family Foundation and Mercer, both of which link the Cadillac Tax to higher cost-sharing or consumer-directed health plans (CDHPs). This explanation for the news, for example, was considered by journalists at Bloomberg, the New York Times, the Wall Street Journal, and the Los Angeles Times, in today’s papers alone. It may behoove Vox to give it a look.

Kliff has a documented history of recycling information, but this is getting ridiculous — and, yes, awful! — for a former Washington Post writer.

Three articles on increased worker cost-sharing and yet NO mention of the Cadillac Tax? 

While some may have previously believed Sarah Kliff was just goofy, inattentive, and lazy, there’s no reason to think she wants her reader(s) to be anything but ignorant.

Shame on you, Sarah Kliff. Like your boss, you’re nothing but a progressive propagandist.

How awful of you!

H/T Citizen researcher Kathy in Alabama

Kliff’s Clunker Coverage of the Cadillac Tax

There’s no doubt about it: the faux-educational website Vox had a very unfortunate week.

First, alleged wunderkind and intellectual giant Ezra Klein nixed an essay an editor commissioned because the topic might challenge its reader(s) to think different thoughts. “The concern is that people will misinterpret it as implying opposition to abortion rights and birth control.”  Can’t have free discussion of ideas, huh?

Steven Hayward eviscerated Klein, concluding that he is a “a petty and small-souled human being.” 

Ouch.

Then someone at the outlet, apparently thinking the National Rifle Association produced chocolate products, confused the organization’s image with FDR’s National Recovery Administration. Twitchy, T. Becket Adams, and The Daily Caller ridiculed the site until Vox deleted the tweet and the image. 

Finally, our favorite Vox writer, Sarah Kliff — after more than a month of teasing us — offered her ‘splainer of Obamacare’s Cadillac Tax, the excise tax on employer plans designed to deliver a sucker punch to workers. 

First let’s note that Kliff wrote two previous articles complaining that those nasty little business owners are offering “crummier” insurance plans.

In neither article did she mention the Cadillac Tax as the reason. And it IS the reason. 

In her piece on the excise tax, Kliff only tells part of the story. Worse yet, she implies Republicans support it (this is not true).

She first admits this:

The point of the Cadillac tax isn’t to tax health insurance. It’s to change health insurance.

Do you remember being told you could keep your health insurance? Kliff fails to mention the 2013 Lie of the Year.

And do you remember this pie chart? 

Oh, yes, during all the outrage over cancelled plans in late 2013, Jonathan Gruber, who helped design the Cadillac Tax, claimed that worker plans wouldn’t be touched. And then someone made a pie chart for us.

Go ahead and peek at it. That big blue area representing the “unaffected” 80 percent of Americans?

“Largely people who keep their current employer plan.” 

Kliff apparently doesn’t remember any of this when she confesses that your job-based insurance is, after all, required to change. 

She is correct when she says people of all political stripes hate what’s called “the tax exclusion” allowing workers to receive benefits tax-free. But as Duke University research scholar Chris Conover points out, there’s a BIG difference between limiting the exclusion, as various policy analysts have suggested, and wiping it out through the highly regressive Cadillac Tax:

In short, whereas capping the tax exclusion even-handedly eliminates the tax subsidy for all workers above a certain premium dollar threshold, the Cadillac tax is far more pernicious–imposing a far heavier burden on low-wage workers than high-wage workers. That is, instead of merely reducing the low-wage worker’s tax subsidy to zero, the Cadillac tax goes overboard by using the tax code to actually penalize the provision of employer-provided health benefits to low wage workers. In contrast, while it obviously reduces the magnitude of the subsidy for high wage workers, it nevertheless leaves in place a net taxpayer subsidy for the identical health coverage for which a low-wage worker would face a tax penalty! Leave aside fairness: does that make any policy sense to you?

So when Jon McDonough told her the Cadillac Tax is “working just as Republicans wanted,” he either lied or is wildly uninformed about the law he helped write. 

And Kliff swallowed it whole.

Furthermore, Kliff writes that Economists think the Cadillac tax will give Americans a raise. Let’s put aside the proposition that A TAX can increase your take-home pay and proclaim that this is almost true. 

