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Tuesday, December 01, 2009

Posted by: Hugh Hewitt at 5:27 PM

Another e-mail:

Hi Hugh,

My wife is a practicing dermatologist. Although it may be crazy, we're actually in the process of opening a new micro practice. From our perspective, one of our biggest fears is that the government will mandate physicians accept any/all government sponsored insurance under threat of losing or revoking medical licenses. There may not be an option out. I believe New York State does this already. If that's the case, our new business won't last long. As it is margins for small practices are very tight and overhead is unbelievable high. Add even more complicated medical billing and reduced physician compensation and I don't see how any private practices will survive. Maybe that's the plan.

The government knows most physicians have to much time invested in their education and care too much about their patients to simply walk away. I believe that's why Medicare has continued to cut or keep static their rates. Physician compensation will be a large target for cuts. I guess eight to twelve years of post graduate education and training don't deserve high compensation. It's shocking that most people don't realize how long it takes, how much work it is, and how expensive it is to become a licensed practicing physician.

The worst part about all of this is the feeling of helplessness. The politicians know the people don't want this, but they're going to jam it down anyway. We've donated to Reverse the Vote, and my wife has attended and spoken at any local town hall meeting that comes around, but it seems like none of it matters. Maybe the fickle politicians will yet respond to falling approval ratings and negative healthcare polling, but I feel like the power grab temptation is just too much to resist.

Michael

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Tuesday, December 01, 2009

What Killing Medicare Advantage Will Mean to the Millions of Seniors Covered By It

Posted by: Hugh Hewitt at 1:02 PM

All of the proponents of Obamacare extol the necessity of "reforming" (by which they mean killing) Medicare Advantage. Most people have no idea how this program operates or what Obamacare's changes to it will mean to the millions of seniors covered by it. Here's one example that spells it out:

I listened to your interview with Jonathan Cohn last night and not only did he have no specifics, but neither did you.

I recently (effective Oct 1) signed up for an Advantage HMO plan after three months of research. I pay nothing extra for the plan, only the $96.40 for Medicare B.

Here's what I get extra by signing up for Advantage HMO:

Under Medicare A, if I go into a hospital I would pay the first $1,068 and Medicare pays the balance for the first 60 days. For the next 30 days, I would pay $267 a day ($8,010) and Medicare pays the rest. For the next 60 days - a one-time lifetime benefit - I would pay $534 a day ($32,040) and Medicare pays the rest. After that, I would pay everything for as long as I remain in the hospital.

Under Medicare Advantage HMO, I pay $100 per day co-pay for the first 5 days (maximum of $500) and the insurance company pays the rest. For the first year, my out-of-pocket cost is $500 vs. a minimum of $41,118.

Under Medicare B, I would pay the first $135 for doctor services and 20% - 25% (depending upon services) of everything over that.

Under Medicare Advantage, I pay a $5 co-pay for my Primary Care physician visits, a $25 co-pay for a Specialist visit, and $100 co-pay for outpatient surgery and hospital services and nothing after that.

Under Medicare D, I have to pay a fairly large premium for drug coverage.

Under Medicare Advantage HMO, Medicare D is included at no additional cost.

For additional - but modest - premiums, you can sign up for other types of Medicare Advantage such as a PPO if your doctor and hospital are not a member of the HMO model (mine were).

So, essentially, the private insurance company gets paid a flat fee (based upon bids) by Medicare as a premium for taking over the administration and risks, adds substantial additional benefits to induce seniors to sign up, and still makes a profit. Can anyone say efficiency and eliminate of fraud and abuse?

Apparently, it is this profit that has President Obama so upset that he calls it a "subsidy" and he wants to "save" money by killing Advantage and dumping all of us back into regular Medicare, with catastrophic costs for any of us who beccome seriously ill.

If Obama kills MediCare Advantage and I don't want to take the high deductible risks of regular Medicare, I will have to buy a MediCare Supplement (MediGap) policy at a current price of $203 per month for comparable coverage (in addition to my continuing $96.40 per month for MediCare B). This premium will increase as I age. So ObamaCare will cost me at least $2,436 a year to avoid the limitations of regular Medicare.

He might get away with it because almost nobody except the 9 million seniors who have done their homework understand anything about Medicare Advantage (or have even heard of it), including President Obama!

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Monday, November 30, 2009

Do These Supporters of Obamacare Inspire Confidence In The Scheme?

Posted by: Hugh Hewitt at 11:59 PM

Two Obamacare supporters joined me on Monday's show: The New Republic's Jonathan Cohn (interview transcript here) and Brookings Dr. Henry Aaron (interview transcript here.)

Both of these gentlemen are smart and articulate students of the health care debate. But neither can seem to provide concise answers to very basic and very important questions about the bill before the Senate. The key questions --where are the Medicare cuts coming from and what will they mean for seniors, for example-- should be softball questions after nearly a year of debate. The facts about what the bill will actually do to people shouldn't be in dispute and should be widely known and easily agreed upon. Voters deserve at least that much.

Voters also deserve candor on the fact that the Senate bill's alleged budget neutrality is built on deep cuts in reimbursement payments to doctors --cuts that Cohn and Aaron both seem to find either highly unlikely or irrelevant to the debate. (Dr. Aaron sent my producer an e-mail explaining that he had misstated the situation concerning doctor reimbursements --a conscientious effort that I appreciated.) The fact is that the Senate bill will never come close to being budget neutral unless devastating cuts are made to Medicare, particularly in the payments Medicare makes to doctors. Thus the whole debate is proceeding on the fiction that this massive new entitlement program is paid for. It isn't. If it passes, the yawning budget deficits will grow enormously and very quickly.

