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3 July, 2009

How Other Countries Judge Malpractice

The health-care systems Democrats want to emulate don't allow contingency fees or large jury awards

In his recent speech to the American Medical Association, President Barack Obama held out the tantalizing possibility of reforming medical malpractice law as part of a comprehensive overhaul of the U.S. health-care system. As usual, he hedged his bets by declining to endorse the only medical malpractice reform with real bite -- a national cap on damages for pain and suffering, such as the ones enacted in more than 30 states.

These caps are usually set between $250,000 to $500,000, and they can make a substantial difference. Other reforms, such as rules that limit contingency fees, shorten statutes of limitation, or confine each defendant's tort exposure to his proportionate share of the harm, have small and uncertain effects.

Medical malpractice, of course, is not just an American issue. And now that the U.S. is considering universal health-care systems similar to those found elsewhere, it's worth a quick peek at their medical malpractice systems -- which usually attract far less controversy, and are far less expensive, than our own.

Litigation in the U.S. has at least four distinctive procedural features that drive up malpractice costs. The first is jury trials, which can veer out of control and in any case introduce significant uncertainty. The second is the contingency-fee system, which allows well-heeled lawyers to self-finance litigation. The third is the rule that makes each side bear its own costs. This induces riskier lawsuits than are undertaken in most other countries, such as Canada, England and most of Europe, where the loser pays the legal costs of the winner. The fourth is extensive pretrial discovery outside the direct supervision of judges, which occurs far more readily here than elsewhere.

Even these features aren't the whole story. American judges frequently let juries decide whether honest mistakes are negligent. Judges in other nations are less likely to do so. American courts commonly think it proper for juries to infer medical negligence from the mere occurrence of a serious injury. European judges usually will not.

American plaintiffs are sometimes spared the heavy burden of identifying particular acts of negligence, or of showing the precise causal connection between a negligent act and an actual injury. Lastly, damage awards for lost income and medical expenses in the U.S. tend to dwarf awards made elsewhere -- in part because governments elsewhere provide this medical care from their nationalized systems. In sum, the medical malpractice system provides incentives for plaintiffs that really do matter. Americans, for example, file claims about 3.5 times more often than Canadians.

The overall picture is still more complex, since there are major variations in medical malpractice rules in different American states, and differences within states, such as between juries in big cities and those in small towns. Doctrinal reform cannot stop these abuses. What is needed is the replacement of juries with specialized commissions like those in France, which help reduce litigation expenses and promote uniformity in case outcomes across regions.

What then does this quick survey teach us about the ability of our system to deter medical injuries and compensate its victims? Not much that's encouraging.

A study led by David Studdert published in the 2006 New England Journal of Medicine concluded that the administrative expenses of the malpractice system were "exorbitant." And worse, it found errors in jury verdicts in about a quarter of the litigated cases. Juries denied compensation properly due in 16% of the cases, and awarded it about 10% of the time when it was unwarranted. These error rates don't include damage awards set at improper levels.

More disturbingly, a careful 1992 study by Donald Dewees and Michael Trebilcock in the Osgood Hall Law Journal concluded that the frequency of medical malpractice in Canada was about the same as in the U.S. -- for about 10% the total cost. In other words, our costly system doesn't seem to do much to deter malpractice. On medical malpractice at least, Canada does better than we do.

The U.S. cannot ignore serious reform. To be sure, medical malpractice premiums constitute well under 1% of the total U.S. health-care bill. But defensive medicine adds perhaps as much as 10%. High malpractice costs can shut down clinics that serve vulnerable populations, leading to more patient harm than the occasional case of malpractice.

The best reform would be to allow physicians, hospitals and patients to contract out of the liability mess by letting the parties reject state-imposed malpractice rules. They could, for example, choose to arbitrate, to waive jury trials, or to limit damage recovery. Stiff competition and the need to maintain reputation should keep medical providers in line in such a system. Market-based solutions that make the private sector more responsive should in turn undermine the case for moving head-first into a government-run health-care system with vast, unintended inefficiencies of its own.

SOURCE




Health Care Reform Could Harm More Than It Helps

Congress has started in earnest its effort to enact President Obama’s promise for universal health care. Many in the mainstream media repeat the meme that this effort will finally ensure quality health care for all Americans, but the truth is that enactment will bring profound changes for the average insured person -- changes that will more likely lower the quality of coverage particularly for those individuals reliant on advanced medicines.

Besides creating a federally run insurance network to compete with existing private sector insurance, the main bill introduced by Senator Edward Kennedy (D-MA) requires the federal government to subsidize insurance premiums for families of four with incomes up to $100,000. It creates a national mandate for every American to obtain health insurance with penalties on as many as 5 million Americans who don’t have coverage (although the bill does include an “exceptional financial hardship” exemption for a few). Not leaving employers out of the picture, the bill places a similar mandate on all medium and large businesses forcing them to provide coverage and it expands Medicaid to cover people with incomes up to 150 percent of the poverty level ($16,245 for an individual and $33,075 for a family of four). The end result is that the already ballooning deficit will expand beyond any comprehensible level and private insurance will be crowded to the periphery.

Perhaps the most consequential change will be the additional cost controls the Kennedy bill places on the existing insurance sector including eliminating nearly all options for insurers to either deny or price different applicants according to their health needs. Taken together with the expansions in the government sector, these changes will lead to radically different treatment tomorrow for patients who already have coverage. For these individuals the changes could be deadly.

One particular area of concern is the potential changes in access to life saving statins - a class of drugs that lowers cholesterol levels for those at risk of heart disease - that will come as a result of this bill. Heart disease is the number one killer in the United States and any changes to our health care system should improve this situation, not exacerbate it.

Unfortunately Senator Kennedy’s bill will likely limit or reduce access to life saving statins for existing patients which is likely to lead to more deaths, not fewer. Why? The cost sharing and non-discrimination mandate which will herd high risk and already ill patients into the pre-existing insurance pool provided in Kennedy’s bill will force insurers to reduce coverage and spend less per patient. This means that on top of the existing pressures being pushed by today's insurance providers, tomorrow's patients will face an even greater array of restrictions on the choices of doctors and medical care they receive.

Like many pharmaceuticals, there are a variety of cholesterol-lowering statin medications and they each have different benefits and uses. Different patients with different risk factors require different medications. It is those attributes – gender, race, family history, age – and other medical risk factors which have traditionally been the primary decision drivers for prescribing statins.

But because Kennedy’s bill requires rationing to achieve its goals, the cost of statin medications will drive health care decisions, not patient needs. Many critics of the existing insurance network rightly recognize the existing pressures by the insurance industry to try to lower costs by limiting patients pharmaceuticals, the Kennedy bill would dramatically exacerbate this phenomenon.

Getting all patients including existing covered patients to meet or exceed their cholesterol goals should be the priority, not assuming that the cheapest statin medication is the best.

Just as night follows day, the health sector will respond to these federal mandates by requiring the lowest priced statin to be used regardless of applicability and this will have deadly consequences. There simply is no good reason for this kind of cost containment experimentation, particularly for the high risk populations that rely on statins. In the long run it won’t be more cost effective, and it will cost lives.

The costs for brand name medications and insurance formularies are constantly changing and today most boomers have access to the most effective heart disease medications without realizing it. Before rushing headlong into a system of government controlled health care layered on top of an already over-regulated industry patients should determine what the impact on their own personal health care needs will occur with these proposed changes. Unless dramatic changes are made, this health care bill could prove to be a major bust for existing patients.

SOURCE




Canada's Single-Prayer Health Care

A critically ill premature baby is moved to a U.S hospital to get the treatment she couldn't get in the system we're told we should emulate. Cost-effective care? In Canada, as elsewhere, you get what you pay for.

Ava Isabella Stinson was born last Thursday at St. Joseph's hospital in Hamilton, Ontario. Weighing only two pounds, she was born 13 weeks premature and needed some very special care. Unfortunately, there were no open neonatal intensive care beds for her at St. Joseph's — or anywhere else in the entire province of Ontario, it seems.

Canada's perfectly planned and cost-effective system had no room at the inn for Ava, who of necessity had to be sent across the border to a Buffalo, N.Y., hospital to suffer under our chaotic and costly system. She had no time to be put on a Canadian waiting list. She got the care she needed at an American hospital under a system President Obama has labeled "unsustainable."

Jim Hoft over at Gateway Pundit reports Ava's case is not unusual. He reports that Hamilton's neonatal intensive care unit is closed to new admissions half the time. Special-needs infants are sent elsewhere and usually to the U.S.

In 2007, a Canadian woman gave birth to extremely rare identical quadruplets — Autumn, Brooke, Calissa and Dahlia Jepps. They were born in the United States to Canadian parents because there was again no space available at any Canadian neonatal care unit. All they had was a wing and a prayer.

The Jepps, a nurse and a respiratory technician flew from Calgary, a city of a million people, 325 miles to Benefit Hospital in Great Falls, Mont., a city of 56,000. The girls are doing fine, thanks to our system where care still trumps cost and where being without insurance does not mean being without care.

Infant mortality rates are often cited as a reason socialized medicine and a single-payer system is supposed to be better than what we have here. But according to Dr. Linda Halderman, a policy adviser in the California State Senate, these comparisons are bogus.

As she points out, in the U.S., low birth-weight babies are still babies. In Canada, Germany and Austria, a premature baby weighing less than 500 grams is not considered a living child and is not counted in such statistics. They're considered "unsalvageable" and therefore never alive.

Norway boasts one of the lowest infant mortality rates in the world — until you factor in weight at birth, and then its rate is no better than in the U.S.

In other countries babies that survive less than 24 hours are also excluded and are classified as "stillborn." In the U.S. any infant that shows any sign of life for any length of time is considered a live birth.

A child born in Hong Kong or Japan that lives less than a day is reported as a "miscarriage" and not counted. In Switzerland and other parts of Europe, a baby is not counted as a baby if it is less than 30 centimeters in length.

In 2007, there were at least 40 mothers and their babies who were airlifted from British Columbia alone to the U.S. because Canadian hospitals didn't have room. It's worth noting that since 2000, 42 of the world's 52 surviving babies weighing less than 400g (0.9 pounds) were born in the U.S.

It must be embarrassing to Canada that a G-7 economy and a country of 30 million people can't offer the same level of health care as a town of just over 50,000 in rural Montana. Where will Canada send its preemies and other critical patients when we adopt their health care system?

As we have noted, in Canada roughly 900,000 patients of all ages are waiting for beds, according to the Fraser Institute. There are more than four times as many magnetic resonance imaging (MRI) units per capita in the U.S. as in Canada. We have twice as many CT scanners per capita.

Expensive? Wasteful. Just ask the Jepps or the parents of Ava Isabella Stinson.

SOURCE




Another NHS failure

'Thousands of Britons' travel abroad for IVF, research finds. Shameful for the country that invented IVF

Hundreds of British couples are travelling abroad for IVF treatment every month, says the first study to evaluate the extent of “fertility tourism” around Europe. Restricted access to fertility treatment on the NHS, the high cost of private therapy at domestic clinics and a serious shortage of donated eggs are driving couples to visit overseas clinics for help in starting a family.

Almost two thirds involve women over 40, who do not qualify for free IVF on the NHS. Britons are more likely than those from any other country to cite access to treatment as the chief reason for going abroad, the study reported. A private IVF cycle typically costs at least £4,000 in Britain — twice the amount charged in parts of Southern and Eastern Europe. IVF patients who need donated eggs are particularly likely to travel. Domestic donors are in short supply because of the removal of anonymity and tough rules against selling eggs.

