Sunday, December 29, 2013

Duck...If You’re a Conservative.

I've been too preoccupied of late with personal issues and holiday distractions to pay much attention to the ever continuing decline of the once great American experiment! It goes on, I'm sad to say at an ever increasing fever pitch, unabated by rhyme or reason. My funk exacerbated in politically correct dribble imitating from the mouths of younger generations, advising my generation, once described as the greatest generation as racist, homophobes, anti-feminist, socially inept bigots.Their ranks bolstered by the ever present malcontent ignoramuses of all ages playing with themselves as America burns! As you might have suspected after my rather lengthily hiatus the saga of  Phil Robertson struck a relevant chord and fostered this pent-up sarcasm and vitriol..... 


Call me prophetic, but it’s reaching the point where I can read liberals like a comic book.  A number of weeks ago, it was suggested by some of my more rural acquaintances, that I tune into Duck Dynasty, a reality TV show brought to you by A&E.  For those of you not familiar with the Duck Dynasty phenomenonthe series follows the daily meanderings of the Robertson family, a rural Louisianaclan known for their exceptionally shaggy facial hair, preference for all things camouflage, conservative Christian values, willingness to hunt and eat virtually any critter that walks flies or crawls, and most importantly their successfulfamily business.  They are the founders of Duck Commander, a line of duck calls and now a media and cultural empire with merchandising worth in excess of some 400 million dollars.  The family patriarch, Phil Robertson is a 67 year-old former substance abuser, a man of few words, who created the Duck Commander duck call in 1972, repented, found God, and lives with his wife, Miss K on the family’s original property in the Louisiana woods.  His oldest son is a pastor, with the remaining boys, most notably Willy, Jase, and Jep, running the family business and being prominently featured in the television show.  Phil’s brother Si, a Vietnam vet and at the ripe old age of “I don’t give a damn” is also featured as the village idiot, whether he actually is, or if it is an act, is not alwaysentirely clear. The amusement is derived from thesuperimposition of their back woods appearance, lifestyles and values with the running of a family business empire and all the material trappings that come with success.  Big houses in the suburbs, attractive salon-ready wives, yuppie children, and all the toys. Granted, like all reality TV, it appears to be largely staged, particularly the portrayal of the manufacturing end of the business with the suggestion that only 5 or 6 guys of questionable intelligence are fabricating the product, when in fact they spend the vast majority of their TV time refusing to work, hunting, going on unrelated errands, and generally goofing off. It all makes for mindless, preposterous, yet engaging, entertaining television.  America just cannot get enough of the voyeuristic appeal of reality TV.


Back to my prophesy.  After my first viewing, I was struckby four deadly sins that would make the Robertsons prime targets for the liberal cultural snipers.  One:  they are conservative. Conservative values and most likely conservative political leanings. Two: they are religious.  They close all their shows with the family gathered around the dinner table where they bow their heads in prayer.  Three:  Guns.  Lots of Guns. And they shoot those guns.At animals.  And lastly, number four:  They are wealthy.  They are the 1%.  And they got to be the 1% by, see above, being conservative, religious, and shooting animals.  You could not possibly find a better recipe for becoming a liberal target.  Remember, conservatives are all bad people, religion is for the simple minded, guns should all be banned and the 1% have ruined America.  Or so goes the liberal chant.  Even our President has publicly condemned at least two of these deadly sins.  You all recall the infamous “clinging to guns and religion” diatribe.  Toss in redistribution, income inequality, and a few Harry Reid “party of no” rants and it amazes me that the Robertsonshave not been declared public enemy number one.


Enter GQ.  Some of you may recall GentlemanQuartlerlyback when it was relevant.  It used to be the gentleman’s reference for sartorial splendor, the “how to” manual for dressing and looking your best, fashion and grooming articles interspersed with the occasional interview with someone to be admired in the business world or entertainment.  My, how times have changed.  GQ has now morphed into Cosmo for men.  Skinny, androgenous, models glare at you in impossibly tight, trendy and pricey designer clothing.  Hollywood rules, fawning liberal references ooze from the articles, and sex is the order of the day.  Even their reference for suit fitting suggests buying a suit a size smaller than usual and hemming your straight leg, cufflessflat front pants higher to “show some sock”.  How many American men are following this kind of fashion advice, or are even built to do so, as they head to the office?  The typically liberal, hypocritical juxtaposition of progressive media social values in print accompanied rather incongruously by 20-something models in $3000 suits and $1200 shoes when the only segment of society that can possibly afford to buy them is the hated, andgenerally despised 1%.  Hated and despised unless you’re Hollywood….or a politician.  


In any event, GQ chose to interview the aforementionedPhil Robertson.  Please.  Where exactly did you think this was headed?  Sooner or later the interviewer gets around to what is apparently the only issue that seems to concern America today:  Gays.  Not a nuclear Iran, not North Korea threatening to attack the South, not Putin walking all over Obama in dealing with Syria, not Obama’s back room deal with Iran leaving Israel to ponder its future in the middle-East.  Not even the stagnant economy or Obamacare.  Gays.  Now having watched Duck Dynasty a couple of times, I could have told you what Phil’s answer would have been. He is a strict Bible-thumper and what the interviewer received was a strict interpretation of the Bible’s take on homosexuality.  Sin. Period. End of discussion.


