Skip to comments.Myths of Health Care Reform
Posted on 12/17/2012 6:04:30 PM PST by Advocatus Sancti Sepulchri
Information technology does not stop bleeding, start IVs, defibrillate the heart, or put in a breathing tube. In an emergency, those are the things that save your life. If you need them, the doctor does not have time to look at your EMR.
In an emergency, the doctor needs to know your blood sugar NOW, not what it was 6 months ago. Ditto for your chest xray. If the test needs to be done STAT, the old results are probably irrelevant, and if it doesnt need to be done STAT, theres time to make a phone call and ask for a faxed report.
The most important information in an emergency is what just happened to you, and that will not be in your EMR.
If you have a serious allergy or other problem that your doctor needs to know in an emergency, wear a MedicAlert bracelet or something else attached to your body. In a bad emergency, your ID may be lost, the computer may be down, or the power may be off.
The EMR is being promoted for the convenience of bureaucrats and lawyers, and for the profits of vendors. Sometimes it helps doctors; sometimes its a hindrance. Only the doctor can decide.
The EMR costs a huge amount of money, and the costs never stop. It might save a few dollars in preventing unnecessary tests for people who have bad memories or cant keep track of paper records.
The whole record could be destroyed by a power surge (especially if its an electromagnetic pulse or EMP). Or it could become unreadable; tapes, disks, and other media become obsolete and are not necessarily durable. On the other hand, it can be nearly impossible to extirpate errors.
The EMR may prevent some errors, but introduce others, especially ones caused by identity theft, sloppy data entry, poor typing skills, confusing software, dry-labbed information entry by macro, and failure to check data once entered. It could even kill you.
EMR systems are a nonconsented experiment, the results of which may be kept secret by the vendors.
If youre desperately ill or critically injured, you need a doctor, not a computer. Your doctor needs to be able to keep his records in a way that works for him, and to choose his own tools, computers included.
It is frequently asserted, especially by groups such as Physicians for a National Health Program (PNHP), that a single payer (government) system could save enough money on administration to buy coverage for all the uninsured.
The basis for the assertion is the claim that Medicare spends only 2% to 3% of its outlays on administration, compared with private plans alleged costs of 20% to 25%.
In fact, data from the Congressional Budget Office (CBO) shows that insurance companies spend at least 50% less on administration than government does on its health programs. (The Congressional Budget Office Reports: Comparing health care admin cost: whos less costly?)
CMS (Centers for Medicare and Medicaid Services ) divides spending data into care (paid to doctors, hospitals, pharmacies, and others for patient care) and non-care (everything else). For 2009, CMS projects spending on care at $2.13 trillion, and non-care at $424 billion or 16.7% of total spending.
Of the $879 billion projected to be paid in 2009 by private insurance, CMS estimates $128 billion for non-care12.7%. For all public programs except Medicare, the comparable percentage is 26%, without adjustment for the taxes and assessments paid only by private insurers. Unlike Medicare, other public programsMedicaid, SCHIP, Veterans Administration, and military programsare internally administered.
Medicare is externally administered by private companies; its non-care costs are 5.7%. If it were administered like other government programs, administrative cost would increase by $1 trillion over the next 10 years.
There are many reasons why private companies have higher non-care costs for their private plans than for Medicare:
Greg Dattilo and Dave Racer conclude: Though one has to dig for the truth, the CBO report makes the case: Competition in a private health insurance market saves tens of billions each year that government agencies would waste on administrative cost.
Benjamin Zycher of the Manhattan Institute for Policy Research also notes that it costs the economy more than a dollar to send a dollar to Washington (Wall St J 10/29/07). The lowest plausible assumption for the excess economic cost of the tax burden, 20%, would raise the cost of delivering Medicare benefits to at least 24% to 25% of Medicare outlays, and a more realistic estimate to about 52%, or four to five times the net cost of private insurance.
Other facts to remember about Medicare administration:
For years, advocates of single payer health care have been warning that middle-class Americans are only one serious illness away from bankruptcyeven if they have insurance. Obama has claimed that medical costs cause a bankruptcy in America every 30 seconds. Divided We Fail claims that millions go bankrupt every year because of medical costs.
American companies are also going bankrupt and losing out to global competition, allegedly because they are having to bear workers high health costs.
Both problems would be solved, say proponents of a government takeover, if the U.S. adopted a universal tax-funded medical system, which would purportedly drive down expenditures, while imposing them on taxpayers instead of individuals and employers.
The facts are these:
Universal tax-funded medical care only compounds the bankruptcy problem. The existing single-payer systems in AmericaMedicare and Medicaidare themselves unsustainable and on a course to bankrupt both federal and state treasuries. The price controls they impose on physicians and hospitals lead to cost shifting to private insurers and self-paying patients.
European social welfare systems are even more financially challenged than those in the U.S. Spending growth is about the same in the U.S. and other developed countries.
The entire world is in an economic crisis. Universal health care is much more likely to be a contributory cause than a solution.
A number of countries report lower infant mortality than the U.S., but it has nothing to do with the source of payment for medical care.
In Japan, which has the best statistics (3.3 die per 1,000 live births), the national system does not cover normal childbirthor prenatal, postnatal, and postpartum care (Your Health Matters by Gregory Dattilo and David Racer, Alethos Press, 2006).
In the U.S., mortality is only 3.0 per 1,000 for full-term babies weighing at least 5.5 lbs (ibid.). Premature, low-birth-weight babies, who have a much higher risk of early death, have a better chance of survival in the U.S. than anywhere else, because of the excellent medical care they receive here.
The incidence of prematurity and low birth weight is relatively high in the U.S.; one reason is ethnic composition. Black American mothers give birth before 37 weeks twice as often as whites, and 3.8 times as often before 28 weeks (Future of Children, Spring 1995).
Predictors of premature birth include socioeconomic factors such as age under 20, single marital status, being on welfare, and not having graduated high school (Lieberman E, et al. N Engl J Med 1987;317:743-748) ; chronic health problems such as diabetes, hypertension, or clotting disorders; certain infections during pregnancy; use of cigarettes, alcohol, or illicit drugs (CDC); and prior abortions (Rooney B, Calhoun BC, J Am Phys Surg 2003;8:46-49). Increasing Medicaid coverage for pregnant women had no effect on birth outcomes (Ray WA, et al. JAMA 1998;279:314-316).
Many nations do not count very small babies as live births. Hence, they dont count as deaths either. In France and Belgium, for example, babies born before 26 weeks are automatically considered stillborn, states Bernardine Healy.
In the U.S., all our babies count, even if they make our statistics look worse. The tiny ones we now save could be the first casualties of reform.
[A question] that assumes even greater significance as we contemplate the finances of health care reform [is] how much capital are we willing to invest to save the lives of the most extremely preterm infants? (Future of Children, op. cit.)
Congress appropriated $1.1 billionthe total worth of 1,100 millionairesto comparative effectiveness research (CER). It promised that CER would not turn out to be cost-effectiveness researchand the rationale for treatment rationing and denialalthough it defeated a proposed amendment that would have codified that promise into law.
In his talk to the AMA, Obama said, [We] need to do figure out what works, and encourage rapid implementation of what works into your practices. Thats why we are making a major investment in research to identify the best treatments for a variety of ailments and conditions. He wants a system where doctors can pull up on a computer all the medical information and latest research theyd ever want to meet that patients needs.
Unlike other research funded by the $30 billion spent annually by the National Institutes of Health (NIH), or by pharmaceutical companies, universities, and others, CER has nothing to do with discovering better treatments or achieving a better understanding of disease. CER is simply supposed to rank existing treatment methods.
The Institute of Medicine (IOM) has winnowed down some 1,300 topics suggested by stakeholders. Of the IOMs 293 recommended primary and secondary research priorities, 50 (by far the largest number) pertain to health care delivery systems; 29, to racial and ethnic disparities; and 22, to functional limitations and disabilities (John K. Iglehart, N Engl J Med, posted 6/30/09).
Half the recommended primary research priorities for delivery systems concern how or where services are provided, rather than which services are provided.
An IOM committee also recommends determining the most effective dissemination methods to ensure translation of CER results into best practicesi.e. enforcement.
The goal of CER is indistinguishable from that of managed care: delivering the right care to the right patient in the right place at the right time.
Cancer is the focus of only six primary CER topics, of which one is related to congressional concern about increased use of advanced imaging.
The $1.1 billion is only a down payment. A new nonprofit corporation is expected to carry on, financed by a $1 annual contribution from each Medicare beneficiary and each privately covered life (ibid.).
CER, by proponents own admission, achieves nothing in itself. It merely represents a significant investment in one of the translational steps toward improving the quality of health care for all (Patrick H. Conway and Carolyn Clancy, N Engl J Med 2009; posted 6/30/09).
Operationally, CER means setting up a bureaucracy and dividing the funding among stakeholders. The content for the materials and methods section of a standard research reportconsent, an institutional review board, control groups, validated data collection tools, defined endpoints, statistical proceduresappears to be absent.
There is no evidence that CER will decrease costs, improve qualityor produce any scientifically meaningful data. But for its proponents, there is no danger that the reformed system will be proved inferior, as there is no usual care arm to the protocol.
For example: determining patients needsby talking to patients. Determining the comparative effectiveness of various treatments in individualsby interviewing and examining patients. Determining the cost and value of differing optionsby permitting prices to equilibrate in a direct-payment model.
The longest-lived people are probably the Japanese. They have good genes, are seldom overweight, and eat lots of fish. They have had a government-funded medical system since 1927and they also have a robust private medical sector. Japanese, like all people except Canadians and North Koreans, are not restricted to a single (government) payer. How do we know they wouldnt live even longer without their government medicine?
International comparisons are tricky because of ethnic diversity in the U.S. While Japanese men in Japan live longer (mean 78.4 years) than the average American man (74.8 years), Asian-American men live still longer (80.9 years). (Bureau of the Census, cited by John Goodman)
If we look at illnesses in which aggressive, timely medical care makes a difference, Americans live longer. For example, American women have a 63% chance of living five years or more with cancer, compared with only 56% for Europeans. For men, the figures are 66% for Americans, and 47% for Europeans, writes Betsy McCaughey.
Some European countries with universal coverage have better life expectancies than the U.S. They also have less gang warfare, less racial diversity, fewer traffic deaths, and a different diet. Americans who dont die from homicide or car crashes outlive people in every Western country (David Gratzer, IBD 7/26/07).
Problems like gangland wars, drug abuse, and unhealthy lifestyles are not caused by lack of universal tax-funded health coverage, and would not be eliminated by enacting it. The suggestion that U.S. life expectancy would increase with universal coverage is faith-based or hope-based, not evidence-based or logic-based. In fact, such an increase is neither sought nor expected by advocates of radical reform such as Tom Daschle, who urge Americans to accept the infirmities of old age and the inevitability of death.
Universal access to a ticket in a waiting line is not a way to improve life expectancy; quite the contrary.
According to the implicit hypothesis underlying the rush to health care reform, the main barrier to ideal care for all at an affordable cost is the absence of universal coveragepayment and supervisionby an appropriate (governmental or government-credentialed) third party.