Spain and the Czech Republic are prime destinations, due to laws allowing donors to be paid €900 (£765) and €500 respectively for eggs. British donors get no more than £250 in expenses.

The new figures come from a study that counted all overseas patients treated by 44 clinics in Belgium, the Czech Republic, Denmark, Slovenia, Spain and Switzerland over a one-month period last autumn. The participating clinics performed 1,230 IVF cycles on overseas patients in this period, 53 involving British women. As the study ran only for a month, in a small fraction of Europe’s clinics, the true number of Britons who travel for treatment each year will probably run into thousands.

Françoise Shenfield, of University College Hospital, London, told the European Society of Human Reproduction and Embryology conference in Amsterdam that she understood why couples might consider travelling, but they should know that foreign clinics were not regulated to UK standards. Many overseas doctors, for example, will transfer more than two embryos to the womb — a practice largely banned in Britain because of the high risk of causing hazardous twin and triplet pregnancies.

SOURCE





2 July, 2009

NHS doctors warn Stafford Hospital deaths scenario will repeat

The problems at Stafford Hospital, where more than 400 deaths were caused by poor care, remain a real risk in the NHS and could easily happen elsewhere, doctors warned yesterday. The preoccupation with budgets and targets is exposing the NHS to pressures that compromise care standards, with managers too quick to pursue financial incentives, such as turning their hospitals into foundation trusts, the British Medical Association’s annual conference was told.

George Rae, a member of the BMA’s council, said that the Government’s reform agenda and its “misplaced confidence in markets getting the right solutions” was one of the main reasons that problems had arisen at Mid-Staffordshire NHS Foundation Trust.

A highly critical report from the Healthcare Commission, published in March, detailed a catalogue of failings at the trust, which runs Stafford and Cannock Chase hospitals, prompting apologies from the Prime Minister and the Health Secretary. Shocking standards of care for patients admitted through A&E put many people at risk and led to deaths, the report concluded. Its authors said that between 400 and 1,200 more people had died than would have been expected in the three-year period to 2008. The report, the most damning yet compiled by regulators on an NHS hospital in England, also raised serious questions about the monitoring and regulation of Mid-Staffordshire, which was awarded elite foundation status and continued to receive positive annual reports despite its many problems.

Gordon Brown said it was an isolated incident, adding that the Healthcare Commission, the predecessor to the newly formed Care Quality Commission, had assured him that there were no other hospitals or parts of the NHS that had displayed similar failings.

But Dr Rae said that the failings in Mid-Staffordshire were “an inevitable, almost inexorable result of a market-based health agenda in England”, which made co-operation and collaboration in the NHS “almost an anathema”.

Speaking in support of a motion highlighting the concerns and condemning the perverse impact of targets and financial incentives, Mary McCarthy, a doctor from Shrewsbury, said that other hospitals were under similar pressures. “The problems that occurred at Mid-Staffs are not unique,” Dr McCarthy said. “The concentration on targets distorts clinical care and the pressure by trusts to keep patients out of hospital may not be clinically safe.” Dr McCarthy said that England had fewer beds per 100,000 population than anywhere else in Europe “by a long way” — 388, compared with 640 in Belgium, 720 in France and 870 in Germany. “The concern is that the Mid-Staffordshire problem is not an isolated incident but has the potential to happen in every other area,” she said.

Families described “Third World” conditions at Mid-Staffordshire, with some patients drinking water from vases because they were so thirsty and others screaming in pain. The Healthcare Commission found deficiencies at virtually every stage, including inadequately trained staff who were too few in number, junior doctors left alone in charge at night, and dirty wards and bathrooms.

The motion, which was passed unanimously, also called for greater support of whistleblowers who raise patient safety concerns.

Speaking on the opening day of the BMA’s conference, Hamish Meldrum, the association’s chairman, issued a warning to the Government. “Don’t play around with our health service. It’s not a toy you cast aside and replace with the latest product off the shelf when you’ve tired of it. It needs looking after. It’s our NHS, make it yours too,” Dr Meldrum said in his keynote address. He said that there had never been a better time to abandon the market reforms in England, calling on Andy Burnham, the new Health Secretary, to “end this ludicrous, divisive and expensive experiment of the market in healthcare in England”.

He added that a target-driven culture had “infested the NHS in recent years and that seems to put financial outcomes for trusts above clinical outcomes for patients”. “We will not tolerate a substandard service for our patients and we will not tolerate a culture of muzzling or bullying of our staff,” Dr Meldrum said.

SOURCE




California Slashes Health Benefits to Save Money

Effective July 1st, the state-run health care insurance system (Medi-Cal/Denti-Cal) will eliminate adult dental care benefits, podiatry benefits and optometry benefits in an effort to save money.

Apparently, health care decision-makers blew right past any thoughts of rationing the benefits and opted to make them simply disappear completely.

The California Primary Care Association pitched a complaint but a Superior Court judge ruled against them.

In any event, one might logically expect a similar approach to cost-saving when a national health care scheme is adopted.

SOURCE




Public schools and the public healthcare option

Imagine a private school where students sat in a math class for weeks misbehaving and learning nothing. Imagine that school gets on TV news because the administrators suspended the young lady who blew the whistle by taking a cell phone video and giving it to her mom who confronted them. Do you think that school would have enough students to start the next school year? Well, this happened at a public high school in the SF Bay Area:

A freshman at Clayton Valley High School in Concord, California says that’s just what she had to endure in algebra as her classmates went wild. “People smoking marijuana in the classroom. They smoke cigarettes.” Arielle said. “There was one kid who peed in a bottle and threw it across the room.'

Clayton Valley High School is a public high school, and I have no doubt that it will open with just as many students next year as it did this year. When parents pay for an education, they absolutely will not tolerate a school run like Clayton Valley HS. When the state provides an education for free, a vast majority of parents will generally take what they can get and call it good enough. They might picket and protest for improvement, but they won’t take their kids out of the school.

What does this have to do with health care? The public option being created as part of “ObamaCare” is rather similar to public schools, in that it is designed to undercut private health insurance on the basis of price:

The Lewin Group crunched the numbers through their health care model and found that premiums for the public option plan would be 30 to 40 percent lower than private plans.

A price difference of that magnitude would lead employers to throw their employees into the ObamaCare option:

Overall, the Lewin Group estimates that if Medicare reimbursement rates are imposed, the number of Americans with private health insurance would decline by almost 120 million, leaving only 50 million Americans in the private insurance market.

That would leave approximately 15% of the population in non-government health care, just slightly more than the percentage of students that go to private school. At that point, ObamaCare will have similar monopoly power to the public schools. I expect abuses and incompetence similar to that captured by Arielle Moore at Clayton Valley High when the public option achieves its monopoly power. The scary difference is that instead of not learning algebra, the people who have to suffer that abuse and incompetence will be missing out on life-saving medical treatments.

A human life is too important to waste on government health care.

SOURCE





1 July, 2009

Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits

As this presidential campaign continues, the candidates' comments about health care will continue to include stories of their own experiences and anecdotes of people across the country: the uninsured woman in Ohio, the diabetic in Detroit, the overworked doctor in Orlando, to name a few. But no one will mention Claude Castonguay — perhaps not surprising because this statesman isn't an American and hasn't held office in over three decades.

Castonguay's evolving view of Canadian health care, however, should weigh heavily on how the candidates think about the issue in this country. Back in the 1960s, Castonguay chaired a Canadian government committee studying health reform and recommended that his home province of Quebec — then the largest and most affluent in the country — adopt government-administered health care, covering all citizens through tax levies. The government followed his advice, leading to his modern-day moniker: "the father of Quebec medicare." Even this title seems modest; Castonguay's work triggered a domino effect across the country, until eventually his ideas were implemented from coast to coast.

Four decades later, as the chairman of a government committee reviewing Quebec health care this year, Castonguay concluded that the system is in "crisis."

"We thought we could resolve the system's problems by rationing services or injecting massive amounts of new money into it," says Castonguay. But now he prescribes a radical overhaul: "We are proposing to give a greater role to the private sector so that people can exercise freedom of choice."

Castonguay advocates contracting out services to the private sector, going so far as suggesting that public hospitals rent space during off-hours to entrepreneurial doctors. He supports co-pays for patients who want to see physicians. Castonguay, the man who championed public health insurance in Canada, now urges for the legalization of private health insurance.

In America, these ideas may not sound shocking. But in Canada, where the private sector has been shunned for decades, these are extraordinary views, especially coming from Castonguay. It's as if John Maynard Keynes, resting on his British death bed in 1946, had declared that his faith in government interventionism was misplaced.

What would drive a man like Castonguay to reconsider his long-held beliefs? Try a health care system so overburdened that hundreds of thousands in need of medical attention wait for care, any care; a system where people in towns like Norwalk, Ontario, participate in lotteries to win appointments with the local family doctor.

Years ago, Canadians touted their health care system as the best in the world; today, Canadian health care stands in ruinous shape.

Sick with ovarian cancer, Sylvia de Vires, an Ontario woman afflicted with a 13-inch, fluid-filled tumor weighing 40 pounds, was unable to get timely care in Canada. She crossed the American border to Pontiac, Mich., where a surgeon removed the tumor, estimating she could not have lived longer than a few weeks more.

The Canadian government pays for U.S. medical care in some circumstances, but it declined to do so in de Vires' case for a bureaucratically perfect, but inhumane, reason: She hadn't properly filled out a form. At death's door, de Vires should have done her paperwork better.

De Vires is far from unusual in seeking medical treatment in the U.S. Even Canadian government officials send patients across the border, increasingly looking to American medicine to deal with their overload of patients and chronic shortage of care.

Since the spring of 2006, Ontario's government has sent at least 164 patients to New York and Michigan for neurosurgery emergencies — defined by the Globe and Mail newspaper as "broken necks, burst aneurysms and other types of bleeding in or around the brain." Other provinces have followed Ontario's example.

Canada isn't the only country facing a government health care crisis. Britain's system, once the postwar inspiration for many Western countries, is similarly plagued. Both countries trail the U.S. in five-year cancer survival rates, transplantation outcomes and other measures.

The problem is that government bureaucrats simply can't centrally plan their way to better health care.

A typical example: The Ministry of Health declared that British patients should get ER care within four hours. The result? At some hospitals, seriously ill patients are kept in ambulances for hours so as not to run afoul of the regulation; at other hospitals, patients are admitted to inappropriate wards.

Declarations can't solve staffing shortages and the other rationing of care that occurs in government-run systems.

Polls show Americans are desperately unhappy with their system and a government solution grows in popularity. Neither Sen. Obama nor Sen. McCain is explicitly pushing for single-payer health care, as the Canadian system is known in America.

"I happen to be a proponent of a single-payer health care program," Obama said back in the 1990s. Last year, Obama told the New Yorker that "if you're starting from scratch, then a single-payer system probably makes sense."

As for the Republicans, simply criticizing Democratic health care proposals will not suffice — it's not 1994 anymore. And, while McCain's health care proposals hold promise of putting families in charge of their health care and perhaps even taming costs, McCain, at least so far, doesn't seem terribly interested in discussing health care on the campaign trail.

However the candidates choose to proceed, Americans should know that one of the founding fathers of Canada's government-run health care system has turned against his own creation. If Claude Castonguay is abandoning ship, why should Americans bother climbing on board?