Phil expressed his opinion and referenced his source, pure and simple.  A&E responded in politically correct fashion by hailing themselves as champions of gay rights and promptly placing Phil on hiatus.  The family responded by saying that Phil is their patriarch and the show cannot go on without him.  All of this theater and complete bluster, of course, because 9 of the 10 episodes for next season were already in the can.  Now everyone is getting all wrapped up in First Amendment rights to free speech on one side and the gay rights activists are responding with horror,indignation and outrage on the other.  Now, wait a second.Nobody is suppressing Phil’s right to free speech and the gay folks can be fabulously outraged all they want.  And for that matter, A&E can choose to cancel the show and fire Phil if they so desire and they certainly have the right to do so.  Or perhaps the Robertsons can just walk away from the whole debacle as well, providing they can exercise that right within the context of their contract.  All of the parties involved are well within their rights to express their opinions and apparently we have no shortage of that in this instance.  Even the consistently volatile Charley Sheen has tossed his opinion into the ring.  Now there is a touchstone for societal values and morality. But what truly annoys me is that this is nothing more than a set-up, an example of “gotcha” journalism to further a liberal agenda.  What should have happened? Should Phil have lied to the interviewer, gone against his Biblical teachings, and spewed the politically correct party line to protect his brand and thus worship the almighty buck? Should Phil have done the political two-step, backtracked, issued an apology and claimed to have had an epiphany regarding homosexuality, and promptly donated twenty grand to GLAAD? Absolutely not, and I wouldn’t have expected him to do so.  Politically correct or not, he expressed his opinion.  He is neither right nor wrong. It is his opinion and, frankly, it remains the same opinion of a majority of religious leaders all over the world.  If Phil were to condone a homosexual lifestyle, he would have gone against his religion, his personal moral compass, and his family values, all to preserve what?  His popularity with his fan base?  I doubt that the core Duck Dynasty viewer, or the purchasers of Duck Commander merchandise even have homosexuality on their radar.  To lie about one’s personal feelings on any issue just to appeal to a wide swath of the public for reasons of popularity, standing, power, or wealth makes you less of a man and more of a….. politician.  And we surely don’t need anymore of those.


But I predict that A&E will bend to the lure of the dollar.  Apparently Phil has already been reinstated for January.  So much for the hiatus.  And let’s not be too surprised bythis stance.  If you’re looking for a moral compass, you’re not going to find one at A&E.  A perusal of their programming puts Duck Dynasty as one of their most family friendly offerings.  I for one will not be sitting down with the kids for an episode of Rodeo Girls, The Bates Motel, The Killer Speaks, or Bonnie and Clyde, a slate of programming glorifying murder, promiscuity, crime, rape and incest, some of which is portrayed in excruciating detail. Well done, A&E.  


So, liberal left and those infected with political correctness, face the facts.  Phil is in the driver’s seat on this one.  Happy, happy, happy. He has money, he has popularity, he has faith and he just can’t fathom why a man would find another man sexually attractive.  Imagine that.  

Monday, November 18, 2013

What If? (prompted by your response to my previous blog's enquiry)

What if our Liberal Democrat brethren did not have to tolerate we Conservative Republican's opposition to their utopian socialist aspirations? Can we construct a model, a computer simulation to test its principals, prove its  prophecies? No need I say, we have a preponderance of historical precedence readily available, and unequivocally disparaging the premise of socialism as an economic system and political philosophy; as a true form of governing, that great nations and their citizens alike have adopted, practiced and thrived upon! Think about it, in the annals of recorded time not one sustaining example of pure socialism as a governing platform worthy of emulation..., and not for the lack of trying mind you! We tried it our selves and failed! Begging the question: So why are we trying it again? I dare say a great many of us don't even suspect we, they, them are trying, for all the masking disinformation, misinformation and of course plain ignorance emanating from every nook and cranny of our political spectrum! Want a more current example, one closer to home? Surely you are familiar with our own "Great Socialist State of Illinois"? Without a Republican of any strip or color in sight-, how are they doing? I know I harp on this theme of what are you liberal Democrats seeing, listening to, that have you convinced our constitutional republic has gone awry and our only salvation lies in socialism. I just can't imagine how anyone fails to fathom the consequences of the slippery slope we are on! And, while you are perusing for pertinent data to state your case take a good look at the salaries and benefit packages our politicians realize as our "public servants". Historically Socialist's reward their practitioners, at the expense of their citizens, exorbitantly!
Suffice to say, your response to my last blog's enquiry prompted all sorts of interesting, imaginative, distorted, unverifiable data to the contrary (not all, but most). If you will stick to our government's stats (CBO) reporting on our budget and economy so that we can be on the same page, I promise to be more specific in my comments. 

Tuesday, November 5, 2013


Why is it that so many of us seemingly refuse to see the handwriting on the wall; that are seemingly too lazy to read or add up the numbers for themselves; that are seemingly so gullible to accept the premise that if we stay this course of socialism, all will be well, dispite the overwhelming precedence of those who tried and failed miserably before us! Can you tell me what you are seeing (not hearing from others, but seeing and deducing for yourself) that is advising your lot, or that of your fellow Americans is improving? What can you point to that lends this encouragement? Anything, you who have paid your dues and those of you still paying your dues to be a member of the great middle-class, the great working-class of this country of ours! If you are, or were a member of that class, help me out here, think of it as a humanitarian gesture in giving me something to hold onto-, I'm losing purchase, debilitated in searching in vain for myself! Throw me a line, please!

Saturday, November 2, 2013


....a while back I advised I would be less available to respond to bloggers requesting a  conservative slant on their political observations and inquires. And, as you may have noted, you have heard less from me of late. However this Obamacare debacle and it's defenders encouraged me to take the time to gather further insight to just what we are dealing with here, and respond accordingly. Please pardon my wordiness, but in being afforded a unique opportunity I was carried away!  

Despite the recent partisan bickering in Washington that has become a hallmark of the current administration, the Affordable Care Act continues to plow ahead like a glacial behemoth.  The debt debate was cleverly spun out of control and in my estimation was allowed to reach a conflagration by the White House in their sophomoric refusal to come to the bargaining table, preferring to view their democrat majority as a public mandate, and at times a simple monarchy.  The bigger the conflagration, the more attention was diverted from the real disaster here: the rollout of Obamacare.  In a rare change of format for Conservative Slants, I have chosen to interview an actual healthcare provider, someone actually in the trenches with an insider’s view of how the Affordable Care Act will affect the delivery of healthcare, what is the current state of healthcare, and what can we expect as this monstrosity is forced on the American public.

