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« Reply #400 on: September 11, 2009, 12:24:12 AM »

Obama’s Trouble with Numbers
The funniest parts about Obama’s speech.

By Mona Charen

Let’s stipulate that it was wrong of Rep. Joe Wilson (R., S.C.) to shout “You lie” during President Obama’s health-care speech. It was a violation of courtesy and etiquette. Wilson apologized — which is more than the Democrats who booed President Bush’s State of the Union address in 2005 ever did.

But I confess that watching at home, similar exclamations were heard. Some seemed to have burst, irrepressible, from my own lips.

There was, for starters, this misleading assertion: “If you are among the hundreds of millions of Americans who already have health insurance through your job, or Medicare, or Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have.” Ah, shades of Clintonesque lawyerly evasion. No, it won’t “require” you to change, but if the tax treatment changes (and Obama proposes, among other things, to tax high-end plans) and the public option is available, employers may choose to change their offerings and employees will then no longer get to keep their current insurance.

The president then adverted to “more than 30 million American citizens who cannot get coverage.” As the Washington Examiner’s Byron York notes, the 30 million figure represents a climb down from the president’s oft-repeated claim (most recently in August) that there are “47 million uninsured in this country.” (The president’s track record on numbers is not inspiring. Remember his claim — since debunked — that medical expenses caused a bankruptcy every 30 seconds? Even ABC News called it “unsupportable.”)

Perhaps by downgrading to 30 million, President Obama is attempting to exclude an estimated 9.3 million illegal aliens. But look closely at the rest of the uninsured. According to Census and HHS data, 10 million have incomes more than three hundred percent of the poverty line, meaning they could afford coverage but for some reason choose to forgo it. And speaking of those who forgo, 5 million are single childless adults between the ages of 18 and 34. An estimated 6.4 million are “Medicaid undercount,” meaning they receive Medicaid or SCHIP but tell census takers otherwise. Another 4.3 million are eligible for Medicaid or other government health programs but have failed to enroll. That leaves just 10.6 million U.S. citizens below 300 percent of the poverty line, not eligible for an existing government program, and not between 18 and 34.

So the president’s claim that 30 million Americans “cannot get coverage” is, not to say more, inaccurate. So too was his statement, uncivil accusation really, that opponents of health-care reform have “lied” about his plan’s providing coverage for illegals. The supposed bar on illegals’ receiving health coverage applies only to a section of the bill. And Democrats rejected a Republican proposal that would have required verification of eligibility. Ditto for the claim that the Obama plan would not cover abortion expenses. It would not explicitly do so. But money is fungible and it would be impossible to prevent public funds from subsidizing abortions. Again, Republican amendments to prevent taxpayer money from paying for abortions failed. That’s revealing.

And then there was this: “Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan.” I didn’t think until now that President Obama had much of a sense of humor. Perhaps I was wrong. He also claimed that his plan will 1) extend coverage to all; 2) force insurance companies to cover “at no extra charge” routine check ups and screening tests like mammograms and colonoscopies; 3) place limits on how much people can be charged for out-of-pocket expenses; 4) forbid yearly or lifetime caps on coverage — and 5) spend less than we are currently spending! He’s not a president — he’s a wizard.

But no, the funniest part of the speech was Obama’s supposed overture to Republicans on malpractice reform. He is directing the secretary of HHS, he grandly offered, to pursue local “demonstration projects” in tort reform. But states like Texas have already proved the effectiveness of, for example, caps on pain and suffering damages. In any case the idea that some piddly demonstration project that would take several years to complete should be offered as a sop to Republicans while Democrats go about the business of revamping the entire health delivery system today is pretty much a joke.

The rationale for the speech — that lies, distortions, and misunderstandings account for public opposition to a health-care overhaul — was misconceived. This administration — anodyne phrases about bipartisanship notwithstanding — does not see beyond its narrow ideological keyhole. That weakness may prove crippling.

— Mona Charen is a nationally syndicated columnist.

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« Reply #401 on: September 11, 2009, 08:48:14 AM »

Also the part that doctors and nurses support him and his plan.
Some undoubtedly do.  But many do not.
The msm continues to back him:

All the opponents are liars, distorters, and playing the "fear" card.
Everything he says is truth.

Has anyone noticed the countless fact checks and the keeping em honest CNN stuff?
Yet always the facts and the honesty concludes that the right is wrong and the leftist views are the truth.

He still has the msm media in his back pocket.
Ideologically they are all one in the same.

I doubt his speech will win people over long term.
Yet the Dems will try to ram this through nonetheless.

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« Reply #402 on: September 11, 2009, 10:35:36 AM »

Not one ioda about Bamas calling his opponents claims as "lies" "distortions" and "bogus" as *erroding* debate.
As always he is off the hook.  The opponents can never get away with his and his parties tactics.

Typical AP writer.

****Analysis: 'You lie!' further erodes discourse
        Associated Press Writer Liz Sidoti, Associated Press Writer – 1 hr 17 mins ago
WASHINGTON – Screams of "Socialism!" Conservative talk show hosts peddling debunked "death panels." Placards likening Barack Obama to Hitler. And now, to the president's face: "You lie!" A breach of civility? Absolutely. A strategic political mistake? Maybe.

Republican Rep. Joe Wilson's personal attack on Obama and jeering from other GOP lawmakers as the president spoke to Congress escalated the opposition's outrage machine that over the summer framed the health care debate and knocked the White House back on its heels.

The rare lack of decorum on the House floor as Obama addressed lawmakers could provide him with a much-needed opening to retake control of the national conversation over a health care overhaul by turning off Americans to his critics' acerbic claims.

Or, people could dismiss derisive laughter and head-shaking from Republicans and embrace the opposition's broader argument that Obama's prescription for the ailing health care system would expand the government's reach into people's lives.

At the very least, Wednesday night marked the further erosion of long deteriorating discourse in a country where political opponents increasingly try to out-yell each other, vocal extremes of each political party shape the debate and a 24/7 media focused on ratings amplifies the tit for tat while latching onto phrases that fan the flames.

"What we've seen all summer was the worst of debate," said Kathleen Hall Jamieson, director of the Annenberg Public Policy Center at the University of Pennsylvania and an expert on political communication. "It does suggest a decline."

That's not lost on voters.

"We are becoming more adversarial and more shrill," says Jeffrey Howell of Cincinnati, 43. "We don't have discourse anymore."

It's become so bad that Donna Schwinghammer of Washington, Pa., 54, has stopped listening — to both sides. "I'm tired of all of it. There's so much fingerpointing," she says.

The latest low point in the nation's political dialogue came Wednesday when the vitriol of the summer's town-hall style events spilled into the Capitol as Obama addressed a joint session of Congress, saying: "The time for bickering is over ... Now is the season for action."

Some Republicans applauded and gave standing ovations through the speech. But, at times, GOP critics also shouted "not true" and "shame." There were boos, hisses and grumbles. One Republican, Rep. John Shimkus of Illinois, left the chamber, his spokesman says in frustration, even before the president had finished.

But it was Wilson's boorish outburst that froze Republicans in their seats.

"You lie!" the South Carolina congressman shouted and jabbed a finger in the air when Obama said that Democratic plans do not cover illegal immigrants.

Taking advantage of the extraordinary accusation, Obama calmly replied, "That's not true," and went on with his speech.

Will personal attacks on a president who people generally like — even if they disagree with his policies — ultimately prove to have gone too far?

Certainly, in the short-term, the chorus of criticism painted an unflattering — many Republicans say embarrassing — picture of the GOP. Wilson apologized shortly after the speech, which some say may have limited the fallout.

But the outbursts also gave Obama an opportunity that he seized, pleading for civil discourse and bipartisan solution-making. And they added fuel to Democratic arguments that Republicans simply belong to "The Party of No."

The Democratic-aligned Americans United for Change quickly rolled out a Web video, saying: "It's Official — The Party of NO Has Become the Party of No Shame."

What's more: the behavior highlighted personal volleys coming from the GOP's far right wing just as party leaders in Congress are trying to position themselves as centrists debating policy. The Republican base and right flank may be energized by what they saw and heard but independents and moderates may have cringed.

That could spell trouble for Republicans looking ahead to next year's midterm elections.

While midterms typically are base elections and vitriol will get hard-core party loyalists to turn out, Republicans also don't want to look too extreme as they try to pick up seats in Congress.

Several Republicans called the outbursts unhelpful — particularly Wilson's.

"It combined two things that just aren't the same: legitimate outrage people feel over government-run health care and manufactured vitriol that I think most people dismiss," veteran Republican communications strategist Todd Harris said. That, he said, plays into the Democrats' hands.

But Republicans also are betting that there's no long-term damage to the GOP's strategy because Republicans have tapped into fear among Americans about the government intruding into their lives.

"Intemperate and clearly a mistake," Phil Musser, the former executive director of the Republican Governor's Association, said of Wilson's remark. But, he added: "It didn't shift the debate."


EDITOR'S NOTE — Liz Sidoti has covered national politics for The Associated Press since 2003.****
« Reply #403 on: September 12, 2009, 08:49:55 AM »

Where Is Obama’s ‘Center’?
Look at his Rolodex and then figure out just where such a man would estimate it to be.

By Mark Steyn

So why can’t the silver-tongued post-partisan healer seal the deal on this health-care business? Surely it should be the work of moments for the greatest orator in American history to whip up a little medicinal Gettysburg, a touch of Henry V-in-the-Agincourt-casualty-tent, and put this thing away. Yet there he was the other night with the usual leaden medley of tinny grandiosity (all the this-is-the-moment, now-is-the-hour stuff), slippery reassurances (don’t worry, you won’t be “required” to change your present health arrangements), imputations of bad faith to anyone who takes a different view (they’re playing “games”), and the copper-bottomed guarantee that you can have it all for no money down, no interest, no monthly payments, no nuthin’ (“I will not sign it if it adds one dime to the deficit”).

This would barely have passed muster four months back. After a summer of seething town halls and sliding approval numbers, it was a joke. Or, rather, it would be a joke if the president’s intention was to persuade an increasingly skeptical if not downright hostile electorate. On the other hand, if the intention is to ram it down America’s throat whatever the citizenry thinks, then the joke’s on us.

If it was about “health care,” it would be easier. It was assumed, for example, that the president’s sly revision of “47 million people without health insurance” in his summer speeches to the substantially lower 30 million was a concession to those who said that his “plan” (he hasn’t actually produced one, but why get hung up on details?) will cover gazillions of illegal immigrants.

If so, it’s a rhetorical feint that’s otherwise meaningless. The minute a first-world country has “free” health care, it becomes the provider of choice to anyone who can get there, particularly for any long-term ailments requiring state-of-the-art medications. In 2004, Britain’s Health Protection Agency revealed that 44 percent of HIV patients being treated by the National Health Service were not residents of the United Kingdom at all, but from southern Africa. In essence, a huge number of AIDS patients in South Africa, Zimbabwe, Zambia, Malawi, Swaziland, and Lesotho have decided to outsource their health-care needs to British taxpayers. Similar trends will manifest themselves here in nothing flat.

But, for the sake of argument, let us concede the president’s current number of 30 million. In order to do something for the 10 percent of the population outside the current system, why is it necessary to destabilize the arrangements of the 90 percent within it?

Well, says the president, not so fast. Lots of people with insurance run into problems when they change jobs or move to another state. Okay, In that case, why not ease the obstacles to health-care portability?

Well, says the president, shuffling his cups and moving the pea under another shell, we’re spending too much on health care. By “we’re,” he means you and you and you and you and millions of other Americans making individual choices over which he casually claims collective jurisdiction.

And that, ultimately, gets closer than anything else he says to giving the game away. For most of the previous presidency, the Left accused George W. Bush of using 9/11 as a pretext to attack Iraq. Since January, his successor has used the economic slump as a pretext to “reform” health care. Most voters don’t buy it: They see it as Obama’s “war of choice,” and the more frantically he talks about it as a matter of urgency the weirder it seems. If he’s having difficulty selling it, that’s because it’s not about “health.” As I’ve written before, the appeal of this issue to him and to Nancy Pelosi, Barney Frank, et al., is that governmentalization of health care is the fastest way to a permanent left-of-center political culture — one in which elections are always fought on the Left’s issues and on the Left’s terms, and in which “conservative” parties no longer talk about small government and individual liberty but find themselves retreating to one last pitiful rationale: that they can run the left-wing state more effectively than the Left can. Listen to your average British Tory or French Gaullist on the campaign trail pledging to “deliver” government services more “efficiently.”

Three stories bubbled up in the last week, although if you read the New York Times and the administration’s other airbrushers you’ll be blissfully unaware of them; the resignation of Van Jones — former (?) Communist and current 9/11 “truther” — from his post as Obama’s “Green Jobs Czar”; the “re-assignment” of Yosi Sergant at the National Endowment for the Arts after he was found to be urging government-funded arts groups to produce “art” in support of Obama policy positions; and, finally, the extraordinary undercover tape from Andrew Breitbart’s Big Government website in which officials from ACORN (the Obama chums who’ll be “helping” with the next census) offer advice on how pimps can get government housing loans for brothels employing underage girls from El Salvador.

What do all these Obama associates have in common? I mean, aside from the fact that Glenn Beck played a key role in exposing them. We are assured by the airbrushing media and “moderate” conservatives that Beck is crazy, a frothing spokesnut for the lunatic fringe. By contrast, Van Jones, Yosi Sergant, and ACORN are all members of the lunatic mainstream, embedded philosophically and actually in the heart of Obamaland.

What all these individuals share is a supersized view of the state, from a makework gig coordinating the invention of phony-baloney “green jobs” to Soviet-style government-licensed art in support of heroic government programs to government-funded “community organizers” organizing government funding for jailbait bordellos. Okay, government-funded child prostitution’s a bit of an outlier even for this crowd — for the moment. But you get the general idea.

The New York Times’s in-house conservative David Brooks was an early champion of Obama and is profiled in the current edition of The New Republic cooing paeans to the then-senator”s “pant leg and perfectly creased pant.” Alas, for David Brooks, the bottom has dropped out of Obama’s perfectly creased pants. The other day he was tutting that the Obama administration is in trouble because “it joined itself at the hip to the liberal leadership in Congress.” My National Review colleague Jay Nordlinger was reminded of an old observation by the great Theodore Dalrymple. During his time as an English prison doctor, Dalrymple frequently met ne’er-do-wells who said they’d “fallen in with the wrong crowd,” but, oddly enough, in all those years, he never met the wrong crowd.

Likewise, Obama didn’t “join” himself to the liberal leadership; he is the liberal leadership. The administration didn’t fall in with the wrong crowd; they are the wrong crowd. Van Jones, Yosi Sergant, and ACORN are where Barack Obama has chosen to live all his adult life. Even if he wanted to be the bipartisan centrist of David Brooks’s fantasies, look at his Rolodex and then figure out just where such a man would estimate the “center” to be.

My sense from Wednesday’s speech is that the president’s gonna shove this through in some form or other. It may cause a little temporary pain in Blue Dog districts in 2010, but the long-term gains will be transformative and irreversible.

— Mark Steyn, a National Review columnist, is author of America Alone. © 2009 Mark Steyn
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« Reply #404 on: September 14, 2009, 10:02:12 AM »

In his speech to Congress last week, President Barack Obama attempted to sell a reform agenda by demonizing the private health-insurance industry, which many people love to hate. He opened the attack by asserting: "More and more Americans pay their premiums, only to discover that their insurance company has dropped their coverage when they get sick, or won't pay the full cost of care. It happens every day."

Clearly, this should never happen to anyone who is in good standing with his insurance company and has abided by the terms of the policy. But the president's examples of people "dropped" by their insurance companies involve the rescission of policies based on misrepresentation or concealment of information in applications for coverage. Private health insurance cannot function if people buy insurance only after they become seriously ill, or if they knowingly conceal health conditions that might affect their policy.

 .Traditional practice, governed by decades of common law, statute and regulation is for insurers to rely in underwriting and pricing on the truthfulness of the information provided by applicants about their health, without conducting a costly investigation of each applicant's health history. Instead, companies engage in a certain degree of ex post auditing—conducting more detailed and costly reviews of a subset of applications following policy issue—including when expensive treatment is sought soon after a policy is issued.

This practice offers substantial cost savings and lower premiums compared to trying to verify every application before issuing a policy, or simply paying all claims, regardless of the accuracy and completeness of the applicant's disclosure. Some states restrict insurer rescission rights to instances where the misrepresented or concealed information is directly related to the illness that produced the claim. Most states do not.

To highlight abusive practices, Mr. Obama referred to an Illinois man who "lost his coverage in the middle of chemotherapy because his insurer found he hadn't reported gallstones that he didn't even know about." The president continued: "They delayed his treatment, and he died because of it."

Although the president has used this example previously, his conclusion is contradicted by the transcript of a June 16 hearing on industry practices before the Subcommittee of Oversight and Investigation of the House Committee on Energy and Commerce. The deceased's sister testified that the insurer reinstated her brother's coverage following intervention by the Illinois Attorney General's Office. She testified that her brother received a prescribed stem-cell transplant within the desired three- to four-week "window of opportunity" from "one of the most renowned doctors in the whole world on the specific routine," that the procedure "was extremely successful," and that "it extended his life nearly three and a half years."

The president's second example was a Texas woman "about to get a double mastectomy when her insurance company canceled her policy because she forgot to declare a case of acne." He said that "By the time she had her insurance reinstated, her breast cancer more than doubled in size."

The woman's testimony at the June 16 hearing confirms that her surgery was delayed several months. It also suggests that the dermatologist's chart may have described her skin condition as precancerous, that the insurer also took issue with an apparent failure to disclose an earlier problem with an irregular heartbeat, and that she knowingly underreported her weight on the application.

These two cases are presumably among the most egregious identified by Congressional staffers' analysis of 116,000 pages of documents from three large health insurers, which identified a total of about 20,000 rescissions from millions of policies issued by the insurers over a five-year period. Company representatives testified that less than one half of one percent of policies were rescinded (less than 0.1% for one of the companies).

If existing laws and litigation governing rescission are inadequate, there clearly are a variety of ways that the states or federal government could target abuses without adopting the president's agenda for federal control of health insurance, or the creation of a government health insurer.

Later in his speech, the president used Alabama to buttress his call for a government insurer to enhance competition in health insurance. He asserted that 90% of the Alabama health-insurance market is controlled by one insurer, and that high market concentration "makes it easier for insurance companies to treat their customers badly—by cherry-picking the healthiest individuals and trying to drop the sickest; by overcharging small businesses who have no leverage; and by jacking up rates."

In fact, the Birmingham News reported immediately following the speech that the state's largest health insurer, the nonprofit Blue Cross and Blue Shield of Alabama, has about a 75% market share. A representative of the company indicated that its "profit" averaged only 0.6% of premiums the past decade, and that its administrative expense ratio is 7% of premiums, the fourth lowest among 39 Blue Cross and Blue Shield plans nationwide.

Similarly, a Dec. 31, 2007, report by the Alabama Department of Insurance indicates that the insurer's ratio of medical-claim costs to premiums for the year was 92%, with an administrative expense ratio (including claims settlement expenses) of 7.5%. Its net income, including investment income, was equivalent to 2% of premiums in that year.

In addition to these consumer friendly numbers, a survey in Consumer Reports this month reported that Blue Cross and Blue Shield of Alabama ranked second nationally in customer satisfaction among 41 preferred provider organization health plans. The insurer's apparent efficiency may explain its dominance, as opposed to a lack of competition—especially since there are no obvious barriers to entry or expansion in Alabama faced by large national health insurers such as United Healthcare and Aetna.

Responsible reform requires careful analysis of the underlying causes of problems in health insurance and informed debate over the benefits and costs of targeted remedies. The president's continued demonization of private health insurance in pursuit of his broad agenda of government expansion is inconsistent with that objective.

Mr. Harrington is professor of health-care management and insurance and risk management at the University of Pennsylvania's Wharton School and an adjunct scholar at the American Enterprise Institute.
« Reply #405 on: September 15, 2009, 03:04:53 PM »

Health-Care Reform and the Constitution
Why hasn't the Commerce Clause been read to allow interstate insurance sales?

Last week, I asked South Carolina Congressman James Clyburn, the third-ranking Democrat in the House of Representatives, where in the Constitution it authorizes the federal government to regulate the delivery of health care. He replied: "There's nothing in the Constitution that says that the federal government has anything to do with most of the stuff we do." Then he shot back: "How about [you] show me where in the Constitution it prohibits the federal government from doing this?"

Rep. Clyburn, like many of his colleagues, seems to have conveniently forgotten that the federal government has only specific enumerated powers. He also seems to have overlooked the Ninth and 10th Amendments, which limit Congress's powers only to those granted in the Constitution.

One of those powers—the power "to regulate" interstate commerce—is the favorite hook on which Congress hangs its hat in order to justify the regulation of anything it wants to control.

Unfortunately, a notoriously tendentious New Deal-era Supreme Court decision has given Congress a green light to use the Commerce Clause to regulate noncommercial, and even purely local, private behavior. In Wickard v. Filburn (1942), the Supreme Court held that a farmer who grew wheat just for the consumption of his own family violated federal agricultural guidelines enacted pursuant to the Commerce Clause. Though the wheat did not move across state lines—indeed, it never left his farm—the Court held that if other similarly situated farmers were permitted to do the same it, might have an aggregate effect on interstate commerce.

James Madison, who argued that to regulate meant to keep regular, would have shuddered at such circular reasoning. Madison's understanding was the commonly held one in 1789, since the principle reason for the Constitutional Convention was to establish a central government that would prevent ruinous state-imposed tariffs that favored in-state businesses. It would do so by assuring that commerce between the states was kept "regular."

The Supreme Court finally came to its senses when it invalidated a congressional ban on illegal guns within 1,000 feet of public schools. In United States v. Lopez (1995), the Court ruled that the Commerce Clause may only be used by Congress to regulate human activity that is truly commercial at its core and that has not traditionally been regulated by the states. The movement of illegal guns from one state to another, the Court ruled, was criminal and not commercial at its core, and school safety has historically been a state function.

Applying these principles to President Barack Obama's health-care proposal, it's clear that his plan is unconstitutional at its core. The practice of medicine consists of the delivery of intimate services to the human body. In almost all instances, the delivery of medical services occurs in one place and does not move across interstate lines. One goes to a physician not to engage in commercial activity, as the Framers of the Constitution understood, but to improve one's health. And the practice of medicine, much like public school safety, has been regulated by states for the past century.

The same Congress that wants to tell family farmers what to grow in their backyards has declined "to keep regular" the commercial sale of insurance policies. It has permitted all 50 states to erect the type of barriers that the Commerce Clause was written precisely to tear down. Insurers are barred from selling policies to people in another state.

That's right: Congress refuses to keep commerce regular when the commercial activity is the sale of insurance, but claims it can regulate the removal of a person's appendix because that constitutes interstate commerce.

What we have here is raw abuse of power by the federal government for political purposes. The president and his colleagues want to reward their supporters with "free" health care that the rest of us will end up paying for. Their only restraint on their exercise of Commerce Clause power is whatever they can get away with. They aren't upholding the Constitution—they are evading it.

Mr. Napolitano, who served on the bench of the Superior Court of New Jersey between 1987 and 1995, is the senior judicial analyst at the Fox News Channel. His latest book is "Dred Scott's Revenge: A Legal History of Race and Freedom in America" (Nelson, 2009).
« Reply #406 on: September 16, 2009, 11:39:20 AM »

Young Adults Likely to Pay Big Share of Reform's Cost
By Shailagh Murray
Washington Post Staff Writer
Wednesday, September 16, 2009

As health-care legislation advances through Congress, the young adults who were so vital to President Obama's election are emerging as a significant beneficiary of his top domestic priority, but they are also likely to play a major role in funding any reform.

In a campaign-style rally Thursday at the University of Maryland at College Park, Obama will aim to tap his richest vein of support -- voters younger than 30 -- to help sell his reform plan to a more skeptical general public. "We're at an important turning point in our push for real reform," read the e-mailed invitation, "and it's critical that we seize this moment."

A 2008 study by the Urban Institute found that more than 10 million young adults ages 19 to 26 lack health insurance coverage. For many of those people, health-care reform would offer the promise of relatively inexpensive individual policies, which do not exist in many states today.