SOURCE




NHS children's emergency doctor high on gas

"Chahal" is an Indian surname

A DOCTOR inhaled laughing gas for "fun" while he was treating children in an emergency ward, a medical tribunal has been told. The paediatrician, Dr Jonathan Chahal, who work at Royal Liverpool Hospital in England’s north was found out when nurses overheard him giggling in a resuscitation room in 2007, the tribunal heard. The 33-year-old doctor then allegedly persuaded several nurses to breathe in the anaesthetic gas Entonox after telling them: "It makes me feel floaty."

The drug has a warning from manufacturers saying people should not use machinery for up to 12 hours after taking it, the General Medical Council was told.

The Daily Mail reports that the tribunal was told how nurses Christine Timmons and Siobhan Fitzgerald were on duty at 2pm on June 27 when they went into the resuscitation room and spotted Chahal taking Entonox. "There was a blue canister behind the desk and it made a characteristic hissing sound," counsel for the General Medical Council Craig Sephton said. "They were invited by Dr Chahal to sample the Entonox. "Siobhan Fitzgerald was on duty that evening at 9.15pm she was talking to a colleague when they heard the sound of giggling from the resuscitation room.

"They went in and found the doctor taking Entonox again. They got into a discussion and he asked them if they had tried it before. He said it was fun and made him feel floaty. He invited them to do it so they did."

Just days later two other nurses, Briony Routledge and Amanda Howe, were on duty at the emergency ward when they spotted Chahal using Entonox consistently throughout the night. Mr Sephton added: "He offered it to them and also offered it to a student nurse Helen Aspinall - two of them accepted Doctor Chahal's offer."

Chahal was later quizzed by bosses who asked about his use of "recreational drugs." He said he smoked cannabis as a student but otherwise nothing. But Mr Sephton said one doctor took hair samples from Chahal - tests of which showed he had taken cocaine.

The doctor denies his fitness to practise was impaired.

SOURCE





30 June, 2009

Welcome to Canada!

By Mark Steyn

Somewhere in America Alone, I cite an example of the logical reductio of socialized health care: "the ten-month wait for the maternity ward". I've been adding to the file ever since. Here's the latest entry, from Hamilton, Ontario: "Hamilton's neonatal intensive care unit (NICU) was full when Ava Isabella Stinson was born 14 weeks premature at St. Joseph's Hospital Thursday at 12:24 p.m. A province-wide search for an open NICU bed came up empty, leaving no choice but to send the two-pound, four-ounce preemie to Buffalo that evening."

Well, it would be unreasonable to expect Hamilton, a city of half-a-million people just down the road from Canada's largest city (Greater Toronto Area, five-and-a-half million) in the most densely populated part of Canada's most populous province (Ontario, 13 million people) to be able to offer the same level of neonatal care as Buffalo, a post-industrial ruin in steep population decline for half-a-century.

But wait! The fun and games are only just beginning. When a decrepit and incompetent Canadian health bureaucracy meets a boneheaded and inhuman American border "security" bureaucracy, you'll be getting a birth experience you'll treasure forever: "Her parents, Natalie Paquette and Richard Stinson, couldn't follow their baby because as of June 1, a passport is required to cross the border into the United States. They're having to approve medical procedures over the phone and are terrified something will happen to their baby before they get there".

Once Buffalo enjoys the benefits of Hamilton-level health care, I wonder where Ontario will be shipping the preemies to. Costa Rica?

SOURCE




British doctors want right to pray for patients without fear of reprisal

Doctors are calling for the legal right to be allowed to pray alongside their patients. The British Medical Association is to debate whether the threat of disciplinary action should be lifted from NHS staff who try to meet patients' spiritual or religious needs. There has been concern among doctors and nurses that even offering to talk about such matters could be grounds for suspension.

Guidance issued by the Department of Health in a document called Religion Or Belief: A Practice Guide For The NHS has fuelled anxieties. It says such requests could be seen as harassment or intimidation and could lead to staff being disciplined.

Cancer specialist Dr Bernadette Birtwhistle, of the Christian Medical Fellowship, said the debate on Wednesday at the BMA's annual meeting in Liverpool would clarify how doctors and other staff could provide spiritual care for patients. She said: 'It's getting to where many of us feel we cannot talk to patients about their spiritual or religious needs or ask them about praying. 'Christianity is being seen as something that is unhelpful. 'Freedom of speech is being curtailed too much, and I don't think it is always in the benefit of patients.'

The move follows the case last year of nurse Caroline Petrie, from Westonsuper-Mare last year, who was suspended after a patient complained that she had offered to pray for her. North Somerset NHS Trust agreed she could return to work and pray for patients as long as she asked them first if they had any spiritual needs.

The Department of Health guidance states that members of some religions are expected to convert other people. It adds: 'To avoid misunderstandings and complaints, it should be made clear to everyone from the first day of training or employment that such behaviour could be construed as harassment under the disciplinary and grievance procedures.'

Dr Hamish Meldrum, chairman of the BMA Council, said the importance of the issue for a minority of people 'could not be underestimated'. He said no healthcare professional should be able to impose their beliefs but it was 'perfectly acceptable' for patients with a terminal illness to be asked if they wanted to see a chaplain. Dr Vivienne Nathanson, director of professional activities at the BMA, said: 'It's hugely important that it's allowed, but it's not an opportunity to impose your views on patients.'

The BMA will debate the matter, making it clear that offering to pray for a patient should not be grounds for suspension. The Department of Health said the document was a guide to encourage awareness for staff and patients.

SOURCE




States consider opting out of federal healthcare

Lawmakers in six states are considering legislation to "protect" citizens from a federal health care plan by creating statewide initiatives to vote on whether to opt out of the national program -- even before Congress has created the program

Congress has yet to come up with a clear prescription for the nation's health care system. But some state legislators are already urging voters not to take the medicine. Under Arizona's Health Care Freedom Act, which was passed by the state legislature this week, a voting initiative will be placed on the 2010 ballot that, if passed, will allow the state to opt out of any federal health care plan. Five other states -- Indiana, Minnesota, New Mexico, North Dakota and Wyoming -- are considering similar initiatives for their 2010 ballots.

"Our health care freedoms are very much at risk by health care reforms proposed in Washington, D.C.," said Arizona state Rep. Nancy Barto, the Republican legislator who sponsored the measure. "We needed to act as a state to protect our citizens and ensure that they will always be able to buy their own health care and not be forced into a plan they don't want."

But an opponent of the bill, state Rep. Phil Lopes, says the measure has less to do with individual freedom and more to do with the protecting the status quo. "The proponents of this are saying the system we have now works and we don't want any kind of reform," the Democratic legislator said. "This flies in the face of what the public tells us they want."

Not so, says Christine Herrera, director of the Health and Human Services Task Force for the American Legislative Exchange Council (ALEC). The group's 1,800 state legislator members have endorsed a resolution opposing a Medicare-modeled federal health plan and a national health insurance exchange, two concepts that are gaining ground in Washington. "Our state legislatures are looking at what's going on in Washington as trampling state's rights," Herrera says.

Some state legislators say they worry that a government-mandated program will effectively eliminate their traditional role in regulating health insurers -- an important power base. Others raise constitutional concerns. "The real goal of national health insurance exchange isn't competition -- it's a federal power grab that flies in the face of the Tenth Amendment," says Wisconsin state Rep. Leah Vukmir, a Republican.

The Tenth Amendment ensures that "the powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." It's the same constitutional roadblock Franklin D. Roosevelt ran into during the Great Depression when he tried to ram through the first round of recovery programs under the New Deal. In a series of rulings, the U.S. Supreme Court found the National Recovery Act, the Agricultural Adjustment Act and several other recovery programs unconstitutional.

But constitutional scholars say it's unlikely history will repeat itself with health care reform efforts. "It's hard to imagine Congress passing anything that would be plausibly challengeable under the Tenth Amendment, but it's certainly theoretically possible," said Paul Bender, professor of constitutional law at Arizona State University. He said Congress has broad powers to regulate interstate commerce, which would include something as big as health care.

But Bender also said he sees a striking similarity between the current makeup of the Supreme Court and the "Nine Old Men" who stymied FDR's sweeping reform efforts in the 1930s. "Both sets of jurists seem to share a belief that the balance of power has shifted too far in favor of Congress at the expense of the states," Bender said.

Some state lawmakers who oppose President Obama's efforts to implement a national health care plan say the inevitable result will be socialized medicine. "The public plan and national health insurance exchange will squeeze out private insurance and put us on the road to single-payer health care," warns Georgia state Sen. Judson Hill, a Republican. "Having the public plan now will mean socialized medicine later," he said.

Hill and other state legislators expressed concerns that millions of people will drop their private coverage if there is political pressure to keep a public plan's premiums low and benefits high. And if private insurers leave the market, they say, consumers will essentially be left with no choice of plans and no control over how their health care dollars are spent.

"Pure speculation," says Lopes. "In 1964 this was the same argument insurance companies made with President Lyndon Johnson when he proposed Medicare. Medicare did not do away with private insurance companies. They did very well."

"Protecting the rights of individuals to be in control of their health and health care must be a fundamental component of health care reform," says Dr. Erick Novack, chairman of Arizonans for Health Care Freedom, which promoted the state's ballot measure. "We are confident that the people of Arizona will vote to ensure their own rights."

With a constitutional challenge to health care reform problematic at best, that vote may turn out to be largely symbolic. But for now, that doesn't seem to be stopping other states from following Arizona's lead.

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29 June, 2009

A Duty to Die?

Coming to you sooner than you may think. Don't get old in Obama's America. Withdrawing at least some care from the elderly is going to be very tempting once costs balloon they way they will

About twenty-five years ago, then-Colorado Governor Richard D. Lamm stirred up a bee's nest of controversy with his assertion that elderly, terminally ill patients have “got a duty to die and get out of the way.” While the Governor has since waffled on whether he actually meant the words he actually said, plenty of others have not on this issue. A good example of this, and perhaps a good gauge of where the debate in this country is headed as we come closer to the reality of a one-payer system for health care is the claim by British Baroness Warnock that dementia patients “should consider ending their lives because they are a burden on the NHS [National Health Service] and their families.”

How does one get to the point of saying that some members of society have an actual duty to die? What moral reasoning lies in back of such a stance? While it is possible to produce a full-blown Marxist-Socialist argument in support of such a position—for example that these people cannot actively support and indeed may actually hinder Marxist Revolutionary progress, hence they have a duty to get out of the way—in Western Society, arguments underpinning a “duty to die” have usually arisen instead from the moral theory of Utilitarianism. Not itself a Socialist Ethic, it more often than not comes down with the same moral prescriptions as Socialism because like it, Utilitarianism emphasizes the supposed general good of society over the interests of the individual.

Invented in the nineteenth century by philosopher Jeremy Bentham as a means to provide moral support for reforms to the British legal system, Utilitarianism has become one of the dominant systems of secular ethics. Its deceptive simplicity has lured many into its camp for, under this view, we as human beings have only one all-encompassing moral duty: to act so as to promote the greatest good (as far as the consequences of our actions are concerned) for the greatest number of people (be it those immediately affected by what we do or society as a whole).

Its founder Bentham originally understood as ‘good’ that which increases the overall balance of happiness in society or at least lessens unhappiness. Optimistically, Bentham initially thought that we could work out our moral duty with near mathematical precision by comparing the consequences of two possible courses of action in terms of their production of overall societal happiness. Unrealistically, he thought we could talk about it in measurable units. This turned out to be a non-starter because we cannot know whether we have two or ten of something until we know what counts as having one of that thing. And how can we say with any precision what is to count as one unit of happiness?

