Monthly Archives: July 2009

Will the Chinese veto U.S. Health Reform

Are the only people watching our government spending located in Beijing?

Now that the Blue Dog Democrats and some Republicans in the house have agreed on a watered down health care reform package, yet to be fully outlined, we can start actually looking at how and who is going to pay for this reform.   Of the six goals outlined in the Presidents wish list on health care reform, it looks like only two are going to come to full fruition in a bill.   Guaranteed access to insurance for individuals, and a tax on health care packages that exceed $25,000 of annual value.  

This scaled down model of health care reform might not meet with approval of the American Public.  Polls taken between July 17-20, before the latest outrage, showed that President Obama did not have a plurality of support from those with private health plans.  It;s fair to say that if a poll were taken this week, the support would probably be even less.   This is even before any middle class family (defined as 4x the federal poverty level per proposed subsidy cut offs at 300% of FPL) realizes that their taxes would be going higher to pay for a plan that they will most likely not benefit from.  

Once the actual bill is published.  It will be gone over with a fine tooth comb by those on the left and the right.  One can expect that Fox News will bash it, and MSNBC will be supportive.  CNN and the NYT will most likely present both sides with a moderately left leaning.   BIg deal, I say.   What will Beijing say?

In June , Tim Geithner, US Treasury Secretary went to China to address the budget deficit issue and explain our 13% of GNP deficit this year, and a predicted 3% of GNP deficit next year, assuming a economic recovery, and to tell the Chinese not to worry.   China who currently owns an estimated $2 trillion of our bonds, and we assume will pick up another $500 billion soon, may ultimately have something to say about how health care reform goes, if it does.   They won’t necessarily offer public statement, but while most American’s think that ‘health care reform’ means “saving me money”, if the bill doesn’t deliver, and the government has to sweeten the deal to make it more attractive (meaning additional deficit spending), China might start dumping dollars and bonds.  

With the U.S. deficit financed by China, much like AIG is financed by the US Government, If you are looking to the political party that might really have the say so if we have health care reform in 2009, look East..  Far East…  

Bulletin: Blue Dog Democrats in House have reached Health Care compromise

  • Bill to be voted on in September.   
  • Senate Majority Leader HArry Reid says that bill will be bi-partisan.

Rumored components:

  • Small business exempt from mandates and penalty tax from not providing it.
  • Mandate for individuals to carry insurance.  
  • Taxation of benefit packages that exceed $25,000 per year for the employee.  

And for fun,  I am quoting here:   “have agreed that the full House would not vote on the legislation until September so lawmakers can read the bill and listen to constituents.  (Wow, these guys are SWELL!!)

Late Night Bulletin – Preview of the Senate Bill

Late Night Extra:  The Senate Finance Committee has leaked some big changes to the House Bill.  As I posted my summary of the bill I would create, A major leak of the Senate bill hit the wires. 

  • Individual Mandate to obtain insurance.
  • No employer mandate but a tax to reimburse subsidy’s to low income workers obtaining insurance.
  • Scaled deductibility of high cost insurance.   Those with $25,000 of annual benefits might only get to deduct 65% of the cost, much like the current entertainment 50% deduction.
  • Limit on Flexible Spending Accounts.   HSA’s not mentioned, but HRA’s probably also limited. 
  • Formation of a non-profit co-op to compete with insurers.   A government run plan is off the table. 
  • Elimination of pre-ex clauses
  • Major changes to Medicare enforcement of reimbursement cuts as mandated in previous legislation. 

First look is a big improvement. 

Enough Criticism – What’s your plan

It’s easy to be critical, it’s tougher to present an alternative.    Today’s entry will focus on an outline of the components that should be debated point by point and my suggestion of a bill that would probably be palatable to the majority of American’s.   Even though this debate is less than two weeks old, most are already tiring of the hyperbole being thrown from all the special interests.  

To design any plan, the problems we want to address must be clearly defined.  I also want to be out front with my perceptions and biases so that you can judge them accordingly and take issue with them, if you disagree.  (although most criticism is coming via personal email)

Here are the key components of designing a more cost effective health care system, as authored by me. 

  • Providers are mandated to charge all customers the same amount and declare their fee for service.   
  • The Government creates an agency to take all the pricing data nationally and break all providers into a group of 6 pricing models with regional adjustments based on service area of providers.   All providers fees would then be compiled into the national price levels and each provider would charge the average level based on the price group of 1,2,3,4,5 or 6. 
  • The Federal Health Agency is the only legal wholesaler of FDA approved drugs.    
  • The Federal Health Agency provides direct-to-insurers credits to insurers for those with income less than 300% of  Federal Poverty level.  

