The Politics of Health Care

[DougMacG]

November 3, 2009
The "Costs" of Medical Care
By Thomas Sowell
http://www.realclearpolitics.com/articles/2009/11/03/the_costs_of_medical_care_98986.html

We are incessantly being told that the cost of medical care is "too high"-- either absolutely or as a growing percentage of our incomes. But nothing that is being proposed by the government is likely to lower those costs, and much that is being proposed is almost certain to increase the costs.

There is a fundamental difference between reducing costs and simply shifting costs around, like a pea in a shell game at a carnival. Costs are not reduced simply because you pay less at a doctor's office and more in taxes-- or more in insurance premiums, or more in higher prices for other goods and services that you buy, because the government has put the costs on businesses that pass those costs on to you.

Costs are not reduced simply because you don't pay them. It would undoubtedly be cheaper for me to do without the medications that keep me alive and more vigorous in my old age than people of a similar age were in generations past.

Letting old people die would undoubtedly be cheaper than keeping them alive-- but that does not mean that the costs have gone down. It just means that we refuse to pay the costs. Instead, we pay the consequences. There is no free lunch.

Providing free lunches to people who go to hospital emergency rooms is one of the reasons for the current high costs of medical care for others. Politicians mandating what insurance companies must cover is another free lunch that leads to higher premiums for medical insurance-- and fewer people who can afford it.

Despite all the demonizing of insurance companies, pharmaceutical companies or doctors for what they charge, the fundamental costs of goods and services are the costs of producing them.

If highly paid chief executives of insurance companies or pharmaceutical companies agreed to work free of charge, it would make very little difference in the cost of insurance or medications. If doctors' incomes were cut in half, that would not lower the cost of producing doctors through years of expensive training in medical schools and hospitals, nor the overhead costs of running doctors' offices.

What it would do is reduce the number of very able people who are willing to take on the high costs of a medical education when the return on that investment is greatly reduced and the aggravations of dealing with government bureaucrats are added to the burdens of the work.

Britain has had a government-run medical system for more than half a century and it has to import doctors, including some from Third World countries where the medical training may not be the best. In short, reducing doctors' income is not reducing the cost of medical care, it is refusing to pay those costs. Like other ways of refusing to pay costs, it has consequences.

Any one of us can reduce medical costs by refusing to pay them. In our own lives, we recognize the consequences. But when someone with a gift for rhetoric tells us that the government can reduce the costs without consequences, we are ready to believe in such political miracles.

There are some ways in which the real costs of medical care can be reduced but the people who are leading the charge for a government takeover of medical care are not the least bit interested in actually reducing those costs, as distinguished from shifting the costs around or just refusing to pay them.

The high costs of "defensive medicine"-- expensive tests, medications and procedures required to protect doctors and hospitals from ruinous lawsuits, rather than to help the patients-- could be reduced by not letting lawyers get away with filing frivolous lawsuits.

If a court of law determines that the claims made in such lawsuits are bogus, then those who filed those claims could be forced to reimburse those who have been sued for all their expenses, including their attorneys' fees and the lost time of people who have other things to do. But politicians who get huge campaign contributions from lawyers are not about to pass laws to do this.

Why should they, when it is so much easier just to start a political stampede with fiery rhetoric and glittering promises?

[ccp]

"Britain has had a government-run medical system for more than half a century and it has to import doctors, including some from Third World countries where the medical training may not be the best."

Well we have been doing this since the 1970s to some extent here.
There are many doctors who are here trained elsewhere and two thirds of those in NJ medical schools and residency programs were born overseas.
There is no doubt part of the allowance for this was to increase supply of doctors and to increase supply of those who were willing to take less AND accept Medicare when that was having problems finding doctors accepting "assignment".  There was a day believe it or not that those doctors who were willing to take Medicare pay (which was I think around 70% of usual pay) were considered traitors.  The start of the slippery slope to where we are inevitably heading - single payer, government controlled health care.
The concept of importing those from around the world who will accept what we won't is certainly not new.

Why so many born Americans complain including minorities, yet there are those from overseas who are willing to work their behinds off and are kicking our own asses with accomplishments I am not sure.

But it is only recently I have heard some foreign born colleagues actually say they would consider returning to their native country to practice medicine at the rate things keep going.

As for the lawsuits stuff I am not defending doctors or blaming lawyers.  There are enough in all fields that are bilking the "system" that can share some blame as well as those in all fields who do an excellent and ethical job.

Yet the idea that the House bill actually makes everyone payfor this stuff, and regulates everybody and everything BUT the lawyers and fails to address malpractice if obviously a gross injustice and just pure slime.
I am really bnot sure how much of costs are in any way related to malpractice.  How many have merit and how many are just ambulance chasers trying to make a buck I really don't know.  Personally  I don't think there is a flood of "frivolous" lawsuits although there are some.

As far as us ordering tests that can be considered really unneeded and are purely defensive in nature is totally a sugjective call.
When is a test defensive and not really needed?  If the risk of a serious disease is 1/2 of one percent or 2 percent or 5 percent?

