Quick Links: Barr, Puzder, CER

Andrew Barr: "Obamacare, Europe and the Sophistries of Socialized Medicine". (Via @sonodoc99.)

Andrew Puzder: "Job Creation Is Price for New U.S. Health Law". (Via J.G.)

AP News: "New fee soon to be added to health insurance". To pay for the "comparative effectiveness research" used to limit your future access to medical care(!)

Hsieh: Who Will Your Doctor Work For Under ObamaCare?

The 12/30/2011 TownHall.com has published my latest OpEd, "Who Will Your Doctor Work For Under ObamaCare?"

The theme is that ObamaCare will pressure doctors to sacrifice their individual patients' welfare for a collectivist concept of "social justice".

Here is the opening:

Suppose you move to Las Vegas, and you hire a real estate agent to help you buy a house. She returns with several inappropriate choices -- all too expensive and too far from your work. She explains, "I know these aren't what you wanted. But you'd really help the struggling Nevada housing market by purchasing one of these."

Most people would fire her on the spot. Your real estate agent has a professional obligation to look out for your individual interests, not some nebulous "Nevada housing market." Yet under ObamaCare, your doctor will be increasingly pressured into sacrificing your individual medical interests for a nebulous "social justice"...

(Read the full text of "Who Will Your Doctor Work For Under ObamaCare?")

I'd like to thank Diana for her assistance editing an early version of this piece.

I'd also like to thank Dr. Hal Scherz, Dan Rene, and Docs4PatientCare for helping to arrange its publication!

Wolf: In Obama He Trusts

Dr. Milton Wolf has a new Washington Times OpEd, "In Obama He Trusts".

An excerpt:

Where once the American flag was hailed universally as the ultimate symbol of freedom, we who live under it have slowly but surely surrendered our liberties to an insatiable government. Consider our decline in just the past two generations. Our grandfathers, who stood against evil and shed their blood to stop it, never would have tolerated their own government becoming so totalitarian that it would dictate to them what car they should drive, what (if any) health insurance they should choose or even what light bulb they should buy...

The sum total of Mr. Obama's political philosophy, the unifying theme of his presidency, amounts to this: You cannot be trusted to live as a free American.

Dr. Wolf spells our more details of our steady erosion of freedom in, "In Obama He Trusts".

And he has this crucial warning for the Republicans:

The GOP should resist the temptation simply to become a cleverer version of autocrats who pull the same powerful levers of government but in different directions. Instead, they should become the party that embraces liberty.

Let's hope they heed his advice.

Dr. Wes On The Future

Physician-blogger Dr. Wes has some good insights on the future of American medicine in "A Look Ahead".

In particular, he highlights trends to anticipate under the growing centralization of health care such as loss of privacy, less contact with primary care physicians, and increasing reliance on algorithms.

Although some of these trends may be good if they had evolved in a free market context, in the context of ObamaCare they often represent market responses to external government compulsion.

The Coming Squeeze On Private Insurance

One of my friends here in Colorado received this letter from his health insurance company a few weeks ago.

This will just be the beginning of the shakeout in the private market due to "uncertainty brought on by the regulatory environment" (i.e., the slow strangling of the private insurance industry under ObamaCare):

Dear [name omitted]

We are writing to inform you of an important decision World Insurance Company ("World") has made regarding individually underwritten comprehensive major medical insurance in Colorado, which impacts your coverage.

This letter contains important information about the cancellation of your policy/certificate.

Like all companies, we continually monitor our business strategy to ensure a competitive presence in the rapidly changing insurance market. With the changes in the major medical insurance marketplace and the resulting uncertainty brought on by the regulatory environment, World has decided it is no longer able to provide the kind of major medical protection our customers have come to expect. During a recent review of World's overall businesses, the difficult decision was made to exit the individually underwritten comprehensive major medical insurance business in all of our existing markets.

You can click on the image below to see it full size.

Brian Schwartz also discusses this topic at, "State regulations force insurers out of market, Obamacare will make it worse".

Merry Christmas!

Merry Christmas! (Note: Posting may be lighter than usual next week due to the holidays.)

Quick Links: Mandates, Kagan, Bad Year

Brian Schwartz: "Feds won't add any insurance coverage mandates in exchanges -- for now"

Michael Ostrolenk: "Elena Kagan: The Justice Who Knew Too Much"

Paul Conner: "Obamacare's terrible, horrible, no good, very bad year"

Zycher on Medical Innovation

In the 12/21/2011 PJMedia, Ben Zycher of PRI discusses "Coal In Our Stockings: The Destruction of Medical Innovation".

In particular, he warns how "comparative effectiveness research" mandates will slow medical innovation as well as cause politicization of results. Patients will be the ultimate victims, deprived of treatments they could have received if the government interference hadn't existed.

Hsieh PJM OpEd on Gingrich and Personhood

PJMedia has published my latest OpEd, "Would a President Gingrich Ban The Birth Control Pill?"

My theme is that if Newt Gingrich wins the 2012 GOP nomination, it would introduce the controversial "fetal personhood" issue into the presidential race and potentially tip the election to Obama.

Here is the opening:

If history is any guide, Newt Gingrich's views on birth control, abortion, and the controversial "personhood" movement will be likely targets for Democrats if he wins the 2012 GOP nomination for President.

Gingrich recently signed the "Personhood Republican Presidential Candidate Pledge" which affirms that "unborn children" should be regarded as persons with full legal rights "from the moment of conception… without exception and without compromise." Gingrich signed the pledge after taking heat for an earlier statement stating that human life began after embryo implantation in the womb (which occurs a few days after fertilization). His campaign has since clarified: "Newt believes that human life begins at conception, that is, at the moment of fertilization." If enacted into law, this seemingly small distinction could have serious implications for the legality of many forms of birth control.

The "personhood" movement represents the most ideologically consistent endpoint of the anti-abortion movement. In their view, once a human sperm fertilizes an egg, the zygote deserves full protection as a legal "person" comparable to a born child. Under this standard, abortion would become illegal even in cases of rape and incest -- one of the goals of "personhood" advocates. However, recognizing fertilized eggs as legal persons would also have serious implications for issues other than abortion. As Ari Armstrong and Diana Hsieh describe in their 2010 paper, this includes potentially limiting women's ability to receive in vitro fertilization and physicians' ability to treat women with life-threatening ectopic pregnancies. But one of the biggest political issues would be the legality of many forms of birth control...

I'd like to thank both Diana and Ari Armstrong for their earlier writings on this topic, as well as giving me feedback on earlier drafts of this OpEd.

Pipes On Socialized Medicine

In her 12/19/2011 Forbes column, Sally Pipes reminds us that "The Ugly Realities Of Socialized Medicine Are Not Going Away".

In her critique of the UK National Health Service she notes, "The British healthcare system may 'guarantee' access to care -- but that doesn’t mean patients actually receive it."

In addition to the poor quality care and rationing, there are indiginities such as:

A report released in October by Britain's health regulator found that a stunning 20 percent of hospitals were failing to provide the minimum standard of care legally required for elderly patients.

As part of the study, inspectors dropped by dozens of hospitals unannounced. They found patients shouting or banging on bedrails desperately trying to get the attention of a nurse. At one hospital, inspectors identified bed-ridden patients that hadn’t been given water for over 10 hours.

The upcoming austerity measures will only amplify maladies like these.

The NHS is broken -- and not in some superficial way that a simple tweak would fix. The incentives are wrong. The government's main priority is keeping costs low -- not providing quality care. Patients can't choose how they receive their care -- it's one-size-fits-all medicine. And the entrenched NHS bureaucracy has no reason to improve efficiency.

For more details (and implications for the US), read the full text of "The Ugly Realities Of Socialized Medicine Are Not Going Away".

Bolick: Obamacare's Other Unconstitutional Provision

Clint Bolick of the Goldwater Institute discusses, "Obamacare's Other Unconstitutional Provision".

In particular, he addresses the many problems with the Independent Payment Advisory Board (IPAB):

Three features combine to make IPAB's regulatory power unprecedented: its decisions are largely uncontrollable by Congress, its actions are unreviewable by the courts, and -- amazingly -- the agency's existence is virtually unrepealable.

