Sunday, August 30, 2009

What Constitutes Torture: Minotaur Edition

Is Using A Minotaur To Gore Detainees A Form Of Torture?

Friday, August 28, 2009

Confessions of a Health Care Rationer

Written by a medical oncologist who does consultation work for a private insurance company, this is perhaps the best discussion of how health care is currently rationed and what, if anything, can be done about it. An excerpt: (but read it all since an excerpt does not do it justice):

Limiting health care’s availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual. Are the lives of the poor not of the same intrinsic value of those of the wealthy? To be fair, it is rare in the United States that poverty alone prevents the uninsured poor from receiving lifesaving intervention in a healthcare crisis. A poor man having a heart attack is not turned away from the emergency room, nor is the poor woman in labor sent away to have her baby at home. (I am not arguing that such enormities never occur, but the fact that such occurrences remain scandalous and newsworthy is a testament to their rarity.) Yet it is equally undeniable that the poor get a lesser share of the preventive care that can maintain health or of the quotidian care for the less dramatic challenges to their health.


All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan—they’ll say—waste, fraud, and abuse will be abolished. There will be chicken—or at least chicken soup—in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.

Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick?


On its face, one might think that the question of medical necessity is best answered by the physician who is actually taking care of the patient, rather than one who has never met him and is basing his decisions on a limited amount of information. But that will not do. That thought is one of the many illusory ways of denying the inevitability of rationing. To have the providers determine medical necessity is to have no limits at all on expenditures for health care, since all providers at all times believe (or at least claim) that the service they are providing is medically necessary. To have the providers be the arbiters of medical necessity is to abjure rationing altogether. The insurance company that does that will be very popular—very briefly. Then it will either go bankrupt in short order, or sharply adjust its premiums upward to have its income match its hemorrhaging outflow. If premiums rise enough, people will not buy the insurance. The result will quickly be the most generous insurance policy that nobody can afford.


As Congress and the people consider restructuring the American healthcare system, they must keep in mind that rationing health care may not be undeniable, but it is unavoidable. To claim that Congress will devise a new federal healthcare plan that will not involve rationing is like claiming that it will invent a triangle that doesn’t have three sides. Currently, within the private sector of health care, we have a large number of private insurance companies vying for the business of their customers. They ration health care on the basis of evidence-based medical necessity. The Obama health plan, the details of which are still being worked out, will also ration health care. The alternative to that is an accelerated escalation of aggregate healthcare costs. But the single-payer system to which Obama’s plan will lead will have no competitor and no pressing financial incentive to please its customers. No competitor for the single payer means no alternative for the patient. We can reasonably expect that a single-payer system of rationing will be largely implicit rather than explicit, and governed as much by cost and political considerations as by medical evidence. Such a system would likely combine the fiscal responsibility of the Postal Service, the customer friendliness of the Bureau of Motor Vehicles, and the smooth efficiency of the Immigration and Naturalization Service.

Read the entire thought-provoking piece. I may disagree with his conclusions, but it certainly does not detract from his eloquent explanation of the way we must allocate the scarce resources of health care. Comparing single payer to only the worst aspects of the Post Office, Immigration Services, the Dept of Motor Vehicles, etc., is a low blow. Like health care, these agencies serve necessary functions within society, and in the case of the Post Office, a place is definitely reserved for private players (UPS, Fedex, etc.) who enjoy a profitable existence. Even the Medicare system has a competitive aspect in allowing private insurers to provide supplemental coverage.

(hat tip Megan McArdle, whose site is sure to have a vigorous debate in the comments.)

Links to Drink By: Health care edition

Exhaustive side-by-side comparison of all available health care proposals. This shows that the discussion has been on-going and the current bills are alloys of ideas that have been developed over decades and not things that have been "rushed through."

The New York Time supplement on health care reform topics.

Charles Krauthammer has a health care proposal? Well, not really.

Several links to pertinent articles regarding health care reform.

The Ted Kennedy Plan: Simple, elegant, straightforward. No need for new bureacracies, just use the ones we have.

