The Obama administration and its public health agencies have mishandled the Ebola crisis

October 13th, 2014

The CDC has been aware of the lethality of Ebola for decades.

 I have been listening to the Obama administration’s public health officials continually state that there is no need to terminate incoming travel into the U. S. from the West Africa Ebola hot zones. These public health officials justify their inaction with statements that limiting travel from countries in the hot zone will damage the West African nations’ economies, or make it difficult to get supplies and healthcare personnel into these countries, or make other nations less likely to announce, in the future, that they may have similar disease scenarios. These are baseless reasons for not enforcing a travel ban into the U. S. They defy common sense. They abandon the duty of the Obama administration’s public health officials to protect the American people from a deadly disease.

 The correct public health action would have been to ban travel from West Africa until the Ebola crisis could be contained and managed. That would have eliminated the present situation of Ebola becoming a viable entity in the U. S.

 Common sense dictated a ban.

 The Obama administration should rethink its Ebola policy and initiate a travel ban immediately.

U. S. House Bill to address primary care physician shortage has only a 1% chance of being enacted

October 9th, 2014

An important U. S. House of Representatives Bill designed to increase primary care physicians is only given a 1% chance of being enacted. If the Bill is structured differently, its chance of passage would be greater.

 On September 16th, a Bill [H.R. 5498] was introduced to the U. S. House of Representatives. It attempts to reduce the primary care physician shortage by enticing primary care physicians, who have left active clinical practice, to return to active practice. The Bill is titled: “To establish a demonstration program to facilitate physician reentry into clinical practice to provide primary health services.“

 The justification for the demonstration pilot programs is a forecasted shortage of primary care physicians that will reach 45,000 by the year 2020. The shortage of all types of physicians will surpass 130,000 by 2025.

 The Bill wants to conduct a demonstration pilot project in each of the 10 regions served by the U. S. Department of Health and Human Services.

 The Bill authorizes grant funds to be appropriated to carry out the projects for fiscal year 2015.

 Any physician participating in these reentry projects must agree to provide primary care services in a health center for the medically underserved, a Veterans Administration Medical Center, or a school based health center for not less than two years.

 There are two primary structural flaws to this attempt to induce primary care physicians to reenter active clinical practice:

 1.    There is no need of demonstration projects.

 Primary care physicians, who have previously been educated, trained, and engaged in active clinical practice, simply need a three to six month re-introduction to clinical practice.  Such a program should be aligned with existing primary care residency and fellowship programs. These programs have the structure needed for a reentry program. Participating in these programs would be enough to update reentering physicians. The institutions, residents and reentering physicians would all benefit from this arrangement.

2.    The Bill has a built in penalty for any physician that seeks reentry through it.

If you want to entice primary care physicians to reenter active clinical practice you must make it worth their while. Requiring a two-year period of indentured servitude is not an enticement. It is the opposite and will severely limit the pool of physicians who will consider reentry.

 Also, most reentering primary care physicians may only want to work part-time. Forcing them to make a full-time commitment will limit the pool of primary care physicians considering reentry.

The need to bring back primary care physicians to active clinical practice has to be done simply and quickly. There is no need for demonstration projects. Structured vehicles to accomplish this already exist. Use them.

A military strategy is needed to deal with ISIS

September 1st, 2014

Fact: ISIS has explicitly stated it intends to attack, terrorize and destroy the United States mainland and Western Europe.

Fact: The U.S. government has known about this threat for a long time but has not reacted to it.

Fact: In January of 2014, President Obama told New Yorker magazine’s David Remnick that ISIS, which was then still considered a part of al Qaeda, fighting in Syria was like a JV basketball team.

Fact: President Obama, on August 29, 2014, told the World that “We don’t have a strategy yet” for ISIS in Syria.

Fact: ISIS leadership is based in Syria.

Fact: ISIS is a much greater threat to Western Civilization than Al Qaeda ever was.

Fact: ISIS is a splintered form of Saudi Arabia’s Sunni Wahabi Islam that has become more dogmatic and barbaric than the Saudi’s anticipated.

Fact: The ISIS form of Islam operates on the premise that any person who declares that he or she will not conform to the ISIS form of Islam must be killed.

Fact: The Sunni’s of Iraq have become acutely aware that ISIS’s Sunni Wahabi form of Islam does not accept or support all Sunni’s and Shiites.

Fact: All Middle East Muslims, including Saudi Arabia, now fear the spread of ISIS.