Ordinarily, the delegation of legislative power to regulatory agencies is accompanied by numerous safeguards. First, as a matter of separation of powers, courts require that the delegation of regulatory powers be guided and restricted by "intelligible standards." Second, most regulatory powers are exercised through the administrative rule-making process, which provides for public notice and comment. Third, both Congress and the courts can review the rules. Finally, of course, Congress can repeal the agency or change the delegation of power. None of those safeguards are present with IPAB...

One interesting point:

The law says that certain proposals are off-limits, including any that "ration health care, raise revenues or increase Medicare beneficiary cost sharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility requirements."

[However,] crucial terms such as "rationing" are undefined, and the requirements are confusing and contradictory. Elsewhere, the law directs IPAB to "protect and improve Medicare beneficiaries’ access to necessary and evidence-based items and services." So IPAB is not allowed to ration health care, but it must decide which services are "necessary and evidence-based" -- which, of course, is rationing.

(For more details, read the full text of "Obamacare's Other Unconstitutional Provision".)

As financial pressures mount on Medicare, this de facto rationing will occur even if IPAB bureaucrats claim it's not rationing.

Fortunately, there's growing opposition from members of both political parties to this radical empowering of IPAB. Let's hope it's enough.

Dorin: Why Your Doctor Will Not Be Happy Under ObamaCare

Dr. Adam Dorin discusses, "Five Reasons Your Doctor Will Not Be Happy Working Under the Yoke of Obamacare".

Specifically, he cites the following factors:

1. Technology Gone Wild
2. The Ghost of Donald Berwick
3. Medical Coding Monopoly
4. The Downgrading of the Medical Degree
5. Misrepresentation

(For more details on each point, read the full text of "Five Reasons Your Doctor Will Not Be Happy Working Under the Yoke of Obamacare".)

Renegade Doctor Doesn't Accept Insurance

Dr. Susan Rutten Wasson doesn't accept insurance, and it helps her practice better medicine.

From the article:

It's more a scene from the days of frontier medicine than from the modern health care system. And that's because Rutten Wasson, 42, is a throwback to a time before HMOs, electronic health records and hospitals with fountains in their lobbies. She sees patients the same day they call if she's not booked up, spends at least a half-hour per visit — compared to the more typical 15 minutes -- and usually charges only $50 for a consultation. She takes cash or check, but no insurance -- and sometimes accepts gratuities of a dozen fresh eggs or a pie.

"I have a few bottles of homemade wine in the fridge from patients," says Rutten Wasson. "In summer, I'll get pickles or tomatoes. I've received pork sausage, the kind that would convert a vegetarian."

Rutten Wasson is decidedly not a vegetarian. She and her husband raise sheep and chickens she butchers herself. "Occasionally, I have people pay me more than my fee because they think I've earned it. It's nice. I don't complain."

In an era of high overhead, ever more byzantine regulations and payment models, cuts to Medicaid and Medicare benefits, and large medical systems swallowing independent practices, Rutten Wasson relishes her straight-forward manner of practicing. Since many federal health care reforms -- such as those requiring electronic medical records -- are tied to Medicare, they tend not to apply to her.

Her practice serves as a critique of the modern health care system, the complexity of which has pushed some providers and clinics to find dramatic work-arounds, despite the fact that it can be tough to make a living outside the mainstream. A small but growing number of physicians practice "concierge medicine," charging patients annual retainers for basic medical care. A 2010 nationwide survey commissioned by a congressional agency pegged the number of concierge doctors at 756, up from 146 in 2005.

Walk-in clinics are another alternative. MinuteClinic, for example, started in Minnesota in 2000 and has spread to 26 states. At these clinics, nurse practitioners and physician assistants treat a menu of common illnesses and injuries and perform physicals for reasonable, stated fees, no appointment necessary. Exams typically run between $79 and $89...

(Read the full text of "Doctor as renegade—accepts cash, checks, eggs or pie, not insurance".)

The freedom from federal mandates will become increasingly valuable in the future to physicians like her.

Bach: When Care Is Worth It, Even if End Is Death

In the 12/12/2011 New York Times, Dr. Peter Bach discusses, "When Care Is Worth It, Even if End Is Death".

First, Dr. Bach lays out the "conventional wisdom" currently being promulgated by the cost-cutters:

You've probably heard that we spend a lot of money on patients who die. It's true: about one-tenth of the money spent on direct care goes to people who die each year. Among Medicare patients, the figure is much higher, about one-quarter.

You may be shocked by those statistics. What health care system would squander so many dollars on patients who don't benefit? Or maybe you’re saddened. No humane system would subject patients to painful interventions and procedures that serve no purpose.

The idea that we waste money on terminal patients has caught on; the simplicity of the conceit makes it appealing to policy makers. And the data to support it keep coming, because it is easy for researchers to measure how much is spent on patients before they die.

Then he points out the following "inconvenient truths":

Providing care means reducing the chance they may die -- not eliminating it. My supervisor noted this the moment he saw my patient...

Put another way, the policy conceit that spending money on patients who die is a waste overlooks the core purpose of health care -- to prevent or forestall illness, disability and death among patients at risk of those outcomes.

It also overlooks a key correlation in health care. When people get sicker, they need more intensive -- and expensive -- health care services. But when they get sicker, they are also more likely to die. When I met my patient, I took him to the intensive care unit, the second-most-expensive place per minute in any hospital. The other place he went, twice, was the operating room -- the most expensive place.

Healthy people, who are unlikely to die, are also very unlikely to find themselves in those settings. Thank goodness.

Thus, spending will always be concentrated on people who are the sickest. When one examines spending on patients who die, dollars will be concentrated there, too.

I am not saying that every health care dollar is well spent. But five carefully done studies have now shown that hospitals that spend more on caring for sick patients have better outcomes than those that spend less. So some of the spending is improving health.

(Read the full text of "When Care Is Worth It, Even if End Is Death".)

It's impossible to ascribe "value" for a health care dollar in the abstract. As author Ayn Rand once noted, the concept of "value" presupposes "to whom and for what". No government central planner can determine what is the appropriate value to a particular patient for a dollar spent on his health care.

One of the biggest problems with ObamaCare is that it presumes that health care "value" (and thus what constitutes "appropriate" vs. "inappropriate" care) can be best determined by bureaucrats, rather than by those whose very lives are at stake.

As a corollary, payment for health services is also the responsibility of those who wish to receive them. If someone desires health services because it would be of value to them, they should pay for it from their own funds, through contractually-promised voluntary agreements (such as private insurance or mutual-aid groups), or via private charity. They don't have the right to demand that others write them a blank check for services they deem valuable.

(NYT article link via Dr. Kathleen Brown.)

Quick Links: Agents, ERs, Exchanges

Nigam Arora describes how, "Obamacare Mandate Kicking Insurance Agents To The Curb".

This is yet another part of the squeeze on the private insurance industry. (Link via Dr. Art Fougner.)

In the Annals of Emergency Medicine, Wiler, et al ask, "Episodes of Care: Is Emergency Medicine Ready?"

Their conclusion: Despite the push for payment "reforms" in the form of "episodes of care", this will hurt ER departments and ER patients. Instead, they advocate retaining the current fee-for-service model. This is, of course, a very politically incorrect conclusion.

Robert Book describes, "Unreasonable Rate Review for Health Insurance". In particular:

So, the Exchange cannot exclude a plan because its premiums are too high, but it can take high premiums into account in decided whether or not to exclude it.

This is a recipe for arbitrary decisions by state and federal bureaucrats as to which health plans will be permitted.

Just another reminder that government-run health insurance exchanges will not be any sort of a "free market", but rather a pseudo-market where the government determines if the prices are "reasonable".

Study Ranks US First In Overall Health

Julian Pecquet of The Hill reports, "Study ranks US first in overall health".

This an interesting variance from the oft-cited study arguing that the US ranked 37th in the world, based on numerous fallacious arguments.

I haven't yet read the new study in detail, so I can't vouch for its methodology. But at least it gives more reason to doubt the reliability of the old "37th in the world" claims.

(Via @sonodoc99.)

