Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 13 Mar 2017 10:09:27 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHWX4VTiwr5oqmn3Mgp607vXJ3YSQT9tWUAfQEZoN4cKRGTdjvBu40C9cKkmnvDDHMNX8XqutbELeESov57wMkNy3Z3LKcpfyAjgCie8fBQ0ASlXf3AEUHHAntRsBTXOeV9pYmd03mlD&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
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The Fickenscher Files, Vol. 5, Issue 2
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhPvA29G0Bw3fAszwjjtaTTbLOu0Yh0GeyCTGkSnKdt5ro32admoK5ameIQNR6PC9ouqJtjtc-YI5DdHyEtz8SzOX4DIYiFhQlfaryRxsIK0ErRj9rocw11M-20gcG_Ww4X4b5_sYtHCd9sc1wUKAtPwLnwkPldBCLCwv_nucUUw9FmFHccyfU0W6_txXR89IMUX1A0L1INcEn66ub96s7HM=&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==],
MD, CPE, FACPE, FAAFP
@MDKev
A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
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Quote(s) Of The Week
"Without those immigrants, cancer treatment today would never be in the kind of 
position that it is today.  For me, the core of innovation - the heart of innovation
- resides in America. It resides here because of the borders that we've opened to
these scientists that have come from abroad; it resides here because of the tremendous
capital and infrastructure we've built."
Jeremy Levin, chief executive of Ovid Therapeutics
"Nobody knew health care could be so complicated."
Donald Trump - in comments before the members of the National Governors Association
"Against the insidious wiles of foreign influence, the jealousy of a free people
 ought to be constantly awake."
George Washington, in his 1796 farewell address [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3MiiF18JA_KSgh-NjcBI92Fhq9QKi5iwGXjbpc_ya4BgdeG1W0RjarMaLH8Vo3dabHFnwuJ7aAUuPU60R9cJRxycHRnK6OR77Pe7QYMszsSMnhJrpDIRolYux5ceW3OITUFixB194PsgmZfGN52pZUBK4rk7XdZtky6j4BzaW8Ja1jOFXBZwOzfHw==&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
to the American people
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Consulo Indicium
Information for your Consideration...
What Have We Come To? - I don't generally get very excited about the continuous 
streaming of news emanating from our new Administration nor any of the other politicians.
 I'm a "middle of the road" kind of guy.  But, the mis-information flowing out of
the pores of our society is disheartening.  The one that got me apoplectic was the
re-emergence of the totally untrue statement that the Accountable Care Act contained
requirements for older citizens to face death panels [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3Mi7jBkdCyM5XtOIbzkVJ8SXJaBX6Sv0hy81--YyEpCAwr_jyln9oMVeUjqqkDX-ObHVVl7U69x4O78ss3g2JF5bksvJ3t2Z6Yin7RETNSuhQ0Hx951jbmoh6IR0hdDKI490AT8mUJrBLz05U4weEV0HQLPdU6Lt-tE3ADk1C2hGbA1H1z_2nOVjCOLWo8VG0pePbABTc_Tobg=&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==].
 Totally untrue.  It's been checked over and over so many times over the last several
years.  It's disheartening that these kinds of accusations keep percolating up. 
 Rather, our focus should be on the truth.  There are issues with the structure 
of ACA - just like there were issues with the Medicare program when it was first
 passed in 1966.  We should be focused on those problems rather than the specious
arguments that keep circulating as untrue.  It's unfortunate that the politicians
on BOTH SIDES don't band together to tamp these untruths down but...then again, 
that would force everyone to focus on the REAL ISSUES...  Oy vey - it's going to
 be a long four years...
STOP,  GET THIS BOOK AND READ IT! - My long-time readers know that every once in
 a while, I'll get real excited about a book.  Well, it happened again recently 
when a friend recommended that I read Thank You for Being Late [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3MiXx3bFgHVzyFZZJMNJDeePch0Xw6qcSZtWKxMiKXE68nVHxe2dHJWt3vLyqIb802DEJVUidqu684TU0t3mbiPuxy_pMnMYFaG8C5V67dD28gXkv8s7P3Sc1oKXTjzCJ8ccjndkAzS5eqrlnnJbJw_ctiUkm9yD3Tn&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
by Thomas Friedman.  It is one of the best books that I have read in a long, long
time.  While I'm generally a fan of Friedman anyway, I think this is one of the 
best books he's written.  It's about the age of accelerations and how societies 
are being challenged as we continue down the path of the information revolution.
  The number of underlined and dog-eared pages in the book (I'm still a bit of an
old school kind of reader) tells me that it's one of those books I will need to 
re-read in a couple of months. Get it.  Read it.  Ponder the message and consider
your role in helping to make the future a better place for those we leave behind...
A Bit Late But, The Annual HIMSS Synthesis - Each year at the annual Health Information
Management Systems Society (HIMSS) meeting - a confab of 42,000 of my closest friends
- it's always interesting to determine what the "theme" of the year is in the world
of health information technology.  In the early 2000s it was all about the electronic
health record.  Having just returned from the meeting, I can report that there were
three words that described the conversations which were ongoing at HIMSS 2017.  
They were: Intelligence, Analytics and Cybersecurity.  Ginni Rometty, the CEO of
 IBM, gave one of the keynotes and also spoke about "cognitive healthcare" or, the
application of real-time knowledge to health care problems with tools like Watson.
 I suspect we'll be hearing more about that in the coming months as well.  It's 
clear; however, that we're moving beyond the tools of record systems into the domain
of knowledge.  The next couple of decades are going to be a fascinating period in
the overall transformation of the health care experience.  Stay tuned...
The Long Awaited "Repeal and Replace" Is More Of A "Retain and Revise" Bill - The
House Republicans under the leadership of House Speaker Paul Ryan (R-WI) finally
 released their long awaited "Republican repeal and replace plan [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3MiCp8_VUoUH3RriwNRZMUYQMx7aZHfUtfrlnW9i4yvgSCgpPFsXtJ8Ug9gen6Kjy2S4rcP9EmOCRNTdvxsZmj2xJB6LsN57JNVdZ92yHDOvgN4YI7Xikbi3CTn-5SSsAysWx9VXixQPOVLQXVE44x3C85XF5HXvNht70opyufjjmjLvXNrlGIYMVTrsx3PlzUKMA36rhSbu2ztpIZ4Z-4_osq_E2Q2eEZz&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]"
with what appears to be more of a "retain and revise" piece of legislation.  While
there are clearly some areas where change has been incorporated, much of the Accountable
Care Act (ACA - aka ObamaCare) legislation is retained.
Here are a few of the highlights you need to be aware of as this debate moves forward:

* The legislation is focused on the provisions of the ACA that can be modified through
the "budget reconciliation" process in which no filibuster is allowed.  The use 
of this strategy requires that at least 51 Senators vote in favor of the budget 
reconciliation legislation.  It is an open question; however, whether Senate Majority
Leader Mitch McConnell (R-KY) can muster the needed support for the legislation.
  In fact, most observers do not believe there are 51 Republicans who would vote
 in favor so for many policy watchers, the proposed "Repeal and Replace" is dead
 on arrival or, DOA.
* In the House, the proposal must clear the Ways and Means Committee and Energy 
and Commerce Committees before heading to the House floor for a vote.  The intent
has been to get the legislation through the Committee structure very quickly but
 in the last couple of days, it has become mired down in legislative amendments 
and other parliamentary maneuvers to prevent it from moving forward.
* Once the bill makes it through the House and Senate, it will go to "mark up" where
the two sides of the Legislative Branch negotiate on a single piece of legislation
which again requires a majority vote.
So, what has been left in place?

* Probably the most important part of the ACA from a consumer standpoint is the 
ban on excluding pre-existing conditions.  The ban will be continued.  In addition,
there is a provision to guarantee availability and renewability of coverage.  Likewise,
the ban on health status underwriting will remain in place.
* For those of us with young Millennials, adult children up to the age of 26 will
continue to be allowed to stay on their parent's insurance program.
* The caps for out-of-pocket expenditures as well as the lifetime and annual limits
will remain in place
* The ban on discrimination based on race, nationality, disability, age, or sex 
remain in place.
* Ten (10) categories of Essential Health Benefits (EHBs) will be retained under
 the Republican legislation.
So, what is "repealed", "replaced" or "revised"?

* The market place plans are gone under the Republican proposal.  Based on the initial
analysis, it appears that the proposed changes in the premium assistance tax credit
structure result in younger and wealthier folks doing better under the Republican
plan.  It's notable that the older and lower income people will be hit the hardest
under the new model.  There are already interactive tool sets [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3Mi7MR9de6lMjWq0amWWQsUxDXllCjOZxQA66hIdycwpaMb31V0XGFX-6PVqyLSwOdqC2TflwrkPFH8kIPbr_DMgP4nr8ZNmkiobEK1X_HmZYGnCxKWN6GSRV0G7IcPhK0seOUU508WzVmubSRTf2tzdmzWXO7-Hhc7vVWaYLZs4ZU8BqPOzG627UYERkQpzBXD23Ds8ip1WDOcRG_K5g3Ie6NqaW6B2p3w&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
available for determining the impact on individuals.  The reason for the change 
is that the GOP plan calls for issuing a refundable tax credit to individuals who
purchase health plans with the value of the credit tied to their age and income.
 The tax credits start at $2,000 for people in their 20s and increase gradually 
to $4,000 for people over age 60. The added feature of the Republican plan is that
the credits can be used for a broader array of health plans than are currently allowed
under the ACA.  For example, those high deductible plans would be eligible for the
credit even if the deduction is exceptionally high.  Under the ACA program, tax 
credits are used to lower the premiums for individuals and families that sign up
 for the government-run insurance exchanges with the value of credits tied to their
income and the cost of the coverage.  With the exchanges going away, the stipulations
are also gone...
* The Republican plan would also nearly double the current allowable contribution
levels for Health Savings Accounts (HSAs) with the limits increasing to $6,550 for
an individual and $13,100 for a family in 2018
* In another stipulation that will no doubt raise the ire for some and cheers from
others, the Republicans will also prohibit federal funding from going to Planned
 Parenthood for all services.
* The Individual Mandate - which required that everyone obtain health insurance 
or face the possibility of a fine - is repealed and replaced with requirement for
continuous coverage, which is similar to what was in place for individuals before
the ACA.  Furthermore, the requirement is retroactive back to 2016 so that individuals
who did not purchase insurance under the ACA would no longer be susceptible to a
 penalty.  In essence, if coverage lapses, the insurance companies will be allowed
to impose a 30% surcharge on a new policy for the individual as a penalty.  The 
idea is to assure that coverage is adequate for any pre-existing problems.
* One of the biggest concerns for many consumers in the first days following the
 release of the bill was the fact that the cost sharing assistance program (for 
deductibles, co-pays or co-insurance) for marketplace customers is repealed.  For
older Americans, the premium setting rules for insurance companies will allow them
to charge 5X what the younger population can be charged (NOTE: Under the ACA, the
difference was capped at 3X).  And, finally, the actuarial value requirements are
repealed.  Basically, what these requirements do is stipulate that the insurance
 must spend a certain amount on actual "health" insurance rather than overhead. 
 For example, the "Bronze Plans" were set at a minimum of 60 cents for every dollar
of medical expenses. The silver, gold and platinum plans were higher. Those requirements
are now gone...
What's the biggest proposed change?

* The Medicaid changes are the most significant - with most of them starting on 
January 1, 2020.  The program will move to a "per capita funding cap", which will
limit the spending per enrollee.  It also eliminates the option by the states to
 extend coverage to adults above 133% of the Federal Poverty Level (FPL).  The "enhanced
match" for the Medicaid expansion is also eliminated and the share of funding provided
by the Federal government to the states is lowered.  The Governors - in many cases
from both the Republican and Democrat parties - are weighing in with their concerns
about the new proposals.  In the weeks ahead, you should expect that further concerns
will be raised.
* In many respects, the approach toward Medicaid is far more comprehensive and complicated
than just these few changes - which are raising eyebrows across the political spectrum.
 The intent of the Ryan legislation is to allow the states to make decisions.  However,
many argue that the proposals will also allow a return to the marked disparities
 between the states which existed prior to ACA.
* The plan would also eliminate the ACA rule that requires employers with 50 or 
more full-time workers to offer an affordable health coverage plan or pay a penalty.
In sum, the proposed changes are significant with the primary focus on moving the
Medicaid program back to its more original state prior to ACA and retention of the
more popular aspects of the ACA.  However, the change in the insurance market requirements
is causing a stir among consumers.  We should expect that this legislation will 
likely not see the light of day as "final" legislation.  In addition - at this point
- I will be surprised if the Republicans are able to move it quickly through the
 House to the Senate.  In fact, I agree with most policy analysts who state that
 the legislation is DOA.  But, it has been an interesting first less-than-100-days-for-the-new-Trump-Administration
so who knows.  If you are interested in reviewing the entire bill go here [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3MiSjcak0o5Qw7JQKvGku8MgOA8DVRaaOCQkx9ZQvG-cSwAhyzssk2NQRHI90FiQpUSgTl5QiystbY1KmbLn3J_3DG6LEbF-DCpKHGKCPADsO9at9tDRqokz2yk8spOpFXurFkA1qVxL25vTE4BXyOer2clELDZg_aAYNuBTeYMWtuM34ziYIqjl8zXcM3T6CXw4Kj0XZYRagPTknq1EfxNVjjZRIG8konAnNKGdB7Lay8l_Q-oLwKd-g==&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
and a description for each of the sections of the proposed legislation can be reviewed
here. [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3Mi9gQ7yhTwNT8aozJQimO8LzZYh41FPDnMuC5lBLAHKsBEM90HBTltwjOJwQBoKVObLpqH4defKTbj7WwGp4ztSb2xKucwczhut7ugbH5A_46txV6sX-dKoe_CDNkBV7G-_cB1bT6oHnkV8nDt7aeKG2ksbVa23j-8tRhl_FIgiMmZW3fhkB8k5B0PAjVhrtAfhzAxXiSCs5w4HCIvNs_Y1uIFSFBEvPNhJR3HXIJlvLr555178Xg_reiur4RIj_uT7Z3SNO7vSfQ=&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
Stay tuned...
The Opposition Grows - The litany of health care organizations opposed to the proposed
changes put forward by the Republicans has been growing by the day.  In addition
 to the American Medical Association, American Hospital Association, Association
 of Health Insurance Plans and many specialty societies, there is a long list of
 other health care providers who have come out in opposition to the modifications,
"repeal", "replace", "revision" or whatever "R" word you can think of...  In looking
back on health care legislation proposed over the last 50+ years, this degree of
 opposition from the industry itself represents a major obstacle to final approval.
There is also a considerable backlash among the Freedom Caucus, which represents
 the most conservative element of the traditional Republican Party in large measure
because the "cost" of the bill has not been set. The usual approach is for the Congressional
Budget Office (CBO) to "score" a bill in terms of its potential costs so that lawmakers
are provided a neutral analysis on the costs of the proposed program.  Over the 
years, the CBO has done a relatively good job of estimating the impact of proposed
legislation across the board despite the rhetoric floating around on the web.  In
this case, Ryan, et. al. decided to forego a CBO scoring - perhaps because of the
anticipated cost of the changes they are offering up to the American public.  In
 fact, the Freedom Caucus is arguing that there is very little "repeal" in the proposed
legislation.
The Telemedicine / Telehealth / Telecare Debate - The American Medical Association
(AMA) brought together experts last month for the annual AMA State Legislative Strategy
Conference.  One of the hot topics was telemedicine.  It's increasingly clear that
telemedicine can speed diagnoses and increase access to care - especially for rural
and remote areas of the nation.  In addition, proponents argue that it reduces health
care costs and is a strategy for relieving the increasingly important problem of
 physician shortages - again, especially in rural and remote areas. One of the major
impediments; however, has been the fact that physicians who treat patients using
 telemedicine in multiple states must have a medical license from each state. Since
2014, the Federation of State Medical Boards has been working on an effort to develop
the Interstate Medical Licensure Compact, a process that would offer a speedier 
licensure with fewer administrative burdens for physicians seeking licensure in 
multiple states.  To date, 18 states have signed up to participate in the Compact,
which is slated to start in the next month.
One of the leaders in the telehealth space has been the University of Mississippi
Medical Center (UMMC) which started its telehealth program in 2003.  Initially deployed
as a link between rural hospital emergency rooms and specialists at UMMC, the program
has grown exponentially to include more than 30 specialties across more than 200
 clinical sites through most of the state of Mississippi.  As my regular readers
 know, I'm a very strong proponent on the use of technology for actually delivering
care.  In fact, I make a point of distinct between telemedicine (= the interaction
of clinicians with patients and other clinicians), telehealth (= the passive collection
of health indices for the purposes of monitoring patients); and, telecare (= the
 proactive delivery of care services on a virtual basis using technology as the 
foundation under clinically driven protocols and guidelines).  It is this latter
 phase that is now coming to fruition - and, which I believe will show remarkable
savings and enhanced care delivery.
The big stumbling block; however, has been provider adoption of these technologies
as part of the standard care process.  And, that stumbling block has been made larger
by the lack of insurance payment for services rendered under the tele-medicine/health/care
models.  In a recent poll of physicians [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3MiNQtWR3Q_9dHJ4KqqlxzAir3qL0iSMSPP7esRD3qoJScYVZajcjGHUpe_xkvGr9It8Ws5gds1J9dI_5Lf2RxvRFoqQVoQfkwl0Wku_n2s_b55VbTyBrICVCUz2NpJaGWzgtEtCOC4QKJtp40RbLCsQUxMTZS1yjHeSK_ld8NwEvLcLa8x6_kQMKltfh1QCD2zTKFNgdZw4gRWmsQJA_HNYM_EGDeKdygG&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
conducted by the Medical Group Management Association (MGMA), nearly 17% of the 
respondents were already offering telemedicine services, with another 21% making
 plans to use the technology in the near future.  As we move toward value-based 
reimbursement models from volume-based traditional payment models the trends will
only accelerate.
The technology used makes care more efficient for patients and easy to use in clinical
practice settings.  Couple those factors with the changes in payment and the shift
toward wholesale acceptance of telecare programs could be dramatic and swift.  I
 predict that in ten years, we will have major telecare programs sponsored by leading
health care organizations - both academic and non-academic - that will be altering
the landscape of who, what, and where care services are delivery.  Mark my word.
  You can see the changes happening now...
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The Weekly Whisk
Musings from a foodie...
I recently had the opportunity to revisit a restaurant that didn't just call itself
"Mexican" but was, in fact, "Mexican".  If you head out west, just north of San 
Francisco across the Golden Gate Bridge is Sausalito.  Tucked away on the main avenue
is Copita Tequileria y Comida [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3Mi1KdagwQWBnz6-aalj9J3o3X8uTbAAzZIBZfob0QRdC6CCCqrD5PpizF9qSVybOtKBAcvhpE1MUpegk1LXSSc0ezmgrt_---6rf4forv_HGkV7pd4zp_Vuw==&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
[* * * *] - a wonderful Mexican restaurant in the very best tradition.  Chef Raul
Plascencia has developed quite a following with his more-than-just-a-bit-spicy preparations.
 The guacamole is some of the best that I've ever tasted with a background of lime
and onion overlaying the smooth but spicy avocado foundation.  Add in the seasonal
salsa and you don't even have to go past the starters!!
Although the taco shells were a tad soggy, the fried pork belly tacos were great.
 The sweet ceviche of lobster, bay scallops, and snapper was also a great way to
 get started on the mains.  But, the best was the 24 hour carnitas topped with a
 special tomatillo habanero salsa.  Unbelievable.  The options go far beyond these
few mentions.  If you're in the mood for Mexican, I highly recommend it.  It's worth
the trip and besides - you get to travel across my very favorite bridge in the world
- The Golden Gate.  Oh how I miss the neighborhood.  Check 'em out at: Copita - 
739 Bridgeway -  Sausalito, CA 94965 - (415) 331-7400 - www.copitarestaurant.com
 [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhClk33-aqx3Mdzb3TuCrmpXOtk8myeNu45L6COfl41wJ2SJbmthCg7_FZa1RComIlz2YwD8p32DHifHyLzaLJg-ORABtJQPXtaRmJO_g4Rpvz79Cjuh_WeMtH9VpXKM8Qw==&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - For those who are looking for diversions from the steady stream of Trumpian
news, here [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3Mijvbrf1WYeaGl_M6qoDF-y_GOwVi_iLHjRAnY8VrVgDpa-_XTFMIrr2M-2hSG4u4eLZyDFqPfXQyWD-n8TuIq_6-nrEaGqmeFt6RLGDct5tLNvlsZ8E9pkWYucZjHIMq3DQ-E6c5oOTx_w7XTJmsDXVhrFOD2UPuLlOqcO5BQS8I6ztQBK36pRHEcNX27gsePpMmJz34UXLav_3oEMXGT6vbGW4yyOjwQruwSQbiePkeFB-WRMeqduA==&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
is an option - consider learning about a cruise for Trekkies!!  Now that is good
 diversionary journalism...
The Good - The Republican proposal for "repeal and replace" is finally on the table.
 Now a true comparison of options can be considered and debated.  The American people
deserve a forthcoming comparison.
The Bad - This will be considered piling on...but, really - accusing President Obama
of wiretapping goes beyond the edge...
The Ugly - Despite the revisions to the original immigrant travel ban, the proposed
Trump Administration policies [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHVc9p7Jg3MiueH3GAwkc4EoSJrGgbeZh7yudnMjbxGl2KVDzCbRjcEXVCAA85i65ze6uF3JWXZ7mvqZPWUXa_KQ_eaEO9b6izz3upZv5JMl7Zm4QcTMEk6Ygz1Kt3d8jQAaYuaSNmzzktTrnZiJ7fH12V0c9lnEAbt2tPmZm-Mf7dXF2oHaHBqgFg36g1eWC7bMF4OC72pa_P6ZmefCB_mlVCahL6f1IVXEkT7Mchhc9Gop7I3z4kYCVPS9PMoqa6T0Hm5sbFU9PJ-yzTEmgchIbHKHVUCTpKI6e-1JdbtIJ1HDRtNjyHBxpIN3uKAY-HnLP3Bx4VBvmab4FugKHvhtOpuQjeiOlu5Q8qSKpx7xpXCNszBxvQqljaflaOl008F_ybKOCZ8XaFnQ4KLMp6FCpyCP0tfP3curW3HwB9X2&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
may be forcing young enrolled medical students or, as they are called - "dreamers"
who happen to be DACA (= Deferred Action for Childhood Arrivals) recipients to be
deported.  These are aspiring dreamers not terrorists.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001khsU4m3wNMPokR7JCjxCTEym1cRYUmtioMbqf1mKuEWOj3FcBpTyhHWX4VTiwr5oqmn3Mgp607vXJ3YSQT9tWUAfQEZoN4cKRGTdjvBu40C9cKkmnvDDHMNX8XqutbELeESov57wMkNy3Z3LKcpfyAjgCie8fBQ0ASlXf3AEUHHAntRsBTXOeV9pYmd03mlD&c=zm3__o_c3v4l0wDGqVxa7VGqsCyKXZlp49VfmX2hlp4JD1yHFsBaJA==&ch=eI_UlLMZVBvvewTURqnjlJBvQ_q12-CT1HgXWZL79z_uewX3ouAtpg==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
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Name | Company | Phone | Email [mailto:[email-masked]] | Website
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