Hsieh PJM OpEd: "America's Other Drug Problem"

The February 5, 2011 PajamasMedia published my latest OpEd, "America's Other Drug Problem".

My theme is that the current critical shortage of many life-saving legal drugs should be solved not by yet another new government program (as the Obama Administration is planning), but by getting government out of the way.

Here is the introduction:

America has a serious drug problem, but it's not one most Americans have heard of. The problem is not illegal drugs, but rather a critical shortage of many life-saving legal drugs. And the federal government is about to make things worse.

During the past year, medical professionals have received alarming reports about critical shortages of important drugs. These drugs aren't the common over-the-counter medications that consumers purchase in their local drugstores. Rather, the shortages are in various injectable drugs typically administered to seriously ill patients in hospitals...

(Read the full text of "America's Other Drug Problem".)

For this piece, I drew heavily on (and linked to) the excellent article by Stella Daily Zawistoski in the Fall 2008 issue of The Objective Standard on "How the FDA Violates Rights and Hinders Health". If you're interested in this topic, I highly recommend reading her more detailed article.

Update: Thank you, Instapundit, for the link!

Wolf: USS Obamacare Takes On More Water

Dr. Milton Wolf has a new piece in the February 4, 2011 Washington Times, "USS Obamacare takes on more water".

He details how ObamaCare is taking hits on multiple fronts now -- legal, political, and popular. The breadth and depth of opposition to ObamaCare is stunning, and is continuing the snowball. If you value freedom, read the full text of his OpEd for some encouraging news.

ObamaCare is not dead yet. Rather, it is a wounded beast -- and still very dangerous. It's up to Americans to finish the job over the next 2 years and kill it once and for all.

For one legislative strategy on how to proceed, see Keith Hennessey's 2/2/2011 post, "How to Repeal ObamaCare". But this must be accompanied by ongoing grass-roots discussion and activism to keep Americans informed on this issue -- and to keep holding our politicians' feet to the fire. Fortunately, men like Dr. Wolf are doing their part to help.

Quick Links: Drug Shortages, Free Riders, Repeal

The 2/1/2011 Wall Street Journal gives more details on how "Drug Shortages Distress Hospitals".

In the 2/2/2011 Forbes.com, Avik Roy discusses the "Myths of the 'Free Rider' Health Care Problem".

In the 2/3/2011 Washington Post, Jennifer Rubin discusses "Losing a repeal vote, but winning the war against ObamaCare".

Quick Links: Barnett, Scherz, Carney

In the 2/2/2011 Wall Street Journal, Randy Barnett and Elizabeth Foley cover "The Nuts and Bolts of the ObamaCare Ruling".

Dr. Hal Scherz of Docs4PatientCare explains that, "The Healthcare Debate is Far From Over".

John Carney at CNBC points out that ObamaCare is now operating outside the rule of law.

How The Rationing Will Occur

In the 1/27/2011 Daily Caller, Heather Smith explains that "The Obamacare rationing is beginning".

Here's how the rationing will occur:

The government isn't going to say, "We won't treat you for condition X" -- the public outcry would be too great. No, they have learned from other nations that have government health care that that would mean disaster. What they do is much more subtle -- they simply limit options in the hope that patients won’t realize that care is being rationed.

For most diseases, there are several options for treatment and the treatment regimen is based upon the individual patient's history and advice from their doctor. If the government refuses to pay for a particular type of treatment, that arrow is simply removed from the doctor's quiver and the patient will most likely never be made aware of it.

However, sometimes there is a period between the government deciding a treatment is no longer cost effective and when some patients are receiving it. This is the rare time when people can see how their options are being limited and actually stand a chance to do something about it...

(Read the full text of "The Obamacare rationing is beginning".)

Furthermore, as I noted in an an earlier PajamasMedia piece from last year, doctors will be co-opted into participating in this silent rationing -- as has already occurred in the UK:

...[N]early one in four British oncologists admitted to deliberately withholding information from their patients about treatments widely available in other European countries, but not allowed under the NHS system due to cost. These oncologists argued that "there was 'no point' in discussing treatments their patients could not have" and that such a discussions might "distress, upset or confuse" their patients.

But patients rely on their physicians for information about treatment options -- including an honest appraisal of all the risks, benefits, and alternatives -- so they can make fully-informed decisions about their lives. Failure to disclose such information is a serious breach of a doctor's Hippocratic Oath.

Hence, the importance of repealing ObamaCare.

We have been warned...

Catron on Vinson

David Catron has a nice discussion of yesterday's Vinson ruling. Here's the introduction to his latest AmSpec piece, "Roger That!":

Ian Gershengorn, the government lawyer charged with defending ObamaCare in State of Florida v. U.S. Department Health and Human Services, probably knew he was in for a shellacking when in a December hearing Judge Roger Vinson started talking about broccoli. The basis of Florida's challenge to ObamaCare is its claim that the law's requirement that all Americans buy health insurance is unconstitutional because Congress has no legitimate power to impose such a mandate.

Revealing some sympathy with this position, Judge Vinson asked the hapless DOJ attorney, "If they decided everybody needs to eat broccoli because broccoli makes us healthy, they could mandate that everybody has to eat broccoli each week?" Gershengorn lamely responded that the health care market has unique qualities that necessitate the mandate. "It is not shoes, it is not cars, it is not broccoli."

This answer was obviously not very convincing to the Judge...

(Read the full text of "Roger That!")

In particular, he highlights some important differences between the Vinson ruling and the earlier Hudson ruling, such as Vinson's decision that "the entire act must be declared void" because of the lack of severability.

As others have correctly noted, this isn't the end of ObamaCare. But it may be a critical turning point.

The Vinson Ruling

The big news from yesterday is, of course, the ruling from federal judge Roger Vinson that ObamaCare is unconstitutional.

Readers can find the full 78-page ruling here (also mirrored at the end of this blog post).

David Kopel of the Independent Institute summarizes and analyzes some of the major points here.

So does Cornell law professor William Jacobson.

As with the Hudson ruling, there will undoubtedly be tons more commentary in the next few days about the legal, political, and philosophical significance. But for now, I wanted to highlight a few passages:

From page 75: "Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void."

And from page 42:

It is difficult to imagine that a nation which began, at least in part, as the result of opposition to a British mandate giving the East India Company a monopoly and imposing a nominal tax on all tea sold in America would have set out to create a government with the power to force people to buy tea in the first place.

(Hat tip to Dr. Matthew Bowdish.)

And from footnote 30, page 76:

I note that in 2008, then-Senator Obama supported a health care reform proposal that did not include an individual mandate because he was at that time strongly opposed to the idea, stating that "if a mandate was the solution, we can try that to solve homelessness by mandating everybody to buy a house."

The US Supreme Court will have the final say on this matter.

But for now, America still has a chance...

vinsonruling1 31 11

ACOs: Repackaged HMOs?

Americans are beginning to realize what ObamaCare will mean to them, unless repealed.

From the 1/27/2011 New York Times article by Dr.Pauline Chen discussing her conversation with friends about Accountable Care Organizations (ACOs), "The Missing Ingredient in Accountable Care":

Unlike fee-for-service, payers will give A.C.O.'s a lump sum to cover all care, but the A.C.O.'s will be able to keep any savings that result from more efficient and better care.

In this way, I concluded to my friends, A.C.O.'s will be able to stem spiraling costs, increase efficiency and improve quality. Clinicians and hospitals will have a financial motive not to do more procedures and incur more visits but to keep patients healthy and out of the hospital.

..."Thanks for the explanation, Pauline," she said. She pulled her phone out and quickly glanced at its screen. "I hate to break it to you," she continued, "but whatever that care plan is called, it still sounds like an H.M.O. to me."

But at least with an HMO, patients know who their doctor is working for. Under the ACO system, patients may be "virtually assigned" to an ACO without their knowledge (or consent). Hence, the doctor's practice statistics for all his patients (# of referrals, tests ordered, etc.) would be used in determining if he was practicing "efficiently" or not. Patients might naively trust their doctor to be working for their best interests, without realizing that the doctor was also simultaneously trying to please an unseen ACO bean counter.