The trade-off is that young people would no longer be permitted to bet on their good health: All the reform legislation before Congress would require individuals to buy at least minimal coverage.

Another bill will be introduced Wednesday by the chairman of the Senate Finance Committee. Sen. Max Baucus (D-Mont.) will offer in it a proposal to keep premiums manageable: a bare-bones catastrophic policy that would protect young people from financial calamity while providing basic preventive care.

Drafting young adults into any health-care reform package is crucial to paying for it. As low-cost additions to insurance pools, young adults would help dilute the expense of covering older, sicker people. Depending on how Congress requires insurers to price their policies, this group could even wind up paying disproportionately hefty premiums -- effectively subsidizing coverage for their parents.

An array of Democratic senators continued to complain Tuesday about the affordability of reform, insisting that the final package should include much larger tax credits to help people cover the cost of insurance premiums.

"I want to make clear that in its current form I cannot put my support behind the Finance bill -- it will not have my vote," said Sen. John D. Rockefeller IV (D-W.Va.).

In part, young adults are uninsured because they are less likely to work for employers who offer coverage; they may not qualify for public programs such as Medicaid; and even the skimpiest private insurance plans may be too expensive alongside hefty student loan payments and credit card debt.

But some young people -- nicknamed the "young invincibles" -- are also likelier than other Americans to assume that they won't need health insurance or to decide that they'd rather spend their money on other things.

To discourage that attitude, the Finance Committee bill would fine individuals who do not purchase coverage. An early draft of the proposal set the penalty at $750 or $950 per year for single people, depending on income. But according to various insurance experts, even the least expensive plan under the bill could cost more than $100 per month, making it cheaper for people to pay the fine than to buy insurance.

All the bills seek to blunt the additional cost to young adults, mainly through subsidies, but it is not clear what effect that would have. "The primary question is what the premium is and what people get for that," said Mark McClellan, director of the Engelberg Center for Health Care Reform at the Brookings Institution and a former senior Bush administration official.

Adding preventative care to a catastrophic policy makes the Finance Committee bill's bare-bones coverage more appealing, McClellan noted. But for many young adults, health care will become a significant new expense. "It's important for people to know what they're getting into," he said.

But it's also essential that young, healthy people participate, said Linda J. Blumberg, a health-care expert at the Urban Institute, because the requirement that people have insurance "is really a mechanism for financing health-care reform."

The more people steered into the system through such a mandate, Blumberg and others explained, the lower the total subsidies that the government must provide to keep insurance affordable. But if young people slip through the cracks -- or if Congress, facing political pressure, provides generous exemptions from the mandate -- then the government and people who buy coverage will face higher costs.

The Finance Committee proposal also focuses on broadening access to health insurance. For uninsured people without affordable employer coverage, it would open new insurance "exchanges," offering a menu of options at different cost and benefit levels. Additionally, all adults with incomes below 133 percent of the federal poverty level -- or about $14,400 for an individual -- would be eligible for Medicaid.

One group that policy experts worry could be squeezed by reform is young adults with health problems, whose incomes are not high enough to afford the expensive policies they may need to manage chronic conditions. Blumberg said young adults with asthma, diabetes, hay fever and even high school sports injuries are systematically rejected by insurers in states without protections for people with preexisting conditions.

Krisja Hendricks, 28, is a waitress in Brooklyn whose thyroid cancer was diagnosed shortly before she graduated from college, while she was still covered under her father's plan. Crohn's disease was later diagnosed, causing insurers to turn her away. She finally found a health plan for $245 per month, but she just discovered that it will not cover the tests she needs to monitor her health. "I'm willing to pay $400 a month, even though that's a lot," she said. "But I know I have to. I really don't think everyone should required to."

According to a Washington Post-ABC News poll last week, young adults are more optimistic about the outcome of health-care reform than those age 30 and older, but they are evenly divided on the cost implications, with 32 percent expecting their costs to decline and 27 percent expecting an increase.

About 52 percent of young adults support the idea of the individual mandate, about the same proportion as in other age groups. But in terms of the overall package, the under-30 group broadly supports the Democratic effort, with 60 percent favoring the proposed reforms vs. 42 percent among older adults.

And while the number is down from its high point, 63 percent of under-30s approve of Obama's overall job performance, significantly more than in other age groups.

Given the implications of reform, advocates for young voters wonder why they haven't commanded special attention from the White House and Congress, as have seniors, union households and industry stakeholders.

"We can do our part, but we need to hear from the people who are making the policy decisions," said Heather Smith, executive director of Rock the Vote, a nonprofit group aimed at drawing young people into the political process.

Along with other pro-reform organizations, Rock the Vote has begun a national advertising and grass-roots campaign to educate young adults about the emerging legislation. But Smith said she was frustrated that Obama offered few assurances to young adults in his speech before Congress last week, instead chastising as "irresponsible" those who don't buy coverage.

The under-30 crowd remains by far the president's most loyal following, Smith noted. "He needs to talk to them," she said. "Writ large, they are struggling; they are the uninsured."

Staff writer Lori Montgomery and polling director Jon Cohen contributed to this report.
« Reply #407 on: September 17, 2009, 02:25:50 PM »

Public Option Lite
The Baucus plan would make insurance even more expensive.
Senate Finance Chairman Max Baucus finally unveiled his health-care plan yesterday to a chorus of bipartisan jeers. The reaction is surprising given that President Obama all but endorsed the outlines of the Baucus plan last week. But the hoots are only going to grow louder as more people read what he's actually proposing.

The headline is that Mr. Baucus has dropped the unpopular "public option," but this is a political offering without much policy difference. His plan remains a public option by other means, imposing vast new national insurance regulation, huge new subsidies to pay for the higher insurance costs this regulation will require and all financed by new taxes and penalties on businesses, individuals and health-care providers. Other than that, Hippocrates, the plan does no harm.

The centerpiece of the Obama-Baucus plan is a decree that everyone purchase heavily regulated insurance policies or else pay a penalty. This government mandate would require huge subsidies as well as brute force to get anywhere near the goal of universal coverage. The inevitable result would be a vast increase in the government's share of U.S. health spending, forcing doctors, hospitals, insurance companies and other health providers to serve politics as well as or even over and above patients.

The plan essentially rewrites all insurance contracts, including those offered by businesses to their workers. Benefits and premiums must be tailored to federal specifications. First-dollar coverage would be mandated for many services, and cost-sharing between businesses and employees would be sharply reduced, though this is one policy that might reduce health spending by giving consumers more skin in the game. Nor would insurance be allowed to bear any relation to risk. Inevitably, costs would continue to climb.

Everyone would be forced to buy these government-approved policies, whether or not they suit their needs or budget. Families would face tax penalties as high as $3,800 a year for not complying, singles $950. As one resident of Massachusetts where Mitt Romney imposed an individual mandate in 2006 put it in a Journal story yesterday, this is like taxing the homeless for not buying a mansion.

The political irony here is rich. If liberal health-care reform is going to make people better off, why does it require "a very harsh, stiff penalty" to make everyone buy it? That's what Senator Obama called it in his Presidential campaign when he opposed the individual mandate supported by Hillary Clinton. He correctly argued then that many people were uninsured not because they didn't want coverage but because it was too expensive. The nearby mailer to Ohio primary voters gives the flavor of Mr. Obama's attacks.

And the Baucus-Obama plan will only make insurance even more expensive. Employers will be required to offer "qualified coverage" to their workers (or pay another "free rider" penalty) and workers will be required to accept it, paying for it in lower wages. The vast majority of households already confront the same tradeoff today, except Congress will now declare that there's only one right answer.

The subsidies in the Baucus plan go to people without a job-based plan and who earn under three times the federal poverty level, or about $66,000 for a family of four. Yet according to a Congressional Budget Office analysis we've seen, the plan isn't much of an improvement over the current market.

Take a family of four making $42,000 in 2016. While government would subsidize 80% of their premium and pay $1,500 to offset cost-sharing, they'd still pay $6,000 a year or 14.3% of their total income. A family making $54,000 could still pay 18.1% of their income, while an individual earning $26,500 would be on the hook for 15.5%, and one earning $32,400 for 17.3%. So lower-income workers would still be forced to devote huge portions of their salaries to expensive policies that they may not want or be able to afford.

Other Democrats want to make the subsidies even bigger, but Mr. Baucus told reporters on Monday that, "We're doing our very best to make an insurance requirement as affordable as we possibly can, recognizing that we're trying to get this bill under $900 billion total." Another way of putting this is that he is hiding the real cost of his bill by pinching pennies to meet a less politically toxic overall spending number. In that sense, the House health bill which clocked in at $1.042 trillion because it was more generous upfront was more honest, though not by much.

Like the House bill, Mr. Baucus uses 10 years of taxes to fund about seven years of spending. Some $215 billion is scrounged up by imposing a 35% excise tax on insurance companies for plans valued at more than $21,000 for families and $8,000 for individuals. This levy would merely be added to the insurers' "administrative load" and passed down to all consumers in higher prices. Ditto for the $59 billion that Mr. Baucus would raise by taxing the likes of clinical laboratories and drug and device makers.

Mr. Baucus also wants to cut $409 billion from Medicare, according to CBO, though the only money that is certain to see the budget ax is $123 billion from the Medicare Advantage program. Liberal Democrats hate Advantage because it gives 10.2 million seniors private options. The other "savings" come from supposedly automatic cuts that a future Congress is unlikely to ever approve that is, until this entitlement spending swamps the federal budget. Then the government will have no choice but to raise taxes to European welfare-state levels or impose drastic restrictions on patient care. Or, most likely, both.

To sum up, the Baucus-Obama plan would increase the cost of insurance and then force people to buy it, requiring subsidies. Those subsidies would be paid for by taxes that make health care and thus insurance even more expensive, requiring even more subsidies and still higher taxes. It's a recipe to ruin health care and bankrupt the country, and that's even before liberal Democrats see Mr. Baucus and raise him, and then attempt to ram it all through the Senate.

Printed in The Wall Street Journal, page A22
Power User
Posts: 42521

« Reply #408 on: September 18, 2009, 11:16:58 AM »

A doctor friend writes:

I have decided to offer a Mea Culpa for my part of the healthcare spending debacle.  The government made me do it.


A general explanation of some of the high costs of medical care.
Example:  65 yr old male with difficulty voiding

1990 treatment course.

Office visit for initial assessment.
Urine flow rate and cystoscopy to assess for obstruction ($500).
Transurethral Resection of the Prostate was least invasive treatment available and was used for almost everyone.  95% success rate with 3 day hospital stay and 90 f/u for surgical fee of $1500 in 1990 dollars.
Pt was happy and urologist was gratified.
Patient returned to PCP for follow up as the Urologist’s work was done.



2009 treatment course.

Office visit for initial assessment.
PSA, prostate symptom score, flow rate and US postvoid residual determined ($250).
Pt started on alpha blocker($50/mo).
F/U in 2 weeks for prostate symptom score and flow rate ($200).  Partial improvement noted.
Pt started on finasteride or avodart ($50-$100/mo).
F/U in 3 months for PSA, prostate symptom score, flow rate and PVR ($250).
Still some symptoms.
Cystoscopy performed.  Evidence of obstruction is noted ($250).
Pt is offered minimally invasive treatment with microwave or radiofrequency ablation therapy ($3800).
F/U at 6 months for PSA, prostate symptom score, flow rate and PVR ($250).
Pt not happy with persistent irritative symptoms and inability to get off of medications.
Urodynamics performed ($1200).  Obstruction confirmed.
Transurethral resection is performed for $700 in 2009 dollars.  95% success rate.  Pt is happy and system is broke.

The alternate scenario is that the patient gets acceptable results with medical therapy and returns for q6month office visits ($100-$250) with the urologist on top of the PCP visits for the next 15 years ($3000-$8000 total) with periodic reassessment with symptom scores, PVR’s, flow rates, Urinalysis and PSA’s on top of the ongoing cost of his one or two medications.

 For probably 80% of the male patients that I see for obstructive voiding symptoms, a Transurethral resection of the prostate will provide excellent relief of symptoms with relatively few severe side effects.  Incontinence 1%, Impotence in 5-10% (this is an older populations that is prone to ED anyway and  90% retrograde ejaculation (clean sheets and who cares)

Minimally invasive and medical therapy often increases costs without necessarily providing better outcomes or a reduction in complications.


The change in treatment has been driven by patient choice,  industry marketing and physician’s desire to maintain revenue.  A TURP in 1990 was reimbursed by Medicare at $1500.  A TURP (which takes an hour of my time during the procedure with 1-2 postop hospital visits of 15 minutes plus travel time) in 2009 is reimbursed by Medicare is $700 and included 90 days of follow up care.  A flow rate (pee in a device that measures the rate) reimburses $150.  Urodynamics which is a functional test that is the best evaluation for voiding dysfunction is reimbursed at $1200 and is done in my office by a tech under my supervision.  Minimally invasive therapy with microwave or radiofrequency ablation (which takes about an hour in my office) is reimbursed at $3800 in my office with a net after equipment and disposable costs of about $1200.


This pattern in urology is repeated in many fields.  Cardiac surgery is better than cardiac stenting and the bar for performing the procedure is much higher so additional surgical procedures are not offered as cavalierly as additional cath stent procedures.


If TURP reimbursement had remained high enough, medical and minimally invasive therapy for BPH would have never taken off, because every urologist really knows that a TURP is by far the most efficient and effective way to take care of bladder outlet obstruction but the economics don’t favor it anymore, and I have tuition to pay.


If you find yourself in a situation where you have a hard time peeing and you want it taken care of, just tell your urologist that you just want it taken care of and have them do a TURP.  95% of my patients will tell you that they wish they had had it done long ago.
Frequent Poster
Posts: 74

« Reply #409 on: September 19, 2009, 09:56:43 AM »

If the obama healthcare plan passes and everybody has "healthcare" can some one explain to me why it is that we would continue to need medicade,medicare,the VA or that childerens plan(s-chip I believe it is called).Since everyone would allegedly(lol) have care why would these redundant agencies continue to exist and absorb money better spent else where?

Boyo evil
Power User
Posts: 7837

« Reply #410 on: September 19, 2009, 01:44:46 PM »

the urologists note is interesting.
The advent of PSAs is also driving up urologic care with questionable outcomes.
One huge study suggested we reduce the rate of death from prostate cancer by 20% because of PSA screeing.
Another study suggested there is absolutely no difference.
For every life we may save with PSA screening there are probably at least many more men who go through screening testing anxiety for nothing. 

The problem is we still can't tell which is the occasional patient who may benefit from the one who will never have had any problem with his prostate if we didn't go on fishing expeditions.

Yet we have parades of famous people with prostate cancer getting on Larry KIng telling their stories as though it applies to anything in reality to large populations of people.

Cardiology costs have also gone crazy and out of control.
Cardiologists are in my view the biggest spenders in medicine that are not a surgical specialty.

It used to be a stress test once every two years or only if there were symptoms or other specific reasons to get them.
Now I see some cardiologists who are part or wholly owners of stress nuclear machines getting them as often as yearly.
They are ordering tests on everyone.
Their reimbursements per procedure etc are down so they simply order more.
Patients think they are being more thorough and as long as a third party pays they are delighted to get more and more tests.

Another example from the drug industry.  Plavix a blood thinner is marginally better than a two cent aspirin - roughly 20% at preventing heart or stroke events in selected patients.  Sound like a big difference?  We may be talking a reduction in "events" from five per hundred to four per hundred total patients treated.  Doesn't sound like as big a gain now does it?  The cost between using plavix and aspirin would be huge.  State it a different way though and if we treat say one milliion people per year and reduce the "event" rate from 50,000 to 40,000 we could be "preventing" 10,000 more events (stroke, heart attack, death).  Now it sounds like alot again.  People who push for tiny incrementle gains as being "huge" or great progress are happy to state the statistics either the first or thrid way and always avoid the latter.

To add insult to injury recent publication of an even newer drug then plavix points that it now reduces event rates by again by "20%".   Again that sounds like a lot from that point of view.  The people on wall street who invest and the bitg shot carediologists who researched the drug make it sound like it is a huge breakthrough (noted is that the newer drug does have an increased risk of bleeding that may hold down use of it to some extent).  But the actual reduction number is from around 5.8% to something like 4.5%.  So for every hundred people treated we could prevent only *one* more event.  The kicker is plavix may go generic in a few years (I am not sure) while this newer drug will of course be mega bucks.
All the cardiologists will of course want and brag how they give there patients the most modern and perfect care without consideration of cost.  Patients are fine with this as long as the pill is covered.  A few patients will have to pay more for it out of pocket and are willing.

So where does it end?

Answer:  it doesn't.

Small incremental gains made in modern medicine have huge costs.

People want to live for ever, everyone one perfect cutting edge care and no one wants to pay for it.
Nothing new.

Now we have a government who believes it is everyone's right to have equal access and equal care.
Yet they can't pay for it either.  They even want to extend it to millions of people who don't even belong here.
Their argument/idea is rationed care is smarter care.
There is some truth to that argument.  Is it smart to spend endless billions for small incremental gains?

At present the health system says yes.   
Power User
Posts: 9481

« Reply #411 on: September 19, 2009, 09:20:18 PM »

I don't doubt Crafty's friend or his example but Dr. CCP's example is more instructive for the health care choices we face. 

In the first example we order more tests, receive more treatments and pay far more and receive no gain.  In that scenario it was bogus to order the tests, treatments and expenses that yielded no gain so the answer is simple - stop doing it. 

CCP's example is far more instructive:  Pay a zillion more (rounded numbers) and your chances improve from 5.8 to 4.5 per hundred. 

To me the question is not should we pay the zillion to make the one in a hundred improvement, the question is WHO should make that decision.

The more that we can get good information on the choices and their consequences and the more that we pay with our own money, the more accurately we will value that gain in our health or quality of life.

If you ask me how much of YOUR money is it worth to me to improve my chances by one in a hundred, it will be very hard to get a good number.

As Margaret Thatcher said (I think I read it here): The problem with socialism is that you will eventually run out of other people's money.

Remove third party pay as much as possible and the price will likely fall and fall rapidly.  Very people will choose to pay the introductory price for such a small gain.  Or leave the artificial subsidy and the price stays high or escalates. (cf. college tuition, healthcare costs, 'affordable housing', etc.etc.)
Power User
Posts: 7837

« Reply #412 on: September 20, 2009, 02:56:37 PM »

"The more that we can get good information on the choices and their consequences and the more that we pay with our own money, the more accurately we will value that gain in our health or quality of life"

My little opinion FWIW is that I couldn't agree more.

Instead OBama wants to obtain the information so HE can make the choice for all of us.

And it is THAT reason along with the rest of his big government philosophy that we must stop.  It ain't because he is black.

Do any of these idiots in the MSM, Carter, Dowd, and the rest think we who are on the right would be any less fighting mad if the President who was pushing this sutff was a white like Biden, Pelosi, or Reid??
« Reply #413 on: September 22, 2009, 09:51:29 PM »

Long piece examining US mortality rates that concludes mortality is impacted more by lifestyle choices than by medical efficacy.

 Life expectancy in the United States fares poorly in international comparisons, primarily
because of high mortality rates above age 50. Its low ranking is often blamed on a poor
performance by the health care system rather than on behavioral or social factors. This paper
presents evidence on the relative performance of the US health care system using death
avoidance as the sole criterion. We find that, by standards of OECD countries, the US does well
in terms of screening for cancer, survival rates from cancer, survival rates after heart attacks and
strokes, and medication of individuals with high levels of blood pressure or cholesterol. We
consider in greater depth mortality from prostate cancer and breast cancer, diseases for which
effective methods of identification and treatment have been developed and where behavioral
factors do not play a dominant role. We show that the US has had significantly faster declines in
mortality from these two diseases than comparison countries. We conclude that the low longevity
ranking of the United States is not likely to be a result of a poorly functioning health care system.
« Reply #414 on: September 22, 2009, 09:54:33 PM »

Second post that interprets the previous piece:

To Explain Longevity Gap, Look Past Health System

If you’re not rich and you get sick, in which industrialized country are you likely to get the best treatment?

The conventional answer to this question has been: anywhere but the United States. With its many uninsured citizens and its relatively low life expectancy, the United States has been relegated to the bottom of international health scorecards.

But a prominent researcher, Samuel H. Preston, has taken a closer look at the growing body of international data, and he finds no evidence that America’s health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis.

“The U.S. actually does a pretty good job of identifying and treating the major diseases,” says Dr. Preston, a demographer at the University of Pennsylvania who is among the leading experts on mortality rates from disease. “The international comparisons don’t show we’re in dire straits.”

No one denies that the American system has problems, including its extraordinarily high costs and unnecessary treatments. But Dr. Preston and other researchers say that the costs aren’t solely due to inefficiency. Americans pay more for health care partly because they get more thorough treatment for some diseases, and partly because they get sick more often than people in Europe and other industrialized countries.

An American’s life expectancy at birth is about 78 years, which is lower than in most other affluent countries. Life expectancy is about 80 in the United Kingdom, 81 in Canada and France, and 83 in Japan, according to the World Health Organization.

This longevity gap, Dr. Preston says, is primarily due to the relatively high rates of sickness and death among middle-aged Americans, chiefly from heart disease and cancer. Many of those deaths have been attributed to the health care system, an especially convenient target for those who favor a European alternative.

But there are many more differences between Europe and the United States than just the health care system. Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be exceptionally heavy smokers. For four decades, until the mid-1980s, per-capita cigarette consumption was higher in the United States (particularly among women) than anywhere else in the developed world. Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries.

As it is, the longevity gap starts at birth and persists through middle age, but then it eventually disappears. If you reach 80 in the United States, your life expectancy is longer than in most other developed countries. The United States is apparently doing something right for its aging population, but what?

One frequent answer has been Medicare. Its universal coverage for people over 65 has often been credited with shrinking the longevity gap between the United States and other developed countries.

But when Dr. Preston and a Penn colleague, Jessica Y. Ho, looked at mortality rates in 1965, before Medicare went into effect, they found an even more pronounced version of today’s pattern: middle-aged people died much more often in the United States than in other developed countries, but the longevity gap shrunk with age even faster than today. In that pre-Medicare era, an American who reached 75 could expect to live longer than most people elsewhere.

Besides smoking, there could be lots of other reasons that Americans are especially unhealthy in middle age. But Dr. Preston says he saw no evidence for the much-quoted estimates that poor health care is responsible for more preventable deaths in the United States than in other developed countries. (Go to for details.)

For all its faults, the American system compares well by some important measures with other developed countries, as Dr. Preston and Ms. Ho enumerate. Americans are more likely to be screened for cancer, and once cancer is detected, they are more likely to survive for five years.

It’s been argued that the survival rate for cancer appears longer in America merely because the disease is detected earlier, but Dr. Preston says that earlier detection can be an advantage in itself, and that Americans might also receive better treatment. He and Ms. Ho conclude that the mortality rates from breast cancer and prostate cancer have been declining significantly faster in the United States than in other industrialized countries.

Americans also do relatively well in surviving heart attacks and strokes, and some studies have found that hypertension is treated more successfully in the United States. Compared with Europeans, Americans are more likely to receive medication if they have heart disease, high cholesterol, lung disease or osteoporosis.

But even if the American system does provide more treatment for more sick people, couldn’t it do something to reduce its workload?

When I brought up Dr. Preston’s work to Ellen Nolte and C. Martin McKee, two prominent European critics of the American system, they suggested that he was taking too limited a view of health care. They said the system should take responsibility for preventing disease, not just treating it.

Dr. Preston acknowledges that the United States might do more to keep young and middle-aged people from getting sick, but he says it’s not clear that other countries’ systems are more effective.

“The U.S. has had one spectacular achievement in preventive medicine,” he says. “It has had the largest drop in cigarette consumption per adult of any developed country since 1985.” If Americans keep shunning cigarettes, the longevity gap could shrink no matter what happens with the health care system.
« Reply #415 on: September 23, 2009, 11:08:52 AM »

U.S. health insurers say they face gov't gag
By Susan Heavey
Tuesday, September 22, 2009 9:14 PM

WASHINGTON (Reuters) - Health insurers accused the U.S. Medicare agency on Tuesday of political interference in a battle over whether the industry can lobby its customers directly over healthcare legislation.