Without such a mechanism, some patients will avoid needed care or needlessly jam emergency rooms. Some clinicians and facilities will not get paid, or not provide care, or shift costs, or perform unnecessary but well-remunerated services. Insurers will avoid the sick.
The hypothesis is summarized by Linda J. Blumberg and John Holohan: Some of the most prominent shortcomings of the U.S. health insurance market are rooted in the fact that the system is a voluntary one (N Engl J Med 7/2/09). The market segments health risks, and avoids the sick rather than managing their care.
Massachusetts is the grand bipartisan experiment to test this hypothesis. The individual mandaterequiring purchase of insurance by lawbrings in funds from free riders who use care without paying for it, or low-risk persons who decline to pay their fair share to subsidize coverage for higher-risk persons. (The latter phenomenon is called adverse selectionlow-risk persons drop coverage rather than pay the high premiums resulting from community rating or guaranteed issue.)
To compensate for the perceived unfairness of forcing people to buy an unaffordable product, the Commonwealth subsidizes persons too well off to qualify for Medicaid but judged too poor to afford premiums. This expense is supposed to be offset by decreasing (redirecting) payments for uncompensated care.
The Connector is supposed to help people choose suitable coverage that meets all its requirements.
The results of the experiment, which took full effect on July 1, 2007:
Already called the New Big Dig in May 2008, the Massachusetts nonmiracle should be a warning to Washington. The Obama plan, however, is Massachusetts on steroids (Wall St J 5/21/08).
The idea of having a wellness rather than a disease orientation is politically appealing, and politicians on both sides of the aisle promise painless savings of billions by incenting doctors to keep people healthy.
No-cost and low-cost choicesdiet, exercise, avoiding risky behaviorare available to all Americans, without any involvement by health plans or government. The question in the healthcare reform debate is the forcible reallocation of resources from treatment of the sick and the injured to third-party-funded health programs ranging from smoking-cessation counseling to early detection of disease to drug therapy for blood pressure or lipid levels.
The blame-the-stakeholders approacha dollar spent on medical care is a dollar of income for someoneusually sidesteps or minimizes the issue of denying or delaying care to patients who could immediately benefit, in order to reduce the future burden of illness in hypothetical others.
For the rationale of achieving cost control by this means, it is time to write an obituary, writes John Goodman.
The Obama Administrations options for cost control represent hope vs. reality, write Theodore Marmor et al. (Ann Intern Med 2009;150:485-489). Emphasis on prevention, better chronic-disease management, outcome-based payment, and comparative effectiveness research are ineffective as cost-control measures, they conclude.
A review of 599 articles on preventive interventions published between 2000 and 2005 concluded that the vast majority do not save money, notes Victor Fuchs (JAMA 2009;301:963-964). In fact, 80% add more to medical costs than they save (Louise B. Russell, Health Affairs 2009;28:42-45).
The White House claims that the choice of a public plan operating alongside private plans would spur private plans to improve. It also promises that all plans would be playing by the same rules.
According to a July 2 letter from the Congressional Budget Office (CBO), the addition of a government-run plan provision to the Dodd/Kennedy bill, the Affordable Health Choices Act, did not have any substantial effect on the cost or enrollment projections, largely because the public plan would pay providers of health care at rates comparable to privately negotiated ratesand thus was not projected to have premiums lower than those charged by private insurance in the exchanges.
In other words, the government either keeps its word about competing on a level playing field, in which case the plan is pointless, or the government plan gets unfair advantages, notes Andy Chasin in a memo to Republican Health Policy Staff.
Advocates for the public option, such as former Secretary of Labor Robert Reich, say it is the lynchpin of health-care cost containmentbecause without it, the other parties that comprise Americas non-system of health careprivate insurers, doctors, hospitals, drug companies, and medical suppliershave little or no incentive to supply high-quality care at a lower cost . (Wall St J 6/24/09).
In other words, the public plan is expected to use its monopsony power to squeeze providers.
Economist Paul Krugman agrees: A public plan would have the bargaining power needed to bring down costs (NY Times 6/22/09).
Gregory Mankiw points out that it wouldnt really bring down costs, just shift them from consumer to provider. The same thing could be accomplished by taxing providers and using the proceeds to subsidize consumer purchases (NY Times 6/28/09).
Cost-shifting from the big public plans called Medicare and Medicaid already adds an estimated $89 billion to private insurance costs. Crowd-out is amply demonstrated: up to one-half of children newly enrolled in the State Childrens Health Insurance Program (SCHIP) previously had private coverage. A Robert Wood Johnson survey of 22 studies concluded that substitution of government for private coverage seems inevitable (Michael Tanner, Obamacare to Come: Seven Bad Ideas for Health Care Reform, Cato Policy Analysis No. 638, May 21, 2009).
Bargaining power is not the only potential source of lower prices charged by government, notes John Calfee: just look at Fannie Mae and Freddie Mac. They were viewed as less risky because the government was expected to bail them out if they failed (Wall St J 6/26/09).
The other advantage of the government is that it can always change the rules, observes Michael Tanner.
Lets get this straight: 1300 insurance companies arent enough to have competition? We need 1301 to suddenly make it all OK? asks Rossputin.
And if the government wanted more competition among insurers, why not repeal the McCarran-Ferguson exemption that shields the business of insurance from antitrust law?
One enormous advantage the federal plan will almost certainly have is exemption from 50 sets of state mandates that make health insurance unaffordable for so many.
The reason that the President needs to promise that he wont take away your health plan or your doctor is that he believes that he could. After all, there is no right to choose a doctor or form of payment enshrined in the Constitution. And as to the right to contract privatelythat has been whittled away by statute and precedent to almost nothing.
The President and other advocates of radical health reform do say they believe that health care should be a rightthat can never be taken away. However, since this right is to be conferred by government, it is by definition an entitlementa privilege. And even if it couldnt actually be taken awayunless the political situation changes, of courseit can and certainly will be limited, subject to the societal goal of improving the overall health of the collective. How will we reduce the number of tests or procedures, or the amount of GDP spent on medical care, without taking something away?
Even if he doesnt force you to change, the President cannot promise that the health plan or doctor of your choice will still be available under new rules.
And if the reform leads inexorably to single payer, that means no choice of plan.
The President denies that he is aiming to end up where he thinks the system should have begun: single (government) payer. When you hear the naysayers claim that Im trying to bring about government-run health care, he said in one speech, know this: Theyre not telling the truth. He said it is illegitimate to argue that his program is a Trojan horse for single payer.
Its not a Trojan horse, said Professor Jacob Hacker of the University of California at Berkeley, who developed the intellectual architecture for the public option in the 1990s. Its just right there.
Economist Paul Krugman notes that single payer may not be feasible to accomplish politically, but once people have the option of a public plan, it can evolve into single payer.
In other words, the public option is single payer by stealth, writes Conn Carrell.
No one, to our knowledge, has actually come up with an estimate of the number of residents in America, legal or illegal, who are denied life-saving medical careif indeed there are any. Even accusations of violating EMTALAthe Emergency Medical Treatment and Active Labor Act, which requires screening and stabilization of any patient presenting to an emergency roomare apparently rare.
The 46 million are the uninsured. They lack coverage, not care.
The Institute of Medicine and the Kaiser Commission on Medicaid and the Uninsured have published widely cited 2002 reports concluding that uninsured people have worse health than insured people. The IOM guesstimates that 18,000 people a year die for lack of insurancean impressive sound bite that has no factual basis, writes Greg Scandlen.
In the actual report, the number 18,000 occurs only once, in Appendix D, with a description of the convoluted method for calculating itextrapolating from one questionable estimate from one study.
Scandlen observes that neither IOM nor Kaiser did any original research, but simply compiled previous studies. These identify a correlation between lack of insurance and poor health, but cannot determine whether one is caused by the other, or both are caused by some other factor.
In the U.S. 37% of people with below-average income reported that they were in fair or poor health, while only 9% of people with above-average income said the same. A similar disparity is seen in the UK, New Zealand, Canada, and Australia, despite their universal coverage.
People in lower income groups are more likely to be uninsured, but only 18 of the 164 separate studies made any effort to control for income. The Medicaid population, being low income and well-insured, could serve as a control group. In 61% of the 31 studies that identify three populations (privately insured, uninsured, and Medicaid), Medicaid recipients appeared to do as badly or worse than the uninsured in receiving medical services or maintaining good health. In many cases, they have worse outcomes than the uninsured. This is consistent with other information suggesting that income is a much better predictor of health than is insurance status (ibid.).
Smoking and education level were other confounding variables that the IOM failed to consider (David Hogberg, American Spectator 9/22/09).
While the increasing number of uninsured is presented as a crisis, the proportion of Americans without health coverage has changed little in the past decade. The increase in number is owing to immigration and population growth, writes Devon Herrick.
In 2006, 15.5% of Americans were uninsured, compared with 16.2% in 1997.
Of the claimed 46 million uninsured, 12.6 million (27%) are immigrants, either legal or illegal. Up to 14 million (30%) are eligible for government insurance, but havent bothered to enroll. They can sign up the instant they need medical attention.
The percentage of low-income people (<$25,000/yr) without insurance actually decreased 24% over the past 10 years. The highest rate of increase in uninsured status, 90%, was in families with incomes over $75,000, who presumably could have bought insurance if they considered it worth the price.
Insurance coverage is not the same thing as medical care. It is not necessarily the best way to pay for medical carealthough it probably is the most expensive. And there is no actual evidence, only inference from uncontrolled observational studies, that increasing the level of insurance coverage improves health outcomes. If expanding coverage means restricting care, the opposite could occur.
The uninsured are frequently vilified as free riders who receive care but shift the cost onto otherswhen they are not being portrayed as victims who dont get as much medical care as some think they should.
Thus they deserve punishment by higher taxes if they dont accept their individual responsibility to buy costly insuranceor else public subsidies to buy coverage (instead of public payment for care actually received).
The problem is purportedly magnified by overuse of the more costly emergency room by uninsured patients who delayed care they should have gotten sooner from a lower-cost primary physician.
In fact, the Congressional Budget Office (CBO) finds that uncompensated care is less significant than many people assume. Citing a study by Jack Hadley and others in a Health Affairs web exclusive for Aug 25, 2008, the CBO noted that the $35 billion in uncompensated care provided by hospitals in 2008 constituted less than 2% of total expenditures, and the estimates are much smaller for other providers. The amount potentially associated with cost-shifting from the uninsured is at most 1.7% of private health insurance costs, conclude Hadley et al.
The amount supposedly lost because of uncompensated care is, moreover, likely calculated from grossly inflated chargemaster prices.
The uninsured paid $30 billion out of pocket for medical care in 2007. According to a California HealthCare Foundation study, 50% of uninsured residents with incomes at least twice the federal poverty level obtained some medical care in the past year for which they were charged; 80% paid in full, and 10% were paying in installments. About 8% received pro bono care (Wall St J 11/21/08).
A much more serious cause of cost-shifting is underpayment by government programs, Medicare and Medicaid. The leech therapy that these programs use to hold down their own costs by sucking about $90 billion from the private sector adds some 11% (or $1,800 for the average family) to the cost of private plans, writes Shikha Dalmia (Forbes 6/17/09).
