Orient: Is it Always Better to Have Health Insurance?

Dr. Jane Orient asks the provocative question, "Is it Always Better to Have Health Insurance?"

In particular, she describes a patient who lost her insurance and paid $900 out-of-pocket for treatment to save her eyesight. She didn't have $900 immediately, but was able to work out a time payment plan with the treating physician.

In contrast, she describes what would have happened if the patient had "coverage" from the government:

...Now, what would have happened if the Medicaid program hadn't cut her off -- because she earns $100/month too much? In that case, she wouldn't have had to worry about the bill.

But -- the receptionist would have had to say: "You'll need to fax over a referral."

A Medicaid patient can't be billed, except for a nominal copayment. Without a referral, Medicaid can’'t be billed. So if the specialist, or in this case subspecialist, sees the patient, he cannot be paid. Moreover, he is probably violating a rule and conceivably might be prosecuted for soliciting business (that's called "fraud"). Discounts and freebies are marketing strategies, after all, and the poor and vulnerable have to be protected.

Not just any doctor can give the patient a referral. This doctor couldn't. It has to be the patient's primary care provider, who is contracted with the patient's plan. And the specialist has to be in the plan too.

Say that a seizure patient needs to see a neurologist promptly to have his medications adjusted. Sorry, the emergency room doctor can't write the referral. Neither can the hospitalist who is discharging the patient from the hospital. It has to be the "primary." If the primary happens to know the patient, he might just send the referral. But most of the time, the patient will have to come in. The primary won’t want to risk getting an unnecessary referral or an incident of "inadequate documentation" on his report card.

For a retinal problem, there are probably three hurdles: the primary gatekeeper (who might not even think of the diagnosis), then the general ophthalmologist (who will make the diagnosis but can't treat it), and finally the subspecialist. All probably have waiting times for appointments, especially for Medicaid patients. Most doctors can’t afford to see very many of those.

Not just Medicaid, but all managed-care plans have a structure like that. It's part of the cost-containment strategy. I know of three insured patients who had retinal detachments. They all had premonitory symptoms, and they all -- eventually -- had elaborate and costly operations, as many as six procedures. They were "covered," and they didn't get a bill for $900, but they had a poor visual outcome that might have been prevented by prompt treatment.

(Read the full text of "Is it Always Better to Have Health Insurance?"; link via JG.)

Dr. Orient's analysis vividly illustrates the point that "coverage" does not equal care.

Furthermore, government policies that attempt to guarantee "coverage" will create bureaucratic regulations and cost-control guidelines that will restrict the ability of physicians to offer actual care to their patients.

Or as Dr. Orient puts it:

Insurance is supposed to help you pay bills in the rare event of a catastrophe. If it morphs into a scheme for emptying your wallet in advance, and then prevents bills by preventing treatment, we just might be better off without it.

Ralston: Twelve Ways to Increase the Cost of Health Insurance

Richard Ralston, executive director of Americans for Free Choice in Medicine, dissects the many problems with the recently-passed Senate bill. (This was written on December 22, before the bill was passed).

Here is the full text of his piece, "Twelve Ways to Increase the Cost of Health Insurance":

Health care legislation now being debated in the Senate will do nothing to make health care more affordable but quite a lot to make it more expensive. It serves the purpose of a massive and permanent expansion of the size and power of government and the political class as an end in itself. Twelve of the many provisions that will increase the cost of care include:

The increase in government spending is largely unfunded. The ten years of increased taxes and fees to cover six years of spending conceals the true long-term cost. Taxes collected for four years before the new spending begins will of course not be set aside and hidden under a mattress by Senator Reid and Speaker Pelosi. The government will blow right through it and spend it on other things until the new spending begins. More taxes will accompany much more debt and the cost of serving the debt, which will increase the cost of health care for everyone.

The requirement that insurers take a loss and issue policies to those with pre-existing conditions will shift costs for their care to other premium payers.

The limit on co-payments will shift costs to premium payers.

The limit on deductibles will shift costs to premium payers.

New fees and taxes on medical equipment manufacturers will increase the cost of equipment and insurance.

The cost of medical liability insurance -- and the defensive medicine it forces physicians to practice in order to protect themselves -- punishes financially the states that currently limit the size of non-economic damages and the fees lawyers take from settlements. Rather than limiting such costs, it will provide strong incentives for trial lawyers to increase litigation, which will increase the cost of health care and insurance for everyone.

The tax on insurance companies for policies that provide the most benefits will increase premiums on those policies.

More health care providers will be reimbursed for less than the cost of their services, shifting those costs to other patients and premium payers.

Pre-tax contributions to flexible savings and health savings accounts will be limited and their use made more difficult, increasing the taxes and cost of care for those with such plans.

The legal requirement to buy insurance under penalty of fines and imprisonment will force the purchase of insurance with provisions specified by the government, in response to providers with the political pull to force coverage of their services. That will increase the cost of insurance.

Higher costs will not be limited to private insurance: Medicare taxes will be increased while Medicare benefits are decreased.

Medicare Advantage plans will be eliminated, reducing benefits for the ten million seniors who have them, and forcing them to pay more for "Medi-Gap" insurance -- creating a financial jackpot for the AARP in disregard for the interests of its members.

Other provisions will increase spending and debt, such as forcing states to provide Medicaid to millions of additional people without any revenue to pay for it.

Even though the Congressional Budget Office has not taken many of these costs into consideration -- especially cost shifting -- they have determined that a bill that would create more than one hundred new agencies, boards, and commissions, and that would spend trillions of dollars, would not cut the cost of health insurance.

The Senate bill is a deliberate, systematic deception for the purpose of concealing the cost of a huge expansion of government -- and the forced dependence of citizens on politicians for another crucially important aspect of their daily lives. Senators need to hear from voters now that they must not vote for legislation that increases our medical costs while eliminating our rights and personal choices.

Richard E. Ralston is Executive Director of Americans for Free Choice in Medicine.

(Original link to "Twelve Ways to Increase the Cost of Health Insurance".)

Watkins and Brook: Repudiate The Morality Of Need

The December 28, 2009 Investor's Business Daily carried this piece by Don Watkins and Yaron Brook of the Ayn Rand Center for Individual Rights entitled, "Memo To Foes Of Health Reform: Repudiate The Morality Of Need".

Here is an excerpt:

...The reason we continue to move toward socialized medicine is that everyone -- including the opponents of socialized medicine -- grants its basic moral premise: that need generates an entitlement.

So long as that principle goes unchallenged, government intervention in medicine will continue growing, as each new pressure group asserts its need and lobbies for its entitlement, until finally the government takes responsibility for fulfilling everyone's medical needs by socializing the health care system outright.

They also note:

...The only way to effectively oppose socialized health care is to reject the morality of need in favor of a genuinely American alternative. According to the American ideal, men are not their brother's keeper -- we are independent individuals with inalienable rights to support our own lives and happiness by our own efforts.

That means taking responsibility for your own medical needs, just as you take responsibility for your grocery shopping and car payments. It means no one can claim that his need entitles him to your time, effort, or wealth.

Where is the willingness to defend this ideal by saying, "Your health care is your responsibility -- and if you truly cannot afford the care you need, then you must ask for private charity -- not pick your neighbor's pocket to pay for it"?

(Read the full text of "Memo To Foes Of Health Reform: Repudiate The Morality Of Need".)

Watkins and Brook also note that the Republicans are failing to make this kind of principled moral opposition to the Democrats' plan, instead relying predominantly on more derivative economic arguments.

America will likely soon learn the consequences of this failure.

Socialized Or Not?

The AAPS responds to the common claims by ObamaCare supporters that it's not "socialized medicine", because doctors and hospitals remain private.

In their December 24, 2009 Mythbuster article, they point out the fact that ObamaCare is:

(1) Compulsory; (2) redistributive; (3) collectivized; (4) centralized; (5) dictatorial; (6) oppressive; and (7) intrusive.

(Read the full text of "Myth 30. Healthcare reform is not 'socialized medicine'")

Merry Christmas!

Merry Christmas!

(Unless there is some incredible breaking news, regular posting will resume Monday, December 28.)