Enter the Cost-Benefit Analysis. While we may not be able to specify with any precision what counts as a unit of happiness, we do know what counts as one dollar. Because of the impracticality of talking about moral right and wrong in terms of the promotion of human happiness, a number of modern utilitarians have tied together their theory with the business practice of developing a cost-benefit analysis. Here the morally right course of action then becomes what on balance produces the greatest benefits for the costs involved. This marriage of an essentially value-neutral accounting practice with utilitarian moral theory produces a deadly combination. For now, in the realm of health care spending, it is not just financially prudent—a matter of good business sense—to make decisions in terms of what produces the most benefits for the costs involved, it is our moral duty to do so!

The costs of treating elderly patients whose prognosis is poor and who have much less to give back to society than those much younger, even if their course of treatment is successful, result in insufficient benefits to justify them for the utilitarian. In a health care system governed by the free market, individuals may nonetheless choose to incur these costs of treatment because they are spending their own money either directly or for insurance premiums to their private insurer. But in a single-payer system, the costs of health care for individuals are the costs of it to society. If in it officials deciding on the allocation of care see it as their moral obligation to do so in a way that produces the most benefits for society for the costs involved, then elderly patients whose treatment will likely produce far fewer benefits will invariably lose out and be denied care. But moralists like Baroness Warnock argue that they should accept this consequence as their moral duty to society as it reduces society’s costs and the emotional burden on their families. It is, she argues, their moral duty to die!

At this point, some readers may want to ask, “But isn’t human life itself an unqualified good, to be preserved no matter what the costs? Does not this patient have an inalienable right to life that alone would justify his or her treatment?” What would a utilitarian say of an appeal to this right? For utilitarians, rights are derivative on duties, any rights we have are derived from duties others have toward us and these duties are determined by what produces the greatest good for the greatest number of persons. If it does so to provide members of society with universal health care, as some utilitarians would claim, then society has a duty to do so. As a result, individuals have a right to expect this provision from society. Utilitarianism can thus support this supposed positive right to universal health care. Conversely, however, we have no rights that are not derived from our sole obligation to promote society’s greater good and, what is more important, can have no rights that would conflict with this obligation. So, if providing care to an elderly, terminally ill patient conflicts with this obligation then that patient has no right to expect such care. Thus, utilitarianism is destructive of rights like the right to life —as will be government-administered universal health care.

SOURCE




Beware New York Times Polls, “46 Million Uninsured” and Other ObamaCare Hoaxes

If Barack Obama’s health care overhaul is such a good idea, why must its proponents resort to deception when advocating it?



When something can stand on its own merits, there is obviously no need to prevaricate. And the fact that efforts to socialize America’s health care sector cannot stand on their own logical merits betrays the dangerous nature of Obama’s scheme. The latest example came this past week, when ObamaCare proponents trumpeted a New York Times/CBS News opinion poll purportedly showing that large majorities of Americans support government-run health care.

The June 12-16, 2009 poll indicated broad, substantive support for Obama’s plan, as 72% of its respondents favored a government health care provider to compete with private insurers. Suspiciously, the poll also reported that by a 57% to 39% margin, respondents are “willing to pay higher taxes for insurance for all.”

Revealing its predictable ideological bias, CBS News’ website could hardly contain its enthusiasm: “A clear majority of Americans – 72 percent – support a government-sponsored healthcare plan to compete with private insurers, a new CBS News/New York Times poll finds. Most also think the government would do a better job than private industry at keeping down costs, and believe that the government should guarantee healthcare for all Americans. The new poll shows the idea of a government-sponsored plan, or ‘public option’ to be fairly non-controversial.”

It turns out, however, that the poll was stacked with a disproportionate number of Obama supporters. Of the poll’s 895 respondents, some 48 percent stated that they voted for Obama this past November, whereas only 25 percent reported they voted for Senator John McCain. That disproportionate two-to-one margin contrasts with the actual November 2008 election results, in which Obama’s margin was 53% to 46%. If the CBS News/New York Times poll had been representative, Obama would have defeated McCain by a 66% to 34% margin last November. As polling expert Kellyanne Conway noted, “was the vote 66 to 34? You tell me.”

Of course, this is merely the most recent instance of distortion in the current healthcare debate. Perhaps the most pernicious deception advanced by those who allege a health care “crisis” and advocate a socialized system is that 46 million Americans are uninsured. But a closer examination reveals the dubiousness of that claim.

First and foremost, approximately 21 percent of that number, or 10 million, are not American citizens. Is it the responsibility of American taxpayers to subsidize health insurance for ten million non-citizens? Of course not.

Second, it’s estimated that as many as 14 million of the 46 million are already eligible for existing government insurance programs, such as Medicaid and S-CHIP, but for whatever reason have failed to -- or have chosen not to -- enroll.

Third, approximately 19 million of the uninsured are people between the age of 18 and 34, according to the National Center for Policy Analysis. As they note in their study, “most of them are healthy, and know that they can pay incidental expenses out-of-pocket. Using hard-earned dollars to pay for healthcare they don’t expect to need is a low priority for them.” Consequently, they have little incentive to insure themselves, and instead refrain from buying coverage unless and until they suddenly need emergency care.

Fourth, 9 million of the oft-cited 46 million live in households with incomes above $75,000 per year, and another 9 million in households earning above $50,000. While nobody would contend that these income levels qualify as “wealthy,” both levels far exceed the federal poverty level.

Together, these realities expose the deceptive nature of the “46 million” statistic routinely cited by advocates of government-run health care. Moreover, scientific polling regularly shows that between 70% and 80% of Americans are actually satisfied with their level of healthcare. In fact, a recent USA Today/ABC News/Kaiser Family Foundation survey reveals that 89% of respondents were pleased with their plan.

Accordingly, improvements to the nation’s health care system must focus on free-market principles and empowering individuals and families, not stifling government takeovers. Through medical tort reform, for example, we can limit the litigation costs and frivolous “jackpot justice” awards that drive up medical costs. We can also allow citizens to purchase insurance policies across state lines, which would drive down insurance costs and provide individuals and families the freedom to choose health care coverage that best suits their needs from a national marketplace.

In any case, beware the fraudulent numbers cited by those who advocate a wholesale government takeover of the American health care system. The fact that they must resort to deception is the surest sign that they’re prescribing the wrong medicine.

SOURCE





28 June, 2009

Health care reform: Questions for the president

Health care reform is on life support," says Rep. Jim Cooper of Tennessee. And he's a Democrat. President Obama has spent months building momentum for health care reform. But when the Congressional Budget Office put the price tag near $2 trillion, it stopped reform dead in its tracks.

What Senate Finance Committee chairman Max Baucus, D-Mont., once called "nearly inevitable" now seems much less so — and that's before supporters have confronted the really tough questions. Before this debate is over, Obama should answer a few questions about his plans for reform, including:

Mr. President, in your inaugural address and elsewhere, you said you are not interested in ideology, only what works. Economists Helen Levy of the University of Michigan and David Meltzer of the University of Chicago, where you used to teach, have researched what works. They conclude there is "no evidence" that universal health insurance coverage is the best way to improve public health. Before enacting universal coverage, shouldn't you spend at least some of the $1 billion you dedicated to comparative-effectiveness research to determine whether universal coverage is comparatively effective? Absent such evidence, isn't pursuing universal coverage by definition an ideological crusade?

A draft congressional report said that comparative-effectiveness research would "yield significant payoffs" because some treatments "will no longer be prescribed." Who will decide which treatments will get the axe? Since government pays for half of all treatments, is it plausible to suggest that government will not insert itself into medical decisions? Or is it reasonable for patients to fear that government will deny them care?

You recently said the United States spends "almost 50 percent more per person than the next most costly nation. And yet ... the quality of our care is often lower, and we aren't any healthier." Achieving universal coverage could require us to spend an additional $2 trillion over the next 10 years. If America already spends too much on health care, why are you asking Americans to spend even more?

You have said, "Making health care affordable for all Americans will cost somewhere on the order of $1 trillion." Precise dollar figures aside, isn't that a contradiction in terms?

Last year, you told a competitiveness summit that rising health care costs are "a major anchor on the ability of American business to compete." In May, you wrote, "Getting spiraling health care costs under control is essential to ... making our businesses more competitive." The head of your Council of Economic Advisors says such claims are "schlocky." Who is right: you or your top economist?

You recently told an audience, "No matter how we reform health care, we will keep this promise to the American people. ... If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what." The Associated Press subsequently reported, "White House officials suggest the president's rhetoric shouldn't be taken literally." You then clarified, "What I'm saying is the government is not going to make you change plans under health reform." Would your reforms encourage employers to drop their health plans?

You found $600 billion worth of inefficiencies that you want to cut from Medicare and Medicaid. If government health programs generate that much waste, why do you want to create another?

You and your advisors argue that Medicare creates misaligned financial incentives that discourage preventive care, comparative-effectiveness research, electronic medical records, and efforts to reduce medical errors. Medicare's payment system is the product of the political process. What gives you faith that the political process can devise less-perverse financial incentives this time?

You claim a new government program would create "a better range of choices, make the health care market more competitive, and keep insurance companies honest." Since when is having the government enter a market the remedy for insufficient competition? Should the government have launched its own software company to compete with Microsoft? Are there better ways to create more choices and more competition?

When government entered the markets for workers compensation insurance, crop and flood insurance, and disaster insurance, it often completely crowded out private options. Do you expect a new government health insurance program would do the same?

You have said there are "legitimate concerns" that the government might give its new health plan an unfair advantage through taxpayer subsidies or by "printing money." How do you propose to prevent this Congress and future Congresses from creating any unfair advantages?

President Obama needs to address questions these directly. The health of millions depends on his answers.

SOURCE




Whistleblower helpline for NHS doctors as concerns for patient safety grow

Hospital doctors wanting to raise fears about patient safety are to be given an anonymous “whistleblower” helpline because of growing evidence of staff reluctance to speak out for fear of recriminations. The dedicated phoneline has been set up as part of new guidelines issued by the British Medical Association, and seen by The Times, designed to help to formalise the process of “whistleblowing” in the NHS.

Doctors will be presented with two motions at the BMA annual conference next week calling for action to address staff concerns about reporting malpractice. One motion, proposed by the BMA’s agenda committee, warns that the NHS risks another patient safety scandal like that of Mid-Staffordshire where 400 deaths were linked to poor care, such is the scale of the problem. It calls for trusts and regulators to pool all complaints from clinicians to identify worrying trends. A second motion, proposed by junior doctors, calls on the General Medical Council to recognise formally that the harassment of whistleblowers is a serious breach of medical regulations. It also requests guidance on whistle-blowing.

Tom Dolphin, a junior doctor specialising in anaesthesia based in East London, said he had felt compelled to act after hearing of the experiences of colleagues who had to work without some patient-monitoring equipment. “One colleague needed equipment that wasn’t there, and was told there wasn’t any. There can be a culture of ‘that’s the way it's always been and no one’s come to harm yet anyway’. Others tried to raise concerns, got nowhere and had pretty much given up.”

The BMA guidelines, released today, follow research suggesting hospital doctors are frequently frustrated in their attempts to raise concerns about standards of care, despite recommendations by the Department of Health for the development of whistleblowing policies six years ago. A survey of 565 doctors working in hospitals in England and Wales found that three quarters had had concerns about issues relating to patient safety, malpractice or bullying in the NHS, the majority linked to standards of patient care.

Many said that their experiences of reporting issues had been negative — either because they were ignored or because their complaint was shared more widely than they were comfortable with. One in six doctors who reported concerns said that their trusts had indicated that their employment could be negatively affected.