Additionally, two-thirds of all medical bad debt is caused by insured patients, who decline to pay their copayments and deductibles, leaving thousands of uncollected balances averaging $500 to $1,000 (WSJ Market Watch 9/9/08).
As to the burden on emergency rooms, uninsured patients are underrepresented there (JAMA 2008;300:1914-1924)after all, they worry about the cost. In Massachusetts, despite the decrease in the number of the uninsured, there has been little change in ER use for routine problems (Kevin Sack, NY Times 5/28/09). One reason might be that expanded insurance coverage leads to expanded demand, and nothing was done to increase available supply.
Hadley et al. estimated the increased demand that would come from insuring all the uninsured: an increase of some $112 billion in medical spending.
The experiment has already been done north of the border. An ER physician in Thunder Bay, Ontario, estimated that nearly half of the residents of his town could not find a family physician and thus flocked to the ER for every medical need, reports Dave Racer.
If democracy means a nationally televised speech by the Leader, the expenditure of tens of millions of dollars by pressure groups, and a frenzied process of voting on a short deadline, then this is a Democratic processwith a capital D for the Party in power.
The level of spending by advocacy groups is unprecedented. Through mid-July, the Campaign Media and Analysis Group (CMAG), which monitors the airwaves, identified $9.7 million in advertising in support of Obamas position, $4.7 million opposed, and $19.7 million by groups staking out a position. MoveOn will be sending activists to every town hall, as well as buying ads. Healthy America Now will add $12 million to what it has already spent on ads favoring legislation that expands health coverage.
MoveOn is deploying its strong, practiced field infrastructure. Spokeswoman Ilyse Hogue said that during August recess, the full force of the progressives pressure will be brought to bear on those who are on the wrong side of history (Politico 7/26/09).
The democratic process does not involve reading the bills. Rep. John Conyers (D-MI), chairman of the House Judiciary Committee, asked what was the point in reading the bill, when its 1,000 pages long, and you dont have two days and two lawyers to find out what it means.
It does not involve responsiveness to letters, emails, or calls from constituents, reportedly running 15 to 1 against the government takeover.
It does not involve hearings or serious consideration of amendments, much less legislation drafted by the minority party. A representative of the Republican Study Committee reported that 200 amendments had been blocked. House Republican Leader John Boehner listed 31 common-sense amendments that were defeated.
These include what might be called stop loss provisions: a $1 trillion deficit cap, delaying spending for disease prevention measures such as bicycle trails until the budget deficit drops below the cap; a repeal of the government-run plan if wait times exceed those in private plans; suspending the job-killing employer mandate if unemployment reaches 10%; and waiving the employer mandate if it causes layoffs, pay cuts, or reductions in hiring.
Also killed were freedom amendments, such as: barring bureaucratic interference in treatment decisions; preventing medical professionals from being forced into a government-run plan; preventing tax funding of abortions (which is opposed by 70% of Americans); protecting health savings accounts and their accompanying high-deductible plans; shielding employer-provided coverage from complex, costly new mandates; and repealing the prohibition against new enrollees in individual plans.
An amendment to require members of Congress to immediately enroll in the government-run plan was approved by voice vote in the Education & Labor Committee, but killed in Ways & Means at the behest of Speaker Pelosi and Chairman Rangel.
Also nixed were tort reform; protecting workers who earn less than $200,000 from tax increases, and prohibiting unfair advantages for the government-run plan.
What is really happening, according to high-level inside sources, is back-room deal-making by power brokers unknown to the public.
The process resembles that which passed the cap and trade energy bill. It was not passed because Congressmen bought into flawed science or listened to climate Rasputins. The terrible truth is much worse than that, writes Arthur Robinson. The truth is that Congress has become so corrupt that it is incapable of acting on principleseven misguided principles.
Congressmen do not care whether the bill is a good one or not. This past month I watched an awful spectaclechronicled approvingly in the presswhile the cap and trade bill moved forward, picking up votes as its sponsors bought one Congressman after another with provisions that would enhance their careers. It was reported that the last major hurdle was cleared by giving farm state Congressmen a few goodies for farmers.
There was essentially no discussion of science or of the revocation of human freedom in the bill. The entire process was one of trading favors. Bribery in the form of handouts to constituents is far less cost-effective than simply handing the legislator a suitcase full of money.
The strategy during the August recess was outlined by Paul Begala, a Democrat strategist close to the White House: Supporters of reform have to put the status quo on trial (Politico.com 7/26/09).
If somebody told you that there is a plan out there that is guaranteed to double your health care costs over the next 10 years, thats guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to the federal deficit, I think most people would be opposed to that, Obama said. Well, thats the status quo, he claims (ibid.).
Members of Physicians for a National Health Program (PNHP) identify the 70-some health plans with which they have voluntarily contracted as the status quo, or even as the free market, and complain bitterly about the poor remuneration and costly administrative hassles.
AAPS does not support the status quo, but over years and decades has advocated fundamental reforms thatunlike the Democrat plans
Instead, AAPS supports reforms that:
Reform can begin immediately at the individual level, as physicians quit participating in third-party arrangements, and patients fire health plans that insist on intruding into the patient/physician relationship.
Specific desirable legislative changes include the following:
A coalition of state and specialty medical societies has drafted a letter to Congress espousing a patient-centered system rather than a government-controlled systemthe right kind of change from the status quo.
Based on 173 deaths in the Harvard Medical Practice study, and extrapolating to the entire U.S. population, the Institute of Medicine (IOM) has been claiming for almost a decade that as many as 98,000 Americans are killed by medical errors every year.
Moreover, it is asserted that Americans have only about a 50/50 chance of receiving proper health care.
The proposed solution: electronic records with constant surveillance of compliance with government-approved protocols. The IOM claims that its methods could reduce errors by 50% over 5 years.
The IOMs definition of error, the assumption that a death was a result of the error and would not have occurred anyway, and its guesstimate of the number of deaths all lack independent confirmation. The IOM number is three to seven times higher than a 1998 estimate by the National Safety Council.
Although the IOM analysis is uncritically accepted by the AMA and other influential bodies, there is no evidence at all that the proposed solution would result in any improvement in mortality or other patient outcome measurements. More likely results are:
The usual response to concerns about the months-long waiting lists for surgery in Canada and Britain is that this is a mere inconvenience, a small price to pay for universal free care. If you have a really serious need, youll get immediate attentionor so Michael Moore and others tell us.
Although one can surely come up with anecdotes about someone who got good emergency care in a Canadian or British hospitalespecially if the person is a prominent journalistthis is not the norm.
The average wait in Canadian emergency rooms is 23 hours, stated John Stossel on ABCs 20/20.
Once admitted, a Canadian patient may wait three days in the emergency department for a bed (Michael A. Platokov, A Temple for Human Sacrifice, Western Standard 12/4/06).
Actress Natasha Richardson suffered an epidural hematoma from head trauma while skiing Mont Tremblant in Quebec. Prompt neurosurgical treatment probably would have saved herbut it took 4 hours to get her to a properly equipped hospital after she started to deteriorate and called 911 from her hotel room. Quebecunlike the U.S.has no medical helicopters (CBSNews.com 3/21/09).
But the flip side, advocates for the Canadian system say, is that U.S. helicopters are way overused. A person with a non-life-threatening injury might get killed in a helicopter crash, as has happened (Slate.com 3/27/09).
Because of lack of a single bed in any neonatal intensive care unit in southern Ontario, 10 to 15 babies per year have to be transferred to Buffalo, N.Y. Parents of Ava Isabella Stinson were amazed at the way their daughter was treatedand ended up with a different view of Americans.
Even the security guards care about how you feel. And the Ronald McDonald House was like living in a mansion, said Stinson (Buffalo News 7/2/09).
Cancer might be considered an emergency by the patientbut not by the Canadian or British health bureaucracy. Those who want prompt surgery generally have to come to the U.S., as Stuart Browning shows in the video A Short Course in Brain Surgery, which has been seen by more than 3 million viewers.
In Britain, the National Health Service is supposed to cover necessary treatment, but people are selling their homes to get cancer care (Daily Express 12/22/2008). One British cancer patient waited for an appointment with a specialist, only to have it cancelled48 times (David Gratzer, The Ugly Truth about Canadian Health Care, City Journal, summer 2007).
Kidney failure is fatal, if you cant get dialysis. In Britain, you are ineligible for this life-saving treatment once you reach the age of 55. The mother of Beth Ashmore, a past president of the National Association of Health Underwriters, developed kidney failure while visiting England. Treatment was denied because of her mothers age, so Ashmore arranged for a specially equipped jet to bring her home. The hospital, however, had placed her in a back room to die, aloneand could not locate her! Thus, she died while an aircraft that could have saved her waited on a runway in Atlanta to find out its destination.
Mere pain, no matter how severe or disabling, is not considered life-threatening, so orthopedic surgery that could relieve it is usually long delayed. Dr. Brian Day, former president of the Canadian Medical Association, saw his operating room time reduced from 22 hours to only 5 hours per week, 10 hours less than recommended for minimal competence by the Canadian Orthopaedic Association. He had 450 patients waiting for care (National Post 10/23/07).
Everybody in a country with universal health care has a right to health care, but Americans do notor so it is argued. Health care reform is supposed to correct a moral deficiency in the United States, and, at long last, grant a fundamental human right to Americans.
At present, Americans who have purchased insurance have a contractual right, enforceable in court, to whatever benefits are agreed to in the contract. Federal law entitles them to a screening examination and stabilization if they present to an emergency facility, even if they have no ability to payand the hospital and on-call physicians are obligated by law to provide the service.
In an American hospital, women in labor will be delivered; patients with a surgical emergency will have an operation; and patients with a life-threatening medical emergency will be admitted. But later, the hospital will try to collect payment. Americans have no right to receive medical services at taxpayer expense. Those enrolled in Medicare, Medicaid, or other government program have an entitlement to certain benefits, determined by politicians and bureaucrats. About half of U.S. medical expenditures are made by government through such programs.
How is the situation different under universal health care?
In Canada, patients are entitled to treatment only after they present their insurance card. If they lack a card, say because they are homeless and havent signed up for the program, treatment will be denied.
One man in Quebec forgot his card at home, and was denied care, even though his name was in their computer. No card, no service. When he went home to get the card, his appendix ruptured, and by the time the ambulance arrived, he was dead. At age 21. As Mark Steyn writes, He didnt make it to 22 because he accepted the right of a government bureaucrat to deny him medical treatment for which he and his family have been confiscatorially taxed all their lives.
Under universal health care, one has no right to care that is timely, convenient, or state-of-the-art. Under a single payer (government-payer-only) system, one has no right to pay extra to allow the operating room, imaging center, or clinic to stay open longereven though this would decrease the waiting time for everyone, including those who could not afford to pay more. One has the right to receive only the services that society (politicians and bureaucrats) has decided to make available.
Most nations of the world have a private sector that relieves some of the strain on the public system, though people who receive private services have paid twice for medical careonce for the public services that they do not use, and again for the care they do receive. Canada and North Korea have a single payer; Canadians have the right to pay twice if they go abroad for treatment.
Rights that Americans would lose under proposed reforms include: the right to buy true insurance, for which premiums are based on risk; the right to decline to buy a plan they dont want; the right to self insure; the right to reap the benefits of healthful living, hard work, and prudent spending; and the right to keep their medical records confidential. If the reforms evolve into a single payer, as many advocates intend, Americans would lose the liberty to use their own property to prolong or enhance their own lives.