Hence, these "virtual assignments" are even scarier than explicitly joining HMO.

Furthermore, the article highlights the other problem with ACOs theoretical strategy for cost containment. If patients are allowed to freely go outside of the network (i.e., "no lock-in") for their care, then the ACO will have a hard time controlling costs (i.e., "leakage") -- and will fail.

On the other hand, if patients are forbidden from going outside of the network (or subject to heavy financial penalties for doing so), then the ACOs operate much like the much-reviled HMOs that Americans resoundingly rejected in the 1980s.

Fortunately, Americans are starting to catch on to the fact that ACOs may be harmful to their health.

(Via @Lucidicus.)

Wolf: ObamaCare's Privileged Escapees

Dr. Milton Wolf has a new OpEd in the January 29, 2011 Washington Times, "Tawdry details of Obamacare".

Here's an excerpt:

f you would like to know what the White House really thinks of Obamacare, there's an easy way. Look past its press releases. Ignore its promises. Forget its talking points. Instead, simply witness for yourself the outrageous way the White House protects its best friends from Obamacare.

Last year, we learned that the Department of Health and Human Services (HHS) had granted 111 waivers to protect a lucky few from the onerous regulations of the new national health care overhaul. That number quickly and quietly climbed to 222, and last week we learned that the number of Obamacare privileged escapes has skyrocketed to 733...

(Read the full text of "Tawdry details of Obamacare".)

This kind of selective enforcement (or selective exemption) from the law cuts to the heart of the American system. In effect, the Obama Administration replaces the rule of law with the rule of men.

Benefits From EHR or P4P?

Two recent articles add fuel to skepticism about two ObamaCare initiatives -- EHRs (electronic health records) and P4P (pay for performance).

How much do Electronic Health Records (EHRs) help patient care?

According to this article, not much: "Electronic Health Records and Clinical Decision Support Systems" (By Max J. Romano, BA; Randall S. Stafford, MD, PhD, Arch Intern Med. Published online January 24, 2011.)

EHRs may not help patients. But they will be used by the government to determine if doctors are complying with government practice standards.

(Via @MatthewBowdish.)

How about P4P ("Pay for performance") incentives? Those are another big part of planned savings under ObamaCare.

According to "Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study", the answer is "no". (By Serumaga et al, BMJ 2011; 2011; 342:d108; 25 January 2011)

(Related article: "Financial Rewards for a Doctor’s Care", New York Times, 1/26/2011.)

Surprise -- when the government tells doctors how to practice and makes them jump through hoops, rather than letting them use their own training and judgment, it does not improve patient care!

Government Official Tells Truth About ObamaCare

A little bit of refreshing truth at, "Medicare official doubts health care law savings":

Two of the central promises of President Barack Obama's health care overhaul law are unlikely to be fulfilled, Medicare's independent economic expert told Congress on Wednesday.

The landmark legislation probably won't hold costs down, and it won't let everybody keep their current health insurance if they like it, Chief Actuary Richard Foster told the House Budget Committee. His office is responsible for independent long-range cost estimates.

Foster's assessment came a day after Obama in his State of the Union message told lawmakers that he's open to improvements in the law, but unwilling to rehash the health care debate of the past two years. Republicans want to repeal the landmark legislation that provides coverage to more than 30 million people now uninsured, but lack the votes.

...The comments Wednesday were unusually direct because Foster generally delivers his analysis in complicated technical memos.

(Read the full text of "Medicare official doubts health care law savings".)

Those points mirror some of the issues raised by Dr. Milton Wolf in his OpEd from last fall, "ObamaCare's Unkeepable Promises".

Let's hope more people start raising these questions, both inside and outside of government.

(Via Dr. Beth Haynes.)

Quick Links: Catron, Zawistowski, Rich

More good blog posts to read while I'm busy this week on nightshift duty:

David Catron: "Magical Thinking About ObamaCare"

Stella Zawistowski: "Drug dealing by the federal government"

Dr. Rich: "Fugitive Busted By His Pacemaker (And His Doctor)"

One excerpt from Dr. Rich's post:

To DrRich, the interesting part of the storyline only peripherally involves the pacemaker. The real story is this:

* A patient goes to a hospital for medical help.

* A medical procedure is done which generates certain data for the medical record.

* The data in the medical record is immediately cross-referenced with data from a federal database that lists persons of interest.

* The FBI shows up at the bedside in less time than it takes to raise a nurse with a bedpan.

Now, that's actually a pretty interesting story.

(And people wonder why the Central Authority is so hot to have electronic medical records.)

Quick Links: Wolf, Rhoads, Schwartz, Scandlen

My personal schedule continues to be busy, so I won't be blogging much this week. But in the meantime, go check out:

Milton Wolf: "If ObamaCare is such a great law, why does the White House keep exempting its best friends from it?"

Jared Rhoads: "Four brief observations about repeal"

Brian Schwartz: "Yes, Medicare is an (unsustainable & bankrupt) welfare program"

Greg Scandlen: "How Accountable Care Organizations Came About"

Light Posting

Admin Note: Because of my work schedule, blogging may be lighter than usual this upcoming week.

Catron: A Natural Born Job Killer

David Catron has a new piece in AmSpec, "A Natural Born Job Killer". In it, he describes the many ways in which ObamaCare will destroy jobs and worsen unemployment in this country.

I especially liked this point he raised:

...[R]emember that reform-induced job losses will not be limited to the health care industry. As health care economist John Goodman points out, the various mandates imposed by Obamacare will effectively raise the cost of labor across the economy.

He estimates that they will add "$2.28 an hour for full time workers (individual coverage) and $5.89 an hour (family coverage) for fulltime employees." Many businesses simply cannot absorb such increases without cutting labor costs. This is why we have heard so many cris de coeur from low-margin employers like White Castle, which says the financial hit "will make it hard for the company to maintain its 421 restaurants, let alone create new jobs."

(Read the full text of "A Natural Born Job Killer".)

This is a vitally important point. As economist Frederic Bastiat pointed out many years ago in "What Is Seen and What Is Not Seen", we must not focus only on the immediately visible jobs that are destroyed by ObamaCare. We must also consider the jobs that would never be created by businessmen who choose not to expand.

Instead of letting ObamaCare kill our economy, Congress should kill ObamaCare.

People Can Handle the Truth About Their DNA

In the January 17, 2011 New York Times, John Tierney reports that ordinary Americans are able responsibly handle the information provided by personal DNA testing services. Here's an excerpt from, "Heavy Doses of DNA Data, With Few Side Effects":

In two separate studies of genetic tests, researchers have found that people are not exactly desperate to be protected from information about their own bodies. Most people say they'll pay for genetic tests even if the predictions are sometimes wrong, and most people don’t seem to be traumatized even when they receive bad news...

Although they were offered sessions, at no cost, with genetic counselors who could interpret the results and allay their anxieties, only 10 percent of the people bothered to take advantage of the opportunity. They apparently didn't feel overwhelmed by the information, and it didn't seem to cause much rash behavior, either...

"The medical field has been paternalistic about these tests," says Peter J. Neumann, the lead author of the study, who is director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center. "We've been saying that we shouldn't give people this information because it might be wrong or we might worry them or we can't do anything about it. But people tell us they want the information enough to pay for it."

(Read the full text of "Heavy Doses of DNA Data, With Few Side Effects".)

I took a similar position in my PajamasMedia piece from July 2010, "Should You Be Allowed to Know What’s in Your DNA?"

One of the core principles of medical ethics is to respect and preserve patient autonomy. The FDA should not interfere with a patient's right to use personal DNA testing to learn medically important information about himself that could help him treat, mitigate, or prevent bad diseases. And ethically responsible physicians should support -- not thwart -- their patients who wish to benefit their lives in such fashion.

