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Author Topic: The Politics of Health Care  (Read 447442 times)
Power User
Posts: 42529

« Reply #350 on: August 17, 2009, 11:02:14 AM »

A third question to add to my other two:

3) What do we make of the proposed exchanges?

Power User
Posts: 9483

« Reply #351 on: August 17, 2009, 11:44:27 AM »

Marc,  I don't understand the remaining question on "2) What happens now when an insurance company discontinues insurance when someone develops a problem?"

I carry a catastrophic policy. I bought it and have been paying for it since I was young and healthy.  If I am tomorrow discovered to have a hugely expensive disease, I assume that I have coverage for as long as I keep the policy up to the limits of my coverage.  If not, there is certainly a role for government regulation because anything short of paying according to the agreed terms is IMO theft by swindle.  Why would anyone buy health insurance while healthy if coverage is canceled when diagnosed?

On point 1), very few people and no serious, electable politicians oppose some sort of a safety net.  We already have that. The point would be that if you decline insurance while healthy you may have to exhaust your own resources before submitting your bill to the other taxpayers.  I know there are those who think ordinary people shouldn't be troubled to pay their own living expenses like college or health care.  Margaret Thatcher put it best: "Margaret Thatcher quote: "The trouble with socialism is that you eventually run out of other people's money."

3) Health care exchanges could be a way to energize a free market that is sorely lacking in health care or could be just another way to bring the heavy hand of government down on health care, dependinig on how they are set up.  From a jurisdictional point of view, I would like to see a federal plan written to help consumers-patients-providers that allow states to OPT-IN rather create more coercion from Washington.  This recent discussion sheds only a little light on the subject:

Transcripts: "Reviving the Economy"-Health Insurance Exchange
Friday, June 05, 2009 (PBS Nightly Business Report)

PAUL KANGAS: Next week, lawmakers on Capitol Hill are expected to roll out proposals to overhaul the country's health care system. President Obama wants to hold down costs and provide health coverage for 50 million uninsured Americans. To help make that happen, one idea in the works is what's called a health insurance exchange. In tonight's installment of "Reviving the Economy," Dana Bate explains what that exchange might look like and how it would work.

DANA BATE, NIGHTLY BUSINESS REPORT CORRESPONDENT: Whether it's shopping on eBay or searching for a phone plan, Americans love a good deal. But if you decided to shop around for a health care plan today, chances are it wouldn't be easy. Health economist Linda Blumberg says that's because the health insurance market is broken.

LINDA BLUMBERG, HEALTH ECONOMIST, URBAN INSTITUTE: It's kind of the wild, wild west out there, particularly in the non-group insurance market, but also in the small group market and people who are making purchasing decisions don't have the information they need to make good choices.

BATE: That's why she and many others in the health care community want to bring a sheriff to town in the form of a health insurance exchange. The idea is to create one-stop shopping for health insurance. Consumers could go to this insurance marketplace, compare local plans, find out what government aid is available and figure out which plans are best. Former Medicare director Mark McClellan says an exchange would spread risk across plans so that it's easier and cheaper to insure more people.

MARK MCCLELLAN, DIR., HEALTH CARE REFORM, BROOKINGS: So the idea is to try to set up a system in which people could have guaranteed access to coverage that they can afford, that doesn't necessarily charge them more just because they have existing health problems.

BATE: So who would be eligible to use this exchange? That's for Congress to decide. But to start, the exchange would probably focus on small businesses and individuals who can't get insurance through their employer. How much the government will regulate the exchange is also a question.

MCCLELLAN: On the one hand, you want to try to give people clear, comparable choices, so anything that you can do to simplify the range of choices and the number of choices can potentially help with that. On the other hand, the point of competition is to encourage people to be able to sign up for plans that do health care better.

BATE: Blumberg worries too little regulation could lump high risk people together, defeating the system's purpose.

BLUMBERG: The way that insurers behave is in their interest to have the lowest cost, lowest risk enrollees in their plans. The more that they can differentiate the plans that they're offering, the more they can attempt to attract individuals of different risk.

BATE: Lawmakers also need to decide who would run a health care exchange, whether there would be a single national marketplace or whether states would create their own. And, of course, there's the question of whether the government will offer its own health plan to compete with private insurers. Dana Bate, NIGHTLY BUSINESS REPORT, Washington.

« Reply #352 on: August 17, 2009, 06:02:02 PM »

A doctor responds to Obama's NYT op-ed

G. Wesley Clark, MD
Mr. President, I just read your op-ed in the New York Times.  You must either be incredibly ignorant (e.g., pediatricians performing tonsillectomies, surgeons being paid $50,000 for an amputation), or else you believe that Americans are incredibly stupid.   

You justify a hasty and massive healthcare "reform" to save money, by spending an additional trillion dollars.  You would fix a "broken" and broke Medicare system by adding another 47 million beneficiaries to government programs while arguing this will reduce overall costs.   

I've itemized your inaccurate claims, with my comments in italics.

You assert that your healthcare reform will:
Force insurance companies to insure pre-existing conditions. That's like allowing bettors to wait till after the race has been run, to place their bets. That won't cut costs.

Eliminate lifetime limits on coverage. Unlimited lifetime coverages must increase premiums to pay for them and will raise total costs.

Require insurance companies to pay for routine examinations, preventive care, and screening tests like mammograms and colonoscopies. Once again, how can you be insured against a sure thing? The only way my company can pay for a colonoscopy is to add enough onto the premium to pay for it, plus their overhead.

Make Medicare more efficient, so tax dollars won't enrich insurance companies. Insurance companies do not derive income from Medicare, because it is a federal program. Incidentally, its costs per patient have increased much faster than private insurance.

Cut hundreds of billions of dollars in waste and inefficiency in federal health programs like Medicare and Medicaid. These programs have been in effect over 40 years -- and I've seen the waste and inefficiency for most of that interval. Did you just find out about the waste and inefficiency now, and why hasn't something already been done about it?

You claim that:

"If you like your health care plan, you can keep your health care plan." But didn't you just imply this week that Medicare Advantage subsidizes insurance companies and should be eliminated to save money?

"If you like your doctor, you can keep your doctor." But large numbers of doctors have indicated that they will quit or retire if this plan is enacted

"You will not be waiting in any lines." Maybe you won't but we will. Your plan will add up to 47 million new insureds, with no increase in the supply of primary care physicians that are already in short supply.

We physicians live with our healthcare system, all day and every day.  We care about being able to heal.  We hate disputing with insurance companies, and especially with government bureaucrats.  Certainly changes in insurance practices are needed, and would have occurred long ago, absent a government record of 60 years of meddling with the market.

As you say, "...let's disagree over issues that are real, and not wild misrepresentations" such as those in your op-ed, "that bear no resemblance to anything that anyone has actually proposed."

And I agree, this is about America's future:  whether Americans will remain free, or be ruled by an increasingly intrusive and authoritarian statist government.

G. Wesley Clark, MD

(Doctor Clark is not related to the retired general of the same name)
Page Printed from: at August 17, 2009 - 06:56:56 PM EDT
Power User
Posts: 9483

« Reply #353 on: August 17, 2009, 07:11:54 PM »

BBG, What a great letter! Crafty wrote earlier that "Simply going NO to BO's liberal fascist agenda will not be enough."  This is true of course but the first step is to persuasively and emphatically say NO to Obama' liberal, fascist agenda.
« Reply #354 on: August 17, 2009, 10:21:02 PM »

Jumpin' the gun here, IMO, but an interesting read nonetheless.

How the Battle of ObamaCare Was Won

By Daniel Greenfield  Monday, August 17, 2009

With Obama’s allies sounding the retreat on the public option, ObamaCare has taken a decisive blow. And Obama has taken his first major political defeat. What is particularly extraordinary is that he has suffered this defeat, despite interrupted media sycophancy delivering programming that reflected every single White House talking point.

From smearing Republicans as in the pockets of the insurance industry and Town Hall protesters as extremist racists, to treating ObamaCare as the only reasonable thing that only lunatics would resist-- the media delivered on its end of the propaganda. And yet minds kept getting changed in the other direction.

So how did it happen?

We can turn for starters to the man whose shadow Obama has occasionally sought to fill (when he isn’t filling the shadows of FDR, JFK, Ronald Reagan and the Messiah of all Mankind), Abraham Lincoln. It was Honest Abe who said, “You can fool some of the people all of the time, you can fool all of the people some of the time, but you can’t fool all of the people all of the time.” With Obamacare, Barry Hussein discovered that he couldn’t fool all of the people, all of the time after all.

The media’s great faith in itself notwithstanding, most Americans don’t put very much faith in what they hear on the news. The media’s propaganda works best when it’s going the way they want to go. For years Americans tuned out the media’s Bush bashing, except when they came to feel frustrated about the war and the economy. This resulted in the media taking credit for something that didn’t have nearly as much to do with them, as they would like to believe. The media may pride themselves on playing the liberal Iago to the flyover country Othello, but the rumors and lies they feed only work when Othello is already suspicious of Desdemona.

This time around the American public sided with critics of ObamaCare and with the Town Hall protesters, despite the media’s White House orchestrated smear campaigns against them, because the American public was itself suspicious of ObamaCare and found some of the issues that were raised to be valid. The hurt and baffled stories in the press only demonstrate the cluelessness of the liberal bi-coastal elites and their inability to understand that they are not actually in control of the American people.

And what goes for the media, goes double for the Obama Administration, who’s commitment to style over substance, and image over reality, blinded it to the fact that many of those mainstream Americans who did vote for Obama, were giving him a chance, rather than an open ended mandate. With ObamaCare, Barry trotted out a high flying media campaign and did what he’s always done, put on a show. But the show never went on as scheduled because ordinary Americans, including those who voted for him, had actual questions they wanted answered.

If up till now Obama had successfully played the slick car salesman, waving banners, hiding behind grand but hollow phrases, and showing off how shiny the car was-- with ObamaCare, the customers for the first time began asking questions about what’s under the hood. And that’s not something Obama is equipped to answer in anything but vague generalities. Obama has shown himself to be a Master of Distractions, but with all the money that Americans had spent on Stimulus packages and the automaker bailouts, for the first time the American taxpayer put his hand on his wallet and asked, “So tell me pal, how much is all of this gonna cost me.”

But public skepticism alone may not have been enough, the key ingredient was that for the first time in his career, Obama ran into some serious opposition that he couldn’t gladhandle his way out of. Not opposition from the Republican party, which has become too fixated on finding new ways to lose gracefully, while trying not to piss off its base too much. But from a growing grass roots movement.

One of the fatal mistakes of the Obama Administration was its attempt to demonize and suppress that grass roots movement. The first phase of the mistake got the media to focus on the protesters, by smearing them as extremists, violent disruptors and all around dangerous folk. This was par for the course in the Obama camp, but it put a vocal protest movement on television, and as Obama should have known from his own radical roots, once you put people on television, even in order to smear them, their message can’t help but be heard.

Obama’s people understood their mistake a little too late, and released a followup meme which blasted the media for focusing on the protesters, a message delivered from the top down from Obama himself, to his media stooges like Jon Stewart. But it was too little, too late. The damage had been done.

Obama’s people had sought to frame the ObamaCare debate as being between the reasonable health care reform advocates, and the ugly extremists protesting it. Marginalizing them was meant to marginalize criticism of ObamaCare itself, which would make mainstream conservatives distance themselves from it. It was a classic Alinsky tactic, but this time it backfired badly, even before Obama’s bussed in SIEU thugs began beating people up at Town Halls.

From the start Obama’s people had sought to create the image of a Republican party split between a helpless leadership and an extremist base. It was the tactic used in targeting Rush Limbaugh with the meme that he was the real head of the Republican party. It was the tactic used in giving airtime to the likes of Meghan McCain. And the Republican party appeared to be living up to it.

Michael Steele and all too many GOP Senators seemed willing to provide the helpless leadership side of the ticket, as recently as the Sotomayor debacle. No wonder then that the Obama Administration was caught flatfooted by the opposition they faced at Town Halls when it came time to try and sell ObamaCare to the American public.

Liberals have never taken seriously the idea that anyone but them is capable of fielding a grass roots movement, which is why the initial smear campaigns against the Town Hall critics claimed that they were astroturfed Republican operatives in Brooks Brothers suits, apparently the same ones who kept that nice Mr. Gore from becoming President and saving all the Polar Bears.

When this quickly exposed itself as ludricious nonsense, the panicked left dragged out the race card, condemning critics as racists and neo-nazis. Newspapers described a photoshopped image of Obama as the Joker with the tagline ‘Socialism’, as racist, a claim that never made sense to anyone. Not even them. Pelosi conjured up Swastika bearing mobs descending on Town Halls.

Not only did these tactics fail, but they backfired badly. The American public wanted a serious discussion of health care reform. Instead what they got was FUD that had absolutely nothing to do with the issue. The American public, on either side of the aisle, had very little interest in hearing about the paranoid ravings of the Democratic party. They wanted answers. What they got were already unpopular Senators and Congressmen trying to rush people through the process, yelling at constituents and admitting they had no idea what the legislation actually said.

The game was over even before the SIEU purple mobs got on the scene. The relative passivity of the Republican leadership had suckered the Obama Administration into believing they were facing a cakewalk. It was seemingly obvious that the same inept Republican leadership that had let the Chrysler, GM nationalizations and the Sotomayor nomination slide by, could not seriously challenge them on an issue that they were certain had such broad appeal.

But the defanged Republican leadership had opened the way for the grass roots to play a larger role than ever. Congress’ falling ratings had made many representatives nervous about going into an election, and the split between conservative and liberal Democrats did not help matters. Obama had thrown the ball to congress, forgetting that congress had been unpopular for a while. What emerged was a tremendous disaster.

The Republican party may have been paralyzed at the top, but Town Hall protesters demonstrated that its ideas were quite vital, active and alive. The public was faced with the sight of already unpopular politicians being confronted by people demanding answers. And since they wanted answers too, the entire situation pushed them to do the research better. The internet had made a media monopoly of limited use, which allowed people to bypass the press in many cases, and allowed anyone interested to read contrary opinions very easily.

The resulting outcome demonstrated that while the Democratic party may be stronger than the Republican party, the grass roots of people who are suspicious of big government may be stronger than either one. The war is not over, but Obama has suffered a series crisis of both image and legislation, as shifting poll numbers quickly convinced him to retreat. Like Clinton’s own health care defeat, this shows a sign of weakness, and one that should embolden congressional Republicans who until now have been far too inept at seizing opportunities, particularly in comparison to party figures such as Sarah Palin, Newt Gingrich and Rudy Giuliani, who do not even hold any actual public office at the moment.

Obama meanwhile has been shown an extremely painful lesson about the limits of his cult of personality. Whether or not he has actually learned that lesson is something we have yet to see. But what is truly important is that the Republican party learn the lesson that its strength lies not in media consultants or grappling for some middle ground, but by confronting, challenging, risking and daring. The public does not reward political complacency for very long. To be average in politics, all you need to do is warm a chair and return some political favors. To triumph you must dare to do great things.

The protesters who went out to confront their politicians, did so against the odds. No one in Washington D.C. thought they would succeed or even make an impact. And once again Washington D.C. on both sides of the aisle, proved to be wrong. Lincoln’s timeless words represent a warning to would be monarchs and messiahs in American politics, that they cannot long succeed in controlling an entire nation with their lies. Americans may given in to the political circus of elections, but eventually the tents are rolled up, the elephants lie down to sleep and the public demands more than entertainment, they demand results.

The focus on specific issues, on questioning actual legislation and being in tune with the public’s own questions helped bring us here. The Town Hall protesters became the standardbearers for growing American skepticism toward the Obama administration. Harnessing that skepticism through grass roots movements marks the path toward victory.

Daniel Greenfield is a New York City based writer and freelance commentator. “Daniel comments on political affairs with a special focus on the War on Terror and the rising threat to Western Civilization. He maintains a blog at

Daniel can be reached at:
« Reply #355 on: August 18, 2009, 05:39:21 PM »

It's not like there are not a lot of examples out there demonstrating convincingly what single payer systems inevitably bring.

Agency to rule on new cures
By TRACY WATKINS - The Dominion Post

A powerful agency will decide which treatments to provide at public hospitals under a major revamp of the health system.

The Government yesterday made public a long-awaited report on the health system after details of a Ministerial Review Group's recommendations were leaked to The Dominion Post last week.

The report recommends gutting the Health Ministry by shifting many of its functions to a new National Health Board. It also recommends extending the powers of the national drug-buying agency, Pharmac, to decide which medical equipment should be bought and significantly boosting the powers of the existing National Health Committee to decide what new diagnostic procedures and treatment should be provided by the public health system.

It recommends that hospital services be decided on a region-wide basis, rather than leaving it to individual district health boards to decide saying "parochial interests" risked leading to poor decisions and determining access to services and treatment by "post code".

The report was written against the backdrop of warnings that New Zealand's ability to pay for world-class health treatment is increasingly under threat.

It recommends putting the National Health Committee in charge of determining what new treatments should be eligible for public funding "and the conditions under which they should be applied".

"For example, as well as defining the patient group most likely to benefit, a new treatment might only be suitable for trial, or use in tertiary hospitals, or where everything has failed an individual patient.

"As part of its reprioritisation process, the National Health Committee should also be asked to identify and assess a number of existing interventions annually that ... appear to be low priority."

The group appears to be using a Pharmac-like model for the plan. Pharmac determines what drugs should be subsidised on the basis of cost and effectiveness, but it has courted controversy for refusing to fund some drugs. The most recent example was the breast cancer drug Herceptin, which the Government eventually agreed to fund.

Labour MP Ruth Dyson said the recommendations "dangerously point to a rationing of frontline health services". "Mothers, the elderly and others not in paid employment should be extremely worried by any suggestion of rationing healthcare to those in paid work."

Green MP Kevin Hague said the idea that healthcare should be rationed on the basis of an ability "to contribute to economic growth" was "obnoxious in the extreme".

But the Ministerial Review Group, which was headed by former Treasury secretary Murray Horn, said it was only proposing "service prioritisation at the margin", acknowledging that experience in New Zealand and overseas showed that any attempt to identify which core services should be publicly funded was "unlikely to succeed in the current environment".

Association of Salaried Medical Specialists executive director Ian Powell said the proposals were radical and destabilising. "It has the feel of a Stalinist monolith about it."

It was "bananas" to suggest that "creating more bureaucracy reduces bureaucracy".

Health Minister Tony Ryall said the Government was not obliged to accept any of the report's 170 recommendations, and he would not support any that increased bureaucracy. The Cabinet is likely to consider the report in the next few months.