I invite close scrutiny of these transcripts and encourage anyone who blogs on either or both of them to send me their analysis via e-mail or a link via hugh@hughhewitt.com. Many doctors who listened to the interviews have already sent me passionate e-mails (some reproduced below) about the errors they detected in the Cohn/Aaron arguments. I think close examination of either conversation will reveal that neither Mr. Cohn or Dr. Aaron could not provide concise, precise, and direct answers to the obvious and straightforward questions I posed because the Senate bill is a hodgepodge of concepts lacking detail or even a summary of details. Whenever estimates of costs are no better than within tens of billions of dollars, for example, it is a certainty that no one really knows how the proposal will work.

Passing a bill this thin on detail is madness of course, but especially so when it will dramatically impact every single American, and especially seniors. Gambling with everyone's health care on the basis of huge mirages like the savings to be achieved by productivity gains and the reduction in the incidence in infections in hospital is just nuts. What do I mean? Here's a key exchange with Cohn on where the "savings" in Medicare are coming from:

HH: Jonathan, you were going to tell me how much are the cuts to Medicare Advantage in the present iteration of the bill?

JC: Yes, yes. And now the reason I couldn’t remember if it was closer to $100 or $200 billion is because the House and the Senate actually have different numbers. The House number is around $180 billion, so that’s closer to $200 billion. The Senate’s actually lower than I remembered. It’s closer, it’s around $120 billion.

HH: Okay, if it’s only $120 billion, where are they going to get the other $300-400 billion dollars in cuts to Medicare?

JC: Well, you know, most of these are changes, they’re sort of stacked one on top of the other, lots of little changes in the way that Medicare pays for health care. And the good news here is that as opposed to the past, now we’ve made cuts to Medicare in the past, and we’ve actually, contrary to what you may have heard, you know, we made cuts, and we actually let them stand. But in the past, often, you know, we wanted to cut Medicare spending, because we decided that the program was too expensive. We were just going to whack off, you know, the top 5, and say oh, we’re just going to cut payments, period. These changes are targeted to do very specific things, because we have…one thing we’ve learned, and really, it’s in the last ten, fifteen years, we’ve become aware of this, is that we waste a ton of money in our health care system. You know, we waste money because we send people with chronic disease to ten different doctors, when they’d be better off having two or three that communicate with each other well. And we pay hospitals the same, even if some hospitals clearly aren’t doing a very good job, and have a high rate of something like hospital infections, which is something that no hospital should have. There’s no reason you have to be…any rudimentary hospital can all but cut out in-hospital infections if they just follow the right procedures. So the changes that we’re going to see in Medicare are things like we’re going to start penalizing hospitals if they have high rates of inpatient infection. We’re going to take away, we’re going to say we’re not going to pay you as much for treating this patient, because you did a lousy job.

HH: But now that would be preventative, and hopefully they would change.

JC: Right.

HH: And so that would not lower the cost of Medicare.

JC: Well no, it does, because you see, this is what’s great about it, is that it happens to be that actually treating those infections is really expensive. So one of two things is going to happen. Either they’re going to keep giving people the infections, or we’re just going to pay them less, or they won’t keep giving people the infections, in which case they’ll run up lower charges.

HH: And how do they get the money to prevent people from getting the infections, because that’s got to be a costly transaction, right?

JC: Well no, this is one of the…and I am giving you the easiest example here…

HH: Sure you are.

JC: …because it’s easy to explain over the phone and everything. But they have done studies that show there’s actually a very easy, five step process that you can follow to drastically reduce the number of infections in hospitals. It was actually tested here in Michigan, as it happens, pure coincidence. Somebody did a study across the state, and they found that, you know, all the hospitals, the big ones, the small ones, the teaching ones, the community ones, all they did was very simple stuff like making sure everybody washes their hands, making sure you always apply a clean dressing…

HH: Jonathan, time out for a second. My law firm has represented hospitals for a long time when they’re sued for malpractice, et cetera. Hospitals across the United States are not indifferent to infection rates. Do you really believe that hospital administrators are walking around the United States not doing simple, easy, inexpensive things that will keep down infection rates?

JC: Yeah, actually I do, because this is what they found. They looked, and you know, everybody knows what you’re supposed to do. Obviously, everybody is taught it, but then, you know, we’re talking about human beings here, and they don’t. What these studies found was that if you actually do, and this is going to sound silly, but you know how when you go on an airplane, and the pilots have a checklist?

HH: Jonathan, that’s fine. I’ve read Clayton Christenson’s book, and I know all about that sort of stuff. But I want to go back. Have you posted yet, I’ll put it in this term…

JC: Okay.

HH: Have you posted yet a detailed analysis of where these $300-$450 billion dollars in Medicare savings are going to come from?

JC: I have not gone through every single one. I can tell you where you can find one if you want. I’ve done some of them. I did the infection one last week, which is one of the reasons that it’s in my brain right now.

HH: But isn’t it fair to say, I haven’t seen it anywhere, where they actually spell out in specific detail here is where we’re going to carve up Medicare to save the money? Now how much money are we going to save from stopping infections by washing hands?

JC: I think the figure on that was, and I’m going off the top of my head here, so don’t quote me on this, or at least check it before you use it, I think it’s about $40 billion over ten years, or something like that.

HH: Okay, so we’re down…let’s just give you the $40 billion in washing hands. We’re down to between $260 billion and $410 billion.

JC: Right, right. So there’s a bunch of things like this, is what’s I’m talking about. It’s not just one. I mean, there’s a whole list of these things.

HH: How many times can you stop an infection? I mean, it’s…come on, Jonathan, where are the cuts coming? Tell us where the cuts are coming.

JC: I am telling you. There is what’s called a productivity adjustment, and a lot of that is a bit part of the bang here, which is basically saying look, we are expecting over the next several years, and this ramps up gradually, so that hospitals and doctors can sort of plan on this in advance, and not just have it hit them in the face tomorrow, that look, we’re expecting that you can become more productive using information technology, coordinating your treatments better, so you can expect that we’re going to adjust your, every year there’s an adjustment in the rates to Medicare, and we’re just going to slightly lower that curve.

HH: So they’re just going to stop sending the money they currently send, and tell them to make up the difference in productivity?

JC: Yeah.