TS:  Welcome to Conservative Slants.

DR:  Thank you.  It is a rare opportunity indeed to have the media actually ask a doctor about the state of healthcare and the Affordable Care Act.  All too often we are left on the sidelines while the future of healthcare is decided by the insurance industry, politicians and bureaucrats.

TS:  I get that same impression.  It always seems with this administration that they cherry pick their sources and all too often, the actual experts are left out of the discussion……from global warming to gun control.

DR: Don’t get me started.  I have always found it amusing that CO2 has been branded a pollutant by the carbon police.  It seems to me that the best way to reduce the emission of that particular hot gas is to eliminate politicians.

TS:  (laughter) That would be a start.  Let’s talk about healthcare in America.  Without going into too much detail, give me a short background of your career and why you have some perspective.

DR:  Sure.  I have been practicing a surgical sub-specialty for 25 years.  I am a solo practitioner with hospital affiliations but perform most of my surgery on an outpatient basis in my own facility.  So in addition to practicing surgery, I am also a small business owner with a staff of six employees.

TS:  Ouch. The worst of both worlds.  Government intrusion into healthcare and having to adhere to the myriad of regulations required to run a small business.  What kind of environment do you practice in?  Are you in a big city?

DR:  No, but I used to be.  I practiced for years on the East coast just outside a major city. I had a midlife epiphany and moved inland to a more rural small town America setting to escape not only urban sprawl but also to escape the expanding control of the healthcare landscape by the insurance industry and the fierce competition for an ever shrinking piece of the healthcare pie.

TS:  What do you mean by that?

DR:  Certain parts of the country have evolved into insurance dominated environments where the insurance companies have, in an effort to stay profitable, been reduced to only a few players, allowing them to control the reimbursement profiles.  To reduce their premiums and remain competitive against each other, they have to cut costs somewhere, and the easiest place to make those cuts is the reimbursement for services to the actual providers.

TS:  But can’t you just refuse to accept the insurance reimbursement and not become one of their network providers?

DR:  Well, sure you can.  But these environments have also become so saturated with providers, that the competition is fierce between them for patients, so they have an extremely high rate of participation in the plans.  With patients seeking the best bang for the buck, they will gravitate to a participating provider rather than pay out of pocket for services covered by their insurance plan.

TS:  Is there that much of a difference?  And wouldn’t the patient gravitate towards the best doctor anyway?

DR:  There usually isn’t that much of a monetary difference, but the insurance company inserts all sorts of punitive clauses into their contract that makes going out of network financially unattractive.  And patients are not very loyal when it comes to money.  The insurance industry has done an effective job in treating us like a commodity and the patients have bought into it.  All services are thought of like widgets, all the same product.  That is why you see so many doctors trying to differentiate themselves in the marketplace by offering all sorts of comfort services like beverages in the waiting room, or massages, and swanky new offices.  All efforts to attract patients by offering something that the other guy doesn’t.

TS: Marketing 101.

DR: Exactly.  And that is also why you have seen medicine evolve into big group practices.  With more doctors under one roof, they can share overhead and be more cost effective on the business side.  If your reimbursement is low, then you have to lower your expenses and be efficient in managing your overhead.  Remember, the insurance industry is essentially fixing your price so your income is stagnant.

TS: Or another option would be to increase your productivity.

DR:  True, but you can only go so fast before you become sloppy.  Mistakes are made and patient care will suffer.  One of the biggest complaints doctors get these days is that they do not spend enough time with their patients.   Patients feel like numbers and fail to have a relationship with their physician.  Medicine has become procedure  and code driven where productivity comes from maximizing allowable procedures, procedures all identified by universal codes that have to be paired with diagnostic codes.  Patients often complain of unnecessary tests.  These tests serve two purposes: they cover the doctor’s backside in the event that something could possibly be missed, but they also provide more billable procedures.   Unfortunately the doctor becomes shackled to his keyboard and is rapidly becoming a data entry clerk.  Case notes, exam entries, test results, correspondence with specialists, follow-up notes, contacting the patient with results, referrals to other doctors, prescriptions, and the inevitable battle with insurance companies over billing and denials………all that takes time that could be spent in direct patient care.

TS: But isn’t that an argument in favor of government run universal healthcare?  You provide the medicine and they do the rest.

DR:  No, the government would just be a different devil.  Seriously Mr. Swift, is there anything the government runs that isn’t a colossal disaster?  Why would we consider allowing the government to run healthcare and control one-sixth of the economy?

TS:  But the left will proclaim that a single payer system is the ideal and will look to Canada and the UK as examples of success.

DR:  And when the Canadian prime minister needed surgery where did he go?

TS:  To the US of course.  I don’t see much traffic going the other way, either.

DR:  Because we have the best healthcare in the world.  You just can’t make that comparison either. Everyone forgets just how big the United States is.  We have 313 million people as compared to Canada’s 35 million and the UK’s 63 million.  We intend to inject as many Medicaid recipients into our system as Canada has people.  And Canada doesn’t have the demographics we do. They do not have Detroit, Houston, Los Angeles, Chicago…….big cities with big city problems of crime, drug use, poverty….. unhealthy lifestyle choices of that magnitude.

TS:  But you often hear from the liberals about Canada’s success with their single payer system.  I often hear quotes about more successful treatment outcomes as compared to the US.