Some economists — like Gruber — have maintained for years that Americans are going to see pay raises as the tax forces companies to dilute the value of health plans they offer. (See Obamacare’s Wage Growth Hoax for more detail.) But other economists, health policy experts and even some Congress members find this doubtful. 

Linking to only one study, Kliff writes, “There’s a vast body of economics research that shows workers bear the cost of more expensive health plans with lower wages. These papers suggest there’s a lump sum amount that companies spend compensating workers. It goes into either wages or benefits.”

A lump sum, huh? Employers have no other options for savings they reap? What about distributing dividends or cutting the price of products they market? What about hiring more workers, say in Human Relations, to comply with Obamacare reporting requirements?

Have Gruber or Kliff ever run a business?

Keep in mind that at the time the tax was being debated, Megan McArdle demonstrated that she’d actually put some thought into the proposition:

What if employers just cut their costs and don’t raise their employees wages? What if employers just cut their costs and don’t raise their employees wages, because they’re in a dying unionized industry? What if they shift workers to other forms of tax-deferred compensation, like 401(k) matching or HSAs?

Indeed. What if this doesn’t work? What if employees suffer both higher health care costs and no pay raises?

After reading Kliff’s article, Gruber researcher Rich Weinstein tweeted:

Sara kliff impossibly explains Cadillac tax without naming gruber Kerry Emanuel or Obama. https://t.co/7UkHLTjdhN

— Rich Weinstein (@phillyrich1) August 26, 2015

And he’s right. Here’s what she omitted:

• In his ’08 campaign the President swore his health reform plan wouldn’t tax worker benefits. He spent $100 million hammering John McCain for proposing a cap on the employer exclusion. 

• But on July 20, 2009, convinced by Gruber and “medical ethicist” Ezekiel Emanuel that it was far too much money to forego, he “bravely” changed his mind. 

• And because they all understood the tax would be a political nightmare, John Kerry, to quote Gruber, “had a very clever idea. He said, ‘Let’s call it instead a tax on insurance companies and not a tax on insurance plans.’…Now, you and I know, economists know, that that will just get passed on in the price of insurance.”

• Three days later, Obama said this to his Shaker Heights, Ohio, audience:

First of all, in terms of taxing benefits, I said I oppose the taxing of health care benefits that people are already receiving, so that’s not a proposal that I’m supportive of…But what I said and I’ve taken off the table would be the idea that you just described, which would be that you would actually provide — you would eliminate the tax deduction that employers get for providing you with health insurance, because, frankly, a lot of employers then would stop providing health care, and we’d probably see more people lose their health insurance than currently have it. And that’s not, obviously, our objective in reform. OK?

But that was the objective. Bye-bye, employer-sponsored coverage. “Everybody, into the exchanges!” As analyst Patrick Garry writes:

Obamacare was sold as supporting the employer-based system, not eroding it. But at its core, Obamacare is designed to do precisely that: to eventually force every American with employer-based coverage onto the Obamacare exchanges, whether they like it or not.

So there’s your ‘splainer, Vox. You’re welcome. Feel free to update your article with this material. 

We would have made corrections in your comments section instead of writing a long and embarrassing blog post, but you don’t allow comments on your articles.

And it’s pretty clear why.

Sarah Kliff’s Recycled Mess

Among the many recently trotting out heart-breaking tales of woe — to shamelessly pressure the Supreme Court in King v. Burwell — is Sarah Kliff, with a piece titled:

“The Supreme Court’s Obamacare decision will determine
if this cancer patient gets chemotherapy.”

You can be forgiven for not having seen the article. In fact, our crack research team almost missed it. It was published on June 12 in an outlet called Vox, led by America’s alleged wunderkind and intellectual giant Ezra Klein. 

Vox is a site hosting writers who enjoy referring to themselves as “wonks” and “nerds” because it makes them sound brighter than they really are. Actually, they’re just partisans.

Lefties like these are growing increasingly nervous as Decision Day draws near in King v. Burwell. Perhaps that’s why Kliff re-ran her story of Marilyn Schramm, which she first posted — with the same title — on February 26, 2015. 