If the doctor really thinks it very unlikely a patient has a disease but orders a test "just in case this is the rare person who really does have it" is this defensive or just carefull and cautious and safe medicine being sure a person doesn't have a uncommon or rare disorder?

Ask five doctors on five different scenerios and you might get five answers.  So what is defensive medicine?  I read a big shot doctor who wrote and article and scoffed at the idea of "defensive testing" altogether.  His theory was if the doctor was worried enough to get a test because if he missed something he would get sued - well then he should order the test.  With that theory in mind the country can go broke ordering tests.  Yet this was some professor at some IVY league place who had an opinion just like he had an Ahole.


 

[Body-by-Guinness]

Is ObamaCare Constitutional?
Posted on 18 August 2009

by Rob Natelson

During the Bush administration, many within the dominant culture expressed concern about the constitutionality of detaining several hundred alleged enemy combatants in Guantanamo.

Whenever legal restrictions on abortion are proposed, many express doubt about the constitutionality of interjecting government between patients and their doctors.
But those voices have been mostly silent about the constitutionality of empowering the federal government with decisions over the life, death, and health of three hundred million Americans.

In fact, the constitutional difficulties are profound.  This is certainly so for those who believe the Constitution means what our Founders understood it to mean.  But it is even true for those interested only in modern Supreme Court jurisprudence.

Following are some of the ways in which current health care proposals potentially clash with our nation’s Basic Law:

Enumerated powers. The Constitution grants the federal government about thirty-five specific powers – eighteen in Article I, Section 8, and the rest scattered throughout the document.  (The exact number depends on how you count.)  None of those powers seems to authorize control of the health care system outside the District of Columbia and the federal territories.

To be sure, since the late 1930s, the Supreme Court has been tolerant of the federal welfare state, usually justifying federal ad hoc programs under specious interpretations of the congressional Commerce Power.  But, except in wartime, the Court has never authorized an expansion of the federal scope quite as large as what is being proposed now.  And in recent years, both the Court and individual justices – even “liberal” justices – have said repeatedly that there are boundaries beyond which Congress may not go.

The greatest Chief Justice, John Marshall, once wrote that if Congress were to use its legitimate powers as a “pretext” for assuming an unauthorized power, “it would become the painful duty” of the Court “to say that such an act was not the law of the land.”

But health care bills such as the Obama-favored HB 3200 do not even offer a pretext.  The only reference to the Constitution in HB 3200 is a severability clause that purports to save the remainder of the bill if part is declared unconstitutional.  HB 3200 contains no reference to the Commerce Power or to any other enumerated power.

Excessive Delegation. The Constitution “vests” legislative authority  in Congress.  Congress is not permitted to delegate that authority to the executive branch.  This is another realm in which the modern Supreme Court has been lenient, while affirming that there are limits.

Thus, in Schecter Poultry Corp. v. United States (1935), a unanimous court struck down a delegation of authority that looked much like the delegations in some current health care proposals.

Substantive Due Process. The Substantive Due Process doctrine was not contemplated by the Founders, but the courts have engrafted onto constitutional jurisprudence.  The courts employ this doctrine to invalidate laws they think are unacceptably intrusive of personal liberty or privacy.

The most famous modern Substantive Due Process case is Roe v. Wade, which struck down state abortion laws that intruded into the doctor-patient relationship.  But the intrusion invalidated in Roe was insignificant compared to the massive intervention contemplated by schemes such as HB 3200.  “Global budgeting” and “single-payer” plans go even further, and seem clearly to violate the Supreme Court’s Substantive Due Process rules.

Tenth Amendment. Technically, the Tenth Amendment is merely a declaration that the federal government has no powers beyond those enumerated in the Constitution.  However, the modern Supreme Court has cited the Tenth Amendment in holding that Congress may not “commandeer” state decision making in the service of federal goals.

It is permissible for Congress to condition grants of funds to the states, if the conditions are related to the funding program and are not “coercive.”  Thus, in 1986 the Court ruled that Congress may, because of highway safety issues, reduce highway grants by five percent to states refusing to raise their drinking ages to 21.

But the mandates that some health care plans would impose on states certainly could be found “coercive,” both because they are excessive (HB 3200, for instance, would withdraw all Public Health Service Act money from non-cooperating states) and because they are unrelated to the program.

A major goal of our Constitution and Bill of Rights is to limit government power, especially federal power.  National health care proposals would increase that power greatly, so it is not surprising that those proposals have constitutional difficulties.

Whatever the merits of federal control of health care, moving in that direction is (as former Justice David Souter might say) a change of “constitutional dimension.”  The proper way to make such a change is not through an ordinary congressional bill.  The proper way is by constitutional amendment.