Here's a key exchange with Dr. Aaron:

HH: How many are enrolled in Medicare Advantage?

HA: About 20% of all Medicare enrollees are in Medicare Advantage. It’s going up, because of these very, very, because of overpayments to Medicare Advantage plans.

HH: And so what, in terms of millions of people, how many does that work out to?

HA: Well, I don’t have the exact number, but 20%, there are about 35 million Medicare enrollees, so 20% is probably in the vicinity of seven, eight million, but heading up.

HH: Okay, so between seven and eight million Americans are going to get less services after this passes than they are used to?

HA: They’re going to get the same services that the rest of Medicare enrollees receive.

HH: I understand that part, Dr. Aaron. But for clarity’s purposes, those seven million are going to get less than they’ve been getting before.

HA: That may well be the case. I don’t know.

HH: And what…

HA: It’s going to vary from plan to plan, depending on exactly what the fee structure is, how efficiently they operate, and what services they’ve been providing.

HH: Has anyone studied, are you aware of any study of the impact on the quality of life of those seven million people?

HA: No, I’m not.

HH: Okay, that’s fine. That’s fair. I don’t think anyone has, actually. So I…

HA: The story is that if one is going to extend coverage as the Senate plan would do to 25 to 35 million, or currently uninsured Americans, they’re going to consume some more health care services. And the money to pay for that needs to come from somewhere. Most of the money would come from projected growth in productivity of health care delivery under Medicare. And some of it from taxing excessively generous, or very expensive health insurance plans for the non-elderly, and some of it from other revenue sources, that those sources are different in the House and the Senate bill. But there’s no free lunch. If 25-35 million more people are going to be receiving health care that they don’t currently receive, the President has sworn that he won’t sign a bill that increases the federal budget deficit, so you’ve got to pay for it.

This sort of vagueness --on the part of key and expert advocates for Obamacare-- ought to scare everyone, even supporters of so-called reform. The truth is that no one really knows how this is supposed to work, but the pressure for a political win has grown so great that otherwise responsible people are just urging on anything for the sake of declaring victory.

This is a nightmare that can be avoided. I think concerned citizens best amplify their voices through contributions to ReverseTheVote.org. ReverseTheVote.org is designed to send an unmistakable message to the 24 most vulnerable House Democrats who voted for Obamacare, a message that says they will lose their jobs if this bill passes. As it progresses through the Senate, the backlash should grow, especially as the public learns that the Senate doesn't really know what the bill will do. A thousand slogans cannot obscure the fact that this is a wildly risky scheme that will profoundly change the way Americans get their medical care.

UPDATE: One more e-mail:

Hugh,

I am a pediatric physical therapist and co-owner of a practice that provides physial, occupational and speech therapy for children with cerebral palsy, autism, Down syndrome, and various other genetic or neurological diagnoses. We contract with about 40 therapists and employ 10 people in our front office.

I believe the new healthcare bill will eventually put us out of business. As you know the stimulus bill provided for creation of a National Coordinator of Health Information who will guide doctors decisions about healthcare. This board has already weighed in on frequency of mammography, our first inkling of how they will ration care. This type of board will more than likely base all decisions on researched evidence of outcomes. Unfortunately, it is almost impossible to do this type of research with neurological patients. Damage to the central nervous system is unique, so while there may be general categories (hemiplegia, diplegia, Asperger's, Down synddrome, etc) even within these categories there are wide variations. Thus, a double blind study is difficult since no two patients are exactly the same in terms of scope of neurological damage so most of the studies end up comparing apples to oranges. As a result there is little "evidence" that therapy is effective in patients with neurological issues, although those of us in the trenches see significant improvements as a result of our treatments as do the doctors who work with our patients and the parents and families of our children. While we are unable to cure anyone, we make dramatic differences in quality of life both for our patients and their families. When a bureaucrat in Washington begins making the decisions regarding whether these children can receive therapy, based on research that is difficult to do, I believe they will quickly decide this type of treatment is not "cost effective". Furthermore, I think that it is possible that disabled children will be the second group of people, after the elderly, who will be considered of questionable value and as a result find that their healthcare benefits are rationed or altogether discontinued.

I am heartsick first at the thought that the people of America may lose such a huge percentage of their liberty and second at the thought that children (and adults) with neurological issues, whatever they may be, are possibly going to lose the quality of care they deserve to regain function and live as fulfilling a life as possible.

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Monday, November 30, 2009

What Will Obamacare Do --To You? Part 5

Posted by: Hugh Hewitt at 10:13 PM

More e-mails:

#1:

As a physician (rheumatologist) listening to your guest, Jonathan Cohn, I found myself yelling at the radio “you have no idea what you are talking about!” repeatedly during the interview.

If he is going to hold himself up as an informed “expert” on the subject then he should know that physicians, after years of static reimbursement, are now facing a 21.5% cut in fees in January 2010 increasing to a total 40% cut in, I believe, 2014. In addition, starting Jan 1 2010, consultation fees for specialists are being eliminated (watch as seniors no longer have access to specialist care).

His comments on nosocomial infections and the ease with which they can be eliminated “if everyone would just wash their hands” exudes ignorance. Please send him into the ICU where someone has been on a ventilator for weeks, or the dialysis unit where the disease causes immunosuppression, or the oncology unit where chemotherapy has just wiped out an immune system. Every effort is made to prevent infections, but they occur anyway.

Then he tells me that once we all have electronic records we are going to become SOOO much more productive that they will easily be able to cut the reimbursement for the productivity part of the calculation! Funny, but every practice I know that implements EMR loses productivity and the records these things generate are generic and tell me, on the receiving end little about what is really going on with the patient. (Then there is the privacy issue…). I will have said goodbye to my Medicare patients long before.

I could go on. But the sad fact, as related to me by Phil Roe, a physician (OB-GYN) and Congressman from Northeast Tennessee, is that in neither the House or Senate was even one physician legislator asked for input on the healthcare bill. The law of unintended consequences is going to have a far reaching effect if this abomination becomes law.