The Centers for Medicare & Medicaid Services (CMS), which oversees the Medicare program for the elderly and disabled as well as privately run Medicare alternatives, said on Monday it was investigating a letter Humana Inc <HUM.N> sent enrollees about efforts to overhaul the nation's healthcare system.

Humana's letter, sent in an envelope citing important plan information, told customers the Democrats' bills could hurt "millions of seniors and disabled individuals could lose many of the important benefits and services that make Medicare Advantage health plans so valuable," according to CMS.

The agency also warned other insurers against sending potentially misleading health reform mailings to customers.

America's Health Insurance Plans, the industry lobby group, called the CMS action a "gag order."

The group argued that any cuts, including those in various Democratic proposals, would raise costs and reduce benefits for those who want private plans.

"Seniors have a right to know how the current reform proposals will affect the coverage they currently like and rely on," said AHIP spokesman Robert Zirkelbach.

Republicans seized on the spat. "It looks likes CMS is engaged in government intimidation, pure and simple," said Representative Dave Camp, the ranking Republican on the U.S. House of Representatives Ways and Means Committee.

Senate Republican Leader Mitch McConnell of Kentucky, where Humana is based, also blasted the CMS "effort to squelch free speech."

A spokesman for Senate Majority Leader Harry Reid said it was "indefensible for insurance companies to send out propaganda" to scare the elderly.

"It's clear that we are closer than ever to meaningful reform because defenders of the status quo are ginning up scare tactics to stand in the way of fixing our broken system," Jim Manley said.

CMS dismissed the criticism, saying it wanted to ensure companies do not violate marketing rules or improperly use protected Medicare mailing lists.

"Our goal is to safeguard beneficiaries' personal information," agency spokesman Peter Ashkenaz told Reuters.


Democratic Senator Max Baucus had urged CMS to get involved and later welcomed the investigation of what he called "scare tactics" by Humana.

The Senate Finance Committee that Baucus chairs began work on his health reform bill on Tuesday.

The Wall Street Journal criticized Baucus in an opinion piece, saying he had sicced federal regulators onto Humana for daring to criticize one part of his health bill.

But consumer advocacy groups welcomed the CMS move, saying private Medicare customers should not be directly targeted over political issues.

"It's about time... that CMS is cracking down on plans using their enrollees as a captive audience for their political agenda," said Medicare Rights Center spokesman Paul Precht.

Precht said CMS did not forbid Humana from stating its position. "What they're saying is they cannot send letters to their plan members under the guise of plan communication that is really political propaganda."

CMS warned Humana it would take necessary enforcement action but it is unclear when the investigation will conclude. The company said it is cooperating.


Privately run Medicare plans, also known as Medicare Advantage, make up more than 20 percent of Medicare coverage, with more than 10 million elderly or disabled Americans choosing them over government-run fee-for-service plans.

CMS' Ashkenaz said the agency is not yet aware of other companies that have sent direct political mailings to enrollees. Aetna Inc <AET.N>, Cigna Corp <CI.N> and WellPoint Inc <WLP.N> also offer Medicare plans.

Medicare Advantage plans are already under scrutiny because they cost more than traditional Medicare. An advisory group has urged Congress to curb payments to help lower the overall costs of Medicare, which could run out of money as early as 2017.

Representative Camp said AARP, the nation's largest lobby group for older Americans which offers its own Medicare plan with UnitedHealth Group Inc <UNH.N>, touts Democratic healthcare reform efforts on its website.

"CMS may be selectively and inappropriately using its regulatory powers," he wrote in a letter to CMS.

AARP Executive Vice President Nancy LeaMond said her group is a membership organization that regularly advocates on a variety of issues and contacts members accordingly. AARP does not sell insurance directly but lends its name to other plans, she added.

(Additional reporting by Donna Smith, editing by Gerald E. McCormick, Tim Dobbyn, Gary Hill)
« Reply #416 on: September 24, 2009, 07:32:47 AM »

I find a lot on the Mises site to be esoteric and often dogmatic, but this presents a exploration of how to deal with the uninsured I hadn't seen and, in doing so, addresses questions Crafty has asked in the past.

Is Emergency Care a Failed Market?
Mises Daily by Eric M. Staib | Posted on 9/24/2009 12:00:00 AM

"Those who are most in need of low-cost care are forced out of the market in the name of social justice."
In response to my recent article on health-insurance mandates, I received many emails from readers who argued that mandates, as unappealing as they may be, are necessary to prevent market failure in emergency medical services.

Specifically, they argued that there is a "free-rider problem" in emergency care because individuals are currently able to visit the emergency room (ER) without insurance or the means to pay, receive care, and then skip out on the bill. Such free riders force the hospital to either accept the losses or spread the costs to other patients. Therefore, the readers reasoned, there is a market failure in that health insurance is under-demanded and ER care is over-demanded, increasing health care costs and dumping them onto those consumers who do purchase insurance and pay for their visits.

As accurate as this common depiction of the symptom is, however, it misdiagnosis the disease. The free-rider problem in ER care is not a market failure, but a government failure. The Hippocratic Oath notwithstanding, hospitals only accept all patients irrespective of their ability to pay because they are required to by government regulations. These laws, which are in place in countries around the planet, result in a simple welfare scheme whereby the costs of the uninsured are transferred to insured patients. With this reality in mind, it is easy to see that the free-rider problem in ER services is not a market failure, but rather a government failure.

A Libertarian Alternative
How, then, would truly free-market hospitals handle patients who are now free riders? There is every reason to expect that these uninsured, mostly low-income people would be treated more humanely and with greater dignity than they are in the current quasi-socialist system.

Without government regulations on their payment collection methods, hospitals would be free to offer more flexible prices and payment options, and to negotiate contracts with individual consumers. Those patients with little financial leverage would be able to form creative payment plans, and those without any savings or insurance could even contract to pay for their services with labor.

Furthermore, in a truly free market for medical care, even patients who intentionally try to skip payments and thus dump the costs on others cannot. This is because, in the absence of supposedly compassionate hospital legislation, to admit oneself or someone else to emergency care is to agree to the terms and conditions of service at that hospital — most importantly, to pay for treatment.

Thus, in the libertarian society, checking out without arranging payment would constitute a violation of contract, and therefore these malicious free riders would be held accountable. In the current situation, however, such predatory patients are subsidized by others in the name of social compassion.

Another advantage of contractual enforcement of payment for ER services on the free market is that it removes hospitals from financial responsibility for those patients who are admitted to the ER by another party while incapacitated. Which party will be held responsible for the hospital bill in each case would be decided by negotiation between the two parties and perhaps even by court arbitration. Which party eventually pays is not important for this matter, though; what matters is that the hospital will be paid either way, and that other patients will no longer be stuck with the bill.

Now that we've seen that the free rider problem does not exist in a free market for medical care, we can address other readers' concern that the profit-driven market process is unsympathetic to the suffering of those patients who are truly unable to pay in any way and can't afford market insurance, but who shouldn't simply be left to suffer.

The Market for Free Riders?
To argue that the market discards those it regards as undesirable is to both ignore the prevalence of private charity and deny the existence of the entire public-relations industry. Indeed, setting socialist doctrines aside, we can see that affectionate treatment of the poor and downtrodden is actually a very profitable endeavor.

In every market, firms of all sizes expend resources to maintain a positive public image. There are few actions better received by a community than healing and treating their vulnerable and disabled at a discounted or zero price. As such, it is absolutely foolish to believe that hospitals would not take in such customers for treatment.

In fact, if we examine the nature of prices and income differentials closely, we arrive at another instance of destructive government intervention. Price discrimination of almost every form is illegal in almost every market, and health care is certainly no exception.

Price discrimination may feel unfair, but if allowed by law it can lead to much more efficient market outcomes and higher market quantities of all goods and services. Using price discrimination, hospitals would be free to provide additional and cheaper services to low-income consumers without decreasing the price for high-income consumers.

Price discrimination would benefit the hospitals as well, because they would not only increase the quantity of services they perform and add potentially loyal new customers, but would also be able to increase the price of services to their high-income patients without losing their business.

Viewing the converse of this market outcome, then, we can observe that laws against price-fixing necessarily decrease quantities of goods and services, and squeeze marginal consumers out of the market. In the health care market, this means that those who are most in need of low-cost care are forced out of the market in the name of social justice.

In contemplating competition between medical service providers, we can deduce that the market will indeed treat people who are now free riders with dignity, but that those consumers will no longer actually be free riding on others. Instead, they will provide a valuable good to society — namely, the satisfaction that comes with supporting others in their time of need. While it may seem strange to think of this as an economic good, it certainly is, as evidenced by consumers' willingness to forgo other forms of consumption in favor of charity.

While caring for these patients would still redistribute costs to other consumers, it would do so only to the extent that these paying consumers would tolerate it by continuing to purchase care and services. That is to say that consumers' choices between competing hospitals' services would, just as in any market, force those hospitals to provide equilibrium quantities of charitable care.

This efficient market quantity would therefore be determined by the charitable inclinations of insured and higher-income patients. And in a truly libertarian market, which would lack taxes, we can say that these individuals would inarguably be more giving of their own income.

Perhaps the best feature of the free-market process in a libertarian health market is that it would allocate charitable funds to their best use. In our emergency services case, this axiom of market behavior implies that hospitals will spend their charity budgets on the most destitute and impoverished patients.

Whereas government funds are allocated according to political cronyism and electoral opportunism, free-market hospitals will always attempt to maximize the benefit to their public image — nothing more than profit maximization — by providing for those patients who are most in need.

With rigorous examination, we can see that emergency medical services function like any other market, and that the free-rider problem is the result of a government failure. Furthermore, we can safely expect that the free market would treat the most deserving of these free riders more humanely than does the supposedly compassionate central health administration.
« Reply #417 on: September 25, 2009, 04:21:31 PM »

The Baucus Health Bill: A Medicare Physician Payment Shell Game
by Dennis G. Smith
WebMemo #2629
My colleagues, this is our opportunity to make history. Our actions here, this week, will determine whether we are courageous enough and skillful enough to change things for the better.

--Senator Max Baucus, addressing the Senate Finance Committee on September 22, 2009

For all of the bold talk of reform, the provisions of the Senate Finance Committee bill are simply more of the same. This is evident in the way the committee is evading the systemic problems that Congress created with its updates to its flawed Medicare physician fee schedule.

Since the federal government apparently cannot ensure beneficiary access in the current Medicare program--and since government price controls like those used in Medicare do not work--trapping more Americans into such a system through a government health insurance plan does not make sense.

Medicare Payment Update

Medicare reimburses doctors and other medical professionals for their services according to a congressionally created fee schedule that is annually adjusted by the Sustainable Growth Rate (SGR) formula. Enacted in the 1990s, the SGR is primary evidence of how Congress tries and ultimately fails to "bend the curve" of the health care costs in Medicare.

The idea is relatively simple: If Medicare spending grows faster than our overall economy (which is almost always the case), then payments to Medicare providers are to be reduced proportionately to keep expenditures in line over a period of time. Each year, the Centers for Medicare and Medicaid Services estimates how much the physician fee schedule update will have to be reduced the following year in order to meet the target Medicare expenditures on physician payment. The 2010 update, for instance, reflects expenditures from April 1, 1996, to December 31, 2009.

A Political Volcano

If the SGR update goes into effect in 2010 as planned under current law, it will result in massive Medicare payment cuts. But every year, Congress--under both Democratic and Republican leadership--routinely blocks the cuts from going into effect for a year or two at a time. At the same time, House and Senate leaders have left intact the underlying requirement to keep doctor payment below the rate of GDP growth.

Subsequently, the necessary cumulative cut in Medicare payments grows bigger. Without a change to current law, payments to physicians would be reduced by 21.5 percent as of January 1, 2010, and by an additional 5.5 percent each year from 2011 through 2014 (and a small reduction in 2015).[1]

The Baucus Proposal

In his opening statement to the Senate Finance Committee on September 22, Chairman Baucus acknowledged the failure to address the problem: "On one point, I want to acknowledge up front that we did not do as much to correct the payment of doctors under the incredibly misnamed 'Sustainable Growth Rate.' The SGR needs to be fixed permanently."[2]

But instead of fixing the SGR, the Senate Finance Committee bill repeats the prior pattern by providing a payment increase for 2010 and then pretending it did not happen. The reason for this one-year change in the update is obvious: Fixing the problem long-term would cost $200 billion over 10 years.[3] Steny Hoyer (D-MD), the House majority leader, rightfully called the Senate Finance Committee proposal a façade.[4]

Earlier this summer, the American Medical Association told its members that Congress would "erase" the SGR problem.[5] Fat chance.

The Price of Price Controls

The SGR issue should be appropriately viewed as a microcosm of current efforts to overhaul the health care system. The inclusion of the SGR provisions in the Senate and House bills is a tactical admission that Medicare beneficiaries' access to care is being threatened--potentially a form of rationing. Two years ago, when proposed SGR reductions were more modest than they are now, a poll of physicians found that 60 percent would limit the number of Medicare patients they accept and 14 percent would stop seeing Medicare patients entirely if these cuts went into effect.[6]

The SGR does not even accomplish the objective it was created to achieve: to bend the cost curve in Medicare. Payments to physicians continue to exceed overall economic growth. Two years ago, Dr. Cecil B Wilson testified that "spending targets cannot achieve their goal of restraining volume growth by discouraging inappropriate care. Spending targets apply to a whole group and, therefore, do not provide an incentive at the individual physician level to control spending. In addition, they do not distinguish between appropriate and inappropriate growth because they apply across-the-board to all services. In addition, spending target systems are based on the fallacious premise that physicians alone can control the utilization of health care services, while ignoring patient demand, government policies, technological advances, epidemics, disasters, and the many other contributors to volume growth."[7]

Special Interest Lobbies

In addition to the budget problem, fixing the SGR poses a problem for seniors as well. Physicians are paid out of Medicare Part B, the Supplementary Medical Insurance Trust Fund (SMI) portion of Medicare. Even though SMI is heavily subsidized by taxpayers, non-disabled Medicare enrollees are required to pay 25 percent of Part B costs. (Originally, beneficiaries paid 50 percent of the costs.) So if physician payments go up, the cost of the entire program goes up, increasing the amount of the 25 percent share that beneficiaries must pay.

Congress enacted a temporary "hold harmless" provision to shield most seniors from a premium increase in 2010 because they will not receive an increase in their Social Security benefits. The cost, however, is passed along to other Medicare beneficiaries. Of course, now that that reality approaches, Congress is considering spending another $2 billion to pick up the tab.

Central Planning Failures

As SGR and the history of Medicare demonstrate, the federal government has constantly intervened in the payment systems and increased massive cost shifting. The classic scenario is constantly repeated: Politicians over-promise (more benefits, lower costs to the beneficiary), the budget hemorrhages, politicians apply a tourniquet to stop the fiscal bleeding, and the short-term fixes create even greater long term problems.

History, not hysteria, is why so many Americans (especially seniors) are skeptical of the political promises of more while achieving budget neutrality. Government cannot deliver more services for less than the value of what is being provided. Government surpasses the private sector only in its ability to hide the true cost by forcing someone else to pick up the tab. Someone has to pay, which means politicians are constantly trying to pass the burden around like a hot potato among providers, beneficiaries, current taxpayers, and future taxpayers. Whoever is left with the unwanted cost protests, and the contest starts all over again.

The very idea that government is more efficient than the private sector is comical. Why did so many state and local governments get out of the direct delivery of health care services in the 1960s and 1970s? Because of government inefficiencies.

Medicare's SGR problem is another chapter in the big book of government central planning, an epic failure and a fountain of unintended consequences.

Dennis G. Smith is Senior Fellow in the Center for Health Policy Studies at The Heritage Foundation.

[1]2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, May 12, 2009, p. 22, at (September 24, 2009).

[2]Press release, "Opening Statement of Senator Max Baucus (D-Mont.) at Today's Mark-Up of the America's Healthy Future Act," September 22, 2009, at (September 25, 2009).

[3]Douglas W. Elmendorf, director, Congressional Budget Office, letter to Charles B. Rangel, chairman, Committee on Ways and Means, U.S. House of Representatives, July 17, 2009, at (September 25, 2009).

[4]Corey Boles, "Rep Hoyer Calls for 10-Year Fix for Medicare Payments,", September 22, 2009, at
itle=update-rep-hoyer-calls-for-10-year-fix-for-medicare-payments (September 25, 2009).

[5]American Medical Association, "AMA Support for H.R. 3200: Answers to Frequently Asked Questions," July 20, 2009, at
/HR3200FAQs_72009_AMA.pdf (September 24, 2009).

[6]Medical News Today, "60% of Physicians Would Limit Number of New Medicare Patients If Scheduled Payment Cut Is Enacted, AMA Survey Finds," June 7, 2007, at (September 24, 2009).

« Reply #418 on: September 29, 2009, 07:24:32 PM »

Wow. Simply wow. If you only read one more article about healthcare, let it be this one.

After the needless death of his father, the author, a business executive, began a personal exploration of a health-care industry that for years has delivered poor service and irregular quality at astonishingly high cost. It is a system, he argues, that is not worth preserving in anything like its current form. And the health-care reform now being contemplated will not fix it. Here’s a radical solution to an agonizing problem.

by David Goldhill
How American Health Care Killed My Father

Illustration by Mark Hooper

ALMOST TWO YEARS ago, my father was killed by a hospital-borne infection in the intensive-care unit of a well-regarded nonprofit hospital in New York City. Dad had just turned 83, and he had a variety of the ailments common to men of his age. But he was still working on the day he walked into the hospital with pneumonia. Within 36 hours, he had developed sepsis. Over the next five weeks in the ICU, a wave of secondary infections, also acquired in the hospital, overwhelmed his defenses. My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

About a week after my father’s death, The New Yorker ran an article by Atul Gawande profiling the efforts of Dr. Peter Pronovost to reduce the incidence of fatal hospital-borne infections. Pronovost’s solution? A simple checklist of ICU protocols governing physician hand-washing and other basic sterilization procedures. Hospitals implementing Pronovost’s checklist had enjoyed almost instantaneous success, reducing hospital-infection rates by two-thirds within the first three months of its adoption. But many physicians rejected the checklist as an unnecessary and belittling bureaucratic intrusion, and many hospital executives were reluctant to push it on them. The story chronicled Pronovost’s travels around the country as he struggled to persuade hospitals to embrace his reform.

It was a heroic story, but to me, it was also deeply unsettling. How was it possible that Pronovost needed to beg hospitals to adopt an essentially cost-free idea that saved so many lives? Here’s an industry that loudly protests the high cost of liability insurance and the injustice of our tort system and yet needs extensive lobbying to embrace a simple technique to save up to 100,000 people.

And what about us—the patients? How does a nation that might close down a business for a single illness from a suspicious hamburger tolerate the carnage inflicted by our hospitals? And not just those 100,000 deaths. In April, a Wall Street Journal story suggested that blood clots following surgery or illness, the leading cause of preventable hospital deaths in the U.S., may kill nearly 200,000 patients per year. How did Americans learn to accept hundreds of thousands of deaths from minor medical mistakes as an inevitability?

My survivor’s grief has taken the form of an obsession with our health-care system. For more than a year, I’ve been reading as much as I can get my hands on, talking to doctors and patients, and asking a lot of questions.

Keeping Dad company in the hospital for five weeks had left me befuddled. How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient’s room? Considering the importance of a patient’s frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient’s care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

I’m a businessman, and in no sense a health-care expert. But the persistence of bad industry practices—from long lines at the doctor’s office to ever-rising prices to astonishing numbers of preventable deaths—seems beyond all normal logic, and must have an underlying cause. There needs to be a business reason why an industry, year in and year out, would be able to get away with poor customer service, unaffordable prices, and uneven results—a reason my father and so many others are unnecessarily killed.

Like every grieving family member, I looked for someone to blame for my father’s death. But my dad’s doctors weren’t incompetent—on the contrary, his hospital physicians were smart, thoughtful, and hard-working. Nor is he dead because of indifferent nursing—without exception, his nurses were dedicated and compassionate. Nor from financial limitations—he was a Medicare patient, and the issue of expense was never once raised. There were no greedy pharmaceutical companies, evil health insurers, or other popular villains in his particular tragedy.

Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value.

These are the impersonal forces, I’ve come to believe, that explain why things have gone so badly wrong in health care, producing the national dilemma of runaway costs and poorly covered millions. The problems I’ve explored in the past year hardly count as breakthrough discoveries—health-care experts undoubtedly view all of them as old news. But some experts, it seems, have come to see many of these problems as inevitable in any health-care system—as conditions to be patched up, papered over, or worked around, but not problems to be solved.

That’s the premise behind today’s incremental approach to health-care reform. Though details of the legislation are still being negotiated, its principles are a reprise of previous reforms—addressing access to health care by expanding government aid to those without adequate insurance, while attempting to control rising costs through centrally administered initiatives. Some of the ideas now on the table may well be sensible in the context of our current system. But fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform.

I’m a Democrat, and have long been concerned about America’s lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system—largely problems of incentives—our reforms won’t do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy.

These ideas stand well outside the emerging political consensus about reform. So before exploring alternative policies, let’s reexamine our basic assumptions about health care—what it actually is, how it’s financed, its accountability to patients, and finally its relationship to the eternal laws of supply and demand. Everyone I know has at least one personal story about how screwed up our health-care system is; before spending (another) $1trillion or so on reform, we need a much clearer understanding of the causes of the problems we all experience.

Illustration by Stephen Savage

Health Care Isn’t Health (Or Happiness)
“Money is honey,” my grandmother used to tell me, “but health is wealth.” She said “health,” not “health care.” Listening to debates over health-care reform, it is sometimes difficult to remember that there is a difference.

Medical care, of course, is merely one component of our overall health. Nutrition, exercise, education, emotional security, our natural environment, and public safety may now be more important than care in producing further advances in longevity and quality of life. (In 2005, almost half of all deaths in the U.S. resulted from heart disease, diabetes, lung cancer, homicide, suicide, and accidents—all of which are arguably influenced as much by lifestyle choices and living environment as by health care.) And of course even health itself is only one aspect of personal fulfillment, alongside family and friends, travel, recreation, the pursuit of knowledge and experience, and more.

Yet spending on health care, by families and by the government, is crowding out spending on almost everything else. As a nation, we now spend almost 18 percent of our GDP on health care. In 1966, Medicare and Medicaid made up 1 percent of total government spending; now that figure is 20 percent, and quickly rising. Already, the federal government spends eight times as much on health care as it does on education, 12 times what it spends on food aid to children and families, 30 times what it spends on law enforcement, 78 times what it spends on land management and conservation, 87 times the spending on water supply, and 830 times the spending on energy conservation. Education, public safety, environment, infrastructure—all other public priorities are being slowly devoured by the health-care beast.

It’s no different for families. From 2000 to 2008, the U.S. economy grew by $4.4 trillion; of that growth, roughly one out of every four dollars was spent on health care. Household expenditures on health care already exceed those on housing. And health care’s share is growing.

By what mechanism does society determine that an extra, say, $100 billion for health care will make us healthier than even $10 billion for cleaner air or water, or $25 billion for better nutrition, or $5 billion for parks, or $10 billion for recreation, or $50 billion in additional vacation time—or all of those alternatives combined?

The answer is, no mechanism at all. Health care simply keeps gobbling up national resources, seemingly without regard to other societal needs; it’s treated as an island that doesn’t touch or affect the rest of the economy. As new tests and treatments are developed, they are, for the most part, added to our Medicare or commercial insurance policies, no matter what they cost. But of course the money must come from somewhere. If the amount we spend on care had grown only at the general rate of inflation since 1970, annual health-care costs now would be roughly $5,000 less per American—that’s about 10 percent of today’s median income, to invest for the future or to spend on all the other things that contribute to our well-being. To be sure, our society has become wealthier over the years, and we’d naturally want to spend some of this new wealth on more and better health care; but how did we choose to spend this much?

