Opponents of Health Care Reform go Cra-a-a-zy!

Alright, 1000 pages seems unwieldy for any government bill and that is what we have with the current House bill on health care reform. But on further perusal, it's double spaced and outline form, and actually not that difficult to navigate.

Watching Hannity* this weekend (I do this occasionally just to see the most extreme wackiness being proposed) and also reading a couple blogs, I have come up with some criticisms of the health care bill to answer.

The right wing has gone nuts finding all manner of complaint with the current House bill. Fleckman has gone point by point and page by page to give his commentary on the bill. I admire his completeness, the problem is that he has large gaps in his knowledge base and his views are peppered with outright anger over "government control". I'll address three points specifically.

1. "Government will tell grandma that she has to give up her right to care and just die." This is the anti-rationing argument and opponents reference page 425-430 of the bill for their ammo. The background on the legislation, however, is that currently Medicare does not pay physicians to sit down with patients to discuss end-of-life care. If the doctor makes time for this important discussion, like many things in Medicare, it's a freebie. Hospitals are now required to offer "advanced directives" for anybody being admitted either for a routine outpatient surgery, or life threatening emergency; patients can refuse to fill out the papers and they often do because of their lack of understanding. Wouldn't is be much better if that same patient who is now coming in with chest pain at 2:00 a.m. had already discussed all the interventions in a leisurely visit with their own physician in the office? That's all the legislation is saying: insurers must pay for the discussion once every 5 years, or if the patient's health changes significantly. Duh.

2. "Telemedicine is health care by telephone." (p 379-382) Again, Medicare and most private insurers do not currently pay for telephone calls by physicians to patients. As a consequence, for doctors to get paid for their time, it is required that patients come into the office to discuss routine lab and x-ray results in order that the visit can be billed. The problem is that many old and/or sick patients have difficulty making a special trip just to discuss things that can be done over the phone, so the compassionate doctor does it for free. This provision in the legislation would allow a fee to be billed for telephone calls. Better medicine, long overdue... just ask Thomas Edison. In addition, the current legislation adds a provision for a telemedivcine advisory board in order to monitor the progress and keep up with newer communication technologies.

3. "Government is being big brother by telling doctors they cannot own surgicenters, diagnostic centers and pharmacies." (p 316) Actually, these restrictions have been extant for a couple decades for Medicare providers and the legislation would just make it formalized for non-Medicare providers. The rationale is that many studies show that physicians who own such health care vendors tend to over-utilize their own facilities, i.e., they order more needless xrays and do more unnecessary surgery if they can double-dip on billing. Under the current legislation, physicians can still own such entities, they would just not be allowed to refer patients to their own facilities and bill for such services.

Of course, there are many more criticisms and I took these at random. These provisions are all common sense and really just formalize or clarify or update the status quo. Insurers will be required to cover certain things under comprehensive care, so women will know that Pap smears and mammograms are covered benefits, for example. No more will private insurers be able to game the system by calling their coverage comprehensive and then refusing certain well-accepted things, and don't tell me that doesn't happen-- it does.

Are there things missing from the bill that I would like to see? Sure. If we must have all these various private insurers, the least we could do is make all the forms the same. Currently, a typical doctor's office must be adept at filling out a couple dozen different forms to bill all the different insurers. There is no reason all the insurers could not use the same forms, which would cut down administrative costs and allow patients a better understanding. Also, the same payment for the same service would be beneficial, although I know this will never happen. It has always seemed strange to me that Insurance Co A may reimburse 20% more than Insurance Co B for the exact same service, but that's just a contracting issue with physician groups.

As you can see, health insurance is being treated more like the utility it is. Certain things must be covered, policies must be portable, pre-existing illnesses must be accepted... the insurers can no longer game the system by cherry-picking healthy and wealthy patients. So it begs the question, why do we even need health insurance companies... except to take their 15% or 20% profit off the top?

My take is admittedly extreme and I subscribe to the school that believes that private insurers have nothing of value to add to the health care product and we would be better off bypassing the for-profit insurance industry altogether. Patients have this delusion that they have a vast amount of choice in what can be done. They don't. Doctors by and large follow standards of care and insurers choose whether they want to cover it or not. The current health care bill is long overdue and is merely formalizing statutes that are long overdue. The talk of "rushing" through a bill all bullshit, too. Policymakers have been mulling these basic and necessary changes for 20 or 30 years, only now do we have the political will to make it happen.

*I lasted 5 minutes watching Hannity and had to change the station due to his complete lunacy about the issue. Every statement was punctuated with his "fear" of what might happen or that he is "scared" of all the potential "unintended consequences." Geez, what about the intended consequences of the insurance lobby's efforts to delay reform all these years? It's bankrupting us. Maybe we can add a special clause in the bill that pays for diapers for right-wing commentators so guys like Hannity don't have to wet their pants over every single news item. The fact that anybody is listening to him-- and a lot are-- is a sad testament to the notion of an informed electorate. (No wonder we had such broad support for the idiotic war in Iraq!)

Martin Feldstein lies about health care

It's difficult for me to imagine anybody filling one newspaper page with more distortions, omissions and outright lies than Martin Feldstein has done in his recent Washington Post piece. The rhetoric is becoming so shrill and misleading that I suppose this is evidence that health care reform is really going to happen (although I have little confidence any current proposal will be beneficial). Feldstein's op-ed is such a piece of crap that I'll go over it in its entirety. He starts (in italics, my response is not italicized):

For the 85 percent of Americans who already have health insurance, the Obama health plan is bad news. It means higher taxes, less health care and no protection if they lose their current insurance because of unemployment or early retirement.