Real World Effects of ObamaCare

One of my friends posted the following to Facebook, and she has graciously given me her permission to repost it here. She has asked that I refer to her as "Dr. Monica H.":

In Which I Detail How Obamacare Will Work for Me

Currently, I am a college professor at 3 campuses in the Denver area. I prefer not having administrative duties and would rather focus on teaching and research. Until we move (this is complicated), finding a FT job isn't likely, but I'm basically happy. I make what a full time faculty member makes, but that means I don't get healthcare because my work is split at multiple institutions, 2 of them community colleges. So I am responsible for my own healthcare, but I am OK with that, since I don't really use the traditional healthcare system for anything but very serious emergencies. I am not a big fan of medicine as it is practiced in this country, so I do most of my own lab testing and "alternative" treatment.

But never fear. My healthcare "problem" will be solved in 2014 when Obamacare kicks in. That's because the college has been told by the Feds that they must provide community college instructors who work more than 3/4 time (that's me) with health insurance. That would be me. I'm going to get health insurance! Yay, right?

How will the college respond to this? Likely by hiring more very part time instructors and taking work away from current instructors that teach nearly a full-time load. This is not speculation: I expect this to gradually be implemented over the coming 2 years, as detailed in an email I just received from the administration. This will be so they don't have to pay the insurance mandated by the federal government. I won't simply be able to spread out my work over 4-5 community colleges in response, because the new regulations apply to all community colleges in Colorado as a whole. In other words, the state won't view, say, Front Range CC and CC of Denver as two separate institutions when it comes to health insurance. It will view them as one. That means instead of teaching 4-5 classes per semester, I'll be limited to 1. The number of instructors will probably triple, depending on the department.

Yep, I'm sure on a salary 1/4 to 1/5 what I make now, I'll be ever so capable of paying for mandated insurance! Thanks, Obama!

A very practical example of the types of unanticipated effects of such legislation. For those of you who wonder why I'm no longer all that excited about the government thinking it knows best for me and every aspect of my life, this is why.

First, I very much appreciate this sort of "in the trenches" real-world report of how ObamaCare is hurting Americans. I hope more of our elected officials take heed of what their policies are doing to their constituents.

Second, many on the Left actively want Americans to be frustrated with private insurance industry under ObamaCare. That way they can say, "See, we tried it the 'free market' way and it failed; that's why we need a government 'single-payer' system". (Of course, the failure would be due to government policies that destroyed the free market, not the free market itself.)

Finally, these perverse effects of ObamaCare will affect many people all across the economic spectrum by making it harder for employers to offer full-time jobs to willing employees. For more details, see the following from James Sherk of The Heritage Foundation: "Obamacare Will Price Less Skilled Workers Out of Full-Time Jobs".

Here's a critical image:

Quick Links: Gingrich, Dumping, Autonomy

Jared Rhoads of the Center for Objective Health Policy discusses "Newt Gingrich: 3 hits and 3 misses on transforming healthcare".

Dr. Michael Hurd offers his own analysis at, "Gingrich on Health Care".

At best, Gingrich is a very mixed bag with some good ideas and some bad ideas masquerading as "reform".

Jeffrey Anderson notes, "Under Obamacare, Employers Will Likely Engage in 'Targeted Dumping' of Employees".

Dr. Ken Murray describes, "How Doctors Die":

It's not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What's unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Many doctors choose to decline aggressive end-of-life treatment -- as is their right. Of course, this is precisely the sort of decision that each person should be able to make for themselves -- not the government.

Three Major Cognitive Errors Physicians Make

This isn't directly related to health policy, but I thought it was a darned good read: "Three major cognitive errors physicians make".

The authors, Jerome Groopman and Pamela Hartzband, describe the "Three 'A' errors" of "Anchoring", "Availability", and "Attribution Error".

Read the whole thing.

Quick Links: MLR, HSA, Concierge Medicine

At his 12/6/2011 Forbes blog post, Avik Roy offers his own take on the new MLR insurance rules.

Roy argues that it won't destroy the private insurance market and lead to a government-run "single-payer" system. Rather, "they will usher in a new era of private insurance monopolies and significantly drive up the cost of health insurance, things that neither liberals nor conservatives should cheer."

Meanwhile, at the 12/7/2011 Investor's Business Daily, David Hogberg warns that the MLR rules may mean that many Americans may no longer be able to use Health Savings Accounts (HSAs) for their medical expenses.

On 12/5/2011, CNN Money discusses, "Concierge medicine: The doctor will see you now".

More patients and physicians are finding this model attractive. The patients get better care and physicians get to practice better medicine in a more satisfying manner.

A Liberal Speaks Out on Kagan and Recusal

In Slate, Eric Segall gives "A Liberal's Lament on Kagan and Health Care".

A key excerpt:

So far it appears that only Republicans and conservatives want Kagan to recuse herself from hearing the case, while liberals and Democrats take the opposing view. I have been a liberal constitutional law professor for more than 20 years, and a loyal Democrat. I believe the Affordable Care Act is constitutional and that it would be truly unfortunate for the country (and the party) if the court strikes it down. I also recognize that there is a much greater chance of the court erroneously striking down the PPACA if Kagan recuses herself. That said, I believe that as a matter of both principle and law, Kagan should not hear the case...

I am not arguing that Supreme Court justices should recuse themselves any time they are called upon to hear a case involving a law supported by the president for whom they once worked. But this situation is far more complicated than that. This isn't just about parsing the words of the recusal statute for plausible defenses; it's about the appearance that a Supreme Court Justice with a conflict of interest is sitting on a major case. This is the perfect storm of events that should require Kagan’s recusal.

(Read the full text of "A Liberal’s Lament on Kagan and Health Care".)

Via Dr. Matthew Bowdish and @D4PCCO.

Catron On Economic Illiteracy

David Catron's latest American Spectator piece notes that, "Democrat Economic Illiteracy Has Consequences".

After citing some examples, he observes:

It is precisely this kind of ignorance that led so many Democrats to believe Obamacare would somehow render health care less expensive. One of the first items covered in any introductory economics course is that the price of any good or service will rise if the quantity demanded increases without an accompanying increase in the available supply of that commodity. Nonetheless, it held no message for the average Democrat that the supply side of the equation was ignored by "reform," though it increased the number of patients in the health system as well as the range of services to which they are entitled.

Of course, the law of supply and demand keeps working regardless of whether or not policy makers recognize that fact. To paraphrase Ayn Rand, they can evade reality, but they cannot evade the consequences of evading reality.

Although Catron concentrates mainly on Democrats, plenty of Republicans fall prey to economic illiteracy as well.

(Read the full text of, "Democrat Economic Illiteracy Has Consequences".)

The Fight Over Necessary Care

The 12/4/2011 Forbes describes how, "CMS Tightening the Screws on Unnecessary Procedures in Florida and 10 Other States".

There are more articles such as this one ("The Doctor's Dilemma -- What Is 'Appropriate' Care?") arguing that physicians should abandon "the primacy of patient welfare" in favor of "collectively caring for a defined population within a fixed annual budget."

Of course, what counts as "necessary", "appropriate", or "essential" will be driven by ferocious political lobbying. If you have political "pull", then your favored medical treatments will be considered "necessary"; if you don't, then you're out of luck.

But just don't call the politically-driven granting (or restricting) of "necessary" care, "rationing".

Quick Links: Waste, Special Interests, Spending

Jaan Sidorov: "Retrospective Vs. Prospective Identification of 'Wasteful' Medical Care".

It's easy to declare something as "waste" when it didn't work out in retrospect. But if the patient lives, they certainly don't regard their survival as "waste".

Brian Schwartz: "'Thanks Obamacare' for special-interest politics & higher insurance premiums".

John Goodman: "Do We Really Spend More and Get Less?"

Gottleib on Drug Shortages

Scott Gottleib recently testified in front of Congress on, "The causes of drug shortages and proposals for repairing these markets".

Although the problem is multifactorial, he groups them into three major:

The first are regulatory challenges that have made the manufacturing of these products safer and more reliable, but also in some cases more challenging and expensive.

The second are mechanisms that make prices sticky, limiting profitability and precluding new investment in additional supply and better and more efficient manufacturing.

The third and final category is market structures that prevent firms from branding their products, and reflecting by how they price them, legitimate improvements in manufacturing that allow drugs to be produced more reliably and in scalable facilities.

Hence, the best way to alleviate these shortages is not more government regulations but rather free market reforms.

For more details, read the full text of "The causes of drug shortages and proposals for repairing these markets".