DR:  It is a model devoid of business incentives.  Canadian private practice doctors have salary caps established by the government where they are told how much money they can make.  When they reach that number they have the choice to continue to serve their patients for free or to go on vacation.  I have a colleague who capped in October and went fishing for two months.  That hardly serves your patients and it seriously affects access to care.  There is no incentive to work harder, a theme that appears to be recurrent in socialism.  And as far as the better outcomes:  I read that study that was comparing breast cancer survivability in which Canada was superior.  But on closer inspection, it appeared that it was all about case selection and rationing.  From what I understand, patients were placed on waiting lists to receive care.  The more severe cases went untreated because they died while waiting for treatment, thus only the cases with a better prognosis were left and responded well, skewing the results towards success.  US doctors who took on the more difficult cases naturally had higher rates of mortality because they actually treated the more complex cases. 

TS:  So this was an access to care issue.  If you have to wait for your surgery it is essentially a form of rationing.

DR:  The democrats made a big deal about Republican claims that the system would have “death panels”.  That may have been harsh, headline grabbing terminology, but when care is rationed, whether it is because of access to care or cost cutting measures, it may end up a death sentence for some.  I have a colleague with a mother who lives in the Netherlands, where she required a hip replacement.  She went on a waiting list.  After two years of steady deterioration and pain that affected her lifestyle, she hopped a plane to Belgium and paid for the procedure out of pocket.

TS: The death panel concept is not too far of a stretch when you hear some of the comments made by Rahm Emanuel’s brother.

DR:  Yes, Ezekial Emanuel is a former professor at Harvard Medical School and a medical ethicist for those of you not familiar with him.  He has been called on by the White House and appointed Special Advisor For Health Policy.  I think a lot of his comments were misconstrued by the conservatives as being policy when, as an “ethicist”, he is delving into the realm of philosophy where he was making statements based solely on the application of a finite set of resources. 

TS:  But his comments regarding elder case and the Hippocratic Oath……

DR:  Yes, I agree that they were disturbingly Orwellian.  Brought to mind the level of societal engineering that you would see in a science fiction movie.  Some of you may recall Charlton Heston in “Soylent Green”.  It is not particularly wise to have your healthcare advisor making these sorts of public statements. They are best left in the classroom.

TS:  (laughs) That is a reference I may have to look up.  Not to belabor the point, but in particular that one statement about allocating resources…..

DR:  I have it here someplace.  Ah, here it is. Emanuel essentially believes that “communitarianism” should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those, and I quote: “who are irreversibly prevented from being or becoming participating citizens … An obvious example is not guaranteeing health services to patients with dementia” (Hastings Center Report, Nov.-Dec. ’96). He also stated that “Savings will require changing how doctors think about their patients: Doctors take the Hippocratic Oath too seriously, as an imperative to do everything for the patient regardless of the cost or effects on others” (Journal of the American Medical Association, June 18, 2008).

TS:  I don’t care if he was waxing philosophic or not.  That is scary stuff.

DR:  Agreed. But again you have to look at it in context as an argument against government run healthcare.  He is saying that if we are all in the government run pot together, with only so much in the way of resources, and you can define resources in an access to care context with only so many providers available, or in the economic context of only so many healthcare dollars available, then the only logical solution is to ration healthcare.  So essentially he just made the Republican case that there is going to have to be “death panels”.  Someone has to be sitting in the emperor’s box giving a thumbs up or a thumbs down on treatment.  And who is that going to be?  Doctors, philosophers, statisticians or the accountants?

TS:  It is positively frightening. But then again, his father was a pediatrician active in a Jewish paramilitary organization and his mother was a psychiatric social worker who was active in the civil rights movement including the Congress of Racial Equality.  He comes from a rather radical background.

DR:  It is frighteningly radical thinking. Especially when you consider that it is factoring in a person’s worth.  You have worked your whole life, played by the rules, and paid into the system.  But in the end you have no more worth than someone who didn’t pay into the system, never worked a day in their life and didn’t abide by society’s rules.  And to suspect that someone will be the beneficiary of your labor merely based on the fact that their parents had state sanctioned reproductive rights and are judged to be participating citizens?  Where do you draw that line? And you can bet that our politicians will be a level up on the worth scale as compared to the masses.  Who decides these things?

TS:  Depressing topic.  Let’s move on.  Back to the ACA.  What about the implementation?

DR: The Obamacare rollout cost the taxpayers over 634 million dollars for a system that doesn’t work and no one seems to be accountable.  The website was fundamentally flawed, and despite government claims that the system was simply overwhelmed with traffic, it turns out that was just spin.  The system is filled with bugs and errors and is just not ready for prime time.  The government shut down got all the press.  Meanwhile the public’s attempt to sign up for insurance through the exchanges was, and still is, a complete disaster.

TS:  But today Sebelius stated the system didn’t crash, it just wasn’t working.  Hysterical.

DR:  Just more spin that will be followed by finger pointing. This administration loves to talk and is intent on pushing their socialist agenda consequences be damned.  But they are extraordinarily poor at implementing anything.  All we seem to get is more partisan rhetoric and nothing gets accomplished.  We have a President with no experience in the private sector, surrounded by staff with no experience in healthcare delivery, pushing a defective product that does not work, that they themselves will not have to use.  And if you don’t buy it, you are penalized.  You can’t make this stuff up.

TS:  Why wouldn’t they have succumbed to Republican demands for a provision to delay Obamacare implementation for a year? It seemed like the Republicans were offering them a  way out.

DR:  Right, knowing full well that the system was not ready for implementation, why wouldn’t they have allowed another year to get it right?  They gave out exemptions to all of their campaign donors, big corporate cronies and supporters like Halloween candy and even chose to exempt themselves, but rammed a second rate system down the throat of every day Americans.

TS: So I take it you’re not a big supporter of socialized medicine?

DR:  As far as I am concerned, the government has already auditioned for universal healthcare and failed miserably.  Medicaid is perhaps the most inefficiently run, financially draining, government run disaster ever conceived.  I assume you are aware of the recent study that compared Medicaid patients to those that had no healthcare whatsoever and found no statistical difference in health between the two groups?

TS: Yes, incredibly sobering statistics.