Senate Passes Bill, Now Things Get Interesting

Now that the US Senate has passed its version of ObamaCare, it has to be reconciled with the House version through the "conference" process.

However, Dan Perrin thinks this might not be as easy at it seems. For his interesting analysis, see his post "The Best Christmas Present Ever: Senator DeMint Objects to the Appointment of the Conferees".

This may explain why there's talk from the White House that the health care issue won't be sorted out until February 2010.

A lot can happen in the next few days and weeks. Who know what sorts of back room deal-making, compromising, and favor-trading will take place?

But we know one thing for sure -- it isn't over yet.

10 Lumps Of Coal In The Health Care Bill

The December 23, 2009 Investor's Business Daily published an informative analysis by Betsy McCaughey discussion ten specific problems with the proposed Senate health care bill.

Here are some of the points she discusses in, "10 Lumps Of Coal In The Health Care Bill":

1. Higher premiums
2. A cost you can't afford and can't avoid
3. A one-size-fits-all health plan

I also wanted to highlight two points in particular, because they represent a hitherto-unprecedented degree of government interference in the doctor-patient relationship:

5. Government controls on your doctors' decisions:

The Senate bill bars doctors from participating in the private insurance system unless they implement whatever regulations the secretary of health and human services chooses to impose to "improve health care quality" (p. 149). That broad phrase encompasses everything in medicine.

This would be the first time in history that the federal government is given power over how doctors treat privately insured patients.

10. A tell-all relationship with every doctor you see

What happens in your doctor's office must be recorded in an electronic data base that can send the information to insurers and other medical offices (Senate bill, p. 62-66). Every doctor you see will have access to your medical history. See a psychiatrist? Your foot doctor will know about it.

(Read the full text of "10 Lumps Of Coal In The Health Care Bill".)

Advocates of individual rights (including the corollary privacy rights) should be deeply concerned.

Parker WSJ LTE on Health Care Entitlements

The December 23, 2009 Wall Street Journal published an excellent LTE by Dr. Richard Parker that cuts to the heart of the health care debate (second one down):

Scott Harrington rhetorically asks, "How can a new entitlement reduce deficits?" As he concludes, a massive new entitlement cannot and will not reduce government debt. As our experiences with Medicare and Medicaid have clearly demonstrated, whenever the government promises a "free" service, costs will necessarily rise as more and more people scramble to receive their share of "free" health care. Ultimately this can only lead to ballooning deficits and health-care rationing.

It is precisely this type of government intrusion in what should rightly be a free market that has caused health-care expenditures to skyrocket.

You cannot have your cake and eat it too. This focus on costs, however, misses a more fundamental issue with the proposed nationalization of health care -- the rights of physicians and patients.

Under ObamaCare, patients will lose their freedom to choose what health care they receive and which doctor treats them. Physicians will lose the last of their freedom to practice according to their best judgment.

The battle for medicine will be lost or won not on actuarial analysis of costs, but rather on the more fundamental principle of the rights of individuals.

Richard Parker, M.D.
McKinney, Texas

Pipes: Get Ready To Wait

As the US Senate prepares to pass its version of ObamaCare, Sally Pipes warns us "American Patients, Get Ready to Wait".

Here is an excerpt:

...Democratic politicians, liberal leaders, and the mainstream press are fond of criticizing America for spending a greater share of GDP on health care -- 16 percent -- than other countries do. Their remedy for "fixing" our country's high-cost system is more government control.

Yet they rarely disclose the high nonmonetary costs posed by government-controlled healthcare systems. Countries like Canada only spend less on health care by consigning their citizens to waiting lists and depriving them of access to effective cutting-edge treatments.

As of this year, 694,161 Canadians are on a waiting list for medical procedures. Assuming one person per procedure, that means 2.08 percent of the population is queued up for "free" care, according to the Fraser Institute's annual survey on wait times.

These Canadians pay for their health care in both taxes and the hard currency of pain, anguish, and lost wages.

She notes:

...[A]n incredible 16 percent of the population -- five million people -- is waiting to get a primary care doctor.

Once they get one, they have to wait yet again. On average, Canadians waited 16.1 weeks from the time their general practitioner referred them to a specialist until they actually received treatment in 2009, according to the Fraser Institute. That's 73 percent longer than the wait in 1993, when the Institute first started quantifying the problem.

Some specialties fare particularly poorly. Seniors should take note. In the United States, the average wait to see an orthopedic specialist is 16.8 days, according to a survey by medical consulting firm Merritt Hawkins and Associates. Canadians wait 17.1 weeks for the same appointment.

(Read the full text of "American Patients, Get Ready to Wait".)

Under universal health care, governments only promise theoretical "coverage", not actual health care. And the policies they adopt actually worsen the ability of patients to seek and receive actual care.

Canadians have already learned this lesson the hard way. Will Americans be next?

Lewis: "Arbitrary Power, Dictatorship, and Health Care"

Duke University professor John Lewis has a great essay up at PajamasMedia (12/22/2009) entitled, "Arbitrary Power, Dictatorship, and Health Care".

Here is the opening:

The essence of a dictator's method is not to write harsh laws and enforce them rigidly. The world's most destructive thugs have wanted something different. They have wanted to impose their wills on a compliant populace using arbitrary power -- power not limited by laws or constitution, but power that was open-ended, ill-defined, and could be expanded based on the whims of the moment.

Well-written laws are the enemy of the dictator. As philosopher Ayn Rand put it, "When men are united by ideas, i.e., by explicit principles, there is no room for favors, whims, or arbitrary power: the principles serve as an objective criterion for determining actions and for judging men, whether leaders or members." Laws, properly formulated, are based on principles, and serve to translate those principles into firm criteria for judging particular cases. What a dictator wants is to be free of such principles and to use his power as he wishes.

Professor Lewis then proceeds to show how the current ObamaCare health bill gives an unprecedented degree of arbitrary power to bureaucrats to determine what sort of health insurance you may buy and what sort of health care you may receive.

Some examples:

If you are an employer, you will not escape punishment if a bureaucrat decides that your health plan is not "acceptable" and that you must be fined for your failure to meet his decision. If you are an individual who does not want to purchase full-coverage health insurance, but would rather buy catastrophic insurance that covers hospitalization only, your decision will not be "acceptable" and you may face a government audit and a new tax.

Do you have a serious disease? Does your doctor wish to readmit you to the hospital? A bureaucrat will decide whether or not you get treatment, based on a statistical analysis of the number of such readmissions by the bureaucrats: "excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the secretary) of discharges for such applicable condition for the applicable period and such hospital" (Sec. 1151).

(Read the full text of "Arbitrary Power, Dictatorship, and Health Care".)

As Dr. Lewis notes, the current health care debate is not just about health care. It's about basic American freedoms.

Negative Reviews Of Senate Bill

In the wake of the Senate vote to end cloture on the health care bill, numerous analysts have chimed in with negative reviews. Here are some excerpts from a few of them:

"Passing health reform could be a nightmare for Obama" (Samuelson, Washington Post, 12/21/2009):

...Even if Congress passes legislation -- a good bet -- the finished product will fall far short of Obama's extravagant promises. It will not cover everyone. It will not control costs. It will worsen the budget outlook. It will lead to higher taxes. It will disrupt how, or whether, companies provide insurance for their workers. As the real-life (as opposed to rhetorical) consequences unfold, they will rebut Obama's claim that he has "solved" the health-care problem.

"Change Nobody Believes In" (Wall Street Journal, 12/21/2009):

...The rushed, secretive way that a bill this destructive and unpopular is being forced on the country shows that "reform" has devolved into the raw exercise of political power for the single purpose of permanently expanding the American entitlement state.

The WSJ also criticizes the following specific elements:

Health costs
Steep declines in choice and quality
Blowing up the federal fisc
Political intimidation

Finally, this essay has been circulating around the blogosphere: "Why the Reid Bill is Unconstitutional" (Richard Epstein, 12/12/2009). His central point:

In effect, the onerous obligations under the Reid Bill would convert private health insurance companies into virtual public utilities. This action is not only a source of real anxiety but also a decision of constitutional proportions, for it systematically strips the regulated health-insurance issuers of their constitutional entitlement to earn a reasonable rate of return on the massive amounts of capital that they have already invested in building out their businesses.

