Dr. William Dale on End-of-Life Medical Choices

[This was an excellent interview!  Highly recommended. Information below from Diana Hsieh. --PSH]

On Wednesday's episode of Philosophy in Action Radio, I interviewed Dr. William Dale about "End-Of-Life Medical Choices." An audio recording of the episode is now available as a podcast on the show's archive page:

Philosophy in Action Radio: 28 November 2012

This was one of my favorite episodes ever, because I learned so much more than I expected.  It would be a great interview to listen to and then discuss with your spouse, siblings, parents, and adult children.

Many people struggle with difficult decisions about complex medical problems as they near the end of their lives. That time is wrenching for family too. How can people make good decisions about medical care? What mistakes should they try to avoid? How can people prepare for that future now?

Dr. William Dale is a geriatrician at The University of Chicago Medicine with a doctorate in health policy and extensive experience in oncology. He has devoted his career to the care of older adults with cancer – particularly prostate cancer. Dr. Dale has a special interest in the identification and treatment of vulnerable older patients who have complex medical conditions, including cancer. He is actively researching the interactions of cancer therapies with changes associated with aging.

The topics covered include:

• Dr. Dale's work
• End-of-life challenges for the patient
• End-of-life challenges for others
• The choice of more versus less treatment
• Doctors telling patients the whole truth
• What patients can do to get more and better information
• Patients' regrets about treatment
• The importance of knowing one's own preferences
• Dealing with family problems
• Living will versus power of attorney
• Talking to the person with your power of attorney
• The emotions of dealing with death
• Being a supportive and reasonable family member
• Conflicts between in-town-and out-of-town family
• Conflicts in the family over care
• The "five stages of grief"
• Differences between ethnic groups about end-of-life care

Philosophy in Action Radio broadcasts on Sunday mornings and Wednesday evenings. For information on upcoming shows, visit the Episodes on Tap.

— Diana Hsieh (Ph.D, Philosophy)

Quick Links: Energy Drinks, GOP Reform

Michelle Minton: "Senator Durbin is wrong on energy drinks ban" (The Hill, 11/28/2012)

Milton Wolf: "GOP must fight corporate welfare" (Washington Times, 11/28/2012)

Atlas: When ObamaCare Fails

At the 11/25/2012 Forbes, Dr. Scott Atlas discusses "The Democrats' Fallback Plan For When Obamacare Inevitably Fails".

In particular, he predicts:

1) A push for "single-payer" system, using the "public option" as the wedge.
2) Government mandates that physicians accept patients with government insurance.

Forewarned is forearmed.

Tonight: Dr. William Dale on End-Of-Life Medical Choices

[Special event -- tonight!  Cross posted from Diana's "Philosophy In Action" page. -- PSH]

In the next episode of Philosophy in Action Radio, philosopher Dr. Diana Hsieh will interview University of Chicago geriatrician Dr. William Dale on end-of-life medical choices. The live broadcast and chat starts promptly at 6 pm PT / 7 pm MT / 8 pm CT / 9 pm ET on Wednesday, 28 November 2012. If you miss the live broadcast, be sure to listen to the podcast.

Upcoming Talk Radio: Wednesday, 28 November 2012

Dr. William Dale on End-Of-Life Medical Choices

Join the live broadcast of Philosophy in Action Talk Radio on the evening of Wednesday, 28 November 2012, when philosopher Dr. Diana Hsieh interviews Dr. William Dale on end-of-life medical choices. The show airs at 6 pm PT / 7 pm MT / 8 pm CT / 9 pm ET in Philosophy in Action's Live Studio.

Many people struggle with difficult decisions about complex medical problems as they near the end of their lives. That time is wrenching for family too. How can people make good decisions about medical care? What mistakes should they try to avoid? How can people prepare for that future now?

Dr. William Dale is geriatrician at The University of Chicago Medicine with a doctorate in health policy and extensive experience in oncology. He has devoted his career to the care of older adults with cancer – particularly prostate cancer. Dr. Dale has a special interest in the identification and treatment of vulnerable older patients who have complex medical conditions, including cancer. He is actively researching the interactions of cancer therapies with changes associated with aging.

Listen Live or Listen Later

To join the live broadcast and its chat, just point your browser to Philosophy in Action's Live Studio a few minutes before the show is scheduled to start. By listening live, you can call the show with your questions and experiences, as well as post comments and questions in the text chat.

• Who: Dr. Diana Hsieh, with special guest Dr. William Dale
• What: Philosophy in Action Talk Radio: Dr. William Dale on End-Of-Life Medical Choices
• When: Wednesday, 28 November 2012, 6 pm PT / 7 pm MT / 8 pm CT / 9 pm ET
• Where: Philosophy in Action's Live Studio

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NYT on Doctors Who Take Only Cash

The 11/23/2012 New York Times had a surprisingly positive article on "Dealing With Doctors Who Take Only Cash".

The writer looked at a range of so-called "concierge practices".  One such primary care practice charged $38 per month, and does not accept insurance. Another charged $1800 per year, but offered a wider range of services.