Quick Links: Opting Out, Cookbook Medicine, MLRs

Kaiser Health News and OPB discuss the growing trend of doctors opting out of accepting health insurance. (Via @AAPSonline.)

Many doctors find this lets them to practice better medicine. The big question is how long they will be allowed to do this by the government or whether they will be compelled to take patients with insurance under ObamaCare. (This was proposed in Massachusetts to address the problem of long waits, but did not become law.)

Dr. David Gelber discusses how, "Rigid regulation can become detrimental to patient care".

We can expect to see much more of this "cookbook medicine" as payments to hospitals and physicians becomes increasingly linked to adhering to government-specified "quality" measures under ObamaCare. People will choose to adhere to these "quality" guidelines, even if it harms patient care.

The 12/2/2011 Kaiser Health News reports, "Final Medical Loss Ratio Rule Rebuffs Insurance Agents". The effect of these insurance regulations will be to make private health insurance less available to the public.

Here's a related story from Forbes, "The Bomb Buried In Obamacare". (Note: I don't endorse his glee at the impending end of private health insurers.)

Old Boss, New Boss

Now that Dr. Donald Berwick is out as head of Medicare, what do we know about the new director, Marilyn Tavenner?

David Catron has a nice rundown at his latest American Spectator piece, "Donald Berwick's Replacement".

She apparently has some "issues" of her own. Plus she has stated a clear sympathy with Berwick's policies and similar hostility to reducing the level of government in medicine.

Don't expect much to change under the new boss.

Wolf on Romney

Dr. Milton Wolf's latest piece in the Washington Times deals with GOP presidential candidate Mitt Romney. He debunks the myth of Romney's "electability".

Here's an excerpt from "Candidate in the Cross Hairs":

At the core of Mr. Obama's failed presidency are the two intertwined, evil strands of DNA, Obamacare and Obamanomics, and with them the era of failed bailouts, high unemployment, government takeovers, crony payoffs and a downgraded America. Luckily for Mr. Obama, his two chief vulnerabilities -- Obamacare and jobs -- are the very ones most easily neutralized should he face Mr. Romney.

Obamneycare: Mr. Romney's Massachusetts Romneycare is the forebear of Obamacare. Both are premised on the notion that the governing class may force its subjects into government-knows-best health-insurance servitude. Mr. Romney will continue in vain to deny the similarities between Obamacare and Romneycare, but there isn't enough hair gel in the world to straighten that hairdo. Every minute spent trying is a lost minute.

Jobs: Mr. Romney, founding partner of Bain Capital, acknowledges laying off workers but has claimed that his business ventures have, on net, created jobs. I believe him. I also appreciate the economic benefit of "creative destruction." But this matters little in campaigns. Perception becomes political reality. Mr. Obama’s counter for his own abysmal jobs record -- 2 million lost -- will be to showcase every person who was ever laid off by Mr. Romney. Recall the dagger in the heart of Mr. Romney's 2008 campaign, Mike Huckabee’s simple statement, "I want to be a president who reminds you of the guy you work with, not the guy who laid you off."

(Read the full text of "Candidate in the Cross Hairs".)

There are many Tea Party supporters and advocates of limited government who view Romney as just a watered down version of Obama. If the GOP nominates Romney, they'll turn off many of those potential supporters. Running on a platform of "I'm still bad, just not quite as bad as the other guy" is hardly a winning formula.

(Side note: Curious how Dr. Wolf's metaphor of "cross hairs" has failed to elicit the self-righteous rhetoric about violence and civility that we've seen when similar metaphors were used against Democrats. It's almost as if there were some kind of media double-standard or something...)

Frezza: Science in Thrall to the FDA

In the November-December 2011 issue of Bio-IT World magazine, Bill Frezza of the Competitive Enterprise Institute describes, "Science in Thrall to the FDA".

He describes how FDA regulations hamper medical innovation at a time we need it most. From his article:

A report recently released by the Milken Institute -- "The Global Biomedical Industry: Preserving US Leadership" -- documents how the wheels of progress have been slowly grinding to a halt as the FDA raises the bar for drug approval. The length of time required to complete clinical trials over the past decade is up 70%. The median number of procedures required per trial is up 50%, as is the total work burden per protocol. Meanwhile, volunteer enrollment and retention has been driven down by 21% and 30% respectively. And, of course, new drug approvals are down 50%. Keep this up and it won't be long before clinical trials follow U.S. manufacturing to China, with other elements of the pharmaceutical industry trailing closely behind.

Even as trials drag on with preliminary information kept blinded, new laboratory developments that could improve results are banned due to an insistence on maintaining rigid conformity to outdated protocols. In what other industry does this happen? The calls for "adaptive trials" that might be more suitable in an age of personalized medicine remain unheeded. And the shameful spectacle of denying Americans access to drugs that are approved and available in Europe and elsewhere defies justification.

Frezza also offers steps to move us in the direction of greater freedom:

But there are modest steps we can take in the meantime. How about carving out one or more FDA-free Enterprise Zones where doctors, scientists, and volunteer patients can make their own decisions unfettered by the heavy hand of regulators? Imagine an experimental terminal-illness wing of the Cleveland Clinic where informed consent was the only law. How hard would it be to draft enabling legislation?

Defenders of the FDA's prerogatives would fight such proposals tooth and nail. But what kind of nanny state arguments can be made against conducting such a policy experiment when anyone who objects doesn’t have to be treated? Breakthroughs that emerge would still have to pass through the FDA gantlet before they would be generally available. The difference is that researchers could continue making improvements while treating volunteers during this long process.

If we fail to arrest the regulatory assault on medical progress in the U.S., sooner or later out-of-the-box solutions like the one described above will pop up—elsewhere. And American patients will follow. The price of a plane ticket is trivial compared to the cost and consequences of cancer.

Sick patients will naturally seek the freedom to pursue their best medical interests. A proper government will respect that desire by reducing the regulatory obstacles, not reinforcing them.

(Read the full text of "Science in Thrall to the FDA".)

Why The AMA Supported ObamaCare

In his 11/28/2011 Forbes blog post, Avik Roy discusses, "Why the American Medical Association Had 72 Million Reasons to Shrink Doctors' Pay".

The "money quote" (figuratively and literally):

When the AMA gets twice as much from the government as it gets from its own members, we can hardly be surprised that the AMA today is more a tool of Washington's interests than those of doctors. This is why the AMA decided to support Obamacare...

(Read the full text of "Why the American Medical Association Had 72 Million Reasons to Shrink Doctors' Pay".)

This is one of many reasons I'm not a member of the AMA.

Hsieh PJM OpEd: Screening For Terrorists vs. Screening For Cancer

Today's PJMedia has published my latest OpEd, "Screening For Terrorists vs. Screening For Cancer".

My theme is that the seemingly contradictory policies of the government of terrorist screening vs. cancer screening actually demonstrate a common theme.

Here is the opening:

As the holiday travel season approaches, millions of American air passengers will become painfully reacquainted with Transportation Security Agency (TSA) screening measures. Passengers must submit to either medically unnecessary X-rays or intrusive gropings.

Yet in the realm of health care the federal government has adopted a new policy of discouraging routine screening tests for many cancers. Although these two policies may seem superficially contradictory, they demonstrate an underlying common theme of the government seeking ever-greater control over our bodies and our freedom.

In particular:

Our government currently tells air travelers, "Submit to our screening despite the dubious effectiveness, bodily invasion, and needless emotional distress" while simultaneously telling patients, "Don't undergo cancer screening because it might lead to further bodily invasion and emotional distress."

Despite this seeming contradiction, in both cases the government is really saying, "We'll decide who can do what with your body." The American founding fathers would never have imagined that the federal government would someday presume to restrict citizens' medical or travel freedoms in such a fashion.

(Read the full text of "Screening For Terrorists vs. Screening For Cancer".)

Wolf Bids Farewell To Berwick

Dr. Milton Wolf has a new OpEd in the 11/28/2011 Washington Times, "Bye-bye, Berwick".

As Dr. Wolf notes, ObamaCare has been so politically toxic for the Obama administration that their choice to head Medicare, Dr. Donald Berwick, had to step down after his recess appointment expired. Berwick is, of course, an unapologetic supporter of UK-style medical rationing. Wolf cites some representative quotes from Berwick in which he makes his position perfectly clear.