The housing bubble offers some important lessons for health-care policy. The claim that something—whether housing or health care—is an undersupplied social good is commonly used to justify government intervention, and policy makers have long striven to make housing more affordable. But by making housing investments eligible for special tax benefits and subsidized borrowing rates, the government has stimulated not only the construction of more houses but also the willingness of people to borrow and spend more on houses than they otherwise would have. The result is now tragically clear.

As with housing, directing so much of society’s resources to health care is stimulating the provision of vastly more care. Along the way, it’s also distorting demand, raising prices, and making us all poorer by crowding out other, possibly more beneficial, uses for the resources now air-dropped onto the island of health care. Why do we view health care as disconnected from everything else? Why do we spend so much on it? And why, ultimately, do we get such inconsistent results? Any discussion of the ills within the system must begin with a hard look at the tax-advantaged comprehensive-insurance industry at its center.

Health Insurance Isn’t Health Care
How often have you heard a politician say that millions of Americans “have no health care,” when he or she meant they have no health insurance? How has a method of financing health care become synonymous with care itself?

The reason for financing at least some of our health care with an insurance system is obvious. We all worry that a serious illness or an accident might one day require urgent, extensive care, imposing an extreme financial burden on us. In this sense, health-care insurance is just like all other forms of insurance—life, property, liability—where the many who face a risk share the cost incurred by the few who actually suffer a loss.

But health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We’ve become so used to health insurance that we don’t realize how absurd that is. We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and deliveries are predictable many months in advance, yet they’re financed the same way we finance fixing a car after a wreck—through an insurance claim.

Comprehensive health insurance is such an ingrained element of our thinking, we forget that its rise to dominance is relatively recent. Modern group health insurance was introduced in 1929, and employer-based insurance began to blossom during World War II, when wage freezes prompted employers to expand other benefits as a way of attracting workers. Still, as late as 1954, only a minority of Americans had health insurance. That’s when Congress passed a law making employer contributions to employee health plans tax-deductible without making the resulting benefits taxable to employees. This seemingly minor tax benefit not only encouraged the spread of catastrophic insurance, but had the accidental effect of making employer-funded health insurance the most affordable option (after taxes) for financing pretty much any type of health care. There was nothing natural or inevitable about the way our system developed: employer-based, comprehensive insurance crowded out alternative methods of paying for health-care expenses only because of a poorly considered tax benefit passed half a century ago.

In designing Medicare and Medicaid in 1965, the government essentially adopted this comprehensive-insurance model for its own spending, and by the next year had enrolled nearly 12 percent of the population. And it is no coinci dence that the great inflation in health-care costs began soon after. We all believe we need comprehensive health insurance because the cost of care—even routine care—appears too high to bear on our own. But the use of insurance to fund virtually all care is itself a major cause of health care’s high expense.

Insurance is probably the most complex, costly, and distortional method of financing any activity; that’s why it is otherwise used to fund only rare, unexpected, and large costs. Imagine sending your weekly grocery bill to an insurance clerk for review, and having the grocer reimbursed by the insurer to whom you’ve paid your share. An expensive and wasteful absurdity, no?

Is this really a big problem for our health-care system? Well, for every two doctors in the U.S., there is now one health-insurance employee—more than 470,000 in total. In 2006, it cost almost $500 per person just to administer health insurance. Much of this enormous cost would simply disappear if we paid routine and predictable health-care expenditures the way we pay for everything else—by ourselves.

Illustration by Stephen Savage

« Reply #419 on: September 29, 2009, 07:25:23 PM »

The Moral-Hazard Economy
Society’s excess cost from health insurance’s administrative expense pales next to the damage caused by “moral hazard”—the tendency we all have to change our behavior, becoming spendthrifts and otherwise taking less care with our decisions, when someone else is covering the costs. Needless to say, much medical care is unavoidable; we don’t choose to become sick, nor do we seek more treatment than we think we need. Still, hospitals, drug companies, health insurers, and medical-device manufacturers now spend roughly $6 billion a year on advertising. If the demand for health care is purely a response to unavoidable medical need, why do these companies do so much advertising?

Medical ads on TV typically inform the viewer that a specific treatment—a drug, device, surgical procedure—is available for a chronic condition. Many also note that the product or treatment is eligible for Medicare or private-insurance reimbursement. In some cases, the advertiser will offer to help the patient obtain that reimbursement. The key message: you can benefit from this product and pass the bill on to someone else.

Every time you walk into a doctor’s office, it’s implicit that someone else will be paying most or all of your bill; for most of us, that means we give less attention to prices for medical services than we do to prices for anything else. Most physicians, meanwhile, benefit financially from ordering diagnostic tests, doing procedures, and scheduling follow-up appointments. Combine these two features of the system with a third—the informational advantage that extensive training has given physicians over their patients, and the authority that advantage confers—and you have a system where physicians can, to some extent, generate demand at will.

Do they? Well, Medicare spends almost twice as much per patient in Dallas, where there are more doctors and care facilities per resident, as it does in Salem, Oregon, where supply is tighter. Why? Because doctors (particularly specialists) in surplus areas order more tests and treatments per capita, and keep their practices busy. Many studies have shown that the patients in areas like Dallas do not benefit in any measurable way from all this extra care. All of the physicians I know are genuinely dedicated to their patients. But at the margin, all of us are at least subconsciously influenced by our own economic interests. The data are clear: in our current system, physician supply often begets patient demand.

Moral hazard has fostered an accidental collusion between providers benefiting from higher costs and patients who don’t fully bear them. In this environment, trying to control costs is awfully tough. When Medicare cut reimbursement rates in 2005 on chemotherapy and anemia drugs, for instance, it saved almost 20 percent of the previously billed costs. But Medicare’s total cancer-treatment costs actually rose almost immediately. As The New York Times reported, some physicians believed their colleagues simply performed more treatments, particularly higher-profit ones.

Want further evidence of moral hazard? The average insured American and the average uninsured American spend very similar amounts of their own money on health care each year—$654 and $583, respectively. But they spend wildly different amounts of other people’s money—$3,809 and $1,103, respectively. Sometimes the uninsured do not get highly beneficial treatments because they cannot afford them at today’s prices—something any reform must address. But likewise, insured patients often get only marginally beneficial (or even outright unnecessary) care at mind-boggling cost. If it’s true that the insurance system leads us to focus on only our direct share of costs—rather than the total cost to society—it’s not surprising that insured families and uninsured ones would make similar decisions as to how much of their own money to spend on care, but very different decisions on the total amount to consume.

The unfortunate fact is, health-care demand has no natural limit. Our society will always keep creating new treatments to cure previously incurable problems. Some of these will save lives or add productive years to them; many will simply make us more comfortable. That’s all to the good. But the cost of this comfort, and whether it’s really worthwhile, is never calculated—by anyone. For almost all our health-care needs, the current system allows us as consumers to ask providers, “What’s my share?” instead of “How much does this cost?”—a question we ask before buying any other good or service. And the subtle difference between those two questions is costing us all a fortune.

There’s No One Else to Pay the Bill
Perhaps the greatest problem posed by our health-insurance-driven regime is the sense it creates that someone else is actually paying for most of our health care—and that the costs of new benefits can also be borne by someone else. Unfortunately, there is no one else.

For fun, let’s imagine confiscating all the profits of all the famously greedy health-insurance companies. That would pay for four days of health care for all Americans. Let’s add in the profits of the 10 biggest rapacious U.S. drug companies. Another 7 days. Indeed, confiscating all the profits of all American companies, in every industry, wouldn’t cover even five months of our health-care expenses.

Somebody else always seems to be paying for at least part of our health care. But that’s just an illusion. At $2.4 trillion and growing, our nation’s health-care bill is too big to be paid by anyone other than all of us.

In 2007, employer-based health insurance cost, on average, more than $12,000 per family, up 78 percent since 2001. I’ve run several companies and company divisions of various sizes over the course of my career, so I can confidently tell you that raises (and even entry-level hiring) are tightly limited by rising health-care costs. You may think your employer is paying for your health care, but in fact your company’s share of the insurance premium comes out of your potential wage increase. Where else could it come from?

Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings—say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime—roughly $4 million in total.

Would you have guessed these numbers were so large? If not, you have good cause: only a quarter would be paid by you directly (and much of that after retirement). The rest would be spent by others on your behalf, deducted from your earnings before you received your paycheck. And that’s a big reason why our health-care system is so expensive.

The Government Is Not Good at Cost Reduction
Every proposal for health-care reform has featured some element of cost control to “balance” the inflationary impact of expanding access. Yet it goes without saying that in the big picture, all government efforts to control costs have failed.

Why? One reason is a fixation on prices rather than costs. The government regularly tries to cap costs by limiting the reimbursement rates paid to providers by Medicare and Medicaid, and generally pays much less for each service than private insurers. But as we’ve seen, that can lead providers to perform more services, and to steer patients toward higher-priced, more lightly regulated treatments. The government’s efforts to expand “access” to care while limiting costs are like blowing up a balloon while simultaneously squeezing it. The balloon continues to inflate, but in misshapen form.

Cost control is a feature of decentralized, competitive markets, not of centralized bureaucracy—a matter of incentives, not mandates. What’s more, cost control is dynamic. Even the simplest business faces constant variation in its costs for labor, facilities, and capital; to compete, management must react quickly, efficiently, and, most often, prospectively. By contrast, government bureaucracies set regulations and reimbursement rates through carefully evaluated and broadly applied rules. These bureaucracies first must notice market changes and resource misallocations, and then (sometimes subject to political considerations) issue additional regulations or change reimbursement rates to address each problem retrospectively.

As a result, strange distortions crop up constantly in health care. For example, although the population is rapidly aging, we have few geriatricians—physicians who address the cluster of common patient issues related to aging, often crossing traditional specialty lines. Why? Because under Medicare’s current reimbursement system (which generally pays more to physicians who do lots of tests and procedures), geriatricians typically don’t make much money. If seniors were the true customers, they would likely flock to geriatricians, bidding up their rates—and sending a useful signal to medical-school students. But Medicare is the real customer, and it pays more to specialists in established fields. And so, seniors often end up overusing specialists who are not focused on their specific health needs.

Many reformers believe if we could only adopt a single-payer system, we could deliver health care more cheaply than we do today. The experience of other developed countries suggests that’s true: the government as single payer would have lower administrative costs than private insurers, as well as enormous market clout and the ability to bring down prices, although at the cost of explicitly rationing care.

But even leaving aside the effects of price controls on innovation and customer service, today’s Medicare system should leave us skeptical about the long-term viability of that approach. From 2000 to 2007, despite its market power, Medicare’s hospital and physician reimbursements per enrollee rose by 5.4 percent and 8.5 percent, respectively, per year. As currently structured, Medicare is a Ponzi scheme. The Medicare tax rate has been raised seven times since its enactment, and almost certainly will need to be raised again in the next decade. The Medicare tax contributions and premiums that today’s beneficiaries have paid into the system don’t come close to fully funding their care, which today’s workers subsidize. The subsidy is getting larger even as it becomes more difficult to maintain: next year there will be 3.7 working people for each Medicare beneficiary; if you’re in your mid-40s today, there will be only 2.4 workers to subsidize your care when you hit retirement age. The experience of other rich nations should also make us skeptical. Whatever their histories, nearly all developed countries are now struggling with rapidly rising health-care costs, including those with single-payer systems. From 2000 to 2005, per capita health-care spending in Canada grew by 33 percent, in France by 37 percent, in the U.K. by 47 percent—all comparable to the 40 percent growth experienced by the U.S. in that period. Cost control by way of bureaucratic price controls has its limits.

In 2007, health companies in the Fortune 1,000 earned $71 billion. Of the 52 industries represented on Fortune’s list, pharmaceuticals and medical equipment ranked third and fourth, respectively, in terms of profits as a share of revenue. From 2000 to 2007, the annual profits of America’s top 15 health-insurance companies increased from $3.5 billion to $15 billion.

In competitive markets, high profits serve an important social purpose: encouraging capital to flow to the production of a service not adequately supplied. But as long as our government shovels ever-greater resources into health care with one hand, while with the other restricting competition that would ensure those resources are used efficiently, sustained high profits will be the rule.

Health care is an exceptionally heavily regulated industry. Health-insurance companies are regulated by states, which limits interstate competition. And many of the materials, machines, and even software programs used by health-care facilities must be licensed by state or federal authorities, or approved for use by Medicare; these requirements form large barriers to entry for both new facilities and new vendors that could equip and supply them.

Many health-care regulations are justified as safety precautions. But many also result from attempts to redress the distortions that our system of financing health care has created. And whatever their purpose, almost all of these regulations can be shaped over time by the powerful institutions that dominate the health-care landscape, and that are often looking to protect themselves from competition.

Take the ongoing battle between large integrated hospitals and specialty clinics (for cardiac surgery, orthopedics, maternity, etc.). The economic threat posed by these facilities is well illustrated by a recent battle in Loma Linda, California. When a group of doctors proposed a 28-bed private specialty facility, the local hospitals protested to the city council that it was unnecessary, and launched a publicity campaign to try to block it; the council backed the facility anyway. So the nonprofit Loma Linda University Medical Center simply bought the new facility for $80 million in 2008. Traditional hospitals got Congress to include an 18-month moratorium on new specialty hospitals in the 2003 Medicare law, and a second six-month ban in 2005.

The hospitals’ argument has some merit: less complicated surgical cases (the kind specialty clinics typically take on) tend to be more profitable than complex surgeries and nonsurgical admissions. Without those profitable cases, hospitals can’t subsidize the cases on which they lose money. But why are simple surgeries more profitable? Because of the nonmarket methods by which Medicare sets prices.

The net effect of the endless layers of health-care regulation is to stifle competition in the classic economic sense. What we have instead is a noncompetitive system where services and reimbursement are negotiated above consumers’ heads by large private and government institutions. And the primary goal of any large noncompetitive institution is not cost control or product innovation or customer service: it’s maintenance of the status quo.

Our Favored Hospitals
In 1751, Benjamin Franklin and Dr. Thomas Bond founded Pennsylvania Hospital, the first in America, “to care for the sick-poor and insane who were wandering the streets of Philadelphia.” Since then, hospitals have come to dominate the American medical landscape. Yet in recent decades, the rationale for concentrating so much care under one roof has diminished steadily. Many hospitals still exist in their current form largely because they are protected by regulation and favored by government payment policies, which effectively maintain the existing industrial structure, rather than encouraging innovation.

Between 1970 and 2006, annual Medicare payments to hospitals grew by roughly 3,800 percent, from $5 billion to $192 billion. Total annual hospital-care costs for all patients grew from $28 billion to almost $650 billion during that same period. Since 1975, hospitals’ enormous revenue growth has occurred despite a 35 percent decline in the number of hospital beds, no meaningful increase in total admissions, and an almost 50 percent decline in the average length of stay. High-tech equipment has been dispersed to medical practices, recovery periods after major procedures have shrunk, and pharmaceutical therapies have grown in importance, yet over the past 40 years, hospitals have managed to retain the same share (roughly one-third) of our nation’s health-care bill.

Hospitals have sought to use the laws and regulations originally designed to serve patients to preserve their business model. Their argument is the same one that’s been made before by regulated railroads, electric utilities, airlines, Ma Bell, and banks: new competitors, they say, are using their cost advantages to skim off the best customers; without those customers, the incumbents will no longer be able to subsidize essential services that no one can profitably provide to the public.

Hospitals are indeed required to provide emergency care to any walk-in patient, and this obligation is a meaningful public service. But how do we know whether the charitable benefit from this requirement justifies the social cost of expensive hospital care and poor quality? We don’t know. Our system of health-care law and regulation has so distorted the functioning of the market that it’s impossible to measure the social costs and benefits of maintaining hospitals’ prominence. And again, the distortions caused by a reluctance to pay directly for health care—in this case, emergency medicine for the poor—are in large part to blame.

Consider the oft-quoted “statistic” that emergency-room care is the most expensive form of treatment. Has anyone who believes this ever actually been to an emergency room? My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation. The doctors and other workers are hardly underemployed: typically, ERs are unbelievably crowded. They have access to the facilities and equipment of the entire hospital, but require very few dedicated resources of their own. They benefit from the group buying power of the entire institution. No expensive art decorates the walls, and the waiting rooms resemble train-station waiting areas. So what exactly makes an ER more expensive than other forms of treatment?

Perhaps it’s the accounting. Since charity care, which is often performed in the ER, is one justification for hospitals’ protected place in law and regulation, it’s in hospitals’ interest to shift costs from overhead and other parts of the hospital to the ER, so that the costs of charity care—the public service that hospitals are providing—will appear to be high. Hospitals certainly lose money on their ERs; after all, many of their customers pay nothing. But to argue that ERs are costly compared with other treatment options, hospitals need to claim expenses well beyond the marginal (or incremental) cost of serving ER patients.

« Reply #420 on: September 29, 2009, 07:25:55 PM »

In a recent IRS survey of almost 500 nonprofit hospitals, nearly 60 percent reported providing charity care equal to less than 5 percent of their total revenue, and about 20 percent reported providing less than 2 percent. Analyzing data from the American Hospital Directory, The Wall Street Journal found that the 50 largest nonprofit hospitals or hospital systems made a combined “net income” (that is, profit) of $4.27 billion in 2006, nearly eight times their profits five years earlier.

How do we know whether the value of hospitals’ charitable services compensates for the roughly 100,000 deaths from hospital-borne disease, their poor standards of customer service, and their extraordinary diseconomies of both scale and scope? Might we be better off reforming hospitals, and allowing many of them to be eliminated by competition from specialty clinics? As a society, couldn’t we just pay directly for the services required by the poor? We don’t know how many hospitals would even survive if they were not so favored under the law; anyone who has lost a loved one to a preventable hospital death will wonder how many should.

You Are Not the Customer
What amazed me most during five weeks in the ICU with my dad was the survival of paper and pen for medical instructions and histories. In that time, Dad was twice taken for surgical procedures intended for other patients (fortunately interrupted both times by our intervention). My dry cleaner uses a more elaborate system to track shirts than this hospital used to track treatment.

Not every hospital relies on paper-based orders and charts, but most still do. Why has adoption of clinical information technology been so slow? Companies invest in IT to reduce their costs, reduce mistakes (itself a form of cost-saving), and improve customer service. Better information technology would have improved my father’s experience in the ICU—and possibly his chances of survival.

But my father was not the customer; Medicare was. And although Medicare has experimented with new reimbursement approaches to drive better results, no centralized reimbursement system can be supple enough to address the many variables affecting the patient experience. Certainly, Medicare wasn’t paying for the quality of service during my dad’s hospital stay. And it wasn’t really paying for the quality of his care, either; indeed, because my dad got sepsis in the hospital, and had to spend weeks there before his death, the hospital was able to charge a lot more for his care than if it had successfully treated his pneumonia and sent him home in days.

Of course, one area of health-related IT has received substantial investment—billing. So much for the argument, often made, that privacy concerns or a lack of agreed-upon standards has prevented the development of clinical IT or electronic medical records; presumably, if lack of privacy or standards had hampered the digitization of health records, it also would have prevented the digitization of the accompanying bills. To meet the needs of the government bureaucracy and insurance companies, most providers now bill on standardized electronic forms. In case you wonder who a care provider’s real customer is, try reading one of these bills.

For that matter, try discussing prices with hospitals and other providers. Eight years ago, my wife needed an MRI, but we did not have health insurance. I called up several area hospitals, clinics, and doctors’ offices—all within about a one-mile radius—to find the best price. I was surprised to discover that prices quoted, for an identical service, varied widely, and that the lowest price was $1,200. But what was truly astonishing was that several providers refused to quote any price. Only if I came in and actually ordered the MRI could we discuss price.

Several years later, when we were preparing for the birth of our second child, I requested the total cost of the delivery and related procedures from our hospital. The answer: the hospital discussed price only with uninsured patients. What about my co-pay? They would discuss my potential co-pay only if I were applying for financial assistance.

Keeping prices opaque is one way medical institutions seek to avoid competition and thereby keep prices up. And they get away with it in part because so few consumers pay directly for their own care—insurers, Medicare, and Medicaid are basically the whole game. But without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will.

Here’s a wonderful example of price opacity. Advocates for the uninsured complain that hospitals charge uninsured patients, on average, 2.5 times the amount charged to insured patients. Hospitals defend themselves by contending that they earn from uninsured patients only 25 percent of the amount they do from insured ones. Both statements appear to be true!

How is this possible? Well, hospitals bill according to their price lists, but provide large discounts to major insurers. Individual consumers, of course, don’t benefit from these discounts, so they receive their bills at full list price (typically about 2.5 times the bill to an insured patient). Uninsured patients, however, pay according to how much of the bill the hospital believes they can afford (which, on average, amounts to 25 percent of the amount paid by an insured patient). Nonetheless, whatever discount a hospital gives to an uninsured patient is entirely at its discretion—and is typically negotiated only after the fact. Some uninsured patients have been driven into bankruptcy by hospital collections. American industry may offer no better example of pernicious “price discrimination,” nor one that entails greater financial vulnerability for American families.

It’s astonishingly difficult for consumers to find any health-care information that would enable them to make informed choices—based not just on price, but on quality of care or the rate of preventable medical errors. Here’s one place where legal requirements might help. But only a few states require institutions to make this sort of information public in a usable form for consumers. So while every city has numerous guidebooks with reviews of schools, restaurants, and spas, the public is frequently deprived of the necessary data to choose hospitals and other providers.

The Strange Beast of Health-Care Technology
One of the most widely held pieces of conventional wisdom about health care is that new technology is relentlessly driving up costs. Yet over the past 20 years, I’ve bought several generations of microwave ovens, personal computers, DVD players, GPS devices, mobile phones, and flat-screen TVs. I bank mostly at ATMs, check out my own goods at self-serve supermarket scanners, and attend company meetings by video conference. Technology has transformed much of our daily lives, in almost all cases by adding quantity, speed, and quality while lowering costs. So why is health care different?

Well, for the most part, it isn’t. Whether it’s new drugs to control previously untreatable conditions, diagnostic equipment that enhances physician productivity, or minimally invasive techniques that speed patient recovery, technology-driven innovation has been transforming care at least as greatly as it has transformed the rest of our lives.

But most health-care technologies don’t exist in the same world as other technologies. Recall the MRI my wife needed a few years ago: $1,200 for 20 minutes’ use of a then 20-year-old technology, requiring a little electricity and a little labor from a single technician and a radiologist. Why was the price so high? Most MRIs in this country are reimbursed by insurance or Medicare, and operate in the limited-competition, nontransparent world of insurance pricing. I don’t even know the price of many of the diagnostic services I’ve needed over the years—usually I’ve just gone to whatever provider my physician recommended, without asking (my personal contribution to the moral-hazard economy).

By contrast, consider LASIK surgery. I still lack the (small amount of) courage required to get LASIK. But I’ve been considering it since it was introduced commercially in the 1990s. The surgery is seldom covered by insurance, and exists in the competitive economy typical of most other industries. So people who get LASIK surgery—or for that matter most cosmetic surgeries, dental procedures, or other mostly uninsured treatments—act like consumers. If you do an Internet search today, you can find LASIK procedures quoted as low as $499 per eye—a decline of roughly 80 percent since the procedure was introduced. You’ll also find sites where doctors advertise their own higher-priced surgeries (which more typically cost about $2,000 per eye) and warn against the dangers of discount LASIK. Many ads specify the quality of equipment being used and the performance record of the doctor, in addition to price. In other words, there’s been an active, competitive market for LASIK surgery of the same sort we’re used to seeing for most goods and services.

The history of LASIK fits well with the pattern of all capital-intensive services outside the health-insurance economy. If you’re one of the first ophthalmologists in your community to perform the procedure, you can charge a high price. But once you’ve acquired the machine, the actual cost of performing a single procedure (the marginal cost) is relatively low. So, as additional ophthalmologists in the neighborhood invest in LASIK equipment, the first provider can meet new competition by cutting price. In a fully competitive marketplace, the procedure’s price will tend toward that low marginal cost, and ophthalmologists looking to buy new machines will exert downward pressure on both equipment and procedure prices.

No business likes to compete solely on price, so most technology providers seek to add features and performance improvements to new generations of a machine—anything to keep their product from becoming a pure commodity. Their success depends on whether the consumers will pay enough for the new feature to justify its introduction. In most consumer industries, we can see this dynamic in action—observe how DVD players have moved in a few years from a high-priced luxury to a disposable commodity available at discount stores. DVD players have run out of new features for which customers will pay premium prices.