The big question is whether these arguments will gain any traction against the back room deal-making by the politicians. We'll find out soon...

Rebutting the Mammography Rationers

As many readers know, the US Preventive Services Task Force (USPSTF) recently issued a controversial statement recommending that screening mammography be restricted to women between ages 50-74.

This is at variance with the standard recommendations from the American Cancer Society and American College of Radiology recommendations that women begin screening at age 40 and continue as long as they are in good health.

The political implications have already been discussed elsewhere.

For those who are interested in some detailed scientific rebuttals of the USPSTF rules, here are a few helpful references:

"The importance of mammograms"
Lora Barke, Denver Post, November 20, 2009

(Lora D. Barke, D.O., is the medical director of the Invision Sally Jobe Breast Network and one of my practice partners.)

"American Cancer Society Responds to Changes to USPSTF Mammography Guidelines"
November 16, 2009

"Why the critics of screening mammography are wrong"
Daniel Kopans, Diagnostic Imaging, December 4, 2009

(Daniel B. Kopans, M.D., is a professor of radiology at Harvard Medical School and a senior radiologist in the breast imaging division at Massachusetts General Hospital.)

"Frequently Asked Questions about Mammography and the USPSTF Recommendations: A Guide for Practitioners"
Wendie Berg, MD, PhD, R. Edward Hendrick, PhD, Daniel Kopans, MD, and Robert Smith, PhD

Society of Breast Imaging, December 11, 2009

(Berg - American Radiology Services, Johns Hopkins Green Spring, Lutherville, MD; Hendrick - Department of Radiology, University of Colorado, Denver, CO;
Kopans - Department of Radiology, Massachusetts General Hospital, Harvard University School of Medicine, Boston, MA; Smith - Cancer Control Sciences Department, American Cancer Society, Atlanta, GA)

Coburn: The Health Bill Is Scary

The December 16, 2009 Wall Street Journal published the following OpEd by US Senator Tom Coburn (himself a practicing physician) entitled, "The Health Bill Is Scary".

He warns that even though the "public option" may be off the table for now, there are still several frightening provisions of the ObamaCare bill that would lead to rationing. Here is an excerpt:

...Additionally, the Reid bill depends on the recommendations of the U.S. Preventive Services Task Force in no fewer than 14 places. This task force was responsible for advising women under 50 to not undergo annual mammograms. The administration claims the task force recommendations do not carry the force of law, but the Reid bill itself contradicts them in section 2713. The bill explicitly states, on page 17, that health insurance plans "shall provide coverage for" services approved by the task force. This chilling provision represents the government stepping between doctors and patients. When the government asserts the power to provide care, it also asserts the power to deny care.

...But the most fundamental flaw of the Reid bill is best captured by the story of one my patients I'll call Sheila. When Sheila came to me at the age of 33 with a lump in her breast, traditional tests like a mammogram under the standard of care indicated she had a cyst and nothing more. Because I knew her medical history, I wasn't convinced. I aspirated the cyst and discovered she had a highly malignant form of breast cancer. Sheila fought a heroic battle against breast cancer and enjoyed 12 good years with her family before succumbing to the disease.

If I had been practicing under the Reid bill, the government would have likely told me I couldn't have done the test that discovered Sheila's cancer because it wasn't approved under CER. Under the Reid bill, Sheila may have lived another year instead of 12, and her daughters would have missed a decade with their mom.

(Read the full text of "The Health Bill Is Scary".)

Senator Coburn is completely right about this. Americans who value their health must not let down their guard. Instead, we must continue to let our elected officials know where we stand.

(Note: I agree with Coburn on most of his health care policy positions, but I have sharp disagreements with him on a variety of so-called "social issues".)

The Public Option In 40 Seconds

This video pretty much sums it up:



(Via State House Call, who correctly notes "The legislative proposal may be dead -- for now -- but the idea isn't. Not yet, anyway.")

How Leftists View America

The leftist health care advocacy group Public Option Please recently held a contest for the best pro-public option art.

Here's the winning entry:



(Click on the image to see it full size.)

As Jonathan Adler noted:

I suspect many health care reform supporters find this poster inspiring for the same reasons many health care reform opponents find it disconcerting.

"Freedom To Contract" Article Now Available On Audio

My print article from the Fall 2009 issue of The Objective Standard entitled "How the Freedom to Contract Protects Insurability" is now available on audio.

Audio files of selected TOS articles are available here.

The audio version of the article is also available as a downloadable MP3.

I'm deeply grateful to editor Craig Biddle for posting it!

Mythbusting From McCaughey

Former New York lieutenant governor Betsy McCaughey debunks some common myths about the US health system.

Here is an excerpt from her December 14, 2009 New York Post OpEd, "US Health Care Still Tops":

... On Nov. 20, for example, Sen. Kent Conrad (D-ND) pointed to a large blue chart showing the United States in last place in health performance. "All of these countries have much lower costs than we do," he said, "and they have higher-quality outcomes than ours."

Conrad was duped by a bag-of-tricks report from the Commonwealth Fund (Health Affairs, vol. 27, no. 1, 2008). This put America in 19th place due to our nation's large number of preventable deaths -- meaning deaths from diseases that are curable if treated soon enough.

Yet most of these deaths are caused by heart disease and circulatory diseases. The United States has a high incidence because for 50 years Americans were the heaviest smokers and now are among the most obese. Bad behavior, not bad medicine, is to blame. Our health-care system treats these diseases very effectively.

As the National Bureau of Economic Research concluded, "It seems inaccurate to attribute... high death rates from these causes to a poorly performing medical system."

She also debunks other commonly promulgated myths about prostate cancer, breast cancer, and life expectancy which are often used by leftists to justify government-run health care.

For more details, read the full text of "US Health Care Still Tops".

The US health care system does have some serious problems. But those would be addressed by genuine free-market reforms, not bogus "reforms" that merely result in a government takeover of health care.

Goodman on the Senate Bill

John Goodman discusses several problems with the current incarnation of the Senate Bill.

Some of his points include:

1. Millions of jobs lost.
4. Very high marginal tax rates.
6. Fewer insurance choices.
10. Exacerbating the problems of cost, quality and access.

These economic problems are a predictable consequence of the fundamental problem with the Senate Bill -- namely it violates the rights of individuals and insurers to voluntarily contract for their mutual benefit.

Hsieh OpEd at PJM: "ObamaCare: Tightening the Noose Around Private Health Care"

The December 15, 2009 PajamasMedia.com has just published my latest OpEd, "ObamaCare: Tightening the Noose Around Private Health Care".

My theme is that some little-discussed provisions of the health care bill will increasingly limit the freedom of patients to seek (and doctors to deliver) medical services based on the patient's best interest. Instead, doctors will be increasingly forced to practice according to collectivist "cost-effectiveness" government criteria.

Here is the introduction:

The U.S. Senate is making increasingly Byzantine backroom deals in an attempt to pass some form of universal health care by the end of the year. But even though the final bill isn't settled yet, one fact is becoming increasingly clear. Any plan they pass will result in the government seizing an unprecedented degree of control over previously private health spending decisions.

Two of these proposed new controls are worth highlighting, because they are not often discussed in most mainstream media reports...

(Read the full text of "ObamaCare: Tightening the Noose Around Private Health Care".)

Note: This is an expanded version of my earlier blog post, "Tightening The Noose Around Private Medicine".

Message From Louisiana

"LT" sent me the following:

This past Saturday, hundreds of people gathered in the pouring rain in New Orleans, Louisiana, to tell Senator Harry Reid and Senator Mary Landrieu that they do not support a government takeover of health care. As you may know, Senator Reid was supposed to attend a fundraiser in New Orleans, but cancelled his plans to attend when he started taking heat for "asking Republicans for the weekend off."

Despite Reid's cancellation, the protest still happened. This video tells the story of the people who participated in the protest and why they want to see the health care bill rejected in the Senate:

Most of these ordinary Americans understand that government promises of "free" health care will result in a government takeover of their lives.

More such protests take place here in Colorado (and the rest of the country) tomorrow (12/15/2009) as part of the "Code Red" series of rallies.

