Friday, May 29, 2009

Ups and Downs in Massachusetts

The May 28, 2009 New York Times reports on continued problems in the Massaschusetts system of "universal" health care.

As we've noted before, patients now have "coverage", but do not have access to actual care. The article notes:
Massachusetts, Model for Universal Health Care, Sees Ups and Downs in Policy

...The difficulties in receiving care were severest among low-income residents, who have gained the most from expanded access under the state's law, passed in 2006. It requires most residents to have health insurance and provides state-subsidized plans for the poor. Massachusetts now has the country’s lowest percentage of the uninsured -- 2.6 percent, compared with a national average of 15 percent.

But the study, which was scheduled for publication Thursday in the journal Health Affairs, found that increased demand for care from the newly insured was confronting an insufficient supply of willing physicians. One in five adults said they had been told in the last 12 months that a doctor or clinic was not accepting new patients or would not see patients with their type of insurance. The rejection rates for low-income adults and those with public insurance were double the rates for higher-income residents and those with private coverage.
The government could attempt to "solve" this problem by next forcing doctors to take patients who have the public plan. Or outlaw private plans altogether. Doctors will then no longer be independent providers of medical services, but serfs of the state. This is the path towards socialized medicine.

Or the government can abandon its attempt to guarantee universal health care and instead implement free market reforms.

The next few months will tell us which way this country will head.

Thursday, May 28, 2009

Video: Universal Car Care

The Galen Institute has sponsored a contest for the best short video (less than 90 seconds) on the dangers of "universal health care".

You can see their entries here.

Brian Schwartz especially liked this one, "Universal Car Care":

Tuesday, May 26, 2009

Luntz's Talking Points

I've had a busy Memorial Day weekend on call at the hospital, so I don't have a blog post for today.

But take a look at Brian Schwartz's post on Frank Luntz's health care talking points.

Many of the points that Luntz raises are good ones.

But as the debate over universal health care descend into a nitty-gritty battle of power politics, it is critical that advocates of free market health care reform find ways to communicate their message in terms that resonate with average Americans without resorting to emotionalism or pragmatism. Our victory or defeat may will depend on whether we can articulate our ideas in a way that is both principled and persuasive.

Friday, May 22, 2009

How Washington Will Ration Health Care

The May 19, 2009 Wall Street Journal explains "How Washington Will Ration Health Care":
Try to follow this logic: Last week the Medicare trustees reported that the program has an "unfunded liability" of nearly $38 trillion -- which is the amount of benefits promised but not covered by taxes over the next 75 years. So Democrats have decided that the way to close this gap is to create a new "universal" health insurance entitlement for the middle class.

Such thinking may be a non sequitur, but it will have drastic effects on the health care of all Americans -- and as it happens, this future is playing out in miniature in Medicare right now. Desperate to prevent medical costs from engulfing the federal budget, the program's central planners decided last week to deny payment for a new version of one of life's most unpleasant routine procedures, the colonoscopy. This is a preview of how health care will be rationed when Democrats get their way...
Unless Americans speak out against "universal" health care, this will be our future...

Thursday, May 21, 2009

Bernstein On Innovation

David Bernstein raises a good point on medical innovation that more politicians should be thinking about:
I don't have the expertise to discuss the various health care reform proposals that are being bandied about, but I do know that it's important to ensure that whatever is implemented doesn't interfere with innovation.

Consider my own immediate family. I was born a month premature, a bit over three pounds, in my parents' bedroom after an extremely short (like 5 minutes) labor. I was rushed to the hospital, where I stayed for over a month in a "warmer". A decade or two earlier, I would have been a goner. Two and a half decades later, my cousin's son survived being born three months premature and weighing less than two pounds...

[Multiple other examples]

...Oh, and you can add my wife, who not too long ago would have died due to complications in one of her pregnancies. Indeed, before the invention of ultrasounds, the doctors wouldn't have even known about the problem until it was way too late.

Given all this, it's not surprising that I get a bit antsy when I hear some politicians talk as if health care is a fixed good, and the only question is how to distribute it properly.
Fortunately, we already know what system has led to innovation and advancement in the rest of the American economy. It was the free market.

Perhaps we should let it work in health care as well.

Wednesday, May 20, 2009

Massachusetts Cost Containment

Due to continued rising health care costs in Massachusetts under their "universal" plan, the May 7, 2009 Boston Globe reports that the government plans "another bold healthcare experiment":
State seeks to revamp way doctors, hospitals are paid

...Commission [Special Commission on the Health Care Payment System] members said they will urge Governor Deval Patrick and the Legislature to replace the current system, in which insurers typically pay doctors and hospitals a negotiated fee for each individual procedure or visit, with a set payment for each patient that covers all that person's care for an entire year.

Massachusetts would be the first state to broadly adopt such a system, which would essentially put doctors and hospitals on a budget in an effort to restrain health spending.

A single, yearly fee is intended to discourage doctors and hospitals from providing unneeded tests and treatments, so patients could find it harder to get procedures of questionable benefit. And because doctors and hospitals would have to work together more closely to manage the budget, the hope is they will better coordinate care for patients, which could improve quality.
But Scott Keays correctly noted that this is nothing new in this May 10, 2009 LTE to the Boston Globe:
Patients' care would be compromised

Adopting a system to pay doctors and hospitals a single, yearly fee for each patient is neither bold nor experimental. It's just another variation of capitation: a system that would lead to the government rationing and ultimately compromising patient care.

Before making another costly healthcare mistake, Beacon Hill lawmakers should ask themselves how they would react if their doctor said, "We've already spent your annual healthcare allowance, and anything else we could do to treat your condition would put us deeper in the red." My guess is that it would only take one really sick lawmaker (or governor) to realize the error of their ways.

Scott Keays
Keays is completely correct. This sort of capitation creates a financial incentive for hospitals and physicians to provide the minimum care necessary. So if you come to your doctor with abdominal pain and he has a choice between a more expensive surgery which will cure your condition or less expensive medications that will be less effective, he may choose to delay surgery for as long as possible to avoid losing money on your case.

Can patients trust medical advice in such circumstances, knowing that their doctors are rewarded financially for undertreatment and penalized for recommending more expensive treatments?

Patients hated this sort of indirect rationing during the heydey of HMOs. They won't like it any better when the government does it.

Tuesday, May 19, 2009

More Waiting in Massachusetts

The cracks continue to widen in the Massachusetts "universal" health care plan. The May 15, 2009 Boston Globe reports that patients are waiting even longer for access to specialists:
Waits to see Hub doctors grow longer

Despite Boston's abundance of top-notch medical specialists, the waits to see dermatologists, obstetrician-gynecologists, and orthopedic surgeons for routine care have grown longer - to as much as a year for the busiest doctors.

A study of five specialties shows that the wait for a nonurgent appointment in the Boston area has increased in the past five years, and now averages 50 days - more than three weeks longer than in any other city studied.
Read the whole thing.

Too many politicians conflate "coverage" with actual medical care. Under "universal" systems, governments can promise plenty of theoretical "coverage", but not actual medical care.

Massachusetts patients know the difference between "coverage" and medical care. So do patients in Hawaii.

Will the rest of the country have to learn this lesson the hard way?

Monday, May 18, 2009

How ObamaCare Will Affect Your Doctor

The May 12, 2009 Wall Street Journal warns that the current push towards government-run health care will squeeze patients and physicians alike, with massive unintended consequences. Here are a few excerpts:
How ObamaCare Will Affect Your Doctor

...Physician income declines will be accompanied by regulations that will make practicing medicine more costly, creating a double whammy of lower revenue and higher practice costs, especially for primary-care doctors who generally operate busy practices and work on thinner margins. For example, doctors will face expenses to deploy pricey electronic prescribing tools and computerized health records that are mandated under the Obama plan. For most doctors these capital costs won't be fully covered by the subsidies provided by the plan.

...Right or wrong, more doctors will close their practices to new patients, especially patients carrying lower paying insurance such as Medicaid. Some doctors will opt out of the system entirely, going "cash only." If too many doctors take this route the government could step in -- as in Canada, for example -- to effectively outlaw private-only medical practice.
Read the whole thing.

The end result will be a total government takeover of medicine.

If you want the US health care system to look like the Department of Motor Vehicles, you won't have to wait long.

Friday, May 15, 2009

Medicare is Unsustainable

John Goodman runs some numbers and shows that Medicare is unsustainable.

There are two important consequences.

1) If we move towards any form of government-run universal health care (such as the proposed "Medicare for all"), the problem will become quickly worse.

2) The government will eventually have to cut health care spending. In other countries, this has taken the form of draconian rationing (e.g., "no dialysis if you're over a certain age"). Basically, the government determines what their citizens' lives are worth.

That's why we need to adopt free market health care reforms as quickly as possible, where the usual market mechanisms can lower costs while preserving quality. We don't have much time to act. All we need is the political will.

Thursday, May 14, 2009

Simpson on Licensing

During an online discussion on whether physicians should be forced to work during pandemics as a condition of retaining their medical license, the discussion turned towards the appropriateness of medical licensing in general.

Steve Simpson of the Institute of Justice had the following excellent comments to make in response to some questions. With his permission, I'm reposting his remarks here.

With respect to the question that doctors know up front that they agree to certain terms before they accept a license, hence they've voluntarily contracted to any associated obligations:
First, doctors do not consent to medical licensing in the sense in which that consent could legitimately be said to impose further obligations on them, the way one consents to the obligations in a contract.

Doctors do not get to decide to practice with a license or without a license. They are compelled to practice with a license whether they want to or not. So it is wrong to claim that they somehow consent to whatever obligations come with licensing. The state offers them the "choice" of practicing with a license or not practicing at all. That is not a choice the state has to authority to impose upon doctors, any more than it has the moral authority to offer citizens the "choice" of being enslaved citizens or not being citizens at all. I could say much more about this, but I'll leave it at that.
With respect to the concern that private medical licensing groups would have a conflict of interest between setting high standards vs. retaining their members (and hence government would be better at protecting the public from shady practitioners):
Second, your view that private medical licensing would constitute an inherent conflict of interest because it would be doctors essentially engaging in self-regulation is wrong on many fronts. The fallacy at the root of your view is that individuals are capable of objectively governing the lives of others but not capable of governing their own lives because of their own self interest in the latter situation but not the former. There is much to say to this, and reading Atlas Shrugged would be a good place to start in learning why that view is the exact opposite of the truth, but let me say just a couple things.

You say that there is no guarantee that private medical boards will set high standards or improve them as necessary. But there is, and it's the best guarantee that has ever existed--rational self interest. Doctors are neither insane, nor irrational (indeed, if they were, I submit they would not be doctors now would they). Nor are their patients. Doctors have no desire to harm or injure their patients, for, among other reasons, if they do they will not remain doctors for very long, they will have no patients, they will get sued, etc.

Moreover, there is no guarantee that state regulatory boards will set high standards either. Indeed, state regulatory boards have no incentive whatsoever to keep current with the latest developments in medicine and to ensure that their standards are high. What is the cost to them if they do not do so? They are committees, and thus each individual can always shuffle off the responsiblity for their failures to someone else, and even if they are found to have failed to set high enough standards, they suffer no consequences whatsoever. Their income and careers are not on the line, they will never be fined or sanctioned for their failures, and rarely, if ever, are any regulatory boards ever held accountable for their failures.

But there's another mistake in your thinking about this that many people make, which is to consider any regulatory boards to be separate from the professions they regulate. This is flawed as a matter of both history and common sense. Historically, occupational licensing has typically been championed by the very professionals who are to be licensed. They do this both to "professionalize" their industries--because it is much better to be "state licensed" than simply to be qualified--and to make it much harder for others to compete with them.

As a result, all occupational licensing agencies or boards that exist today are composed of the very professionals that they regulate. This makes perfectly good sense when you consider that no one else is qualified to regulate them. Who is going to decide what the proper standards for doctors are but doctors? Likewise lawyers, plumbers, carpenters, engineers, architects, stenographers, morticians and funeral directors, barbers and cosmetologists, florists, etc. Do you know what standards even a licensed florist or interior decorator must meet to be qualified? I don't. So who, but other florists and interior designers are going to regulate the florists and interior designers?

The term for what I am talking about is "regulatory capture," which simply means that the idea that regulatory boards and agencies of any type are somehow "separate" from the industries they regulate and thus "objective" is utter, unbridled nonsense. It is a pipe dream. It is the sort of thing that we all believed in fourth grade when we thought that committees should run the whole wide world because that would be "fair." My point is not simply that regulatory capture is likely to happen.

My point is that occupational and industrial or economic regulation is virtually impossible without regulatory capture, and, indeed, the regulators actively want the participation of the industries they regulate because otherwise they would not know what the hell they were doing. So your view that regulatory boards are somehow more "objective" and less "conflicted" than private boards is just not true factually and by the very logic of what such regulation aims to do.
And with respect to occupational licensing in general:
I could go on about occupational licensing all day. At IJ, we've done quite a lot of work on the subject, so if anyone is interested in more concrete examples of how licensing evolves in a given profession, check out our website, particularly the economic liberty cases and some of our research publications ( Or just shoot me an email (or ask a question here) and I'll do my best to answer it or direct you to more information.

The idea that licensed workers voluntarily consent to the obligations imposed on them by states is really unjust in more ways than I mentioned. As a lawyer, I see this all the time.

The states in which I'm licensed are constantly imposing new requirements, like mandatory pro bono, additional "continuing legal education" and the like to which I never consented and that are burdensome, costly, almost always a complete waste of time, and useless from the standpoint of improving my qualifications. In fact, what does motivate me to do a good job is precisely the opposite of all of these (and more) unchosen obligations.

I am motivated by the chosen obligations I freely decided to accept when I became a lawyer. My own desire to produce excellent work, to give my client the best work I can, to win my cases or at least to outlitigate the other side at every step, and to constantly produce a better brief or better argument or better analysis than I did the last time out.

But even if those things didn't motivate me, I and every other regulated professional would be motivated by the desire not to be embarrassed or to develop a bad reputation (and I have both colleagues, clients, and judges to worry about) or the other things I mentioned in my last post. In fact, I have never in my 15 year career met anyone who was ever motivated to produce good work by the states in which they were licensed. I could produce consistently incompetent and crappy work for years before any of the three states in which I'm licensed would take notice. My colleagues, my employer, my clients, and all the judges I appear before would take notice long before the state bars.

So my point is that the notion that we voluntarily assume the obligations of our state licenses is both a classic moral inversion--because it is in fact the voluntary obligations that motivate professionals and regulated occupations to produce high quality work--and it is illogical in that it contradicts the supposed purpose of licensing, which is to impose obligations on regulated occupations that they did not choose, because, allegedly, they can't voluntarily regulate themselves. See the contradiction? On the one hand, the obligations of licensing are "voluntary." On the other, licensed occupations can't be self-regulated because "voluntary" regulation would not work. Heads they win, tails we lose.
Thank you, Steve, for this great impromptu analysis!

Here's the full discussion thread, which includes links to additional articles on licensing by Alex Epstein ("End Government Licensing") and Shirley Svorny ("Medical Licensing: An Obstacle to Affordable, Quality Care").

Tuesday, May 12, 2009

Steve Forbes on Health Care

Steve Forbes discusses why we shouldn't look to other countries for health care reform.

Much of what he cites can be found in the NCPA paper, "Health Care Reform: Do Other Countries Have the Answers?" by John C. Goodman, Linda Gorman, Devon Herrick, and Robert M. Sade.

Monday, May 11, 2009

Dalmia Debunks Obama

Shikha Dalmia debunks President Obama's claim that government-run health care will save our economy in this May 5, 2009 piece from Forbes. Here is an excerpt:
Obama's Health Care Reform Tactics

True to the advice of his chief of staff to never let a good crisis go to waste, President Barack Obama is using the current economic crisis to sell a top item on the liberal wish-list: universal health care. "You can't fix the economy," he has repeatedly said, "without fixing health care."

But the president needs to take a chill pill before committing America to a huge new entitlement: One is hard pressed to find any evidence from abroad showing that universal coverage has grown the major industrialized economies more than ours in the past--or shielded them more than us from the global slump now.

...But whatever else universal coverage might bring, there is no evidence that it will bring economic nirvana. If anything, contrary to what the president suggests, the correlation runs the other way for countries with universal coverage such as Canada, England, France, Germany and Japan. On nearly every economic front, their performance has been worse than America's--even, surprisingly, in controlling health care costs.

...All in all, there is no major industrialized economy with universal coverage that has performed as well--let alone better--than the United States in the last decade
(Read the whole thing.)

Friday, May 8, 2009

Admin Note: Light Posting

Due to external obligations, posting will be light next week.

Thursday, May 7, 2009

Quote of the Day from Mark Steyn

Canadian writer Mark Steyn has the quote of the day on President Obama's plans for government-run medicine:
Socialized health care in particular changes the nature of the relationship between citizen and state into something closer to junkie and pusher.
And as David Catron notes:
...[O]nce all Americans find themselves dependent on Big Brother for health care, they will do anything to keep the supply flowing. No matter how badly it works, the voters will resist any change.

...That's why the Democrats and our new President want to foist government-run health care on you. They want the kind of power over you that a crack dealer has over a crackhead.
Bill Whittle nails the essential issue here:
"Free" health-care costs us something precious, and no less precious for being invisible. Because there's a word for someone who has their food, housing and care provided for them... for people who owe their existence to someone else.

And that word is "slaves."

Wednesday, May 6, 2009

Hsieh OpEd at PJM: "Health Care Reform vs. Universal Health Care" has just published my latest health care OpEd, "Health Care Reform vs. Universal Health Care".

