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You cannot judge a book by its cover. This will bring tears!!!!!
BRAVO............ The Video is wonderful. Two unlikely contestants in an unbelievable performance. I could see in Simon's eyes, that he will be recording them and make another few million off them.
I believe the greatest period when America blossomed because of its own uniqueness was in the late 1800's to the early 1900's. In art The Ash Can School, in literature Theodore Dreiser's novels, in poetry Walt Whitman and in music George and Ira Gershwin to name a few.
While Israelis produce music, Arabs send rockets. You decide!
Gershwin: To all my music loving friends & family, this is wonderful!
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The story of Detroit is the story of Obama's vision for America except for the fact that he has a Treasury that prints money and thus, can forestall bankruptcy.
Detroit is basically bankrupt and a receiver has been appointed from the prestigious Jones Day law firm to oversee its finances and try and save the city from declaring bankruptcy which would be the largest municipal bankruptcy ever.
This happened for four basic reasons: inordinate union wage and benefit demands, government laws which favored labor over management, incompetent management which felt compelled to bend to labor's demands and. Finally all of this led to a shoddy product allowing foreign competition to eat America's car Manufacturer's lunch.
After four years we now have a Democrat Senate's budget which reflects our un-serious, duplicitous president's demand to raise more taxes so he can continue to fund his loopy policies. (See 1, 1a, 1b, 1c and 1d below.)
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Big Government is seldom better and in the case of your medical care it Big Government will produce smaller but that is what 'Obamascare' will produce because it will result in Big Government control and Obama has played the nation for suckers .
Welcome to the Affordable Health Care Act which has ballooned costs and reduced the quality of care.
What were the dolts who voted for him thinking? Big Government is better? (See 2 below.)
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Dick
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1)Detroit Dems Enrich Wall Street As City Goes Bust
Michigan made it official this week: Detroit can no longer survive without adult supervision. Michigan’s governor named Kevyn Orr, a DC bankruptcy lawyer, to handle the city’s affairs on an emergency basis as the deep blue city makes a last ditch effort to avoid the biggest municipal bankruptcy in American history.
During the long grim slide, much of Detroit’s population fled the implosion; those who remained suffered through declining city services. Schools, police, fire, infrastructure: all the vital services cities are supposed to provide have gone into steep decline.
But while the city’s mostly low-income and mostly African-American residents struggled to survive civic decline, the ill wind from Detroit blew somebody good: well connected Wall Street firms have feasted on the Motor City’s carcass.
Ever since the long death spiral began, Detroit has relied on periodic bond sales to keep its bills paid. The thinking was clear: borrow now, pay it back later when the city’s finances recover. Of course, Detroit’s finances never recovered, and now it’s on the hook for much of this borrowing, in addition to the fees that these banks charged.
And these are serious fees. Bloomberg reports that since 2005, Wall Street banks have charged the city a whopping $474 million. As a comparison, that’s about as much as the city’s current entire police and fire budget for this year:
“The banks promise to get you the money and say you can pay later,” said Greg Bowens, spokesman for Stand Up For Democracy, a Lansing group that campaigned last year to repeal the law allowing appointment of a financial manager. “They get their fees off the top, and you trust that they’re doing what’s in your taxpayers’ best interest.”
As Detroit is learning now, in many cases they weren’t. And Detroit is not alone: In city after city, struggling pension funds have turned to exotic Wall Street investments claiming high returns and minimal risks. In some cases this is working out, in many more it isn’t, but either way, Wall Street is collecting its fees and leaving taxpayers and pensioners to pick up the pieces when it falls apart.
Democrats are shocked, shocked by the news that there is gambling going on in America’s blue cities. They do their best to avert their eyes from the close political ties between corrupt urban political machines and exploitative Wall Street banks. In the lame progressive mindset that characterizes these decadent times, Wall Street is bad, and urban politicians are good. There can’t possibly be some sort of symbiotic relationship between them. How could something so good, so honest, so dedicated to serving the poor as the Detroit Democratic machine be engaged in a vicious conspiracy with Wall Street to bleed the poor and suck the city dry?