The article notes:

All the doctors I spoke with said that they had switched to a fee-for-service model for three reasons: to preserve their incomes, to avoid the administrative hassles of insurance and to provide better care.

However, another doctor opposed to such a system stated that:

[F]rustrated primary care physicians have other options, like becoming a doctor in a hospital or selling their practice to a larger group that will handle the administrative issues. 

That may be true.  But doctor who sell their practices to larger entities (such as hospitals or Accountable Car Organizations) lose significant autonomy in how they can practice.  Instead, they often must follow the practice guidelines specified by the larger entity -- which may or may not be appropriate for the individual needs of specific patients.

I don't know how many doctors will eventually opt out of the current system and "go concierge".  Nor do I know how long this option will remain legal.  But for now, I'm glad that more doctors and more patients are considering this option and asking if it's right for them.

(Read the full text of "Dealing With Doctors Who Take Only Cash".)

Quick Links: Concierge ER, Lawbreaking, Servitude

Bloomberg News: "ER Concierge Services at Hospitals Boost Bottom Lines" (via Dr. Matt Bowdish).

Dr. Peter Weiss: "A Physician's New Reality: Patients Ask Me to Break the Law" (PJ Media)

Dr. Jane Orient: "The right not to work for Obamacare"(Washington Times)

Quick Links: Delays, Closures, Consolidation

New York Times: Proposed new ObamaCare rules "had been delayed as the administration tried to avoid stirring criticism from lobbyists and interest groups in the final weeks of the presidential campaign" (11/20/2012).

Human Events: "Obamacare shutters D.C. family practice" (11/1/2012).

Washington Examiner: "Obamacare helps big hospitals, kills small practices, drives up costs" (11/20/2012).

Happy Thanksgiving! (Plus Safety PSA!)

Happy Thanksgiving, everyone!

In honor of the holiday, here is the classic William Shatner deep fried turkey safety PSA.

Just remember: "Fire, metal, oil, and turkey are glorious when in harmony".

(Regular posting will resume tomorrow.)

Catron on the OK Doctors Video

David Catron is long-time vocal supporter of free-market health care reforms.

He also offered friendly criticisms of what he regards as factual errors in a recently-circulated video by ReasonTV, "Oklahoma Doctors vs. Obamacare".

Read Catron's post, "About That Doctors Vs. Oklahoma Video", for more details.

Catron is also careful to note:

I am not, by the way, advocating more government control over free-standing centers. I am, instead, arguing for less government control over community hospitals.

I greatly respect Dr. Smith and his colleagues for promoting price transparency and for offering high-quality medical services at lower prices.

But I also wanted to highlight some constructive criticisms of the ReasonTV video.  Such open discussion and debate should strengthen our ability to pursue our ultimate goal of free-market health reforms.

Quick Links: Battles, Audits

The Hill: "Five 'ObamaCare' battles to watch"

Medical Economics: "Physicians better get ready for a lot more auditing and a lot more scrutiny of their claims submission"

Goodman on the Emerging Market For Medical Care

John Goodman describes, "The Emerging Market for Medical Care".

In particular, he highlights:

Two relatively new services are facilitating a market for medical services — with price and quality competition, as well as transparency. We have previously reported on MediBid, which takes a Priceline approach to medical care.

Another service, Healthcare Blue Book (HCBB), offers a free service for patients — showing the average price for various procedures in almost every zip code in the country. Moreover, both businesses have created new tools that are valuable for employer plans — especially those with high-deductible health insurance.

As more Americans investigate HSAs (Health Savings Accounts), these services will give them valuable information to help them find the best value for their medical dollar.

The new government controls of ObamaCare are getting most of the press attention.  But I also find it encouraging that these relatively free-market health care developments are also growing.

I hope this is the just the beginning of a larger movement.

Catron: States Fighting Back

In the 11/19/2012 American Spectator, David Catron discusses how, "The States Fight In the Last Ditch Against Obamacare".

One excerpt:

...[T]he grim reality is that Washington won't be content to merely control the exchanges. Federal bureaucrats have already begun rewriting the law when the provisions of the actual statute prove inconvenient. When it became obvious that many states would refuse to create exchanges, the Obama administration decided to funnel tax credits and subsidies through federally-created exchanges, ignoring clear language in the law indicating that such premium-assistance was restricted to state-run exchanges. The IRS recently finalized a regulation signaling its intention to illegally provide premium assistance through federal exchanges.

This outrage prompted the state of Oklahoma to file an amended complaint in the U.S. District Court for the Eastern District of Oklahoma...

I don't know how successful these legal challenges will be.  But I'm glad there are still some politicians resisting the federal takeover of health care.

By the way, there are two more recent related pieces discussing state-level opposition to ObamaCare.

In USA Today, Texas governor Rick Perry has an OpEd, "Another Federal Power Grab".

In the Wall Street Journal, Capretta and Levin explain "Why ObamaCare Is Still No Sure Thing".