Americans are starting to speak out!

"Doing Nothing" Is An Option

Remember when President Obama insisted that health care "reform" had to be done his way, and that doing nothing was "not an option"?

Well, the American people disagree.

In "Do Nothing, Majority Says" (Wall Street Journal, December 10, 2009), James Taranto notes a recent Fox News poll showing:

While 41 percent of Americans want Congress to pass major health care reform legislation this year, a 54 percent majority says they would rather Congress "do nothing on health care for now," up from 48 percent who felt that way in July.

Taranto also adds:

...[A] CNN poll found that an even bigger majority -- 61% -- oppose the Senate's version of the ObamaCare bill.

One of the core principles every first-year medical student learns is "Primum non nocere", which is Latin for "First, do no harm". In other words, it's better to do nothing than to take a positive action that will make the situation worse -- a principle that should apply to politics as well as to medicine.

Our current health care system has many problems. But the proposed ObamaCare "reforms" would make things worse, not better. In this case, doing nothing is an option, at least until genuine free-market reforms are on the table.

The American people understand this. Will our politicians?

John Lewis Talk: "Individual Rights and Health Care Reform"

Duke University professor John Lewis give the following lecture to the Davison Council, Duke University Medical School on November 13, 2009.

Over 100 medical students heard his talk, "Individual Rights and Health Care Reform" followed by an energetic Q & A. Here is his talk, in 6 parts:

Part 1



Part 2



Part 3



Part 4



Part 5



Part 6

Schwartz: Why To Condemn Insurance Companies

In the December 5, 2009 Boulder Daily Camera, Brian Schwartz explains why we should or should not condemn insurance companies:

Why to condemn insurance companies

Is the for-profit insurance industry a "predator" that "prevent[s] us from having a decent health care system"? Letter writer Bruce Robinson says so (Daily Camera, December 1). He's partially right. The real predators are politicians who inhibit needed health policy reform. But insurers are guilty for concealing how they benefit from Congress's predatory practices, which shield them from competition and accountability to patients.

Predators gain value by using force or threats of force. Politicians prey upon patients who prefer to finance their own medical care in "politically incorrect" ways. As a result, insurers need not compete for your business. Politicians punch you with a tax penalty for buying insurance directly from an insurer instead of through your employer. They prohibit you from buying affordable policies available in other states. They tax you more for paying cash for routine medical expenses rather than buying an expensive health plan with tax-deductible premiums.

Like a true predator, politicians support legislation that backs you into a corner -- where as the patient, you are the consumer but not the customer. Hence, neither insurers nor doctors aim to please you. They cater to who pays them. Employers pay the insurers and insurers pay the doctors.

So don't condemn for-profit insurance. The profits are "anemic," reports the AP. Condemn insurers for supporting an un-free market, where profit is disconnected from pleasing consumers. Only in a free market insurers' profits would depend on satisfying you, the patient, rather than satisfying employers and politicians.

(The original is here, and a version with HTML hot links can be found on the PatientPowerNow.org website.)

Tightening The Noose Around Private Medicine

As many know, the U.S. Preventive Services Task Force (a government task force) made headlines recently when it recommended new restrictions on screening mammography for women.

There are two critical dangers these sorts of government guidelines pose for private insurance plans if ObamaCare becomes law.

First, plans may be required to include certain types of preventive care as covered services, whether or not patients want them. Such benefits mandates would raise prices and violate the rights of patients and insurers to freely contract for lower-priced plans without such mandates.

In the December 2, 2009 Baltimore Health Examiner, Dr. Delia Chiaramonte notes that it will do exactly that. From her article, "What the healthcare reform bill says about preventive care":

The section on preventive care has a hidden limitation that is likely to escape the notice of non-physician Senate reviewers. It states "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force."

That is, health insurers must pay for preventive services that the U.S. Preventive Services Task Force (USPSTF) recommends.

(Emphasis in the original.)

Second, government rules may make it more difficult for patients to receive preventative care that diverges from government guidelines.

Sue Blevins of the Institute for Health Freedom notes in her December 2009 article, "Health-Reform Bills: Would Restrictions on Cost-Sharing for Preventive Services Outlaw Private Payment?":

Regardless of whether you agree or disagree with the U.S. Preventive Services Task Force's recommended changes for mammograms, its recent proposal raises important questions for all Americans: Do you want government panels making preventive health-care decisions for you? And do you want government to outlaw private payment for preventive care? Government could end up with both powers under the health-reform bills being considered.

...[I]t appears the House version could prevent Americans from paying privately for covered preventive care. That's because H.R. 3962 states that there shall be no cost-sharing for covered preventive services. (The Senate bill includes a similar provision.) The definition of cost-sharing appears to include out-of-pocket spending. Thus without further clarification, this provision could be interpreted to prevent anyone from paying out of pocket for covered preventive care.

If this were to become law, what would happen if a physician doesn't accept insurance payments? Would he or she be legally free to bill patients directly for covered preventive services? And would patients be legally free to pay out of pocket? If the answer to both of these questions is no, then physicians who currently do not accept insurance will either have to begin doing so or stop offering preventive services.

It appears the following provisions in the House bill would infringe on both patients' and physicians' freedom to contract privately for preventive health-care services...

(Emphasis in the original.)

In other words, under ObamaCare you will be forced to pay for certain kinds of preventative care whether you want it or not. And you may not be able to pay for other kinds of medical care outside of government-set guidelines, even if you want to!

Note that the latter problem is already a serious issue in other countries with "universal health care". Canada and the UK typically forbid patients from paying out-of-pocket for many medical services on the private market on the grounds that it would permit a "two-tiered" system of care. The way they avoid having a two-tiered system (one good and one bad) is to force everyone into a single-tiered bad system.

Let's hope this doesn't happen in the US.

Five Questions On Health Reform Americans Should Be Asking Now

The December 9, 2009 Investor's Business Daily published an analysis piece by Parente and Howard discussing the "Five Questions On Health Reform Americans Should Be Asking Now".

Their questions include:

How will health reform legislation affect existing insurance coverage?

Does the final bill lower the government's unsustainable spending commitments for existing programs (Medicare and Medicaid) or expand them?

Given Congress' track record on spending, what is the realistic projection for the cost of health reform when it's fully implemented?

If health reform does generate a surplus, will this money be used to pay down the debt — or fund new government spending?

How will adding a new, government-run insurance program increase competition in private insurance markets?

(Read the full text of "Five Questions On Health Reform Americans Should Be Asking Now".)

From an economic perspective, those are all good questions.

But unless opponents also challenge the more fundamental moral and philosophical underpinnings of these proposals, raising such primarily economic concerns will be insufficient.

As Dr. Leonard Peikoff pointed out in "Health Care Is Not A Right":

Most people who oppose socialized medicine do so on the grounds that it is moral and well-intentioned, but impractical; i.e., it is a noble idea -- which just somehow does not work. I do not agree that socialized medicine is moral and well-intentioned, but impractical. Of course, it is impractical -- it does not work -- but I hold that it is impractical because it is immoral. This is not a case of noble in theory but a failure in practice; it is a case of vicious in theory and therefore a disaster in practice.

Durand On Rationing

I don't know much about Sarah Durand, but she wrote an interesting piece on PajamasMedia on the planned health care rationing algorithm entitled, "Health Care vs. the Value of Human Life".

Here is an excerpt:

...In fact, most countries with socialized medicine, including Britain, are already using a mathematical formula that expresses the numerical value of one year of a human life in a measurement called the QALY, or "quality-adjusted life year." In terms of determining medical care, the mathematical formula of the QALY is based on both how much a treatment may lengthen your lifespan and the quality of the life you will be living.

Basically, if you are in optimal health, the QALY of one year of your life is 1.0. But if you have any underlying conditions, like asthma or muscular dystrophy, your QALY is much lower. Under the QALY system, the blind are worth less than those with sight, as those who can walk are worth more than those in wheelchairs. Sound like discrimination against persons with disabilities? It gets worse.