Some Democrats don’t like this kind of talk because they are cynical and others don’t like it because they are naive. The cynics are either in the game themselves or knowingly agree to look the other way because they value the support of political allies and don’t care how much those allies bleed the poor. The naive ones, and there are lots of starry eyed intellectuals in this country who don’t know a hawk from a handsaw, think that because many of these urban thugs are African-American, and because they advocate for more government programs to help the poor, they must obviously be sincere and be part of a general wave of good progressive people fighting to make this world a better place. Surely nobody is so cynical as to lobby for government programs because they plan to cream off the money?
Others have an uneasy sense that something is amiss, but a combination of historical ignorance and race sensitivity strikes them dumb. They look around America and see a number of urban areas with predominantly African-American populations. They see that many (not all) of these cities are run by incompetent, race-baiting hacks and criminals who use identity politics to bond themselves to the voters they exploit.
Because they don’t understand that corruption and identity politics have been the hallmark of American municipal government since the 1830s and 184os, they think the ghastly spectacle of demagogic corruption ruining our cities today is somehow a racial phenomenon. The racists among us see that picture and want to draw racist conclusions about African-American capacity for self governance; most of the rest of us are made so uncomfortable by the whole topic that we let the subject slide.
But thieves like the despicable Kwame Kilpatrick in Detroit are anything but a racial phenomenon. There were Irish, Jewish, Italian, Polish and Greek Kilpatricks in their day. We can confidently expect a wave of Latino Kilpatricks as Latino voting power pushes African-American machines aside in more urban areas.
And there’s another thing American history teaches: unscrupulous politicians will find unscrupulous bankers who will float them abusive loans in exchange for fat fees.
If our so-called ‘progressives’ today weren’t so intellectually decadent and, well, historically challenged, they would be leading the charge to clean up American cities. Instead they are mostly silent — and sometimes even defend the machines.
It’s a terrible shame because reformers and progressives really can fight the rot and help the poor — if they can get past their messed up ‘political correctness’ illusions long enough to recognize the basic facts of the case. Some people are trying. Politicians like (one hopes) Cory Booker are part of the wave of renewal and change that slowly and bit by bit can make a change. Courageous prosecutors, crusading attorneys-general, fiercely determined governors are part of the solution. And so are presidents who believe that their oath of office obliges them to attack with special force and determination the organized political machines that use a whole series of corrupt and collusive procedures to deprive American citizens of their right to a republican form of government.
Meanwhile, back in Detroit, Governor Snyder’s choice of Kevyn Orr to take the reins in Detroit is looking good. For one thing, Orr has a history of turning around failing organizations in Michigan. He was partially responsible for guiding Chrysler through bankruptcy in 2009. Given that many expect Detroit to enter bankruptcy as well, Orr’s skill set in this area is likely to come in handy. But perhaps most importantly, Orr, along with 82 percent of Detroit’s population, is black.
The mix of political machines, unscrupulous bosses and low income voters is not inherently a racial issue, but Detroit’s problems can’t be separated from racial concerns. Ever since the state of emergency was announced, many in Detroit have been concerned that the emergency manager law is effectively taking control away from the city’s black population and putting it in the hands of a manager appointed by a white Republican governor.
Michigan has a real mess on its hands. AsBloomberg notes, Detroit now joins Flint, Benton Harbor, Pontiac and a few other, smaller cities under emergency management. These cities account for nearly 50 percent of the state’s black population, so that almost half the black people in Michigan now live in places where local government has effectively lost power. In Benton Harbor in particular, the current situation has sparked racial concern:
“If I’m a young, African-American person growing up in Detroit or Benton Harbor or one of these mostly black areas, what is the message that sends?” Pilgrim said. “It certainly looks like the message is that people that look like you can’t govern.” [...]“I don’t see how it couldn’t be racially motivated,” Williams, 30, said of the law. “We will stop this because of folks who stood before us, like Medgar Evers, who fought for voting rights.”
