The Affordable Care Crisis

 

Opposition to the current roll-out of the Affordable Care Act has grown and has come center-stage. Proponents of the new law seem to have taken a less visible role, and public opinion has gradually drifted to changing the mandate deadlines. From a practical stand point the health benefit exchanges do not seem to be entirely ready, and have generated confusion and more anxiety.  The Dept. of HHS hyped the HBX and raised unrealistic expectations.  It became more of a marketing ploy than a real value proposition.

It is time to back off and take a breath to re-evaluate the goals and what must be implemented to assure a smooth and successful health reform .  It may require major revisions during the next 24 months.   The compressed time schedule from 2010 when the law was passed until 2013 is really a very short time to transition a huge industry. Much of it evolves only if all the steps take place in an orderly fashion. It is a bit of a domino game and a false step or missed opportunity may crash the project entirely. 

Health care has not and will not been reformed by the Affordable Care Act.

Another indicator of the error in thinking, HHS failed to realize that health will still operate in an open marketplace, save for those at the bottom tier who will have to rely on a legacy medi-caid system, an antiquated poverty level, and a maze of federal-state-county eligibility system.

In the current system counties calculate benefits based upon maintance costs, also legacy and badly out of date poverty level figures. For one thing poverty levels are determined for the nation at large. Poverty level in California is far different from Poverty levels in the midwest or Arkansas as one example.  In fact poverty levels vary greatly in each state, such as a state with wide disparity  in income zones.One size will not fit all and nothing has been mentioned regarding specifics of how the medi-caid system will be modified to adapt to ObamaCare.

Obamacare and the Federal Poverty Level

Who gets help from Medicaid (AHCCCS in Arizona) and who gets help with their health insurance premiums under Obamacare?  It all depends on a person’s, or a family’s income in relation to the federal poverty level.

An individual or a family will get help with their health insurance premiums if their income is between 133% and 400% of the federal poverty level (FPL).

In addition to getting help with health insurance premiums, some people will get help with co-pays that are part of their health insurance plan. Individuals or families making less than 200% of the federal poverty level (but higher than 133%) will get this help if they enroll in a Silver plan. (I guess I need to explain the coverage levels next.)

Here is a chart that shows the FPL changes based on the number of people in a family.

The Beginning or The End to the Affordable Care Act

 

By now perhaps 20 million or more Americans have tried to log into the National Health Benefit Exchange, or one of the State-run portals.

There is probably no way to tell exactly since the analytics are not working for the site. However Google could probably tell us. (Maybe HHS should have contracted with  them.

These are not glitches,” said an insurance executive who has participated in many conference calls on the federal exchange. Like many people interviewed for this article, the executive spoke on the condition of anonymity, saying he did not wish to alienate the federal officials with whom he works. “The extent of the problems is pretty enormous. At the end of our calls, people say, ‘It’s awful, just awful.' ”

The reluctance for many states to join the national HBX effort is outlined by the following.

Interviews with two dozen contractors, current and former government officials, insurance executives and consumer advocates, as well as an examination of confidential administration documents, point to a series of missteps — financial, technical and managerial — that led to the troubles.

Politics made things worse. To avoid giving ammunition to Republicans opposed to the project, the administration put off issuing several major rules until after last November’s elections. The Republican-controlled House blocked funds. More than 30 states refused to set up their own exchanges, requiring the federal government to vastly expand its project in unexpected ways.

Deadline after deadline was missed. The biggest contractor, CGI Federal, was awarded its $94 million contract in December 2011. But the government was so slow in issuing specifications that the firm did not start writing software code until this spring, according to people familiar with the process. As late as the last week of September, officials were still changing features of the Web site, HealthCare.gov, and debating whether consumers should be required to register and create password-protected accounts before they could shop for health plans.

 

From the Start, Signs of Trouble at Health Portal

Dr. Donald M. Berwick, the administrator of the federal Centers for Medicare and Medicaid Services in 2010 and 2011, said the time and budgetary pressures were a constant worry. “The staff was heroic and dedicated, but we did not have enough money, and we all knew that,” he said in an interview on Friday.

There are opposing opinions as to how long it will require to unravel another Gordion knot.  Some say weeks and others say several months.

How much will it cost? Like every government project it will most likely come in over budget, which can also be said about the entire Affordable Care Act.