Obligations that reform would impose on Americans include: continually proving that they had paid for coverage that the federal government deems acceptable; paying what the government deems to be their fair share for insuring persons below a certain income threshold; paying for procedures they deem to be harmful or immoral if coverage is mandated by government; and paying for expanded, costly bureaucracy.
Americas extraordinary prosperity and technological progress occurred in an atmosphere of freedom. The losses resulting from a central chokehold on innovation are incalculable. Advocates of reform often attribute the high cost of American medicine to new drugs, devices, and procedures, and want still-heavier regulation to restrain these advances. Both Americans and the result of the worlds peoples will lose if America is no longer the engine of progress.
Americans are being asked to exchange their birthright of freedom forpoliticians promises. And to trade their natural, God-given rights to life, liberty, and property for government-granted privileges or entitlements.
If you have to show a card that proves you are eligible to receive a certain service in a certain facility, you do not have a right, only a privilege. A privilege that can be revoked by bureaucrats calculating the gains and losses to society from your treatment.
People have come to trust their government entitlement programs, just as they once trusted Bernie Madoff. However, Americans have no constitutional or contractual right to their Social Security benefits, for which they have been taxed all their lives. This was established decades ago by the U.S. Supreme Court, in the case of a man who was deported for being a Communist after paying Social Security taxes for 19 years. In upholding the 1954 law that revoked the Social Security privilege for such persons, the Court cited the necessity of Section 1104 of the 1935 Act, entitled Reservation of Power, reads: The right to alter, amend, or repeal any provision of this Act is hereby reserved to Congress.
The Court ruled: To engraft upon the Social Security system a concept of accrued property rights would deprive it of the flexibility and boldness in adjustment to ever- changing conditions which it demands . (AAPS News, August 2008). Remember that Medicare is part of the Social Security Act.
Fundamental rights guaranteed by the U.S. Constitution must be abridged to grant a right to taxpayer-funded medical treatment. The tradeoff is of true rights for what is actually a privilege or entitlement.
What the government gives, the government can take away. And of course, whatever it gives was first taken from someone.
The phrase death panel does not actually occur in any of the proposed health care reform bills. MoveOn.org has seized on Sarah Palins characterization of the outcome of reform in its mass email piece entitled Top Five Health Care Reform Lies: and How to Fight Back:
Lie #1: President Obama wants to euthanize your grandma!!!
When asked about the end-of-life counseling provision at an AARP-sponsored tele-town hall, Obama grinned and told the woman called Mary: I guarantee you, first of all we just dont have enough government workers to talk to everybody to find out how they want to die (Judi McLeod, Canada Free Press 8/13/09).
This argument is a straw man.
In fact, neither the President nor cadres of government workers would be doing the job personally, and euthanasia is not being discussed. Rather, the bills incentivize doctors to counsel patients about optionswhich must include orders to withhold life-sustaining treatment, such as food and water.
While signing a directive to withhold treatment or food and water, or to implement a do not resuscitate order, may be voluntary, suggestible patients may bow to white-coated authority, especially when the directive is presented to them to sign immediately. Vulnerable patients may be especially susceptible to guilt-provoking scenarios, such as being a burden on their families.
The counseling provision has been removed from one of the Senate bills, but many believe the enabling legislation for treatment denial is already law, in the Stimulus Package, as comparative effectiveness research. While proponents denied that there was any intention to turn this into cost-effectiveness research, an amendment to codify that reassurance into law was defeated. This research program is supposed to collect information on every medical visit by every patient for a national electronic database.
This is the infrastructure for a program like Britains NICE (National Institute for Clinical Excellence), which determines the dollar value of a Quality Adjusted Life Year (QALY). NICE allows payment for treatments that cost less than that, and disallows treatments that cost more.
Doctors who want to violate the voluntary guidelines will likely have to appealto a body that is not called a death panel (Greg Scandlen, American Spectator 8/13/09).
What are the beliefs and principles of the leading reformers? Obama himself has said, Maybe youre better off not having the surgery but taking the painkiller.
As Betsy McCaughey points out, prominent Administration advisor Ezekiel Emanuel, M.D., believes that communitarianism should guide care. He says that medical care should be reserved for the non-disabled, not given to those who are irreversibly prevented from being or becoming participating citizens . An obvious example is not guaranteeing health services to patients with dementia (Hastings Center Report, November/December 1996) (NY Post 7/24/09).
More recently, Emanuel and others write that they recommend an alternate system, the complete lives system, which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, saves the most lives, lottery, and instrumental value principles (Lancet 2009;273:423-431).
This system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated.
Obamas regulatory czar Cass Sunstein, who will play a major role in defining governments role in controlling medical care, prefers the QALY formula (Joseph Ashby, American Thinker 8/15/09).
Seniors are worried. Having lost about 60,000 members, AARP is back-pedaling on its endorsement of the reform push (Wall St J 8/21/09).
Its not just seniors who are worried. There are also the 10 million American cancer patients whose access to expensive treatments may be cut off, as it routinely is in Britain. In addition, progress in treatments may stall because of the likelihood that new technology can never repay the cost of development (Wall St J 7/31/09).
The highly touted Oregon health plan already denies payment for advanced chemotherapy, but offers to buy physician-assisted suicide instead.
Then theres the Death Book for Veterans, entitled Your Life, Your Choices. The primary author is Robert Pearlman, who in 1996 advocated for physician-assisted suicide before the U.S. Supreme Court in Vacco v. Quill, and is known to support rationing of medical care. The 52-page book presents choices in a way that steers users to predetermined conclusions, like a political push poll. Withdrawn from the VA by the Bush White House, the book has been resuscitated by the Obama Administration. The only organization listed in the updated version as a resource on advance directives is Compassion and Choices (formerly the Hemlock Society). A July 2009 directive instructs VA primary physicians to raise advance planning issues, using this book, with all patients, not just the aged or debilitated (Jim Towey, Wall St J ).
An angry disabled Marine veteran shared his views at a recent town hall with Congressman Brian Baird.
Hospice Patients Alliance, led by Ron Panzer, is concerned that U.S. federal and state government are already trying to balance budgets by hastening deaths, without raising the issue of explicit euthanasia. In the UK, where euthanasia is illegal, continuous deep sedation (CDS) may account for as many as one in six deaths (BBC News 8/12/09).
Palin quotes NY State Senator Ruben Diaz, a Democrat, chairman of the Aging Committee: Section 1233 of [H.R.] 3200 puts our senior citizens on a slippery slope and may diminish respect for the inherent dignity of each of their lives (Hawaii Free Press 8/12/09).
To the consternation of the Obama Administration and congressional Democrats, many Americans have shown up at tea parties and town halls with symbols warning about where that slippery slope has led before.
Daniel Greenfield observes the similarity in thoughts expressed by Dr. Ezekiel Emanuel and Dr. Hermann Pfannmüller, who stood trial at Nuremberg for his Starvation Hospitals for those he deemed unfit:
The idea is unbearable to me that the best, the flower of our youth must lose its life at the front in order that feebleminded and irresponsible asocial elements can have a secure existence in the asylum.
Pfannmüller preferred the simpler, more natural method of starvation to poisons or injections, which might supply inflammatory material for the foreign press.
[A]t the heart of the difference between socialized medicine and free market health care, writes Greenfield, is that in the free market no one gets to class an entire category of people as Life Unworthy of Life (Canada Free Press 7/28/09).
Greenfield notes that it takes time for the consequences of changing from an individual to a collective morality to become manifest. Most systems dont turn monstrous over the weekend. Even Nazi Germany took nearly a decade to follow through on to the logical conclusion . (Canada Free Press 8/11/09).
General Dwight D. Eisenhower ordered extensive photographs of those consequences to be taken, predicting that in 60 years some would try to deny that the events ever happened.
Spokesmen for the Democrats health care reform proposals say that all those ordinary-appearing Americans waving hand-made signs are either operatives of powerful vested interests, especially insurance companies, or political enemies bent on destroying the Obama presidency.
Even people in conservative Montana are strongly supportive, and continue to adulate the President, according to mainstream media coverage of a forum he held in Belgrade, MT.
But poll numbers suggest otherwise. The percentage of people with very negative feelings about Obama has tripled since the beginning of the year, hitting 20% nationally, 23% in those older than 65 (Jonathan Weisman, Wall St J 8/20/09). Congressional approval ratings sit at 30% (Daniel Henninger, Wall St J, 8/20/09). A poll conducted Aug 4-9 found that 49% disapproved of Obamas handling of health care, and 43% approved (Washington Examiner 8/14/09).
Although the Obama campaign made extensive, skillful use of the internet and social networking, David Axelrod, Senior Advisor to the President, sent an email on White House letterhead complaining of viral emails that fly unchecked and under the radar, spreading all sorts of lies and distortions.
The White House launched its own chain email and a new website, http://www.WhiteHouse.gov/realitycheck. AAPS has been hearing complaints from people who received spam from the White House, wondering how the White House got their email address. After a riotous response to the snitch mailbox for fishy misinformation, firstname.lastname@example.org, the government disabled it. Reality check might serve the same purpose.
Who is pushing the Democrats proposals? The people with the bullhorns and professionally made signs appear to be bussed-in, paid agitators from unions or left-wing advocacy groups. The town-hall meetings held by the Administration look utterly stacked, writes Peggy Noonan (Wall St J 8/15-16/09).
A number of the few people selected to ask questioners were shown to be campaign donors, Organizing for America volunteers, lobbyists for single payer, or union plants (WorldNet Daily 8/13/09).
Will Americans need to resort to samizdat to disseminate news ignored by the media? Bill and Kathy of Bozeman, MT, who dont want their email address disseminated, write that the Montana event was held in a secluded, remote, difficult-to-reach hangar at the airport. The Administration shipped in tons of cargo, including chairs and thousands of dollars worth of lobster. Montana folks who wanted to protestnurses, doctors, cowboys from around the statewere given a permit to assemble far away from the event, invisible to the media. A busload of SEIU members (Service Employees International Union) came in to disrupt their gathering and tried to start fights.
Everything was orchestrated down to the last detail to make it appear that Montana is just crazy for Obama and government healthcare, Kathy writes. I felt I was not living in the United States of America, more like the USSR! Bill and I have been around when Presidents or Heads of State visit. It has never been like this. I am truly very frightened for our country.
So who is lined up behind the Administration? In addition to political advocacy groups, theres the AMA, with $70 million in annual revenue from CPT-coderelated materials. And the Pharmaceutical Research and Manufacturers of America (PhRMA) is spending $150 million on advertising to support Obamas plancompared to McCains $84 million for his presidential campaign (AOL News). Certain health insurers, such as UnitedHealth, that stand to benefit from forcing people to buy their product, gave some $19 million in political contributions, 56% to Democrats (Business Week 8/6/09). Against insurers who oppose government-run health care, Rep. Henry Waxman (D-CA) and Rep. Bart Stupak (D-MI) have launched Soprano-style tactics, writes Newt Gingrich. On short notice they have demanded detailed information on executive compensation packages and business practices from 52 large insurance companies.