Dick Armey supports the public option. Shows the cognitive dissonance and politicization of the debate.

Tort reform is important-- but not a national scale. Let the states handle it, as the AMA proposes.

Private insurance companies investigated for fraud.

American Health Care Killed His Father?

The Atlantic has a good-- albeit long-- article this month by David Goldhill concerning health care, called How American Health Care Killed My Father. I'll make a few comments and leave a few unsaid. The dramatic title actually belies a more thoughtful attitude within the essay.


The economics of health care are the most complicated of any product in human society because of all the competing interests and weird incentives. Surgeons make more money when they do surgery, yet an ethical surgeon can spend most of his or her day talking people out of having surgery. And on and on. The entire fee-for service system has a huge inherent flaw, which Goldhill has noted.

The author states his father died from a nosocomial infection that could have been prevented by simple handwashing. Perhaps, but hosptials are inherently dirty places and even strict hygeine practices can leave patients vulnerable, especially elderly and infirm patients such as his father. Hospitals are constantly reviewing "best practices" for patient safety and cost-savings and I would compare this to aircraft maintenance and air traffic control in may respects. Does the free market improve air travel safety? Maybe, but everyone would agree that the federal government, working in league with the indutry, has a role to play, and I am the first to agree that more can be done.

"Government-run" health care is different from "government-financed" health care and this author has drawn that distinction, which is commendable. He also notes that we have had deflation of costs in almost all technologies with microwave ovens, computers and televisions all costing less today than they did 15 years ago, and then he tries to draw an analogy to the 20 yr/old MRI technology his wife had, implying that health care has not kept pace. This isn't quite accurate. The advances in medical technology proceed at least as quickly as kitchen appliances, and while I cannot speak about MRI's, I can say that ultrasounds and CT's have higher resolution and are much better quality than just five years ago, yet the reimbursement is the same or even lower. Also, the interpretation of the imaging by a clinician is the lion's share of the cost and that theoretically improves from decade to decade as we improve our knowledge base... again, at no increase in reimbursement in my 15 years in practice. The things we have to look at and rule out in an obstetric ultrasound have increased and the pay has not.

I fully understand the moral hazard issue and the whole disconnect with having a third party pay the bills and thus removing the responsibility of cost control and quality control from the consumer. Instead of comparing the health care product to Toyotas or lawnmowers, I would compare it, again, to air travel safety. It has to be of excellent quality ALL the time, and consumers really have no way of judging the quality of their care at the time they are consuming it. That c-section I did last week may have been done wrong, damaging the fallopian tubes and rendering the patient infertile. She won't know for a few more years, so what the hell. Likewise the treatment of asymptomatic hypertension, can be mistreated for decades before the 59 year-old drops dead prematurely from a stroke. This poses a dilemma that is handled in myriad imperfect ways to ensure quality: board certification, state licensing, hospital privileging, professional referral, etc. Quality-control is not something that can be done by the average patient and I think that we would be deluding ourselves and perhaps promoting a false sense of security to think otherwise. Sure, we could see a cottage industry crop up within the free market that evaluates health care delivery and I suppose such an argument could be made thusly to put more trust in the free market to find a solution, but it certainly would be no better than the tools we have now.

The author summarizes this sentiment:

Many experts oppose the whole concept of a greater role for consumers in our health-care system. They worry that patients lack the necessary knowledge to be good consumers, that unscrupulous providers will take advantage of them, that they will overspend on low-benefit treatments and under-spend on high-benefit preventive care, and that such waste will leave some patients unable to afford highly beneficial care.

They are right, of course. Whatever replaces our current system will be flawed; that’s the nature of health care and, indeed, of all human institutions. Our current system features all of these problems already—as does the one the Obama reforms would create. Because health care is so complex and because each individual has a unique health profile, no system can be perfect.