It’s true that the emergency manager law is taking power away from Detroiters and other Michigan urbanites, and we certainly hope that the state can return control to the people as soon as possible. But despite the fears of a hostile outside takeover, most of Detroit’s problems come from the corrupt political machine that has been looting the city for decades — and from the indifferent state and national prosecutors and politicians who failed to address the lawless state of city government and left the city’s poor to the mercies of heartless thugs.
Following in the footsteps of cheap foreign demagogues like Robert Mugabe, Kwame Kilpatrick and others of his ilk have played relentlessly on identity politics to earn support from poor, minority communities while using the power of their office to funnel money out of these same communities and into their own pockets. And while Kilpatrick—who was just convicted of 24 charges of corruption—may be the worst of the lot, he was far from alone.
What they have left behind is a city where taxes are among the highest in the nation, yet which can’t afford to pay its pensions, provide adequate police service, or keep the lights on.
The best way to stop future tragedies like this is to enforce the law. From voting fraud to corrupt relations with contractors and financiers to fraudulent accounting on pensions, many American cities are being run more like criminal conspiracies than anything else. And the cost isn’t just the money the politicians steal, or the inflated profits that those doing business with a crooked city can earn or even the sweetheart deals with public sector unions who function as part of the machine. It is the shambolic education offered to generations of poor kids, the lack of protection for person and property, the burden of a government that is both costly and ineffective and the enterprises and jobs such a government kills or drives away: corrupt big city machines may be the most important single civil rights issue in America today.
This is not, repeat not, a black thing. Historically, most of America’s worst urban machines have been white criminal enterprises. Often in American history, a combination of identity politics, fear and hopes of getting scraps from the machine have prevented poor people in the cities from organizing against their criminal masters. In the past it was often progressives and middle class reformers, some of the same ethnicity as most of the victims, others from different groups, who banded together to drive out the crooks. The criminals did their best to smear the reformers and identity politics was part of their shtick. Tammany Hall accused its critics of being anti-Catholic or anti-Irish bigots. Prosecutors who attacked the mafia were called anti-Italian. And so it goes.
Urban machines have a legitimate place in American politics. New waves of immigrants into urban America — whether from Europe, Asia, Latin America or the rural South — benefit from organizing to protect their economic and political issues. The machines allow them to assert themselves, claim a share of city patronage and business, and direct city resources to communities that might otherwise be overlooked.
But unchecked and uncontrolled, these machines have a tendency to go over the line. Graft proliferates; crony appointments degrade the quality of governance to the point that city administration is no longer able to function. This is where the reformers come in, pushing back against the tendency of political machines to jump the shark, imposing some limits and discipline on what goes on. Partly because today’s progressives are moral cowards who have allowed themselves to be shamed by the race card, this process of balance and reform didn’t really get underway in Detroit (and perhaps elsewhere) until enormous damage had already been done.
By overlooking the corruption and a mafia thinly disguised as a political party for so long, the authorities of the United States deprived the citizens of Detroit of the equal protection of the law. That must not happen in our other cities; municipal government in this country needs to be much more transparent, and law enforcement really needs to crack down.
Without this, all the federal block grants or social programs in the world will not help those trapped in the inner cities escape poverty and get the education and skills they need to build the kind of future all Americans want.
This is the pre-eminent civil rights problem of our day and is devastating minority communities throughout the country. Our political establishment, our university faculties and fashionable intellectuals, our newspaper editorialists, our legal profession and our clergy stand essentially silent; it is the silence of shame.
1a)The Senate's Tax Reform Poison Pill
As the president mounts a charm offensive, his Senate allies ask for$1 trillion in new revenue.
President Obama went to Capitol Hill on Wednesday to assure House Republicans that he honestly and truly wants to work with them. A few hours later, the Democratic Senate released a budget that took a meat cleaver to one of the better prospects for bipartisan cooperation. So it goes with the Obama charm offensive.
