Category Archives: Zeke

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.

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.

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. 

NEW YORK, NY - MARCH 09:  Donald Trump and Melania Knauss-Trump attend the Comedy Central Roast Of Donald Trump at the Hammerstein Ballroom on March 9, 2011 in New York City.  (Photo by Andrew H. Walker/Getty Images)   Original Filename: GYI0063876060.jpg

“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 Kliffafter 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:

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. 
  • 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.

How Obama Learned To Stop Worrying And Love The Obamacare Bomb

Last fall Duke University research scholar Chris Conover wrote a powerful piece titled “Obamacare’s Three-Legged Stool of Deception,” in which he explained the covert way Obamacare crafters aimed to eliminate job-based health insurance through the Cadillac Tax.

  • The first leg is that the Cadillac tax is paid by insurance companies, when in reality it is paid by employees. 
  • The second leg is that the Cadillac tax is aimed at “lavish” high cost plans, when in reality it is designed to eventually hit virtually every employer health plan (even those with lower-than-average costs). 
  • The third leg is that the Cadillac tax is functionally equivalent to a reform long championed by conservatives: a cap on the tax exclusion for employer-sponsored health insurance. 

Dr. Conover hit a home run in detailing the duplicitousness of the law’s architects, and his piece is probably the best exposé of the Cadillac Tax you’ll find.

But who designed the Cadillac Tax, and how did Obama come to love it?

In his first presidential campaign, Obama repeatedly maintained that he was dead-set against taxation of health insurance benefits. He even chastened his opponent, Senator McCain, for proposing that Americans receive tax credits instead of tax-free insurance benefits.

“This is your plan, John: for the first time in history,
you will be taxing people’s health care benefits.”

Ezekiel Emanuel, special advisor for health policy during the law’s creation, gives us important insights into how, in the summer of 2009, Obama decided campaign promises weren’t as important as was more money in the federal coffers.

Zeke describes a “hot Friday July afternoon” in the White House when he says the “core health team” was working on Obamacare. After about an hour, he recalls, the president walked in, “in his shirt sleeves with his cuffs rolled up. He was there to give us a sort of uplift.” After pleasantries were exchanged,

“I raised with the President one of the issues that had been burning up the staff — the issue of something called the Tax Exclusion.”

In both videos linked above, Zeke describes the issues he and others had with tax-free employee benefits: 

“The big argument we were having was, people on what was called the economic part of the health team…we wanted to do something about the tax exclusion because it’s inflationary, it’s regressive, it’s a lot of money.”

One obstacle? Obama wasn’t clear on his stance: 

“We got into some weeds, and he would say, ‘What did we say about that? What was my position on that? ‘Cos the people should know I stand by my position.’” 

And since David Axelrod, his senior advisor, pointed out that he’d spent $100 million running ads against McCain’s position, the Campaigner-in-Chief stalled, worried that he’d be contradicting his promises.

“David Axelrod, as part of this debate internally, created a montage of all the ads that President Obama had run against John McCain attacking McCain’s proposal — which was basically to get rid of the tax exclusion and give people a tax credit instead to buy health insurance.”

Eventually the economic team won Obama’s heart by showing him how much power and money ($250 billion per year) the Cadillac Tax would grant him.

“I said, you know, Mr. President, as President, you can control a lot related to the public provision of health care insurance — Medicare, Medicaid, CHIP, veterans health benefits — but you don’t have a lot of power over the private side. And that, after all, is the bigger side. It’s most of the money, covers half the American population.” 

That “hot Friday” was July 17, 2009, when the Washington, D.C., temperature soared to 90.9º.

“(O)ver the course of the next few days, this was Friday, then Monday and Tuesday we had meetings around this, the idea began to hold that we should do something about it, we shouldn’t roll it back, but we should modify it.”

The following Monday and Tuesday were July 20 and July 21, 2009. White House visitor logs show an “Economics Team” indeed met the morning of the 20th. (White House visitor logs also indicate that the beloved Jonathan Gruber was in attendance!)

So why did THIS happen, on Thursday, July 23, 2009, in Shaker Heights, Ohio?

“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.”

Dear President Obama, wasn’t that exactly the goal? That we lose our plans and have to join your lousy exchanges?

It’s very odd that Obama repeatedly characterizes his views using terms like “what I’ve said is,” rather than “what I believe is.” 

But it’s more than disappointing to learn that Obama lied to his Shaker Heights audience — and America — mere days after he fell in love with the bomb that will blow up job-based insurance.

H/T Citizen researcher Kathy in Alabama