With the advent of ISIS taking control of part of Syria and Iraq the remainder of the Islamic countries in the region are aware that ISIS is not simply interested in creating a limited Islamic State. ISIS wants to conquer the remainder of Islam and then proceed to conquer the remainder of the non-Islamic world.

Strategy to deal with ISIS:

The only strategy that can be considered is a military strategy. Such a strategy must have a clearly defined end, ways of applying force to reach the end and means consisting of instruments and resources that can be used in order to achieve the end.

End: The only end that can be applied to ISIS, is the clear destruction of ISIS. A Carthaginian Solution that results in the total destruction of ISIS so that it can never be reborn.

Ways: A coalition of regional forces must be quickly assembled to respond to the ISIS threat.

ISIS leadership based in Syria must be destroyed quickly.

The remainder of ISIS must then be destroyed.

Means: U.S. and Western Europe must join the coalition and give the regional powers the support needed in the form of intelligence, arms, airpower and ground support as needed.

Saudi Arabia has sufficient airpower to make a major contribution. The Kurds have the desire and ability to defend their territory. The Iraqis, both Sunni and Shiite, know that ISIS intends to make both subservient. Jordan’s survival is on the line. Syria’s survival is also on the line. Iran, as a Shiite nation, is a target for ISIS. The entire Middle East is subject to the ISIS threat. The entire region has a vested interest in destroying ISIS. They should supply effective manpower to do so.

If the regional powers do not marshal their forces, then the West should act alone and destroy ISIS. But, do so with the utmost efficiency possible. Do not fight in major cities with ground forces, simply bomb the cities with ISIS presence to the ground. Then go in when everything is leveled.

Send a message to the World that the West must not be threatened. Make those, who desire to terrorize us, think twice before acting. Machiavelli said it best: “Better to be feared than loved, if you cannot be both.”

War weary U. S. does not want to go back into the Middle East. But sometimes, reality does not give one a choice. President Obama should have little trouble in coming up with a strategy to deal with ISIS. I am sure that the Department of Defense has presented multiple strategies to him already. It is better to act sooner than later in this situation.

Speaker Boehner’s lawsuit against President Obama will be accepted and heard by the Court

August 4th, 2014

Again, the “political experts” on cable TV continue to state that Speaker Boehner’s lawsuit against President Obama is a “stunt” and will not be accepted by the Court because it addresses a “political question.” But, the problem with this argument is that Speaker Boehner’s lawsuit will address a question of constitutional law, not a political question.

President Obama and his administration unilaterally delayed the clearly defined implementation date of the employer mandate of the Affordable Care Act [Obamacare].

A political question is an issue that is controlled by the decision-making authority of elected politicians that is outside of the domain of constitutional law. When a law is clear on when it must be executed, there is no decision to be made by the President concerning the time to implement. He must execute the law and implement it as the law requires. Article 2 of the U. S. Constitution directs the President to “take care that the laws be faithfully executed.” A failure to do so is a breach of the U. S. Constitution, the supreme law of the land.

The lawsuit will ask the Court to resolve a legal question, not a political one. Simply put, did President Obama violate the U. S. constitution by refusing to implement a law, which the President acknowledges was prescribed by Congress and is a valid and constitutional law?

Even if there was some political undertone to the issue, the Court must still address it as Chief Justice Burger confirmed in 1983:

 “It is correct that this controversy may, in a sense, be termed ‘political.’ But the presence of constitutional issues with significant political overtones does not automatically invoke [462 U.S. 919, 943] the political question doctrine. Resolution of litigation challenging the constitutional authority of one of the three branches cannot be evaded by courts because the issues have political implications in the sense urged by Congress. Marbury v. Madison, 1 Cranch 137 (1803), was also a ‘political’ case, involving as it did claims under a judicial commission alleged to have been duly signed by the President but not delivered. But ‘courts cannot reject as ‘no law suit’ a bona fide controversy as to whether some action denominated ‘political’ exceeds constitutional authority.’ Baker v. Carr, supra, at 217.” INS v. Chadra, 462 U.S. 919, 942-43 (1983).

Chief Justice Burger continued on to say:

“Chief Justice Marshall observed: ‘It is the peculiar province of the legislature to prescribe general rules for the government of society; the application of those rules to individuals in society would seem to be the duty of other departments.’ Fletcher v. Peck, 6 Cranch 87, 136 (1810). In my view, when Congress undertook to apply its rules to Chadha, it exceeded the scope of its constitutionally prescribed authority.’” INS v. Chadra at 967.