Right off the bat, Feldstein includes the 90 million Americans who are currently in a government-paid health plan (Medicare and Medicaid) as part of the 85% with insurance. Perhaps he shows us later how the provision of health care for more will deprive these 85% of care, or is this a scare tactic? (Hint: he doesn't).

President Obama's primary goal is to extend formal health insurance to those low-income individuals who are currently uninsured despite the nearly $300-billion-a-year Medicaid program. Doing so the Obama way would cost more than $1 trillion over the next 10 years. There surely must be better and less costly ways to improve the health and health care of that low-income group.

What's the gripe here, that "formal health insurance" is better than the piss-poor, underfunded Medicaid that low-income individuals and their doctors must navigate now? Medicaid is a minimally-funded charity program that relies in large part on the beneficence of physician groups and health care entities who accept the ultra-low reimbursement as a service to their communities. Should we just put another 46 million people into this program? Feldstein intimates that "there surely must be" a better plan, yet this great Harvard economist offers nothing. Some Republicans admit now that health care reform is necessary, yet they stood by when they had control of the government and did nothing as health care costs eroded our GDP, and now just lob grenades at anything proffered by the Democrats in power. Unproductive. The $1 trillion cost estimate from the CBO does not take into account any of the potential cost savings from health care reform such as economies of scale, preventing catastrophic health events, the increased productivity of a mobile labor force and other intangibles.

Although the president claims he can finance the enormous increase in costs by raising taxes only on high-income individuals, tax experts know that this won't work. Experience shows that raising the top income-tax rate from 35 percent today to more than 45 percent -- the effect of adding the proposed health surcharge to the increase resulting from letting the Bush tax cuts expire for high-income taxpayers -- would change the behavior of high-income individuals in ways that would shrink their taxable incomes and therefore produce less revenue. The result would be larger deficits and higher taxes on the middle class. Because of the unprecedented deficits forecast for the next decade, this is definitely not a time to start a major new spending program.

Completely misleading. The House plan calls for a 1% surtax on those making over $280,000 per year and up to 5.4% for those making over $1 million. The increase "35% to 45%" to which Feldstein alludes has nothing whatsoever to do with health care reform, but rather, as he says, is the sunset of the Bush tax cuts. The fact is that the federal budget became unbalanced due to two wars, a Medicare Part D pharma boondoggle and other frivolous spending over the past 8 years. If the GOP-controlled government had been more frugal, then there would be no need to allow the tax cuts to sunset. Feldstein is lying and for him to say that income tax rates will rise from 35% to 45% because of health care reform is a complete abrogation of any duty he has to the truth. Also, a news flash to Dr Feldstein: we are already spending money on health care for the uninsured, the problem is that the health care they are getting is the most expensive type, least efficacious, rendered only after delay and through an emergency department... so he can stop with the BS about a "major new" spending program.

A second key goal of the Obama health plan is to slow the growth of health-care spending. The president's budget calls explicitly for cutting Medicare to help pay for the expanded benefits for low-income individuals. But the administration's goal is bigger than that. It is to cut dramatically the amount of health care that we all consume.

A recent report by the White House Council of Economic Advisers claims that the government can cut the projected level of health spending by 15 percent over the next decade and by 30 percent over the next 20 years. Although the reduced spending would result from fewer services rather than lower payments to providers, we are told that this can be done without lowering the quality of care or diminishing our health. I don't believe it.

Feldstein doesn't believe it? I always thought economists fancied themselves mathematicians and scientists, so where is his fact-based study loaded with formulae to support his belief? Or, I suppose, we should just take his word for it. The fact is the White House report, as referenced, is replete with charts, graphs and liberal use of all manner of economic jargon... which, sure, could be 56 pages of bullshit, but we wouldn't know it by Feldstein's assessment. He just wants us to accept his belief-system. Feldstein was given an opportunity in a major paper to answer the White House report, and he whiffed.

To support their claim that costs can be radically reduced without adverse effects, the health planners point to the fact that about half of all hospital costs are for patients in the last year of life. I don't find that persuasive. Do doctors really know which of their very ill patients will benefit from expensive care and which will die regardless of the care they receive? In a world of uncertainty, many of us will want to hope that care will help.

I'll let Dr Bob Wachter, a hospitalist MD who cares for the infirm, answer this question: "I just finished a couple of weeks on the wards, and once again cared for several patients – cachectic, bedbound, sometimes stuck on ventilators – in the late stages of severe and unfixable chronic illnesses whose families wanted to “do everything.” ...There are limits (like chest compressions) on what I am willing to do in these circumstances, but they are mostly symbolic – basically, I am a bit player in this crazy house, with no choice but to flog the helpless patient at a cost of $10,000 a day in a system that is nearly broke and whose burn rate threatens to ruin our country. Go figure... Is there anything we can do? The favored solution [is]..."