As Wolf notes:

Politically, White House operatives had little choice but to jettison the toxic Dr. Berwick, ironically for simply saying aloud what they themselves privately think.

(Read the full text of "Bye-bye, Berwick".)

President Obama has now chosen to nominate Berwick's second-in-command, Marilyn Tavenner, to take over Medicare. For more information on what to expect from her, see this piece in the 11/26/2011 American Thinker "Obama's Problematic New Nominee for Top Medicare/Medicaid Post". Meet the new boss, same as the old boss.

The names may change, but the battle for health care freedom continues...

Catron Dissects A Newt

In his latest American Spectator OpEd, David Catron takes a closer look at Newt Gingrich's health care policies. It's not a pretty sight.

In his piece "Newt's Health Problems", Catron notes:

Gingrich praised many of Donald Berwick's ideas, based on bad study on medical errors.

Gingrich supported government-financed end-of-life counseling.

Gingrinch has supported an individual insurance mandate.

(Read the full text of "Newt's Health Problems".)

Gingrich may be an articulate intelligent politician with some good idea on some issues. But don't mistake him for a principled defender of free-market health care reforms.

ACOs May Raise Costs and Lower Quality

In his 11/21/2011 Forbes blog post, Avik Roy wrote about recent comments by FTC commissioner J. Thomas Rosch on the ObamaCare "Accountable Care Organziations".

In particular, Rosch warned that net result of ACOs could be "higher costs and lower quality health care -- precisely the opposite of its goal" (emphasis Rosch's, not mine.)

His remarks can be found on page 15 of this transcript of his 11/17/2011 speech before the American Bar Association’s Antitrust Fall Forum.

ACOs represent the government creation of large consortiums of doctors and other medical providers, which may exert near-monopoly power in many markets. The various government financial carrots and sticks tilt the playing field away from smaller private practices which have otherwise thrived in the American medical marketplace for many years.

By driving small private practices out of business, the subsequent problems created by these de facto monopolies (or quasi-monopolies) should be attributed to the government, not a non-existent free market.

(Note: This should not be construed as an endorsement of the legitimacy of "antitrust" laws.)

HHS Restrictions on Neurosurgery: Just Don't Call It Rationing

An Illinois neurosurgeon discusses upcoming new guidelines from the Obama administration restricting how doctors can deliver medical care.

A few key points with respect to neurosurgery procedures:

Patients over age 70 with government insurance will receive "comfort care", but not the full range of aneurysm treatment, stroke therapy, etc.

Patients are referred to as "units", not patients.

Various devices currently approved by the FDA for "humanitarian use" and widely regarded by surgeons as medically safe and appropriate for clinical use will likely have that approval withdrawn to save money.

According to this surgeon, this information is straight from Obama administration HHS officials, although not yet published.

The physician summarizes the issue quite nicely:

You know, we always joke around -- 'it's not brain surgery' -- but I did nine years after medical school, I've been in training ten years, and now I have people who don't know a thing about what I'm doing telling me when I can and can't operate.

(Read the full blog post, "Neurosurgeon Briefed by HHS". Link via @SonoDoc99.)

Anyone who's read Atlas Shrugged will recognize the similarity between this surgeon's observations and this quote from the fictional Dr. Hendricks (also a neurosurgeon):

Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I could not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward...

Many Americans (including my own and Diana's parents) are over 70 years old yet in reasonably good health. They'd likely be denied life-saving neurosurgical care in the near future if these guidelines take effect.

But just don't call it rationing.

Note: There isn't any official confirmation from HHS on this, so we're still awaiting further information one way or another. It may also be that unfavorable publicity from the original story may lead HHS to reconsider these proposed guidelines.

Quick Links: Life Expectancy, ObamaCare

Avik Roy debunks, "The Myth of Americans' Poor Life Expectancy" (Forbes, 11/23/2011). A few key points:

If you measure outcome based on how well you do after you get sick, the US comes out on top.

Deaths from car accidents and homicides are unrelated to the quality of the US health system, and unfairly skew US statistics.

America doesn't have one health care system, but three.

Jeffery Anderson discusses, "What Else Is Wrong with Obamacare?" (PJMedia, 11/22/2011). It's not just the individual mandate.

Happy Thankgiving!

Happy Thanksgiving, everyone!

Regular posting will resume after the holiday.

Get Ready For the Feeding Frenzy

The Obama administration is now working on what services should be included in the government's mandatory insurance package (the so-called "Essential Health Benefits Package").

As part of this process, HHS (the federal Department of Health and Human Services) has been holding a series of "Listening Sessions" around the country to solicit public opinion on this issue.

I received an interesting report from someone who attended (via teleconference) the 11/18/2011 Denver "listening session". He was kind enough to give me his permission to post this excerpt from his summary and analysis:

Speakers included individuals and representatives of various organizations and companies. I would say that in the two-hour meeting, representatives of health care organizations and related service/medical device providers accounted for more than 95% of the total time. It became immediately clear that for many this was a well-orchestrated lobbying effort.

(Footnote: I am not one who condemns lobbying by individuals, companies or organizations so long as it isn't accompanied by graft or other corrupt activities. Lobbying in its pure sense should be protected free speech.)

The handful of individuals who spoke appealed primarily for expanded benefits for people afflicted with autism and phenylketonuria (a condition I had never heard of.) These speakers were parents of children (including adult children) for whom the burden, expense and heartache of dealing with the afflicted ones has become overwhelming.

Organizations whose representatives spoke today included groups that provide research, support, technologies and care in a wide range of areas. They all made well-scripted pitches for their causes to be deemed "essential" when the government mandates are imposed upon insurance plans. Nearly every one argued that the cost of their services, when utilized early, would produce much greater savings in the future.

Organizations and companies making their "pitches" are too numerous to list, but here's a glimpse of what was proposed:

* Expanded services for Autism and PKU
* Expanded care for mental and behavioral health
* Expanded pediatric vision care
* Expanded services to reduce pediatric injuries and obesity
* Expanded coverage for orthotics and prosthetics
* Expanded coverage for chronic disease management
* Expanded testing for STDs
* Expanded coverage for arthritis and psoriasis
* Coverage for foster care for Autistic developmentally disabled persons
* Expanded coverage for chronic pain
* An emphasis on "consumer satisfaction" with their health care coverage
* Coverage for "eating coaches"
* Expanded coverage for physical therapy
* Provisions for nutrition counselors
* Coverage for medical nutrition therapy, especially for the African-American population
* A heightened emphasis on utilization management
* An emphasis on flexibility
* Expanded coverage for maternity, newborn care and "reproductive rights" (abortion)
* An expanded emphasis on Latina healthcare needs
* Coverage for "medical foods"
* Expanded coverage for HIV testing
* Expanded coverage for hemophilia
* Expanded coverage for chiropractic care

Proponents of these services would benefit greatly if their services and products are deemed "essential" by the government. Hence, the virtual "feeding frenzy" that these listening sessions seem to be. (Why not? If your product or service can be declared "essential", you've hit the jackpot. And, would anyone care to take bets on how many corrupt members of Congress are secretly investing in some of these companies or organizations?)

Note as well the political "angle" for African-Americans and Latinas. Draw your own conclusions about that.

There may be perfectly viable cases to be made for some of these therapies being cost-effective preventive care. Others may simply be opportunists seeking to benefit from more "crony capitalism" with big money rolling in from insurance companies.

Politicians who are pushing for making insurance companies pay for more "essential benefits" will ever-so-predictably scream bloody murder when premiums rise to cover these services. These are the very politicians who will come to our "rescue" by advancing the notion that the government can provide all of them for "free", and gullible Americans will sadly believe them.

So, there you go. Remember this as the government takeover of American healthcare advances. It may not be the pure, noble and virtuous thing the politicians want you to believe it is.

Similar lobbying took place in Massachusetts after that state imposed its individual insurance mandate:

In the three years since Massachusetts enacted its individual mandate, providers successfully lobbied to require 16 specific types of coverage under the mandate: prescription drugs, preventive care, diabetes self-management, drug-abuse treatment, early intervention for autism, hospice care, hormone replacement therapy, non-in-vitro fertility services, orthotics, prosthetics, telemedicine, testicular cancer, lay midwives, nurses, nurse practitioners and pediatric specialists.