Caryn

Orlando, FL

#2:

Hugh,

My sister-in-law graduated from medical school in May, 2010. She will have a tremendous amount of debt as most medical students. She told us that she and her colleagues are very worried about how they will be able to pay off their debt. I don't know if most people understand how difficult medical school is, how hard they work, the hours spent on call, studying, loss of vacation/holidays and cost. The number of doctors will go down if there isn't some type of monetary incentive for all of the difficulties they incur.

Also, I heard on another show over the weekend a bit about Massachusetts where they have a similar plan to what is now being debated in the Senate. I was surprised to learn health insurance plan restrictions there, for example, the highest deductible plan allowed is $2000 a year. I currently have a $4000 deductible plan which I'm sure is less expensive. Also, in Mass. they have a mandate that the insurance plans have to cover invitro fertilization. That surely drives up the cost of insurance (who knows what other mandates they have there?). Mitt Romney's future is not helped by what's gone on in Mass.

It was scary to hear your guests and their uncertainty about what the plan will or won't do. They are unable to foresee the consequences of the legislation, which is not surprising due to length and complexity of the bill.

This will be a disaster. My youngest son was diagnosed with type-1 diabetes last year. I just worry that the great care we have had so far is going to deteriorate in the future.

Karen

#3:

Hugh:

Well, you said you thought those Docs for Obamacare would view the real world from a distance, and that guy from Brookings sounded like just what you were talking about. When he claimed that Obamacare would increase efficiencies in health care delivery, would that be like the increased efficiencies of the Indian Health Service? Or the efficiencies of the Medicare billing center that the insurance IT caller deals with every day? Or would they be like the efficiencies of Britain's NHS?

Talk about out of town!

Ken

Glendale

#4:

Hi, Hugh,

Thanks for keeping up an informative discussion on healthcare. I’m sure you are getting swamped with e-mails on this!

First, here is a little about our healthcare situation. My husband lost his job at the end of August 2008. One of the first things we did was look for our own health insurance. A quick online search gave us 20 pages of offers. (So much for the argument that individual policies are hard to find). The costs range from $220 to $2,500 per month, depending on the coverage. When we found out that our COBRA would cost us $1,100 a month we wisely decided on a low premium ($370)/high deductible with a health savings account (HSA). The money we saved on the premiums would go into the HAS, tax free. In the mean time, my husband found a temporary job, making him self-employed so our entire premium amount also became tax deductible.

We are healthy, active, and in our mid-fifties. Our health emergency struck in March, and my husband needed emergency gall bladder surgery. Even after paying the premiums and the deductible, we still spent less than our COBRA would have cost. We had complete control over the treatment, and did not need permission to be seen. We are paying premiums we can afford, since my husband is now unemployed again. We are protected against a catastrophic health emergency that could wipe us out.

Here is where I see Obamacare having a profound effect on us. If there is a limit placed on the deductible, and the elimination of the HSA, our plan would be eliminated. We would be forced into a higher premium plan. So much for “if you like your insurance, you can keep it”. With the shortage of the vaccine for the H1N1 virus, the change in the recommendations for mammograms and pap smears, I can see the future, and I don’t like it. Right now I have complete freedom to seek my own medical treatments without having to ask the government, or any one else for permission. If I don’t like the decision by my insurance company, I can dispute it, and I have an 800 number to speak to Customer Service. Under Obamacare the treatments and innovation won’t even be there for me to use, and who will we be able to call to complain? The short answer to the effect on us is MORE expensive insurance and LESS choice in medical treatment.

I live in Illinois, and the person I would like to hear interviewed to defend Obamacare is our own Senator Dick Durbin. I have written to him at least two dozen times over the course of the summer and fall. I have asked him how I can keep my insurance, which he keeps insisting I can, when he will mandate what I must purchase. I have asked him how he can vote for a bill when he does not know what is in it, or how it will affect us, or how the inevitable mistakes in it will be corrected. I have asked him how I will dispute a denial of service from the public option, and who I would sue for any resulting damages. That is just a sample of some of the concerns I have, but I have received NO satisfactory response. I know it is just wishful thinking, but I would really like to hear him defend this in a tough interview. He actually sent me an e-mail claiming that 80% supported the public option! I’d like to know where he got that figure.

Thanks for seeking our thoughts on this important issue.

Diane
Mundelein, IL

P.S. I just finished listening to Jonathon Cohn while I was typing this. He sounds like a kid with book smarts and no common sense! He needs to get out into the real world.

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Monday, November 30, 2009

What Will Obamacare Do --To You? Part 4

Posted by: Hugh Hewitt at 7:55 PM

After guests Jonathan Cohn of The New Republic and Henry Aaron of Brookings --both supporters of Obamacare-- appeared on today's program, the e-mails began to flood in. The transcripts of both interviews will be posted here later. Here's a long thread of e-mail responses:

#1

I have a cancer that, like so many, is treatable, but not curable at present. The same disease that has killed Peter Boyle and Roy Shieder, and that Geraldine Ferraro and Hobie Alter are currently suffering from - multiple myeloma.

Treatable means that big horrible greedy pharma co's need to keep coming up with treatments. I'm taking Revlimid, which is a derivative of Thalidomide - so consider the faith that Celgene had to have to stick with such a scary drug to use today to save my life.

I have no confidence at all that once things shake out, and the Public Option sucks the INVESTORS out of the game, that the funding of what the miracle of medical science will continue at nearly the same rate that capitalism brings to game.

And as someone that once the president of an Ins. co that booked 90% of its premium in A & H I know that a public option funded by by a printing press in Philadelphia, controlled by a Congress in D.C. that within 10 years there will be no choice left.

Which, I guess to end my digression, will parallel the hospital industry, which has the same investor paradigm and will leave us with gov't run hospital/clinics where we can wait in line.