DR:  And even more sobering is the fact that much of the Affordable Care Act is based on the Medicaid model.  It would be like basing the design of all new cars on the Ford Pinto.

TS:  Interesting analogy………

DR:  But accurate.  Why would you use a poorly functioning model of healthcare as your template?  Obamacare has expanded Medicaid into the middle class and will inject upwards of 30 million more participants into a system that functions poorly already.

TS:  Many doctors currently don’t accept Medicaid.  Do you take it in your practice and if so, what has been your experience?

DR:  I accepted Medicaid in my practice years ago, but it was financially unsustainable. An analysis showed that we were actually losing money seeing Medicaid patients.  We could just not work fast enough to make it profitable and the reimbursement is positively draconian.  The fee profiles in Medicare are even worse.

TS: That bad?

DR:  Some parts of the country have not seen fee increases in decades. Some reimbursement profiles are as low as 30% of the usual and customary fee.  In New York, last year Medicaid actually cut their reimbursement profile retroactively during a budget shortfall.  So they cut the fee on procedures that had already been done where doctors were awaiting payment.

TS:  That’s unbelieveable.  They can do that?  What was the response?

DR:  It’s the government and yes, they can do that.  A lot of providers like myself abandoned the program, a lot of specialists.  Many states have flirted with the idea of tying licensure to a requirement to accept Medicaid, but fortunately I’m not aware of any state where that has come to pass.  A Wall Street Journal poll of doctor’s  opinions showed that 56% are still evaluating or don’t know if they will participate in the new plans offered by the exchanges, but 55% thought the plans will  have a negative impact on their practices.  So it appears that doctors are waiting to see what the plans have to offer, whether they may have to accept the plans to remain viable, but they do not have high hopes.

TS:  But if practitioners do not accept Medicaid, or the plans offered by the exchanges, where do they go?

DR:  Precisely.  It then becomes an access to care issue.  Now think about it.  Medicaid is the model for Obamacare and we are about to inject some 30 million more patients into the system.  It has been estimated that we will need another 42000 primary care doctors in this country to treat that influx of patients.  And many doctors are not going to be willing to accept those patients.  We are already seeing doctors retire early, become salaried staff members at hospitals or adopting a “concierge” style of practice that reduces patient access to the few that can afford it.

TS:  Based on the miserable reimbursement?

DR:  Not only that, but we have to look at exactly who makes up the Medicaid population.  Many of them are elderly.  But a great deal of them are young, indigent, unemployed, undereducated, disabled.  This is an extremely difficult patient population to treat.

TS:  How so?

DR:  Take my practice for instance.  My patient population is approximately 30% state-run managed care.  Mostly lower income folks with jobs who make too much to qualify for Medicaid, but have low incomes that qualify for state subsidized programs, much like what we can expect from the sliding scale of Obamacare exchanges.  As I said, I no longer accept Medicaid due to its low reimbursement profiles.  State run plans reimburse better because they are currently managed more efficiently by insurance companies, but they are taxpayer subsidized.  They are the next rung up from Medicaid.

TS:  So a very similar socioeconomic group as compared to Medicaid recipients, but a better run program, and a little better off.

DR: Exactly.  In my practice we have found that this demographic has some interesting characteristics. These lower income patients are often less educated and less medically astute, and therefore extremely apprehensive, so they wait until late in a disease process to seek treatment.  They are more often smokers, more often substance abusers, more likely to have complex medical histories, more allergies to medications, with higher drug tolerances.  In other words, a significantly higher risk population to treat. 

TS:  For example?

DR:  As an example, in the ER this morning I saw an obese 24 year old woman, multiple tattoos, complaining of shortness of breath, unemployed, single, with three children aged 8, 6, and 2 with a history of sexually transmitted disease, asthma, anxiety and chronic back pain.  She was taking Albuterol [author note: a bronchodilator to prevent wheezing, difficulty breathing, chest tightness and coughing caused by lung diseases such as asthma or COPD], Klonipin [author note:  sedative, hypnotic class drug used to treat anxiety and act as a muscle relaxant], Lamictal [author note: an ant-seizure medication also used to treat bipolar disorder] and round the clock Hydrocodone [author note:  a potent prescription narcotic pain reliever found in Vicodin]  She was a 2 pack per day smoker with a history of multiple prescriptions for the narcotic pain medication every two weeks for the last ten months.  In the next bed was a 13 year old with a facial infection caused by one of perhaps 12 decayed teeth.  He had a history of an abusive home, a pregnant 16 year old sister, and was in the custody of his grandmother. He had a history of depression and was taking Prozac. He was unmanageable and combative in the treatment room and had to be scheduled to be put to sleep in the OR to address his dental problems.  Both of them were on state plans, both using the ER as their primary care physician.  The Affordable Care Act will not change their self-destructive behavior, but will have to pay for it.

TS:  And higher risk patients like this means more complications?

DR:  Amongst other things.  Anesthetic cases are more difficult to manage due to higher drug tolerances.  Anesthetic complications are higher due to the effects of smoking.  Irritable airways, COPD, asthma, bronchitis are all very high in this patient population. Sometimes it seems like I’m trapped in an episode of Mad Men when I treat these folks.  They are more likely to call after hours and require additional procedures and time to treat their complications.  All time and treatments for which I am not compensated.

TS:  So you work harder for less money. And most of us that live in yuppie-land think smoking has been largely irradicated. How can they afford that habit?  Aren’t cigarettes up to 8 bucks a pack now?

DR: When the government entitlement programs pick up the tab for all your necessities:  rent subsidy, heat subsidy, SNAP (food stamps), WIC, cell phones, transportation to and from your doctors appointments, not to mention earned income tax credits………that frees up a lot of cash for booze, drugs and cigarettes.

TS:  That always infuriates me.  The recent government glitch in Mississippi where they failed to put a limit on their SNAP, WIC and EBT cards…….