The BMA advises hospital doctors to err on the side of raising any concerns about malpractice or systemic failures, and to do it as soon as they can, rather than allowing the situation to reach a point where patient safety is threatened. It points out that employees who are victimised after raising their concerns can go to an employment tribunal, and that employers can be heavily fined. “If told not to raise or pursue any concern, even by a person in authority such as a manager, you should not agree to remain silent,” it states, adding that “raising concerns is not just a matter of personal conscience — in some circumstances it is a professional obligation”.

Last month Jonathan Fielden, the chairman of the BMA consultants committee, called for sweeping changes to reporting problems in the NHS. He said that “a culture of inactivity and despair is preventing issues from coming to light, and putting patient care at risk”.

Margaret Haywood, a nurse, is appealing to the High Court against a decision by the Nursing and Midwifery Council to strike her off the register for secretly filming at a Brighton hospital. Footage showed examples of neglect, including an elderly patient sitting in clothes he had soiled the night before.

Earlier this month the National Patient Safety Agency (NPSA) called for greater reporting of safety issues in hospitals in a report on paediatric healthcare. It said that 10,000 alerts over medication given to children were being issued annually in the NHS, including errors in the calculation of drug doses and health workers forgetting to give patients their medicine. The NPSA report concludes that over the period of a year 33 children and 39 newborn babies died with “indicators of avoidable factors”.

SOURCE





27 June, 2009

Dr. Obama’s Swamp Root Snake Oil

Amazing negligence and incompetence at the VA again

Tough break for Barack Obama. Just when he is merrily rolling along peddling his socialized stealthcare as it were the most potent elixir since Violet Blossom’s Swamp Root snake oil, along comes NY Times with a decidedly sordid tale about government medicine gone awry. And since ABC (Always Barack Channel) wasn’t about to interrupt its infomercial to reveal the full facts of the matter, let’s take a quick look behind the Barakathon.

Those who can’t wait to turn their lives and limbs over to Big Government’s pseudo-sawbones need first to pay a visit to the government-run Veterans Administration hospital in Philadelphia, PA. But, first, a word of warning: if you’re a guy, leave the family jewels at home. Because, if you think the Liberty Bell is irreparably damaged … well, you ain’t seen nothin’ yet.

One of the most popular (if I can use that word) procedures for treating prostate cancer is the implantation of dozens of radioactive seeds to attack and destroy the cancerous cells. True, it’s drastic. But, it sure beats a long-drawn, painful death. Unless, of course, they plant the radioactive cells in the wrong organ. Which is exactly what Dr. Gary D. Kao did at the VA Medical Center in Philadelphia, citadel of socialized medicine. Obama should be proud. In fact, he should have covered it in his ABC infomercial – perhaps while waving his arms and shouting, “But, wait, there’s more!”

You see, Dr. Kao implanted the 40 radioactive seeds not in the patient’s ailing prostate, but in his perfectly healthy bladder. So much for Tenet One of the Hippocratic Oath – “First, do no harm.”

But, wait, there’s more! Of course, the ever vigilant federal bureaucrats in charge of VA stealthcare (coming soon to a hospital near you) knew that this probably wasn’t a good idea. So they investigated—and promptly allowed the doctor to doctor his report to match the number of seeds in the prostate.

This, naturally, did little for the patient. So, like any conscientious government employee, Dr. Kao decided to cover his tracks by doing over what he hadn’t done right—whereupon he planted the seeds in the patient’s rectum. Which, apparently for the good doctor was “close enough for government work”—since this time, he didn’t even bother filing a report.

But, wait, there’s even more! With the eager acquiescence of his government overlords, Dr. Kao was on a roll. Two years later, Dr. Kao rewrote another surgical plan after once again putting half the seeds in the wrong organ. And, once again, the socialized stealthcare regulators did not object. Perhaps the reason they did not object is that they had long since become past masters at doing well what bureaucrats do best—absolutely nothing. As the NY Times story reveals:

“Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years -- and then kept quiet about it, according to interviews with investigators, government officials and public records. “The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show.”

I have a distinct feeling that any guy reading this piece is by now already squirming around in his chair, praying diligently that the Avodart, Cipro, Doryx, or Floxin works well if his prostate ever needs it. Because, clearly, Obama’s socialized stealthcare won’t. And for the women: let’s just say that if you have even the remotest idea of remaining sexually active with your hubby in your Golden Years, pray equally hard that Dr. Obama gets his license lifted.

Here’s the bottom line: socialized medicine doesn’t work. Whenever and wherever it rears its malignant head, it is poorly conceived, pathetically organized, and callously administered. If the VA is the microcosm (or the MVA, Amtrak, or the U.S. Congress, for that matter), imagine the horror of the macrocosm.

It was said that Violet Blossom was the Queen of Pitch Doctors.” Barack Obama may be the “King of Pitch Presidents.” But if the American people end up catching what he’s pitching, the result may be the most deadly medical crisis since the flu epidemic of 1918. And all the ABC snake oil in the world isn’t going to cure that devastating blight.

SOURCE




New models for real health care reform

Paying for health care has been a problem since ancient times. In the Middle Ages, guilds collected funds to provide care for infirm members. In 1789, imitating the British, the U.S. Congress funded the Marine Hospital Service by taxing American seamen 20 cents a month.

As U.S. governments grew, they continued passing laws to regulate the kind of health coverage people could purchase. By 1960, most people with coverage got it through their employer. Plans provided by hospital monopolies controlled the coverage market. The true cost of health care was hidden from covered individuals. Vast spending increases were the result. The introduction of Medicare and Medicaid in 1965 made the situation worse. Finkelstein found that Medicare increased real hospital expenditure by 23 percent between 1965 and 1970. Extrapolating from the Medicare estimates suggests that the spread of health coverage may “explain at least 40 percent of the rise in real per capita health spending” between 1950 and 1990.[1]

Only in the last two decades have economists reconsidered the effect that government regulations have had on the form health coverage takes, its cost, and how it encourages people to use health care. Government coverage programs obscure the real cost of health care and increase health spending by shifting the out-of-pocket cost of health care spending from the savings of individuals to the paychecks of working Americans.

Unlike government coverage or coverage purchased through employers, private coverage purchased directly by individuals encourages people to choose between health coverage and all other goods. It controls health spending by pricing individual risk, encourages substantial variation in plan design to accommodate differences in individual risk tolerance, and provides incentives for cost minimization.

All private health coverage arrangements must solve two problems. The first is to collect enough money to deliver enough health care to satisfy people who can stop paying if dissatisfied. The second is to control moral hazard, the tendency to use more care when other people are paying for it.

Early History of Health Insurance

By 1910, an estimated one third of all adult males in the United States belonged to fraternal societies. Like modern HMOs, some societies provided prepaid health plans that controlled the supply of medicine to member patients by refusing to provide care considered beyond the organizations’ means. They hired “lodge doctors” who worked for the plan and were less likely to side with patients in recommending more care than the plan wanted to deliver. The societies used a variety of tools to control moral hazard. These tools included home-visiting committees, waiting periods for benefits, and curfews on members receiving benefits. People not covered by the fraternal societies could choose from plans operated by trade and industrial unions, various governments, commercial insurers, and company-sponsored mutual benefit societies.

The Birth of the Blues

The Depression produced a dramatic change in health coverage. One year after the stock market crash of 1929 “average hospital receipts per person fell from $236.12 to $59.26, and average hospital deficits rose from 15.2 to 20.6 percent of disbursements.”[2] To boost revenues, hospitals created community-wide hospital benefit plans. The American Hospital Association created Blue Cross to promote hospital benefit plans that conformed to guidelines that reduced interhospital price competition.

The hospital benefit plans offered guaranteed services in exchange for an annual premium. The Blue Cross monopolies were extraordinarily successful, particularly after the hospitals persuaded state officials to exempt them from insurance company capital requirements and taxes. By 1950, Blue Cross sold almost half of all hospital insurance. As economist John Goodman notes, Blue Cross and Blue Shield (the equivalent organization for physician services) so dominated the market that “they made it difficult for a commercial insurance company to adopt reimbursement procedures that differed fundamentally from those of Blue Cross and Blue Shield. If a commercial company attempted radical deviation, the medical community could threaten a boycott.”[3] At the beginning of the 1990s, Goodman estimated that “net revenues (premiums minus benefit payments) on group policies [were] usually less than 5 percent of total premiums, [therefore] a 2 to 3 percent premium tax is equal to about 50 to 60 percent of net revenues.”[4]

Medicare and Medicaid expanded the Blue Cross coverage model to government coverage programs. It paid minimal attention to controlling moral hazard. It encouraged patients to use any hospital they saw fit. It reimbursed hospitals on a cost-plus basis. It emphasized one price for everyone in a given community, and it had little cost sharing and no waiting requirements. A structure that made sense when hospitals could do relatively little for patients ended up creating unprecedented increases in medical expenditures as medical technology improved.

The fraction of the U.S. population with health coverage stabilized in the 1980s. Since then, the percentage of Americans with health coverage has fluctuated in a narrow range between 84 and 87 percent. The favorable tax treatment bestowed on employer-based coverage after World War II encouraged most people to purchase coverage through their employers. In 2007, roughly 59 percent of Americans had employer-based coverage. Government plans, state-subsidized high-risk insurance pools for the uninsurable, Medicaid, Medicare, SCHIP, the Veterans Administration, and other forms of military health care, covered 28 percent of Americans. Just 9 nine percent of Americans with health care coverage purchased their own coverage directly from insurers.[5]

After nearly 50 years in which employer-based coverage modeled after Blue Cross dominated, researchers in health policy often implicitly assumed that Blue Cross, Medicare, and Medicaid defined the form that health coverage should take. As costs exploded, researchers focused on cost control, ways to charge the same premium for all regardless of health risk, and ways to control costs in a system that bypassed patients with direct payment to providers. The tight controls on health care demand used by the guild systems and the fraternal societies were variously reborn in the managed care, evidence-based medicine, pay-for-performance, and “comparative-effectiveness” movements. Like the fraternal societies, some state governments forced insurers to issue policies to everyone at the same price, and focused on controlling the practitioners that people in state plans could see, denying certain kinds of care altogether, and rationing care by waiting.

The Market for Individual Insurance

Recent research has shown that such tight controls can do harm by reducing overall coverage and making medical care difficult to access. Economists have also realized that health policy has paid so little attention to direct-purchase health coverage that policy makers know very little about it. As late as 2002, Pauly and Nichols published an article entitled “The Nongroup Health Insurance Market: Short on Facts, Long on Opinions and Policy Disputes.”[6] They wrote that “there is considerable disagreement among policymakers and policy analysts about how the nongroup insurance market works now” and that “factual disagreements about this market are true impediments to policy consensus.” In 2006, Marquis et al. noted that while a variety of proposals have been offered to overcome perceived weaknesses in the direct-purchase market, “until now, this market has been the subject of relatively little study. As a result, there is much disagreement about the importance of the advantages cited for this market, the extent of the barriers to participation, and the likely effects of policy proposals.”[7]

Direct-purchase coverage is owned by an individual. Premiums are based on the costs that an insurer expects a particular individual will generate in the future. People with low health risk, where risk is shorthand for expected future expenditure, pay less in premiums. Because premiums in the direct-purchase market are paid with after-tax dollars, individuals know exactly what their coverage costs. Because paying for health care with insurance coverage is more expensive than paying cash, people who buy direct-purchase coverage are more likely to insure against large costs, relying on out-of-pocket cash to cover routine expenses.