Adalja On The Responsibility Of the Individual

In the 11/18/2012 Forbes, Dr. Amesh Adalja explains: "Want To Fix Healthcare? Acknowledge That It's the Responsibility Of the Individual".

A key excerpt:

It is indisputable that, for the majority of individuals, obtaining health insurance of some sort -- catastrophic or ordinary -- is an advisable financial decision. Health care plays a crucial role in one’s life and can literally be life-saving in certain situations; health insurance can protect financial solvency in such situations. It is also clear that having healthy employees who maintain their health is in the interest of every corporation, as employee well-being is an important component of profitability.

While these facts suggest that it may be a prudent decision for an individual to purchase health insurance or firms to offer health insurance as an employment perk, there is no justification for the government to nullify individual rights by forcing individuals to provide for the healthcare of others -- irrespective of the effect on the national economy.

A government’s sole function is the protection of individual rights; all other functions the modern U.S. government has assumed are usurpations which have required the violation of the very rights the government was established to protect. This strictly delimited function of government requires the establishment of a police force, a military, and a judiciary system. As such, the government’s position on the economy of the nation should not be to steer it or bolster it, but to stay out of it...

Dr. Adalja also makes the point that government policies have artificially increased the costs of health care and health insurance, thus contributing to the very "problem of the uninsured" that ObamaCare is supposed to address.

The current approach wrongly elevates collectivist goals ("the national economy") over the individual.

The only antidote is to return the focus where it belongs -- to the individual. This means respecting the individual's right (and responsibility) to make his own health insurance and health care decisions according to his own best judgment for his own benefit free from government compulsion.

(Read the full text of "Want To Fix Healthcare? Acknowledge That It's the Responsibility Of the Individual".)

Russak Promotes Concierge Medicine

Dr. Floyd Russak, the head of my local county medical society (the Arapahoe-Douglas-Elbert Medical Society) has written a nice article in our bimonthly newsletter defending concierge medicine.

Here's a link to his piece, "Concierge Medicine: A Revolution In Primary Care" (PDF).

Dr Russak is a primary care doctor himself and recent switched to a concierge model for his own practice, both so that he could provide better care to his patients as well as to help sustain his economic viability.  

He also addresses 3 common questions:

1) Is it too expensive?
2) Will this exacerbate the shortage of PCPs (primary care physicians)?
3) Is it ethical?

Here is his answer to question #3, "Is is ethical?":

It is morally wrong to practice inferior care. As noted above, it is just not practical to provide good care to patients in the current reimbursement model without maintaining a full-time practice of nearly 2000 patients, which requires 10-15 minute appointments to see everyone. Good care requires time, and with the overhead of a primary care practice running $200K/year per physician, time and reimbursement are at odds with each other.

Because of this, one year ago, I took the leap of faith and decided to convert my personal practice to concierge. The PA’s and other less-busy physicians in our larger group practice were happy to take over the patients who preferred not to pay the retainer fee.

I now practice a much more rewarding style of Internal Medicine, where I have time for the vastly improved care that comes with longer appointments and following my own patients wherever needed, including the hospital, office, home or rehab. Being on call all the time is not easy, but with only 300 patients, there are very few calls and most are appropriate and timely. I truly believe this is a better way to practice primary care medicine. 

(Read the full text of "Concierge Medicine: A Revolution In Primary Care".)

Benjamin Rush Society Medical Ethics Debate at GWU

The Benjamin Rush Society will be sponsoring an excellent-sounding medical ethics debate at George Washington University on November 28, 2012.

The title is, "The Requirements of Social Justice are in Conflict with the Requirements of an Ethical Doctor-Patient Relationship".

One of the participants is Dr. Rich Fogoros, who has written extensively about the ethical implications of collectivized medicine.

More details below, courtesy of Dr. Beth Haynes (director of the Benjamin Rush Society):

November 28 Debate at GWU

The Benjamin Rush Society Presents
The Arthur N. Rupe Debate Series

Be It Resolved That:

"The Requirements of Social Justice are in Conflict with the
Requirements of an Ethical Doctor-Patient Relationship"

George Washington University School of Medicine

Wednesday, November 28, 2012, 7:30 p.m.
Pre-Debate Reception at 7:00 p.m

In Favor Dr. Richard Fogoros, MD (Philadelphia, PA)Cardiologist Author of The Covert Rationing Blog Dr. Lee Hieb, MD (Logan, IA)Orthopedic Surgeon Past President, American Association of Physicians and Surgeons

Opposed Dr. Nilesh Kalyanaraman, MD (Baltimore, MD)Internal Medicine Chief Medical Officer, Health Care for the Homeless Dr. Chris Lillis, MD (Fredericksburg, VA)Internal Medicine Board of Directors, Doctors for America

MODERATOR: Mark Tapscott
Executive Editor, Washington Examiner

George Washington University School of Medicine
Marvin Center Continental Ballroom
800 21st Street, NW, Washington DC 20052

Parking is available at the Marvin Center Garage.
Entrances on 21st Street and H Street.
Google Map: http://goo.gl/maps/tlhhj

---

Event is Free but seating is limited.
Please reserve your seat at http://tinyurl.com/BRSdebateGWU

For more information or to volunteer,
contact Bruce Shaver, BRS chapter leader, at BenjaminRushSociety@gmail.com .

