Small ALR Facility Workgroup meeting April 16, 2019

To: Assisted Living Residence Providers and Stakeholders 

From: Elaine McManis, Home & Community Facilities, Branch Chief

The next ALR Small Facility Workgroup meeting will be Tuesday, April 16 2019, 12:00-2:00 p.m., Building C, Room C1C on our Cherry Creek Campus. 

Due to space constraints, non-workgroup members are invited to attend by phone.

To participate by telephone:
Step #1: Dial 1-712-770-8066 
Step #2: When prompted, dial participant passcode 727084
Step #3: You will be on music hold until a few moments before 12:00 P.M.
Step #4: Very important: Please press 4* and mute your telephone to prevent background noise. 

If you would like to make a comment or ask a question, press 4* to unmute. When you are finished talking, please re-mute your telephone using 4* again. 

Very Important: Do not use speakerphones or wireless headsets; they are not compatible with the audio conferencing technology.

Meeting documents can be found at: 

Registration Open for Rocky Mountain Conference on Dementia

To: Home Health Agency, Nursing Home & Outpatient Physical Therapy, Hospice, Rural Health, Assisted Living Residence, HCBS, Community Mental Health Centers, Community Clinics and Hospital (Long Term)

From: Alzheimer’s Association Colorado Chapter

An estimated 750 medical professionals, persons living with Mild Cognitive Impairment and early dementia, and professional caregivers will gather on Monday, April 29, for the 30th annual Rocky Mountain Conference on Dementia, hosted by the Colorado Chapter of the Alzheimer’s Association. 

Registration is now open for the one-day conference, which will be held from 7:30 a.m. to 4:30 p.m. at the Hyatt Regency Denver Tech Center, 7800 E. Tufts Ave., Denver. Certificate of attendance for 8 hours of education is included. 

The current state of research to develop a prevention, treatment or cure for Alzheimer’s will be the focus of opening keynote speaker Dr. Rebecca Edelmayer, director of Scientific Engagement for the Alzheimer’s Association. 

To learn more about the Rocky Mountain Conference on Dementia, or to register, go to or call the free Alzheimer’s Association Helpline at 800-272-3900. 

Thank you

Alzheimer’s Assoc Rocky Mt Conference on Dementia 042919-Register Now

Small ALR Facility Workgroup meeting April 9, 2019

To: Assisted Living Residence Providers and Stakeholders 

From: Elaine McManis, Home & Community Facilities, Branch Chief

The next ALR Small Facility Workgroup meeting will be Tuesday, April 9, 2019, 2:00-4:00 p.m., Building C, Room C1D on our Cherry Creek Campus. 

Due to space constraints, non-workgroup members are invited to attend by phone.

To participate by telephone:
Step #1: Dial 1-712-770-8066 



First the NIH Came for the Iranian Born Legal US Resident Scientists

Transparency, honesty, and collaboration are necessary to do science, including biomedical and clinical science right.  In the US, the National Institutes of Health (NIH) have always had a good reputation for transparency, honesty and collaboration, although they have had some revolving door and conflict of interest issues of late (look here, here, here here, and here).

However, an April 3 article in the Washington Post suggests that things are going downhill. The lede was:

The National Institutes of Health is requiring all visitors — including patients — to disclose their citizenship as a condition of entry, a policy that has unnerved staff scientists and led to recent disputes with at least two Iranian scientists invited to make presentations, only to be blocked from campus.

The most important point was that although the two scientists were born in Iran, they were both legal US residents who had apparently lived in this country for a long time.

In one incident, a Georgetown University graduate student arriving for a job interview was held up at security, then allowed to proceed to one of the campus buildings. But as he prepared to make a presentation, NIH police arrived, removed him from a lab and escorted him off campus, according to a complaint Monday to a group that represents staff scientists.

In another, a brain researcher said he was told to leave, then delayed at security for nearly an hour filling out online forms. After interventions by NIH police and other officials, he was told an exception had been made that would allow him to deliver his presentation to the two dozen waiting researchers.

Both men had green cards and U.S. driver’s licenses and had previously visited NIH without incident.

There was no obvious reason,other than their Iranian birth, to be suspicious of these two men. In particular,

‘I am very surprised and disappointed that there are all these restrictions,’ said the brain researcher, who spoke on the condition of anonymity to avoid jeopardizing his relationships at NIH. He said he worked at NIH from 2009 to 2014 on an H-1B visa and had been invited to speak on his specialty last week. As recently as two months ago, he said, he had no problem entering the campus.