Because employer-related coverage is tax advantaged, employer plans generally follow the more expensive route of insuring even low-cost routine care. Employees “pay” the bulk of their employer-provided group health premium in the form of lower wages. Their artificially low out-of-pocket costs insulate them from the true cost of health care. This increases the demand for health care. According to Manning et al., data from the RAND Health Insurance Experiment show that the higher out-of-pocket payment characteristic of direct-purchase plans “reduces expenditures 31 percent relative to zero out-of-pocket price.”[8]

In 2008, the Kaiser Foundation Survey of Employer Coverage estimated that the average cost of employer-based group coverage was $4,704 for a single person and $12,680 for a family. On average, the out-of-pocket “premiums” that employers charged employees equaled about 16 percent of the total premium for single coverage, roughly $60 a month, and 27 percent of the total premium for family coverage, roughly $280 a month.[9] According to the AHIP 2006-2007 individual market survey, average annual premiums for roughly 2.3 million direct-purchase individual policies sold to single adults, were $1,359 for people aged 18-24 and $5,090 for people aged 60-64.[10]

Direct-purchase markets pool risk extensively, charging high risk people far lower premiums than their health status might indicate. Most direct-purchase policies are renewable without additional underwriting. This means that as long as he pays the premium, an insured person can keep his policy no matter how sick he gets. Contrary to popular claims, state laws generally prohibit raising a sick individual’s premiums unless an insurer also raises the premiums of everyone else in his rating class.

Pauly and Herring report that direct-purchase insureds who had medical expenses about 4 times that of other people enjoyed premiums that were only 1.6 times as high. People who buy a policy and become ill have a strong incentive to continue paying. This may explain why age and sex were generally better predictors of direct-purchase premiums than chronic conditions.[11] Marquis et al. concur, reporting that the individual direct-purchase market is “an important source of long-term coverage for many who purchase it” and that “there is substantial pooling” that “increases over time because people who become sick can continue coverage without new underwriting.”[12]

Adverse Selection Due to Community Rating

In states that are so wedded to the Blue Cross model that they have community rating laws requiring that premiums be the same for everyone in a given geographic region, premiums are higher for everyone. In a study of 26.8-million commercially insured people, Willey et al. found that just 0.8 percent of the population was severely ill. That group had average annual expenses of $29,273. Those with less-serious chronic disease spent $8,225 a year. Half of the population had expenses below $989 a year.[13]

Charging everyone the same price does lower the premium for high-risk people. This increases the probability that they will buy coverage. However, as more high-risk people enroll, premiums must increase for everyone in order to cover the plan’s higher costs. Some low-risk people respond by refusing to pay the artificially high prices for coverage caused by the one-price-for-all requirement. Insurance economists call this phenomenon “adverse selection.” Although economists usually use the term “adverse selection” to refer to the result of the individuals having more information than the insurance company, this is adverse selection due to regulation.

There are more low-risk people harmed by one-price requirements than high-risk people who benefit from them. Pauly and Herring find that regulations on insurance premiums raise the average premium considerably, by 12 to 15 percent, and that the number of people who drop coverage exceeds the number of higher-risk people who sign up. In all, “the overall proportion of eligible people in the individual market with insurance [falls] by 6.0-7.4 percent.” They note that policies that reduce administrative costs and create high-risk pools are likely to cover more people than government control of premiums. Avoiding price controls on premiums also “avoid[s] regulation-induced incentives to insurers to avoid money-losing high risks.” In short, allowing competitive markets to set the price for coverage will end up covering more people.

The Benefits of Variety

Results like this underline the fact that health insurance has value only because it allows those who buy it to pay for expensive medical care without forcing them to liquidate their assets or suffer big drops in current consumption. Some people are willing to pay a lot to have an insurance company bear the risk of large medical payments. Others are willing to pay very little. Cutler, Finkelstein, and McGarry find that individuals who have a higher risk tolerance, as revealed by engaging in risky behaviors such as smoking, drinking, and employment with high mortality rates, are less likely to purchase all kinds of insurance, including life insurance, private health insurance, annuities, long-term care insurance, and Medigap coverage.[14] This suggests the variety of plans offered in the individual direct-purchase market, a variety not present in employer-based coverage or government plans, adds to individual welfare. Health coverage is not necessarily the most important thing in life, and as circumstances, finances, and risk tolerance change, people are better off if they can change their coverage to match their circumstances.

Assertions that people without coverage have no access to health care ignore the fact that people can and do access care by paying cash. Though the self-employed are less likely to have health coverage than comparable wage earners, Perry and Rosen show that they use health services at roughly the same rates as insured wage earners.[15] Glied’s findings on the spending patterns of the uninsured suggest that, in addition to cash payment, even low-income “uninsured people have some de facto insurance coverage available to them through the uncompensated care system and Medicaid conditional coverage.”[16] Overall, national estimates suggest that the uninsured pay for about half of their care and that government and private spending for uncompensated care equals roughly 3 percent of total personal health spending, about $150 for an average annual premium of $5,000. As the budgetary disasters in Massachusetts, Kentucky, and Tennessee have shown, government programs seeking to eliminate uncompensated care by requiring insurance for all typically cost more than the uncompensated care they seek to eliminate.[17]

Recent work also makes it clear that people adjust their coverage as their estimate of their individual risk changes, something that mandated coverage, controlled enrollment seasons, and government standardized policies discourage. Bundorf et al. find that higher-risk people are more likely to have coverage, even at incomes of less than 200 percent of the poverty level. Regardless of income, the probability that someone will have coverage rises 17 percent when his health risk changes from low to high.[18] This increase in coverage is remarkable in view of the fact that low-income people are especially sensitive to premium cost. In Massachusetts, a $10 increase in monthly MassHealth premiums increased the odds of leaving the MassHealth program by five percent.[19] Small increases in already low subsidized premiums have been associated with significant enrollment declines in government programs in Oregon, Vermont, Wisconsin, and Rhode Island. Gruber and Simon conclude that price-sensitive people substitute government insurance for private insurance in large numbers. For every 100 newly enrolled children in state children’s health insurance programs, they estimate, 60 had previously been privately insured.[20]

The substitution may also go the other way. George Borjas found that the 1996 law limiting Medicaid eligibility for immigrants increased the likelihood that affected households worked and, therefore, increased the probability of eligibility for employer-sponsored health insurance. Their health insurance coverage rates at least remained the same after their Medicaid eligibility was curtailed.[21] Without government coverage programs, he wrote, “the targeted immigrants themselves would have taken actions to reduce the probability that they would be left without health insurance coverage.”

Although some people genuinely cannot pay even the small premiums charged by government programs, Bundorf and Pauly show that income based “affordability” calculations are not good predictors of whether or not a person chooses to sign up for coverage. For example, while 36 percent of people in families with incomes less than 200 percent of the federal poverty level are uninsured, 44 percent have private coverage. By some measures, coverage in 2000 was affordable for over 50 percent of the uninsured.[22]

Conclusion

Eighty years after governments began seeking to determine the shape of U.S. health coverage, economists who study direct-purchase insurance have created a body of literature suggesting that market-oriented health care reform has far more promise than the decades-old plans that seek to impose the Blue Cross model on the entire population. In view of Medicare’s insolvency, reform plans calling for further expansions of the Blue Cross single-price guaranteed-issue model, both via Medicare/Medicaid expansions and so-called “public” policies designed by government and sold through government run connectors, are unlikely to succeed in providing more medical care for more people at current expenditure levels.

Direct-purchase of health coverage, along with guaranteed renewability, flexible premiums, and high-risk pools, is a promising approach to reducing health care costs, increasing the value received for health care expenditures, and making more healthcare available for all. Given that roughly the same percentage of people has had health coverage for the last 20 years despite numerous expansions of government coverage programs and a massive increase in illegal immigration, the direct-purchase results also suggest that expecting everyone to have coverage is not a sensible policy goal.

Another danger, one too infrequently considered in the drive to lavish government funds and attention on extending the 70-year-old Blue Cross model to basically healthy people, is that insuring everyone is an unattainable goal. No one can make an adult alcoholic or drug abuser sign up for anything. If government gets out of the way, basically healthy people should be able to make their own health financing arrangements. Furthermore, the focus on universal coverage diverts attention from the radical reforms necessary to save Medicare and Medicaid, two government programs based on the Blue Cross model that are dysfunctional, insolvent, and already failing the frail and vulnerable people who depend on them.

SOURCE





26 June, 2009

The real crisis is Obamacare

President Obama has never met a crisis he didn't love; particularly the ones that involve spending trillions of dollars. What fun it is to propose programs that involve borrowing or taxing Americans to death.

On June 9, the Associated Press reported, "President Barack Obama on Tuesday proposed budget rules that would allow Congress to borrow tens of billions of dollars and put the nation deeper in debt to jump-start the administration's emerging health care overhaul."

Since the stealth heathcare "reform" that Bill and Hillary Clinton tried to foist on Americans during the 1993-94 Congress, this "crisis" has been off the radar screen of Americans who have the audacity to think they should decide whether and how much health insurance they want, and to expect healthcare that is not rationed on the basis of how old they are and other factors determined by some faceless government bureaucrat.

Liberals obsess over healthcare options because, of course, they want "fairness" no matter how much it will cost Americans in general and the economy in particular.

To that end, various "progressive" (liberal) groups have gotten together and have launched an $82 million campaign to support President Obama's healthcare program. The umbrella for this massive public brainwashing is called Health Care for America Now. Why is it that everything Obama wants has to be done "now"? Oh yes, I forgot. It's a "crisis." Health Care for America is directed by Richard Kirsch and has been joined by the AFL-CIO, MoveOn.org, and Democracy for America, a group founded by former Democrat National Committee Chairman, Howard "the scream" Dean. The group is essentially a re-branded version of liberal lunatic groups.

An excellent analysis of Obamacare has been published by the Cato Institute in a May 21 Policy Analysis (No. 638) titled, appropriately, "Seven Bad Ideas for Health Care Reform." Authored by Michael Tanner, it points out some very ugly truths.

* At the time of rising unemployment, the government would raise the cost of hiring workers by requiring employers to provide health insurance to their workers or pay a fee (tax) to subsidize government coverage.

* Every American would be required to buy an insurance policy that meets certain government requirements.

* A government-run plan similar to Medicare would be set up in competition with private insurance.

* The government would undertake comparative-effectiveness research and cost-effectiveness research and use the results to impose practice guidelines on providers, initially in Medicare and Medicaid, but ultimately extending the rationing to private insurance plans.

* Private insurance would face a host of new regulations.

* Subsidies would be available to help middle-income people purchase insurance while expanding Medicare and Medicaid.

* Finally, the government would subsidize and manage the development of a national system of electronic medical records.

According to a June 8 Bloomberg News report, "President Barack Obama wants Congress to consider taxing the wealthy instead of workers to pay for a health-care overhaul." This is yet one more lie by the Obama administration in the run-up to impose the most vile form of government control over everyone's lives imaginable.

The American Medical Association, the nation's largest physician organization, has let it be known that it will oppose creation of a government-sponsored insurance plan.

The promise of the Declaration of Independence that everyone has a right to life, liberty and the pursuit of happiness will be rendered meaningless by Obamacare if your life depends on government policies regarding healthcare.

A June 1 Business Week commentary pointed out that "there are only three ways to pay for universal coverage: Raise taxes, cut payments to medical providers, or ration care." All three are the worst possible options imaginable.