The issue is (of course) taxes. Budget Chairman Patty Murray chose to craft the Senate's first budget in four years entirely around her party's political priority of grabbing another $1 trillion in revenue. By hiding this tax hike under the guise of tax reform, and dictating what that "reform" must look like, Mrs. Murray and the White House made it that much harder to ever get a real rewrite of the code
Why is this notable? While the media swoon over an amorphous grand bargain over the deficit, wiser Washington heads have understood that the best chance for cooperation on the economic and budget front rests in tackling the tax beast. Throughout all the election and tax-cliff and sequester drama, both the Senate and the House have been slowly laying the groundwork for tax reform.
House Ways and Means Chairman Dave Camp has already released draft rewrites of the code, and Speaker John Boehner has said that reform will get top legislative priority. Senate Finance Chairman Max Baucus has called this a "once-in-a-generation opportunity," has held dozens of hearings, and is moving toward producing his own product. The White House has been promising (at least corporate) tax reform for years.
Then there is the political impetus. Republicans see reform as a way to re-energize their tax debate and reconnect with voters. The White House knows that tax reform is politically its only conceivable vehicle for more revenue—maybe, if done right. The House GOP is adamant that its own tax product will be "revenue neutral," but some Democrats have held out hope that—were Mr. Baucus to produce a reform Republicans liked—the GOP might be talked into swallowing some modest additional revenue.
Left to his own devices, that is the route Mr. Baucus would likely travel. The Montana Democrat isn't exactly known for bravery, and he would probably buckle under party demands to use his bill to produce some revenue. At the same time, he seems to understand the economic merit of a simpler code with lower rates. He is also aware that the technical realities of tax reform, and a Senate filibuster, would likely limit any new revenue to, at most, a few hundred billion dollars.
Enter Mrs. Murray, whose budget—with assists from Senate Majority Leader Harry Reid, New York's Chuck Schumer and the White House—knocked this process sideways. In thrall to the president's call for higher taxes, Mrs. Murray has used her budget to dictate that Mr. Baucus's committee must produce a tax "reform" by October that raises $1 trillion in revenue. The Montanan fought the move, warning that such a stunt would stalemate the process—only to be dissed by his own leadership. Asked why he was tying Mr. Baucus's hands, Mr. Reid bluntly replied that "Baucus isn't chair of the Budget Committee."
While Mrs. Murray's budget didn't specify how Mr. Baucus has to drum up the dough, its few suggestions left no doubt about whom liberal Dems expect him to target. "One potential approach," wrote Mrs. Murray in her budget, "is an across-the-board limit on [deductions] claimed by high-income taxpayers (specifically, the top 2 percent of income earners)." All of this—tax hikes, complexity, class warfare, the revenue figure—is the opposite of tax reform and a non-starter with the GOP.The Murray diktat blows up bipartisanship. In hijacking the Finance Committee's work, she has decreed that the push for a streamlined code with lower rates be turned into a partisan tax-hiking adventure. The only way Mr. Baucus can gin up $1 trillion is by raising rates—on corporations, small businesses and higher-income Americans—and by adding more tax complexity than he eliminates.
So too is the piecemeal approach the Murray budget requires. Putting tax reform through budget "reconciliation" subjects it to arcane budget rules. Critical parts of tax reform—compliance, the issue of territorial taxation, even tax-filing dates—couldn't be considered. This too is a non-starter for the GOP, which is intent on comprehensive reform.
Tax-reform optimists note that the budget is nonbinding—Mr. Baucus can buck his party and go his own way. But that's putting a lot of faith in the mettle of a man who has proved one of the more reliable Obama votes these past years. And no matter how Mr. Baucus proceeds, Mrs. Murray has dramatically upped the ante for what the liberal Democratic caucus will accept.
Republicans might ask themselves why. Perhaps this was a White House negotiating ploy, a high opening bid designed to wangle big revenue out of a compromise. President Obama may be betting that Republicans are so eager to take credit for passing tax reform that they're willing to barter away their principles in the process.
Then again, maybe the White House has decided that any revenue it might get in a real compromise won't come close to sating its spending desires. Maybe it figures it would get a lot more if it took back the House in 2014 and again ran Washington. Maybe it is therefore teeing up the impossible—as it has with guns and other issues—solely to make Republicans look obstructionist. Maybe.
These are, after all, the days of the charm offensive.