I envision my nightly television littered with ads for Crazy Lenny's colonoscopy shop with promises of "low low prices." Physicians always tread carefully around the line of crass commercialization and self-promotion versus collegiality and professionalism. In our community, for example, there are a fixed number of babies born and the competition for paying patients is tight between obstetricians, midwives and family doctors. By adding even more profit motive into the system, the risk is that we would swerve head-long into a bidding war that would get ugly. Would it lower prices? Maybe, but it could disrupt a delicate balance between quality and cost and could even decrease access if good providers chose to stop doing a service because the reimbursement was too low. Or worse, physicians might refuse to back up midwives in emergencies sensing competition from these more cost-effective providers.

Sure, the author notes that LASIK surgery has seen prices come down as competition has increased, but LASIK is a completely elective procedure unlike what is covered in Medicare and most insurance plans. The only thing that makes LASIK resemble "health care" is that it is done by people who attended medical school at one time. Period. The same goes for aesthetics, infertility care and some orthopedic sports procedures.* It is completely irrelevant to the discussion of providing urgent or semi-urgent care to sick, scared people, or to the long term management of chronic conditions.

Goldhill's discussion of health savings accounts (HSA) is appropriate for most of us, and this will likely continue to have a place in the panoply of options available in the system, and it may even have a material effect on lowering prices and streamlining the the process of payment by bundling, etc. I cannot see, however, how a mentally disabled individual could navigate the vicissitudes of HSA's, vouchers, deductibles, peer-provider groups, etc. The French have, arguably, the best health care system in the world and it's really similar to what's proposed by House 3200: namely, a mish-mash of various public and private options that are highly regulated by the federal government.

Remember that 70% of your health care dollars will be spent in the last 6 months of your life-- much like the author's father. So while we can scrimp $5 here on antibiotics or save $250 by being frugal and choosing to forgo a mammogram this year (not necessarily good economic decisions), an entire lifetime of perfect consumerism is completely erased by four hours in the ICU--- and are you going to shop around for a cheaper ICU? The information is asymmetric which makes for very bad decisions by consumers. Besides, what would prevent free market hospitals and doctors from just jacking up the prices when they have you captive?

One more quick point about the estimated "cost" of the plan on the table, by which I assume he means the House Resolution 3200 (he calls it "Obama's plan" which isn't correct, but WTH) which was evaluated by the Congressional Budget Office. The CBO (he says "the administration" which isn't quite right, but WTH) figures every expense that would be imposed by the bill to the federal government and does not figure the private sector savings. For example, over the next ten years the CBO predicts a net cost to the federal government of $1 trillion to ensure 46 million people and put through the insurance reforms such as limiting pre-exiting illness discrimination and allowing more portability. But the total cost of health care-- public and private sector-- is estimated to be $35 trillion over the same ten year period. So, for a 2.6% increase in cost to the nation we would be able to insure an additional 15% of the population... seems like a pretty good deal and certainly cheaper than could be accomplished in the private sector. Furthermore, part of the increased $1 trillion cost factored into the CBO estimate is the fact that people would live longer and thus collect more Social Security and Medicare benefits! Thus we can see yet another disconnect between economics and health care when a plan is punished because it helps people live longer, implying that a true patriots would pay all his payroll taxes for 45 years and then drop dead on his 65th birthday.**

I applaud the author for his thoughtful approach and I am heartened that such a discussion is taking place. I remember 16 years ago having all these same Socratic dialogues with colleagues when I was just finishing residency, and coming to no real solution. Having been in favor of Hillarycare at the time, I attracted the ire of one fellow resident in particular who adamantly opposed any intervention by the government and was convinced that the costs would come down on their own by the power of the free market. Here we are now, a decade and a half later, with costs up from 11% of GDP to 17% of an even larger GDP... and rising parabolically. And I'm convinced more than ever that Hillary was right in 1993 (although perhaps naive that it could be accomplished on such a daring scale)... and the discussion is being broached yet again.

*Some would add obstetrics into the pool of "elective medical conditions" and I would accept that since this is usually an elective, and almost always a preventable, condition.