DR: ……and they went wild at the local WalMart and cleared the shelves?  When management realized what was happening and shut it down, they rioted. 

TS: Welcome to the Entitlement States of America……

DR:  It is just amazing that the Affordable Care Act has been touting monthly premiums less than your cell phone bill.  If you are that broke, you shouldn’t have a cell phone, and you sure shouldn’t be smoking.  A colleague of mine once told me that nothing is more infuriating to him than accepting a Medicaid patient only to find him in your waiting room streaming video on his iPhone.

TS:  That’s awful. Since when did a cell phone become a necessity? We have all heard the stories about Obamaphones.  Yet another entitlement.

DR:  I recently heard an interview on NPR where a woman and her husband supposedly made less than twenty thousand dollars per year, but sailed through the exchange and emerged with government subsidized healthcare for $60 a month. And she proclaimed it was just like Obama said:  less than her cell phone bill.  Now from my experience, it is likely she has children and more than likely she is a smoker.  If you and your husband have a two pack a day habit, then you are spending in excess of $900 per month on cigarettes in addition to a $60 per month cell phone bill.  And you can’t afford healthcare?

TS:  And from what I’ve heard about access to the government website, NPR must have found the only woman in the country who managed to sign up.

DR:  That truly is some feat of investigative reporting.  Despite claims that 40000 people signed up for healthcare through the New York exchange, it was determined that after day three precisely zero had actually acquired a healthcare plan.  And New York has their own exchange, not the federal exchange.

TS:  I read the same thing.  After the first three days, only one signed up in North Carolina, none in New York.  As of day 18 reports had Maryland at just over 1000 enrollees and Colorado at 226.  Most states, naturally, are not releasing data. It has been reported that nationally, despite 3.72 million people who entered the registration section of the website, only one million registered successfully and only 36000 actually completed enrollment.

DR:  Not very encouraging statistics.  But what I find infuriating is the fact that this is nothing more than another massive redistribution of wealth.  Why was Obama against any form of income verification?  Who exactly is going to pay for a system where there is no premium bias for pre-existing conditions? 

TS:  I assume you are being rhetorical as we all know where the money is coming from.

DR:  Yes we do.  We are going to be subjected to massive premium increases to fund the currently uninsured.  I read that in the first year they expect 7 million people to sign up, with the requirement that 2.3 million of them have to be young and healthy to subsidize the program.

TS: And according to Sebelius, after three weeks of the exchanges being open, she cannot give us an accounting of what the ratio of sign-ups has been thus far.  In fact, she wouldn’t even reveal any figures regarding the number of people that have signed up through the exchanges at all. She kept repeating that the results will not be available until mid-November.

DR: More stalling.  You know they have the numbers. The youth of America, those healthy individuals who probably would go without healthcare, are going to be forced to foot the bill by paying for healthcare that statistically they are unlikely to need.  And Seniors…….I just don’t understand why there hasn’t been a massive gray-haired revolt……have been sold down the river by this administration and the AARP, who backed this debacle.  716 billion dollars cut from Medicare to fund the 30 million newly insured.  Good Lord.

TS:  Just when we need it. It won’t be there.  Or at least not what we have now. According to a report in Investor’s Business Daily (October 10, 2012), within the ACA there exists a point system to award points to hospitals for reducing spending specifically on seniors.  They call the parameter “Medicare spending per beneficiary”. 

DR: They are attempting to reduce the cost by eliminating expensive senior procedures like knee or hip replacements.  They even punish hospitals for care that is consumed 30 days after a patient is discharged, such as the physical therapy required after a hip or knee replacement. 

TS:  How short is the public’s memory?  In 2009 at a town hall meeting, Obama actually told a senior “maybe you are better off not having the surgery and taking the painkiller”.  So now he is an expert in orthopedics when the body of medical evidence clearly shows the benefits of these procedures for seniors.

DR:  It irks me to no end that when I will need Medicare to be there, after working my entire life, I will be unable to find a doctor, will be subjected to long waits to see a doctor, or more likely a nurse practitioner or some other mid-level provider, and then I may not be allowed to have the procedure at all. Or perhaps we will have to pay out of pocket in a fee-for-service practice as the healthcare system evolves into a two-tier system like England, where agonizingly long waiting lists for cheap national healthcare exist side-by-side with no wait, but expensive, private fee-for service medicine.  Meanwhile the political elites are basking in their boutique medical plans that they reserved for themselves by exempting our elected officials and their staff from the Affordable Care Act. 

TS:  That’s depressing. 

DR:  It is.  But it is simply unsustainable.  Where will the money come from?  We are sacrificing the best healthcare in the world on the altar of socialism.

TS:  That’s good, let me write that down.

DR:  It’s true.  It has been estimated that the Affordable Care Act will cost three to four times the original estimate.  And that comes from the Congressional Budget Office, not some partisan think tank.  This administration is lying to us.  Already it has been estimated that premiums for males will increase on average 99% and for females 62%.  And with figures just released that report only 63.2% of Americans participate in the labor force, the lowest rate since the 1970’s, how is this sustainable? Costs have to be contained and there are only so many ways to do it.  Remember the Medicaid model:  you can reduce the reimbursement to providers, you can increase the premiums, or you can cut the services offered.  With so many participants not working, and so many participants with serious health issues injected into the system, that group is hardly a revenue source.  You can continue to cut the reimbursement to doctors, but that too will reach a point of diminishing return.

TS:  How so?

DR:  With no future in medicine, the best and brightest will look to Wall Street or technical fields as a source for accumulating wealth.  Medical School already produces young graduates who average debt loads in the vicinity of $300000 after spending their entire twenties in school. They emerge to face long hours of internship and residency at abysmal pay scales, only to face servitude as an associate or a hospital employee or perhaps an exorbitant buy-in for a private practice.  And the Affordable Care Act never addressed tort reform, so medical malpractice remains a daunting beast with high insurance premiums and astronomical awards.