One wonders why she couldn’t locate another anecdote.

Here’s what Kliff wrote, in both pieces:

Marilyn Schramm is thinking about moving. She is a 63-year-old retiree who lives in Texas, and since November 2013 she’s purchased health insurance through Healthcare.gov. She has a policy that costs about $800 per month. Schramm, who earns $28,000 from her pension, pays about half the cost, and the federal government covers the rest with a subsidy.

Her best back-up plan right now, she says,
is moving to a place with a state-run exchange.
(emphasis added)

We’ll refer you to John Sexton of Breitbart to give you his take on Kliff’s first post. 

We’ll also add that Ms. Schramm appears to be an attorney who retired from the Texas state government in 2010 and started her own consultancy business in 2011.

And Kliff doesn’t tell us why Ms. Schramm had to sign up with Healthcare.gov. Was she one of the millions whose coverage was canceled in late 2013? Kliff conveniently omits those details.

What’s more important is that Ms. Schramm, and everyone else in her position, receive some sound financial advice. 

Kliff could have been trying to antagonize the Justices when noting Ms. Schramm may choose to relocate, but she inadvertently described a solution for Americans in Healthcare.gov states. 

Yes, Ms. Schramm, you can — and should — move to a state with its own Obamacare exchange. It’s only logical.

Think about it. Older Americans migrate to certain states to avoid taxes on pension benefits and estates. Some move to states with lower income taxes, while others favor states with minimal property taxes. 

Americans rightly gravitate to states that meet their personal needs. Even on a local level, undocumented immigrants are attracted to sanctuary cities.

So if the King plaintiffs prevail, Americans in states with federally-established exchanges won’t really lose taxpayer subsidies. They can still receive them — in the Progressive states who will welcome them with open arms. 

Those states can be referred to as Medical Sanctuary States (or MeSSes).

Keynesian theorists understand that states with greater public spending promote economic growth. And, as our national treasure Jonathan Gruber explains, Progressive states, since they also embrace the expansion of Medicaid, will experience a major economic stimulus from the influx of federal dollars. 

In other words, the MeSSes will economically thrive!

And it just keeps getting better. Liberal voters, eager for Obamacare subsidies, Medicaid, and other government benefits, should flood these MeSSes, thereby tipping census figures in those states and changing the numbers in the House, Senate, and Electoral College. 

They’ll also overtake Conservatives in their state legislatures, improving state economies further through mandated minimum wages, higher state income, sales, and inheritance taxes, and other socially Progressive policies.

The best part? As Gruber notes, Conservative states will be paying federal taxes for the perks available in the MeSSes, thus accelerating the redistribution of wealth.

Given these obvious results, Progressives should cheer if the Obama administration is defeated in King v. Burwell. They just don’t realize this due to their basic “lack of economic understanding.”

Hmm. In originating the Obamacare subsidies cases, including King, what were Michael Cannon and Jonathan Adler thinking? Are they really just Progressives in sheep’s clothing? (Snark intended.)

Where do I turn in my wonk credentials, SIGH. https://t.co/sh4X0A2Mrq

— Sarah Kliff (@sarahkliff) June 16, 2015

Obamacare’s “Wage Growth” Hoax

Families across the country are facing escalating out-of-pocket health care costs and, as a result, less disposable income, thanks to Obamacare’s Cadillac Tax. A major funding mechanism for the law, the 40 percent excise tax forces employers to cut back on health benefits, leaving workers increasingly subject to higher deductibles and copayments.

(Note: See here, here, and here for more details on the Cadillac Tax.)

The drive-by media originally maintained the Cadillac Tax was merely a justified penalty on unusually expensive gold-plated plans — such as those owned by Goldman-Sachs executives — that theoretically encourage over-utilization of medical care. 

However, we now know that the tax was designed to eventually target every employer-sponsored insurance (ESI) plan. We’re talking about 158 million Americans.

Since employers have already begun reducing the generosity of their plans to prepare for the tax’s 2018 implementation, even the drive-by media has had to pay attention to a flurry of reports — from sources like Forbes, The Los Angeles Times, Bloomberg, the Institute for Policy Innovation, The Wall Street Journal, and more — on soaring employee cost-sharing.