**This reminds me of the famous story that came out of the Czech Republic after the fall of the Soviet Union. The tobacco companies, looking to gain access to previously unavailable markets, made the pitch to Czech officials to promote cigarette smoking by allowing advertising and decreasing taxation. Philip Morris funded a study that showed that the government would save money in the long run on pensions and health care because smokers would die younger and lung cancer is relatively cheap to treat because the patients die so quickly. Corporations are pricks, really.

Thursday, August 27, 2009

AARP Poll: 80% Support Public Option

In a new poll sponsored by AARP, 8 out of 10 Americans support a "federal health insurance plan" for people who cannot afford private plans. Fully 86% think that all citizens should be coverd by health insurance. In a stunning finding, 78% of Republicans agree that pre-existing illness should not preclude an individual from getting insurance. Across all demographics and party affiliations, 63% prefer that health insurance remain "mainly a private industry but allowing the government to serve as an industry watchdog to help expand coverage and keep an eye on costs.” (The entire PDF is here.)

A stark difference in answers is noted with 62% of Republican respondents saying that we "cannot afford health care reform right now", versus only 14% of Democrats. Only 27% of Republicans said "it's more important than ever" to reform health care now, versus 75% of Democrats. To me, this is the seminal point of the debate. Republicans do not view health care reform as potentially "bending the cost curve down" while Democrats believe that the runaway costs will only worsen if nothing is done now.

So, with so much consensus on the most important aspects of health care reform, why all the angst? President Obama needs to come back refreshed from his vacation and start a real conversation about health care reform. Passing a bullshit watered down bill just to "do something" would be ridiculous.

BTW, this is what a rational discussion of the public option looks like: video here.

Wednesday, August 26, 2009

McCain Booed for Defending Obama

See the look on McCain's face.

McCain Booed for Defending Obama

He's devoted his life-- nearly gave his life-- fighting for these dunderheads. Has it been worth it, Johnny? You got the Beer Princess and the applause, and now ridicule, of the idiots. Was it really worth your soul?

Is Health Care a Public Good?

If you read one thing on the health care reform debate, read Jeffrey Gordon's post at KevinMD on the economics of health care. He outlines in succinct form the dilemma of delivering a complex but necessary product to a population that varies in it's ability to understand and pay for this product.

One useful tidbit before you read Dr Gordon's post in its entirety is the definition of a "public good." From Wikipedia:

In economics, a public good is a good that is non-rivaled and non-excludable. This means, respectively, that consumption of the good by one individual does not reduce availability of the good for consumption by others; and that no one can be effectively excluded from using the good.[1] In the real world, there may be no such thing as an absolutely non-rivaled and non-excludable good; but economists think that some goods approximate the concept closely enough for the analysis to be economically useful.

Health care certainly approaches the definition of a public good, certainly as much as any public utility would. Therefore, it might behoove us to make sure this product is supplied in a safe manner to those who need it. As Dr. Gordon states:

By definition “public goods” are not well distributed by market mechanisms. Americans are very accepting of some public goods, i.e. police and fire departments, national military forces, the GPS system, water distribution and sewage treatment plants, education, radio frequencies and the internet. Looked at from an economic and a public policy perspective, health services are the epitome of a “public good.” This is what is meant by the phrase “Health Care is A Human Right!” Hospitals, ambulance systems, mosquito control, TB control, restaurant inspections, sanitation, and vaccines are all good examples.

When a person gets sick he or she functions poorly as a consumer. Often there is no opportunity to investigate or shop around for quality, never mind price. A seriously ill person has no price sensitivity - care is needed now and many patients will face even bankruptcy to get needed care in spite of looming bills. Even the most intelligent and computer literate sick patients are often seriously deficient in relevant knowledge both of disease states and who is well qualified to treat them.

Under our insurance system, the patient is rarely the consumer. Most purchasing decisions are made by a doctor acting as the patient’s surrogate. While one can discover a price for one item or service, it is totally impossible to have any sense of the ultimate charges for any significant package of medical services, so it is impossible to price shop even when there is time.