Last Updated (Wednesday, 14 November 2012 20:52)

Copyright © 2010 Benjamin Rush Society.

Quick Links: HSAs, Exiting Medicare

Blogger "Mockerena": "I Need To Vent About Healthcare For A Minute, You Guys".

She underwent a very interesting psychological shift after she started using an HSA and became responsible for her own health spending.

Dr. Natasha Deonarain discusses, "Why I decided to opt out of Medicare as a provider".

Many more doctors will likely follow suit, for the reasons she describes.

IT Costs Driving Doctors Out of Private Practice

eWeek reports: "Health IT Mandates, Costs Force Doctors to Leave Small Practices".

From earlier reports, we know that the government-mandated push for electronic medical records won't necessarily control costs.  But it will control doctors.

Everything is proceeding as I have forseen.

Cancer Crisis for Canadian Women

The 11/13/2012 Montreal Gazette reports on lengthening wait times for female patients: "It's a crisis for Quebec women".

Some chilling excerpts:

A leading Montreal gynecologist said that these days, she cannot look her patients in the eye because the wait times are so shocking...

The worst cases are gynecological cancers, experts say, because usually such a cancer has already spread by the time it is detected. Instead of four weeks from diagnosis to surgery, patients are waiting as long as three months to have cancerous growths removed.

“It’s a crisis for Quebec women,” said Lucy Gilbert, director of gynecological oncology and the gynecologic cancer multi-disciplinary team at the McGill University Health Centre.

(Read the full text of "It's a crisis for Quebec women" for more details.)

Sure, the medical care may be "free".  But what this means is that patients pay in time, rather than money -- time they may not have when the cancer clock is ticking away.

(Link via Docs4PatientCare.)

Quick Links: Rollbacks, Shortages, Guidelines

Sally Pipes: "In The Aftermath Of Obama's Re-Election, What's Next For Health Care?"

She discusses some partial rollbacks to ObamaCare we might still be able to achieve, such as repealing the medical device tax.

ABC News: "Doctor Shortage Could Cause Health Care Crash"

As Dr. Randy Wexler noted, "Coverage does not equal access."

Fox News: "Hospital guidelines not linked to readmissions".

Top-down practice guidelines don't appear to actually improve patient health or reduce their requirement for future hospitalization.  Of course, these centralized practice guidelines are supposed to be one of the cornerstones of projected ObamaCare cost savings.

(Links via Dr. Beth Haynes and Dr. Richard Amerling.)

Hsieh Forbes OpEd: Protect Yourself Against Obamacare

The 11/13/2012 Forbes has published my latest OpEd: "5 Ways To Protect Yourself Against Obamacare".

I discuss 5 practical strategies ordinary Americans should consider now, even as the fight for health care freedom continues. They include:

1) Get a good primary care doctor, if you haven't already done so.
2) Use a Health Savings Account (HSA).
3) Consider a concierge or "direct pay" physician.
4) Consider medical tourism, when appropriate.
5) Help your doctor work on your behalf.

For more details, see the full text of "5 Ways To Protect Yourself Against Obamacare".

I've also discussed some of these ideas in my 7/25/2012 interview on Diana's "Philosophy In Action" podcast, "Surviving Socialized Medicine". 

See also my article in the Summer 2010 issue of The Objective Standard, "How to Protect Yourself Against ObamaCare". (Link goes to free preview, full text is subscriber gated).

Update #1: Dr. Richard Amerling of AAPS offers similar suggestions at: "Defensive Medicine: How To Survive ObamaCare".

Update #2: Thanks, Instapundit, for the link!

Wolf On ObamaCare Taxes

Dr. Milton Wolf has a new piece in the 11/12/2012 Washington Times, "Obamacare taxes mean Obamacare layoffs".

He discusses the "Top Five Worst Obamacare Taxes Coming in 2013" as highlighted by Americans for Tax Reform.

Furthermore, the new law discourages employers from hiring full-time employees. The estimated job losses could reach 800,000 jobs. As Dr. Wolf notes:

Small businesses are especially vulnerable, particularly without the resources for throngs of lobbyists and lawyers. A recurring theme is unfolding: "Elections have consequences," said one Las Vegas business owner as he explained that the survival of his company demands that he lay off 22 of his 114 employees.

The Twitter aggregator website Twitchy.com has compiled distraught business owners facing the new normal. One user tweeted: "I own a small business... as of today. I will be laying off 10 of my 60 employees... Thanks Obamacare."

These tragic stories are accumulating, and the human toll is devastating...

Although we may not be able to change the law in the near term, we can remember who is responsible for the consequences.  And when the time is right, we can hold them accountable.

(Read the full text of "Obamacare taxes mean Obamacare layoffs".)

Catron On 5 Stages of Grief

In the 11/12/2012 American Spectator, David Catron described "The Five Stages of a Conservative's Grief".