The Massachusetts Legislature is considering more than 70 additional requirements.

Unless ObamaCare is repealed, we should expect a similar special-interest feeding frenzy at the national level.

Fogoros Explains Drug Shortages

Dr. Rich Fogoros cuts through the Obama administration smoke and discusses, "What's Really Causing The Drug Shortages".

In short, it's price controls. Here's an excerpt:

In general, truly persistent shortages will only occur when the product-makers cannot increase the price they get for their finished product sufficiently to keep up with a rising cost of production. In this case profit margins shrink or even become negative, and the incentive to expand production, or even to stay in that business, disappears. This is a true shortage – the demand is still there, and customers are willing and able to pay the price being asked, but the product-makers are no longer able to supply the product at that price. Unless the mismatch between the cost of production and the price of the finished product is repaired, the product shortage becomes persistent or even permanent.

Such a persistent cost/price mismatch does not occur in a free market. It occurs when some Central Authority acts to control prices (often, to be sure, while simultaneously acting to increase the cost of production). A Central Authority can cap effective price a product-maker can get for his/her product by implementing overt or hidden price controls; by increasing marginal tax rates high enough to push the product-maker’s risk/reward calculation to favor inaction; and by instituting windfall profit taxes that do the same thing.

Furthermore, Dr. Fogoros explains how changes in the law in 2005 have had a predictable effect leading to ever-worsensing drug shortages that have now hit a crisis in 2011. For this reason, the Obama administration's proposed "solutions" will not alleviate the problem, because they do not address the root causes. The basic laws of supply-and-demand cannot be overruled by political fiat.

(Read the full text of "What's Really Causing The Drug Shortages".)

Kurisko on Canada and ObamaCare

Dr. Lee Kurisko discusses "Why Obamacare Will Be Worse than Canadian Healthcare":



Dr. Kurisko is a radiologist who used to practice in Canada before he relocated to the US.

One of his key themes is the "fatal conceit" of the central planners in both Canada and the US who think they can devise top-down health care "systems" more efficiently than the marketplace. Of course, the inevitable result is shortages.

Another is the difference between genuine insurance (to protect against expensive but rare unforseen problems) and the current US system of inefficient 3rd-party prepaid care masquerading as insurance.

Dr. Kurisko also discusses a variety free-market reforms as an alternative to ObamaCare.

Catron On Aaron and Rationing

In the 11/18/2011 American Spectator, David Catron discusses "A Rationing Advocate to Head Social Security Advisory Board?"

From his article:

Henry J. Aaron, the President's nominee for Chair of the Social Security Advisory Board... is an unapologetic admirer of Great Britain's notorious socialized medical system, the National Health Service (NHS). Why? Because NHS administrators unabashedly practice the dark art of health care rationing.

Aaron, a Senior Fellow in Economics at the Brookings Institution, is unable to imagine any route to cost control that doesn't involve government coercion. In a 2005 Brookings white paper titled "Health Care Rationing: What it Means," he represents the NHS as a system that has come to grips with what he sees as the inescapable necessity for rationing. Predictably, he rejects any alternative involving the market: "The key to efficient market outcomes is that prices reflect costs of production. The market for health care does not operate that way." In other words, Aaron believes health care is a unique universe in which the market mysteriously fails to function and therefore can't be relied upon to contain costs. It never seems to have occurred to him that the market's alleged failure might be the result of government meddling...

(Read the full text of "A Rationing Advocate to Head Social Security Advisory Board?")

At least now they're being explicit in their calls for medical rationing.

Curious how just a short while ago, opponents of ObamaCare who warned that it would lead to rationing were accused of hyperbole and paranoia.

(Note: I'm pro-choice on abortion. But the references to abortion politics in this piece are tangential to the author's primary point.)

Quick Links: Mandate Trap, Adverse Selection, Kopel

Dr. Rich Fogoros warns, "Republicans Blithely Enter The Individual Mandate Trap".

Hence, the GOP must stand for free-market reforms, not just oppose the individual mandates.

Greg Scandlen discusses adverse selection vs. moral hazard.

David Kopel asks, "Will the Necessary & Proper clause save Obamacare?" (He thinks not.)

Killing Small Medical Practices

Walter Russell Mead discusses how ObamaCare is killing small medical practices in his 11/15/2011 blog post, "Big Oil, Big Pharma, Big Obama?"

Mead notes:

The rise of enormous, super-empowered HMOs closely tied to government regulations suggests we are headed further in the direction of building a corporatist, medico-industrial complex whose powerful lobbies will fight reforms, abuse monopoly powers and further congeal the American health care system into an unmanageable and unaffordable form that will undermine living standards while providing ever-less-satisfactory care.

He also wonders whether this is a deliberate policy or a so-called "unintended consequence". (Read the full text of "Big Oil, Big Pharma, Big Obama?".)

I offered my own thoughts on this topic in my 7/11/2011 PJMedia piece, "The Coming Collectivization of American Health Care":

The Obama administration regards this collectivization of medical providers as a desirable outcome, not merely some "unintended consequence." As Obama health advisor Nancy-Ann DeParle wrote last year in the Annals of Internal Medicine, the new law will "accelerate physician employment by hospitals and aggregation into larger physician groups" and "physicians will need to embrace rather than resist change." Translation: "Doctors should get with the program -- or else!"

Furthermore, such collectivization is merely a continuation of a much older strategy. Jonah Goldberg's book Liberal Fascism described how the Roosevelt administration sought similar consolidations of American agriculture and business during the New Deal. As Goldberg noted:

[If] you want to use business to implement your social agenda, then you should want businesses themselves to be as big as possible. What's easier, strapping five thousand cats to a wagon or a couple of giant oxen?

Similarly, it will be much easier for the federal government to regulate 100 large ACOs than 10,000 small private practices.

(Read the full text of "The Coming Collectivization of American Health Care".)

Regardless of whether this is a deliberate policy or not, the end result will be the same: the stagnation of American medicine as doctors are increasingly compelled to practice according to the dictates of their bureaucratic masters, rather than according to their independent minds.

Quick Links: Kagan, Jobs, Rationing

Doug Mataconis has a nice roundup of information and links on the question, "Should Justice Kagan Recuse Herself From Health Care Reform Case?"

Mark Perry describes another effect of the medical devices tax: "Obamacare Destroys 1,000 Jobs at Stryker Corp". (Via Kelly V.)

Jeffery Anderson writes, "Obama Nominee for Social Security Board Favors Rationing Health Care". At least they're no longer hiding their true intentions. (Via Dr. Matthew Bowdish.)

Catron Discusses SCOTUS

David Catron has a nice follow-up piece on the issues the US Supreme Court will tackle when it hears the ObamaCare challenges.

More information at, "Supreme Court Agrees to Hear 'Frivolous' Obamacare Case".

His breakdown of how much time will be allotted to each critical subissue (the individual mandate, severability, "commandeering", etc.) was especially interesting.

SCOTUS To Hear ObamaCare Challenges

The big news is, of course, that the US Supreme Court will hear ObamaCare challenges this session. Here are a couple of representative pieces:

"Supreme Court to Hear Challenge to Obama Health Care Law", FoxNews, 11/14/2011.

"Obama Health Care Law Case Reaches Supreme Court", Huffington Post, 11/14/2011.

More analyses and prediction from SCOTUS watchers are sure to follow!

Palmisano on CER and Rationing

In this 11/11/2011 New Orleans Times-Picayune OpEd, Dr. Donald Palmisano explains why we should "Beware use of data to ration health care".

In particular, he describes how federally-funded "comparative effectiveness research" (or CER) will be used as a stepping stone to government medical rationing. One excerpt:

How exactly would this work? Take rheumatoid arthritis, for example. If tests done on rheumatoid arthritis drugs A and B revealed that Drug A was effective for 80 percent of patients, while Drug B was only effective for 20 percent, the government could refuse to cover Drug B for patients, leaving 20 percent of patients no choice but to purchase the drugs themselves or go without treatment.

At the last minute, language was inserted into the legislation to alleviate growing public concern that CER could be used for rationing. However, at a time when lawmakers are desperate to find cost savings in health care, I believe that the law eventually could be manipulated to meet the needs of these lawmakers.

