by Kristin S. Held, M.D.
Deceptively, pollsters report that “Medicare For All” is popular with Americans, as the media proclaims healthcare a top concern on voters’ minds a mere two weeks before the midterm election. While many candidates are indeed running on a “Medicare For All” platform, few Americans realize that a Medicare for All bill actually exists, and that it already has 123 Democrat cosponsors. H.R.676, “The Expanded and Improved Medicare For All Act,” was introduced January 24, 2017, by former Representative John Conyers, Jr. (D-MI). Representative Keith Ellison (D-MN) assumed sponsorship when Conyers resigned after 52 years in Congress, amidst multiple allegations of sexual harassment.
If Americans actually knew what was in this bill, pollsters would find rare few supporting it.
The following is a dissection of H.R.676, The Expanded & Improved Medicare For All Act, including much of the exact language as written, which is in bold print.
Who is eligible to be registered in the Medicare For All program?
101. ELIGIBILITY AND REGISTRATION.
(a) IN GENERAL.—All individuals residing in the United States (including any territory of the United States) are covered under the Medicare For All Program entitling them to a universal, best quality standard of care. Each such individual shall receive a card with a unique number in the mail. An individual’s Social Security number shall not be used for purposes of registration under this section.
All individuals residing in the U.S., including any territory of the US, are covered under the Medicare For All program. Notice, the bill covers residents, not just citizens. The HHS Secretary is given the power to define what constitutes residency. Clearly, the political ideology of the party in the White House will impact this definition. Do you become a resident when your caravan crosses the bridge at the U.S. border? Or will there be something more to show, like a water or electricity bill? And, each individual shall receive a card with a unique number in the mail. Congress has repeatedly refused to fund a previous law to assign another number to Americans. Given the government’s record on privacy breaches, what new possibilities for identity theft and other abuses would be unleashed!
What entitlements will Medicare For All provide to all residents of the U.S. and U.S. territories (potentially everyone in the world)? As seen from the text of the bill below, everyone will be theoretically entitled to everything from inpatient care, outpatient care, and prescription drugs to nutritional therapy, long term care, and, of course, palliative care. Again, the presiding political philosophy will play a huge role in determining what care will be provided and for which patients (remember Ezekiel Emanuel’s Complete Lives System of rationing by age and return on society’s investment). Provision of such procedures as abortion and euthanasia may be prohibited, allowed, or even required, and will depend on political ideology in the Congress, White House, and Supreme Court.
SEC. 102. BENEFITS AND PORTABILITY.
(a) In General.—The health care benefits under this Act cover all medically necessary services, including at least the following:
(1) Primary care and prevention
(2) Approved dietary and nutritional therapies.
(3) Inpatient care.
(4) Outpatient care.
(5) Emergency care.
(6) Prescription drugs.
(7) Durable medical equipment.
(8) Long-term care.
(9) Palliative care.
(10) Mental health services.
11) The full scope of dental services, services, including periodontics, oral surgery, and endodontics, but not including cosmetic dentistry.
(12) Substance abuse treatment services.
(13) Chiropractic services, not including electrical stimulation.
(14) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes).
(15) Hearing services, including coverage of hearing aids.
(16) Podiatric care.
Who will provide all the care? The definition of “legally qualified” is unspecified and remains of concern. The government regulatory strings attached to legal qualification and licensure could be long, expensive, coercive, and destructive to physician and patient autonomy.
(b) Portability.—Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits.
What will each beneficiary pay? Reportedly nothing at the time of service; however, I could find no specific mention of premiums in the 18 pages of the bill. Currently, Medicare beneficiaries pay premiums, which are means tested. I suspect means-tested premiums will eventually become part of this as additional layers of compounded redistribution will be added in response to the reality that this Utopian scheme must be paid for.
(c) No Cost-Sharing.—No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.
Section 104 is huge and astounding. This section makes it illegal for health insurers to sell insurance that duplicates benefits of Medicare For All. Government completes the takeover of the entire health insurance industry in one small paragraph. Government becomes the single payer, and the transformation from free-market, patient-centered medicine to socialized medicine that serves the common good of the state is complete.
SEC. 104. PROHIBITION AGAINST DUPLICATING COVERAGE.
(a) In General.—It is unlawful for a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act.