Rob Natelson is Professor of Law at The University of Montana, and a leading constitutional scholar.  (See www.umt.edu/law/faculty/natelson.htm.) His opinions are his own, and should not be attributed to any other person or institution.

http://www.tenthamendmentcenter.com/2009/08/18/is-obamacare-constitutional/

[DougMacG]

BBG,  Interesting piece.  In the abortion debate, everything was about total privacy between woman and her doctor.  Same folks now have no qualm about opening everything else to do with your health care decisions up to the bureaucrats, policy makers and even the IRS. Third party pay means third party decision making - mandated.  This crowd isn't curious if their bill is constitutional; remaking the court and the meaning of that 'outdated' document is next on their agenda.

CCP, Thanks always for insights from the inside.  I agree that pretending to quantify frivolous lawsuits or unnecessary tests in the aggregate isn't going to give you good numbers - just like measuring jobs created or saved.  Is a one in a hundred or one in a million test worth it and at what cost?  All you really can do is judge it intuitively and anecdotally, compare it with other risks we take on like putting the car on the road in difficult conditions, or martial arts, sports, etc. and keep the decision with the person who has to live with it, both cost and consequence.   I don't want or need anyone from DMV there when I consider difficult choices with my doctor.

Seems to me that without malpractice lawsuits, you can still have doctors by the short hairs with licensing.  If their practices are not up to snuff, if their errors are excessive, if their procedures are sloppy, etc. the state can investigate and pull their license.  That I assume is a multimillion dollar penalty and then some.  I know of a situation right now that involves state licensing but not an MD - one bogus complaint in a half century of practice and everything is under review.

If there is a shortage of doctors, it is a managed or contrived shortage.  Seem to me that medical schools do everything they can to keep people who want to be doctors out.  In most cases, thank goodness, but I'm sure plenty of capable and competent applicants get turned away.  The Hillary-Obama-socialist view is that more doctors mean more pay and cost, so we need to get by with fewer.  In a market based world, more supply to keep up with demand is what keeps the cost per visit or procedure down and affordable.  If drought causes food prices to go up, and oil shortage or refinery outages shoots gas prices go up, why would an adequate supply of available doctors and specialists cause a higher cost to the patient (if there was any semblance of a market in place)? 

[Body-by-Guinness]

Wow. Reminds me of this Tom Waits tune:

[youtube]http://www.youtube.com/watch?v=qpUbX2-lJWw[/youtube]

November 03, 2009
Oh joy. 108 new federal bureaucracies created by health care reform bill

Rick Moran
The list comes to us via The Weekly Standard who cribbed it from a press release issued by the office of Rep. Mike Pence.

What was it Obama said on the stump about not wanting to grow the size of government?

Doesn't matter. People had to deliberately delude themselves to believe him anyway. Here's the list of new federal health care bureaucracies:

1. Retiree Reserve Trust Fund (Section 111(d), p. 61)
2. Grant program for wellness programs to small employers (Section 112, p. 62)
3. Grant program for State health access programs (Section 114, p. 72)
4. Program of administrative simplification (Section 115, p. 76)
5. Health Benefits Advisory Committee (Section 223, p. 111)
6. Health Choices Administration (Section 241, p. 131)
7. Qualified Health Benefits Plan Ombudsman (Section 244, p. 138)
8. Health Insurance Exchange (Section 201, p. 155)
9. Program for technical assistance to employees of small businesses buying Exchange coverage (Section 305(h), p. 191)
10. Mechanism for insurance risk pooling to be established by Health Choices Commissioner (Section 306(b), p. 194)
11. Health Insurance Exchange Trust Fund (Section 307, p. 195)
12. State-based Health Insurance Exchanges (Section 308, p. 197)
13. Grant program for health insurance cooperatives (Section 310, p. 206)
14. "Public Health Insurance Option" (Section 321, p. 211)
15. Ombudsman for "Public Health Insurance Option" (Section 321(d), p. 213)
16. Account for receipts and disbursements for "Public Health Insurance Option" (Section 322(b), p. 215)
17. Telehealth Advisory Committee (Section 1191 (b), p. 589)
18. Demonstration program providing reimbursement for "culturally and linguistically appropriate services" (Section 1222, p. 617)
19. Demonstration program for shared decision making using patient decision aids (Section 1236, p. 648)
20. Accountable Care Organization pilot program under Medicare (Section 1301, p. 653)
21. Independent patient-centered medical home pilot program under Medicare (Section 1302, p. 672)
22. Community-based medical home pilot program under Medicare (Section 1302(d), p. 681)
23. Independence at home demonstration program (Section 1312, p. 718)
24. Center for Comparative Effectiveness Research (Section 1401(a), p. 734)
25. Comparative Effectiveness Research Commission (Section 1401(a), p. 738)
26. Patient ombudsman for comparative effectiveness research (Section 1401(a), p. 753)
27. Quality assurance and performance improvement program for skilled nursing facilities (Section 1412(b)(1), p. 784)
28. Quality assurance and performance improvement program for nursing facilities (Section 1412 (b)(2), p. 786)
29. Special focus facility program for skilled nursing facilities (Section 1413(a)(3), p. 796)
30. Special focus facility program for nursing facilities (Section 1413(b)(3), p. 804)
31. National independent monitor pilot program for skilled nursing facilities and nursing facilities (Section 1422, p. 859)
32. Demonstration program for approved teaching health centers with respect to Medicare GME (Section 1502(d), p. 933)
33. Pilot program to develop anti-fraud compliance systems for Medicare providers (Section 1635, p. 978)
34. Special Inspector General for the Health Insurance Exchange (Section 1647, p. 1000)
35. Medical home pilot program under Medicaid (Section 1722, p. 1058)
36. Accountable Care Organization pilot program under Medicaid (Section 1730A, p. 1073)
37. Nursing facility supplemental payment program (Section 1745, p. 1106)
38. Demonstration program for Medicaid coverage to stabilize emergency medical conditions in institutions for mental diseases (Section 1787, p. 1149)
39. Comparative Effectiveness Research Trust Fund (Section 1802, p. 1162)
40. "Identifiable office or program" within CMS to "provide for improved coordination between Medicare and Medicaid in the case of dual eligibles" (Section 1905, p. 1191)
41. Center for Medicare and Medicaid Innovation (Section 1907, p. 1198)
42. Public Health Investment Fund (Section 2002, p. 1214)
43. Scholarships for service in health professional needs areas (Section 2211, p. 1224)
44. Program for training medical residents in community-based settings (Section 2214, p. 1236)
45. Grant program for training in dentistry programs (Section 2215, p. 1240)
46. Public Health Workforce Corps (Section 2231, p. 1253)
47. Public health workforce scholarship program (Section 2231, p. 1254)
48. Public health workforce loan forgiveness program (Section 2231, p. 1258)
49. Grant program for innovations in interdisciplinary care (Section 2252, p. 1272)
50. Advisory Committee on Health Workforce Evaluation and Assessment (Section 2261, p. 1275)
51. Prevention and Wellness Trust (Section 2301, p. 1286)
52. Clinical Prevention Stakeholders Board (Section 2301, p. 1295)
53. Community Prevention Stakeholders Board (Section 2301, p. 1301)
54. Grant program for community prevention and wellness research (Section 2301, p. 1305)
55. Grant program for research and demonstration projects related to wellness incentives (Section 2301, p. 1305)
56. Grant program for community prevention and wellness services (Section 2301, p. 1308)
57. Grant program for public health infrastructure (Section 2301, p. 1313)
58. Center for Quality Improvement (Section 2401, p. 1322)
59. Assistant Secretary for Health Information (Section 2402, p. 1330)
60. Grant program to support the operation of school-based health clinics (Section 2511, p. 1352)
61. Grant program for nurse-managed health centers (Section 2512, p. 1361)
62. Grants for labor-management programs for nursing training (Section 2521, p. 1372)
63. Grant program for interdisciplinary mental and behavioral health training (Section 2522, p. 1382)
64. "No Child Left Unimmunized Against Influenza" demonstration grant program (Section 2524, p. 1391)
65. Healthy Teen Initiative grant program regarding teen pregnancy (Section 2526, p. 1398)
66. Grant program for interdisciplinary training, education, and services for individuals with autism (Section 2527(a), p. 1402)
67. University centers for excellence in developmental disabilities education (Section 2527(b), p. 1410)
68. Grant program to implement medication therapy management services (Section 2528, p. 1412)
69. Grant program to promote positive health behaviors in underserved communities (Section 2530, p. 1422)
70. Grant program for State alternative medical liability laws (Section 2531, p. 1431)
71. Grant program to develop infant mortality programs (Section 2532, p. 1433)
72. Grant program to prepare secondary school students for careers in health professions (Section 2533, p. 1437)
73. Grant program for community-based collaborative care (Section 2534, p. 1440)
74. Grant program for community-based overweight and obesity prevention (Section 2535, p. 1457)
75. Grant program for reducing the student-to-school nurse ratio in primary and secondary schools (Section 2536, p. 1462)
76. Demonstration project of grants to medical-legal partnerships (Section 2537, p. 1464)
77. Center for Emergency Care under the Assistant Secretary for Preparedness and Response (Section 2552, p. 1478)
78. Council for Emergency Care (Section 2552, p 1479)
79. Grant program to support demonstration programs that design and implement regionalized emergency care systems (Section 2553, p. 1480)
80. Grant program to assist veterans who wish to become emergency medical technicians upon discharge (Section 2554, p. 1487)
81. Interagency Pain Research Coordinating Committee (Section 2562, p. 1494)
82. National Medical Device Registry (Section 2571, p. 1501)
83. CLASS Independence Fund (Section 2581, p. 1597)
84. CLASS Independence Fund Board of Trustees (Section 2581, p. 1598)
85. CLASS Independence Advisory Council (Section 2581, p. 1602)
86. Health and Human Services Coordinating Committee on Women's Health (Section 2588, p. 1610)
87. National Women's Health Information Center (Section 2588, p. 1611)
88. Centers for Disease Control Office of Women's Health (Section 2588, p. 1614)
89. Agency for Healthcare Research and Quality Office of Women's Health and Gender-Based Research (Section 2588, p. 1617)
90. Health Resources and Services Administration Office of Women's Health (Section 2588, p. 1618)
91. Food and Drug Administration Office of Women's Health (Section 2588, p. 1621)
92. Personal Care Attendant Workforce Advisory Panel (Section 2589(a)(2), p. 1624)
93. Grant program for national health workforce online training (Section 2591, p. 1629)
94. Grant program to disseminate best practices on implementing health workforce investment programs (Section 2591, p. 1632)
95. Demonstration program for chronic shortages of health professionals (Section 3101, p. 1717)
96. Demonstration program for substance abuse counselor educational curricula (Section 3101, p. 1719)
97. Program of Indian community education on mental illness (Section 3101, p. 1722)
98. Intergovernmental Task Force on Indian environmental and nuclear hazards (Section 3101, p. 1754)
99. Office of Indian Men's Health (Section 3101, p. 1765)
100. Indian Health facilities appropriation advisory board (Section 3101, p. 1774)
101. Indian Health facilities needs assessment workgroup (Section 3101, p. 1775)
102. Indian Health Service tribal facilities joint venture demonstration projects (Section 3101, p. 1809)
103. Urban youth treatment center demonstration project (Section 3101, p. 1873)
104. Grants to Urban Indian Organizations for diabetes prevention (Section 3101, p. 1874)
105. Grants to Urban Indian Organizations for health IT adoption (Section 3101, p. 1877)
106. Mental health technician training program (Section 3101, p. 1898)
107. Indian youth telemental health demonstration project (Section 3101, p. 1909)
108. Program for treatment of child sexual abuse victims and perpetrators (Section 3101, p. 1925)
109. Program for treatment of domestic violence and sexual abuse (Section 3101, p. 1927)
110. Native American Health and Wellness Foundation (Section 3103, p. 1966)
111. Committee for the Establishment of the Native American Health and Wellness Foundation (Section 3103, p. 1968)