New Zealand on average spends less per person on health than other developed countries.

Spending on health has been growing much faster in New Zealand than overseas up 30 per cent since 1995, compared with an OECD average of 18 per cent.

The number of senior medical staff has increased by 46 per cent in the past 10 years but more than half of the doctors were born overseas and only 50 per cent of international medical graduates are still working in New Zealand after a year.

Real health costs are set to almost double if they continue to grow at the current rate in the next 20 years, requiring nearly twice as many hospitals, doctors and nurses.

GPs are working fewer hours, not more, since the Government put a cap on GP fees.

Medical error is estimated to harm 44,000 people a year at a cost of $570 million.
« Reply #356 on: August 19, 2009, 10:06:22 PM »

The Waxman Inquisition

David Jeffers
In what can only be described as Soviet-style intimidation of the free market, Rep.  Henry Waxman (D-Ca), Chairman of the House Energy and Commerce Committee, along with Rep. Bart Stupak (D-Mich), Chairman of House Energy and Commerce investigations and oversight subcommittee, have sent letters to 52 of nation's largest health insurance companies demanding to see these companies detailed financial records.

Is this just good congressional oversight or something more sinister?  FOXNews reports:

Nick Choate, a spokesman for Stupak, said 52 letters were sent late Monday to the nation's largest health insurers, those with $2 billion or more in annual premiums. He said letters were not sent to other industry groups, some of which have been airing television advertising in support of Obama's call for legislation. (Emphasis added)

These Stalinist punitive measures should be aggressively opposed by these 52 companies and the GOP needs to publicly castigate the Democrats for these Chicago-style gangster tactics.  I cannot imagine anything more intimidating to a businessman than the fear of congressional oversight into your private enterprise if you decide to oppose invasive legislation.

It is time to let Congressmen Waxman and Stupak know that this type of intimidation of American business men will not be tolerated.

Page Printed from: at August 19, 2009 - 11:04:46 PM EDT
Power User
Posts: 7838

« Reply #357 on: August 20, 2009, 03:18:55 PM »

***WASHINGTON – President Barack Obama guaranteed Thursday that his health care overhaul will win approval and said any bill he signs will have to reduce rapidly rising costs, protect consumers from insurance abuses and provide affordable choices to the uninsured — while not adding to the federal deficit.***

He still doesn't get it.

Who is going to pay for this???

He still is not being honest with the public.

« Reply #358 on: August 20, 2009, 04:04:48 PM »

Who is going to pay for this???

Easy, the Tooth Fairy, that's who.

Amuses me that Obamacare supporters get so wrapped around the axle over "death panel" claims, when the very ambiguity of the nebulous yet sweeping overhaul they seek just about assures that kind of extrapolation will occur. Their gonna insure more people, claim to pay for it by by forcing saving, though they'll need 80 billion dollars a year to do so in a fiscal climate where we've already run up $2,000,000,000,000 deficit, and in spite of the fact we already have similar programs like Medicare that are rife with waste and abuse. Something's gotta give and the quality of care for older folk is as likely a candidate as anything.
Power User
Posts: 7838

« Reply #359 on: August 20, 2009, 04:09:56 PM »

Can anyone think of any other profession whose pay is and will become even more complicated?
I would rather sit and attempt to invent calculus that try to figure this out.
One real concern is the incentive under these situations to with hold care.
Otherwise it is so complex I have no clue whether I should be for or against.  Whether it would save money, improve care, make my life better or God knows what.

All the more reason not to ram 1000 pages of craziness down our throats.

****Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model
Posted by NEJM • August 19th, 2009 • Printer-friendly
François de Brantes, M.S., M.B.A., Meredith B. Rosenthal, Ph.D., and Michael Painter, J.D., M.D.

In the current debate over health care reform, many observers are proposing new delivery structures to move U.S. health care away from fragmentation, poor performance, and dysfunction toward accountability for high-value care. Ideally, these new structures would promote clear accountability for both improving quality and controlling costs and would encourage health care professionals to organize themselves into teams working on behalf of patients. For such structures to be sustainable, however, the payment system must reward professionals for the quality and efficiency of services, rather than the quantity.

Our fee-for-service payment schemes have contributed to, if not largely created, the current fragmentation. Fee-for-service payments create incentives to provide high volume rather than high value — more, not better, care. So what kinds of payment could promote and sustain high-value care and motivate the development of accountable care organizations? Most experts agree that some sort of bundled, episode-based payment would help to move the system in the right direction. Our own approach, the Prometheus Payment model, for instance, bundles services and provides a budget with three components: evidence-informed base payment with patient-specific severity adjustments and an allowance for potentially avoidable complications (see box, “The Prometheus Model”).1,2 The model has been developed and evaluated through several small pilot projects, which offer some lessons about the ability of episode-based payment to improve cost and quality within the current fee-for-service system. This kind of payment aims to foster outcomes-focused collaboration among otherwise unaffiliated providers and offers a bridge from our fragmented system to a more integrated, accountable one.

The model encourages two behaviors that fee for service discourages: collaboration of physicians, hospitals, and other providers involved in a patient’s care; and active efforts to reduce avoidable complications of care (and the costs associated with them). It accomplishes these goals by paying for all the care a patient needs over the course of a defined clinical episode or a set period of management of a chronic condition, rather than paying for discrete visits, discharges, or procedures.

When incentives are used to drive changes in behavior, it is important that people and organizations are held accountable only for the variables that are actually under their control.3 That’s why, in designing the Prometheus model, we decided to focus on the potentially avoidable costs of patient care. We separated the costs attributable to patient-related factors from those attributable to providers’ actions. These latter costs are critically important in terms of accountability. In Prometheus, these potentially avoidable costs are called PACs and are recognized as the result of “care defects” — problems necessitating technical care that are under the professionals’ control and that, with the best professional standards, could have been avoided. PACs might include the cost of hospitalization of a patient with uncontrolled diabetes or the readmission for a wound infection of a patient who had recently been discharged after cardiac bypass surgery.

The opportunities for improving quality while reducing costs are substantial, reaching far beyond the well-publicized problem of avoidable readmissions. Our analyses of several national and regional data sets, in addition to our pilot work, show that PACs account for 22% of all private-sector health care expenditures in the United States.4,5 The data show that PACs can account for as much as 80% of all dollars spent for conditions such as congestive heart failure that require intensive management and that there are significant regional variations in PACs. On the basis of our current findings, we project that even a modest reduction in PACs from one year to the next would have a considerable effect on the private sector’s portion of health care spending over the next 10 years (see graph). If such results were replicated in a Medicare population, the potential savings would double, reducing the country’s health care bill by more than $700 billion over 10 years.

Projected Private-Sector National Health Expenditures under Current Assumptions and If Potentially Avoidable Costs Were Reduced by Either 10% or 15% Per Year.

Data are from the Department of Health and Human Services 2009 and our own analysis. PAC denotes potentially avoidable cost.

Unlike the current payment system, Prometheus provides larger profit margins for providers who can eliminate these complications, since they keep any unused PAC allowance — they profit by delivering optimal care, not a greater volume of care. Prometheus also avoids some of the classic pitfalls of capitation. Capitation has the unfortunate effect of transferring essentially all risk (including insurance risk) to providers and then encouraging them to pursue undifferentiated reductions in services in order to maximize financial gain. Prometheus mitigates those capitation problems — in part because the occurrence of a new case simply triggers a new patient-specific, severity-adjusted case rate and in part because typical costs and PACs are tracked and accounted for separately and, for now, opportunities for increasing financial gain are limited to decreases in PACs.

Clinical integration may be one way for providers to succeed under Prometheus, but it’s not the only way. In fact, for most of the delivery system, the changes that are required to achieve full integration are neither feasible nor desired by many potential participants. Though there may be minimal organizational requirements for managing patient care in ways that minimize PACs, it is the act of collaboration, not a particular form of organization, that Prometheus attempts to promote.

One lesson from our pilots is that hospital-centric provider organizations can expect increased internal tension when they implement an episode-of-care payment system. Prometheus does provide a sort of bonus to the hospital and physicians for working together to avoid readmission (see box, “Prometheus in Practice”). However, physician groups that are paid under the model for managing chronic conditions have substantial opportunities to increase the profits that come from avoiding expensive hospitalizations. This incentive can highlight potential conflicts between the financial interests of physicians and those of hospitals and cause us to question the proposition that hospital-centric provider organizations will deliver the best results for the country.

Prometheus does not require that a single integrated organization accept payment for an entire episode of care; we recognize that unrelated providers often overtly or tacitly comanage a patient’s care. A limitation of many episode-payment programs is their reliance on prospective payment, which forces the payer to find organizations that will accept the global fee. The Prometheus model, by contrast, can be implemented in a fragmented, largely fee-for-service delivery system if the payer retains the role of financial integrator. Over time, as providers collaborate to improve patient care and optimize their margins, they could more formally integrate into accountable organizations. However, it will and should be their choice to do so.

To facilitate this transition, the current Prometheus pilot sites are not using prospective payment. Instead, budgets are set prospectively, and payers reimburse providers for all fee-for-service claims submitted. Quarterly actual spending for typical and potentially avoidable care is reconciled against the budgets, and detailed reports are made available. Yet the incentives are the same as they would be with prospective payment: if actual spending is under budget, the difference is paid out as a bonus; if it is over budget, some payment is withheld.

Prometheus is not appropriate for reimbursements for all conditions, but there is sufficient evidence to define both typical care and PACs for types of episodes that account for half to two thirds of health care expenditures. At a minimum, our efforts to translate our conceptual model into practice suggest that it can effectively provide a bridge from the current fragmented delivery system to an accountable care system in which collaboration and the pursuit of excellence are the norm.

The Prometheus Model

Developed in 2006, the Prometheus Payment model now has three pilot programs in operation, supported by the Robert Wood Johnson Foundation. The model attempts to go beyond pay-for-performance approaches to pay for individual, patient-centered treatment plans that reward providers fairly for coordinating and providing high-quality and efficient care. Prometheus packages paymentaround a comprehensive episode of medical care that covers all patient services related to a single illness or condition. Decisions about which services will be covered for a given type of episode are made according to commonly accepted clinical guidelines or expert opinions that outline the tested, medically accepted best method for treating the condition from the beginning of an episode to the end. The prices of all included treatments are tallied to generate an “evidence-informed case rate” (ECR),which becomes a patient-specific budget for the entire care episode. ECRs include all the covered services related to the care of a single condition — services provided by everyone who would typically be involved (hospital, physicians, laboratory, pharmacy, rehabilitation facility, and so forth). The ECR isadjusted for the severity and complexity of the individual patient’s condition, and it incorporates an allowance for a portion of the current costs associated with potentially avoidable complications.

Prometheus in Practice

A 63-year-old white man with chest pain and a history of unstable angina is admitted to a teaching hospital. The patient has hypertension and diabetes. An electrocardiogram reveals ST-segment elevation in the lateral leads. The man is taken to the cardiac catheterization laboratory, where coronary angiography reveals severe triple-vessel disease as well as 60% stenosis of the left main coronary artery. A left ventriculogram shows mitral regurgitation (grade 2 to 3) with papillary muscle dysfunction. The patient is then taken urgently to the operating room, where he receives two venousgrafts and a left-internal-thoracic-artery graft. In addition, a mitral-valve reconstruction procedure is performed to correct the mitral regurgitation. The surgery is a success, and the patient returns to the intensive care unit in stable condition. However, his blood sugar is out of control, and he requires an insulin drip. His stay in the intensive care unit is prolonged by 2 days, and he must stay another day in the step-down unit. He is discharged 8 days after surgery in stable condition. One week after discharge, he is readmitted for a wound infection in his leg from the vein harvest site. He requires wound débridement and a course of antibiotics.

Under fee-for-service payment, the hospital would receive $47,500 for the bypass surgery, and the surgeon would receive $15,000 for performing the procedure. The extended hospital stay that was necessitated by the uncontrolled diabetes would result in an additional $12,000 for the hospital and $2,000 for the physician, and the readmission costs would total $25,000, for a grand total of $101,500.

Under Prometheus, the case-payment rate for this patient would include a severity-adjusted budget for typical costs of $61,000 for the hospital and $13,000 for the physician. The severity-adjusted allowance for PACs would be $15,300, for a total budget of $89,300. Had the readmission been prevented, the hospital and physician would effectively have earned a bonus of $12,800 ($101,500 – $25,000 = $76,500, which is $12,800 less than the Prometheus budget).

Mr. de Brantes reports serving as chief executive officer of Bridges to Excellence, which runs the Prometheus Payment model. Dr. Rosenthal reports having served on the original design team for Prometheus Payment and on the board of Prometheus Payment and participating in the evaluation of Prometheus pilots with funding from the Robert Wood Johnson Foundation. Dr. Painter reports supervising the implementation grant for the Prometheus Payment pilots for the Robert Wood Johnson Foundation. No other potential conflict of interest relevant to this article was reported.

Source Information

From Bridges to Excellence, Newtown, CT (F.B.); the Harvard School of Public Health, Boston (M.B.R.); and the Robert Wood Johnson Foundation, Princeton, NJ (M.P.).

This article (10.1056/NEJMp0906121) was published on August 19, 2009, at


de Brantes F, Camillus J. Evidence-informed case rates: a new health care payment model. Washington, DC: The Commonwealth Fund, April 17, 2007. (Accessed August 13, 2009, at–A-New-Health-Care-Payment-Model.aspx.)
Gosfield A. Making Prometheus Payment rates real: ya’ gotta start somewhere. Princeton, NJ: Robert Wood Johnson Foundation, June 2008. (Accessed August 13, 2009, at
Rosenthal MB, Fernandopulle R, Song HR, Landon B. Paying for quality: providers’ incentives for quality improvement. Health Aff (Millwood) 2004;23:127-141. [Free Full Text]
Rastogi A, Mohr BA, Williams JO, Soobader MJ, de Brantes F. Prometheus payment model: application to hip and knee replacement surgery. Clin Orthop Relat Res 2009 June 23 (Epub ahead of print).
de Brantes F, D’Andrea G, Rosenthal MB. Should health care come with a warranty? Health Aff (Millwood) 2009;28:w678-w687. [Free Full Text]***
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Posts: 7838

« Reply #360 on: August 20, 2009, 04:23:26 PM »

Another NEJM:

01:53:23 PM August 20, 2009
from web
Reform, Regulation, and Research — An Interview with Gail Wilensky
Posted by NEJM • August 19th, 2009 • Printer-friendly
John K. Iglehart

Gail Wilensky, Ph.D., is an economist who served in the administration of President George H.W. Bush, first as the administrator of the Health Care Financing Administration (forerunner to the Centers for Medicare and Medicaid Services) and later as White House health policy advisor. In 1997, she became the first chair of the Medicare Payment Advisory Commission, and during the 2008 presidential campaign, she was an advisor to Senator John McCain (R-AZ). She is a senior fellow at Project HOPE. John Iglehart, a national correspondent for the Journal, interviewed Dr. Wilensky on August 7, 2009.

John Iglehart: Many Republicans oppose reform proposals put forward by Democrats. Do you consider the pursuit of health care reform an urgent matter?

Gail Wilensky: There is obviously a deep divide between the parties about what reform legislation should look like, but I do believe it is important that we press on with reform. We can’t continue the unsustainable health care spending of the past several decades, not to mention problems regarding the value of care, its clinical appropriateness, and a large and growing uninsured population.

Iglehart: How confident are you that by the end of 2009 a reform measure will be signed into law?

Wilensky: I think it’s likely that we will see a significant expansion in insurance coverage, maybe get to 93 to 95% of the population, through reform legislation. I’m quite discouraged that we will do anything significant about the other problems — slowing spending or improving value and clinical outcomes.

Iglehart: There are provisions in the Democratic reform bills that you oppose.1 Of them, which one gives you the greatest pause?

Wilensky: The public plan is one of the most contentious issues, and I hope it will not be in a final bill. I believe that a public plan would ultimately unravel private insurance coverage in the United States.

Iglehart: Do you favor the increased regulation of private insurance plans that their advocates, America’s Health Insurance Plans, volunteered to accept early in the negotiating process, such as guaranteed issue of insurance, elimination of preexisting-condition requirements, and so forth? Is that good public policy?

Wilensky: I believe it is good policy. I favor regulations that would guarantee renewability of insurance policies, place limits on how much premium rates could vary according to the health status of an individual, and eliminate preexisting-condition exclusions, as long as most people are covered. If large blocks of people are allowed to remain uncovered, the system could saddle some insurers with a higher risk profile of covered lives that could make their products unaffordable. But as long as most people are covered, these regulations are an appropriate quid pro quo, and they should be adopted.

Iglehart: Over the past generation, the GOP’s interest in health-related legislation has been modest compared with the emphasis that Democrats have placed on these issues. One exception was the relentless drive of President George W. Bush to enact a Medicare outpatient prescription-drug benefit, a pursuit that most Democrats opposed because of the enhanced role it gave private health plans. In your view, what’s the reason for the modest Republican record on health care issues?

Wilensky: People sometimes accuse the Republicans of not having any ideas in health care. But I don’t think that’s true; it’s more a failure to aggressively promote their ideas once they are introduced. For example, the first President Bush introduced a very good proposal that would have provided coverage to every individual whose income was below 133% of the federal poverty level, reformed private insurance, and changed the medical liability system. But it was released too late in his term, and perhaps even more importantly, the passion for health care reform that President Clinton demonstrated and that now engages President Obama has never been articulated by Republican leadership in the executive branch or, in some instances, the Congress.

Similarly, you could say that George W. Bush put forward a reasonable reform proposal to expand coverage by providing tax deductions for people without employer-sponsored insurance. John McCain offered a plan that called for taxing the employer-paid insurance premiums of workers, just as their salaries are taxed. At the same time, his plan would have granted refundable tax credits to employees so they could purchase their own coverage rather than accept the insurance offered by their employers. Don’t forget, during the election campaign, Obama attacked McCain repeatedly for this proposal, although equalizing the tax treatment of all workers has long been supported by virtually all economists because the current policy favors people with higher incomes. Health issues have just not been a primary focus for Republicans. Even on an issue that Republicans feel passionate about — reforming how professional liability issues are addressed — they have been unable to enact legislation during the brief periods when they controlled Congress and the White House, or at least Congress, in the past decade or so.

Health care reform is a difficult challenge for both parties, as the August [2009] town hall meetings are underscoring. We can see it now with our Democratic president and substantial Democratic majorities in the House and Senate, and still some uncertainty about if, let alone what kind of, health care reform may be enacted.