Criminalizing Independent Physician Practices

Physician-blogger "Dr. Rich" talks about how government rules are "Criminalizing Independent Physician Practices".

In particular, the Federal Trade Commission is using antitrust rules to punish physician groups that negotiate better prices with insurance companies in what the government considers a too aggressive fashion. This trend will accelerate under ObamaCare, as the Justice Department starts getting involved in such cases (not just the FTC.)

The end result:

...[U]nder Obamacare all doctors are to be driven into federally-sanctioned organizations that will operate strictly under government directives. The current parlance for such an organization is the "Accountable Care Organization."

The ACOs will be run by administrators who (theoretically) will become expert at navigating the morass of rules and regulations now being conjured up under Obamacare. These administrators will interpret the rules and regulations in such a way as to determine The Way It Must Be Done, and then will pass The Way It Must Be Done down to the ACOs' clinical chiefs (doctors who perhaps used to practice medicine, and maybe still do, a little, but who are now mainly brevet administrators), and the clinical chiefs will finally pass the restrictive rules of engagement down to the doctors who will actually take care of the patients.

These doctors, struggling in the trenches, will attempt assiduously to follow those rules without exception, if they would like to keep their jobs as well as avoid a federal fraud rap. The patients, of course, will get whatever they get, but always with official assurances that whatever it is they get, it will be of the highest quality.

(Read the full text of "Criminalizing Independent Physician Practices".)

When independent private practices are driven out of business by ObamaCare, all that will be left will be "Accountable Care Organizations" which will be accountable to the government -- not the patient.

ObamaCare must be repealed.

Quick Links: Medicaid, Mandates, FDA

In the 1/15/2010 Boulder Daily Camera, Brian Schwartz writes, "Colorado Medicaid reform: federal matching funds promote waste".

(Eventually, Medicaid and Medicare should be phased out entirely. But there are good intermediate steps we could take towards that goal.)

John Graham of the Pacific Research Institute warns, "The End of the 'Individual Mandate' Is Not the End of Obamacare".

(Hence, Americans should continue the pressure on Congress for a complete repeal of ObamaCare.)

In response to the latest FDA regulations on painkillers such as Vicodin and Percocet, Stella Zaiwistowski argues, "You don't ban cars because people drive them off cliffs".

(Read her whole post, especially for her discussion of free-market alternatives to more cumbersome FDA regulations.)

ObamaCare's Ticking Time Bomb

In the 1/16/2011 Washington Examiner, Tim Carney explains that the future costs of ObamaCare are the ticking time bomb.

As with the Massachusetts plan, supporters' first priority was to expand coverage -- and control costs later.

And if the recent history of other states (such as MA and TN) are a guide, when the bills for ObamaCare come due to the federal government, they will (1) attempt to shift the blame onto "greedy" insurance companies and (2) start imposing price controls.

The end result will be a collapse of the mixed partially-private-partially-socialized system, and a full government takeover of American health care.

(Read the full text of, "Tick, tick, tick: The cost of Obamacare is a time bomb". Link via @TOSjournal.)

End of Medicare?

Carla Fried asks the provocative question, "Is 2011 The Beginning of the End for Medicare?"

Here is an excerpt:

As the red bars in the chart below show, it is Medicare and Medicaid, not Social Security, that looms as the biggest federal budget buster in terms of its growing demand on federal dollars.

...[T]he bottom line is that all Americans — not just Boomers getting ready to sign up for Medicare — must recognize Medicare is the really big federal deficit elephant in the room. What we're all paying into the system through payroll deductions is in no way close to the amount of Medicare benefits we will consume.

Medicare in its current form is unsustainable. The only real question is whether it will crash-and-burn in a dramatic fashion or whether it will be phased out with a fiscal equivalent of a "controlled landing".

But younger Americans should start planning now for neither Medicare nor Social Security being there when they retire.

Catron: Some Vitriolic Rhetoric About Repeal

David Catron has a new piece in today's AmSpec, "Some Vitriolic Rhetoric About Repeal".

In particular, he warns Republicans that they should not let the Democrats use the Tuscon murders to derail their efforts to repeal ObamaCare. Here's an excerpt:

The repeal effort will presumably begin moving forward again next week, and the debate will no doubt be more restrained than might have been the case before Tucson. The Republicans will certainly be less aggressive in their rhetoric. The Democrats will, in turn, see this as weakness and attempt to exploit the gesture, just as they have exploited Tucson. They will brand as "vitriolic" every floor speech in favor of repeal and repeatedly demand that the GOP water down its agenda.

House Republicans would do well to ignore these tricks. They know that Tucson had nothing to do with the health care debate or any other political exchange. And the Democrats know it as well. In fact, according to a CBS poll taken early in the week, even the public gets it. The survey showed that "57 percent of poll participants said the country's harsh political tone was unrelated to the shooting." So, there really is no excuse for the GOP to wave the white flag on repeal.

(Read the full text of "Some Vitriolic Rhetoric About Repeal".)

Catron is absolutely right. The Republicans need to "stick to their guns" (so to speak) on this issue and not capitulate.

Again, this highlights the importance of having the moral confidence that repealing ObamaCare is right.

Rhoads: Let's Petition with Conviction

Jared Rhoads of the Lucidicus Project has a new OpEd out, "Let's petition with conviction".

In his piece, he makes the following critical point about the Morris petition to oppose ObamaCare:

Republicans need to stop hinting that they support individual rights -- if indeed they do -- and instead come out and uphold rights as a matter of firm, moral conviction.

I used to think that Republicans did stand for individual rights on principle, but that they shied away from moral arguments because they deemed it better public relations to be "big-tent," inclusive, neutral. Well, over the past two years, the Tea movement has demonstrated that pro-individualist moral sentiments are popular and effective. We are still waiting for the Republicans to catch up.

(Read the full text of "Let's petition with conviction".)

Basically, Republicans (and other would-be defenders of limited government) have to stop ceding the moral high ground to the Left. Unless they fully grasp that individual rights and limited government are good (and must be defended as such), they'll ultimately lose.

Let's hope enough Republicans are listening...

Quick Links: Free Riders, MA, Privacy Breaches

Greg Scandlen talks about free riders in "Revisiting the Individual Mandate":

There is not yet a proposal that would end “free-ridership.” ObamaCare will continue a large number of people who are uninsured and getting free services, including illegal immigrants and people who simply don’t pay their bills. For all of the contortions and intrusions, the current law would at best reduce the problem, not solve it.

Further, virtually all of the expansion in coverage under ObamaCare is subsidized, either by free care under Medicaid or subsidized care under the Exchanges. If consuming, but not paying for, health services is free-riding, isn’t this institutionalized free-ridership?

Sally Pipes asks, "Has Massachusetts Experience Put ObamaCare On A Path To Repeal?" (IBD, 1/12/2011.)

The 1/11/2011 Denver Post reports on electronic security breaches in Colorado leading to the disclosure of private medical information of over 100,000 Medicaid patients.

As more hospitals and doctors' offices start adopting mandatory electronic medical records, how many more such incidents will we see?

Are CO Insurers Bailing?

Brian Schwartz notes that Colorado health insurance companies are quietly shifting out of the sector -- both into other branches of insurance (e.g., worker's compensation and life insurance) as well as moving into non-insurance products.

Read the details at, "Health insurance takeover alert: Insurers selling different products".

One natural question is whether this is their form of contingency planning for an eventual government takeover of health insurance. If the insurance companies are worried, we should be as well.

Rubin's Question

In the 1/9/2011 Washington Post, Jennifer Rubin discusses the latest arguments about the costs of ObamaCare.

Here's the key question from "Now ObamaCare debate moves to the real world":

If the bill is vastly more expensive than advertised, causes great upset to consumers and negatively impacts care, shouldn't we repeal and replace it?

Rubin is absolutely correct -- we need to repeal and replace it. And in this process, the debates about the numbers (i.e., costs, deficits, etc.) are important.