Dr Wachter goes on with a rather lengthy discussion about the problems and costs of end-of-life care and the issue of rationing. So, yes, physicians can be a part of a health care system that looks at outrageous costs that are incurred with little or no benefit rendered. Feldstein fails to realize that health care costs approach a zero sum situation whereby every dollar spent on a ventilator for an end-stage emphysema patient is a dollar unavailable for prenatal care for a 25 year-old with two young lives at stake. While we can scare everyone by invoking the spectre of "rationing", the reality is that we are now constantly allocating scarce resources, and it's about time economists like Feldstein got in the game before our whole country goes bankrupt.

We are also often told that patients in Minnesota receive many fewer dollars of care per capita than patients in New York and California without adverse health effects. When I hear that, I wonder whether we should cut back on care, as these experts advocate, move to Minnesota, or wish we had the genetic stock of Minnesotans.

The administration's health planners believe that the new "cost effectiveness research" will allow officials to eliminate wasteful spending by defining the "appropriate" care that will be paid for by the government and by private insurance. Such a constrained, one-size-fits-all form of medicine may be necessary in some European health programs in which the government pays all the bills. But Americans have shown that we prefer to retain a diversity of options and the ability to choose among doctors, hospitals and standards of care.

Americans worship at the altar of the specious "diversity of options", but physicians by and large follow standard protocols for screening, diagnosis and treatment of nearly every problem and diagnosis. We are more technical in our decision-making than one might realized-- or at least we should be. Every medical specialty provides guidelines for the standard of care for all manner of procedures and tests which are easily understood and based on science, and any deviation from these standards is almost never warranted. Insurance companies and Medicare and Medicaid currently understand these protocols and pay for these services accordingly. Furthermore, many think that government-financed health care will limit their choice of doctors, but no evidence points to this conclusion. Regardless, individuals will retain the ability to purchase more coverage as they see fit for their needs or peace of mind. Feldstein is merely engaging in fear mongering and cites no references in refutation.

At a time when medical science offers the hope of major improvements in the treatment of a wide range of dread diseases, should Washington be limiting the available care and, in the process, discouraging medical researchers from developing new procedures and products? Although health care is much more expensive than it was 30 years ago, who today would settle for the health care of the 1970s?

And, again, what evidence exists that medical research would diminish due to an expansion of the government financed health care system? Pharmaceutical and device manufacturers now need to show efficacy to government panels to be awarded patents and FDA approval, and without acceptance by Medicare no innovation will be successful in the market. This has not seemed to slow such advances. The remuneration for innovation has always been sacrosanct in our culture, why would that change? The military, NIH and NASA are all government financed entities that have a long history of working with private industry to develop some of the most advanced technologies in the history of humankind. Why would Obama's health care plan change that? In fact, the one thing that is currently limiting more money being put into research here is the runaway costs of health care in the US now. Feldstein is delusional which is clear by the fact that he cites no references to support his argument.

Obama has said that he would favor a British-style "single payer" system in which the government owns the hospitals and the doctors are salaried but that he recognizes that such a shift would be too disruptive to the health-care industry. The Obama plan to have a government insurance provider that can undercut the premiums charged by private insurers would undoubtedly speed the arrival of such a single-payer plan. It is hard to think of any other reason for the administration to want a government insurer when there is already a very competitive private insurance market that could be made more so by removing government restrictions on interstate competition. [bold is mine]

Outright, flagrant Lie. Obama has never said anything close to this. The nearest he has gotten to this topic was his support for Medicare-for-all in 2002 while running for the Illinois Senate. Medicare does not "own hospitals", nor do they "salary" physicians. Either Feldstein is purposely misleading for what ever reason, or he has no understanding of Obama's position, or he has no idea what Medicare is, or he's senile. This is the seminal paragraph because it betrays Feldstein's flaws and bias, and this alone should have alerted the WaPo editor to throw this entire op-ed in the trash.

There is much that can be done to improve our health-care system, but the Obama plan is not the way to do it. One helpful change that could be made right away is fixing the COBRA system so that middle-income households that lose their insurance because of early retirement or a permanent layoff are not deterred by the cost of continuing their previous coverage.

"Much that can be done..." What, pray tell? "Fixing Cobra"? How, by having the government pay the premiums for those in need? For how long..., until the individual gets another job or qualifies for Medicare? This would allow some private insurer to obtain a government-financed premium for probably the most expensive health insurance plan on the planet, while the individual would have no better coverage than the average Medicare recipient. And COBRA participants are only a small fraction of the uninsured and underinsured.

Now that congressional leaders have made it clear that Obama will not see health legislation until at least the end of the year, the president should look beyond health policy and turn his attention to the problems that are impeding our economic recovery.

(Martin Feldstein, a professor of economics at Harvard University and president emeritus of the nonprofit National Bureau of Economic Research, was chairman of the Council of Economic Advisers from 1982 to 1984.)

Conclusion: I may have disagreements with the health care reform plans put forth by Obama and the other Democrats, but Martin Feldstein is completely dishonest in his portrayal of the plans and the problem at hand. When the rhetoric becomes so unreasonable, we can only conclude that these detractors are becoming desperate in their defense of the status quo. Feldstein adds nothing to the debate, he merely lowers himself to distortions and lies. He was given a perfect opportunity to outline his solutions and ideas and he chose to use this valuable newspaper space to engage in shameful untruths not becoming an academic economist.

Universal health care is necessary for no other reason than we are currently providing it anyway. Nobody is allowed to die in this country and when individuals come to the hospital after years of neglecting their health, their patient care is ALWAYS MORE expensive. You are paying for it one way or the other in the form of increased premiums and misallocated resources. As Ben Franklin said, an ounce of prevention is worth a pound of cure. So, why not find the pennies to pay for the prevention?

Europeans spend 7 to 10% of their GDP on health care while we pay upwards of 17%, with no dicernible difference in quality. Just imagine what we could do with another 7% of our massive GDP liberated for other things besides insurance executives' salaries and wastesful health care expenditures.

Buehrle on Letterman and SI Cover

Letterman Here.



Sports Illustrated:

The Implosion of the Right Wing

G. Gordon Liddy needs to be fitted for a tinfoil hat.

I realize there are folks who are convinced Man never walked on the moon, "world govt" is run by a cabal of 50 people, Clinton killed Vince Foster and raped half of Arkansas, the Cubs will someday win a World Series...

... and now G. Gordon Liddy, war criminal and convicted felon, believes there's an affadavit signed by Obama's Kenyan step-grandmother which "proves" he's Kenyan? Ri-i-i-ight! And where could that affadavit be, Mr. Liddy? And he gives this fictional affadavit more credence than he does the Republican Governor of Hawaii, the state medical dirctor, an official Certificate of Birth (he keeps saying "well, it says certificate of live birth and not birth certificate"... WTF?) and a newspaper birth announcement from 1961.

Carter never should have commuted this nutjob's 20 year felony sentence in the 1970's. That's what prisons are for: to keep the criminally insane out of circulation.

Neither will Liz Cheney denounce the birther idiocy... she wants to "look forward", which is code for "I need these nutjobs to vote for me in my 2012 House or Senate race."

Oh well, the GOP lasted 150 years which is all anybody could reasonably ask of a political party. I'm sure Honest Abe is beaming with pride over the intellectual devolution of his party.

The Catch

... that saved Perfection:

This video won't last long on Youtube, so watch it now!

PERFECTION!!!

Don't cancel the postgame show. Video of Buehrle's masterpiece here. Watch Dewayne Wise make the greatest catch in Chicago baseball history.

"One nation under Gawd..."

Rick Sanchez on CNN this afternoon covered this story about the "birthers" taking over a town hall meeting in Delaware. The gist of Sanchez' commentary was to ask what President Obama has to do to show that he is a natural born citizen. The obligatory couplet of partisan strategists were on the show and the Republican guy said that while he the strategist believes Obama was born in Hawaii, Obama still "needs" to prove he is a citizen to all these idiots in the hinterlands by "communicating, because he is such a great communicator (he said smugly), with a press conference, or something."

Watch the video, and I'll comment below.

My question: Why does Obama "need" to do anything more? He's provided his birth certificate, signed and sealed. He has also shown the newspaper from that week announcing his birth. Why does he "need" to do more?

These dunderheads would never vote for him anyway, and they would never sign onto any of his programs, or even try to understand his motivations. In fact, look at the video and see this Representative Castle, who most likely is a rational well-meaning public servant, flail about and finally surrender his meeting to the morons who cheered the flag and jeered the President. Castle must be thinking, Geez, I gotta pander to these muttonheads to keep my job? There's gotta be a better way to serve my community.

This video is one for the ages, folks. It shows all the irrationality of our modern body politic rolled into a few short minutes: we have the "birther" inanity, the flag fetish, the invocation of WW2, the jeering, even the emphasis of 'under Gawd' in the Pledge of Allegiance... hard to believe we're 400 years out from the Age of Enlightenment; it's like a scene from the Auto-de fe.

Also, in the video, watch the panel of folks look back at Representative Castle once the lady gets going. The look of bewilderment, like, what the hell are we going to do here? Also remarkable, in addition to the shaking emotion of the lady crying "I want my country back", are the loud cheers of approval from her fellow citizens. The hatred is palpable.

Scary stuff. I give Obama a lot of credit for his committment, even if I may have differences of opinion on certain policies. These people are nuts. I'm sure I couldn't be their president, I'm sure I couldn't do it.

Furthermore, I would think the onus is on the GOP to educate their own electorate. This has all the makings of a slow-motion train wreck with 10 or 15% of their voters going off the reservation in the next election cycle: Maybe start a 3rd Party with Sarah Palin as the candidate, and drain off any hope for a Republican win. I doubt Obama or the Democrats want to go to any length to stop this process.

When your opponent is running off the cliff, the smartest thing you can do is get out of the way.

There's more video and discussion at Think Progress.

Barack Obama on Single Payer

The shame is that we have a president who understands the need for a basic health care plan for all, but has settled for the completely disjointed morass that is coming out of the sausage maker in Washington. While health care reform is necessary, passing an inferior bill would be the only thing worse than doing nothing.

Sure, political considerations will always take precedence, but the current bill, in all it's thousand page glory, does not achieve the goals as outlined by President Obama: 1) universal care, 2) paid for within the budget, 3) containing quality standards. None of these three goals are met in the current bill.

Which plan could fit all these criteria? Answer: Medicare for all. This is a program that has been around for two generations with a bureaucracy already in place which has high standards that have been tested and revised, and can be implemented over the entire population fairly easily... certainly more easily than a brand new 'system' made from the existing mish-mash of private insurers with all the various models.

Peter Singer on Rationing Health Care

The third rail of any health care debate is the topic of rationing. The fact is that health care is rationed every day by consumers, doctors and payers. The buzzwords in medicine are 'best practices' and 'evidence-based' to determine the optimal interventions. When do you order a head CT for someone with headaches? When is hysterectomy warranted for dysfunctional bleeding? These are decisions made every day and while any individual decision is hardly going to break the bank, the total allocation of the health cae budget, not to mention risk to the patient, for any intervention muat be weighed against the potential benefit.

Peter Singer has an excellent discussion in the New York Times on rationing health care. He notes that at present health care is rationed, but now it is not necessarily based on any applicable standard, only the whim of a particular insurance payer. Standards on such things exist and he elucidates the mechanism very well.

We all relish the thought that WE can decide what is the best practice: what is best for us in a particular situation. WE want to be the captain of our ship. Granted, nobody enjoys abiding by the dictates of a large bureaucracy, but the goal of a health care "system" is to provide the optimal care for the greatest number of people, and the problem in the US is that we lack a "system" and health care is too often doled out by whim. In every publicly administered health system-- Britain, Canada, Australia, France, etc.-- there exists a provision for individuals to purchase additional insurance and care as they desire. The United States would be no different, but provision of tha basic health care is necessary.

The employer-based health care model is flawed

My response to commenter Mike: Health care becomes an issue of national security and interstate commerce when it has such far-reaching consequences for businesses and the well-being of our workforce, thus it comes under the purview of the federal government. This may be a stretch, but it's the opinion of economists from the frugal Pete Peterson to advocates of single-payer.

The Safeway stores' employee plan, as outlined in one of your references, has merit and should be pursued. No question. The health insurance market in the US will always be a mix of public and private plans and the more efficient will win out... We need to pursue innovation, that's how markets work, and that is why my initial post had the wording single-payer "option" that covers all. There is a baseline level of care that has been accepted as necessary, a de facto right, and this needs to be covered financially somehow or we need to express unequivocally that health care in NOT a right. If you seriously believe that uninsured and underinsured should be left to die (and that is a valid philosophical stance), then your gripe is not with the proponents of single-payer, rather you should be advocating for the rights of hospitals and doctors not to participate in the care of the uninsured. As it stands now, acute care hospitals are required to accept all patients according to EMTALA statutes regardless of their ability to pay, and hospitals in turn require physicians to take emergency call for these patients in order to maintain privileges. Seriously, fight for the rights of the indentured hospitals and physicians! This would definitely lower health care costs dramatically since the uninsured will no longer be a burden to us all.

Opponents of big government health care, such as Rep. Ron Paul, have long held that the implementation of Medicare was flawed from the beginning, and that may be a valid opinion, but we cannot turn back the clock 40 years. My opinion is that Medicare served a severe need at the time it was introduced and has covered people who were unable to get insurance coverage otherwise. Non-union retirees and the disabled were essentially left without any options for private insurance and thus the need for Medicare was born. Opinions of hard-liners such as yourself, Mike, and Rep Paul, should be respected, but realize that Medicare has filled a dire need, done it reasonably well, and could have a place in an expanded role. You may never be convinced and I'll listen to any alternatives you can present*.

My question is why a grocery store like Safeway would even want to be in the business of providing health insurance at all, but if they are concerned with their employees' health, then more power to them and they should be able to continue their plan. Another question is what happens when a Safeway employee gets sick enough to lose his/her job? Does his entire family go without insurance, or would they then be thrust onto the public dole? Finally, if the Safeway plan is so efficient and beneficial, then what is stopping all employers from going to this model now? Mr Burd, the CEO, should not be going to Capitol Hill, but rather the Better Business Bureau and the Chamber of Commerce. We have been living in an environment of free market employer-based private health insurance, now covering 180 million of us, for a couple generations and have only seen costs rise exponentially. Why is that? Furthermore, the current employer-based insurance model drastically limits the mobility of the workforce, which leads to decreased productivity and a stifling of the labor market.

You said previously that Medicare does not "add value." I never said it did; and I would add neither does private insurance. For the most part these entities are benefit administrators-- they collect premiums and send out (or deny) reimbursement checks-- using actuarial data. Incentives to withhold coverage are rampant and care should be dictated by health professionals and standardized evidenced-based data in either model. The corporate executives are very well paid for doing nothing more than collecting premiums and writing reimbursement checks, which is a rather utilitarian function.

You said you worked in a large unwieldy government bureaucracy which has obviously affected your opinion. Have you ever sat in on a private insurance company board meeting? There are just as many cases where private insurance has chosen not to cover life-saving treatments due to cost considerations. The recourse in such a situation is just as dire as when Medicare does it. I'm not saying the profit motive is evil, only that it is no better than the alternative.

My opinion is that there is no way the average Joe or Jane can really know the efficacy of various treatments and screening tests-- heck most physicians are confused once they stray away from their specific specialty-- and the standards need to be more uniform. Pap smears yearly and per a protocol; High blood pressure medicine under a certain protocol based on evidence; Heart transplants when the ejection fraction goes below a certain percentage, etc.

I'm all for websites for cost comparison, but I'm suspicious on where this leads: "Come down to Crazy Lenny's for your colonoscopy! We can't be undersold!" Maybe that has merit, just don't say you weren't warned. The classic example nowadays is "robotic surgery" for prostatectomy and hysterectomy. I know of no reputable non-proprietary study that shows significantly improved results, yet we are inundated with patient requests for "robotic surgery" due presumably to an active marketing campaign by the manufacturer of the robot. The CNN story shows a guy riding a bike who says he wanted this type of surgery, which costs more than double the standard surgery, because he wanted to ride his bike a couple weeks earlier! Now, maybe two weeks of bike riding is worth $10,000, but we should at least pause and stop wondering why health care costs are rising so dramatically. Note the quote by the urologist at the University of Kansas: no evidence that robotic surgery is better. I guess the Intuitive Surgical, Inc. marketing representative hasn't taken him out to dinner yet!

The same goes for a plethora of other screenings and treatments from vaginal mesh to coated cardiac stents to herbal supplements to erectile dysfunction pills, which become popularized, not so much by evidence-based data, but by marketing. And consider pharmaceutical advertising on the evening news: by my recent count the percentage was over 70% of the ads are for drugs. What do you think the odds are that Katie Couric or Charlie Gibson will present a negative story about the pharmaceutical industry? Bought and paid for, my friend. Sure this happens with government lobbying too, but let's not be naive in either camp.

I take this debate seriously. It has been brewing since 1992 when Hillary Clinton was first tasked with the implementation of health care reform. I was a medical resident at the time and I remember having discussions then about the perceived need for such reform. Other thoughtful people were opposed and said emphatically that the failure of Hillarycare was a good thing and that costs would come down by free market mechanisms. Now we are 16 years on and the costs have gone parabolic-- and perhaps they would be even higher had the Clinton proposal passed, but I doubt it, and it's long overdue to try something different.

If someone asked me, and nobody has, I would vote emphatically for a single-payer option for acute care and screening. People would have the option of purchasing further coverage if desired, and employers could certainly offer additional benefits, but a basic care plan needs to be in place for everyone. Our economic survival requires it.

*The WSJ cites the GOP Health Care Alternative, and I admit this has merit. However, it keeps intact the employer-based model and has other flaws that I can point out in a longer post.

Everyday haiku

Dog and Fly

He caught it

and spit it out, crippled and wet.

I killed it.

Medicare, consumption taxes and serfdom...

Hey, I got a comment on a recent post, and since I don't get that many I'll elevate this to it's own post.... even if it's probably just some guy taking a personal swipe at me. My reply follows below.

Mike Szymanski said...

You wrote: "...Medicare program, the lowest cost/ highest quality program in the country..."

Not sure what you are smoking but I sure would like some. Obviously, that massive hit of hopium is still coursing through your system. Please take an economics course and another concerning the Constitution. You will learn that the federal government adds no value to our economy and that it obtains its financing by confiscating private property from the productive members of society. It's a zero sum game. Less resources for the productive side of the economy means a lower standard of living for all. FDR's New Deal set in motion a trampling of the 10th Amendment. We are fast heading down the road to serfdom. Half the people in the country pay no income tax and will certainly vote for anyone promising more "free" goodies. If this half becomes a majority how do you propose the large and bloated federal government finance its ever increasing handouts? Economic illiteracy is as dangerous as ignoring history.

"We all declare for liberty; but in using the same word we do not all mean the same thing. With some the word liberty may mean for each man to do as he pleases with himself, and the product of his labor; while with others, the same word many mean for some men to do as they please with other men, and the product of other men's labor. Here are two, not only different, but incompatible things, called by the same name - liberty. And it follows that each of the things is, by the respective parties, called by two different and incompatible names - liberty and tyranny." Abraham Lincoln

12:21 PM

Tony said...

Mike, Thank you for the personal insult! My self-esteem has been getting a little ahead of itself lately. As for "what I'm smoking", if you must know, it's currently Santa Damiana #600, a mild Honduran blended cigar, rolled between the thighs of virgins (presumably), and finished with a dark Cameroon wrapper. (JR Cigar, $89 per box of 25). Highly recommended.

As for health care, I'm puzzled at your apparent disgust and at first had you pegged as simply a "no-tax" nutjub, but after closer reading, I'll correct my first impression and give you the benefit of the doubt.

I fully understand your angst over a few people paying the lion's share of the taxes while the free-loaders all benefit. Trust me, I pay ALOT of income tax, so I feel you pain, which is the reason that I included the paragraph about health care being paid with a value-added CONSUMPTION tax. Liberal do-gooders typically hate consumption taxes because they are regressive (ie, everyone pays them), so this is the seminal issue of the post.

As for debating whether we should have Medicare-for-all or some conglomeration of private plans, that is really of minimal consequence. The fact is that Medicare is very efficient, as health insurance goes, and comparing private plans versus Medicare is impossible since the demographics, the economies of scale and collection systems are all vastly different.

A large plan like Medicare has inherent benefits such as the huge risk pool, the huge data base that can be studied and, as mentioned above, the economies of scale for cost-cutting. Likewise, Medicare has inherent liabilities, but I would argue that they are fewer. I realize that some folks such as yourself will eschew anything "gov't run", but I would add that Medicare is not really "gov't run", but more gov't financed. As a physician, I can tell you that private payers, for the most part, are at least as intrusive as Medicare in the medical decision- making process.

One other thing about Constitutional rights and your comment about serfdom: health care is a de facto right in this nation whether you like it or not, so we should find a way for everyone to have the means to pay for it. Currently, physicians and hospitals are required to accept all emergency patients without regard for their ability to pay (your A. Lincoln quote is quite appropriate), and emergency patients always could have been managed much more cost-effectively if they had been seen earlier... and the number one reason the uninsured go to the emergency room? Lack of insurance.