(b) Construction.—Nothing in this Act shall be construed as prohibiting the sale of health insurance coverage for any additional benefits not covered by this Act, such as for cosmetic surgery or other services and items that are not medically necessary.
How on earth will all the elements of this monstrosity be funded? The federal government will dole out monthly lump sums to regions to cover all operating expenses. This is capitation on an unprecedented, mammoth, untested scale. Most of the government’s experience with capitation thus far has been a huge failure.
202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.
(a) Establishing Global Budgets; Monthly Lump Sum.—
(1) IN GENERAL.—The Medicare For All Program, through its regional offices, shall pay each institutional provider of care, including hospitals, nursing homes, community or migrant health centers, home care agencies, or other institutional providers or pre-paid group practices, a monthly lump sum to cover all operating expenses under a global budget.
Who will be conscripted to provide all the free care to all “residents” of the U.S. and U.S. territories? Medicare For All commandeers all “Healthcare” Professionals to work for whatever the system deigns to pay. Medicare’s perverse scoring system (MACRA/MIPS) will likely apply.
(1) IN GENERAL.—The Program shall pay physicians, dentists, doctors of osteopathy, pharmacists, psychologists, chiropractors, doctors of optometry, nurse practitioners, nurse midwives, physicians’ assistants, and other advanced practice clinicians as licensed and regulated by the States by the following payment methods:
(A) Fee for service payment under paragraph (2).
(B) Salaried positions in institutions receiving global budgets under paragraph (3).
(C) Salaried positions within group practices or non-profit health maintenance organizations receiving capitation payments under paragraph (4).
Who will decide what medications are available to you? The government will establish the drug formulary. In other words, the government will decide the list of medications from which clinicians will be able to prescribe. These may not be the best, most effective, most innovative, safest, or even cost-effective drugs, but they will no doubt be the drugs that special interests have paid-off politicians or other players in order to gain favored status. Hundreds of billions of dollars will be squandered and laundered here annually, just as is happening now with the Pharmaceutical Benefits Managers (PBMs) and Group Purchasing Organizations (GPOs) via their racketeering scheme that siphons more than $200 billion annually from patients and taxpayers, inflates drug prices by 30-50%, and creates drug shortages. The government negotiations will continue to be influenced by countless special interest groups that pay to play. Conversely, if politicians refuse to play, the special interests may fund opposition candidates. The level of corruption in the swamp will mushroom. What is best for patients will be nothing but an annoying afterthought.
205. PAYMENT FOR PRESCRIPTION MEDICATIONS, MEDICAL SUPPLIES, AND MEDICALLY NECESSARY ASSISTIVE EQUIPMENT.
(a) Negotiated Prices.—The prices to be paid each year under this Act for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Program.
(b) Prescription Drug Formulary.—
(1) IN GENERAL.—The Program shall establish a prescription drug formulary system, which shall encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.
Where will the money to pay for this impracticable behemoth come from? There is not enough money for Medicare to cover its 60 million beneficiaries now. How will more than 300 million additional U.S. residents be covered? This part is shocking and maddening. The money does not exist, so the Medicare For All bill magically creates a new Medicare For All Trust Fund. It confiscates all money that previously went to Medicare, Medicaid, CHIP, and any other healthcare allocation and transfers it into the Trust Fund. It creates a multitude of new taxes on the American taxpayers—“small” and “modest” being undefined—and increases existing taxes. It then grants itself a blank check and empowers the HHS Secretary to estimate what might have been spent on all healthcare, take that amount from the U.S. Treasury, and deposit it in the Medicare For All Trust Fund. There is no limit on the amount that could be transferred.
211. OVERVIEW: FUNDING THE MEDICARE FOR ALL PROGRAM.
(a) In General.—The Medicare For All Program is to be funded as provided in subsection (c)(1).
(b) Medicare For All Trust Fund.—There shall be established a Medicare For All Trust Fund in which funds provided under this section are deposited and from which expenditures under this Act are made.
(1) IN GENERAL.—There are appropriated to the Medicare For All Trust Fund amounts sufficient to carry out this Act from the following sources:
(A) Existing sources of Federal Government revenues for health care.
(B) Increasing personal income taxes on the top 5 percent income earners.
(C) Instituting a modest and progressive excise tax on payroll and self-employment income.
(D) Instituting a modest tax on unearned income.
(E) Instituting a small tax on stock and bond transactions.