Perhaps MRIs have too. After a long run of high and stable prices, you can now find ads for discount MRIs. But because of the peculiar way we pay for health care, this downward price pressure on technology seems less vigorous. How well can insurance companies and government agencies judge the value of new features that tech suppliers introduce to keep prices up? Rather than blaming technology for rising costs, we must ask if moral hazard and a lack of discipline in national health-care spending allows health-care companies to avoid the forces that make nonmedical technology so competitive.

In 2002, the U.S. had almost six times as many CT scanners per capita as Germany and four times as many MRI machines as the U.K. Traditional reformers believe it is this rate of investment that has pushed up prices, rather than sustained high prices that have pushed up investment. As a result, many states now require hospitals to obtain a Certificate of Need before making a major equipment purchase. In its own twisted way, this makes sense: moral hazard, driven by insurance, for years allowed providers to create enough demand to keep new MRI machines humming at any price.

But Certificates of Need are just another Scotch-tape reform, an effort to maintain the current system by treating a symptom rather than the underlying disease. Technology is driving up the cost of health care for the same reason every other factor of care is driving up the cost—the absence of the forces that discipline and even drive down prices in the rest of our economy. Only in the bizarre parallel universe of health care could limiting supply be seen as a sensible approach to keeping prices down.

The Limits of “Comprehensive” Health-care Reform
A wasteful insurance system; distorted incentives; a bias toward treatment; moral hazard; hidden costs and a lack of transparency; curbed competition; service to the wrong customer. These are the problems at the foundation of our health-care system, resulting in a slow rot and requiring more and more money just to keep the system from collapsing.

How would the health-care reform that’s now taking shape solve these core problems? The Obama administration and Congress are still working out the details, but it looks like this generation of “comprehensive” reform will not address the underlying issues, any more than previous efforts did. Instead it will put yet more patches on the walls of an edifice that is fundamentally unsound—and then build that edifice higher.

A central feature of the reform plan is the expansion of comprehensive health insurance to most of the 46 million Americans who now lack private or public insurance. Whether this would be achieved entirely through the extension of private commercial insurance at government-subsidized rates, or through the creation of a “public option,” perhaps modeled on Medicare, is still being debated.

Regardless, the administration has suggested a cost to taxpayers of $1 trillion to $1.5 trillion over 10 years. That, of course, will mean another $1 trillion or more not spent on other things—environment, education, nutrition, recreation. And if the history of previous attempts to expand the health safety net are any guide, that estimate will prove low.

The reform plan will also feature a variety of centrally administered initiatives designed to reduce costs and improve quality. These will likely include a major government investment to promote digitization of patient health records, an effort to collect information on best clinical practices, and changes in the way providers are paid, to better reward quality and deter wasteful spending.

All of these initiatives have some theoretical appeal. And within the confines of the current system, all may do some good. But for the most part, they simply do not address the root causes of poor quality and runaway costs.

Consider information technology, for instance. Of course the health system could benefit from better use of IT. The Rand Corporation has estimated that the widespread use of electronic medical records would eventually yield annual savings of $81 billion, while also improving care and reducing preventable deaths, and the White House estimates that creating and spreading the technology would cost just $50 billion. But in what other industry would an investment with such a massive annual return not be funded by the industry itself? (And while $50 billion may sound like a big investment, it’s only about 2 percent of the health-care industry’s annual revenues.)

Technology is effective only when it’s properly applied. Since most physicians and health-care companies haven’t adopted electronic medical records on their own, what makes us think they will appropriately use all this new IT? Most of the benefits of the technology (record portability, a reduction in costly and dangerous clinical errors) would likely accrue to patients, not providers. In a consumer-facing industry, this alone would drive companies to make the investments to stay competitive. But of course, we patients aren’t the real customers; government funding of electronic records wouldn’t change that.

I hope that whatever reform is finally enacted this fall works—preventing people from slipping through the cracks, raising the quality standard of the health-care industry, and delivering all this at acceptable cost. But looking at the big picture, I fear it won’t. So I think we should at least begin to debate and think about larger reforms, and a different direction—if not for this round of reform, then for the next one. Politics is, of course, the art of the possible. If our health-care crisis does not abate, the possibilities for reform may expand beyond their current, tight limits.

« Reply #421 on: September 29, 2009, 07:26:23 PM »

A Way Forward
The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.

A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance.

For years, a number of reformers have advocated a more “consumer-driven” care system—a term coined by the Harvard Business School professor Regina Herzlinger, who has written extensively on the subject. Many different steps could move us toward such a system. Here’s one approach that—although it may sound radical—makes sense to me.

First, we should replace our current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans—indeed, all Americans should be required to buy it—with fixed premiums based solely on age. This program would be best run as a single national pool, without underwriting for specific risk factors, and would ultimately replace Medicare, Medicaid, and private insurance. All Americans would be insured against catastrophic illness, throughout their lives.

Proposals for true catastrophic insurance usually founder on the definition of catastrophe. So much of the amount we now spend is dedicated to problems that are considered catastrophic, the argument goes, that a separate catastrophic system is pointless. A typical catastrophic insurance policy today might cover any expenses above, say, $2,000. That threshold is far too low; ultimately, a threshold of $50,000 or more would be better. (Chronic conditions with expected annual costs above some lower threshold would also be covered.) We might consider other mechanisms to keep total costs down: the plan could be required to pay out no more in any year than its available premiums, for instance, with premium increases limited to the general rate of inflation. But the real key would be to restrict the coverage to true catastrophes—if this approach is to work, only a minority of us should ever be beneficiaries.

How would we pay for most of our health care? The same way we pay for everything else—out of our income and savings. Medicare itself is, in a sense, a form of forced savings, as is commercial insurance. In place of these programs and the premiums we now contribute to them, and along with catastrophic insurance, the government should create a new form of health savings account—a vehicle that has existed, though in imperfect form, since 2003. Every American should be required to maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap in total dollar contributions. The income percentage required should rise over a working life, as wages and wealth typically do.

All noncatastrophic care should eventually be funded out of HSAs. But account-holders should be allowed to withdraw money for any purpose, without penalty, once the funds exceed a ceiling established for each age, and at death any remaining money should be disbursed through inheritance. Our current methods of health-care funding create a “use it or lose it” imperative. This new approach would ensure that families put aside funds for future expenses, but would not force them to spend the funds only on health care.

What about care that falls through the cracks—major expenses (an appendectomy, sports injury, or birth) that might exceed the current balance of someone’s HSA but are not catastrophic? These should be funded the same way we pay for most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs; the government could lend directly, or provide guidelines for private lending. Catastrophic coverage should apply with no deductible for young people, but as people age and save, they should pay a steadily increasing deductible from their HSA, unless the HSA has been exhausted. As a result, much end-of-life care would be paid through savings.

Anyone with whom I discuss this approach has the same question: How am I supposed to be able to afford health care in this system? Well, what if I gave you $1.77 million? Recall, that’s how much an insured 22-year-old at my company could expect to pay—and to have paid on his and his family’s behalf—over his lifetime, assuming health-care costs are tamed. Sure, most of that money doesn’t pass through your hands now. It’s hidden in company payments for premiums, or in Medicare taxes and premiums. But think about it: If you had access to those funds over your lifetime, wouldn’t you be able to afford your own care? And wouldn’t you consume health care differently if you and your family didn’t have to spend that money only on care?

For lower-income Americans who can’t fund all of their catastrophic premiums or minimum HSA contributions, the government should fill the gap—in some cases, providing all the funding. You don’t think we spend an absurd amount of money on health care? If we abolished Medicaid, we could spend the same money to make a roughly $3,000 HSA contribution and a $2,000 catastrophic-premium payment for 60 million Americans every year. That’s a $12,000 annual HSA plus catastrophic coverage for a low-income family of four. Do we really believe most of them wouldn’t be better off?

Some experts worry that requiring people to pay directly for routine care would cause some to put off regular checkups. So here’s a solution: the government could provide vouchers to all Americans for a free checkup every two years. If everyone participated, the annual cost would be about $30 billion—a small fraction of the government’s current spending on care.

Today, insurance covers almost all health-care expenditures. The few consumers who pay from their pockets are simply an afterthought for most providers. Imagine how things might change if more people were buying their health care the way they buy anything else. I’m certain that all the obfuscation over prices would vanish pretty quickly, and that we’d see an end to unreadable bills. And that physicians, who spend an enormous amount of time on insurance-related paperwork, would have more time for patients.

In fact, as a result of our fraying insurance system, you can already see some nascent features of a consumer-centered system. Since 2006, Wal-Mart has offered $4 prescriptions for a month’s supply of common generic medications. It has also been slowly rolling out retail clinics for routine care such as physicals, blood work, and treatment for common ailments like strep throat. Prices for each service are easily obtained; most are in the neighborhood of $50 to $80. Likewise, “concierge care,” or the “boutique” style of medical practice—in which physicians provide unlimited services and fast appointments in return for a fixed monthly or annual fee—is beginning to spread from the rich to the middle class. Qliance Medical Group, for instance, now operates clinics serving some 3,000 patients in the Seattle and Tacoma, Washington, areas, charging $49 to $79 a month for unlimited primary care, defined expansively.

It’s worth pausing over this last example. Many experts believe that the U.S. would get better health outcomes at lower cost if payment to providers were structured around the management of health or whole episodes of care, instead of through piecemeal fees. Medicare and private insurers have, to various degrees, moved toward (or at least experimented with) these sorts of payments, and are continuing to do so—but slowly, haltingly, and in the face of much obstruction by providers. But aren’t we likely to see just these sorts of payment mechanisms develop organically in a consumer-centered health-care system? For simplicity and predictability, many people will prefer to pay a fixed monthly or annual fee for primary or chronic care, and providers will move to serve that demand.

Likewise, what patient, when considering getting an artificial hip, would want to deal with a confusion of multiple bills from physicians, facilities, and physical therapists? Aren’t providers likely to organize themselves to provide a single price to the consumer for care and rehabilitation? And won’t that, in itself, put pressure on providers to work together as efficiently as possible, and to minimize the medical errors that would eat into their joint fee? I suspect we would see a rapid decline in the predominance of the fee-for-service model, making way for real innovation and choice in service plans and funding. And the payment system would not be set by fiat; it would remain responsive to treatment breakthroughs and changes in consumer demand.

Many consumers would be able to make many decisions, unaided, in such a system. But we’d also probably see the rise of health-care agents—paid by, and responsible to, the consumer—to help choose providers and to act as advocates during long and complex care episodes.

How else might the system change? Technological innovation—which is now almost completely insensitive to costs, and which often takes the form of slightly improved treatments for much higher prices—would begin to concern itself with value, not just quality. Many innovations might drive prices down, not up. Convenient, lower-cost specialty centers might proliferate. The need for unpaid indigent care would go away—everyone, recall, would have both catastrophic insurance and an HSA, funded entirely by the government when necessary—and with it much of the rationale for protecting hospitals against competition.

Of course, none of this would happen overnight. And the government has an essential role to play in arming consumers with good information. Congress should require maximum transparency on services, prices, and results (and some elements of the Obama administration’s reform plan would move the industry in this direction). We should establish a more comprehensive system of quality inspection of all providers, and publish all the findings. Safety and efficacy must remain the cornerstone of government licensing, but regulatory bias should favor competition and prevent incumbents from using red tape to forestall competition.

Moving from the system we’ve got now to the one I’ve outlined would be complicated, and would take a long time. Most of us have been paying into an insurance system for years, expecting that our future health-care bills would be paid; we haven’t been saving separately for these expenses. It would take a full generation to completely migrate from relying on Medicare to saving for late-life care; from Medicaid for the disadvantaged to catastrophic insurance and subsidized savings accounts. Such a transition would require the slow reduction of Medicare taxes, premiums, and benefit levels for those not yet eligible, and a corresponding slow ramp-up in HSAs. And the national catastrophic plan would need to start with much broader coverage and higher premiums than the ultimate goal, in order to fund the care needed today by our aging population. Nonetheless, the benefits of a consumer-centered approach—lower costs for better service—should have early and large dividends for all of us throughout the period of transition. The earlier we start, the less a transition will ultimately cost.

Many experts oppose the whole concept of a greater role for consumers in our health-care system. They worry that patients lack the necessary knowledge to be good consumers, that unscrupulous providers will take advantage of them, that they will overspend on low-benefit treatments and under-spend on high-benefit preventive care, and that such waste will leave some patients unable to afford highly beneficial care.

They are right, of course. Whatever replaces our current system will be flawed; that’s the nature of health care and, indeed, of all human institutions. Our current system features all of these problems already—as does the one the Obama reforms would create. Because health care is so complex and because each individual has a unique health profile, no system can be perfect.

I believe my proposed approach passes two meaningful tests. It will do a better job than our current system of controlling prices, allocating resources, expanding access, and safeguarding quality. And it will do a better job than a more government-driven approach of harnessing medicine’s dynamism to develop and spread the new knowledge, technologies, and techniques that improve the quality of life. We won’t be perfect consumers, but we’re more likely than large bureaucracies to encourage better medicine over time.

All of the health-care interest groups—hospitals, insurance companies, professional groups, pharmaceuticals, device manufacturers, even advocates for the poor—have a major stake in the current system. Overturning it would favor only the 300 million of us who use the system and—whether we realize it or not—pay for it. Until we start asking the type of questions my father’s death inspired me to ask, until we demand the same price and quality accountability in health care that we demand in everything else, each new health-care reform will cost us more and serve us less.

Ten days after my father’s death, the hospital sent my mother a copy of the bill for his five-week stay: $636,687.75. He was charged $11,590 per night for his ICU room; $7,407 per night for a semiprivate room before he was moved to the ICU; $145,432 for drugs; $41,696 for respiratory services. Even the most casual effort to compare these prices to marginal costs or to the costs of off-the-shelf components demonstrates the absurdity of these numbers, but why should my mother care? Her share of the bill was only $992; the balance, undoubtedly at some huge discount, was paid by Medicare.

Wasn’t this an extraordinary benefit, a windfall return on American citizenship? Or at least some small relief for a distraught widow?

Not really. You can feel grateful for the protection currently offered by Medicare (or by private insurance) only if you don’t realize how much you truly spend to fund this system over your lifetime, and if you believe you’re getting good care in return.

Would our health-care system be so outrageously expensive if each American family directly spent even half of that $1.77 million that it will contribute to health insurance and Medicare over a lifetime, instead of entrusting care to massive government and private intermediaries? Like its predecessors, the Obama administration treats additional government funding as a solution to unaffordable health care, rather than its cause. The current reform will likely expand our government’s already massive role in health-care decision-making—all just to continue the illusion that someone else is paying for our care.

But let’s forget about money for a moment. Aren’t we also likely to get worse care in any system where providers are more accountable to insurance companies and government agencies than to us?

Before we further remove ourselves as direct consumers of health care—with all of our beneficial influence on quality, service, and price—let me ask you to consider one more question. Imagine my father’s hospital had to present the bill for his “care” not to a government bureaucracy, but to my grieving mother. Do you really believe that the hospital—forced to face the victim of its poor-quality service, forced to collect the bill from the real customer—wouldn’t have figured out how to make its doctors wash their hands?

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« Reply #422 on: October 01, 2009, 12:02:59 PM »

Its the NYT, so caveat lector.  That said, this seems interesting.

Swiss Health Care Thrives Without Public Option

Published: September 30, 2009
ZURICH — Like every other country in Europe, Switzerland guarantees health care for all its citizens. But the system here does not remotely resemble the model of bureaucratic, socialized medicine often cited by opponents of universal coverage in the United States.

Swiss private insurers are required to offer coverage to all citizens, regardless of age or medical history. And those people, in turn, are obligated to buy health insurance.

That is why many academics who have studied the Swiss health care system have pointed to this Alpine nation of about 7.5 million as a model that delivers much of what Washington is aiming to accomplish — without the contentious option of a government-run health insurance plan.

In Congress, the Senate Finance Committee is dealing with legislation proposed by its chairman, Max Baucus, Democrat of Montana, which would require nearly all Americans to buy health insurance, but stops short of the government-run insurance option that is still strongly supported by liberal Democrats.

Two amendments that would have added a public option to the Baucus bill were voted down on Tuesday. But another Senate bill, like the House versions, calls for a public insurance option.

By many measures, the Swiss are healthier than Americans, and surveys indicate that Swiss people are generally happy with their system. Switzerland, moreover, provides high-quality care at costs well below what the United States spends per person. Swiss insurance companies offer the mandatory basic plan on a not-for-profit basis, although they are permitted to earn a profit on supplemental plans.

And yet, as a potential model for the United States, the Swiss health care system involves some important trade-offs that American consumers, insurers and health care providers might find hard to swallow.

The Swiss government does not “ration care” — that populist bogeyman in the American debate — but it does keep down overall spending by regulating drug prices and fees for lab tests and medical devices. It also requires patients to share some costs — at a higher level than in the United States — so they have an incentive to avoid unnecessary treatments. And some doctors grumble that cost controls are making it harder these days for a physician to make a franc.

The Swiss government also provides direct cash subsidies to people if health insurance equals more than 8 percent of personal income, and about 35 to 40 percent of households get some form of subsidy. In some cases, employers contribute part of the insurance premium, but, unlike in the United States, they do not receive a tax break for it. (All the health care proposals in Congress would provide a subsidy to moderate-income Americans.)

Unlike the United States, where the Medicare program for the elderly costs taxpayers about $500 billion a year, Switzerland has no special break for older Swiss people beyond the general subsidy.

“Switzerland’s health care system is different from virtually every other country in the world,” said Regina Herzlinger, a Harvard Business School professor who has studied the Swiss approach extensively.

“What I like about it is that it’s got universal coverage, it’s customer driven, and there are no intermediaries shopping on people’s behalf,” she added. “And there’s no waiting lists or rationing.”

Since being made mandatory in 1996, the Swiss system has become a popular model for experts seeking alternatives to government-run health care. Indeed, it has attracted some unlikely American admirers, like Bill O’Reilly, the Fox News talk show host. And it has lured some members of Congress on fact-finding trips here to seek ideas for overhauling the United States system.

The Swiss approach is also popular with patients like Frieda Burgstaller, 72, who says she likes the freedom of choice and access that the private system provides. “If the doctor says it has to be done, it’s done,” said Mrs. Burgstaller. “You don’t wait. And it’s covered.”

While many patients seem content, the burdens fall more heavily on doctors, especially general practitioners and pediatricians.

Dr. Gerlinde Schurter, Mrs. Burgstaller’s physician, says she feels squeezed by government regulators and insurance companies that have fought to hold down costs — most recently with a 15 percent cut in lab fees that forced her five-member group to lay off its principal technician.

Dr. Schurter also fears a so-called blue letter, a warning from an insurance company that she is prescribing too many drugs or expensive procedures.

If doctors cannot justify their treatments, they can be forced to repay insurers for a portion of the medical services prescribed. And while prescriptions are covered, the government has insisted that consumers fork over a 20 percent co-payment if they want brand-name drugs, rather than 10 percent for generics.

Similarly, the government health office also lowered reimbursements across the board for medical devices in 2006.

These are among the reasons health care costs consume 10.8 percent of gross domestic product in Switzerland, compared with 16 percent in the United States, the highest level of spending among industrial countries, according to the Organization for Economic Cooperation and Development.


Page 2 of 2)

Still, along with lower costs and the freedom to choose doctors come bigger bills for individual patients. On average, out-of-pocket payments come to $1,350 annually. That is the highest among the 30 countries tracked by the O.E.C.D. and well above the $890 average for the United States, which comes in second.

Then there are the hefty prices of the insurance policies themselves, which can top 14,000 Swiss francs a year for a family of four in Zurich, or about $13,600. That is roughly comparable to the national average annual premium for a family policy under employer-sponsored group plans in the United States, but in high-cost American cities the figure can be much higher.
Direct comparisons are hard to make, however, because in the American system, employers and employees share the cost of premiums, which are also exempt from individual and corporate income taxes.

Nevertheless, Swiss citizens relish the lack of bureaucracy, especially compared with systems in Britain and Germany, even if their doctors grumble.

As in the United States, practitioners typically are paid on a fee-for-service basis, rather than on salary. But they make less than their American counterparts. According to the O.E.C.D., specialists in Switzerland earn three times more than the nation’s average wage, compared with 5.6 times for American specialists. General practitioners in Switzerland make 2.7 times more than the average wage, versus 3.7 in the United States.

That is partly because the Swiss health insurers are not shy about using their muscle with physicians.

Pius Gyger, director of health economics and health policy at Helsana, the country’s biggest insurer, cannot suppress a smile when asked about the effectiveness of the so-called blue letters.

“If there’s something strange, we knock at the doctor’s door,” he said. “For doctors, it’s an incentive to treat economically, but often perceived as a threat.”

He estimates that only about 3 percent of doctors get the letters and that fewer than 1 percent actually have to return money. Still, Mr. Gyger said, “it’s an easy exercise for us and it has an effect.”

Despite pressure on general practitioners, hospital physicians like Edouard Battegay at the University of Zurich say universal coverage also lowers costs by reducing emergency room visits.

Indeed, his E.R. is as quiet and efficient as a Swiss watch, and he still expresses amazement at what he saw when he worked briefly in Seattle.

“I’ve seen things in the U.S. that I’ve never seen here; it was a state of disaster,” he said. “Chronic disease management is better here. If you don’t treat hypertension, you treat strokes. Not treating patients is expensive.”

And even Dr. Schurter — who says her income has been flat for the last five years — praises the virtues of the Swiss system for patients struck by catastrophe.

When her daughter was found to have leukemia seven years ago, “I never worried for a second how and if she’d get treatment and if it would be paid for,” she said. “All was granted as naturally as the air we breathe.”
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« Reply #423 on: October 01, 2009, 08:20:19 PM »

Controlling health care by targeting the costliest.  That conclusion is the easy part.  Now for the hard part.  Actually doing it.  Keep people out of the hospital have nurses become an extended family member and of course all the while improve the "quality" of care.

Controlling Expenditures by Improving Care for Patients Needing Costly Services
Posted by NEJM • September 30th, 2009 •

Thomas Bodenheimer, M.D., M.P.H., and Rachel Berry-Millett, B.A.

In the United States today, 10% of patients account for 70% of total health care expenditures. Many patients who require high-cost care are people with multiple chronic conditions, many medications, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental, or psychosocial challenges. Some well-researched programs have been shown to reduce costs for these patients with complex health care needs, but major payment reform would be needed to spread these programs throughout the United States. 

In 2002, Medicare beneficiaries with five or more chronic conditions accounted for 76% of Medicare expenditures. Health care spending for people with five or more chronic conditions is 17 times as high as that for people with no chronic conditions (see graph).1 Because Medicare expenditures will soon become unsustainable, we urgently need to find a way to reduce the cost of care for this rapidly growing group.

As we found when we reviewed the evidence for a forthcoming report from the Robert Wood Johnson Foundation Synthesis Project (, care management may be a health care delivery innovation that can reduce costs while enhancing quality for people with complex health care needs. Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services. Care management is generally provided by a registered-nurse care manager, often working with a multidisciplinary team.

The specific activities of such care managers include assessing the risks and needs of each patient; working with the patient, his or her family, and the primary care physician to prepare a care plan; teaching patients and their families about their diseases and medications; coaching patients and families on how to respond to worsening symptoms in order to avoid emergency department visits and hospital admissions; tracking patients’ status over time; and revising care plans as needed.

Because care management is an intensive and expensive service, it should be targeted to people with complex health care needs who are at high risk for requiring costly care, but not to patients who are too sick to benefit. A number of predictive models have been introduced to risk-stratify populations of patients to identify those who are most likely to benefit from care management. Models that incorporate diagnostic and medication information are better at predicting future costs than models limited to measuring past costs.