No matter if you are 65, worth $100mm, or on Medicaid, the doctor charges you the same amount, and your insurance, if you have it, the same amount.   A very simple premise.   Let the market compete for health care.   Insurance would provide insurance to provide coverage at the level of provider you choose.  

To address the insurance issue of a jolt to correct the system as it stands. 

  • A once in a lifetime waiver of the pre-existing condition clause. The waiver is offered on a national level based on the month of your birth, rolled out over 12 months.  
  • Those not electing coverage at the initial creation of the plan would be entitled to get insurance via underwriting at any time, or during the annual open enrollment period. 
  • If you do not elect insurance at the initial enrollment, you are subject to a 24-month pre-existing condition clause.  If you elect your once-in-a-lifetime waiver of the pre-ex clause, you pay a higher rate of 1%, per month for each month past the initial election period, up to 100%.  If you decide to change carriers, your rate premium would remain for a period of 5 years.   ( if you decided to roll the dice and go uninsured for 2 years, you would pay 24% more than the maximum allowed for each the next 5 years, with the original insurer receiving the 24% premium addition even if you changed carriers)  
  • Insurance carriers would offer open enrollment one time per year, if an individual wanted to change coverage or carriers in between that open enrollment period, they would be fully underwritten and could be declined.   ‘
  • Individual insurance would be offered nationally in a Plus or Minus 20% underwriting risk.    If the Standard Premium is $200, the healthiest person would pay $160, the sickest group $240.    
  • Group/Employer based Health Insurance would be offered at Plus or Minus 10% underwriting risk.
  • Unmarried children eligible to age 26 regardless of student status.
  • Cobra benefits offered for 12 months maximum.   

If the initial premise that a provider must charge are insurers, public or private , the same amount for the same procedure, then you can have a government health plan without unfair competition. 

A Mandate that all people must be covered by a minimum coverage health plan.  A government body would determine the minimum coverage parameters that all private plans must cover.   No plan could have out pocket expenses, including copayments, that exceed $2,500 per person.   

How it would work for individuals and businesses in greater detail later this week.   (Unless the Senate bill comes out, and then I will read and critique that bill)

Organizational Chart of the Public Health Plan

I just received this organizational chart outlining the Public healthcare plan.    It is provided by a Republican congressman, and has a bias tone to it, but it factually represents the governmental plan as proposed.   

I also want to mention that if I were critiquing the current plan, it would be less complicated, but have some different, and sometimes very unfair, obstacles.   You must remember that while private insurance will be grandfathered, it will not be available to most going forward, most private carriers will most likely fold or be non-competitive,  and you will lose your ability to make decisions without a governmental approval in this system.   


Obama Press Conference Review and the Truth-O-Meter:

President Obama opened his conference with a clear, passionate, and generally accurate depiction of the state of current health system with some broad goals for reform.  Most importantly there was the new admission, as we have been pointing out in previous entries, that the main reason for this reform is “the biggest driving force in the federal deficit is the skyrocketing cost in Medicare and Medicaid. If we do not control these costs, we will not be able to control our deficit” .   The President’s admission of waste and excess in Medicare and Medicare is a helpful acknowledgment of truth and provides some ground rules when trying to fix the problem.   No claim, in his opening, that the government does it better, and that is appreciated. 

The tone of last night’s review shed some new light on a few of the issues that may be foreshadowing the early demise of HR 3200.   Will a Senate Finance Committee bill be better in some way?  That’s yet to be determined, but we know it will be more favorable towards increasing provider reimbursements.  

Let’s look at some of the specific information last nights Q&A, with some Truth-o-Meter reviews.  (Truth-o-meter a scale from 0=nope, to 100=truth)


OBAMA:  14,000 people a day are losing their health insurance.
Truth-O-Meter Score:  80 – Sounds about right.  The economy is losing about 525,000 jobs per month.  With 85% of American’s with healthcare, that number makes sense.  Not outlined  is how many people get new health insurance per day or that the government is providing a 65% subsidy for those offering COBRA under ARRA.  The most recent data (2007) shows that 1.3 million less people are uninsured than the previous year.


OBAMA:  If you have insurance, this will provide more stability. This will prevent you from insurance dropping you if you get to sick, you can move and keep your coverage.   
Truth-O-Meter Score: 50. – Part 1 – Sort of True; A government plan will provide more stability. If you move, you will be able to keep your coverage with the federal plan.  There is nothing indicating that if you have private insurance, the same right would exist In fact if you move, you would not be able to get new private insurance. . Part 2- FALSE:  Insurance companies do not have the right to cancel you if you get too sick.  The regulation authority currently exists within each State, and each State prevents it. Health insurance is not like homeowners insurance. 


Obama: The Status quo is going to double costs over next 10 years. 

Truth-O-Meter Score: 90 – While no one has a crystal ball, it’s fair to say that looking at the current system is not a pretty picture.  The health insurance industry is not abusive, but there is a confusing and frustrating system for people when they try to change coverage.  A mandate that all carriers offer coverage with no pre-ex clause and level pricing, that would accompany taxation, mandates and subsidies for those with lower income would solve all the issues in getting the bill passed.  We all agree that reform is needed, but not this bill. 


Obama: It’s (this healthcare reform) about every small business that has been forced to cut back their coverage or lay off employees because coverage became too expensive. 

Truth-O-Meter Score: 20 – The only reason that this is not a zero score is that the truth lies in the government mandating to the business your coverage versus giving an employer an option to reduce or eliminate benefits.  A small business would not have an OPTION to not pay tax or insurance.   Under the current bill small business would not have a right to choose a private plan. They would be able to choose only the Public healthcare exchange plans. The tax structure outlined for businesses with more than $250,000 of annual payroll exceeds the median amount that small employers currently pay for employee’s coverage.  In many cases, it will more than triple the cost of coverage for their employees.  It appears to be statistical certainty that many jobs will be lost from small business, especially in businesses with less than 10 employees.     


Obama:  (About who supports this bill) AMA, Big Pharma, and AARP

Truth-O-Meter Score: 100 – The AMA supports this because under the current structure of the bill, their reimbursements get increased.  Big Pharma, although they are apparently giving back at least $80 billion over the next 10 years, they like it.  AARP, the union of seniors because they will get preferential treatment, for now. If you include some oil drilling credits, you might get BIG OIL to join in support…  I am concerned about who supports this.   No business groups or commerce groups. Even the independent Congressional Budget Office says that “fully paid for” reference that President Obama calls for would not include nearly $250 billion of other costs. 

( Is anyone else get the feeling that aligning with the AMA, AARP and Big Pharma is the political equivalent of voting in the U.N. with only North Korea, Venezuela and Iran?&nbsp

Obama:  It (the plan) will keep government out of health care decisions.

Truth-O-Meter Score: 0 – The public plan has the benefits committee to decide what will be covered, what can be done, and how much you pay. (Page 30-34 HR 3200)(Page 30-34 HR 3200)  To be Clinton-esque, I guess we need to know what t “Government” means.   If it means a White House Cabinet position that selects a committee to manage all aspects of care and cost,  I think that means “government”.  


OBAMA:  The Current system does not provide incentives for you to take the Blue Pill at half the cost of the Red Pill.  

Truth-O-Meter Score:  03 – Perhaps the biggest misrepresentation about the current system.  This statement may have hurt his credibility since it is probably one of the few things that American’s with Rx Cards know about first hand.   If the Blue Pill (generic) is ½ the cost of the Red Pill (name brand, or non-formulary) and you want the Red Pill, you the consumer pay 100% of the cost difference.   Now, in most government plans, that penalty does not exist.  In the VA or Medicare Part D just doesn’t’t offer the Red drug in any form.  Guess what he meant by “incentive” is to “ban”.

Jake Tapper, Sr. White House Correspondent asked: What Sacrifices will the American People going to have to make aside from taxes?   “You aren’t telling people about what they give up, like end of life care, tests and choice”…  President Obama answered that people will have to give up paying for things they don’t need.  He went on to say ‘Now it might be the right thing to take out kids tonsils, but we want the doctor to check for allergies.  (Huh?)  If the President believes that your doctor is about putting kids into surgery to get money, we have a problem. 


If the government took over the now profitable banking industry (including Goldman Sachs), the oil industry and the insurance industry together, we could all have this healthcare at a low-low cost, no new taxes, Gasoline for $1.50 per gallon, and much lower interest rates.   All in favor?   NO, I hope.