Please note the "issues" that many of these agencies address. Every single liberal complaint about American society over the last 40 years will now have its own, special bureaucratic office to which the left can go to plead for relief, or seek redress, or initiate more legislation. The bureaucracies listed will worm their way into every corner of American life - snooping, hectoring, issuing grandiose proclamations, initiating "public service" campaigns - a nightmare of government intervention and it will lead to the death of the individual - and individual rights - in America.

No behavior will go uncriticized. No habit, left alone. No little personal joy will escape notice. We are ready to become a nation that walks on eggshells lest we offend some bureaucracy. Already thick with laws and regulations, American life will become a nightmare of looking over one's shoulder to make sure the government has its eyes trained elsewhere.

To call what the Democrats are doing by creating this gaggle of nanny state health nazis irresponsible is a given. More than that, it is a recipe to drastically curtail human freedom - all done with the excuse that your "freedom" doesn't give you the right to do anything that might cost the government more than a fair share of resources and money.

Will Americans sit still for this? Sure. We are mostly a nation now of children who like the idea of government taking care of us. Most will accept the new regime on that basis. Others are too apathetic to care one way or another. This is what the Democrats are counting on - and it appears that they will succeed.

Hat Tip: Ed Lasky


Page Printed from: http://www.americanthinker.com/blog/2009/11/oh_joy_108_new_federal_bureauc.html at November 03, 2009 - 03:42:41 PM EST

[Body-by-Guinness]

http://reason.com/blog/2009/11/04/the-public-option-is-displacin
Reason Magazine


"The public option is displacing private insurance."

Peter Suderman | November 4, 2009

What happened when Florida instituted a government-run insurance option in response to rising property insurance premiums? Alex Tabarrok points us to the following history lesson by the Independence Institute's Randall Holcombe:

After Hurricane Andrew hit Florida in 1992 some Floridians were having difficulty purchasing homeowners’ insurance.  (The reason: rates are regulated, and at the regulated rates some properties are too great a risk.)  So, the state government formed Citizens Property Insurance Corporation, which is owned and operated by the State of Florida.

As originally envisioned, Citizens would charge rates above those charged by private insurers, to make Citizens the insurer of last resort.  Nevertheless, Citizens found plenty of customers.

After two bad hurricane seasons in 2004 and 2005 property insurance rates in Florida rose, and in his campaign for the office, current Governor Charlie Crist promised voters that if elected he would see that their property insurance bills “dropped like a rock.”

One tactic he used was to change Citizens’ rate structure so it was competitive with private insurers.  His idea, like President Obama’s idea with health insurance, is that with a public option, private insurers would have to keep their rates in line or risk losing customers to the government insurer.

That’s what’s happened in Florida. Today about 30% of homeowners’ policies are written by Citizens, which is the largest property insurer in the state.  It’s about to get bigger too.  The largest private insurer, State Farm, had a rate request rejected last year, and now is pulling out of the state altogether (for property insurance; they’ll still insure your car).  As the largest private insurer pulls out over a three-year period (that period negotiated with the state), Citizens will get an even larger share of Florida’s property insurance.