This is not a far-fetched idea. In fact, CER data is already used for just this purpose in England, where the National Health Institute routinely denies patients treatments that CER has determined insufficiently cost effective.

In other words:

Although the authors of the report seemed to understand that CER is not meant to be used for rationing, they nevertheless recommend that services included in the essential health benefits package should be "cost effective, so that the gain for individual and population health is sufficient to justify the additional cost to taxpayers and consumers."

It is only a matter of time before cost-cutting bureaucrats turn to CER results as an excuse to cut health care costs.

(Read the full text of "Beware use of data to ration health care".)

The other half of the rationing piece is the widespread use of government-mandated electronic health records (EHRs). That way, physicians who stray too far from government CER guidelines can be punished for failure to deliver "appropriate" care. Even if few physicians are actually punished, the threat of punishment will be enough to keep most physicians in line with government controls.

Those Americans who still value their medical freedom still have time to act to protect it. But time is running short. Once these programs (CER and EHRs) are fully implemented over the next few years, it will be much harder to undo them.

Private vs. Public Health Care in the UK

A current UK resident posted this short report of private vs. government-run health care onto Facebook. He has given me his permission to repost it here. (I'll refer to him by his initials "OMM".)

Two days ago, while in London, I visited a private (non-NHS) drop-in medical clinic to check on a sore and aching eye. The medical doctor, a nice Indian woman, examined me for two minutes and then advised me to go to an eye clinic. The reason why was that only at the eye clinic could they rule out a serious, but unlikely, eye condition. Since her brief examination was ”so little,” in her own words, and since she weren't prescribing anything, she wouldn’t charge me for the consultation. Instead, she gave me a free map and explained how I could get to the eye clinic. She also advised me to bring some food.

The eye clinic was not private. The first thing that met me was a line and no-one behind the counter. After a little while, a man came, and after another little while, it was my turn. The man did not look at me, but mechanically typed my name, date of birth, and address, and then said – pointing to a crowded waiting room with wooden chairs – that there was a three hour waiting time today. I asked if I could go to a cafe in the meantime. No, he said, I had to remain in the waiting room until they called my name.

After two hours, someone said ”OMM” loud. I jumped up, and was taken to another room where a nurse asked me what was the problem. I answered. 20 minutes later, someone said ”OMM” again. I was taken to another room and a new nurse asked the exact same question. I answered again.

10 minutes later, I met with a medical doctor. He complained that he had insufficient equipment and that the light in his office (which he shared with two other doctors) did not work properly.

After some tests, he concluded that I probably just have conjunctivitis, and prescribed some eye drops.

When I got out of the clinic, I noticed that on the prescription it read ”Use every 2 days.” I thought the doctor had said ”2 times a day,” so I went back in and asked. And, yes, he had written it down wrong. He meant two times a day.

The closest counterparts we have in the US to the British National Health Service is the Veterans Administration medical system. Most medical students who have rotated through a VA hospital know how bureaucratized and inefficient they can be compared to a decent private hospital. The last thing we need is for all of American medicine to become like a bad VA Hospital (or the UK NHS).

Public vs. Private Initiatives In the US

One of the latest "new" ideas proposed by government health policy gurus to reduce costs is through "bundled payments". Doctors and hospitals would get a fixed amount to take care of a patient's health problems. In theory, this should increase efficiency and reduce unnecessary tests and procedures. But this is simply a variation of the HMO-style "capitation" system that many Americans rejected during the 1980s.

The 11/7/2011 Wall Street Journal health blog reports on results from this latest attempt, "Study Raises Questions About 'Bundling' To Pay Doctors".

They note:

...[A] new study published in Health Affairs raises questions about the feasibility of bundling. The researchers, from the Rand Corporation and the Harvard School of Public Health, looked at three sites that were trying to implement a bundling methodology developed by the nonprofit Health Care Incentives Improvement Institute. (The method is called Prometheus.)

The short version of their findings: the efforts moved along slowly. In two to three years of trying, none of the providers or insurers actually made or received a bundled payment, or even implemented a contract to start them. That "lagged months or years behind their planned milestones," notes the study, which reflected results up to May of this year.

Of course, setting hard payment caps in the form of "bundling" will reduce costs, but by creating incentives to ration and/or deny care.

Meanwhile in the private sector, NPR reports, "Wal-Mart Plans Ambitious Expansion Into Medical Care".

These "retail health clinics" have proven successful in providing patients will affordable access to decent primary care services. As is typical, the profit-driven private sector is meeting the needs of patients in away that the government central planners do not and cannot.

Catron SCOTUS Update

In his latest American Spectator piece, David Catron gives a nice rundown of upcoming US Supreme Court action with respect to ObamaCare.

For details, see "Supremes About to Decide Which Obamacare Cases Make the Cut".

Quick Links: Montana, Ralston, Benjamin Rush

The Heartland Institute asks, "Canadian-Style Health Care Coming to Montana?"

In the 11/4/2011 Orange County Register, Richard Ralston of AFCM asks, "Richard Ralston: Who do you trust: doctors or the feds?"

In the 11/3/2011 Forbes, Avik Roy asks, "Can the Benjamin Rush Society Bring Free-Market Ideas to Medical Schools?" (Via Scott K.)

Price Controls in New York State

Doug Ross describes, "Obamacare-style price controls succeed in New York: 'tens of thousands' to lose their health care coverage"

If a business (such as insurance) cannot operate in a particular location due to onerous government regulations, it's entirely rational for them to withdraw.

The key is to make sure we place the blame where it belongs -- on the government -- and not on the free market.

Hsieh PJM OpEd: In Praise of Capitalist Inequality

The 11/6/2011 PJ Media has published my latest OpEd, "In Praise of Capitalist Inequality".

My theme is that the economic inequality that the "Occupy Wall Street" protestors oppose is not something to be condemned, but to be celebrated. Here is the opening:

For several weeks now, the Occupy Wall Street protestors in New York City and around the country have been demanding "economic justice," which includes a mishmash of leftist goals including universal health care, forgiveness of student loan debt, and higher taxes on the wealthy. To the extent the OWS protestors have a unifying theme, it's that capitalism is bad and that redistributing wealth to reduce "inequality" is good.

The Irish socialist playwright George Bernard Shaw once wrote, "A government that robs Peter to pay Paul can always depend on the support of Paul." The Occupy Wall Street protestors demanding government redistribution of wealth from the richest Americans ("the 1%") to themselves ("the 99%") would certainly agree. But as some of them are starting to learn, if their ideas were actually put into practice they'd end up being the Peters, not the Pauls.

Already, some of the OWS protestors are finding their ideas coming back to bite them...

And as to the dirty little secret that motivates many who want to "redistribute" (i.e., steal) others' wealth, read the full text of "In Praise of Capitalist Inequality".

Quick Links: ObamaCare Surprise, PSA Screening

In the 10/27/2011 Washington Examiner, Diana Furchtgott-Roth discusses "Another unpleasant surprise from Obamacare".

Basically, new ObamaCare rules will create enormous incentives for employers to offer unaffordable health insurance plans to their workers, so the workers' families can qualify for government-subsidized plans on the new exchanges. The ObamaCare rules will also discourage marriage.

In the 10/28/2011 Medical Progress Today, Paul Howard discusses "The PSA debate: to screen, or not to screen?"

He raises the following good point:

It is true that the PSA test has a high number of "false positives" that can drive men who don't have cancer, or don't have life-threatening cancers, to get biopsies or treatments that may have serious side effects but not actually save lives. But this is like saying that the first generation of cell phones was ridiculously expensive, clunky, and didn't work very well -- and so we shouldn't invest in better cellphones since the early ones were so crappy.

Since we don't adhere to that philosophy in technology markets, relatively cheap, fast, and powerful smartphones now rule the world.

Medical technology is benefitting from the same underlying forces that drove the telecommunications and computing industries into producing incredibly rapid, consumer-friendly innovations.

For instance, take a new biomarker test from the San Diego company Gen-Probe, which is under review by the FDA. Unlike PSA, which is produced by inflamed prostate tissue (which may or may not be cancerous), Gen-Probe screens urine for a prostate cancer antigen (PCA3) which is "overproduced in more than 90 percent of patients with prostate cancers."