"The Congressional Budget Office estimates that covering the uninsured could add anywhere from $1 trillion to $2 trillion to the federal budget over ten years," said the BW commentary. "On top of that, government economists expect Medicare to run out of money in 2017 if current spending trends continue."

Here's a handy tip regarding estimates by government economists. Multiply them by a factor of ten! As this healthcare horror awaits its run through Congress, think of it as a massive Medicare, the government program for seniors that cost 3.2 percent of the country's Gross Domestic Product in 2008 and which will become insolvent this year! Medicare faces $34 trillion in unfunded liabilities; the cost of services for which seniors are eligible in the future. According to the Medicare Trustees, the program will require a 134 percent increase in the payroll tax paid by every working American in order to remain solvent!

And this insane Democrat-controlled Congress wants to expand on Medicare while requiring everyone to purchase healthcare insurance, even if they don't want to. Then it will compete against existing private insurance companies without having to have the funds in place as they must to meet their obligations.

This isn't healthcare reform. It is the destruction of the best healthcare system in the world. It is the destruction of the nation's economy. It, along with the tax on energy use, must be stopped. We are being attacked by one "crisis" after another when the only one that matters is the restoration of the full faith and credit of the U.S. dollar. If the "health" of the U.S. dollar is not restored, nothing else will matter very much.

SOURCE




Rhetoric vs. reality in the health care debate

Half-truths about "rationing"

Last week, the Democratic leadership in the House of Representatives unveiled their discussion draft of a sweeping bill to reform America's health care system. The bill would create health insurance exchanges and a government insurance scheme, require insurers to sell insurance no matter a purchaser's health status, set minimum benefit standards, subsidize insurance purchases to families up to 400 percent of the federal poverty level ($43,000 for an individual or $88,000 for a family of four), mandate that all Americans carry health insurance, and impose price controls on what doctors and hospitals may charge. The Democratic leadership hasn't the faintest idea what its reform proposals will cost.

The draft bill also would establish a public-private Health Benefits Advisory Committee to recommend covered benefits and an essential benefits package. This is the only section of the bill that mentions the word "rationing." It declares that "the Committee shall take into account innovation in health care and ensure that essential benefits coverage does not lead to rationing of health care." Of course, it would be helpful to know what the bill means by "rationing."

Earlier in the week, New York Times economic columnist David Leonhardt set out to explain what rationing is. First, let's acknowledge that Leonhardt does identify many dysfunctional aspects of our current health care system, including how we reimburse primary care physicians and specialists.

But in the article, Leonhardt claims that "health care rationing rhetoric overlooks reality." Leonhardt asserts that health care is already being "rationed." Since this is so, those who warn against proposed government health care rationing, according to Leonhardt, are either confused or liars. Such people, Leonhardt explains, are deploying "a clever set of buzzwords that tries to hide the fact that societies must make choices." The phrase "societies must make choices" is the first hint of how confused Leonhardt is about the concept of rationing. Rationing is all about who gets to make those choices.

Leonhardt goes on to cite what he thinks are three supposedly telling examples of rationing. "We ration spots in good public high schools. We ration lakefront homes. We ration the best cuts of steak and wild-caught salmon," he writes. Which one of those examples doesn't fit? Figuring this out is another key to Leonhardt's misunderstanding of the debate over health care rationing.

Next up he cites the dictum of one of capitalism's great defenders, economist Milton Friedman: "There is no such thing as a free lunch." True. But Leonhardt follows up this insight by writing: "The choice isn't between rationing and not rationing. It's between rationing well and rationing badly." Does Leonhardt think that lakefront homes are rationed badly? Steaks? Or for that matter clothing, restaurant meals, shoes, cars, computers, or airline tickets?

Moving beyond lakefront homes and steaks, Leonhardt eventually gives readers three examples of current health care "rationing." The first example is that employers are forced to decide between paying higher wages or providing higher health care benefits to their employees. He notes that the tradeoff between wages and benefits is often "invisible" to employees and thus it appears to them that their compensation is not increasing much.

Of course, the way to avoid this kind of "rationing" would be to just pay the employees all their money and let them buy their own health insurance. Thus health insurance would become "rationed" just the same way that we ration cars and cellular telephones. Allowing consumer choices in health insurance and health care will also help drive down prices and increase the range of health insurance products in just the same way consumer choice operates in other areas of our economy.

The current provision of medical care to the uninsured is Leonhardt's second example of rationing. This example is closer to the mark since health care for the uninsured is already mandated and/or paid for (Medicaid and SCHIP) by federal and state governments. He notes the poor quality of care that such people receive without musing for a moment that such poor government-funded care might be a harbinger for what "universal" health care would become.

Leonhardt's third alleged example of current health care rationing is the "failure to provide certain types of care, even to people with health insurance." The fact that certain health insurance policies chosen by individuals and/or their employers don't cover certain treatments is no more "rationing" than it is when people choose not to eat a USDA prime steak or pay tuition for a private college education.

On the other hand, Leonhardt is right to say that our dysfunctional health care system misses opportunities to offer good treatments to people in need. The current system misses those opportunities, in part, because there is so little competition and thus very little incentive for health care providers to supply information to consumers. Consumers can competently choose between complicated computer technologies and evaluate automobile performance because competitors are motivated to supply consumers with relevant information. The same kind of competitive dynamic could work with the provision of health care and health insurance.

So if Leonhardt gets it so wrong, what is rationing? Leonhardt is correct when he writes, "In truth, rationing is an inescapable part of economic life. It is the process of allocating scarce resources." The crucial question that Leonhardt misses is that "rationing" depends on who is allocating the scarce resources. It's not rationing if an individual decides to spend his money on a 16-ounce steak—but it is rationing if he can only purchase a USDA prime rib eye when he has a coupon issued from a government agency. In other words, true rationing occurs when individuals are forbidden from spending their money on products or services they want to buy.

Imperfect as private health insurance markets are, if a customer doesn't like the decisions made by Blue Cross Blue Shield, Kaiser Permanente, or Golden Rule insurance bureaucrats, he can look elsewhere for his health insurance coverage. But if the government health care scheme becomes a monopoly, when the bureaucrats at the new Health Benefits Advisory Committee decide that a treatment should be withheld, that treatment will be withheld. That's rationing.

"Americans should get the first chance to limit their own health spending," Rep. Jim Cooper (D-Tenn.) observed recently. "Once they learn the true cost of what they are buying, share a larger portion of the cost, and can judge the benefits—if any—of treatment options, then they will choose more wisely than the government." He's right. Congress should think about "rationing" health insurance and health care the old-fashioned way—through the market.

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25 June, 2009

ObamaCare will save money? Don’t believe a word of it

President Obama is selling government health insurance to the American people as the way to save money. That government health insurance will merely provide competition to keep private insurance companies from gouging their customers.

Indeed, Obama even claimed on Monday, in a speech before the American Medical Association, that a government insurance system is essential to holding down medical costs: “if we fail to act, federal spending on Medicaid and Medicare will grow over the coming decades . . . . and impose a vicious choice of either unprecedented tax hikes, overwhelming deficits, or drastic cuts in our federal and state budgets.”

There are a couple of problems with Obama’s argument. Government is just not known for its cost effectiveness or quality. And the way for government enterprises to survive is with massive taxpayer subsidies and charging customers prices below the firm’s actual costs, driving more efficient private firms out of business. These subsidies mean that when government enterprises “win” they do so by driving more efficient private firms out of business.

Milton Friedman was well-known for pointing to a very good rule of thumb in evaluating government enterprises: “on the average anything government does costs twice as much as if it were being done by private enterprise.” Whether it is education or the post office, the reason is very simple: When people have their own money at stake they are much more careful in how it is spent.

Despite lower costs, private schools still do a better job. Americans send their kids to private schools despite having to pay taxes for public schools, too. How bad must public schools be if parents are willing to pay private school tuitions even though price for public schools is “zero.” Academic evidence consistently shows that children in private schools learn faster than those in public ones.

A second problem with government-run firms is that they typically engage in what is called “predatory pricing.” Obviously public schools don’t charge anything for students attending them, limiting competition from private schools. Also take the post office. The U.S. Postal Service would often increase its first-class mail rate, where it had a monopoly, to raise money to subsidize its overnight delivery service where it faced stiff competition. For example, it raised first-class mail to thirty-three cents in January 1999 and simultaneously reduced the price of domestic overnight express mail from $15.00 to $13.70, even though it was already losing money at the $15.00 rate. The price, which was lowered in response to increasingly successful competition in overnight delivery from FedEx and UPS Overnight, remained below $15.00 for the next seven years. Clearly the Postal Service was not able to drive its competitors out of business with this maneuver, in part because its on-time delivery record and quality was poorer.

The Postal Service lost money on its overnight deliveries despite advantages that FedEx and UPS could only dream of. The Postal Service is exempt from paying state sales, property and income taxes. And it uses some of the most expensive real estate in the country — rent-free. The competition that Obama advocates between government and private insurance companies isn’t going to be any fairer.

The reality of the situation has begun to enter into the health care discussion. Larry Summers, Obama’s chief economic adviser, claimed in April that the government insurance would be so efficient that $700 billion would be saved each year just from stopping unnecessary surgeries –- that is almost 30 percent of all heath care costs he claimed were wasted just on unnecessary surgery. He argued that the efficiencies would be so large that government insurance program actually wouldn’t cost any money. Yet, on Monday night, even the Democratically controlled Congressional Budget Office acknowledged that the cost of the health care proposals would cost at least $1.6 trillion over 10 years, and it warned that the total could go much higher depending upon what features were added to the program. Even at that cost the program would only cover one-third of the uninsured.

The government has consistently underestimated the costs of government health care programs in the past. The biggest problem with current CBO estimates is that they assume that only “15 million individuals” will give up private insurance to get what the government offers. Others have put the number at almost 120 million — massively increasingly the cost of the program.

There is also the question of whether there will be any gain in physical health for those who are currently uninsured. Being uninsured is not the same thing as not getting health care. The uninsured received health care worth $116 billion in 2008. In addition, 2.3 percent of Americans are both uninsured and very dissatisfied with the quality of the health care that they receive.

Already the Congressional Budget Office is predicting a federal budget deficit of over $9.3 trillion. Just that new debt alone means an extra $103,000 for each of the 90 million tax filers who actually pay taxes. Depending on government to magically find ways to create efficiency will only ensure huge additional expenditures and debt. It can also jeopardize a health care system where 89 percent of Americans are happy with the health care that they receive.

SOURCE




No right to health care

What virtually no one has addressed in the debates on health care is that there is no such thing as a fundamental “right to health care.” Even more to the point, health care provided by the coerced expenditure of the time and money of others is even more destructive of rights and freedom.

While medical insurance and health care are certainly desirable values, “forced charity” is a contradiction in terms. Few people would condone a private citizen (or group of citizens) walking into a neighbor’s home, placing a gun to that person’s head, and demanding money. Even if the intruders claimed they needed the money for themselves or for someone else in need, any decent individual would still condemn such robbery. The (“good”) ends do not justify the (bad) means.

Somehow, though, voting for such an immoral set of actions and outcomes is supposed to make such policies okay. But hiding behind an anonymous vote and relying on the government and its armed agents to impose one’s wishes on unwilling others is neither honorable nor moral. Legalized theft is no less theft simply because one group of people is more politically powerful than another. Might does not make right.

Only voluntary actions have moral value. In the end, no one has a right to anyone else’s life, money, or property without that person’s consent. The Thirteenth Amendment to the Constitution abolished involuntary servitude. Congress, the President, and the majority of the American public have brought it back.