Don’t be Against Healthcare Reform, be against HR 3200.  Be against a government run health care plan that will take away your competitive choice and will outlawing your choice to get private health care.

Who is uninsured and who pays?

It’s not just Federal Taxes that will go up.   State and local taxes will too. 

We all know that there is going to be a cost for healthcare reform.   Collectively we all know that major reform is necessary and that most of the criticisms of the current system have some serious validity.   The majority of the issues will be addressed by mandating coverage for all, eliminating preexisting condition clauses, and allowing for guaranteed access to health insurance.   It isn’t the need for reform that is contended here.   It is how these changes are implemented that are, and should be, seriously debated.  

We believe that the implementation of current legislation is predatory, unfair, and a power grab to federalize the health care industry.   Please note, not the insurance industry, the ENTIRE HEALTH CARE INDUSTRY.

The argument that a federal bureaucrat is less desirable than an industry bureaucratic is a debate that can last for years, so let’s avoid it.   Let’s focus simply on what it means to each of us. 

Aside from the federal tax burden and structure, each State will be burdened with additional responsibilities that will require significant amount of additional revenue.   Medicaid roles will likely grow by 40-50% based on the mandatory enrollment of those currently not enrolled and the expansion of the rules of eligibility for Medicaid.  

Under the current structure, the State and Federal government share the cost of Medicaid by a formula where wealthier States pay 50%, poorer States pay as little as 23%.   The additional members into Medicaid would most likely increase the ballooning Medicaid costs by another $200 billion annually.   You can figure that half of that will fall to the State to be paid.   States with higher uninsured percentages might see their actual Medicaid costs rise by 100%.  

Let’s do some Math for my home State of Illinois using population averages.   The current Total Medicaid Cost per year, estimated $350-400 billion.   Illinois is about 3.25% of the national population.    That puts Illinois at total costs around $12-$14 billion.   With Illinois being in the middle of uninsured and income qualification, Illinois would add about 50% to their roles, adding perhaps $6-$7 billion in annual costs.   Of that $6-$7 billion, the State would need to fund another $3-$3.5 under the new federal plan, per year, increasing at 12% per year.     In States like California, the additional burden could exceed $25 billion per year using the same formulas.  

With sales tax revenues in each State falling (prediction) due to higher federal tax burdens, leaving less disposable income and purchasing power, this plan looks to be worse each day.  

Obama Healthcare speech :update 7/21/09

President Obama appears to be giving daily updates on Healthcare legislation and progress.   Here is a bullet point review of some of his noon statements today with  and fact checks.     