TS:  No one ever mentions that.  How high are malpractice premiums?

DR:  It depends on where you practice and what you do. Internists generally are at the low end of the scale paying $6000 per year on average but it can be as high as $50000 in some states like Florida. General surgeons average about $22000 to $34000 per year.  OB/GYN suffers the most with premiums that can be as high as $200000 per year in some states.

TS:  But surely the reward is high in the form of salary.

DR:  Sure, it is in some cases of the surgical specialties.  But your average pediatrician or general practitioner, those guys who will bear the brunt of the Affordable Care Act, those guys are looking at average starting salaries in the low to mid 100,000 dollar range.

TS: Good money, but not much of a return on investment.

DR:  No, not at all. Especially if you consider that doctors in private practice medicine have to self fund their own benefits and retirement contributions.

TS:  Are you pushing your kids into a career in medicine?

DR:  Hell no.  The generation before me was in the golden years of medicine.  Respected in the community, low insurance penetration, and even when it existed, good reimbursement.  High degree of patient compliance, low overhead, low malpractice, less government regulations.  Those days are over.  None of my colleagues have advised their kids to go into medicine.  And that too will lead to physician shortages.  Medicine is just not sexy anymore.

TS:  How about your own personal experience with insurance plans and Mr. Obama’s claim that “if you like your current plan you can keep it”?  He also stated that your plan would remain affordable or that you would even save money under the ACA.

DR:  Bullshit.  The Affordable Care Act’s parameters for plans to satisfy those guidelines are so stringent that it has been shown that 51% of current plans cannot meet the qualifications to continue to operate under ACA mandates. And we all know what will happen.  Those people that lose their plans will not lose coverage, but will be herded into other plans that are either more expensive for the same benefits or are similarly priced with lesser benefits.  My personal family plan was cancelled last year and I was moved into a vehicle of similar cost, but with a higher deductible and less benefits.  And this from a plan that in eight years has nearly doubled in cost.

TS: Yes, the Wall Street Journal reported that more people may actually lose their current coverage than those that gain it through the exchanges.  Let me see here (reading from the WSJ October 22, 2013)…….Florida Blue has already terminated 80% of individual policies in the state, Kaiser in California has put 160000 subscribers on notice and Blue Cross of Philadelphia ha dropped 45% of its customers.

DR:  And as you said, this behemoth continues to plow ahead.

TS:  But some conspiracy theorists think it’s all part of a larger plan.

DR:  It does make you wonder.  Remember, our President is on record saying that he “is a proponent of a single payer system”.  The suspicion is that requirements that insurance companies adhere to a set of ACA minimum guidelines is so demanding that they will be forced to cancel current plans and offer ACA compliant alternatives at a higher premium.  This will cause widespread revolt and the insurance industry will implode as they are unable to be profitable given the mandates for taking on pre-existing conditions and poor health risk patients without premium bias.  The only thing left to do is turn to the government and voila….Obama has his single payer system that he wanted all along.

TS:  It’s frightening.  So in summary, what is your take on this?  Can the ACA survive?  What can be done to make government healthcare in this age affordable?

DR:  Well, Mr. Swift, we both know that this isn’t about healthcare.  This is about socialism, government control and power of you and the economy.  Mostly this is about the democrat pipedream of universal healthcare……a lovely ideal, mind you, but economically impractical to implement in this format.  This is a redistribution-of -wealth scheme of massive proportions.  And what is truly frightening is that this administration continues to mislead the public, punish the producers, punish business, punish the elderly and now in a strange turnaround, has actually hit youth in the pocketbook , the very demographic that supported them.  Obamacare is being funded on the premise that they can get healthy young people to buy premiums that they statistically do not need, in conjunction with a reappropriation of funds from Medicare, all to fund a program that will provide entitlements for a non-productive demographic that will disproportionately suck up a huge share of resources.  Our elderly and our healthy young people will bear the burden of the Affordable Care Act. 

TS:  Do you think it can be fixed?

DR:  No, I don’t.  Like most government programs that have been proven by hard data to be non-productive or at the least poorly functioning, the government will continue to throw money at it until it becomes entrenched.  The ACA will morph into another form, perhaps a single payer system, but I think we’re stuck with it.  The public will just get used to a new poorly functioning version of healthcare.  The only way to make a program work is the same way it would work in the private sector:  make it profitable, or in the government’s case, where they are spending someone else’s money, make it less of a debacle.  The usual response will be to cut costs by providing less services, lower reimbursement to doctors, and inject more money into it with higher taxes on the wealthy, which everyone knows means people with jobs.  I logged into and was met with a line that said, in summary, if you make less than $46000 as an individual and $96000 as a four person family, your premiums will be less than those indicated.  In other words, if you make more, expect to have a radical increase in your costs to fund those folks.  That was two days ago.  Interestingly, that statement was gone when I logged in today.

TS:  What would you do to make the system functional?

DR:  We have essentially given a blank check to the most irresponsible members of society.  Now don’t get me wrong, Medicaid is a necessity to act as a safety net to catch those unfortunates that cannot provide for themselves: the elderly, the disabled, the handicapped and to act as a short-term crutch for the jobless.  It is not, nor was it ever meant to be a permanent way of life for the physically able-bodied.  The average welfare recipient in this country has been in the system for three generations.  If the American public is going to pay for your health care, then a contract of sorts has to be devised, just as if you were an employee.  There are certain things that you should not be allowed to do if it will take resources away from the program….resources that could be better spent.  Zeke Emanual should be all over that concept. Pregnancy is one of them.  Why do we allow unchecked reproduction when pregnancy avoidance can be easily implemented.  There has to be a carrot and stick form of incentive here.  If you maintain your health in certain parameters, you will be rewarded with benefits.  Not the other way around.