1:11 PM

Neil Armstrong's Small Step

"Apollo 40th anniversary: I spent most of my childhood puzzling over difference between "man" and "mankind" (one small step for...). I understand now that he dropped the "a." [before 'man'] but it sure confused me as a kid." -- Tom Tomorrow

Yeah, it's sublime how we can be confused for four decades over something that is so much a part of our childhood and our popular culture, something that goes unexplained for so long and we are expected to marvel at it with an almost religious awe when it makes no real sense, and then someone finally explains that it's been mistaken and incomplete all this time... and now I wonder why I was expected to be so amazed at the misquote (or at least the incomplete quote) for so many years.

Kinda reminds me of the accepted iterations of biblical literalism, religious dogma and religion in general: like how much of that stuff has an "a" left out? But that's a much longer discussion.

The Republican Museum Exhibit: featuring Judge Sotomayor

If you are watching the Sotomayor confirmation hearings, I strongly recommend following along with Glenn Greenwald on Twitter. As a constitutional law attorney and august civil libertarian, he adds essential real-time insight. (h/t Eric for the cartoon.)

The obvious item of note is the incessant deconstruction of Judge Sotomayor's 8-year-old speech invoking the now infamous "wise Latina" comment. The white, predominantly Southern, GOP Senators have taken this opportunity to (ironically) harangue us all on the evils of racism and preferance. Greenwald commented at one point that these hearings are like watching a museum exhibit-- and I would have to agree.

This is history being made, indeed, and at some future point we will be able to tell our grandchildren and grand-nieces and nephews that we actually saw Sen. Jeff Sessions (R- circa 1830) lecture someone on --anything let alone-- racism.

My only comment on Judge Sotomayor's speech is that it really should be read in full to get the full context. What she really is saying is the exact opposite of what the Republican senators are implying: Sotomayor is actually saying that we all bring our own prejudices to whatever we are asked to judge everyday, and we need to recognize that fact. One small excerpt:

Whether born from experience or inherent physiological or cultural differences, a possibility I abhor less or discount less than my colleague Judge Cedarbaum, our gender and national origins may and will make a difference in our judging. Justice O'Connor has often been cited as saying that a wise old man and wise old woman will reach the same conclusion in deciding cases. I am not so sure Justice O'Connor is the author of that line since Professor Resnik attributes that line to Supreme Court Justice Coyle. I am also not so sure that I agree with the statement. First, as Professor Martha Minnow has noted, there can never be a universal definition of wise. Second, I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than a white male who hasn't lived that life.

Let us not forget that wise men like Oliver Wendell Holmes and Justice Cardozo voted on cases which upheld both sex and race discrimination in our society. Until 1972, no Supreme Court case ever upheld the claim of a woman in a gender discrimination case. I, like Professor Carter, believe that we should not be so myopic as to believe that others of different experiences or backgrounds are incapable of understanding the values and needs of people from a different group. Many are so capable. As Judge Cedarbaum pointed out to me, nine white men on the Supreme Court in the past have done so on many occasions and on many issues including Brown.

However, to understand takes time and effort, something that not all people are willing to give. For others, their experiences limit their ability to understand the experiences of others. Other simply do not care. Hence, one must accept the proposition that a difference there will be by the presence of women and people of color on the bench. Personal experiences affect the facts that judges choose to see. My hope is that I will take the good from my experiences and extrapolate them further into areas with which I am unfamiliar. I simply do not know exactly what that difference will be in my judging. But I accept there will be some based on my gender and my Latina heritage.

Never mind that her nearly 400 decisions from the federal bench are being ignored. Never mind that she agreed with her conservative Republican colleagues over 95% of the time. Never mind that her academic and professional career is deeper and wider than anyone else on the Supreme Court. Fox talking heads will continue to dissemble her 8-year-old speech and confound the facts of her record for apparently purely partisan reasons.

I can understand guys like Jeff Sessions and John Kyl and Zach Wamp going after Sotomayor for no other reason than their constituencies eat this stuff up like lions on fresh zebra. They love the sturm and drang of the theme that "brown people are taking over our country" (after we took it from the red-man fair and square.) But I don't understand Fox' strategy. Let's face it, this racism stuff is pretty long in the tooth and the demographic is dying off fairly rapidly, either by old age or firearm accidents, so why perpetuate the theme? We have a unique opportunity as a nation and a culture to come together to rejoice in our diversity, a culture that has allowed all people to contribute. Prejudice is far from dead, but we could now put a withering hit on it.

Fox "pundits" continue to state that Judge Sotomayor has had "more decisions overturned by the Supreme Court than anyone else, up to 80%!". The horror! The incompetence! Well, the fact is that Judge Sotomayor has been involved in more decisions than anyone else by mere fact of her lengthy career on the bench, and the number of overturned decisions is exactly in line with other judges on a percentage basis. The Supreme Court only chooses to hear controversial cases and as such they are usually making a statement that a certain precedent needs to be changed, so they often overturn lower court decisions. Many famous cases-- Brown v. Board overturned part of Plessy v. Ferguson, Planned Parenthood v. Casey revised Roe v. Wade, and others-- do this. This does not mean the lower court was "wrong" or that it misjudged the case, in fact the lower court is obligated to follow precedent.