Depending on how the FDA approves the test, it could be used as a second line screen for patients with unusual PSA readings, allowing doctors and patients to make better decisions about when to seek a biopsy or leave well enough alone.

That's what we really want, right? More confidence that we're seeking treatment when we need it, and it might save lives, and less treatment when we don't. And the PCA3 test isn't the only promising technology in the pipeline.

As always, by stifling current technology through regulatory mandates, we may never know the downstream benefits of future improvements -- the classic issue of "the seen vs. the unseen".

Finally, blogger Glenn Reynolds notes:

EARLY CANCER DETECTION: Suddenly, it's not good for you after all...

Many people are concerned that the new "science" that has led to a sudden about-face on testing, coincident with the passage of ObamaCare, is driven by costs rather than patient welfare. This may be unfair, but one of the hazards of politicizing the health care system is that suspicions of, well, politicization of the health care system become unavoidable.

Amerling on the Danger of Practice Guidlines

Dr. Richard Amerling gives a detailed analysis of the problems with so-called "practice guidelines".



The many problems he identifies include:

1) They wrongly promote "cookbook" care that glosses over individual variations in patients.
2) They are too often based on faulty or biased data.
3) They are too often obsolete by the time they are codified.
4) If current political trends continue, physicians can be held accountable for failing to adhere to these guidelines, even if that is the correct care for their particular patient.

In short, they remove the practicing physicians mind from clinical care -- the most essential aspect of high-quality medicine. Instead, they create the "illusion of knowledge" while stifling genuine innovation. Interestingly enough, he shows how faulty guidelines can result of both inappropriate undertreatment and inappropriate overtreatment of patients.

Dr. Amerling illustrates these points with real-world examples from his specialty of nephrology. His summary of how such practice guidelines are playing out in Europe is especially disturbing (timestamp 26:15).

Watch the full video at: "Practice Guidelines: More Harm Than Good?"

More information on Dr. Amerling:

Richard Amerling, M.D. is a nephrologist practicing in New York City. He is an Associate Professor of clinical medicine at Albert Einstein College of Medicine in New York, and the Director of Outpatient Dialysis at the Beth Israel Medical Center. Dr. Amerling studied medicine at the Catholic University of Louvain in Belgium, graduating cum laude in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on health care issues and is a Director of the Association of American Physicians and Surgeons. Dr. Amerling is the author of the Physicians' Declaration of Independence.

Wolf on Repealing ObamaCare

Milton Wolf has another strong OpEd in the 11/3/2011 Washington Times, "Save America: Repeal Obamacare".

He lays out numerous current and future problems of ObamaCare and offers a number of practical steps that move us closer to genuine free-market solutions. Here are a few excerpts:

There's more Congress can do immediately. Members of the supercommittee -- the extraconstitutional select bipartisan deficit-reduction panel -- can save about $2 billion in the current budget year by withdrawing early Obamacare implementation grants. Taxpayers should not be forced to pay for a law that, as currently adjudicated, is unconstitutional...

States should rescue their patients from Medicaid. This welfare program, as administered by Washington, has become an undeniable second-class health care system, and Obamacare expands it enormously... Survival rates for Medicaid patients are worse than those of private insurance patients. No surprise. Sadly -- and take a moment to ponder this -- survival rates for many ailments, including some of the most common cancers, are worse for Medicaid patients than for uninsured patients. Only Washington could create an insurance plan whose use is a worse fate than being uninsured. It’s called Medicaid...

States also have it within their power finally to kill the artificial and destructive health care insurance state boundary rules. With two identical families living across the street from each other, one could see insurance premiums tripled compared to the other's premiums because of these rules. Stop protecting the insurance companies. Health care compacts between two states would force companies to face competition from across the state line... States should eliminate well-meaning but harmful regulations that prevent carriers from providing affordable mandate-lite policies. And federal and state tax penalties that discriminate against individual policies should end.

(Read the full text of "Save America: Repeal Obamacare".)

Dr. Wolf offers both a good diagnosis and a good prescription for our health care problems. But it will be up to ordinary Americans to act.

WSJ: The Bush-Obama Drug Shortages

The 11/3/2011 Wall Street Journal explains how government interventions have created "The Bush-Obama Rx Shortages".

Here is the opening:

This week President Obama finally confronted a major U.S. health-care disgrace—the growing shortages of lifesaving drugs, especially anticancer therapies. For some reason the White House lumped its executive order with its "we can't wait" campaign against House Republicans, but the pity is that we will have to wait, because the only genuine fix is a liberal anathema: market prices...

The problem is compounded because Food and Drug Administration rules cause pointless delays. It takes as long as two and a half years to receive FDA manufacturing approval for a generic, so other drug makers can't ramp up production if a company cancels a product line due to these disincentives or even if the fragile supply chain for sterile injectables is contaminated and manufacture is delayed.

(Read the full text of "The Bush-Obama Rx Shortages".)

Adding yet more regulations and price controls to the current system won't solve the problem of shortages.

(Via Dr. Evan Madianos.)

Fougner on Defensive Medicine

Dr. Art Fougner has a nice discussion of defensive medicine and how it harms medical care in this country.

Here's an excerpt from his piece in the 10/28/2011 "Weekly Update" for the Medical Society for the State of New York:

I'm Dr. Art Fougner and I'm a recovering obstetrician.

Defensive medicine consists of office visits, lab tests, imaging studies, and procedures that have less to do with patient care and more to do with chart care. Defensive medicine measures are primarily used not to ensure patient health, but to safeguard against a potential medical malpractice suit.

Defensive medicine is pervasive. In the September 2011 issue of the Archives of Internal Medicine, Sirovich, et al noted that 83% of primary care physicians admit to defensive practices and concluded, "the extent to which fear of malpractice leads to more aggressive practice (so-called defensive medicine) has been hotly debated; based on our findings, we believe it is not a small effect.”

In the ACOG 2009 survey, more than two-thirds of the OB/Gyns made changes to their practice because of liability concerns— 11% of OBs stopped delivering babies; 1.5% retired. In 2009, seven New York Counties did not have a board-certified obstetrician.

In a 2005 survey, Studdert found that 93% of physicians practice defensive medicine.

I submit that number is a low-ball estimate...

(Read the full text for additional discussion by Dr. Fougner of the costs of defensive medicine.)

As a radiologist, I see this every day. ER physicians, primary care doctors, and specialists order many imaging tests that they don't want to (and don't feel are medically necessary) because of the fear of malpractice lawsuits if they don't order a test and the patient turns out to have a rare-but-dangerous condition.

Given the current medico-legal climate, that's an entirely rational response by these doctors. Why should they risk their careers in order to save the hospital (or the 3rd party payors) a few dollars if they'll risk legal penalties for doing so?

Genuine free-market health care reform (as opposed to ObamaCare) will have to include rational tort reform as part of the solution.

Wolf Challenges OWS

In his latest Washington Times OpEd, Dr. Milton Wolf issues a bold challenge to former Obama aide Van Jones and the Occupy Wall Street movement.

From "My challenge to Occupy Wall Street":

...[T]here actually may be honest common ground between the seemingly diametrically opposed Tea Party and Occupy forces: Government bailouts are wrong. Tea Partyers recognize the destructive nature of the bailouts and conclude that they must end; in fact, all corporate handouts should end. Occupiers also recognize the destructive nature of the bailouts, but - curiously - agitate not for the end of bailouts but instead, that they get their own piece of the action.

If there’s any honesty in the Occupy Wall Street movement, even a shred, I call upon its protesters to join me, to join Tea Partyers, and demand the end of all forms of corporate welfare. No more bailouts. No more subsidies. No more targeted tax breaks, loan guarantees or loopholes. No more stimulus spending, protective tariffs or favoritism. No more waivers. No more more allowing the government to pick and choose winners and losers. No more plundering the 99 percent to enrich the well-connected 1 percent.

If we want politicians to quit peddling favors, we have to take away their inventory.

(Read the full text of "My challenge to Occupy Wall Street".)

As he notes, the issue is tyranny vs freedom. Or autocracy vs. the free market.

Dr. Wolf was also gracious enough to quote something Diana once said on Twitter, "Crony capitalism is capitalism just like sea horses are horses."

I don't know if the OWS crowd will take him up. But I hope they do!