...As if that's not bad enough, the health advisor to the president, Ezekiel Emanuel, is proposing a system even more deleterious. His system, similar to the QALY, is "the complete lives system," which not only allows for discrimination against the elderly and disabled, but also targets the very young, i.e., our children.

Emanuel says of his system: "When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated."

Leave it to American progressives to take the QALY one step further by defining quality of life as how useful you are to society -- that is, how likely you are to increase the government's tax revenue, hence the emphasis on those between ages 15 and 40. Health care gets a lot cheaper by rationing care to all non-taxpayers.

(Emphasis mine.)

This collectivist mindset towards human life will be the inevitable outcome if we let the government control our health care.

(Read the full text of "Health Care vs. the Value of Human Life".)

Mundy: Comparing Screening of Breasts and Shoes

Lee Mundy asks the following very perceptive question in this LTE in the December 7, 2009 Wall Street Journal:

Compare Screening Of Breasts and Shoes

The U.S. Preventative Services Task Force feels that mammograms are a waste of time and money because of false-positive exams, and anyway, the risk is evaluated at a meager 0.05% (Letters, Dec. 2). If, indeed, mammograms for women under 50 are not cost effective, and only save a few lives, then why are we taking our shoes off at every airport in the country?

Lee Mundy
Ellensburg, Wash.

Spot the Fallacy

According to Senator Harry Reid, if you oppose his plan for health care "reform" then it's comparable to supporting slavery.

Can you spot the logical fallacy?

Hint: Supporters of free market health care reform are fighting for individual rights, whereas slaveholders (and Senator Reid) want to violate [fill in the blank]...

(Via LT.)

Arguing That Less Choice Is Good

Linda Gorman of the Independence Institute points out a new rhetorical tactic being adopted by advocates of "universal" health care.

They're now claiming that the current semi-free market offers too much choice, and that government-run health care would eliminate that pesky burden of choice.

In essence they're arguing, "Don't worry. Let the government do your thinking for you!"

Light Posting Notice

Administrative note: Blogging might be sporadic this upcoming week due to external obligations.

John Lewis: What HR3962 Actually Says

Professor John Lewis of Duke University has posted a detailed analysis of the most recent House health care bill HR3962.

In particular, Professor Lewis asks the following key questions in his essay: "What the House Health Care Bill, HR3962, Actually Says":

1. Will the plan punish Americans who do not carry the required insurance, or employers who do not provide it?
2. Will the plan make private insurance illegal?
3. Will the plan ration medical care through budgets?
4. Will the plan ration care through waiting lists?
5. Will the plan impose special, higher taxes on Americans who earn more than others?
6. Will the plan levy special taxes and surcharges on medical devices?
7. How will the plan affect health insurance provided by employers?
8. Does the plan allow the government to set fees?
9. Can the government officials audit taxpayers, employers, and insurance plans to enforce compliance?

Most Americans aren't going to like the answers.

Professor Lewis also lists "new boards, committees, programs, and other bureaucratic encumbrances" established by the bill.

Read the full text of "What the House Health Care Bill, HR3962, Actually Says".

(Thanks to Jason C for the summary!)

ObamaCare At Any Cost

The December 2, 2009 Wall Street Journal notes that the alleged cost savings of ObamaCare are illusory.

Here is an excerpt from their piece, "ObamaCare at Any Cost":

...Instead, CBO is confirming that new coverage mandates will drive premiums higher. But Democrats are declaring victory, claiming that these higher insurance prices don't count because they will be offset by new government subsidies. About 57% of the people who buy insurance through the bill's new "exchanges" that will supplant today's individual market will qualify for subsidies that cover about two-thirds of the total premium.

So the bill will increase costs but it will then disguise those costs by transferring them to taxpayers from individuals. Higher costs can be conjured away because they're suddenly on the government balance sheet. The Reid bill's $371.9 billion in new health taxes are also apparently not a new cost because they can be passed along to consumers, or perhaps will be hidden in lost wages.

This is the paleoliberal school of brute-force wealth redistribution, and a very long way from the repeated White House claims that reform is all about "bending the cost curve." The only thing being bent here is the budget truth.

Fortunately, David Catron notes, most Americans don't believe the "cost cutting" BS.

They're wise not to.

And the WSJ reaches the natural conclusion:

...Democrats don't care because their bill isn't really about "lowering costs." It's about putting Washington in charge of health insurance, at any cost.

(Read the full text of "ObamaCare at Any Cost".)

Turner: Ten Reasons Public Won't Buy Senate Health Plan

The November 25, 2009 Washington Examiner published an OpEd by Grace-Marie Turner discussing, "Ten reasons public won't buy Senate health care plan".

Here are her key points:

1. Exploding costs
2. Losing your current coverage
3. Job-killing taxes on employers
4. Budgetary gimmick -- tax now, spend later
5. Increasing future health care spending
6. Cost-shifting gimmick
7. Taxpayer-financed abortion
8. Twenty-four million uninsured -- still
9. Scarce subsidies
10. Mandates cause higher premiums and more uninsured

(For further details on each of her points, read the full text of "Ten reasons public won't buy Senate health care plan".)

Some of her points are at the level of economic analysis. Her points 2, 3, and 10 also touch on more fundamental issues of individual rights.

Polls consistently show that a majority of Americans are opposed to ObamaCare.

The big question is whether Congress will disregard Americans' wishes and ram their agenda down our throats anyways.

(Via Patient Power.)

UK Health System FAIL

The November 30, 2009 Investor's Business Daily describes the "Deadly Decline" we can expect in our health care if we adopt ObamaCare:

..."Up to 10,000 people," the British Guardian reported Sunday, are dying needlessly of cancer each year "because their condition is diagnosed too late, according to research by the government's director of cancer services."

...Researchers at Durham University have identified four other types of delays patients encounter in receiving cancer care: doctor delay, delay in primary care, system delay and delay in secondary care. All are part of a state-operated system that has a poor record of keeping its trapped patients alive and healthy.

And Elbert County Forum links to more problems in the UK health system.

5 Paragraphs You Must Read In Senate Health Bill

The November 23, 2009 Christian Science Monitor published an OpEd by Sue Blevins and Robin Kaigh on how the Senate health bill will undermine Americans' health freedom and privacy.

They cover five specific points, including what the bill says, what that translates into in real life, and the bottom line. Here are excerpts from their essay, "Senate health care bill: the five paragraphs you must read":

1. Mandatory insurance

Translation: Uncle Sam will now serve as your national insurance agent and force you to buy "minimum essential coverage" -- or else you'll have to pay an annual fine.

2. Electronic data exchanges

Translation: Requiring everyone to buy federally sanctioned health insurance, and then forcing qualified plans to comply with Administrative Simplification requirements, provides the government and health industry with power they would not be able to exercise in a free market.

3. Real-time health and financial data

Translation: Administrative Simplification rules are being expanded to gather real-time financial and health data on individuals through a tracking ID, possibly a "machine readable" ID card (electronic device).

4. Health data network

Translation: Your personal health information may soon be studied by government scientists. Washington is creating a new research center that plans to use patients' electronic health records for conducting research and creating disease registries. The data network is comprehensive and includes use of electronic health records.

5. Personal health information

Translation: Think your health privacy is protected? It's not. This language refers to "applicable confidentiality and privacy standards," but HIPAA's so-called privacy law permits individuals' personal health information to be exchanged – for many broad purposes – without patients' consent (See 45 CFR Subtitle A, Subpart E – Privacy of Individually Identifiable Health Information; section 164.502(a)(1)(ii) "Permitted uses and disclosures").

(Read the full text of "Senate health care bill: the five paragraphs you must read".)

Congress is prepared to seize an unprecedented degree of power over individuals' personal medical information and decision making.

Schwartz LTE On Public Option

Brian Schwartz just alerted me to an LTE of his which had been published in the October 30, 2009 Denver Post.

The topic was the so-called "public option":

Health care reform and the public option

Say your neighborhood deli rigged its scales so that customers who paid for a pound of meat left the store with less. Does such fraud justify a government-run "public option" for delicatessens?

Surely not, but this is how Colorado AFL-CIO Director Mike Cerbo argues for a new government-run insurance plan. Cerbo says it should "impermissible" for insurers to "drop coverage due to pre-existing medical conditions" -- presumably when patients had been honest about medical histories.