The actions seemed to have had their genesis in a post 9/11 policy that was never previously enforced.

NIH officials say the policy is not new — although they acknowledge posting a sign recently that says all visitors must disclose their citizenship in the NIH security building, known as the Gateway Center. People who work at the Bethesda, Md., campus said they had never heard of such questioning until the past few weeks.

An April 2 email obtained by The Washington Post describes a senior-level meeting Tuesday, at which the chief executive of the NIH Clinical Center, James Gilman, recounted how a long-standing policy ‘was never followed, and apparently in the past few days, security started following it, including signs at the visitor entrances that say they will ask for it [citizenship],’ according to a person who attended the meeting.

The excuse may be that the agency has recently come under congressional pressure to be more vigilant about industrial espionage, especially having to do with China.

In recent months, NIH and the FBI have warned U.S. scientists to beware of Chinese spies intent on stealing biomedical research from NIH-funded laboratories at universities.

Under pressure from lawmakers, led by Sen. Charles E. Grassley (R-Iowa), NIH said in January it had referred 12 allegations of foreign influence over U.S. research to the HHS inspector general.

What the reported events had to do with China or industrial espionage is not obvious.  The Post article did suggest that

NIH — a research institution built on collaboration — is apparently following protocols used by federal security agencies that deal with highly sensitive or classified information and require top-secret security clearances for their employees. Visitors to those facilities must disclose their citizenship, and foreign nationals are provided with a badge different from those worn by U.S. citizens, security officials said.

Again, why the NIH should be viewed as similar to agencies dealing with top-secret information is unclear.

At least some NIH scientists are voicing concern about the new policies

One NIH researcher, G. Marius Clore, forwarded a complaint Monday to an elected committee that represents scientific staff, according to a summary of his remarks obtained by The Post. In the summary, Clore is quoted as saying that the incident involving the Georgetown graduate student is ‘something that [NIH leadership] needs to address right away. If this sort of thing gets out, nobody is going to want to come and work at NIH.’

An Apology, but No Clear Changes

A second Washington Post story, of course published late on a Friday, indicated that Dr Francis Collins, Director of the NIH, apologized for the treatment of the two Iranian born US legal residents:

In an email Friday to all NIH personnel, Collins said he is ‘deeply troubled’ that a Georgetown University graduate student was interrupted during a presentation that was part of an application for a postdoctoral fellowship and escorted from campus. He said he has ‘extended a personal apology to this individual.’

‘I also have learned of another non-U. S. citizen who had to miss the first day of a two-day meeting because of visitor clearance issues. I am also reaching out to that person to express regret,’ Collins wrote.

In the email, Collins said the visitor clearance process ‘was mishandled by security staff.’

Note that he did not acknowledge that the two scientists were legal US residents.

More importantly, Dr Collins did not personally acknowledge responsibility for his security staff’s actions, indicate that he actually could control their actions, or promise any change in the policy.  At best, his email stated:

This policy has not been well communicated.


We are reviewing procedures associated with this policy to ensure that all our guests, no matter where they are from, are treated with utmost respect and consideration, and that NIH staff understand their responsiblities in ensuring the necessary requirements are met.

Again, he did not state that NIH security would stop asking visitors about their citizenship, or would not restrict access to non-secret activities or facilities according to peoples’ place of birth.

So far, despite its implications, this case seems to be relatively anechoic.  The first WaPo article has appeared in other papers, and a summary of it appeared in The Scientist.  However, I have found nothing more so far other than the WaPo story of the “apology.”


Impeding collaborations at the NIH with scientists who come from particular disfavored countries obviously could impede the progress of biomedical and clinical science.

Note that the WaPo article suggested that citizenship questions are also being asked of patients entering the campus, raising the spectre of patients born in disfavored countries being denied care.  That could obviously harm their care.

Furthermore, active discrimination by a US government agency against scientists and patients according to their place of birth seems to deny their “equal protection under the law,” as promised by the 14th amendment to the US Constitution.

Finally, a government institution involved in science and health care discriminating against people according to their ethnicity has a certain whiff of dictatorship and fascism. This whiff is accentuated under a regime that has a track record of singling out people by their ethnicity and/or religion.  As we noted here, its previously proposed bans of immigrants from certain countries has already impacted health care.  As Martin Neimoller famously wrote regarding the Nazi regime in Germany,

First they came for the socialists, and I did not speak out—because I was not a socialist.