Many controlled studies of care management targeting the transition from hospital to home have demonstrated that this approach results in substantial reductions in hospital utilization and costs. In one study, there was a 38% reduction in total costs during a 12-month period, as compared with usual care. Advanced practice nurses, who underwent 2 months of care-management training, made daily in-hospital visits and at least three home visits, and then followed up through telephone encounters.2 In a different type of intervention, nurses were trained as “transition coaches” and then helped patients and their families to actively participate in their care. After only five contacts between the coaches and patients or their families, the rate of rehospitalization and associated hospital costs were significantly reduced.3 In-hospital discharge planning alone does not reduce hospital costs; the success of these two interventions in reducing readmissions depends on the employment of well-trained care managers and the extension of care management into the home.

Care management that is provided in a primary care setting, if carefully implemented, can also reduce hospital use and cut health care costs. Two models currently under study — Care Management Plus and Guided Care — feature well-trained nurse care managers working closely with primary care physicians. The Care Management Plus intervention resulted in a significant reduction in hospital use by the subgroup of patients with multiple diagnoses. During the first 8 months of a 32-month, multisite, randomized, controlled trial, Guided Care reduced the number of hospital days by 24% and insurers’ net health care costs by 11% for the intervention group, though the differences were not statistically significant; final results have not yet been published.4 A third model that was the subject of a positive study, Geriatric Resources for Assessment and Care of Elders (GRACE), involved the use of a team consisting of a nurse practitioner and a social worker who worked closely with primary care physicians and a geriatrician. The higher-risk intervention subgroup had a significantly lower hospitalization rate than the higher-risk patients who received usual care. Each of these programs has placed substantial emphasis on training the care managers, keeping care managers’ patient panels reasonably small, fostering a close relationship between care managers and primary care physicians, and including interactions between care managers and patients in medical settings and at home. Telephonic care management has been effective when combined with face-to-face visits but has not worked by itself.5

Several organizations have launched innovative care-management programs for patients with complex health care needs. Such programs have appeared to reduce costs but have not yet been fully evaluated. Kaiser Permanente, recognizing that traditional primary care may lack the resources to offer high-intensity care management to its highest-risk patients, is creating high-risk clinics. In Kaiser’s Ohio region, the 1% of patients who were identified by predictive models as accounting for 27% of Kaiser’s total costs were referred to a high-risk clinic in which a geriatrician-led multidisciplinary team provided home care for a small panel of 150 patients. As compared with similar patients receiving usual care, high-risk clinic patients had fewer hospitalizations, fewer emergency department visits, and lower hospital expenses; since the numbers have been small, the changes have not yet reached statistical significance.

Capital Health Plan in Florida opened a high-risk clinic, staffed by a geriatrician and two registered nurses, for the 1% of the health plan’s enrollees who account for 25% of its total expenditures. The team can manage the care of 300 patients. Hospital admissions, emergency department visits, and total costs were substantially lower for the patients in the high-risk clinic than for those receiving traditional primary care.

The Veterans Health Administration, SCAN Health Plan in Southern California, PeaceHealth Oregon Region, and a number of projects in the Program of All-Inclusive Care for the Elderly (PACE) have also invested in intensive primary care that is focused on patients with complex health care needs, with the aim of providing better care at a lower total cost through reductions in the use of hospitals and emergency departments.

Care management, with its cost-reducing potential, will not spread widely in the health care system without substantial changes in payment policy. If hospitals profit from unnecessary readmissions, they are unlikely to adopt effective hospital-to-home care-management programs. If primary care practices are not reimbursed for the work of a registered-nurse care manager, they will not hire one unless they share in the savings generated by reducing hospital admissions and emergency department visits. Other obstacles include nursing shortages and the paucity of training programs for nurses to become effective care managers.

The evidence is strong that well-designed care management can substantially reduce costs for patients with complex health care needs. Cost-control measures, particularly in Medicare, must be targeted to the group of patients who account for the great majority of health care expenditures. Investment in care management should become a focus of the cost-containment discussion that is now dominating the debate over health care reform.

No potential conflict of interest relevant to this article was reported.

Source Information

From the Center for Excellence in Primary Care in the Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, San Francisco.

This article (10.1056/NEJMp0907185) was published on September 30, 2009, at

Anderson G. Chronic conditions: making the case for ongoing care. Baltimore: Johns Hopkins University, November 2007. (Accessed September 11, 2009, at
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 2004;52:675-684. [CrossRef][Web of Science][Medline]
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006;166:1822-1828. [Free Full Text]
Leff B, Reider L, Frick KD, et al. Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care 2009;15:555-559. [Medline]
Bodenheimer T, Berry-Millett R. Care management of patients with complex healthcare needs. Princeton, NJ: Rober
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« Reply #424 on: October 02, 2009, 08:31:46 AM »


As health reform legislation hurtles toward its finale, corporate America has rushed to the barricades to make sure that big business remains at the heart of the welfare state. The Business Roundtable, the Chamber of Commerce and the National Association of Manufacturers are united in their belief that Sen. Ron Wyden's (D., Ore.) "free choice amendment" must be stopped.

Mr. Wyden's measure, which is being offered as an amendment to the Baucus bill in the Senate Finance Committee, would come into play if employers failed to offer their workers meaningful choice of affordable plans. In that case, employees would be allowed to turn the cash employers currently spend on their health benefits into vouchers with which they could buy coverage from newly created insurance exchanges.

Big business thinks that giving employees this choice would be a calamity. To which one can only ask: Have these business lobbies lost their minds?

When the post-mortems on the health-care reform debate are written, the biggest mystery will be why big business fought so hard to stay in the health-care business even as soaring health costs surpassed corporate profits and diverted executive time better devoted to actually running companies.

America's employer-based health-care system may have made sense 50 years ago, when care was cheap, U.S. business faced little global competition, and fending off socialism was a Cold War priority. Circumstances have changed radically since that time. Yet corporate America—egged on by human resources executives threatened by change—remains caught in a time warp.

It's bad enough that business didn't do the smart thing up front and urge President Barack Obama to move the nation beyond employer-based care. That was major lost opportunity No. 1.

But on what possible theory does big business now assert that the 175 million Americans who get coverage on the job deserve no new choices? Most firms offer just one insurance plan, or narrow set of plans, to their workers. Why shouldn't these Americans also benefit from the myriad options that will become available from newly established competitive insurance exchanges?

The language used in a letter sent Tuesday to the Senate Finance Committee from something called the "National Coalition on Benefits"—a body controlled by corporate HR execs—reveals the confusion and paternalism still permeating the executive suite when it comes to the employer's role.

Mr. Wyden's proposal, the coalition asserts, would "fundamentally frustrate employers' attempts to administer integrated health improvement strategies." As a factual matter, this is incorrect. But why should "health improvement strategies" be the job of American businesses? Sounds more like a job for American doctors, in conjunction with their patients.

The status quo crowd also writes that Mr. Wyden's measure "would likely harm employer-employee relations because most employees have a longstanding expectation that their employer will be their primary source for health coverage." But employees already chafe at the shrinking coverage now available on the job. And who wouldn't want more options?

It's clear to anyone who looks that the edifice of employer-based coverage is crumbling. A recent survey sponsored by the Committee for Economic Development, a business-led think tank, showed that 62% of senior executives think the system is unsustainable. While the under-65 population has grown by 25 million since 1999, the number of people who get health care from their employers has declined. Numerous CEOs have told me privately that they'd just as soon get out of the benefits business altogether, which makes one wonder who the National Benefits Coalition really represents.

Mr. Wyden's measure would strike a modest but meaningful blow for modernity by making it possible, for the first time, for American workers to access group coverage outside their jobs. Once the infrastructure of these insurance exchanges is established, more firms will offer more people more choices over time. If business is smart, it will then strike a grand bargain in which government picks up the costs of the health-care voucher in exchange for business lending its support to the modest consumption tax needed to replace the corporate money being withdrawn from the system.

If this plays out as it should, the result will not be the single-payer system of Britain or Canada, but an American version of the Swiss or Dutch model of universal coverage in which private insurers and providers organize and deliver care. A decade or so from now, finally freed from this antiquated health-care system, everyone in corporate America should be happy.

Except for HR executives at big companies, who will have surrendered the commanding heights of the welfare state. So here's a thought, Sen. Wyden: Sweeten your amendment with a generous buyout plan for HR chiefs at the Fortune 500. And watch opposition to more freedom and choice for millions of Americans melt away.

Mr. Miller, a management consultant, is the author of "The Tyranny of Dead Ideas: Letting Go of The Old Ways of Thinking To Unleash a New Prosperity," (Times Books, 2009).
« Reply #425 on: October 03, 2009, 09:48:00 AM »

Making the World Safe for Medicaid Fraud
Democrats don't believe in identity fraud.

Americans expect to show a photo ID when they board a plane, enter many office buildings, cash a check or even rent a video -- but rarely in voting or applying for government benefits such as Medicaid. Many Democrats seem to view asking citizens for proof of identity as an invasion of privacy -- though what's really being protected is the right to commit identity fraud.

Exhibit A is Tuesday's 13 to 10 party-line vote in the Senate Finance Committee rejecting a proposal to require that immigrants prove their identity when signing up for federal health care programs. Chuck Grassley, the ranking Republican on the committee, said current procedures make it easy for illegal immigrants to use false or stolen identities to get benefits. But he ran into a buzz saw of opposition. Democratic Sen. Jeff Bingaman of New Mexico insisted such fraud was too rare to be worth worrying about: "The way I see the amendment, it's a solution without a problem."

Mr. Grassley admits to being "very perplexed as to why anyone would oppose this amendment." So does Senator Tom Coburn, one of the only two physicians in the Senate. He cites studies suggesting that fraud will cost Medicare and Medicaid about $100 billion this year. Harvard's Dr. Malcolm Sparrow, author of the book "License to Steal," estimates that the losses could easily be higher -- as much 20% or 30% of the trillion-plus dollars of spending represented by Medicaid and Medicare.

You'd think Senate Democrats would be interested in finding out just who is committing that fraud. But Tuesday's vote puts them firmly in the "see no evil, hear no evil, speak no evil" camp when it comes to the misuse of taxpayer dollars.
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« Reply #426 on: October 05, 2009, 07:33:25 AM »

We aren't among the doctors invited to a Rose Garden event today to "join the President in pushing for health insurance reform this year and [who] have offered their help and support," as a White House press release put it. It's unfortunate only supporters of the president's plans will be there. Mr. Obama has missed an opportunity to learn more about the real issues facing patients and doctors and to formulate a plan that truly puts patients in control with doctors as trusted advisers.

The United States has the best health care in the world today, and thanks to the ever-expanding frontiers of science and medical innovation the brightest days are ahead. It is true that there are Americans who fall through the cracks of our medical system every day—and as a caring nation, we must do what we can to expand access to medical care to those who need it. But this can be accomplished without a costly and inefficient government overhaul of the entire system. One easy reform would be to enable individuals to buy policies offered in any state, not just where they live. This will enhance competition. But more government-run health insurance will only lead to disaster.

Government cost-cutting would threaten medical innovation.

.Today, Medicare already reimburses doctors less than what many of their treatments cost to provide. Now the government is saying that additional Medicare cuts are coming—thus forcing doctors to try and make up the difference in volume, by seeing more patients. If you ask patients about this, they understand that more volume means less time with the doctor. That's something that all patients and doctors should oppose. In time, it will be difficult to find a physician.

If the goal of reform is to provide the best possible patient care, let's take the government-controlled "public option"—and any legislative trick that could lead to a public option—off the table. It will result in long waiting lines to see a doctor, substandard care, and an end to medical discovery.

There are many other ways to expand access to health care for uninsured Americans. We could strengthen incentives to purchase low-cost health savings accounts, provide tax credits for individuals and families buying health policies on their own, and extend subsidies for those who need financial help. Also, the right of patients to privately contract with physicians to ensure they have the medical care they want, without penalty—regardless of what the government pays—must be recognized and protected. Today, if a doctor wants to bill a patient for additional payment over the Medicare reimbursement, he has to withdraw from Medicare entirely for two years. A patient who agrees with this arrangement can't receive any Medicare money for that service, either.

We need to maintain a plentiful supply of medical expertise. But cuts in payments and bureaucracy could mean fewer individuals entering the medical field—and a dearth of health-care professionals down the road as specialists retire early or limit their practice. Every patient wants to be taken care of by the best medical professional possible. A patient with cancer wants to see a doctor who has had years of training in oncology and is knowledgeable about the latest ways to beat the cancer. But in some provisions in the proposed legislation (such as the medical home model of HR 3200), physician assistants and nurse practitioners may get the authority to make important medical decisions.

The federal government should also continue its investment in medical research through agencies like the National Institutes of Health, and it should better reward innovative discovery in the private sector with tax incentives and patent protection. Americans are living longer, healthier lives thanks to the trillions of dollars in public and private research investment in medical devices, pharmaceuticals, and advanced surgical techniques. We must not put future progress in jeopardy.

Finally, the nation needs comprehensive medical malpractice reform. It is the surest and quickest way to slow down the rising cost of health care. Statistics from private insurers, as well as a Justice Department report of 2007, indicate that upwards of 80% of malpractice cases are closed without payment—and when there is a trial, the physician-defendant wins 89% of the time. Yet these lawsuits, even when dismissed or closed without payment, cost doctors time and money, and encourage defensive medicine. This adds billions to the cost of medical care. It also increases malpractice insurance premiums, the costs of which get passed on to patients. In too many cases, the malpractice environment forces doctors to leave communities, depriving patients of their trusted medical advisers or specialists whom they might need in an accident or other crisis.

The drive to reform health care has led to an acrimonious and often divisive debate. Yet we still believe that doctors, patients and legislators working together with goodwill can improve the medical system and extend its benefits to all Americans.

Dr. Palmisano, president of the American Medical Association from 2003-2004, is spokesman for the Coalition to Protect Patients' Rights, a group of more than 10,000 physicians. Drs. Plested and Johnson were presidents of the American Medical Association from 2006-2007 and 1996-1997 respectively.
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« Reply #427 on: October 05, 2009, 11:53:07 AM »

"Today, Medicare already reimburses doctors less than what many of their treatments cost to provide. Now the government is saying that additional Medicare cuts are coming—thus forcing doctors to try and make up the difference in volume, by seeing more patients. If you ask patients about this, they understand that more volume means less time with the doctor. That's something that all patients and doctors should oppose. In time, it will be difficult to find a physician."

Well the left has answers for this too.  It is called bundling payments for outcomes and better quality care.
There is some merit to this concept yet it is also a veiled way of pushing through a form of rationed care.

Salaries for all doctors is also discussed.  This way there is less incentive to see more and more and do more and more.

Yet I have no illusions.  We will have capped salaries and still be asked to do more for less.  No one is kidding me.

Why don't we discuss other fields salaries and driving up costs to all of us.

Thanks to baseball players and owners take people who go to a ballgame have to pay 6 bucks for a  lousy hotdog.
What does it cost in NY to see a game?   Go with two kids and we are talking what a 100 bucks?

How about accountant fees?

How about the fees realtors use?  They should make less no?  It would help the ailing real estate market.

Do I even need to mention lawyer fees?  Why is the best legal care cost several hundred dollars per hour?

Is that fair?

Why do people have to pay several dollars to cross a lousy bridge from NJ to NY?

Is that fair?  It is nuts, no?

Why are politicians getting any more than life support pay?  They can all make a bundle any time they want with books, lecture tours, lobbying, peddling their influence.

Do I even need to bring up bankers, and financiers?

It is fair for me to make less but ok for people in this country who employ illegals, knowingly for slave wages and make money off their sweat and pass the benefits they receive to every other single tax payer?

What would be damn hard about going after employers who hire illegals?  They know they are doing it.  Cut off the jobs and illegals would stop coming here.

OK lets talk about fairness.

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« Reply #428 on: October 05, 2009, 02:26:40 PM »

Doctors are not a single block anymore than any other group.  Some will love Obama some will not.
There is something absurd about him surrounding himself with all these guys with white coats.
It is reminicent of both Reb and Dem presidents surrounding themselves with soldiers for photo ops.

How bizzare - a bunch of live doctor props.

****Surrounded by doctors, Obama pitches overhaul
         Barack Obama  AP – Doctors, wearing lab coats, who were audience members, take photos in the Rose Garden of the White House …
 Slideshow:President Barack Obama By CHARLES BABINGTON, Associated Press Writer Charles Babington, Associated Press Writer – 1 hr 30 mins ago
WASHINGTON – On the cusp of a key legislative push, President Barack Obama on Monday filled the Rose Garden with doctors supportive of his health care overhaul, saying "nobody has more credibility with the American people on this issue than you do."

Obama's White House event gave him another chance to frame the debate on his terms as his top domestic priority enters its most critical phase.

The Senate Finance Committee is expected to approve its long-debated, intensely scrutinized bill this week. Then, Senate Democratic leaders will meld it with a more liberal-leaning version passed by the Senate Health, Education, Labor and Pensions Committee. The House also must combine differing versions of its own bills.

For a visual plug from some medical pros, the White House arranged for Obama to have some 150 doctors representing all 50 states arrayed in the sunsplashed lawn area just outside the West Wing. To make sure no one watching at home or catching news footage later would miss the point, the physicians wore their white medical coats for the cameras.

"When you cut through all the noise and all the distractions that are out there, I think what's most telling is that some of the people who are most supportive of reform are the very medical professionals who know the health care system best," said Obama, flanked by four doctors on stage for good measure.

But Sen. John Barrasso, R-Wyo., an orthopedic surgeon for 25 years, said many doctors, nurses and patients strongly oppose Obama's proposals.

They are greatly alarmed at proposed cuts in Medicare, which is the main source of health care for many people in Wyoming and elsewhere, Barrasso said in an interview Monday. He said doctors and hospitals also want provisions to protect them against "abusive lawsuits" by people claiming malpractice.

Obama broke no ground in his comments. He outlined the tenets of his health reform plan: expanded and affordable health coverage options for tens of millions of people, strengthened protections for those who already have insurance, and more time for health professionals to help patients with preventative and healing care.

Obama said the country has heard all sides of the debate over the last few months and the time to act is now.

"I want to thank every single doctor who is here," Obama said. "And I especially want to thank you for agreeing to fan out across the country and make the case about why this reform effort is so desperately needed. You are the people who know this system best. You are the experts."****

« Reply #429 on: October 08, 2009, 03:28:41 PM »

Baucus Bill Would Cost More than $2 Trillion

Posted by Michael F. Cannon

Sen. Max Baucus’s (D-MT) health care overhaul would cost more than $2 trillion.  It would expand the deficit.  But he has carefully and methodically hidden those facts – so well that he has completely hoodwinked nearly all the major media.

The media are reporting that the Baucus bill would reduce the deficit by $81 billion over 10 years.  Wrong.

The Baucus bill assumes that Congress will allow the “sustainable growth rate” cuts in Medicare’s physician payments to occur beginning in 2012.  Yet Congress has routinely and repeatedly blocked those cuts, making Baucus’s assumption preposterous.  The CBO handled the issue delicately, but essentially said, “Sure, provided that the sun rises in the west in 2012, then yes, this bill would reduce the deficit.”

That means Baucus will come up at least $200 billion short on the revenue side, making his bill a budget-buster.

The media are reporting that the Baucus bill would cost just $829 billion over 10 years.  Wrong.

As Donald Marron observes, that number omits as much as $75 billion in new federal spending.  It also omits a $33 billion unfunded mandate on state governments.

But the worst part is that the Congressional Budget Office’s preliminary cost estimate omits the cost of the private sector mandates in the Baucus bill.  In Massachusetts, those costs accounted for 60 percent of the total cost of reform.  That suggests the actual cost of the Baucus bill – $829 billion plus $75 billion plus $33 billion, times 2.5 – is well over $2 trillion.

Yet the CBO score pretends those costs aren’t even there.  It’s like a mystery novel that’s missing the last 50 pages.  And the media aren’t even curious.

In the words of Brad DeLong, why, oh why, can’t we have a better press corps?

Cross-posted at Politico’s Health Care Arena.
Power User
Posts: 7837

« Reply #430 on: October 08, 2009, 03:51:21 PM »

"The Baucus bill assumes that Congress will allow the “sustainable growth rate” cuts in Medicare’s physician payments to occur beginning in 2012."

I don't see why they can't or won't.
The claim that doctors would leave medicine or retire is just a lot of hot air.
Where are we going to go?

Most can't retire.  Sure some have done well and may be able to walk away if they are near retirement and have planned well.
I don't think most of my Indian colleagues are really going to pack their bags and return to India though I have heard some say that.

If government said to every lawyer in the US, or say every accountant in the US:  you will have to take an immediate 15% pay cut, sure they would rumble, they would huff and puff, but then what?

They would have to eat it.  Just like most of the non procedure oriented doctors, including me have had to do for years.
Nothing new.  No one cared about primary care then.  So what's the beef with the specialists?

So, in conclusion I am not so sure pay cuts won't happen.

That said adding 27 million to the rolls, one third of them not even citizens, will have NO chance of reducing costs UNLESS rationed health care occurs.

OTOH watching my own health care costs going up year after year with zero end it sight is also unsustainable.

So what the hell.

I got to watch dozens and dozens make millions or less off my wife's song lyrics while she is locked sitting in the house and rotting away.

But I still have spirit in me.  LIke the Chinese general said, "what doesn't kill you makes you stronger." (or close to that)

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Posts: 9481

« Reply #431 on: October 08, 2009, 11:34:40 PM »

"The claim that doctors would leave medicine or retire is just a lot of hot air."

If I understand correctly, the plan isn't in place until 'Obama's 2nd term'.  I think the more the plan looks like public employee union civil service work in place of private practice, the more likely a certain number will be to re-evaluate their future during the interim rather than join and learn the new system.  it wouldn't take too many planned retirees plus early retirees to totally screw up the already screwed up numbers in the plan IMO.  The same number of doctors and nurses at the same cost are already planning to treat 20-30 million more people as it stands? As I look for a Dr. myself it seems all the ones I know are already too close to retirement to be of much use to me in my upcoming old age.

If they eased the burden of malpractice lawsuits and insurance, an aging MD could continue to practice on an eased up schedule longer instead of taking normal retirement.  Seems to me that keeping them in practice a little longer would be a better course than forcing them out if we were trying to give better treatment to more patients.  But we aren't headed in that direction right now.
Power User
Posts: 7837

« Reply #432 on: October 09, 2009, 10:54:08 AM »

"I think the more the plan looks like public employee union civil service work in place of private practice,"

Well that's it exactly.
It would be like a higher end civil service job like a police officer, teacher, federal beauracracy employee, fireman, city hall worker.
Is it worth going through 11 to 17 years of school and training?  Is it worth the regulation, the oversight, the liability, the control, the loss of autonomy, and the endless pressure, stress, aggravation, etc.

Certainly foreign born immigrants think so.
2/3 of medical students in NJ are from other countries or are the offspring of immigrants.

A wonderful Egyptian couple who I consider to be friends as well as my patients came in with their 2 yr. old son.  They said they want him to be just like me.  A doctor.

What can I say?

As a side note, they came here to make a life for themselves.  To work hard and live the American dream.

They didn't come here illegally.  They don't ask for handouts.

They don't come over the boarder and demand rights and privileges of citizens and have their offspring here who are thus automatic citizens and then send them to public schools paid for by property tax payers, and the rest we are all familiar with....
« Reply #433 on: October 12, 2009, 07:40:05 PM »

Why the Democrats’ Health Care Overhaul May Die

Posted by Michael F. Cannon

The problem that Democrats have faced from Day One is finally coming to a head.

The Left and the health care industry both want universal health insurance coverage.  The industry, because universal coverage means massive new government subsidies. The Left, because that’s their religion.

But universal coverage is so expensive that Congress can’t get there without taxing Democrats.

Sen. Jay Rockefeller (D-WV) is the biggest opponent of Sen. Max Baucus’ (D-MT) tax on expensive health plans because that tax would hit West Virginia coal miners.

Unions vigorously oppose that tax because it would hit their members.

Moderate Democrats in the House oppose Rep. Charlie Rangel’s (D-NY) supposed “millionaires surtax” because they know it would hit small businesses in their districts.
And on and on…

But if congressional leaders pare back those taxes, they lose the support of the health care industry, which wants its subsidies.

That’s why the health insurance lobby funded this PriceWaterhouseCoopers study saying that premiums would rise under the Baucus bill: the $500 billion bailout they would receive isn’t enough.  They also want – they demand –  steep taxes on Americans who don’t buy their products.