Completely blindsided by these revelations, Progressives are now referring to copayment and deductible victims as “underinsured” and calling for action, including government requirements that insurers lower deductibles. Some are even demanding a repeal of the Cadillac Tax.

This situation shouldn’t have been a surprise to anyone. This is, as they say, a feature, not a bug, of the law; the Cadillac Tax was always intended to discourage patients from consuming health care. This is Obamacare’s promised “cost control.”

Law professor (and big-time Cadillac Tax fan) Edward Zelinsky explains:

 “Those who drafted the Cadillac Tax presumed that this tax…would be passed on to the employer and that the employer, in turn, would transfer this additional cost to its employees. In this indirect fashion, the Cadillac Tax should sensitize employees to the high costs of their health care coverage.”

Steve Wojcik of the National Business Group on Health described the policy’s intention:

“If employees have more cost sharing…then they’re more mindful when they access health care to choose a more efficient provider or say, ‘You know, I don’t need to go to the doctor every time I have a cough.’” 

America, you were conned from the very start. Not only did politicians lie — including Obama, dozens of times — in maintaining we could keep our plans, period, but so did Progressive reporters, who insisted that job-based coverage would be untouched.

Young Jonathan Cohn explained that for most of those with employer-sponsored insurance, Medicare, or Medicaid, 

“Very little about their health plans are changing because of the law,
at least outwardly.” 

America’s alleged wunderkind and intellectual giant Ezra Klein told us: 

“For most companies, the Affordable Care Act won’t bring much change at all.” 

And Ryan Lizza  assured readers that:

“About eighty percent of Americans are more or less left alone by the health-care act—largely people who have health insurance through their employers.” 

To prove that most people wouldn’t be affected by Obamacare, the liberals even paraded a pie chart, because apparently, in their view, “stupid” Americans understand colorful pictures more clearly than words. 

Even now, in the midst of this massive shift to higher employee cost-sharing, at least one of the law’s engineers is still perpetrating the fable that Obamacare isn’t affecting company plans.

Why did Obamacare’s designers aim to abuse American workers this way? Why was it necessary that Americans lose their policies to make Obamacare work?

To rake in more federal money, of course. The tax was devised to undercut the IRS provision that allows workers to receive tax-free company benefits. Policy experts estimate the government is robbed of $250 billion per year through this arrangement. 

And Progressive lawmakers rationalized that as employers scaled back or eliminated tax-free plans, they’d offset the loss with pay raises — in other words, taxable wages.

Here’s then-Senate Finance Committee chair Max Baucus explaining your raise.

Progressive politicians — backed by the Congressional Budget Office (CBO) — predicted that the excise tax itself would raise relatively little, since companies would have no choice but to bring plan costs below the tax’s threshold. Obamacare crafter Jonathan Gruber is quoted to say, “I would be surprised if [the IRS] even collect[s].’” 

Most of the $201.4 billion revenue over 2013-2019 was predicted to result from payroll and income taxation of, yes, your raises.

Are you following? America’s gonna get a raise, any day now.  There’s even an econo-wonk term for this phenomenon — the “Wage Growth” effect.

So what about this “Wage Growth?” And who was the genius predicting with absolute certainty how companies would react to any savings on benefit costs?

Let’s flip the calendar back to 1993-94, when Hillary Clinton and Friends were busily at work trying to accomplish a very similar government takeover of America’s health care sector. 

“Wage Growth” was a major assumption in the Clinton bill: employers were expected to “shift to wages” any savings or costs they experienced due to the employer mandate to offer insurance. Those offering ESI for the first time were predicted to offset costs by reducing wages; companies that had previously offered ESI would receive government subsidies and were expected to pass along those savings to employees. 

The proponent of the Wage Growth hypothesis was 28-year-old Jonathan Gruber — yes, that Jonathan Gruber — who explained it to a health reform group in December 1993, and in testimony before a House committee five days later. When testifying before a Senate committee in July 1994, he again maintained the legitimacy of his unproven assumption.

Gruber was successful in persuading the 1994 CBO to accept the same premise: “employers facing an increase in their premiums would probably shift most of the added cost to their workers by reducing cash wages” and “employees of firms that would pay less would receive higher wages.” CBO’s evidence? Two research papers (one of which was still “forthcoming”) written by Jonathan Gruber.

Fifteen years later, in the midst of the Obamacare battle, Gruber was again peddling Wage Growth, offering professional papers and articles attempting to prove that Wage Growth would materialize with Obama’s reform package as well. Gruber, then more heavily involved with the CBO, influenced the body to repeatedly make the same Wage Growth assumption with Obamacare. (That’s for a subsequent post.)

For now, remember that it was critical that CBO find that Obamacare would pay for itself, as Obama promised and demanded a reform package that didn’t increase the deficit by a dime. Also remember that CBO analysis killed HillaryCare when it found the proposal increased the deficit by $74 billion. 

Obama and his Progressive Senate buddies couldn’t endure such an outcome. And government control of one-sixth of the economy couldn’t wait. 

So Jonathan Gruber rode in to save Obama by convincing just about everyone who mattered that the plan was deficit-friendly. Gruber then effectively went “on tour” to sell his claim to the American people, citing the support of the “independent CBO” — that’s right, the CBO that relied upon his Wage Growth hypothesis. 

Why is this important now, six years later? Because a wage increase has not occurred, despite ever-increasing benefit cuts, and was known to be improbable before Obamacare was passed. In a December 2009 Mercer employer survey, only 16 percent of respondents said they’d convert any cost savings into pay raises. In Towers Perrin’s September 2009 survey, a paltry nine percent said they’d increase wages.

It’s less than clear that even Jonathan Gruber believed in the Wage Growth hypothesis, since he appears to have solely relied on his analysis of wage and health insurance trends in the late-90s. And he doesn’t appear entirely convinced he hadn’t overlooked some confounding variables.

Gruber told The New York Times in January 2010, “‘There are many academic studies showing that when health costs rise, wages fall,’ he said. ‘In the mid- and late-1990s, when we got health costs under control, wages rose nicely.’ But he added that other factors could have also lifted wages during that period.” (More on that later, too.)

Additionally, liberal economist Lawrence Mishel, a critic of Gruber’s Wage Growth hypothesis, wrote on January 12, 2010, that ”Gruber clearly overreached with the argument about health care driving wage trends and has acknowledged that to me privately (yesterday).”

Given this, one must wonder: would Obamacare have passed if not for the false narrative of deficit reduction? Even in Gruber’s 2011 comic book, he admits this about the law:

“There are risks.  But we have the benefit of
the independent projections of the CBO
…to suggest that this should work out.” 

Now we’re discovering that those CBO projections were not very “independent” and instead were biased by Gruber’s assumptions.

Stay tuned. A subsequent post will explain how Jonathan Gruber manipulated economic research to advance his Wage Growth hoax.

Reprehensible Republicans Ruin Medicare

Do you remember reading this from the Associated Press in mid-April? 

Suddenly, bipartisanship has broken out on Capitol Hill.

We were supposed to feel so proud of our Congress! They worked together, reached across the aisle, and enacted a permanent repeal of Medicare’s reviled SGR Fix (or Doc Fix)! 

Well, the Drive-By Media didn’t tell the rest of the story. What happened is this:

212 House Republicans and 46 Senate Republicans
joined the Democrats in radically changing the way
Medicare providers are paid
— and controlled —
by the federal government.

That’s right. The same GOP leaders vowing to repeal Obamacare just grafted it Big Time onto Medicare.

We expect this from the progressive members of Congress. But weren’t we supposed to expect a Republican Congress to lessen the size and scope of government? Didn’t last November’s election results reflect “a mandate to pass sensible legislation?”

And they wonder why we don’t take them seriously.

So who’s gonna pay for this knucklehead move? Eventually, you. 

Thanks to Congress, it’ll soon be very difficult to find a health care professional who’ll accept your Medicare card, since MACRA (Medicare Access and CHIP Reauthorization Act) applies Obamacare’s experiments to the whole program.