In the spirit of Joe McCarthy, Gingrich says, Waxman and Stupak are attempting to use raw political power to silence their opponents (Washington Examiner 8/21/09).
Attempts by the White House to set Americans against each othergood Americans protecting the presidents health-care program versus bad Americans fighting it and undermining truth and goodnesshas not played well. Americans dont take well to bullying, especially of the moralizing kind, writes Dorothy Rabinowitz (Wall St J 8/15-16-09).
The response at town halls gives reason for hope, writes market strategist John Browne of Euro Pacific Capital. It may be that the deep resentment expressed in town halls will embolden ordinary people to pressure Congress to stop the train. If that happens, America will begin the long and painful road towards economic restructuring, individual freedom and enterprise. Under those conditions, America would represent a great investment opportunity (Asia Times).
Despite the fact that support for the Plan is down 21% in 3 weeks, Obama may still be right when he proclaims, Were going to get this done one way or the other (Wall St J 8/21/09). Constituents outrage may not matter. To win the ultimate prize of a government takeover of medicinethus setting what Lenin called the keystone in the arch of the socialist stateDemocrats might risk it all, even their congressional majority (Jim Geraghty, National Review Online 8/13/09).
Obama has promised that doctors, not bureaucrats, will be making the decisions under his health care reform plan.
If Obamas promise is true, why do central planners need extensive data on every encounter with every patient?
Doctors, it appears, would indeed be making day-to-day decisions about what to do for individual patients. The centralized planning authority, however, would make the decisions on resource constraints and permitted options, within which physicians would have to function.
Physicians would be freeto comply or to accept the penalties for deviations.
Some American physicians, who have contracted with managed-care plans, long for what they believe is the simplicity and professional autonomy in nationalized systems.
Physicians who actually work in these systems generally do not share this sanguine view.
In Germany, doctors complain, on video with English subtitles, that they are inundated by the masses and cannot focus on the individual. They must work faster and faster, with less and less to show for it. A fundamental change in values has crept in, and the patient/physician relationship is deteriorating. Doctors say they are in a bureaucratic straitjacket. Politicians have them by a nose ring. Drugs and procedures are all constrained by a budget; some treatments simply cannot be offered. Thus, care is expedient, rather than optimal. There are so many forms that you could paper the office with them. Overall, the situation is deplorable, critical, the worst in 31 years of practice. Physicians conclude that state medicine is rationed medicine.
Elsewhere in Europe, headlines read: Belgian Doctors Take to the Streets, Spanish Physicians Strike for More Time [10 Minutes] with Patients, and French Doctors Are Burned Out.
According to a poll conducted by Pfizer of 1,741 physicians in 13 countries, 51% of European physicians are concerned about a negative direction for medicine, compared with 44% in the U.S. The majority report spending less time with patients (53% in Europe and 55% in the U.S.); bureaucratic demands were cited, unprompted, as a reason for that by 51% of Europeans and 21% of Americans. In both Europe and America, physicians have a negative view of the politicians panaceas for efficiency and quality: 83% of American and 61% of European physicians think that treatment guidelines have an adverse effect on patient health, while 70% of Americans and 64% of Europeans think that health technology assessment and evidence-based medicine have a negative impact on quality of care.
Gammons Law of Bureaucratic Displacement was developed in a London (National Health Service) hospital. Gammon defined bureaucracy as a rigid system governed by fixed rules and tending to exclude human initiative. He found that bureaucracy was destroying British medical servicesnot destroying the NHS, he emphasized, as it is the [NHS] itself which is the destroyer.
Its not just that the number of administrators has increased in a close correlation with a decrease in the number of NHS hospital beds (correlation coefficient a remarkable 0.99). Its the displacement of productive by nonproductive activity throughout the organization.
An example is the progressive transformation of nurses from patient-centred carers to administroids whose requirement to produce detailed patient care plans leaves them little time to attend to patients basic dietary needs or prevent them from developing pressure ulcers (Australian Doctors Fund teleconference, Jan 24/25, 2005).
The proposal before the House, H.R. 3200, establishes some 53 new bureaucratic agencies (Human Events 8/10/09).
Obama can keep his promiseby turning doctors into bureaucrats.
White House spokesman Robert Gibbs used the phrase choice and competition three times, and variations on the words choice and competition five times each, in a 1 minute, 10 second interview with CBSs Face the Nation, noted Mike Gonzalez. That is once every 8.7 seconds.
Kathleen Sebelius, Secretary of Health and Human Services, used one of these words or a combination only once every 16.7 seconds in a 1 min, 56 second interview with CNNs State of the Union.
If choice means abortion, then proposed reforms will probably increase it, while decreasing or eliminating ones freedom to choose not to pay foror performabortions.
For people who have only one health plan offered by their employer, proposed Exchanges might increase the number of choiceswithin the narrow range approved by the authorities.
Proposed plans would, however, markedly reduce freedom, and eliminate many choices. Keep in mind that proponents of reform generally believe that most Americans are incapable of understanding complex medical issuesexcept those involving abortion or refusal of life-saving careand are confused by having too many choices.
Beware of choice overload, write Richard G. Frank, Ph.D., and Richard J. Zeckhauser, Ph.D. (N Engl J Med 7/22/09). Consumers facing complex, high-stakes choices are prone to make predictable errors.
Ironically, one way to enhance the prospect of informed choices is to limit the number of options, they say.
Among the choices to be eliminated soon after reform passes:
True casualty insurance for medical expenses
Except for individual grandfathered plans, for as long as they survive without enrolling new subscribers or making changes in the policy, health insurance must meet rigid bureaucratic requirements. Insurers will not be able to price according to risk. Americans will not be allowed to save money through prudent lifestyle or personal assumption of risk as through high deductibles. Everyone will have to pay a fair share, based primarily on ability to pay, into the collective pot for paying everyone elses medical expenses.
In a mailing of facts AMA members need to know, the AMA says it is a myth that the current House bill makes private insurance illegal. Of course the bill does not (at this time) make private coverage illegal. But it does outlaw true insurance, replacing it with prepayment schemes that function like social welfare/wealth redistribution programs.
Self insurance or sharing ministries
Americans will not be allowed to opt out of mandatory insurance and choose another way of meeting their financial obligations, as by saving, borrowing, or sharing expenses through a private, voluntary Christian community. Rather, they will all be forced to contribute to the revenue stream to bureaucrats, as well as to the care of the less productive, less frugal, or less prudent.
Medicare Advantage plans
Reformers have targeted these for savings to help fund expansions in coverage. At least one in five seniors, most of them with low or moderate income, chose to enroll in such a plan (Karl Rove, Wall St J 8/27/09 ; John Goodman, Health Alert 8/24/09).
Trading cash for better, more timely care
While providers may negotiate rates with the plan, there will be fixed paymentsprice controls. Reformers are very concerned about the percentage of GDP, or of a persons income, spent on medical services. Leading-edge methods may be costly, but many would trade everything they have for a chance to extend their own, or a loved ones life. Our representatives should commit themselves to action that will preserve the ability of Americans to choose life over money, writes Chris S. Karpel (Wall St J 8/17/09). That ability is threatened.
White House spokesmen promise that reform will outlaw lifetime limits on coverage. That is possible only by assuring that no one will be able to choose treatments that would make him a six-million-dollar [bionic] man.
Some people might be willing to pay more for treatment in a facility that has no bureaucracy to be negotiated with the skill of a white-water canoeist. Or one in which there is no tension, no feeling that one more patient will bring the system to a point of collapse, and all the staff go off with nervous breakdowns. Or one with perfect calm in the waiting room, where relatives are not on the verge of hysteria and do not suspect that the system is cheating their loved one.
This description applies to veterinary clinics in Britain, as contrasted with National Health Service facilities, according to Theodore Dalrymple (Wall St J 8/8/09). In Canada, human patients dont have the right to choose private payment for covered services. This choice is now threatened in America, at least for those who cant afford to pay twice, once through mandatory, costly insurance that they dont use.
Unapproved tests or treatments the patient wants
Because any reform initiative must control spending, writes Allan S. Brett, M.D., of the University of South Carolina School of Medicine, unproven or unnecessary medical interventions should not be available in any system (N Engl J Med 7/29/09). Policymakers debating health care reform should stop hiding behind the smoke screen of American values. Those values include individualism.
Note that Brett does not say that government should not pay nor force insurers to pay for such procedures; he says they should not be available. Period. Not to anyonerich, poor, severely disabled, terminally illno matter how desperate.
Anointed authorities, of course, set the standards for proof and necessity.
A plan that a commissioner disapproves of
According to Congressman Michael J. Rogers (R-MI), the House bill gives officials the power to disenroll an individual from his current chosen plan, or to even to disenroll all employees from their employer-sponsored plan.
Direct access to specialists
Innovations such as the medical home or accountable care organizations are variations on the HMO gatekeeper model. In Canada, patients must have a referral from a primary care physician to get an appointment with a specialist. In proposed Massachusetts reforms, likely to serve as a model for federal plans, all health plans would require the selection of a primary-care physician, and all payments would go to the organization with which the physician was affiliated. Restricting patients in this way would be a huge change and is a sensitive issue. However, allowing a greater choice
for patients who were willing (and able) to pay more would undermine the cost-control, quality-improvement, and care-coordination purposes of global payment (Robert Steinbrook, M.D., N Engl J Med 7/29/09).
The only choice you will have, writes Bill Turner, is one you must make now, to give the government control over our life and 20% of the economy, or to draw the line in the sand and say no, you cannot take away my freedom (Canada Free Press 8/19/09).
To many reformers, proposals now under consideration are but a stepping stone to their ultimate objective: involuntary universal participation in a system totally financed and controlled, even if not formally owned, by governmentthe single payer.
While the Administration has denied trying to enact single payer, Obama has previously expressed his support for the idea, and has never disavowed it on principle.
In a telephone call to clergymen, also broadcast over the internet, Obama dismissed the concerns of opponents of his health agenda as fabrications. Dissenters were making up allegations about death panels, government funding of abortions, and a government takeover of medicine, he said, because they want to discourage people from meeting a core ethical and moral obligation that we look out for one another that I am my brothers keeper (Commentary by Star Parker 8/25/09).
Forgive me if sermons about morality are a little hard to swallow from a man who supports partial birth abortion, Parker writes.
She also notes that reform proposals would outlaw the voluntary Christian sharing communities through which 100,000 Americans take care of their own medical expenses, independently of government and insurance companies.
In contrast, government compelling taxpayer A to pay provider B for care of patient C is not the same thing as looking out for one another.
There are in fact core moral issues involved in health care reform: a radical change in the physicians code of ethics. The New Ethics transforms the physician from a healer, who places his individual patients welfare first, to a tool of the state, sacrificing individuals for the good of the collective.
Rationer-in-chief Ezekiel Emanuel describes his ethics as communitarian. He blames the Oath of Hippocrates for the overuse of medical care, regardless of cost of the effect on others, and he favors the complete lives concept for allocating scarce resources. Those resources (including peoples earnings) are assumed to belong to the collective, to be appropriated and redistributed as the rulers think best.