Can we shop for electricity suppliers? or water and sewage providers? or schools? Actually, we can. People choose to upgrade their water all the time, and go to private schools, and we also buy batteries and generators for portable electric power. Under any health care reform proposal, people would be allowed to purchase more insurance as they saw fit, and they could pay for premium care if they perceived added value. None of this would change under any proposed reform bill, but safe and affordable electricity, water and public schools are considered necessary for a civilized society, and so should health care.

Read the whole thing to see what his conclusion is. Hint: the town hall screamers' teabags would explode.

What if there had been no bailouts?

Tyler Cowan posits the thesis and Megan McArdle follows the thread, as does Julian Sanchez.

One interesting conclusion is that the success of the bailouts may have stalled the passage of significant health care reform. In 1929, the Hoover administration chose a libertarian tact and did nothing to mitigate the unrelenting pain from the Great Depression. This brought a dramatic political change and FDR came forth to bring about fundamental structural changes to social safety nets and federal regulation.

If the bailouts and stimulus package had not been passed this past year, we may would very likely have had more short term pain, but 2012 would have brought in a wave of more liberal lawmakers and a stronger political will for such things as single payer health care.

Bottom line: Pelosi, Reid and Obama saved the private health insurance companies.

White Sox Struggle

"Right now, it's a little too late to get the tight ass. You get the tight ass right now, pack it in. Right now, this is a man's game. I know what I've got. I'm still waiting for it to show up."

--Ozzie Guillen, Mgr of White Sox, as pennant hopes dwindle.

Tuesday, August 25, 2009

"That little box of crazy...."

Jon Stewart's tags are the only intro needed:

Tags: health, reform, town hall, rage, right-wing, monkey washing cat, Sarah Palin, protests, mongering, conservative, monkeys!, animals, Bill O'Reilly, Nazis, media, Glenn Beck, flashbacks

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End-of Life Counseling Already Covered

Republicans were for end-of-life counseling before they were against it.

The "Welcome to Medicare" visit includes such counseling, the current revision is to to cover the discussion every five years.

"No, Mr. Jones, I realize you're 85 now and it's been 20 years since we discussed this topic, but it's not covered anymore. You are just going to have to review our notes from 1989 and read a couple medical journals to see what's standard of care now."

Monday, August 24, 2009

Another Bushie Comes In Out of the Cold

In just the latest revelatory memoir, former Homeland Security Chief Tom Ridge has come clean on all those terror alerts that were issued in the weeks before the 2004 Presidential election, and it appears these were a ploy to scare the bejesus out of the electorate in order to gain support for the President. A book excerpt via TIME:
[Attorney General John] Ashcroft strongly urged an increase in the treat level, and was supported by [Secertary of Defense Donald] Rumsfeld. There was absolutely no support for that position within our department. None. I wondered, "Is this about security or politics?" Post-election analysis demonstrated a significant increase in the president's approval rating in the days after the raising of the threat level.

Atrios has bottom-lined this better than anyone:

"And just so it's clear: using the threat of terrorism to try to achieve political goals is, you know, what terrorists do."

Glenn Greenwald notes the tenor at the time and the lack of media questions in 2004 when terror alerts were raised. He has dug out Tucker Carlson's quote admonishing key Democrats who called foul at the time.

Tucker Carlson -- at the height of the August, 2004, controversy triggered by Howard Dean's accusation that the Bush administration manipulated terror alerts for political gain -- labeled those who believed the alerts were being exploited for political purposes as "insane conspiracy nuts" and said: "what they really need is psychological help, obviously." Separately, Carlson said that Dean had gone "berserk" and demanded that the Kerry campaign repudiate Howard Dean for suggesting that this was the case. I've emailed Carlson and asked him:

In light of Tom Ridge's belief that this is exactly what happened -- that, as the official responsible for assessing terrorist threats, he was pressured to raise the terrorist threat alert in order to benefit Bush's re-election campaign (something he also strongly suggested in 2005 after he resigned) -- do you still believe that? Or do you merely now believe Ridge to be one of the berserk, insane conspiracy nuts in need of psychological help?