Iglehart: The Obama administration has been promoting the idea of creating an Independent Medicare Advisory Council within the executive branch,2 with the authority to make recommendations to the president on annual Medicare payment rates and other reforms, shifting some power from Congress to the executive branch. If the president disapproved the recommendations or Congress passed a resolution of disapproval, the recommendations would be null and void, although Congress would have to enact a bill with comparable savings within a short period. What’s your view of that idea?

Wilensky: I think it’s a bad idea. It would be trading off the difficulty Congress encounters when legislators face tough choices for granting power to a body that is unaccountable to the electorate. I find it very odd that the Congress has been unwilling to grant greater discretionary authority to the Centers for Medicare and Medicaid Services [CMS] at the same time that a few legislators — Senator Jay Rockefeller [D-WV] and Representative Jim Cooper [D-TN] — are sponsoring measures that would provide almost unlimited authority to an independent body of individuals who, once appointed, would be completely unaccountable to the American people. I think the right strategy is for Congress to approve the general structure of provider payment and the spending it deems appropriate, enact payment reforms, broadly defined, that it favors — bundling payments for physicians, moving to more accountable alignment between physicians and hospitals or between physicians and health care plans — and grant CMS far greater discretionary authority to implement these changes. After all, the CMS administrator is a presidential appointee, subject to confirmation by the Senate, reporting to a secretary who is similarly subject, who reports to the president, who is ultimately accountable to the American people.

Iglehart: So you favor providing CMS with greater resources to administer Medicare and Medicaid, even though members of Congress seem to criticize its performance at every turn?

Wilensky: Yes, and I’ve been one of a number of Republicans and Democrats3,4 who have indicated that all recent administrations — and Congress as well — have starved CMS in terms of providing the kind of management resources and administrative support the agency needs to capably run Medicare and Medicaid.

Iglehart: You’ve been a strong advocate of greatly expanding the government’s investment in comparative-effectiveness research [CER].5 The administration’s stimulus package included $1.1 billion to fund an accelerated CER program. Do you anticipate that reform legislation will expand the available CER resources? And what kind of impact will such research have on practicing physicians and the content of medical care?

Wilensky: I am hopeful that we will continue to see additional funding and program implementation policies for CER in whatever reforms are passed by Congress. There are many questions — about governance, about where an entity should be located, about how priority setting should occur, about the involvement of patient advocates and industry in some of these deliberations — that were not addressed in the stimulus package. That was a jump-starting action for CER, but these critical questions of place and priorities must soon be resolved.

We invest so much in the NIH’s pursuit of basic research but often fail to rapidly translate the results of those efforts into clinical care. It is just enormously frustrating to me that many interests, including quite a few physicians, do not recognize CER as a companion project to NIH’s basic research that would help doctors and patients determine what are the most effective therapies for a particular condition or disease. And I am frustrated and disappointed by some of the Republican posturing, too, which asserts that additional information provided through CER is a threat or a first step to rationing care. I believe that providing information about what works when, and allowing that information to be used as part of a reimbursement decision, is reasonable and sensible.

Iglehart: You have been emphatic that, initially, a CER agenda should focus its greatest attention on medical and surgical procedures and their value, rather than on drugs and devices. Why?

Wilensky: Because that’s where the money is. I’m looking at this as a way to learn how to spend smarter and treat better, and that involves the use of medical procedures because we’ve had so little investment in comparative-effectiveness information in that area.

Dr. Wilensky reports serving on the boards of Cephalon, Quest Diagnostics, SRA International, and UnitedHealth Group.

Source Information

This article (10.1056/NEJMp0907415) was published on August 19, 2009, at


Antos J, Wilensky GR, Kuttner H. The Obama plan: more regulation, unsustainable spending. Health Aff (Millwood) 2008;27:w462-w471. [Free Full Text]
Orszag PR. Letter to House Speaker Nancy Pelosi, July 17, 2009. Washington, DC: Executive Office of the President, 2009.
Butler SM, Danzon PM, Gradison B, et al. Crisis facing HCFA & millions of Americans. Health Aff (Millwood) 1999;18:8-10. [CrossRef][Medline]
Iglehart JK. Doing more with less: a conversation with Kerry Weems. Health Aff (Millwood) 2009;28:w688-w696. [Free Full Text]
Wilensky GR. The policies and politics of creating a comparative clinical effectiveness research center. Health Aff (Millwood) 2009;28:w719-w729. [Free Full Text]
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« Reply #361 on: August 21, 2009, 04:32:23 PM »

Hmm, it appears a vast Federal medical care system has already drafted and circulated end of life planning guides. Perhaps some of the "death panel" hysteria is not quite as fictional as some claim.

The Death Book for Veterans
Ex-soldiers don't need to be told they're a burden to society.

If President Obama wants to better understand why America's discomfort with end-of-life discussions threatens to derail his health-care reform, he might begin with his own Department of Veterans Affairs (VA). He will quickly discover how government bureaucrats are greasing the slippery slope that can start with cost containment but quickly become a systematic denial of care.

Last year, bureaucrats at the VA's National Center for Ethics in Health Care advocated a 52-page end-of-life planning document, "Your Life, Your Choices." It was first published in 1997 and later promoted as the VA's preferred living will throughout its vast network of hospitals and nursing homes. After the Bush White House took a look at how this document was treating complex health and moral issues, the VA suspended its use. Unfortunately, under President Obama, the VA has now resuscitated "Your Life, Your Choices."

Who is the primary author of this workbook? Dr. Robert Pearlman, chief of ethics evaluation for the center, a man who in 1996 advocated for physician-assisted suicide in Vacco v. Quill before the U.S. Supreme Court and is known for his support of health-care rationing.

"Your Life, Your Choices" presents end-of-life choices in a way aimed at steering users toward predetermined conclusions, much like a political "push poll." For example, a worksheet on page 21 lists various scenarios and asks users to then decide whether their own life would be "not worth living."

The circumstances listed include ones common among the elderly and disabled: living in a nursing home, being in a wheelchair and not being able to "shake the blues." There is a section which provocatively asks, "Have you ever heard anyone say, 'If I'm a vegetable, pull the plug'?" There also are guilt-inducing scenarios such as "I can no longer contribute to my family's well being," "I am a severe financial burden on my family" and that the vet's situation "causes severe emotional burden for my family."

When the government can steer vulnerable individuals to conclude for themselves that life is not worth living, who needs a death panel?

One can only imagine a soldier surviving the war in Iraq and returning without all of his limbs only to encounter a veteran's health-care system that seems intent on his surrender.

I was not surprised to learn that the VA panel of experts that sought to update "Your Life, Your Choices" between 2007-2008 did not include any representatives of faith groups or disability rights advocates. And as you might guess, only one organization was listed in the new version as a resource on advance directives: the Hemlock Society (now euphemistically known as "Compassion and Choices").

This hurry-up-and-die message is clear and unconscionable. Worse, a July 2009 VA directive instructs its primary care physicians to raise advance care planning with all VA patients and to refer them to "Your Life, Your Choices." Not just those of advanced age and debilitated condition—all patients. America's 24 million veterans deserve better.

Many years ago I created an advance care planning document called "Five Wishes" that is today the most widely used living will in America, with 13 million copies in national circulation. Unlike the VA's document, this one does not contain the standard bias to withdraw or withhold medical care. It meets the legal requirements of at least 43 states, and it runs exactly 12 pages.

After a decade of observing end-of-life discussions, I can attest to the great fear that many patients have, particularly those with few family members and financial resources. I lived and worked in an AIDS home in the mid-1980s and saw first-hand how the dying wanted more than health care—they wanted someone to care.

If President Obama is sincere in stating that he is not trying to cut costs by pressuring the disabled to forgo critical care, one good way to show that commitment is to walk two blocks from the Oval Office and pull the plug on "Your Life, Your Choices." He should make sure in the future that VA decisions are guided by values that treat the lives of our veterans as gifts, not burdens.

Mr. Towey, president of Saint Vincent College, was director of the White House Office of Faith-Based Initiatives (2002-2006) and founder of the nonprofit Aging with Dignity.
« Reply #362 on: August 21, 2009, 05:49:34 PM »

2nd post.

Killing Obamacare -- By: Andrew C. McCarthy

Earlier this week, some of my National Review colleagues recoiled from Sarah Palin’s bracing allegation that Obamacare would foist government “death panels” on vulnerable Americans. I recoiled from the recoil, which I thought exemplified the same sort of “hysteria” the editorial in question, “Rationing and Rationality,” condemned. There followed a debate (see The Corner archives for August 17 and 18), largely a fine parsing of how -- rationally, of course -- the term “death panel” ought to be defined. As we went back and forth, I kept having this nagging thought:

We could still blow this thing.

Obamacare and its proponents have taken a drubbing in the polls. Americans are passionate about matters of life and death and who gets to decide them. Unlike appropriations for the F-22 or another billion or so in “stimulus” so the NEA can underwrite simulated-sex dances, the health-care issue aroused the public. Citizens read the bill (something their legislators haven’t been anxious to do) and blew a gasket. Saul Alinsky’s bag of tricks doesn’t say what to do when the opponent to be smeared in the public mind is the public itself. So our organizer-in-chief is adrift at sea, and sinking.

But this battle is far from over. Since Barack Obama first emerged in national politics, it’s been chattering-class wisdom to throw both caution and Occam’s Razor to the wind. No need for concern, the pundits proclaimed, about Ayers and Dohrn and Khalidi and Wright and Pfleger and Frank Marshall Davis and ACORN and the Chicago New Party and infanticide and#...#and#...#and#...#. No matter the fever swamps of his past, they insisted, Obama has a first-rate intellect and a winning temperament -- why, he even writes his own books (about himself) and knows who Reinhold Niebuhr was. Once he takes the reins and grapples with the concrete complexities of governing, we were assured, ideology will dissolve. He’ll become moderate and pragmatic, if for no other reason than his own political survival.

But we knuckle-draggers figured that if it walks like a radical and quacks like a radical it’s probably not all that moderate and pragmatic. Nothing we’ve seen so far calls for revising that assessment. If anything, these last seven months ought to tell us that the usual political rules don’t apply when predicting this president’s behavior. His purpose is revolutionary change in an American society he grew up understanding to be fundamentally unjust, racist, materialist, imperialist, and the agent of global misery. He is in Washington to transform the nation from the top down. Nationalized health care is key for him. If he gets it, sovereignty shifts from the citizen to the state. By law, government will be empowered to manage minute details of our lives. Over time -- when, as the American Thinker’s Joseph Ashby observes, a “1,000-page health-care law explodes into many thousands of pages of regulatory codes” -- that is precisely what government will do.

Obama is not a normal politician. He’s a visionary, and using health care to radically expand the scope of government happens to be central to his vision. For my money (if I have any left), achieving it is more important to him than is getting reelected. His poll numbers and those of congressional Democrats may keep plunging (for the latter, there must come a point where that is statistically impossible), but they have the votes to Rahm this thing through.

To be sure, Washington is still populated with normal politicians, and that is why you can almost touch the Democrats’ desperation. They don’t want to walk this plank, and they are praying to Gaia, night and day, for that magic moment when the usual RINO rabbits spring from the bipartisan hat to give them cover from their fuming constituents. But at its highest levels, this Democratic government is being steered by the party’s most extreme leftists. Obamacare is their life’s dream, they have the power to make it happen, and if they have to go it alone, they will try going it alone.

Even if Obama were a normal politician, 2012 is three years away, and he’ll worry about that later, if he has to worry at all: With his Justice Department green-lighting election fraud, ACORN and the New Black Panther party riding high, and amnesty for millions of illegal aliens on the horizon, 2012 may take care of itself.

Things may appear to be going well at the moment for opponents of Obamacare, but the stubborn fact remains that only one thing can stop this monstrosity: wavering congressional Democrats’ discovery that they have more to fear from their districts than from their leadership and the White House. The ardor of public opposition will determine whether this battle is won or lost.

That’s why I found our “death panel” debate so disconcerting. The editorial that pooh-poohed the label acknowledged, as my friend Rich Lowry later emphasized, that the legislation gave great reason (I’d say grave reason) to be concerned about “government rationing and a general slide toward euthanasia.” The editorial’s contention was that there wouldn’t “literally” be death panels. To me, that’s not much different from quibbling over “what the meaning of ‘is’ is.” The stakes here couldn’t be higher, time is short, and “death panel” cuts to the chase.

What, after all, is “end of life” counseling in a bill that, we here all agree, rations care (i.e., redirects it away from those who consume most of it now: the elderly and the infirm) and raises fast-track-to-euthanasia worries? In the Wall Street Journal, former Bush White House official Jim Towey alerts us that, at the Veterans Administration, Obama has reinstated a 52-page “end of life planning document” authored by a medical ethicist who has advocated doctor-assisted suicide in a Supreme Court brief. This Orwellian “Your Life, Your Choices” questionnaire, in the familiar “push poll” manner, methodically steers the patient toward the notion that he is a malingering near-vegetable causing a “severe emotional burden” for his family. I don’t know what the correct, non-hysterical term for such a process is, but “Grim Government Reaper” strikes me as more accurate than “Your Life, Your Choices.”

Imagine a woman lying dead of stab wounds and a man holding a bloody knife in his hand. If the reaction of the first cop on the scene is, “You killed her,” I don’t think that’s hyperbole. Most of us would find it weird if he instead said, “Well, now, wait just a second. There are complex issues of causation here, to say nothing of the epistemology of mind -- intentional, involuntary, insanity, crime of passion? Let’s scrutinize this dispassionately, have the five-week trial with all the due-process trimmings, and then rationally decide what to call this. No point in leaping to rash conclusions.”

The second reaction might be sound, but it’s neither natural nor practical. Like your health, murder is a gripping matter -- it’s not your everyday material misstatement in the exchange of commercial paper. “You killed her” gets to the heart of the matter, to the big things you need to think about. Plus, most of us don’t have a year for scrutiny, discovery, and settlement negotiations. We have lives to live. What we need to know is whether he probably did kill her, so we can evaluate some practical concerns, like whether he should be free to walk the streets while he waits for his five-week trial.

Obama, of course, wanted health-care “reform” done -- all 1,000-plus pages of it -- before the summer recess. In essence, Democrats want to repeal individual liberty; move one-sixth of the private sector into the same government-controlled model that has produced bankruptcy in Social Security, Medicare, and Medicaid; add additional trillions to the already exploded national debt; and they want to do it all right now -- no discovery, no settlement negotiations, no five-week trial, no delays.

Given this Democratic whirlwind, I don’t see why we owe them better than “death panels.” They are what we’re sure to get if Obamacare isn’t killed first.
« Reply #363 on: August 21, 2009, 10:11:13 PM »

3rd post. Oh my, the following graph would seem to tinkle on some of the predatory insurance company narratives currently being foisted to inspire a single payer stampede.

Longest. Lives. Ever.
Quit griping about health-care costs.

By Jerry Bowyer

The Centers for Disease Control released its “National Vital Statistics Report” this week, and BuzzCharts was especially interested in the latest figures for life expectancy. It turns out that Americans are living longer than they did at any time in the nation’s history. The average lifespan is just shy of 78 years, with women living slightly longer than 80 years. Males and females, blacks and whites — we’re all living longer than ever before.

So what’s all this noise coming out of D.C. and the left-wing media about how terrible our health-care system is? Why are we told of its unsustainability, its inherent greed and corruption, and its tolerance for tonsillectomy mills? Watching all this hand-wringing, one might think that Americans had the highest death rates ever recorded, rather than the lowest. But men who are ambitious for power find good news to be the least useful news of all. Hence, four-score life expectancies — the dream of previous generations — go unheralded.

Our chattering classes chatter on about derivative abstractions, such as the increase in the percentage of GDP that we allot to health care. The cable-television pundits remind us that we’re spending about 16 percent of our national output on health care, and conclude that this is some kind of national scandal. Why? What percentage should we be spending? Is 10 percent more acceptable? Is 5 percent?

Let’s be clear: Prosperous countries spend more on doctors and medicine than non-prosperous ones. The poor allocate almost everything they earn to food, rent, and clothes, and have little to spend on medicine and even less to squander on fun. When a nation gets wealthy, however, food, roofs, and pants become less of a cost issue, while more money is funneled to matters such as health.

Our great-grandparents spent much less than 16 percent of GDP on health care, and they barely made it into their 60s. Would any of you willingly give back 20 years in exchange for less health-care spending?

— Jerry Bowyer is an economist, CNBC contributor, and author of the upcoming Free Market Capitalist’s Survival Guide.
National Review Online -
« Reply #364 on: August 22, 2009, 01:17:40 AM »

And yet another post. I'd throw in some massive tort reform on top of this all of which would make sure it would never get past this congress, but it would sure short circuit the whole "Republicans don't have an alternative" snivel.

We Need a Republican Response to ObamaCare

By Paul Shlichta
The current attempt to steamroller a drastic healthcare reform bill through Congress has created a rift between the Obama-Pelosi (OP) Democrats and what might be called the "blue-chip" (BC) faction---the moderate mainstream Democrats whose alliance, or at least acquiescence, is probably essential for the passage of any legislation.  These two factions have very different ideas of what "healthcare reform" should mean.
It is difficult to pin down exactly what BCs want. Caught in the crossfire between the Chicago-style strong-arming of the White House and the anger of the electorate, they have become evasive [1]. But it is likely that most would accept, as a minimum:

B1. Available healthcare insurance for all citizens who want it, with most BCs being willing to exclude illegal aliens.

B2. A reasonable level of healthcare with no rationing or curtailment for the elderly or chronically ill.

B3. The deletion of a "public option" to compete with private insurers, although there is considerable divergence of opinion on this point.

B4. Avoidance of controversial issues such as abortion, medical rationing, and assisted suicide.

B5. A convincing estimate of a total cost that will not aggravate our huge deficit or endanger the economy.

In contrast, the OP agenda, as set forth in House Bill 3200 and diagrammed by the staff of Rep. Kevin Brady, is vastly more grandiose [2]. It includes:

O1. Mandatory healthcare insurance for everyone, including illegal aliens.

O2. Federally set standards of healthcare, leading to inevitable rationing, restriction to "cost-effective" treatments, and exclusion of preventative measures such as prostate cancer screening

O3. Mandatory inclusion of abortion coverage and provisions for "end-of-life" counseling that smell suspiciously like medical rationing and/or assisted suicide.

O4. Inclusion of a government-run public option and a delayed-action "poison pill" calculated to force private insurers out of business.

O5.  A frighteningly high cost with no convincing plan for cost management except arm-waving and evasion [3].