Although I don't describe myself as a conservative, I can certainly sympathize with his reaction. And I'm glad to see he's gearing up to resume the good fight.

Instapundit Citation on Voter Turnout and Messaging

Glenn Reynolds (aka Instapundit) recently posted a quick link on the importance of voter turnout in the recent election:

THE CIRCULAR FIRING SQUAD CAN DISBAND: 407,000 Votes in Four States Away from the Presidency. Romney got out-hustled in a base-turnout election. Bigthink concerns about demographics, messaging, etc. may or may not have merit, but aren’t why he lost. 

I sent him a quick e-mail reply, and he was gracious enough to add it to his main post:

I share your observation that voter turnout was critical. But I don't think you should too quickly discount the bigger concerns about messaging.

Like many others, I also thought that the enthusiastic turnouts at the October GOP rallies in CO and OH, as well as voters stating they'd "crawl on their hands and knees through broken glass" to pull the lever for Romney indicated a hidden enthusiasm edge not reflected in the polls.

But in retrospect, the vote totals showed that Romney's support may have been deeper than McCain's in 2008, but not significantly broader.

So in that respect, those GOP rallies indicated something akin to the small-but-intense fan base for Apple computers in the mid-1990s. Of course, one of Steve Jobs' key accomplishments in the 2000s was to turn that into an LARGE-and-intense fan base for Apple products.

I won't rehash the "bigthink" arguments about the best next direction for the GOP. I just want to propose that *if* they can improve their message and inspire genuine enthusiasm for a positive pro-freedom agenda, then rallying (and growing) the base won't be a problem. Although I have a mixed opinion of Ronald Reagan policies, he was an acknowledged master at communicating an inspiring, upbeat message to the voters. If the GOP finds a good message and a good messenger, then the turnout problem will take care of itself.

 (Glenn Reynolds also linked to another interesting piece by Jededia Bila: "Outreach is not pandering".)

DetNews: Obamacare Favors Big Hospital

The 11/8/2012 Detroit News notes, "Obamacare favors Big Hospital, less competition".

This is just the latest incarnation 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 government to control 100 large "Accountable Care Organizations" than 100,000 individual hospitals and private practices. (Via AAPS.)

Smith: Will My Doctor Still Care if I Point a Gun at Him?

Dr. G. Keith Smith asks a very relevant question: "Will My Doctor Still Care if I Point a Gun at Him?"

Here's an extended excerpt:

About two weeks after I quit [taking Medicare], an angry cardiac surgeon, inconvenienced by my departure from the group of available cardiac anesthesiologists and with his finger in my face, told me that he was going to see to it that I was forced to do these anesthetics, so as not to disrupt his schedule.  I guess he thought he had a "right" to my services.

It didn't help things that I laughed.  I said,  "Dr. X, I’ll be happy to visit with the family before their loved one's elective surgery and inform them that I want no part of this and that I don't really want to be here, but someone is making me do this.  Maybe you all would like to wait on an anesthesiologist who wants to be part of this, because I certainly don't."

This cardiac surgeon suddenly understood.  Now imagine this on a large scale.  Angry mobs of folks waiving their Obamacare "insurance" cards in the street demanding their free health care outside a closed and vacant doctor’s office.  This supposed "right" to health care, cannot undo human nature and the delicate and myriad market forces at work to ensure that all parties in a transaction are willing participants. 

If government points its guns at the doctors to make them participate, I maintain that the "healthcare" that is delivered under these conditions will be a different variety than the mobs expected.  In fact, it won't be healthcare at all.  I don't know what it will be, but it won't be healthcare...

(Read the full text of "Will My Doctor Still Care if I Point a Gun at Him?")

Fortunately, some patients and doctors can still "opt out" of the current system through various "direct pay" or "concierge" practices which respect free-market principles and allow physicians to practice according to their best judgment for their patients' best interests without government interference. 

I don't know how long these options will remain legal.  But prudent patients may wish to look into these possibilities before it's too late.

As Dr. Smith notes: "Staying as far away as you possibly can from a 'coerced' doctor’s office may be the most self-preserving move you can make in the near future."

Don't Give Up The Ship

Joshua Lipana (free-market advocate and cancer survivor) recently asked both Dr. Beth Haynes and myself about the recent election on his blog, "Liberty Against Cancer".

He posted our responses here: "Dr. Paul Hsieh and Dr. Beth Haynes on President Obama's Re-election".

I said:

It means that ObamaCare will be the law of the land, with no realistic chance of repeal. We’ll see an erosion in the quality and availability of health care in America over time, although it’s difficult to know yet how long it will take.

I personally predict that the failure of ObamaCare cost control will lead to calls for a government “single-payer” system by the end of Obama’s second term. If this goes through, then the US system will end up some variant of Canada’s or the UK’s. Unless this trend is reversed, it will not end well for either American patients or American doctors.