1b)A tale of two budgets
By Rep. Jack Kiingston
It is budget season in Washington. Last week, dueling proposals were introduced by House Republicans and Senate Democrats. Each offers a stark contrast and vision for our country.
House Republicans offered a proposal – the Path to Prosperity – that would balance the budget within ten years. It reduces deficits by $4.6 trillion by targeting wasteful Washington spending and reforming the drivers of our debt.
In addition to relieving the economic uncertainty created by debt, our plan would fix our broken tax code to create jobs and increase wages. It equips the American people for success in the 21st century by fostering innovation in education programs.
We would harness America’s energy potential – the largest natural gas, oil, and coal reserves in the world – and approve the Keystone XL pipeline. This energy plan would create thousands of jobs, create billions in private-sector infrastructure investment, and achieve North American energy independence without costing taxpayers a dime.
The Path to Prosperity also repairs the safety net for the poor by building on the success of bipartisan welfare reform of the 1990s which led to child poverty falling by double digits. It gives states more flexibility to tailor programs and empowers those closest to the people to improve effectiveness.
Our plan strengthens and protects retirement security for current and future generations. Those who rely on the program today would see no changes. Beginning in 2024, eligible seniors would be given a range of insurance plans to choose from – including traditional Medicare – and would be provided assistance to ensure they can afford them.
In contrast, Senate Democrats have offered a budget that, as theWashington Post puts it, “gives voters no reason to believe that Democrats have a viable plan for – or even responsible public assessment of – the country’s long-term fiscal predicament.”
It relies on budget gimmicks and accounting tricks to claim $1.85 trillion in deficit reduction. When you get past the double counting and get to the real numbers, the total comes to a paltry $279 billion. Their plan calls for $7.3 trillion in new debt, increases spending over current projections, and fails to balance the budget – ever.
Just two months after the American people saw their tax bill go up by $618 billion, the Senate Democrat budget is back for more. They seek another $1.5 trillion in new taxes in order to fund more wasteful government spending.
By failing to offer a plan to preserve the safety net or shore up programs like Medicare or Social Security, their plan is implicit in the demise of these programs on which so many rely. In fact the Senate Democrats offer no real reform of anything.
Four years without a budget proposal and this is the best they could come up with?
America needs a serious and honest budget that makes Washington accountable, protects taxpayers, and provides a path to a stronger America. The simple truth is that Washington Democrats have once again refused to provide one.
We cannot defy gravity. Every day we fail to address our fiscal problem, the solution becomes harder. The more we spend, the more we borrow and the further indebted we become to countries like China.
The less we owe, the more we own our future. In the Path to Prosperity, we have put forward a plan that would re-establish America’s economic independence and renew the American dream.
1c) A deficit of ambition
Senate Democrats would let rivers of red ink flow on forever
There is no one alive more revered and beloved among Democrats than Bill Clinton, who showed at last year's national convention what a rock star he is. One of his most historic achievements as president was something that eluded Gerald Ford, Jimmy Carter, Ronald Reagan and George H.W. Bush: balancing the federal budget. He did it four straight years. For Democrats, it was cause for great pride.
But that was a long time ago. Last week, Senate Budget Committee Chairman Patty Murray, D-Wash., produced a budget plan — the first one to come from the Senate in four years. She did so shortly after House Budget Committee Chairman Paul Ryan, R-Wis., unveiled his.
The two blueprints have many differences, but the biggest of all is that Ryan's aims at eliminating the annual federal deficit by 2023. Murray's would balance the budget ... well, never. In 2023, the Democratic budget's deficit would be $566 billion. Over the coming decade, her plan would add $5.2 trillion to the total debt — more than four times the $1.2 trillion the Ryan version would add.
The House GOP approach has been criticized on several grounds — making excessive cuts in domestic discretionary spending, promising lower income tax rates without specifying how the lost revenue would be made up and relying on the repeal of Obamacare, which is not going to happen anytime soon. But you can't fault Ryan's budget for aiming too low.
It sets a bold marker that would reverse the government's slide toward insolvency. It establishes a sensible goal that voters can understand and support.