The drug companies, the hospitals, and the physician groups are likewise demanding big subsidies, and will run ads to kill the whole effort if those subsidies aren’t big enough.
As always, health economist Uwe Reinhardt put it colorfully:

It’s no different from Iraq with all the different tribes…‘How does it affect the money flow to my interest group?’  They are all sitting in the woods with their machine guns, waiting to shoot.

Once the shooting starts, industry opposition will sway even Democratic members, because there are physicians and hospitals and employers and insurance-industry employees in every state and congressional district.

Can President Obama and the congressional leadership satisfy both groups?  My guess is, probably not, and this misguided effort at “reform” will therefore die.  Again.
Power User
Posts: 7837

« Reply #434 on: October 13, 2009, 09:49:09 AM »

The Dems like to throw around the idea that Medicare is much more efficient than private industry.  I have not heard any mainstream media types question this assertion.  So where is CNNs bogus "keeping them honest" look at this?

Here is one analysis of this:
« Reply #435 on: October 14, 2009, 03:17:52 PM »

The Senate Finance Health Bill Has No Clothes
Readers of this blog know that I have lots of concerns for the Senate Finance health bill primarily because it does not so much represent health care reform as just an expensive entitlement expansion.

Readers also know the insurance lobby--AHIP--is not one of my favorite organizations.

But I will tell you the report by Pricewaterhouse Coopers (PwC) commissioned by the AHIP and released this morning is accurate. The Senate Finance bill would do nothing short of blowing up the insurance market.

You don't need to be Einstein or a PwC actuary to come to that conclusion. Common sense is all the credential you need.

Beginning in 2013, the Senate Finance bill would make uninsured individuals eligible for premium credits to buy a health policy. But those credits would leave these people far short of being able to really afford a health insurance policy. A family of four at 250% of poverty and making $55,000 a year ($52,000 is the median household income in the U.S.) would have to pay about $4,000 toward their premiums and that for a policy with a $1,000 deductible and a maximum of about $7,000 in out-of-pocket costs each year.

At 300% of poverty, $66,150, a family would be required to pay $8,000 in premium for a policy with a $3,000 deductible!

How many families making $55,000 a year or $66,000 a year do you know that could add this kind of expense to their annual budgets?

It is really no better for a family making 400% of poverty, or $88,200 a year. They would have to pay $10,600 a year in insurance premiums for that policy with a $3,000 deductible!

Senate Finance, knowing they could not enforce this kind of individual mandate to buy health insurance then set about to exempt many from paying a fine (if it costs more than 8% of income) or just gutting the fine if they did not buy the coverage.

In 2013, for example, there would be no fine for not having insurance. By 2014 the penalty would be $200 per adult and it would rise to $400 in 2015, $600 in 2016, and $750 by 2017.

But starting in 2013 the Senate Finance bill says that the insurance companies have to get rid of medical underwriting and pre-existing conditions provisions.

So in 2013, any consumer could simply go to the health insurance company and demand to be covered under any one of the mandated benefit plans. No medical underwriting before getting in and no pre-existing condition limitations. Just sign the application and go to the doctor.

In one sense you can understand the political logic here--the Democrats can't very well mandate middle class families to pony-up $4,000, or $8,000, or $10,000 out of their already challenged budgets. So they just found a way to exempt them or make the fine a tiny one.

But they left the insurance reforms in place.

Let me ask you a question. Why would any family buy health insurance under such a scheme?

I will suggest the answer is that they will buy it when they need it. No sooner. Even in 2017, a family with two adults would pay no more than a $1,500 annual fine against a premium that would be $4,000 to $10,000 a year in these middle class income brackets.

I'll give you another one. Why would any small employer provide health insurance?

I will suggest the answer to that one is the smart small employer will just cash-out any benefits they do provide today and tell the employee t0 pay the fine until they need it and then go to the exchange and get it (there is also no small employer mandate in the bill to provide coverage). The worker would likely be thousands of dollars ahead each year!

The problem the Democrats have here is that they are trying to get a health bill to cost under $1 trillion. That has made them back off on premium subsidies and policy benefits. They have had to back so far off that the Democratic proposals are not offering health insurance policies anything close to being affordable for middle class families.

The political response in Senate Finance has been to waive the individual mandates but keep the underwriting reforms.

The sum of it all is a health insurance market disaster in the making. In the business we refer to it as a "death spiral." Simply, the higher the premiums go the fewer that will buy, the sicker the pool, the higher the premiums go once again, even fewer people are left in the pool, and so on until all of the sick are in the pool and all of the healthy have left it.

The PwC report says that average family premiums of $12,300 today will rise to $25,900 under the Senate Finance proposals in 2019. They say premiums would be driven by these underwriting reforms, cost shifting from Medicare cuts, and new insurance taxes simply being passed through to consumers.

I don't know if the PwC report is exactly correct, but as to its conclusions regarding the gutting of the mandate to buy insurance and that insurance company taxes will be passed through to customers, common sense certainly takes one to about the same conclusion. Frankly, I thought it would be worse.

The Senate Finance Democrats could not have created a bigger insurance pool train wreck in the making than the one they have devised here.

What is really amazing is how all of these Senators sitting around that Senate Finance table have just sleep walked their way through all of this as if they don't have the common sense to figure this out on their own.
Power User
Posts: 7837

« Reply #436 on: October 15, 2009, 02:41:47 PM »

Now I see Obama offering seniors $250 on Drudge.
In my other post in the music thread I noted that anyone could be bought off. 
So Obama thinks he will win over the senior vote with this.
Folks I don't know how you all feel but the endless give aways, taxes, spending proposals from the Democrats on a daily basis
is to me just so depressing.
I know I am going to be holding the bill.

Our country is screwed.

The entitlements are expanding exponentially, the number of people who are giving in and jumping on the dole is exploding and those left holding the bag like myself just have to sit and watch them GIVE our money all away.


I have a pt. in his 50s who came to me with wear and tear arthritis of his shoulders.
He does do a very physical job.

I suggested he can't do that work anymore and needs to think of something else.
Supervisory etc.

He comes back in a few weeks later with a permanent disability form from Social Security and says to me "you told me I am disabled".

I think to myself I never said that but it is difficult to tell him no when I am his, his wife's, his childrens primary doctor.

So I filled out the form that he has some worn rotator cuffs thinking and I thought SSI will have him evaluated by their own doctor and he will be denied.  This has always been the case in the past.

Low and behold within a few short months he is approved.  I assume his case was reviewed and they didn't go by only what I wrote but I admit I don't know what the details of the events were in the process.

He has no more arthritis then me.  But because I am a doctor I must work forever while this guy goes on the dole.

I hear stories all the time about people getting endless 6 month extensions on their unempolyement.  They can get jobs but since they are lower wage from what they are used to they decide they may as well stay on unemployment.

Yet we have millions and millions of illegals working here also using services.  A Russian doctor just told me she prefers to care for Americans over Russians.  I said really?  She said yes,  care in Russia is free and they come here expecting free care.  Like I said the immigrants of today are not like those of my ancestors at the turn of 1900.

And because the Democrats are all about taxing and spending to buy votes and as long as people decide they may as well get on the dole this country is screwed.

From where I sit there is NO END in sight.

For those of us who are working and paying all these bills I don't want to pay for the health care of all these other people.

Why do the 90% have to suffer for the 10%?  I am tired of it.  I agree with Levin.  Health care is *not a right* and I don't care about all these other people.  I have had enough.
Power User
Posts: 7837

« Reply #437 on: October 15, 2009, 03:09:30 PM »

Just a thought.

We are not a country of haves and have nots.

We are a country of earners vs takers.

or perhaps earners vs. handouts.

or earners vs spongers.

or workers vs. spongers.

It is all out of control.
Power User
Posts: 7837

« Reply #438 on: October 15, 2009, 03:37:34 PM »

OF course the headlines suggest doctors will get raises  (of course) when in reality the proposal postpones CUTS.

And no I can't be bought off either.
No Dem gets my support.  Go screw yourselves.

Senate Dems seek higher doctor payments
By DAVID ESPO (AP) – 19 hours ago

WASHINGTON — Maneuvering to boost prospects for sweeping health care legislation, Senate Democrats hope first to win quick approval for a bill that grants doctors a $247 billion increase in Medicare fees over a decade but raises federal deficits in the process, officials said Wednesday.

By creating a two-bill approach, Democrats intend to claim the more comprehensive health care measure meets President Barack Obama's conditions — that it will neither add to deficits nor exceed $900 billion in costs over 10 years.

If approved and signed into law, the legislation would avert a 21 percent reduction in Medicare fees paid to doctors that is scheduled to take effect in January as well as additional cuts in future years.

Lawmakers frequently draft budgets that assume payment rates for doctors treating Medicare patients will fall rather than rise, part of a sleight of hand set of assumptions to make deficits appear smaller than they actually are. They then convene the following year and restore the money.

The disclosure of Senate Democrats' plans came as senior lawmakers sat down with White House chief of staff Rahm Emanuel and other top administration officials for the first time to draft a health care bill expected to be voted on in the full Senate beginning in about two weeks.

Two Senate committees have approved different versions of the legislation, requiring the unusual set of negotiations.

The bill to restore planned Medicare cuts for doctors was introduced without fanfare in the Senate on Tuesday and set aside for swift floor action next week, rather than sent to the Senate Finance Committee for hearings as would normally be the case.

"This is a bill that would permanently change the payment system for physicians to a fairer system," Sen. Debbie Stabenow, D-Mich., said as she introduced the bill.

Jim Manley, spokesman for Senate Majority Leader Harry Reid, D-Nev., said the decision to move quickly and apart from the health care bill was made in consultation with the White House. House Democratic leaders were also involved in the discussions.

House Democrats, in particular, have grumbled about trying to adhere to Obama's price tag.

In the Senate, the immediate impact of a two-bill approach is to slice $10.7 billion from the cost of the health care bill that cleared the Finance Committee bill, money that could then be spent on other priorities.

A 60-vote Senate majority will be required to pass the measure, potentially placing Republican senators in a quandary.

If they oppose it, they may anger doctors who have made restoration of the planned payment cuts a top priority. If they support it, they may open themselves up to charges they helped raise deficits and facilitated passage of a health care bill that conservatives oppose vigorously.

Stabenow's office did not immediately return a call seeking additional information.

Dr. J. James Rohack, president of the American Medical Association, issued a statement welcoming the developments. "Without repeal, the current formula projects steep cuts of about 40 percent over the next five years. As we work to improve the health system, permanent repeal of the payment formula is an essential element of health reform to ensure the security and stability of Medicare," he said.

Manley said the measure does not need to be offset by spending cuts or higher taxes because "it does not increase spending. It simply restores a more honest picture of what future physician spending will actually be."

But Democrats saw the issue differently more than a year ago, the last time Congress acted to head off a cut in payment rates.

Then, they insisted on cutting payments to insurance companies providing private Medicare coverage in order to cover the $13.5 billion cost of the increase in doctor payments. The result was a showdown in which the legislation was passed over President George W. Bush's veto.

Copyright © 2009 The Associated Press. All rights reserved.
Power User
Posts: 42521

« Reply #439 on: October 16, 2009, 11:58:43 AM »

"Enlightened statesmen will not always be at the helm." --James Madison

Baucus and Pelosi work on their health care potionGovernment & Politics
Double, Double, Toil and Trouble

The headlines triumphantly announced Tuesday that the Senate Finance Committee had passed its version of the health care takeover bill with the help of Republican-In-Name-Only Olympia Snowe of Maine. But as the Heritage Foundation's Brian Darling writes, there is no bill. In fact, Darling says, "The Senate is using a non-transparent and rare -- if not unique -- process to pass Obamacare."

Though Sen. Max Baucus (D-MT) gathered Democrats and Republicans to craft a bill, they couldn't do it, even after weeks of meetings. So, Darling continues, "Baucus then scheduled a markup of an outline of his version of health care reform. Many call it a 'Vapor Bill,' because it's only a description of legislation. No member of the Committee has seen actual legislation, just a 262-page description. That Vapor Bill never will be voted on in the Senate, so many detractors are calling this a 'make believe markup.' It's to fool people into thinking the Senate is actually crafting a bill."

Not only that, but Darling adds, "I have called around Capitol Hill to find out who has a copy of the bill and none of my high-level contacts know." Now that's transparency.

Meanwhile, based on what language is actually accessible, the PricewaterhouseCoopers accounting firm performed an analysis commissioned by America's Health Insurance Plans (AHIP), a group representing the industry. Warning that the Baucus bill will saddle everyone who has insurance (including the Democrats' beloved middle class) with a load of new taxes in various forms, the report highlights an excise tax on employer-provided high-value health plans, Medicare payment cuts that would result in cost-shifting to the private market, and new taxes on the health industry that will inevitably be passed on to consumers.

According to Investor's Business Daily, "The study estimates that the average family-coverage cost of about $12,300 [per year] could reach $17,200 in 2013 if these provisions were implemented, $21,300 in 2016 and $25,900 in 2019. Meanwhile, average single coverage -- $4,600 today -- could reach nearly $10,000 in 2019." No wonder Democrats are afraid to discuss the details of this witch's brew.

Still, AHIP is no stalwart defender of the Constitution and Rule of Law. As The Wall Street Journal writes, "The irony is that AHIP is now arguing for a more left-wing bill, claiming the Baucus plan isn't 'universal' enough." Obviously, insurance companies are looking out for their own best interests. It's too bad they don't understand that those interests are best served by the free market.

The BIG Lie
"[The AHIP report is a] hatchet job ... bought and paid for by the same health insurance companies that have been gouging too many consumers for too long as they stand in the way of reform yet again." --Sen. Max "The Gouger" Baucus, who predicts that all Democrats and possibly more than one Republican will support his bill

This Week's 'Braying Jenny' Award
"When you think of the campaign that's been launched against the public option by the insurance industry -- because they can't take the competition. Anyone who had any doubts about the need for such an option need only look at the health insurance industry this week." --House Speaker Nancy Pelosi (D-CA)

Pelosi is reduced to taunting and threatening anyone opposed to her schemes, saying that it only further makes the case for a government-run "public option" for health insurance. But how could any industry compete with the federal government's ability to run at a deficit forever? She went on to mock the "discredited" AHIP report. No one has actually discredited the report, mind you, Pelosi only says it's been discredited.

Hope 'n' Change: About That Free Lunch
Creative accounting allows Washington to get away with a lot, and the current health care debacle is no exception. Recent analyses of House and Senate proposals by the Congressional Budget Office rely upon static scoring (i.e., not factoring in behavioral changes caused by the legislation,) fantastically optimistic projections and simple omissions of unfavorable facts that trumpet deficit-neutral bills having no basis in reality. The libertarian Cato Institute, for example, took a close look at the CBO's numbers and discovered a variety of unsupportable claims.

For starters, the 10-year projection that measures out the trillion-dollar House bill in itself is misleading. Most of the bill's major provisions don't kick in until 2014, making for a 6-year projection in which costs ramp up slowly. After the first three years of the program, around the time of the 2012 election, costs would accumulate to about $100 billion, relative chump change that will allow Obama's re-election campaign the opportunity to pledge that health care has been a cost-saving success. But four years beyond that, long after the current president passes the threshold of electoral accountability (assuming he wins, perish the thought), costs catch a fever. Cato estimates a $2.4 trillion tab (even Sen. Harry Reid admits as much), double what the House bill and the CBO project. And what happens after 2019 is a true horror story.

The Baucus bill, all the rage on Capitol Hill these days, is another fraud of epic proportions. It claims to have no impact on the deficit by assuming, in part, that growth rate cuts in Medicare's physician payments will help offset its $829 billion price tag. All well and good, but Congress never makes those cuts because no one wants to be on record as cutting an entitlement for one of America's most powerful voting blocs. Just by taking these cuts out of the equation, the bill automatically goes $200 billion into the red. Additionally, there is no reckoning of the built-in costs that will hit consumers, including penalties for high-price insurance plans, penalties for not having insurance and the general rise in cost of various health care procedures over the span of several years.

Obama and his Democrat lackeys have either bullied or beguiled the CBO, once a reliably non-partisan entity, into fabricating analyses concluding that Congress has produced sweeping legislation that does not negatively affect the deficit. If ever the phrase "voodoo economics" applied, it's now.

This Week's 'Alpha Jackass' Award
"I will actually give you a speech made up entirely -- almost at the spur of the moment, of what a candidate for president would say if that candidate did not care about becoming president. In other words, this is what the truth is, and a candidate will never say, but what candidates should say if we were in a kind of democracy where citizens were honored in terms of their practice of citizenship, and they were educated in terms of what the issues were, and they could separate myth from reality in terms of what candidates would tell them:

'Thank you so much for coming this afternoon. I'm so glad to see you, and I would like to be president. Let me tell you a few things on health care. Look, we have the only health care system in the world that is designed to avoid sick people. [laughter] That's true, and what I'm going to do is I am going to try to reorganize it to be more amenable to treating sick people. But that means you -- particularly you young people, particularly you young, healthy people -- you're going to have to pay more. [applause] Thank you.'

'And by the way, we are going to have to -- if you're very old, we're not going to give you all that technology and all those drugs for the last couple of years of your life to keep you maybe going for another couple of months. It's too expensive, so we're going to let you die.' [applause]

'Also, I'm going to use the bargaining leverage of the federal government in terms of Medicare, Medicaid -- we already have a lot of bargaining leverage -- to force drug companies and insurance companies and medical suppliers to reduce their costs. But that means less innovation, and that means less new products and less new drugs on the market, which means you are probably not going to live that much longer than your parents. [applause] Thank you.'" --Robert Reich, President Clinton's labor secretary, in a speech at Berkeley in 2007. Democrats, death panels and dying early -- it's all in there, folks.
Power User
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« Reply #440 on: October 18, 2009, 05:13:05 PM »


Yesterday we received an email from a loyal reader who nonetheless seems to disagree with everything we write--a type of reader for whom we have a special, if slightly perverse, affection. Our correspondent included a quote that he attributed to Aristotle:

If we believe men have any personal rights at all, then they must have an absolute moral right to such a measure of good health as society can provide.
Could an ancient philosopher, a man who lived and died many centuries before the advent of either socialism or modern medicine, really have been in favor of socialized medicine? We were skeptical, to say the least, and decided to do a bit of Web sleuthing.

We punched the quote into Google, and up popped a series of references, mostly from left-liberal outfits like and Bill Moyers Journal. This heightened our suspicion that the quote is a "progressive" urban legend, but it didn't prove it.

James Taranto on the supposed Aristotle quote.
.Then we tried searching Google Books, figuring that if this appeared anywhere in Aristotle's works, it would turn up there. The only reference to the quote was from Thurston Clarke's 2008 book, "The Last Campaign: Robert F. Kennedy and 82 Days That Inspired America." Clarke reports that RFK, during his 1968 presidential campaign, attributed the quote to Aristotle in a speech at the "University of Indiana Medical School" (presumably he means the Indiana University School of Medicine).

Of course, Aristotle wrote in ancient Greek, not modern English, so it's possible that Kennedy was using his own translation. But a March 2008 paper by Edmund D. Pellegrino, a professor of medicine and philosophy at Georgetown University, suggests that in fact RFK was using a fabricated quote. Here is what Pellegrino, with the assistance of the staff at the National Reference Center for Bioethics Literature, found:

In attempts to establish the provenance of the text in question we have conducted an extensive search for its source and original wording. We have not been able to locate it. Our initial curiosity was aroused by several things, including that rights language did not seem to have the Aristotelian context, and health care, as such, was not included in Aristotle's works. We searched Nicomachean Ethics and Eudemian Ethics, and the Magna Moralia without successfully locating the quote. Nor could we find it in other of works of Aristotle: On Length and Shortness of Life, De Anima, Economics or the Fragments. "Rights" language certainly would stick out in Aristotle's virtue-based ethics.
Curiously, the earliest reference to the purported quote that Pellegrino was able to find was from an article published in 1979, more than a decade after RFK's death, whose author claimed to have translated it himself from a Latin edition of the Nicomachean Ethics. We haven't been able to find a transcript of the RFK speech, or any contemporaneous account of his quoting Aristotle in it.

Maybe he was quoting Aristotle Onassis.

'Futile' Vassals
Whatever Aristotle might or might not have said, the flip side of establishing a "right" to medical care is that it also entails empowering the government to define the limits of that right. An Associated Press story offers a chilling hint of the potential implications:

A surprising number of frail, elderly Americans in nursing homes are suffering from futile care at the end of their lives, two new federally funded studies reveal.
One found that putting nursing home residents with failing kidneys on dialysis didn't improve their quality of life and may even push them into further decline. The other showed many with advanced dementia will die within six months and perhaps should have hospice care instead of aggressive treatment.
Medical experts say the new research emphasizes the need for doctors, caregivers and families to consider making the feeble elderly who are near death comfortable rather than treating them as if a cure were possible--more like the palliative care given to terminally ill cancer patients.
We have no basis on which to quarrel with the findings of the study, and certainly it is true that some treatments are futile and circumstances exist in which palliative care is the least bad of all available options. But when government becomes the decision-maker, you end up with stories like the one we noted Wednesday, in which a British hospital manager tried to persuade a woman to make her grandmother "comfortable" (read dead) when, as it turned out, the old lady's breathing difficulties were easily treatable.

In that same item Wednesday, we called attention to a speech Robert Reich, President Clinton's labor secretary, gave, in which he set forth what he described--approvingly--as the "truth" about so-called health-care reform: that it amounts to telling old people, "We're going to let you die," forcing young people to pay more for insurance, and suppressing medical innovation.

We weren't the only one to notice this Reich speech, and Reich has posted a response on his blog to the commentary that has ensued:

Lou Dobbs, Sean Hannity, Rush, and the right-wing blogosphere seem interested in a talk I gave in September, 2007 to students in a political science class here at Berkeley, in which I played the role of a presidential candidate so politically incorrect and tone-deaf as to pummel every sacred cow in sight--including the notion that our society could afford and would continue forever to pay whatever amount of money was required to keep everyone alive forever. The whole point of the mock exercise was to show that presidential candidates can't state what everyone knows to be the truth because they'll be taken apart by the Right or the Left. I slew many other sacred cows in that mock exercise, some of which are held dearly by the Left. Nonetheless, two years later the Right has exhumed the lecture and taken my words completely out of context purportedly to show that Obama and the Democrats plan death panels.
If their desperation weren't so pathetic it would be funny. After all, they have proven the whole point of my lecture. UC Berkeley maintains an archive of webcasts and my speech is available there verbatim, should you wish to listen to it in its entirety.
This is bizarre. We don't know exactly what Dobbs, Hannity and Rush Limbaugh said, but we were in complete agreement with "the whole point" of Reich's lecture, at least as it applies to President Obama and other politicians currently pushing "health-care reform": that they are not telling the truth about their intentions. Reich almost certainly gave a far more accurate description of how ObamaCare would work in practice than Obama has ever given.
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Posts: 7837

« Reply #441 on: October 19, 2009, 10:03:04 AM »

This New England Journal of Medicine article.  Note all these studies addressing end of life issues showing up in this journal now while we debate end of life care.  It is no coincidence.  Republicans I think would want to leave this a private decision for patients and their doctors.  Liberal/radical Democrats of course want to transfer the decision making to government.  I have no problem with this being discussed in the medical journal.  Caveat emptor from those who don't usually read the NEJM.  Its editors are clearly and obviously big liberals up in Boston academia so they are not unbiased.  They do have the say in what does and what does not get published so I don't trust them fully.  Many of them have their agendas like all of us to an extent.
Infections, Eating Problems Signal The End in Advanced Dementia
By John Gever, Senior Editor, MedPage Today
Published: October 14, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner  Earn CME/CE credit
for reading medical news
The final months of advanced dementia are marked by "distressing symptoms and burdensome interventions," investigators concluded in the first systematic, prospective investigation of the disease's late-stage clinical course.

Among 323 patients with advanced dementia in nearly two dozen nursing homes who were followed for 18 months, more than 40% developed pneumonia, while half had at least one febrile episode, and 85% suffered eating problems, according to Susan L. Mitchell, MD, MPH, of the Hebrew Senior Life Institute for Aging Research in Boston, and colleagues.