Dr. Haynes said:

With the re-election of President Obama, our country takes another giant step toward statism. ObamaCare will become embedded not just into our healthcare system, but into our national way of being. Because of their continued support of conservative social agenda, Republicans failed to consistently embrace self-determinism and equality before the law. The positive case for individual rights and capitalism was not convincingly made and so a slight majority of our country still can not envision solutions that do not include a heavy dose of government interference. The belief in the moral goodness of the Welfare State remains insufficiently challenged.

That said, the difference in the popular vote is <1% of our populace. Nine million fewer people voted for Mr. Obama than in 2008. There was no landslide. There is no mandate.

This is what I posted on FB yesterday morning before any of the returns were in, and I stick by it:

“No matter who/what wins in this election, it is clear to me there is no consensus in this country. We all must continue to look for paths forward that more people are comfortable walking on, together.”

I won't sugar-coat the truth.  The battle for health care freedom suffered a serious blow this week. But the fight is not yet lost, and I plan on working to protect the freedoms we still enjoy and reversing the bad trends where possible. 

When my wife Diana and I visited the US Naval Academy Museum earlier this year, I had the privilege of seeing Oliver Hazard Perry's historic battle flag from the War of 1812 that read, "Don't Give Up The Ship".

(Taken with my iPhone, 12 Sep 2012, US Naval Academy, Annapolis MD)

That pretty much sums up how I feel right now.

As long as we still enjoy free speech and as long as ordinary Americans still value their health and their lives, we have a chance.  I'm glad Dr. Haynes and Joshua Lipana will remain in this fight.  I hope you'll stay with us as well.

ObamaCare Winners?

In the 11/7/2012 Forbes, Bruce Japsen picks his, "Five Obamacare Winners In Second Presidential Term".

His list includes:

1. The health insurance industry.
2. The hospital industry.
3. The retail pharmacy chains.
4. The generic drug industry.
5. The health care workforce.

(Read the full text of "Five Obamacare Winners In Second Presidential Term" for more details.)

In the short-to-medium term he may be right, in the sense that government laws now tilt the playing field in their favor.  For example, insurance companies will likely reap a temporary windfall as more people purchase insurance policies (often with the help of government subsidies).

But insurers will also be under increasing pressure to cover more "mandatory" services, while limited in how much they can charge.  Over time, they'll likely become the equivalent of heavily regulated utilities, "private" in name only.

Similarly, as initial government cost controls fail, we'll see continued ratcheting down of reimbursements to doctors/hospitals for their services, and increasingly restricted patient access to more expensive medications and services deemed "unnecessary" or insufficiently "cost effective" by the government.  Drug companies and health service workers will feel the pinch.

The economic future of all five "winners" will be in the hands of bureaucrats committed to cutting costs, rather than patients and service providers seeking to exchange values in a free market on mutually beneficial terms.  

Right now, both consumers and Apple are enormous winners when they can make voluntary exchanges in our still relatively free market for smartphones.  But both would lose if the government required everyone to own a smartphone, but specified what features it must have, what price consumers must pay, and was committed to lowering the "global phone spending" amount each year.

Although it may take a few years, Japsen's "winners" will ultimately end up losers.

State-Level Election Results

Kaiser Health News summarizes the results of some state-level health care ballot measures from last night.

For example, 4 states (Alabama, Florida, Montana and Wyoming) had ballot measures to invalidate the "individual mandate".

Result: "While three of these provisions passed (in Alabama, Wyoming and Montana) states can’t override federal law: citizens of those states will still be subject to the mandate."

Also: "Missouri voters approved Proposition E, which prohibits state officials from creating a health insurance exchange. Missouri joins eight other states that have already decided not to create a state exchange".

(Click through to the full text for more information on other measures, including assisted suicide in MA, and various abortion and marijuana initiatives.)

Full Steam Ahead With ObamaCare

Now that President Obama has won re-election, ObamaCare will be the law of the land.

Kaiser Health News quotes health care consultant Dan Mendelson, "It’s full-steam ahead with implementation".

For two good round-ups on what that means:

Modern Medicine, "Obama's re-election ensures continued rollout of Affordable Care Act measures in 2013"

Politico, "Obamacare survives -- now what?" 

Some of the key changes will include the rollout of state health "exchanges", the enforcement of the individual mandate, and the shift towards "bundled payments" for doctors and hospitals.  The potential Medicare cuts under budget "sequestration" could also be an enormous issue.

Dr. Marc Siegel summarizes in, "What Obama's victory means for your health care -- a doctor's take":

Prices will continue to rise and access to actual care will decline in an already overcrowded system.

Biotech companies and drug companies may feel that the climate is no longer ripe for innovation.

Hospitals and other health care providers will continue to struggle amid shrinking reimbursements.

Bottom line: my patients who gain a new insurance card may find that it doesn't buy them the care they were expecting.

I also anticipate some critical flashpoints will be Health Savings Accounts (HSAs), concierge physicians "opting out" of the system, and the scope of "practice guidelines" for physicians remaining in the system.

Stay tuned for more.

The 2012 Election Results

Although I wish the election had gone the other way, I do give credit to those who argued that Nate Silver and his polling methodology was more accurate than I expected. (I had anticipated a larger "intensity" gap for the GOP supporters).