But the key political driver behind the support for universal health care has never been economic but rather moral. Supporters of government-run health care simply believe it's "the right thing to do" on the grounds that a need to health care entitles one to an alleged "right" to health care -- even if it must be "guaranteed" via creating a huge new government program.

Hence, to effectively challenge ObamaCare, one must address the underlying issue as well -- namely, should government compel one man to pay for another's health care solely because the other man needs it? Or should government leave people alone to act as they wish -- to let them freely donate (or not) according to their own values and priorities to help others in need via private charity?

The "right thing to do" is not a government that redistributes wealth but one which protects individual rights, including the right to own and dispose of one's property as one wishes.

As Thomas Jefferson noted:

A wise and frugal Government, which shall restrain men from injuring one another, shall leave them otherwise free to regulate their own pursuits of industry and improvement, and shall not take from the mouth of labor the bread it has earned.

President Jefferson, not Obama, correctly understood what was "the right thing to do".

Squeezing Your Medical History Into 7 Tweets?

Can your doctor fit your medical history into 7 "Tweets" (1000 characters)?

As more physicians start adopting government-mandated Electronic Medical Records (EMR), they will be faced with such challenges. Dr. Danielle Ofri reported her frustrations with her EMR system in her 12/30/2010 New York Times piece, "The Doctor Vs. The Computer".

Here's an excerpt:

Estimating my patient's surgical risk and planning for his operative care is not a straightforward process. After our physical exam, I sit down to write a detailed evaluation, because I want the surgeons and anesthesiologists to fully understand the complexity of his situation.

As I type away, I feel like I'm doing the right thing, explicating my clinical reasoning rather than just plugging numbers into a formula. I'm midway into a sentence about kidney function when the computer abruptly halts.

I panic for a moment, fearful that the computer has frozen and that I've lost all my work -- something that happens all too frequently. But I soon realize that this is not the case. Instead, I've come up against a word limit.

It turns out that in our electronic medical record system there is a 1,000-character maximum in the "assessment" field. While I've been typing, the character number has been counting backward from 1,000, and now I've hit zero. The computer will not permit me to say anything more about my patient.

I go back and remove excess articles: the, a, an. Then I try to gain a few characters by using abbreviations: DM for diabetes mellitus, CRF for chronic renal failure. Still, I am over the limit.

A new trick dawns on me. Maybe if I cut back on my descriptions of the clinical problems I’ve already assessed, then I can gain enough characters for his cardiac status and operative assessment.

I nip and tuck my descriptions of his diabetes, his hypertension, his aortic valve stenosis, trying to placate the demands of our nit-picky computer system. Nevertheless, I am still unable to fit a complete assessment into the box.

In desperation, I call the help desk and voice my concerns. "Well, we can't have the doctors rambling on forever," the tech replies.

I want to retort with something snarky, like I hope that his next critical illness clocks in at less than 1,000 characters, but I hold my tongue. Instead I focus on eliminating verbs and prepositions, wondering just how skeletal my text can become...

(Read the full text of "The Doctor Vs. The Computer".)

Dr. Ofri did finally manage to squeeze her patient's medical assessment into the 1000-character limit -- roughly 7 Tweets (Twitter posts). And she did so without compromising patient care, although it took a great deal of work on her part.

Her specific 1000-character limit was undoubtedly set by her particular EMR vendor (as opposed to the federal government). But the fact that hospitals and medical offices will be de facto required to purchase some government-approved EMR system under ObamaCare rules is unlikely to make vendors more responsive to customer preferences. After all, how good will customer service be in an industry when you have to buy one their products?

Welcome to ObamaCare...

Wolf: Buck Up and Stop Obamacare

Dr. Milton Wolf has a new OpEd in the January 8, 2011 Washington Times entitled "Buck up and stop Obamacare".

In it, he has a very simple message for the GOP:

Republicans won this year's historic landslide election primarily by virtue of not being Democrats. The year of the Tea Party was 2010, and the GOP is the beneficiary - for now. It's not often that fate - or, in this case, the Tea Party - grants you a second chance for a rendezvous with history. Now is the time to earn it.

...A word of caution here: America is not clamoring for Obamacare Lite. Congressional Republicans should not fall for the Democrats' trap of tinkering around the edges of Obamacare because doing so accepts the underlying fundamental flaw that the government takeover of the health care system is acceptable. After all, even Mr. Obama wants to fiddle around with removing unpopular provisions, such as the 1099 rule that forces ordinary Americans to become tax snitches for the state. Don't fall for it. Make them lie in the bed they made.

(Read the full text of "Buck up and stop Obamacare".)

If the GOP doesn't listen to the Tea Party voters who put them into power in the House, they'll quickly learn the meaning of Dr. Wolf's warning phrase, "46-12-4".

(Related story: "GOP: Dance With The One Who Brung You".)

Hsieh RCM OpEd: "A Defense of High-Frequency Trading"

The January 7, 2011 RealClearMarkets published my OpEd, "A Defense of High-Frequency Trading".

This piece is not directly about health care, but rather the critical economic infrastructure that makes health care innovation possible -- namely, efficient capital markets. I contrast the recent reporting in Wired vs. the New York Times on "flash trading" (high speed computer stock trading), and rebut three fallacious concerns raised by the NYT -- its supposed "unfairness", the loss of human control, and the difficulties it creates for government regulators.

Here is the opening:

Wired magazine and the New York Times both recently published detailed stories on "flash trading" -- the increasing use of high speed artificial intelligence algorithms in the financial markets. Both asked the same question: Will flash trading help the markets by improving efficiency -- or will it destroy them?

But while both stories covered the same basic facts, they took strikingly different approaches. Wired discussed the technology in a generally balanced fashion, whereas the New York Times adopted a more alarmist attitude, including emphasizing the problems the technology would create for government regulators.

However, the concerns raised by the Times against flash trading are variations of fallacies frequently raised against free markets. Hence, identifying and rebutting those fallacies will help one better appreciate and defend flash trading in particular, as well as market capitalism in general...

(Read the full text of "A Defense of High-Frequency Trading".)

I'd like to thank Wendy Milling for helping me get this published at RCM, and Ari Armstrong, Brian Schwartz, and Jimmy Wales for their helpful feedback on an earlier draft of this piece.

Catron: Bringing the Bureaucrats to Heel

In his latest piece at AmSpec, David Catron discusses the importance of "Bringing the Bureaucrats to Heel".

Whether it be strangling Medicare Advantage or restricting access to drugs like Avastin or technologies such as personal genetic testing, the bureaucrats will be looking for ways to restrict our freedoms. As Catron notes, the FDA is even sticking its nose into international cycling!

(Read the full text of "Bringing the Bureaucrats to Heel".)

And with a divided Congress, President Obama will be relying more than ever on executive orders and the regulatory apparatus to impose his agenda on the American people. Hence, the importance of keeping our eye on what they're doing.

While you're at it, check out Catron's blog, Health Care BS. I especially liked his recent post, "End-Of-Life Counseling Meets the Death Panel"

Hsieh WashTimes OpEd: Best Health Care Political Pull Can Buy

The January 6, 2011 Washington Times has published my latest OpEd, "Best Health Care Political Pull Can Buy".

My theme is that unless ObamaCare is repealed, it will foster the wrong kind of health care competition.

Here's an excerpt:

When President Obama signed his health care plan into law, he promised it would foster "choice and competition." Nine months later, Americans can count this as another Big Lie. Obamacare has instead reduced competition in the marketplace for health services...

Yet while Obamacare is suppressing genuine marketplace competition for medical services, it is also spurring a more sinister facsimile of competition -- for political favors...

(Read the full text of "Best Health Care Political Pull Can Buy".)

I'd like to thank the organization Docs4PatientCare.org for helping to facilitate publishing this article -- especially Dr. Hal Scherz and Dr. Richard Armstrong.

And I'd like to thank Diana Hsieh, Ari Armstrong, and Brian Schwartz for their help in editing my early drafts of this OpEd.

Update: Thank you, Instapundit, for the link!

Quick Links: 2011, Dead Hospitals, Repeal

The Christian Science Monitor has a list of new ObamaCare provisions in effect for 2011, "Health care reform 101: What will kick in Jan. 1?"

(Short summary: More rules and regulations doctors, patients, and insurers. Plus a few small benefits thrown to some Medicare providers and recipients to sugar-coat the rest of the bitter pill.)

ObamaCare will end the construction of 45 new physician-owned hospitals.

The ObamaCare Repeal Bill is 2 pages long.

Hsieh PJM OpEd: "Will the GOP Walk the Walk On The Constitution?"

PajamasMedia has just published my latest OpEd, "Will the GOP Walk the Walk on the Constitution?"

My theme is that not only should the GOP pay lip service to the Constitution, they must defend in action the principles of individual rights and limited government. Defunding "ObamaCare" would be a good start.

Here is the opening:

Now that the Republicans have won control of the House of Representatives, they've chosen to demonstrate their respect for the U.S. Constitution in two important ways.

First, they plan on reading the full text of the Constitution on Thursday, January 6, 2011, one day after swearing in John Boehner (R-OH) as the new speaker of the House. Second, they've promised that every new bill will contain a statement citing the constitutional authority for the proposed law.

But while these are important symbolic steps, the real test will be whether the GOP-controlled House will defend the Constitution with deeds and not just words -- especially on high-stakes issues like health care. In other words, will the GOP "walk the walk" as well as "talk the talk" on the Constitution?

(Read the full text of "Will the GOP Walk the Walk on the Constitution?")

Hat tip to Brendan Casey for the quotes from Nancy Pelosi and George Washington.

Scandlen on American Style Death Panels

Greg Scandlen has a new blog up entitled, "Real Health Reform: Our Money, Our Health, Our Choice".

Here's his superb analysis on the 4-step approach to "Death Panels American-Style". The 4 key steps are:

1) Health information technology -- which doesn't save money, but does let the government know what doctors are doing.

2) Comparative effectiveness guideliens -- in which the government decides which treatments "work" and which treatments "don't work".

3) Practice incentives -- in which the government rewards doctors who follow those guidelines, and punishes those who don't.

4) End of life counseling -- in which the doctor denies care to patients.

As Scandlen notes, the end-of-life counseling is not the first step but the final step towards de facto death panels:

End-of-Life Counseling will pay physicians to deliver the bad news to the patient -- "I'm afraid your breast cancer is quite advanced and there isn't anything further we can do. How can I help you get your affairs in order?"

Now, notice the physician is not explaining there IS something that can be done, but the government decided to not pay for Avastin because it costs too much. Or any of the other life-enhancing treatments that would be available if not for federal intervention. No, Medicare would not pay the doctor to deliver this information because it might upset the patient.

We have been warned.

(Read the full text of "Death Panels American-Style" and check out the rest of Scandlen's blog as well. Link via IBD.)

Wolf On Death Panels

Dr. Milton Wolf has a new OpEd in the Washington Times, "Lies, damn lies and death panels".

In particular, he makes a powerful point about the new government policy of "encouraging" end-of-life counseling:

...[T]here is nothing certainly inappropriate about discussing end-of-life care with patients so long as the patient and their family can maintain complete trust that their doctor is providing caring -- and this is crucial -- uncoerced advice. Quite the contrary, it absolutely should be done, but it's a far too important part of the doctor-patient relationship to permit the government to determine how and when. These difficult decisions are undermined unless they are made freely by the patient and his or her family...

Not only have I, as a physician, counseled many families in these trying end-of-life times - a heart-rending and life-changing experience for all of us involved -- but I learned firsthand of their importance when my father, himself a physician, made his own wishes known to us in the final months of his life. If ever a family's decision should be held sacred from the government, this is it.

(Read the full text of "Lies, damn lies and death panels".)

Once the government starts specifying which medical options are "reasonable" or "effective", it undermines physicians' ability to be honest advocates for their patients and instead turns them into agents of their government paymasters.

The end result: Bureaucrats then determines whether patients live -- or die. But just don't call them "death panels".

Criminalizing Patients and Doctors

In the 12/24/2010 Daily Beast, Shikha Dalmia describes how ObamaCare will criminalize both patients and doctors.

In particular, if physicians render "unnecessary" or "ineffective" care to Medicare patients, they could be punished for committing Medicare fraud. Of course, the government gets to decide what counts as "ineffective". Patients may not have heard much about "comparative effectiveness research" -- but they soon will.

With respect to Medicare patients the government is in effect saying, "We won't tell you how to practice medicine -- we don't presume to interfere with your professional judgment. But by the way, if you treat patients in a way we don't approve of, you'll be punished."

(Read the full text of "Obamacare Criminalizes Medicine".)

ObamaCare must go.

Effects of ObamaCare

How have insurers responded to new ObamaCare rules? This list discusses the various rate increases and coverage drops across the country.

Read more at, "Hurtling to Single-Payer: A Reference Guide to ObamaCare's Trail of Destruction".

Of course, government official keep insisting that we can't blame ObamaCare for these rising costs.

Is your state next?

(Via WolfFiles.)

New Rules For 2011

Paul Gessing explains that, "ObamaCare hits my health care (and maybe yours) starting Jan. 1".

In other words, more government controls over how you can spend your own money for your own benefit.

Price Controls and Life Controls

The New York Times published a couple of interesting stories lately on government plans for health insurers and for you:

"Health Insurers to Be Required to Justify Rate Increases Over 10 Percent" (12/21/2010)

"Obama Returns to End-of-Life Plan That Caused Stir" (122/25/2010)

In other words, the government will tell insurance companies how much they will be allowed to charge for their services.

And they will "encourage" doctors to help patients plan for their deaths.

My prediction: Over time, this will inevitably lead to government "encouraging" doctors to help patients decide that certain treatments to extend their lives are too expensive and not worth considering. The government will hijack the the trust patients currently place in their physicians to be their honest advocates and instead use financial incentives to have physicians promote the government's preferred end-of-life spending priorities.

But just don't call them "death panels"!

Unless ObamaCare is repealed, expect to see more such price controls and life controls.

(Links via ReasonPharm and Instapundit.)

Holiday Break

Because of the Christmas holiday, I'll be taking a short blogging break. Regular posting will resume next week.

Merry Christmas, everyone!

Quick Links: Turner, Ralston, Fraser

In the 12/21/2010 Washington Examiner, Grace-Marie Turner explains why "Obamacare is a government takeover".

In the 12/17/2010 Orange County Register, Richard Ralston discusses the FDA Avastin ruling at "Political mugging of a valuable drug".

The Fraser Institute has published, "Waiting Your Turn: Wait Times for Health Care in Canada 2010 Report". A couple of excerpts:

The total waiting time between referral from a general practitioner and delivery of elective treatment by a specialist, averaged across all 12 specialties and 10 provinces surveyed, has risen from 16.1 weeks in 2009 to 18.2 weeks in 2010.

Canadians wait nearly 3 weeks longer than what physicians believe is "reasonable" for elective treatment after an appointment with a specialist.

Full Fraser Institute report (PDF version) here.

Catron: Obamacare and the Broccoli Mandate

David Catron has a new OpEd in AmSpec, "Obamacare and the Broccoli Mandate".

As he notes, the issues run much deeper than health care. Instead, the key issue is freedom -- specifically, should the government be able to deprive you of your freedom to act on your own best judgment and instead force you to do what it thinks is "best" for you?:

...[T]he Obama administration... presumably believes that the commerce clause gives the federal government the authority to regulate virtually every decision we make in our day-to-day lives. Indeed, the belief that Washington can -- and should -- supervise us as if we were a nation of children is the core tenet of their nanny-state political philosophy.

This is the belief system that prompted First Lady Michelle Obama to say, as her husband signed a law that will regulate what children eat during summer vacations and what can be sold in school vending machines, that child nutrition is something "We can't just leave... up to the parents." Without the "help" of the federal government, some mother might fail to force broccoli on her kids.

