Get the government out of your doctor’s office?

El-Sayed, the Michigan Democratic Senate candidate and card-carrying Democratic Socialist, made a comment on Jessie Watters' program last night that seemed to pass unnoticed, as everyone focused on his comparison of circumcision to castration ("gender-affirming" surgery), which was about as asinine a statement as any politician has ever made.

El Sayed, who advocates Medicare for All, stated that he didn't want the government interfering in doctor-patient healthcare decisions—two positions that are diametrically at odds. All Medicare is interference in doctor-patient decisions. In fact, Medicare defines what qualifies as healthcare, what does not, what can be paid for and how much. Medicare claims superior omniscence to any private market system, as it claims to calculate the cost of each healthcare product and service. That is the resource-based relative value scale (RBRVS) formula promulgated by Dr. Hsiao of the Harvard School of Public Health, written into law in 1992, contracted out by the supposedly conservative free market types Reagan and Bush I administrations.

The RBRVS formula is: [(Work RVUxWork GPCI) + (Practice Expense RVUxPractice expense GPCI) + (Malpractice Expense RVU x Malpractice GPCI)] x Conversion Factor = Price.
- RVU is Relative Value Unit. GPCI is Geographic Practice Cost Index.
- The Conversion Factor is an amount the government chooses. It is adjusted year by year to gradually increase reimbursement.

All private insurers use this system, but pay a fractional multiple of the Medicare amount. This means we have a de facto "Medicare for All" system in place already. Price fixed and government-controlled, top to bottom.

Orwellian concepts apply in this system. Whatever is not explicitly permitted is forbidden. Private insurance companies are not mandated to cover only what Medicare covers (but most do). Further, what is permitted for intermediaries like pharmacy benefit managers is both obscene and corrupt, driving costs higher. Fraud is a built-in feature of this system, aided and abetted to an extreme by politicians and the collaborators they abet.

How does Medicare come between me and my patients? One way is Medicare's refusal to designate obesity as a chronic disease. I have many patients who come to see me for weight loss. Usually they have tried every diet known to man. They exercise like crazy and keep gaining weight. They may or may not have associated disorders such as diabetes. If they have no associated disorders, Medicare will not cover the only truly effective medications for weight loss, the GLP-1 analogs (Ozempic or Wegovy) and dual-acting analogs (Mounjaro or Zepbound). These have achieved an efficacy that rivals bariatric surgery. But Medicare will not cover them. They will, however, cover bariatric surgery at the drop of a hat.

For 40 years I have been told to prevent obesity. Medicare might as well have had a poster in my office of Dr. Uncle Sam pointing a finger at me and declaring, Smokey Bear style, "Only YOU can prevent obesity." Medically, I had no way of doing that. Now I do, but Medicare bans me from using that method. Ever since the recent generation of GLP-1 meds became available, interested professional societies have lobbied Medicare to change course and designate obesity as a chronic disease. Obesity is associated with higher rates of hypertension, cardiovasular disease, renal dysfunction, hepatic disease, diabetes, arthritis, sleep apnea, and cancer. Medicare in its infinite wisdom ignores all of that. Every American medical school has a department or a division of obesity medicine, and there are boarding entities that provide certification in the field. Yet Medicare won't relent, even when women and children are most affected.

Because Medicare doesn't cover medical treatment for obesity, private insurers do not have to cover it. When Mounjaro (Zepbound) and Ozempic (Wegovy) became available for weight loss—approved by the FDA for weight loss, though Medicare pays no attention to the FDA!—private insurers initially covered these agents. In short order, the large corporations who pay premiums for health insurance for their employees saw insurance premiums rise. They went to the insurance companies and demanded they cease covering these agents, and, since Medicare did not cover them, the private insurers could exclude coverage.

So, indeed, the insurance companies bowed to their corporate clients and stopped covering the medications for weight loss ( though they have to cover them for diabetes). The offshoot is that many patients with pre-diabetes (A1C below 6.5%) tried gaining weight and eating poorly to get their A1C levels up above 6.5% to get insurance coverage for these agents. Then programs like the Oscar Diabetes Care Plan began requiring that A1C be above 7.5% to qualify for GLP-1 analogs. Of course, prediabetes is not a benign entity. It is part of a continuum, rather than a discrete disease entity from type 2 diabetes, except insofar as risks of microvascular complications are concerned, as someone who has prediabetes type 2 has already lost half their insulin production capacity. The GLP1 analogs actually restore that, turn back the clock, and to an almost complete extent prevent the development of type 2 diabetes mellitus (DM). Medicare is working from a mindset established in the last century, rather than encouraging the optimal use of current agents. "The Science" is 30 years behind. Obesity is the most common chronic disease in the nation. Medicare policy in this area threatens public health.

Just in the past month, under the supposedly enlightened leadership of Dr. Oz, with input from other notables like Dr. Makary and Bhattacharya, Medicare has partially relented on the GLP-1 use for weight loss. They have instituted their "bridge program" whereby they will cover GLP-1s for obesity for patients who do not have type 2 DM, hepatic steatosis, obstructive sleep apnea, or cardiovascular disease. (GLP-1's are approved for these disorders, but many, if not most, health plans restrict their use with prohibitive criteria that make it impossible to use them for these indications), are overweight (BMI 25-30) with comorbidities like hypertension or hyperlipidemia, or are obese (BMI above 30). This appears to be an attempt to mollify or partly respond to critics of Medicare policy without actually designating obesity a chronic disease. They may be considering a change, but like all things in government, motion is glacial if perceptible at all. So far, Medicare is unwilling to make that designation.

Yet, again, Medicare will happily pay for bariatric surgery for obesity, making the new policy completely inconsistent. This covers procedural treatments—which are mostly effective but do not necessarily permanently fix the obesity problem, as many patients regain weight to a higher BMI than before the bariatric surgery—but not medical treatments. Medicare is completely incoherent, as bad or worse and as harmful in its policies as the guidance provided during the COVID-19 epidemic.

So I can only wince every time a Democrat demands "Medicare for all." Nothing could be more harmful to the nation's health, save perhaps a nuclear strike by Iran. Heaven help us if Democrats manage to impose Medicare for All.