The existence of disparities or of profits is taken as evidence of immorality. Disparities of concern are those based on invidious discrimination, as by race or gender. Allocation by age can be just and rational. See: Persad G, Wertheimer A, Emanuel EJ. Principles for allocation of scarce medical interventions. (Lancet 2009;373:423-431).
Disparities have not been eliminated by nationalized health systems; quite the contrary. Thirty years into the British National Health Service (NHS), an official task force (the Black Report) found little evidence that access to care was any more equal than when the NHS began. Almost 20 years later, a second task force (the Acheson Report) found that access had become even less equal. There is also pervasive inequality in Canada, with differences in per capita spending as great as seven-fold between urban and rural areas ( John Goodman, Cato Policy Analysis 1/27/05).
One of the features of the NHS that has persuaded the British of its social justice is the difficulty and unpleasantness it throws in the way of patients, rich and poor alike, writes Theodore Dalrymple. For equality has the connotation not only of justice but of hardship and suffering (Wall St J 8/8/09).
Additionally, the differences in health between the rich and poor in Britain are not only among the greatest in the western world, but they are as great as they were in 1948, when health care was de facto nationalized precisely to bring about equalization, Dalrymple continues.
The whole population has been pauperized in the name of an inalienable right to health carein the dirtiest, most broken-down hospitals in Europe, writes Dalrymple in an earlier article (Wall St J 7/29/09).
Morality is always the justification, writes Mark Steyn. Inaugurating Britains National Health Service on July 5th 1948, the Health Minister Nye Bevan crowed, We now have the moral leadership of the world.
Roy Romanow, the Canadian politician who headed the most recent of numerous inquiries into problems with the Canadian system, defends the states monopoly on medical care by saying that Canadians view medicare as a moral enterprise, not a business venture. But Steyn asks, Whats so moral about relieving the citizen of responsibility for his own health care?
If the man who died of a ruptured appendix, after being turned away from a Quebec clinic for not having an insurance card (see Myth 17) had entered a business venture, they wouldve greet him with: Youve got stomach pains? Boy, have we hit the jackpot! Lets get you some big-ticket pills and sign you up for surgery! Steyn suggests. But because its a moral enterprise they sent him away with a flea in his ear.
But if disparities cannot be eliminated, profit surely can be. Government has consistently succeeded, if profit elimination was its purpose.
We constantly hear that the United States is the only nation in the developed, or industrialized world (we no longer say civilized world or free world) that doesnt have taxpayer-funded medical care for all.
It is therefore past time for the U.S. to relinquish the traditional idea that the voluntary way is the American way and join the progressive march to coercive, state-funded and state-directed medicineas instituted by Chancellor Otto von Bismarck in Germany in 1884. These days, the state-owned variant, adopted by Britain in 1948 based on a model developed by Lenin in 1911, is considered politically unfeasible in America.
We need to give up our own perception of having the best medical care the world has ever known (in the eyes of individual American citizens and foreign visitors) and aspire to move from the 37th position closer to the 1st position held by France in 2000 (in the eyes of the World Health Organization, which prefers equal misery to unequal blessings)or so say advocates of reform.
Meanwhile, countries outside the U.S. are moving away from failing single-payer systems. Health insurers worldwide added over 100 million covered lives in 2008 in one of the strongest markets since health insurance was invented in 1880s, according to official government statistics (HealthPlanWire 8/24/09). The number is projected to exceed 1 billion by 2012.
Single-payer systems are declining because they are based in countries with static or declining populationsmany of which are also adopting market-based reforms. Private insurance is growing rapidly in countries with the fastest growing populations. Building a health financing system for the first time, countries on five continents are choosing the private way. Examples include China, South Africa, Mexico, India, Australia, and most of eastern Europe. But in at least 25 of the 125 nations with national health systems, private insurance is growing faster than the government-run system (ibid.).
Democrat-proposed reform plans would restrict out-of-pocket payment for covered serviceswhile U.S. patients already have the lowest out-of-pocket costs (OOP) as a percentage of total national health spending of any developed country except France, Luxembourg, the Czech Republic, and Ireland. They are even lower than in Canada. OOP spending in the U.S. represented about 60% of real per-capita spending on medical care in the U.S. in 1960, and dropped to 10% by 2002. This surely has a lot to do with escalating costs. But Democrat reformers would eschew financial incentives to patients in favor of health information tools enabling payment denials right in the doctors office (Scott Gottlieb, Wall St J 8/15-16/09).
A few facts about private insurance and self payment in nations with national health systems (Gregory Dattilo and Dave Racer, Your Health Matters, Alethos Press; 2006):
The French system, held up as the example now that Canada and Britain have lost appeal, is also in trouble. Citizens must pay more and doctors must alter their behaviour said a government-commissioned report (BBC News 1/23/04). In 2009, the total cost of the system, from employee and employer combined, is more than half the workers wages (Investors Business Daily 8/26/09).
In France, the supply of doctors is so limited that during an August 2003 heat wave when many doctors were on vacation and hospitals were stretched beyond capacity15,000 elderly citizens died, wrote David Gratzer (ibid.).
While upcoming nations are choosing the private, voluntary path, American reformers are pushing for a regression to 19th century, consistently failed systems of centrally planned coercion.
Medicare is immensely popular, has very low administrative costs, is already a working model, it is said: Why not just have Medicare for all?
At one time, calling Medicare socialized medicine for the elderly caused stunned silence in the Congress. Now, if one opposes socialized medicine, at least one listener is bound to dare you to say youre opposed to Medicare.
Government may bumble at almost everything, but in a handful of areas it does better than the private sector, writes Nicholas Kristof. He lists firefighting, police protection, and health care. Also postal service and education (NY Times 9/3/09).
And even if government is inefficient, he writes, at least it is fair. It doesnt cancel your coverage if you get sick.
Heres a reality check on Medicare:
In his address to Congress on health care reform, Barack Obama cited Alabama as a state in which almost 90% of health insurance is controlled by one company. [A]n additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchanges.
The People Before Profits slogan also reflects the belief that it is not only inefficient and costly but morally wrong to make a profit from providing health insurance or medical care. (Also see Myth 22.)
A reality check on health insurers and profit:
Dr. William Summers of Albuquerque provides a contrast between two California hospitals in the 1980s. At one, the cost of a room started at $850/day, plus extras adding up to more than $1,000. They had plastic utensils, styrofoam cups, and surly nurses. Across town, there was a hospital that charged $115, with few extras. It served food on china with real silverware and linen tablecloths. It had an excellent chef, a polite staff, and a swimming pool. The first hospital took government insurance; the second was cash-only.
It all sounds very reasonable: to set priorities, to use the most effective therapies, to serve the neediest first. Rationing is a given, say reform advocates. Insurance companies already do it. Lets just make it rational and fair.
Some say that Comparative Effectiveness Research (CER) isnt really about rationing. Nothing in the legislation provided for payment restriction based on CER findings, writes Jerry Avorn (N Engl J Med 2009;360:1927-1929). Its Orwellian to suggest such a thing. Anyway, unaffordability rations care far more than comparative studies ever could.
The end-stage of rationing actually has little to do with comparative effectiveness. There are more basic questions: Have you suffered enough yet? And Can you get through the clinic door?
One young Canadian mother suffered from pain and incontinence and required a walker, because of spondylolisthesis. She aggressively presented herself at four surgeons offices before or after hours or at lunch, pleading her case. Four surgeons saw her. Three said she was shed just have to wait, as others were either older than she was and/or had already suffered longer. Finally a surgeon took pity on her and worked her inonly 6 months laterbecause she was too young to have to live like that. Never mind the need for emergent surgery in the event of neurologic compromise, or more than 2 years of total disability.
CER results cant be applied until a patient can get a diagnosis. A video team documented efforts to get help from Canadian clinics, and then interviewed a number of Canadians.
CER is not needed to determine that it is traumatic and less safe to give birth in corridors or reception areas because labor beds are fullas 4,000 mothers did in the UK in 2008. The government cut maternity beds by 22%, although birth rates were up 20% in some areas, and spending on the National Health Service was tripled (Daily Mail 8/26/09).
A pediatric ophthalmologist, in the only such practice in Georgia still accepting Medicaid, writes that Medicaid will not pay for the antibiotic needed for an infected corneal ulcer. It takes a year to approve a contact lens after surgery for neonatal cataract. Private funding fills the gap. No research is needed to tell the difference between successful treatment and likely blindness (Zane F. Pollard, M.D., American Thinker. August 2008).But how many such treatments would be denied while approval wended its way through a system with 111 bureaucracies?
With or without CER, government plans always ration care. The idea of an omnipotent board that makes unpopular decisions on access and price isnt a new construct. Its a European import. In countries such as France and Germany, layers of bureaucracy like health boards have been specifically engineered to delay the adoption of new medical products and services, thus lowering spending (Scott Gottlieb, Wall St J 6/25/09).
We have our own examples in the U.S., as in Oregon.
Throwing $1.1 billion into CER is guaranteed to produce no new knowledgeonly poorly controlled data about the implementation in different practice settings of methods already tested for safety and efficacy in well-controlled studies (Naik AD, Petersen LA. The neglected purpose of comparative-effectiveness research. N Engl J Med 2009;360:1229-1231). It will provide the rationale for rationing.
Calling something affordable, even in the title, doesnt make it so.
Making somebody else pay the bill doesnt make it affordable either. A massive redistribution scheme adds costs, and makes the total cost less affordable.
A CBO score less than Obamas target of $900 billion isnt affordable either. Thats the total net work of 900,000 millionaires.
Just looking at the gross numbers: the total cost of the bill Sen. Reid presented to the Senate was estimated to be $848 billion. It was said to extend insurance coverage to 31 million Americans (maybe, in a few years). That would be about $27,000 per additional insured person.
What will the cost be for individuals?
What about the cost to government? CBO director Doug Elmendorf himself admitted that estimates were subject to substantial uncertainty (Dow Jones Newswires). For example, CBO apparently assumed that Medicare cuts will happen, that people wont change their behavior to blunt tax consequences, and that a worsening economic crisis wont slash revenues.
Elmendorf testified that, far from bending the cost curve, current legislation significantly expands the federal government responsibility for health care costs, writes John K. Iglehart (N Engl J Med 2009).
Since Medicare and Medicaid funding began in 1967, total state and federal government spending has increased by 1,791%. This is a real annual growth rate of 44%, 10 times the annual economic growth rate, writes Jim Simpson (Faultline USA 8/14/09).
In making its projections for the first decade, CBO just used accounting sleight of hand. It starts the decade in 2010, although only 1% of the 10-year costs hit before 2014. If the decade starts in 2014, the 10-year costs are $1.8 trillion (Pacific Research Institute).
Note that these costs include only on-budget costs, not the additional costs imposed on taxpayers.
Some private sources calculate estimates as high as $3.5 trillion to $4.1 trillion, writes Peter Ferrara (American Spectator 8/5/09).
Can the U.S. sustain the current level of spending? Debt service cost $202 billion this year, and could exceed $700 billion annually by 2019. The Fed will eventually have to raise interest rates to more normal levels, greatly increasing the debt-service cost (NY Times 11/23/09).
For an analogy to help understand the breakneck acceleration in U.S. indebtedness, watch this video. For those who feel reassured when hearing about the debt-to-GDP ratio, remember that that is a comparison of the governments debt to the amount that everybody in the country produces.