I'll have more substantial commentary (especially with respect to health care policy) later.

Some Heartfelt Thanks

Today is Election Day and we'll soon find out who will be the next US President. In the meantime, I'd like to offer my heartfelt thanks.

1) I'm thankful that despite all its imperfections, we still have a system of government that allows ordinary Americans to have their say and to influence the outcome. (In contrast, China will also change its leadership this week and ordinary Chinese citizens will have almost zero say on who rules over them.)

2) I'd like to thank the many physicians and non-physicians who have fought for health care freedom these past weeks, months, and years.

In no particular order, some of these physicians include Milton Wolf, Jill Vecchio, Beth Haynes, Evan Madianos, Matt Bowdish, Hal Scherz, Richard Armstrong, Megan Edison, Tod Rubin, Kathleen Brown, Jane Orient, Richard Amerling, Alieta Eck, Art Fougner, Rich Fogoros, Doug McGuff, Brad Hennenfent, Lou Magdon (MD-to-be), and Amesh Adalja.

Some of these non-physicians include Ari Armstrong, Jared Rhoads, Craig Biddle, Alan Germani, (the late) John Lewis, Joshua Lipana, Daniel Wahl, Stella Zawistowski, Brian Schwartz, David Catron, Michelle Minton, Linda Gorman, Richard Ralston, Scott Keays, and Donna Rovito.  Lin Zinser also deserves special credit for starting FIRM and encouraging my activism.

(I'm sure I've inadvertently left some good friends off these lists, and I apologize in advance for any  omissions!)

3) I'd like to thank the editors at PJMedia, Forbes, and The Objective Standard, for their assistance and for providing me such good outlets for my writing.

4) I'd like to thank all my friends for your feedback and moral support. And for circulating via blogging, Facebook and Twitter, the many good articles, essays, and videos making the case for free-market health care reform.  There are too many of you to name, but you all have my heartfelt thanks.

5) I'd like to give special thanks to my wife Diana for her unwavering support, especially for putting up with me all the times I stayed up "just another 15 minutes" working on another OpEd.  And for her patience while I was arguing with someone online, because "someone was wrong on the Internet!"

6) I'd like to thank every American who values his or her freedom and who will keep up the fight for life and liberty, regardless of the outcome tonight.

Catron, DeMuth: America's Last Chance

David Catron reminds us that tomorrow is our "One Last Chance to Kill Obamacare".

In his latest American Spectator column, he notes:

It isn't possible to cover all of Obamacare's flaws in one column, but the point can be made by a brief summary of its worst provisions. Among these are mandates that restrict individual liberty and freedom of conscience, tax increases totaling more than $800 billion, the creation of perverse economic incentives that will kill millions of jobs, and the creation of a rationing board whose power will be virtually unchecked.

(Read the full text of "One Last Chance to Kill Obamacare" for more details.)

Christopher DeMuth makes a similar point in today's Wall Street Journal: "A Referendum on ObamaCare and Liberty":

If President Barack Obama is re-elected, ObamaCare's controls over doctors, hospitals, pharmaceutical firms and other providers of medical care will be tightened, and the operations of private insurance companies will be progressively restricted. Everyone involved will know where the process is going—to a single-payer system or one with a few chosen insurers subject to national public-utility controls—and will negotiate the best possible accommodations to it. Within a few years, a new political equilibrium will be in place, making the system irreversible and subject to only marginal adjustment...

Which direction voters choose on Tuesday will have profound consequences for the cost, quality and availability of health care in America.

If Americans re-elect Obama to a second term, Jennifer Haberkorn at Politico notes "Post-election flood of 'Obamacare' rules expected".

I also anticipate that we'll soon see more explicit calls for overt medical rationing.  For details, see my 10/3/2012 Forbes piece: "Get Ready For Obamacare's Medical Rationing".

Tomorrow will be our only realistic chance to avoid this deadly endgame for American health care.  We'll find out soon what our country decides.

(Addendum: The biggest question mark in my mind is what happens if the GOP wins the White House and retains the House of Representatives, but fails to win control of the Senate.  In that case, a President Romney would likely be unable to repeal ObamaCare although he might conceivably be able to mitigate some of the worst effects.  But that's a topic for a future post)

PA and NJ Doctors Speak Out

As the election comes down to the wire, some doctors in Pennsylviania and New Jersey have taken out a full page ad in the Philadelphia Inquirer speaking out against ObamaCare.

As Dr. Evan Madianos explains:

It is a letter drafted and signed by myself and over 40 doctors in Pennsylvania to our patients here -- and elsewhere -- expressing our unadulterated opinions and best medical advice about how this election will impact on the future of your health care system and country. I hope you will read it. I also hope you will circulate it to others. Take it as an emergency alert.

Your current crop of inept politicians are deadly serious about their intention to  barge into our examination rooms and offices to control how we practice medicine, and dictate your care. Their plans are incompetent, irresponsible and dangerous. So your doctors have no choice but to practice politics- to get them out of our lives, out of our offices, out of your life and *OUT OF OUR WAY* -- so that we, as doctors, can practice the profession we are trained to do - which is also in your best interest as a patient.