Then they came for the trade unionists, and I did not speak out— because I was not a trade unionist.

Then they came for the Jews, and I did not speak out—because I was not a Jew.

Then they came for me—and there was no one left to speak for me.

 Visitors stand in front of the quotation from Martin Niemöller
that is on display in the Permanent Exhibition of the United States
Holocaust Memorial Museum. Niemöller was a Lutheran minister and early
Nazi supporter who was later imprisoned for opposing Hitler’s regime. – US Holocaust Memorial Museum

Who will speak for the Iranian born scientists kept out of the NIH?

It certainly make sense for the US to be on guard for industrial espionage.  But this goes way too far. 

OASIS D Classes *FREE*

To: Federally Certified Skilled Home Health Facilities Administrators, Directors of Nursing, OASIS Coordinators, Billing and Coding Personnel, Licensed Home Health Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

ETA will offer classes on specific OASIS topics in Craig, Colorado Springs, Pueblo and Montrose featuring OASIS D items and guidance. Boulder sessions are waiting list only. You may choose to take sessions all at once or individually as your interest and needs dictate. All registration is first-come, first-served, even for sessions within a hosting facility.

ETA reserves the right to cancel classes with low registration. Early registration is helpful.

OASIS D Basics (One Session): Course ID 1082008
This beginning three-hour class is how to get started with OASIS D.

OASIS D Item-by-Item (2 Sessions): Course ID 1082009
This practical application class reviews item-by-item data set completion. We will follow Mrs. Green’s assessment, which will require two sessions to complete. Attendance at both sessions is required to complete this class.

OASIS Quality Measures (One Session): Course ID 1066910
This course assumes familiarity with the OASIS D Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to 
2. Log in to your existing TRAIN account, or new users click “Create an Account”
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course.
5. Click the “Registration” tab.
6. Click the “Register” button for the session you wish to attend.
7. Remember to register separately for each desired course.

A detailed example of the above process (if needed)

Questions?: Please email

Why Did the Head of the Center for Medicare and Medicaid Services Outsource Communications Functions to Private Public Relations Firms? – Ethical and Legal Questions

There is now never a dull moment at the Center for Medicare and Medicaid Services (CMS) an agency of the US Department of Health and Human Services (DHHS).  Its current director, Seema Verma, has developed a more efficient way to combine conflicts of interest with self-interest, bad management, and possibly worse.

Outsourcing CMS Communications to Private Public Relations Firms

In summary, Politico reported

The Trump appointee who oversees Medicare, Medicaid and Obamacare [Seema Verma] quietly directed millions of taxpayer dollars in contracts to Republican communications consultants during her tenure atop the agency — including hiring one well-connected GOP media adviser to bolster her public profile.

The communications subcontracts approved by Centers for Medicare and Medicaid Services Administrator Seema Verma — routed through a larger federal contract and described to POLITICO by three individuals with firsthand knowledge of the agreements — represent a sharp break from precedent at the agency. Those deals, managed by Verma’s deputies, came in some cases over the objections of CMS staffers, who raised concerns about her push to use federal funds on GOP consultants and to amplify coverage of Verma’s own work. CMS has its own large communications shop, including about two dozen people who handle the press.

The move to give large contracts to outside public relations (PR) firms seems unprecedented and seems unnecessary.  Per CNN

whether the issue was Medicare, Medicaid or Obamacare, prior heads of the agency were often quoted, profiled and in the news, so current officials said they’re puzzled why so much work is being outsourced.

‘The head of Obamacare doesn’t need outside consultants to get reporters to talk to her,’ said one CMS official, who asked for anonymity. ‘The job pitches itself.’

Ethical and Legal Issues

In addition, outsourcing communications to private PR firms raises multiple ethical, and possibly legal questions:

‘Outsourcing communications work to private contractors puts the agency’s ability to protect ‘potentially market-moving’ information from premature disclosure at considerable risk,‘ said Andy Schneider, a Medicaid expert who worked at CMS during the Obama administration and is now a researcher at Georgetown University.


But some career CMS staff have voiced their concerns to political appointees within the agency about routing taxpayer dollars to GOP consultants and helping a federal official like Verma improve her personal brand, said two individuals aware of those conversations. Oversight groups also have raised concerns, saying the behavior, as described to them by POLITICO, would appear to cross ethical lines.