And while I compare apples to oranges, at  $150 million USD a pop for a state of the art F35 stealth fighter, that will sound like a Walmart special, as compared to Obamacare.  

And like Health Benefit Exchanges, there is a web site dedicated to the F35 Raptor .

Twinkies and Ding Dongs Democrats or Republicans

 

Republicans, or Democrats.  Who is the Twinkie and who is the Ding Dong?

Depending upon whom you ask the PPACA is the best thing since the advent of the Twinkie. And although PPACA passed congress we are not certain how it will survive. It will survive as the Twinkie and the Ding Dong are surviving despite skeptics and outright hostility from some quarters.

What about some bi-partisan support and remediation by Republicans and Democrats, alike?

Physician medical groups seem the happiest of all segments of medicine.

Don Crane, the CEO of CAPG (California Association of Physician Groups) in the December issue of their newsletter had this to say in 2010.

“As we watched the election results, it became clear that the Accountable Care Act (ACA) is, in fact, established policy. Regardless of our political views, we now have a more accurate picture of what the future holds for physician groups. At last we can put long-term planning back on the table and base our decisions on fact instead of speculation. That is good new”

Don Crane sees the big picture overall as he eloquently and accurately states,

“The most urgent issues facing our country are the deficit and the federal budget,

and both will have a huge impact on the healthcare community. The sustained

growth rate (SGR) provider payment measurement, which dates back to 1997 when

spending costs were increasing much more slowly, will probably get another

“patch.” That isn’t enough. What it needs is a genuine and lasting “fix” that includes

incentives for coordinated care, primary care and Accountable Care Organizations

(ACOs). We will continue to press for those kinds of improvements to the ACA. Another critical issue associated with the ACA is the expansion of healthcare coverage to 32 million million uninsured. It will be costly, and implementation may be difficult. In California, however, voter-approved Proposition 30 provides additional taxes which should prevent serious cuts to Medi-Cal.”

Don Crane summarized well in the newsletter,

“I expect to see an acceleration of the mergers and acquisitions trend, with well managed physician groups among the most sought-after entities. CAPG physician groups and others practicing in our accountable care model know how to provide better care at lower costs. They know how to measure and improve clinical quality. They know how to establish effective management. Those who also understand how to adapt and innovate in a new environment will be among the success stories of the next decade”

Managers love to manage, and the bigger the group they manage the greater their esteem. It’s a little bit like government.

Physician medical groups will adopt quickly to ACA and even possibly to the ACO concept. Small medical practices, individual solo practices will struggle with much more, setting up an organization. Much of the transition has to do with infrastructure and professional management.

HHS says that ACOs will create great cost saving measures, and improve quality of care. Both claims will require some hard evidence. These early claims are based upon already formed large medical group systems (already in place) with very early statistical evidence for a short time period.

Engaging small systems will require careful and prudent management. In a sense this is a new enterprise model, subject to all of the vagaries of all startups. Management costs, health information technology, and capital requirements could tip the balance into insolvency very quickly.

The incentives offered by HHS for adoption of EHR are misleading and do not allow for continuing maintenance, nor software updates. It is well known that EHR hardware and software maintenance costs over the long run far exceed the capital expenditure to purchase a system.

Of course all of this was before “Sequestration” precipitated by the debt crisis. There is much uncertainty as to how this will be implemented for Medicare plans.

 

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We Are Behind, or are We ?

It would seem that healthcare is changing rapidly. But has it and is it really ?  The Department of Health and Human Services, Medicare and the Affordable Care Act have mounted a huge and expensive campaign using hype, and a lot of money to convince potential patients that all will be well (or maybe better) with government guidance, incentives, mandates, and a ‘battle plan’ for revolutionizing health care. This was accomplished with preconceived ideas and a partisan plan developed behind closed doors.

Is it so?

Michael L. Millenson reminds us that we are behind. Demanding Medical Excellence came out in October, 1997. What progress has been made since then, and where we have fallen short? He addresses that question in a short article, “The Long Wait for Medical Excellence,”

“I set out to review this topic and found his excellent observations in The Health Care Blog, featuring “Still Demanding Medical Excellence”.