Oops; one more digression. The abuses that will be used by those looking to make money off of such a large part of our economy suddenly run by Feds will be a thing to behold. Maybe you remember what we used to call "Rolling Labs"; they were big old RV's that would roll into a strip mall offering free physicals. Once they had your Soc. Sec. and health plan number the diagnosis started coming in from all angles. Can you imagine the Fed plan giving a rip? My wife worked for IRS in Ziggaraut Bldg in Laguna Niguel and I'm here to tell you that one walk through the hallways of that facility give you great pause as to who we actually even employ in our Fed gov't... but there needs to be a place for everyone willing to work, sort of work that is... ;-)

Your guest was not accurate about Medicare fee cuts to doctors. There is a 21.5% cut scheduled for 2010. By 2014 the total cut will be 40% according the Center for Medicare and Medicaid Services. The are cuts in nominal dollars. Doctors' fees will also be reduced by inflation, as we have experienced the past few years when fees were "frozen."

#3

Hello Hugh,

For 2010, Medicare Advantage [ obtained through my former employer]
will cost me $273.93 per month. Traditional medicare [also through
my former employer] would cost me $357.90 per month. Both totals
include prescription drug coverage. Jonathan Cohen's statement that
traditional Medicare would cost less for the Medicare participant
LESS is clearly wrong!

Ed
New Kensington, PA

#4

Hugh,

The gentleman you're speaking with has the preprogrammed salespitch for single payor healthcare down quite well. Unfortunately it’s a ruse. The spiel that the "savings" are based on savings in Medicare Advantage programs is made for publication. In reality, there is NO way the gov't would save more than a pittance by eliminating Advantage coverage. All Advantage participants pay a premium for additional services. Often the benefits received by the plan participant do not exceed the premium. (I.e., there are a lot of "services" offered for partial coverage, but the number of enrollees that utilize the majority of those services is not that significant)

Medicare supplements (that provide coverage for patients with Medicare part A, part B, and part D) are increasingly expensive. The graph of the cost escalation for this coverage is necessitated by the "gap" from Medicare reimbursement.

The number of medical clinics that are refusing new Medicare patients is rising. In the twin cities, MN, there are more each and every day. Without private pay or "good" third party payors, there is no way a competent physicians' practice can afford Medicare. Good examples are radiology, anesthesiology, specialty surgeons, and a growing number of professionals with outstanding quality care.

With the collossal number of states well within the financially destitute range, the amount of Medicaid expenditures for poor seniors necessary medical services that Medicare does not cover is skyrocketing. This is no where in the media. Since the number of poor elderly patients is growing rapidly, the state outlay is growing. It is easy to see why Arizona is marketing the state capital. The question is... What is the state budget item that is growing the fastest? The answer is clearly Medicaid for the elderly.

Your guest's statement regarding nosocomial infection prevention is somewhat valid, but horrendously myopic. It is liberalism without objective thought. Realistically, dialysis patients with multiple depressed immune status', immunosuppresssion, and a high need for medical treatment, are at major risk for acquired infections. No resistance and multiple ports of entry are a virtual guarantee. To not cover care for these patients is ridiculous. Liberalism is devoid of fundamental analysis. Conclusions based on trend line analyses fail to incorporate legitimate facts pertinent to quality medical care. Generic criteria used to generalize "how to save" by policy makers have a chronic history of ineptness.

Have a good week,

Gene in St Paul

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Monday, November 30, 2009

What Will Obamacare Mean --To You. Part 3.

Posted by: Hugh Hewitt at 12:08 PM

From another reader:

Thanks for the invitation for input.

First my mind-set. I don’t think Democrats give a rats backside about what the American people think. Polls could be 65 / 35 against and they will still impose the Obamanation.

Next my situation. I am 69 years old and have worked for Lockheed-Martin for 30 years. I had hoped to retire at 70, but since the economic melt-down, will probably work to 75. For 30 years we have been covered by one HMO or another (“worker-bee” coverage, not executive level). We have been very satisfied with the coverage. This year, Lockheed-Martin is instituting its own coverage. We will see how that works out. If Obamacare becomes law, the corporation will dump us into the government system. That’s what corporations do.
Read More...

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Monday, November 30, 2009

What Will Obamacare Mean --To You? Part 1.

Posted by: Hugh Hewitt at 9:48 AM

Below I asked for first person accounts of what the Senate's version of Obamacare is likely to mean for readers. Here's the first response, from Andrea in Sacramento:

Hi Hugh -

Thank you for taking input from plain, ordinary citizens about the horrendous "health care" the legislature wants to thrust upon us. We are a homeschooling family, and my husband Mark is self-employed, so we don't represent the bulk of the nation; but I am very well acquainted with the costs of health care because I have had to buy it for our family for nearly 20 years. Our income is low enough that we qualify for Healthy Families and quite likely qualify for Medicare or Medicaid or whatever they call it, but we don't believe it is the government's job to provide health insurance for our family.
Read More...

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Monday, November 30, 2009

"A Fine First Year for the First Lady"

Posted by: Hugh Hewitt at 9:46 AM

My Washington Examiner column is posted.

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Monday, November 30, 2009

"Global Eyes on the President at West Point"

Posted by: Hugh Hewitt at 9:45 AM

The Monday morning column from Clark Judge:

Global Eyes on the President at West Point
By Clark S. Judge, managing director, White House Writers Group, Inc.

As everyone knows, President Obama will address the nation on Tuesday night and reveal his decision on what to do in Afghanistan. Most weekend commentary has focused on the announcement’s political implications at home and how various players in and around Afghanistan will see it. But there will be another and in the long run at least as important audience: national and diplomatic leaders of the major nations of the world.

As reported at the time, during the last several months I have attended conferences and presentations in various European capitals. All in one way or another concerned global security. On the side I spoke with additional political and journalistic players. The result has been a global snapshot of official and semi-official opinion from places as diverse as China, India, Russia, Palestine, and various parts of Europe, both in and out of the E.U.