So, if Congress’s action against Chadra exceeded the scope of Congress’s constitutional authority and required the Court to rule against Congress, then so should the Court rule on the President’s refusal to exercise his constitutional duty to execute a law that was prescribed by Congress. Each is a constitutional question.

Congress represents the citizens of the United States. The U. S. Constitution gives Congress the duty to enact laws for the benefit of U. S. citizens. A President’s unilateral refusal to see that these enacted laws are faithfully executed disenfranchises the citizens of the United States from their Congressional representation. This is a clear violation of the U. S. Constitution.

Congress has a duty to move to correct this.

Recent Court decisions on Obamacare subsidies highlight political judicial activism

July 28th, 2014

Recently, two separate Federal Courts ruled on whether or not the payment of Obamacare health insurance tax credits [subsidies] are conditioned upon an individual purchasing health insurance through an Exchange run by a State rather than a Federally run exchange. One Court ruled it did matter whether or not the insurance policy was purchased on a State exchange rather than a Federal exchange. The other Court ruled that it did not matter. Two separate rulings on the same issue and same facts. Why did this difference occur?

The Court ruling that health insurance tax credits [subsidies] were only available to those who purchased their insurance from a State exchange was composed of two Judges appointed by Republican Presidents and one judge appointed by a Democratic President. The Democratic judge dissented against the ruling of the two Republican judges who favored the position that tax credits [subsidies] were only available for health insurance policies purchased on State exchanges.

The other Court consisted of three judges appointed by Democratic Presidents. They all ruled that it did not matter if an individual purchased insurance from a State or Federal exchange.

The decisions in each Court were strictly along party lines. It seems like political judicial activism.

Obamacare provides a tax credit [subsidy] for a qualified health plan offered in the individual market within a State which covers the taxpayer, the taxpayer’s spouse, or any dependent of the taxpayer … “that was enrolled in through an Exchange established by the State under [§] 1311 of the Patient Protection and Affordable Care Act.”

The verbiage of Obamacare is specific. It says that tax credits [subsidies] are only allowed for insurance policies purchased through State exchanges. It does not say they are available for policies purchased on Federal exchanges.

In January 2012, Jonathan Gruber, an MIT professor, who played a key role in helping write the Affordable Care Act [Obamacare] for Congress, publicly said:

“What’s important to remember politically about this is if you’re a state and you don’t set up an exchange, that means your citizens don’t get their tax credits—but your citizens still pay the taxes that support this bill.”

Professor Gruber publicly supported this logic during another speech on a separate occasion.

It seems that a major architect of Obamacare supported the specific verbiage of Obamacare which limits tax credits [subsidies] to policies purchased only on State exchanges.

A Court must ask itself whether or not the verbiage in the statute at issue unambiguously expresses the intent of Congress. The verbiage is not ambiguous. It is specific and does not say that tax credits [subsidies] are available to policies purchased through a Federal exchange. The statutory text is not ambiguous and that is all a Court has to determine.

If the statute’s text, at issue, was ambiguous, the Court could then look into legislative history to determine if the intent of Congress differed from the language of the statute. But, Professor Gruber’s statements support the specific verbiage of the statute at issue.

In the Halbig v. Burwell case, the Court, ruling in favor of the literal acceptance of the statute’s verbiage, correctly said:

“As the Supreme Court explained just this term, ‘an agency may not rewrite clear statutory terms to suit its own sense of how the statute should operate. UARG, 134 S. Ct. at 2446. And neither may we. ‘The role of th[e] [c]ourt is to apply the statute as it is written—even if we think some other approach might ‘accor[d] with good policy … [T]he fact that Congress might have acted with greater clarity or foresight does not give courts a carte blanche to redraft statutes in an effort to achieve that which Congress is perceived to have failed to do.’”

You have to ask yourself why four judges, with Democratic affiliations, ruled the other way?

Democrats in Congress state that they simply forgot to include Federal exchanges in the statute at issue and this should be overlooked. But, it was a statute written by a Democratic Congress and signed into law by a Democratic President. The text is unambiguous. Dr. Gruber’s statement supports that the intent of Congress was the same as the text of the statute. Now, the only recourse is to have the statute changed by Congress. The Courts must not change the statute.

This issue will be resolved when the King v. Burwell case [in which the Court changed the statute to include Federal exchanges] is reviewed by the U. S. Supreme Court.