More and more investors are betting that rich countries will default on their bonds, through credit default swaps (Financial Times 11/22/09).
Healthcare reform could pull the trigger.
As George Jonas of Canada pointed out, If the problem with private medicine was that not everybody could afford it, the with socialized medicine turned out to be that nobody could afford it . (National Post 9/22/07).
The growing number of 48 million uninsured includes perhaps 15 million illegal aliens (Phoenix Business Journal 7/22/09).
Obamas statement that the reforms Im proposing would not apply to those who are here illegally elicited the notorious You lie outburst from Rep. Joe Wilson (R-SC).
Currently proposed legislation does not explicitly extend coverage to illegal aliens, only to legal non-citizen residents. Of course, illegals could be made legal through other legislation. Some say that amnesty is on the legislative agenda immediately after healthcare reform and energy taxes (cap and trade), writes James R. Edwards, Jr. (Center for Immigration studies 10/2/09).
All four bills that had passed committees as of September would allow illegal aliens to take part in Health Insurance Exchanges (Charles Krauthammer, Ariz Daily Star 9/19/09).
And what about the taxpayer subsidies (affordability credits)? On July 16, an amendment by Rep. Dean Heller (R-NV) that would have required use of the Systemic Alien Verification for Entitlements (SAVE) program to prevent illegals accessing these credits was defeated by the House Ways and Means Committee.
At present, 71 other means-tested federal programs require use of the SAVE system.
The National Council of La Raza launched a flood their voice mail campaign to pressure Sen. Baucus to drop verification language (Stephen Dinan, Wash Times 9/28/09).
If all uninsured illegal aliens with incomes below 400% of poverty accessed the credits, it would cost federal taxpayers $30.5 billion annually. The current cost to all levels of government for treating uninsured illegals is estimated to be $4.3 billion, primarily at emergency rooms and free clinics (Newsmax.com 9/8/09).
Uninsured illegals use less medical care than average because they tend to be young. Affordability credits, however, would be the same for all regardless of age or preexisting condition (ibid.).
Medicaid also does not require identity verification for those claiming U.S. birth. Illegals would also likely benefit from proposed expansion of eligibility to 133% of poverty (ibid.).
Illegals might not sign up for benefits, especially if it required filing a tax form. It is not clear that the private sector, especially hospitals, would see any relief from the enormous unfunded mandate (www.youtube.com/watch?v=bLJxmJZXgNI) to treat indigent illegals not covered by government programs.
The Democrats reform plans would have a powerful allythe Roman Catholic Church and its huge network of hospitalswere it not for the perception that plans as currently drafted would permit taxpayer funding of abortions. Without the Stupak Amendment, legislation probably would not have passed the House. A similar battle on amendments is likely to occur in the Senate.
Some within the hierarchy of the Roman Catholic Church appear to be in favor of socialized medicine, and certainly have no objection to taking money from taxpayers.
Some media organizations reported that Catholic bishops, or even the Vatican itself, engineered the compromise that deleted abortion funding so that the bill could pass the House.
The Stupak Amendment has an effect virtually identical to that of the Hyde Amendment, which is added yearly to the Labor, Health and Human Services (LHHS) appropriations bills. Before Stupak, the Hyde Amendment would not have applied to H.R. 3962.
In the Senate, Majority Leader Harry Reid (D-NV) has assumed full ownership of a 2,074 page bill that would institute the most far-reaching changes to the system in generations. He is a veteran of the Senate Appropriations Committee, where writing bills is done one favor at a time, writes Shailagh Murray (Washington Post 12/4/09).
Among the moderates who have hijacked a potentially historic health-care overhaul is Sen. Ben Nelson (D-Neb.). Nelson is expected to offer an amendment prohibiting abortion coverage in the public plan, and also prohibit people who receive tax subsidies for private plans from buying policies that include abortion coverage.
Reids game plan is to allow Nelsons amendment to come to a vote, where it would presumably fail, and then begin negotiations on a compromise (ibid.). Once the bill is passed, it goes to conference committee, and there is no guarantee that amendments will survive the final process.
The Mikulski Amendment, which passed 61-39, was supposedly about correcting a problem with coverage of mammograms. It would, however, bind every health plan in the nation to cover, without cost sharing, anything that the Secretary of HHS defines as a preventative service. The National Abortion Federation considers comprehensive primary preventive health care to include abortion care.
The key point is that the plan as a whole places unprecedented power in the hands of the Secretary of Health and Human Services. Twila Brase notes that the word secretary occurs 2,489 times in the House bill H.R. 3962, and 2,500 times in the Senate bill.
Through coverage decisions, the Secretary could take much of the liberal social agenda out of the hands of a politically accountable legislature, and simply enact it.
Abortion is not the only service that the Secretary might define as essential. Dr. Louis Keeler of New Jersey notes that the legislation gives the government wholesale entry into the death and dying process.
Other services that might be deemed essential, for the goal of nondiscrimination or eliminating disparities, could be sex-change operations or in-vitro fertilization for lesbians, at taxpayer expense.
Beyond the provision of medical services, legislation could be a way to monitor and control behavior. AAPS generral counsel Andrew Schlafly notes that injury control could be a back-door way to achieve gun control (Sec. 5301, p. 1342).
The bills wellness program would use national databases to offer lower insurance costs to those with a health lifestyle. This might mean eschewing gun ownership, getting all recommended vaccines, attending prescribed sex education sessions, or receiving implanted contraceptives until or unless certified for healthy childbearing. Anything that is not unambiguously proscribed by law might be at some point implemented by the Secretary.
The extensive reporting requirementsand penalties for failure to report or inaccurate reportingcould enable the government to identify owners of firearms or dissenters from politically correct recommendations. Brase notes 878 occurrences of report/reports/reporting in the House bill, and 789 times in the Senate bill.
Many critics of the Democrats healthcare reform call it socialized medicine. Advocates respond, condescendingly, that since the government would not own the means of production, and physicians would not be salaried by the American equivalent of the British National Health Service, this is not socialism. Physicians and hospitals would still be private, as in Canada.
So lets work backward: Start with the definition, then think of the word. These are the characteristics of the plan. It is: (1) compulsory; (2) redistributive; (3) collectivized; (4) centralized; (5) dictatorial; (6) oppressive; and (7) intrusive.
Even if there is as means of opting out and seeking private care, everyone will be forced to pay, either through premiums, taxes, or both.
Effective premiums, net of subsidies, will be based on income, and are thus a mechanism for redistributing wealth.
Not only is payment collectivized. The whole ethic of medicine is to be transformed. Physicians are to be held responsible for optimizing the health of the state, and patient care is to be prioritized on that basis. The individual patient may be sacrificed to the good of the whole.
Planning is to be centralized. Thousands of decisions will be delegated to the Secretary of Health and Human Services or other unelected federal executive agencies.
Decisions will be immune from administrative or judicial review, as well as from political influence. The power of the Secretary or Board is supreme and absolute.
Everyone will be subject to constant reporting requirements: to the IRS for determining premiums, subsidies, and compliance with purchasing requirementsand to health plans for determining eligibility. Before each and every encounter, the plans infrastructure will enable a decision about whether a particular patient is eligible to receive a particular treatment from a particular provider at a particular timeas well as the charge and the responsibility for payment. Penalties for failure to report, or inaccurate reporting, are very severe. Clearly, universal coverage does not mean universal access to care, but rather barriers and checkpoints at every step.
To enable the detailed calculus of benefits and payments, monitoring will be very intrusivehence the requirement for everyone to have an electronic health record, which could include practically anything of interest to the government, including gun ownership or political attitudes.
The Democrats reform empowers the federal government to control all Americans, whether as patients or medical professionalsand one-sixth of the economy. As most people are willing to spend their last dime for medical treatment that could relieve pain or extend their lives, what better source for extracting the revenue to keep the bankrupt federal government, with its 20 million mostly overpaid employees, functioning for a few more years?
The plan fulfills the fundamental axiom of socialism: from each according to his means, and to each according to his need, with terms defined by the central planners. Socialized medicine, however, does not adequately describe this plan. It is even more audacious than a Ponzi scheme, as it attempts to postpone the real emergencythe day of reckoning for earlier Ponzi schemesbeyond the next election.
The word is tyranny.
Legislation heavily promoted by the AMA and passed by the House of Representatives, H.R. 3961, would eliminate the 21% scheduled Medicare pay cut for doctors required by the sustained growth rate (SGR) formula. Yearly last-minute reprieves have postponed the cuts year after year; the accumulated 21% is now coming due.
H.R. 3961, the Medicare Physician Payment Reform Act of 2009, the doc fix, would repeal the SGR and provide a Medicare Economic Index (MEI) update for 2010; eliminate all SGR debt; and establish new updates for 2011 and beyond. The target for evaluation and management (E&M) and preventive services would be GDP + 2%, and for other services GDP + 1%.
Republican Study Committee chairman Tom Price, M.D., (R-GA) calls the doc fix a doc trick used as a political tool to buy support for the Pelosi bill. The fix would add more than $200 billion to our already unprecedented debt and has no chance of becoming law.
The CBO estimates that combining H.R. 3962, Pelosis Affordable Health Care for America Act, with the doc fix would add $89 billion to the budget deficit between 2010 and 2019, according to Nina Owcharenko.
Ralph Weber, C.L.U., points out that the doc fix means a pay cut. If the GDP grows by 1%, Medicare funding grows by 2%. But as baby boomers retire, the number of people covered could increase by 8% each year. This means a theoretical decrease in physicians payments of 6% per enrollee. It is not clear why the AMA is applauding this.
The Senate bill would avert the 21% cut without permanent SGR reform, according to AMA CEO Michael Maves, M.D. In determining the price tag for this bill, the Congressional Budget Office (CBO) assumed that Medicare participating providers would get a 23% pay cut in 2011, according to the California Association of Health Underwriters (CAHU).
The CBO projects extracting $436 billion in cost savings in Medicare over the next 10 years, mainly by changing the way doctors and hospitals are paid, write James Oliphant and Kim Geiger (LA Times 11/22/09).
CAHU states that $464 billion in Medicare cuts include the following: $192 billion from permanent reductions in annual payment updates for most services in the fee-for-service sector; $118 billion in cuts to Medicare Advantage; $43 billion in disproportionate share hospital (DSH) payment cuts; and $23 billion in unspecified cuts by the Medicare Advisory Board. Enrollment in Medicare Advantage is expected to drop by 64%.
One of the changes in payment methodology that is already occurring, according to a webinar sponsored by the American Academy of Neurology, is that consultation codes will no longer be reimbursed.
As John Goodman points out, Medicares method for paying physicians is totally dysfunctional. This is the reason, for example, that we are discussing whether Medicare should pay doctors for end-of-life counseling. Medicare has 7,500 tasks that it will pay physicians to perform, with an approved fee for each task; end-of-life counseling is not among them. Nor are services such as telephone consultations, helping a patient shop for low-cost procedures, care coordination, or education on use of the internet.
Goodman asks what would happen if you paid your defense attorney by task: say $20 per hour for jury selection, and $500 per hour for preparing the final summation.
Allowing patients to contract privately outside the rigid Medicare fee structure is an urgently needed reform that is not even being considered.