Written at a time  (1997), well before the Institute of Medicine’s (IOM) scathing analysis of dangers in the health system Millenson points out;” the 1998 report on errors from the IOM estimated that 44,000 to 98,000 patients die each year in hospitals from preventable mistakes. The Agency for Healthcare Research and Quality (AHRQ), using a different methodology, recently estimated the number to be 97,000. Put it all together and this is what you’ve got: for the past decade (or, maybe, for several decades), 100,000 Americans (or maybe upwards of 200,000 Americans) have lost their lives each year in hospitals through preventable medical mistakes. Add it up: a million preventable deaths? Two million? Plus preventable injuries? Pick your time frame and your toll.”

In a 2010 Health Affairs blog, “Why We Still Kill Patients,” I bluntly blamed the lack of progress on a combination of errors’ invisible consequences, professional inertia and the income hospitals quietly reap from substandard care. I believe that new standards of transparency, in addition to government and private sector financial incentives, are making care safer.”

All is not lost, just that progress has been very slow as compared to product recalls for defective devices, infectious disease outbreaks. and more.  Perhaps processes and system are more difficult to change. One cannot recall a process without bringing the system to a dead halt.

Now consider that all of the above is about hospital care. Now, consider that 15 years after the IOM error report there is no reliable estimate at all of the death and injury toll in the outpatient environment. Why? And why no outrage?

 

Commentary and Opinions are invited and encouraged. Guest bloggers are also welcome to contribute here.  Send requests to gmlevinmd@gmail.com

 

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Government Shutdown vs. Health vs. Debt Ceiling

 

The present stalemate in Washington reflects how ridiculous it is for anyone to think that government can really “run’ health care.  Does the world’s economy really depend upon making the right decision regarding the American Health Care system, or how it will effect the American Debt Ceiling. How much grandstanding is taking place in D.C. ?  What is true?  That depends upon which side of the aisle you live in.

It may be a good thing that we have become more of a paperless society, because the sheer weight of what might have been printed regarding the affordable care act (not to speak of the law itself) would tip the spinning globe off it’s orbital axis.

The real issue now before us in regard to the Affordable Care Act is how to amend it and maintain it’s worthy, lofty and principled goal to provide good health care to all. No one can even define what ‘good health care’ means.  Let alone to fund it.

The law was passed, and Speaker Pelosi said we would not know what was in it until it passed.  So be it. Neither Pelosi, Obama, Reid, and others knew how this law could or would play out.

The beginning is not promising as we have seen with several delays and one of the principle components, the health benefit exchange portals being  broken and incomplete.  Despite input from credible business, and healthcare sources the reaction of the administration is both defensive, and arrogant.

The segment of the industry that seems to complain the least is the insurance companies, for they have gained the most, and lost the least. Even with the mandate that they must allocate 85% or more of their income to direct patient care, insurers have other means of restricting their cost and maintaining profitability hidden away in increased deductibles, and larger copays as well as raised premiums.The government claimed that health spending is out of control, and the only means to correct it is for them to ‘regulate’ it more.  The truth is that most of the increase in cost has been fueled by regulations in all areas of healthcare.

Haste does make waste and it is time to call a time-out and halt further mandate deadlines.  During this period an assessment needs to be made in regard to repairing what is already in place.

The real uncertainties of the Affordable Care Act, in addition to the funding impact, now include whether it will be fully implemented at all.  The final word is not yet out. (this despite Democrats clearly pointing out it is the law of the land).Clearly there are many Americans, democratic and republican opposed to it’s present form. Any law popular or not must face the test of logic, and rational thought. Pipe dreams do not fit in this category.

Do we need to sacrifice 40 million people to be without health care? Certainly not, while a means can be had to insure almost all Americans with a sound business model.

The current form of Obama care is fraught with chaos, and an attempt to manage, manipulate and coerce different health segments with economic sanctions and reward. The problem is that a sanction to one segment is a reward to another, and rewards to one segment may be a sanction to another.  Each segment may have competing interests.  The result of this Gordian knot is the unpredictability of what secondary effects will occur, as has been shown during the run up to the employer and the individual mandates, and it’s effect on employment by small businesses.

The verbal assurances by the Obama administration of lowered insurance premiums are in doubt as real figures begin to emerge.  There is great fluctuation in premium estimates on a state wide basis. This seems to fly in the face of a National Health Care System.

While many of the previously uninsured will receive an “insurance card” there is real expert opinion that it may not be worth the paper it is printed on.  Like many patients with Media-Cal’s blue and white “BIC” for many it will be worthless or even worse, a liability.  Many providers will not deal with programs that require inordinate bureaucratic burden for inadequate reimbursement.

In a recent non scientific sidewalk study by FOXNEWS there were many who thought Obama care was not the same as the Affordable Care Act.  Some even thought that Obama care was better than the Affordable Care Act.

Leading the Charge in Wireless Health

 

Who and what is leading the growth of wireless technology in health care? You would be surprised.

According to Leslie Saxon MD in a special to CNN, Technologic advances don’t happen in isolation. There are many different elements— cultural and technologic — that must come together to turn an innovation into a scalable business product, and then, possibly—but rarely—a cultural phenomenon.

When it comes to digital health products, the prevailing attitude among physicians is still deep suspicion. While many people look at physicians as the drivers of change in digital health, I am in the minority of innovators in this field. There are some physicians who are on the vanguard of talking about it, but only a few are actual innovators. Many of the advances will come from non-healthcare innovators–the “pull through” demand will come from the public who recognize the benefits of new technology to help them become healthier and smarter about their lives.

Read on: Digital Health Space

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Paul E. Zimmerman.com: Don't Buy Health Insurance, Don't Pay The Fine, Do Enjoy Yourself

Paul E. Zimmerman.com: Don't Buy Health Insurance, Don't Pay The Fine, Do Enjoy Yourself

Arriving Track 1 on the Affordable Care Act

 

Where you stand depends on where you sit

Please stand back to avoid being ‘sucked’ under the train. Wait until the train has come to a complete stop before boarding or exiting (that may take some time)

Take some time to read the entire blog post from Phil Levy, the author of “Not running a hospital”

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House Bill Links Health Care Law and Budget Plan

 

Your Health and How has it become a “Crap Shoot”

Politics and health never have been a good mix. The outcome of the evolution of what political game playing and mixing the financing of health with political greed for power is now evident. While Medicare which was put into effect in 1964 has benefited millions of the elder population it too was passed without concern for cost and more important input from physicians (who were largely ignored when they warned it would eventually bankrupt the country. ) Congress was warned by many physician groups that the demand for healthcare can be infinite and by treating Medicare as another insurer without restriction would inflate the national debt and fuel medical inflation.

Despite many wars much of our national debt can be attributed to Medicare liabilities current and future. Now the surge in Gen X, Y and Millennial adds to the disaster. Coupled with the national recession and evolution of the global economy it all crystallizes into what we now face.

Today's New York Times:

 

House Bill Links Health Care Law and Budget Plan

Sylvia Mathews Burwell, the White House budget director, told executive branch officials to begin preparing by updating their contingency plans. This has become so common that we now have what is a several thousand page manual on shutting off our government.

All or none? The Congress is using our health care as a political football. Neither side will not negotiate and it has gradually evolved into the present quagmire. Congress is having it's usual tantrum and is acting out it's negligence. 2010 was the time when this might have been avoided if the law was read and experts were allowed to apply the appropriate fixes to the bill(s).

“House Republicans muscled through a stopgap bill Friday that would fund the government only if all spending for President Obama’s health care law is eliminated. Senate Democrats and President Obama quickly made it clear they had no intention of going along, putting the government on a course toward a shutdown unless one side relents.'

'The 230-to-189 party-line vote in a bitterly divided House set in motion a fiscal confrontation with significant implications — politically and economically — but with an uncertain ending. Without a resolution, large parts of the government could shut down Oct. 1, and a first-ever default on federal debt could follow weeks later.

Each side predicted that the other would be held responsible, but determined House Republicans knew they were taking a risk even as leaders of the party’s establishment warned about the threat of destructive political consequences.'

Mr. Obama called House Speaker John A. Boehner on Friday evening but only to reiterate that he would not negotiate with him on raising the federal debt limit and said it was Congress’s constitutional obligation to pay the nation’s bills. Both sides described the call as brief and fruitless.

Congressional gridlock. It occurs frequently, not just in healthcare. We pay our Presidents and Congressmen well enough to do the 'people's business'. Through a variety of decisions government has forcibly intruded into your physician's and hospitals duties to provide for your health. The football has been intercepted and a one hundred yard game ending run to the goal is now in progress.

The conundrum is that Congress is really not interested in health....it is only interested in a 'victory dance' sponsored by either Elephants or Donkeys. The result will be a stable full of excrement on the floor....needing to be mucked out by the people's assets in the name of taxes and debt to foreign countries.

There must have been a better way to accomplish this goal.

A brilliant physician, Donald Berwick MD, was run out as head of HHS by his choice of words regarding the NHS of the U.K. Berwick is a highly respected former head of the Institute of Medicine, a credible authority on medicine, but a novice in the world of American politics. Our country has an anaphylactic reaction to words such as 'socialism','entitlement',

Berwick holds a position at Harvard Medical School. His N.H.S.remark was poorly worded and timed also a politically unwise statement in public about his wishes for our US health system. Other physicians, including Mike Leavitt and others have been ground up and spit out by politicians. Congress defies expert opinions in many areas of their decision making. Their bad choices overflow into all areas of society, from IT to immigration.

My health is not a Republican vs. Democratic issue....to be kicked around for political expediency and headline news. Nor should it be for you either.

The real truth is Obama's statement when speaking to a labor group,

““They’re focused on politics,” Mr. Obama told autoworkers at a Ford plant in Liberty. “They’re focused on trying to mess with me; they’re not focused on you.”

Mr. President, no one is focused on your narcissistic goal of being the President who forced the wrong treatment on our health system. Inaccurate dosing, error in prescribing and malpractice.

(see non-disclaimer and waiver on the right hand banner.)

September 21, 2013

GML

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Fait Acompli ? Affordable Care Act

The top of this week’s health news have been the  debate over funding Obamacare and the Debt Ceiling.  There is little doubt that funding the Affordable Care Act will increase the National Debt.  Without accomplishing this the Mandate will be an empty one.

As we mentioned previously politics and health care do not mix well, they are immiscible.  They are two individual complex entities and mixing the two results in a ‘melt down’. The National Debt has become inextricably bound to health care financing as funding from government sources has increased as a percentage of GDP

 National Debt Clock is running.  Of course there are other contributing factors which are in the equation as outlined by this Bank of America Analysis/Merrill-Lynch white paper published in February 2013.

The Republicans know this and despite the unpopular act of closing the federal government they have stood fast, believing that the Affordable Care Act would severely impact the short and long term recovery of our economy. In the political scheme of things (which often are irrational) Republicans have much more to lose by alienating more Americans as the enemy of social progress and Democratic proclamation that Republicans are obstructionist bent on defeating Obama’s singular accomplishment, the Affordable Care Act.

This week signals the opening round of the Health Benefit Exchanges which will allow consumers to search health plans in their state and to register for them. The most significant portion of consumers are those that are presently uninsured.

News this week clearly shows that less than 50% of the population know anything about Affordable Care Act, and even fewer understand or how to access Health Benefit Exchanges (HBE)  This week many kiosks are popping up at shopping malls answering questions and distributing literature about the ACA.  I don’t think this is part of the “NAVIGATOR’  program.  It is most likely budgeted from the marketing budget announced by HHS.  Rumor has it that funds have been limited due to ‘sequestration’.

HBE is one form of Health Information Technology which directly impacts consumers as a necessary focus, unlike mobile health apps.  Because January 1, 2014 is the commencement data for eliminating  prior illness or increasing rates due to prior conditions, the enrollment period is brief. (however like all government programs lately it will most likely be delayed)

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Hurricane Medicine

 

 

No, the title is not about weather or tropical storms. The current cyclone is in health reform, specifically the Affordable Care Act. I think we should stop calling it  ObamaCare.  Labelling any piece of legislation or policy ‘Obama…..” elicits strong reactions, either positive or negative and it triggers partisan political loyalties.

The swirl of controversy regarding the Affordable Care Act continues as it is approaching a category 3 intensity.  The storm has made landfall with it’s outer bands on shore.  The eye of the storm remains offshore tracking along parallel to the beaches, and it is currently stationery pounding health care and the economy with uncertainty.  Should we board up the windows and evacuate or continue to battle with sandbags and a storm shelter.

The Affordable Care Act infrastructure is not complete in many states.  HBX amounts to a health information technology portal (clearing house).  No one installs a new computer system without ‘bugs’.  The platforms may have worked well in the “alpha” rollout. This week we are in the ‘beta’  test.  Betas are never stable and anyone receiving an invitation to use new software is   always warned that it may be subject to unexpectd ‘bugs’.

Our government in it’s proclivity to prove the Affordable Care Act has opened the first act with an unproven system.  This could be a fatal error.

Standard operating procedures for high tech new venture is a competitive process before the contracts are awarded. This project involved over 300 million Americans.

The Air Force gives out contracts for aircraft only after a rigorous planning and demonstration project. No company such as Boeing or Lockheed is going to demonstrate their aircraft to buyers without a very high probability of success. Having your product crash or fail miserably to meet the standards will lose the battle..

 

Success                                                          Failure

This is the way it should be in  not only health care but many areas of government. No doubt this program was let out to bid several years ago using standard grant process.

Anyone who applies for a Federal or State Grant realizes the complexity and length of time to  navigate the process.  It is so complex that specialized grant writers and companies offer these services to enterprises that want a grant.  Some times ‘form’ outweighs ‘function’.

The workings of the individual mandate are striking the shores, and very soon the inner bands of the employer mandate will strike shore.

The Affordable Care Act portends to improve patient wellness, access, and affordability.  Much of this is yet to be demonstrated.

ObamaCare and You: The Health Insurance Marketplace and Small Business (from Health Works Collective)

Small business experts tell a different story than what we are hearing from media sources:

John Arensmeyer is founder and CEO of the Small Business Majority, a nationally recognized small business organization and advocacy group on critical public policy issues facing America’s small businesses —including health care reform. Arensmeyer has said that the Affordable Care Act (ACA) will help lower small businesses' high healthcare costs and give them more choice in the insurance market.

Here are some of the  items discussed:

What is the SBM looking for as the ACA goes live?   Our primary focus is making sure small businesses know what their options are. That they know about the small business exchanges or the individual exchanges. That they have the facts and know if they have any responsibilities -- which most of them don’t, if they are under 50 employees -

What small businesses are leaving insurance for their employees to solve and dropping any existing insurance coverage(s) they currently have for them?

JA: We haven’t heard many stories of that from around the country. There are businesses that have been unable to provide and they’re not all of a sudden going to begin providing. But in terms of businesses that have been providing thinking of dropping it, no, they are thinking the other way, looking at the options in the new marketplaces and seeing if they can continue to offer. 

Will enough healthy folks sign up to balance the sick and newly covered?

JA: Yes, that’s one of the major cost containment features of the new law.

Will exchanges generally feature a narrower network of doctors and hospitals than SBM would prefer? Do you see any hope for expansion?

JA: We don’t see a narrowing of networks within the plans at the moment.

What if any special issues or challenges will you be monitoring?

JA: The biggest issue for us is seeing how information is being understood, or not, by small business owners and how we can improve that. Now we’re making sure that owners know what their options are, making sure that agents and brokers working with them know how the system works. We’ll be looking if there are breakdowns in any of that and how we can fix it.

HWC: What has surprised you about the rollout thus far?

JA: We’re pleasantly surprised by the sheer volume of interest. It’s created some technical issues, but in a way it’s a good problem to have. We’d rather have reports of glitches than reports of no one showing up.

Lot’s of surprises there.  Have we been mislead ?

 

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How did you learn about Obamacare? Social Media

 

At least in name the first stage of Obamacare is here.  With the official opening pitch both federal and state Individual health benefit exchanges have their online portals working or flashing messages when they will be accessible.

I had a chance to test several state portals for health benefit exchanges. The best one is healthcare.gov a central clearing house that directs traffic to the individual state exchanges.  This morning it took 20 seconds to load, actually not a bad load time compared to other web sites.

The portal in California (CoveredCalifornia.com) has a calculator to estimate eligibility and subsidies. It also outlines several levels of plans, the approved insurers and the estimated premiums..

Obamacare does little to change what is required from providers. In  some states the insurers on the HBX are limited.

 

 

 

It mostly impacts insurers to provide a standard benefit package, limit their profits, and determines eligibilty for subsidies and/or tax credits.

The biggest change for consumers is the individual mandate and the employer mandates.  This is put in place to offset insuring the uninsured and  uninsurable with pre-existing conditions.

Another very interesting question is how the reader learned about Obamacare. One of the answers is ‘SOCIAL MEDIA”.  That was a first for this writer.  It confirms how important social media has become in our society.  Social media is not just optional and the use of the internet becomes almost essential for banking, navigating marketplaces,shopping, and for mobile health as well as telemedicine.

No one factors in the dividend from a healthier population, with good preventive care, nor the decrease in disability from chronic disease by early treatment. The additional infusion of capital into health care facilities will stimulate our lagging economic recovery.

The transition period will be a challenge for some, and flexibility is essential to make this acceptable to business and individuals as well.