‘There are a host of ethical and contractual problems with appointees steering contracts to political allies and subcontractors, and possibly a violation of the ban on personal services contracts if the work is being performed at the direction of the appointee,’ Scott Amey, general counsel of the Project on Government Oversight, told POLITICO. ‘Contracts are supposed to be above reproach, with complete impartiality, and without preferential treatment, and the HHS Inspector General should review this [Porter Novelli] contract and the activities under it to ensure they are proper.’

The choice of PR firms led to the concerns about steering contracts to “political allies.”

The subcontracts are part of a $2.25 million contract administered by Porter Novelli, an international public relations firm that performs a wide variety of government services. CMS’ new top communications official Tom Corry confirmed the arrangement. Two other individuals said CMS also spent at least $1 million on earlier contracts with GOP communications consultants.

One subcontract is with Pam Stevens, a longtime GOP media adviser who specializes in setting up profiles of Republican women. A second subcontract is with Marcus Barlow, whom Verma worked with in Indiana and considered hiring as a top communications official in 2017 before he was blocked by the White House.


A third contract is with Nahigian Strategies, a firm run by a high-profile pair of brothers. Keith Nahigian consulted with several GOP presidential campaigns; Ken Nahigian briefly led President Donald Trump’s presidential transition team in 2017.

In other words, hiring contractors because of their political affiliations for the purposes of burnishing the image of particular government bureaucrats appears to be an abuse of power.

Also, Porter Novelli subcontracted with one Brett O’Donnell, who was involved in the following controversial episode which could be interpreted as a threat to the free press, which is protected by the Bill of Rights:

In a February 2018 incident, contractor Brett O’Donnell barred a Modern Healthcare reporter from a media call for refusing to alter a story that had rankled Verma. CMS officials walked back that threat within days and said a week later that Porter Novelli’s subcontract with O’Donnell, a longtime GOP consultant, would not be renewed. But CMS never provided any explanation of O’Donnell’s role or responsibilities. O’Donnell declined to comment for this article.

We wrote about his incident here

Given that federal officials like Verma swear

I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same;

for Ms Verma to have enabled the hiring of a contractor who tried to suppress press freedom could certainly be interpreted as mission-hostile management, or worse. 

Questions About Conflicts of Interest

Although not mentioned in the Politico article, the choice of Porter Novelli as the main contractor may raise concerns about conflicts of interest, it seems to me.

Porter Novelli is a huge public relations firm.  It has substantial business with the government.  However, it is also known for its “health and wellness” practice, per its profile in EverythingPRAccording to SourceWatch, its clients have included multinational pharmaceutical companies: Pfizer, Wyeth, and GlaxoSmithKline.  One of the practice’s leaders once was Peter Pitts, who frequently spun stories to advance pharma interests, and who founded the Center for Medicine in the Public Interest (CMPI), which received considerable money from pharma and has often seemed to be an advocate for the industry.  Some examples of Pitts’ work were discussed here, and his apologia for opioid manufacturers here.


Perhaps there is more to come on this story.  Today, Politico reported that after the publicity of Ms Verma’s contract with Porter Novelli et al, those contracts have been suspended. 

 Previously, US News & World Report noted that

Energy and Commerce Chairman Frank Pallone on Friday called on an
inspector general to investigate
a report that a top health official
appointed by President Donald Trump spent millions of taxpayer dollars
on GOP communications consultants.


called the contracts a ‘highly questionable use of taxpayer dollars’
and wants investigators to determine how the contracts got approval and
if there was any breach of regulations and ethical guidelines.’

that this agency should be spending tax dollars to ensure Americans can
access quality health care, it is particularly egregious that it is
using millions to ensure its Administrator has access to outside public
relations and image building services,’ Pallone said in a statement.

intend to ask the HHS OIG [the U.S. Department of Health and Human
Services Office of Inspector General] to immediately begin an
investigation into how these contracts were approved, whether all
regulations and ethical guidelines were followed, and why taxpayers are
stuck paying for these unnecessary services. This is not the way to
drain the swamp.’

In any case, the Trump administration continues to come up with new and innovative conflicts of interest affecting health care policy and regulation.  We have discussed the rotational velocity of the revolving door that has supplied health care industry stalwarts to become government health care policy-makers and regulators (most recent example is here, and most recent example involving CMS is here).   Now a top DHHS official has decided to commission and big PR firm well known for its pharmaceutical industry clients to promote her attempts to bolster “her tenure running Medicare and Medicaid … marked by attacks on both programs and their beneficiaries,” per a commentary in the National Memo.