In short, the ObamaCare plan would create an elaborate political machine that would give the federal government total control of a bureaucratic healthcare empire so far-reaching and destructive of existing private institutions that, like a deeply rooted and metastasized cancer, once established, it would be impossible to remove. The czar of this empire, the Health Care Administration Commissioner, answerable only to the President, would set benefit rates, select and regulate participating insurance companies, and administer a rival Public Health Plan that Obama and his colleagues have previously admitted would be merely a stepping stone to a federal single payer system.

Diagram of HR 3200 as analyzed by the staff of Rep. Kevin Brady

BC Democrats are justifiably alarmed by many of these provisions. Moreover, with an apprehensive eye on the 2010 elections, they are concerned about the vigorous voter resistance they have encountered in town meetings. But, since they are still committed to universal healthcare insurance and will need party support for next year's election campaigns, they may be arm-twisted or bludgeoned into acquiescence to the passage of HR 3200.

But what have the Republicans proposed? A few, such as Kevin Brady, have acknowledged the need for reform and published detailed proposals. But most Republicans, although dissenting about questionable aspects of HR 3200, have either made no counterproposals of their own (thereby implying that they regard the status quo is acceptable) or have introduced alternative legislation, such as the Patients' Choice Act, that does not meet BC expectations and has no chance of passage through a Democratic congress.

This is political suicide. A majority of Democrats do want some sort of healthcare reform, almost all of the Democratic candidates campaigned for it, the Democrats control both houses of Congress and virtually all its committees---and so, like it or not, we will almost certainly have some form of healthcare reform measure enacted this year.

Therefore, it is urgently necessary that Republican leaders unite in a counterproposal that will gain widespread BC acceptance. By way of example, I hereby suggest a provisional plan based on:

(a)  modifying an existing bill, e.g. using the HR 3200 organizational plan as a starting point,

(b)  paring down the ObamaCare empire, so that it conforms to the basic aims of the BC Democrats while eliminating anything that is not essential to those aims, and

(c)  proceeding cautiously and economically by making every change potentially reversible and by using existing agencies and institutions as much as possible.

These guidelines lead to deletions and changes in the current structure of HR 3200 such as the following:

There is no need for a Health Choices Administration or HCA commissioner. In fact, these duties would conflict with those of state agencies and might even be a violation of the tenth amendment. Instead, the federal government should begin by accepting any insurance company and/or professional certification that is already accepted by a state agency. This might be facilitated, without excessive federal regulation, by establishing interstate health insurance as proposed last year by McCain and more recently by several members of Congress.
There is no need for a federal one-size-fits-all standard for healthcare insurance. In fact, as Robert Veach has pointed out in Patient, Heal Thyself, this would be a gross violation of the bioethical right of a patient to chose an insurance plan that fits his own set of value judgments.
There is no need for a "Public Health Plan" insurance organization. Instead, the insurance of otherwise uninsurable families and individuals, such as people thrown out of work, would be assigned to existing private insurers by a system similar to the assigned-risk methods currently used for auto insurance. This would be the primary function of the so-called Health Insurance Exchange and could be handled by the proposed "Reinsurance Program" office [4].
There is no need to create a National Health Service Corps or Public Health Workforce Corps. There are numerous private volunteer and faith-based agencies that already carry out the activities proposed for these 'corpses' and that have frequently demonstrated their superiority to federal agencies in effectiveness and efficiency. Such organizations should be encouraged and honored, instead of being shoved aside.
There is no urgent need for a Bureau of Health Information or for the related IT, civil rights, and minority offices. Other federal and state agencies currently carry out these functions and can continue to do so. Similarly, there is no urgent need for any of the special offices colored yellow in the Brady diagram. Offices and agencies of this kind could be added later, when and if they prove to be necessary.
There is an urgent need for assurance of cost reduction. Therefore the Obamacare machinery must be reduced by at least 50%.
When these deletions are made, the Brady diagram begins to look more reasonable, while still fulfilling the basic requirements of most BC Democrats.

Proposals like this, which reduce healthcare reform to its essentials and make maximum use of existing federal, state, and private agencies and institutions, would greatly reduce the proposed levels of administration costs and the inevitable tax burden. Moreover, in sharp contrast to the Obamacare empire, such a system would be emendable and would be ultimately answerable to Congress and the American people rather than solely to the POTUS.

I therefore hope that Republican congressional leaders will, in the few weeks remaining, draft, publicize, and introduce a counterproposal of this type and implement it by major amendments to pending bills. Otherwise, it is probable that some virulent form of HR 3200 will be rammed down our throats (or some other orifice) and that the prognosis of our healthcare system will change from "serious" to "critical" while the costs continues to soar [5]. When this happens, Doctor Obama, like any other quack, will simply yell for more turpentine.


[1]  The "blue chip" faction may be substantially larger than the 52 member Blue Dog Coalition of House members that have vocally criticized HR 3200.  Some, caught between OP coercion and voter rebellion, are "closet BCs", as evidenced by the disparity between what they proclaim on their websites and what they say to voters at town meetings.

[2] HR 3200 is an excellent example of Hilaire Belloc's observation that:

...three characters appear which are the concomitants of all revolutions, and the right management of which alone can prevent catastrophe. The first character is [that] change of every kind and every degree is proposed simultaneously, from reforms which are manifestly just and necessary---being reversions to the right order of things---to innovations which are criminal and mad.

[3] Even the advocates of Obamacare admit that:

We're not sure it's even possible to nail down a firm answer to the cost question. The president's health-care plan is a work in progress, relying on a host of long-term projections...Can Obama and the Democrats really squeeze $70 billion of waste out of Medicare? The Congressional Budget Office, looking at earlier drafts of health-care reform, has expressed doubts.

These doubts are exacerbated by the "now or never, all or nothing, take it or lose it forever" urging of the POTUS, which has a strong odor of con-man hustle.

[4] As part of his retreat strategy, Obama has proposed replacing the public option with co-op insurance organizations. This might be an acceptable compromise, but looks suspiciously like one of the Trojan horses for which the Obama administration is so justly famous.

[5] All of the healthcare reforms discussed to date are concerned primarily with insurance, which is only one of the factors driving up healthcare costs. No plan, least of all HR 3200, has yet directly addressed the basic issue that is the root of all of our concerns about healthcare -- the high and ever-spiraling costs of physicians' fees, clinical tests, medicines, hospitalization, and medical schools. Alleviation of this burden would require basic but not infeasible changes in our healthcare system that are not at all addressed in current legislation. This issue will be discussed elsewhere.

Page Printed from: at August 22, 2009 - 02:03:18 AM EDT
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« Reply #365 on: August 22, 2009, 08:25:24 AM »

With regard to post 363 please take note of the increase in life expectancy from around 70 to close to 80 since the 1970s.
This is true.  Yet we have the self promoting Andrew Weil, the constantly reminding us guy who graduated Harvard Medical school  poinint out that medical htechnology only saves about one in 16,000 lives.  That was what I read in his post on the Huffington Post about a week ago.
Almost all the increase in lifespan since 1900 is imporved sanitation vaccines etc.
Well the last statement is true and obvious.
That was the easy gain.

But what about the increase since 1970?  Is he telling me that is from a decrease in cholera, typhoid, better sanitation and hepatitis B vaccine?

And the increase since than while only a couple of years is still an increase and no one would argue it is due to healthier life styles.

In fact the average lifespan would be even greater if it were not for less healthy lifestyles.
The only major killer that kills more today than then is diabetes obviously because of the epidemic of this from obesity.

So DESPITE less healthy lifestyles the field of medicine has achieved an increase in lifespan. 

Anyone who denies this is a total blow hard - as is Weil.

Perhaps this post would be better on the Huffington Post but I don't really want to bother.
Power User
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« Reply #366 on: August 22, 2009, 12:51:43 PM »

"the increase in life expectancy from around 70 to close to 80 since the 1970s"

We may not know precisely the reasons for increased longevity but it also weakens the arguments that our food supply, drinking water, air quality, CO2 level and climate change are increasingly unhealthy to human life. 
« Reply #367 on: August 22, 2009, 01:40:41 PM »

The more I think about it the more I believe Obamacare opponents should be highlighting the lack of tort reform in all versions of the bill as nothing is more emblematic of the complex, convoluted usurpation of all medical spending and placing it in the hand of bureaucrats and lawyers than the failure to reform the structures than inspire defensive medicine.

Palin: 'No Health Care reform without legal reform'

Ethel C. Fenig
Fresh from spurring a discussion of end of life issues with her mention of death panels under Obamacare in Facebook, former Governor Sarah Palin (R-Alaska) is at it again:

No Health Care Reform Without Legal Reform


[W]e cannot have health care reform without tort reform. The two are intertwined. For example, one supposed justification for socialized medicine is the high cost of health care. As Dr. Scott Gottlieb recently noted, "If Mr. Obama is serious about lowering costs, he'll need to reform the economic structures in medicine-especially programs like Medicare." [1] Two examples of these "economic structures" are high malpractice insurance premiums foisted on physicians (and ultimately passed on to consumers as "high health care costs") and the billions wasted on defensive medicine.

Quoting Dr. Stuart Weinstein of the American Academy of Orthopedic Surgeons she praises him as he

details the costs that our out-of-control tort system are causing the health care industry and notes research that "found that liability reforms could reduce defensive medicine practices, leading to a 5 percent to 9 percent reduction in medical expenditures without any effect on mortality or medical complications."

(Got that former tort lawyer, senator and vice presidential candidate John Edwards; known for channeling the words of a fetus unfortunately born with cerebral palsy that helped him win $6.5 million for his client--of which he kept a third.)

She then asks some questions about Obamacare.

Why no legal reform? Why continue to encourage defensive medicine that wastes billions of dollars and does nothing for the patients? Do you want health care reform to benefit trial attorneys or patients?

Aha! Did that last question--and its answer--strike home?

That can be solved, she proves, by citing her non community organizer experience from her state and Texas.

Many states, including my own state of Alaska, have enacted caps on lawsuit awards against health care providers. Texas enacted caps and found that one county's medical malpractice claims dropped 41 percent, and another study found a "55 percent decline" after reform measures were passed. [4] That's one step in health care reform. Limiting lawyer contingency fees, as is done under the Federal Tort Claims Act, is another step. The State of Alaska pioneered the "loser pays" rule in the United States, which deters frivolous civil law suits by making the loser partially pay the winner's legal bills. Preventing quack doctors from giving "expert" testimony in court against real doctors is another reform.Texas Gov. Rick Perry noted that, after his state enacted tort reform measures, the number of doctors applying to practice medicine in Texas "skyrocketed by 57 percent" and that the tort reforms "brought critical specialties to underserved areas." These are real reforms that actually improve access to health care. [5]

She concludes

Dr. Weinstein's research shows that around $200 billion per year could be saved with legal reform. That's real savings. That's money that could be used to build roads, schools, or hospitals. If you want to save health care, let's listen to our doctors. There should be no health care reform without legal reform. There can be no true health care reform without legal reform.

Stay tuned for further Facebook and Twitter insights.

hat tip: Mark Tapscott

Page Printed from: at August 22, 2009 - 02:31:17 PM EDT
Power User
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« Reply #368 on: August 25, 2009, 10:18:35 AM »

Here comes the Dem response from those who benefit from big government who will give their case for big gov health care.
Here comes the big push back.  We'll see who shouts the loudest I guess - because that is what it is in our daily politics now.
Bo makes it worse.  The wolf in lambs clothing.  Pretend you are one of them and you can subtly shove your radical agenda through.
Then when the opposition voices dissent - blame them for not coming to the compromise table.

Yeah yeah.

anyway - here it comes. 

***"Health care reform supporters will hold more than 500 events between Wednesday and when lawmakers return Sept. 8.
Faced with a souring public mood on health care reform, Democrats and their supporters are launching a national grassroots push Wednesday to show lawmakers that the majority of Americans still support overhauling the system.

Reform supporters are planning to hold more than 500 events between Wednesday and when lawmakers return to Washington Sept. 8, ranging from neighborhood organized phone banks to professionally staffed rallies with hundreds of people.

The Democratic National Committee and its grassroots arm, Organizing for America, are helping to organize the effort along with the Health Care for America Now, a group pushing to create government-run insurance plan.

“In these last few weeks of recess we want to demonstrate the energy, passion and commitment that the American people have to health insurance reform so that when members return after Labor Day they know that they can turn their attention to getting this done because they have the backing of the American people,” said DNC spokesman Brad Woodhouse.

Supporters have their work cut out for them. Many lawmakers were thunderstruck over the August recess by the anger and outrage expressed by their constituents in town hall meetings across the country. And in poll after poll, support for reform has eroded throughout the month.

But Democrats and their allies insist that the majority of Americans still support reform and have organized the grassroots campaign to buck up lawmakers as they get ready to head back to Washington.

A health-insurance-reform-now bus will travel the country starting Wednesday and anchor events in 11 cities: Phoenix, Albuquerque, Denver, Des Moines, Pittsburgh, Raleigh, Charlotte, Milwaukee, St. Louis, Indianapolis and Columbus, Ohio.

But the talk of broad health insurance reform does mean that progressives have backed off their push for a government-run insurance option.

“We want members of Congress to get back to work and pass reform that means something. We need affordable care. We need real insurance regulation. And we need a strong public health insurance option,” said HCAN spokeswoman Jacki Schechner. “It’s doable and we expect it to get done now.”***

Power User
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« Reply #369 on: August 25, 2009, 11:36:36 AM »

Sen Kent Conrad (D) on Face the Nation: "...the country heading for the cliff, and we're headed for a cliff because costs in health care are spiraling out of control."

Yes but the mechanism that controls costs with every other product and service in every other industry is not in place - supply and demand.  You cannot charge what your customers are not able or willing to pay for anything - until you open the door for third party money to make up an ever-expanding difference.

So the answer is open the rest of the system to the backing of unlimited third party pay.  That is NOT how innovation flourishes or how costs are best controlled.
Re. Death Panels: CCP, as an industry professional you know better than the rest of us that difficult choices are faced and difficult decisions are made every day every moment somewhere about the life and death of a patient. Those difficult times in our lives don't go away under any plan. The difference with this is to enter the government, uninvited, into the room during the discussions, holding all the cards, on a mission to control costs - for the children... sounds like a death panel to me.
Power User
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« Reply #370 on: August 25, 2009, 12:30:42 PM »

****The difference with this is to enter the government, uninvited, into the room during the discussions, holding all the cards, on a mission to control costs - for the children... sounds like a death panel to me.****

Well the problem is that governement already does foot a huge proportion of our health care bill through medicaid / medicare.

And we doctors don't often do our jobs. and patients and sometimes the families have unrealistic expectations.
So it is not totally unreasonable that payers have a right to some input.

And that IS part of the problem when we have others paying for the health care of others and the costs are not with the people using the care.

To say we should spare no dollars at the end of life is a nice thought from Shawn Hannity but in the meatime we are going broke.

Power User
Posts: 9483

« Reply #371 on: August 25, 2009, 01:17:52 PM »

A must see video depicting America under ObamaCare:
Maybe written as humor but not very far fetched!

CCP: "So it is not totally unreasonable that payers have a right to some input." 

Totally agree. And also to gather information and limit choices regarding behaviors that add risk to health care costs.

As a limited government advocate, I oppose expanding the gov't footprint into areas where the private customer was already satisfied with their plan.  IMO people like Hannity earned the right to spend his own money on their own services, just as I have 'earned' the right to spend up to my Blue Cross coverage limits.  sad  From Canada they drive into Duluth MN and Mayo Clinic and countless other areas across the border to get the things their own panel denied or delayed.  In the US, we won't just drive across the border and find a freer and richer country with wider choices and immediate availability.

« Reply #372 on: August 26, 2009, 12:40:27 PM »

Obamacare bails out union pension plans, too
Commentary Staff Writer
08/25/09 4:19 PM EDT
Union bosses who have mismanaged benefits for their own members are poised to receive a $10 billion bailout from U.S. taxpayers in the form of a “reinsurance program” that has been folded into the healthcare bill, according to the Workforce Fairness Institute (WFI).
This provision should be viewed as part of a larger payback effort the Obama White House and top congressional figures have set up in exchange for the support they have received from organized labor, Katie Packer, executive director of WFI said.
Section 164 of the Affordable Health Choices Act of 2009 provides that the government pay 80 cents on the dollar to corporate and union insurance plans for claims between $15,000 and $90,000 for retirees age 55 to 64. Union health insurance funds only have about 30 cents available to cover each dollar of anticipated claims, according to the Lewin Group and other research outfits.
If this provision were to be passed as part of the overhaul package favored by the Obama Administration, the $10 billion figure would probably expand overtime as union plans continue to come under financial pressure, Packer said. 
“What we want to see is some kind of accountability,” she said. “These union bosses make promises that they can’t keep. I don’t know what exactly they are doing with union dues and other money but they seem to have hundreds of millions of dollars to spend every time there is a campaign. It’s the labor bosses that have put the companies over a barrel and extracted commitments that they know were unsustainable. Now they expect the taxpayers to bail them out and they use their own workers as victims.”
In an email letter to supporters, the United Auto Workers (UAW)  urged their membership to support the Obama plan and specifically cites the benefits outlined in section 164. It concludes with a call for activism that draws from key alliances.
“Not surprisingly, insurance companies and various right-wing groups are mounting a campaign to block health care reform. To counter their dishonest, disruptive scare tactics, UAW activists need to join with our progressive allies in sending a strong message to members of Congress that NOW is the time to pass genuine health care reform,” the letter says.
The union bailout provision can be found in multiple versions of the bill, which indicates it is being pushed by powerful labor officials who maintain influence with the White House and Congress, Packer said.
In the 2008 election cycle, labor union political action committees (PACS) contributed over $66 million dollars to congressional candidates with 92 percent of those contributions going to Democrats, according to
The Employee Free Choice Act, which includes the controversial Card Check and binding arbitration measures, remains the major priority for labor bosses, Packer said. But the bailout money labor backers in Congress attempted to conceal in the healthcare bill shows that union paybacks remain in motion, Packer said.
“We see paybacks to labor bosses over and over again,” she said. “We saw it with the bailout to General Motors and Chrysler, we also saw it with the restrictions on companies that don’t use union workers with the stimulus bill. The Employee Free Choice Act is the coup de grace, but the payback remains on going.”
President Obama received almost $28 million in independent expenditures from the Service Employees International Union (SEIU) for his 2008 campaign, while Labor Secretary Hilda Solis received $10,000 from the SEIU’s PAC for her congressional race.
SEIU has been a leading proponent of  Card Check and binding arbitration.
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« Reply #373 on: August 27, 2009, 03:12:50 PM »

"IMO people like Hannity earned the right to spend his own money on their own services, just as I have 'earned' the right to spend up to my Blue Cross coverage limits."

I agree.

I am sick and tired of endless instrusion by government into our lives and am not for expanding medicare/medicaid at all.

I read through about 1/4 of Mark Levin's bestseller Liberty and Tyranny and agree with most of what I read.
To me he is a hero for opening our eyes to what is going on with the increasing and sometimes subtle and sometimes not so subtle encroahment of the government into every aspect of our lives.

On the other hand I was personally offended by Rush Limbaugh telling the "moderates" who ciriticized him that the recent uproar against Bama et al's health plan has caused a cratering of the Dems and BO in the polls that "let this be a lesson to you".

I love Levin but I am sick of Rush.  While they both come from the right Levin makes more sense to me for reasons that I am not even totally clear about.  Maybe because he is not such an egotist as Limbaugh who also comes off as a blowhard.

As far as Hannity all I can say he is one of the world's greatest salesman.  He could sell anything from a potion that cures all sexual dysfunction to promoting eternal life.

Can't you just picture walking into any retail store and seeing him standing there ready to move in for the kill (I mean sale)?

« Reply #374 on: August 28, 2009, 12:27:50 PM »

Obamacare: The Only Exit Strategy
Hook us with government-subsidized universal and virtually unlimited coverage.

By Charles Krauthammer

Obamacare Version 1.0 is dead. The 1,000-page monstrosity that emerged in various editions from Congress was done in by widespread national revulsion not just at its expense and intrusiveness but at the mendacity with which it is being sold. You don’t need a Ph.D. to see that the promise to expand coverage and reduce costs is a crude deception, or that cutting $500 billion from Medicare without affecting care is a fiction.

But there is an exit strategy. And a politically clever one, if the Democrats are smart enough to seize it.

(1) Forget the public option. Whatever the merits, and they are few, it is political poison. It dies by the Liasson Logic, the unassailable observation by NPR’s Mara Liasson that there are no liberal Democrats who will lose their seats if the public option is left out, while there are many moderate Democrats who could lose their seats if the public option is included.

(2) Jettison any reference to end-of-life counseling. People see (correctly) such Medicare-paid advice as subtle encouragement to voluntarily refuse treatment. People don’t want government involvement in a process they consider the private province of patient, family, and doctor. The Senate is already dropping it. The House must follow.

(3) Soft-pedal the idea of government committees determining “best practices.” President Obama’s Federal Coordinating Council for Comparative Effectiveness Research was sold as simply government helping doctors choose the best treatments. But there are dozens of medical journal review articles that do just that. The real purpose of the FCCCER is ultimately to establish official criteria for denying reimbursement to less favored (because presumably less effective) treatments — precisely the triage done by the NICE committee in Britain, the Orwellian body that once blocked access to a certain expensive anti-blindness drug until you went blind in one eye.

(4) More generally, abandon the whole idea of Obamacare as cost-cutting. True, it was Obama’s original rationale for creating a whole new entitlement at a time of a sinking economy and a bankrupt Treasury. But, as many universal-health-care liberals complain, selling pain is poor salesmanship.

(5) Promise nothing but pleasure — for now. Make health insurance universal and permanently protected. Tear up the existing bills and write a clean one — Obamacare 2.0 — promulgating draconian health-insurance regulation that prohibits (a) denying coverage for pre-existing conditions, (b) dropping coverage if the client gets sick, and (c) capping insurance company reimbursement.

What’s not to like? If you have insurance, you’ll never lose it. Nor will your children ever be denied coverage for pre-existing conditions.

The regulated insurance companies will get two things in return. Government will impose an individual mandate that will force the purchase of health insurance on the millions of healthy young people who today forgo it. And government will subsidize all the others who are too poor to buy health insurance. The result? Two enormous new revenue streams created by government for the insurance companies.

And here’s what makes it so politically seductive: The end result is the liberal dream of universal and guaranteed coverage — but without overt nationalization. It is all done through private insurance companies. Ostensibly private. They will, in reality, have been turned into government utilities. No longer able to control whom they can enroll, whom they can drop, and how much they can limit their own liability, they will live off government largesse — subsidized premiums from the poor; forced premiums from the young and healthy. 

It’s the perfect finesse — government health care by proxy. And because it’s by proxy, and because it will guarantee access to (supposedly) private health insurance — something that enjoys considerable Republican support — it will pass with wide bipartisan backing and give Obama a resounding political victory. 

Isn’t there a catch? Of course, there is. This scheme is the ultimate bait-and-switch. The pleasure comes now, the pain later. Government-subsidized universal and virtually unlimited coverage will vastly compound already out-of-control government spending on health care. The financial and budgetary consequences will be catastrophic.

However, they will not appear immediately. And when they do, the only solution will be rationing. That’s when the liberals will give the FCCCER regulatory power and give you end-of-life counseling.

But by then, resistance will be feeble. Why? Because at that point the only remaining option will be to give up the benefits we will have become accustomed to. Once granted, guaranteed universal health care is not relinquished. Look at Canada. Look at Britain. They got hooked; now they ration. So will we.

— Charles Krauthammer is a nationally syndicated columnist.

National Review Online -
Power User
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« Reply #375 on: August 29, 2009, 07:57:21 AM »

CK wrote:

(5) Promise nothing but pleasure — for now. Make health insurance universal and permanently protected. Tear up the existing bills and write a clean one — Obamacare 2.0 — promulgating draconian health-insurance regulation that prohibits (a) denying coverage for pre-existing conditions, (b) dropping coverage if the client gets sick, and (c) capping insurance company reimbursement.

What’s not to like? If you have insurance, you’ll never lose it. Nor will your children ever be denied coverage for pre-existing conditions.

So my fellow free marketeers, what do we think about the three proposed ideas by CK?  In particular,

What is to be done about pre-existing conditions?

What is to be done when someone gets sick and gets cancelled?
Power User
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« Reply #376 on: August 29, 2009, 12:31:04 PM »

"What’s not to like? If you have insurance, you’ll never lose it. Nor will your children ever be denied coverage for pre-existing conditions."

Well we will still go broke and care will be rationed.

That is what is not to like.

Crafty your questions need TO BE answered by the cans and I have not heard any of them do that explicitly.

Not even supersalesman Shawn Hannity.  He can sit there and rattle off five changes he would make to health care and not one addresses these issues directly.

That is why I can barely stand him.  He is just another blowhard - but from the right.

Power User
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« Reply #377 on: August 29, 2009, 05:33:28 PM »

I too find Hannity a blowhard.

Waiting for the Reps to come up with answers to these questions seems rather futile to me (BTW childcare allowing, we will be going to a Tea Party event tomorrow night) and I would like to challenge our little braintrust here to come up with good answers-- ideally that are also politically plausible too-- to these questions.

I would also like to add the question of what to do about the overspending of Medicare and Medicaid.
« Reply #378 on: August 29, 2009, 07:11:27 PM »

Sat all day in an air rifle range/4 bay garage in 90 degree heat with high humidity learning how to reload ammo, so a member of the brain trust I am currently not. Be that as it may, CK wasn't making the proposal, though he was suggesting the means by which BHO might turn the debate around.

Me, I'm all about market mechanisms so that's what I'd be trying to engineer into the system.
Power User
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« Reply #379 on: August 29, 2009, 07:50:53 PM »

Understood about CK's point. 

Agreed that free market/market mechanisms is the way to go. 

So let us brain storm.

Is our answer to be purely economic, or are there any additional analytical variables to be brought to bear?

What IS our answer to the unaffordable spending of Medicare and Medicaid?  Have a bigger mesh in the safety net so more can slip through?  Simply set a finite amount to be set instead of the current (and fraudulent IMHO) baseline budgeting?  Would this not mean that a decreasing % of price would be paid by the govt and concurrently an increasing % paid by the consumer/patient and therefore that some people would not receive care that they currently receive?

I'm sorry, but as best as I can tell at present all the attack on BO's liberal fascist proposals fails to address this question. 
« Reply #380 on: August 30, 2009, 08:42:43 AM »

You're right, the current attack on Obamacare does not address looming fiscal train wrecks. Unfortunately this train wreck and the one that looms for social security are based on ill-advised, fiscally unsustainable entitlements that get passed by politicians for political reasons that then have to be lived with as they morph into political third rails. This reality won't be altered by a single piece of legislation or response; instead we need start by changing the terms of the debate.

The Republicans are already in disarray so perhaps it's time to urge them to reform around straight forward principles by asking questions like: so you want to be in charge of making your own medical decisions and utilize the most innovative and advanced medical system in the world, or do you want your government to make those decisions for you and control costs by limiting innovation and ceding advance status? Similar questions could be asked about social security and those who favor autonomy and sustainable fiscal structures could coalesce into a new voting block.
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« Reply #381 on: August 30, 2009, 11:53:26 AM »

While finding an acceptable proposal let's not forget underlying principles regarding what is the state and county role, what role does charity play, and what is a constitutionally-based federal government role.  If we decide that health care is a constitutionally unenumerated right, it will be the vaguest right ever established with denial of service decisions made in every state and every hospital, every minute or so, challenging that right, with costs spirally up to economic collapse, not down to containment.  It will be the first right I know of that creates a burden on someone else to perform an act of service for you, like having freedom of speech require people to tune in and pay attention while you speak, with federal enforcement.
Seems to me Feds could make a huge difference with tort reform.  A doctor does not need the threat of punitive damages because he/she can be punished through state licensing (lose your license you lose your income) and because the doctor doesn't pay, malpractice insurance does and its all wrapped in the cost.

I can see a federal role in encouraging insurance competition across state lines.

Feds play a role in the federal tax code.

Feds could play a role in mandating easy access for consumers to know costs before treatment choices.
For the most part we are not arguing health care, we are arguing about finance and control, who decides and who pays.  Insurance is designed to protect your assets against large unforeseen future costs, so that you won't have to pay your life savings on catastrophic costs or so that your up and down medical costs as needed can be budgeted nicely into predictable monthly costs.  If you have no significant income, assets or likelihood of future income or assets, you are already covered by public plans and receive treatment today not only in emergency rooms.

The only thing that really controls cost other than rationing/denying service is the extent that INFORMED consumers make their own choices and pay their own bills.  (Current bills stomp out Health Saving Accounts and catastrophic coverage only - high deductible plans.)
"Universal" should refer to the availability of choices for everyone, not the mandate that you take one of them.

To one of Crafty's questions, people already diagnosed with diabetes for example while not covered might expect a higher cost than signing up healthy.  A millionaire with colon cancer or in need of heart surgery but no health plan might have to exhaust his own assets before qualifying for public assistance.  Or be offered a plan for people in that circumstance more expensive than was available to him before he was diagnosed.  That seems logical to me.  Making providers cover you for what they insure after you are diagnosed and keep you as long as you continue to pay the premium is only common sense as a regulation IMO.  If I find out that is not already the case I would cancel my plan today.
The current healthcare system is built very largely off of Medicare reimbursement schedules even for private coverage outside of Medicare.  Because of this, there is almost no innovation in the system in terms of lower cost ways to administer common services that we all need.

Under the current system even a self-paying customer has NO IDEA what kind of money he is spending while being treated until after the bill comes.  Better consumer cost disclosure requirements and regulations are a proper role for government at some level and we certainly want to be treated across state lines so a common sense federal standard seems justified to me.
Proposals under consideration don't add to the number of doctors, nurses, facilities, hospitals, etc. because that would add to the total cost. True - but bringing down the cost per procedure using market pressure can never happen in a zero competition environment.

National Health Insurance of any kind will totally wipe out every aspect of any libertarian's view of their informational privacy.  Please review again the 'humor' video of national pizza ordering that both Freki and I posted.  You call and they already know where you live, where you work, what you make, what you drive, what foods and activities you need to stay away from and on and on and on.  Not very funny.

Once everything is under the federal government responsibility, does anyone think a bill to end mountain climbing shouldn't follow?  Motorcycle jumping, obviously out.  Then what? French fries? I hate to even be facetious because nothing is out of the realm. Soccer players with federal helmets or banning the header altogether...

Gentlemen, do you really think MARTIAL ARTS will still be legal in a few years as acceptable risk? Sparring with knives?

As this is a finance/insurance bill, does everyone understand that the enforcement agency is the IRS?  That is no joke or exaggeration and they cannot perform their federally mandated duties without more agents, larger budgets and more powerful informational tools.  Let's poll that question and see how many favor 'universal' coverage.
If the CBO says the cost of this will be a trillion, the cost will be tens of trillions.  Go back to original social security projections and original medicare projections and learn to translate government numbers.  If it doesn't grow at double-digit, compound rates, it is a cut that will kill innocent people.
I disagree with Crafty that we have to offer specific alternatives right now more than "NO".  IMHO moving forward now starts with a resounding defeat of the current takeover attempts.  Let's get real clear and articulate on 'no' and why 'no'. Then proposals and solutions will be offered by the candidates and parties who want to compete in 2010 and 2012.

I quibble with CCP over the idea that the 'cans (Republicans) need to answer to all these questions.  It is the party in power that currently needs to answer the objections raised - and they haven't!  The 'cans who need to figure out a better way are the Ameri-cans, including 'blue-dog' Democrats, blue-collar Democrats, non-class-envy Democrats (if there are any) who don't have a goal of making someone else pay for their expenses, deficit-weary Democrats who previously railed against fiscal irresponsibility and independent voters who make up about a third of the electorate and need to sort out what kind of country they want to live in and who always swing the outcomes of the elections.

JMHO.   - Doug

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« Reply #382 on: August 30, 2009, 07:49:32 PM »

Gentlemen, thanks for getting the conversation going.
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« Reply #383 on: August 31, 2009, 12:06:21 AM »

When and where has the federal gov't ever gotten involved in anything and the end result was that it became cheaper and more effective?
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« Reply #384 on: August 31, 2009, 08:32:08 AM »

Here are some things that occur to me:

The situation with Medicaid and Medicare (btw, someone please define each for me please) is unsustainable.  Even if we succeed in knocking BO back, this problem remains (similar to the Dems knocking back Bush's substantial and sincere efforts to reform Social Security)

The problem is that the structure of an entitlement creates a consumer unrestrained by cost.  (Indeed, the dynamic of insurance itself creates a consumer little restrained by cost).   If we stay within the entitlement structure AND limit our spending to what we can afford, then as best as I can tell, are not death panels inevitable?

If we cannot answer this connundrum, are not our criticisms full of sound and fury that lacks substance on this essential point?

Two part question:

A) What do we think should be done?

B) How do we get there?

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« Reply #385 on: August 31, 2009, 11:49:18 AM »

Some different thoughts on the matter:

Political considerations
Obama must pull a Clinton - "triangulate" if that is what you want to call and move to the center guided strictly aka D. Morris style by daily polls.
If he wants to maintain power this is what he will do.  This is what I suspect he will do; esp. with the armey of Clintonites in his administration.
I really doubt he will continue to shove his radical agenda down Americans and throw away his power - and the Dems.
The cans can only gain so much by being the party of NO.  They really gain traction then thye do need to come up with alternatives.
I guess the risk to them if they do is BO will steal their thunder aka CLinton with welfare reform.

Economic considerations
with or without trying to cover 50 million new peopel the system is broke.
First are there really 50 million people or is it the rights alleged much lower number that can't get insurance?
I don't know who to believe.

As Body points out
"so you want to be in charge of making your own medical decisions and utilize the most innovative and advanced medical system in the world, or do you want your government to make those decisions for you and control costs by limiting innovation and ceding advance status?"
I think most would agree that people would rather be able to choose though I am speculating.
We must ration somehow.
either insurance will decide for us or we have some sort of tiered system wherein people can decide with their doctors what they are willing to pay for meds, procedures, etc.

People who get dropped from insurance need to be albe to get it somewhere.
Those with preexisting conditions need to get it somewhere without having to go into poverty and get medicaid or go on disability.
We do need to decide what we are doing with illegals who are here.
WE do need to know in the medical field which things we do are more expensive than less cheaper alternatives if the option exists.  We need more studies but as Charles Kruathammer points out the publication of these in journals is not enoght for us doctors who neither pay attention or don't want to be bothered with cost savings when it doesn't do anything for ourselves.
We do need some tort reform.
There is no quesiton we order tests "just in case" the one person in front of us is the one that happens to have the cancer or other hidden though rare condition.  Miss it and our lives and carreers are in jeopardy.
But when is rare 'rare enough' to not justify a an expensive test?  It depends who you talk to.

I think it a terrible mistake to make health care a gigantic government entiltilement though a lot of it already is.
I prefer reversing this not expanding this.
Of course those in this country who like to have others pay for them thnk the opposite.

« Reply #386 on: August 31, 2009, 07:52:47 PM »

Sorting Fact From Fiction on Health Care

In recent town-hall meetings, President Barack Obama has called for a national debate on health-care reform based on facts. It is fact that more than 40 million Americans lack coverage and spiraling costs are a burden on individuals, families and our economy. There is broad consensus that these problems must be addressed. But the public is skeptical that their current clinical care is substandard and that no government bureaucrat will come between them and their doctor. Americans have good reason for their doubts—key assertions about gaps in care are flawed and reform proposals to oversee care could sharply shift decisions away from patients and their physicians.

Consider these myths and mantras of the current debate:

• Americans only receive 55% of recommended care. This would be a frightening statistic, if it were true. It is not. Yet it was presented as fact to the Senate Health and Finance Committees, which are writing reform bills, in March 2009 by the Agency for Healthcare Research and Quality (the federal body that sets priorities to improve the nation's health care).

The statistic comes from a flawed study published in 2003 by the Rand Corporation. That study was supposed to be based on telephone interviews with 13,000 Americans in 12 metropolitan areas followed up by a review of each person's medical records and then matched against 439 indicators of quality health practices. But two-thirds of the people contacted declined to participate, making the study biased, by Rand's own admission. To make matters worse, Rand had incomplete medical records on many of those who participated and could not accurately document the care that these patients received.

For example, Rand found that only 15% of the patients had received a flu vaccine based on available medical records. But when asked directly, 85% of the patients said that they had been vaccinated. Most importantly, there were no data that indicated whether following the best practices defined by Rand's experts made any difference in the health of the patients.

In March 2007, a team of Harvard researchers published a study in the New England Journal of Medicine that looked at nearly 10,000 patients at community health centers and assessed whether implementing similar quality measures would improve the health of patients with three costly disorders: diabetes, asthma and hypertension. It found that there was no improvement in any of these three maladies.