I'll post any reply I receive.

One other note is that Ridge's tell-all may have ulterior motives since he has signed on as a consultant for a security firm and also is reportedly considering a Senate campaign against Arlen Specter in 2010. Distancing himself from his role in the Bush administration may have more tangible benefits.

Saturday, August 22, 2009

Obama's dilemma: Example #237

President Obama is losing the debate on health care due to nutjobs on the right buying the propaganda from industry groups of "death panels" and "big gummint." But equally as insidious is the misguided demagoguery from the left that mischaracterizes Obama's stated goals of health care reform.

Rep Danny Davis (D-IL-7) said today at a rally: “No matter the cost, quality health care should be provided for every citizen.”

Wrong! No where in any of the priorities of Mr. Obama's plan, either on the campaign trail or in the White House, did he ever say "No matter the cost..." The goal has always been to "bend the cost curve down...", as the president has said in the past.

One commenatator said recently that Obama is like Michael Jordan on a really bad team, and Rep Davis' remark is one of many examples of this. Nobody with any sensibility would agree with Davis' characterization and such rhetoric is counter-productive to the cause.

The proper tact, and the truthful one, is that health care is a value-add for society and is cost-effective if delivered properly. The current system is too expensive and leaves too many people sick and in jeopardy of financial ruin.

The President needs to have a team meeting. STAT. And get this message right.

Democrats and the "Super-majority"

Now Senator Grassley (R-IA) and Rep Mike Enzi (R-WY) are calling for a super-majority of 80 Senators to pass any health care reform bill, in other words, they do not want any reform at all. Grassley also thinks that a few screamers in several town hall meetings somehow should dictate the debate. That's incredible to hear, but WTF, that's his gig.

The larger question is why the Senate Democrats even consider the opinion of the marginalized leadership of the shrinking GOP. This latest laughable request should be met with, well.... laughter. This is, after all, the same party that had Sarah "death panels" Palin slated to be #2 on the list to lead the free world.

When the Medicare Part D drug benefit passed in 2003, with all the benefits going to the pharmaceutical industry, it passed with 54 votes. The same goes for the Bush tax cuts in 2001 which passed with 58 votes. Each of these votes had a similar monetary impact on the budget as the proposed House bill on health care reform.

The President and the Congressional Democrats need to do what is best on health care and ignore the noise from the Republicans. The GOP is clearly are not voting for any bill anyway, anyhow. This is why they were voted out of office in 2006 and 2008.

Note that the total votes cast for Republican Senators-- representing a lot of tiny square states-- is 40 million and those who voted for Democrats is 82 million. Even negating the 4 Democrats who would likely support a filibuster, the total is still 79 million. The Democrats in the Senate already have a "super-majority" when taking into account ballots cast.

Maybe the message here is that neither side has enough votes to pass the currently considered health care reform bill. It goes too far for conservative s and not far enough for liberals. The far left will be pissed with anything short of a public option clause-- arguing that significant conciliation has been inserted into existing legislation-- and the right will not vote for anything, with both sides digging in, leaving only a 40% plurality who would favor a watered down "insurance reform". If the two extremes both oppose this moderate tact, the bill fails: So we may have a situation where the votes are split 40-20-40 and nothing will pass.

Who wins? The private insurance industry who really add no value to the health care product but benefit greatly from the continuation of the existent system. Who loses? Everyone else.

Or, Reid, Pelosi and Obama can recognize that the only chance is to join with the progressive left wing and ignore the GOP altogether. Take the 51 votes and pass something that works.

Tom Tomorrow Adds the Truth

Beck Adds the Humor

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Friday, August 21, 2009

Did Rachel Maddow "lie" about MoveOn's Nazi "ad"?

In a word: no. But there is a bigger question....

This is a meme gaining traction amongst even moderate conservatives after Rachel Maddow's appearance on Meet the Press last Sunday. While I'm not a huge fan of her specific views in every instance, I do think she adds constructively to the political debate and I was glad to see her fresh face on Meet the Press which is usually a forum for the Washington/New York establishment dinosaurs.

Last Sunday, Dick Armey was trying to paint the picture that MoveOn was "comparing Bush to Hitler" in 2004 and Maddow interrupted Armey to say that Moveon did not compare Bush to Hitler. Is she correct? Let's look a the evidence.

Right wing sites have presented the video in question as well as protesters who have vile pictures of Bush and Cheney in Nazi uniforms, etc. White House spokesman Robert Gibbs said it best when he said that such imagery misses the point and we should lower the heat a little bit on the debate.

Back to the question at hand. Did MoveOn "run an ad" comparing Bush to Hitler? The "ad" in question was part of a contest and was uploaded onto their site along with hundreds of other entries without being screened. This would be akin to a call-in show having a caller say something that the host may not necessarily agree with. As Media Matters put it:

...two videos submitted to a advertisement contest had included Hitler imagery in their 30-second attacks on President Bush. (They were just two of the 1,500 clips submitted.) MoveOn never endorsed the efforts or promoted them; the clips simply appeared on MoveOn's crowded contest website. But when news spread about their mere existence, a controversy erupted, and the liberal netroots group quickly pulled the ads, apologized for their inclusion, and denounced the use of Nazi imagery.

Did MoveOn endorse Nazi imagery? Not even close. Of course, as Media Matters and Glenn Greenwald point out, Fox News and other outlets were quick to present the MoveOn "ad" as an endorsement when it was actually one opinion from an anonymous commenter (and the Nazi "ad" could have easily been planted by pro-Bush forces as a gotcha to garner sympathy from moderates against MoveOn, if you want another scenario.) This whole manufactured controversy was one tactic in the effort to falsely paint Bush's critics as unreasonable screechers in the run-up to the 2004 election. It worked.

Was Rachel Maddow correct to call foul on Dick Armey? Absolutely. The bigger question is why would Dick Armey make this cryptic statement about a five year old pseudo-controversy on the widely watched Meet the Press show now out of the blue? Maybe it's just because he's an asshole. But my bet is that it's to go on mainstream TV to take the heat off conservative commentators who have a long history of using Nazi imagery to lather up their meathead listeners. Or to resurrect this anti-MoveOn sympathy amongst ill-informed moderate voters in the heartland yet again. Nothing happens by accident.... expecially in Dick Armey's world.

Any use of Nazi imagery is really just an attempt to sensationalize a situation and invoke an emotional response. In practice, it backfires amongst rational people and ends up with your opponent gaining more sympathy since nobody in the modern mainstream (not even Limbaugh) comes close to the evil of the Third Reich. Some call this Godwin's Law (of Hitler Analogies.) Among idiots who fall for the Nazi comparisons, however, it can be beneficial in stoking up rage.

For the record, did Nancy Pelosi call protesters at town hall meetings Nazis? Again, the answer is no... but that hasn't stopped right wing outlets from using this in their appeal to moderates. This entire debate has devolved into a shouting match and the forces who benefit from the broken status quo are the only winners. Dick Armey's clients in the health insurance and pharmaceutical industries will continue to see record profits and shovel money into their coffers while the rest of us pull each other's hair out over who's a Nazi and who isn't.

Maddow was just trying to politely re-focus the conversation.

Thursday, August 20, 2009

Why pro bono labor from doctors won't help

David Lazarus of the Los Angeles Times wins the Knucklehead Idea of the Week Award. In his recent op-ed he posited that doctors should be required to provide one week of free labor for people without insurance in order to "help fix the healthcare system."

Thousands of people lined up last week for free medical treatment at the Forum in Inglewood. The arena floor resembled a vast healthcare assembly line as hundreds of patients at a time were seen by dozens of doctors, dentists and optometrists.

But many others had to be turned away because of a shortage of medical professionals willing to volunteer their time and expertise.

Stan Brock, founder of Remote Area Medical, the nonprofit group that organized the Forum mega-clinic, was clearly frustrated by being unable to match the overwhelming demand for healthcare with a sufficient supply of caregivers.