Speaker Boehner’s lawsuit against President Obama is not a stunt nor is it an attack on Obamacare

July 15th, 2014

I hear “political experts” on cable TV deride Speaker Boehner’s future lawsuit against the President as a cheap stunt and as an attack on Obamacare.  Some in his administration say that the suit will “have no legs,” meaning it will get nowhere because the Speaker has no “standing” to bring a lawsuit.

They are wrong. The suit is not a stunt. Nor is it an attack on Obamacare.

The suit is a means of correcting a harm that has been done to Congress.  The U.S. Constitution created the “Separation of Powers” as a check and balance against an abuse of power by one branch of government.  Article 1 of the Constitution vests the power of creating laws solely with Congress. Article 2 of the Constitution directs the President to “take care that the laws be faithfully executed,” and “preserve and defend the Constitution.”

Congress makes law and the President must insure that law is faithfully executed. The President cannot ignore or change a law. If the President wants a law to change, he must ask Congress to change it.

If the President unilaterally and arbitrarily fails to execute a law or decides to change it, he has usurped the power of Congress. He has harmed the constitutionally granted power of Congress. Congress cannot allow this to occur. If they do, it will indicate that they agree to an unconstitutional erosion of Congressional power and an undermining of the “Separation of Powers.”

President Obama and his administration unilaterally delayed the implementation of the employer mandate of the Affordable Care Act [Obamacare]. The Obama administration did this without getting the agreement of Congress. The employer mandate, as part of Obamacare and to begin in 2014, requires certain employers with 50 or more “full-time equivalent” employees [working 30 or more hours a week] to be fined if they do not provide health care coverage for their employees.

Speaker Boehner’s suit uses this particular constitutional violation as a clear example of the President’s illegal encroachment on the constitutional power of Congress. The problem with the Obama administration’s action is that it cannot ignore a Bill that a Democratic Congress has passed and the Democratic President has signed into Law. That is a clear violation of Article I, Section 7 of the U. S. Constitution.

Speaker Boehner, representing the Congress, must show an injury caused by the President’s action that can be remedied by a favorable decision.  The President’s unconstitutional encroachment on the Congressional power to make law has injured Congress. If the President’s act is allowed to stand it could damage the future of constitutionally granted powers of Congress. A decision in Congress’s favor will remedy the injury to Congress. If the courts look at standing in this fashion, the suit will “have legs.”

President Obama has given Congress no other alternative then to move forward with the lawsuit.

The U.S. Veterans Administration must redefine its mission to that of serving the patient first.

June 10th, 2014

While on sentry duty, in a past war, an unknown soldier etched the following into a checkpoint wall:

“God and the soldier, all men adore in time of danger and not before. When the danger is passed and all things righted, God is forgotten, and the soldier slighted.”

This is what happened during and after the Vietnam War. No one wanted it to happen again, but it has.

The unprepared for demands on the Veterans Administration have insured that many returning soldiers will be and have been “slighted.”

The soldiers, men and women, have and will continue to return home. They have been touched by war both mentally and physically. Let’s make sure that they are not “slighted.” Let’s make sure they get the services and care they need to return to a productive civilian life.

A poem, “The Sacrifice”, by Nancy Meeks aptly describes the long-term effects of war on soldiers: 

“Will he ever find peace here on this earth?

Before death’s fingers encircle his throat

Or will peace remain just beyond his girth

Abandoning him eternally to a land remote

Will no one heed the gutteral cries

Of this bleeding soldier swaying in the wind

Seeing his own soul burning in demonic eyes

Fighting eternal battles which refuse to end.”

Let’s make sure that they find some peace and do not have to continue to fight “battles which refuse to end.”

The VA must redefine its mission as that of serving the patient first and not as serving the bureaucracy first.  

A new Secretary of Veterans Affairs will have to be able to roll up of his or her sleeves and be able to work down to the level of the weeds in order to insure that change will take effect. He or she will also need to have the authority to make changes without delay. This means that he or she must have the authority to terminate and replace bureaucrats.

Military code dictates that no soldier will ever be left behind. When you bring a soldier home and do not care for physical and mental injuries, he or she may be home, but they have been left behind. That is morally and ethically wrong.

A simple fix for the long U. S. Veterans Administration Primary Care wait times

May 21st, 2014

There has been a great deal of press about long primary care appointment wait times and the fact that the Veterans Administration [VA] has intentionally falsified records concerning these long wait times. The long primary care wait times are a result of the VA not having enough primary care physicians.