This is called "post-claim underwriting," and it violates the insurer's contract with the policy-holder. But this is no justification of a "public option." Rather, if it happens frequently and without penalty, it shows that government has been lax in one of its legitimate duties: enforcing contracts.

Brian T. Schwartz, Boulder

Letters from Peck and Stoddard

Recent polls show that even more Americans are opposed to ObamaCare than ever before.

The November 23, 2009 Rasmussen poll reports, "Support for Health Care Plan Falls to New Low".

Rasmussen notes that only 38% of Americans now support the proposed changes vs. 56% against -- "the lowest level of support measured for the plan in nearly two dozen tracking polls conducted since June".

And more Americans are speaking out against the plan. I especially liked these two recent letters and want to highlight them.

The first was written by Tim Peck of Ashville, NC, and published in the November 28, 2009 Ashville Citizen-Times. The second was written by William Stoddard, and sent to his two California Senators. Both are reposted here with their permission.

First Tim Peck's letter:

Health pitch a violation of basic American rights

The health care legislation in Congress contains mandates to obtain individual health insurance coverage. With this provision, Congress would violate my rights, rather than protect them, which is Congress's constitutional mandate.

This provision is a clear violation of my right to voluntarily associate and contract with health care professionals and insurance providers to our mutual benefit without the interference of a predatory third party.

It violates my right to economic freedom by forcing me to purchase health insurance services against my will. It violates my right to property by forcing me to pay penalties for declining to participate in a coercive program. It violates my right to liberty by forcing me to submit to incarceration for nonpayment of penalties or additional taxes.

It violates my right to self-determination. It violates my right to use my mind to make judgments regarding my own interests and actions.

In short, this legislation violates my right to peaceably live my life as I see fit. I oppose these violations. I say "no" to the coercive mandates contained in this proposal.

And it is my hope and wish that Senator Hagan will stand with me and say "no" to this rights-violating health care bill.

Tim Peck, Asheville

And William Stoddard's letter:

One of the principal stated purposes of the Democratic Party's proposed health care legislation is to better meet the health needs of those who are currently uninsured. As a self-employed man of 59 who cannot afford health insurance, I am strongly concerned with that issue, and have followed it closely over the past year and a half. I regret to say that the passage of the proposed legislation will make my situation worse, rather than better. I urge you to protect the uninsured by voting against it.

The reason I'm uninsured is that health care, and therefore health insurance, costs too much. But the proposed legislation would require me to purchase health insurance from the same insurance industry that is now failing to restrain the growth of health care costs, either from the uncompetitive private firms that now dominate it, or from a government-run system that is likely to charge even more. It offers subsidies for this purchase so inadequate that they would be laughable, if not for the real hardship they will inflict on people who pay them. And when the many people who still can't afford insurance remain uninsured, it fines them nearly $1,000 yearly... which will only make it harder for them to get health care. The CMS estimates that of the uninsured people who won't be eligible for Medicaid, 12 million will become insured, but 18 million will remain uninsured and suffer punishment for it.

Advocates of this punitive approach attack the irresponsibility of people who remain uninsured, and who depend on emergency rooms for health care. But under this bill, the people added to Medicaid will largely continue to do exactly that, as most doctors don't want to take patients at Medicaid rates. And the many millions of people who can't afford insurance will often have to do the same... until they are diagnosed with some serious and costly illness, when they will be able to sign up for insurance, and insurance carriers will be compelled to accept them despite their "preexisting conditions," further driving up insurance costs and premiums. And in any case, the reason many self-employed people and employees of small businesses don't have insurance is not irresponsibility, but fear of financial ruin if they have to pay for it.

If buying health insurance remained voluntary, and you came up with a system under which it cost too much, the uninsured could remain uninsured, and at least not be any worse off... and send you a message that your efforts weren't good enough. By resorting to compulsion, you are making it a violation of law to send that message. And that very fact is the strongest reason to believe that your plan will not make health care affordable, but make its costs even more ruinous.

I urge you to reconsider, and reject this proposal.

William Stoddard

I liked both letters because they show the bad consequences that will result from basic violations of the right to contract in a free market.

Americans are speaking out to oppose ObamaCare. Will our elected officials listen?

Who Will Determine Who Gets a Mammogram and How Often Under ObamaCare?

Hint: It's not you and your doctor.

As John Goodman notes:

...Ever since the U.S. Preventive Services Task Force called for fewer mammograms and fewer Pap smears, the Obama Administration has been trying to distance itself from the organization -- referring to its recommendations as "nonbinding."

Yet the National Center for Policy Analysis has discovered that the Reid health care bill refers to the task force no less than 26 times. And, yes, the task force will determine what screenings will and will not be included in the minimum coverage that everyone will be required to buy.

No matter how much the government says it's not engaging in rationing, Americans are starting to catch on to the double-speak.

(Via David Catron.)

Happy Thanksgiving!

Admin Note: Because of the holiday, we'll be taking a break today.

Happy Thanksgiving!

An American Physician Reports From New Zealand

Dr. Ross Stevens is an American radiologist currently working temporarily in New Zealand. He recently composed this detailed analysis of the NZ state-run medical system, which I received as an e-mail forward from a colleague.

Dr. Stevens has graciously given me permission to post the full text of his e-mail here. Any American who wants to know what his or her health care future will look like under "universal health care" should read this eye-opening piece:

I am currently on a sort of sabbatical and am working in New Zealand for a public government hospital. New Zealand has a purely socialist medical system although there is also private insurance that can be obtained as well. This is a single payer system from a government ministry that controls all care through District Health boards. Each District Health Board gets a lump sum of money each year to provide for their population.

Primary care physicians (general practitioners) are private contractors and are paid fee for service from the government plus a copay from the patient. Specialists (including radiologists as well as surgeons, pediatricians, internists, cardiology, gastroenterology, urology, etc) are paid a salary which is based only upon the number of years since board certification plus bonus for after hours call coverage.

All specialists are paid the same. The top salary band (15 years + after certification) is about NZ $200.000 which is about $150,000 US. Call coverage can add another 15-25% depending on how busy and how frequent. All New Zealand citizens and permanent residents are covered by the National Health Service.

General practitioners see one patient every 7 minutes and, I am told, can make up to NZ$600K - $800K with their fee for service.

Patients must go first to their GP for all initial care--adult and pediatric. Pediatricians are specialists and only see patients after referral from GPs. All routine obstetrics is handled by midwives who receive 2 years training post high school. To go to the ER you must have a referral from your GP unless it is emergent (trauma, etc).

How does this work? Well, my hospital is over budget for the year, so they are closing the hospital (the only one within a 3-4 hour driving radius) to all but emergent patients for 6 weeks in December and January!! No elective surgery or non emergent patients. I could give many stories about delays in diagnosis that would be unheard of in the US.

That said, patients are generally happy with their healthcare and are glad that it is "free". The mentality of patients here is different from the US. Patients are not as demanding. No one gives a second thought to waiting 4-6 weeks for a staging CT for their newly discovered lung cancer prior to treatment -- many don't accept treatment anyway. If they are told they have a cancer, they just go home to die. They are generally happy for what they have and don't worry (or know) what they don't.

For radiology, I am working in a small rural district, so our waiting times are good, but in many of the urban districts, the waiting times for a routine CT scan are up to 9 months. GP's cannot order CT or MRI -- only specialists. The radiology department runs 8:30 am - 5:00 pm and I read about half of what I would read in the US. If it is not done by 5:00, it doesn't get done until tomorrow. In some cases, it might be weeks until a routine film is read. Call back after hours are pretty much only for trauma or surgical emergencies. Everything else can wait until the next morning, or Monday.

Our department is over budget, because they forgot to include the $35,000 equipment maintenance contract in this years budget. They installed a PACS system but didn't buy the Physicians Hanging Protocol software or the RIS [Radiology Information System] -- they are using a 20 year old system that is no longer supported.

Physicians who live here are generally satisfied due to the light workload and the lifestyle. However, there is a huge brain drain from the country. Many New Zealand doctors emigrate to Australia, Canada, or the US where the pay is better.

