LEGAL LEANINGS: Mental Health Parity

By ERICA MORRIS, GREGORY MOORE AND RUSSELL KOLSRUD
Mental Health Parity Really Does Mean Equal Benefits
By Erica Morris, Gregory Moore and Russell Kolsrud

In Danny P. v. Catholic Health Initiatives, 891 F.3d 1155 (9th Cir. 2018), the Ninth Circuit clarified the full extent of the “parity” required in the federal mental health parity law1 which has been in place since 2008.

In Danny P., the Ninth Circuit held that a particular group health plan (the Catholic Health Initiatives Medical Plan—Blue Cross Blue Shield) was prohibited from denying the same or equivalent room and board coverage in behavioral health facilities that it provided in non-behavioral health facilities, overturning the district court’s decision in favor of the plan. Specifically, the Court held the plan could not be permitted to deny inpatient room and board costs at a behavioral health inpatient residential treatment facility while simultaneously allowing coverage for non-behavioral health (medical and surgical) inpatient room and board costs at a skilled nursing facility.

The plan at issue was a self-funded group health benefit plan covering Catholic Health Initiatives employees and their dependents, and provided for coverage of “mental health services,” bed, board, and general nursing care, ancillary services provided at skilled nursing facilities, and also provided coverage for residential treatment facilities (licensed facilities that deal with illnesses affecting mental health). The health insurance plan here was trying to limit payments for behavioral health residential services. Many plans attempt to limit residential behavioral health services because they are much more costly than the physical medicine corollary (e.g. a skilled nursing facility).

As stated in the opinion:

The Parity Act requires that benefits in a plan that provides for “both [ (a) ] medical and surgical benefits and [ (b) ] mental health or substance use disorder benefits,” must not impose more restrictions on the latter than it imposes on the former. 29 U.S.C. § 1185a(a)(3)(A). Specifically, the Parity Act states the following:

In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that—

(i) the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits; and

(ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.

Id.

See Danny P., 891 F.3d at 1157–58.

The Ninth Circuit explained that neither the Parity Act nor the regulations specifically address every situation, leaving room for interpretation but reasoned the regulations “did indicate that mental and medical/surgical benefits must be congruent, and that limiting the former while not placing a similar limitation on the latter would be improper.” Id. at 1159.

As the opinion’s mandate ripples outward from the Ninth Circuit and impacts other enforcement actions, the next area of advocacy for parity will likely focus on qualitative or nonquantitative treatment limitations, which will be harder to identify, but equally if not more important to the successful and comprehensive treatment of mental health and substance use disorders envisioned by the Parity Act.

1 Most health plans must include behavioral health benefits as the Patient Protection and Affordable Care Act mandates. As such, under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), plans containing behavioral health benefits must offer them on par with medical/surgical benefits. For more information, see https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html.

LANSING LINES

He’s Running As A Doctor But Can’t Practice . . . Does It Matter?
Matt Longjohn’s chief selling point in his Michigan 6th Congressional district run is that he’s a medical doctor. But he can’t practice medicine in Michigan because he isn’t professionally licensed in this state or in Illinois, where he formerly worked.

Longjohn, the Democrats’ nominee in the southwest Michigan district, has made a career on the administrative side of health care, most significantly as the first-ever National Health Officer for the 2,700 YMCAs in the United States when he worked in Chicago.

In campaign materials, he refers to himself as Dr. Matt Longjohn, MD, and uses the squiggly heartbeat signal to punctuate the point. But according to the Department of Licensing and Regulatory Affairs, he’s never been licensed as a health professional in Michigan.

And whether he’s allowed to describe himself as such under the Michigan Public Health Code is an open question in the legal community.

The Public Health Code (333.16261) reads “an individual who is not licensed or registered under this article shall not use an insignia, title or letter . . . to induce the belief that the person is licensed or registered in this state.” Asked if that means Longjohn is in violation of the code by presenting himself in a political campaign as a doctor when he is not licensed to practice, LARA spokesperson Pardeep Toor simply referred MIRS back to this section of law.

Four attorneys that specialize in healthcare that were contacted by MIRS were split on the question.

Mike Stevenson from the East Lansing firm of Willingham & Cote said this type of question about the use of the title “doctor” has come up before among his colleagues and there are “varying opinions” on it.

“In my opinion, it’s not untruthful. If he has a medical degree, he is telling the truth. As long as he’s not practicing,” Stevenson said he doesn’t see a problem.

A second attorney questioned by MIRS agreed that as long as Longjohn wasn’t advertising his services as a medical professional, he not sure there’s a problem.

However, practicing medicine in Michigan without being a licensed doctor is a felony and while what Longjohn is doing doesn’t rise to that level, attorney Ronald Chapman II, of Troy, isn’t comfortable with it. He viewed the usage of the terms as “problematic” in that it gives people the impression he can perform medical services when that is not the case.

“I would advise my client against using these titles, particularly using the combination of the ‘MD’ and the ‘Dr.’ It insinuates you are in the practice,” Chapman said. “I don’t think that’s appropriate.”

A fourth healthcare attorney for a major Michigan firm told MIRS MCL 333.17011(5) specifically limits those using “MD” to those “authorized to use the term” as they are written. The only people who can claim to be an “MD” are those allowed by the state to be doctors of medicine, this attorney said.

Longjohn may be able to use the term “doctor,” but that’s not clear under the law, either.

“Whether he can use ‘Dr.’ depends on several factors. Does he have any other degrees? Many professors and other professionals with doctorates use the title ‘Dr.’ Technically, I can call myself a ‘Dr.’ since I have a JD degree. Is he trying to induce the belief that he is licensed?” this attorney asked.

Longjohn said he earned his medical and public health degrees from Tulane and did his internal medicine internship at Northwestern University. During that time in 2001, he received a “temporary medical permit in Illinois,” according to the state of Illinois.

Since then, he’s been a teacher, a researcher, and a leader of non-profit organizations.

“My achievements as a health care innovator came as a result of work done outside of clinical settings, where my teams developed programs, policies, and coalitions to improve the health of millions of people’s lives,” he said. “I have never once said during this campaign that I am a currently practicing physician.”

Told of Longjohn’s resume, former U.S. Rep. Joe Schwarz, a physician by trade, said “it’s not unheard of” for the carrier of a medical license to not get licensed as a doctor in the state in which he or she is living, but “it is odd.”

“It raises the question to me, ‘Why do you not have a Michigan license?'” Schwarz asked. “To me, I can see where, if I were running against him, this would be duplicitous. He can call himself a doctor, but he can’t practice? I just find it odd.”

MRP Says Longjohn Playing Doctor On TV
The Michigan Republican Party believes Democratic 6th Congressional District nominee Matt Longjohn is “misrepresenting himself” as an “MD” in conflict with Michigan law, because he is calling himself a doctor when he isn’t licensed to practice in Michigan or seemingly anywhere else.

Longjohn is calling himself “Dr. Matt Longjohn MD” in his campaign materials, while using a heartbeat monitor line to his campaign material to stress his medical competence.

Longjohn did complete medical school at Tulane and held a temporary medical license in Illinois during his residency at Northwestern, but that expired in 2001, MIRS reported.

He’s since gone on the administrative track with his medical degree, working on issues such as diabetes and running health issues for the YMCA in Chicago. However, Michigan Republican Party Deputy Chief of Staff Sarah Anderson concurs with an attorney contacted by MIRS that Longjohn is running afoul with the Public Health Code by claiming to be a MD when he isn’t licensed to see any patients.

“Matt Longjohn may not be a doctor, but he plays one on TV,” Anderson said. “Matt Longjohn is lying about his experience to win votes on the critical issues of healthcare. Voters deserve better. If Longjohn is willing to misrepresent himself about this, where does he draw the line?”

But speaking on Michigan’s Big Show recently, Dr. Rob Davidson, the Democrats’ congressional candidate in the 2nd District, said he went to medical school with Longjohn and he doesn’t believe there is any false advertising in Longjohn using the titles “MD” or “Dr.”

“He’s a doctor. He’s chosen a path of post-training to promote policy in a bigger way,” Davidson said. “He was YMCA national health director. He did many things for diabetes, education, prevention, health eating. He worked with Michelle Obama.

“I know Matt. Matt and I went to college together. We lived down the hall from each other and it’s exciting to me that people who come at health care from many different angles are running for Congress.”

Groups Band Together To Create Health Plan For Small Businesses
Two of Michigan’s leading small business organizations announced the creation of a new health insurance program, known as an Association Health Plan (AHP), that they say could actually lower rates for small businesses.

Rob Fowler, president and CEO of the Small Business Association of Michigan (SBAM), predicted savings “with some confidence of 3 to 5 percent in the first year.”

In the longer term, we will be able to negotiate on behalf of a very large group—and the rates will be based on the experience of the group so it is experience-rated as a group, not each of the companies themselves but the group—so in the third and fourth years, if we have good experience … We have talked a lot about the trajectory of health care costs or bending the cost curve. I think we are actually going to bend it down, not just not going up so fast,” he said.

“Rates have been going up year over year for many years. We are talking about rates going down,” said Jennifer Kluge, president and CEO of the Michigan Business and Professional Association.

Under an executive order signed by the president in October 2017 reforming the Affordable Care Act and under new rules drafted by the U.S. Department of Labor to implement it, SBAM and MichBusiness joined together to form a nonprofit 501-c6 and create one of the first AHPs in the country, named TranscendAHP.

An AHP allows small businesses and their employees and self-employed workers to band together by geography or industry to obtain health care coverage as if they were a single large employer. The strength of an AHP is creating negotiating power by creating large risk pools with greater economies of scale.

Fowler said a key to getting rates as low possible is getting bigger numbers in the plan.

“Actuaries believe that about 40 percent of the marketplace would do better in an association health plan. Forty percent of Blue Cross’ small group market would be 90,000, that’s employees,” he said.

“Access to comprehensive health insurance programs continues to rank at the top of small business owners’ concerns. Combined with a tight labor market, our members need options that allow them to compete with much larger companies for the talent they need to be successful,” Kluge said.

Blue Cross Blue Shield of Michigan and the Blue Care Network was selected as the provider, which will give small businesses access to options that previously had only been available to larger companies.

TranscendAHP will be available to businesses of between one and 50 employees. There are membership requirements, but the new plan will be ready to start providing quotes this week to businesses interested in signing up for coverage beginning Jan. 1.

More information about the plan is available at the plans website at https://transcendmichigan.org/

“We are happy to say that we designed this to benefit the small business community, we also made it open to all independent insurance agents, so we are not competing. We are open to everyone. That’s the whole thing, we are open to everyone and we are not creating more competition. We really want to make this successful,” Kluge said.

Union-Backed Health Care Bus Rolls Into 6th, 8th CD
A pro-Affordable Care Act group fueled by organized labor money rolled its bus in front of the Capitol Oct. 3 as a backdrop to a general condemnation of U.S. Rep. Mike Bishop’s (R-Rochester) support of the U.S. House Republicans’ healthcare bill.

Protect Our Care is drawing attention to how congressional Republicans passed a re-work of the ACA earlier in the term, but the reforms never made it out of the U.S. Senate.

Former gubernatorial nominee Mark Schauer, Sen. Curtis Hertel Jr. (D-East Lansing) and House Minority Leader Sam Singh (D-East Lansing) stood with a pair of cancer survivors in arguing how Republicans “need to be held accountable” for wanting to dismantle the ACA.

The bus rolled on later in the day to Kalamazoo, where 6th District Congressional candidate Matt Longjohn held a press conference with state Senate candidate Sean McCann.

In Lansing, cancer survivor Amanda Itliong apologized for being delayed in getting to the press conference. Moments earlier, she was in a parking lot throwing up. It’s something that she’s had to get used to as she’s gone through treatment.

She proceeded to give emotional testimony about how the certainty of the ACA has helped her get through the challenges for her multiple bouts with cancer and the anxiety that comes with worrying about losing her health insurance. She fingered Bishop House Republicans for wanting to gut the law.

“Mike Bishop is my representative, but he doesn’t represent me,” Itliong said.

Laura Packard added that as a stage four cancer survivor, she’d be either bankrupt or dead if it weren’t for the ACA.

“President Trump may have blocked me on Twitter, but he can’t stop me and the American people from fighting to protect our care,” Packard said.

The Protect Our Care bus tour is rolling from late September to early November through 23 mostly swing states, such as Ohio, Florida, Wisconsin, Iowa, Arizona, Colorado, Missouri, Tennessee and Virginia.

Supremes Decline To Hear Appeal Requesting Flint Water Case Goes To COC
The Michigan Supreme Court declined Oct. 2 to hear an appeal of a lower court’s decision that transferred a Flint water case from the Court of Claims to Genesee County Circuit Court.

The Court of Appeals said COC Judge Christopher Murray “properly transferred” the case, Melissa Mays et. al v. Governor, State of Michigan, et. al.

The MSC also declined the plaintiffs’ motion to dismiss the defendants’ June 19 application to appeal and a motion to stay the lower court proceedings.

Justice Elizabeth Clement did not participate in the court’s decision due to her prior involvement as chief legal counsel for Gov. Rick Snyder, a named defendant.

Mays and 18 other named plaintiffs allege Snyder, State of Michigan and former treasurer Andy Dillon violated the Elliott-Larsen Civil Rights Act.

Flint switched its water source from Lake Huron to Flint River in April 2014 and the river was not properly treated, allowing lead to leach.

In related news, Mays was one of a number of Flint community leaders and residents speaking out against Attorney General Bill Schuette for allegedly “trying to brush off his record of failing and then ignoring” Flint residents’ complaints about the water in 2014 and 2015. The press conference was held this afternoon in Flint.

Meanwhile, the U.S. Supreme Court declined Tuesday to hear Michigan Department of Environmental Quality (DEQ) employees’ writ of certiorari in Nappier et. al v. Stephen Busch et. al, which also is related to the Flint water crisis.

Applicants Will Know Early If An Old Conviction Will Keep Them From License
License applicants will be able to learn early in the process if an old criminal conviction is going lead to denial, under three bills reported out of House Regulatory Reform Committee Oct. 2.

The bills, HB 6058, sponsored by Rep. Scott Vansingel (R-Grant); HB 6059, by Rep. Terry Sabo (D-Muskegon); and HB 6060, by Rep. Jim Lilly (R-Holland) allow the applicants to get a preliminary determination of eligibility from the state before they sign up for courses or put down money for testing fees.

“We don’t want people to spend the money for the licensure and then not being able to get it, taking the course work and not being able to get a license,” Committee Chair Rep. Brandt Iden (R-Kalamazoo) explained.

The bills were added into a four-bill package intended to remove barriers to licensure for people with old convictions.

Some 200 occupations and professions in Michigan require a license, equaling about 20 percent of available jobs.

“This is really an issue that so many folks, as I talk to them throughout the state, talk about. People that have got past criminal convictions that cannot get licensure because one issue that happened 20, 30 years ago. And if we want to talk about filling gaps in the workforce, which we hear from all of our employers in the state of Michigan, we need to make sure we are addressing that,” Iden said.

Iden’s HB 6110 would change the definition of “good moral character” to keep a conviction from being the sole reason for license rejection or a permanent ban. Licenses would still be reviewed by the department, most often the Department of Licensing and Regulatory Affairs.

Many licenses have a list of specific crimes which would result in denial. HB 6111, by Rep. Beth Griffin (R-Paw Paw), would address health occupations; HB 6112, Rep. Michele Hoitenga (R-Manton), skilled trades; HB 6113, by Rep. Joseph Bellino (R-Monroe), addresses eligibility requirements; and HB 6381, by Rep. Jeremy Moss (D-Southfield), would require an annual report on the denial of licenses based on lack of good moral character.

All bills were reported out in 15-0 votes.

Iden has a related bill, HB 5881, to ease the prohibition of employing casino workers and suppliers who have convictions, but the bill is being reworked to make general updates to the Gaming Control Act.

Supremes Decline To Stop Healthy Kids Contract
The Michigan Supreme Court denied a Florida insurance company’s request to halt implementation of the state’s Healthy Kids Dental Contract until the courts decide whether the state violated the statutory competitive bid mandate.

Scott Eldridge, attorney for the MCNA Insurance Company, said the company was disappointed in the MSC’s decision, but they will “continue to fight to shine a light on the dark corners of state government and provide much-needed transparency and accountability to a deeply flawed bidding process.”

“Michigan taxpayers deserve a full accounting of how their tax dollars are being spent and to know why a $659 million Healthy Kids Dental contract was awarded in a process fraught with illegalities and improprieties,” he said.

MCNA alleges the Department of Technology, Management and Budget (DTMB) showed “blatant favoritism” in awarding a $659 million contract for its Healthy Kids Dental Program to Blue Cross Blue Shield, whom the state acknowledged was allowed to change its bid.

Ingham County Circuit Court Judge Joyce Draganchuk ordered state officials and DTMB to submit an affidavit and testify under oath about the awarding of the dental contract.

The state appealed Draganchuk’s decision and it went to the MSC who remanded it to the Court of Appeals for “plenary” consideration on an “expedited basis.” The contract went into effect Oct. 1.

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

Drugmakers Play The Patent Game

By SARAH JANE TRIBBLE
David Herzberg was alarmed when he heard that Richard Sackler, former chairman of opioid giant Purdue Pharma, was listed as an inventor on a new patent for an opioid addiction treatment.

Patent No. 9861628 is for a fast-dissolving wafer containing buprenorphine, a generic drug that has been around since the 1970s. Herzberg, a historian who focuses on the opioid epidemic and the history of prescription drugs, said he fears the patent could keep prices high and make it more difficult for poor addicts to get treatment.

“It’s hard not to have that reaction of, like … these vultures,” said Herzberg, an associate professor at the University at Buffalo.
James Doyle, vice president and general counsel of Rhodes Pharmaceuticals, the Purdue subsidiary that holds the patent, said in an email statement that the company does not have a developed or approved product and “therefore no money has been made from this technology.”
“The invention behind the buprenorphine patent in question was developed more than a dozen years ago,” he wrote. “If a product is developed under this patent, it will not be commercialized for profit.”
Yet, the patenting of a small change in how an existing drug is made or taken by patients is part of a tried-and-true pharmaceutical industry strategy of enveloping products with a series of protective patents.
Drug companies typically have less than 10 years of exclusive rights once a drug hits the marketplace. They can extend their monopolies by layering in secondary patents, using tactics critics call “evergreening” or “product-hopping.”

Lisa Larrimore Ouellette, a patent law expert at Stanford University, said the pharmaceutical industry gets a greater financial return from its patent strategy than that of any other industry.

AztraZeneca in 2001 famously fended off generic versions of its blockbuster heartburn medicine Prilosec by patenting a tweaked version of the drug and calling it Nexium. When Abbott Laboratories faced multiple generic lawsuits over its big moneymaker Tricor, a decades-old cholesterol drug, it lowered the dosage and changed it from a tablet to a capsule to win a new patent.

And Forest Laboratories stopped selling its Alzheimer’s disease drug Namenda in 2014 after reformulating and patenting Namenda XR to be taken once a day instead of twice.

Another common strategy is to create what Food and Drug Administration Commissioner Scott Gottlieb calls “patent thickets,” claiming multiple patents for a single drug to build protection from competitors. AbbVie’s rheumatoid arthritis drug Humira has gained more than 100 patents, for example.

The U.S. Patent and Trademark Office awards patents when an innovation meets the minimum threshold of being new and non-obvious. Secondary patents are routinely granted to established drugs when an improvement is made, such as making it a once-a-day pill instead of twice a day, said Kristina Acri, an economist and international intellectual property expert at the Fraser Institute and Colorado College.

“Is there a better way? Maybe, but that’s not what we’re doing,” Acri said.

The controversial patent that Sackler and five co-inventors obtained is widely known as a “continuation patent.” (The original patent application for the wafer was filed in August 2007.)

Continuation patents do not necessarily extend the patent life of a drug, but they can have other uses. In 2016, Rhodes filed a lawsuit against Indivior alleging patent infringement.

Indivior, formerly part of Reckitt Benckiser, sells a film version of the popular addiction treatment drug Suboxone that is placed under the tongue — an oral medicine similar to what Rhodes has patented. Indivior’s comes in a lime flavor.
Indivior’s film, which federal regulators approved in 2010, dominates the market with a 54 percent average market share, according to the company’s most recent financial report. And the company has vigorously fought rivals, including filing lawsuits against firms such as Teva Pharmaceutical Industries, which sought approval to manufacture generic versions. Indivior declined to comment.

The Rhodes Pharmaceuticals version would be a wafer that melts quickly in the mouth. The inventors list potential flavors including mint, raspberry, licorice, orange and caramel, according to the patent.
For opioid historian Herzberg, the patent battles between companies like Rhodes and Indivior are “absolute madness.”

Decisions on what is available on the market to treat addicts should be based on what is the best way to treat the people who have the problem, he said.
Patent battles, Herzberg said, are “not how you want drug policy getting made.”

Attempts to change the patent system have intensified over the past decade as prices of prescription drugs continue to climb.

In 2011, President Barack Obama signed the America Invents Act, which included the creation of the Patent Trial and Appeal Board. The PTAB is an alternative to using the cumbersome U.S. court system to challenge weak patents. Generic drug manufacturers have used the board’s “inter partes review” process and overturned 43 percent of the patents they challenged, according to recent research.

Critics of the administrative process, including the pharmaceutical industry trade group PhRMA, said it creates “significant business uncertainty for biopharmaceutical companies.” Often companies have to defend their products twice — both in the courts as well as before the PTAB, said Nicole Longo, PhRMA’s director of public affairs.

Drug giant Allergan attempted to overcome the PTAB’s review process by arguing that the patent couldn’t be challenged at the review board because they sold the patent to the St. Regis Mohawk Tribe, which had sovereign immunity. A federal appeals court ruled this summer that Allergan could not shield its patents from the PTAB review this way.

This year, several members of Congress proposed bills that would unwind or limit changes made by the America Invents Act, though nothing is likely to happen before the midterm elections. The STRONGER Patents Act, introduced in both the House and Senate, would weaken the PTAB board by aligning its claims standards with what has been established by court rulings.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. http://www.kaiserhealthnews.com

Dems Call For Immediate PFAS Hearings; They Won’t Happen

House Democrats called on Republicans to hold hearings this week, specifically in the Natural Resources and Oversight committees, to have the Department of Environmental Quality present what it knows about PFAS contamination and how extensive the problem is in Michigan.

Eight Democrats, led by Minority Floor Leader Christine Greig (D-Farmington Hills), held a press conference Sept. 4 to demand the hearings and that lawmakers take immediate action to strengthen water quality standards for perfluoroalkyl and polyfluoroalkyl substances (PFAS), a diverse group of compounds resistant to heat, water and oil. Such chemicals have been used in hundreds of consumer products and industrial applications including carpeting, apparels, upholstery, food paper wrappings, fire-fighting foams and metal plating.

The chairs of those committees, Rep. Gary Howell (R-North Branch) and Rep. Joseph Graves (R-Linden), called the press conference “political” and said hearings won’t be happening in early September. Howell said he is committed to holding hearings, but will wait until after the election.

“It is a pattern of indifference. That’s why we need the public pressure right now to call for hearings, call for oversight, and get back to an empowered DEQ that understands the issue, listens to the scientific data, listens to the public health concerns, and actually takes action,” Greig said in the press conference.

“I think the big concern is we have very few session days left,” said Rep. Kevin Hertel (D-St. Clair Shores). “They have already cancelled a few weeks between now and the election and our concern is that we are here this week. There is no reason we cannot have hearings this week. The Oversight Committee meets at 9 a.m. on Thursdays and legislators will be here this Thursday. So, let’s bring the department in and ask them the important questions.”

Howell was not convinced.

“I don’t see, in the current atmosphere, it being a productive hearing. I’m not wanting to hear people demagogue this issue one way or the other. I want calm, clear testimony from scientifically qualified people to explain what the level should be going forward. And I just believe that we are not in the right atmosphere, at the moment, to have that kind of calm discussion and work out the best possible solution. But I am committed to doing hearings in November,” Howell said.

Graves noted the state legislature gave the DEQ $23 million a few months ago to study the problem.

“We want to give the DEQ an opportunity to do their job, conduct a study, take the proper empirical measurements, be analytical because this is a new animal . . . We need to know what this is. They are doing their testing. They are working with the feds. And we want to make sure they understand what’s a safe level and what’s an unsafe level,” he said.

Acceptable levels of PFAS in drinking water are a key issue. Rep. Winnie Brinks (D-Grand Rapids) noted that currently there are 30 communities in Michigan which have PFAS levels above the current advisory level of no more than 70 parts per trillion.

“Even more troubling is that that level is only an advisory. We still do not have an enforceable drink water standard established in law to protect our citizens from PFAS contamination,” Brinks said. She introduced legislation last year to set a much lower level for drinking water of 5 ppt. She said that is more in line with new recommendations from the Centers for Disease Control of no more than 7 to 11 ppt.

Brinks also said Democrats are proposing to increase the funding for PFAS response to $39 million. She noted Gov. Rick SNYDER originally asked for that amount in the budget. She said Republicans in the legislature cut the amount to $23 million.

And Democrats have called for the Legislature to provide communities with alternate water supplies in cases of contamination, instead of relying on impractical bottled water for washing, bathing and cooking.

Since the introduction of legislation in December, House Democrats say they have repeatedly called on the chairman of House Oversight to hold hearings on PFAS contamination, yet their calls for action have gone unanswered.

Both Howell and Graves said they had not been contacted by Democrats about the call for hearings the week of Sept. 4.
“We are finally back in session tomorrow,” Greig said. “The time for excuses is past. This administration and legislative Republicans have an opportunity to show that they can do more than the bidding of the wealthy corporate donors. As the Great Lake State, our water is part of our collective identity. Yet, even as we are surrounded by the most abundant freshwater source on Earth, we are unable to assure the water coming out of our taps is safe for us to drink or bathe in. Pure Michigan has to be more than a marketing slogan.”

This story presented in cooperation with MIRS, a Lansing-based news and information service.

Toxic Déjà Vu – PBBs And Now PFAS

By GERALD NATZKE, JR., DO
Do you remember Polybrominated Biphenyls (PBBs) sowing fear and disease into the lives of Michigan citizens approximately 43 years ago? Those PBB’s entered the larger food chain through a single error made by a Gratiot County chemical company worker when a ton of Firemaster (a toxic fire retardant) was added to cattle feed. PBB’s were ingested by cattle throughout this area and spread throughout Michigan and the Midwest, producing one of the largest chemical poisonings in the Western world. Another much larger and more dangerous toxic chemical exposure has been discovered. This family of toxins, through ignorance, and poor oversight has been introduced to Michigan’s and U.S. citizens in multiple insidious ways. These chemicals are called Per- and Polyfluoroalkyl Substances (or PFAS and PFOS).

U.S. Rep. Dan Kildee said that “the seriousness of PFAS contamination cannot be overstated.” Frankly, like the PBB issue in the ‘70s the PFAS poisoning ushers in another era of ecologic crisis. These perfluorinated compounds are linked to cancer, liver damage, birth defects, infertility, thyroid and autoimmune disease, neurologic disorders and hypercholesterolemia. According to Kildee at a recent meeting with physicians, these compounds have been found in more than 30 sites throughout Michigan and are entering aquifers and the Great Lakes. Recently, large amounts have been measured in Lake St. Clair, near 1,000 parts per trillion. Because of this, there is a fish consumption advisory and concern among the cities supplied by water from this lake. All of the Great Lakes will eventually be affected.

The State of Michigan was warned back in 2012 by Superfund section specialist Bob Delaney, a Department of Environmental Quality employee. Not until five years later did Gov. Rick Snyder’s office set up a PFAS response team.

These chemicals have been used in military installations and businesses for a variety of purposes. Some of the most common are water repellant clothing, non-stick pans (Teflon), stain resistant fabrics including carpets, tanning products, cosmetics and fire-fighting foam. There are more than 3,000 of these man-made fluorinated organic chemicals. M-Live reported that it had been found in high concentrations in both Flint’s Gilkey Creek and the Coldwater Road landfill. The EPA has set the concentration for a lifetime consumption limit for humans at 70 ppt. Like with the Lead and Copper Rule used by the federal government, many feel these toxic exposure limits should be lower.

Should physicians desire further information regarding these chemicals for their patients, laboratory tests exist that will evaluate levels of these chemical families in the water and in the blood. Water testing can be done with Pace Analytical Lab, Watercheck and TapScore, to name a few. For testing blood samples there are at least two labs available, NMS and Vista Analytical Laboratory.

The Precautionary Principle was not applied to the PFAS family of chemicals. This is a rule that is used in other countries and Europe but not often in the United States. It is also part of an accepted resolution by the AMA produced by the Genesee County Medical Society. It states that prior to the release of a new chemical into an environment the chemical must be studied and its potential for harm thoroughly understood. In the United States, traditionally many chemicals are released first with little safety evaluation and if significant harm comes, then they are removed. Unfortunately, the fines are much less in many cases than the profits gained.

PFAS contamination was a disaster just waiting to happen. It was not adequately studied for disease-causing potential in people, animals or fish. The sad thing is that people will be injured and die because the Precautionary Principle had not been applied.

In both environmental disasters, PBBs and now PFAS chemicals, serious mistakes were made with their testing, handling and use. It is clear that an in-depth study of chemical safety prior to release into the environment of all chemicals are required. Following this, strict regulation of all discovered toxins needs to be enforced. Perhaps by doing so the ecosystem our children and grandchildren inherit will be healthier than the one that we now share.

This column comes to Healthcare Michigan courtesy of the Genesee County Medical Society. Natzke is GCMS President. The article was previously published in the Genesee County Medical Society Bulletin and appears here with permission.

I’m Voting For Healthcare Interoperability In November. How About You?

By EWA MATUSZEWSKI
We know that “Fix the Damn Roads” is a critical imperative for one of Michigan’s gubernatorial candidates—and hopefully for both. But is “Fix the damn interoperability problem with electronic health records” another? The intersection of healthcare and politics is obviously not new. I would contend it’s more visible—and viscious—than ever. Still, the focus tends to be on access to care and delivery of care, and I understand that. Interoperability of EHR hardly pulls at the heartstrings or incites passionate conversation from either side of the aisle. Accordingly, it doesn’t garner much attention from the consumer media either. That is why it is important for healthcare decision makers to individually and collectively raise awareness of the issue, not just in the healthcare community, but with our elected officials.

To make sure we’re clear on the topic (and in case some politicians are reading this,) interoperability in this context refers to the ability to share and interpret patient data and information electronically across systems and devices among hospitals, insurers, clinics and private practice physicians.

I’ve said it before, and I’ll say it again: there ought to be a law. While I disdain the proliferation of excessive laws that seemingly aim to control our every move, legislation embraced by both parties to establish requirements for the interoperability of individual healthcare records is critical element of health reform. It empowers both patients and their providers to get sensible, timely care without excessive testing, over-testing and re-testing. It is patient-focused and cost conscious, while consistent with population health goals.

If I’m hospitalized and then transferred to another hospital, the assumption is that my records will be immediately available electronically to the receiving hospital. Let’s also touch on emergency room or urgent care activities. These “urgent” encounters become part of the patient’s permanent health record seamlessly. Right? Similarly, if I had an ultrasound done at hospital “X” last year, the ultrasound results should be available online, with my permission, at hospital “Y” this year, correct? The response to all these scenarios is, “Not necessarily.” Similarly, unless a physician practice uses a registry or an EHR that “speaks” to a data repository, health plans are also forced to send auditors to the provider to extract much needed HEDIS information, which can get needlessly complicated when the physician doesn’t use a registry at all. (Yes, some physician practices still rely on paper documentation.) Why is this lack of patient data transfer acceptable in 2018?

Surprising to many, interoperability also plays a role in chronic illness surveillance and treatment. Among our organization’s patient population, primary care physicians have dramatically increased compliance with diabetic patients for retinal eye exams, thanks to the affordability of a mobile eye scanning device that allows the scan to be taken in the PCPs office. The scans are then immediately sent electronically to a retinal specialist for interpretation; a referral to a local retinal specialist is provided when merited.

Despite multiple state-wide initiatives in recent years to make interoperability a reality, including those spearheaded by state agencies, none of our collective efforts have moved the needle far enough. Rather than getting all the players to the table to discuss interoperability, new silos are being created to mask communication inefficiencies. Maybe legislation would help us finally achieve the goal?

Updated Opioid Laws Enact More Stringent Reporting And Usage Requirements

By JESSE A. MARKOS, ESQ.
Wachler & Associates, P.C.
The Michigan Opioid Laws include a 10-bill package of legislation passed in December, 2017, to help curb Michigan’s increasing substance abuse and drug diversion problem. The majority of these provisions came into effect on June 1, 2018 and healthcare providers must become familiar with and incorporate these provisions in to their practice to ensure they are compliant with the changes.

Healthcare providers use the Michigan Automated Prescription System (MAPS) to review a history of any Schedule 2-5 controlled substances that a patient has legally obtained. Not only does MAPS list the prescriber and type of controlled substance that has been prescribed, but it also lists the location of the pharmacy it has been dispensed at. MAPS data assists healthcare providers in identifying evidence of potential diversion such as: obtaining controlled substance prescriptions from more than one provider, filling prescriptions early, filling prescriptions at multiple different pharmacies, and filling prescriptions at distant pharmacies. In the past, providers were not required to register for or use MAPS, although it was highly encouraged and likely to be considered the standard of care when prescribing a controlled substance. Nevertheless, while it was largely considered the standard of care to run and review a MAPS report when prescribing a controlled substance, the issue of how frequent such reports should be run for a chronic patient was less certain. The new laws make it both an express requirement that a prescribing healthcare provider register with MAPS and that they run and review such data every single time a prescription is written that exceeds a three-day supply.

Another important provision in the Michigan Opioid Laws is the “Start Talking” consent form, which must be filled out whenever a prescriber issues a controlled substance containing an opioid to a minor or adult. This form not only has signatures from all involved parties, but it contains all of the relevant information about the risks of taking the opioid, such as: acknowledgement that the drug has potential for abuse, how to properly dispose of an expired or unused controlled substance, and that the delivery of a controlled substance is a felony, among other things. Again, although obtaining prior consent was certainly a standard of care requirement previously, the new laws make it an express requirement that the specific notice listed in the new laws must be adopted in any Consent Form being utilized by a health care provider moving forward.

The Michigan Opioid Laws contain ten (10) new provisions that were passed by the Michigan Legislature, and providers who prescribe or dispense controlled substances must familiarize themselves with these new laws in order to remain compliant and protect their licensees. For additional information or assistance, contact Jesse A. Markos, Esq., of Wachler & Associates, P.C., at (248) 544-0888.

IRS: The Good, Bad and Ugly for Health Care Providers

By RALPH LEVY
In early August, the Internal Revenue Service issued proposed regulations that provide guidance to owners of pass-through businesses as to eligibility for a federal tax deduction of 20 percent of the income generated by the businesses. This deduction was part of the Tax Cuts and Jobs Act (TCJA). Although the stated purpose of the proposed regulations is to provide clarity on eligibility for and the means to compute the deduction, this guidance is lengthy and complex. However, for healthcare providers, there are two important takeaways.

Takeaway No. 1: Guidance on whether a healthcare business is a “specified service trade or business.”

One of the important limitations to the pass-through deduction in the TCJA is that owners of pass-through businesses that conduct a specified service trade or business (SSTB) and whose income exceed the so-called income limitation ($207,500 for single taxpayers and $415,000 for married taxpayers who file jointly) are not entitled to claim the 20 percent deduction. The TCJA provides that a SSTB includes a trade or business that involves the performance of services in the health field.

The proposed regulations provide guidance as to what types of businesses involve the performance of health services:

The performance of services in the field of health means the provision of medical services by physicians, pharmacists, nurses, dentists, veterinarians, physical therapists, psychologists, and other similar healthcare professionals who provide medical services directly to a patient (emphasis supplied).
Prop Reg. 1.199A – 5(b)(2)(ii).

Providers of certain types of healthcare services might be able to avoid the SSTB limitation if their services are not provided directly to patients. For example, radiologists who are partners in a professional limited liability company and who merely read test results may be eligible for the deduction but the treating physician will not be entitled to the deduction since the treating physician provides services “directly to patients.”

Similarly, if an orthopedic group also owns a physical therapy clinic, because that clinic’s services are directly related to the medical field, it is likely that the clinic will be deemed to be engaged in a SSTB. However if the same physician group also operates a health clinic “that provide[s] physical service or conditioning to their customers (i.e., not medical related)”, the clinic will not be engaged in a SSTB.

Takeaway No. 2: The use of a “captive MSO” will not work.
Prior to issuance of the proposed regulations, one of the planning suggestions that many advisors had recommended for consideration by owners of healthcare businesses whose income exceeded the income limitation was segregation of the billing, collection, accounting and other “back office” activities of the practice into a separate legal entity under common ownership with the practice group. This new legal entity would in reality be a management service organization (MSO) that provides services only to the affiliated practice group. Such a new entity was referred to by some as a “captive MSO”.

Under the proposed regulations, if the captive MSO provides services only to the practice group under common control, the MSO would be deemed to conduct a SSTB. This of course eliminates the tax advantage of establishment for the MSO.

By contrast, if more than 20 percent of the income of the MSO is generated from providing management services to other payors such as unrelated medical practice groups, the MSO would not be found to engage in a SSTB.

Similarly, if a dentist is the sole member of a limited liability company that owns a two story office building and rents the first floor to the dentist’s dental practice but leases the second floor to an unrelated business, half of the income generated by the LLC from the building will be deemed to be generated from a SSTB.

Although the proposed regulations limit the ability of health care providers to use affiliated entities to maximize the 20 percent deduction, planning opportunities still exist if the ancillary business is owned by a trust or other entities not under “common control” or if the business provides services to unrelated service providers.

In summary, even though they are complex and cut-off some available planning opportunities, the newly issued proposed regulations do not eliminate all planning opportunities to maximize the 20 percent deduction for owners of pass-through businesses that provide health care services.

LANSING LINES

Lyon’s Attorneys Seek To Dismiss Criminal Case
As expected, attorneys for Michigan Department of Health and Human Services Director Nick Lyon are asking the Genesee County Circuit Court to quash the bind over from district court and dismiss all criminal charges.
In court filings Sept. 10, defense attorneys John J. Bursch, Larry Willey and Charles “Chip” Chamberlain Jr. say Genesee County District Judge David Goggins’ made his “decision by closing (his) eyes to numerous principles well-settled in Michigan law” and that his decision to send Lyon to trial on two counts of involuntary manslaughter and misconduct in office is the first in the state’s history to hold a director criminally liable for subordinates.

“The families of Mr. (Robert) Skidmore and Mr. (John) Snyder desire justice, as do the people of Flint,” Bursch wrote. “But that desire cannot be satisfied subjecting Director Lyon to a trial for criminal charges that fail as a matter of law. That would be the exact opposite of justice.”

A 9 a.m. Sept. 26 hearing was set, but it’s unclear if Circuit Judge Joseph J. Farah will hear the defense’s motions that day.

The state had not filed a response as of Sept. 10.

The state argued at a preliminary examination that Lyon’s failure to notify the public about Legionnaires’ disease in the Flint area in 2014 and 2015 led to the deaths of Skidmore, 85, of Genesee Township, and Snyder, 83, of Flint-area.

Lyon also faces one count of misconduct in office for allegedly misleading and withholding information about Flint’s Legionnaires’ disease outbreaks and directing a health official to discontinue analysis to find the source.

In a separate motion, the defense also seeks to dismiss a misdemeanor count of willful neglect of duty, which automatically moved to Circuit Court with the felonies when Goggins didn’t make a ruling on the defense’s motion to dismiss the charge.

The defense says Lyon had no ministerial duty and any alleged duty to “protect the public health” is too vague to be enforceable. To support their argument, the defense points to preliminary examination testimony in which witnesses testified whether, when and how to give notice of an outbreak is professional judgment and discretion.

“As far as the MDHHS director is concerned personally, the statute requires only that he ‘be qualified in the general field of health administration.’ . . . Indeed, the MDHHS director’s oversight of his epidemiologist and health officers in the event of a Legionnaires’ outbreak is the epitome of discretion,” Bursch wrote.

“Based on this legal defect in the charge, the lack of any evidence of willful neglect, and the additional reasons described below, the defense moves to dismiss (the charge),” he added.

Health Policy Considers Creation Of Statewide Mental Health Hotline
A state-wide mental health hotline—which would connect callers experiencing a mental health crisis to facilities that have psychiatric beds available and other service providers — would be created under legislation taken up Sept. 5 in the House Health Policy Committee.
Rep. Mary Whiteford (R-Casco Twp.) told the committee her HB 6202 was inspired by an experience she had with a friend who had become depressed after the death of her grandmother. Whiteford said she contacted local mental health services, one of which said if her friend was not suicidal there was nothing they could do. Another behavioral help group said it usually takes three to five months for new patients to see a provider.

Eventually, Whiteford took her friend to an emergency room where the friend was admitted. After a one-week stay, the bill was $10,000, Whiteford said, of which the friend owed $5,000.

How many would persevere after getting turned away twice, she asked.

“The answer is most people don’t know where to go. They don’t know who to ask for help. They do nothing. What happens to the struggling person? They hurt themselves. They commit suicide. They hurt others. What would have helped? What can help others in the same situation?” she said.

Such a hotline was called for in the House CARES (Community, Access, Resources, Education, and Safety) task force report members worked on last year and was unveiled in January. The task force reviewed the status of mental health services across the state, and found that availability of services is inconsistent from county to county.

Rep. Daniela Garcia (R-Holland) had several questions. For one, Community Mental Health services in counties are required now to have hotlines. Why is that not sufficient? she asked.

“Did you know that it is easier for somebody on Medicaid to access services than it is for someone who is uninsured, or someone who is insured. This allows access to everybody,” Whiteford answered.

Garcia also asked who would be assigned to answer that hotline, how they would be trained and evaluated.

“At this point, I don’t want to be so prescriptive that we lose innovation that we lose the ability for a company to make those judgment calls. So, the way I see it, is that the department will put out a request for proposals,” Whiteford responded.

Under the bill, the Department of Health and Human Services would contract for the design, operation, and maintenance of the hotline. DHHS would work with the contractor as well as the Department of Licensing and Regulatory Affairs to tap into existing databases and lists of service providers. Any operator company would be expected to run the hotline using various methods of communication including phone calls, texts, e-mails and internet chats.

Garcia put the estimated cost of creating the hotline at around $6 million. The bill analysis states the annual cost of operation would likely be similar to other hotlines the state operates, which range between $1 million and $2.5 million.

The committee ran out of time for further testimony. No vote on the bill was taken.

Proposal 1 On November Ballot: Marijuana Legalization
Michigan Director of Elections Sally Williams released Aug. 31 draft ballot language for the Coalition to Regulate Marijuana Like Alcohol’s initiative to legalize marijuana.
The proposal, 18-1, would initiate a law to “authorize possession, use and cultivation of marijuana products by individuals who are at least 21 years of age and older, and commercial sales of marijuana through state-licensed retailers.”

The Board of State Canvassers was expected to consider the recommended language at its 10 a.m. Sept. 6 meeting at Delta Charter Township Hall, 7710 W. Saginaw Highway, Lansing.

In addition, the proposal would:

– Allow individuals age 21 and older to grow up to 12 marijuana plants for personal consumption;

– Impose a 10-ounce limit for marijuana kept at residences and require that amounts over 2.5 ounces be secured in locked containers;

– Create a state licensing system for marijuana businesses including growers, processors, transporters and retailers;

– Allow municipalities to ban or restrict marijuana businesses.

– Permit commercial sales of marijuana and marijuana-infused edibles through state-licensed retailers, subject to a new 10 percent tax earmarked for schools, roads and municipalities where marijuana businesses are located.

CRMLA was formed this year to support the ballot initiative to end marijuana prohibition in Michigan and establish a system in which it is regulated and taxed, similar to alcohol.

In April, the Board of State Canvassers approved the coalition’s petition.

In June, the Michigan Legislature didn’t have the votes to pass the legalization ballot initiative, which means the issue appears on the Nov. 6 ballot.

If approved, Michigan would become the 10th state to legalize, regulate and tax marijuana, according to CRMLA’s website.

Agencies, businesses and organizations opposing recreational marijuana legalization have mobilized in recent months.

Witness: Finding Cause of Flint Water Crisis ‘A Luxury’
A former state epidemiologist testified Aug. 30 that finding the cause of elevated blood-lead levels in Flint’s children during the water crisis would have been “a luxury.”
Cristin Larder returned to the stand for the fourth time in the preliminary examination for Nancy Peeler, director of Michigan Department of Health and Human Services Program for Maternal, Infant, and Early Childhood Home Visiting, and Robert Scott, data manager for the department’s Healthy Homes and Lead Prevention program. The hearing, which will determine if there is probable cause to send criminal charges to Circuit Court for trial, resumes Sept. 20.

The state alleges Peeler hid Larder’s report and joined Scott to create a second report that falsely indicated no statistically significant rise in blood-lead levels of children in July, August or September 2014.

Larder’s testimony remains consistent that Peeler asked her in February 2015 to analyze data to determine if there was an uptick in blood-lead levels in Flint children during the water crisis, which began in April 2014 when the city switched its drinking water source to the Flint River, and that she learned during a Freedom of Information Act file dump that her report wasn’t in the state files.

Larder also maintained that she didn’t have enough raw data to explore more thoroughly or to reach a conclusion about the cause.

“I cannot say and I couldn’t say at the time,” she said.

Larder was the only witness today and at times the proceedings felt slow as Special Prosecutor Todd Flood sparred with Scott’s attorney, Mary Chartier, who carefully questioned Larder about emails she wrote in 2015 about her analysis and whether Peeler and Scott were recipients of those emails.

Chartier argued that information Larder penned in a February 2016 email wasn’t sent to Peeler or Scott and therefore, isn’t relevant, but Flood countered that the email shows Larder’s report “was basically suppressed,” which is the basis for the charges against Peeler and Scott.

“Bob Scott is not misleading anyone,” Chartier told the court as she questioned Larder.

“Bob Scott is not in charge of anyone. He’s there to provide data and what I’m trying to get from Miss Larder is smart people are looking at a challenging issue and trying to come up with ideas,” the attorney added. “He’s not directing what they do or don’t do and that goes to the heart of what Mr. Flood is trying to put on the shoulders of my client, who is not even involved in these matters.”

Peeler and Scott are each charged with misconduct in office and conspiracy, both of which are felonies. They are also charged with misdemeanor count of willful neglect of duty in connection with the Flint water crisis.

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

LETTER

Editor:

Just A Few Questions
How can it be expected that all physicians and all citizens will succumb to the idea of socialized medicine without inquiring as to why they should? Is it somehow mandatory that we U.S. citizens duplicate the socialist-lite bloated welfare states that are the examples of how the rest of the “advanced” world’s approaches healthcare? How is it always correct to increasingly subvert the medical profession by employing ever more restrictive regulatory shackles? Isn’t it interesting to witness how the left-leaning elites write a check with money they do not have that comes from our bank accounts so that they can snoot and virtue signal? Isn’t social justice great when some elites can redistribute wealth to achieve equal outcomes in a world of humanity with individual cultures and aspirations? It seems I read somewhere that God created each person as unique and in His own likeness.

As the cadre of newly enlightened devotees to the alleged equality of their social justice platform prescribe socialized medicine for all of us, will this not steal coveted freedoms from physicians and citizens? Critical thinking versus emotional feel-good stuff?

You know, let these great new falsely pious warriors have at it. But leave the rest of the doctors and patients out of their unfunded, freedom-sapping never in history workable plans for us all.

Is not the pitifully decreasing physician morale in this country sufficient? Does it need to be at the pathetic levels of physicians functioning in those socialized medicine havens of provider underpayment for rationing care their governments can increasingly not afford? We already have two physician suicides a day in the United States.

Duplicating failure seems a strange goal, does it not?

The ‘Right’ To Healthcare?
When healthcare is presumed a right, the provider, doctor, has no rights. That someone would expect a service from another without payment seems much like the scourge of slavery that was belatedly banished from this country in the mid-19th century. There seems a hypocrisy here as the loud screams of the virtue signalers for social justice are joined by equally loud screams for physician services on demand for “free.” Is it not abusive to expect care without any expectation of payment or even a hint of appreciation? Explain the moral basis of those who want healthcare for “free” and those who benefit from this politically. There seems a loud and clear message here regarding the progressive movement and the duplicity of virtue signaling and social justice.

Then there is a mandatory obligation to preach false magnanimity devoid of any relationship to economic realities. With government-run healthcare, would there be any incentive for capital investment? Let me give a unambiguous answer, ‘no.’ Without capital investment, innovation disappears. Entrepreneurs are eradicated. And remember, financial capital effects human capital in direct correlation, and this includes the number, type and quality of future physicians. You cannot stave off voluntary and intelligent capital flow to the innovators in exchange for political favoritism, mercantilism, and expect anything other than the status quo at best. The emotional “feel good high” of the Medicare for all crowd can’t have it both ways, progress versus increasing government control.

Yes, for a person to share the most private aspects of their life often with nothing covering them other then a drape, this truly is a special bond, “a sacred relationship.” It cannot be legislated. In fact legislation has consistently eroded it. God help us if the bureaucrat elites are able to destroy it. The profession of medicine will be lost. This is a tragedy for all of us who will at some point need healthcare. You can meet your favorite bureaucrat or hospital administrator in the ER. The real doctors are likely a rapidly diminishing group in an environment of mandatory capitulation. There must be consequences, and these will most assuredly be negative.

—Allan Dobzyniak, MD

The opinions expressed above are those of the author and not necessarily those of Healthcare Michigan or its advisors.