Dr. Rodney Hayward, a respected health-services professor at the University of Michigan, wrote about this negative result, "It sounds terrible when we hear that 50 percent of recommended care is not received, but much of the care recommended by subspecialty groups is of a modest or unproven value, and mandating adherence to these recommendations is not necessarily in the best interest of patients or society."

• The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact.

The World Health Organization ranks the U.S. No. 1 among all countries in "responsiveness." Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). This is what Americans rightly understand as quality care and worry will be lost in the upheaval of reform. Our country's composite score fell to 37 primarily because we lack universal coverage and care is a financial burden for many citizens.

• We need to implement "best practices." Mr. Obama and his advisers believe in implementing "best practices" that physicians and hospitals should follow. A federal commission would identify these practices.

On June 24, 2009, the president appeared on "Good Morning America" with Diane Sawyer. When Ms. Sawyer asked whether "best practices" would be implemented by "encouragement" or "by law," the president did not answer directly. He said that he was confident doctors "want to engage in best practices" and "patients are going to insist on it." The president also said there should be financial incentives to "allow doctors to do the right thing."

There are domains of medicine where a patient has no control and depends on the physician and the hospital to provide best practices. Strict protocols have been developed to prevent infections during procedures and to reduce the risk of surgical mishaps. There are also emergency situations like a patient arriving in the midst of a heart attack where standardized advanced treatments save many lives.

But once we leave safety measures and emergency therapies where patients have scant say, what is "the right thing"? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications. Conclusions about what works and what doesn't work change much too quickly for policy makers to dictate clinical practice.

An analysis from the Ottawa Health Research Institute published in the Annals of Internal Medicine in 2007 reveals how long it takes for conclusions derived from clinical studies about drugs, devices and procedures to become outdated. Within one year, 15 of 100 recommendations based on the "best evidence" had to be significantly reversed; within two years, 23 were reversed, and at 5 1/2 years, half were contradicted. Americans have witnessed these reversals firsthand as firm "expert" recommendations about the benefits of estrogen replacement therapy for postmenopausal women, low fat diets for obesity, and tight control of blood sugar were overturned.

Even when experts examine the same data, they can come to different conclusions. For example, millions of Americans have elevated cholesterol levels and no heart disease. Guidelines developed in the U.S. about whom to treat with cholesterol-lowering drugs are much more aggressive than guidelines in the European Union or the United Kingdom, even though experts here and abroad are extrapolating from the same scientific studies. An illuminating publication from researchers in Munich, Germany, published in March 2003 in the Journal of General Internal Medicine showed that of 100 consecutive patients seen in their clinic with high cholesterol, 52% would be treated with a statin drug in the U.S. based on our guidelines while only 26% would be prescribed statins in Germany and 35% in the U.K. So, different experts define "best practice" differently. Many prominent American cardiologists and specialists in preventive medicine believe the U.S. guidelines lead to overtreatment and the Europeans are more sensible. After hearing of this controversy, some patients will still want to take the drug and some will not.

This is how doctors and patients make shared decisions—by considering expert guidelines, weighing why other experts may disagree with the guidelines, and then customizing the therapy to the individual. With respect to "best practices," prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.

• No government bureaucrat will come between you and your doctor. The president has repeatedly stated this in town-hall meetings. But his proposal to provide financial incentives to "allow doctors to do the right thing" could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions.

Further, at the AMA convention in June 2009, the president proposed linking protection for physicians from malpractice lawsuits if they strictly adhered to government-sponsored treatment guidelines. We need tort reform, but this is misconceived and again clearly inserts the bureaucrat directly into clinical decision making. If doctors are legally protected when they follow government mandates, the converse is that doctors risk lawsuits if they deviate from federal guidelines—even if they believe the government mandate is not in the patient's best interest. With this kind of legislation, physicians might well pressure the patient to comply with treatments even if the therapy clashes with the individual's values and preferences.

The devil is in the regulations. Federal legislation is written with general principles and imperatives. The current House bill H.R. 3200 in title IV, part D has very broad language about identifying and implementing best practices in the delivery of health care. It rightly sets initial priorities around measures to protect patient safety. But the bill does not set limits on what "best practices" federal officials can implement. If it becomes law, bureaucrats could well write regulations mandating treatment measures that violate patient autonomy.

Private insurers are already doing this, and both physicians and patients are chafing at their arbitrary intervention. As Congress works to extend coverage and contain costs, any legislation must clearly codify the promise to preserve for Americans the principle of control over their health-care decisions.

—Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.
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« Reply #387 on: August 31, 2009, 11:12:59 PM »

CCP: "I think it a terrible mistake to make health care a gigantic government entitlement though a lot of it already is.  I prefer reversing this not expanding this."  Couldn't agree more.  Like most of politics, it would be something of an accomplishment to just stop moving in the wrong direction.

Medicaid - free health care for poor people, Medicare - government plan for older people.  And S-CHIP which goes up to something like 3 times the poverty level, was supposed to be aimed at children but means all kinds of different things now.  No one proposes to end any of these so reform can only mean to tighten up eligibility, ration care more or raise taxes in an upward spiral until we collapse (even worse than now).

Crafty: "If we stay within the entitlement structure AND limit our spending to what we can afford, then as best as I can tell, are not death panels inevitable?

  - Yes.  The success rate of saving lives in the long run is zero so death panels are part of the ordeal. That panel is hopefully is small room of people you trust including loved ones and a second medical opinion. They will come to tell me or you someday that we've got til Friday if untreated, but if we take the aggressive million dollar treatment we have until maybe next Tuesday.  Then we look at coverage and options and make the hard choices.  We just don't want the government in the room as we sort it out.  Besides inefficiencies and incompetencies, they would come in with other biases, such as the fact that you are taking up one of their beds in short supply, or that someone else has more income tax paying years left than you and should move past you in the line.

Instead we plan ahead hopefully and get the best advice on the best plans and coverage to anticipate our future circumstance and hopefully match coverage to the type of aggressiveness that we will want to fight off whatever nasty ailment is going to attack us.  When we go to one size fits all, then for sure it will be third parties instead of us deciding the size of the coverage and the level of cost.
« Reply #388 on: September 01, 2009, 08:21:27 AM »

Does Obama Take Health Costs Seriously?
His stand on generic competition for biotech drugs will provide the answer.

By James K. Glassman

Revelations of an $80 billion bargain between the White House and PhRMA (Pharmaceutical Research and Manufacturers of America) are upsetting many Democrats. “We were never part of that deal,” said Rep. Henry Waxman (D., Calif.), chairman of the House Energy and Commerce Committee, one of three panels that wrote the House bill. “We are not bound by that deal. It was not particularly a deal I would have made.” As the Daily Kos, a popular left-wing blog, put it, “Congressional Democrats should say ‘hell, no’ to this deal.”

But the deal may have a bigger problem than anger on the left. It threatens to come apart over a seemingly arcane question: When a company develops a drug called a “biologic” — a complex medicine derived from living plant and animal cells — how long should it keep its exclusive right to sell said drug? “Drug companies that had agreed to support the Obama administration on healthcare reforms have found themselves once more at odds with the president” on this issue, reported recently.

The reason for the possible unraveling is evident: The companies PhRMA represents have an immense interest in keeping the profits that come with exclusivity. But if the president can’t show he wants to tame drug expenses through competition — the best and simplest means to an important end — it’s hard for anyone to take him seriously on the critical issue of controlling health-care costs overall.

Aside from biologics, the deal seems to be going well. PhRMA agreed to cut drug costs by $80 billion over ten years, mainly by offering discounts for medicines in the “donut hole” not covered by the Medicare drug benefit enacted during the Bush administration and by paying out higher rebates for drugs under Medicaid. PhRMA also agreed to run advertisements — reportedly valued at $150 million — in support of health-care reform. (Some of those ads were produced by AKPD Message and Media, formerly headed by Obama adviser David Axelrod.)

In return, the White House agreed to retain restrictions on importing cheaper drugs from abroad and to continue to deny the government the ability to negotiate drug prices downward by using the enormous bargaining power of Medicare. These are both important concessions by Obama.

But the biologics issue was so contentious that the White House and the large drug companies could not reach a consensus. Ryan Grim, a former reporter who now covers Congress for The Huffington Post, revealed the contents of a memo, dated July 7, that described the terms of the White House–PhRMA deal. One clause said this: “Agree to get FOBs done (but no agreement on details . . . ).”

The issue involves what are called “follow-on biologics” (FOBs) — essentially generic versions of biologic drugs that are currently patented (drug patents last 20 years). The big question is over drug companies’ retention of exclusive access to the data they compiled in testing the drug — data that competitors can use to speed along FDA approval of generic drugs. Until this period of exclusivity ends, FOBs can’t compete, and the makers of the original drugs effectively keep monopolies.

Monopoly is appropriate and crucial to innovation — and enshrined in Article I, Section 8, of the U.S. Constitution: “Congress shall have power . . . To promote the progress of science and useful arts, by securing for limited times to authors and inventors the exclusive right to their respective writings and discoveries.” The difficult matter is how long the “exclusive right” should last — how long should we give drug inventors monopoly power to make research profitable before introducing competition to bring down prices?

In 1984, the Hatch-Waxman Act (named for Republican senator Orrin Hatch and Waxman) created just such a pathway for conventional, or “small-molecule,” drugs, and the result has been billions of dollars in savings for consumers and, it is generally agreed, a great deal of innovation as well. It did this by giving companies five years of test-data exclusivity.

So what about biologics? A quarter-century ago, there was no inkling that biologics would register $40 billion in annual sales in the United States alone and account for one in seven prescriptions — a proportion that is rising rapidly. So no provision was made in Hatch-Waxman for FOBs, and to this day they receive no test-data exclusivity at all.
Everyone agrees that some exclusivity is in order, but patented biologics can be expensive — Remicade, which treats rheumatoid arthritis, costs $20,000 for a year’s course of treatment, and some cancer-fighting biologics cost more than twice that — and enduring monopolies put a enormous burden on consumers and government programs. Peter Orzag, the president’s budget director, and Nancy-Ann DeParle, who heads the White House health-care reform effort, said in a June letter to Waxman that “seven years of exclusivity . . . strikes the appropriate balance between innovation and competition.”

Drug companies have been lobbying hard for an exclusion of 12 to 14 years. A National Journal article on August 11 said that PhRMA “spent $13 million lobbying in the first six months of 2009, compared with $8.63 million for the first half of 2008. . . . Forms list that PhRMA used the funds to promote comparative effectiveness research, health information technologies and patent procedures and regulatory approval pathways for biologics.”

Individual drug firms have spent heavily as well. Amgen, the largest biologic maker, pledged $5 million recently to help create the Edward M. Kennedy Institute for the United States Senate. The late Senator Kennedy supported an exclusion of at least twelve years.

On the other side is a remarkably diverse collection of actors. The Obama administration opposed such a lengthy period, as did organizations ranging from the AARP, AFL-CIO, and Consumers Union on the left to the Council of Citizens Against Government Waste, the Competitive Enterprise Institute, and FreedomWorks on the right.

But efforts by the long-exclusion forces — led by the Biotechnology Industry Organization (BIO) under former Democratic congressman Jim Greenwood, and including such notables as former Vermont governor Howard Dean — have so far paid off. On July 13, the panel that Senator Kennedy chaired, the Senate Education, Labor and Pension Committee, approved a twelve-year exclusion, and on July 31, the House Energy and Commerce Committee, by a vote of 47–11, did the same.

The argument of PhRMA and BIO is that a long exclusion is needed to provide drug companies with the incentive to invest the large sums needed to bring a biologic to market. As already mentioned, the Constitution itself acknowledges that innovators need a term of monopoly status as an incentive to invest and create. But a twelve-year exclusion is clearly excessive. It will almost certainly mean no competition for biologics at all.

What’s required, especially at a time when health-care costs are preoccupying the nation, is balance. A Federal Trade Commission study released June 10 said flatly that a 12-to-14-year exclusion is “too long . . . particularly since [biologics makers] likely will retain substantial market share after FOB entry.” That’s because of other restrictions on competition, including a prohibition on pharmacies’ automatically substituting FOBs for biologics.

No wonder there’s tension between the administration and the drug companies. Still, the White House has not explicitly attacked the long-exclusion measures that Senate and House committees have passed and, until lately, it has seemed reluctant to draw attention to what has become an important battle.

In an op-ed in the New York Times on August 16, Obama wrote that “reform will finally bring skyrocketing health care costs under control.” But if the president and members of Congress can’t take a firm stand against a twelve-year ban on competition with biologic drugs — the medicines of the future — how can the public possibly take them seriously on broader matters of cost control?

— James K. Glassman, former undersecretary of state for public diplomacy and public affairs, writes frequently about technology, health, and public policy.

National Review Online -
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« Reply #389 on: September 01, 2009, 09:49:56 AM »

"Americans only receive 55% of recommended care."

Well it depends on what measures.  Probably they are looking at flu vac. rates, objective BP, cholesterol, diabetes goals, cancer screening, such as pap smears, mammograms and colononoscopies.

It could very well be that 55% are not at the goals that are recommended.

But there are many reasons for this, including but not limited to patients simply refusing such tests.  I have many patients who outright refuse flu shots.

"In March 2007, a team of Harvard researchers published a study in the New England Journal of Medicine that looked at nearly 10,000 patients at community health centers and assessed whether implementing similar quality measures would improve the health of patients with three costly disorders: diabetes, asthma and hypertension. It found that there was no improvement in any of these three maladies."

Actually, my experience is somewhat different.  I believe there can be some improvement in measures and some patients can be caught that fall throught the cracks.  However the improvement may be only short lived and the long term cost savings is still rather dubious despite what anyone may tell you as far as I know at least.

I do care coordination work and results are mixed and so far appear to be somewhat short lived though this is just one small experience.  There are probably many reasons for this and multifactorail.

"Even when experts examine the same data, they can come to different conclusions. For example, millions of Americans have elevated cholesterol levels and no heart disease. Guidelines developed in the U.S. about whom to treat with cholesterol-lowering drugs are much more aggressive than guidelines in the European Union or the United Kingdom, even though experts here and abroad are extrapolating from the same scientific studies. An illuminating publication from researchers in Munich, Germany, published in March 2003 in the Journal of General Internal Medicine showed that of 100 consecutive patients seen in their clinic with high cholesterol, 52% would be treated with a statin drug in the U.S. based on our guidelines while only 26% would be prescribed statins in Germany and 35% in the U.K. So, different experts define "best practice" differently. Many prominent American cardiologists and specialists in preventive medicine believe the U.S. guidelines lead to overtreatment and the Europeans are more sensible. After hearing of this controversy, some patients will still want to take the drug and some will not."

The above is so true of how complicated it is.  For example, we could treat 100 people with a drug for the rest of their lives and perhaps to extend one person's life.  Some including the greats from the Cleveland Clinic who are now proponents of their own supposed cost saving system might say this is great.  Some years ago there was a debate between two editorialists on which clost busting drug was better TPA vs streptokinase.   The guy from the Cleveland clinic who did research on TPA (the newer one and ten times more expensive one) would state how it could save one or two more lives per at best 100 people.  The article writer suggested that if we don't take a stand against the extra cost to society we "NEVER WILL".  We as a profession have to say enough already.  We can't keep spending more and more for trivial gains.  In my opinion he was right.  But it is just that - my opinion.  It is not unreasable for some to say that any gain in human life has no limits on how much we spend.

Needless to say the expensive drug won out.  Streptokinase was essential never ever used again.  What Er doctor or cardiologist would use a drug that is 1 or 2% inferior for no other reason than to save money.  If YOUR patient dies no one can say THAT was the one who would not have died if only the more expensive drug was used.  No one wants to be sued.   And no lawyer will mind loking at taking such a case and arguing their client died because a drug known to be "inferior" was used. 

And the other side of it is if you, or I are lying in the ER with a massive heart attack and you or I can choose which drug to use AND if the cost goes to someone else which would you or I pick??

The answer is obvious.

"Dr. Rodney Hayward, a respected health-services professor at the University of Michigan, wrote about this negative result, "It sounds terrible when we hear that 50 percent of recommended care is not received, but much of the care recommended by subspecialty groups is of a modest or unproven value, and mandating adherence to these recommendations is not necessarily in the best interest of patients or society."

I would say this statement is for the most part certainly true - at least the second half of the sentence.

• The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact.

By some measures this is probably true.

But why?

probably many reasons one being some don't or can't pay to see a doctor.
I am not sure how much is obesity, drug addiction, too many people refuse to bother to get health care for whatever reason.

« Reply #390 on: September 01, 2009, 12:44:33 PM »

Dialysis treatment in USA: High costs, high death rates
By Rita Rubin, USA TODAY
Deb Lustman was late getting to work a few days every week, and often felt she wasn't thinking as clearly as she once did.
PHOTOS: Dialysis at home
The reason: Lustman, 50, was spending four hours a day, three days a week, undergoing kidney dialysis at a dialysis center, where a machine filtered toxins and fluids from her blood. Normally, that's the job of the kidneys, but for reasons doctors have never figured out, hers had failed.

Nine months into her treatment, as soon as her doctor raised the possibility of home dialysis, Lustman decided to switch. So, in July 2008, after she and her husband learned the ins-and-outs from a nurse, she began dialyzing five evenings a week at her Magnolia, N.J., home, with her two Maltese, Sophie and Jake, often lounging next to her. Now Lustman, an optician, dialyzes on her own schedule, not the center's, and she's not late for work anymore. And, she says, "I'm healthier."

Thanks to more frequent dialysis, totaling 15 or 16 hours a week, "I feel not only physically better but … mentally better" and no longer "loopy," she says.

Lustman is a rarity, however: Only 8% of U.S. dialysis patients treat themselves at home. The vast majority of the more than 350,000 Americans on dialysis are treated in centers, where three treatments a week, three or four hours each, is the norm — not because it's optimal but because that's the way it has been done for nearly four decades.

A growing body of evidence suggests that longer and/or more frequent dialysis treatments, either at home or in a dialysis center, are far superior to the status quo. Although the USA spends more per dialysis patient than other countries, that does not result in higher survival rates or even, many argue, a better quality of life.

"The standard of care is really inappropriate," says Brenda Kurnik, Lustman's doctor, who practices in Marlton, N.J. "Basically, it prevents people from dying, and that's about all it does."

So why doesn't the USA do better? Many blame Medicare's End Stage Renal Disease Program. Launched in 1973, it's the only federal program that entitles people of all ages to health-care coverage on the basis of a single diagnosis: chronic kidney failure. By paying for lifesaving care for hundreds of thousands of Americans, the program is a testament to what health insurance reform might achieve if Congress were to adopt it.