Consider carefully -- with the full knowledge that we- as practicing physicians working daily in the system -- have the best knowledge of what is wrong with the system and how to fix it.  It is to your doctors that you come in life and death situations  and who give you the facts, straight up about a threat to your life and health -- and what to do about it. In an age where politicians distort the truth shamelessly and are emboldened to make fantastic, economically ridiculous empty promises, unrestrained by agenda-driven complicit media, you'd be a fool to trust them with the power to make life or death decisions over your health care. Choose wisely.

Here's a PDF version of their ad.

Let's hope the voters are listening.

Magdon On Wrongs and Rights

4th year medical student Lou Magdon has published a nice piece on the AAPS website, "Two Wrongs Don’t Make [Healthcare] a Right!"

He emphasizes the importance of making the moral argument for freedom, in addition to the economic arguments.

One excerpt:

Unable to see the distortions of supply and demand for medical care because of government meddling and how it makes healthcare less affordable and less accessible, the Left doubles down on their support for more government control. They advocate for the second wrong. Because of the perceived inequality in the consumption of healthcare resources, out of “fairness”, they wish to have bureaucrats decide what physicians can and can not offer and what care patients will and will not receive. They support government coercion to take both property and freedom of choice away from Americans to redistribute the healthcare resources how they choose. They accomplish this task by fraudulently proclaiming the artificial right to healthcare. Your individual rights to live peacefully no longer matter. Your liberty is essentially stolen from you.

(Read the full text of "Two Wrongs Don’t Make [Healthcare] a Right!")

Brendan Loy Electoral College Contest

BTW, you can still enter Brendan Loy's Electoral College Contest.

Here's my prediction.  (Like with any good NCAA basketball pool, I predicted a few unlikely upsets, which by definition go against the conventional wisdom).

Naffah Video: The Risks and Perils of Obamacare

Dr. Farid Naffah, the Ohio physician who posted a full-page newspaper ad to educate patients about the problems of ObamaCare, has made a video version of "The Risks and Perils of Obamacare":



Here's the original print ad. (Via Dr. Evan Madianos.)

Quick Links: Insurers, Tourism, Retail Clinics

AP News: "Insurers nervous over prospect of Romney victory".

Just another reminder that the insurance industry has not been (and is not) a big fan of free-market health care reforms.

Washington Post: "Medical tourism doesn’t necessarily mean leaving the country to get treatment"

New York Times: "The Family Doctor, Minus the M.D."

We'll likely see more medical care performed by mid-level providers (nurse practitioners, physician assistants, etc.) because of physician shortages. Low-cost health clinics staffed by mid-level providers can be a very reasonable option for people needing routine services (e.g., a sprained ankle or a flu shot). And in a free market, these could exist alongside higher-end clinics staffed by MDs.

As long as patients are given appropriate disclosure about what services they are receiving (and by whom), they can decide if such clinics suit their needs or not.

Quick Links: Liberty Against Cancer, Profits in Medicine

Joshua Lipana (free-market advocate and cancer survivor) has a new blog: Liberty Against Cancer:

Welcome to Liberty Against Cancer, a place where you’ll find high-priority news and commentary on health and liberty as it relates to the fight against cancer. Topics will range from the importance of animal testing in finding better treatments, to Vitamin D, to physician-assisted suicide, to cruciferous vegetables, to defeating the Obamacare tax on medical devices, and many more.

Go check it out!

Dr. Amesh Adalja has a new OpEd in Forbes: "Why Are Profits In the Healthcare Sector So Demonized?"

In particular, he makes both the moral and economic cases for profits:

[P]hysicians are often considered by the public to be part of an exalted class who labor tirelessly with no thought other than serving their fellow man and are, for the most part, paid well for their sacrifice. To ascribe profit-seeking to a profession that is heralded as an embodiment of self-sacrifice would offend the sensibilities of the public and many physicians. Moreover, the idea that a physician might refrain from life-saving action because of a concern for remuneration is considered akin to extortion by many. Indeed, amongst physicians, those who practice in such "elective" fields as plastic surgery are held to be crasser than, for example, the medical oncologist.

What is ignored by those who subscribe to this view of profits is the fact that profits are not just something to be tolerated; they are a vital—and completely moral—motivation for anyone engaged in productive activity. Without the prospect of earning a profit, all activity above bare subsistence would cease (or would never have occurred) and mankind might still be in the caves. Given that healthcare involves life-or-death decisions, it is all the more important that this indispensable factor be present...

(Read the full text of "Why Are Profits In the Healthcare Sector So Demonized?")

Haynes On Reframing the Moral Narrative

Dr. Beth Haynes discusses, "Paving the Road to Health Care Freedom by Reframing the Moral Narrative":



She demonstrates several ways activists can seize the moral high ground and make the positive case for health freedom.

Beth Haynes, M.D. is the Executive Director of the Benjamin Rush Society.