The country is critically short of physicians, especially specialists such as radiologists. In my hospital, about 2/3 of the medical staff in not native New Zealander -- most from South Africa or Europe) and about 1/4 of the staff is made up of locum tenens like me -- people from outside of New Zealand who come here for 6-12 months for the experience.

It is an interesting system and I have had an interesting time here. They spend about 1/4 per capita compared to what we spend in the US for health care. The care is good but not great here. They have a hard time recruiting and keeping physicians and are critically in short supply. I do not think that the American public would accept the level of care that is provided here. We will see what our future brings!

Ross Stevens, MD

Dr. Stevens is absolutely correct. Americans would not accept the levels of restrictions on access and quality of care caused by New Zealand's government policies.

Long waits, outdated technology cost overruns, patients going home to die -- this is not change I can believe in.

Let's hope the US health system never gets to this point!

Sticking It To The Young People

The November 23, 2009 Washington Post carries a column by Robert Samuelson explaining why the AARP (the major lobbying group for Americans over 50) are so in favor of health care "reform" -- because it allows them to stick young people with the bill.

Here is an excerpt from "Health 'reform' that burdens our young":

...Now comes the House-passed health-care "reform" bill that, amazingly, would extract more subsidies from the young. It mandates that health insurance premiums for older Americans be no more than twice the level of that for younger Americans. That's much less than the actual health spending gap between young and old. Spending for those age 60 to 64 is four to five times greater than those 18 to 24. So, the young would overpay for insurance that -- under the House bill -- people must buy: Twenty- and thirtysomethings would subsidize premiums for fifty-and sixtysomethings.

...Not surprisingly, the 40-million-member AARP, the major lobby for Americans over 50, was a big force behind this provision. AARP's cynicism is breathtaking. On one hand, it sponsors a high-minded campaign called "Divided We Fail" and runs sentimental TV ads featuring children pleading for a better tomorrow. "Join us in championing your future and the future of every generation," ended one ad.

...AARP justifies the cost-shifting as preventing age discrimination. Premiums based on age should be no more acceptable than premiums based on medical expenses reflecting race, gender or preexisting health conditions, it says. The House legislation bans those, so it should also ban age-based rates. AARP dislikes even the 2-to-1 limit. It thinks premiums for someone 22 and someone 62 should be identical. (In insurance jargon, that would be full "community rating.")

This is unconvincing. All insurance aims to protect against risk -- but within groups facing similar risks. Put differently, most insurance is risk-adjusted. Auto insurance premiums vary by age; younger drivers pay higher rates because they have more accidents. Homeowners' policies for similar houses cost more in high-crime areas. This is not "discrimination"; it's a reflection of risk and cost differences. Insurers that ignored these differences would soon vanish because they'd suffer heavy losses and lose customers.

(Read the full text of "Health 'reform' that burdens our young".)

Young, healthy adults will be the most unjustly affected by this proposed legislation. These patients consume the fewest medical resources and therefore most heavily subsidize the costs of the older, more-frequently-ill patients.

ObamaCare would rob them of money they could use for their own goals, such as saving to buy a first house or to start a business or a family. In essence, it would force them to sacrifice their lives and futures for the sake of the collective.

(For more on the fallacy behind the "anti-discrimination" argument, see "In defense of health insurance discrimination" by Don Watkins of the Ayn Rand Center.)

The End Of HSAs?

The November 23, 2009 Wall Street Journal warns that the Senate health care bill could destroy Health Savings Accounts for many Americans.

Here are some excerpts:

Liberals claim people who choose these options aren't helping as much to finance a common pool and may encourage adverse selection if too many young or healthy people opt out. While all insurance involves some degree of risk-sharing, Democrats want to impose true social insurance a la Europe by obliterating the flexibility of insurers to design products that are tailored to suit different individual needs.

In other words, the government wants to prevent you from spending your own money for your own health based on your judgment, on the grounds that you are failing to live up to your obligation to pay for everyone else's health care.

The Wall Street Journal also notes:

...David Goldhill, a media executive, recently wrote in the Atlantic Monthly that if a 22-year-old starts at his company today earning $30,000 and health costs grow at 3%, by the time he retires he'll have paid out $1.77 million in premiums, lower wages, out-of-pocket costs and both sides of the Medicare payroll tax.

If all that money were instead available via an HSA, including by borrowing against future contributions, "wouldn't you be able to afford your own care?" Mr. Goldhill asks. "And wouldn't you consume health care differently if you and your family didn't have to spend that money only on care?"

This is precisely the future liberals fear because it would make health care less susceptible to political control. The Reid bill makes it impossible for people to choose better reform alternatives, the ones that can only be discovered through innovation and competition in a dynamic marketplace.

The politicians don't want you to control your own money. Instead, they want to do your spending (and your thinking) for you.

Will we let them?

(Read the full text of "The End of HSAs". Article link via Brian Schwartz.)

Jane Orient: View From 35,000 Feet

Dr. Jane Orient, author of Your Doctor Is Not In, has posted a good analysis of the health care debate taking a "view from 35,000 feet".

Here's an excerpt from her essay, "Forget the Trees; Look at the Forest on Healthcare":

...The question is whether we want to put the federal government in control of American medicine. And about the related question of what medicine should be.

Traditionally, medicine is practiced by physicians, one patient at a time. The outcome is assessed by that patient. The right decision is the one chosen by the patient, in consultation with the physician, based on what is optimum for that patient, considering all aspects of his circumstances. The standard of care is the Oath of Hippocrates: providing treatment for the good of each patient according to the best of the doctor's ability and judgment.

In the "reformed" delivery system, healthcare is practiced from on high by committees of "experts" pulling the strings of marionette physicians (rankings, payment rates, other incentives and disincentives) who are judged on how well they achieve population-based outcomes. Patients are like sheep in the flock, categorized by race, income level, quality-adjusted remaining years (QARYs), compliance, functional ability, diversity score, or whatever metrics the rulers adopt. Any individual can be sacrificed for the good of the whole.

All information is to be coded and fed into a huge database, so that the herd's behavior and health can be monitored on a "granular" (minutely detailed) level. Non-reporting is punishable by fines or exclusion or worse.

One of the most common words in the House healthcare reform bill is "eligible." Obviously if you have to be eligible, you can also be ineligible -- and probably are, until proved otherwise. If subsidies can be given, they can be denied, or taken away. If the price-fixers can raise the doctor's pay, they can also cut it. If a committee can mandate coverage and level of payment for a service, it can refuse coverage or set the allowable charge below cost. If it has to certify need, it can declare that there is no need.

There is no need to report something to an official, unless the official has the power to act on the report: by allowing, disallowing, punishing, or making additional demands.

There is no need for a 2,000-page bill unless it is enabling government control over formerly private matters.

There is no need for a "place at the table" unless the czars can serve you a share of the collective goods -- or carve you up.

There is no need to read the bill -- unless it will affect your life. And a bill that creates winners and losers on every page, and that concerns everyone who is born, lives, and dies, will affect your life.

Some Americans may gain something from the bill, at least temporarily. But all lose freedom.

(Read the full text of "Forget the Trees; Look at the Forest on Healthcare".)

The Importance of Mammograms

The November 20, 2009 Denver Post published an OpEd by Dr. Lora Barke, one of my practice partners, rebutting the newly proposed government restrictions on mammograms.

Here's the full text of her piece, "The Importance of Mammograms":

The Importance of Mammograms
Dr. Lora Barke

Recently, the U.S. Preventive Services Task Force issued recommendations suggesting women refrain from getting their mammograms until age 50, and continue every two years thereafter.

With my colleagues at Invision Sally Jobe, I reject the USPSTF recommendations and support the American Cancer Society, American College of Radiology, Society of Breast Imaging, and many other respected professional organizations in their strong opposition to the new guidelines.

These new guidelines, if taken to their logical conclusion, will lead to diagnosing later stage cancer, resulting in more drug therapy, more radiation therapy and more late-stage intervention.

The American Cancer Society's (ACS) current screening guidelines state that women at average risk for breast cancer should have their first mammogram by age 40 and should repeat mammograms every one to two years thereafter. This can reduce the risk of dying of breast cancer by 20 to 25 percent for women aged 40 years or older. The ACS also says to continue routine mammograms beyond age 74, as long as the patient is in good health and has 10 years of life left.