The Democrats, unfortunately, are feigning fiscal responsibility instead of practicing it. They would boost outlays by 58 percent over the coming decade — which, by the way, would follow a similar hike over the past decade. The renewed spending binge explains why the Democratic plan's annual deficits would remain high despite its tax increases designed to bring in nearly $1 trillion in additional revenue.
As a share of the economy, the debt Democrats envision would hardly shrink at all — going from 77 percent of gross domestic product this year to 70 percent in 2023. The Republicans, by contrast, would slash it to less than 55 percent of GDP — much closer to the historical norm.
Democrats say their approach is more than adequate because there's nothing magic about having a balanced budget. They think the important thing is merely to "stabilize" the debt — that is, to keep it from ballooning any more as a share of the economy.
But after the recent explosion of the national debt — now approaching a staggering $17 trillion — that's not good enough, as nonpartisan research groups such as the Committee for a Responsible Federal Budget keep warning:
In the first place, the Democrats' plan stabilizes the debt only if things go well. If another recession hits, it will produce another huge increase in deficits, this one even more damaging that the last. In the second place, it adds way too much to the load that will burden future generations. That's a problem with deficits and debt. Sooner or later, somebody has to divert spending on tomorrow's priorities to pay for yesterday's.
What's more, reports The Christian Science Monitor, "stabilizing the debt through 2023 doesn't mean it will remain stable thereafter. Rather, health care spending will likely push the debt persistently upward after that time, forecasters say."
What is needed is a lot more ambition than the Murray plan reflects. If Democrats don't like the Republican plan for balancing the budget, they should produce their own. And when it comes to deficit reduction, they need to go big or go home.
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1d)Senate Democrats’ long-awaited budget fizzles
By Philip Klein
Is this what we waited four years for?
There was a lot of buildup to the first budget released by Senate Democrats since 2009, but the actual document didn’t even meet low expectations.
After blasting House Republicans for being overly intransigent and unwilling to compromise, Senate Democrats unveiled a budget that not only raises taxes by nearly $1 trillion by closing unspecified loopholes, but it actually increases spending on a net basis.
In theory, the plan authored by Senate Budget Committee Chair Sen. Patty Murray claims to cut spending by about $975 billion from fiscal years 2014 through 2023. That includes $240 billion in defense cuts accounting for the winding down of the war in Afghanistan, $240 billion in claimed “responsible savings across domestic spending” and $275 billion in Medicare savings from “further realigning incentives throughout the system, cutting waste and fraud, and seeking greater engagement across the health care system.” The budget also assumes interest payment savings.T
The problem is that these paper spending cuts are more than offset by the proposal to spend $960 billion to replace the automatic sequestration spending cuts as well as the $100 billion in new stimulus spending.
The deficit reduction that does exist comes in the form of tax increases. The budget says, it, “Achieves $975 billion in deficit reduction by closing loopholes and eliminating wasteful spending in the tax code that benefits the wealthiest Americans and biggest corporations.” But it doesn’t specify which loopholes will be closed.
The plan also offers no specific, broader reforms to the nation’s entitlement programs.
Democrats’ clear political calculation here is that their vague budget will be less of a target, allowing them to focus on blasting the House Budget Committee Chair Rep. Paul Ryan’s proposal for being cruel. But in the process, they’ve shown themselves to be completely un-serious.
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2)The Doctor Won't See You Now. He's Clocked Out
ObamaCare is pushing physicians into becoming hospital employees. The results aren't encouraging.
Big government likes big providers. That's why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain.
Why? Because when doctors practice in small offices, it is hard for Washington to regulate what they do. There are too many of them, and the government is too remote. It is far easier for federal agencies to regulate physicians if they work for big hospitals. So ObamaCare shifts money to favor the delivery of outpatient care through hospital-owned networks.
The irony is that in the name of lowering costs, ObamaCare will almost certainly make the practice of medicine more expensive. It turns out that when doctors become salaried hospital employees, their overall productivity falls.
ObamaCare's main vehicle for ending the autonomous, private delivery of medicine is the hospital-owned "accountable care organization." The idea is to turn doctors into hospital employees and pay them flat rates that uncouple their income from how much care they deliver. (Ending the fee-for-service payment model is supposed to eliminate doctors' financial incentives to perform extraneous procedures.)The Obama administration also imposes new costs on physicians who remain independent—for example, mandating that all medical offices install expensive information-technology systems.
The result? It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that sharply accelerated around the time that ObamaCare was enacted. The biggest shifts are in specialties such as cardiology and oncology
Estimates by hospitals that acquire medical practices and institutions that track these trends such as the Medical Group Management Association show that physician productivity falls under these arrangements, sometimes by more than 25% (more on this below). The lost productivity isn't just a measure of the fewer back surgeries or cardiac catheterizations performed once physicians are no longer paid per procedure, as ObamaCare envisions. Rather, the lost productivity is a consequence of the more fragmented, less accountable care that results from these schemes.------
Once they work for hospitals, physicians change their behavior in two principal ways. Often they see fewer patients and perform fewer timely procedures. Continuity of care also declines, since a physician's responsibilities end when his shift is over. This means reduced incentives for doctors to cover weekend calls, see patients in the ER, squeeze in an office visit, or take phone calls rather than turfing them to nurses. It also means physicians no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.
Most hospitals exacerbate these strains by measuring the productivity of the physician practices they purchase in "Relative Value Units." This is a formula that Medicare already uses to set doctor-payment rates. RVUs are supposed to measure how much time and physical effort a doctor requires to perform different clinical endeavors.
Medicare assigns each clinical procedure a different RVU and then multiplies this figure by a fixed amount of money to arrive at how much it will pay a doctor for a given task. A routine office visit has an RVU of about 1.68, while removing earwax has one of 1.26. Setting a finger fracture rates a 3.48.
This system misses all of the intangible factors that help gauge the quality and efficiency of the care being delivered. It focuses physicians on the wrong goals for promoting health, such as how well they code charts to capture higher-value "units."
Hospitals are beholden to the RVU system only because that is how they get paid by the government. Data from the Medical Group Management Association shows that physician productivity in these employed relationships, measured simply by RVUs, declines up to 25% compared with independent practices. The Advisory Board ABCO +0.62% Company, a health-care consulting firm, estimates that when hospitals last went on a physician-acquisition binge in the late 1990s, productivity fell by as much as 35%. Those arrangements mostly failed, and the hospitals divested the stakes they had in individual doctor practices. The physicians went back to practicing out of their own offices.
All of this reduced productivity translates into the loss of what should be a critical factor in the effort to offer more health care while containing costs. Yet hospitals aren't buying doctors' practices because they want to reform the delivery of medical care. They are making these purchases to gain local market share and develop monopolies. They are also exploiting an arbitrage opportunity presented by Medicare's billing schemes, which pay more for many services when they are delivered at a hospital instead of an outpatient doctor's office.
This billing structure exists because hospitals are politically favored in Washington. Their mostly unionized workforces give them political power, as does their status as big employers in congressional districts.
ObamaCare pushes this folly largely based on a naive assumption that models that worked well in one community can be made to work everywhere. President Obama has touted "staff models" like the Geisinger Health System in Pennsylvania and the Mayo Clinic in Minnesota that employ doctors and then succeed in reducing costs by closely managing what they do. When integrated delivery networks succeed, they are rarely led by a hospital. ObamaCare seeks to replicate these institutions nationwide, even though their successes had more to do with local traditions and superior management. That's hard to engineer through legislation.
Dr. Gottlieb is a physician and resident fellow at the American Enterprise Institute.-------------------------------------------------------------------------------------------------------------------------------e problem is that these paper spending cuts are more than offset by the proposal to spend $960 billion to replace the automatic sequestration spending cuts as well as the $100 billion in new stimulus spending.The deficit reduction that does exist comes in the form of tax increases. The budget says, it, “Achieves $975 billion in deficit reduction by closing loopholes and eliminating wasteful spending in the tax code that benefits the wealthiest Americans and bigge
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