What I sensed in total was growing doubt about the president. He speaks well, everyone acknowledged, but is there substance behind the rhetoric? He is given to sweeping pronouncements. But will he, can he follow through? He commands the most capable military force on the globe. But does he have the stomach for a fight? Does he have the strength to make and stick with hard choices, or any choice at all? As one globally prominent (and I would have thought friendly to the president) American journalist summed up global opinion at a conference in Geneva: “Machiavelli said it is better to be feared than loved. Mr. Obama is loved.”

So when the president addresses the nation tomorrow night, he will be addressing these global players as well as the rest of us. How they grade his presentation will have a profound impact on what he and his administration will be able to achieve in international circles in the next three years.

What we have heard about the speech and the substance of the announcement so far is not encouraging.

First, the speech itself: we have not yet heard it, of course. Drafting may not even have been completed. Different administrations work differently. But even in the Reagan Administration (where I was a speechwriter for the president and where we never had the kind of cliffhanger, last-minute drafting dramas that seems to have been common in, say, the Clinton White House) on major foreign policy speeches editing and even drafting by the president himself and appeals from various parts of the national security establishment could continue almost until Mr. Reagan appeared stepped to the podium. When he returned from his meeting with Mr. Gorbachev in Reykjavik, President Reagan was writing in long hand, on a yellow pad, parts of his report to the nation within an hour of going on camera.

But we do know one detail about Mr. Obama’s speech, its location. Virtually all past major presidential addresses on global security matters have been broadcast from either the White House itself – usually the Oval Office – or the House of Representatives, as the president addressed a joint session of Congress. I am talking about all presidential addresses here, going back to Franklin Roosevelt. These settings convey majesty. They convey the seriousness of the moment and weight of the Constitutional office the man occupies. When addressing Congress on such matters, they represent an appeal for the coming together of all the branches of the American government behind the common mission of ensuring the nation’s security.

On Tuesday Mr. Obama will speak from West Point. Surely the speech will be well advanced. The visuals will be impressive, perhaps even moving. But on at least on a subliminal level, the choice of setting is more likely to heighten rather than ease global doubts about the man and the administration. For Team Obama has chosen to give their man a stage set that, in the context of this moment, suggests they and he are thinking in terms of a candidate in campaign, not a president of the United States at a moment of decision. And here, too, is the essence of global doubts about the president -- that he is a campaigner, not a leader.

Regarding the speech’s substance, the one detail – no one seems to know if it is true or not – is that, while announcing troop levels in the 30,000 range, he will also announce a comparatively slow deployment, more like Johnson in Vietnam than Bush for the surge in Iraq. If true, the international impression of indecision, lack of strength, dearth of seriousness in the president and his circle will become larger and more vivid.

There come moments in presidential communications when impressions coalesce and either the man in the office becomes larger – as Reagan and Roosevelt unfailingly did at such moments – or smaller in global eyes. For the nation’s sake, let’s hope Mr. Obama is seen as larger after last night.

But first signs are not encouraging.

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Sunday, November 29, 2009

What Will Obamacare Mean --To You?

Posted by: Hugh Hewitt at 5:41 PM

The next month of broadcasting and blogging will be given over almost exclusively to the debate over Obamacare in the Senate. The bill will mean massive changes to the future of every American if it passes, and unless a major disaster strikes, most of media, new and old, should be focusing on it and the stakes involved. That coverage should also be specific and in-depth: What will the Senate version of Obamacare mean if passed, exactly?

I'd like to ask my readers and listeners for (1) suggestions on whom they would like to hear interviewed on this topic, both opponents and supporters and (2) what exactly you think the passage of anything like the Senate version will mean for you.

Seniors, how much more do you expect to be paying? How much longer do you expect to wait for appointments? Do you think you'll be able to get the same level of service you are currently enjoying?

Employers: Do you expect to make changes in your group coverage?

Doctors: Do you expect your income to fall and if so, by how much?

Here's an illustration of the sort of coverage that does more harm than good to the debate ahead.

Nicholas Kristoff has his typically very well-written column in Sunday's Times, and it tells a heart-tugging-tale about John Brodniak. Mr. Brodniak has been living a medical nightmare, one that compellingly illustrates many of the woes of our current health care system.

But what the column doesn't tell us is if the Senate's version of Obamacare will do anything for Mr. Brodniak. Indeed, there is buried in the column an alarming warning about the Senate bill:

In August, [Brodniak] qualified for an Oregon Medicaid program, but he hasn’t been able to find a doctor who will accept him as a patient for surgery, apparently because the reimbursements are so low.

The Senate version of Obamacare promises a big expansion of Medicaid-like coverage for the poor and near-poor, but will it simply worsen the already large and growing problem of providers refusing to treat patients whose coverage simply doesn't provide enough of a reimbursement to make it worth a doctor's while to treat? This single sentence in Kristoff's column hints at and then abandons the crucial issue of reimbursement rates, but if these are pushed too low, doctors will simply refuse to treat patients that cannot help them pay the overhead or make a living. As the Investors Business Daily poll of 10 weeks ago showed, doctors will simply leave the field rather than work for reimbursement rates that drive them towards longer and longer hours for declining income and lousy quality of life. Mr. Brodniak's situation won't be improved by a bill that shatters the current system and drives providers from the profession.

That's the real question in the debate ahead, one every senator even those from the hard left have got to ask themselves: Are they making the system better or just scoring political points? Right now, as Charles Krauthammer argued on Friday, the answer is very clearly the latter. I'd like to see Nicholas Kristoff follow up with another column about Mr. Brodniak, one that tells us how the Senate bill will work to improve his life, and if so when? One that will also tell us the impact of the Senate bill on his one-time employer as well as on the doctors that will be treating him if the new system arrives, as well as on the economics of the hospitals in his area, or the medical research that ultimately allows for any sort of new cure or innovation in treatment.