Likewise, we "can't just leave it up" to the patients to decide for themselves if they should buy health insurance. Indeed, according to the Obama administration, there is something sinister in the very suggestion that we must allow them to do so.

In other words, "We're from the government, we're here to help you -- And if you don't let us, we'll punish you."

Fortunately, more and more Americans aren't buying it. A recent Rasmussen poll shows, "For First Time Ever, Most Voters Think Health Care Repeal Likely".

Let's hope our new Congress and our judges take heed.

What Every Medical Student Should Remember About Randomized Clinical Trials

Classic story by Dr. E. E. Peacock, Jr.:

One day when I was a junior medical student, a very important Boston surgeon visited the school and delivered a great treatise on a large number of patients who had undergone successful operations for vascular reconstruction. At the end of the lecture, a young student at the back of the room timidly asked, "Do you have any controls?"

Well, the great surgeon drew himself up to his full height, hit the desk, and said, "Do you mean did I not operate on half the patients?"

The hall grew very quiet then. The voice at the back of the room very hesitantly replied, "Yes, that's what I had in mind."

Then the visitor's fist really came down as he thundered, "Of course not. That would have doomed half of them to their death."

God, it was quiet then, and one could scarcely hear the small voice ask, "Which half?"

Dr. E. E. Peacock, Jr., University of Arizona College of Medicine; quoted in Medical World News (September 1, 1972), p. 45, as quoted in Tufte's 1974 book Data Analysis for Politics and Policy.)

(Quote via Raw Meat, found via Marginal Revolution.)

Flirting With Unintended Consequences in Massachusetts

The December 18, 2010 Boston Globe illustrates yet another unintended consequence of mandatory insurance benefits in Massachusetts, this time involving flirtatious models wearing short skirts and blue wigs (!)

Here's an excerpt from, "Surge in marrow testing probed":

The state’s largest health insurers began noticing at least a year ago that UMass Memorial Medical Center was submitting an extraordinary number of expensive claims for bone marrow testing and charging higher rates than other providers.

But it was not until this week that one reason for the surge in claims became clear: The Worcester hospital hired models who wore short skirts, high heels, and sometimes sported neon blue wigs to recruit bone marrow donors at malls in Massachusetts and New Hampshire, Red Sox and Patriots games, and flower shows.

The article continues:

The situation is a window into how costs can spiral in the health care system, and the unintended consequences that can occur, when insurers are required to pay for a particular service, even a worthy one.

In the last decade, Massachusetts, New Hampshire, and Rhode Island became the only states where legislators mandated insurers pay for bone marrow testing.

(Read the full text of "Surge in marrow testing probed". The issue is also covered in this December 16, 2010 New York Times story "Flirty Models Were Hired in Bid to Find Bone Marrow".)

This should come as no surprise to journalists. Whenever the government compels insurance companies to pay for a specific service, it creates a natural incentive for others to artificially inflate both the price and the demand for that service. The only unusual aspect about this case was how blatant the manipulation was, which was what allowed the hospital to get caught more easily.

Otherwise, the high costs incurred by the hospital of hiring these attractive young models would have been quietly passed along to the insurance companies, then eventually to Massachusetts residents forced to purchase mandatory insurance (or to the taxpayers).

What we don't know yet is how many more similar-but-stealthier examples of this are still happening with respect to other medical services in Massachusetts? Or how much of this will happen in the other 49 states under ObamaCare?

(Link via @Bettina702.)

Cuba Banned Michael Moore Film "Sicko"?

According to the December 17, 2010 Guardian, Cuba banned the Michael Moore film "Sicko" because it falsely portrayed their socialized health system as better than it really was.

From the article:

Cuba banned Michael Moore's 2007 documentary, Sicko, because it painted such a "mythically" favourable picture of Cuba's healthcare system that the authorities feared it could lead to a "popular backlash", according to US diplomats in Havana.

The revelation, contained in a confidential US embassy cable released by WikiLeaks , is surprising, given that the film attempted to discredit the US healthcare system by highlighting what it claimed was the excellence of the Cuban system.

But the memo reveals that when the film was shown to a group of Cuban doctors, some became so "disturbed at the blatant misrepresentation of healthcare in Cuba that they left the room".

Castro's government apparently went on to ban the film because, the leaked cable claims, it "knows the film is a myth and does not want to risk a popular backlash by showing to Cubans facilities that are clearly not available to the vast majority of them."

(Read the full text of "WikiLeaks: Cuba banned Sicko for depicting 'mythical' healthcare system".)

I don't condone the actions of Wikileaks in releasing secret US diplomatic documents.

But the irony in this particular case was simply too perfect.

Update: Michael Moore is disputing this story.

Hmm, who should we trust here: US government officials or Michael Moore? Unfortunately, neither have a great track record with respect to unassailable honesty!...

Hsieh PJM OpEd: "Beware Counterfeit 'Responsibility'"

PajamasMedia has published my latest OpEd, "Beware Counterfeit 'Responsibility'":

My theme is that the Obama Administration's version of "individual responsibility" (also shared by many Republicans) is a counterfeit version of the concept aimed masking its drive to subvert genuine responsibility and freedom.

Here is the opening:

The ObamaCare individual insurance mandate met its first courtroom defeat when Judge Henry Hudson ruled it unconstitutional in Commonwealth of Virginia v. Sebelius. But while the legal battle is likely to smolder on for years until it reaches the U.S. Supreme Court, the rhetorical battle is heating up in the court of public opinion.

In particular, the Obama administration is attempting to defend the individual mandate as a matter of "individual responsibility." If Americans allow them to get away with this counterfeit notion of "responsibility," it will jeopardize the freedoms that make genuine individual responsibility possible...

(Read the full text of "Beware Counterfeit 'Responsibility'".)

Domestic Medical Tourism

As health costs continue to rise, some entrepreneurial doctors and patients are taking advantage of domestic medical tourism for elective procedures. From the article:

Employers who fund their workers' health coverage are also eager to contain mounting medical costs, Stephano says. They may offer a range of inducements to persuade a patient to have a more affordable procedure, she says.

A $100,000 heart bypass could be had for as little as $32,000 at hospitals working with a facilitator (according to figures provided by BridgeHealth).

Bob Ihrie, senior vice president for employee rewards and services at Lowe's Companies Inc., led a group of five large employers who negotiated special rates with the highly respected Cleveland Clinic to perform heart, back/spine and knee/hip surgeries. While the other companies have not yet announced their plans, Lowe's has already sent 16 employees to Cleveland for surgery since the program launched on April 1, with 14 others scheduled for procedures or awaiting approval.

(Read the full text of "Healthcare: Pay Less, Travel Less".)

As with overseas medical tourism, patients can shop around for quality care at heavily-discounted prices. And one advantage of domestic (as opposed to foreign) medical tourism is that US malpractice laws still apply -- thus giving patients legal recourse if something goes wrong.

This isn't a complete solution to the problems raised by ObamaCare. But it may help in the short-to-medium turn until our politicians finally repeal that law.

For other strategies patients can adopt in the meantime, see "How to Protect Yourself Against ObamaCare" from the Summer 2010 issue of The Objective Standard.

(Article link via J.G.)

Quick Links: Forbes, Florida, and II

Forbes recently published two pieces on ObamaCare:

"The Irresponsible Individual Mandate" by Yaron Brook and Don Watkins of the Ayn Rand Center for Individual Rights.

"Don't Tweak ObamaCare; Repeal It" by Dr. Scott Atlas. (Dr. Atlas is both a senior fellow at the Hoover Institute as well as a professor of radiology at Stanford. I used Dr. Atlas' excellent neuroradiology textbook during my residency.)

HealthCareLawsuits.org discusses the next big legal challenge to ObamaCare happening today in a Florida court.

Brian Schwartz of PatientPower links to this audio from the Independence Institute (aka "II"), "Kopel & Natelson discuss Virginia v. Sebelius".