TS:  So you propose standards of preventative care that must be met to receive your benefits?

DR:  Exactly.  No pregnancy allowed and adherence to a contraception regimen.  I don’t want any more kids and I shouldn’t have to pay for someone else to have them either.  And in this patient population with high incidence of smoking and substance abuse, poor health habits and diet choices, we are going to get premature babies in need of neonatal care.  An expensive, and avoidable proposition.

TS:  But the liberal argument is that government cannot dictate the reproductive rights of the people.

DR:  No it can’t.  But it can dictate the rights of the taxpayer.  I don’t have ten kids because I am responsible and I know that I cannot afford that luxury.  Medicaid recipients shouldn’t have ten kids because they cannot afford them either.  If you want to have a child then have at it.  But know that you will not be rewarded with an increase in your benefit package.  That premise is moronic.

TS:  And other health guidelines……

DR:  Smoking.  You do not smoke on my dime.  Period.  Children of smokers suffer higher rates of asthma and childhood illness, and smokers are more likely to suffer more upper respiratory tract illness and eventually chronic obstructive pulmonary disease.  Bronchitis, Emphysema, not to mention risk of cancer.  All preventive and all expensive drains on the healthcare system.  Money going towards a destructive habit is better served in supplementing your healthcare premiums.

TS:  and……..?

DR:  Testing for illicit drug use and alcohol.  In my rural locale, meth is running rampant.  Heroin is also making a comeback.  Addiction and alcoholism is treatable and the health risks associated with addiction are frightening.  Why would be possibly allow these wards of the state healthcare system to engage in recreational drug use?  It’s preposterous.  You want a check?  Test clean.

TS: And other healthy lifestyle choices?

DR:  How many times have you been in the supermarket and have seen the two cart technique?  One cart full of food covered by the state welfare plan:  chips, Mountain Dew, twinkies…….hardly healthy choices.  And the other cart full of beer and cigarettes.  It’s absurd.  In this age of the bar code scanner we can know what the welfare recipients are buying and can have an effect on their purchases.  NPR actually did a report that concluded that giving people free money makes them happy.  Their conclusion was that charitable organizations should reconsider spending money on programs and instead just give people money.  That’s what the states are doing now with benefit cards.  Credit cards that the recipients can spend freely as they wish.  The result is that these cards are being sold for cash and being used in strip joints and amusement parks.  I don’t think that is what the public wants their hard earned tax dollars to go towards.

TS:  But once again, the liberals will argue that you cannot infringe on their right to eat junk food or drink beer.

DR:  And again I have to agree with you.  I have absolutely no intention of telling my fellow Americans whether or not they should smoke, eat junk, consume illicit drugs or engage in other risky behavior.  I tend to lean libertarian in this case.  I will happily advise you on what you should do to maintain optimum health.  But I draw the line when the taxpayer has to pay for your indiscretions.  If I have to pay for your healthcare benefits, which amounts to me paying for the consequences of your poor lifestyle decisions, then you have essentially given up your right to make your own health choices and I will make them for you.  And that should be a contractual agreement. 

TS:  Rather than stretch the healthcare dollar and be fiscally responsible, the liberals just want more of our dollars.

DR:  It is amazing that they are willing to cut the amount they pay doctors and hospitals, hobble the medical device manufacturers with innovation-killing taxation, cause premiums to rise for the currently insured, and even consider rationing healthcare, yet they will not address the preventative measures that can be taken to reduce consumption of medical services by the those that are not paying their own way.  And I’m not talking about pre-existing conditions.  I’m talking about lifestyle choices that result in serious medical conditions that are entirely preventable.

TS: It will be interesting to see if after Obama administration debacles that include Benghazi, the IRS targeting of conservative groups, the Syria embarrassment, the NSA spying on our allies, the quantitative easing money pit, the poor handling of the economy, the shakedown of JP Morgan, the exemptions of Congress and their political cronies from the ACA, the wasted green energy investments…..and the list goes on……..if finally the American public will see in Obama’s signature piece of legislation the incompetence and idealistic march towards America’s demise that are the hallmarks of this failed Presidency.

DR:  Never, ever underestimate the stupidity of the American public.  Especially if they continue to think that they are getting something for free.

TS: It has been a pleasure speaking with you.  I’m sure this interview will ruffle some liberal feathers.  Any final words?

DR:  Thank you for letting me voice my opinions.  Let me be clear.  As a physician I do believe in healthcare for all, but not necessarily the same healthcare for all.  No one should be without access to healthcare and it should not bankrupt your family. And as a civilized society we have an obligation to care for the aged, the handicapped, the sick and infirmed. But we have to be smart and manage the health of that other segment of the market that is heavily subsidized, those that will disproportionately utilize more resources relative to the amount that they put in. This can’t be another entitlement that is written with a blank check by the taxpayer. Being a good Samaritan is one thing, but exorbitant, punitive, progressive redistribution of wealth is another. And if this plan is so American, so special, let’s stop the exemptions for the politicians and the politically well connected.  Let them have some skin in the game.  This class warfare and class envy has to end. This administration is all about fairness and equality. But fairness does not necessarily mean that you should be forced to enroll in a healthcare plan with benefits that you do not need, just to pay for benefits needed by someone else.  Healthcare is not a one size fits all proposition.  You should be rewarded for healthy lifestyle choices, not forced to pay for the indiscretions of someone who has chosen to ignore those choices. We all may be born equal, but I’m sorry to say, if you are able bodied and able to work and choose not to, choose to game the system, choose not to work as hard as your brother to better yourself, then you are not his equal and do not deserve to enjoy the same benefits.  There are just too few horses pulling the wagon. Healthcare for all shouldn’t mean mediocre healthcare for all, and especially not at the expense of our seniors.  Let’s be smart and end this entitlement era.  Fairness should not mean entitlement, it should mean getting what you deserve.