If local doctors aren't willing to donate their time -- a big enough problem on its own -- why can't physicians from other states come here to do
pro bono work?

See, this is the problem we have with "fixing the healthcare system": everyone with a keyboard has an idea and throws it out there with the admonition that if we just do this or that, it might help. Pro bono work from random physicians certainly couldn't hurt, so why not do it? In fact,let's require it. I'll leave alone the whole disconnect of requiring charity work, and go over the counterpoints to Lazarus' plan from a systems standpoint.

1. Doctors already give steeply discounted service when they accept Medicaid. The reimbursement from this payer is so low that it is universally subsidized by an outside entity or other paying patients.

2. Working in free clinics is horrendous for professionals and patients alike. Shotgun doctor-patient relationships are inadequate to manage complex problems. Any labs, xrays or meds would not be covered and the patient would be left with recommendations that could not be followed.

3. Physicians are just one part of a large, intricate system. We rely on our trusted staff and other professionals in the community to help deliver the health care product. To force a doctor to work in a foreign setting without his/ her staff and referring colleagues would be counter-productive.

4. Health care delivery is best done with continuity. To go to a free clinic one week per year is ludicrous. The physician could not verify that proper follow-up has been rendered and that progress is being made in a treament protocol.

5. Free clinics could give the uninsured and underinsured a false sense of security that they will be provided quality care without payment, and thus disincentivize people to get necessary insurance coverage. It sends the wrong message.

6. As presented in the Lazarus' column, clinics would have difficulty verifying that these traveling doctors are qualified and safe.

Let's review a scenario. Dr. Jones, a surgeon from a suburban practice, goes to the inner city free clinic to see patients pro bono for his required week. On Monday he sees Mr. Pickins who has right upper quadrant abdominal pain, boating, jaundice and nausea. Dr. Jones suspects gall stones and orders lab tests and an ultrasound. Mr. Pickins has no insurance or family physician. Dr. Jones has no idea if Mr. Pickins has any money or insurance to pay for these tests or surgery if it is necessary; Dr. Jones does not know the office staff well enough to be confident that they will follow up with Mr. Pickins to make sure he doesn't have a pancreatic tumor. If the labs and ultrasound are actually done-- very unlikely-- and gallstones are diagnosed, then who will do the surgery? The surgeon on the list for next week?

The entire week is full of patients with suspected hernias, meningitis, chest pain and pressure sores. Dr. Jones has created doctor-patient relationships with dozens of people with no ability to ensure that proper follow-up has been carried out. This would be a disaster that corrupts the little semblance of "system" that each doctor struggles to create.

Lazarus tries another approach:

So let's try this instead: As a condition of licensing, a medical professional would be required to demonstrate that he or she treats at least a tenth of patients on a pro bono basis annually.

That is, for every 10 patients that a healthcare provider sees, one would receive the same level of care as all the others but at no cost.

Here are the problems with this scenario:

1. Nothing is free. The costs would merely be transferred to paying patients seen in the office.

2. Again, labs, xrays, surgery, medications and hospital care would still need to be covered. We work within an integrated system and doctors' labor is just one very small part of the cost.

3. Again, this sends the wrong message that patients don't really need to be responsible because every physician in the country will be required to have "free" appointment slots. Heck, patients could even shop around!

4. Who would do the means testing to ensure this free care is for truly indigent people?

5. In my experience, patients who are not required to pay are also at high risk for being noncompliant with appointments and care. They have very high rates of failing to keep appointments. This is costly and disruptive to a medical practice.

The problems with health care in the US are myriad, but the two universal issues are that 1) we lack a system approach, and 2) our costs are too high. David Lazarus' hare-brained scheme would exacerbate the first problem and do nothing to alleviate the second. It is typical of quick-fixes that try to avoid the heavy lifting of actually fixing the healthcare problem.

A much better idea would be to hook these uninsured and underinsured into an existing program that does means testing and provides comprehensive coverage. Half-measures are dangerous for everyone involved.