Wolf: Mr. President, Tear Down This Law

In the 12/15/2010 Washington Times, Dr. Milton Wolf offers some good advice to the President, "Mr. President, tear down this law".

From the OpEd:

...[I]t was the individual mandate to purchase insurance that was determined to exceed the letter and spirit of the Constitution. But this ruling threatens the entire edifice of Obamacare because that mandate is the central linchpin of the Affordable Care Act. In the simplest of terms, the goodies Obamacare promises depend on the money brought in by compelling young, healthy Americans to purchase more insurance than they need. It's a clever version of redistribution, but it's not immune from this one simple reality: no money, no goodies.

Dr. Wolf then goes on to explain how the combination of requiring insurers to take all comers regardless of pre-existing conditions but without the mandate will make private insurance quickly unaffordable. Many patients will "game" the system and only purchase insurance when they become ill.

Or as Amanda Teresi once explained, "It would be the equivalent of not having any car insurance, hitting a tree, and then calling Geico and saying you want to sign up. It doesn't make sense."

Dr. Wolf advises the President:

Be bold. Lead the charge to repeal Obamacare. I know this is against every instinct you have, but look where your instincts have gotten you. This is your chance to hit that reset button.

This is excellent advice from the good doctor. Whether the President listens is a separate matter altogether...

(Read the full text of "Mr. President, tear down this law".)

Quick Links: Orient, Cowen, Siegel

Dr. Jane Orient of AAPS explains, "What Healthcare Reform “Comparative Effectiveness Research” Means to You".

In the 12/11/2010 New York Times, Tyler Cowen notes, "Following the Money, Doctors Ration Care"

In the 12/10/2010 New York Post, Dr. Marc Siegel discusses the "Flight of the MDs" from ObamaCare.

Some Hudson Ruling Reactions

Now that Judge Hudson has ruled the ObamaCare individual mandate to be unconstitutional, what does that mean and what's next? Here are some helpful reactions and analyses:

"A Noxious Commandment", Randy Barnett, New York Times.

"Highlights From the Ruling", and a more detailed analysis, "ObamaCare Loses in Court", Wall Street Journal.

"Key points in Virginia v. Seblius", David Kopel, Volokh Conspiracy.

"Initial Thoughts on the Virginia Health Care Ruling", Jonathan Adler, Volokh Conspiracy.

"Health Care Law Individual Mandate Unconstitutional", Doug Mataconis, Outside the Beltway.

Breaking News: ObamaCare Ruled Unconstitutional

This is obviously a fast-breaking story.

From AP, "Federal judge in Va. strikes down health care law".

You can read the full ruling by Judge Hudson here in PDF format (mirrored here) or here on Scribd.com.

Law professor William A. Jacobson also quotes from Hudson's ruling:

However, the bill embraces far more than health care reform. It is laden with provisions and riders patently extraneous to health care -- over 400 in all.... [at p. 38]

This will almost certainly now go to the US Supreme Court.

Severability Update

At the Volokh Conspiracy law blog, Randy Barnett notes, "White House Concedes Individual Mandate is Not Severable".

If so, this could make today's expected court ruling on ObamaCare very interesting, as Thomas Lifson notes in, "Court to rule on ObamaCare constitutionality Monday" (American Thinker, 12/10/2010).

Today's Wall Street Journal has a nice background piece, "Federal Judge to Rule on Health Law's Constitutionality".

If you missed it earlier, David Catron covered some important background information in his 12/7/2010 article, "Of Severability and Sins of Omission".

The Avastin Travesty

At today's PajamasMedia, Thomas Bowden of the Ayn Rand Center for Individual Rights discusses "The Avastin Travesty".

In particular he describes why the flawed view of a "right" to health care leads to insoluble problems of rationing and cost control in this Pajamas Media piece. The collectivist approach to health policy necessarily harms individual patients in the end. Read the full text.

(For more on this topic, see my related PajamasMedia piece, "Avastin and Your Life".)

Why Health Care Costs Are Still Rising

Devon Herrick at NCPA discusses, "Why Health Costs Are Still Rising".

The short answer:

A primary reason why health care costs are soaring is that most of the time when people enter the medical marketplace, they are spending someone else's money. When patients pay their own medical bills, they are conservative consumers.

In particular, Herrick notes that our current third-party payor system results in:

* For every $1 worth of hospital care consumed, the patient pays only about three cents out of pocket, on the average; 97 cents is paid by a third party.

* For every $1 worth of physician services consumed, the patient pays less than 10 cents out of pocket, on the average.

* For the health care system as a whole, every time patients consume $1 in services, they pay only 12 cents out of pocket.

Herrick contrasts that with the sectors of medicine where consumers pay the bills rather than third parties, such as cosmetic surgery. He notes that in those sectors, demanding consumers seek the best value for their dollar -- and the result is that providers offer ever-improving services at lower prices.

(Read the full text of "Why Health Costs Are Still Rising".)

Suppose food were treated the same way as health care, where one paid a monthly premium to a "food co-op", then got to eat at restaurants where the coop would pay 88-97% of the bill. Hence, consumers only had to cover a "food co-pay" of 3-12%. Would most people eat frugally? Or would they eat lavishly as if they were dining from their boss' expense account?

Of course, this would be unsustainable. Under such a system, the food co-ops (or eventually the government) would quickly have to set strict limits on what foods members could purchase. The end result would be the government telling you what you could or could not eat -- on the grounds that others are paying for your meals. Americans may consider such arguments absurd in the realm of food, but the precise same arguments are currently being made in the realm of health care.

Of course third-party payors play a valuable role in providing voluntary catastrophic insurance. Such a service would be of value to many Americans and would thus naturally arise in a free market. But the current system of third-party employer-based insurance is an artifact of bad government tax policies, and would never have arisen in a true free market.

(For more details, see "Moral Health Care Vs. 'Universal Health Care'" from the Winter 2007-2008 issue of The Objective Standard.)

Prospective Vs. Retrospective Medicine

This ER physician discusses a typical "damned if you do and damned if you don't" scenario in, "Inevitable Malpractice".

As he notes, this the difference between prospective and retrospective medicine: "Doctors have to make decisions in five minutes and lawyers have 5 years to tell you why those decisions were wrong".

Although our broken tort system is not the primary contributor to rising health costs, from personal experience, I know that the amount of defensive medicine that ER doctors must practice in the form of ordering radiology tests is enormous. And given the legal climate in which they must operate, I don't blame them one bit.

(Via @DrVes and @KevinMD.)

Catron on Severability

One of the interesting aspect to the legal challenges to ObamaCare is the fact that the legislation does not contain a "severability" clause. Hence, some argue that if the courts strike down the individual mandate provision as unconstitutional, then the whole law is deemed unconstitutional. At least, that's the argument.

David Catron analyzes this issue in depth in his most recent article, "Of Severability and Sins of Omission".

In particular, he discusses:

1) Was the omission of a severability clause a screw-up or a clever Machiavellian maneuver?

2) Will it make a difference in the long run?

(Read the full text.)

We'll find out soon enough...

Quick Links: Schwartz, Catron, Eck

Brian Schwartz asks, "Should you trust the Colorado Trust?" on the cost-shift argument.

David Catron discusses, "ObamaCare vs. Kids and Seniors".

The rich and powerful always do well under socialized medicine because they have "pull".

Dr. Alieta Eck warns about, "Electronic Medical Records in the Age of Wikileaks".

Can a government that can't even guard its own classified diplomatic secrets be trusted with your personal medical data?

Tech Blogger Vs. FDA

Technology blogger James Kendrick describes how the FDA interfered with a medically necessary treatment for his blocked carotid artery:

It became apparent to me on the table that things weren’t going as the specialists anticipated. It turns out the imaging clearly demonstrated that the blockage was only 70-75 percent, and not the 80-90 percent previous imaging had indicated. That turned out to be very significant, as the FDA only allows the stents to be used in patients like me when the blockage is 80 percent or greater.