It wasn’t as if Medicare was untouched before MACRA, despite what HuffPo’s Jeffrey Young thinks. Thanks to Obamacare, pay-for-performance schemes like Accountable Care Organizations (ACOs) began in Medicare in 2012, and they’ve produced less than impressive results thus far. That didn’t stop our 2015 Republican “leaders” from expanding them.

What are ACOs? Think of the Health Maintenance Organizations (HMOs) of the 1990s, an idea that proved so wildly unpopular that patients revolted in near-universal protests about limited provider networks and rationed care. 

Still, the Obamacare Congress thought it was wise to apply HMO 2.0 to Medicare patients, but with an additional feature: patient satisfaction scores. That means ACO providers are financially rewarded for limiting care and procedures, but also have to make the patient feel happy about it!

(Never mind that payment for satisfaction is associated with higher health care expenses and a greater likelihood of hospitalization and death. The Obamacare Congress knows best.)

MACRA essentially forces all Medicare providers into Obamacare’s experimental ACOs. This spells the end to private independent healthcare practices, as providers must align themselves with a huge health system to survive.

Well, to be fair, doctors do have a choice. They can continue in traditional fee-for-service care, but anti-Obamacare warrior and ophthalmologist Kris Held explains the dangers of this route:

Government bureaucrats and committees will call the shots for Medicare patients. The law actually creates Alternative Payment Models (APMs) and a Merit-based Incentive Payment System (MIPS) which require physicians to follow a government rubric on which we will be graded in grade school fashion. Physicians, now defined as “eligible providers,” will get grades from 0-100 as determined by the Secretary of Health and Human Services. The grade for doing what the Secretary prescribes is called the Composite Performance Score. The score is publicly posted on the Physician Compare Internet Website of CMS, and the Secretary of HHS assigns each physician a payment adjustment factor based on this score. The payment adjustment factor will be positive, 0, or negative. Based on how well a doctor “performs” for the Secretary, the pay could be adjusted 9% up or 9% down, meaning the Secretary’s most compliant doctors will be paid 18% more than those who don’t perfectly make her wishes our commands. What will doctors put up with, and what will we do or not do for patients in order to be paid 18% more than those government deems “less quality” doctors and to avoid public humiliation on the government website? This is indeed chronic and continued abuse taken to a higher, institutionalized level.

That’s right. In either scenario, doctors will be scrutinized by federal bureaucrats aiming to reduce Medicare expenses by dictating care according to one-size-fits-all treatment protocols.

Since the passage of MACRA, many doctors are considering resignation from Medicare. “Opt out providers” will still treat you, but you’re gonna have to pay privately, outside Medicare’s supervision and reimbursement mechanisms.

This has one obvious disadvantage for the typical Medicare patient, since, depending upon the arrangement negotiated, costs may be higher to see these opt-out doctors. 

But it also means Creepy Uncle Sam won’t be in the exam room, and you’ll have care that is tailored to the individual, not forced onto you by Washington DC bean counters.

And it’s likely to be far more affordable than you may think, since health care professionals who opt out of arrangements with government and private insurance have reduced overhead costs. These doctors can charge less than their hand-cuffed peers, who can’t reduce fees for cash patients without violating government and insurance contracts.

As the Association of American Physicians and Surgeons pointed out when MACRA was passed, “opted-out physicians are able to charge a mutually agreeable fee (sometimes lower than the Medicare copayment), drastically reduce administrative overhead, give their patients the time that they need, keep records confidential, and prescribe according to their best judgment rather than a government-approved protocol.”

It’s reasonable to expect that, due to the “rising misery index” and increasing retirement rates among physicians, there will be far fewer of them in coming years. Among those that remain, a growing number will opt out of The System.

And you’ll know who to blame. This time, Republicans are the ones who apparently didn’t bother to read the bill.

Medicare providers wishing to learn how to opt out can visit here.

Americans wishing to do business with liberty-minded physicians can find them here.

Obamacare Scorecard: Takers Taking, Makers Breaking

When market research company J.D. Power released its 2015 Health Insurance Marketplace Exchange Shopper and Re-Enrollment (HIX) Study last Thursday, progressive health care reporters rushed to their laptops to declare Obama’s remarkable achievement:

Wowie!
Obamacare customers
are more satisfied
than people with job-based plans!