Everybody in Florida knows Citizens is a fiscal time bomb.  Already, every Florida insurance policy (on homes, boats, cars, etc.) pays a surcharge that goes to Citizens, but Citizens still doesn’t have sufficient reserves to weather a major hurricane.  When one comes, Florida taxpayers will be on the hook for the bill.

The legislature knows this, and actually passed a bill last year that would have done a great deal to solve the problem by partially deregulating rates private insurers could charge.  State Farm would have stayed in Florida had that bill taken effect, but it was vetoed by the Governor.  The public option is displacing private insurance.

Now, it's not clear that something similar would happen immediately if the House's variant on the public option for health insurance became law. According to the CBO, under the House bill, the public plan would actually have higher premiums than private insurance options, and only about 6 million people would be enrolled. But if Congress eventually decided to "fix" this by forcing premium rates down by, say, pegging reimbursement fees to Medicare, as many of the most liberal legislators want to do now, it's more than plausible that we could see a similar situation develop in the health insurance market.

[Body-by-Guinness]

The Central-Planning Conceit
This weekend, House Democrats are planning to pass two health-care bills. One is a sweeping plan that would shift nearly all power over the organization of American health care to Washington, D.C. The other — a full repeal of the “sustainable growth rate” (SGR) formula governing Medicare physician fee payments — is proof positive that the first bill’s strategy of centralized planning is ill-conceived and dangerous to the quality of U.S. medical care.

To understand why, it is worth reviewing how the SGR came to be. In the late 1980s and 1990s, the Medicare bureaucracy set out to reform the way physicians are reimbursed for providing services to the program’s enrollees. The idea was to shift more resources toward generalists, who were then thought to be undercompensated for spending time with patients, and to control overall costs by limiting the growth of aggregate payments to growth in the size of the U.S. economy. After several years of study, lengthy payment regulations were issued, including a predecessor to the SGR formula, which had immediate and profound financial consequences for nearly every practicing physician in the United States.

And so what happened? The exact opposite of what was intended. Instead of encouraging more physicians to enter into primary care, the Medicare physician-fee schedule has rewarded more specialization. The fee schedule only controls prices, not volume. As Medicare’s administrators have tried to hold down costs with fee cuts, specialists increased their share of the pie with more tests and procedures, at the expense of primary-care reimbursement rates. Not surprisingly, the trend of physicians entering specialist practices has accelerated dramatically in the last twenty years. Moreover, overall costs have never been brought under control. With volume soaring, the SGR formula governing annual fee updates has gone completely off the rails. In 2010, fees are supposed to get cut by 21 percent unless Congress overrides it yet again. To secure the AMA’s endorsement of their health-care bill, House leaders are planning to scrap the SGR component of the physician fee system altogether, at a cost of more than $200 billion over a decade.

The irony of the situation seems to be lost on House Democrats: Congress is moving to repeal a prime example of health-care central planning run amok while simultaneously extending federal control to every corner of American health care.

For its part, the Obama administration has been promising for months that it would deliver new and improved central planning to “bend the cost-curve.” The White House Budget Director, Peter Orszag, in a February interview with Politico, suggested that the incoming Obama team was working on groundbreaking ideas that would use the levers of government payment policy to painlessly eliminate inefficiency in American health care. As Orszag put it, “Medicare and Medicaid are big enough to change the way medicine is practiced.”

Now, nine months later, it turns out the Obama administration doesn’t actually have any new ideas of what to do. It is instead proposing to empower an unelected, unaccountable commission to come up with the whiz-bang ideas, which would go into effect automatically without further congressional action. But House Democrats found the commission approach unacceptable, as it would take too much of the central planning power away from them. And so they have instead filled their bill with assorted pilot projects and tests of new Medicare payment approaches. Orszag touts these as good ideas with potential, too. But these ideas would have virtually no impact on federal spending, according to the Congressional Budget Office, and they certainly are not up to the task of offsetting the costs of the massive increase in entitlement spending contemplated in the House leadership bill.

Instead of clever new ideas that painlessly root out waste and inefficiency, the House bill finds savings the same way all central planners ultimately do: with deep and arbitrary across-the-board payment rate cuts. Despite all of the talk of delivery system reform, there’s no real effort to make distinctions based on the quality of patient care. Everyone gets cut the same.

And that’s the real danger of the House bill. There’s no prospect that the federal government will become more nimble overnight at managing the vast and complex health sector in the United States. To control costs in health care, the federal government will do what it always does — it will set prices. In time, that will have the predictable result of driving out willing suppliers of services, leading to queues and access problems. Call it centrally-planned rationing of care.

http://www.thenewatlantis.com/blog/diagnosis/the-central-planning-conceit

[ccp]

The writer in this article somewhat contradicts himself.
ON one hand he states the ONE is appointing a commission to come up with plans to cut costs.
On the other hand he states the plan is to ration care.