I'll be happy to interview any credentialed advocate who wants to defend the bill on the Senate floor, because that is the only question that matters right now. We know there are problems, but will the senate version of Obamacare fix them? If the answer is either "no" or "we don't know," or even "there's a good chance it will help some people while hurting others," it is not just a lousy bill, but an immoral one, a feel-good bit of posturing that won't help Mr. Brodniak, and may in fact condemn millions more to the same scarcity that he is presently experiencing.

So, please send along your e-mails suggesting experts and predicting your own personal outcomes. The e-mail box is hugh@hughhewitt.com.

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Sunday, November 29, 2009

Free Election in Honduras - Against All O(bama)dds

Posted by: Jude at 3:22 PM

The Presidential election is underway today in Honduras. Very little thanks to the Obama administration, which has treated our poor neighbor like a banana republic, ignoring the Honduran constitution - and virtually all of Honduras' governing bodies - while threatening to not recognize the results of today's election unless the criminal Chavez crony, "Mel" Zelaya were reinstated. Along the way, of course, we (Omerica) sanctioned the country and punished its people by cutting off aid while also trying to deligtimize the government by revoking travel visas, so that no representative of the current administration could appear at the UN. I've gone on about this before, but for now I'm glad our State Department has finally wrapped its collective head around some obvious truths after two months of supporting a would-be strongman in order to align more closely with Hugo Chavez and his acolytes in the region. We officially "support" the election process, which at this point may well be a surprise to democratic dissidents around the world. Of course, Obama also officially, wants Zalaya to be reinstated after the election for a brief term, but thankfully the Honduran Congress gets to decide that one....

Maybe the big moment came when Zalaya told the press that he was being bombarded with some kind of alien technology by Israeli commando mercenaries, or something, while holed up in the Brazillian Embassy... maybe then Ian Kelly told Secretary Clinton that she had to break the news to President Obama that there just wasn't enough cover left for him to side with Chavez, Castro, Arias, Ortega (the latest Latin American leader trying to extend his term beyond constitutional limits), probably FARC, and Zalaya, and against representative constitutional democracy, rule of law, good old truth, the will of the people, and President Micheletti, who has been calmly tryng to shepherd his country though an election in which he himself was never a candidate. Or maybe the integrity and character of the Honduran people won the day, by never taking the bait laid all around them by Zelaya and Chavez toward more civil unrest. Here's to tomorrow in Honduras!

Update: the NYTimes gives the Obama administration a press release on the whole crisis. Also reports that Panama and Costa Rica are the only OAS members also pledged to recognize today's election.

Update II: Neither Barack Obama's election as the first African American President nor his premie Peace Prize are being cited by Hondurans in exit pols as to why they are excercising their right to vote...

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Sunday, November 29, 2009

An Obamacare Final Exam

Posted by: Hugh Hewitt at 11:06 AM

Hank Adler is my co-author on The Fair Tax Fantasy, and he raises some very basic questions as the big denate on Obamacre opens this week:

Finals are approaching in most universities and high schools throughout the country. With a 2000 page Senate Healthcare proposal, it is unlikely that anyone could pass an examination on the specifics of the legislation. However, we should expect that the members of the United States Senate should be able to pass an examination regarding the general aspects of the current Senate proposal. Below is a series of essay questions, each of which should be answerable on two pages of a blue book, which should be presented to each member of the Untied States Senate:

Questions related to the overall economics of the Senate proposal:

1.    Including the proposed tax increases, the current proposal is promised to be revenue neutral over the first decade. Are there any recently passed Senate bills or future Senate proposals which will positively or negatively impact the revenue neutrality of the current bill? If so, how do/will such bills impact the revenue neutrality of the proposal? (Please include a discussion of any current proposals to permanently improve doctor's compensation under Medicare.) As perhaps the strongest argument supporting the current proposal is its revenue neutrality, is it appropriate for each Senator to commit to vote against any future proposals which would increase healthcare costs?

2.    The current bill is not revenue neutral after year ten, what revenue increases or expenditure reductions would you propose and/or expect beginning in year eleven to pay for the healthcare proposal?

3.    Over $400 billion dollars of new taxes will be collected during the first four years of the Healthcare proposal without a significant expenditure of funds. What are the underlying economic theories supporting the raising of taxes in the midst of the most severe recession in over fifty years? (Please include a discussion that contrasts the current proposal with President Hoover's increase of taxes during the early years of the Depression.)

4.    Assuming that a public option is included in the final proposal, please identify the timing and impact of employment in the private sector versus the public sector for the healthcare system. Please identify concerns and solutions with respect to geographic dislocations and system creation issues.

5.    Given that several states, including California, are currently virtually bankrupt resulting from systemic budgetary issues, please explain the significant expansion of state funded Medicaid requirements in terms of the financial viability of such states.

Questions regarding the health delivery impact of the Senate proposal:

1.    The Senate proposal anticipates increases in preventative care and increased access to the healthcare system outside of free clinics and hospital emergency rooms. Please explain how citizens without sufficient funds to pay the required co-pay included in virtually all insurance policies will be accessing the healthcare system under the current proposal.

2.    Please explain why the exact coverage to be required and the amount of co-pays is not specified in the legislation and why that lack of specificity does not cause you to be concerned as to the cost estimates and ultimate access to the healthcare system.

3.    Please explain the impacts of the current proposal on charitable contributions to hospitals and clinics in the United States and indicate whether these organizations will be viable with any decrease in contributions anticipated. What do you see as the continuing role, if any, of charitable organizations or free clinics in general after implementation of the current proposal?

General Questions:

1.    Please explain why the current proposal is preferred over either of the following other options:

A "Marshall" type plan to train doctors and nurses wherein the government would provide loans to all individuals being trained which would therefore result in minimal costs over the ensuing decades or

The creation of government operated free clinics throughout the country providing preventive care etc., therefore avoiding all of the accompanying complications of the insurance driven strategy encased in the current healthcare proposal.