SOURCE




Medicare for all: Wrong answer, right question

If America HAS to have a "public" insurer for all, the VA would be a better model than Medicare -- though instrument sterilization practices would need to be much improved

Jacob Hacker's enthusiasm for a 'real' public plan option is laudable. It also dramatically overstates the strengths of Medicare. I'm not entirely convinced that we need a public plan option, and am even less sure that Medicare should be the basis for a public plan option. That said, there are at least three solid arguments for a public plan option;

1.) at least one public health provider actually does a terrific job of holding down costs while delivering outstanding care (hint it's not Medicare);

2.) most markets are already dominated by one or two large private insurers, making it extremely difficult for another private insurer to effectively compete. a government plan may (emphasize MAY) offer more competition which might (emphasize MIGHT) lead to lower costs/better outcomes, and

3.) private insurers have done a lousy job of holding down costs, delivering better outcomes, and servicing their insureds. It is hard to see how a governmental plan could be any worse, and easy to envision much better results.

In my mind those arguments tip the scales in favor of a public plan option, and give the lie to opponents' arguments against said option. But Hacker overstates the case for Medicare, and in so doing weakens the case for a public plan option. Specifically, he argues that Medicare has lower administrative costs and does a better job holding down medical trend. I disagree.

As has been well-documented, government plans have unfair advantages over private plans: they don’t need to maintain reserves, earn profits to attract capital, or pay premium taxes. These result in big dollar 'savings' over private plans. It is also important to note that Medicare's cost structure is dramatically different in other ways. Here are a couple examples:

1.) Medicare has no underwriting or sales expenses or marketing costs. No commissions, either. This saves a lot of admin dollars. This differential would disappear in a health connector-type system, with the playing field leveled by dramatically reducing commercial healthplans' marketing costs and elimination of their underwriting expense.

2.) Medicare has one-time enrollment and dis-enrollment, and greatly simplified eligibility processes. This cuts their costs, but would not continue under a connector model.

As significant as the admin expense argument is, it is Hacker's contention that "Medicare has increasingly out-performed private plans in restraining the rate of increase of health spending while maintaining broad access" that is the real problem with his argument for a public plan option. The unfunded liability for future Medicare costs clearly and convincingly demonstrates that Medicare is not earning enough revenue to pay for future expense. In commercial insurance terms, they are dramatically under-reserved. Why? Premiums are not keeping pace with medical inflation, and Medicare is not controlling the primary driver of medical costs - utilization of services.

Here are a couple examples. Medicare's imaging expenses doubled between 2000 and 2007. Utilization of physician in-office services went up more than 10% in 2006. Back surgery rates for Medicare patients in Fort Myers Florida are five times higher than they are in Miami. And physician fees are scheduled to be cut 20.5% next January because total physician expenses under Medicare are way over budget. Not to mention the cost-shifting that currently has private insurers making up lost revenue from Medicare underpayments.

I could go on, but the point is clear - Medicare's supposed administrative and medical cost advantages are not real. That does NOT mean a public plan option isn't viable. In fact, there is a government plan that is kicking the collective private health plan industry's rear end. It's the Veteran's Administration, and rather than Medicare, I'd base a national plan on a dramatic expansion of the VA. Here are a few factoids...

- compared to commercial managed care plans, the VA provided diabetics with better quality care on seven out of eight metrics (NCQA report).

- In 2005, VA hospitals were the highest-rated health system, outperforming other systems including the Mayo Clinic and Johns Hopkins.

- the VA achieves higher scores than private hospitals for patient satisfaction, staffing levels, surgical volume and other significant quality measures

- for six years running, VA hospitals scored higher than private facilities on the University of Michigan's American Customer Satisfaction Index.

And costs haven't increased nearly as fast as they have in the private sector. In the ten years ending in 2005, the number of veterans receiving treatment from the VA more than doubled, from 2.5 million to 5.3 million, but the agency needed 10,000 fewer employees to deliver that care - as a result the cost per patient stayed flat. (costs for care in the private sector jumped 60% over the same period).

The VA did this by closing down unneeded facilities, developing an industry-leading electronic health record system, opening clinics, and dramatically increasing the quality of care, especially for patients with chronic conditions. Oh, and patients can access their own health records - securely - anytime on the web.

Medicare's not the answer. A public plan option based on an expanded VA would force private plans to get better - a lot better - or lose share quickly to this very efficient, and very effective, health system.

SOURCE





24 June, 2009

Is Government Health Care Constitutional?

The right to privacy conflicts with rationing and regulation

Is a government-dominated health-care system unconstitutional? A strong case can be made for that proposition, based on the same "right to privacy" that underlies such landmark Supreme Court decisions as Roe v. Wade.

The details of this year's health-care reform bill are still being hammered out. But the end result is sure to be byzantine in complexity. Washington will have immense say over how, when and through whom Americans are treated. Moreover, despite the administration's public pronouncements about painless cuts in wasteful spending, only the most credulous believe that some form of government-directed health-care rationing can be avoided as a means of controlling costs.

The Supreme Court created the right to privacy in the 1960s and used it to strike down a series of state and federal regulations of personal (mostly sexual) conduct. This line of cases began with Griswold v. Connecticut in 1965 (involving marital birth control), and includes the 1973 Roe v. Wade decision legalizing abortion.

The court's underlying rationale was not abortion-specific. Rather, the justices posited a constitutionally mandated zone of personal privacy that must remain free of government regulation, except in the most exceptional circumstances. As the court explained in Planned Parenthood v. Casey (1992), "these matters, involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment. At the heart of liberty is the right to define one's own concept of existence, of meaning, of the universe, and the mystery of human life."

It is, of course, difficult to imagine choices more "central to personal dignity and autonomy" than measures to be taken for the prevention and treatment of disease -- measures that may be essential to preserve or extend life itself. Indeed, when the overwhelming moral issues that surround the abortion question are stripped away, what is left is a medical procedure determined to be "necessary" by an expectant mother and her physician.

If the government cannot proscribe -- or even "unduly burden," to use another of the Supreme Court's analytical frameworks -- access to abortion, how can it proscribe access to other medical procedures, including transplants, corrective or restorative surgeries, chemotherapy treatments, or a myriad of other health services that individuals may need or desire?

This type of "burden" analysis will be especially problematic for a national health system because, in the health area, proper care often depends upon an individual's unique physical and even genetic history and characteristics. One size clearly does not fit all, but that is the very essence of governmental regulation -- to impose a regularity (if not uniformity) in the application of governmental power and the dispersal of its largess. Taking key decisions away from patient and physician, or otherwise limiting their available choices, will render any new system constitutionally vulnerable.

It is true, of course, that forms of rationing already exist in our current system. No one who has experienced the marked reluctance to treat aggressively lethal illnesses in the elderly can doubt that. However, what may be permissible for private actors -- including doctors and insurance companies -- is not necessarily lawful when done by the government.

Obviously, the government does not have to pay for any and all services individual citizens may desire. And simply refusing to approve a procedure or treatment under applicable reimbursement rules, as under the government-run Medicare and Medicaid, does not make the system unconstitutional. But if over time, as many critics fear, a "public option" health insurance plan turns into what amounts to a single-payer system, the constitutional issues regarding treatment and reimbursement decisions will be manifold.

The same will be true of a quasi-private system where the government claims a large role in defining acceptable health-insurance coverage and treatments. There will be all sorts of "undue burdens" on the rights of patients to receive the care they may want. Then the litigation will begin.

Anyone who imagines that Congress can simply avoid the constitutional issues -- and lawsuits -- by withdrawing federal court jurisdiction over the new health system must think again. A brief review of the Supreme Court's recent war-on-terror decisions, brought by or on behalf of detained enemy combatants, will disabuse that notion. This area of governmental authority was once nearly immune from judicial intervention. Over the past five years, however, the Supreme Court (supposedly the nonpolitical branch) has unapologetically transformed itself into a full-fledged, policy-making partner with the president and Congress.

In the process, the justices blew past specific congressional efforts to limit their jurisdiction and involvement like a hot rod in the desert. Questions of basic constitutionality (however the court may define them) cannot now be shielded from judicial review.

It is, of course, impossible to predict how and when the courts will ultimately rule on the new health system. Much depends on the details and the extent to which reasonable and practical private alternatives to the national plan remain. In crafting the law, however, its White House and congressional sponsors must keep privacy -- that near absolute right to personal autonomy they have so often praised and promoted -- squarely before them. The only thing that is certain today is that the courts, and not Congress, will have the last word.

SOURCE




NHS still going around in circles over dentistry

NHS dentists should be paid according to the number of patients on their list and penalised for shoddy operations that require repeat visits, an independent review has recommended. The proposals, which have been accepted in principle by the Government, include changes to improve access to NHS dentists and to end the “drill-and-fill” culture of operations. The review said that dentistry had become too preoccupied with treatment rather than prevention over the past 60 years.

The recommendations include rewarding dentists for registering new patients and building up relationships with existing ones, similar to those between GPs and their patients. Jimmy Steele, the lead author from Newcastle University, said that dentists’ responsibilities must be as much about ensuring that people understand oral health and diet as carrying out fillings.

A series of pilot trials will start in the autumn. Income will be determined on patient list size, quality of care and the number of courses of treatment.

The plans for patient registration have marked the return of a policy scrapped by Labour in its much-criticised dental reforms of 2006 — and which the Government said at the time would end the “drill-and-fill” culture. Figures show that around a million fewer people now have access to an NHS dentist in England than before the contract came into force three years ago. Andy Burnham, the Health Secretary, said yesterday that he recognised that dentistry was “an area of unfinished business”. He accepted that the contract had been problematic and that some decisions could have been taken differently.

Professor Steele said that dentists would have as much as 50 per cent of their income linked to the number of patients on their books. “It’s an incentive to take more patients on,” he said.

The review also recommends that dentists have greater accountability. This could mean being penalised for faulty work and having to carry out repairs at no extra charge to the NHS. At present, dentists can charge local health trusts for a procedure and then charge again even if they are the reason why a patient has had to return for further treatment. Under the new plans, the points dentists receive for carrying out an operation would not be awarded a second time if restorative work had to be carried out within three years.

Professor Steele said: “It’s a basic principle of quality and warranty. If I think the filling that I’m about to put in, or the crown I’m about to prepare for, is not going to last three years, then I shouldn’t be picking up that handpiece.”

Other plans include a new system of patient charges, replacing the current three-band system with one of between five and 12 bands. This was in response to the view of some patients that they did not always receive value for money.

Professor Steele said that patients should be called in for check-ups based on their individual need between every three and 24 months. “The six-month recall has no basis in science,” he said. “It’s just got a long history.”

The review also calls for more focus on preventative healthcare, with the aim of teaching people how to better look after their teeth. Mr Burnham said this could include looking at people’s diet. He has long been in favour of adding fluoride to the water in deprived areas.

The 2006 contract, which was supposed to allow dentists to spend more time with their patients, was criticised by dentists, while they were accused of playing the system. Yesterday’s report included examples of dentists recalling patients too often, or choosing more profitable treatments for patients when a less lucrative alternative was available.

Professor Steele added: “In the last 60 years, dental services have all been about quantity. We need to make a jump — and it’s a difficult jump — to move on to quality, to accept that less is usually actually better.”

Norman Lamb, the Liberal Democrat health spokesman, said the “near-destruction of NHS dentistry will be one of Labour’s most shameful legacies”. He added: “The Government has repeatedly botched efforts to reform dentistry services