Why is there a lack of primary care physicians? Is it money? Probably not. The VA has sufficient funding to hire available primary care physicians. The VA is very picky about what primary care physicians it hires. It ignores many qualified physicians for many reasons that do not apply to their clinical skills. To make matters worse, the VA hiring and credentialing process is onerous and takes many months. Most primary care physicians cannot endure an extended credentialing period and opt out of taking a VA position. Because of this, the VA is dependent upon government contractors to supply primary care physicians to the VA on a temporary basis.

So, how can the VA fix this problem? It can:


Recruit and directly hire local retired primary care physicians to work for the VA clinics on a part-time basis. This would take the contractors out of the equation and allow the physicians to make more money. This would naturally result in greater retention of these physicians. The VA would be getting the benefit of primary care physicians with decades of experience. There is no substitute for experience in medicine. There are a lot of retired primary care physicians who would be eager to assist our veterans and insure that they get the care that is their right.


If you want to hire a primary care physician, you cannot expect he or she to wait four to eight months to be credentialed. They cannot start work until they are credentialed. So, make the credentialing process no more than four weeks. Get them working as quickly as possible. That means limiting the hoops you make the physicians jump through.

If the VA did these two things, it would be on the road to recovery and those in need would be insured of receiving the care they deserve.

Physician led Accountable Care Organizations will find long term success difficult to achieve

April 23rd, 2014

There is a basic truth in business management that responsibility requires the authority to match a specific level of responsibility. When there is a mismatch, the probability of management success is very low. Obamacare’s Accountable Care Organizations [ACO] have neglected to consider this truth. ACO’s are designed to impose the responsibility to reduce healthcare costs on the primary care physician, but do not give him the authority needed to execute this responsibility.

Primary care physician led Accountable Care Organizations [ACO] are risk based practice models that should not be attempted by those without prior risk experience, who cannot accept significant upfront costs or accept the possiblity of financial loss. The key to success in managing an ACO is the ability to have the authority to manage the risk necessary to control a patient’s healthcare costs. Without this authority, a primary care ACO cannot succeed on a long-term basis. You may be able to achieve some initial success by trimming low hanging fruit, but continued success will become more difficult to attain over time.

Today, physicians do not have the authority to effectively manage risk. If they did have this authority, there would be no such thing as “defensive medicine.” The fear of medical malpractice litigation is the primary cause of “defensive medicine.” Its impact severely limits the authority a physician has to control the cost of healthcare. Is a physician going to deny a service to a patient or family’s demands if there is the possibility that they may sue him or her or report them to a regulatory board for the refusal? Unlikely.  So, physicians do not have the actual authority needed to practice their profession with the actual authority they need to control healthcare costs.

This mismatch in responsibility and authority will result in an illusion of short-term success which will quickly be replaced by diminishing returns and ever increasing costs needed to manage the administrative systems required by an ACO.

Long term success with physician led ACO’s will be difficult to attain.

Is the American Medical Association ambivalent about Medical Malpractice Reform?

March 10th, 2014

Dr. Ezekiel Emanuel, an architect of Obamacare, recently reported in a Wall Street Journal essay that the American Medical Association’s [AMA] main priorities were concerned with payments for physicians.

Dr. Emanuel reported meeting with his brother, then the White House Chief of Staff, and informing him that he was working on a medical malpractice proposal as part of Obamacare. Dr. Emanuel reported that the White House Chief of Staff told him:

“We are not doing malpractice. Period. Every time the AMA comes in here, they don’t talk about malpractice.”

In referring to his brother’s further comment, Dr. Ezekiel Emanuel continued with:

“Their first, second and third priority, he [the White House Chief of Staff] said, was the formula used by Medicare to determine doctors’ pay.”

The White House Chief of Staff then stated:

“We don’t need to do malpractice for the doctors, and I am not alienating the president’s base for nothing.”

So, it was evident that there was no need to push forward with Medical Malpractice Reform because it was not needed to get the AMA’s support for Obamacare.

As a physician, I find this disconcerting. The AMA is supposed to represent the physicians of the United States. One of the greatest burdens that physicians bear is being subject to medical malpractice litigation. Medical malpractice litigation is the driving force behind the practice of defensive medicine. Defensive medicine is a major component of ever increasing healthcare costs in the United States. So, why would the AMA not aggressively pursue Medical Malpractice Reform when its support for Obamacare was being solicited by the White House? The AMA had the leverage to do it.

You cannot have effective healthcare reform without Medical Malpractice Reform.

I think the AMA has to explain to the physicians of America why it allowed the opportunity for Medical Malpractice Reform to slip through its fingers.

My solution for Medical Malpractice Reform can be found at: