Will Modern Medicine Reject Deadly Sovereignty Transplants?

Salvation in the Bible means literally health, health of life in relation to God, and also health of body, since the body is God's creation. The biblical fruits of medical practice are in the Levitical ministry. The relation between patient and Pastor or Dr. is immune from man's controls and intervention, because it is a facet of God's ministry to man's total life. ~ Chalcedon Medical Report No. 6: Sovereignty and Medical Practice¹

Today, this isolated relationship [between doctor and patient] is no longer tenable or possible ...  Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care ... The primary function of regulation in health care...is to constrain decentralized individualized decision making. ~ Troyen A. Brennan and Donald M. Berwick M.D., New Rules: Regulation, Markets, and the Quality of American Health Care (Josey Bass/Ana Press Series, 1995)²

A vast part of the American public has been deeply concerned about the implications of the passage in 2010 of Patient Protection and Affordable Care Act (PPACA). Recognizing the collectivist implications of the Act and the threats to individualized medical care, taxpayers put tremendous pressure upon their Congressional legislators to defeat it, to no avail. Now that the lawsuit filed against it upon constitutional grounds has failed, the bureaucracies are proceeding with all speed to continue implementing the Act through the regulatory process.

R. J. Rushdoony aptly described the role of the doctor as a priestly calling in his series of Chalcedon Medical Reports published in Roots of Reconstruction. He discusses how the early church regarded the profession:

So seriously did the early church regard the priestly vocation of the doctor that, by the fifth century A.D., it became a popular requirement that doctors, like monks, be celibates ... this high regard for doctors as holy and priestly men, because of their healing work, was Biblical and Hebraic to the core. Medicine was plainly seen as a holy profession.³

The priestly vocation of doctor is immune from the controls of statist government. But man, seeking salvation from law and civil government, has attempted to transfer sovereignty from God to man's institutions. This is the root of our problems in medical care: the claim of sovereignty by the state over doctors. This claim seeks to divide the loyalties of doctors, with the lion's share going to the state rather than the patient, and sets doctors up as targets for hostility when the smallest infraction of the massive regulatory scheme is committed. The major claim the statists make is ethical:

Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care ... The primary function of regulation in health care ... is to constrain decentralized individualized decision-making.⁴

This statement appears in a book co-written by Dr. Donald Berwick, who is the technocratic face of the statists who favor complete governmental control of medicine through the formation of a monolithic healthcare "system." He is a proponent of rationing and the single-payer model, and he is a spokesman for those who claim healthcare is a "right." On April 19, 2010, just days after the enactment of PPACA, Dr. Berwick was nominated to be Administrator of the Centers for Medicare and Medicaid. Because he could not obtain Senate approval, he was installed as a recess appointment. A man who seeks to destroy the religious relationship of doctor and patient was tasked with leading the agency that has implemented much of the regulatory rule-making scheme undergirding PPACA. Though Berwick has left the position, the new leader will carry on in the same vein.

The rest of this article will discuss what I, as a Christian who practices health law, see as the continuing transformation of medicine and healing into a humanist, unbiblical thing. I will discuss the future of medical privacy, the consolidation of medical care into a "system," and the top-down control of the "system."  There are other terrifying aspects of this regulatory scheme being developed, but it would take a dissertation to cover them all.

Medical Privacy

Communications between doctor and patient have long been considered religious and therefore privileged in nature: 

Privileged communications to a doctor, priest, or pastor are different: they are religious communication. In confessing to a pastor, we are in effect confessing to God through the medium of His servants, and we seek spiritual healing and health. In both cases, the purpose is religious in the Biblical sense and a part of the redemptive process. The "confession" in either case is privileged communication and is closed to other men, and to the agencies of man and the state.⁵

Introducing third-party payers hacked away at this privilege. Third-party payers are "institutions that stand between patients and doctors to fund health care" via employer-provided health insurance or government health insurance such as Medicare and Medicaid. The third-party payer system, seen first during WWII with employer-provided insurance, has taken us down the path to where the state will no longer recognize the Biblical immunities in doctor-patient communications. This will be a necessary step in the increasing controls that the state places upon medicine, including controls of cost through rationing. The result is that:

The infringement of this privileged communication by the state is religious: the state usurps the place of God and claims the right to be privy to all that goes on between man and man, and between man and God, because it claims to be the acting god of this world.⁶

HIPAA

Statist interference with the privileged nature of doctor-patient communications began in earnest with the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996. This act followed the 1994 routing of "HillaryCare."⁷ Although Americans believed they dodged a bullet with that defeat, they failed to realize that determined politicians and bureaucrats never give up. What politicians can't enact wholesale, they will effect incrementally.  That is the case with HIPAA.

HIPAA was co-sponsored by Ted Kennedy (D-Mass) and Nancy Kassenbaum (R-Kan). It had virtually no opposition. The dirty little secret about the Act is it incorporated many of the provisions of HillaryCare that were so feared, such as the requirement for a medical identification number for each patient and requirements for uniform electronic databases of personal medical information nationwide.⁸ This was done through the Administrative Provisions of the Act, which also address the security and privacy of health data. Fortunately, due to the hue and cry by privacy experts over the medical identification numbers, Congress has each year refused to fund the measure. But as the system continues to assimilate doctors, you can expect it will eventually prevail.

The stated purpose of HIPAA was to protect health coverage for workers and their families upon leaving or loss of a job. The public knows it mainly for its provisions regarding security and privacy of personal health information which spawned the privacy rules written and adopted by the Department of Health and Human Services (HHS).

When passing HIPAA, Congress ignored the web of medical record privacy protections that already existed. Those ran the gamut of established ethical and professional requirements, state licensing board enforcement, contract, and market-based and legal theories such as tort. While most of the foregoing included individual patient recourse for wrongful disclosure of such information, HIPAA expressly precludes a private cause of action, reserving enforcement and discipline to the state. Although enforcement was benign for the first years after HHS implementing the Privacy Rules, the federal government is now stepping up its enforcement efforts due to reported increased numbers of medical privacy breaches.⁹ As admitted by the director of the U. S. Department of Health & Human Services' Office for Civil Rights (OCR) which enforces HIPAA privacy requirements, seventy-six percent of the breaches involved electronic data on computers as opposed to twenty-four percent involving paper.¹⁰ Electronic data is one of the biggest threats to the doctor- patient privilege-as well as the linchpin of total statist control of medical care.

Electronic Records

Prior to HIPAA, many hospitals and other health care providers were moving away from paper medical charts to electronic formats.  HIPAA was written to capture control of that process and to form a national database of the information contained in electronic records.  Charlotte Twilight, a professor of economics, has done extensive research on the HIPAA privacy rule and the implications of the Act regarding electronic medical charts and the plan for a national database of patient information. In 2002, after the HIPAA privacy rule had become final under the administration of G. W. Bush, she said:

Copied almost verbatim from the 1993 bill [Hillarycare] were HIPAA's requirements for uniform electronic databases of personal medical information nationwide and for the creation of a "unique health identifier" for every American. The 1996 act empowered the federal government, at its discretion, to require detailed information on what lawmakers called "encounters" between doctors and patients.
The secretary of the U. S. Department of Health and Human Services (HHS) adopted standards to enable "health information"-that is, everything a doctor, employer, university, or life insurer ever learns about an individual- "to be exchanged electronically." The legislation aimed to create a "health information system" through the "establishment of standards and requirements for the electronic transmission of certain health information" by medical practitioners (Public Law 104-191, Title II). Issuing privacy regulations to protect this new electronic flow of personally identifiable medical information was not required until three and a half years after passing HIPAA.¹¹

The combination of HIPAA privacy rules that facilitate disclosures of information without your consent, an electronic format subject to standards dictated by the federal government, a "health information system" created by those standards and a unique health identifier for every American-all of this portends disaster for the privacy of your interactions with your doctor. Constructing this "health information system" was accelerated by combining the HIPAA privacy rules with the Health Information Technology for Economic and Clinical Health Act (HITECH) in the 2009 stimulus package.  As Dr. Twight explains, the vaunted privacy rules of HIPAA are more akin to a sieve than a protective shield. The numbers of entities (especially governmental entities) to whom your records can be disclosed belies the rhetoric.¹²

Though presented as a measure limited to strengthening the privacy and security of electronically transmitted health care records, HITECH includes incentives to health providers to adopt Electronic Health Record Technology (EHR).¹³ Though rarely mentioned, HITECH includes mandates regarding the adoption of EHR, seeking the complete integration of the healthcare system through the adoption of Health Information Technology and Electronic Health Record system:

The National Coordinator shall, in consultation with other appropriate Federal agencies (including the National Institute of Standards and Technology), update the Federal Health IT Strategic Plan (developed as of June 3, 2008) to include specific objectives, milestones, and metrics regarding the following:
(i) The electronic exchange and use of health information and the enterprise integration of such information.
(ii) The utilization of an electronic health record for each person in the United States by 2014.¹⁴

"Enterprise integration" is defined as "the electronic linkage of health care providers, health plans, the government, and other interested parties, to enable the electronic exchange and use of health information among all the components in the health care infrastructure in accordance with applicable law, and such term includes related application protocols and other related standards."¹⁵ By 2014, we will have a nationwide EHR system (and database), even if the Republicans repeal PPACA.

With this, we can expect that the national medical ID will become a reality, and HHS has taken steps in that direction, working through stakeholder groups such as the Workgroup for Electronic Data Interchange.¹⁶ HIPAA privacy rules allow disclosures of your records without consent. It is estimated that 2.2 million entities, including government agencies, can access your medical records.¹⁷ For such access to be meaningful, patient ID numbers will be necessary.

The threat to your private medical records is imminent. Health and Human Services mandated in October of 2011 that private insurance companies must transmit their medical records on patients to the federal health information database, without the consent of the patient.^{18 19 20} Therefore, the state is instituting the infrastructure to access all information about the state of your health. With EHR mandated under federal standards and a federal database to which private insurers submit health records:

[T]hey will know who has cancer, heart disease, or diabetes, or other conditions of interest, and will also know how much patients with a certain disease profile "cost." This is the ominous death panel feature that without EHR has no teeth.²¹

But there is another purpose of the EHR mandate: to herd physicians into organizations that will turn their allegiances away from patients to the collective. Not only will records be stored in a monolithic database, doctors will be practicing in collectives.

The Tower of Babel

That the outlines of a new Tower of Babel in health care emerged in HIPAA and HITECH should be obvious. Now, with PPACA came legislative support for grouping physicians into Accountable Care Organizations. An Accountable Care Organization (ACO) is an organization of healthcare providers sharing responsibility for the cost and quality of care for a specific patient population. More than any other policy the Patient Protection and Affordable Care Act ("PPACA"), enacted in March 2010, encourages such integration in health care by incentivizing the herding of physicians into ACOs. ACOs integrate local physicians with other members of the health care system, such as hospitals, and reward them for controlling costs and improving health care quality. Doctors will be financially rewarded for stinting on your care. A blunt if inflammatory description of how they will work is offered by Dr. Fogoros, author of Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare, on his indispensable blog: The Covert Rationing Blog.²²

The ACOs will be run by administrators who (theoretically) will become expert at navigating the morass of rules and regulations now being conjured up under Obamacare. These administrators will interpret the rules and regulations in such a way as to determine The Way It Must Be Done, and then will pass The Way It Must Be Done down to the ACOs' clinical chiefs (doctors who perhaps used to practice medicine, and maybe still do, a little, but who are now mainly brevet administrators), and the clinical chiefs will finally pass the restrictive rules of engagement down to the doctors who will actually take care of the patients. These doctors, struggling in the trenches, will attempt assiduously to follow those rules without exception, if they would like to keep their jobs as well as avoid a federal fraud rap. The patients, of course, will get whatever they get, but always with official assurances that whatever it is they get, it will be of the highest quality.²³

Therefore, not only will physicians be financially rewarded for cost savings, they will be subject to civil and criminal penalties for failing to ration. This is the true structure of PPACA. It goes further than any previous program, including Medicare/Medicaid and HMOs, to dislocate the physician's responsibility to their patients, transferring it to the collective. In an article in the Annals of Internal Medicine published in 2010, Ezekiel Emanuel from the White House's Office of Management and Budget, and Nancy-Ann M. De Parle, Mr. Obama's Czar of Healthcare Reform said:

[Obamacare] will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination ... As physicians organize themselves into increasingly larger groups -patient-centered medical home practices and accountable care organizations- they are, out of necessity, investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physicians groups ... For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal.²⁴

The darkly humorous Dr. Fogoros, in his new book entitled "Open Wide And Say Moo! - The Good Citizen's Guide to Right Thoughts And Right Actions Under Obamacare," published at his blog, has helpfully interpreted the true meaning of this statement:

Physicians! You have been neglecting your moral obligation to the collective, in favor of your archaic devotion to the individual patient. Under Obamacare you will need to join organizations which are devoted to the proper collective goals, and which therefore will guarantee the proper moral ideals. You must function not as individual decisionmakers, but as integrated cogs in a vast healthcare continuum, which will stretch from the centralized bastion of gleaming moral authority (from which we pen this message) all the way down to the humble tip of your stethoscope. You will be rewarded for your cooperation, or suffer for your resistance (resistance, of course, being futile). So rejoice for the health of the collective, and for your own well-being, and prepare to be assimilated!²⁵

Dr. Alieta Eck, of the Association of American Physicians and Surgeons, has compared Accountable Care Organizations to collective farms where "Obamacare will centralize payments to ACO's where care would be controlled and physicians compensated according to strict government guidelines, including dollars saved by giving less care. Patients would be expected to do what they're told."²⁶ The logical outcome of such vertical integration of medical care will be to deny patients needed care, to diminish your chances to obtain objective second opinions because of fewer independent physicians and entities, and to place parents seeking to direct the care of their children in a worse position because of the size of the bureaucracies they oppose.

At the present, participation in an ACO is voluntary. However, that is an illusion. The economics and the regulatory requirements will make it extremely difficult for independent practitioners to survive and thrive. One specific reason for this is the federal take-over to control electronic medical records described earlier. Instituting such a system and maintaining it in compliance with the regulations is a massive expense. Huge health systems and electronic medical record companies have supported government coercion, as pointed out by Dr. G. Keith Smith, who has written for the Journal of American Physicians and Surgeons:

Hospitals wanted this EHR requirement for two reasons:  First, desperate physicians are more likely to fold when big hospitals attempt a takeover of their practice. The doctors may think: "I've got employee expenses, malpractice insurance, office rent, and now this EHR thing! I can't take it any more! I just want to practice medicine. I'm going to give these problems to someone else and just take a salary, or I'm quitting." This is the perfect entrée for the hospital.²⁷

The second reason the hospitals wanted EHR was that once the physicians surrendered and become employees the EHR would be the remote control of those doctors and their practices.

Dr. Smith explains that a physician will be constrained from ordering needed tests, or sending patients to the best surgeons if those surgeons are outside the network-upon pain of being removed from his position. Big hospital systems will crush small hospitals that can't afford EHR.

Dr. Fogoros also describes it:

Doctors, and all other healthcare workers, are to be integrated into localized healthcare delivery collectives, which will dance to the ever-changing tunes set by the Central Authority. Everything in these ACOs will be shared collectively, including the financial risk, the medical decisions, and even the ethics of those medical decisions. The notion of doctors working as independent professionals, answerable only to their professional standards and to their patients, is to be abolished once and for all. In an Accountable Care Organization doctors do not owe the featured accountability to the patients, but rather, to the ACO itself, and to the Central Authority that regulates it.
This, then, is the fundamental structure of Obamacare. It finally places doctors into their proper place. They become interchangeable cogs in an integrated healthcare machine, a machine which is tied irrevocably, flesh to flesh, to the Central Authority.²⁸

Further, says Dr. Fogoros:

Under this structure patients will lose their personal advocates once and for all. They will finally be reduced to the position that Progressive healthcare requires of them. They will no longer be individuals whose doctors owe them a duty. They will be members of a herd which an ACO is charged with husbanding at the lowest cost possible. And so, assimilating doctors into the Borg is the final step. It removes the last remaining obstruction to the widespread implementation of herd medicine.
Everything else about Obamacare-all those new agencies and all that new bureaucratic complexity-is just details.²⁹

So we see the ultimate intrusion of an unholy (fascist) alliance of government and giant, monolithic health systems into the religious and priestly relationship between patient and doctor. The function of the doctor's vocation as a healing one is transformed into priestly service to a collective that requires rationing of care to save costs. This transformation turns "his vocation upside down."³⁰ It is no exaggeration to compare what is happening in healthcare to the abortuary. Just as the abortionist brings death, so will a system that rations care in the service of a god that controls resources. In the service of that god, doctors will become "false confessors" as described by Rushdoony, because the relationship of doctor to patient is a healing one which is "...a medical form of the confessional, and its purpose and goal is healing. A false confessor, whether in the church or in medical practice, is a great evil, and a menace to the life of the one who seeks healing."³¹

Sovereignty over medical care is being usurped by the federal government, the new god. And every pagan god has high priests representing its will. One of the most significant "high priests" presiding over this Tower of Babel is the Independent Advisory Payment Board (IPAB).

The High Priest

The Independent Payment Advisory Board was formed under Obamacare.³² A prominent health care lawyer describes it as having a "goal of reducing the growth rate in Medicare spending" and being "responsible for developing payment reform proposals if projected Medicare spending exceeds certain targets."³³ Claims that the IPAB will be confined to Medicare spending are disingenuous. Section 10320 gives IPAB the authority to limit all healthcare expenditures beginning in 2015.*³⁴

Dr. Fogoros describes exactly how dictatorial the role of the IPAB will be:

Each year, once the Medicare's Chief Actuary determines that the projected per capita growth rate for Medicare exceeds the designated target growth rate (which is an inevitability), the IPAB is required to submit a plan which will cut healthcare costs sufficiently to bring the growth rate back in line; which is to say, the IPAB will determine what will be paid for and what will not. Then, the Secretary of HHS is required to implement the IPAB's plan in its entirety, without exception-unless Congress acts to block implementation. However, the ability of Congress to do so is severely limited. The representatives of the people are forbidden from taking any action "that would repeal or otherwise change the recommendations of the Board," unless it: a) votes to halt the IPAB mandates with a supermajority of the Senate; and b): devises its own specific cost cutting scheme that will achieve equivalent results. If Congress had the will to do such a thing, however, we never would have needed Obamacare in the first place.
So, in practice, the cost-cutting "recommendations" which the IPAB will "propose" for "consideration" by the Secretary and by the Congress will be implemented in their entirety, automatically, without revision, and will be backed by the full authority of the Federal government.
For all practical purposes, the IPAB will become a new agency of the executive branch with near-dictatorial authority to cut healthcare spending, public and private, where and when and for whom it sees fit.³⁵
The IPAB is not only armed with immense power, Congress also purported to make its decisions immutable:
It shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment, or conference report that would repeal or otherwise change this subsection.³⁶

As Dr. Fogoros observes:

One can only bask in the utter audacity of our Progressive leaders, who are so sure they know what's best for us that they were willing to engage in all manner of legislative legerdemain to pass Obamacare, not only against the apparent expressed will of the people, but also (as it turns out) against the objections of any future American Congress that is sent to Washington by those people.
Not even our Constitution itself -a document that attempted to establish a government for all time-was as audacious as this. For the Constitution, at least, provided a mechanism for its own alteration.
...I believe we need to go all the way back to Moses, coming down from Mt. Sinai and holding aloft his awesome Tablets filled with divine writ, to find a law or set of laws that, from the moment they were written, were decreed to remain in force for ever and ever.
Only God has ever tried this before.³⁷

Conclusion

Christians, including Christian doctors, have a huge challenge before them in confronting this massive federal system. The tools of coercion inherent in it have already been demonstrated regarding Obamacare's requirement for the provision of birth control. One lawsuit against that requirement has already been dismissed by a federal judge.³⁸ Another has survived and is going through the system.³⁹ Lawsuits filed on constitutional bases against both HIPAA and Obamacare have failed.^{40 41}

How shall Christians confront this usurpation of sovereignty by the state? There will be confrontations provoked by the unbiblical nature of Obamacare as evidenced by the birth control lawsuits. Christians must be prepared for the challenge, especially Christian doctors.

Christians must resist politically and legally and to search for every vulnerable chink in this Tower of Babel to use in those confrontations. But first, Christians must return to the basic presupposition that the doctor-patient relationship is religious and under God's sovereignty.

As Rushdoony said of Christian doctors caught in the struggle against statist controls, "[I]f the doctor stands in terms of humanism, and in terms of a purely personal desire to be free and uncontrolled, he is religiously defenseless and easily attacked as ‘socially irresponsible.'"⁴² We all-doctor and patient-must ensure that any actions taken against Obamacare be premised and based upon a "full-orbed Biblical faith" and in terms of "the sovereignty of God as against the sovereignty of the state."⁴³

Any resistance not based upon these premises is doomed to fail. We must go forward solely in the armor of God, for "if God be for us, who can be against us?" (Rom. 8:31) The massive transplantation of sovereignty envisioned by the state must be challenged by those equipped to defend the crown rights of the true Sovereign.

Co-founder of Garlo Ward, P.C., Jerri Lynn Ward provides legal representation in the areas of business and commercial litigation, including complex healthcare and regulatory litigation, and health facility operational matters. Her background and prior experience also includes litigation work in the areas of insurance defense, employment, toxic tort, products liability, medical malpractice, business and commercial, as well as criminal matters.

1. R. J. Rushdoony, Roots of Reconstruction (Vallecito, CA: Ross House Books, 1991), 493.

2. Troyen A. Brennan and Donald M. Berwick M.D., New Rules: Regulation, Markets, and the Quality of American Health Care (Josey Bass/Ana Press Series, 1995), 6-7.

3. Rushdoony, Roots of Reconstruction, 458.

4. Brennan and Berwick New Rules: Regulation, Markets, and the Quality of American Health Care, 17.

5. Rushdoony, Roots of Reconstruction, 458.

6. Ibid.

7. Health Privacy in the Hands of Government: "The HIPAA Privacy Regulation: Troubled Process, Troubling Results"; A Special Report Issued by Privacilla.org; April, 2003; http://www.privacilla.org/rele...

8. Charlotte Twilight, "Medical ‘Privacy' Regulations Destroy Privacy," Newsmax.com, August 5, 2002, http://archive.newsmax.com/arc...

9. Marla Durben Hirsch, "Rodriguez: HIPAA Enforcement to Increase," Fierce HealthIT, March 27, 2012,|http://www.fiercehealthit.com/...

10. Ibid.

11. Twilight, "Medical ‘Privacy' Regulations Destroy Privacy."

12. Charlotte Twilight, "'Privacy' Rules Spread Your Personal Medical Information," Newsmax.com., Aug. 8, 2002, http://archive.newsmax.com/arc...

13. "HITECH EMR Stimulus Information for Physicians," Practice Fusion http://www.practicefusion.com/...

14. 42 U.S.C §300jj-119 (C)(3)(A)

15. 42 U.S.C. §300jj(3)

16. Twila Brase, "National Patient ID," Policy Insights: Government Health Surveillance, Vol. 1, July 2012, 9-11.

17. Ibid., 9.

18. Elizabeth Lee Vliet, M.D., "Unelected Bureaucrats Confiscate Your Property and Your Private Medical Records Without Your Consent," AAPSonline.org, April 22, 2012 http://www.aapsonline.org/inde...

19. "Patient Protection and Affordable Care Act; Standards Related to Reinsurance Risk Corridors and Risk Adjustment, Final Rule," Federal Register, Vol. 77, No. 57, Friday, March 28, 2012, Rules and Regulations.

20. Edwin Park, "Allowing Insurers to Withhold Data on Enrollees' Health Status Could Undermine Key Part of Health Reform: Data Collection Needed to Ensure Insurer Accountability and Reduce Risk of Error and Fraud," Center on Budget and Policy Priorities, December 12, 2011, http://www.cbpp.org/cms/?fa=vi...

21. G. Keith Smith, M.D., "The Affordable Care Act: Does the Supreme Court Decision Matter to Its Proponents?," Journal of American Physicians and Surgeons, Vol. 7, No. 2, Summer 2012, 41.

22. Dr. Richard N. Fogoros, "Criminalizing Independent Physician Practices," The Covert Rationing blog.com. http://covertrationingblog.com/primary-care-in-america/criminalizing-independent-physician-practices.

23. Ibid.

24. Robert Kocher, M.D., Ezekiel J. Emanuel, M.D., and Nancy-Ann M. DeParle, J.D, "The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges," Annals of Internal Medicine, 153(8):536-539, October, 19, 2010, http://annals.org/article.aspx...

25. Dr. Richard N. Fogoros, Open Wide and Say Moo!-The Good Citizen's Guide to Right Thoughts And Right Actions Under Obama-care, "The Real Infrastructure of Obama-care," 2012, http://covertrationingblog.com...

26. Alieta Eck, M.D., President, "Accountable Care Organizations and Collective Farms," AAPS, February 20, 2012, http://www.aapsonline.org/inde...

27. G. Keith Smith, M. D., "The Affordable Care Act:  Does the Supreme Court Decision Matter to its Proponents?," Journal of American Physicians and Surgeons, Vol. 17, No. 2, Summer 2012, 41.

28. Fogoros, Open Wide..., "The Real Infrastructure of Obamacare."

29. Ibid.

30. Rushdoony, Roots of Reconstruction, 509.

31. Ibid.

32. 42 U.S.C. § 1395kkk; Section 1899A of the Social Security Act

33. Larry L. Lanham, II, "The Independent Payment Advisory Board: The Stalking Horse of Payment Reform," AHLA Connections, Vol. 16, Issue 6, 46.

34. 42 U.S.C. 1395kkk(o)(1054) * Section 3403 and other sections of the ACA refer to the new entity as the "Independent Medicare Advisory Board." Section 10320(b), added by the Manager's Amendment, and changed the name to "Independent Payment Advisory Board."

35. Open Wide and Say Moo; Chapter 8-The Real Infrastructure of Obamacare

36. 42 U.S.C. 1395kkk(d)(3)(C)

37. Fogoros, Open Wide..., "The Real Infrastructure of Obamacare."

38. Ken Klukowski, "ADF Scores First Victory Against Obama's Unconstitutional HHS Mandate," Breitbart TV, July 28, 2012, http://www.breitbart.com/Big-G...

39. Ibid.

40. Jon Dougherty, ‘Judge Tosses Medical-Privacy Suit,' WND, June 30, 2002, http://www.wnd.com/2002/06/144...

41. Lynn Sweet, Dave McKinney, Abdon M. Pallash, "Supreme Court Rules Obamacare Individual Mandate Constitutional," Chicago Sun-Times, June 27, 2012, http://www.suntimes.com/news/p...

42. Rushdoony, Roots of Reconstruction, 495.

43. Ibid.