As far as I am concerned there are MANY radical ideas out there and the goal IS for single payer government controlled with an eye to ration care by looking at what gets statistical improvement over POPULATIONS of patients.

For example, get infant mortality down, vaccination levels up, screening tests up etc.

This is nice but if a person gets really sick the US is the place to be for the most advanced technology, medicines, specialty access etc.

Obama has not a clue other than the above = single payer, government control over distribution, payment, and everyone is covered and gets same access whether they like it or not.

There are many liberal think tanker liberals in health care - most of whom are at the IVy League liberal meccas who know what is best for everyone (including their own interests) who have worked this all out a long time ago.

Don't let them fool you into thinking the goals and plans are not already there.  Sure there may be wrinkles to iron out but the overall goal and methods are already very well outlined, and in the dogma for all of us.

The ONE is just their spokesman; there front man.

So some of what this guy writes is silly and wrong.
Folks - as far as the ONE and the rest of the big time liberals - it is a done deal.  The goal is etched in stone.
It is just how we get there in their minds.

[ccp]

What Anthony (A)Weiner today says:
There are no provisions for illegals in the House bill.
What AWeiner doesn't say:
One cannot verify if the person who is asking for health insurance is legal or not.
In other words if the illegal simply asks for it - then well....

What a scumbag.

[Crafty_Dog]

I am still on the road and was shaken to see that the house passed the Pelosi bill.  What are the prospects looking like in the Senate?

[G M]

Lindsey Graham (gag) and Joe Lieberman have promised to filibuster it.

Then there is this:

http://www.politico.com/livepulse/1109/Dr_No_threatening_to_have_bill_read_on_Senate_floor.html?showall

[DougMacG]

"shaken to see that the house passed the Pelosi bill.  What are the prospects looking like in the Senate?"

We are at the fork in the road and the precipice of the cliff.  There are large forces pushing in at least two directions.  Dems have their own 60 possible plus an unknown number of RINOs.  If they pass anything, it goes to conference.

Whether there are any conservative Dems with a backbone remains to be seen, maybe Lieberman.  The opposing force is that we know more than 50 senators that do not represent far left states.  The polls vary greatly and they have their own polls to tell them how to survive this.

The abortion amendment was the opposite of a poison pill.  They left out increased abortion funding certain to go back in, just like they failed to address health care for illegals - sure to be provided, and they removed a few ojjections of the swing votes.  Same type of thing will happen in the senate.  The controversial aspects will be watered down just to get the vote and get the program started.

The opposition strategists need to find the wedge that kills the deal.  I'd like to see an amendment  to keep the federal government from seeing any private medical records, making government management of the system impossible, and an amendment to preclude the IRS from taking part in any enforcement mechanism.

Better than 'improving' the bill would be load it up with ALL of what the far left wants, attach a full honest price tag and then vote it up or down.  (That isn't what's going to happen.)

The worst part of having our freedoms hinge on a stand taken by L. Graham or Lieberman is that after they hold out for their demands, their demands will be met and we are headed off the cliff.

[Crafty_Dog]

Speaker Nancy Pelosi defied policy logic and public opinion late Saturday night, ramming through the House a nearly 2,000-page health-care leviathan that counts as the biggest expansion of the federal government since the New Deal. As President Obama likes to say, this was a "teachable moment" about our current government.

The vote was 220 to 215, with 39 House Democrats joining all but one Republican in opposition. Mrs. Pelosi had to cajole and bribe her way to the magic 218, and the list of her promises must be stacked to the ceiling.

The lone Republican, Joseph Cao, represents a Democratic-leaning Louisiana district and extracted a promise that Mr. Obama would increase Medicaid payments to his state, and even then he only voted after Democrats had already hit 218. Let no one suggest this was the "bipartisan" health reform that Mr. Obama has long promised.

The bill is instead a breathtaking display of illiberal ambition, intended to make the middle class more dependent on government through the umbilical cord of "universal health care." It creates a vast new entitlement, financed by European levels of taxation on business and individuals. The 20% corner of Medicare open to private competition is slashed, while fiscally strapped states are saddled with new Medicaid burdens. The insurance industry will have to vet every policy with Washington, which will regulate who it must cover, what it can offer, and how much it can charge.

We have little sympathy for the insurers, or for that matter most of the other medical providers who signed on to this process only to claim now to be appalled by the result. The insurance lobby—led by Aetna CEO Ron Williams—made the Faustian bet that it could trade new regulations for more new subsidized customers who would face a tax penalty if they didn't buy their insurance. The Pelosi bill includes the regulation but guts the tax penalty because it's unpopular. Insurers will thus have to cover more sick people with fewer dollars, as healthy folk opt out of coverage until they are sick.

This writing was on the wall months ago, but the insurers chose to play an inside game rather than shape public opinion. Judging by their weekend statement—criticizing the House bill but vowing to seek "bipartisan" reform—they will now throw themselves at the mercy of the Senate. Good luck with that. The real victims are their customers, most of whom will pay more for insurance as the new mandates raise costs.