This is not the first time we have discussed Ms Verma’s conflicts of interest.  Here we noted how she advised the Indiana, Kentucky, and at least seven other states’ Medicaid programs while working for Hewlett-Packard, a contractor for those programs.  (Note that Hewlett-Packard was also a big Porter Novelli client, per SourceWatch.)  But she continues to expand her reputation for mingling government functions and commercial interests.

Ms Verma also apparently has used outsourcing to add a propaganda element to government communications (Recall that public relations was just the term Bernays picked because he thought sounded better than “propaganda.”)  Furthermore, that propaganda seemed meant not to improve the health of the public, but to enhance Ms Verma’s personal image. That seemed to be an abuse of power, in my humble opinion.

Moreover, there was at least one incident in which the propaganda function may have turned into a threat against press freedom (the O’Donnell incident above), and hence was certainly an example of mission-hostile management, and could easily also be viewed as an abuse of power.

We have long written about conflicts of interest, but until 2016, our cases were mostly conflicted academics, health care professionals, or leaders of private health organizations, e.g., hospitals, academic organizations, pharmaceutical companies etc.  Now the most striking cases are coming from the Trump regime.

We have long written about self-interested and mission hostile management, but again, until 2016, our cases were mostly about leaders of private health organizations.  Now the most striking cases are coming from the Trump regime.

How can be talk about true health care reform without talking about true reform of our current government?

MDS 3.0 Classes *FREE*

To: Federally Certified Skilled Nursing Facilities Administrators, Directors of Nursing, MDS Coordinators, Billing and Coding Personnel, Licensed Nursing Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

Classes on specific MDS topics are available in Craig, Pueblo, Boulder and Montrose. Sessions in Aurora are waiting list only. You may choose to take them all at once or individually as your interest and needs dictate. All registration is first-come first-serve, even with sessions held within a hosting facility site.

ETA reserves the right to cancel sessions without adequate participation. This is a possibility for Craig. Early registration is recommended.

MDS Basics (One Session): Course ID 1066903
This beginning three-hour class is how to get started with MDS.

MDS Item By Item (2 Sessions): Course ID 1066907
This practical application class reviews item-by-item data set completion. We will follow Miss Scarlett’s assessment, which will require two sessions to complete. Attendance at both sessions on subsequent days is required to complete this class.

MDS Quality Measures (One Session): Course ID 1066904
This course assumes familiarity with the MDS Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to: 
2. Log in to your existing CO.TRAIN account, or new users click “Create an Account”.
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course. Note open session options.
5. Click the “Register” button for the session you wish to attend.
6. Remember to register separately for each desired course.

Detailed Instructions for Using (if needed) 

Questions?: Please email

What the hell do we have to lose?

If you live or work in Washington DC, your number one health care question is how do I (or my meal ticket people) win the next election. If you live or work in Caruthersville MO, chances are that your most pressing health care question is how do I (or my immediate family members) get a hold of some insulin this month. Theoretically speaking, in a healthy democracy, the answers to both questions would be one and the same. In America, in the year 2019, this is no longer the case.

The Washington jetsetters most aligned with the Caruthersville culture (whatever that means), will pop up on your TV screen promising at least fifty insulin shops on Main Street, all competing for your insulin business, until insulin prices plummet to gas station coffee levels. Not to be outdone, the opposing Washington faction, will promise you free insulin for life, and to sweeten the deal, they will throw in free college for your semi-literate children who couldn’t pass a college entrance exam with a gun to their head. They will also promise free childcare for your grandkids, so just in case your daughter does not make it into that free college and does not become an astrophysicist as planned, she can still pursue her Walmart career.

We are being hoodwinked. We are being robbed. We are being disrespected and infantilized. Stealing our votes has become easier than stealing candy from babies. There are more of us by orders of magnitude than there are of them. They certainly have better and bigger weapons. They are better trained and better organized and have better discipline. We also have collaborators in our midst, who are difficult to spot. Let’s face it, in every conceivable way, Washington DC and its sprawling appurtenances have become what the Court of St. James was to our forefathers.


Health care is complicated because it has so many degrees of freedom, few of which we can reliably identify. Some degrees of freedom are yet to be discovered, others look independent, but are not, and vice versa. Furthermore, the boundaries of what we call the health care system are ill-defined and in a perpetual state of flux. At our current state of knowledge, deterministic theories of health care systems are not possible, i.e. you cannot infer past states or future developments of the health care system based on its current state, which is why both health care historians and “futurists” consistently fail to produce any valuable insights, let alone solutions.