Even though the specialists felt I needed the stent to correct my problem, they were not allowed to put it in. [Emphasis mine. -- PSH] So after three hours of intense work by a great medical team, and even though I was already on the operating table ready for the full treatment, the doctors had to pull out without doing anything other than the angiogram. They faced serious sanctions by the FDA had they continued as planned with the actual correction of my medical problem.

(Read the full text of "FDA Takes Over in the OR".)

The FDA claims to be protecting patients against unscrupulous doctors and medical device makers. However, it appears that what patients really need is protection against the FDA.

(Via R.K.)

Update: Reader J.S. correctly points out that the FDA does not directly regulate the practice of medicine. However, it does set the legal climate in which uses of certain devices in certain settings are permissible (or not).

For instance, the FDA might authorize the use of a device only for certain clinical trials until the FDA gives the green light for broader use. In that case, a doctor who strayed beyond the FDA restrictions might risk lawsuits or penalties from licensing/credentialing boards. Or if the physician has commercial ties with the device maker, his use contrary to FDA rules might viewed as "promotion". In either case, the physician is thwarted from using the device as he deems appropriate, even if that would be in the patient's best medical interests.

Hence, the FDA still exerts tremendous indirect effect on how innovative new devices can be used by physicians, even if it doesn't directly overrule the physician's judgment at the time of treatment.

A Day In The Life Of A Neurosurgery Resident

What does it take to become a neurosurgeon?

At KevinMD.com, one aspiring neurosurgeon wrote up a detailed description of a typical day of residency. The countless number of crucial decisions he has to make each day is staggering. I highly recommend reading the full text of his post, "A neurosurgical resident's typical day".

(My own residency in radiology was not as grueling as his, but still pretty damned busy. I saw how hard the neurosurgery residents worked at Washington University of St. Louis during their 7-year program, and I had tremendous respect for them.)

Some day, if you ever have a serious head injury (or develop a brain tumor), your life may lay in the hands of a well-trained neurosurgeon like this one, practicing according to his best independent rational judgment. Yet this the kind of person whom the government wishes to regulate via "universal health care" and "cost effectiveness guidelines". When your life is on the line, who should decide what's best for you -- your neurosurgeon or the government bureaucrat?

In Ayn Rand's classic novel Atlas Shrugged, one of the characters is physician Thomas Hendricks who put the issue into essential terms:

..."I quit when medicine was placed under State control some years ago," said Dr. Hendricks. "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.

"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything -- except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, but 'to serve.' That a man's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards -- never occurred to those who proposed to help the sick by making life impossible for the healthy.

"I have often wondered at the smugness at which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind -- yet what is it they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn.

"Let them discover the kind of doctors that their system will now produce. Let them discover, in the operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man they have throttled. It is not safe, if he is the sort of man who resents it -- and still less safe, if he is the sort who doesn't."

We have been warned.

Health Reform and the Decline of Physician Private Practice

A recent report from Merritt Hawkins discusses how ObamaCare will "will dramatically change how physicians conduct business and likely will mean the end of full-time, independent, private practitioners".

The full report can be found here (PDF version).

The report notes:

[R]esults from a national survey of 2,400 physicians, only 26% of whom said they would continue practicing the way they are in the next one to three years. The remaining 74% said they would retire, work part-time, close their practices to new patients, become employed and/or seek non-clinical jobs.

The physicians who remain in practice will increasingly be herded into large "accountable care organizations" which will require them to practice according to government "cost-effectiveness" guidelines. This trend has already been noted by the New York Times, and will accelerate in the next few years.

If you loved the "managed care" of the 1980s, including the denial of service to save money, then you'll love the new "Government Managed Care version 2.0"!

Medical Bribery in Canada and Japan

Under the system of medical rationing in Canada, some patients are resorting to very desperate measures:

A Quebec woman who claims that she paid a doctor $2,000 to expedite surgery for her cancer-stricken mother is raising questions about whether bribery is being practiced in the province's health-care system.

Vivian Green said she was doing what she had to in an effort to save her elderly mother, who had been diagnosed with pancreatic cancer after she developed a pain in her side.

"When you're desperate you don't care who you bump and how sick they are," Green told CTV News. "I was desperate."

(Read the full text of "Quebec woman claims she bribed doctor for treatment".)

Basically, the Canadian medical system puts decent people in an impossible situation where they must choose between following the rules vs. saving their own lives.

Nor is this limited to Canada. In Japan, those willing to pay appropriately large "gifts" to doctors and hospital administrators get bumped to the head of the waiting lists.

Under such socialized medicine, those who are able to "grease" the system through money or political influence will always do well. In contrast, ordinary people will lose out.

(Link via Zip and K.V.)

Update: More details at the Montreal Gazette, "Want fast care? Slip an MD some cash":

Minimum $2,000 to guarantee that a woman's doctor will be there for the birth. "And it can go up to $10,000," he added.

For general surgery, the cost runs between $5,000 to $7,000 to jump the wait list into the operating room, he said.

For Green and Marcus, the $2,000 got their mother's operation bumped up -- but not the surgeon they wanted.

(Via @debbywitt and Mark Perry.)

The Medicare Squeeze

The November 26, 2010 Washington Post notes that Medicare patients continue to have difficulty seeing their physicians, and that such problems are likely to worsen soon.

Here's an excerpt from, "Doctors say Medicare cuts force painful decision about elderly patients":

Want an appointment with kidney specialist Adam Weinstein of Easton, Md.? If you're a senior covered by Medicare, the wait is eight weeks.

How about a checkup from geriatric specialist Michael Trahos? Expect to see him every six months: The Alexandria-based doctor has been limiting most of his Medicare patients to twice yearly rather than the quarterly checkups he considers ideal for the elderly. Still, at least he'll see you. Top-ranked primary care doctor Linda Yau is one of three physicians with the District's Foxhall Internists group who recently announced they will no longer be accepting Medicare patients.

"It's not easy. But you realize you either do this or you don't stay in business," she said.

The article also notes that this is the current situation after the temporary one-month government "fix" -- but that the underlying problems with Medicare will soon return with a vengeance after the latest fix expires.

As always, these Medicare patients have theoretical "coverage" -- but that's not the same as access to actual medical care.

Perhaps those on the political Left who advocate for universal health care as "Medicare for all" should first try to find a doctor as a new Medicare patient.

(Link via Dr. Milton Wolf.)

Senators Barrasso and Coburn To Medical Students

US Senators John Barrasso, M.D., (R-Wyoming) and Tom Coburn, M.D. (R-Oklahoma) have written an open letter to American medical students about ObamaCare. Both of them are practicing physicians as well as US senators.

Here are a couple of key excerpts, discussing both current problems -- and future problems under ObamaCare:

Today, many physicians face a series of obstacles. They are forced to watch the clock. They are over-burdened by Washington mandates, paperwork requirements, and low reimbursement rates. And they feel tremendous pressure to increase the volume of patients they see each day—rather than having sufficient time to give each patient the attention they deserve. Unfortunately, even bigger changes for the medical community lie ahead.

...Instead of making it easier for doctors to connect with their patients, the new health care law gives Washington more power to determine care. Washington already funds 60 percent of health care in America. The health care law increases Washington’s role by creating more than 150 boards and entities invested with new powers that will inevitably intrude on the patient-physician relationship.

The new law also encourages "cookbook medicine" with new comparative effectiveness authorities that will make coverage determinations based on cost -- rather than what may be best for individual patients.

Another similar new entity is an Independent Payment Advisory Board -- a panel of unelected, unaccountable bureaucrats who are empowered to administer top-down reimbursement cuts designed to reduce federal health care spending.

(Read the full text of their open letter.)

Note: Although I don't necessarily agree with all of Coburn's proposed alternatives expressed elsewhere, they have nicely summarized some critical problems with ObamaCare.

Holiday Hiatus

I'll be taking the rest of the week off from health care blogging due to the Thanksgiving holiday. Regular posting will resume on Monday, November 29.

Happy Thanksgiving, everyone!