Vox’s Sarah Kliff offered her ‘splainer of the study, which was based on data collected from December 9, 2014, through February 24, 2015. 

People who had coverage through Obamacare had an average satisfaction score of 696 in 2014, thinking back to their last year of coverage. During that same year, people in mostly employer-based plans had a satisfaction rating of 679 — 17 points lower.

So did Sarah Ferris at The Hill:

People who bought coverage through ObamaCare are generally more satisfied than those with other types of insurance, according to a new national survey. ObamaCare customers rated their satisfaction over the last year as 696 out of 1,000, compared to the 679-point rating by customers with employer-based plans, according to a large survey by the consumer research firm J.D. Power.

And let’s not forget young Jonathan Cohn, who wrote a Huffington Post piece titled Obamacare News That Should Make Conservatives Happy, But Won’t:

J.D. Power uses a numerical index, from zero (low) to 1,000 (high), to measure consumer satisfaction. The figure for Affordable Care Act consumers was 696. To put that in perspective, the figure for people with employer-sponsored insurance — the source of coverage for most working-age Americans — was 670 [sic].

Here’s a question for Kliff, Ferris, and Cohn:

Are you really surprised that getting free stuff is popular?

…especially since J.D. Power found that “cost is the most influential attribute driving satisfaction among Marketplace plan members?”

Reporters of all stripes ought to know why Obamacare customers are happier than those in employer plans.

• Obamacare enrollees enjoy the taxpayer’s helping hand with their premiums: in 2014, 90 percent received premium subsidies, and 69 percent paid $100 or less per month. 
• Those in job-based plans are being increasingly hammered by rising out-of-pocket costs, as employers reduce benefits to avoid Obamacare’s Cadillac Tax. 

The New York Times provides one example of the excise tax’s impact on workers.

Starting this year, they have a combined deductible of $2,300, compared with just $500 before. And while she was eligible for a $1,400 hospital contribution to a savings account linked to the plan, the couple is now responsible for $6,600 a year in medical expenses, in contrast to a $3,000 limit on medical bills and $2,000 limit on pharmacy costs last year. She has had to drop out of school and take on additional jobs to pay for her husband’s medicine.

Remember: Obamacare enrollees don’t have to pay the Cadillac Tax; only those with company plans suffer that burden.

The real story in the J.D. Power release, though, is not found in comparisons of people with different types of coverage: it’s found when one examines the insurance satisfaction index over time.

In 2009, the year before Obamacare was passed, that number was 712 out of 1000. In 2010, it plummeted to 701. And now, for those with employer-provided insurance, that number is 679 — and 696 for those in the individual market.

In their reports, the research firm (strangely) never mentions the sampling errors and confidence intervals that would allow for meaningful year-by-year comparisons. However, they do say they consider a ten-point change to be significant.

So overall, Americans are vastly less satisfied with their health insurance since Obamacare started monkeying around with it. That’s the story.

But our progressive health care journos didn’t write about that tidbit, did they? 

Instead, they put a happy face on the numbers, gleefully announcing that those getting freebies are happy with their free provisions, and those subsidizing those freebies are much less so. 

Duh. They must think their readers were educated at the Jonathan Gruber School of Stupid.

[Sigh] It’s all fun and games until we “run out of other people’s money.”

Meet Jeffrey Young, HuffPo’s Medicare Donut Hole

On April 17, Huffington Post’s Jeffrey Young admitted he doesn’t know squat about Obamacare. 

Referring to a Bloomberg article on Obamacare polling, he asked his Twitter followers to enlighten him as to one woman’s claims.

I'm puzzled by this line in that Bloomberg article. Anyone have an idea what it refers to? http://t.co/XwdBhbSVSU pic.twitter.com/g8IGrhSOzA

— ''Jeffrey Young'' (@JeffYoung) April 17, 2015

And then he revealed that he has no idea whatsoever as to Obamacare’s impact on Medicare.