(3) ADDITIONAL ANNUAL APPROPRIATIONS TO MEDICARE FOR ALL PROGRAM.—Additional sums are authorized to be appropriated annually as needed to maintain maximum quality, efficiency, and access under the Program.
212. APPROPRIATIONS FOR EXISTING PROGRAMS.
Notwithstanding any other provision of law, there are hereby transferred and appropriated to carry out this Act, amounts from the Treasury equivalent to the amounts the Secretary estimates would have been appropriated and expended for Federal public health care programs, including funds that would have been appropriated under the Medicare program under title XVIII of the Social Security Act, under the Medicaid program under title XIX of such Act, and under the Children’s Health Insurance Program under title XXI of such Act.
The most frightening part of all is this: the Medicare For All Bill establishes the National Board of Universal Quality and Access, and not even one actual physician is guaranteed to be on it. The Board might include a dietician, a long-term care facility administrator, the head of Planned Parenthood, a labor union representative, and a patient advocate (perhaps an Antifa member), making all our medical decisions for us. They serve six-year terms, but there are no term limits.
305. NATIONAL BOARD OF UNIVERSAL QUALITY AND ACCESS.
(1) IN GENERAL.—There is established a National Board of Universal Quality and Access (in this section referred to as the “Board”) consisting of 15 members appointed by the President, by and with the advice and consent of the Senate.
(2) QUALIFICATIONS.—The appointed members of the Board shall include at least one of each of the following:
(A) Health care professionals.
(B) Representatives of institutional providers of health care.
(C) Representatives of health care advocacy groups.
(D) Representatives of labor unions.
(E) Citizen patient advocates.
(3) TERMS.—Each member shall be appointed for a term of 6 years, except that the President shall stagger the terms of members initially appointed so that the term of no more than 3 members expires in any year.
These unelected government appointees, like Senators and Judges wrapped into one, will decide everything from what equipment can be bought to how much a nurse will be paid and how many hours everyone can work. -The potential for foul play and the weaponization of medicine is breathtaking.
(1) IN GENERAL.—The Board shall meet at least twice per year and shall advise the Secretary and the Director on a regular basis to ensure quality, access, and affordability.
(2) SPECIFIC ISSUES.—The Board shall specifically address the following issues:
(A) Access to care.
(B) Quality improvement.
(C) Efficiency of administration.
(D) Adequacy of budget and funding.
(E) Appropriateness of reimbursement levels of physicians and other providers.
(F) Capital expenditure needs.
(G) Long-term care.
(H) Mental health and substance abuse services.
(I) Staffing levels and working conditions in health care delivery facilities.
The scope of power of these 15 government Appointed Arbiters of Americans’ lives is astounding. They literally have the power to make every single medical decision for every one of us. And when there is no money left in the U.S. Treasury to do anything but offer “healthcare”—not care for the sick or injured—these 15 will allocate the scarce medical resources as they see fit. In ultimate irony, our seniors, the very Americans Medicare was created to help, will likely be the first group to de denied care—other than “palliative” care.
(3) ESTABLISHMENT OF UNIVERSAL, BEST QUALITY STANDARD OF CARE.—The Board shall specifically establish a universal, best quality of standard of care with respect to—
(A) appropriate staffing levels;
(B) appropriate medical technology;
(C) design and scope of work in the health workplace;
(D) best practices; and
(E) salary level and working conditions of physicians, clinicians, nurses, other medical professionals, and appropriate support staff.
The last remaining segments of the medical system would be absorbed soon: the VA in 10 years, the Indian Health Service Program in just five.
TITLE IV—ADDITIONAL PROVISIONS
401. TREATMENT OF VA AND IHS HEALTH PROGRAMS.
(a) VA Health Programs.—This Act provides for health programs of the Department of Veterans’ Affairs to initially remain independent for the 10-year period that begins on the date of the establishment of the Medicare For All Program. After such 10-year period, the Congress shall reevaluate whether such programs shall remain independent or be integrated into the Medicare For All Program.
(b) Indian Health Service Programs.—This Act provides for health programs of the Indian Health Service to initially remain independent for the 5-year period that begins on the date of the establishment of the Medicare For All Program, after which such programs shall be integrated into the Medicare For All Program.