Option One

The first and most common strategy for changing complex systems is to essentially ignore the complexity, zero in on one’s pet peeve, kick it hard in the shins, and hope for the best. That’s what LBJ did in 1965 and that’s what President Obama did in 2010. One was wildly successful, the other less so. Why? Both LBJ and Obama identified a segment of the population driven into misery and poverty for lack of affordable medical care and passed legislation to have the government assume financial responsibility for their medical care, to various degrees. Both LBJ and Obama faced militant opposition to their proposals. Both had to compromise and twist arms to make it happen.

However, the health care system wasn’t nearly as complex when LBJ acted on it. As luck would have it, LBJ was able to separate a piece of the system from the whole in a relatively clean way and move on that piece and that piece alone. It would take half a century for the ripple effects of LBJ’s kick in the shins to reach all other parts of health care, for better or for worse. By the time Obama got his shot, the health care system became almost impossible to detangle. Almost. Instead of working hard to carve out his pet peeve from the bigger mess, expose its shins, and deliver a blow, President Obama chose to kick the whole system softly in multiple spots, hoping the change will materialize only where intended. It did not.

Obamacare’s main thrust was to provide health insurance to the 45 million Americans who were then uninsured, mostly because they couldn’t afford to buy insurance. If that’s all Obamacare endeavored to do, it would have probably been a resounding success. Instead, Obamacare chose to partially address the uninsured problem directly, while simultaneously attempting to lower the overall costs of health care, so the unaddressed portions of the problem will address themselves. It was too much intervention for the system to absorb at once, particularly since the underlying philosophy was old, unimaginative and empirically proven to be morally and operationally bankrupt.

At the very core of Obamacare is Richard Nixon’s (or rather Edgar Kaiser’s) notion that health care is best when throngs of people, devoid of agency, submit themselves to medical decisions of expert organizations whose job is to minimize the costs of health care. This idea is why we are told that the job of doctors is to “keep” people healthy and be “stewards” of scarce resources, why we need a health system instead of a “sickness” system, and why Obamacare mandated preventive care to be “free” across all health care. This idea is why most Medicaid, large chunks of Medicare and the Obamacare exchanges were surrendered to “managed care” and “accountable” organizations, why fee-for-service is incessantly vilified, and why massive medical surveillance by computers has been instituted.  And this idea is why independently minded private practices had to be demolished.

Remember those vaguely defined degrees of freedom? It turns out some of them had to do with pricing. You want free preventive care? Sure, no problem, just pay a higher deductible. You don’t want to pay a fee for each service? Oh well, then pay a hell of a lot more for each “bundle”. You want a “health” system? Perfect, just pay more for “sickness”. You want billion-dollar precision surveillance of the herd? Easy peasy, just pay more for everything. You don’t like how things turned out? Too bad, because while you were busy pontificating, we all merged ourselves into too-big-to-push-around “health” entities, so take it or leave it, see if we care.

Option Two

The health system we have today is very different than the one we had when Obamacare became law. It has bigger teeth, sharper claws and spectacularly buff muscles, and its grip on our lives has tightened significantly. You can’t close your eyes and click your heels to go back to pre-Obamacare times. You may be able to strip twenty million people of the lousy health insurance they now have, but you can’t “repeal” the mergers and acquisitions of the last nine years, you can’t resurrect thousands upon thousands of small practices and pharmacies, and you can’t rip out trillion dollars of computerized surveillance. You can certainly indulge in fantasies of shooting it dead with your Medicare for All silver bullet, but the post-Obamacare health system is no fictional werewolf. It’s a very real animal. You can certainly wound it, but nothing is more dangerous than a wounded beast.

The only way forward is to do what Obamacare should have done, albeit under much more difficult circumstances. You still have around 30 million people with no health insurance, and over 100 million who are underinsured because they can’t afford the new deductibles. You also have small limited opportunities to lower expenditures on certain health related items such as prescription drugs and extra payments to hospitals. You also have a slew of Federal regulations and administrative programs that make everything a bit more expensive, with no added benefits to either buyers or sellers of medical services. Before you do anything though, you must overcome a very painful mental hurdle. Medical care is and will remain very expensive for the foreseeable future, and that’s okay.