But it also may be a cautionary tale: Its cost has far exceeded initial projections, and some doctors and other analysts question whether Medicare get its money's worth and whether patients get the best treatment. Less than one-quarter of dialysis patients ages 18 to 54 are well enough to work or go to school.

In 2007, Medicare spent $8.6 billion on the treatment and medications of dialysis patients, from babies to the elderly, according to the Medicare Payment Advisory Commission's March report to Congress.

In addition, Medicare pays billions each year for the hospitalization of dialysis patients. Although they are younger on average than most Medicare beneficiaries, who must be 65 to qualify for coverage, "this is an incredibly sick population," says epidemiologist Paul Eggers of the National Institute of Diabetes and Digestive and Kidney Diseases. Such patients, Eggers says, enter the hospital six times more often than Medicare beneficiaries who don't have chronic kidney failure.

Despite the costs, a substantial proportion of dialysis patients die every year. In 2006, 20.1% of U.S. dialysis patients died, most often of heart disease or infections. In Japan, the death rate was about half that; Australia's rate was halfway between the USA's and Japan's.

Explanations for why the USA has the highest dialysis death rate in the world vary. Some U.S. kidney doctors say that countries with national health programs, such as Britain, withhold dialysis from the oldest, sickest patients, while the Medicare program takes all comers. But foreign doctors deny that their countries ration dialysis. They — and many of their U.S. colleagues — attribute the higher U.S. death rate in part to Medicare's own payment system and the resulting "one-size-fits-all" treatment.

The standard of care has become the three treatments a week for which Medicare pays, usually in a dialysis center, and no longer than four hours each. Home dialysis, which allows for longer, more frequent treatments, is more common in most countries with better survival rates.

'Capable of doing better'

The status quo has many critics. In June, a group of nephrologists, or kidney doctors, who had met at a Harvard teaching hospital to discuss the issue sent a letter to White House and Medicare officials urging "substantial changes in the delivery and financing of care … to improve patient outcomes" for those with chronic kidney failure.

"We are capable of doing better," they wrote to White House health policy czar Nancy-Ann DeParle and Barry Straube, chief medical officer at the federal Centers for Medicare & Medicaid Services, or CMS. "Small, incremental improvements in the outcomes for patients with kidney failure are no longer acceptable."

When Medicare's kidney-failure program started in the early 1970s, "the science was such that somewhere between three and six hours of dialysis three days a week was sufficient. Things sort of settled into that pattern," says Dallas nephrologist Thomas Parker III, co-organizer of the conference at Harvard's Beth Israel Deaconess Medical Center.

But normal kidneys work 24/7, not a few shifts a week, so the standard treatment replaces only 10% to 13% of their function, Parker says. How much dialysis is enough isn't clear, he says, because few studies have randomly assigned patients to different amounts to test which approach is more effective.

In his July 22 prime-time press conference, President Obama endorsed the use of such studies, called comparative effectiveness research, to ensure that the U.S. health-care system gets the most value for its money. The economic stimulus package has earmarked $400 million for such research. "If doctors and patients have the best information about what works and what doesn't, then they're going to want to pay for what works," Obama said.

In a report issued June 30, the Institute of Medicine listed its top 100 priorities for comparative effectiveness research. Dialysis and kidney transplantation were high on the list.

Parker said Friday that the nephrologists had received a "very promising" response from Straube, indicating that federal officials "are open to further communications" about the future of dialysis.

Only the wealthy had dialysis

When President Nixon signed the 1972 bill establishing the End Stage Renal Disease Program, only 10,000 Americans were on dialysis, and more than one-third were doing it at home. Only the wealthy could afford long-term treatment.

The world's first outpatient dialysis center, the three-bed Seattle Artificial Kidney Center, predated Medicare by 11 years. There wasn't enough money or machines to go around. So an anonymous committee of Seattle community leaders decided which candidates would get dialysis and live and which would not and die.

The Medicare program opened up treatment to thousands who would have died without it. "We were naive in estimating how much this was going to cost," says Brandeis University professor Stuart Altman, an economist who advised Nixon on health policy and now advises Obama. "People didn't realize how many more people were going to go on it, how much longer we were going to keep these people alive."

It soon became clear: If you pay for it, they will come. "All of a sudden, large numbers of people who were not traditionally on Medicare qualified," Altman says. "We created this giant money machine that made a lot of nephrologists and entrepreneurs rich."

Dialysis became big business, with free-standing centers established in hundreds of cities by corporations, not hospitals. The number of U.S. centers has increased 4% every year, according to a June report by the Medicare Payment Advisory Commission. In 1998, there were 3,394; in 2008, 4,957. About 60% are owned by Denver-based DaVita, a Fortune 500 company, and Fresenius Medical Care North America, a Waltham, Mass.-based subsidiary of a German company that operates centers in 28 countries and also sells dialysis machines and other supplies.

And about 70% of Medicare dollars spent on dialysis and injectable drugs goes to DaVita, which runs more than 1,500 U.S. dialysis centers, and Fresenius, which runs more than 1,700. In the first quarter of this year, DaVita's revenues were $1.45 billion, up more than 8% from the first quarter of 2008. Fresenius' revenues from dialysis in North America were $1.57 billion, up 5% over the first quarter of 2008.

Since 1983, Medicare has paid dialysis providers, whether for-profit centers, non-profit centers or hospitals, a "composite rate" per treatment, which averaged about $155 in 2007. And because Medicare pays the same amount no matter how long the treatment, there's no financial incentive to dialyze patients longer than a few hours at a time.

On top of the composite rate, Medicare pays extra for newer, expensive injectable drugs — namely erythropoietin, or EPO, a hormone that stimulates red blood cell production, and vitamin D, which plays a role in bone health — and lab tests. These extras added an average of $75, or 50%, to the cost of each treatment in 2007. Countries with national health systems don't use the injectables nearly as much. They use less EPO and prescribe oral vitamin D pills that cost about one-quarter of the injectable versions but, their doctors say, are equally effective.

Longer, more frequent dialysis

Longer and/or more frequent dialysis can improve quality of life and survival and reduce hospitalizations, some doctors and patients believe, although the government isn't yet convinced.

"If you ever see patients who are dialyzing six or seven times a week, they are totally different" from those who receive the standard three treatments, says nephrologist Christopher Blagg, a University of Washington professor emeritus who for many years served as director of the Northwest Kidney Centers in Seattle.

Besides improved blood pressure control and lower use of EPO, they generally feel better, with more energy. And chances are they live longer, Blagg says. As he told the House Committee on Ways and Means in March, "dialysis patient deaths and cardiac incidents are significantly more frequent on the day after the two-day gap between treatments that occurs with three dialyses in the seven-day week."

From Medicare's point of view, though, the End Stage Renal Disease Program "is a pretty expensive program, and it needs the best justification imaginable that more dialysis would be better," says Eggers, the kidney disease institute epidemiologist.

Most of the evidence that longer and/or more frequent dialysis is superior has come from observational studies, in which patients decided on their own to try it. Perhaps some characteristic of the patients who choose to dialyze at home or overnight in a center — and not the dialysis itself — explains why they feel better and require less hospitalization than patients at centers.

A randomized trial, in which patients are randomly assigned to a particular therapy, is generally considered the gold standard for comparing treatments. Eggers is the project manager for two such dialysis trials, funded by the National Institutes of Health. One is comparing traditional thrice-weekly, four-hour dialysis treatments with six short daily treatments, adding up to about 16 or 17 hours a week. The other is comparing the traditional in-center approach to six nocturnal, or overnight, treatments a week.

Yet, neither of the trials enrolled as many patients as had been hoped, Eggers says, and he figures he knows why. "You have to go to a patient and say, 'here is something that you do three times a week that you hate,' " he says, and then tell them that they might have to do it twice as often. "It's a pretty significant thing you're asking a patient to do without a huge guarantee."

Because of the studies' limited size, they won't be able to determine conclusively whether more dialysis saves lives, Eggers says. "We might show that patients feel a lot better and have better heart function."

Blagg says he is so convinced of the benefits of more dialysis that he felt it was unethical to enroll patients in Eggers' trials, in which they had a 50-50 chance of getting the standard treatment.

30% could be treated at home

Home is a convenient setting for longer or more frequent treatments. About 30% of U.S. dialysis patients are candidates for home treatment, though only 8% now do it, Blagg says. By comparison, about 55% of dialysis patients in New Zealand dialyze at home, as do 30% in Australia and 20% in Canada.

Some U.S. patients don't even know home dialysis is an option. To fix that, Congress passed a law last year requiring dialysis providers to tell patients about all dialysis methods, beginning Jan. 1.

Home dialysis may also be more cost-effective, according to a May report by the U.S. Government Accountability Office which collected information from the large for-profit chains and non-profit and hospital-based dialysis providers. All of them said their per-treatment costs are lower when patients dialyze at home.

Centers recoup the "serious upfront costs," mainly for the machine they provide, after the patient has been dialyzing at home for a year or 18 months, Blagg says.

J. Michael Lazarus, Fresenius Medical Care North America's chief medical officer, says he wishes more patients would dialyze at home, because it would cut his company's overhead and help it deal with a nursing shortage. But, he says, home dialysis is a hard sell to U.S. patients. "When you build enough dialysis units so there's one on every corner," Lazarus says, patients think " 'why should I go home when I can go to your dialysis unit that's 10 minutes away?' "

Some patients find home dialysis too disruptive for their families. After doctors in 2007 had to remove the kidney her oldest son had donated to her, Michelle Adams-Walton, 46, tried hemodialysis at her Seaside, Calif., home for a couple of months. Her youngest son, now 20, served as her dialysis partner, a requirement for home dialysis.

"That machine did not work out for me," Adams-Walton recalls. "We were both starting to feel the dialysis was taking over our entire lives." However, she says, she had seen enough evidence to convince her that the more dialysis, the better. For her, nocturnal dialysis has been the answer.

On Mondays, Wednesdays and Fridays, Adams-Walton, who works full time as a librarian, drives 90 minutes to one of the few centers set up to provide overnight treatment. She goes on the machine at about 8 p.m. and is taken off at 4 a.m. Then she drives home and tries to catch some more sleep.

Since starting nocturnal dialysis, she says, "I certainly feel so much better." Before, "I was able to function, but just function."

What happens next

Congress has ordered Medicare to revamp the current pricing system. Payments for injectable drugs and lab tests not currently covered by the composite payment are to be "bundled" into it, effective Jan. 1, 2011. Details aren't expected to be released for a few weeks, so the potential impact on dialysis care is difficult to predict.

The open questions:

• Will Medicare keep home dialysis training costs outside the composite payment? Home dialysis advocates fear that rolling such costs into the bundle will discourage centers from offering the home option.

• Will the expanded composite payment be based on what Medicare already pays for dialysis and injectable drugs? That wouldn't result in any savings but could lead to an excessive reduction in the drugs' use, says Bill Peckham, 45, a Seattle dialysis patient and blogger.

• Will Medicare start paying on a weekly or monthly basis, instead of per treatment? Peckham fears that would lead to fewer, not more, treatments.

Straube of CMS emphasizes that a "quality incentive program" will accompany the new payment structure. Instead of paying only on the basis of quantity, he says, Medicare will also begin rewarding dialysis providers on the basis of quality standards, such as how well they manage patients' side effects.

Lazarus, of Fresenius, predicts "a number of (dialysis) units will close because of the bundle. Where are they and who's going to be deprived?" If they're rural, for example, that could greatly impact some patients.

Still, expanding the composite payment is "the right move," Lazarus says. "We have to do something about cost. We have to do something with a system that's out of control. It's a broken system, and we need to fix it."


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« Reply #391 on: September 03, 2009, 08:22:50 AM »

September 3, 2009
NHS may need to lose 137,000 staff to meet £20 billion savings target

David Rose, Health Correspondent

The NHS may need to cut its workforce by about 10 per cent — the equivalent of 137,000 staff — to help to meet planned savings of £20 billion, according to a leaked Department of Health report.

A study commissioned from the consultancy firm McKinsey and Company recommends cutting clinical staff posts as well as administrators to meet efficiency savings by 2014, suggesting a knock-on effect to patient care.

The report, seen by the Health Service Journal (HSJ), recommends a range of possible actions, such as a recruitment freeze starting in the next two years, a reduction in medical school places from October and an early retirement programme to encourage older GPs and community nurses to make way for “new blood/talent”.

The report was presented to the Department of Health in March, the HSJ says today. It carries the department’s logo and has been distributed among senior NHS managers.

The study said £2.4 billion could be saved if hospitals with the lowest levels of staff productivity improved to become nearer the average levels. It added that almost 40 per cent of patients in a typical hospital did not need to be there.

Productivity is notoriously difficult to measure in an organisation as large as the NHS, which employs 1.5 million staff, but the biggest causes for patients staying unnecessarily long in hospital were delays in receiving tests or therapies, or a lack of suitable carers or facilities that meant patients could not go home.

The report also said that if four million of the 29 million outpatient appointments each year could be cut, it would save £600 million.

A further £700 million could be saved if procedures with limited clinical benefits — such as tonsillectomies, varicose vein removal and some hysterectomies — were no longer performed.

The analysis also suggests that up to £8.3 billion of hospital estates could be “freed up” or sold to generate income.

Andrew Lansley, the Shadow Health Secretary, said: “Yet again Labour ministers are failing to be straight with the British people.

“Andy Burnham [the Health Secretary] promised to protect the NHS, but now we find out that his department has been drawing up secret plans for swingeing cuts.

“Clearly, we need to get better value for money from the NHS, so we applaud any drive for greater efficiency, but it is extraordinary that Labour plan to take an axe to the hospital budget rather than to the bloated health bureaucracy.

“Only a fifth of job cuts would be within the bureaucracy, meaning the vast majority to go would be frontline NHS staff.

“After years of declining productivity, this report shows that Labour still doesn’t get it.

“Instead of relying on plans drawn up by management consultants for top-down cuts, they should be looking to create incentives through the way hospitals are paid, which would drive up standards and drive down costs.”
« Reply #392 on: September 03, 2009, 09:23:29 AM »

Second post:

Health care: while government dithers, private enterprise delivers

Nicholas J. Kaster

While Barack Obama schemes to enlarge the government's control over health care, private enterprise has stepped in to provide low cost, quality health care to Americans. Since 2000, over 1,200 private in-store clinics, typically staffed by nurse practitioners, have been opened by such companies as Wal-Mart, Walgreens, Target, and CVS and have served more than 3.5 million patients, providing treatment for minor ailments, routine physicals, immunizations, and the like, and doing so more cost-effectively than traditional medical facilities.

A new study, to be published in the September edition of the Annals of Internal Medicine, found that clinics in drug stores provide care for minor ailments "on par with, or better than, other medical facilities at significantly lower costs."

The quality of care offered at the in-store clinics was in line with doctors' offices and urgent care centers and slightly better than at emergency departments, Dr. Ateev Mehrotra of the University of Pittsburgh School of Medicine and the Rand research institute and colleagues found.

And the health care is being delivered at a lower cost. Nearly all of the clinics treat both the insured and uninsured. With a more price-sensitive market, it is not surprising to find that "the fees are low - and conspicuously posted." According to the study, the average cost for treatment at private drug store clinics was $110, including the evaluation, pharmacy, laboratory and other costs. This compares to an average cost of $156 at an urgent care facility, $166 at a doctor's office and $570 at an emergency department. What's more, "there is little or no waiting time."

Mehrotra characterized the retail clinics as "an innovative new way of delivering health care." Its just the kind of innovation sure to be stifled under a one-size-fits-all regime of socialized medicine.

Page Printed from: at September 03, 2009 - 10:22:43 AM EDT
Power User
Posts: 7838

« Reply #393 on: September 04, 2009, 02:07:21 PM »

I can only hope OBama is as stupid as Weiner.  Then we are assured of acute total destruction of BO and the Dems in the next election cycle.   But I doubt he could be that stupid.  This guy Weiner is in total denial lala land.  From yesterday's (I think) Rachel Maddow show:

****Rep. Anthony Weiner (D-N.Y.) said Obama has been hurting the cause of health care reform by sitting out the fight.

"David Axelrod said on your show that this is like we're in the ninth inning," he told MSNBC's Rachel Maddow last night. "That's not true. Our cleanup hasn't even come to the plate."

Weiner is a forceful advocate of a public health insurance option. He's said he thinks about 100 Democratic House members would vote against a bill that didn't include it.

"We've been in a scrap through the month of August, but we really haven't had presidential leadership in the way we need it most," Weiner told Maddow. He told he thought Obama's speech next week would turn things around. "If he stands up Wednesday and says to the country, we need to have a public option and here's why, it's going to get done. If he don't we'll settle for less and that will be a tragedy."

Weiner dismissed talk of an incremental approach or a bill that only deals with some problems of the health care industry. "That's not the change that a lot of people think they voted for," he said****
« Reply #394 on: September 05, 2009, 07:52:49 PM »

Dying patient scheme should be examined, campaigners warn
Campaigners have called for an investigations into an NHS scheme which helps to end the lives of terminally patients after a group of leading doctors warned that some were dying prematurely.
By Kate Devlin, Medical Correspondent
Published: 7:00AM BST 04 Sep 2009
In a letter to The Daily Telegraph the medical experts warned that Britain was facing a “national crisis in care” because some patients were having fluids and drugs removed after being wrongly judged to be close to death.
Many were also being sedated, making it more difficult for doctors to tell their true condition.
The experts warned that the scheme was encouraging a "tick box" culture in which healthcare staff stopped questioning whether a patient was really dying or not.
The scheme, called the Liverpool Care Pathway, is being used in more than 300 hospitals across the country to advise staff on how to deal with the dying.
Dignity in Dying, which campaigns for patients to have a choice in all aspects of their end of life care and death, called on ministers and the health service to investigate how the system was being used in practice.
Sarah Wootton, the chief executive of the group, formerly the Voluntary Euthanasia Society, said: “Further research on the practice of the Liverpool Care Pathway is needed.
"The concerns raised ... suggest that some health care professionals need further training in the care of dying patients and on communication with both patients at the end of life, and their families and loved ones."
She added: "People approaching the end of life need to feel confident that their wishes will be respected and that they will be given the best care possible.
“All efforts to improve the care and support available to dying patients should be welcomed - including programmes such as the Liverpool Care Pathway, which aims to bring the best practice of hospice care to patients dying in hospital.”
She added that the recent finding that 16.5 per cent of deaths in Britain involved continuous deep sedation was “concerning”.
The Liverpool Care Pathway (LCP) was drawn up by Marie Curie and has been recommended for use across the NHS.
A spokesman for the charity said: "The letter talks about death being an inexact science and that is absolutely right. The Liverpool Care Pathway is not about ticking boxes, all decisions are made by a multi-disciplinary team so they're constantly reviewed and any decisions are made by a range of experts in palliative care.
"The Liverpool Care Pathway we know has already improved the end of life experience for thousands of people,” he added.
Power User
Posts: 15533

« Reply #395 on: September 08, 2009, 08:44:48 AM »

Barry's pastor of 20 years speaks.
« Reply #396 on: September 08, 2009, 02:19:29 PM »

Whoa, Trigger
The latest gimmick to disguise a health-care 'public option.'
President Obama has decided that another oration will rejuvenate his health-care agenda—despite having given 27 speeches entirely on health care, and another 92 in which it figured prominently. We'll see how tomorrow night's Congressional appeal works out, but the important maneuvers are taking place in the cloak rooms, as the White House tries to staple together a majority.