Ricci follows this theme. Affirmative action has brought about considerable impact on American society over the past generation and the goal of evening the playing field has had unintended consequences of inadvertently making some winners into losers. The fact is that admissions into law school or promotions into certain jobs are a zero-sum game: for every individual given the slot, another individual is denied. Affirmative action was never intended to be a permanent policy, and every hope was that such preference based on race or ethnicity would be unnecessary at some point.

The precedent, as it stood before Ricci, needed to be respected and Judge Sotomayor did just that. Now the Supreme Court has overturned Ricci, and I would think that if Judge Sotomayor were to rule on a case similar to Ricci, her decision would be different. That's how the system works.

The reality is that Judge Sotomayor will be confirmed, the world will turn one more time, and racism will, thankfully, be dealt another blow. But in the meantime, watch the hearings because the videos will someday be in the Smithsonian along side McCarthy's tantrums and Nixon's race baiting Southern Strategy.

Is Health care a "privilege"?

According to Sen Deputy Dawg it is...

Visit msnbc.com for Breaking News, World News, and News about the Economy

So I suppose we'll just let people die in the Emergency Room if their credit card bounces. Newsflash: the world don't work that way, Ass-hat. Sure, half choose not to have insurance, but doctors are still required to treat all of them... so get them insurance: NOW.

Obama's Health Care Mess

Obama has promised to make health care universal, to pay for it with current revenues, to improve or maintain quality and to reduce the cost of health care in the US as a percentage of GDP.

These are quite desirable goals and certainly much more than the GOP had ever approached in their tenure, which was marked by costly warmongering and deregulation. While it is commendable that the loyal opposition voice their opinions, I find it difficult to believe that their goals are to fulfill the priorities of the average Joe and Jane.

The Wall Street Journal uses a similar title for their recent editorial, but the issues thay have with the Democratic health care fix are 180 degrees off. They oppose Obama by comparing the current proposal to the Massachusetts plan and they go out of their way to show the failings. First and foremost, health care insurance is not automatic and many people choose to open policies only when they are sick and then cancel them once their health is restored becauase the penalties for non-coverage are too small. Other problems are outlined as well.

The fact is that Obama's and the Democrats' proposals are terrible and the GOP is correct that none of the initial goals will be met. The failing of Massachusetts do not support eschewing reform, however... rather it underlines this fact: the only solution is a single payer Medicare-for-all option and anything less will not satisfy the goals as verbalized.

To wit, Obama's plan does not require coverage, so the risk pool will be too small. Obama's plan burdens employers, so the incentive would be to refrain from hiring employees. Obama's plan has no provision for cost containment or quality enhancement. The faults outlined by the GOP and the WSJ only show that Obama has not gone far enough in his proposal.

The Democrats are trying too hard to appease the Republicans and their small-government ideology. The fact is that the only way to reduce costs and cover everyone is to meld everyone into the Medicare program, the lowest cost/ highest quality program in the country, whcih is especially impressive considering it manages the highest risk and sickest patients. Quality and costs can be controlled in such an environment, as they are now. By increasing the risk pool, Medicare would become immediately solvent. People would still have the option of purchasing a private policy, as they do now with Medicare, but at least everyone would have basic coverage.

Paying for the system with a value-added or consumption tax seems the most rational approach, thereby releasing employers from the burden. My employer doesn't pay for my auto or homeowners insurance, so why should they pay for my health insurance?

The political realities that the Democrats much face are daunting, but with such massive control of the Congress and the public's overwhelming support for reform, this is the time for single payer to be passed and, as the WSJ has shown, anything less is foolish.

Resolved: Goldman Sachs "Caused" the Economic Crisis

Argument for the Affirmative: Matt Taibbi

Argument for the Negative: Megan McArdle

Support for the Affirmative #1: Glenn Greenwald

Support for the Negative: Joel Weisenthal

Support for the Affirmative #2: Barry Ritholtz

Versions of this debate will go on for the rest of our lives, and I'm not sure which side I favor at this point.

GOP unraveling over Palin article

When the Vanity Fair article debauching (yet again) Sarah Palin was publicized I was not at all interested. The reports were that the author, while highly regarded, relied on "unnamed" officials form the McCain-Palin camp to put forth a bunch of meaningless gossip about how Sarah Palin ruined McCain's chances of becoming president.

My opinion about John McCain was made long before Sarah Palin came on the scene, and her politics are so far afield from what is needed in the world today that any furhter re-hash of last fall's nightmare would be pointless. Besides, such tabloid journalism is likely only to give Palin's followers more material to support her martyrdom.

But an interesting thing is happening. Two of the three wings of the Republican party are lashing out at each other over the alleged sources from the Vanity Fair piece with finger-pointing and name calling, even to the point of mentioning Dan Quayle! McCain campaign chairman Steve Schmidt is taking offense at comments made by warmonger Bill Kristol about the piece. Listen, when Dan Quayle's name is ever uttered by a fellow Republican, it cannot be good for the party. Cue Keyboard Cat.

I'm not going to venture into worry-troll mode about what's good or bad for the Republican party, but's let's just say this is starting to get interesting.

Michigan's new growth industry

Gov. Granholm to the Governator: Maybe we can't make cars, but we sure can keep folks in prison.

Well, maybe not.