A careful look at the most recent data shows us that about 17 percent of breast cancer deaths occurred in women who were diagnosed in their 40s, and 22 percent occurred in women diagnosed in their 50s. Furthermore, the risk of dying of breast cancer in women diagnosed in their 40s is reduced by 35 to 44 percent, not 15 percent as the USPSTF analysis incorrectly reported.

The USPSTF methodology greatly underestimates the benefit of modern mammography, while the ACS takes a more thorough and valid approach. The ACS looks at all the data used in issuing the USPSTF guidelines, more carefully reviews each individual study, and reviews many newer studies that have not been examined by the USPSTF. Despite this shortcoming, the USPSTF's own evidence review shows that mammography reduces the risk of dying in women in their 40s and women in their 50s at about the same rate.

Because fewer women develop breast cancer in their 40s compared with women in their 50s, the USPSTF has said the small benefit isn't worth the cost of screening in that age group. Among the costs are false positive examinations, including procedures. The USPSTF fails to cite the literature that reveals that women do not regard these costs as important drawbacks.

As for the screening interval, annual screening is especially important for women under age 55, and still produces better results for women 55-plus. As for false positives, remember that false positives do not double when comparing yearly mammograms to mammograms done every two years. In fact, research shows that going to the same high quality imaging facility on a regular basis reduces the likelihood of false findings.

Screening mammography in women in their 40s saves just about as many lives as it does for women in their 50s, and the breast cancer death rate in the U.S has decreased by 30 percent since 1990, primarily due to screening mammography. The USPSTF relies on old data, ignores compelling new data, creates confusion and ultimately concludes that it's just not worth it to save the lives of women in their 40s.

Screening mammography saves lives, and regular mammograms should remain an important part of women's preventive health care beginning at age 40.

Lora D. Barke, D.O., is the medical director of the Invision Sally Jobe Breast Network.

Her Denver Post OpEd is a slightly modified version of her open letter to patients and doctors, "Stick with the evidence: Women should begin mammograms in 40s".

(Note: My writings for FIRM are my own opinion only, and do not necessarily reflect the views of any of my professional colleagues or practice partners.)

Hsieh Cited in Heartland Article on Insurance

The November 3, 2009 article by the Heartland Institute, "Baucus Health Care Legislation Advances" contained a brief quote by me.

The topic was the PricewaterhouseCoopers (PWC) report for the health insurance industry which stated that the Baucus plan would result in higher prices and less flexibility for the insured.

The quoted section includes:

..."The PWC report correctly notes that the Baucus bill would impose tremendous financial hardships on many middle-class Americans by forcing them to purchase expensive state-mandated insurance on terms set by the politicians," said Paul M. Hsieh, M.D., cofounder of Freedom and Individual Rights in Medicine in Denver, Colorado.

...Hsieh believes insurers ultimately will regret not fighting the reform package by arguing for market freedom.

"Earlier this spring the insurance industry could have taken a principled stand in favor of genuine free-market reforms, such as repealing laws banning sales across state lines as well as laws mandating guaranteed issue and community rating," Hsieh said.

"Such reforms could have greatly reduced insurance costs for millions of Americans currently priced out of the market," Hsieh continued. "Instead, they chose to make a deal with the devil and accept new regulations requiring them to cover everyone regardless of preexisting conditions, in exchange for a Massachusetts-like individual mandate."

(Read the full text of "Baucus Health Care Legislation Advances".)

I'm grateful to the Heartland Institute for allowing me to appear again in its newsletter.

Liggett DP LTE on Junk Food Tax

The November 17, 2009 Denver Post printed the following LTE by Gina Liggett opposing proposed new taxes on so-called junk food:

Governor's proposal to tax candy and soda

The Post reported on Gov. Bill Ritter's proposal to tax candy and soda pop. Ritter said, "We thought that people would be willing to pay 3 cents on a dollar candy bar." How utterly arrogant of him to decide what any citizen would be willing to pay for anything. What I do with my money and property should be my business in a free society.

America's local, state and federal governments are becoming ever-more authoritarian, serving themselves instead of protecting individual liberty. Wake up! Our individual rights are in serious jeopardy. The people must fight against this creeping and metastatic growth in governmental power or America will die.

Gina Liggett, Denver

Her letter was a response to the November 15 news story, "Ritter's plan to tax soda and candy gets cheers, jeers".

Howard: The Medicaid Monster

In a recent issue of City Journal, Paul Howard describes how a combination of perverse funding formulas, political corruption, regulations on private insurance, and entitlement mentality have driven up New York state's Medicaid costs.

In particular, he describes some of the controls placed on the private insurance market:

Why is private health insurance so expensive? Blame Albany. First, state lawmakers have mandated that all health plans cover a host of procedures and "alternative-medicine" services, far more than companies in most states offer. Even the most stripped-down plan must include coverage of off-label drugs, surgical second opinions, and midwife and podiatrist services. Each mandated benefit makes the policy more expensive. Two state insurance regulations -- "guaranteed issue," which forces insurers to sell to any applicant, and "community rating," which requires them to offer the same price to everyone, regardless of age and health -- inflate prices further. Finally, the state has added billions of dollars in taxes and fees to private insurance policies, making them even pricier.

The perverse result: the young, healthy, and self-employed -- facing higher premiums for insurance that they seldom use, and realizing that they can always wait until they become ill to buy insurance -- tend to drop their coverage. (If New York regulated home insurance like this, you could buy a policy after your house had caught fire.) What's left is an insurance pool of older, sicker people, which drives private premiums higher still. Worse, the large number of uninsured people -- a consequence of Albany's bad policies—then becomes a justification for expanding the Medicaid rolls.

(Read the full text of "The Medicaid Monster".)

Despite the fact that such bad laws have driven up the price of insurance in New York (and in other states such as Massachusetts and New Jersey), these laws are being proposed at national level.

That's a recipe for disaster.

(Note: I agree with some but not all of his proposed reforms. In my opinion, he moves partially in the direction of free market reforms, but could go further.)

Mammography and Rationing

The mammography and rationing story is now big news. I don't have time right now to write up a detailed discussion.

But here are a few good pointers for more information and analysis of this story:

"A Breast Cancer Preview: Mammograms Provide Preview of ObamaCare"
Wall Street Journal, November 19, 2009

"Rationing's First Steps"
Investor's Business Daily, November 18, 2009

"Former Red Cross chief: Feds' new mammography policy is 'a shocking thing'"
HotAir.com, November 18, 2009

Here's the original Washington Post story that started much of the discussion:

"Breast exam guidelines now call for less testing"
Rob Stein, Washington Post, November 17, 2009

Health Care Hoops

CMPI explains the danger of unfair competition between a "public plan" and private insurance in their latest video, "Health Care Hoops":



Do we really want a government that competes against its own people (and is the referee to boot)?

Failing Grade For ObamaCare

Dr. Jeffrey Flier, the Dean of Harvard Medical School, has just given ObamaCare a failing grade in the November 18, 2009 Wall Street Journal.

He cites the current and pending problems in Massachusetts as part of his reasons:

...There are important lessons to be learned from recent experience with reform in Massachusetts. Here, insurance mandates similar to those proposed in the federal legislation succeeded in expanding coverage but—despite initial predictions -- increased total spending.

A "Special Commission on the Health Care Payment System" recently declared that the Massachusetts health-care payment system must be changed over the next five years, most likely to one involving "capitated" payments instead of the traditional fee-for-service system. Capitation means that newly created organizations of physicians and other health-care providers will be given limited dollars per patient for all of their care, allowing for shared savings if spending is below the targets. Unfortunately, the details of this massive change -- necessitated by skyrocketing costs and a desire to improve quality -- are completely unspecified by the commission, although a new Massachusetts state bureaucracy clearly will be required.

(Read the full text of "Health 'Reform' Gets a Failing Grade".)

I strongly share his concerns about the effect of capitation on quality of patient care, as I mentioned in my own November 2, 2009 LTE in the Wall Street Journal.