Some 55% of the sample died during follow-up, the researchers reported in the Oct. 14 New England Journal of Medicine. Most suffered from Alzheimer's.

Action Points 

Explain to interested patients that advanced dementia is irreversible and eventually fatal.

Explain that although earlier studies had suggested that pneumonia and other infections, fractures, eating problems, and agitation are common in advanced dementia, they were not as rigorous as the current study.

Explain that when serious illnesses are considered incurable and terminal, the focus of care usually shifts to making the patient comfortable.

During their final three months of life, 41% of dying patients underwent at least one intensive intervention, such as hospitalization, transport to an emergency room, tube feeding, or parenteral treatment.

"Patients, families, and health care providers must understand and be prepared to confront the end stage of this disease, which is estimated to afflict more than 5 million Americans currently and is expected to afflict more than 13 million by 2050," Mitchell and colleagues wrote.

They also found that when patients' surrogates and guardians understood the expected clinical course, burdensome interventions were much less likely during the final three months of life (adjusted odds ratio 0.12, 95% CI 0.04 to 0.37), relative to proxies with poor understanding.

In an accompanying editorial, Greg A. Sachs, MD, of Indiana University School of Medicine in Indianapolis, said the study "moves the field forward in major ways with respect to both prognosis and the terminal nature of advanced dementia."

Not only should clinicians, nursing home staff, and patients' families be aware of the study results, Sachs suggested, but so should Congress and the government's major health agencies.

"Much more research is needed on the use of palliative care for these patients, including studies on prognosis, patients in less advanced stages of dementia, alternative care settings, intervention trials, and, eventually, the effects of implementing programs designed to improve current systems of care," he wrote.

The study focused on nursing home patients in the Boston area who could no longer recognize family members or walk independently.

About 72% had scores of zero on the Test for Severe Impairment, and the mean scores on the Bedford Alzheimer's Nursing Severity subscale was 21.0 (SD 2.3). The mean age of the group was 85, and patients had been in nursing home care for a median of three years.

Dementia was related to vascular insufficiency in 17% of the patients and to Alzheimer's disease in 72%. Symptoms in the remainder had other causes.

Patients underwent exams every three months. Caregivers and guardians or other surrogate decision-makers were also interviewed regularly.

In particular, each guardian or surrogate was asked whether he or she thought the patient would survive another six months. Also, at study baseline they were asked whether they understood the general clinical complications that might be expected in advanced dementia and whether they had discussed these issues with a nursing home physician.

Median patient survival was 478 days, Mitchell and colleagues reported. They calculated the following probabilities of complications:

Pneumonia: 41.1%
Febrile episode: 52.6%
Eating problems: 85.8%

Patients developing these problems had relatively high mortality rates in the following six months: 46.7% after a bout of pneumonia, 44.5% after a fever, and 38.6% after eating problems began.

On the other hand, patients who could eat normally were very unlikely to die. Only about 10% of these patients died during the entire follow-up period, compared with about 70% of those who developed eating problems at some point.

Other sentinel events included 14 cases of seizure, 11 gastrointestinal bleeds, and seven hip or other bone fractures. But only seven of the 42 sentinel events occurred during the last three months of life for those who died during follow-up.

Symptoms causing acute distress were also common in the study. From 40% to 45% of patients suffered one or more of the following: dyspnea or pain for at least five days per month, pressure ulcers at stage II or higher, and aspiration. Nearly 54% experienced periods of agitation, the researchers found.

Among the entire study sample, about one-third received parenteral therapy, while 17% were admitted to a hospital, 10% had an emergency room visit, and 8% were tube-fed.

Pneumonia accounted for more than two-thirds of the hospitalizations, Mitchell and colleagues said.

Only 30% of those who died during follow-up had been referred to hospice care, and 22% of the overall sample.

The interviews with surrogates and guardians showed that 96% believed that comfort was the primary goal of therapy. Less than 20% said a nursing home physician had discussed prognosis with them.

About 80% indicated that they understood the medical complications likely to occur, but only 33% said they had discussed them with a physician.

Mitchell and colleagues noted that most of these findings had been observed in previous studies, but those were either retrospective or cross-sectional analyses or had focused on hospitalized patients. "The clinical course of advanced dementia has not been described in a rigorous, prospective manner," they said, prompting their study.

They said their results "can be used to inform families and care providers that infections and eating problems should be expected and that their occurrence often indicates that the end of life is near."

They added, "Families and providers should also understand that although these complications may be harbingers or even precipitants of death, as they are in other terminal diseases (e.g., the acquired immunodeficiency syndrome, cancer, and emphysema), it is the major illness, in this case dementia, that is the underlying cause of death."

In his editorial, Sachs said it was important that clinicians and patients' families approach advanced dementia "as a terminal illness requiring palliative care." He argued that these patients should qualify for hospice care whether or not they have other serious illnesses.

He also criticized moves by the government to restrict hospice care in nursing homes. "Although no one can argue against the need to root out fraud and unseemly conflicts of interest, it would be a shame to take hospice away from patients with dementia, who could truly benefit from it," Sachs wrote.

Mitchell and colleagues noted that their study was limited by its narrow geographic focus and its reliance on charts and nursing reports for some data. They also emphasized that their reported survival times do not represent survival from onset of advanced dementia.

They also noted, "We can report only the associations between the health care proxies' perceptions of prognosis and of the complications expected and the use or nonuse of aggressive interventions -- we cannot draw conclusions about cause and effect."

The National Institute of Aging funded the study.

No potential conflicts of interest were reported by study authors.

Sachs reported a relationship with CVS Caremark.

Primary source: New England Journal of Medicine
Source reference:
Mitchell S, et al., "The clinical course of advanced dementia" N Engl J Med 2009; 361: 1529-38.

Additional source: New England Journal of Medicine
Source reference:
Sachs G, "Dying from dementia" N Engl J Med 2009; 361: 1595-96.
« Reply #442 on: October 19, 2009, 10:08:23 AM »

Taking Obamacare Off the Books
By the Editors

You don’t have to be a Washington insider to understand what the Democrats are up to with their last-minute plan to run the “doc fix” — postponing scheduled cuts to doctors’ Medicare payments — on a separate legislative track. It’s all about Obamacare, as is so much this year. The Obama administration and its allies in Congress will do just about anything to get a health-care bill to the president’s desk, and that certainly includes spending whatever amount of taxpayer money they deem necessary — and doing so through a shameless ploy, offloading $247 billion in Obamacare costs onto a separate, standalone, unfinanced piece of legislation. Obama promised not to add “one dime” to the deficit for health care: Democrats now plan to dump $247 billion onto the nation’s already staggering pile of debt, using this piece of accounting trickery to cover their tracks.

The “doc fix” is political shorthand for repeal of the discredited “sustainable growth rate” (SGR) Medicare-payment formula, which determines the annual update of physicians’ fees. A comprehensive failure as a cost-cutting measure, SGR is a prime example of the bureaucratic central planning that Democrats now want to extend across all of American health care. SGR was supposed to keep Medicare spending on doctors’ services in line with economic growth by limiting the annual increases in the prices paid for each particular physician service. The trouble is that Medicare’s total cost is determined by both prices and volume, and the government has no way to control the use of physicians’ services. As fees have been cut, volume has soared — necessitating even deeper cuts to keep spending in line with SGR targets.

The sensible course is a thorough reform of how Medicare operates. So long as the program is dependent on payment schemes devised in Washington, we are doomed to endure SGR-style disasters over and over again.

But the Obama administration isn’t interested in serious entitlement reform. They just want to make the SGR nuisance go away, which is why the House health-care bill included a full repeal of it. Sen. Max Baucus’s plan, however, only delayed the SGR cuts for another year so that he could claim his plan comes in under the $900 billion ceiling the president established for a health-care bill.

Now, as Democrats prepare to take their plans to the House and Senate floors, they are looking to spend even more money to buy votes and to make political problems go away. The catch is that pesky budget limit the president endorsed. The solution? Simply moving some of the spending out of the health-care bills and into other pieces of legislation. Presto! Now there’s even more money to spend!

Fortunately, there is still some sanity on the Democratic side of the aisle. Senate Budget Committee chairman Kent Conrad has restated his opposition to repealing SGR without an offset to cover the $247 billion hole that would blow in the federal budget. Indiana Sen. Evan Bayh says he will join Conrad in opposing the Democratic plan.

So the question is, What will Republicans do when the SGR repeal is called up in the Senate? If they stick together and join Conrad and Bayh, they can defeat it and force the Democrats to address the issue responsibly. No one likes SGR, but there is no real danger of doctors’ facing a Medicare fee cut in 2010 — a bipartisan consensus will ensure that doesn’t happen. So the last thing Republicans should do now is to support an unfinanced repeal outside of a health-care bill. That will undermine any effort to secure meaningful Medicare reform — this year or ever. Worse, it will give Democrats cover to spend even more on Obamacare, buying off special interests and greasing the political machinery.

This is a tactical ploy by Democrats to secure a government takeover of American health care. Republicans have no choice but to oppose it.
National Review Online -
« Reply #443 on: October 19, 2009, 10:15:22 AM »

Second Post

Congress Keeps Gold-Plated Health Care... For Themselves
Jillian Bandes
Monday, October 19, 2009
Personal doctors on call 24/7. Coverage that knows no caps. No exemptions for pre-existing conditions.

Those are the sorts of benefits members of Congress currently enjoy on the taxpayer’s dime, and the kinds of benefits Americans on a government-run public health care plan will never see if Obamacare passes.

“One thing is certain: Congress will exempt itself from whatever lousy health care system it forces on us little people,” said Michael Cannon, director of health policy studies at the Cato Institute. “Congress will get better insurance than you do because politicians always get a better deal under government-run health care.”

While it’s not news that Congressional health insurance plans are posh, CBS News recently uncovered the details of plans – right as the details of the Baucus health care bill are being hashed out.

Members of Congress can choose from five different plans, and have access to both the VIP Bethesda Naval Hospital and a reserved spot Ward 72 at Walter Reed Army Medical Center, an elite division usually reserved for military members. Their everyday medical concerns can be taken care of at a doctors office located inside of Congress.

Their premiums are the same as those of insurance plans with half the benefits, and the plans last a lifetime; not until Medicare kicks in do ex-Members or loose their Congressional health benefits. Congress has repeatedly voted down any provision that would switch their insurance plans to the lower-grade public option if Obamacare goes through.

Helen Evans, the director of Nurses for Reform, a campaign for more consumer-led, sustainable healthcare systems in Britain, said that this sort of elite care for the bureaucracy – and low-brow care for the plebes – is the same thing that happens in the government-run British health care system.

“Independent academic research has shown that on average the professional and managerial types obtain 40% more resource per illness episode than lower down the social spectrum” in Britain, she said.

Evans is certain that the exact same thing would happen in the U.S. if Obamacare was installed.

“The National Health Service, is famous for being a highly politicised bureaucracy that whilst it legitimises itself on the basis of equality favours the powerful, articulate and well connected,” she said. Nurses for Reform is unsurprised that American politicians are pushing for government-run health care “while of course attempting to secretly perpetuate their own elitist system funded by ordinary taxpayers.”

At least one U.S. Congressman is speaking out.

"If we pass a law that says a public option will be made available, I think people like myself should get out of this plan and go into the public option," Sen. Lindsey Graham, (R-S.C.), told CBS.
Power User
Posts: 7837

« Reply #444 on: October 19, 2009, 10:34:03 AM »

"Their premiums are the same as those of insurance plans with half the benefits, and the plans last a lifetime; not until Medicare kicks in do ex-Members or loose their Congressional health benefits"

It seems reasonable that members of our government get the best health care.  But for life?

Wow.  What a racket?  I suppose their families are also covered under the posh plan?  For life as well?

I am sure they get better and more immediate care than our veterans. 
Power User
Posts: 7837

« Reply #445 on: October 29, 2009, 04:09:05 PM »

Democrats issued a statement saying their 1,990-page measure "lowers costs for every patient" and would not add to federal deficits. They put the cost of coverage at under $900 billion over 10 years, a total that excludes several items designed to improve benefits for Medicare and Medicaid recipients and providers, as well as public health programs and more.

What lies.

Decrease the deficit AND lower costs for "every" patient AND cover another God knows how many millions and of course care will not be rationed, will be better "quality".

What a joke.

As always those of us who work and pay taxes  have more taken to pay for those who don't, or are on some sort of dole.

Hopefully it won't get through the Senate.

And no, I don't want to pay for the medicines of that sob story lady who spoke after Pelosi.

We have got to stop the entitlements.  People have got to stop expecting to retire at their convenience, and expecting governemnt to pick up their lives.

I had someone come in requesting disability the other day.  I was astonished.  I asked I  thought you retired from your turnpike job?

He said I did.  On pension.  So I asked what is the disability for?  He says a friend told him he could get more money that way.

I told him he is not disabled and would not write that he is.  He admitted he agreed with me and sheepishly left the office.

I have another daughter of a pt. who told me that one of the first English words the immigrants legal or illegal learn when they come to the US is "medicaid". 

Where is the outrage?  When will this all stop?  I am becoming to hate my own country.

We are broke in spirit, in ethics, in honesty, as a nation.

The crats keep making it worse.

Power User
Posts: 42521

« Reply #446 on: October 29, 2009, 06:01:00 PM »

I share the feelings.

Cato Institute - 1000 Massachusetts Avenue, N.W. - Washington D.C 20001

State ‘Opt-Out’ Proposal: a Ruse within a Ruse
Posted by Michael F. Cannon

President Obama and his congressional allies want to create yet another government-run health insurance program (call it Fannie Med) to cover yet another segment of the American public (the non-elderly non-poor).

The whole idea that Fannie Med would be an “option” is a ruse.

Like the three “public options” we’ve already got – Medicare, Medicaid, and the State Children’s Health Insurance Program – Fannie Med would drag down the quality of care for publicly and privately insured patients alike.  Yet despite offering an inferior product, Fannie Med would still drive private insurers out of business because it would exploit implicit and explicit government subsidies.  Pretty soon, Fannie Med will be the only game in town – just ask its architect, Jacob Hacker.

Now the question before us is, “Should we allow states to opt out of Fannie Med?”  It seems a good idea: if Fannie Med turns out to be a nightmare, states could avoid it.

But the state opt-out proposal is a ruse within a ruse.

Taxpayers in every state will have to subsidize Fannie Med, either implicitly or explicitly.  What state official will say, “I don’t care if my constituents are subsidizing Fannie Med, I’m not going to let my constituents get their money back”?  State officials are obsessed with maximizing their share of federal dollars.  Voters will crucify officials who opt out.  Fannie Med supporters know that.  They’re counting on it.

A state opt-out provision does not make Fannie Med any more moderate.  It is not a concession.  It is merely the latest entreaty from the Spider to the Fly.


Power User
Posts: 9481

« Reply #447 on: October 30, 2009, 10:36:59 PM »

"you can force insurance companies to "cover" preexisting conditions, but the resulting product is not insurance. You cannot insure against something that has already happened. It is merely a bill-paying mechanism."   
 Do They Need the Public Option?
October 30, 2009 John Hinderacker,

Much discussion of the House Democrats' health care bill has focused on its inclusion of the "public option," which most observers see as a Trojan Horse intended to serve, ultimately, as the vehicle for socialized medicine as private insurers are driven from the market--a process that President Obama has said may take ten to twenty years.

What strikes me as I read the House bill, however, is how closely it approximates socialized medicine even without the public option. The bill is classic national socialist legislation, in that it takes ostensibly private entities, the health insurance companies, and perverts them into instruments of the state, run top-down and barred from competing among themselves.

Under the House bill private health insurance companies will still exist, but to what end? They will be legally prohibited from competing in any meaningful sense. They will be required to issue substantially the same coverages at substantially the same rates, changes in which must be justified to the government. They will be prohibited from underwriting insurance risks in any rational way: they must pay all bills resulting from preexisting conditions, and they will be prohibited from charging lower-risk customers lower rates.

As I wrote here, you can force insurance companies to "cover" preexisting conditions, but the resulting product is not insurance. You cannot insure against something that has already happened. It is merely a bill-paying mechanism. Likewise, the House bill prohibits insurance companies from charging premiums on any rational basis. Section 213, titled "Insurance Rating Rules," provides:

    The premium rate charged for a qualified health benefits plan that is health insurance coverage may not vary except as follows:

    (1) LIMITED AGE VARIATION PERMITTED.--By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1.

So young people--who, remember, will now be forced to buy health insurance--will subsidize older people.

    (2) BY AREA.--By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators).

    (3) BY FAMILY ENROLLMENT.--By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for individual enrollment is uniform, as specified under State law and consistent with rules of the Commissioner.

That's it. A lower premium for non-smokers or the non-obese? Forget about it. It's illegal.

Under the House bill, it is scarcely an exaggeration to say that health insurance companies are no longer in the insurance business. They can't rate and underwrite risks, which is the essence of insurance. That's illegal. They can't decide to whom they will issue policies; that's illegal, too. They can't offer novel or innovative coverages; their coverages are dictated by law. To a limited extent they can make decisions on paying claims, but under the watchful eye of government regulators. Meaningful competition among insurance companies will be, in effect, illegal. (In that context, it is a sick joke that the Pelosi bill also subjects health insurance companies to the antitrust laws, from which they had been exempted in consideration of their regulation by state, not federal, authorities.)

In the world that the House bill would create, the money we will pay to insurance companies won't really be insurance premiums. Insurance premiums are contractual payments which the parties voluntarily agree upon and which are based on a mutual assessment of risk. Rather, the checks we write to insurance companies will be taxes--legally compelled, at rates set by the federal government that are designed to punish some and subsidize others.

Isn't this socialized medicine in all but name? The only difference, perhaps, is that when things start to go badly, as they inevitably will--spiraling costs, long waits for treatment--Nancy Pelosi and her colleagues will have someone to blame: the insurance companies. Maybe old-fashioned socialized medicine would be better. Then, at least, the government would have to take responsibility for its folly.
« Reply #448 on: October 31, 2009, 09:33:40 PM »

Obama's Fight to Win or Lose
Mitch McConnell takes a shrewd tack in the battle over Obamacare.
by Fred Barnes
11/09/2009, Volume 015, Issue 08

The easy life is about to end for President Obama. For the first time, he can't defer or delegate or depend on the media to bail him out. He has to stand and fight for the policy that defines his presidency--liberal health care reform. And the fight won't be pleasant.

Obama is exactly where he didn't expect to be. His popularity has declined at a record rate. His supposed power of persuasion has turned out to be nonexistent. More Americans oppose his health care initiative than support it. And Republicans are prepared to combat him and Democrats on every major provision of it.

The large Democratic majorities in the Senate and House may look overwhelming, but they're not. At least a half-dozen Democratic senators are queasy about Obama-style reform. If two of them bolt, Republicans should be assured of the 41 votes that would block a motion to end debate on the legislation. If only a single renegade Democrat emerges, that will suffice so long as all 40 Republican senators, including Maine's Olympia Snowe, hang together.

There's less for Obama to worry about in the House. Speaker Nancy Pelosi can afford to lose about 40 Democrats and still pass Obamacare. Yet there is significant uneasiness in her ranks. When Democrats met last week, 47 said they're opposed to the bill, and four or five sneaked out of the room to avoid declaring themselves. Pelosi softened it ever-so-slightly, and Republicans figure she'll have the votes for passage.

The Senate is the battleground. Republicans are mounting a nonstop, full-court press against Obamacare. Minority leader Mitch McConnell has made an issue of the normally routine "motion to proceed" with discussion of the bill on the Senate floor.

It's at this point that Democrats with misgivings about Obamacare have what McConnell calls their "maximum leverage." Democrats who want non-trivial changes in the bill--Blanche Lincoln of Arkansas opposes the public option, Evan Bayh of Indiana the tax on medical devices--would have great difficulty getting them approved once the bill reaches the Senate floor. It will take 60 votes to remove anything from the bill Senate majority leader Harry Reid introduces at the start of deliberations.

Chances are, the motion to proceed will pass, though 41 votes are enough to defeat it. If it were to lose because of Democratic defections, the bill would have to be altered to accommodate the dissenters, upsetting the balance of taxes, Medicare cuts, and benefits. Liberals would be furious. Reid would be fit to be tied. Obamacare would be thrown off track.

Discombobulating Reid is part of the Republican strategy. Reid is mistake-prone, as he demonstrated recently in trying unsuccessfully to repeal cuts in doctors' fees under Medicare. He is anxious over his dicey reelection prospects next year in Nevada. He's erratic under pressure.

Given the Senate's rules, it's easy for Republicans to prolong the debate into next year. There are two likely benefits. The longer the debate, the more snarled up the Senate becomes in procedural matters and the more likely Reid is to blunder. Even more important is the time it will give Republicans to educate and arouse the public about Obamacare.

They already have a receptive audience. As pollsters Frank Luntz and Lowell Baker noted last week:

The untold story of the past six months is the collapse in support among independents and moderates. Republicans always hated the Obama approach, while Democrats were always in his corner. But to see Americans in the political center turn from cautiously supportive to increasingly opposed is the most significant political consequence of the debate.

Republicans need help from outside Washington to succeed, particularly in states whose senators are less than committed to Obamacare. Grassroots opposition can be pivotal. In 2007, it was largely responsible for derailing an immigration reform bill that might otherwise have been enacted.

Over the past summer, noisy protests at town hall meetings and tea parties had an enormous impact. But the intensity of that opposition has subsided just as counterpressure by liberal interest groups has risen. Republican leaders believe that fervor must be jacked up once more, reminding key Democratic senators of the risk of voting for Obamacare.

There's one tricky part for Republicans in the health care fight. They don't want the bill to be improved--that is, made a bit less sweeping and draconian. The bill can't be improved sufficiently to satisfy Republicans, but it might become more palatable to worried Democrats. Republicans can probably count on liberal Democrats to prevent this by rejecting moderate amendments (which would face the 60-vote hurdle).

The shrewdness of McConnell's emphasis on the vote to proceed will become clear when the final cloture vote--which would end debate on the bill--is taken. Democratic senators with qualms about Obamacare are likely to have voted for the motion to proceed, explaining they'll seek changes in the bill. In all likelihood, those changes won't be approved. Obamacare will have emerged from weeks of debate roughly the same. Will moderate Democrats then vote for cloture on the motion to end debate?

This is the key vote. Reid will likely need to hold all the Democrats. Here Obama's role is crucial. It may be up to him alone to keep Democrats from defecting. One or two votes could decide the outcome. If Obama fails, his health care initiative may die.

We know what the president will say in one-on-one meetings or phone calls. My presidency and our party's future are at stake. So is yours. If I lose, you lose too. If we don't pass health care reform now, we never will. We have to pass a bill. I promise I'll support the changes you want later--after the bill passes. Your constituents who oppose us now will come around. I'll help your reelection. And so on. If that doesn't work, Obama's aides can take the Chicago approach: Vote against us, and we'll make sure you regret it.

In a pinch, a president can usually get the one or two votes he needs on an important issue. The office of the presidency gives him the prestige and influence to do this. But influence can slip away. We'll find out soon if Obama's has.

Fred Barnes is executive editor of THE WEEKLY STANDARD.
Power User
Posts: 9481

« Reply #449 on: November 01, 2009, 01:12:39 PM »

Link to the mis-named house bill 'Affordable Health Care for America Act' of October 29, 2009

Just a note to remember as you read the 2000 pages, the poor in America already have free health care, totally free.  Without any thanks, YOU are already paying for it. 

This bill is about the CONTROL of the rest of the health care system - toward COERCION and away from personal responsibility and market choices.

If you have a doubt, please word search the coercive proclamation "Shall" and you will find it 3,424 times! The framers used the word shall to organize the government, there shall be 2 senators from each state etc. and for what the government 'shall not' do, such as congress 'shall not' pass any law infringing on free speech or right to bear arms, or so it says.  This bill states what 'shall' be more than 3000 times more than does the U.S. Constitution.

From my count, God only needed the word 'Shall' 8 times in the Ten Commandments to guide our behavior as humans.

Maybe that answers the obvious question about this political machine, who do they think they are?
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