Here is the opening:
Health Care Reform vs. Universal Health Care

President Obama and Congress have now shifted their attention towards health care reform. This subject is critically important to anyone who might need medical care someday — namely, all Americans. Unfortunately, too many pundits and politicians erroneously equate "health care reform" with government-run "universal health care." Before we rush headlong into any such program, here are three basic facts that Americans should know about universal health care...
The three basic facts I discuss include:
1) Government-run "universal health care" leads to rationing
2) Health care is not a "right"
3) Free-market health care reform can and does work
Read the whole thing here.

Tuesday, May 5, 2009

McCaughey: Controlling Doctors' Decisions

Former New York lieutenant governor Betsy McCaughey gives us an update on comparative effectiveness mandates and how the will compromise your doctor's ability to practice good medicine.

Here are a few excerpts:
Controlling Doctors' Decisions

...Legislators slipped the framework for top-down government controls into the stimulus package passed in February. One provision called for computer technology that will "guide" doctors' decisions about what care is "cost-effective." Beginning in 2014, Medicare and other federal programs will impose financial penalties on doctors and hospitals who are not "meaningful users" of this system. Private insurers historically have followed Medicare's lead.

...Government controls on health expenditures will reduce the availability of medical technology, such as MRIs, and cause waits for treatment. [Harvard Medical School professor David] Blumenthal says it's "debatable" whether the timely care Americans currently receive is worth the added price.

Ask a cancer patient about waiting, and you'll get a different answer. Delays lower your chance of survival. For example, women in the U.S are more likely to have regular mammograms than are women elsewhere, according to data from the Commonwealth Fund. Their breast cancer is detected sooner. They are also treated faster and have higher survival rates than women in any other developed country, according to the CONCORD study published in 2008 in Lancet Oncology. These statistics include all American women, not just those with insurance.
Read the whole thing.

Advocates of government-run "universal health care" typically criticize insurance companies for denying care in order to save money.

The harm that private insurers can do will pale in comparison to what the government can do when it becomes the the sole monopoly insurer.

Let's hope we don't have to find out.

Monday, May 4, 2009

Four Myths About Universal Coverage

University of Illinois law professor David Hyman has posted a paper entitled, "Employment-Based Health Insurance and Universal Coverage: Four Things People Know That Aren't So".

He covers four commonly-held myths about insurance and universal coverage, including:
* Employers pay for EBC (employment-based coverage)
* There are 45.7 million uninsured Americans
* Universal coverage means everyone will have access to high quality care
* Universal coverage will solve the cost problems of American health care
We do need significant reforms. But his paper explains why government-run "universal health care" will take us in the opposite direction.

And given the fact that the current employment-based system has its roots in bad tax policies, we should eliminate the laws the link employement to insurance, not strengthen them. This would be genuine reform in the right direction.

(For more information on this latter point, see "Healthcare shouldn't be linked to employment" by Jeff Jacoby in the October 19, 2008 Boston Globe.)

Friday, May 1, 2009

Health Care Reform that Will Kill the U.S. Economy

U.S. Senator Tom Coburn (R-OK, and a practicing physician) and Regina E. Herzlinger (Harvard Business School Professor) have written the following OpEd on the perils of Congressional proposals to impose a Massachusetts-style health care system on the entire US. Here are a few excerpts:
Health Care Reform that Will Kill the U.S. Economy

...Massachusetts, which operates a U.S. analogue to a national government-run health-insurance market, is, in fact, a case study illustrating why health insurance run by Washington would collapse on itself. By March 2009, the state's uninsured rate fell to 2.8 percent from about 6 percent. The market, stocked with private-sector insurance policies, had insured 169,000 people in two new programs, one of which directly subsidizes uninsured individuals.

Good news, right? Wrong.
Their piece then describes the rising costs and long waits.

The next step:
By 2009, Massachusetts enacted almost $800 million in new taxes to fund, among other things, the third year of health care reform. Now, the state government, desperate for revenue, is considering setting the prices of health insurance and essentially taking control over all health-care costs, other than Medicare and out-of-pocket spending. If this sounds like a march into a single-payer Soviet-style system, that's because it is.
And the end result:
...In the end, the Democrats' health care reform will require drastic rationing of health care for the sick to control its costs. Consider Canadian patients, who may wait a year or longer to get radiation therapy. Or ask one of the nearly 1.8 million Britons who are waiting to get into a hospital or have an outpatient procedure. Or talk to the German breast cancer patients who are 52 percent more likely to die from the disease than Americans.
We have been warned.