2.    The President has indicated on several occasions that the current proposal is nearly identical to state requirements for auto insurance. However, in many or most states, there is a state requirement to carry insurance for uninsured drivers, which indicates that a significant percentage of the public is not carrying legally mandated auto insurance. What is the underlying data indicating that (1) with penalties for individuals not carrying insurance being drastically lower than the cost of insurance, (2) the requirement for co-pays that many poorer Americans simply will not be able to pay, and (3) the continuing requirement for hospitals to treat individuals in emergency rooms regardless of whether they have insurance, Americans will decide to purchase the insurance being offered? What data supports a result that more Americans will be covered following passage of the proposal? (In your answer, please include a discussion of the ability to get coverage regardless of current health as an incentive to individuals deciding to pay the penalty rather than carry health insurance.)

3.    What is the underlying data that demonstrates that Americans who are currently uninsured because they have not completed sufficient paperwork to be insured under current governmental supported plans will complete the new forms under the proposal?

4.    Please define the term "insurance" in the context of the Senate healthcare proposal. In your definition, please differentiate between automobile and homeowners' insurance where if one is fortunate, he or she may never make a claim and the insurance expected in the Senate proposal.

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Saturday, November 28, 2009

Senator Casey's Fade

Posted by: Hugh Hewitt at 9:53 AM

Whatever one thinks of Obamacare --and a significant majority of Americans think rightly that it should be rejected before it destroys American medicine-- the small drama surrounding Pennsylvania Senator Robert Casey Jr. is illustrative of why the blowback building against Democrats could assume tsunami proportions 48 weeks from now.

As the New York Times details today, Casey Jr.'s father was a very popular Democratic governor of Pennsylvania who was a staunchly pro-life. What the paper passes over is that Casey Jr. defeated Rick Santorum in 2006 by running as his father's son on that issue. Casey Jr. pledged himself to be a staunch pro-life Democrat that Catholics and other pro-life voters in Pennsylvania could trust to uphold the state's consensus that life in the womb is life indeed.

Now that abortion has become an issue in the health care debate, however, Casey Jr.'s commitment on the life issue is starting to melt. Key graphs from the Times:

Frank Cannon, a Republican consultant, published a column on the Web site of National Review suggesting that the late Mr. Casey would be watching and judging his son from above. “The governor’s son and namesake, the current junior senator from Pennsylvania, will be tested by the standard his father set,” Mr. Cannon wrote.

Mr. Casey took issue with such comparisons. “My father’s situation was a broader argument and broader discussion about the issue,” he said. “This is a huge piece of health care legislation, and what I am trying to do is to recognize that we had a consensus about public funding for abortion, and we are trying to continue that.”

Mr. Casey said he set his course on the issue last summer, when the question came before him in the Senate health committee. He broke with his party to vote in favor of an amendment adding the same abortion restrictions as the House bill. But when the amendment failed narrowly, he voted to approve the resulting bill anyway.

In a statement when the Senate opened debate last Saturday, he repeated that he thought the current segregated-accounts provisions still fell short of avoiding taxpayer financing of abortion and “will require more work as the bill is debated on the Senate floor.” But he again stopped short of threatening to vote against the measure as it is.

Of course he stopped short because of course Robert Casey Jr. will vote for cloture even if the bill contains public funding of abortion in bold letters and underlined. If public funding of abortion is the issue, Ben Nelson of Nebraska will be the lone Democrat holding back cloture.

Planned Parenthood is already snarling at Democrats who stray from their extreme line:

“I know he feels a lot of pressure from the Catholic bishops, but the bishops did not elect him and a lot of pro-choice women did,” said Laurie Rubiner, a lobbyist for the Planned Parenthood Federation of America who said she met with Mr. Casey for 45 minutes last month to make her case. “He needs to let the Catholic bishops know that what they are doing could bring down the bill.”
Casey will look for some fix that delivers for his party leadership and for Planned Parenthood, some complex override of the Stupak amendment that passed in the House. In so doing he'll break his promises to the voters of Pennsylvania and hope they don't remember that come 2012.  Casey may even try the "yes on cloture/no on the bill" dodge on the hope that the voters won't figure it out, though fewer and fewer Americans are sufficiently disconnected from new media to allow old tricks like that one to work.

Casey is going to have to choose between the pro-life promises he made the voters and his party bosses. He is in a position to insist on the Stupak Amendment. Robert Casey Jr. could deliver on his promise. He's just not going to do so.

And that is another example of why Democrats are headed for a November 2010 cliff: They are throwing out promises left and right, promises like Casey's on life, but also pledges that people who liked their health insurance and doctors could keep them, pledges about no new taxes on families earning less than $250,000 a year, pledges about not adding to the deficit, and especially pledges to seniors about not cutting their Medicare benefits.

ReverseTheVote.org has gathered close to $125,000 in small contributions in less than two weeks to retire the two dozen Democratic House members who voted for Obamacare against the wishes of their districts. This is just one of many signs of the growing voter revolt against Democrats who are playing craps with the nation's health care. If the Senate actually gets close to passing Obamacre, the electoral prospects of Democrats like Lincoln in Arkansas, Bennet in Colorado, Dodd in Connecticut, Bayh in Indiana, Gillibrand in New York, Wyden in Oregon and Dorgan in North Dakota get very gloomy indeed. Even big names like Harry Reid and even Barbara Boxer in California are endangering their jobs by pushing forward with so unpopular and destructive a bill.

When the left's ideology trumps all practical political considerations, the public notices and the public isn't remotely as ideological as the left side of the Democratic Party wants it to be.  The abortion issue is just one example, but a telling one. The rhetoric of Planned Parenthood aimed at the bishops is really hitting the Democrats, and collapses like Casey's are telegraphs to the electorate about the unreliability of the "moderate" Democrats they thought they were voting for.

It is hard to imagine the Democrats doing this to themselves, except that the leadership of the party is all hard left and more concerned with their "legacy" than the party's prospects in 11 months. The bigs have the money and a comfortable Beltway future ahead of them regardless of the blowback. But many of the House members have no such thing, and some special cases, like Robert Casey Jr. have to decide whether their commitments to voters nattered at all.