  • Objections (to reform) are Politically based –  Doesn’t pan out.  This isn’t about $30 million for the Harvest Mouse in Nancy Pelosi’s district that was essential in the economic stimulus bill in 2/2009.   This is about a $2.5 Trillion threat to scrap a healthcare system that, right or wrong, has existed for 60 years and, with all it’s flaws, does currently cover over 250 million people.  The Auto Industry has been nationalized,  The banking system has been nationalized, now the healthcare system is in the sights.   (*note to union bosses-  if you got one I can join, please add me now, I need to be protected)
  • People will be able to keep their plan if they like it –     Not really.   If your employer plan is changed, and you have employer insurance, you get what your employer decides.   There is no provision that allow you to go rouge.   Since there appears to be little or no ability for a private insurer to remain in business, and since the mandates will change the plans and coverage, it’s a stretch to even imply that you can keep your plan.    Sort of reminds me of being 16 and asking my parents if I can buy something superfluous .    The old “it’s your choice, your 16 now” rings in my head.   I might be able to do it, but I will pay for it in ways that I couldn’t imagine.   
  • If you like your provider you can keep them – FALSE –   Anyone who has ever gone into an HMO knows that your provider must be in the HMO.    The government HMO will NOT include all providers.  
  • Mandated will include Out of Pocket Limits with each policy: –  Probably a good thing – Call it agree  We consistently see people buy insurance for no other apparent reason that to “have” insurance.  If things don’t go right, they can’t afford to pay their share.   Insurance should protect you from catastrophe, not take $10 off your Rx bill.   Having standardized guidelines for Medicare supplements for seniors has been a very good thing.   It protects the seniors and lets carriers truly compete.  
  • Waiver of Preexisting condition clause for all: Definitely Agree –  Without mandates to carry coverage, only those that need coverage today would have it.   With mandates for coverage,  and even if the government kept out of the competition altogether, added taxes, and provided subsidies for insurance based on income, all insurance companies would be glad to compete on that level and offer guarantee to issue coverage with no pre-ex clause.  Please note “insurance carriers would love that”.   That would not be a great thing for consumers.   If you add that the federal government mandated that providers charge the same amount to all members, it would create a private system of competition that would most definitely lower the cost of healthcare for all.    I don’t think this would ever happen because it would mean that Medicare would no longer get private subsidies.     
  • Quoting Here : “Incentive that you get the best care, not just the most expensive”:  What does that mean??  Time for a history lesson from the 1980’s.  During the 1980’s Aetna HMO actuaries concluded that if they could promote preventive care for it’s members that the cost of preventive care for all would reduce the likelihood of major claims later.   A bonus based system to reward their physicians was set up that paid bonuses to doctors who promoted well care and had a healthier group of patients.   What the actuaries couldn’t believe is metaphorically similar to the financial meltdown we nearly had in 2008.   In 2008, financial institutions made loans that they did not believe could be paid back.  In the 1980’s Primary care doctors withheld tests and treatment to their members to meet the “healthy bonus” criteria as defined by Aetna’s HMO bonus program.  Massive litigation found Aetna guilty of conspiratorial actions to incent doctors to present false data.     I don’t how or why the government thinks that they can formulate incentives with adequate protections for patients.   
  • The cost of benefits has risen 3x the rate in the growth of wages  –  it’s true.   What is implied is that existing government policies haven’t  demanded more from private system subsidies.   When Medicare cuts it’s reimbursements to providers, the provider turns around and raises the cost to private patients to offset the loss of revenue from Medicare.    You may be reading how Drug companies have agreed to cut the cost of drugs by 50% to Medicare Part D patients who are in their donut hole of coverage.   The end result will be an increase in costs to the private sector to offset that revenue loss.    The government is critical of private insurers denial of claims, yet somehow, omnipresently will be able to reduce costs without rationing healthcare even though a public system would have no profit motive.  This is contrary to logic or sound business principals.   

The tone of rhetoric today was more focused on constructive advances with highlights of several points that the majority of reasonable people agree on, Republican and Democrat.   A thoughtful and purposeful advance of the principals we agree on:  No preex clause, guaranteed access to coverage, and reasonable mandates will make it if we can all keep our wits.   Change can happen.   Not everyone will be thrilled, but the bills, as they stand, are still today unacceptable.  

Special thanks to Mayo Clinic who posted this rebuke of HR 3200 and the current bills under consideration :  
The Clinics Health Policy Blog, one of the most respected medical institutions in the nation said: “The proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite.”

A view of healthcare under HR 3200

If anyone has seen any other general projections of how it would work for individuals or families, please let me fact check it. 

I get a significant number of private emails daily with fears and anxiety about what these bills will do to them.   Some people are for it some against it.   There seems to be a vacuum of conjecture for what healthcare will look like under this bill.    Here is my projection of how it will work for individuals and businesses under HR 3200.. 

Big picture:  Everyone must have health insurance protection.  No exceptions.  

For the Employer:

  • Employers must purchase health insurance for employees or pay a FICA type tax.  The private marketplace would still exist for a while.  A private plan will be the appx. equivalent cost of about $6000 per employee for single coverage from an insurer.   The plan, offered by private insurance, expense will be the will be the employers’ burden.  The plan will have a set of minimum and maximum criteria of coverage. 

  • Link to bill:  (page 146)

    • Employer will pay 72.5% minimum of plan for singles

    • Employer will pay 65% of depednents..

    • Employer will pay percentage of full time hours for part-time EE’s. 

  • If the employer does not want to buy private insurance they would pay a tax of appx 8% of total payroll or enroll in the Federal system.  

  • As time goes on, the bill provides for employers to have to pay the tax for employees who don’t even elect their plan because they are covered by a spouse or other coverage.   

  • The government will offer a basic HMO plan with copayments and out of pocket expenses minimum and maximum criteria.  It will be much lower cost than private insurance,  since it will reimburse providers at much lower levels.      Estimated Cost $5000 per person on the plan of which the employer pays their percentage.   
  • With healthcare being 15% of the GNP, and the FICA type tax being around 8-10%, we believe that most employers will opt for the tax or government plan.  As an employer, I surmise I would enroll my employees in the government plan.    

For Individuals

  • If you don’t have employer based government or private healthcare, you will be mandated to enroll in coverage.  