We don’t know how to cure Alzheimer’s. We don’t know how to cure diabetes, kidney disease, heart disease and most cancers. These things make medical care expensive. Five percent of Americans use fifty percent of health care funds every year. Fifteen million people use around one million dollars each, in any given year. If these very sick people didn’t exist, or if medicine had nothing to offer them, health care would be affordable for everybody else. Alternatively, if medicine had a fully restorative cure for these and other afflictions, health care would be dirt cheap and life would be much better for everybody. Science will do its thing eventually, and nudging it won’t hurt either, but for now, we need to bite the bullet and pay up.

First, we spend lavishly:

  • Expand Medicaid to 200% Federal Poverty Level (FPL). The Obamacare Medicaid expansion was up to 138% FPL. Where did they come up with that number? The FPL is a joke. No person can live on $6.245 an hour when working full time, which is equivalent to the FPL. Expand Medicaid a little bit more (yes, I just said expand Medicaid).
  • Get rid of the individual market for health insurance. Create locally managed group plans for counties or whatever geographical measures make sense in a given area. Let those groups shop for health insurance just like employers do. This will put to rest all the “preexisting conditions” sound and fury.
  • Subsidize these group plans so nobody pays more that a certain percent of their income and establish parity with current employer sponsored insurance. Yes, it is going to cost money, probably more than Obamacare, but it won’t break the bank.

Now let’s save a few pennies:

  • Do the prescription drugs thing. Don’t reimport from Canada, thus taking advantage of “Socialized” medicine, while badmouthing it with gusto. Grow a pair and take on the drug cartels. If the President can threaten China with tariffs, Mexico with shutting down all trade moving through the border, the EU with dismantling NATO, and North Korea with nuclear annihilation, he can certainly negotiate a better deal for America, with a bunch of pharmaceutical sleaze balls, no?
  • Get rid of the “free” preventive care and allow direct primary care, and any cash services that are priced lower than plan negotiated fees, to count against deductibles.
  • Speaking of deductibles, cap those nationally at ten percent of premiums.
  • Incentivize competition in physician services, and discourage shady referral schemes, by paying independent small practices, more than hospitals for the same service. Look at this as a form of reparations for past discrimination.
  • Get rid of all Medicare and Medicaid funded “initiatives” that have no clear purpose or return on investment and disallow anything that is not a direct payment to a medical professional, facility or supplier, from being included in health insurers’ medical loss ratios.
  • Require all sellers of health insurance to submit to yearly value-based performance evaluations and publish the results. This is not about clinical quality. It’s about quality of service, and value-based is the proper term here (for a change).

There is obviously more, a lot more, that we could do, but these are my pet peeves. Other people will have their own. If we keep it simple, and if we are careful when detaching little pieces from the tangled mess that is our health care system, we should be fine. The folks in Caruthersville, MO will be getting plenty of insulin, and the wise men and women brave enough to take this or a similar route to solving the health care conundrum, will get reelected in a landslide. The alternative is that in a pointless battle against Obamacare, those who defend the Obamacare status-quo will win in that landslide (regardless of Medicare for All empty promises), because starving people will not trade the piece of stale bread in their hand, for promises of champagne and caviar due to arrive in two years or so, if all goes well.

The President’s political instinct was correct. Health care must be addressed in a positive and generous manner at this exact moment in time, or the party will be over sooner than anticipated (pun intended). Those who advise the President to postpone the discussion are not serving him or the nation well. These are the same people who pushed the stingy and cruel Paul Ryan agenda that brought the house down last year (pun fully intended).

The truth is that right now, nobody in Washington DC has a realistic solution for health care, so why not try something different? What do you have to lose? I mean, seriously… What the hell do you have to lose?

Chapter 2 Rule Revision Stakeholder Meeting

To: all Health Facilities


Meetings are open to the public.

When: April 4, 2019 from 10:30 a.m. – 12:30 p.m. 
Where: Colorado Department of Public Health and Environment
4300 Cherry Creek Dr. South
Denver, CO 80246
Conference room C1E
(visitors, please check in at the front desk in building A, doors near the flag pole) 

UPDATED Audio line: 669-900-6833, conference code: 882 201 285 
UPDATED Webinar: Zoom meeting (

To view the Chapter 2 meeting agenda go to:

Meeting documents, schedules and archived agendas are available on the department website :

To sign up to receive email communications regarding Chapter 2 go to:

For further info: