What's Wrong With American Health Care Today

Dr. Truth Hurts on "Why we must repeal Obamacare"

2012-01-01T16:38:00.000-08:00

http://actualgrit.wordpress.com/2011/12/31/dr-truth-hurts-why-we-must-repeal-obamacare/

Doctors Say Obamacare Is No Remedy for U.S. Health Woes

2011-12-26T16:29:00.000-08:00

From Forbes Online, 12/26/11

America’s doctors have conducted a full examination of the president’s health reform law — and their diagnosis of its effects on our healthcare system isn’t good.
Nearly two-thirds of doctors expect the quality of care in this country to decline, according to a new survey from consulting giant Deloitte. Just 27 percent think that the law will lower costs. And nearly seven of every 10 doctors believe that medicine is no longer attractive to America’s “best and brightest.”

Few people know more about our healthcare system than doctors working on the frontlines. Policymakers should pay heed to their indictment of Obamacare and revisit the disastrous law.

President Obama promised that his reform package would begin to stymie the out-of-control growth in the cost of American health care. He pledged $2,500 in health insurance savings for the typical American family.

But doctors don’t buy it. Only one quarter feel that Obamacare will reduce health insurance costs for consumers. Nine out of ten posit that insurers will raise premiums for employers and individuals.

They have good reason to doubt Obamacare’s cost-cutting potential. Healthcare spending is expected to reach $2.7 trillion this year — or about $1 of every $6 spent in our economy. By 2020, health spending will account for a full fifth of America’s GDP.

That increase is in large part thanks to Obamacare. Instead of relieving high insurance premiums, the nonpartisan Congressional Budget Office estimates that American families in the non-group market will see their premiums rise $2,100.
They’re already trending higher. According to the Kaiser Family Foundation, average family premiums in 2011 topped $15,000 — a 9 percent increase from 2010. Prior to Obamacare’s passage — from 2009 to 2010 — premiums went up just 3 percent.
In April 2010, Richard Foster, the Chief Actuary of the Centers for Medicare and Medicaid Services (CMS), concluded that American spending on health care through 2019 would be $311 billion higher than if the law had never passed.

Even with all that additional money flowing through the system, doctors don’t think that the quality of care will improve. Half of all doctors believe that access to care will diminish because of hospital closures prompted by health reform.
Further, nearly 70 percent of doctors believe that long wait times will plague emergency rooms. A full 83 percent of physicians foresee increased wait times for primary care appointments.

That’s in large part because Obamacare is expected to extend government-subsidized insurance coverage to many folks — even as the supply of providers remains relatively constant.

The United States already faces a shortage of primary-care doctors. Medical schools today produce one such physician for every two our country needs. By 2019, the American Academy of Family Physicians warns that the United States will be short 40,000 doctors.

Expanding insurance coverage to millions more Americans won’t do much good if they can’t get doctor’s appointments. Physicians believe that their ability to provide quality care will be further strained by the law’s attempt to change the way they’re paid — from a fee-for-service basis to a vaguely defined system of paying doctors based on patient health and outcomes.

Nine out of ten physicians fear they will receive inadequate payments and endure higher administrative costs. Fewer than a quarter of doctors expect their paperwork requirements to ease up. Time spent wading though paperwork is also time no longer available for actually practicing medicine.

American doctors’ negative view of Obamacare is telling. Proponents of the law may claim that their griping is misplaced, but as Paul Keckley, Ph.D., the lead author of the report explains, “Understanding the view of the physician is fundamental to any attempt to change the health care model.”

In other words, if physicians aren’t on board with Obamacare, it won’t work. A law that hinders the practice of medicine, obstructs access to care, and costs Americans more is clearly not the right remedy for what ails us.

Sally C. Pipes is President, CEO, and Taube Fellow in Health Care Studies at the Pacific Research Institute. Her next book — The Pipes Plan: The Top Ten Ways to Dismantle and Replace Obamacare (Regnery) — will be released in January 2012.

Can we really afford Obamacare?

2011-12-25T22:40:00.000-08:00

Since Massachusetts instituted Romneycare, the cost, per patient, of healthcare has risen steadily to over $9400.00 per person compared to a national average of about $6800.00. Now, it doesn't take a rocket scientist, a doctor, or an healthcare economist to figure out that when you mandate everyone to have insurance, the incentive for personal responsibility is lost and people will seek and demand more as well as more expensive high tech care of which most is not needed.

Sadly, most people will read this and just shrug...

Share and repost if you believe we cannot afford Obamacare!

CDC issues new alert for new R1P1 Virus

2011-12-25T21:46:00.000-08:00

*****URGENT*****

The CDC has released an urgent advisory to physicians and other healthcare providers warning about a cluster of small epidemics of a serious viral infection that has traditionally been a virus with relatively low virulence and with small, but characteristic spikes every 4 years or so.

Scientists from the CDC are calling this virus the R1P1 virus which is a politico virus that is similar to the polio virus in that it primarily infects the nervous system. Unlike the polio virus which primarily affects the peripheral nerves, the politico virus causes widespread damage in the brain manifested as chronic encephalopathy.

Infection with this virus causes a very characteristic syndrome characterized by a sudden and permanent loss of ability to engage in higher cognitive functioning or reasoning and patients affected are characteristically delusional and paranoid and engage in curious behavior including echolalia (the repetition of words or phrases by a patient of words addressed to him), obsessive rumination (repetitive regurgitation of inane phrases ), persistent dwelling in conspiratorial and paranoid thinking, and an obsessive and compulsive need to a-paul-ogize to radical Islam for American neo-nazi-fascism and intervention. The clinical syndrome is often referred to as pauli-encephalopathy and commonly called Ronpaulitis. It is very similar to another chronic brain-wasting disease (Mad Cow Disease) caused by a slow-virus and because of this similarity is often called “Mad Paul Disease”.

Researchers from the CDC are concerned about the increased incidence and virulence of this otherwise relatively harmless virus that in past years has infected relatively few people (less than 2-3%). The RP viruses are relatively common viruses and arise from a family of viruses called the "cult viruses", included in this family are the BO (B. Obamagotcha) virus, the DK (D. Koreshiae) and the JJ (J. Jonesensei) virus. Researchers at the CDC say they are not sure if it is a mutation in the virus from a R1P2 virus which is the most common variety to a new R1P1 virus, or if instead it is a relative decrease in host defenses brought on by concurrent infection of a similar virus called the BO virus. One researcher believes that the evidence supports a mutation rather than a general decrease in immunity in the population because of areas of sporadic epidemics in the US, such as Iowa, New Mexico, and Texas. While there is no cure for these viruses, researchers do say that they are preventable by engaging in common sense behaviors such as
thinking and avoiding certain books (The Revolution: A Manifesto, End The Fed, etc), documentaries (Conspiracy Theory with Jesse Ventura), or movies such as George Orwell’s 1984 or JFK and the Manchurian Candidate. While, most people have a robust and natural defense against the negative and irrational cerebral influences of this genre of work, it is thought that exposure and infection to the R1N1 virus renders this natural defense weak or even non-existent.

Doctors at the CDC claim they are working on a vaccine for this virus, but do not expect to see a vaccine come to market until after November of 2012 at the soonest and caution that it may take several more decades before a cure or vaccine are found.

Doctors, healthcare workers, and the general public are asked to contact their local health departments and/or the CDC if they have become exposed to the virus or know of anyone that has. Since there is no cure, this would be strictly for demographic and research purposes. (From Neuter's Medical News Service)

Iowa Kool-Aid and How to Form a Cult

2011-12-25T21:28:00.000-08:00

I was surprised to see the results of the Fox News Poll showing Ron Paul leading in who the pollsters thought would win the Iowa caucus vote. While, I consider myself a conservative and lean more towards libertarianism, I am nonetheless, quite frankly concerned about the possibility of Ron Paul winning the primaries and--God forbid--possibly becoming president of the United States. My concern comes as a fellow physician who believes that Dr. Paul suffers from a real psychological disorder characterized by megalomania, narcissism, delusional thinking, paranoia, antisocial characteristics, and (abnormal) feelings of persecution. Now, I am not a psychiatrist, but I did minor in psychology as an undergraduate and most physicians have been educated in the behavioral sciences and have been trained to diagnose common psychiatric disorders. Furthermore, it is estimated that the incidence of Narcissistic Personality Disorder occurs 34 times more often in medical doctors than in the general population.

Over the last several weeks, I have been studying Dr. Paul as well as his followers through his television appearances, his letters (and Newsletters), social media, and video clips from You-tube and have noted a very disturbing pattern of Dr. Paul showing all of the psycopathological characteristics of a genuine "cult leader" and his followers showing all of the characteristics of a cult.

I have studied cults and their leaders and have outlined the "five basic
rules" of being a cult leader. I have also indicated the psychopathology associated with cult leaders as they form their cults:

The number one rule of a cult leader is to polish and cultivate a persona that you--and only you--have been chosen, anointed, or have achieved spiritual, political, or intellectual enlightenment above all others. This shows features of megalomania, delusions of grandeur, as well as narcissism.

1. Dr. Paul has tried to cultivate this persona for over 30 years as the “outsider” and enlightened one within the “Washington establishment”.

2. Dr. Paul has publicly stated that while he believes in term limits, they do not apply to him because (paraphrasing) “there is no one good enough to bring in to replace him”.

3. In 2010, Dr. Paul commented to his wife that he would run for President in 2012 “if things were happening so quickly and fast in our country and we were in a crisis period…and needed somebody…with the knowledge he as, he would do it”.

4. Dr. Paul presents in interviews as haughty and stern and seems to be lecturing rather than engaging in conversation.

The next rule is to appeal to the disconnected, disenchanted, and disaffected in society who are often intellectually, politically, and emotionally immature (i.e., younger people)and convince them that while you have been “chosen” (or more likely self-selected) you are (almost) human just like them and can empathize with their disenchantment and discontent. This shows more tendencies of narcissism and ego-feeding by someone who sees them self as inherently better than others, but with a need to surround one’s self with those less fortunate or less “enlightened”—a “savior complex”, if you will. Often times, the empathy and compassion shown to the acolytes is not genuine (which is a feature of antisocial personality) and is only used for the ulterior motive of personal gain in sex, money, or power (or sense of superiority) or combination thereof.

1. Dr. Paul has always had a relatively small number of fanatical followers who have mostly been drawn from younger people in society. He routinely targets schools,
colleges, and other events where younger people tend to be.

2. His “populist” message today resonates with many, besides young people as social, geopolitical, and economic turmoil are perceived to be worsening and more and more people become disenfranchised, disenchanted, and discontent.

3. Dr. Paul’s ploy of not accepting Medicare payment for his Medicare services or a congressional pension—while on the surface seem like noble gestures—are really means to portray himself as “one of us” and morally higher than his colleagues.

The third step is through indoctrination, coercion, repetition, and/or isolation to exercise mind control over your flock of followers by relieving them of their ability to think rationally (usually by not allowing them to test your theories or have access to “the outside”)—but not emotionally—while simultaneously convincing them that your ideas—while plausible (but generally at the far fringes of mainstream thought) are the “light and the truth”. This shows more elements of antisocial ego-building in that the leader is now getting others to surrender their will and rational thought against deep seated norms of the self and/or society while they align their thinking towards that of the leader.
Furthermore, this shows the disordered or delusional thinking of the leader who generally has delusional thinking of the world and how it operates and he or she is the only one with the power to fix it.

1.Dr. Paul plays on the emotions of his followers by carefully crafting plausible—and easy to understand-- (but highly improbable and at the fringes of mainstream thought)scenarios out of complex geopolitical, political, social and economic issues
that are at “top of mind” of our society and that tug at some of our most basic
interests (individual freedom, economic freedom, nationalism, sanctity of life,
torture, and war) and evoke very basic human responses such as fear, anxiety,
anger, disgust, and etc.

2. Dr. Paul’s views on national defense, monetary policy, isolationism, and constitutionalism are considered by most to be outside of the mainstream of rational political, social, and governmental philosophy.

3. Dr. Paul has consistently repeated his messages over 30 years and as noted above, tends to target younger followers who are easier to indoctrinate.

The fourth rule is to proselytize not only your “enlightened philosophy or beliefs, but also to spread forth the word that while you and your followers are “the enlightened or chosen ones”, there will be naysayers and those that will persecute you and the movement. This clearly shows the elements of paranoia and persecution by the non-believers.

1. Dr. Paul and his followers are very defensive when challenged on the issues and their beliefs. Instead of engaging in earnest discourse, they tend to attack and accuse the “non-believer” as persecuting them for their beliefs or of being ignorant and unenlightened in their philosophy.

2. Dr. Paul and his followers display a common paranoia and decry a “conspiracy” of the right, the political elite, and the left against them and their “lofty ideas that will save America”.

3. Dr. Paul has consistently offered the explanation that others are simply “out to get him” by taking “tongue-in-cheek comments out of context” and things that were written in his newsletters (but purportedly not authorized or written by him).

4. Dr. Paul comes off as defensive and angry when challenged in interviews and becomes condescending.

The fifth and last rule is to convince your followers that it is only through blind faith and rigid adherence to your philosophy—no matter how foreign it may be to self or to society—that that blind adherence or “loyalty” is the only path to salvation, redemption, or the reparation of the “perceived” ills of society. This is more antisocial ego-building and the tightening of control over the flock.

1. Dr. Paul and his followers play the same monotonous drum beat about “smaller government”, defense of our borders,monetary reform and fiscal responsibility, “stop the wars”, and national isolationism over and over again like a Gregorian chant and mantra in a blind and stubborn adherence to their fringe philosophy that is the only path to saving America despite practical, rational, philosophical, and real world
evidence against and “common sense” opposition to their “zany” ideas, Messianic
messages, and Utopian philosophies.

Some authors would add another step which is to construct a “doomsday scenario” for your followers, such as “the end of the world, World War III, or economic collapse as the great incentive to motivate the followers to adhere to and spread your
teachings. This, again, would show delusional thinking as well as narcissistic thinking, especially if the leader and his or her followers will be the only ones saved from the impending calamity.

1. Of course we are all aware of the “doomsday” prophecies of Dr. Paul considering our economy and its impending collapse with hyperinflation if we don’t get rid of the Fed.

After considering this, and seeing Dr. Paul’s rise in the Iowa polls, it makes me
wonder what they are doing out there in Iowa. It seems to me that maybe they are mixing a little Ron Paul Kool-Aid with some fermented corn!

"Arm chair economists" vs MD/MBA and Expert in Healthcare Economics

2011-12-17T15:23:00.000-08:00

I have read with amusement the letters to the editor in today’s (12/17/2011) Albuquerque Journal criticizing Dr. J. Deane Waldman’s recent editorial regarding out of control health care costs and the government’s role in regulating and/or contributing to those costs. It is interesting that all three letters published were all critical of Dr. Waldman’s analysis with no counter opposing view(s) supporting his analysis. I don’t know if that means there were no letters to support Dr. Waldman or if the Journal simply chose not to include any letters that supported his views.

Regardless if there was any supportive letters sent to the editor, it is both interesting and amusing to see three non-medical (and assuming, non-health care economics) professionals—unless one counts “45 years experience as a health care advocate” as qualifying as a health care professional—trying to rebut the thoughtful analysis of not only a practicing physician who has practiced for more than 2 decades within our “sick system”,but is also an MBA who is a published author and expert in healthcare economics and reform.

It is obvious from the reading of all three letters that the basis of their rebuttal is not based on any real facts or data from scholarly journals in medicine or economics, but rather simply on personal political ideology and opinion. All three letter writers obviously espouse a more liberal “more government is better” philosophy towards healthcare—vis-à-vis “Obamacare”-- and two of the letter writers ignominiously attempt to discredit Dr. Waldman’s analysis as merely the musings or political ranting of just another ill-informed or unenlightened “conservative”.

Regarding the first letter by Mr. Richard Valdez, he somehow manages to shift the argument that more government regulation is more or less cost efficient based on the merits—or lack of—of governmental bureaucratic efficiency , instead arguing for the benefits of more government regulation in healthcare in order to improve patient safety. In other words, he is trying to compare apples to apples, but using oranges as an example. On top of that,he insinuates that Dr. Waldman just magically pulls his data (of 40% of healthcare expenditures not going to pay for direct patient care) out of the air if not from a “conservative think tank” while offering his own simple statistic from the CDC and Institute of Medicine (which by the way is a liberal think tank) of “100,000 to 135,000 deaths annually due to doctor and/or hospital error”. Now, did I miss something? I thought we were discussing money and bureaucratic efficiency/inefficiency here and not the number of potentially preventable patient deaths per year attributable to medical errors. What does one have to do with the other? I’m deeply sorry that he has lost two sons, but his argument that more government spending or regulations would have saved them may or may not be true, but have absolutely nothing to do with the argument that the government can or cannot be more efficient in managing healthcare!

While this letter is meant to offer a critique of the letters criticizing Dr. Waldman’s analysis and not a separate analysis of how we can best prevent medical errors in healthcare or what the government’s best role is in preventing medical errors, I do want to point out—using Mr. Valdez’ own statistics—how easy it is to pick and choose random statistics disingenuously to support one side or another of an argument. While Mr. Valdez correctly contends that there are anywhere from 100,000 to 135,000 (actual range is 85,000 to 195,000)deaths annually attributable to doctor and/or hospital errors, he conveniently fails to indicate that number one, these are classified as “potentially preventable deaths” and number two, that these potentially preventable deaths represent an extremely small fraction (0.00005%--using the higher number of 200,000) of the nearly 1 billion (995 million) doctors visits, outpatient clinic visits, ER visits, and hospitalizations (CDC data) seen each year!

You don’t have to be a "Black Belt” in Six Sigma --an extremely rigorous business ideal advocating for near perfection or 99.99966% error free processes—to see that in medicine, we get pretty damn close! Now as a physician and a father-- and a healthcare consumer-- I understand that we are talking about human lives here and not the manufacturing of ball bearings and that even 1 preventable death due to medical error is tragic and regrettable, but from the dawn of civilization, we have never been, currently are not, and never will be perfect in medicine or in any other human endeavor!

Mr. Raymond Schall and Mr. Byers both just simply spout standard democratic party line demagoguery in their justification for and defense of “Obamacare” and increased government involvement in one of the most personal aspects of our lives without providing any real or objective data or logic to buttress their criticism of Dr. Waldmam’s analysis. Mr. Schall tries to
also pick and choose some “statistics” to bolster his support of “Obamacare” by citing that the “Health and Human Services recently released their long awaited rules requiring insurance companies to spend at least 80 to 85 percent of their revenue on actual patient care. What he failed to mention is that in the United States, most private insurance companies spend about 6 to 11percent of revenues on “administrative costs” and 89 to 94% on “patient care costs” (multiple sources). He also did not mention that from at least 2000 to 2010, Medicare consistently has spent 19 to 31% more on true “administrative costs” than private insurance companies. He also tries to tout the benefits of “Obamacare” by stating that “more than 100,000” New Mexicans have “received free preventative health care” and “more than 18,000 students have received primary and behavioral healthcare” because of “Obamacare”.

Now Mr. Schall obviously has never heard of or does not believe in the 1st principle of economics which basically states “there is no such thing as a free lunch”. He uses the word “free” as if “the free market tooth fairy”—to borrow a trite little phrase from Mr. Byers (the 3rd letter writer)—suddenly dropped the money into the government coffers to pay for the “free care”! Excuse me, but just because the patients received “free” or discounted health care doesn’t at all mean that it was “free”—somebody(you and I—and not the tooth fairy) in the form of increased taxes and or both increased premiums has to pay for that “free health care”! Beyond that, the medical providers providing the “free care” do so at a deeply discounted government mandated rate that often is below the amount required to sustain a viable practice!

Finally, Mr. Doug Byer’s letter is nothing more than old and tired progressive-socialist and “new” OWS dogma lamenting the evils of capitalism and free markets thinly—as well as feebly--disguised as an attempt in intellectual discourse.

I conclude my critique of the letters to the editor with some rather interesting “statistics” to ponder:

1. There are approximately 1800 pages each in both Harrison’s textbook of Medicine and the American College of Surgeons textbook of Surgery which could be considered the "bibles” of Western Medicine and Surgery and which represent the collection of
at least 3000 years of medical and surgical science and knowledge. This compares to 1000 pages in the Patient Protection and Affordable Act (aka “Obamacare”), 670 pages in the HIPPA regulations, and over 132, 000 pages of Medicare rules and regulations collected over the last few decades (this does not include the various state and local rules and regulations regarding the practice of medicine in States and local localities)!

2. There are approximately 650,000 practicing physicians and surgeons in the United States and it is estimated that for every physician, there is 2 to 5 or (1.2 to 3.25 million) “non-medical administrative” workers (most of them Federal and State employees) per doctor “administering healthcare”!

3. The Medicare Trustees have projected that Medicare (which administers to approximately 30.5 million Americans) will be bankrupt by 2024 at current spending projections and somehow we want to expand that government bureaucratic behemoth to cover 10 times that much? This is what a “real” doctor in health care economics has to say about that:

“Contrary to the claims of public plan advocates, moving millions of
Americans from private insurance to a Medicare-like program will result in
program administrative costs that are higher per person and higher, not lower,
for the nation as a whole.”
Robert A. Book, Ph.D., is Senior Research Fellow in Health Economics in the Center
for Data Analysis at The Heritage Foundation

Sincerely,

John R. Vigil, MD

Dr. Vigil has a blog titled “What’s Wrong With American Healthcare Today;
The Musings of a Working Doc” and has been a practicing physician and surgeon for over 20 years. His interests in medicine are healthcare economics, improving healthcare delivery, and history of medicine and surgery. He has completed 1 year towards his Master’s degree in Business Administration at the Anderson School of Management, University of New Mexico.

Opiates and Pain Management; Pandora's Box

2011-08-31T17:57:00.000-07:00

Opiates and Pain Management: Pandora’s Box

Today is National Overdose Awareness Day and an appropriate time to discuss the terrible epidemic of opiate addiction that we are seeing, not only in our community, but nationally as well. The statistics are staggering as according to SAMHSA (Substance Abuse and Mental Health Services Administration) there were 1.9 million prescription opiate addicts and another 600,000 or more heroin addicts in 2009 and the numbers are increasing. Accidental overdose has overtaken car accidents as the number one killer of young people 18 to 44 who are not only in their prime of life, but also the primary producers in our economy and society. It is estimated that overall, 24 million people in the US have an addiction and only about 1-2% are receiving treatment for their addiction.

I could easily write an entire paper on the staggering cost of addiction, not only in loss of human lives but also in economic costs to this country; however this paper is about the people affected by this horrible epidemic and not about statistics. There have been a number of stories and citizen comments recently in our news and newspapers about young people tragically dying of heroin overdose and doctors over-prescribing narcotic medication. This paper is written to try to bring some insight to the community of the scope of this problem, how we got there, and some possible solutions.

Sometime in the middle of the last decade, several national and international organizations, including the WHO (World Health Organization) drafted and adopted a Patient’s Bill of Rights that dealt specifically with pain management. Specifically and amongst other things, it stated that all patients “have a right to proper, respectful, informed, and non-discriminatory pain management and care”. Prior to this shift change in medicine, opiates had more or less been reserved to manage chronic pain only for patients with advanced cancers or other end-stage painful conditions. Apart from these patients, the only other use for opiates was generally for the short term treatment of severe acute pain postoperatively or for severe acute trauma. Following the lead of the national and international organizations, most state medical boards and societies adopted the Pain Patient’s Bill of Rights and Pandora’s Box was opened.

Since then, millions of patients have been treated and are being treated with opiate pain medication for a variety of conditions including headaches, chronic back pain, arthritis, fibromyalgia, and just about any other disorder that causes pain. While the overwhelming majority of these patients are being treated for legitimate pain by well-meaning, well trained, and legitimate physicians and are not abusing their medication or addicted, many of them do become addicted and/or dependent and a few obtain their medication illegitimately, by ruse or illegally. Unfortunately, there have been—and remain--more than a few unscrupulous and unethical doctors who have been more than happy to provide some of the latter “patients” with prescriptions for narcotic medication.

The opening of Pandora’s Box has produced a schizophrenic medical community with doctors under pressure to respect and adhere to the “Patient Bill of Rights” by providing legitimate patients with adequate and compassionate pain management on the one hand while feeling threatened or intimidated by the DEA and other law enforcement agencies if they chose to treat such patients. Another problem arises when all physicians know and understand that while the majority (more than 80%) of patients treated with opiate pain management will never develop an abuse problem or addiction, about 10% will ultimately develop an addiction with its attendant negative consequences—including risk of accidental overdose-- on those patient’s lives. Unfortunately for us, patients do not carry a sign with them that warn us that a particular patient will become addicted. Furthermore, since pain is a subjective and individual experience and is modified by emotional, physical, and psychological states, it is impossible for any physician to be 100% certain 100% of the time, who is legitimately seeking pain management and who is not.

By some of the reports in the news as well as some of the citizen’s comments, it would appear that there is a perception that most physicians are just “willy nilly” handing out prescriptions for opiates to just anyone who requests them without consideration of the consequences. As I have mentioned earlier and which have been documented in news stories across the country, I acknowledge that there are unethical and unscrupulous physicians who are prescribing for profit, but like the minority of legitimate patients who become addicted and cause problems to themselves and society, they are in the vast minority! In fact, statistics from SAMHSA indicate that in most communities, most “illegitimate” prescriptions are coming from only 1 or 2 doctors. Most doctors take their responsibility to their profession and society seriously and understand the risks of prescribing opiate medication. We also understand that the majority of people prescribed such medication will also be responsible and never develop a problem with it and we are constantly weighing the risks versus the benefits of prescribing such medication to each and every patient. It is inevitable that some of us will be duped by some “patients” and it is also inevitable that some legitimate patients will develop an addiction and that is the risk we take while Pandora’s Box is open.

Another common misperception is that many teenagers and young people are becoming addicted to opiates obtained from doctors. There are very few indications to treat a young person with opiate medication and most physicians are hesitant to prescribe these medications to teens and young people except in cases of moderate to severe pain from orthopedic or operative trauma. Statistics from SAMSHA and from my personal experience as an addiction specialist, most teens and young people (55%) report that they are getting their opiates right from home (friends or family), 17% report getting them from one doctor, and the rest from the street. Of those that reported obtaining their medication from friends or family, 80% of the friends or family members reported getting their medication from only one doctor.

So what can we do about Pandora’s Box? According to legend, once it was open, there was no way of closing it and I do not believe that there is any way of closing our modern day version of the box. However, the one thing that remained in the box was hope and it with hope that we can possibly change things at a variety of levels including personally, professionally, and legislatively to effect positive change in our communities and society at large to combat this insidious and horrible epidemic that is claiming the lives of our youngest and most productive individuals. Every time one of our young people dies from an overdose, it robs us all and our society of a “what if”—what if that person was going to be the next doctor to cure cancer or addiction, a great actress or actor, singer or athlete, or the next CEO of a great company, or even the next President.

While I do not profess to have all of the answers to this complex and vexing problem, I do have some suggestions, some of which will undoubtedly bring much scorn and criticism upon me from colleagues and others. I will outline these suggestions from a personal to professional to a legislative order.

Personally, as individuals we must all become aware of this insidious epidemic and must educate ourselves—and our children-- about the risks and dangers of opiate addiction when given these medications, even for short term use. As parents, we must educate ourselves to the signs and symptoms of addiction so that we may intervene early and decisively should we suspect our children or loved ones of developing a problem or experimenting with opiates. If we are obtaining and using opiate medication we must take measures to safeguard our medication and keep them out of the reach of children and inquiring minds. We can become advocates in our schools and our communities, becoming involved in groups and organizations, such as the Heroin Action Committee, that spread the word about this problem. Lastly, we must learn and understand that addiction is a disease and should be treated like a disease without the stigmatization that surrounds it and which stands as a barrier to many of those who would otherwise seek treatment.

At a professional level, we must take our heads out of the sand and acknowledge the epidemic of opiate addiction that the opening of Pandora’s Box has caused. We must keep up to date on the standards of care for the treatment of chronic pain and we must also keep up to date on the advances that are being made in the non-opiate management of chronic pain as well as the advancements being made in addiction medicine. We too, must divest ourselves of the cloaks of superiority and ignorance and recognize addiction for the disease that it is and not the old stereotypes we might still believe. We must accept our part in this epidemic and be more diligent about truly doing risk analysis every single time we write a narcotic prescription, including opiates, benzodiazepines, and medication for ADD. We must recognize our educational and training limitations and refer those patients requiring complex psychological and concomitant pain management to appropriate specialists. It is our house where Pandora’s Box came from and we must clean our house or others will clean it for us and ultimately, the patients and society will suffer.

At a legislative level, which must occur at both the state and federal levels, there are several things that can be done. First of all, hydrocodone and tramadol should be made scheduled II narcotics and all scheduled II narcotics should be controlled and prescribed only by appropriate specialists or physicians who have demonstrated interest, experience, and proficiency through conferences, courses, and continuing medical education in pain management—as well as addiction-- to their respective state medical boards or licensing agencies. It is interesting that I must demonstrate proficiency to apply for a license to prescribe Suboxone which treats addiction, but I have no restrictions whatsoever to write for all the drugs that cause addiction! For those specialists that may often treat acute severe pain, such as surgeons, orthopedic surgeons, or ER/Urgent Care physicians, strict limits should be made with respect to amounts written for and duration of treatment for all scheduled II drugs. All states should be mandated to have a reporting mechanism through the pharmacy boards where all physicians should be mandated to access and report to before prescribing scheduled II medication. On a broader level, we must enact legislation that shifts the emphasis from punishment to prevention and treatment for those that struggle with addiction. We should encourage and expand dramatically the number of doctors and midlevel providers who wish to provide outpatient opiate addiction treatment with Suboxone. As a society, we too must understand that addiction is a neurobiological disease manifested by abnormal behavior, not abnormal people voluntarily engaging in harmful and bad behavior!

Pandora’s Box may be open, but by coming together as citizens, professionals, and policy makers, we can perhaps reopen the box and bring hope to our communities and to society.

John R. Vigil, MD

Why Healthcare Cannot Be a Right--In a Free Society

2011-02-26T12:47:00.000-08:00

There is a proposed constitutional amendment in our state (New Mexico) to recognize Healthcare as a basic human right. Dr. Bruce Trigg, a local physician and colleague wrote an editorial in our local newspaper titled "Make Healthcare a Right For All". The following is my response:

I have read my esteemed colleague’s (Dr. Bruce Trigg) editorial today (2/25/11), titled “Make Health Care a Right for All.” While I have the utmost respect for Dr. Trigg, I must answer with the counter argument that health care is not a right-- in a free society.

This nation was founded on the principle of “self evident truths” that each of us as individuals are born equal (not that we should share in all equally) and “endowed’” with “certain unalienable rights”, including the right to “life, liberty, and the pursuit of happiness”. Nowhere did our founding fathers mention “health care” or “good health” as a right, neither in our Declaration of Independence nor in our constitution or its Bill of Rights.

Now some would argue that in 18th and early 19th century America, “Health Care” was nothing to brag about and certainly, nothing to pursue as a fundamental right for all citizens. Others would argue that it was simply an oversight that the founding fathers did not include our health as a fundamental right. I would counter the first of those arguments by asserting that many Americans would travel back to Europe for their “health care” which had to be extraordinarily expensive and inconvenient and yet, there was no clamoring to have the fledgling American government, or rather, its citizens pay for such care. As far as the second argument goes, it is incredulous and inconceivable to consider that considering the collective wisdom of our founders who included Benjamin Rush and other physicians, they would have overlooked something as important as a basic and fundamental human right.

I believe that it was with foresight from our founding fathers that “health care” as a right was purposely excluded as a basic and fundamental right. Unlike, our current politicians, our forefathers were well read and versed in history, philosophy, law, economics, and theology and understood the dangers of the government picking and choosing certain rights arbitrarily and compelling the citizenry to pay for such rights. They understood human nature and man’s natural tendency to want and desire what others have and he doesn’t have and they understood how that very human nature could be exploited by politicians and tyrants for political expediency and political power by providing those things as “rights”.

They recognized that man could conjure up an endless list of needs and desires and rationalize any one of them or all of them as being indispensable as basic human rights. Yet, they carefully selected only three basic “unalienable rights” or “natural rights”, none of which another man could provide to another nor could be compelled to pay for or provide to another. These rights are negative rights in that the right is not in the power or the purview of the government (or fellow citizens) to provide such rights, but rather places in the government the power and responsibility to protect such rights from being taken away from us. The government nor our fellow citizens cannot give us or ensure us life, liberty, the pursuit of happiness-- or good health!

Our government may only protect our rights from such things being taken from us and it is our individual responsibility to respect the rights of others and not take such rights from each other, but nowhere in our constitution is it stated or expressed that our government must provide us with anything or compels us to provide our neighbors with anything! They understood that to compel us to provide for the needs and wants of our neighbors would be antithetical to the very principles this country was founded on and for which we fought a war of independence for: That no man should be in servitude to a tyrant, a tyrannical government, or to each other and that no man should be beholding to or dependent on another man or government for his life, liberty, or pursuit of happiness!

Now some would argue that the Bill of Rights and subsequent amendments to the Constitution is where we derive our positive rights from, or those rights that by “social contract”, obligate us or our government to provide us with certain “rights” pertaining to our “general welfare”, yet the first ten amendments, or the “Bill of Rights” were added to further delineate—and limit—the power of the government with respect to both protecting our natural rights of life, liberty, the pursuit of happiness and the right to attain and own private property as well as to define and specify certain liberties, such as the freedom of speech, the freedom to keep and bear arms, and etc. Again, nothing in the Bill of Rights or subsequent amendments explicitly or implicitly allows for or compels the government to provide the citizenry with a minimum standard of welfare or for the citizens to provide for the general welfare of each other for to do so erodes our individual freedoms and places us in the servitude of our government and/or our fellow citizens.

Dr. Trigg in his essay asks “why can’t we guarantee that everyone has medical care on the same basis that we provide police and fire protection and universal free education”? The answer is that the provision of police and fire protection are governmental institutions specifically created and empowered solely to protect our natural and property rights. They cannot provide us with any material needs or desires nor can they deny us or take away from us our property, our lives, or our freedom. With respect to providing “universal free education”, nowhere in the Constitution is it mandated that we all be provided free education. Education from K to 12 is compulsory by state statutes and certainly is not “free” in that we all pay taxes to fund our public education. Access to higher education is protected by law, again, as a negative right only, in that no one, including the government can prevent us access to education—as long as we have the means and money to pay for it!

So far, I have made the argument that our Founding Fathers and Framers of our Constitution purposely excluded “health care” and an endless list of similar human needs and wants as positive rights based solely on a moralistic philosophy that to compel the government or the citizenry to provide for such rights would create the hypocritical and antithetical situation of protecting our freedoms and pursuit of happiness while at the same time placing us into involuntary servitude to our government and/or our fellow citizens. Although I believe that such moralistic and enlightened thinking was behind the decisions of our Founders as they framed and penned our Constitution, I also believe there were more practical considerations as well that influenced their thinking.

Besides being great moral thinkers and products of “the enlightenment”, our Founders were also businessmen and pragmatists and understood that the provision of most goods, needs, wants, and services—including health care—to the citizenry was best, most fairly, and most efficiently accomplished through the time-honored system of free markets. They understood from Adam Smith that free markets are the engines that drive democratic economies and the most efficient way to provide scarce resources to the greatest number. They also understood (unlike modern politicians) that the “invisible hand” of the free markets worked best unfettered and unrestrained by the “heavy hand” of oppressive government, burdensome bureaucratic regulations, onerous taxes, or union extortion.

Dr. Trigg is correct in asserting that a substantial number of our population already receives “[free] medical care either provided directly by the government (VA, Military, Indian Health Service, etc) or paid for by the government (UNM, Medicaid, Medicare, etc)”; however, he fails to mention that, for the most part, care in those systems, is grossly inefficient, very costly, and burdened by layers and layers of costly and onerous government bureaucracy and would best be provided by independent and competing practices in a free market system!

Dr. Trigg states that the proposed state amendment making health care a human right “paraphrases the words of the late Cardinal Joseph Bernardin” who has called since the 1990s for our government to recognize healthcare as a human right which government must “take responsibility” for. That is an interesting proposition from a religious spokesman from a religion that from medieval times has assumed the responsibility of providing access to healthcare and healthcare directly, through charity and charitable hospitals to millions and millions of sick souls! The Catholic Church and other religions have plenty of assets and money, if they believe healthcare is a right, then let them bear the burden of responsibility of providing it! I’m sure that religious leaders would no more appreciate government fiat compelling them to assume the responsibility of providing healthcare to each and every citizen anymore than any free man or woman wishes to be compelled to assume such responsibility!

I am not arguing that access to healthcare is not a right and I do not believe that our Founders believed that access was not a right; they correctly believed that “healthcare” in and of itself is a service and best provided through the marketplace. Every American has access to healthcare right now and our government has enacted statutes to prevent anyone or any government entity from barring us from such access to healthcare and that is the extent of government involvement that our sage Founders purposely wrote into the Constitution. Unfortunately, from Roosevelt, to Obama, modern day politicians have completely disregarded the thought and intent of our great Founders and have transformed an “age of enlightenment” to an “age of entitlement”.

Now before, I am accused and nailed to the cross as an uncaring and self-serving capitalist or hate-monger, it should be known that I have started a free-clinic for migrant workers in Ohio in 1995 that still operates today and I open my clinic as a free clinic in the South Valley to uninsured and underinsured people every 1st and 3rd Sunday of the month. I also have never turned a patient away from any of my clinics because of their inability to pay and every day I provide free or discounted care. As a physician, I took an oath of voluntary servitude to my fellow man, but, as an American, I must resist any call from my government or otherwise well-meaning citizens for my indentured servitude to them, for I am a free man in a free and democratic society!

John R. Vigil, MD

Andrew Napolitano - Health Care Tyranny

2010-04-25T14:14:00.000-07:00

Nearly 4M to pay health insurance penalty by 2016

2010-04-22T18:05:00.000-07:00

Nearly 4M to pay health insurance penalty by 2016

Stephen Ohlemacher
From Real Clear Politics

Nearly 4 million Americans will have to pay a penalty if they fail to get health insurance when that element of President Barack Obama's health care overhaul law kicks in, according to congressional projections released Thursday.

The penalties will average a little more than $1,000 apiece in 2016, the Congressional Budget Office said in a report.

The vast majority of people paying the fine will be middle class, which would violate Obama's 2008 campaign pledge not to raise taxes on individuals making less than $200,000 a year and couples making less than $250,000.

Republicans have criticized the penalties, even though the idea for a mandate was originally proposed by Republicans in the 1990s and is part of the Massachusetts health care plan signed into law by then Gov. Mitt Romney, a Republican, in 2006. Attorneys general in more than a dozen states are working to challenge the mandate in federal court as unconstitutional.

Democrats argue the mandate and the penalties are a necessary part of a massive overhaul designed to expand coverage to millions who now lack it. They point out that getting young, healthy Americans in the insurance pool will reduce costs for others.

Americans who don't get qualified health insurance will be required to pay penalties starting in 2014, unless they are exempt because of low income, religious beliefs, or because they are members of American Indian tribes. The penalties will be fully phased in by 2016.

About 21 million nonelderly residents will be uninsured in 2016, according to projections by the CBO and the Joint Committee on Taxation. Most of those people will be exempt from the penalties.

Under the new law, the penalties will be phased in starting in 2014. By 2016, those who must get insurance but don't will be fined $695 or 2.5 percent of their household income, whichever is greater.

After 2016, the penalties will be increased by annual cost-of-living adjustments. People will not be required to get coverage if the cheapest plan available costs more than 8 percent of their income.

The penalties will be collected by the Internal Revenue Service through tax returns. However, the IRS will not have the authority to bring criminal charges or file liens against those who don't pay.

About 3 million of those required to pay fines in 2016 will have incomes below $59,000 for individuals and $120,000 for families of four, according to the CBO projections. The other 900,000 people who must pay the fine will have higher incomes.
The government will collect about $4 billion a year in fines from 2017 through 2019, according to the report.

Would the Founders Love ObamaCare?

2010-04-22T17:59:00.000-07:00

Would the Founders Love ObamaCare?
THE RESISTANCE TO OBAMACARE IS ABOUT A LOT MORE THAN THE 10TH AMENDMENT.

The left-wing critics are right: The rage is not about health care. They are also right that similar complaints about big government were heard during the New Deal and the Great Society, and the sky didn't fall.

But what if this time the sky is falling—on them.

What if after more than a century of growth in the national government, starting with the Progressive Era, the American people are starting to push back. Not just the tea partiers or the 13 state attorneys general seeking protection under the 10th Amendment and the Commerce Clause. But something bigger than that.

Daniel Henninger discusses the widespread anxiety over the size of government.
The Democratic left, its pundits and academics criticizing the legal challenges to ObamaCare seem to be arguing that their version of our political structure is too big to change.

That's not true. The American people can and do change the nation's collective mind on the ordering of our political system. The civil rights years of the 1960s is the most well-known modern example. (The idea that resistance to Mr. Obama's health plan is rooted in racist resentment of equal rights is beyond the pale, even by current standards of political punditry.)

Powerful political forces suddenly seem to be in motion across the U.S. What they have in common is anxiety over what government has become in the first decade of the 21st century.

The tea party movement is getting the most attention because it is the most vulnerable to the standard tool kit of mockery and ridicule. It is more difficult to mock the legitimacy of Scott Brown's overthrow of the Kennedy legacy, the election results in Virginia and New Jersey, an economic discomfort that is both generalized and specific to the disintegration of state and federal fiscs, and indeed the array of state attorneys general who filed a constitutional complaint against the new health-care law. What's going on may be getting past the reach of mere mockery.

Constitutional professors quoted in the press and across the Web explain that much about the federal government's modern authority is "settled" law. Even so, many of these legal commentators are quite close to arguing that the national government's economic and political powers are now limitless and unfettered. I wonder if Justice Kennedy believes that.

Or as David Kopel asked on the Volokh Conspiracy blog: "Is the tax power infinite?"

In a country that holds elections, that question is both legal and political. The political issue rumbling toward both the Supreme Court and the electorate is whether Washington's size and power has finally grown beyond the comfort zone of the American people. That is what lies beneath the chatter about federalism and the 10th Amendment.

Liberals will argue that government today is doing good. But government now is also unprecedentedly large and unprecedentedly expensive. Even if every challenge to ObamaCare loses in court, these anxieties will last and keep coming back to the same question: Does the Democratic left think the national government's powers are infinite?

No one in the Obama White House, asked that in public on Sunday morning, would simply say yes, no matter that the evidence of this government's actions the past year indicate they do. In his "Today Show" interview this week, Mr. Obama with his characteristic empathy acknowledged there are "folks who have legitimate concerns . . . that the federal government may be taking on too much."

My reading of the American public is that they have moved past "concerns." Somewhere inside the programmatic details of ObamaCare and the methods that the president, Speaker Pelosi and Sen. Reid used to pass it, something went terribly wrong. Just as something has gone terribly wrong inside the governments of states like California, New York, New Jersey, Michigan and Massachusetts.

The 10th Amendment tumult does not mean anyone is going to secede. It doesn't mean "nullification" is coming back. We are not going to refight the Civil War or the Voting Rights Act. Richard Russell isn't rising from his Georgia grave.

It means that the current edition of the Democratic Party has disconnected itself from the average American's sense of political modesty. The party's members and theorists now defend expanding government authority with the same arrogance that brought Progressive Era reforms down upon untethered industrial interests.

In such times, this country has an honored tradition of changing direction. That time may be arriving.

Faced with corporate writedowns in response to the reality of Congress's new health plan, an apoplectic Congressman Henry Waxman commanded his economic vassals to appear before him in Washington.

Faced with a challenge to his vision last week, President Obama laughingly replied to these people: "Go for it."

They will.

As to the condescension and sniffing left-wing elitism this opposition seems to bring forth from Manhattan media castles, one must say it does recall another, earlier ancient regime

The Truth About the Health Care Bill

2010-04-21T15:48:00.000-07:00

A retired Constitutional lawyer has read the entire proposed healthcare bill.Share
Today at 4:20pm

The Truth About the Health Care Bill
A retired Constitutional lawyer has read the entire proposed healthcare bill.Share
Today at 4:20pm

The Truth About the Health Care Bills - Michael Connelly, Ret.
Constitutional Attorney
Well, I have done it! I have read the entire text of proposed House Bill
3200: The Affordable Health Care Choices Act of 2009. I studied it with
particular emphasis from my area of expertise, constitutional law. I was
frankly concerned that parts of the proposed law that were being discussed
might be unconstitutional. What I found was far worse than what I had heard
or expected.

To begin with, much of what has been said about the law and its implications
is in fact true, despite what the Democrats and the media are saying. The
law does provide for rationing of health care, particularly where senior
citizens and other classes of citizens are involved, free health care for
illegal immigrants, free abortion services, and probably forced
participation in abortions by members of the medical profession.

The Bill will also eventually force private insurance companies out of
business, and put everyone into a government run system. All decisions
about personal health care will ultimately be made by federal bureaucrats,
and most of them will not be health care professionals. Hospital
admissions, payments to physicians, and allocations of necessary medical
devices will be strictly controlled by the government.

However, as scary as all of that is, it just scratches the surface. In
fact, I have concluded that this legislation really has no intention of
providing affordable health care choices. Instead it is a convenient cover
for the most massive transfer of power to the Executive Branch of government
that has ever occurred, or even been contemplated If this law or a similar
one is adopted, major portions of the Constitution of the United States will
effectively have been destroyed.

The first thing to go will be the masterfully crafted balance of power
between the Executive, Legislative, and Judicial branches of the U.S.
Government. The Congress will be transferring to the Obama Administration
authority in a number of different areas over the lives of the American
people, and the businesses they own.

The irony is that the Congress doesn't have any authority to legislate in
most of those areas to begin with! I defy anyone to read the text of the
U.S. Constitution and find any authority granted to the members of Congress
to regulate health care.

This legislation also provides for access, by the appointees of the Obama
administration, of all of your personal healthcare -- a direct violation of
the specific provisions of the 4th Amendment to the Constitution
information, your personal financial information, and the information of
your employer, physician, and hospital. All of this is a protection against
unreasonable searches and seizures. You can also forget about the right to
privacy. That will have been legislated into oblivion regardless of what
the 3rd and 4th Amendments may provide...

If you decide not to have healthcare insurance, or if you have private
insurance that is not deemed acceptable to the Health Choices Administrator
appointed by Obama, there will be a tax imposed on you. It is called a tax
instead of a fine because of the intent to avoid application of the due
process clause of the 5th Amendment. However, that doesn't work because
since there is nothing in the law that allows you to contest or appeal the
imposition of the tax, it is definitely depriving someone of property
without the due process of law.

So, there are three of those pesky amendments that the far left hate so
much, out the original ten in the Bill of Rights, that are effectively
nullified by this law It doesn't stop there though.

The 9th Amendment that provides: The enumeration in the Constitution, of
certain rights, shall not be construed to deny or disparage others retained
by the people;

The 10th Amendment states: The powers not delegated to the United States by
the Constitution, nor prohibited by it to the States, are preserved to the
States respectively, or to the people. Under the provisions of this piece
of Congressional handiwork neither the people nor the states are going to
have any rights or powers at all in many areas that once were theirs to
control.

I could write many more pages about this legislation, but I think you get
the idea. This is not about health care; it is about seizing power and
limiting rights... Article 6 of the Constitution requires the members of
both houses of Congress to "be bound by oath or affirmation to support the
Constitution." If I was a member of Congress I would not be able to vote for
this legislation or anything like it, without feeling I was violating that
sacred oath or affirmation. If I voted for it anyway, I would hope the
American people would hold me accountable.

For those who might doubt the nature of this threat, I suggest they consult
the source, the US Constitution, and Bill of Rights. There you can see
exactly what we are about to have taken from us.

Michael Connelly
Retired attorney,
Constitutional Law Instructor
Carrollton , Texas

ObamaCare will drive up costs, burden the healthy

2010-04-19T21:39:00.000-07:00

NYT: ObamaCare will drive up costs, burden the healthy
Posted on April 18, 2010 by Ed Morrissey

From the Hot Air Blog

Perhaps the New York Times needs to change its well-known motto to All the News That’s Fit to Print … Eventually. In today’s edition, buried in its Regional section, comes an analysis of the health-insurance reforms imposed by the state of New York over fifteen years ago. Like ObamaCare, the state required insurance carriers to issue policies to people with pre-existing conditions as a means of making the industry more “fair” and imposed community pricing rather than risk-based premiums.

How did that work for New Yorkers?

About the way ObamaCare critics predicted:

New York’s insurance system has been a working laboratory for the core provision of the new federal health care law — insurance even for those who are already sick and facing huge medical bills — and an expensive lesson in unplanned consequences. Premiums for individual and small group policies have risen so high that state officials and patients’ advocates say that New York’s extensive insurance safety net for people like Ms. Welles is falling apart.

The problem stems in part from the state’s high medical costs and in part from its stringent requirements for insurance companies in the individual and small group market. In 1993, motivated by stories of suffering AIDS patients, the state became one of the first to require insurers to extend individual or small group coverage to anyone with pre-existing illnesses.

New York also became one of the few states that require insurers within each region of the state to charge the same rates for the same benefits, regardless of whether people are old or young, male or female, smokers or nonsmokers, high risk or low risk.

Healthy people, in effect, began to subsidize people who needed more health care. The healthier customers soon discovered that the high premiums were not worth it and dropped out of the plans. The pool of insured people shrank to the point where many of them had high health care needs. Without healthier people to spread the risk, their premiums skyrocketed, a phenomenon known in the trade as the “adverse selection death spiral.”

In fact, that death spiral has nearly wiped out the individual market insurance industry in New York. The state has the highest annual premiums for individual-market policies at over $6600 for single-beneficiary comprehensive plans and about double that for families. The employer-based market has fared better, but mainly because employers subsidize insurance and so keep healthy people in the plans.
ObamaCare supporters will argue that the federal insurance mandate will solve this problem, even though the mandate in Massachusetts hasn’t kept costs in line.

Interestingly, the New York Times also sounds skeptical:

The new federal health care law tries to avoid the death spiral by requiring everyone to have insurance and penalizing those who do not, as well as offering subsidies to low-income customers. But analysts say that provision could prove meaningless if the government does not vigorously enforce the penalties, as insurance companies fear, or if too many people decide it is cheaper to pay the penalty and opt out.

Under the federal law, those who refuse coverage will have to pay an annual penalty of $695 per person, up to $2,085 per family, or 2.5 percent of their household income, whichever is greater. The penalty will be phased in from 2014 to 2016.
It doesn’t take much to do the math here. If one has to pay $6600 per year for a comprehensive policy one doesn’t really need or pay $2500 on a salary of $100,000, which one will healthy, younger earners take? That assumes, of course, that the government will actually enforce the mandate, which Democrats insisted the ObamaCare bill couldn’t do.

The rebuttal to this will be that most young, healthy people earn much less and will get federal subsidies, but that still depends on them deciding whether to pay anything out of pocket at all for a comprehensive policy that clearly doesn’t suit them. That argument neglects the fact that the actual costs will still skyrocket, but that taxpayers will be on the hook for the subsidies, which will have to increase to match the premium hikes to remain effective. Instead of just having premiums based on rational risk assessments, we have the young and healthy subsidizing premiums for the older and less healthy, who then subsidize the younger and healthier through federal handouts. It’s an insane feedback loop.

If nothing else, this proves a couple of points that critics have made all along. The mandates are nothing more than a way to get the young to create a proxy welfare state by forcing them into a usurious insurance model. It does nothing to reduce actual costs, and in fact makes cost increases both more likely and more amplified.

Finally, this problem has unfolded in New York for years. The premium problem in individual markets — the very kind that ObamaCare requires — were well known to the New York Times. They had almost a year to report this during the health-care debate before a vote was taken. Instead, they report it almost a month after Congress passed the bill, and stuck it in the Regional section where national readers might have missed it. Shameful.

Allen West Needs 1000 Patriots

2010-04-18T20:07:00.000-07:00

https://www.completecampaigns.com/public.asp?name=West&page=12

America's Constitutionalist Revolt

2010-04-16T17:52:00.000-07:00

America's Constitutionalist Revolt

Poll Finds Tea Party Anger Rooted in Issues of Class

2010-04-14T15:54:00.000-07:00

Poll Finds Tea Party Anger Rooted in Issues of Class

By KATE ZERNIKE and MEGAN THEE-BRENAN
Published: April 14, 2010

Tea party supporters are wealthier and more well-educated than the general public, tend to be Republican, white, male, and married, and their strong opposition to the Obama administration is more rooted in political ideology than anxiety about their personal economic situation, according to the latest New York Times/CBS News poll.

The 18 percent of Americans who identify themselves as Tea Party supporters look like Republicans in many ways, but they hold more conservative views on a range of issues and tend to be older than Republicans generally. They are also more likely than Republicans as a whole to describe themselves as “very conservative” and President Obama as “very liberal.”

And while most Republicans say they are “dissatisfied” with Washington, Tea Party supporters are more likely to classify themselves as “angry.”

Speculation and anecdotal evidence have often taken the place of concrete data about who supports the Tea Party movement, and the poll offers some surprising findings.
In some ways, Tea Party supporters look like the general public. For instance, despite their allusions to Revolutionary War-era tax protesters, most describe the amount they paid in taxes this year as “fair.” Most send their children to public schools, do not think Sarah Palin is qualified to be president, and, despite their push for smaller government, think that Social Security and Medicare are worth the cost. They are actually more likely than the general public to have returned their census forms, despite some conservative leaders urging a boycott.

Their fierce animosity toward Washington, and the president in particular, is rooted in deep pessimism about the direction of the country and the conviction that the policies of the Obama administration are disproportionately directed at helping the poor rather than the middle class or the rich.

The overwhelming majority of Tea Party supporters say Mr. Obama does not share the values most Americans live by, and that he does not understand the problems of people like themselves. More than half say the policies of the administration favor the poor, and 25 percent, compared with 11 percent of the general public, think that the administration favors blacks over whites. They are more likely than the general public, and Republicans, to say that too much has been made of the problems facing black people.

Asked what they are angry about, Tea Party supporters offered three main concerns: the recent health care overhaul, government spending, and a feeling that their opinions are not represented in Washington.

“The only way they will stop the spending is to have a revolt on their hands,” Elwin Thrasher, a 66-year-old semi-retired lawyer in Florida, said in an interview following the poll. “I’m sick and tired of them wasting money and doing what our founders never intended to be done with the federal government.”

They are far more pessimistic than Americans in general about the economy improving. More than 90 percent of Tea Party supporters think the country is headed in the wrong direction, compared with about 60 percent of the general public. About 6 in 10 say America’s best days are behind us when it comes to the availability of good jobs for American workers.

Nearly 9 in 10 disapprove of the job Mr. Obama is doing overall, and about the same percentage fault his handling on the specifics, too: health care, the economy, and the federal budget deficit. More than 8 in 10 hold an unfavorable view of him personally, and 92 percent believe he is moving the country toward socialism – an opinion shared by about half the general public. Tea Party supporters are also more likely than most Americans to believe, mistakenly, that the president has increased taxes for most Americans.

“I just feel he’s getting away from what America is,” said Kathy Mayhugh, 67, a retired medical transcriber in Jacksonville. “He’s a socialist. And to tell you the truth I think he’s a Muslim and trying to head us in that direction, I don’t care what he says. He’s been in office over a year and can’t find a church to go to. That doesn’t say much for him.”

The nationwide telephone poll was conducted April 5-12 with 1,580 adults. For the purposes of analysis, Tea Party supporters were oversampled, for a total of 881, and then weighted back to their proper proportion in the poll. The margin of sampling error is plus or minus three percentage points for both all adults and Tea Party supporters.

The Tea Party supporters are more likely than the general public to say their personal financial situation is good or very good. But like the general public, 55 percent are concerned that someone in their household will be out of a job in the next year. And more than two-thirds say the recession has been difficult or caused hardship and major life changes. Like most Americans, they think the most pressing problem facing the country today are the economy and jobs.

But while most Americans blame the Bush administration or Wall Street for the current state of the American economy, the greatest number of Tea Party supporters blamed Congress.

Still, while they overwhelmingly disapprove of Congress, 4 in 10 Tea Party supporters, like most Americans, approve of the job their own representative is doing.

They do not want a third party, and say they usually or almost always vote Republican. The percentage holding a favorable opinion of former president George W. Bush — at 57 percent — almost exactly matches the percentage in the general public that holds an unfavorable view.

Dee Close, a 47-year-old homemaker in Memphis, said she was worried about a “drift” in the country. “Over the last 3 or 4 years I’ve realized how immense that drift has been away from what made this country great,” she said. “I’m angry because I feel that those who are elected hijack the country once they are elected to positions of power.”

She blamed Americans for being apathetic. “Most people are not even aware of how gullible they are,” she said. “They’re not educated enough to know what’s going on.”
Yet while the Tea Party supporters are more conservative than Republicans on social issues, they do not want to focus on those issues: about 8 in 10 say that they are more concerned with economic issues.

When talking about the Tea Party movement, the largest number of respondents said that the goal should be reducing the size of government, more than cutting the budget deficit, or lowering taxes.

And nearly three quarters said they would prefer smaller government even if it means spending on domestic programs would be cut.

But in follow up interviews, people said did not want to cut Medicare or Social Security — the biggest domestic programs – suggesting instead a focus on “waste.”
“I do believe we are responsible for the widow and the orphan,” said Richard Gilbert, a 72 year old retired teacher. “But I think there is a welfare class that lives for having children and receiving payment from the government for having those children. They have no incentive to do any better because they have been conditioned into it.”

Others defended being on Social Security while fighting big government by saying they had paid into the system, so deserved the benefits.
Others could not explain the contradiction.

“I guess I want smaller government and my Social Security,” said Jodine White, 62, of Rocklin, Calif. “I didn’t look at it from the perspective of losing things I need. I think I’ve changed my mind.”

Support for repeal of health bill grows

2010-04-14T11:41:00.000-07:00

Support for repeal of health bill grows
From Marketwatch Blog

Support for repeal of controversial health-care legislation is growing, according to the latest poll from Rasmussen Reports.

The tracking service said Monday that 58% of those surveyed are in favor of revoking the measures recently passed by the House and Senate designed to reform health care, with 50% of voters strongly favoring repeal. The 58% figure is up from the 54% of voters favoring repeal a week ago, which remained unchanged from the week before that.

Those strongly opposing repeal dropped by the same margin, down to 38% from the 42% posted a week ago, Rasmussen says.

Rasmussen says support for repeal is growing among Republicans, as 88% of that party’s members are against it, along with 54% of unaffiliated voters. On the other side, 61% of Democrats are opposed to repeal. Republican support grew by eight points while Democratic opposition declined by seven points.

Among likely voters in this latest survey, though, only 38% think it is likely that the health-care bill will be repealed, and 18% say it is not at all likely. And over the weekend, Rasmussen reported that President Barack Obama has received a bit of a boost in his approval ratings.

Those who strongly approve of Obama’s job performance as the nation’s chief executive has grown to 31%, and that metric has hovered in the 28% to 34% range since passage of health reform, Rasmussen says. Prior to that, Obama got a “strongly approve” rating from 22% to 27% of those surveyed.

Still, those who “strongly disapprove” of Obama’s job performance is higher, at 42%, Rasmussen says.

Russ Britt, Los Angeles bureau chief

Medical Schools Can't Keep Up

2010-04-13T13:44:00.001-07:00

Medical Schools Can't Keep Up
As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years

By SUZANNE SATALINE And SHIRLEY S. WANG
From WSJ.com

First-year resident Dr. Rachel Seay, third from left, circumcises a newborn in George Washington University Hospital's delivery wing on March 12.
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.

Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.
The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.
A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.

Medicare pays $9.1 billion a year to teaching hospitals, which goes toward resident salaries and direct teaching costs, as well as the higher operating costs associated with teaching hospitals, which tend to see the sickest and most costly patients.
Doctors' groups and medical schools had hoped that the new health-care law, passed in March, would increase the number of funded residency slots, but such a provision didn't make it into the final bill.

"It will probably take 10 years to even make a dent into the number of doctors that we need out there," said Atul Grover, the AAMC's chief advocacy officer.
While doctors trained in other countries could theoretically help the primary-care shortage, they hit the same bottleneck with resident slots, because they must still complete a U.S. residency in order to get a license to practice medicine independently in the U.S. In the 2010 class of residents, some 13% of slots are filled by non-U.S. citizens who completed medical school outside the U.S.

One provision in the law attempts to address residencies. Since some residency slots go unfilled each year, the law will pool the funding for unused slots and redistribute it to other institutions, with the majority of these slots going to primary-care or general-surgery residencies. The slot redistribution, in effect, will create additional residencies, because previously unfilled positions will now be used, according to the Centers for Medicare and Medicaid Services.

Some efforts by educators are focused on boosting the number of primary-care doctors. The University of Arkansas for Medical Sciences anticipates the state will need 350 more primary-care doctors in the next five years. So it raised its class size by 24 students last year, beyond the 150 previous annual admissions.

In addition, the university opened a satellite medical campus in Fayetteville to give six third-year students additional clinical-training opportunities, said Richard Wheeler, executive associate dean for academic affairs. The school asks students to commit to entering rural medicine, and the school has 73 people in the program.

"We've tried to make sure the attitude of students going into primary care has changed," said Dr. Wheeler. "To make sure primary care is a respected specialty to go into."

Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine in New York, has 1,220 residency slots. Since the 1970s, Montefiore has encouraged residents to work a few days a week in community clinics in New York's Bronx borough, where about 64 Montefiore residents a year care for pregnant women, deliver children and provide vaccines. There has been a slight increase in the number of residents who ask to join the program, said Peter Selwyn, chairman of Montefiore's department of family and social medicine.

One is Justin Sanders, a 2007 graduate of the University of Vermont College of Medicine who is a second-year resident at Montefiore. In recent weeks, he has been caring for children he helped deliver. He said more doctors are needed in his area, but acknowledged that "primary-care residencies are not in the sexier end. A lot of these [specialty] fields are a lot sexier to students with high debt burdens."

Healthcare law to sock middle class with a $3.9 billion tax increase

2010-04-12T14:26:00.000-07:00

The Hill: Healthcare law to sock middle class with a $3.9 billion tax increase
Posted in: Latest News by admin on April 12, 2010

From The Hill:

Taxpayers earning less than $200,000 a year will pay roughly $3.9 billion more in taxes — in 2019 alone — because of healthcare reform, according to the Joint Committee on Taxation, Congress’ official scorekeeper for legislation.

The new law raises $15.2 billion over 10 years by limiting the medical expense deduction, a provision widely used by taxpayers who either have a serious illness or are older.

Taxpayers can currently deduct medical expenses in excess of 7.5 percent of their adjusted gross income. Starting in 2013, most taxpayers will only be allowed to deducted expenses greater than 10 percent of AGI. Older taxpayers are hit by this threshold increase in 2017

Once the law is fully implemented in 2019, the JCT estimates the deduction limitation will affect 14.8 million taxpayers — 14.7 million of them will earn less than $200,000 a year. These taxpayers are single and joint filers, as well as heads of households.

“Loss of this deduction will mean higher taxes for 14.7 million individuals and families making under $200,000 a year in 2019,” Sen. Chuck Grassley (R-Iowa) told The Hill. “The new subsidy for health insurance would not be available to offset this tax increase for most of these households.”

The healthcare law contains tax breaks for individuals purchasing health insurance, but phase out for those making $88,000 a year.

Grassley is the ranking member on the tax-writing Senate Finance Committee and voted against the health reform bill.

Couples earning less than $250,000 will also nicked by the tax, but the exact number is unclear. The JCT lumps this income level in with those making at least $500,000. Joint Tax estimates that 58,000 taxpayers earning between $200,000 and $500,000 annually will pay $74 million more in taxes in 2019.

About 5,000 taxpayers earning over $500,000 a year will pay $43 million more in tax because of the limitation.

…

President Obama in his Saturday radio address said the healthcare law keeps his campaign pledge to not raise taxes on the middle class. On the trail he promised individuals earning less than $200,000 and joint filers earning less than $250,000 would not see a tax increase under his watch

Hate speech, hypocrisy from AFL-CIO chief

2010-04-10T19:28:00.000-07:00

Hate speech, hypocrisy from AFL-CIO chief

Obamacare’s Consequence

2010-04-10T12:32:00.000-07:00

Obamacare’s Consequence
A tarnished presidency
BY Matthew Continetti
The Weekly Standard

April 5 - April 12, 2010, Vol. 15, No. 28
The liberal line is that President Obama has secured his place in history by signing into law the Patient Protection and Affordable Care Act of 2010. And secured it he has. Henceforth Obama will be remembered as the man who accelerated America’s mad dash toward bankruptcy. He will be remembered as the leader who promoted a culture of dependency. He will be remembered as the figure who sacrificed a dream of national unity upon the altar of big government liberalism. It’s true: Obama is now a president of consequence. And almost all of those consequences are bad.

The fiscal picture was bleak before Obama made it worse. Government debt is 60 percent of the gross domestic product and climbing. The deficit is projected to remain above 4 percent of GDP for the next decade. The week before the president signed his health care reform into law, Moody’s warned that America’s AAA bond rating may be downgraded. The day before the signing ceremony, the nation learned that Warren Buffett is a safer investment than U.S. treasuries. One needn’t look across the Atlantic, where a penniless Greece is a supplicant to the IMF, to see our future. Look to California, where the economy is crippled by high taxes, high spending, and burdensome debt.

President Obama is an intelligent man. He knew there was no way a massive entitlement could get through Congress when spending, deficit, and debt are major issues. So he claimed that health care reform would help ameliorate America’s fiscal problem, not exacerbate it. And for support he had the Congressional Budget Office (CBO), which found that, under a certain set of conditions—spending cuts, Medicare cuts, new taxes—health care reform would not only pay for itself but would reduce the deficit.

But what happens under real world conditions? What happens when the Medicare cuts and the excise tax disappear and the subsidies are more generous than expected? When Representative Paul Ryan of Wisconsin asked the CBO these questions, he was told the deficit would increase by a considerable margin. Which outcome is more likely: a Congress that cuts services, imposes taxes on favored constituencies, and refrains from spending? Or a Congress that goes instead on a fact-finding mission to Djibouti while making promises it cannot keep?

But balancing the books was never Obama’s primary goal. Equality was. For decades, liberals have decried America’s patchwork system of health insurance and have sought to provide coverage for all. But rather than deregulate health markets and provide consumers with the tools they need to spur competition, reduce prices, and promote innovation, liberals chose another path. They chose to increase regulation and make government the intermediary between taxpayer dollars and the insurance companies. Through the individual mandate, the Democrats have ordered every adult American to purchase a consumer product. And if an American cannot afford that product, government will subsidize him, thereby directing public money to private profit.

How long before the Democrats figure out that it would be cheaper for government to eliminate the middleman and become the insurer of first resort? Perhaps sooner than you think. (Some already have.) A portent is the student loan industry. Last week Congress, after years of subsidizing loans originating in private banks, decreed that all loans would now originate directly from the federal government. A narrow partisan majority effected the drastic policy change. This is the process by which markets shrink, choice is curtailed, and government dependency grows. It’s become commonplace.

What is most striking is the impact of health care on Obama’s presidency. Liberals are already touting his legislative victory as the catalyst for a domestic and foreign policy rebound. To the contrary: Obama is enfeebled. Health care reform has helped turn large swaths of independents against him. It has nullified the chance for bipartisan cooperation in this Congress. It has exposed him as weak: Despite 39 speeches on the topic, despite a huge investment of political capital, the health bill passed by a margin of five votes. Thirty-two Democrats defected. The public opposed this law.

Gone is the charismatic young man who told the 2004 Democratic National Convention in Boston that there was no Blue America and no Red America, only the United States of America. All that remains is a partisan liberal Democrat whose health care policy bulldozed public opinion, enraged the electorate, poisoned the Congress, and set into motion a sequence of events the outcome of which cannot be foreseen.

This tarnished White House complains incessantly about the crises it inherited from its predecessor. Crises? You ain’t seen nothing yet.

—Matthew Continetti

Is Health Care a Right?

2010-04-07T21:18:00.000-07:00

by Walter E. Williams

From Townhall.com

Most politicians, and probably most Americans, see health care as a right. Thus, whether a person has the means to pay for medical services or not, he is nonetheless entitled to them. Let's ask ourselves a few questions about this vision.

Say a person, let's call him Harry, suffers from diabetes and he has no means to pay a laboratory for blood work, a doctor for treatment and a pharmacy for medication. Does Harry have a right to XYZ lab's and Dr. Jones' services and a prescription from a pharmacist? And, if those services are not provided without charge, should Harry be able to call for criminal sanctions against those persons for violating his rights to health care?

You say, "Williams, that would come very close to slavery if one person had the right to force someone to serve him without pay." You're right. Suppose instead of Harry being able to force a lab, doctor and pharmacy to provide services without pay, Congress uses its taxing power to take a couple of hundred dollars out of the paycheck of some American to give to Harry so that he could pay the lab, doctor and pharmacist. Would there be any difference in principle, namely forcibly using one person to serve the purposes of another? There would be one important strategic difference, that of concealment. Most Americans, I would hope, would be offended by the notion of directly and visibly forcing one person to serve the purposes of another. Congress' use of the tax system to invisibly accomplish the same end is more palatable to the average American.

True rights, such as those in our Constitution, or those considered to be natural or human rights, exist simultaneously among people. That means exercise of a right by one person does not diminish those held by another. In other words, my rights to speech or travel impose no obligations on another except those of non-interference. If we apply ideas behind rights to health care to my rights to speech or travel, my free speech rights would require government-imposed obligations on others to provide me with an auditorium, television studio or radio station. My right to travel freely would require government-imposed obligations on others to provide me with airfare and hotel accommodations.

For Congress to guarantee a right to health care, or any other good or service, whether a person can afford it or not, it must diminish someone else's rights, namely their rights to their earnings. The reason is that Congress has no resources of its very own. Moreover, there is no Santa Claus, Easter Bunny or Tooth Fairy giving them those resources. The fact that government has no resources of its very own forces one to recognize that in order for government to give one American citizen a dollar, it must first, through intimidation, threats and coercion, confiscate that dollar from some other American. If one person has a right to something he did not earn, of necessity it requires that another person not have a right to something that he did earn.

To argue that people have a right that imposes obligations on another is an absurd concept. A better term for new-fangled rights to health care, decent housing and food is wishes. If we called them wishes, I would be in agreement with most other Americans for I, too, wish that everyone had adequate health care, decent housing and nutritious meals. However, if we called them human wishes, instead of human rights, there would be confusion and cognitive dissonance. The average American would cringe at the thought of government punishing one person because he refused to be pressed into making someone else's wish come true.

None of my argument is to argue against charity. Reaching into one's own pockets to assist his fellow man in need is praiseworthy and laudable. Reaching into someone else's pockets to do so is despicable and deserves condemnation.

Dr. Williams serves on the faculty of George Mason University as John M. Olin Distinguished Professor of Economics and is the author of More Liberty Means Less Government: Our Founders Knew This Well

This Just In: America No Longer 'Free' Country

2010-04-07T19:26:00.000-07:00

This Just In: America No Longer 'Free' Country
David Knowles Writer
AOL

(April 6) -- How free is "mostly free"?

The Heritage Foundation, a self-described conservative think tank that espouses a free-market, small-government ideology, today released its annual Index of Economic Freedom World Rankings. And by its metrics, America's status has dropped from "free" to "mostly free."

Ranking countries throughout the world in 10 categories, the index concludes that the United States is now the eighth most economically free nation, down two spots from last year. Hong Kong ranked No. 1, while North Korea, which was categorized as "repressed," took the bottom rung.

Only seven countries actually rated as "free" on the index, which was released in conjunction with The Wall Street Journal (owned by conservative media mogul Rupert Murdoch, owner of News Corp.).

The largest factor in the Heritage Foundation's demotion of the U.S. is the rise in government spending, especially under the Obama administration.

"The national government's role in the economy, already expanding under President George W. Bush, has grown sharply under the administration of President Barack Obama, who took office in January of 2009," the report read. "Economic growth, which collapsed in 2008, had resumed by the second half of 2009, but legislative proposals for large and expensive new government programs on health care and energy use (climate change) have increased prospects for significant economic disruptions and raised concerns about the long-term health of the economy."

Beating out the United States in terms of economic freedom were, in descending order: Hong Kong, Singapore, Australia, New Zealand, Ireland, Switzerland and Canada.

Organized Medicine Split Over Healthcare Reform Along Specialty Lines

2010-04-07T12:53:00.000-07:00

Robert Lowes
From Medscape

April 7, 2010 — The enactment of landmark healthcare reform last month shone a spotlight on deep divisions not only within Congress and the American public but also within organized medicine.

Where medical societies stood on the legislation largely hinged on the answer to the question "What's in it for me?" And the answer to that question depended on whether a given society represented surgical specialists or primary care physicians.

At first glance, the split may not be so apparent. The American Medical Association (AMA), often called "the house of medicine" because it purports to represent all physicians in all specialties, had given qualified support to the legislation. Its stance was a new leaf for an organization that had staunchly opposed major healthcare reform initiatives — think Medicare — going back for decades.

Other major medical societies that applauded the passage of reform legislation with varying degrees of enthusiasm include the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Cardiology, the American Psychiatric Association, and the American Osteopathic Association. By and large, these groups praised the law for extending insurance coverage to 32 million more Americans over 10 years and imposing pro-patient regulations on private insurers, who will no longer be able to deny someone a policy on the basis of preexisting conditions.

"We see this as a good platform for providing people with quality, affordable healthcare," American Academy of Family Physicians President Lori Heim, MD, told Medscape Medical News.

However, the primary care hue of most of these pro-reform groups is telling. Surgeons, by and large, had urged the House to vote down the healthcare legislation that it ultimately approved on March 21. A coalition of 23 medical societies representing 240,000 surgeons and anesthesiologists sent a letter to House Speaker Nancy Pelosi (D-CA) shortly before the vote, stating that the bill failed to build a solid foundation for reform. Signatories included the American College of Surgeons, the American Congress of Obstetricians and Gynecologists, the American Association of Orthopaedic Surgeons, and the American Urological Association.

Some of the major discontents of this coalition were shared by the AMA and other societies that had rallied behind the legislation. The absence of a repeal of the notorious sustainable growth rate formula, which led to a 21.2% Medicare pay cut on April 1, ranked high on the list, as did the creation of an Independent Payment Advisory Board for Medicare that critics consider unaccountable for its decisions. Other gripes were the lack of any major tort reform, such as caps on pain-and-suffering damages in malpractice cases, and penalties for physicians who do not participate in Medicare's Physician Quality Reporting Initiative.

Although the AMA and its allies vowed to work with Congress to correct these sins of omission and commission, the surgical societies concluded that the cons of healthcare reform outweighed the pros, and lobbied against the legislation.

Bonus for Primary Care Physicians, But Not for Most Surgeons

Medical societies representing primary care physicians tended to support healthcare reform more than their surgical counterparts because they stood to gain more from it, experts say.

"There were many things to help primary care physicians, and not very many things to help surgeons," said Kristen Hedstrom, assistant director of legislative affairs for the American College of Surgeons. It is not as if surgeons didn't want to give an economic break to beleaguered internists, family physicians, and pediatricians, Hedstrom explained. Surgeons just wanted a break for themselves as well.

For one thing, the new law attempts to expand a short-handed primary care workforce, which will be further strained by millions of newly insured patients. It pumps more money into scholarships and loan repayment programs for medical students headed into primary care fields, increases the number of residency-training slots for them, and provides economic incentives to practice in underserved areas.

In addition to those carrots, there is a 10% Medicare bonus for primary care physicians and general surgeons in medically underserved areas from 2011 to 2015. However, there is no 10% bonus for an orthopaedic surgeon in suburban Chicago or a urologist in Seattle. Likewise, general internists, pediatricians, and family physicians will see their Medicaid reimbursement rise to Medicare levels in 2013 and 2014 for evaluation and management services and vaccine administration.

"That's a very significant increase," Princeton University healthcare economist Uwe Reinhardt, PhD, told Medscape Medical News. "This bill is friendly to primary care physicians, who have always felt underpaid."

Surgeons Stand to Face Pay Cuts in the Long Term

Other reimbursement advantages accruing to primary care physicians are more subtle than a mere pay hike, said Paul Ginsburg, PhD, president of the Center for Studying Health System Change. The reform law, for example, promotes the medical-home practice model in which a primary care physician receives extra money for coordinating a patient's care.

Another new reimbursement model in the law is the accountable care organization (ACO). The Medicare Payment Advisory Commission defines an ACO as an alliance of primary care and specialist physicians and at least 1 hospital that assumes joint responsibility for meeting performance measures for quality and cost. The new law allows ACOs to share in any cost savings they achieved in treating Medicare patients. Again, a key idea here is coordinated care.

In an ACO, said Dr. Ginsburg, "primary care physicians probably see themselves as becoming a more critical part of the delivery system." As such, they would reprise the central role they played in the heyday of managed care in the early to mid-1990s, "which really enhanced the income of primary care doctors," Dr. Ginsburg said. And by effectively managing chronic diseases like diabetes and hypertension, he said, ACOs can reduce hospitalizations and surgeries, which bodes ill for surgeon income.

To be sure, the new healthcare reform law gives some consideration to what surgeons earn. It's written so that the Medicare bonus for primary care physicians will not be funded by trimming pay for other specialties. However, in the long-term, the handwriting on the wall is reduced reimbursement for surgeons, noted Dr. Reinhardt.
"They know ultimately that their fees will be cut," he said.

The conflicting positions that primary care and surgical societies took on healthcare reform reflect a long-standing rift over these kind of reimbursement issues, said cardiologist Thomas Sullivan, MD, a former president of the Massachusetts Medical Society.

"It's an old battle between procedurally oriented and cognitively oriented physicians, and it's heating up, partly because the government recognizes there's a major shortage of primary care physicians," said Dr. Sullivan. "Surgeons are afraid that primary care will be promoted at their expense."

State Medical Societies Parted Ways Over Reform Legislation

The division in organized medicine over healthcare reform also expressed itself on a state level for reasons that went beyond specialty squabbles. Some state medical societies such as those in Minnesota, Pennsylvania, Massachusetts, and California took a cue from the AMA and hailed the bill's passage as a good first step, or progress, despite its shortcomings.

"It is difficult for the Pennsylvania Medical Society to speak either glowingly or disparaging of the health system reform package," society president James Goodyear, MD, stated in a press release.
Mario Motta, MD, president of the Massachusetts Medical Society, was a bit more positive.

"Even though the bill is far from perfect, our country is much better off with the legislation than without it," Dr. Motta said.

In contrast, at least 10 state medical societies — those in Alabama, Delaware, Florida, Georgia, Kansas, New Jersey, Oklahoma, South Carolina, Tennessee, and Texas — went on record as opposing the bill. The reasons are well summarized in a statement from William Fleming III, MD, the president of the Texas Medical Association.

"[Congress] passed a bill that does nothing to fix glaring problems in our current healthcare system," stated Dr. Fleming. "Instead, it saddles Texans with higher costs, higher taxes, more red tape and more bureaucracy. We believe the bill's unaffordable health system reforms, piled on top of a crumbling Medicare foundation, will create even more dire consequences for all."

Whether a state was politically red or blue appeared to have some bearing on which way its medical society went. President Barack Obama carried California, Massachusetts, Minnesota, and Pennsylvania in 2008, for example, and the medical societies in those blue states also leaned toward the healthcare reform law. Medical societies that came out against "Obamacare" tended to be in states won by Sen. John McCain (R-AZ). Texas and Georgia were prime red examples. However, organized medicine in the blue states of Florida, New Jersey, and Delaware broke this political pattern by siding with reform opponents.

To Dr. Sullivan, how state medical societies lined up on this historic reordering of the healthcare system reflected the inherent diversity in the profession.
"We're like the rest of the United States, and Congress," he said.

Obama's bait-and-switch campaign

2010-04-06T14:03:00.000-07:00

Obama's bait-and-switch campaign
By: Norm Coleman
April 6, 2010 05:00 AM EDT

One telling moment in the 18-month health care debate was at the White House summit. Sen. John McCain (R-Ariz.) reminded President Barack Obama of his campaign promises to "bring us together" on health care.

"We're not campaigning anymore," the president said. "The election is over." The next question should have been, "Does that mean your campaign promises are null and void?"

Enough time has passed, and enough actions have been seen, to conclude that Obama ran as one kind of president but is governing as a very different one.

What the American people want is the kind of president Obama sold them: a post-partisan consensus builder.

They are justifiably angry at the massive bait-and-switch on health care reform, the most important public policy debate in our lifetime. Obama has violated their trust, which is especially devastating with the long list of challenges we need unity for to tackle, like jobs, energy and the deficit.

Health care is an emotional issue for everyone. In my years in government, I learned that the deeper an issue, the more carefully leaders have to listen — and the greater the need for consensus building rather than using raw political power.

Obama promised to expand health care coverage by 32 million people and add not one dime to the deficit. He promised Americans who wanted to keep their coverage that the government would leave it alone.

He promised the bill would help the economy and grow jobs when millions of unemployed Americans are looking for hope.

He promised not to add to states' debts.

But those promises won't come true.

The law will not pay for itself. In a New York Times op-ed piece, former Congressional Budget Office head and American Action Forum President Douglas Holtz-Eakin estimated it could put the country about $560 billion in the hole.

The law could cost jobs, hurt economic growth and hamper innovation. Verizon, AT&T, Caterpillar, John Deere, 3M and other companies have filed SEC reports saying that this bill will cost them a combined $10 billion.

Beacon Hill Institute, the fiscally conservative economic research group of Boston's Suffolk University, estimates 700,000 jobs will be lost, as small and medium-sized businesses try to provide health care for their employees.

The law does not allow seniors to keep the insurance they have. By 2019, 4.8 million seniors will be squeezed out of Medicare Advantage.

The law does not help states with the high cost of health care. It makes the states' budget situations worse. By 2014, states will be required to pay 50 percent of the administrative costs that come with expanding Medicaid.

This law will not let the middle class keep its plans. The CBO projects that by 2016, the basic plan, covering only 70 percent of a family's medical expenses, will cost $14,100 a year. Families making $88,000 or more won't qualify for the government subsidies.

This means a family making $100,000 could spend as much as one-fifth of annual income to keep private insurance.

Everybody understands that the status quo on health care was not acceptable.

This issue cried out for a bipartisan approach. We should have worked together and done things differently.

In fact, Obama promised during the campaign that he would do things differently — with change we could all believe in.

The American people believed that he would change how Washington does business — that he would seek consensus, that he would genuinely listen to the other side, find the best ideas and move forward in such a way as to unify the country.

But he didn't. Instead, he decided to jam legislation down the throats of the American people. Poll after poll shows that a majority of the people do not support this law.

They don't like the cost. They don't like what they believe will be its impact on their personal health insurance.

Most of all, they don't like the process. They don't like the backroom deals. They don't like the arm-twisting. They don't like the exercise of raw power that shows that the politicians are not listening to them.

And it is not just on health care. On issue after issue, Obama campaigned one way and is governing in a different way.

He said he would fight waste, but he signed a pork-filled stimulus bill. He said he would cut taxes on the middle class, but they face tax increases with health care reform. He said he would be Israel's strongest supporter, but we all now know that isn't true.

He said he would unify the country. But the country is more polarized than ever.

The president took great pride in signing this health care law. But that won't help him with the American people.

He is not living up to his promises. This law does not live up to its promise.

We can do better. The president is right: We aren't campaigning anymore.

But it is obvious that Obama the campaigner was more compelling than Obama the president — who looks to be a rather conventional liberal politician.

Norm Coleman, who served as a Republican senator from Minnesota, is chief executive officer of the American Action Network.

The Separation of Health and State

2010-04-06T09:15:00.000-07:00

From the WSJ, April 6, 2010

What happens when all medical decisions are political.

Now that U.S. health care has been annexed by Washington, every medical question will soon become a political question too, and the British elections are foreshadowing what that will mean in practice. Over the weekend, David Cameron and the Conservatives promised that if they win in May they'll devote £1 billion to ensuring that National Health Service patients have access to cutting-edge cancer treatments.

The Tories say the £200 million annual fund will pay for drugs that have been prohibited or controlled by Britain's rationing bureaucracies, and give physicians more latitude in deciding which drugs to prescribe, especially for rare cancers and orphan diseases. Cancer survival rates in Britain lag behind the rest of Europe, and especially the U.S., but the Tory proposal is, believe it or not, controversial.
The Labour government says the plan is unaffordable. Meanwhile, "It's wrong to recommend the use of treatments where the additional benefit is uncertain," Andrew Dillon told the Guardian. "This is misleading for patients and wastes scarce NHS resources."

Sir Andrew leads the National Institute for Health and Clinical Excellence, or NICE, the body that makes hard-and-fast decisions about which patients will benefit from which treatments, and which lives are cost-effective to save or improve amid a tight budget. Recent NICE rejections include the bone-marrow drug Vidaza, multicancer drug Avastin, and Tyverb for breast cancer. Sutent, a breakthrough treatment for kidney cancer, was only approved after a campaign by doctors, against NICE's supposedly better judgment.

One of ObamaCare's core promises is that American technocrats will also use medical evidence to control health spending, but the British experience neatly illustrates the inevitable outcome. In the medical journal Lancet Oncology in 2008, researchers produced the first direct world-wide comparison of five-year survival rates for breast, colorectal and prostate cancers. The U.S. had the highest survival rate for breast cancer at 83.9% and prostate cancer at 91.9%—compared to the U.K.'s respective 69.7% and 51.1%.

While the data are from the 1990s, and British outcomes have since improved somewhat, the authors conclude that "Most of the wide global range in survival is probably attributable to differences in access to diagnostic and treatment services." In other words, advanced tests and drug treatments result in better outcomes.

That kind of innovative health care is costly, and the inescapable logic of a health system dominated by government is that it always ends up with some version of NICE. Scarcity forces choices, which have long been especially severe in Britain where austerity medicine is the norm. Mr. Cameron deserves credit for trying to ameliorate the worst excesses of a system that pits the terminally ill against, say, strep throat.

The open-ended style of American care has the problem of rapidly growing costs, but as the British spectacle shows it is extremely difficult to reverse a command medical economy once it is entrenched, even when the results are morally appalling. The far better option is to extricate politics and give patients more control, which starts by rolling back ObamaCare.

Bush Deficit vs Obama Deficit: Obama Budget Insane? » Right Pundits

2010-04-05T20:55:00.000-07:00

Bush Deficit vs Obama Deficit: Obama Budget Insane? » Right Pundits

snopes.com: Dennis Guthrie Letter to Nancy Pelosi

2010-04-05T17:29:00.001-07:00

snopes.com: Dennis Guthrie Letter to Nancy Pelosi

Posted using ShareThis

The Process of Passing Health Bill Shameful

2010-04-05T13:35:00.000-07:00

The Process of Passing Health Bill Shameful
By Jon Barela
Republican Candidate for Congress

To hear Rep. Martin Heinrich tell the story, as he did in an op-ed for the Albuquerque Journal last week, the majority of New Mexicans and Americans who disagree with the recently-passed 2,500 page health care bill are simply scared of change. He's not giving his constituents just credit, is he?

While I respect Mr. Heinrich and his office, I have a fundamentally different point of view of how to reform health care and reject such a "government knows best" attitude. The bill will increase the cost and decrease the quality of health care in the United States, and it was passed using a thoroughly non-transparent process by representatives who appear to be woefully out of touch with our greatest needs and concerns.

This health care legislation, with a price tag between $940 billion and $2.5 trillion, reflects the misguided priorities that are dominating Washington today. The bill contains a whopping $569 billion in job-killing tax increases and creates a new marriage penalty with new income and investment taxes. It cuts Medicare by approximately $500 billion, a significant portion coming from the Medicare Advantage program.

Worse yet, this bill will lead to a massive bureaucratic expansion that will require the IRS to hire more than 16,000 additional employees just to enforce all the new taxes and penalties in the plan. If it concerns you that the IRS will now be in the thick of personal health care decisions, you are certainly in good company.

Sadly, during the last year, more than 2.5 million American jobs were lost — nearly 7,600 jobs per day — while politicians in Congress spent their time trying to ram through this unpopular piece of legislation. Americans have been quite clear that creating jobs, reducing the national debt and cutting wasteful spending are their top priorities, yet this legislation levies large tax increases on job-creators, raises insurance premiums for American families and heaps greater debt onto the shoulders of our children. When all the spending is done and the bill fully implemented, 23 million people still will be uninsured in 2019.

Just as importantly, the process used by Nancy Pelosi and Harry Reid to pass this bill did not represent American democracy well. It wasn't bipartisan, it wasn't inclusive, it wasn't honest and it wasn't transparent. Instead, it was reckless, distorted and thoroughly undemocratic, and it's no wonder Americans are feeling ignored, angry and shunned.

They pulled out every legislative trick and scheme in the book, with the unfortunate highlight being their consideration of the so-called "Slaughter Solution," where representatives considered trying to pass the bill without actually having to vote for it. Nothing projects courage, confidence, or reassurance quite like that.

Combined with the closed-door, back-room meetings, where sweetheart deals were struck with taxpayer money, along with the efforts to shut down debate and exclude dissenting viewpoints, there is no amount of perfume that Martin Heinrich can spray on this odorous process to mask its stench.Even Pelosi stated, "We have to pass the bill so that you can find out what is in it."

Unlike those who have served the 1st Congressional District in the past, I am convinced that Martin Heinrich lacks the independence necessary to represent New Mexico families well. At every turn, he supported the policy prescriptions of Speaker Pelosi, proving himself to be at the left fringe of his own party by so vocally supporting a robust "public option" that was completely out of the mainstream, was rejected by most of his Democrat colleagues in Washington, and would have further dismantled our free enterprise system.

There is a better way to offer high quality, affordable health care in America, and it begins by discussing proposals that could win bipartisan approval, as well as the support of states, small businesses, and American families. Among other things, these include allowing for the sale of health insurance across state lines, encouraging small businesses to pool together to compete for lower insurance rates for their workers, significant tort reform to reduce the waste that is generated by junk lawsuits and defensive medical practices, and providing tax credits to individuals to use in health savings accounts.

New Mexicans and Americans are not ignorant about what has unfolded in Congress over the past year. They are not scared or confused by what is or is not in this bill, as Martin Heinrich suggests. Instead, they are rightfully concerned that their voices and thoughts were never heard or appreciated, and a bill was passed over their strong objections through a process that was devious and shameful.

It's time for a heavy dose of accountability in Washington.

KING: 100 percent repeal of Obamacare

2010-04-05T12:34:00.000-07:00

KING: 100 percent repeal of Obamacare

Nothing less can prevent American decline

By Rep. Steve King

President Obama, speaking at a rally in Iowa City on March 25, challenged opponents of Obamacare who have vowed repeal. To repeal advocates, the President said, "Go for it."

Before the first light of dawn on the morning after this Pelosi Congress sent Obamacare to the President's desk, I started the process to repeal.My decision to take this fight to and through the next election and probably through the presidential election in 2012 was not a knee jerk response to a legislative defeat.It is a commitment to the Constitution, fiscal responsibility, real health care reform and American Liberty.

President Obama, Speaker Pelosi and Majority Leader Reid - the troika that controls America today - have long had designs to shove America into the abyss of socialism. Their philosophy, political power and cynical effort to expand the dependency class all lined up to make Obamacare the law of the land. The highest price every generation of Americans will pay is not measured in dollars but in lost liberty.

America is a unique nation with unmatched vitality. The rights and liberties which transformed the "Dream" into the reality of American Exceptionalism are written on our hearts. We have a vitality that is unmatched because we have skimmed the cream of the crop off every donor civilization.

Millions have flocked to America because of the promise of liberty. They have joined natural born Americans to form the most vigorous culture on the planet. Every preceding generation has had the freedom to succeed and the freedom to fail.

Obamacare is a reversal of the formula that has produced the world's unchallenged greatest nation. For these reasons, 100 percent of Obamacare must be repealed.
With the massive costs of Obamacare, we cannot hope to pay our debts in our lifetimes or our children's. Under Obamacare, costs will go up and quality will go down. Under Obamacare, we must go all the way to the Supreme Court to reestablish the Constitution as a pact limiting the reach of the federal government.

However, all of the aforementioned will not crush our national spirit like the oppressive weight of mandated dependency. Obamacare takes away the American right to manage our own lives.

The rights to "life, liberty and pursuit of happiness" are prioritized rights. No one has the right to kill in the name of liberty just as no one has the right to take your liberty in pursuit of their happiness. Obamacare is a "taking" of our liberty.

We the People understand this intuitively and reject this injustice which will, if not repealed, bring about the American decline. We cannot "hide the decline" or "manage the decline." We must decline the decline by repealing 100 percent of Obamacare.

Every provision of Obamacare must be repealed - not selective parts of it. Not by preserving a short list of less egregious components. Obamacare must be ripped out completely, lock, stock and barrel - root and branch - no vestige left behind - not a DNA particle of Obamacare retained.

The toxic stew of Obamacare would taint every effort to reform and give the next generation of leftist politicians their talking points for another assault on our liberty. Republicans will either stand unanimously together for 100 percent repeal, as we did against the bill, or our ranks will be split and our effort defeated.
The voracious appetite of the leftists to consume American Liberty has spontaneously created a new class of activists whom I define as the "constitutional conservatives." They are the 9-12 Project groups, all the Tea Party groups, and the organizations who join in their efforts.

Constitutional conservatives are emerging as the new majority makers and will not support a partial repeal. They stood in the streets, town halls and capitols of our states and nation to "Kill the bill."

No one demonstrated to "kill the most egregious aspects" or "preserve the least egregious aspects" of Obamacare. This is an all or nothing fight from this point forward. Either we will be unified, energized and resolute for 100 percent repeal or we will be divided and deservedly conquered by Obama, Pelosi and Reid.

This is a life or death struggle for the soul of America. We are the redoubt of Western Civilization. It is our charge to set the standard for the world.

From an upstart nation formed on the profound belief that all men are "endowed by their Creator with certain unalienable Rights" we have, over the past century assumed "among the Powers of the Earth," the responsibility of sole superpower. We have defeated our enemies and saved Western civilization for the world.

We are not a nation created to mimic mediocrity. Our charge is to take this nation upwards to a new level of liberty and prosperity built upon the pillars of american exceptionalism.

Congressman Steve King is on the House Judiciary Committee and represents Iowa's Fifth Congressional District.

HEALTH CARE CUTS PROFITS AND JOB CREATION

2010-04-05T12:02:00.000-07:00

By Jeremy

Blog: Common Sense Capitalism

In the few short weeks since the passage of the Obama Healthcare Bill, corporations have had to disclose that they will take earnings losses as a result of tax credit reversals under previous healthcare laws. Well, the Obama Administration sounded off to suggest that these write-downs were a vast CEO conspiracy to make a political point, even going as far as calling the write-downs “BS.”

I find it very humorous that these companies are actually following SEC and government regulations to disclose any knowledge of changes in earnings and are being called manipulators by the very people who defend the regulations. What else is there for these companies to do?

Now that we’ve got that “BS” out of the way, let’s focus on the losses these corporations are taking on ObamaCare.

AT&T has announced that ObamaCare will cost it $1 billion.

Caterpillar says ObamaCare will cost $100 million in the first year alone.

John Deere announced ObamaCare will cost them $150 million.
3M ($90 million), AK Steel ($31 million), and Valero Energy ($20 million) announced their ObamaCare costs.

Honeywell announced ObamaCare will cost its company $100 million.

Verizon released an email to employees advising them of an increase in healthcare costs.

Boeing ($150 mil), Prudential ($100 mil), ITW ($22 mil), Goodrich ($10 mil),

Allegheny Tech ($8 mil) have each announced their ObamaCare costs.

So what does this mean for jobs? I believe that each job created costs about $100,000 in salary, taxes, and benefits costs. So, how much are these write-downs when it comes to jobs?

If we take the above (and include Verizon as 0 since we don’t have an estimate yet), we get a total of $1,781,000,000 ($1.781 billion) in write-downs. Divided by the $100,000 in per job costs, we get 17,810 jobs.

While these are non-cash write-downs, they still exemplify real losses in earnings that have to be reported to the investment community. So, if you own stocks, mutual funds, a 401k, a Roth IRA, or any other type of public equity investment, your portfolio could take a hit when earnings of companies are released (especially if real ObamaCare losses are higher than estimates). This includes the above companies and any companies who decide to wait until they announce earnings to disclose ObamaCare related costs.

The above company’s disclosures of ObamaCare related costs immediately as opposed to an earnings announcement should have a short-term effect on the markets. However, if ObamaCare costs continue to be disclosed several months down the road, the market and your portfolio could suffer.

Keep an eye on our new page entitled “ObamaCare Costs” to keep up to date on ObamaCare related costs and the number of jobs those earnings are translated into. Please use our Facebook fan page to disclose any new ObamaCare costs.

Spring forecast: Incivility with a chance of rage

2010-04-04T22:14:00.000-07:00

From Politico
By: David Catanese
April 4, 2010 06:12 PM EDT

MANCHESTER, N.H. – If the experience of this state’s two Democratic House members is any indication, the raw emotion and mistrust emanating from last summer’s congressional town halls never really went away.

Instead, the unrest simmered over the ensuing months only to return to a boil when Rep. Carol Shea-Porter and Rep. Paul Hodes, who is running for U.S. Senate, returned home to meet with their constituents here during the first week of the Easter recess.

Their public events provided a bracing reminder to Democrats that the political pivot from health care to economic and financial issues is going to be much more arduous than they expected.

At a senior center in Manchester Wednesday, one woman turned away when Hodes offered his outstretched hand for an introduction.

"I don't want to shake your hand. You voted for health care, so just go," snapped Carmen Guimond, as she refocused on her lunch of roast beef and mashed potatoes and waved him on.

When Hodes decided to stay at the table and launch a defense of what's considered to be one of the more popular provisions of the law — closing the "donut hole," a gap in prescription drug coverage for Medicare recipients — she challenged whether he had read the entire bill and dismissed his explanation.

"Two hundred and forty dollars in the first year. That's all it is," she said, referring to the initial subsidy. "That's not much."

"And over time, by 2020, it closes the donut hole," Hodes explained.

"We'll all be dead by then," she deadpanned.

While the new landmark health care reform law is driving much of the hostility, in a handful of events here in the week after passage, voters expressed profound cynicism and suspicion not just about the legislation, but about Washington, government and virtually everything that came out of their legislators’ mouths.

A man who did not want to be identified said he pulled Hodes aside at the Manchester event to ask him why he wasn’t wearing a wedding ring. The congressman told him he’s allergic to gold. His constituent remained skeptical.

“It’s a satisfactory answer, but I don’t know if it’s true,” the man said afterward, citing “all the improprieties out there” as the reason he inquired.

For her part, at back-to-back town hall meetings in Bedford and Merrimack, Shea-Porter faced consistent boos, heckles and catcalls after almost every point she rattled off in defense of her vote.

Despite an effort to accommodate questions from the raucous crowds with a ticketed lottery system and a two-minute time limit for speakers, the congresswoman got little credit from the audience. If anything, it gave her opponents fresh ammunition.

"Why can't we ask a question?" yelled one man, objecting to a format that randomly selected numbers out of a tub of tickets to choose questioners.

"Are you a princess or a representative?" chastised another woman.

Yet another man was miffed that he received a form letter from her office in response to six specific questions he sent to her by mail.

"I expect a reply. I heard a position statement that did not answer any of my questions," complained Ben Niles of Merrimack.

Shea-Porter had her defenders too, and they were uncowed. When one heckler mentions polling against health care reform, he was greeted with, “That’s Sarah Palin’s death panel lies!”

Another supporter of the congresswoman responded to a comment with, "What, are you employed by some insurance company? Shut up!"

The raw emotion expressed at the public events—on both sides—left both Shea-Porter and Hodes seemingly resigned to the fact that that act of defending, or heralding, their health care vote will continue to occupy much of their time for the near future.

Hodes said he’s happy to answer the questions and is convinced that the majority of voters don’t have their heels dug in against the bill.

"If two out of twelve people have their minds fixed, that's about the ratio that I would expect. I think now that we have a bill and we're able to talk about what's in it and we're able to give people some very clear information about what's in it,” Hodes told POLITICO.

"Over these next few months, you're going to see growing acceptance of the legislation, growing appreciation for what the legislation does and an open mindedness to the benefits that the legislation will bring," he added.

Kathy Sullivan, a former state Democratic Party chair, said a groundswell of cynicism is to be expected when most of the attention and media coverage thus far has focused on a convoluted process and the colorful opposition.

“All we knew was that this behemoth was coming and that it was going to cost a fortune, and there were a lot of people upset about it. It wasn’t until the bill passed that you started seeing stories about what the bill actually did,” she said. “Cover kids on their parents plans until 26? Excellent! Takes away the companies power to deny pre-existing conditions? Great. Where is the communist stuff, and where is the stuff about the death panels now? It doesn’t exist.”

One question, though, is whether the unseemly horse-trading that to many voters seemed to characterize the process has tainted the final product—and voters’ trust of Congress.

When Shea-Porter referred the health care legislation at one event as a bipartisan effort and noted 200 amendments by Republicans, several in the audience jeered, "What a joke! You have got to be kidding me!"

When she said there was growing support for the legislation, even within her congressional district, a heckler taunted her, yelling, "How are your polls doing, Carol?" Another shouted, "That's a lie! That's a Pelosi line!"

Her statement that "the bill is paid for" led to a hearty round of laughs that made it seem like she had delivered a joke.

Of the 12 questioners who got a chance to speak inside the Bedford High School cafeteria, nine made it clear they flatly opposed the new law. Shea-Porter acknowledged there was strong opposition.

"We are in a swing district. It's split down the middle. This district really is a divided district on this issue," she said at Merrimack Middle School, adding that her support for health care expansion shouldn't have been a surprise to anyone who followed her 2006 campaign.

When she told the crowd the obvious -- that they had the chance to oust her in seven months -- the notion prompted claps and a promise from one man who thundered, "And we will."

New health care law: What does it mean for you?

2010-04-04T13:35:00.000-07:00

By Elizabeth Simpson
The Virginian-Pilot
© April 4, 2010

Jane Prinz has been known to split her prescription pills in half just to afford her medications, so she has paid close attention to the national debate over health care.
Will the new law signed by President Barack Obama last month help the 41-year-old Virginia Beach woman?

She's still not sure. Pills aren't the only thing hard to divide.
"It's hard to divide the actual facts from all the rhetoric," said Prinz, who has a neurological disorder.

It's a view shared by many.

There are numerous unanswered questions as the 2,000-plus pages of law get transformed into even more pages of regulation. The region's patients, doctors and hospitals await the details and consequences, both good and bad.

Roughly 1 million Virginians are uninsured. According to the Virginia Health Care Foundation, it's expected that under the new law about one-third will be newly eligible for Medicaid, the shared federal and state insurance for the poor and disabled. An additional 17 percent of the state's uninsured fall between ages 18 and 24, and they could be added to their parents' insurance. And 700,000 are expected to qualify for insurance subsidies, according to the Commonwealth Institute for Fiscal Analysis.

The law will have consequences for the insured as well, and Prinz falls into two critical categories.

She's a member of a Medicare Advantage plan, an insurance program that the new law targets for cuts. That's a move that some insurance experts say will either reduce benefits or increase premiums with the privately managed plans.

Prinz also is in a category of people that the law is expected to help: Medicare recipients who fall into the so-called "doughnut hole." That's a gap in prescription drug coverage that begins when about $2,800 is spent on drugs.
Prinz hit the doughnut hole last year in March, and she's bumping up against it this year as well.

The new law would provide a $250 rebate this year and give her discounts on name-brand drugs beginning in 2011. The gap will start closing next year, a process that will be complete in 2020.

"It's a start, but it's a weak start," Prinz said. "What am I supposed to do for the next 10 years?"

Because Virginia's current eligibility for Medicaid is one of the most restrictive in the country, the state is expected to pick up more new Medicaid patients - 350,000, by one estimate - than many states. Childless, non-elderly adults in Virginia will be eligible for the first time in 2014.

The gateway for the newly insured will be family-practice doctors, many of whom are already swamped.

"This will unveil the shortage of primary-care physicians," said Dr. Christine Matson, chairwoman of family and community medicine at Eastern Virginia Medical School.

Doctor reimbursements for Medicaid patients are less than those for private insurance and Medicare, the federal insurance for the elderly and some disabled people. The health care law will increase Medicaid reimbursements in 2013 and 2014 to bring them in line with Medicare.

Still, many doctors limit their acceptance of that government insurance, too.
Dr. Cynthia Romero, a family-practice doctor in Virginia Beach, said some of her new Medicare patients tell her it took months to find a doctor who would accept their insurance. "I think we'll be bombarded by the volume of new patients looking for care," she said.

Dr. Daniel Carey, president of the Medical Society of Virginia, said the General Assembly made cuts to the Medicaid reimbursement rates in the most recent budget, and that's expected to reduce the number of doctors willing to accept new Medicaid patients.

He said the new law failed to address what doctors see as a flawed Medicare and Medicaid reimbursement formula. As long as doctors and hospitals lose money on patients with those types of insurance, it will be tough to expand the primary care network.

And health care providers are concerned that state legislators will continue turning to Medicaid to seek cuts during budget shortfalls.

"We are holding our breath," said Howard Kern, Sentara Healthcare's president and chief operating officer.

On the positive side, more insured patients mean people will address health issues sooner, reducing costly emergency-room visits and hospital stays. Medicare will also provide free annual wellness visits and prevention plans under the law.
"The most important thing is it moves us toward the idea that all citizens should have access to health care," said Matson, of EVMS. "It's been embarrassing and tragic not to have had that in place."

Meghan McNamara

Meghan McNamara, 23, of Norfolk hopes the law will help young adults such as herself. She is uninsured because she is working on a short-term basis for an immigration reform organization. The job ends in a few months and doesn't have health insurance.

Within six months, the new law will require new insurance policies to permit adult children to stay on their parents' policies until they are 26.
The years McNamara has spent uninsured have been costly. Last year she spent $4,000 out-of-pocket for testing and removal of some pre-cancerous cells in her cervix.
"I'm still paying that off," she said.

Randy Lassiter

Randy Lassiter, 80, also of Norfolk, is worried that his insurance plan may be subject to change of the negative sort. He describes his Medicare Advantage plan through Optima as "the best thing since sliced bread."
"I'm very concerned it will affect people like me," he said. "I'm concerned it will diminish some of my current coverage."

He's one of 159,150 people in Virginia who have enrolled in Medicare Advantage plans. That's about 14 percent of all Medicare beneficiaries in the state, a rate lower than the national average of about 25 percent.

Michael M. Dudley, president of Optima Health, said it's too soon to know the exact impact of the law on Optima's Medicare Advantage plan. "We will have to stay on our toes as the regulations are written," he said. "We can study the law, but we don't know its implications until regulations are written."

He supports more people having access to insurance but worries the penalties for people who don't buy insurance are not high enough to keep them from for going a policy. The law calls for an annual tax penalty by 2016 of up to $695.
His concern is that people will pay the penalty instead of buying insurance while they are well. But when they're sick, they'll buy health insurance.

"Without those people in the pool," Dudley said, "the practical impact will be the premiums will go up instead of down."

Jim Dahling

Jim Dahling, president and CEO of Children's Hospital of The King's Daughters, said the law holds many positives for that hospital's patients. Insurance companies would no longer be allowed to deny coverage to children with pre-existing conditions or place annual or lifetime limits on coverage.

But for the hospital, the law also has some potential for harm. CHKD qualifies for "disproportionate share hospital payments," which go to hospitals with large percentages of Medicaid and charity patients.

The law reduces those payments, because it's expected that hospitals will have more insured patients and fewer charity cases. However, 99 percent of CHKD's patient base is already insured, so the hospital doesn't stand to gain as much as other hospitals in newly insured patients.

A challenge for hospitals that serve larger adult populations will be connecting patients who turn to emergency rooms for care with new "medical homes," said Kern, of Sentara.

It's a process that won't happen overnight.

Dr. Carl Wentzel

Dr. Carl Wentzel, emergency department medical director at Bon Secours Health Center at Harbour View, said a robust primary care network will be crucial. He said in Massachusetts, which enacted a universal type of health insurance in 2006, emergency department visits initially increased after the law went into effect because people couldn't find primary care doctors.

Community health clinics have long served as an access point for such people, and the law increases their funding by $11 billion. The centers, which accept a mix of uninsured, government-insured and private-pay, expect an upswing in patients.
EVMS' Matson said the law includes some incentives for medical students to choose primary care, which could provide relief down the road. She worries, though, that people will be frustrated if they don't see positive change right away.

"It's been such an emotional issue that the first unintended consequence that comes along will make people think the whole bill is bad," she said.

The phased-in nature of the law also could cause confusion. Cathy Revell, executive director of Chesapeake Care Inc., worries that donations to free clinics - which treat the uninsured - will dry up because people will think everyone's covered now.
The center has 750 people on a waiting list for treatment, and it will be years before new insurance options open for them.

"It's a wonderful start," Revell said. "But it's not an immediate solution."

Florida Doc Tells Obama Voters to Go Away

2010-04-02T17:31:00.000-07:00

Katie Drummond Contributor
AOL News

April 2) -- A doctor in Mount Dora, Fla., has posted a sign on his clinic door that instructs patients who "voted for Obama" to go elsewhere for their medical care.

Dr. Jack Cassell, a urologist in the town of 11,500 people, is a registered Republican who opposes health care reform. The typewritten sign, which he posted earlier this week, reads, "If you voted for Obama, seek urological care elsewhere," and goes on to state that "changes to your health care begin right now, not in four years."

"I'm not turning anybody away -- that would be unethical," Cassell, 56, told the Orlando Sentinel. "But if they read the sign and turn the other way, so be it."

One of Cassell's patients told a friend, Estella Chatman, about the sign. Chatman's daughter then snapped a photo and sent it to Rep. Alan Grayson, an Orlando Democrat who staunchly supported his party's efforts at health care overhaul.

The friend, Chatman said, "is going to find another doctor."

It's illegal for doctors to turn away patients based on factors like race, gender, religion or disability. Political preference, however, isn't specifically protected by civil rights law.

Allen's likely pushing the limit, but not doing anything illegal, according to William Allen, a professor of bioethics at the University of Florida's College of Medicine.

By not directly inquiring about the political stance of his patients, he's "trying to hold onto the nub of his ethical obligation," Allen told the Sentinel. "But this is pushing the limit."

The sign isn't the only indication of Cassell's disdain for new health legislation. The doctor provides leaflets on health reform, along with a sign stating, "This is what the morons in Washington have done to your health care. Take one, read it and vote out anyone who voted for it."

Cassell and his wife, Leslie, have a long history in the area where the doctor practices. She's a Republican Party candidate for the county commissioner's office. He's been a urologist in Mount Dora for more than 20 years and was also chief of surgery at a nearby hospital.

And if you're a pro health reform patient who'd still like an appointment? Cassell says he'll treat anyone. But, he admits, he'd really rather not.

"I can at least make a point," he said.

Rep. Grayson, for one, thinks a doctor's office is the wrong place to make a political stand.

"I think it's disgusting," he said. "I know that most people go into health care because they want to help sick people. They don't have some political agenda. I think it's outrageous that someone would try to press his political agenda."

"I think the sore losers are out in force."

Small Businesses React to the Health Care Reform Bill

2010-04-02T09:27:00.000-07:00

By JULIA L. ROGERS, AOL SMALL BUSINESS

Posted: 2010-04-01 17:50:20
AP

Now that the Health Care Reform Act has officially passed, small businesses -- whether in support of the health care reform bill or against it -- are processing what the future will hold. Many small businesses still feel discombobulated by the very complicated details of the new, tide-changing health care reform.

In 2014, organizations that have 50 or more employees and do not provide affordable health coverage to employees could face penalties of up to $2,000 per full-time employee. The health care reform offers some good news for smaller businesses with fewer than 25 employees and average annual salaries equaling less than $50,000 per worker: They will not face penalties and even receive tax credits for offering health insurance, which could help them provide potentially attractive benefits packages to their staff without breaking their budgets.

Despite the suggested benefits of the health care plan, entrepreneurs and small business owners across industries have expressed concern and confusion about its real impact, and which waves they will actually feel from now until 2014. They have a lot of questions about whether or not the new plan will negatively affect their companies, and some worry it will not actually be legitimately affordable or provide care that suits their specific needs. They are also concerned about how such radical structural change may alter the quality of the overall health care system in the U.S.

The following 7 small business owners weighed in on how they see the Health Care Reform Act affecting the U.S., their businesses, and their families in the future.

Brian C. Greenberg, CPA, Brian C. Greenberg & Assoc., Marlton, New Jersey

"It is a mistake to think the health care bill will only affect individuals making over $250,000 annually. In fact, all working people, particularly those who are employed by companies with greater than 50 employees will be severely affected. If they have single coverage, they will be contributing $4,000 a year, and if they have family coverage, they will contribute nearly $11,000. This is a non-deductible 40% excise tax that hits in 2018 that employers must pay. Of course, these funds will come from future pay increases, wage cuts and/or layoffs. However, the most likely scenario is that many companies will opt for the penalty and drop health insurance for their employees, causing massive migration of Americans to seek government insurance.

"Additionally, the 40% excise tax amount is assessed on insurance companies if their premiums exceed $10,200 for individuals and $27,500 for family coverage. It is indexed at a 2% increase in subsequent years. Thus, if insurance companies are prevented from passing on costs in the form of higher premiums, then their only other option will be to drive coverage to the least costly area. The family doctor will have been long gone, replaced by under-staffed, over-utilized clinics where waits for elective procedures will be months and years rather than days and weeks. Physicians already discouraged by the high cost of education will continue to suffer a decline of new professionals exacerbating the delivery of timely and quality medical services."

Ivor Irwin, Freelance Writer, Chicago

"I am very lucky that my wife's job covers the family well, especially since I got my chest cracked 12 years ago. It's very hard for single freelancers out there especially. As customers grow used to the idea that they've 'got us' and can use the lure of 'maybe I'll need a full-time part-timer soon,' I expect wages to plummet in the freelance writing market, not improve. A lot of self-employed writers will be living along the margins in a kind of Raskolnikov-esque existence. The monolithic power of the insurance companies will surely be felt by us all once they flex their muscles and raise rates.

"A good thing that can come out of this is that insurance companies will surely be no longer able to 'cap' their spending. I grew up in a socialist England. Free medical care and dentistry is a right, but not if you have to wait 12 hours in a queue (which is normal) and if the doctors and nurses have a kind of sarcastic contempt for the public. Seeing a specialist in Blighty means, literally, making an appointment months in advance. When my dad got lymph node cancer as a part of the swath of illnesses that swept across Europe after Chernobyl, he became one of those statistics we write about, waiting for months to see a specialist. I witnessed the English system killing him, because most of the workers were ill-trained, apathetic, inexperienced and overwhelmed by the vast number of patients. All of the good medical people in England head here as fast as they can, of course. Consequently, I fear this will become the rule, rather than the exception over here, too.

"Additionally, if states have to account for every penny and govern responsibly, I wonder what will happen from now on to illegal immigrants?"

Janie Peterson, e-video Executive Producer, Peterson Productions Live, Minneapolis

"I'll be allowed to stay in business on my own, thanks to the Reform Act. Insurance premiums were rising so much, I could not justify the expense for my small business. With three kids and a husband, the monthly premiums were far too high with very little reward. If my husband or I were to get sick, we couldn't keep up the payments anyway. So what good did it do us? We were trying to do the right thing and buy into a plan, but rising costs were causing me to think about another corporate job with health benefits.

"I'm thrilled to have health care reform in place, so we can continue building our small business and see our kids through elementary school and beyond. We used to have media jobs and hated seeing so many of our friends laid off in recent years. At the same time, we're happy we made the switch to open our own e-video shop and feel ahead of our peers professionally. Now we can really make our kids a priority at the same time."

Rick Goetz, Music Consultant, New York City

"I'm not saying the system doesn't need reform, but what concerns me is that there are so many moving parts that no one can tell me how this will impact me or my business. It makes me wonder if those in the positions of power even know for sure, because it is not as if I haven't spent a considerable amount of time trying to understand.

"I have been shopping for a new insurance plan for the last several months, and some of the existing low-cost plans seem like they are not worth having at all. I am hopeful that this health care plan will provide good coverage for everyone, but I must admit to being a bit worried about the idea of having to pay for a plan that might not be worth the money. I personally don't care about the 'socialist' aspects that seem to worry some people but am more concerned that I might get stuck with a mandatory product that isn't worth its weight. I just hope, whatever may come, that getting medical care is a more enjoyable experience than dealing with other government run institutions -- like the DMV."

Kathryn Korostoff, Founder and President, Research Rockstar, Westborough, Massachusetts

"I owned a small business for 15 years and always provided health care. Yes, it was expensive. But I considered it just another cost of doing business. Some employees were on spouses' plans, so that saved me some money. I paid 50% of the premium per employee, and everyone seemed to find it acceptable. The plan was quite good, but I did not offer dental because that was too expensive.

"I sold that company and just recently started a new one, so the potential costs do not yet relate to me. But I can't imagine having employees without offering them basic health care.

"Compared to all the other costs of running a business -- rent, equipment, legal fees, business insurance, salaries, etc. -- I have never considered health care to be something that would 'break' my business."

Dr. Tom Potisk, Holistic Physician and Author, Caledonia, WI

"I'm truly happy that those who were unable to access health care previously will now be able to do so. But I'm concerned that many people assume their health care is a doctor's or an insurance company's responsibility. Statistics truly show that we need additional self care more than we need additional health care. Poor eating habits, lack of physical activity, and even improper posture are examples where self care and doing things differently would result in better long-term health. The reform contains benefits like no co-payment for some tests, but it's important to remember that all those tests are really early detection, not real prevention."

Business Bids to Shape Health Changes

2010-04-02T09:23:00.000-07:00

Business Bids to Shape Health Changes

Chamber of Commerce Plans Effort to Challenge New Regulations and Unseat Those Who Voted for Law

By JANET ADAMY

The U.S. Chamber of Commerce is planning a broad effort to blunt the health overhaul by trying to shape its regulatory language and spending heavily to unseat vulnerable Democrats who voted for it.

The campaign is the latest example of the escalating tensions between proponents of the health overhaul and big businesses, which have become more specific in their criticisms of the new law.

In recent days, a handful of large companies have reported hefty charges because the law eliminates a tax deduction for firms that offer prescription-drug coverage to retirees.

In a letter to board members Monday, chamber president and chief executive Thomas J. Donohue said the business lobby will seek changes to regulations to "minimize the potentially harmful impacts of this bill on our members and the country." If regulators "exceed legislative mandates or try for end-runs around the lawful rule-making process," he wrote, the chamber "will take legal action."

Mr. Donohue also said the group planned to spend $50 million this summer and fall to ensure that voters in pivotal House and Senate races know where lawmakers stand on health and other big issues. The chamber spent $36.4 million in the 2008 election.
At the heart of the effort will be a team of chamber staff that will "participate in the years-long process of writing the thousands of pages of federal regulations that will implement the many provisions of this legislation," Mr. Donohue wrote.
While the chamber can't actually write those provisions, it can lobby for certain language and technical corrections.

Other major lobbies are readying similar efforts. Although the legislation contains more than 2,000 pages of provisions, many details are left to the secretary of the U.S. Department of Health and Human Services to define, and will require more specific regulatory language.

The U.S. Chamber of Commerce plans to spend $50 million this summer and fall to sway election outcomes around the issue. Janet Adamy joins the News Hub to discuss.
America's Health Insurance Plans, the insurance industry's main lobbying group, has formed a task force to coordinate its implementation efforts and plans to give its input as officials draw up the regulations.

The American Medical Association, which represents doctors, hopes to shape provisions including a new panel to impose Medicare payment cuts, as well as increased research comparing the effectiveness of medical treatments, according to a spokeswoman for the group.

Major groups that supported the bill also plan to spend heavily on the 2010 elections. The AFL-CIO labor organization plans to surpass the $53 million it spent during the 2008 elections in this year's fall races.

Meanwhile, Families USA, a liberal advocacy group, has teamed with insurers to launch an educational campaign that will help people sign up for insurance at places like doctors' offices and pharmacies.

President Barack Obama on Tuesday signed into law the final package of changes to the health overhaul. The $938 billion overhaul will extend health insurance to 32 million Americans by expanding the Medicaid federal-state insurance program for the poor and giving lower earners tax credits to offset the cost of buying care.
In exchange, most Americans will be required to carry insurance and employers will be required to help pay for it.

Lawrence Summers, chairman of the president's National Economic Council, said Tuesday that the bill would help large firms in multiple ways. For instance, he said, employers now pay about $1,000 per worker more for insurance to subsidize medical care for the uninsured, an amount the new law would reduce.

"The bill represents our nation's most serious effort ever at health-care cost control, which ultimately addresses for many of these businesses what is their largest cost," Mr. Summers said.

In his letter, Mr. Donohue contended the law would impose $569 billion in new and higher taxes that would eliminate jobs, increase insurance premiums and prompt millions of workers to leave employer plans for government-subsidized insurance. The organization, which says it represents three million employers, was among the most vocal opponents of the legislation while Congress assembled it.

In recent days, a number of large companies, including insurer Prudential Financial Inc., telecom giant AT&T Inc. and heavy-equipment maker Caterpillar Inc. have announced millions of dollars in charges to offset the tax change on retirees' prescription-drug benefits.

In his letter, Mr. Donohue criticized House Democrats for calling the companies to appear before Congress next month to explain the charges.

"They are searching for a way to blame these businesses for a mess that the lawmakers themselves have made," he wrote.

Democrats said they would fight attempts by business to oppose the bill's changes.
"There's going to be a lot of different players in the health-care field that are going to want changes made to protect what they've had in the past," said Sen. Tom Harkin (D., Iowa). "I don't think we're going to be too anxious to continue the kind of subsidies we've had in the past that drain so much money out of the health-care system."

Write to Janet Adamy at janet.adamy@wsj.com

What Does the Healthcare Reform Bill Really Mean for Doctors?

2010-04-01T11:44:00.000-07:00

What Does the Healthcare Reform Bill Really Mean for Doctors?
Leslie Kane, MAC

Posted: 03/23/2010

Introduction
Euphoria or consternation?

Many Americans are cheering about the recent landmark healthcare reform legislation. Others are dismayed, and still others feel a mix of optimism and trepidation.

What do doctors stand to gain or lose in all of this?

As people in a caring profession, many doctors are either truly or theoretically happy that about 32 million more Americans will soon have health insurance.

Yet physicians have every right to be concerned about their own livelihoods and medical practices. For some doctors, the healthcare bill will create benefits and opportunities. Others see no benefits, particularly specialists. And funding the reform -- despite what politicians say -- could portend an ominous future for physicians.

"In the short timeframe, the premises are great," says Thomas N. Ahlborn, MD, President of Medical Staff and Director of the Department of Surgery at Valley Hospital in Ridgewood, New Jersey.

"It appears that internists will get paid adequately, insurers will accept people with preexisting conditions and won't be able to drop patients from insurance plans if they're ill, and there will be subsidies for people who don't make enough to pay for their own insurance," says Ahlborn. "These are all great things."

"But the reality is that the expense is going to be huge and there's nothing in there to control costs," says Ahlborn. Ultimately, a shortfall could come from physicians' pockets, he says.

Also, the proposed 21.2% Medicare reimbursement cuts still loom like a fire-breathing dragon that could wreak havoc on the best-laid plans.

Some Pros, Some Cons for Doctors
Although the currently uninsured population clearly benefits, the new legislation brings both positives and negatives to doctors. The key areas are new Medicaid patients at Medicare reimbursement rates, potential new business opportunities for primary care, funding issues and controlling expenses, lack of tort reform, continued chaos with Medicare reimbursement rates, and prevention efforts.

New Medicaid Patients at Medicare Reimbursement Rates
About 16 million Americans will be added to the Medicaid program. Medicaid reimbursements will be raised to Medicare levels for general internists, family physicians, and pediatricians in 2013 and 2014.

"A number of doctors have said that this is a good thing," says Ahlborn. Many primary care physicians anticipate new patients at what they consider a fairly attractive reimbursement rate.

"Some internists say, 'Medicare pays us better than some of the other plans that pay us only 70% to 80% of Medicare,'" says Ahlborn. "So for them to have these potential new patients and be reimbursed at full Medicare rates is positive."

Still, many doctors have no interest in this new pool of Medicaid patients. Throughout the country, some doctors are trying to lower their percentage of Medicare patients or even eliminate them entirely. Some doctors will also avoid the new Medicaid patients because they say that dealing with government insurance programs is a snarled tangle of frustrating paperwork.

"I think there will be a great number of primary care physicians who will not take either Medicaid or Medicare patients," says Mary Ann Bauman, MD, IM, and Medical Director for Women's Health and Community Relations with Integris Family Care Central, Oklahoma City, Oklahoma. "Doctors want to give the best care to everyone, but sometimes the present insurance system makes it difficult."

Most physicians don't have that choice, says Ahlborn. "A lot of physicians operate on very short margins and are unable to cut their overhead. They get paid relatively little per patient visit and need to have volume. Yes, there are premier practices that won't accept insurers offering less than Medicare rates, but they are the exception rather than the rule."

Although many primary care doctors are eager to start seeing these new patients, specialists get the short end of the stick. The Medicaid reimbursement rate for them will not rise to Medicare levels.

"Congress was very smart to say that they would pay primary care physicians 100% of Medicare rates," says Ahlborn. "But specialists and people who do procedures may simply say they won't see Medicare patients, or they'll see a very small number of them."

New Business Opportunities for Primary Care?
The roster of newly insured patients could turn into a flood or it could turn out to be less than anticipated. But in many cases, it could represent practice opportunities for doctors.

New business models may attract primary care physicians willing to hire more PAs and NPs in order to see patients. Doctors who expand in this way could increase their volume of patients while containing costs by using healthcare providers with salaries less than that of physicians.
Inner-city practices may spring up. Some doctors may be interested in setting up practices in inner cities or areas where patients are now served by clinics or training hospitals. "There might be more demand in inner-city areas or indigent areas where the Medicaid population is greater," says Ahlborn. "Many of those distressed areas probably have a paucity of physicians to begin with."
Payment instead of unpaid charity care. Hospitals currently lose millions of dollars annually on charity care for patients who show up in the emergency room without insurance and who do not pay their bills. Physicians also do not get paid -- or receive a pittance -- for charity care. If patients going to hospital emergency rooms have insurance -- even at Medicare rates -- hospitals and doctors will receive at least some degree of payment.
More primary care doctors will be trained. There are provisions of increasing the number of primary care doctors to be available in the future to care for the additional patients.
However, Ahlborn cautions that it's not a given that all newly insured patients will opt to see primary care doctors in office practices.

"Most uninsured people are being seen now, whether it's in clinics or hospital emergency rooms," says Ahlborn. "There are also people who have the opportunity to see physicians but don't access them. And some patients may not be diligent at managing their healthcare or getting screening tests every year or every 3 years. "

Funding the Plan and Controlling Expenses
A new tax being levied to fund healthcare reform may hit doctors (and other high earners) harder than the rest of the population.

The legislation calls for a 3.8% Medicare Part A (hospital insurance) tax on unearned income for individuals making more than $200,000 ($250,000 for married couples). Many doctors are in that tax bracket.

"You'll pay a tax on your investment capital gains, and if you sell your house, you'll pay a tax on the capital gains," says Ahlborn.

Paying hefty taxes may lead doctors to question working nights and extra hours. When such a large chunk of income goes to taxes, it becomes less attractive to take personal time to bring in more income.

Bauman says, "I don't think Americans have the stomach for the raise in taxes needed to make healthcare a right and not a privilege."

"Ultimately, this is untenable," says Ahlborn. "The cost of these entitlement programs is going to be astronomical. It sounds good that insurers have to accept everyone with preexisting conditions, but where does the money come from?"

Tort Reform Is Overlooked
The inattention to malpractice reform has 2 effects: It fails to lessen the number of lawsuits brought against doctors by plaintiffs looking for a quick jackpot. It also neglects to address the very real issue of defensive medicine, which doctors say jacks up the costs of healthcare.

"If a doctor has ever gone to court, he's going to do anything to never have to go back again," says Ahlborn. "Physicians order hundreds of exams every year just to document conditions that don't exist. Even if they know that the chance of something being there might be 1 in 10,000, they will still order. In this legislation, they did not even toss a little bone to discuss tort reform."

Adds Bauman, "I know that every doctor who is a good doctor practices defensive medicine. So I'm disappointed that tort reform will not be a part of the healthcare reform bill. I think that will make doctors less willing to embrace those newly insured patients."

Continued Chaos With Payment Rates
Notably absent was any mention of fixes to the Sustainable Growth Rate (SGR), which determines physician reimbursement. Medicare reimbursements cuts -- whether or not made at the full 21.2% as proposed -- would be disastrous.

"The biggest issue on the physician's horizon right this minute is the proposed 21.2% Medicare pay cuts," says Ahlborn. "If those cuts were to occur, it would be devastating to primary care, particularly internists, who run on such small margins. Everyone knows that. My understanding is that it can't happen."

Even with that tax, however, private and government insurers are taking in too little to fund healthcare benefits," says Ahlborn. "Part of the budget reconciliation scoring included the 21% cut in physician fees. That's why it could be budget-neutral. However, such a cut would shake the foundation of the system and the consequences would be significant."

A natural place for the government to try to make up the difference is through cuts to doctors' reimbursement, says Ahlborn.

Prevention and Wellness
Many politicians have said that keeping patients healthy through prevention education will be important as far as keeping healthcare costs low.

Where's the beef?

The legislation contains no financial incentives directed at patients to encourage them to lower their cholesterol, quit smoking, lose weight, or in other ways to take responsibility for their health. At the moment, responsibility rests with public education programs and with physicians who are supposed to motivate patients. The patient has little financial incentive to be a collaborator.

"It will be interesting to see what plays out," says Ahlborn.

Authors and Disclosures
Author(s)
Leslie Kane, MAC
Editorial Director, Medscape Business of Medicine

Disclosure: Leslie Kane, MAC, has disclosed no relevant financial relationships.

A Timely Quote from a Founding Father

2010-04-01T10:01:00.000-07:00

"God forbid we should ever be twenty years without such a rebellion.The people cannot be all, and always, well informed. The part which is wrong will be discontented, in proportion to the importance of the facts they misconceive. If they remain quiet under such misconceptions, it is lethargy, the forerunner of death to... the public liberty. ...
And what country can preserve its liberties, if its rulers are not warned from time to time, that this people preserve the spirit of resistance? Let them take arms. The remedy is to set them right as to the facts, pardon and pacify them. What signify a few lives lost
in a century or two? The tree of liberty must be refreshed from time to time, with the blood of patriots and tyrants. It is its natural manure."

~ Thomas Jefferson

Republicans Easing Away From Call To Repeal Healthcare Reform Law.

2010-04-01T09:54:00.000-07:00

Republicans Easing Away From Call To Repeal Healthcare Reform Law.
The AP (4/1, Babington, Elliott) reports that top Republicans "are starting to worry about their healthcare rallying cry 'Repeal the bill,'" which "just might singe GOP candidates in November's elections, they fear, if voters begin to see benefits from the new law." Democrats, "hoping the GOP is indeed positioning itself too far to the right for the elections, are taking note of every Republican who pledges to fight for repeal." While "such a pledge might work well in conservative-dominated Republican primaries, they say...it could backfire in the fall when more moderate voters turn out." The AP notes that GOP Senate candidate Mark Kirk of Illinois has "eased back from his earlier, adamant repeal-the-law stance," and the US Chamber of Commerce, "which fiercely opposed President Barack Obama's health legislation, now urges opponents to pursue a 'more effective approach' of trying to 'minimize its harmful impacts.'"

Would the Founders Love ObamaCare?

2010-04-01T09:22:00.000-07:00

The resistance to ObamaCare is about a lot more than the 10th Amendment.
• By DANIEL HENNINGER

The left-wing critics are right: The rage is not about health care. They are also right that similar complaints about big government were heard during the New Deal and the Great Society, and the sky didn't fall.

But what if this time the sky is falling—on them.

What if after more than a century of growth in the national government, starting with the Progressive Era, the American people are starting to push back. Not just the tea partiers or the 13 state attorneys general seeking protection under the 10th Amendment and the Commerce Clause. But something bigger than that.

The Democratic left, its pundits and academics criticizing the legal challenges to ObamaCare seem to be arguing that their version of our political structure is too big to change.

That's not true. The American people can and do change the nation's collective mind on the ordering of our political system. The civil rights years of the 1960s is the most well-known modern example. (The idea that resistance to Mr. Obama's health plan is rooted in racist resentment of equal rights is beyond the pale, even by current standards of political punditry.)

Powerful political forces suddenly seem to be in motion across the U.S. What they have in common is anxiety over what government has become in the first decade of the 21st century.

The tea party movement is getting the most attention because it is the most vulnerable to the standard tool kit of mockery and ridicule. It is more difficult to mock the legitimacy of Scott Brown's overthrow of the Kennedy legacy, the election results in Virginia and New Jersey, an economic discomfort that is both generalized and specific to the disintegration of state and federal fiscs, and indeed the array of state attorneys general who filed a constitutional complaint against the new health-care law. What's going on may be getting past the reach of mere mockery.

Constitutional professors quoted in the press and across the Web explain that much about the federal government's modern authority is "settled" law. Even so, many of these legal commentators are quite close to arguing that the national government's economic and political powers are now limitless and unfettered. I wonder if Justice Kennedy believes that.

Or as David Kopel asked on the Volokh Conspiracy blog: "Is the tax power infinite?"

In a country that holds elections, that question is both legal and political. The political issue rumbling toward both the Supreme Court and the electorate is whether Washington's size and power has finally grown beyond the comfort zone of the American people. That is what lies beneath the chatter about federalism and the 10th Amendment.

Liberals will argue that government today is doing good. But government now is also unprecedentedly large and unprecedentedly expensive. Even if every challenge to ObamaCare loses in court, these anxieties will last and keep coming back to the same question: Does the Democratic left think the national government's powers are infinite?

No one in the Obama White House, asked that in public on Sunday morning, would simply say yes, no matter that the evidence of this government's actions the past year indicate they do. In his "Today Show" interview this week, Mr. Obama with his characteristic empathy acknowledged there are "folks who have legitimate concerns . . . that the federal government may be taking on too much."

My reading of the American public is that they have moved past "concerns." Somewhere inside the programmatic details of ObamaCare and the methods that the president, Speaker Pelosi and Sen. Reid used to pass it, something went terribly wrong. Just as something has gone terribly wrong inside the governments of states like California, New York, New Jersey, Michigan and Massachusetts.

The 10th Amendment tumult does not mean anyone is going to secede. It doesn't mean "nullification" is coming back. We are not going to refight the Civil War or the Voting Rights Act. Richard Russell isn't rising from his Georgia grave.

It means that the current edition of the Democratic Party has disconnected itself from the average American's sense of political modesty. The party's members and theorists now defend expanding government authority with the same arrogance that brought Progressive Era reforms down upon untethered industrial interests.

In such times, this country has an honored tradition of changing direction. That time may be arriving.

Faced with corporate writedowns in response to the reality of Congress's new health plan, an apoplectic Congressman Henry Waxman commanded his economic vassals to appear before him in Washington.

Faced with a challenge to his vision last week, President Obama laughingly replied to these people: "Go for it."

They will.

As to the condescension and sniffing left-wing elitism this opposition seems to bring forth from Manhattan media castles, one must say it does recall another, earlier ancient regime.

Health Reform Fuels Debate Over Size, Role of Government - AOL News

2010-03-31T13:49:00.000-07:00

Health Reform Fuels Debate Over Size, Role of Government - AOL News

Opinion: Reform's Great, But We Need More Doctors

2010-03-30T20:15:00.000-07:00

Opinion: Reform's Great, But We Need More Doctors
Kevin Pho, M.D.
Special to AOL News
(March 30) -- Health reform has passed, and the United States is poised to join the rest of the industrialized world in providing most of its citizens with affordable health coverage.

But having health insurance doesn't necessarily mean it will be easy to find a doctor. Even before reform, reports projected a shortfall of 40,000 primary care physicians over the next decade. Thirty-two million newly insured Americans, plus the millions of baby boomers entering Medicare age, will only make this shortfall worse.

As a primary care doctor in New Hampshire, I have had the opportunity to observe the effects of health reform in neighboring Massachusetts, which enacted a similar approach to universal coverage in 2006.

To its credit, Massachusetts covers 97 percent of its residents, the highest in the country. But its wholly unprepared primary care system was unable to handle the 500,000 newly insured patients looking for a regular doctor. According to the Massachusetts Medical Society, a primary care internist had an average wait time of 50 days for new patients, with almost half refusing to accept to new patients.

When Amherst, Mass., family physician Kate Atkinson decided to accept newly insured patients, she was forced to close her doors six weeks later. She told the Boston Globe that "there were so many people waiting to get in, it was like opening the floodgates," saying that her office is getting "10 calls a day from patients crying and begging."

And this is a state that already has the highest number of doctors per capita nationwide. It's frightening to imagine how other parts of the country, most of which have significantly fewer primary care doctors, can handle the influx of patients if Massachusetts can't.

Any hope to bolster the primary care work force, unfortunately, is not on the horizon.

With medical students graduating with an average educational debt exceeding $150,000, new doctors overwhelmingly choose to become specialists, which offer salaries several times more than those of primary care doctors. In the 2010 residency match, fewer than half of family practice residency slots were filled by American medical graduates, compared with more than 95 percent in fields like radiology, anesthesiology and orthopedic surgery.

Furthermore, nurse practitioners and physician assistants, who can help alleviate the shortage, are also enticed by the lucrative allure of specialty care. As Newsweek recently reported, "almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is."

Health reform does try to help primary care, through modest improvements to Medicare and Medicaid primary care clinician payments, better funding of loan repayment programs and pilot programs for new primary care models. But these incremental solutions fail to appreciate the enormity of the problem.

Nor do they address the phenomenon of physician burnout currently plaguing the field. A survey published last year in the Annals of Internal Medicine found that nearly half of primary care doctors reported practicing in a work environment "strongly associated with low physician satisfaction, high stress ... and [an] intent to leave." Indeed, almost one-third said they were likely to leave their practice within two years.

At a time when primary care physicians are needed most, health reform does little to relieve these frustrated doctors of the unreasonable time pressures and onerous bureaucratic requirements that worsen their practice conditions and obstruct their patient relationships.

Providing affordable health care to an additional 32 million Americans is certainly worth celebrating. But whether our beleaguered primary care system can meet the challenges that lie ahead will be critical in determining health reform's success or failure.

Obamanomics & Healthcare; 1st Installment

2010-03-30T09:07:00.000-07:00

Here's a little democratic fuzzy math (Obamanomics) for you all:

Congress has appropriated $5,000,000,000 (5 billion) dollars to pay for direct medical care for a "temporary high-risk pool" of individuals that currently do not have insurance until the mandates for insurance take effect in 2014.

These individuals will purchase the insurance through the "government exchange program" adminsitered by each state.

The 5 billion dollars is above and beyond the premiums that will be collected for the new "affordable policies" that cannot be more than what the current market policies are.

Still with me--here's where the fuzzy math comes in?

In 2010 we will spend a little over $3,000,000,000,000 (3.05 trillion) in health care.

If 85% of the population have insurance and about 15% dont (about 30 million individuals), that means that those that don't have insurance will require 15% of the 3 trillion or about 450,000,000,000 (450 billion dollars) per year for health care expenditures.

However, congress has only appropriated 5 billion dollars or 0.16% of the total amount needed to pay for such care expecting to make up the rest or 98.14% needed from premiums collected with the stipulation that if the money runs out, then the Secretary of the Health and Human Services "will take such measures as to raise premiums, limit coverage, or create waiting lists".

Now let's say for the sake of argument that 98.14% of $450,000,000,000 is still pretty much $450,000,000,000--then that means they will need to collect 450,000,000,000 in premiums from 30 million people or about $15,000 dollars each ($1250.00/month).

But--since this is an "affordable plan" and the premiums cannot be more than what the market currently is, that means there are only two alternatives:

The first is that after they run out of the 5 billion plus whatever premiums they collect (which will take about a month), they simply limit care or deny coverage.

The second option is that the rest of us will be asked to pay for the shortcoming through increased premiums, taxes, or both.

What option do you think they will choose?

Furthermore, the above analysis makes the assumption that the "high-risk" pool will utilze the same amount of care as the "average"; however, since by definition, they are "high-risk" and presumably have pre-existing conditions, then that means they will actually utilize more care which, of course, will cost more!

John R. Vigil, MD (1988), MBA (2011)
Fellow, American College of Physician Executives

Cost of Medical Care in 2007

2010-03-29T13:13:00.000-07:00

Cost of Medical Care in 2007

From Medicine & Opera http://medicine-opera.com/2009/03/25/cost-of-medical-care-in-2007/

The aggregate cost of medical care in the US in 2007 was $2.26 trillion. That used to be a lot of money before the federal government started spending trillions like they were millions. The pie chart below shows how this cost was distributed. It also is rising faster than GDP and has been doing so for almost a half century.

It’s as interesting for what it leaves out as well as what it includes. Under what category were diagnostic tests placed? The cost of imaging and laboratory testing is enormous. The clinician doesn’t get paid for these studies, but he does determine which and how many of these tests are performed.

Also note that the cost of prescription drugs is only 10% of all costs. It’s been that for years. Villainizing drug companies for the high price of their drugs has been a popular pastime since the discovery of penicillin, but even if all drugs were free we’d still be left with a $2 trillion bill. Of course if all drugs were free we’d have no drugs.

The current administration wants to fix the US healthcare system. First it’s not a system and before you fix it you have to understand what doesn’t work. Medical care in the US is the best in the world if you’re inside the tent. Students of medicine at every level want to train in this country. Medical research here is also the best in the world. What’s wrong is that medicine costs too much. The reason it costs too much is that there are no incentives to reduce costs. Every incentive out there encourages extra spending.

No attempt to overhaul our “system” will work if it doesn’t successfully deal with cost. More coverage for more people at less cost is impossible without first understanding and then fixing the forces that drive costs up. After that you’d have to drastically lower the cost of every service without restricting its availability.

An MRI doesn’t have to cost $4000, but health insurance and Medicare encourage high prices at the same time they think they’re containing them. Only a system of competition and money incentives will drive prices down. Patients should be able to shop around for the cheapest MRI they can find. They’d have to have an incentive to do so; which means they’d have to bear up front some of the cost. Today the incentives all support paying the highest price to the nearest provider. If MRIs were priced competitively they’d cost about $100 – $200 at the most.

I don’t think either the public or the government is ready for price competition in medical care. Price competition necessarily means price rationing. What we’ll get instead is rationing by delay. The interesting question is how much degradation in the ease and facility of current medical care will the 85% of the public that has health insurance accept to provide care for the 15% that doesn’t. By the time the answer is in the debate may be over.

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Fine Tooth Analysis of the Healthcare Bill

2010-03-28T23:54:00.000-07:00

Dear Friends and Concerned Citizens,

I will be going through the recently enacted Healthcare Reform Bill with a fine toothed comb--unlike the majority of our elected officials that voted on it--and will apply over 20 years of healthcare experience in the trenches as a surgeon, emergency room physician, and a primary care/urgent care provider in interpreting it and posting all relevant aspects of the bill as they affect all of us, including providers and consumers.

In the first 26 pages of the bill under Division A (Affordable Healtcare Choices), Title I (Immediate Reforms)the bill discusses setting up high-risk pools of those that have been denied coverage for a variety of reasons--especially pre-existing conditions--so that they may obtain immediate and affordable coverage.

The problem is that Congress has appropriated 5 billion dollars--not including collected premiums)--to pay for direct medical care provided to those individuals. Now that may sound like a lot of money, but remember, that money must also go to pay administrative costs as well as direct medical care. Since this is a "high-risk" pool of patients, that, by definition means that their medical care is going to be much more costly--but, since they cannot be denied or charged more than anyone else (remember it is supposed to be affordable)that means the money will come from the 5 billion dollar pool which will be burned through very quickly.

Now the second problem--that was never told to the public--is that when the funds run out, then the Secretary of Health and Human Services may " reduce benefits, increase premiums, or establish waiting lists."

Don't believe me? See for yourself and pay attention to the last paragraph:

14 (1) IN GENERAL.—There is appropriated to the
15 Secretary, out of any moneys in the Treasury not
16 otherwise appropriated, $5,000,000,000 to pay
17 claims against (and administrative costs of) the
18 high-risk pool under this section in excess of the pre19
miums collected with respect to eligible individuals
20 enrolled in the high-risk pool. Such funds shall be
21 available without fiscal year limitation.
22 (2) INSUFFICIENT FUNDS.—If the Secretary es23
timates for any fiscal year that the aggregate
24 amounts available for payment of expenses of the
25 high-risk pool will be less than the amount of the ex-
VerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962 rmajette on DSK29S0YB1PROD with BILLS
26
HR 3962 IH
1 penses, the Secretary shall make such adjustments
2 as are necessary to eliminate such deficit, including
3 reducing benefits, increasing premiums, or estab4
lishing waiting lists.

And that is just in the first 26 pages and 11 of those were introduction and table of contents!

John R. Vigil, MD

Health overhaul likely to strain doctor shortage

2010-03-28T22:56:00.000-07:00

Health overhaul likely to strain doctor shortage

Retirement Health Care: Average Couple Needs To Save $250,000

2010-03-28T10:17:00.000-07:00

MARK JEWELL | 03/25/10 06:59 AM |

BOSTON — Relief to seniors facing high prescription drug costs is one of the first changes to come under the new health care overhaul. But ultimately that won't offset the relentless increase in retirees' medical expenses.

A couple retiring this year will need a quarter of a million dollars, on average, to cover medical expenses in retirement, according to a study to be released Thursday by Fidelity Investments.

The estimate is up 4.2 percent from Fidelity's projection last year. The Boston-based financial services company has updated its estimate annually since 2002 as part of its business helping employers design workplace benefits programs.
The study is based on projections for a couple of 65-year-olds retiring this year with Medicare coverage. The estimate factors in the federal program's premiums, co-payments and deductibles, as well as out-of-pocket prescription costs. The study assumes no employer provided insurance in retirement, and a life expectancy of 85 for women and 82 for men.

The estimate has risen 56 percent from Fidelity's initial $160,000 projection in 2002. The average annual increase has been 5.7 percent, so this year's 4.2 percent rise – from $240,000 last year to $250,000 – is modest.

But with broader inflation now near zero amid a recession, health care costs continue to rise faster than other expenses, said Sunit Patel, a senior vice president at Fidelity.

The findings illustrate the importance of factoring in health care alongside housing, food and other expenses in retirement planning.
"It turns out to be a surprise for many, and one of the largest expenses in retirement," Patel said.

The increase in this year's estimate was relatively small because a surge in patent expirations for brand-name drugs meant many cheaper generic versions reached the market, Patel said. That helped limit out-of-pocket prescription costs

Now, Can We Have Health-Care Reform?

2010-03-24T18:25:00.000-07:00

ObamaCare doubles down on a failing system.

By HOLMAN W. JENKINS, JR.

A certain kind of person—we get emails from them all the time—understands exactly nothing about the health-care debate, but thinks they know who the villain is: the insurance industry.

Barack Obama is not one of them. In the desperate hours he played to public ignorance. But from the beginning, the industry was his ally because he set out to solve its biggest problem—which is not the same as America's biggest problem.

We'll let Angela Braly, CEO of insurer WellPoint, take the story from here. She was recently hauled before Congress to justify her company's proposed 39% rate hike in California. She explained the source was two-fold: rising medical costs and healthier customers dropping their coverage, forcing the sick to pick up the tab.

Now this sounds like two problems, but for WellPoint and other insurers it's really only one problem. Once everyone is required by government mandate to buy insurance, the industry's survival is no longer threatened: It can just pass its skyrocketing costs along to customers. Once customers can no longer refuse to buy the industry's product, the problem of costs won't be fixed, but it no longer is the insurance industry's problem.

There, in that one sentence, we give you the failure of ObamaCare, the failure of the congressional health-care debate, the failure of health-care politics in this country.

Health insurers, and indeed Corporate America as a whole, are like monkeys who are caught by staking a glass jar to the ground with a shiny trinket inside. They won't let go so they can't get their hands out of the jar. That trinket is the ruinous and regressive $250 billion-a-year tax benefit for employer-provided insurance.

Corporate America isn't brave enough to argue against a direct subsidy to its employment costs, no matter how perverse its impact in insulating consumers from the true cost of their health care choices. Insurers are not brave enough to say: Give us a tax code that lets us go back to being insurers rather than a tax laundromat for the middle class's health-care spending.

Almost any bill would have been worth having that fundamentally fixed this tax distortion, regardless of its other elements.

We say this because any bill, including the one signed by the president yesterday, will be revisited many times in the future. Millions of pages of rules will be written by regulators before we see how it really works. Congress itself will return in predictable ways: It will reverse the proposed Medicare cuts that created ObamaCare's illusion of fiscal probity. It will tighten the mandate that requires insurers to cover the sick at favorable prices. It will not tighten the requirement that the young and healthy buy insurance at prices that subsidize the old and unhealthy.

More and more tax money will have to be found to keep the jalopy on the road. More and more administrative controls on medicine will attempt vainly to keep the jalopy from bankrupting the nation.

Under the law just signed, employers have even more incentive than they did yesterday to lavish excessive health insurance on their high-end employees. They have less incentive to cover low-end workers, or even hire them.

For the young, healthy or anyone not stumbling into a giant tax handout, buying insurance at the inflated prices available in the marketplace would be an even crazier financial decision today than it was yesterday—because now you can wait and buy it when you're sick.

For insurers, the check is in the mail: So watered down is the individual mandate that it must accelerate the industry's death spiral if not for the massive subsidies the government now has obliged itself to provide to keep the industry afloat and allow insurers to continue scalping their 15% off the top for serving as gatekeeper to a tax loophole.

When all is said and done, with unerring accuracy, ObamaCare has ended up doubling down on the system's existing perversities. The one thing it doesn't do (though it would be perfectly consistent with the Democratic goal of universal access) is incentivize a health-care marketplace based on competition in price and quality.

A world-class hospital in India does heart surgery the equal of any heart surgery in America, but does so at one-tenth the cost (and increasingly attracts a world-wide clientele). The reason is not what you think: low-paid doctors and nurses. The reason is that competition works in medicine as it does in everything else when the patient cares about getting value for money. This is the great low-hanging fruit of health-care reform. It continues to hang.

A Taste of Obamacare

2010-03-21T18:22:00.000-07:00

For all you people that are celebrating this bill, let me give you just a little of what we can expect now:

1. Acute and severe shortage of doctors--especially primary care doctors.

Why: Because this bill does nothing to change the primary problem of incredible waste and inefficiency in the current system which is an overreliance on high cost/high tech care driven by too many specialists, demanding consumers, and medical liability. We already have a critical shortage of primary care doctors in this country and this bill will only make it worse as older doctors retire out of frustration and less and less people enter the specialties of primary care.

2. Number one will be exacerbated by an influx of 30-40 million more people into the system which will increase the volume of people that a diminishing number of primary care doctors will see which will result in shorter visits, longer waits in the office and to get in, and a greater potential for medical errors and mistreatment as the doctor has less time per visit.

3. In a measure to control costs, medical care will move from the time honored system of the patient-physician relationship with the physician using his or her training as well as experience to treat disease to a "best practices" system where treatment guidelines and protocols are based on statistical data and analysis, including cost-benefit analyses and developed by doctors that don't know you. What this means is that instead of treating the individual--we will be treating the patient within the context of populations. It might not sound different, but I can assure you there is a huge difference--let me try to explain:

Today, if you suffer from coronary artery disease or blocked arteries in the heart, you can be treated with medication and/or more invasively with stents or operation. However, statistics show that patients treated with stents and operations (which are very costly) do no better--as a group--than those treated with just medication and lifestyle changes (which is not so costly). The key phrase here, is AS A GROUP, there is no doubt that within that group of people that have more costly treatments, there are some individuals who do much better with respect to mortality and quality of life than those treated with the less costly methods.

So the end result will be that if you are lucky enough to fall within the arbitrary confidence levels set up by the committee that makes the treatment guidelines, then you're treated, if you fall out of the curve---too bad.

4. Since doctors will no longer have much discretion in how you are treated, they will find the challenge of being a mere technician reading a cook book unrewarding and unbecoming the years of training and sacrifice they have endured and will leave the profession or not enter it, further exacerbating number 1 above.

5. As a result of number 1 and 4, you will all be seeing more and more mid-level providers like physician assistants (PAs) and nurse practitioners (NPs) who do not have near the level of training or experience to recognize and treat obscure and rare diseases or complex and complicated cases.

6. The overall quality of specialists will fall and more people with serious or complicated medical problems will not be treated at all.

Why: The current bill aims to reward and punish hospitals and providers based on certain quality benchmarks, like mortality or rates of complications, or infections, and etc. Now on the surface this certainly sounds wonderful--but, if you look a little deeper, what will happen is that a phenomenon that goes on every day in this country called "cherry picking" will become the standard of care.

Let me explain: Cherry picking means that doctors and hospitals will pick and choose only those patients that are going to give them good results....that means that they will be treating patients that are deemed low-risk and that would probably do fine--or even better---without treatment!

Meanwhile, smaller community hospitals and inner city hospitals and doctors that do not have the luxury of picking and choosing only the good risk patients, will have worse scoring on their benchmarks which will mean less money for them (because remember, the "good doctors and hospital" got the money) to invest in research and technology. On the other hand, the "good hospitals" will invest their money on high tech gadgets and technology to treat patients that don't need it (remember, they are low risk anyway) and which will add significantly to the cost of care and which is the major cost driver for out-of-control costs (see number 2 above).

An analogy would be like rewarding a military unit that doesn't fight (therefore has low mortality) with high tech weaponry and protective gear, while punishing the units that have higher mortality (because they are in the trenches fighting)! Which unit do you think would have the higher quality?

7. Of course, there is not a single democrat that will admit it, but someone has to say it. That is, like it or not--there will be rationing!

Why: Look at 1, 2, and 3 above. regardless of what the CBO says or Obama says, healthcare costs will continue to rise exponentially as we rely more and more on costly high tech care (which is again, the biggest cost driver) and since 30 to 40 more million people will be added to a decreasing pool of doctors to take care of them and we obviously will not have unlimited money to pay for that care--that means rationing and very long waiting lists! If you're over 70 and have renal failure--too bad, no dialysis for you. If you're 60 and need a knee replacement--you'll have to wait until all the 50 years olds (and sports celebrities) get theirs because they are more "valuable" to society than you. Need a liver transplant--you better be Madonna or Mickey Mantle. Need a heart bypass--better get in line. Are you 70, 80, or 90 and have a broken hip---too bad, you're not going to get one! You will be given comfort measures and will most likely die of a pulmonary embolus or pneumonia.

8. Insurance premiums will continue to rise and in an attempt to offset that by the government, subsidies will be given which we all know means higher taxes.

Why: Again, this bill does nothing to address the two fundamental problems with American Healthcare: Out-of-control costs spent on high cost/high tech(and even some low cost care such as antibiotics) care and technology--that is often not needed and a third party system to pay for that care.

A third party system does nothing to put the responsibility of (the cost) of health care where it belongs—which is with the patient! As long as there is the perception that someone else is paying for any commodity--then we all by human nature are going to want and expect the best there is and with all the bells and whistles--whether we need it or not! Health insurance should be used only for unpredictable calamities--not routine health care! If we all had to pay for our screening mammograms and colonoscopies, and regular doctors visits, maybe we would shop around and educate ourselves as to whether we really need it and where we could get the best deal! Secondly, as I already mentioned, since the cost will continue to rise and the insurance companies will continue to pay, where do you think the money will come from to pay for it? The tooth fairy?

That is just a short list of what we can look forward to in the next few years--and that's just in health care!

Good luck!

John Vigil, MD (1988), MBA (2011)
Fellow, American College of Physician Executives

Tyranny Must be Resisted

2010-03-20T23:44:00.000-07:00

My fellow Americans,

Please...make no mistake about this healthcare bill. This bill is not about healthcare and it is not about Obama, Pelosi, and Reid. No, this is much more vast and treacherous than that. It is nothing more than the "fundamental transformation of America"--translated as the transfer of power and redistribution of wealth to the socialist working class. This is about Marx, Lewinsky, Soros, Andy Stern, the unions, and other socialist elitists that manipulate the puppet strings attached to Obama, Reid, Pelosi, et al.

What we are witnessing is nothing less then the fruits of seeds that were planted over 60 years ago and only now are bearing fruit. The arrogant disrespect and disregard for the will of the people as they force this bill upon us only shows us that they truly believe that they have succeeded. Their blatant disregard for our constitution and our democratic principles is nothing short of tyranny and their actions are nothing short of treason!

We can wring our hands and express our fears and concerns and write letters and make phone calls and send e-mails that have only fallen on deaf ears. Paradoxically those efforts actually seem to have embolden them more as they trample on our God-given rights and liberty.

We can begrudgingly concede defeat and cry and hope for change in November of 2012; however, they don't care about November of 2012 or 2014--for they feel their time has come. They have shown that they are willing to 'martyr' their own to achieve the end; in this, they are no different than the Taliban or Al Quaida.

We can bow our heads and acquiesce and accept the "fundamental transformation"--Or--we can fight and resist!

But to fight tyranny...we must leave our comfort zones...that means being willing to sacrifice life, liberties, and more! We should take inspiration from those patriots in Iran and China that have risked all and have even died resisting tyranny and opression. If they can do that for even a modicum of freedom, what then can we do for our sacred liberty?

I, for one, stand willing, able, and ready!

And, lest you dismiss me as just another revolutionary, reactionary, fanatic, or red-neck militia member with crazy conspiracy theories, I am a Vietnam era and first Iraqi war vet. I have served both as an enlisted soldier and an officer in the US Army.

I am an upper middle-class surgeon/physician iin a very successful practice and am also completing my MBA. I have a wonderful family with children and live very comfortably in "middle America".

I am Hispanic-American and my family has been here in the US since 1692. I come from a very modest background where my family was very poor and I had about an even chance of going to school or ending up dead or in prison. I chose the military and am proud to be able to say I have served my country honorably. I have worked hard and sacrificed much to achieve what I have and to become who and what I am today.

I have seen and lived the best this country has to offer and now I see and am living the worst! In my 55 years, I never dreamed I would see this happen to my country. Like many of you here and unlike Mrs. Obama, for once in my life, I am truly ashamed of my country.

Slowly but surely, God has been taken out of our government and out of our schools. My children are being indoctrinated in school and not taught. They are introduced to concepts that I disagree with which is fine—as long as dissenting concepts and tenets are also introduced and taught!

But, introducing my children to homosexuality and gay rights in elementary school is NOT alright! Teaching them that we are responsible for global warming without counter evidence is NOT acceptable to me! Teaching them that eating meat is inhumane is not acceptable! Taking Jefferson out of history textbooks discussing ‘the enlightenment’ and replacing him with Voltaire is not OK!

It is MY job to indoctrinate my children in the beliefs, customs, culture, and moral judgments that I and my family hold dear! It is only the job of the school to teach my children how to read, write, communicate, and learn!

I try to teach my children that this is the best country in the world. But it is hard to reinforce that when they see the shameful things our government is doing today in the name of progressive liberalism.

The ACLU claims to defend our civil rights—please! They have done nothing but erode our rights for the benefit of small fringe groups and individuals!

Andy Stern and the unions claim to represent the rights of workers—yet any student of economy will tell you that unions drive up the cost of labor which drives down the demand for labor and which ultimately leads to higher unemployment for all. They also will not tell you that while unions drive up the wages and increase the standard of living for union workers--at the same time, wages for non-union workers and their standard of living is driven down.

This government will tell you that ‘big bad corporations’ are the only ones that will be taxed—what they don’t tell you is that corporations don’t pay taxes...people do...and taxes to corporations are like human waste...it flows downhill! They also do not tell you how taxes cause deadweight losses that decrease the overall wellfare of those that cary the burden of the tax.

The main-stream media and press which is supposed to be our ever vigilant first line of defense has lost all sense of objectivity and has aligned itself with the progressive doctrine and the "fundamental transformation of America".

Enough is enough! I’ve had enough and this latest show of political chicanery and complete disregard and disrespect for the collective will of the people and our constitution by this government has driven me to an anger and discontent that I have never experienced before!

I am not advocating violence and would very much love to just stay in my comfort zone and run my practice and build my businesses and sing "everything is beautiful". But in my heart and in my soul, I cannot just sit back and quiet as just another disaffected American while this great nation crumbles around me. I can’t do that for me, for my children and their children, and I can’t do it for you!

Tyranny is tyranny...whether here or abroad and we don’t need talking heads and politicians to define it for us—we see it, recognize it and it MUST be resisted by whatever means necessary!

Dismiss me as a ranting and raving conservative (I am a middle American!) if you will—but know this—I will fight with my life to defend the rights of even those I disagree with...I guarantee you they will not do the same for you!

John R. Vigil, MD

The ObamaCare Crossroads

2010-03-20T23:23:00.000-07:00

The ObamaCare Crossroads

The vote is really about who commands the country's medical resources.

With the House's climactic vote on ObamaCare tomorrow, Democrats are on the cusp of a profound and historic mistake, comparable in our view to the Smoot-Hawley tariff and FDR's National Industrial Recovery Act. Everyone is preoccupied now with the politics, but ultimately at stake on Sunday is the kind of country America will be.
The consequences of this bill will not only be destructive for the health-care system and the country's fiscal condition, though those will be bad enough.

Inextricably bound up in a plan as far-reaching and ambitious as ObamaCare are also larger questions about the role of government, the dynamism of American enterprise and the nature of a free society. Above anything else, this explains why Democrats have had such trouble convincing the public, let alone their own Members.
***

Most acutely in the balance is the future of U.S. medicine. On the opposing page we reprint a 1996 essay by the great Milton Friedman that is more relevant than ever. Drawing from Alexander Solzhenitsyn's novel "The Cancer Ward," the late Nobel laureate traces the ways that national health care fundamentally alters "the consensual relation between the patient and the physician."

In our world of infinite wants but finite resources, there are only two ways to allocate any good or service: either through prices and the choices of millions of individuals, or through central government planning and political discretion. This choice is inexorable. Stripped of its romantic illusions, ObamaCare is really about who commands the country's medical resources. It vastly accelerates the march toward a totally state-driven system, in contrast to reforms that would fix today's distorted status quo by putting consumers in control.

Friedman lays out how the country arrived at our current pass, starting with the World War II-era decision to offer tax subsidies for employer-sponsored coverage only. Like the company store, this inefficient and inequitable preference encourages workers to be paid in kind rather than cash, and over the years the third-party payer system it entrenched has inhibited competition and desensitized patients to the costs of their own care. With the 1965 creation of Medicare for seniors and Medicaid for the poor, government has come to play the leading role in shaping the way care is paid for and provided.

Naturally, the result has been high and rising costs. Since 1962, the share of the economy devoted to health care has risen to about 17% from 6%. Today, health entitlements account for about 5% of GDP but on current trend will rise to 7% in 2025 and about 15% in 2062.

That is the problem President Obama inherited, as it were. Yet rather than fundamentally changing these incentives, he chose instead to create a new middle-class insurance entitlement that will transform the way U.S. health care is financed, and thus delivered. Such a "universal" system has been the core liberal aspiration since the age of Bismarck. But time and again this political ambition has been thwarted by American individualism, distrust of government power, the checks and balances of the political system, and, every so often, good judgment in Washington.

Once the health-care markets are put through Mr. Obama's de facto nationalization, costs will further explode. The Congressional Budget Office estimates ObamaCare will cost taxpayers $200 billion per year when fully implemented and grow annually at 8%, even under low-ball assumptions. Soon the public will reach its taxing limit, and then something will have to give on the care side. In short, medicine will be rationed by politics, no doubt with the same subtlety and wisdom as Congress's final madcap dash toward 216 votes.

As in the Western European and Canadian welfare states, doctors, hospitals and insurance companies will over time become public utilities. Government will set the cost-minded priorities and determine what kinds of treatment options patients are allowed to receive. Medicare's price controls will be exported to the remnants of the private sector.

All bureaucratized systems also restrict access to specialists and surgeries, leading to shortages and delays of months or years. This will be especially the case for the elderly and grievously ill, and for innovation in procedures, technologies and pharmaceuticals.

Eventually, quality and choice—the best attributes of American medicine in spite of its dysfunctions—will severely decline.

Democrats deny this reality, but government rationing will become inevitable given that overall federal spending is already at 25% of GDP and heading north, and Medicare's unfunded liabilities are roughly two and a half times larger than the entire U.S. economy in 2008. The ObamaCare bill already contains one of the largest tax increases outside the Great Depression or the world wars, including a major new tax on investment income—and no one seriously believes it will be enough.

So a vote for ObamaCare is also a vote against the vitality of American capitalism. Business elites have mostly held their tongues, or calculated that they can later dump their health-care liabilities on the government. Yet ObamaCare will lead to much higher levels of taxation across society. The tax wedge—the share of labor costs that never reaches workers but instead goes straight to government—will start flying towards the 50% that prevails today in most of Europe. In America, without the same welfare state obligations, it hovers near 30%.
***

A self-governing democracy can of course decide that it wants to become this kind of super-welfare state. But if the year-long debate over ObamaCare has proven anything, it is that Americans want no such thing. There is no polling majority or any bipartisan support, much less a rough national consensus, for this expansion of government power. The election of Scott Brown in Massachusetts for Ted Kennedy's seat, of all things, was as direct a referendum as you could have.

So if the health bill passes in the House, it will only do so the way it did in the Senate, with a narrow partisan majority, abetted by political bribery and intimidation, budget gimmicks and procedural deceptions. An entitlement the country can't afford and doesn't want may pass because of sheer ideological willfulness. The ugliness of the bill, and of its passage, means that some or all of it might be repealable, but far better not to make the tragic mistake in the first place.

The Emotion of Reform

2010-03-09T20:23:00.000-08:00

By DAVID BROOKS

Published: March 8, 2010

We all have our emotional hot and cold spots. If you asked me about the New York Mets, you’d see a glow in my eyes. If you asked me about banking reform, words might come out of my mouth, but you’d notice me nodding off midsentence.

For the Democrats, expanding health care coverage is an emotional hot spot. Over the past year, Democrats have fought passionately for universal coverage. They have fought for it even while the country is more concerned about the economy, and in the face of serial political defeats. They have fought for it even though it has crowded out other items on their agenda and may even cost them their majority in the House.

And they’ve done it for almost no votes. The 30 million who would be covered under the Democratic proposals are not big voters, while the millions who would pay for the coverage are strikingly unhappy.

There is something morally impressive in the Democrats’ passion on this issue. At the same time, it’s interesting to compare it to their behavior on other issues in which they have no emotional investment.

For example, Democrats say the right thing when it comes to helping small businesses create jobs, but there’s no passion there. For the past year, small business owners have been screaming that they can’t hire people because they don’t know what the rules will be on health care, finance or energy. Democrats hear them, but those concerns take a back seat to other priorities.
Small business owners have been screaming about the health care bill that forces them to offer coverage or pay a $2,000-per-employee fine but doesn’t substantially control rising costs. Democrats hear their concerns, but push ahead because getting a health care bill is more important.

Then there is the larger issue of exploding federal deficits. A few Democrats are genuinely passionate about this, President Obama among them. He has fought tenaciously to preserve a commission that might restrain Medicare spending. But 90 percent of the people in Congress have no emotional investment in this issue.

They’re going through the motions. They’ve stuffed the legislation with gimmicks and dodges designed to get a good score from the Congressional Budget Office but don’t genuinely control runaway spending.

There is the doc fix dodge. The legislation pretends that Congress is about to cut Medicare reimbursements by 21 percent. Everyone knows that will never happen, so over the next decade actual spending will be $300 billion higher than paper projections.

There is the long-term care dodge. The bill creates a $72 billion trust fund to pay for a new long-term care program. The sponsors count that money as cost-saving, even though it will eventually be paid back out when the program comes on line.

There is the subsidy dodge. Workers making $60,000 and in the health exchanges would receive $4,500 more in subsidies in 2016 than workers making $60,000 and not in the exchanges. There is no way future Congresses will allow that disparity to persist. Soon, everybody will get the subsidy.

There is the excise tax dodge. The primary cost-control mechanism and long-term revenue source for the program is the tax on high-cost plans. But Democrats aren’t willing to levy this tax for eight years. The fiscal sustainability of the whole bill rests on the naïve hope that a future Congress will have the guts to accept a trillion-dollar tax when the current Congress wouldn’t accept an increase of a few billion.

There is the 10-6 dodge. One of the reasons the bill appears deficit-neutral in the first decade is that it begins collecting revenue right away but doesn’t have to pay for most benefits until 2014. That’s 10 years of revenues to pay for 6 years of benefits, something unlikely to happen again unless the country agrees to go without health care for four years every decade.

There is the Social Security dodge. The bill uses $52 billion in higher Social Security taxes to pay for health care expansion. But if Social Security taxes pay for health care, what pays for Social Security?

There is the pilot program dodge. Admirably, the bill includes pilot programs designed to help find ways to control costs. But it’s not clear that the bill includes mechanisms to actually implement the results. This is exactly what happened to undermine previous pilot program efforts.

The Democrats have not been completely irresponsible. It’s just that as the health fight has gone on, their passion for coverage has swamped their less visceral commitment to reducing debt. The result is a bill that is fundamentally imbalanced.

This past year, we’ve seen how hard it is to even pass legislation that expands benefits. To actually reduce benefits and raise taxes, we’re going to need legislators who wake up in the morning passionate about fiscal sanity. The ones we have now are just making things worse.

Compassion and Technology: A Marvelous, Expensive Combination

2010-01-05T09:49:00.000-08:00

Leap, Edwin MD
Author Information

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He welcomes comments about his observations, and readers may write to him at emn@lww.com and visit his web site and blog at www.edwinleap.com.

Does anyone realize that the chaos of modern American health care is not a tragedy but a triumph? We're so busy trying to fix what isn't broken and ignoring what is, so busy casting stones and casting doubts, that we are blind to what we have.

I have practiced medicine in this labyrinth for 16 years. I practice in what may be considered the epicenter of modern medicine. Not for its importance necessarily, but for its strategic location in the health care system. That is, almost every specialty, almost every kind of human illness or injury, ultimately finds its way to an emergency department.

I have seen the good and the bad of American medicine. I have seen fantastic physicians and mediocre ones. I have cared for patients in dire distress, and those who were profane, abusive, and manipulative. I have watched as policymakers, administrators, and surveyors caused improvements and inefficiencies. But on the whole, I'll take it any day of the week because American health care represents, for all its limitations and problems, the best that America has to offer.

Why would I say that, when there are uninsured persons and failures? When people slip through the cracks and the cost of modern health care is enormous? I say it because modern medicine represents a confluence of two great American traditions: compassion and progress, both of which conspire to cause the marvelous madness of modern health care.

Emergency department visits are higher than ever, care is better than ever, and medical practitioners keep coming back to do the right thing at all hours of the day and night.

This behavior is not limited to emergency medicine. Surgeons care for drug-addicted victims of gunshot wounds; internists and oncologists provide care for the oldest and sickest, despite the gravity of their situations. Impoverished premature infants are seen in high-tech hospitals that are the envy of the world. Cardiologists and neurologists help us survive heart attacks and strokes that, not so long ago, would have left us consulting with morticians instead of physicians.

The government and the physicians, nurses, nurse practitioners, physician assistants, and others who care for the sick are all possessed with a constantly renewed surplus of concern and compassion, which combine with technology to make American health care the incredibly complex, expensive thing it is. And that's the problem, isn't it? We all desire compassion; we simply want it to be dispensed at a much lower cost.

But our superb technology is expensive. Our research is always changing; new drugs and procedures always being produced. We clinicians stand on the shoulders of researchers and business leaders who provide the means by which we can treat even the most extreme conditions, and often return the sickest individuals to their regular lives.

American health care happens at the nexus of compassion, science, and industry. The desire to treat everyone causes increased cost. The constant supply of new ways to treat everyone causes increased cost. Our general desire to give the best to everyone in our typical, democratic way causes increased cost.

Do you doubt me? I've seen the poorest, drug-abusing, cigarette-consuming individual receive the best care imaginable for lung disease, renal failure, cancer, or trauma. We as a nation, as a profession, are somehow tied to the Golden Rule, and we have difficulty saying no to anyone, not for fear of litigation, but because it might be us, or our loved ones, in need in the future. American government, professionals, and taxpayers try to give the best of all to as many as possible because we view other humans as having transcendent, unconditional worth.

I don't know the answer. I know suffering remains. I know improvements can be made. I hope that wise leaders engage in a few wise reforms. But I think we need a moment of congratulatory pause. Our health care problems are less the symptoms of a national disease than the side effects of an enormous historical accomplishment. America, land of expensive care and remarkable compassion, should think carefully and move slowly before we constrain the characteristics that make our nation and our national health care exceptional.

Government-Run Health Care Is Here

2009-12-09T10:35:00.000-08:00

Andrea Stone

WASHINGTON (Dec. 8) -- So what if the Senate ditches the public option? Even without so-called "socialized medicine," there still will be plenty of government-run health care to go around.

Never mind that the public debate and advocacy ads depict nightmare scenarios of "government bureaucrats" denying medical care, the recent controversy over breast cancer screening being only the latest. Taxpayers already cover nearly half of the nation's health care spending.

The government paid 46.2 percent of medical bills in 2007, according to the federal Centers for Medicare & Medicaid Services. By 2016, under current law, taxpayers will bear more than half.
Federal, state and local governments combined shell out more than $1 trillion a year for health care. That's an estimated $3,871 this year for every man, woman and child -- regardless of whether they get direct government help.

Consider:

• Medicare, the federal health insurance program for nearly 43 million seniors and disabled people, will cost the government more than $500 billion this year alone. It remains wildly popular even though government experts say the program is hurtling toward bankruptcy unless premiums or taxes are raised or costs brought under control.

During the height of the public tizzy over "death panels" last summer, President Obama spoke at an AARP town hall about a letter he received from a woman decrying "socialized medicine" and warning, "don't touch my Medicare."
"That's what Medicare is," Obama said with a chuckle. "A government-run health care plan that people are very happy with."

One option being considered in Congress is to allow uninsured people between ages 55 and 65 to buy coverage through Medicare.

And Tuesday, the government announced that for the first time Medicare would cover the cost of HIV screening.

• Medicaid, the state-administered program for low-income people, will cost taxpayers $386 billion this year to provide health care for more than 42 million people. Some of those are poor seniors and people with disabilities who also get Medicare.

Another idea being debated is to allow more people to qualify for Medicaid.
• Other government programs. In 2007, the federal government spent $137 billion to provide health care to veterans, children, Native Americans, active-duty military members and their dependents, and drug users.

Tax dollars also went to fund public health services, federal workers' compensation and maternal and child health programs.

"The government has a pretty substantial role, no doubt," said John Holahan, director of the Urban Institute's Health Policy Center. And most are happy with the care they receive.
"People are very satisfied with Medicare," said Holahan, citing numerous surveys. "If you begin to talk to veterans about giving up (VA health care) and getting private insurance, they go ballistic."

The taxpayer-financed share of health spending is near 60 percent, Steffie Woolhandler and David Himmelstein of Physicians for a National Health Program wrote in a recent paper in the journal Health Affairs. They note that federal estimates don't include health care-related tax subsidies and public employee health benefits.

In the United States, "tax-financed costs exceed total costs in every nation except Switzerland," Woolhandler and Himmelstein wrote. That's hardly a hands-off approach.

Federal income-tax subsidies for health care, including the hotly debated exclusion of employer-provided health insurance from taxes, reached $186 billion last year, Holahan wrote in a paper with Stan Dorn last year. That exemption helped 61 percent of those under 65 pay for their health care.

Indeed, "only 5 percent of the insured population in the United States does not receive some kind of government subsidy, either directly or through a tax benefit," Holahan and Dorn wrote.

No wonder some call ours a "health care nation."

Obama Health Overhaul May Fail to Cut Spending on Medical Care

2009-12-04T09:17:00.000-08:00

By Catherine Dodge and Nicole Gaouette

Dec. 4 (Bloomberg) -- White House Budget Director Peter Orszag says the medical-system overhaul now being debated in the Senate puts in place “crucial steps” to help slow the growth of U.S. health-care spending.

As the lawmakers struggle to reach consensus on the nation’s most far-reaching health legislation in four decades, some economists and analysts don’t share that confidence in either the Senate or the House bills.

“None of the bills so far would reduce total health-care costs as a percentage of the economy,” said David Walker, U.S. comptroller general from 1998 to 2008. “If there’s one thing that can bankrupt the country, it’s health-care costs.”

The bills would expand coverage to millions of the uninsured. Yet neither measure definitively moves away from the fee-for-service payment system, which encourages more care, Walker said. While the measures call for a new government entity to compete with insurers and curb costs, the impact is likely to be limited because Democratic leaders scaled back the so-called public option to win over reluctant lawmakers.

And both measures call for hundreds of billions of dollars in savings from Medicare, the federal insurance program for the elderly, an idea some Republicans dismiss.
“We’re going to have to reduce Medicare spending by about $400 billion over a 10-year period to get the math right,” Senator Lindsey Graham, a South Carolina Republican, said on ABC television’s “This Week” on Nov. 29. “We haven’t reduced Medicare spending by 40 cents, so that’s not going to happen.”

18% of GDP

A report last month by the chief actuary at the agency overseeing Medicare found that the $1 trillion bill passed on Nov. 7 by the House would boost spending through 2019 by 0.8 percent more than if no overhaul were carried out.

Unchecked, the money Americans spend on insurance, hospital bills and medicine -- now about 18 percent of the gross domestic product -- will be a third of the economy in 25 years, the Congressional Budget Office says.

Orszag and Nancy-Ann DeParle, the White House health-reform coordinator, last week sought to blunt the criticism, in a conference call with reporters. DeParle said the Senate bill “will have a big impact on the growth of health spending.”

Orszag cited a proposal in the $848 billion Senate bill to tax high-end insurance plans, which may encourage companies to offer less-expensive policies. He singled out studies to determine the most effective drugs, devices and treatments, as well as incentives to promote quality care over more care.

‘Aggressive Pilot Projects’

“What the legislation reflects is an aggressive set of pilot projects to emphasize quality,” he said.

Both bills fulfill Obama’s promise not to raise the federal deficit. The CBO said the House and Senate measures would each reduce the budget gap by more than $100 billion.

A Nov. 27 analysis by economist Jonathan Gruber of the Massachusetts Institute of Technology found that families would save at least $500 a year on insurance premiums in the non-group market under the Senate bill.

Days later, a CBO study concluded that while Americans in the nongroup-insurance market -- the one most affected by the overhaul -- would see premiums rise, those increases would be largely offset by government subsidies.

That bolstered President Barack Obama’s vow in a Sept. 9 address to Congress that his plan “will slow the growth of health-care costs for our families.”

Still, there’s a difference between lowering individual insurance expenses and curbing the growth in health-care spending, said Robert L. Laszewski, an Alexandria, Virginia- based consultant to the insurance industry.

‘Gutless Wonders’

The CBO study doesn’t allay concern over rising medical spending, said Uwe Reinhardt, an economics professor at Princeton University, who backs the legislation. While the Senate bill lays the groundwork to slow spending growth, Congress would need to make many more tough decisions that could take years to have an impact, Reinhardt said.

“They are a bunch of gutless wonders,” he said. “They can’t cut any spending.”
The Senate bill is better at controlling spending, economists say, and that sets up a clash when House and Senate lawmakers meld their legislation.

House Democrats rejected the excise tax on pricey insurance plans, saying consumers would end up paying. They opted for a surtax on millionaires, which is unlikely to curtail health spending.

Cost-Cutting Commission

The Senate version also gives more power to a Medicare commission to limit costs. If Medicare spending exceeds target growth rates, the board would propose ways to scale it down. The health and human services secretary would implement the proposals unless Congress passed legislation reducing growth to the target rate.

Victor Fuchs, a Stanford University economist, said much of the congressional legislation shifts spending from one group to another. Prohibiting insurance companies from excluding those who are already sick increases premiums for healthy people, said Fuchs. Mandating that businesses offer coverage, as the House bill does, will shift costs to workers.

Reinhardt said the battle to contain costs will continue.

To “get that growth curve down in my view is a decade-long fierce campaign that may not be winnable,” he said.

To contact the reporters on this story: Catherine Dodge in Washington at Cdodge1@bloomberg.net; Nicole Gaouette in Washington at ngaouette@bloomberg.net

Opinion: Health Care Reform's Lowered Expectations

2009-12-01T16:13:00.000-08:00

John Merline

Posted: 12/1/09

Dec. 1) -- Perhaps it's a sign of how far health care reform has drifted off course. Or of how worried Democrats are about getting health care reform passed.

How else to explain the Senate leadership's joyful response to a Congressional Budget Office report that finds that their reform plan will do little to lower insurance costs for millions of Americans, will raise premiums for millions more, and will cut costs for others only through heavy government subsidies?

That's not exactly what the public was promised when the health care reform train got rolling.

Consider: When President Barack Obama was campaigning last year, he rightly focused on the rising burden of health care costs. As he put it then: "Skyrocketing health care costs are making it increasingly difficult for employers, particularly small businesses, to provide health insurance to their employees."

And he made a very clear promise to voters: Elect me, and I will cut your premiums by $2,500.

"If you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year," he said.

So what did the CBO find in its review of the Senate plan?

By 2016, employees in small firms (fewer than 50 workers) could actually see their premiums climb 1 percent higher if the Senate reform bill is enacted than if it isn't. At best, the CBO figures, they could see premiums that are 2 percent lower than they would be without reform.

Employees of large companies, meanwhile, would either see no effect, or a slight 3 percent drop in premiums in 2016 compared with no reform.

But keep in mind that already sky-high employee premiums are set to climb rapidly for the next several years. A recent Commonwealth Fund study says they will nearly double by 2020 without reform. So, at best, the Senate plan would make a very small dent in a very large premium increase.

And individual buyers, who already have the hardest time getting affordable coverage, could see premiums climb as much as 13 percent higher as a result of the reform – mainly because of new insurance regulations and government-mandated benefits. About half (18 million) would be spared these extra costs because of new federal subsidies included in the plan.

As Urban Institute scholars noted here Monday, one problem with both the Senate and House reform plans is the lack of an aggressive public option that would inject meaningful competition and lower premiums. But the bigger problem appears to be a lack of concentrated focus on what reformers used to call "bending the cost curve." Now it's considered a success that reform won't cause "insurance costs [to] go up across the board as a result of this legislation," as Sen. Evan Bayh, D-Ind., put it.

Admittedly, cost cutting is far more politically challenging than extending new government benefits. But with insurance premiums already too high and rising fast, why should the public be expected to celebrate a plan that fails to provide meaningful relief to so many?

GM: Bailout or Bust?

2009-11-28T11:44:00.000-08:00

This post has little to do with health care--well actually it does if you consider the ramifications of GM failing and not funding it's health care obligations to thousands of retirees--however, I feel it is an important issue when considered in a historical context of the automobile and GM in America over the last 100 years.

This is a paper that I wrote with the help of some of my classmates in our MBA class on economics for managers.

Introduction

We have been asked to consider whether General Motors should have been ‘bailed out’ by the American tax-payer or whether it should have been allowed to suffer the economic consequences imposed by a free-market system on any other company or enterprise that cannot produce or compete efficiently in a competitive market. Unfortunately, we are tasked with this assignment after-the-fact that the “bailout” has occurred and—of course, being a very recent development—there has not been enough time transpired or historical evidence accumulated to argue the point one way or the other. Therefore, we are left with the task of retrospectively and hypothetically arguing the positions using the economic principles taught to us from our course in micro and macroeconomics.

Now most economists, students of economy, and free-market ideologues would (or should) rightly argue that in a truly capitalistic and free-market economy, it is the forces of the market that should dictate those firms that survive and those firms that do not survive based solely on their ability to produce and compete efficiently in the market. However, the birth and death of firms in the market—unlike the birth and death of stars—does not happen in a vacuum and there are other and compelling factors to consider including political, national, social, cultural, historical, philosophical, and even emotional factors when trying to decide whether we let a firm like General Motors die or survive. Like the social and cultural conundrums of abortion and the death penalty, there is not a black or white or right or wrong answer that can or will be agreed upon—regardless of the ultimate outcome.

Before we lay out the arguments both for and against the ‘bailout’ of General Motors, we must fill in the vacuum and provide a backdrop or context within which we can effectively and pragmatically present, analyze, and discuss the arguments and evidence for and against the ‘bailout’. What follows are two brief discussions on the impact of the automobile in the 20th century and a brief history of the automotive industry in America and General Motors.

The Automobile and the 20th Century

Of all the revolutionary inventions and innovations of the last century, it can safely be argued that it is the automobile that has had the most profound effect in shaping western society in general and American society in particular.

It was the automobile that facilitated the emergence of American suburbia as it allowed workers and their families to live further away from the congested urban cities that they worked in. It also allowed those that lived in rural areas much easier access to goods and services and other creature comforts that were only available in the larger towns and cities. The automobile allowed for much greater mobility and made America and the world smaller. This allowed for greater commerce and opportunity which increased the standard of living for all and especially for those that were directly involved in the automotive industry. Indeed, it can be argued that the automotive industry—primarily GM, Ford, and Chrysler—created an entire relatively prosperous middle class, especially in the Midwest, from workers and people that otherwise would have never had such an opportunity considering their education level and class status.

Apart from the greater mobility and commerce that the automobile allowed, it also spawned or facilitated a variety of other and no less important developments and related industries including, parts, paint, and tire manufacturing, parts retailers, dealerships, road building and maintenance, an interstate highway system, gas and service stations, auto racing, and even drive-up and drive-through eating establishments.

The automobile not only radically changed the way we lived, but it also altered the way we fought wars with the introduction of mechanized infantry and tanks and the ability to transport troops and supplies quickly and in much greater quantities. The automobile allowed for the more rapid transport of the injured and sick to hospitals, but conversely also introduced more severe injuries and deaths and in much greater quantities.

Finally, apart from the direct effects and consequences of the automobile in shaping our world, there have been innumerable indirect benefits—and consequences—derived from the automotive industry including technological spin-offs from research and development and pollution. One cannot talk about the automobile without talking about advances in materials and materials science, propulsion systems, petroleum science, engineering, manufacturing processes, environmental sciences, and even advances in medicine and surgery through the improved understanding and treatment of trauma. Indeed, one could even argue that were it not for the automobile, the other two revolutionary inventions and innovations of the twentieth century that have radically changed the world to make it even smaller—air travel and the internet—could have never been developed.

Today, every American enjoys an affluence and position—and some would include freedom— in the world that would have never been possible without the introduction of the automobile and it’s far reaching and long lasting effects on our society. Indeed, some have even made the cogent argument that were it not for the automobile and its related industries, technological spin-offs, and the production capacity of our automotive industry, we could have possibly lost WWII.

A Brief History of GM and America’s Relationship with the Automobile

In the introduction above we have outlined the impact of the automobile on the 20th century and in particular, how the automobile has shaped American society and culture. From early horseless carriages in the late 1800s to the 57 “Chevys” and “T-Birds” in American Graffiti to sleek “Caddys” and fast pony cars (Camaros and Mustangs) in the 70s and 80s to big Suburban SUVs in the 90s all the way to Martian land-rovers and futuristic Camaro-Transformers, nothing has captured the attention of the American people or has defined our culture like the American automobile.

Americans have always loved their cars and the American automobile has been a symbol of freedom and affluence for most of the last 100 years, not only in America, but also abroad and one cannot talk about the American automobile without talking about “the Big Three” or General Motors, Ford, and Chrysler. Out of the several hundred car manufacturers in the early 20th century, it was these three that survived to become the predominant “car makers” in the United States for most of the century. Indeed, General Motors dominated the world market and was the largest car manufacturer in the world until very recently and held that position from 1931 to 2007.

In 1896 the Duryea brothers and their Duryea Motor Wagon Company sold 13 cars and from 1901 to 1904 Ransome Olds and his Olds Motor Company sold hundreds of Oldsmobiles. By 1927 Henry Ford had produced and sold 15 million Model Ts and was producing 60% of America’s cars. General Motors was formed in 1908 by William Durant and Pierre DuPont as a holding company for Buick and by 1909 he had acquired several car companies including Oldsmobile, Cadillac and a truck company that would later become GMC Trucks. In 1910 Durant lost control of his company (General Motors Company) and a few years later started another car company called Chevrolet. Through Chevrolet, he was able to wrest control of his old company and reorganize it as the General Motors Corporation. Not long after, he again lost control for good as a result of a crash in the market for new vehicles (sound familiar?). After the exit of Durant, Alfred P. Sloan took over and led GM into its postwar global dominance.

While Henry Ford is credited as being the “father of the American automotive industry” with his revolutionary design, low prices, and production innovations, it was Durant and his General Motors Company that quickly surpassed the Ford Motor Company with successful marketing and by offering the consumer variety not only in models, but changes from year to year within models.

Sloan is credited as being the ‘genius’ behind the success of GM through his marketing and management structure innovations which brought huge success to the company through most of its existence, but which would prove to become unwieldy and ultimately lead to the eventual collapse of one of the largest corporations in the world. Consider that in 2008 General Motors was selling 9 million automobiles a year globally in over 120 countries and by 2009 General Motors was broke.

By 2008 General Motors, Ford, and Chrysler were feeling the impact of the greater economic recession and the precipitous drop in demand for cars, compounded by intense competition from Toyota, Nissan, and Honda (the Big Asian three) and volatile gas prices. In October of 2008, the “Big Three” were asking for loans from the government and in June of 2009 GM was forced into reorganization through Chapter 11.

Before we leave the history of the automobile in America and present the arguments for and against the ‘bailout’ of General Motors, we must briefly discuss the history of the United Auto Workers or UAW which is inextricably tied—for better or for worse—to the history of the automobile industry and the history of the “Big Three” automakers.

The UAW was founded in 1935 in Detroit, Michigan under the American Federation of Labor and was one of the first labor unions to organize African-American workers. In December of 1936 the UAW staged a sit-down strike at GM’s Flint, Michigan plant which was not settled until February of 1937 and which had become violent with the strikers and their families taking over the plant and resisting attempts by the police and other officials to evict them. GM was chosen as a target for a strike because it was the largest employer of auto workers at the time. The settlement of the strike and the recognition of the UAW by GM instantly boosted the legitimacy, prestige, and power of the UAW which they would continue to leverage and hold to the present day. The BBC would later comment that the strike at Flint “was the strike heard around the world”. A month later Chrysler recognized the UAW and it was not until 1941 that Ford finally recognized them. UAW membership went from less than 30,000 before the strike at Flint to over 500,000 the following year and in the 70s boasted membership of close to 2 million. Today the UAW has about 480,000 members and is still capable of bringing the auto industry to its knees.

America Should Have ‘Bailed Out’ GM

Since GM and the other two motor companies came to Washington pleading for money last year, there has been raging and acrimonious debate in the media, on the internet, in political circles, in academic circles, in business circles, and in private homes regarding whether we should have bailed out the car companies or not. While some of the arguments are based solely on the strict application of economic principles, much of the argument has become mired in or based on political and philosophical ideology which has complicated the argument both ways. Also complicating the debate is the fact that—as goes in most socio-political debate—data and evidence, even from the same exact source, are routinely taken out of context, spun, and presented as statistical and economical evidence both for and against the proposition!

Arguments for the ‘bailout’ have primarily centered on the expectation of a ‘doomsday scenario’ with catastrophic economic losses and further risks to the economy and other social and political costs associated with the failure of GM and the failure triggering a downward spiral or domino effect on other companies and industries. Those arguments generally fall into four broad categories and include economic arguments, technology and trade advantage arguments, national security and socio-political arguments, and national pride arguments.

Many proponents for the ‘bailout’ argue an economic rationale and point to the risk and costs of a large and rapid influx of unemployed auto workers and other workers from associated industries such as dealerships and parts manufacturers and suppliers into the already large and growing unemployment rolls. They cite the potential loss of 128,000 jobs alone from GM if it were to fail and up to 3 million jobs in a worst case scenario of a domino effect causing the failure of the other two domestic car makers and associated companies and industries. They also point to the fact that a failed GM could cause tens of thousands of retired employees to lose their pension plans and health benefits with additional disastrous results on an already burdened economy and health care system.

Other ‘bailout’ proponents argue that allowing GM to fail could result in the potential loss of sensitive and critical technology and associated comparative advantage in those areas to foreign firms and governments which could also pose potential serious consequences in matters of national security. They argue that throughout our history, ground-breaking technology has evolved from research and development in the domestic automotive industry which has been used in other industries, including national defense. They point to the fact that GM developed the technology for its On-Star navigation system which is being used by our military and is currently developing critical technology in lithium-ion batteries and other alternative propulsion systems. It is not too farfetched, they add, to see that while currently, we may be engaging in friendly competition with our foreign competitors and even some sharing of ideas and technology within a global market, a change in the geo-political winds could easily turn competitors into enemies that could use our own technology against us—industrially, economically, and militarily.

Next, there are those that would argue from a socio-political standpoint that allowing GM to fail would result in the exportation of a large portion of our manufacturing base overseas leaving us dependent on foreign firms and governments for manufactured goods and associated technology—again with a real risk to our national security. They argue that our economy is dependent on a solid manufacturing base and that if we lose GM we will have come dangerously close to becoming a nation of consumers in an economy based on service industries and financial services only while depending on other nations to produce for us—and we have all recently experienced what happens when we rely on financial markets as a source of our economic well-being.

Finally, there are many of us that would argue that, if for no other reason—GM should not be allowed to fail as a matter of national pride, national identity, and national integrity. GM, good, bad, or indifferent is an American icon and has served as a symbol of American prosperity, ingenuity, freedom, and ‘good-old Yankee’ industriousness for the last 100 years. GM, along with Chrysler and Ford are responsible for at least two to three generations of a middle-class in America that never would have gained such prosperity without them. Furthermore, they argue that it was the large production capacity and the technology developed by these companies that helped us win World War II and maintain our prominence on the world stage as the world’s industrial leader.

These three companies have donated hundreds of millions if not billions to American charities and other causes. They have educated and trained thousands of bright young American women and men in engineering, business, and the automotive trades. In 1953, during his senate confirmation hearings[1], General Motors CEO Charles Wilson said “what is good for the country is good for General Motors and what is good for General Motors is good for the country”. Those words ring as true today as they did in 1953. So, if for no other reason—we owe it to them!

America Should Not Have ‘Bailed Out’ GM

There are many free-market ideologues including economists and some politicians and many many angry Americans that feel that we should not have bailed out GM from its dire straits. For the economists and the free-market ideologues, this argument is rather straight forward and based on sound economic principles defined by competitive free markets. It is an emotionless and pragmatic argument based solely on economic rationale without consideration of other social or political costs or consequences. The principle argument is that it is the ‘invisible hand’ of the free market that determines who competes and who doesn’t compete and if GM or any other firm has not been adaptable or flexible enough to remain efficient and competitive, then so be it.

The argument continues with the practical reasoning that as the ‘invisible hand’ determines who competes and who doesn’t compete, it also magically and mysteriously ‘picks up the pieces’ when firms and industries fail or become obsolete as the factors of production move on to other firms and industries and the households change their tastes and demand to accommodate the change and vice versa.

On the other hand are those that are just plain angry and frustrated with our current economic situation and use the argument that we are just tired of doling out our hard earned money to failing enterprises, especially if they are failing because of incompetence or greed or both. Many of these are of a younger generation and have grown up in a relatively stable and prosperous era where globalization is the norm and they are more likely than not to drive a Toyota, a Honda, a BMW, or some other foreign car which to them has been associated with higher quality and higher value. The loss of GM, or Chrysler or Ford means nothing to them—they don’t drive or buy their cars and besides, they wonder—“what have the “Big three” done for me?”

Both of these camps argue that $50 billion dollars is a ridiculous amount of money to pay for a company with a net worth of $-90 billion dollars and that in all likelihood will never pay all of its debt and that that money could better be used for other purposes such as paying for extended unemployment benefits, retraining displaced workers, and investing in other emerging industries that will eventually hire the displaced workers. Many of them also argue that the government has no business in buying and running failing companies just as a matter of mistrust in the government meddling in what otherwise is considered private enterprise.

The opponents of the ‘bailout’ also argue that GM has not been able remain competitive because of corporate arrogance resulting in corporate mismanagement in labor relations, organizational structure, quality control, and production efficiency and costs. They argue that if Toyota or BMW can build a better and cheaper mousetrap, then c’est la vie.

Conclusion

As we noted in our introduction, what we have presented so far has been an ‘after-the-fact’ and hypothetical analysis of the proposition of whether GM should be bailed out or not as if the ‘bailout’ and eventual bankruptcy had not happened. We presented both arguments for and against the ‘bailout’ within a general historical context of the automobile, the automotive industry, and GM over the last century. Of course, the ‘bailout’ has occurred and only the passage of time or history will tell us whether the bailout was a good idea or a bad idea.

Today, all we can do is wait and see what will happen. We have provided compelling arguments both for and against the ‘bailout’ and we can only offer conjecture as to why our government decided for the bailout, but we can look at what has happened to date and offer our analysis, based on the arguments presented above and leave the final decision to each of you.

It is clear to all of us, whether for or against the ‘bailout’, that GM and the other two domestic automakers have made some serious, if not catastrophic miscalculations with respect to their relative positions in their market and have critically, if not foolishly, underestimated their competition. But given this, we also realize that the economic events of the last two years have been anything but typical and have caught us all by surprise—as individuals, as households, as firms and even as a government.

Was this failure of the domestic automotive industry an inevitable outcome after years of corporate mismanagement, poor judgment, and reckless optimism—or was it more likely that a ‘perfect storm’ of economic calamity fueled by individual mismanagement, poor judgment, and reckless optimism, a volatile gas market, and poor government oversight (or more likely, government blindness), that battered the otherwise viable, but marginally competitive ‘Big Three”? We cannot know the answer to that, but the question does offer insight into why we bailed out GM.

While, all of us can acknowledge that foreign automakers have made tremendous strides and significant advances in the automotive industry, especially in the latter half of the 20th century and the beginning of this century, no one can dispute the fact that American automakers have reigned supreme throughout the world for the last 100 years with respect to innovations and contributions to industrial society in general and American society in particular.

Allowing GM to fail with the very real possibility of the entire domestic automotive industry following suit in an uncontrolled chain reaction would effectively represent the national capitulation of our dominance held for over 100 years to foreign interests that have capitalized on patience, competitiveness—and a ‘perfect storm’ to come out on top.

Imagine, an Asian baseball team—patient, innovative, and with good management taking advantage of an injured A-Rod, poor umpiring, marginal management, and an onerous union contract stating all the bench has to play, to win a world series—would we throw the Yankees to the curb and claim that in love, war, economics, and baseball all is fair? We think not.

We can’t decide as a group—let alone as a class or society whether we should have bailed out GM or not, but each of us has decided as an individual. We have provided you with arguments both for and against the bailout and have provided some context within which to ponder the question. Most of you are Americans by birth or by residence and you are all students of economics, therefore—you decide!

[1] Shortly after the war, in 1953 GM’s CEO, Charles “Engine Charlie” Wilson was nominated as secretary of defense by President Eisenhower.

John R. Vigil, MD
Jeff Lambert
Jeff Collins
Natacha Peter-Stein, MS
Tommy Sanchez
Thomas Montano
Marlena Parker
Eric Boatman

Anderson School of Management,
University of New Mexico
EMBA Class of 2011

Bitter pill for taxpayers: Drug ads do nothing but boost drug prices

2009-11-24T16:55:00.000-08:00

Melly Alazraki Nov 24th 2009 at 4:40PM

A new study published in the Archives of Internal Medicine found that direct-to-consumer drug advertising may be associated with increased drug prices -- and little else. Specifically, researchers looked at blood-thinner (anti-clotting) drug Plavix, which is commonly prescribed for heart conditions. They found that advertising aimed at consumers did not actually increase the use of the drug. However, because of the increased expenditure for advertising, the price of the drug increased, and so did the reimbursement cost of Plavix for Medicaid patients.

"The cost of drugs to public and private health insurance programs has been a long-standing source of concern among policy markers," wrote the study's authors, Michael Law of the University of British Columbia and his colleagues. Indeed, several members of Congress have asked the GAO recently to examine allegations of price gouging on drugs, especially in light of the ongoing debate over health-care reform legislation.

Prescription drug prices are cited as one of the three top reasons for Medicaid expenditure growth, and prescription drug costs have increased by an average of 15.4% per year between 1994 and 2004. Meanwhile, spending for direct-to-consumer drug advertising has increased more than 330% in the last 10 years, the authors write.

Bristol-Myers Squibb (BMY) and Sanofi-Aventis's (SNY) Plavix has annual sales of $9.5 billion last year. The researchers chose Plavix because there was no consumer advertising for the drug from 1999 to 2000. Then, from 2001 to 2005, U.S. spending on consumer advertising for Plavix exceeded $350 million, an average of $70 million per year.

The researchers examined data from Medicaid programs in 27 states. Despite all of that advertising, the use of Plavix by patients in those states' programs did not change. More precisely, since Plavix sales were growing, the ad campaign did not accelerate that growth. However, the price of a Plavix pill increased by 40 cents, or 12%, after the ad campaign began. "Overall, this change resulted in an additional $207 million in total pharmacy expenditures," the authors wrote. Add in the additional revenues from the rest of the states' Medicaid programs, and the cost to taxpayers would be much higher. (Perhaps sufficient to cover the cost of the ad campaign?) This latest research builds on results of an older study which also showed drug advertising to consumers had only minimal impact on sales.

Those who are in favor of direct-to-consumer advertising of brand-name drugs argue that advertising makes patients more knowledgeable, allowing them to ask for treatments from their doctors. The opponents of this practice claim that more often, such advertising misleads consumers about the benefits and risks of many drugs. Neither side ever questioned whether ads would increase medication use or not.

Most countries in the world do not allow advertising of prescription medications directly to patients. Meanwhile, Americans spend most than other nations on health-care -- 16% of U.S. GDP in 2007. It seems that both sides in the direct-to-consumer advertising debate are wrong in their estimates of the effect of drug advertising on use. But the research does support what both sides agree on -- that consumer advertising costs contribute to that higher American health-care bill, as the Los Angeles Times wrote.

Not everybody fully agrees with the study's methodology and findings; some suggest, as the authors of the study themselves do, that there need to be more studies done on the matter.

How Small Business Will Suffer With "Obamacare"

2009-11-12T10:17:00.000-08:00

SMALL BUSINESS HAS fought the health-care bill as too costly.

That made Saturday's vote bitter to many of the nation's roughly 30 million such entrepreneurs, if welcome to some."With unemployment at a 26-year high, the punitive employer mandates and atrocious new taxes will force small business owners to eliminate jobs and freeze expansion plans at a time when our nation's economy needs small business to thrive," Susan Eckerly, senior vice president of one of the most powerful small-business lobbying groups, the National Federation of Independent Business, said in a statement Saturday.Added Molly Brogan, spokeswoman for the National Small Business Association: "We have serious concerns about the bill's cost-containment and the long-term implications of the employer mandate and the surcharge tax."

Action now shifts to the Senate, and with many specifics still in doubt, small-business groups are planning to lobby heavily there.The House bill mandates that employers with payrolls above $500,000 must contribute -- for each full-time employee -- 72.5% of the premium cost for single coverage and 65% of the premium cost for family coverage. The penalty for failing to do so is a 2%-to-6% tax on employers with payrolls between $500,000 and $750,000 and an 8% tax for employers with payrolls above $750,000.

The Senate, by contrast, has bills that don't have employer mandates but are highly focused on provisions that give tax credits to those that do contribute to premium costs. One bill from the Committee on Health, Education, Labor and Pensions rewards employers for paying more than 60% of their employees' premiums with tax credits of as much as $1,000 for each single-coverage employee and as much as $2,000 for each family-coverage employee.

Outside Washington, meanwhile, small-business owners are weighing their options and responses.Sharon Evans, chief executive of CFJ Manufacturing Inc., a promotional-products company in Fort Worth, Texas, said she pays 65% of health-insurance premiums for her 100 employees. If she were mandated to pick up more of the cost, as the House bill requires, she said she would consider dropping insurance and paying a penalty. And various tax rebates, as envisioned by prominent other versions, don't necessarily pass muster with her."If you're going to make me pay $100,000 to get everybody insured and you give me an $8,000 tax rebate, well, the answer to that is, pardon my French, 'Hell, no,' " she said. "That's not going to help me out."

Carolyn Morse, president of Powerlung Inc., a Houston medical-device manufacturer, said she hopes a tax credit would help alleviate the cost of paying 100% of health-care expenses for her six employees."I would be in a better position to maintain a status quo, rather than go to my employees and say, 'Guys, you're going to have to pay,' " Ms. Morse said.Under all the bills in Congress right now, Ms. Morse's health insurance would be subsidized, but the amount she would receive would vary based on the amount of the premiums.

The House bill provides that employers with fewer than 10 workers who average an annual wage of $20,000 or less get a full credit of 50% of premium costs. That credit amount decreases as employee count and average salary increases, becoming null once the employee count hits 25 or the average salary hits $40,000.Currently, many employers who don't offer health insurance blame the cost-prohibitive premiums. And those who do say expensive insurance is hindering expansion and hiring.

Premiums for single policies rose 74% for small businesses in the past eight years, a 2009 Kaiser Family Foundation survey found. Firms with fewer than 200 workers are expected to pay an average of $12,696 for family-plan premiums and $4,717 for single-person premiums this year.The price of health insurance is a big concern for Mike Draper, president of Smash, a print-screening and design firm in Des Moines, Iowa. Unlike some business owners, Mr. Draper, who pays 100% of the premiums for his 15 workers, supports a mandate requiring employers to provide health insurance -- as long as small companies get to offer better insurance plans at a more attractive price."If the government offers to pay for 50% of my insurance, I'll say 'sure,' " Mr. Draper said. "But from a macro level, I don't see how that will bring cost down -- that's just selling the same crap but subsidizing it."

Some Thoughts on Healthcare Reform

2009-10-29T14:31:00.000-07:00

by economist Steve Landsburg, from his new blog www.thebigquestions.com Landsburg is known for his brilliant economic articles in Slate.com

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The American health care system desperately needs reform. But there are certain inescapable truths that would-be reformers would do well to heed; otherwise they risk making things worse for everyone, and particularly for the poor.

Here are a few of those truths.

1. Insurance is not part of the solution; it's part of the problem. Many people-and especially poor people- get too little health care in this country. That's largely because many other people-and especially rich people-are overinsured. People with insurance demand more health care, which drives up prices. More insurance coverage will make this problem worse, not better. There are good alternatives to insurance. For example, as David Goldhill points out in a magnificent Atlantic Monthly article called "How American Health Care ..., we could take, say, half of what's currently being spent on insurance and Medicare and use it to give each American family close to a million dollars to put in a health savings account. We'd probably want to couple that with insurance for catastrophic events that cost more than, say, $50,000.

Or, less radically (and therefore less effectively, but at least it's a start) we could restructure medical insurance to look more like car insurance-where nobody asks how you spend your claim check. If you're diagnosed with colon cancer, then instead of paying $X million to doctors and hospitals, the insurance company would pay $X million directly to you. That way, at least some of us would shop around for better prices and forgo treatments we don't think we need-lowering demand and making medical resources easier for everyone else to afford.
The last thing we need is more of the inefficient sort of coverage we've got now. The very last thing we need is to make that coverage universal.

2. Somebody has to say no. Nobody would want to live in a world where we all get unlimited health care, because in that world, health care would be all we could afford. That means we despearately need someone to say "no" from time to time. In a world of health savings accounts, we'd tell *ourselves* "no"; in the world we live in, our insurance companies do it for us.
We all know horror stories of claims delayed and claims denied, and many of those stories are true. They have to be, because no system is free of mistakes. Sometimes insurers say "yes" when they ought to say "no" and sometimes they say "no" when they ought to say "yes".

Now, we could always opt for insurers who err more on the side of "yes"-in exchange, of course, for higher premiums. But almost nobody wants that. I know this because I believe that insurers are consumed by greed, and would therefore happily offer any product as long as consumers were willing to cover the cost. Auto insurers compete on exactly this basis: Some companies hand out claims more easily than others, and their premiums reflect this. But when it comes to health insurance, it appears that the market is pretty satisfied with what we've got.

When your health insurer denies a claim, it's performing a valuable public service. If health care is going to stay affordable for anyone, somebody has to sometimes say no. And as much as we bitch and moan (sometimes rightfully, because some of those denials really are unwarranted), we really wouldn't prefer it any other way.

3. A public option can only make things worse. A government run insurance system can only do one of two things: Mimic the private insurers, or do something different. If it mimics the private insurers, it serves no purpose. If it does anything different, it can only be worse.

After all, what can it do different? Approve more claims? But where will the money come from? Higher premiums? But we've already agreed that if people wanted that kind of insurance it would already be offered. A more efficient bureaucracy? But if there were a way to save money by streamlining the bureacracy, why wouldn't all those greedy private insurers have adopted it already? Does anyone believe that the major insurance companies are too lackadaisical to make an easy extra buck?

You might say that the private insurers, unlike the government, won't always pass cost savings on to the consumer. But that too underestimates the greed of the insurers-and their willingness to undercut each others' prices in the endless competition for customers.

So if public insurance is going to provide anything that private insurance doesn't already provide, it will to have to do it by dipping into general tax revenues-maybe not at first, but surely soon. And that way lies madness.

Once those general revenues get tapped, all discipline goes out the window. With all that cash at hand, it becomes harder and harder to deny a claim. Nobody's saying no, and the cost of health care spirals out of control.

Eventually you're left with the health-care equivalent of Fanny Mae or Freddie Mac-an institution with dual mandates to earn a profit (or at least break even) and to serve the public-and therefore an excuse to fail on all fronts. When it loses money, well, that's because it was trying to serve the public. When it fails to serve the public, well, that's because it was trying to be financially responsible. Nothing counts as failure and nobody's responsible. It was Larry Summers who first (and most eloquently) made this observation about the inevitable fate of dual-purpose institutions; once upon a time, he was a very wise man.

I know, I know-the proponents of the public option insist that it will be self-financing. I don't believe them. What happens the first time a powerful congressman demands that his constituent's claims be treated more respectfully? And the second time, and the third? Where does the money come from? But even if you *could* somehow resist that kind of political pressure, what are you left with? A high-claim-approval high-premium option that nobody wants? What's the point of that?

4. It's always the poor who get screwed. Expanded insurance coverage means higher health care prices; universal coverage means higher prices still; universal coverage with a public option blows the roof off. That's bad for almost everyone, but it's hardest on the poor.
Now you might say that we could make up for that by spending lots and lots of public money to buy health care for poor people. The problem with that is that every dollar you spend on health care is a dollar that's unavailable to help poor people in other ways.

When you're poor, it's hard to buy health care. It's also hard to buy schooling, housing, and groceries. It's a false compassion that tries to alleviate one hardship by exacerbating others. If we make it unnecessarily expensive to help poor people buy health care, we handicap our ability to help them buy milk and eggs.

Consider the disaster that is Medicare. It's easy to fool yourself into thinking that Medicare is working because it provides a lot of medical care. But it does so at a titanic cost that crowds out social programs large and small, some of which might have made a real difference in the lives of struggling people. Without drastic reform, the burden of Medicare will crush the next generation. Tack on a publicly run insurance system with its eyes on the Treasury, and you've made that burden all the harder to shed.

I do not know how much we should be collectively spending to help the poor. I do know that whatever we spend should be spent as helpfully as possible. I also know that the way to accomplish that is not to drive the cost of health care through the roof and then spend a fortune trying to help poor people afford it.

It's also worth remembering that political institutions are not notorious for their responsiveness to poor people. When Congressman Smith comes around demanding better service for his favored constituent, odds are that constituent is a person with the means to make considerable campaign contributions. When you move institutions from the private to the public sector, you skew their responsiveness more toward the politically powerful, which usually means the rich.

****************
The answer is less insurance, not more, and private insurance, not public. In the long run, those health savings accounts are probably the best solution. In the interim, the single most effective way to cut health care costs in a hurry would be to eliminate the tax deduction for employer supplied health insurance. That deduction leads to immense overuse of health care resources, especially by rich people. That's one good reason to eliminate the deduction, and here's another: People would start shopping for insurance on their own instead of taking whatever their employers offer, which would make the insurance companies more responsive to consumer demands.

It saddens me that support for universal coverage and a public option has become, in many circles, a sort of litmus test for compassion and caring about the poor. It particularly saddens me to hear the president say that "What we face is a moral issue; at stake are not just the details of policy, but fundamental principles." It's the details of policy that change people's lives. The moral imperative is to get them right.

What an Honor It Is to Belong to the Family of Physicians

2009-10-29T09:02:00.000-07:00

A wonderful post from a family doctor in California who despite the daily drudgery and abuse that he no doubt endures daily in a busy practice is able to eloquently share his thoughts and uplift the spirits of many of us who feel unappreciated in today's healthcare environment.

What an honor it is to belong to the family of Physicians.

It's Saturday afternoon and from the window of my office I see an Oncology practice where the physician comes in on Saturday to see patients. I see his head down as he goes from his office over to the hospital. I see his step grow a little shorter each day as he struggles to keep up with the work. He has shared with me how difficult it is to keep the practice going. With the new reimbursement for chemotherapy, many of the agents he gives in the office cost more than the reimbursement.

I see another office of cardiologists. They seem to come and go at all hours. I see them there late at night, going between their office and back to the hospital. I always feel apologetic when I call them with yet another case that I need their help with because of the complexity of the patient. How grateful I am for their dedication and professionalism. Never have they just said no. Even though I know they won't be making it home to their daughters performance tonight, I still call them with cases when I need help. Their sacrifice, like mine is personal.

Across the parking lot I see an office of surgeons. There are days that the parking lot is rather empty as they are in surgery most of those days. One of my good friends has worked with that group. The part of the story not reflected in the parking lot, is the many hours they spend in the middle of the night, caring for yet another patient needing their skill. Many of these late night cases do not have insurance and many of them require long hours of dedication. What dedicated men and women these surgeons are to come in and work three or four hours through the night, trying to get someone through surgery. When morning finally arrives they have a full day awaiting their attention, compassion and skill. Some of them drive nice cars but somehow I don't think it really helps at the end of the day when they return home to find their family sleeping at a late hour.

There's a group of obstetricians and gynecologists at the end of the parking lot. Never have I felt that their lifestyle was something I would desire. I remember assisting them at C-sections and found that we would do one or two almost every night when I was on call. The funny thing with those late-night surgeries is that when morning arrives, you don't get to go home and take a nap. Somehow the rest of the world expects them to work through the next day as if nothing happened. I have five wonderful children and I can thank them for their dedication and professionalism in doing their job.

We are a very special community. No one in our society really understands what we do, nor do they understand the sacrifices we make as we obtain our training and practice our profession. Only another physician really understands the lengths to which this profession reaches into our personal lives and removes little pieces of us each and every day as we give of our time, intellect, compassion and dedication.

I for one, am proud to be a member of such a community. I feel a tremendous sense of brotherhood with other physicians, be they radiologists, pathologists, cardiologist or oncologists. All of us have made similar sacrifices. Some of us have continued training another three, four or five years longer than others who share the same title of Doctor. Ultimately, we all belong to the same organization of healers, dedicating our lives, our talents, and our abilities in caring for others.

I've not met a physicians who was in this for the money. What an amazing group of individuals we are.I reject the concept that there is a limited pool of resources that must be divided up among the different specialties. Each one of us provides a valuable service to complement what the other does. None of us could work very long in this arena by ourselves. We need each other and we complement each other. We actually work well together in providing care and sustaining life.

I salute my colleagues who answer my calls when I need a specialist to help me with a complicated case. I give you only the hardest cases as the ones that I can figure out, I keep myself. How grateful I am to have learned colleagues so willing to assume the responsibility for cases that I have not been able to either figure out or provide what they need due to my limited training.As a profession, we need to remind ourselves that we all share in the healing arts.

We must all reject the concept that for primary care reimbursements to go up, there must be a balanced reduction in the reimbursement to specialists. Only a politician would subscribe to this concept. Clearly, we can do more to ensure cost effectiveness in the system. We've never really been asked to contribute to that by providing peer review of interventions that perhaps may not warrant the expenses. Those decisions are now being made by insurance companies, with executives who care little for the health of their clients.

If the system is going to be overhauled at all, and if we are ever to successfully reform the way medicine is delivered, now is the time. For those of you who think that we should sit back and wait and see what happens, I would say that it is unlikely there will come a time where there is more interest in healthcare than that which we find right now.

Over the next few years, this reform will spell perhaps disaster and perhaps opportunity. Now is the time for us as physicians to link arms and band together as a profession to support one another. No more infighting which serves only to strengthen the arms of those who provide no health care at all yet bleed the system dry.

I for one, will be sending out thank you cards to the specialists I work with this next week, letting them know how grateful I am for their support and their care. I invite all of us to do the same. Reach out and connect as we reestablish the bond that we all share. All of us love the practice of medicine. We enjoy the challenge and the intellectual reward that we receive by the practice of our art. We truly do enjoy helping those around us in ways that few people would understand. What a great profession we have and what dedicated men and women we serve with.

Let's close ranks and support one another and provide a beacon of hope for America over the next year as we speak out and address the issues. True form will come from our experience and our leadership. Before we step into those leadership positions though, let's make sure that we as a profession maintain the respect for one another that we all deserve.What an honor it is to be part of this community who practice the healing arts.

Public Option a False Start Without Cost Control

2009-10-27T10:48:00.000-07:00

By Fred Hiatt The Washington Post

The “public option” is dangerous not for what it might do but for what it allows the politicians not to do. From the start, the Obama administration has said that health-care reform has to make health care both more accessible and less costly . If Congress does the first without the second — guarantees a new entitlement without controlling costs — it will bankrupt us, because health-care costs are rising faster than the overall economy is growing. So far, though, that seems to be where Congress is headed, for two reasons: First, no one knows for sure how to control costs; and, second, the reforms that are likeliest to work are politically unpalatable.

What are those reforms? The most logical big thing Congress could do would be to tax, as income, the value of the health-care benefits Americans receive from their employers. By not doing so, the government forgoes $250 billion in revenue every year — effectively, its second-biggest health expense after Medicare. It discriminates against people who have to buy insurance on their own. And it encourages overuse of health care, which drives up costs. If employees had to pay taxes on their plan, they might opt for one that cost, say, $12,000 per year rather than $16,000, and push to receive the difference in wages. The government could use the revenue to subsidize health insurance for those who need help. But many unions oppose this change, because they fear it would jeopardize their members’ hard-won benefits, and so Democrats won’t go for it. Sen. John McCain, R-Ariz., embraced the idea as presidential nominee and was irresponsibly attacked for it by his opponent. Now Republicans oppose it so that, were President Obama to embrace it even in part, they could beat him up for retreating from his foolish campaign promise to reform health care without raising taxes on anyone but the rich.

The second big thing Congress could do would be to cede its power to regulate the minutiae of Medicare coverage. Cost control will come from a series of changes, adjusted and readjusted over time, in how physicians and other providers are reimbursed and what they are reimbursed for. Such decisions should be made based on evidence of what works and what doesn’t. But all such changes make one interest group or another — urologists, MRI operators, oxygen tank manufacturers — unhappy. They go to Congress, and Congress blocks the changes. Now Congress is being asked to cede both power and a reliable fund-raising source. And — surprise! — it doesn’t much like that idea.

Which brings us back to the idea of a government-run insurance plan. It allows Democrats to make their base happy, to bash the unlovable insurance companies — and to claim to be taking care of cost control, too, by ensuring competition in the marketplace. The claim merits skepticism. If, as advocates sometimes argue, a public plan operates without favoritism, it will be simply one more entrant in the marketplace. Like other companies, it will have marketing and administrative costs. In some markets served by few private plans, it could offer a useful alternative. But it won’t radically reduce costs. If, as advocates argue at other times, the point is to insure sick people whom private companies, despite all regulatory efforts, find ways to shun, the public plan could offer a valuable safety net. But that wouldn’t save money.

And if, as seems likeliest — and as House legislation mandates — the plan uses government power to demand lower prices from hospitals and drug companies, those providers may lower quality or seek to make up the difference from private payers. Private companies would have to raise their rates, so more people would choose the public plan, so private rates would rise further — and we could end up with only the public option and no competition at all. Single-payer national health insurance may be the best outcome, but we should get there after an honest debate, not through the back door.

So all the attention on whether Obama will get a public plan, as he says he hopes, misses the bigger point. The question is whether he will allow Congress to use the public option as an excuse to dodge the harder reforms, or whether he will insist on true cost control.

Hiatt is The Washington Post’s editorial page editor.

Canadian Patients Feel Wait Of The World

2009-10-26T15:09:00.000-07:00

Canadian Patients Feel Wait Of The World

Posted 10/22/2009 07:27 PM ET
From: Investors.Com

Socialized Medicine: A group in British Columbia has offered medical waiting-list insurance to members whose government treatment is on hold — another example of why state-run health care must be avoided.

Canadians have a health care system that should be the envy of no one. It's not free, it's funded by taxpayers, and it isn't truly universal. Two Canadian Supreme Court justices made this clear three years ago when they concluded that "access to a waiting list is not access to health care."
Delayed treatment in an overused system has been the root of much unnecessary suffering. To prevent premature deaths and the needless misery that are hallmarks of Canadian care, the British Columbia Automobile Association began offering waiting-list insurance to some of its members in August as part of a pilot program.

Those who bought the coverage would receive treatment in a private clinic in British Columbia or the U.S. if they were placed on a government care waiting list longer than 45 days.
The program, which took two years to develop, never got beyond the pilot phase, however. The association shut it down when critics howled and government officials checked to see if such a program was actually legal in Canada.

"This is an example of a company that's actively soliciting for clients that have the ability to pay for the privilege of queue-jumping," said Adrian Dix, a member of B.C.'s Legislative Assembly. "In my view, and in the view of the legal opinion that we obtained, it is illegal, and it violated both provincial and national health legislation."

It's hard to understand why an elected official, or anyone else, would knowingly trap people in a system that can't take care of the public it is expected to serve. Yet there are many Canadians who would, in the name of "fairness" and "equality," deny others' right to take care of themselves outside of the collective. They are outraged that some of their countrymen could escape the agony of the waiting lists while others languish in the bureaucratic wreckage.

But the real outrage, to quote Brian Day, former director of the Canadian Medical Association, should be that a government would actually force "a citizen in a free and democratic society to simply wait for health care, and outlaw their ability to extricate themselves from a wait list."
That, however, is the system Canadians have been living and dying with for decades. Only in recent years does it seem that they've had enough of it. First in Quebec and now in B.C., private clinics have been opening to treat those who either don't want to wait or are too sick to endure the system's waiting list. Whether they will remain legal and open will be decided this fall by the courts.

Meanwhile, Canadians keep waiting — and waiting. The Fraser Institute in Canada reports that the median wait time from a general practitioner's referral to actual treatment by a specialist was 17.3 weeks in 2008 (see chart). That's a full week better than the previous year, but far worse than a decade and a half earlier when the wait time was 9.3 weeks.
Despite the decline from 2007 to 2008, the long-term trend indicates that wait times will continue to grow. It's a discouraging pattern that the U.S. will follow if Washington forces any kind of government care on this country.

Health care: How the U.S. system is designed to waste your money

2009-10-26T14:53:00.000-07:00

This is a great article. It's what I have been arguing for years (See "What's Wrong With Healthcare Today").

Health care: How the U.S. system is designed to waste your money

Bruce Watson Oct 26th 2009 at 5:10PM

Filed under: Technology, Economy, Healthcare

From: Daily Finance

On Monday, Thomson Reuters released "Where Can $700 Billion in Waste Be Cut Annually from the U.S. Healthcare System," a white paper exploring American health-care costs. The report identified six factors -- administrative inefficiency, provider inefficiency, lack of care coordination, unwarranted use, preventable conditions, and fraud -- that cost the U.S. health-care system roughly $700 billion a year.

That's a shocking figure, but $700 billion is a conservative estimate. The price of waste may be as much as $850 billion annually, the report concluded, and other studies suggest the figure may be closer to $1.2 trillion. Given that the most expensive health-care proposal on the table in Congress would cost about $1 trillion, it's clear that significant industry reform could fund most of the cost of universal health insurance.

Where do these costs come from? As much as $150 billion can be chalked up to inefficient hospital administration. Our hospitals spend 25 percent of health-care revenues on administration -- twice as much as Canada's. Better scheduling and more attention to avoidable errors could save up to $100 billion per year, Reuters says. "If all hospitals reduced their average cost to the average cost of the most efficient 10 percent of hospitals," the white paper says, "operating expenses would [drop] by $73 million per year.

"Another big potential money saver: coordination between caregivers. Duplicated tests and overuse of emergency rooms result in as much as $50 billion of unnecessary expenditures annually. Preventive medicine could save as much as $50 billion. It would be reassuring to pretend that such waste is accidental, but it seems to be part of a larger business plan. Every time a patient has blood taken, the hospital gets to bill for administering the test, analyzing it, and storing additional materials, and the insurer subsequently often challenges the patient over the necessity of the test. By the time the transaction is complete, a few vials of blood have supported doctors, nurses, lab technicians, billing agents, test manufacturers, insurance adjusters, and other health-care professionals; the question of whether the test was necessary in the first place is moot.

One of the central points of today's battle over health-care reform has been the issue of a public option: a government-administered insurance plan designed to encourage competition in the marketplace. Reform's most extreme opponents criticize the public option as a step in an inexorable death march to Soviet-style communism and conjure Kafkaesque fantasies of "death panels" and rationed care in an apocalyptic prophesy of American health care. Reform's most ardent supporters, on the other hand, view the public option as an all-purpose solution to a system with no checks and balances: a government-administered price-setter that automatically injects price cuts, improves service, and increases efficiency.

But the Reuters white paper suggests that the public option is a red herring. The real heart of the debate, it says, lies in wonkier issues like efficiency and oversight. The system is now designed to maximize profits by minimizing efficiency: The longer a patient languishes in the hospital enduring tests and procedures, the more money goes to hospitals, drug companies and the medical industry. As health-care becomes more complex and expensive, insurers reap the harvest. For the health-care industry, making money is the primary goal. Healing the sick is a mere side effect.

While a public option might encourage industry players to strive for efficiency and lower prices, it doesn't directly confront the central issue of waste; nor do the health care proposals on Capitol Hill. The focus on universal health coverage is overshadowing the issue of health-care waste, inefficiency and fraud. In a recent New York Times op-ed, former Treasury Secretary Paul O'Neill warned, "Any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate."

Stealth Socialism

2009-10-26T14:43:00.001-07:00

Stealth Socialism

Posted 10/23/2009 07:30 PM ET
From Investors.com

Health Reform: Congress' planned health care revolution will be bad enough without a government-run option. With it, Euro-style socialism becomes inevitable. It's time for a bipartisan way out of this disaster.

Last week proved Democrats want as much big government control as possible in the huge medical sector of the economy. The president's advisers said he's still committed to a government-run public option, House Speaker Nancy Pelosi lined up three versions of such a plan and the Senate majority leader announced a public plan with a state opt-out.
Why is the public option back at all? It seemed dead after a study earlier this year indicated such a plan would mean private health insurers could lose nearly 120 million customers.
Described as being "prized by liberals as a fundamental pillar of reform," the public option is really a way to put capitalistic America on a path toward socialized medicine.

Senate Banking Committee Chairman Barney Frank, a longtime co-sponsor of single-payer legislation, said in July, "I think the best way we're gonna get single-payer, the only way, is to have a public option and demonstrate its strength and its power." Why not just enact single-payer? "We don't have the votes for it," Frank replied.

The public option was conceived by leftist organizations such as the Campaign for America's Future years ago because polls showed the American people liked private health insurance and would never go for a direct government takeover. Ex-Sen. John Edwards' presidential campaign embraced it as "stealth single-payer," and the campaigns of Hillary Clinton and Barack Obama followed suit.

Renegade Republican Sen. Olympia Snowe of Maine may be the one to thank if this new medical entitlement becomes reality, at a time when government accountants warn that Washington is spending the country toward a fiscal doomsday.

The president is reportedly smitten with Snowe's public option "trigger" — an idea that comes down to this: If private insurers charge customers more than Uncle Sam dictates as they deal with all the new costs Washington imposes, the federal government will become their unfair competitor and wreck the private health insurance industry.

With or without a government-run option, the Democrats' radical transformation of the greatest health care system in the world still means reams of new regulations on private insurers, including the likely end of anti-trust protection.

It means fines for those — especially the young — who won't buy what will become high-priced insurance. It may slap uncooperative employers with an 8% payroll tax. And it may impose a $460 billion, 5.4% income tax surcharge sure to kill private sector jobs.

It's time for new ideas, like the expanded private coverage options of the Patients' Choice Act, backed by Rep. Paul Ryan, R-Wis., and Sens. Tom Coburn, R-Okla., and Richard Burr, R-N.C.
As Ryan warns, the federal government would run health care "with the compassion of the IRS, the efficiency of the Post Office and the incompetence of Katrina."

Does the AMA represent us?

2009-10-26T14:17:00.000-07:00

Esteemed Colleagues,

I recently had a non-physician tell me that a recent survey by the AMA showed that "physicians in the US overwhelmingly supported universal health care". I explained to him that the AMA members only represented about 15% of all US physicians--at which time he explained to me that it was a random survey of all licensed physicians, including non-AMA members.

Is this true--or have I been locked in a time-warp?

(I actually looked at the numbers and found out that approximately 57% of those responding (of 2000 surveyed), actually supported a "public option", but for the sake of argument, I calculated the numbers and pointed out to him that 1200 respondants that supported the "public option" was hardly an overwhelming mandate and that that number actually represented less than 00.0015% of all US licensed physicians. He then proceeded to educate me on "using random sampling" whereby I had to educate him on "sampling error" and the danger of extrapolating any meaningful data from such an infinitesimally small sample to such a large and heterogenous population.)

What are your thoughts?

dximgr Radiology
Posted Oct 25, 2009 at 4:18 PM
From the first lines of the Wikipedia article on the AMA: "The American Medical Association (AMA), founded in 1847 and incorporated 1897,[1] is the largest association of physicians and medical students in the United States. While its membership has declined in recent years, it claims approximately 20% of practicing physicians as members."The number of physicians in the US is guesstimated at 800K by several sources (but 1.5M by WHO). Assuming the smaller #, the AMA would have 160K members. Sermo advertises about 115K members. But the latter # is growing while the former # is shrinking.These are back-of-the-envelope calculations. Use them at your own risk.

lasermed1 OBGYN
Posted Oct 25, 2009 at 4:47 PM
The AMA does not represent me, nor many of the other physicians on Sermo. And I do not support the current version of "Universal Health Care".

Phillip Surgery, General
Posted Oct 25, 2009 at 5:39 PM
Asking whether physicians support universal health care is rather like asking all Americans, "Are you in favor of automobiles?" Well, . . . .sure. But what make of automobile? And what FORM of universal health care? There's the rub. Devil is in the details.

drjrvigil Surgery, General
Posted Oct 25, 2009 at 6:13 PM
Thanks for the feedback. Hell, if we can't come to a consensus on what "universal health care" is, imagine what the public is faced with when asked the same question. Unfortunately, they are played to by the pied piper Obama...

rarmstrong Surgery, General
Edited Oct 25, 2009 at 7:18 PM
drjrvigil, Even in the current debate about HR3200, the AMA came out in support of it within 48 hours. Now, they didn't run this by their house of delegates first and their was no poll of the AMA members. Word on the street is that someone in the corporate side of the AMA threw their support behind HR3200. There is a lot of history here on Sermo about this topic. For me, the AMA does NOT represent my views, and any claim that they represent American physicians is completely false. Does that help?

drjrvigil Surgery, General
Posted Oct 25, 2009 at 7:47 PM
rarmstrong, yes it does...thanks for all your comments. For anyone interested, I have posted a blog on this subject on my blog...at www.doctoroncallnm.blogspot.com I would love any editorial, articles, or comments from all of you on this contentious subject

rarmstrong Surgery, General
Posted Oct 25, 2009 at 8:13 PM
So, if you are interested, those of us who went to Washington on October 1st to protest what is occurring, at the Million Med March were interviewed by Fox News. Part of those interviews will be on Sean Hannity's show at 9:00 pm EST tonight.

wbarrettmd Family Medicine
Posted Oct 25, 2009 at 8:47 PM
Do youthink your going to get a different response, from the other 62 times this ? has been asked over the last 2 weeks

docrww Rheumatology
Posted Oct 25, 2009 at 9:53 PM
JR, I believe that your classmate was probably citing a recent 'survey' published in mid-Sept in NEJM online, based on subjects in the AMA database of physicians (and it did break-out responses of AMA respondents.).The survey reported 'wide support' or overwhelming support' (depending on which politician was describing it) for "The Public Option" - but not "universal health care."The survey was discussed on Sermo. The 2 authors (who designed and executed the survey, and even described placing phone calls to subjects who didn't respond promptly - something smell funny about that?) belong to 'Physicians for America' - a group that was known as "Physicians for Obama" until May, and the first author, Dr. Salomeh Keyhani, now serves as Chairman of their Foundation ('foundation' - you know, the fund-raising arm) - potential conflicts of interest not disclosed to/by the NEJM or in any of the TNTC press releases. It's the sort of baloney that would have been shredded in our 1st-year medical school journal club exercises as hopelessly conflicted and methodologically corrupt - but of course the lay press and your MBA classmates don't understand the need to read things critically... But so goes health care reform.

drnopain Pain Medicine
Posted Oct 26, 2009 at 9:13 AM
NEVER

docvicolo Surgery, General
Posted Oct 26, 2009 at 10:56 AM
Universal healthcare should not be synonymous with Free Universal health care but it seems this is what most people think it is............ On the contrary, I hope people will have affordable healthcare that is by all means NOT FREE. People do not appreciate what they perceive as free and tend to abuse the privilege.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:14 AM
One thing universal health care will do is provide a massive shift of health care from the private sector to the public (your tax increase) sector. At present, your family plan costing $12,000/yr will rise to about $26,000 by 2019 because of the additional 40% tax. Most employers cannot afford this increase and will drop coverage forcing you into the publlic option. And this option will pay like medicare and medicaid. Remember the 21.5% pay cut coming up in medicare? This means most of us will not participate with the public plan and many will have insurance, none will have doctors. The common misunderstanding is between having insurance and having a doctor. It is not one of the same. Other stats...the government ALWAYS underestimates cost of programs. In 1965, actuaries estimated medicare costs for 1990 to be $10 billion....infact it was $107 billion. Now the program is spending more than its taking in. Washington has 2 options, ration medicare or raise taxes. Best place for data and statistics is investors.com and hit the health care in the search bar then hit ibdeditorials. Wealth of information to argue our side of health care.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:17 AM
Most of us that sign pay checks on the front are horrified about the socialization of medicine. Those of us that sign paychecks in the back are often clueless.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:21 AM
To: AMA Members An overwhelming majority of U.S. senators, Democrats and Republicans alike, are on record stating that the so-called Medicare sustainable growth rate (SGR) is flawed and should be replaced. S. 1776, the Medicare Physician Fair Payment Act, introduced last week by Sen. Debbie Stabenow, D-Mich., would have repealed the SGR, erasing the existing debt and freezing physician payments at current rates for 10 years. Yesterday's Senate vote (PDF) on S. 1776 was an opportunity for every senator to deliver on their pledge of support for repealing the SGR. Instead the Senate voted 53-47 to block consideration of S. 1776. The blame game being spun by some politicians over the outcome of that vote should be seen for what it is—pure political gamesmanship. Notwithstanding all of the hard work conducted by physicians who reached out to senators of both parties, this bill was blocked for these basic reasons: There is growing concern on the part of legislators and the public over expanding federal deficits. Therefore, a number of moderate Democrats and Republicans, although concerned about the SGR problem, simply would not vote for a bill they viewed as having negative deficit implications. The Senate Republican leadership cast this as a test vote on Democrats' health reform legislation. The problem is that another temporary fix of the SGR formula will merely exacerbate the very deficit problem that so concerns many senators. In 2005, the cost of repealing the SGR was $48 billion over ten years and physicians were facing cuts of 3.3 percent. Today, the price tag to permanently repeal the SGR is $245 billion and next year's scheduled cut is 21.5 percent.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:21 AM
The AMA shares concerns about federal deficits but we believe the responsible thing to do is to finally stop the Ponzi-like scheme to manage the SGR. Instead, Congress must once-and-for-all fulfill its obligation to senior citizens and the physicians who treat them. They can do this by wiping the slate clean and adopting a realistic baseline not predicated on physician payment cuts of 40 percent over the next several years. This effort to permanently fix the SGR isn't over, but we should acknowledge a few positive developments associated with S.1776 including continuing strong support and leadership by Sen. Stabenow and active support from the AARP and the Military Officers Association of America. We also need to thank the 47 Democratic senators who voted for cloture. We need to take a moment to clear up erroneous trade press reports over an Oct. 13 meeting with Sens. Reid, Baucus and Dodd and senior White House staff. At that meeting, the AMA did not agree to support a Senate bill still being drafted. While expressing our ongoing commitment to achieving meaningful health system reform goals this year, we reiterated clearly the AMA's continuing concerns with a number of provisions of the Senate Finance Committee's recommendations. These concerns have yet to be fully addressed.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:23 AM
In other words, the AMA tried to kiss Obama's arse. Instead, it got bullwhipped.

Physician Responses to Apples are Apples Post

2009-10-26T12:47:00.000-07:00

I posted my "Apples are Apples and Oranges are Oranges..." post on Sermo for commentary from real doctors in the trenches--not from the AMA.

dximgr Radiology
Edited Oct 25, 2009 at 8:11 PM
Dr. Virgil: There are several reasons to cast doubt on the WHO rankings. But this is not one of them: "I then pointed out to them that the average population of the European nations they had compared us to was about 50 million (ranging from 9 to 87 million) compared to 350 million in the US and that it was rather disingenuous to compare economies of scale in delivering and administering health care between countries with 9 to 87 million people (Sweden, Spain, France, England, and Germany) and ours with 350 million."Economies of scale allow one to SAVE money as the number of units increases. So if economies of scale played a role (and as I've expressed elsewhere on Sermo I don't think they do), it would lead one to assume the US, with its larger population, would have a lower cost per capita, not a higher one.So unless I'm completely misunderstanding your point, I don't think your reasoning works.

bpoterjoy Pediatrics
Posted Oct 25, 2009 at 8:18 PM
DrJ Your post here is a much longer version of a discussion I have had in non-professional forums. I have grown tired of continually hammering stat-quoters who really have no background in statistics, or who have had no formal instruction in critiquing data. So as to not rehash your well written post, I will simply say I fully agree with your comments. The one thing you left out is this- any meaningful comparison of the US v anyone is difficult not simply on population size, but on demographics- economics, race, social environment, etc. How does one compare the US, with a landmass the size of Europe and a more diverse population to, let's say Norway? I just don't think any comparison is valid. The dilemma is that the average person most likely does not have any exposure to an academic approach to data analysis, and is left with whatever he/she reads online or in the paper, or hears on television, and then quotes the data as if it is gospel.....sort of like the college student writing a term paper....or a med student doing journal club. Speaking for myself, it has taken a decade in medicine to get to reading the hypothesis, methods, and results...

rarmstrong Surgery, General
Posted Oct 25, 2009 at 8:43 PM
John, this subject has, of course been recognized and thoughtfully debated by many here on Sermo. To expect the media, politicians, pundits and others to be educated and honest about these numbers is kind of refreshing but as you have presented, is naive. So, how do you win a debate about health care in America with an uneducated, uninformed and easily inflamed public? You use statistics to lie, dramatize and support your opinion. This is operative, everywhere you look. If you are trying to sort it out...excellent! More of us should work to sort it out. Then, maybe we could form a rational informed opinion on how to proceed. You will not find this type of analysis in abundance inside of the beltway.

lawdoc Psychiatry
Posted Oct 25, 2009 at 9:49 PM
I would like a link to the reference that the editor was concerned about the methodology of the UN. I have often found the statistics problematic, but I have not seen the criticism you reference.Thanks.

theesist Anesthesiology
Posted Oct 25, 2009 at 9:53 PM
I don't know if you ran across these articles when researching for your blog, but here are a couple more that dispute our ranking:townhall.com health.usnews.com

slatosky Family Medicine
Posted Oct 26, 2009 at 9:09 AM
it is about expenditure not outcomes. if you take a country that has no medical care and everyone with breast cancer dies from it quickly and compare them to a country with great cancer survival rates you can then conclude that the country with no medical care has a lower percentage of people with breast cancer with a much lower expenditure. this is what was done in this study. If you were a patient with breast cancer where would you want to be.

rosevoran Internal Medicine
Posted Oct 26, 2009 at 9:36 AM
Power & Idealogy, this is what "Health Care Reform" is all about. Rarmstrong is right, statistics are used to lie.... This administration's goal is a socialist makeover of America. Controlling medical care is pivotal in this quest. There is no debating with them. Have you ever wondered why every one concerned (patients, physicians, pharmaceutical companies, DME companies, etc) will take a huge hit with the Obama plan...all except lawyers. There is no debate, this is a power grab.

Isledoc34 Pathology
Posted Oct 26, 2009 at 10:27 AM
One of my college texts was "How to Lie with Statistics". It seems to be the most popular texts in the WH today. Any good Socialist Govt. needs control, power, and money and will obtain their ends by whatever means available...lying being one of the best,

docvicolo Surgery, General
Posted Oct 26, 2009 at 10:34 AM
Nice Post and Comments. But can we really have any serious discussion about healthcare reform without showing our individual personal bias?.......... Not on Sermo. " Statistics is the art of drawing a crooked line from an unproved assumption to a foregone conclusion." (~ Emil Frankel )

jabmd1 Surgery, General
Posted Oct 26, 2009 at 11:00 AM
I think the key to the statistics is to compare the apples. When you compare surivial rates from many diseases the US is tops (especially cancers) To get high survivial you need to SPEND money. You spend the money on the screening, you spend the money on the treatment and you spend the money to find better treatments. I am in agreement with those that posted before me. This healthcare reform debate is all about power and trying to get a 50% majority vote for all time. Once a group of people have an entitlement program in place do you think any politician that wants to revoke it will garner any votes from the group that gets the entitlement.

lawdoc Psychiatry
Posted Oct 26, 2009 at 11:47 AM
Most of the time, it is not the statistics, it is the liars. There is rampant scientific illiteracy in this country, so the statistics are simply misused.Again, I would like to see the the actual comments of the editor. It should always be evident that we, in the USA, have social problems that pass as medical. When Farrakhan recently was encouraging black people to avoid the H1N1 vaccine, the outcomes will be reported as a failure of the medical "system." Why is it, that the failure to teach health as a meaningful course in the schools never gets mentioned as the main reason people don't know how to take care of themselves or know when it is appropriate to go see a doctor? Parents who don't know anything will only teach mis information to their kids.

Isledoc34 Pathology
Posted Oct 26, 2009 at 12:30 PM
Lawdoc, Re: "Why is it, that the failure to teach health as a meaningful course in the school never gets mentioned"... The schools all give sex education and hand out condums "to prevent disease" which is great Health Care. The kids also sing songs to BO which encompasses all of Health Care, doesn't it? It's disgusting, really.

drjrvigil Surgery, General
Edited Oct 26, 2009 at 1:04 PM
dximgr...you are absolutely correct that economy of scale allows the ability of producing or supplying a commodity at a decreased price..but this hold true only to a point until discoordination occurs in management, inefficicney rises and average total cost of production increases again forming a U-shaped curve (this is called diseconomy of scale). E.g. General Motors. Hence it is ok to compare economies of scale between 9 million and 50 million, but somewhat of a stretch to go from 50 million to 350 million.

dximgr Radiology
Posted Oct 26, 2009 at 1:06 PM
That's exactly why, Dr. Vigil, I said above (and elaborated in prior Sermo comments) that I don't think "economies of scale" explains much in healthcare comparisons among nations. Economies of scale explain things at the level of the factory. When we talk about larger entities, another economic principle swamps it: Diminishing marginal returns.My point was merely theoretical. IF you believe economies of scale plays a role among national healthcare programs, THEN you'd expect the larger ones to be more economically efficient. But if I read you correctly, you were arguing the opposite: that the US, larger, doing worse than European countries, smaller, was explained by "economies of scale." My apologies if this was not your original claim.(If you wish to make some complicated "U-shaped" curve argument, than it's all an empirical question, and you'd need to provide numbers rather than just say it's all explainable by 'economies of scale'.)

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:06 PM
bpoterjoy, You hit the nail right on the head...in fact that was one of the main reason that the WHO stopped the rankings because of the difficulties in comparing demographics, race, socioeconomic variables, and etc.

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:20 PM
lawdoc, here is the link and a summary. www.thelancet.com Judging health systems: reflections on WHO's methods Philip Musgrove PhD a Summary The attainment values in WHO's World Health Report 20001 are spurious: only 39% are country-level observations. The responsiveness indicators are not comparable across countries; and three values obtained from expert informants were discarded in favour of imputed values. Indices of composite attainment and performance are based on imputations and thus are also meaningless. Member governments were not informed of the methods and sometimes suffered unjust criticism because of the rankings. Judgments about performance should be based on real data, represent methodological consensus, be built from less aggregated levels, and be useful for policy.

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:36 PM
dximgr I think we are argiung the same thing. Diminshing marginal return is what makes the U curve slope upwards again. Economy of scale can apply to factories as well as organizations (goods vs services). My argument was that while a single payer system may--and the key word is may--work in smaller countries with populations of the European countries, that it is impossible to extrapolate or assume that that type of system would work in a country with a much larger economy of scale and that in fact, there would be the real and likely possibility that applying such a sytstem to our population would result in diseconomy of scale

Judging Health Systems: Reflections on WHO's Methods

2009-10-26T12:09:00.000-07:00

Judging health systems: reflections on WHO's methods

Original TextPhilip Musgrove PhD

Summary

The attainment values in WHO's World Health Report 20001 are spurious: only 39% are country-level observations. The responsiveness indicators are not comparable across countries; and three values obtained from expert informants were discarded in favour of imputed values. Indices of composite attainment and performance are based on imputations and thus are also meaningless. Member governments were not informed of the methods and sometimes suffered unjust criticism because of the rankings. Judgments about performance should be based on real data, represent methodological consensus, be built from less aggregated levels, and be useful for policy.

By way of explanation

Readers of the World Health Report 20001 will have noticed that although many numbers are in the Annex tables, there is scant reference in the text to the indicators: “Fortunately…the report appears to make very little connection between the results of the performance analysis and the implications for undertaking [the] functions [of health systems]”.2 Text authors were told essentially nothing about how some of the indicators were estimated until near the end of the report's production. Two exceptions should be noted. I participated in the “fair financing” indicator and coauthored two papers describing its construction.3, 4 Chapter 2 of the World Health Report 2000, which I wrote, was the last written, and reflects what I learned from the team working on the Annex in the last weeks. References to “WHO decision-makers” mean Christopher Murray and Julio Frenk—respectively, Director, Global Program on Evidence (GPE); and Executive Director, Evidence and Information for Policy (EIP). References to “WHO staff” include people who worked on the report but who did not make decisions.

Numbers in the Annex

The main feature of the attainment numbers is that most were not derived from any detailed national-level information. WHO decision-makers chose to run linear regressions on real data, and impute values for countries for which there were no data. The imputed values are indicated in the report by italicised numbers, but the footnote which says “Figures in italics are based on estimates” does not explain anything about the estimates. Even for five countries for which all indicators were measured directly, the performance index is the result of imputations. Because it was evident by the time Chapter 2 was written that a large share of the so-called data were going to be imputed, the only comparisons across countries that include the imputed values are figures 2.6 and 2.7 and the accompanying discussion. I now think it was a mistake to have put these figures in the text, which otherwise omitted such presentations.

Ministers of health of the world may have felt, the day the report was published, in the position of parents whose children had been given grades in courses in which they did not know they were enrolled. WHO representatives and liaison officers were also taken by surprise; the advance copies of the report and press materials they were given could not enable them to explain to outraged or baffled officials where the numbers came from. Only 39% of the indicator values represent real data, which falls to 18.5% if disabilityadjusted life expectancy is set aside. This indicator was the only one not imputed by regression for 118 of the 191 member states of WHO. Among these 118 states are 25 in the top 30 positions by attainment and 23 in the top 30 positions by performance. The panel and the table summarise the amount of imputation by country and indicator.

Panel

Shares of detailed national data in the overall attainment index
The number to the right of each country's name in the large table indicates whether detailed data were used for one, two, or three of the indicators. Somalia is given a zero, and Botswana a value of 1, because their estimates of child survival were not calculated from detailed national data. Health inequality (child survival), responsiveness (level and inequality together), and fair financing each account for 25% of the composite index of attainment. Therefore, the share of that index for a particular country that is based on detailed national-level information is given by 0.25(N+1), where N is the number above, and 1 is added to account for the share of attainment due to health level measured by disability-adjusted life expectancy (DALE).
The number of countries for each value of N, and the corresponding share of the information derived from detailed national data, are as follows:

Number of indicators for which detailed data were used (N)

Table image
For the 191 member states of WHO, the mean value of N is 0.555=[(118X0)+ (45X1)+(23X2)+(3X5)]/191. The corresponding mean share of the composite index derived from detailed national data is 0.389. That is, 61% of the numbers which go into the index are derived from imputations and only 39% are based on detailed analyses without any projection across countries. There are 118 countries for which N=0, because the only detailed national data refer to health level—that is 62% of all the countries, which is coincidentally almost equal to the 61% data share. The mean value of N for indicators other then health level is only 0.234, less than half the overall mean of N. This corresponds to a share of real numbers for those indicators (health inequality, responsiveness, and financial fairness) of only 18.5%, equivalent to having detailed and complete information for 35 countries.

TableTable image
Countries for which detailed national data were used to calculate components of the indexes of attainment and of performance

Responsiveness

Groups of key informants were recruited in each of 35 countries and answered a questionnaire about their own country's health system. The heads of the groups agreed that the results could not be used to compare one country with another, because no informant actually looked at any country but his or her own. “There was a unanimous agreement that the instrument was unsuitable in capturing information universally on the domains that were decided by the WHO. We were made to understand that this was a pilot study and findings of this attempt would enable identified issues to be included in some final survey with a representative sample of adequate number. But ranking countries based on this pilot study has been inappropriate and embarrassing.”(From Appendix 2.2; Protest from India to use responsiveness data).5

Five imputed values were published for responsiveness although actual responses were obtained. In two cases the informants gave opinions on one province (Shandong, China) or state (Andra Pradesh, India) rather than the entire country. One part of such a vast country may not be representative of the whole; nonetheless, it surely represents the country better than an estimate based on 30 other countries. In three cases, the informants’opinions were disregarded, without the excuse of incomplete information: Chile (rating improved), Mexico (lowered), and Sri Lanka (improved). Discussion Papers 21 (pages 22, 23 and 25)6 and 22 (page 9)7 give supposed reasons for replacing the informants’evaluations. In two cases the justification is a health reform, and in the other a civil war. Neither situation was restricted to the countries named, nor was there any explanation why war or reform would make an imputed value more accurate than the opinion of well informed observers. Still less is it clear why health reform would make observers err in one direction in Chile but in the opposite direction in Mexico.
When I discovered this substitution, I wrote to Murray by e-mail on Aug 30, 2000, stating “if that doesn't qualify as manipulating the data, I don't know what does…At the very least, it gravely undermines the claim to be honest with the data and to report what we actually find.”8 Murray replied by e-mail the same day, saying that “if results from any survey lack face validity it would be rather counterproductive to simply go with them. It is the careful interplay of infomed assessment of the quality of the results and empirical findings that is the hallmark of the development of good data systems.” I leave the reader to judge the “face validity” of that justification.

I regard these issues as not merely statistical or even political, but ethical. WHO insists that member governments should not misrepresent the data they send to the organisation. It is important that WHO publications meet the same standards. My efforts to persuade Frenk and Murray that publication of these numbers was unethical were in vain.

The question of whether the numbers are honest has an occasional comic aspect. The Russian Minister of Health, without knowing how the numbers were arrived at to rank Russia 130th among health systems, declared himself unperturbed by WHO's judgment, believing it an honest reflection of the situation.8

Use and interpretation of imputation

Imputation can lead to misleading results: a clear example occurs with fair financing. Regression analysis of correlates of this indicator show, not surprisingly, that high income inequality makes it hard to achieve fairness in paying for health care.9 But what is important is how well the system offsets or compensates for that handicap. A country with a high Gini coefficient that achieves a good distribution of finance burden deserves praise for overcoming income inequality, rather than being penalised. Imputed values can of course err in the opposite direction.10 Finally, when imputations are combined into an overall index, they must be clearly interpretable. There are seven components for level of responsiveness, with an equation for each, and an eighth equation for the distribution. When the equations used to impute these values are added up, the same variable sometimes pulls in different directions and enters in different forms, and it is impossible to make sense of any overall effect.

When governments composing WHO's Executive Board asked for more complete technical explanations in time for their meeting in January, 2001, they were given a collection of existing discussion papers, plus some new material.11 No material that explained the imputations was included.

Usefulness for health policy

The attainment and performance estimates are of no use for judging how well a health system performs. They illustrate the mathematical truth that the difference between two complex numbers can be entirely imaginary. This fact has not stopped WHO staff from attempting to explain differences in countries’performance, as though the performance itself were real and accurately estimated.12 Such analysis amounts to guessing who built the canals on Mars. To discover that richer countries have more responsive systems is of little help to a poor country, nor is much gained from knowing inequality in child mortality is lower when total child deaths are fewer. What a concerned government wants to know is what it can do about systemic failings.

One reason the results are of no use for policy is that WHO decision-makers avoided any real participation by governments. There were consultative meetings in December, 1999, and January, 2000, attended by academic experts and staff from WHO headquarters and regional offices. Although the WHO framework was explained and the indicators described in general terms, participants were not told how any numbers were calculated, nor about the intention to publish imputed values. So far as I can establish, nothing said by participants at either meeting changed anything about the methods or numbers. Subsequent requests for information, even from ministers of health, were not answered (José Serra. Minister of Health for Brazil in letter to Gro Harlem Brundtland, Director-General of WHO, July 5, 2000). WHO staff insisted “We should not underestimate the intelligence of policy makers”,13 but in my view, the organisation did not respect the intelligence of those policy makers when defining and calculating the indicators and failing to explain them adequately. Murray also exaggerated the novelty of ideas and indicators in the report. He accused William Hsiao of Harvard University of plagiarising the WHO framework in a paper that discussed health-system goals,14 necessitating a refutation by Hsiao in an e-mail sent to WHO on Nov 27, 2000.

Why did WHO decision-makers proceed as they did?

Given the scientific and ethical objections, to say nothing of the political risks, the question arises as to why WHO took the course that it did. I was told in several conversations with Frenk, Murray, or both, why they thought WHO had to publish an index of performance, even with no consultation with the governments and with most of the numbers imputed. These reasons included:
The favourable opinion of Amartya Sen, who led the creation of the human development index (HDI). The HDI is not intended to establish a frontier of what countries ought to achieve, so although it has some of the same deficiencies as the WHO index, in that respect it is quite different.

The supposition that no-one was adequately concerned with health-system problems, thus a ranking was needed to call attention to them. This approach gives no credit to those who have been working on health-system reform in many countries for many years.
The assertion that nobody would have paid attention to an incomplete analysis restricted to real data. Possibly a more evidence-based analysis would have attracted less notice, because policy-makers pay too much attention to scorecards—partly because WHO and other organisations push them to do so.

The claim that the estimates, imputations, shortcuts, etc used to fill in the tables were better than any previous ones, such as those in the World Development Report 199315 or the Global Burden of Disease.16

Finally, WHO had to produce rankings in time for the 2000 report: any such urgency did not arise from the nature of the exercise or the needs of member states.
The frontier of the possible

The attempt to measure performance depends on a production function for attainments that is available to all health systems. The most striking result is that performance scores are correlated with health expenditure per person (figure 2.6 in the report).1 At expenditures below US$100, half the countries receive scores of 50% or less; poor performance is rare at higher spending levels. This result does not imply a minimum level of spending for a well functioning system, despite efforts by WHO staff to interpret it that way in Health System Performance: Concepts, Measurement and Determinants (pages 4—5).12 If a supposed frontier of what is attainable passes through a large area where no observations fall close to it and there is no assurance that countries actually could get closer to the frontier, the prima facie evidence is that the frontier has been drawn too far away.

Most countries that seem to perform poorly—all the lowest-ranked 18, and 33 of the lowest-ranking 36—are in sub-Saharan Africa. “A large part of the explanation is the HIV/AIDS epidemic”(page 43 of the report);1 there is no way to distinguish, however, between two interpretations: that AIDS is making it hard to reach the frontier, or that it has moved the frontier downward, reducing the best attainable health status. Have African countries fallen toward the floor, or has the roof collapsed on them?

The second interpretation means that deaths and disruption from AIDS have impaired African societies’capacities to deal with pre-existing diseases. Under the impact of the epidemic, money and education have become less effective in improving health. The first interpretation implies that African governments could and should control the health damage from AIDS with existing levels of expenditure and schooling. What is missing is any sense of the feasibility of controlling AIDS. Some preventive interventions have contributed to slowing the trend toward higher incidence;17 but there is no guarantee that control is feasible everywhere. Beyond the issue of interventions required for control is the question of how much they would cost. Estimates suggest that in sub-Saharan Africa, prevention, care, and antiretroviral therapy would require incremental spending, respectively, of at least $1.17 billion, $1.05 billion, and $0.72 billion yearly by 2007, and two, four, and eight times those amounts by 2015 (Improving Health Outcomes of the Poor, tables A.9—A.11),18 to keep prevalence from increasing. These estimates are equivalent to saying the frontier has moved down because of AIDS.

What money can accomplish depends on knowledge and on how money has been spent in the past. Two countries with the same educational level (measured as average number of years of education attained by the population over the age of 15 years), health expenditure, and other variables, but different recent histories, will not have identical possibilities for progress. Extra money or knowledge takes time to become effective. The time lag differs among diseases because scaling up requires more investment in infrastructure, training or other inputs for some than for others (Improving Health Outcomes of the Poor, page 86).18 In consequence, a frontier of the possible cannot be defined independently of the disease burden and the interval in which a country is supposed to improve.

Where to go from here?

Performance measurement relative to what health systems should be able to achieve is a chimera, at least in the highly aggregated, top-down fashion that WHO decision-makers have pursued. Measurement of attainments of various kinds is still valuable, as is looking for ways that health systems can achieve more and make better use of resources. Breaking down performance along one or more dimensions seems to be a good approach—for example, assessment of how the hospital subsystem functions and contributes to performance. Determining which outcomes to hold hospitals responsible for is complex; outcomes may look bad because primary care does not do its job properly. Getting those assessments right directs attention to specific areas, organisations, and policies. If that process cannot be done in reasonable time and at reasonable cost, it is better to abandon the performance measurement exercise and devote resources to areas of more immediate value to the people for whose benefit health systems exist.

Conflict of interest statement

During Sept 1, 1999, to Aug 22, 2001, I was seconded from the World Bank to WHO, where I served as editor-in-chief of The World Health Report 2000—Health Systems: Improving Performance. The interpretations and conclusions expressed in this paper are entirely my own. They do not necessarily represent the views of the World Bank, its executive directors, the countries they represent, WHO, its executive directors, or its member states. The paper was written after leaving WHO to return to the World Bank. There is no other possible conflict of interest. A full version of this article can be seen at http://image.thelancet.com/extras/02art2029webversion.pdf

Physicians Are Talking About: What to Do to Reform Healthcare

2009-10-25T13:22:00.000-07:00

Nancy R. Terry
Authors and Disclosures
Published: 08/07/2009
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As the healthcare debate heats up, the only point on which all parties agree is that the present healthcare system does not work.

An estimated 50 million Americans are uninsured, and the number continues to rise as more people lose both their jobs and their health insurance. Americans spend more than $2 trillion a year on healthcare, which is, by some estimates, 40% more per person than the next most costly country. President Barack Obama and Congress are mobilizing to reform healthcare. Yet, change alone does not guarantee improvement.

In a flurry of postings on Medscape's Physician Connect (MPC), a physician-only discussion board, doctors debate what reform measures would salvage US healthcare. Many physicians are as wary of increased government intervention as they are frustrated by the bureaucratic, profit-driven excesses of private insurance companies.

"As someone who has lived with illness (a congenital immune deficiency) for longer than I have been a doctor, I know first hand how broken our system is," says a dermatologist. "I live in fear of losing my health insurance since I know I am uninsurable through any private program. A public option is the only way to go."

"What would a greatly expanded role for the federal government mean for healthcare in this country?" asks an anesthesiologist. "Rationing for patients, with fewer treatment options and increased difficulty visiting a physician." An infectious disease physician agrees, "Obama's thrust to mandate a Medicare-for-all, single-payer [program] will ultimately lead to healthcare rationing of services -- not for the young and healthy but rather for the elderly, who are the sickest and most vulnerable among us."

The rationing of medical services is frequently cited by a number of physicians as an alarming but predictable component of a national healthcare plan. Yet, other physicians contend that rationing of services already exists. "The private, for-profit insurance carriers have contributed to the healthcare crisis by cherry picking the insureds," says an orthopedic surgeon. "To have a different premium price for those with preexisting illness denies insurance to those who need it most," adds an emergency medicine physician. Another MPC contributor comments, "Instead of making people wait, we just deny elective procedures altogether to people who don't have insurance. That's American rationing."

Advocates of free enterprise favor maintaining a system of multiple insurance providers because, they argue, free enterprise ensures maximum efficiency. In contrast, other physicians claim the exorbitant cost of healthcare can be largely attributed to profit-maximizing insurance companies. "Insurance companies are responsible for the high cost of healthcare," says an MPC contributor. "THEY set the premiums, and the reimbursement and the schemes that are squeezing everyone. All in the interest of profit -- not healthcare."

A national healthcare plan, according to other physicians, would afford no greater efficiency than the current system. "Already doctors aren't accepting Medicaid because of dwindling payments, hassling paper work, confounding delays, long waits, impersonal attention -- medicine DMV [department of motor vehicles] style," quips a pediatrician. "So, everyone will have insurance. Just not that many will have doctors."

Still others see little difference between the options of private and public insurance plans. "The schism between private health insurers and government is a ruse," says a general surgeon. "Medicare is already outsourced to private health insurers. Medicare-for-all will be a big boon for health insurers. Their volume will go up as will their profit margins as government-sponsored cost-effectiveness research demonstrates how much of the expensive medical treatments are "ineffective." Another win-win for government and health insurers. It's all a numbers game -- shift to preventative healthcare and the healthy are happy and the sick are shoved under the carpet."

Obviously, there is no easy solution. The best option, according to some MPC physicians, is to keep open as many options as possible. "Most of the primary care societies and academies favor a one-payer system," comments an MPC contributor. "If we are to give at least basic healthcare benefits to our citizens, we need it [a public plan]. It is not the perfect system, but at present it is the best option available. If a person wants concierge care, he should buy it."

"Will someone please explain what is wrong with a 2-tiered system?" asks an MPC contributor. "A basic plan with some basic coverage for those who cannot contribute and the premier plan for those who do contribute. The water analogy...everyone can drink tap water, but if you want bottled water, you gotta pay."

"Sounds OK to me," responds another contributor. "Coverage for treatments for which there is good efficacy data (not just statistical significance but clinical significance) and everything else, well, if you want it, feel free to buy it."

Few physicians are comfortable with a proposal favored by Congress that participation in a public plan be mandatory for all physicians who accept Medicare patients, although a nephrologist is "okay with mandatory participation for 1 to 2 years to support the government effort, but the mandatory participation should expire automatically afterwards."

Healthcare reform, however, is not simply a question of the number of insurance plans available. Recognizing that any insurance option must coexist with a reform agenda, physicians offer a range of proposals how a more equitable, efficient healthcare system might be achieved.
Hold the insurance companies accountable to insure patients who have a preexisting illness.
Set one premium level for all insurance participants, with varying deductible and copayment amounts.

Establish a fund, patterned after Alaska's Permanent Fund, to cover the cost of insurance for those who cannot afford it. The fund could be built up by taxing commodities and activities that increase the risk for illness, such as tobacco and alcohol use.

Incentivize preventive medicine, especially in the management of lifestyle diseases, such as diabetes and hypertension.

Reduce redundant and defensive testing.

Reform the tort system and eliminate malpractice insurance.

Initiate a national campaign to promote fitness programs, improved nutrition, self-care programs, and disease prevention.

Establish national licensure for nurses and doctors to decrease the costs of multistate practice.

Eliminate state-by-state variations in insurance laws to unify the method of determining eligibility for healthcare insurance.

Eliminate the fee-for-service model, and put doctors on salary.

Physicians, according to an MPC contributor, are in the best position to offer practical, constructive solutions for healthcare reform. "We need to stop coming to the table primarily motivated by protecting our incomes," said an emergency medicine physician. "Instead we should come to the table as citizens who have insight into why our healthcare system is so sick."