The latest political gimmick is the notion of a "trigger" for the public option: A new government program for the middle class would only come on line if private insurance companies fail to meet certain benchmarks, such as lowering overall health spending or shrinking the number of the uninsured. This is supposed to appeal to Maine Republican Olympia Snowe, who could end up as ObamaCare's 60th Senator, while still appeasing the single-payer left.

Liberals should love the idea because a trigger isn't a substantive concession; it merely ensures that the public option will arrive eventually, instead of immediately. Democrats will goose the tests so that private insurers can't possibly meet them, mainly by imposing new regulations and other costly burdens.

Keep in mind that every version of ObamaCare now under consideration essentially turns all private insurers into subsidiaries of Congress. All coverage will be strictly regulated down to the fine print, and politics will dictate the level of benefits as well as premiums, deductibles and copays. Under the House bill, a "health choices commissioner" will have the final say, no doubt with Democrats Henry Waxman and Pete Stark at his elbow, if not another part of his anatomy.

The same bill also rewrites the 1974 federal law known as Erisa that lets large and mid-sized employers offer insurance with little regulation. Many businesses—including Safeway, General Mills and Marriott—are finding innovative ways to drive down spending, largely with worker incentives to live healthier and be more sensitive to the costs of care. Many Democrats call this discriminatory.

In the individual insurance market, Democrats intend to outlaw medical underwriting: Everyone must be charged the same rate or close to it for the same policies, regardless of health status or history. But this "community rating" tends to price younger and low-risk consumers out of the market. In a 2006 NBER paper, Bradley Herring of John Hopkins and Mark Pauly of the University of Pennsylvania found that community rating results in an overall increase in the uninsured in the individual market, maybe as high as 7.4%. For that reason, 35 states have no community rating at all, and another six allow very wide variations.

The larger reality is that private insurance won't be less expensive until overall health-care costs go down. Democrats may be confused on this point because government, which paid nearly 47 cents of every medical dollar in 2007, simply sets lower prices when Congress feels like it. On average, doctors and hospitals are forced to accept 20% to 30% less for their services in Medicare. That's another reason insurers wouldn't meet a trigger's thresholds, given that providers shift costs onto private under-65 patients to make up government shortfalls.

Conceivably insurers could make their products more affordable by cracking down on treatments and refusing payment more often, much as HMOs held down spending in the 1990s. But both patients and doctors hated this "managed care"—and in any case, Democrats would find a new rationale for the public option in the inevitable voter outcry about private "rationing."

It's true that there was a trigger in the Medicare prescription drug benefit and the world didn't end. But recall the dynamics in 2003: The GOP decided that private stand-alone or Medicare Advantage plans should manage the benefit. As a concession to Democrats, they agreed to trigger a "public option" for drugs—in which the government would have bought them directly, with its typical "negotiating" tactics—if seniors didn't have more than two plans in a given region.

Today, there are 1,689 stand-alone and 2,099 Advantage plans, and on average seniors have 50 to choose from—and costs in 2007 were $26 billion lower than expected. For all its problems, the Medicare drug plan created more choice for seniors and more competition among providers to offer packages that they found most attractive, holding down costs. In short, it created the incentives for multiple "private options."

ObamaCare doesn't bother with incentives, instead merely increasing government command and control of private insurance while making it more expensive in the process. That's why a trigger will inevitably lead to the public option, and also why ObamaCare will make all of our current health problems worse.
« Reply #397 on: September 09, 2009, 05:44:46 PM »

Executive summary of a long piece that addresses many of the questions Crafty has raised:

Political Malpractice

By Gregory Conko
Created 09/08/2009 - 16:42
Health Insurance Misdiagnosis and the Destruction of Medical Wealth

Full Document Available in PDF [1]


President Barack Obama and congressional Democrats have proposed a major restructuring of the American health care system. They argue that Americans spend too much for health care of often dubious quality and that tens of millions of Americans lack meaningful access to health insurance. In turn, they have proposed structural reforms to the existing private and public health care financing systems that are intended to increase coverage, lower costs, and improve health care quality.

Most Americans agree that our health care system is broken and must be fixed. But it is increasingly clear that what ails health care is not too little, but too much government intervention. Federal and state tax preferences for employer-sponsored health insurance distort the market in a way that limits choices for individuals, reduces competition among insurers, and artificially inflates costs for health care services. For most working Americans, switching jobs often entails switching health plans and doctors or losing coverage altogether, while many others find non-employer-sponsored insurance unaffordable or difficult to obtain.

Efforts by federal and state governments over the past few decades to solve these problems have generated additional burdens and distortions, leading to increasingly bigger problems. To ensure affordable coverage for those in poor health or with potentially expensive medical conditions, governments have implemented guaranteed renewability, guaranteed issue, and community rating laws that force healthy individuals to subsidize those with higher health care costs. Many states require insurance policies to pay for niche specialists, including acupuncturists, pastoral counselors, and massage therapists, or to cover alcoholism and substance abuse treatment, smoking cessation, and in vitro fertilization. But these regulations further raise the price of insurance coverage, leading many healthy individuals to forgo insurance altogether.

Similarly, numerous state and federal restrictions on who may provide medical services and how they must be delivered have hindered the development of innovative ways for medical professionals to offer more convenient and lower-cost health services to consumers. A combination of government and medical professional lobbying has restricted the supply of new doctors, creating an artificial scarcity and contributing to rising prices. And medical products regulation substantially raises the cost of producing new drugs and medical devices, often without increasing their safety.

Instead of reducing these burdens, Democratic health reform proposals would impose more regulations on insurers, place mandates on individuals and employers to purchase health insurance, provide subsidies for individuals to pay for health care coverage, expand Medicaid, and create a new government-run “exchange” through which individuals and businesses could purchase strictly defined coverage from private insurers. But more government intervention will only add cost and complexity to the health care system; without solving the underlying problems.

As an alternative, policy makers should eliminate the many layers of market-distorting government regulation that have produced our current crisis. To truly reform America’s health care system, policy makers should:

Modify tax policy to eliminate the disincentives for individual purchase of health insurance and health care.
Eliminate regulatory barriers that prevent small businesses from cooperatively pooling and self-insuring their health risks by liberalizing the rules that govern voluntary health care purchasing cooperatives.
Eliminate laws that prevent interstate purchase of health insurance by individuals and businesses.
Eliminate rules that prevent individuals and group purchasers from tailoring health insurance plans to their needs, including federal and state benefit mandates and community rating requirements.
Eliminate artificial restrictions on the supply of health care services and products, such as the overregulation of drugs and medical devices, as well as state and federal restrictions on who may provide medical services and how they must be delivered.
Improve the availability of provider and procedure-specific cost and quality data for use by individual health consumers.
Reform the jackpot malpractice liability system that delivers windfall punitive damage awards to small numbers of injured patients while it raises malpractice insurance costs for doctors and incentivizes the practice of defensive medicine.
Each of these changes would help to fix our broken health care system by reducing costs and enabling better informed, cost-conscious decision making. By themselves, they will not guarantee access to health insurance among those with chronic preexisting conditions. But if we reform the existing maze of federal and state regulation, we will then be able to address the problem of the truly chronically uninsured. Because they are a fraction of the 46 million individuals who now lack insurance or government health coverage, it would then be possible to create targeted programs to help subsidize their health insurance costs without breaking the bank and without distorting the rest of the health care and health insurance markets.

Source URL:
« Reply #398 on: September 10, 2009, 01:15:12 PM »

ObamaCare: First, Do Some Harm — Then, Exploit the Crisis
Posted By James Lewis On September 10, 2009 @ 12:51 am In . Column2 01, Health, Money, Politics, Science, Science & Technology, Stem Cells, Biotech, US News | 91 Comments

“First, do no harm” has been the guiding philosophy for the medical profession since Hippocrates. It still dominates medical science, technology, and clinical practice. That is why I trust my doctor to do his or her best for me, and that is why at times I have changed doctors when I thought they fell short of that standard.

That is why the cost of developing one medication to FDA standards is about a billion dollars. Entire technical professions have grown up over the past century, dedicated to finding and developing new medical molecules with remarkable sophistication. They are constantly testing thousands of promising drugs, digging into life’s basic biochemical pathways, and finding ways to make precise changes in body chemistry to save lives. We benefit from that extraordinary science  every time we take an aspirin.

It’s an amazing success story, and by far most people in it are personally admirable and dedicated. Needless to say, our pop media understands nothing about it. Sheer ignorance is a big reason the media and political elites can’t think straight about medical care. They just don’t understand even the basics. There are no scientists, no engineers, and few physicians in Congress.

We live in an amazingly arrogant age, at least in politics and the more self-indulgent fields of academia.

Obama is a product of the non-scientific academic world, where Marxist pseudo-philosophy is popular, as long as the colleges themselves can live off the fat of the (capitalist) land. Our academics are revolutionaries who never take a personal risk, just like our Democrats. That’s why the philosophy behind Obama’s Marxoid takeover of our health care seems to be:

Who cares if we do harm? We’ll fix it later! If it’s politically convenient! Whatever we do cannot hurt the apparatchiks, the ruling elite, who will have their own medical system.

Congress and federal bureaucrats will keep their current insurance plans. Academics will keep their tenure and their soft lifestyle at the expense of taxpayers. It’ll be a two-layered system straight out of Soviet Moscow: the nomenklatura versus the workers.

ObamaCare is really, really cheap compared to that one billion dollars for testing a single drug. The cost of testing and developing HR 3200, the current and ever-changing plan for ObamaCare, is zero dollars — because no testing and development has ever been done on more than 1,000 complicated pages. The bill has been thrown together in back-room deals between lobbyists and staffers in Congress. It’s like a hugely complex computer program that’s never been tested to see if it will run.

How likely is it to work? It won’t, which is why there will be tens of thousands of pages of regulations. And if it runs, how likely is it to make one-sixth of the U.S. economy cheaper and better, as Obama claims?

This is the ultimate snake oil.

ObamaCare is a really sweet deal –  if you believe in abysmal ignorance and wild guesswork as a basis for turning over control of a half-trillion-dollar-per-year medical system to a Central Committee of Wise Heads. No sane real-world organization could work this way. But power has its perks, and one of them is to dictate a revolution in the United States without ever trying to understand its consequences.

If Obama were running a drug company he would be criminally liable for fraud. Morally he is no different from a drug maker who skips all the testing, peddling thalidomide [1] around 1960, when 10 to 20 thousand people died from a poorly tested drug.

Nobody knows what will happen if this amazing coup d’etat passes. The European models are much smaller, took half a century to evolve to their present size, and have significant, life-threatening failures that Americans would never accept — including state euthanasia of the elderly, even if it is not called that in public. [2]

China, which owns a chunk of our sky-rocketing debt, is alarmed by U.S. money printing. The Chinese understand very clearly that Obama must raise taxes to prevent dollar devaluation if the O-Care bill passes. They see it as doing harm. He sees it as an historic opportunity [3].

“First, do some harm. Then, claim to fix it.”

In Britain the NHS is draining the public treasury — and all too often failing its patients at the same time. Just in the last weeks the British newspapers have published a slew of scandalous exposes on the National Health Service:

“Restrictions on prescription of osteoporosis drugs ‘defy belief’, says leading doctor [4]”

Professor David Reid, a world expert in brittle bones, said that government guidelines are so stringent that GPs are often prevented from giving alternative treatments to those who have suffered side-effects on the first pill they’ve been prescribed.

“Sentenced to death on the NHS [5]”

Patients with terminal illnesses are being made to die prematurely under an NHS scheme to help end their lives, leading doctors have warned.

A free product is always over-utilized. If gasoline were free, you might be driving a lot more. You’d be using gasoline for backyard barbecues, to heat your house, and to generate home electricity, because the other fuels would be driven out of the market. You can’t compete with free.

The British socialist state has ended up importing hundreds of thousands of Pakistanis from the badlands of Peshawar to vote Labour in order to keep the welfare elites in power. Those are the same Pakistanis who now make up a hotbed of terrorist indoctrination against Britain and the United States — in the middle of London and Birmingham. But anybody who criticizes Britain’s suicidal immigration policies is denounced as a racist. Ordinary citizens have been frightened into submission. Britain is losing its sovereignty to the EU, it can no longer control its borders, and its politicians look forward to fat new careers in Brussels as soon as the ship of state goes belly up.

That is the logical outcome of the socialist establishment in the UK, and it is why we are now importing millions of third world immigrants into the United States. Those are automatic Democrat votes. This is not an accident, but a deliberate policy; it was Ted Kennedy and the Senate Democrats who made it happen. ObamaCare will speed up the flow of easily-bought voters from poor and unstable countries, because we will be giving away free goodies that are inconceivable over there. Those people are just vote-fodder for the left.

This is just your friendly Federales at work.

And yet Obama cannot be wrong, even if he prescribes a dose of poison to our society. That’s because Obama is compassionate by definition. The history of medicine is full of over-confident doctors who ended up killing their patients. We have a special word for physician-caused disease: “iatrogenic.”

Most “grand-scale” politics is iatrogenic.

Lyndon Johnson’s Great Society created decades of welfare pathology among the poor it was supposed to help. FDR’s New Deal is believed to have lengthened the suffering of the Great Depression by almost a decade. Grand politics all.

Mr. Obama is both ignorant and superstitious about the reality of modern medicine. He really seems to believe in bizarre and vile urban myths that demonize doctors. He has alleged in public that doctors take out tonsils just for the money and that diabetics are denied medications because those bloody-minded docs make more bucks by amputating legs. That is unbelievably ignorant and malevolent — slanders against a profession that is generally highly ethical and enormously hard-working. It’s that cheap kind of cynicism that is now seeking to control the future of American medicine.

Notice what Barack Obama does not do. As the first black president Obama could have a huge impact on epidemic drug abuse in the black community, a true scourge that destroys families and individuals in every single city in America every single day. AIDS is a big problem in the black community, probably because young men are poorly informed about high-risk anal intercourse. Or they just don’t believe what they’re told, or they live in such despair that they are vulnerable to self-harm. Or maybe drug addiction makes them desperate for money to get another fix.

Whatever the reasons may be, Obama could use his fabled preaching talents to bring about genuine, positive change among people who live self-destructive lives, both white and black.

Inner city violence is a huge problem. Out-of-wedlock births are still the biggest predictor of social pathology. Chaotic schools fail to teach children and leave them handicapped for life. All those endemic social pathologies could be helped if the first black president focused on changing self-destructive behavior.

Obama could be a great teacher for vulnerable populations — most of which are on the left. Gays, blacks, Hispanics, the multi-generational poor — they all could use better life education from an inspirational leader. Bill Cosby understands that. Oprah Winfrey does, too. Obama does not.

In fact, the first black president is doing exactly the opposite by whipping up the blame game that keeps the underclass fixated on non-solutions to their own, painfully urgent problems. Obama’s veto of the Washington, D.C., school voucher program shows his working philosophy: “First, do some harm.”

Killing welfare reform [6] is the same. That was just as destructive and just as ignorant of the real effects of welfare policies. Those Obama decisions are either malignant or, more likely, just ignorant and harmful. Our self-proclaimed national physician is running loose with a scalpel and he doesn’t know where to cut. But he is bound and determined to have a dramatic surgery.

The Obama “health plan” claims there aren’t enough medical outcome studies, so a special federal bureaucracy has been set up to do more, using Porkulus money. The fact is that Google Scholar shows 3,260,000 citations for the phrase “medical treatment outcome study.” PubMed is the online database for biomedical science, and it shows more than 70,000 published studies in peer-reviewed journals on medical treatments and best practice recommendations. Doctors are swamped with information about the outcomes of their treatments. Far more than any single person can read.

I invite Mr. Obama to read and understand just one medical outcome study — you can get them with just one click on your PC keyboard using Google Scholar. Apparently he has never read a single one. Yes, Mr. Obama has a health prescription for all of humanity, but he hasn’t understood even one study of one medical treatment.

That’s his out-of-control Napoleon complex. Mere human doctors can’t compete with a messiah.

The fact is there is no “Obama Plan” at all, because Obama is abysmally ignorant about real medicine and real science. He is a man who can act like a very thoughtful guy on TV. The liberals love it, because most of them are just as ignorant, and they confuse the act for the real thing.

Marxist scapegoating has nothing to do with real understanding. It is pseudo-understanding. Its prescriptions can only do harm. Yet the left has convinced millions of half-educated Americans that they are the “physicians to society.”

This is the worst kind of cocksure and malignant ignorance. If we had any journalists worthy of the name, they would be telling us that. What we are seeing is a scary and ignorant power-grab, following the ancient political slogan:

First, do some harm. Then, exploit the crisis.

Article printed from Pajamas Media:

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[1] thalidomide:
[2] in public.:
[3] historic opportunity:
[4] Restrictions on prescription of osteoporosis drugs ‘defy belief’, says leading doctor:
[5] Sentenced to death on the NHS:
[6] Killing welfare reform:
« Last Edit: September 10, 2009, 01:17:19 PM by Body-by-Guinness » Logged
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« Reply #399 on: September 10, 2009, 02:57:20 PM »

Does anyone else see THIS as remarkable?  While the media of course focus on the exclamation of the Congressman calling Obama's statement about illegals a lie I don't hear one ioda from the msm about this:

"Some of people's concerns have grown out of bogus claims spread by those whose only agenda is to kill reform at any cost. The best example is the claim, made not just by radio and cable talk show hosts, but prominent politicians, that we plan to set up panels of bureaucrats with the power to kill off senior citizens. Such a charge would be laughable if it weren't so cynical and irresponsible. It is a lie, plain and simple."

I don't recall ever hearing a President call those who disagree with HIM liars in a speech to Congress.
Is this a first?

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