@richard_schmitz It also occurred to me eventually that she's 83, and therefore almost certainly on Medicare, not "Obamacare," anyway.

— ''Jeffrey Young'' (@JeffYoung) April 17, 2015

“Eventually” deducing that she’s “almost certainly on Medicare,” not Obamacare, he writes off her report as nonsense.

Why, it’s as if Medicare and Obamacare are two distinct and unrelated programs! 

His reasoning? On the one hand, some poor schlubs lost their plans and had to sign up for lousy coverage in the exchanges. On the other, there’s Medicare, the insurance plan for the elderly and disabled. And never the twain shall meet, right?

WRONG, Mr. Young.  And Ms. Stone isn’t a befuddled octogenarian who doesn’t know the difference. 

Ms. Stone was treated at physicians’ offices through Russell Medical Center, which has partnered with the University of Alabama at Birmingham Health System (UAB) since August, 2012. At the time, RMC agreed to a plan of “working together to solve problems in health care delivery.”  In September, 2013, UAB embraced Obamacare’s ambition to reduce health care costs.

Ms. Stone has never had heart problems, but during a routine blood draw, her triglycerides tested at 600, almost 10 times her usual result. Her internist put her on multiple medications and referred her to one of RMC’s cardiologists. 

She then became a cardiac patient. 

With three master’s degrees and two specialty degrees, including one in psychometry, Ms. Stone was no fool. “I knew the lab was wrong.” But she couldn’t convince her doctors to retest her.

“They told me I couldn’t get another test for three months and that I’d need to take all of these medicines in the meantime. They said Obamacare was the reason.”

And they explained how Obamacare is influencing patient care: “The doctors are very dissatisfied, and many of them are not able to give their patients the attention that they feel that they need because they can’t have too many appointments, too many tests.”

The unaware and uninterested Jeffrey Young, HuffPo’s Obamacare expert, admits he’s “puzzled” by this. And this revelation is surprising since he’s written about the donut hole repair, Medicare costs, and the increasing out-of-pocket costs Americans are enduring. He even weighed in on King v. Burwell. One could fairly assume he’s researched the law in its entirety. 

Did he stop reading Obamacare when it came to its reforms of Medicare? Did he get sleepy?

As a national health care reporter, Mr. Young ought to know that no other group is as affected by Obamacare as are seniors on Medicare. The law created a variety of pay-for-performance experiments in Medicare, including the following:

Section 3001: Hospital Value-Based Purchasing Program
Section 3002: Improvements to Medicare’s Physician Quality and Reporting System (PQRS)
Section 3003: Expansion of Medicare’s Physician Feedback Program 
Section 3007: Application of Medicare’s Value-Based Physician Payment Modifier (VBPM) to Physicians Payments 
Section 3022: Medicare’s Shared Savings Program for Accountable Care Organizations
Section 3023: Bundled Payment Pilot 

The goals of these experiments are to reduce costs (in large part by limiting tests and procedures) and to improve the quality of care by “rewarding value” rather than the number of services delivered. 

The problem? Federal government bureaucrats, not health care professionals, are the ones defining quality treatment. And when health care providers don’t attest to their compliance with government-approved standards, they’re penalized.

This is what ophthalmologist and Obamacare rebel Kris Held means when she refers to the law’s perverse incentives that shift focus away from what’s best for the patient to what’s best in the eyes of The System’s cost-cutters.

As physician editor of The Hospitalist Danielle Scheurer cautioned last year, “there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.” 

And lower-value care is just what Dell Stone received, thanks to bureaucratic interference with her treatment. When her triglyceride levels tested alarmingly high, her physician clicked the boxes in his electronic health record and prescribed heart medications, including a potentially dangerous statin drug. And due to the drive to keep testing expenses low, a second lipid panel had to wait.

Thankfully, when Ms. Stone returned to her cardiologist two weeks ago, her three-month wait paid off and she was granted a retest. This time her triglyceride reading was 67.

So, yes, Mr. Young, Obamacare did cause harm to this senior — and is in the process of harming countless others. 

When The System begins experimenting with your grandmother’s care, Mr. Young, will you bother to research Obamacare a bit more?