  • Individuals will be offered guarantee issue health plans from the government buying into the Govt. HMO or private health insurers if they exist.   (One of the bills says that if your employer doesn’t offer the healthcare package, you will have to enroll in the Government plan)   The pricing of the government HMO will be low since the government plan will reimburse providers at a lower level than private insurance.   (Please note: For the past two years, several insurance companies have been calling for the elimination of pre-ex clause and underwriting.  This must be paired with mandates to participate else people will buy insurance only after a diagnosis of disease)

  • Individuals must purchase insurance else they pay a tax penalty plus bracket increases in all tax rates.  (it is unclear what happens to someone that decides to go down the penalty route) I think it’s fair to believe that you if you try to go stealth and not purchase anything, the penalties will be significant. 

  • Ultimately, you will end up on a government HMO funded by taxes and fees.   If we optimistically assume that healthcare costs are reduced by 10%, (Congressional budget office says “no”), you should expect your HMO to cost you 15% of your income.   In addition to that you should assume that taxes will take an extra 2-3% of your income off the top to fund coverage for the poor.   Those that make in excess of $300,000 annually might end up paying $40,000-$50,000 in additional government controlled healthcare fees.   (3% income tax – 8% payroll tax, $12,000 in user fees for a family of four)  

Insurance Companies:  

  • As the Government plan takes more “higher priced” payers from the private sector into the public sector, providers will need to drive up the Private sector fees more and more, creating an even wider gap from what the government plan pays and the private plans pay for the same service.  

  • Most Private sector plans, as we know them would quickly disappear because of the inability to compete.   If they pay $3 for the same service that the government mandates only a $1 payment, there won’t be enough members to effectively spread out the fixed cost overhead. 

The Sale able parts of the bills and things most agree would be good:  

  • The preexisting condition clauses will go away. 
  • There will be annual open enrollment periods to pick your plan with no chance of being declined.  (this assumes that private insurance could exist in this environment.    
  • Out of pocket limits on plans offered so that the insurance you have won’t bankrupt you anyway.  

The Danger of HR 3200: 
It’s not t
he Single Payer system that scares me, as a consumer.  It’s the Section 4507 of the Balanced Budget amendment that allows doctors to opt out of the system.  Good providers will exit the system, and create a new system of CASH PAY healthcare. IF you are middle class, or even upper-middle class, I would plan on a system that has longer lines.   Lower income people have faced this indignity for years, perhaps this is payback for a system that has a lack of compassion for those less fortunate.   Indeed the wake up bell is ringing loudly. Perhaps that is the strategy of the Democrats to threaten the majority to be treated like the minority.   Bell Heard, loud and clear.    Perhaps we should all pay-up and support a system that cares for the poor, unhealthy, and indigent better.   I don’t want to have their system.  

Section 4507 of BBA – Denies your right to healthcare, even at your cost.

Huh?  What’s that and why does it matter?

Back when Congress and the American Public cared about having a balanced budget, a section of the 1997 Balanced Budget act was injected to allow high priced doctors to opt out of Medicare and not be subject to any price controls.  In return for that, it prohibits doctors from participating in Medicare for two years and treating any patient without the patient agreeing that the patient is 100% responsible for payment and that Medicare deemed the treatment unnecessary.   This “PRIVATE CONTRACTING” has created a under the radar type, of better quality healthcare available only to those that can and will pay for it.  

Medicare patients may have limited legal access to a private agreement with a physician only if the Medicare bureaucracy considers the particular service desired to be uncovered or “unnecessary” or potentially “unnecessary.” If a medical service is “covered” by Medicare and is deemed “necessary” by the Medicare bureaucracy, then a Medicare patient may not contract privately with a doctor for it, even if that service is vital to improving health or quality of life or would be life-saving.  ( I better source that now:  For a discussion of Section 4507, see John S. Hoff, Medicare Private Contracting: Paternalism or Autonomy (Washington, D.C.: AEI Press, 1998); see also Robert E. Moffit, “How Congress Can Restore the Freedom of Senior Citizens to Make Private Agreements with Their Doctors,” Heritage Foundation Backgrounder No. 1209, August 3, 1998. –

We believe that the middle class, which we define as 2x-5x the 2009 Federal Poverty Level, (for a single $21,660 annual income, to a family of four with $110,250) to be most severely impacted by a rationed healthcare plan.    This group of people will only get healthcare from the “public plan” and may not be able to pay for private healthcare.