A large part of the savings projected from healthcare reform is supposed to come from wider use of information technology. The federal government is expected to invest some $45 billion in encouraging (or compelling) doctors and hospitals to use electronic records systems.
Information is the lifeblood of modern medicine. Health information technology (HIT) is destined to be its circulatory system, writes David Blumenthal, M.D., M.P.P., of the Office of that National Coordinator for Health Information Technology (New England Journal of Medicine 12/30/09). Physicians and institutions trying to practice highest-quality medicine without HIT are like Olympians trying to perform with a failing heart, he states. (Note that Blumenthals numerous financial disclosures are in a separate document.)
In the real world, there are many problems in implementation. The University of California San Francisco Medical Center is one institution that is quietly writing off about a third of the $50 million it has poured into electronic medical records over the past 5 years. The system is still not fully up and running. UCSF terminated its contractor and is prepared to start part of the project from scratch (Huffington Post 11/23/09).
According to one study, between 50% and 80% of electronic health records systems fail. The larger the EHR project, the higher the risk of failure (IEEE Spectrum 1/1/10).
Instructional materials from real institutions include such eye-openers as a complicated 90-page guide for simply entering orders and a 30-page House-Wide Discharge (Depart Process) Training Manual. It is no longer possible to discharge a patient by writing prescriptions and a discharge today order in the record. Its a wonder clinicians can get any clinical work done at all any more, writes Scot Silverstein, M.D. (Health Care Renewal 1/3/10).
For more than a decade, Silverstein has been making the case that health IT is very, very much harder than it looks, especially to those in IT lacking healthcare expertise. Health IT is still largely a social experiment, and hospitals are a highly risky environment for implementing it.
Paper is far from being technologically obsolete, he notes, citing a December 2009 article in the Milbank Quarterly, Tensions and Paradoxes in Electronic Patient Record Research: a Systemic Literature Review Using the Meta-narrative Method, by Greenbaugh et al. of the University College London.
Paper records, being flexible, portable and tolerant of ambiguity, support the complex work of clinical practice remarkably well . [H]igh-tech healthcare environments such as intensive care units often make extensive use of paper charts, white boards, sticky notes, and oral communication (Health Care Renewal 12/15/09).
HIT has become intensely political, note Greenbaugh et al. Publishers need to invite studies that tell it like it is, perhaps using the critical fiction technique to ensure anonymity.
Silverstein calls the idea that investment of tens of billions of dollars on a frenetic timeframe will create massive quality improvements and cost savings the height of magical thinking and political hubris.
Specializing in medical informatics, Silverstein is not opposed to HIT, he in fact supports it and dedicated his career to informatics. He is only opposed to HIT that is badly done. He observes that local projects built by experts are far more likely to provide major benefits than extant shrink-wrapped and massively expensive HIT.
Numerous serious problems have been reported with HIT in operation. Some prompted an Oct 16, 2009, letter from Senator Charles Grassley (R-IA) to Cerner Chief Executive Officer Neal Patterson.
Sen Grassley wrote: Over the past year, I have received numerous complaints from patients, medical practitioners and technologies engineers regarding difficulties with HIT and CPOE devices . These complaints include faulty software that miscalculated intracranial pressures and interchanged kilograms and pounds, resulting in incorrect medication dosages.
Sen Grassley also referred to gag orders that prohibit disclosure of defects, and lack of a system to monitor performance of these devices.
Experienced systems professionals are increasingly raising concerns about the poor design of electronic medical records (EMRs), which frequently require workarounds and patches. The process is unsustainable and could lead to data breakdowns (Design Dialogues 11/12/09).
Some physicians like their EMR system, but one senior internist at a major hospital, who feared losing his job if he spoke on the record, reported on one 2006 system that crashed soon after it went online. He struggled to keep patients alive while vendor employees ran around with no idea how to work their own equipment (Washington Post 10/25/09).
One study showed that more than one in five hospital medication errors were caused at least in part by computers (ibid.).
Emergency physicians in 200 hospitals in Australia were affected by a system credited with decreasing by 50% the number of patients seen within 20 minutes of arrival. Descriptors included user hostile, dangerous, and slow at any task I tried. Vendors offered more support. Clinicians said that was like giving us a defective car and then sending out someone to show us how to drive it (Health Care Renewal 10/20/09).
HIT raises serious liability concerns, note Sharona Hoffman and Andy Podgurski of Case Western Reserve University. EHR [electronic health records] systems cannot remain unregulated and largely unscrutinized. It is only with appropriate interventions that they will become a much-hoped for blessing rather than a curse for health care professionals and patients.
In an earlier report, these authors concluded that the advantages of EHR systems will outweigh their risks only if these systems are developed and maintained with rigorous adherence to best software engineering. Unlike other life-critical medical devices subjected to FDA oversight, EHR systems have not been comprehensively assessed.
The Veterans Administration system of EHRs has been in use since the mid-1990s. While reportedly very successful, a software problem that led to major treatment errors in 2008 is still under review. Though no evidence of harm to any patient was found, the potential for serious injury was staggering (Ann Intern Med 2009;151:293-296).
After a harrowing hospital experience featuring many staff members pushing around laptops on wheeled sticks, his life having been saved by a heroic ICU nurse who worked around the system, and his wife who sneaked his inhaler into his room, a very intelligent patient concluded that electronic health information systems are mostly broken.
The national health information network envisioned by President Barack Obama is a pipedream, he writes (Joe Bugajski, The Data Model That Nearly Killed Me, Syleum.com 3/17/09).
So why did Congress authorize $20 billion for HIT in the stimulus package? Proponents relied on a 2005 RAND estimate of $77 billion in savingsbased on the assumption of an error-free system that would be rapidly implemented by 90% of all facilities. Even if achieved, $77 billion would be only 4.5% of total costs, placed at $1.7 trillion by RAND, writes Greg Scandlen (Heartland Institute 2/20/09).
Most likely, every penny of the $20 billion will be wasted on systems that dont work and can never be implemented. That was the outcome of federal attempts to upgrade technology at the IRS, the FBI, and the air traffic control system.
The cure for excessive U.S. medical spending, according to prominent academics as well as Peter Orszag, director of the Office of Management and Budget (OMB), is called the 30% solution.
Its basis is the Dartmouth Atlas, produced by the Dartmouth Health Policy Group, whose leaders concluded that if we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents.
The recently passed House reform bill, H.R. 3962, would implement the Dartmouth Atlas by force of law, writes Louis Keeler, M.D., past president of the Medical Society of New Jersey, referring to sections 11571160, pp 497-520.
What the Dartmouth group did was to divide the U.S. into quintiles based on levels of Medicare spending. It found that outcomes were the same or better in the lower-spending areas.
The Group claimed to have adjusted the data for age, sex, mortality, disease incidence, and prices. The cause of spending differences must therefore lie in how physicians and others respond to the availability of technology, capital, and other resources in the context of the fee-for-service payment system, conclude Elliott S. Fisher, M.D., of Dartmouth, and coauthors (N Engl J Med 2009;360:849-852).
Other academic agree: It is well-established that higher spending in some regions does not translate into higher quality (Chernew ME, et al., N Engl J Med doi:10.1056/NEJMp0910294).
What we now know about regional variation in costs within the United States suggests that nearly one third of health care costs could be saved without depriving any patients of beneficial care, if physicians in higher-cost regions ordered tests and treatments in a pattern similar to that followed by physicians in lower-cost regions (Brody H, N Engl J Med doi:10.1056NEJMp0911423).
Physicians, Brody writes, are not innocent bystanders watching costs zooom out of control.
Unproven or unnecessary medical interventions should not be available in any system, writes Allan S. Brett (N Engl J Med 2009;361:440-441).
The Dartmouth analysis has, however, been subjected to a devastating critique by The Physicians Foundation, led by Richard A. Cooper, M.D., former dean of the Medical College of Wisconsin.
Dartmouths adjustments are all shadows and mirrors, or simply malarkey, writes Dr. Cooper. The Dartmouth adjusted data looks very much like unadjusted data from MedPAC (Medicare Payment Advisory Commission).
The main source of disparity is poverty, the report concluded, noting that the poorest 15% of Americans consume twice as much medical care as the richest. The 30% solution would reduce the volume of care in communities where the need was greatest.
The poster child for the Dartmouth solution is a study comparing Birmingham, Alabama, with Grand Junction, Colorado. Cooper points out that if Alabama had the resources to provide all needed care to its citizens, utilization should not have been 34-48% higher in Birmingham compared to affluent Grand Junction, but rather 100% higher.
One of the unexplained regional variations is in the use of home oxygen supplementation for patients with chronic lung disease. It is indeed higher in some statesthose where patients live at higher altitude and thus need more oxygen.
The short summary of the report: Dartmouth strikes againat poor people.
The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World - excellent paper full of facts about national healthcare systems around the world.
John Stossel and the Case for Free Market Health Care (Part 1 of 5) [VIDEO] - John Stossel presents a very strong case for the free market in healthcare and demolishes Michael Moore.
Socialism: Where your health care is free, but you are not.
It also contains just plain crap. I caught this one in "Myth #1
The most important information in an emergency is what just happened to you, and that will not be in your EMR.
There are a lot of people with good reason to wear those little "Medical Alert" tags. If a person is in anaphalactic shock, one wouldn't know "what happened" and it would be helpful to know about the relevant allergies. The better point to have made here is that a person can carry their medical records on a chip IF THEY SO CHOOSE. That system would be cheaper and more reliable, thus making the entire centralized system a total waste of money. Hell, the insurer could offer a discount for those who do so choose.
In short,OsamaObamaCare will,in very short order,prove itself to be exactly what it is...the concoction of a community organizer/law "professor" who wants 95 year olds to receive a pain pill rather than a cardiac pacemaker (look it up),who'll never,himself,be subject to *any* of its provisions and who wouldn't know the difference between a rib spreader and a plate of baby back ribs.
Affordable Health Care act is nothing more than a legal way to “thin the herd”, bankrupt private hospitals, hire hundreds of thousand bureaucrats and unionize the whole d@mn thing! Has NOTHING to do with care!
Btw, total hip here too. Affordable Health Care would have probably let me die from necropsy and kidney failure. All the best!
We’ll be treated like animals anyway so necropsy isn’t that far fetched...
As is true with most patients,my hip replacement wasn't a "life saving" procedure...unlike heart surgery,for example.However I,a middle class,not powerful,not "connected" guy was in the recovery room of a major Boston hospital 9 business days after having called the surgeon for an initial consultation regarding my hip pain.And if I had taken the earliest MRI time slot that I was offered it might have been fewer that 9 business days.My understanding is (and I've done a lot of research on this) is that I would have waited at least 3 months...and possibly 6 months or more...under Canada's or Britain's health care system.But I thank God every day that Osama Obama will never be offered a pain pill instead of a cardiac pacemaker as he once suggested to a questioner should be the case with her elderly mother/grandmother.
Very true.And it's funny that you directed your post to "BayStateConservative" rather than me,"Gay State Conservative".If you're curious take a quick peek at my profile for an explanation of my screen name."BayStateConservative" might find it slightly amusing,being from Massachusetts.
Another oops. But a funny one!
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