When will this insanity take effect? If Democrats win the House and Senate in 2 weeks, this bill could theoretically become law and take effect one year thereafter. With the Democrats’ fixation on impeachment and overt hatred of our duly elected President of the United States, the possibility is not all that far-fetched.
TITLE V—EFFECTIVE DATE
501. EFFECTIVE DATE.
Except as otherwise specifically provided, this Act shall take effect on the first day of the first year that begins more than 1 year after the date of the enactment of this Act, and shall apply to items and services furnished on or after such date.
American voters must not be deceived. Medicare for All is not compassionate or sustainable. The estimated cost of Medicare For All is $40 TRILLION over 10 years, but this could be reduced to $32.6 trillion if all providers’ pay is cut 40%. This financial undertaking more than doubles current annual healthcare costs from inception, and we know from history that this will become exponentially more expensive as time goes on, as our highly trained workforce and world-class medical facilities are lost.
Medicare For All will not solve all the problems that Medicare For Some created; it will make things tremendously worse. This Bill is an affront to the American people. No one can in good conscience cast a vote for a candidate that is running on such incompetency. Anyone running on this bill either has not read it or is a devout socialist intent on completing the fundamental transformation of the United States of America, destroying the U.S. economy, and shredding our Constitution once and for all.
If we are to secure our blessings of liberty, we must identify and vote against any candidate that supports this Medicare For All bill.
Kristin Story Held, M.D. is a board certified ophthalmologist and ophthalmic surgeon. She is a Phi Beta Kappa Graduate from the University of Texas at Austin and received her medical degree from the University of Texas Medical School at San Antonio where she was elected to AOA. Following her internship in internal medicine and residency in ophthalmology, Dr. Held joined the faculty at the Univ. of TX Health Science Center at San Antonio where she taught residents and medical students and served as Director of the County Ophthalmology Clinic. She maintains an academic affiliation as a Clinical Professor in the Department of Ophthalmology. For the past 20 years she has been in private practice in San Antonio.
On October 1, 2015 her practice became completely third party free. Kris is actively developing an “alternate universe” with a group of San Antonio physicians, where physicians can practice through a direct patient care model called BridgeTwoHealth.com.
Dr. Held served on the healthcare policy advisory team for Dr. Ben Carson during his presidential campaign. She is on the Board of Directors of the Association of American Physicians and Surgeons (AAPS), Co-Founder of AmericanDoctors4Truth.org (which features a template for true patient centered healthcare reform at www.AmericanDoctors4Truth.org), and serves on the National Physicians Council for Healthcare Policy. Dr. Held has read and reported on the Affordable Care Act, MACRA, and the proposed MACRA rules. She served as a member of the Physicians’ Healthcare Workgroup, working with physicians from across the country, including physician Congressman, to draft a template for true patient-centered, market-driven healthcare reform. She received The Shining Scalpel Award from AAPS “In recognition of her outstanding service to the American people and the profession of medicine by ‘cutting’ through the political rhetoric regarding healthcare reform.” She was a cofounder of rebel.md , a site featuring articles written by physicians related to the practice of medicine from the trenches of real life experiences.
Dr. Held met personally with Mr. Andy Slavitt, Acting Administrator of the Center for Medicare and Medicaid services, and his Deputy Directors at the Department of Health and Human Services in Washington, DC to discuss her dissent to MACRA and CMS’s proposed rules and to offer solutions for patient-centered reform. She has traveled to DC countless times over the past 8 years to participate in health policy work advocating Constitutional and free market principles.
Dr. Held has had numerous articles published, including in the Washington Times, The Hill, Journal of American Physicians and Surgeons and Dr. Carson’s AmericanCurrentsee. She has spoken across the country and on radio, television, film, and internet regarding health policy contained in the ACA and MACRA and its effects on patients, physicians, and the practice of American medicine, advocating for the patient-physician relationship and against the government takeover of medicine. She serves on the Medical Executive Committee of the Methodist Ambulatory Surgical Center North Central in San Antonio and serves on the UT Health San Antonio Development Board.
Dr. Held is married and has four daughters; the oldest is a dermatology resident and the second is a 4th year medical student. Her father is a former chairman of neurosurgery, and her mom is a retired R.N. Kris will be a five-year survivor of breast cancer in 2017. Please follow @kksheld on Twitter and follow her blog at KrisHeldMD.wordpress.com.