View Full Image
healthvote
Associated Press

House Speaker Nancy Pelosi.
healthvote
healthvote

Mrs. Pelosi's craftiest political turn was a last-minute compromise to strip federal funds from insurance plans that cover abortions. The deal—negotiated by Michigan Democrat Bart Stupak and supported by the National Right to Life Committee—gave cover to 40-some Democrats to support the larger bill.

However, as subsidized costs soar, government will have no choice but to ration medical care, starting with the aged and grievously ill. Is pre-natal life more valuable than the elderly? We're reminded of the way pro-lifers supported Anthony Kennedy over Laurence Silberman for the Supreme Court in 1987 merely because Mr. Kennedy was a Catholic who claimed to personally oppose abortion. Mr. Stupak played the right-to-lifers like a Stradavarius.

The real importance of the abortion uproar is as preview of the politics that will dominate every medical coverage issue if ObamaCare becomes law. Every decision of what to insure or not—when an MRI can be used, or whether a stage-four breast cancer patient can get Avastin or some future expensive drug—will become subject to political intervention over moral disputes or budget constraints. Heretofore, these decisions have largely been made between a doctor and patient. This is the real "right to life" issue.

Perhaps the most unsurprising news in this drama was the collapse of the Blue Dog "deficit hawks." Enough of them always cave in the end to give Mrs. Pelosi her way. It's nonetheless worth noting the surrender of that most vocal scourge of deficits, Tennessee's Jim Cooper, who voted aye on grounds that the bill can be improved in the Senate.

But Max Baucus's Finance Committee bill includes a similar gimmick of making the numbers look good by using 10 years of new taxes to finance only seven years of spending (six in the House). The deficits explode in the second decade and beyond in both bills.

The House also contains a new government long-term insurance program that starts collecting premiums in 2011 but doesn't starting paying benefits until 2016 and then runs out of money in 2029. North Dakota Democrat Kent Conrad called it "a Ponzi scheme of the first order, the kind of thing that Bernie Madoff would have been proud of" in an interview with the Washington Post in late October. Mr. Cooper has with a single vote made his entire career irrelevant.

Yet 39 other Democrats were given a pass on the vote, as the leadership knows how unpopular this bill is in most of America. They know this legislation is not the result of some national consensus in favor of expanding state power. Its passage was possible only because of temporary liberal majorities that are intent on fulfilling their dreams of a cradle-to-grave entitlement state. If they lose Blue Dog seats, or even their majority, in the short term, so be it. As the party of government, Democrats believe they will benefit in the long run from a much larger government.

Unless the Senate has an epiphany of common sense, Americans will be paying the bills for this willful exercise for generations to come.

[Body-by-Guinness]

Democrats Checkmate Themselves

November 10th, 2009
Liberals are fond of calling Republicans “the stupid party.” That might need revision. It appears to me that Democrats have checkmated themselves. Here is the logic:

If Obamacare makes it through the Senate, American small businesses will continue to shrink their payrolls to avoid the awful choice of paying higher health care insurance premiums or the 8% added payroll tax. Unemployment is sure to rise. The Dems will face the November 2010 elections with 12% unemployment ... closer to Depression levels of 20% by the so-called broader measures.

If Obamacare fails to pass, the left-wing base will be so demoralized as to not show up at the polls in 2010. Or they will be so angry that they might start a 1968-like interparty war.

My Checkmate Theory is based on small-business fear of Obama’s signature issues--health care, cap-and-trade and union card check. Health care is at the plate now. The fate of health care in the U.S. Senate will set the passage odds for cap-and-trade and union card check next year. All three of Obama's signature issues are opposed by most small businesses, including the American Chamber of Commerce.

Here are two revealing stories reporting the economic struggles and political fears of small businesses:

USA Today

Small businesses often lead the nation out of recession. Not this time.

The unemployment rate jumped to 10.2% in October from 9.8% in September, and economists say a big reason is small businesses. With sales weak, they're still slashing jobs and faring worse than their larger rivals.

"Small business tends to lead the way out, and that's just not happening here," says Mark Zandi of Moody's Economy.com.

The Wall Street Journal

W. Michael Brown has scaled back hiring plans in his Virginia auto-parts stores. Carl Redman halted an expansion project at his Oregon contracting business. Bill Hammack is preparing layoffs at his road-construction company in Georgia.

The economy remains unsteady 22 months after the recession began, with banks restricting credit and consumers hunkering down. For these small businesses, and many others across the country, there's an additional dark cloud: uncertainty created by Washington's bid to reorganize a wide swath of the U.S. economy.

If American small businesses stay hunkered down, unemployment will stay up. That’s because small businesses historically have created the majority of net jobs in any economy. They've created almost all net jobs in the first two years of a recovery. But not this time. Not yet.

The liberal writer Michael Lind is happy to see government put the screws to small businesses. In Lind’s opinion, small businesses are nothing more than a collection of Scrooges and Marleys. No doubt his opinion of small business is shared by many in the Democratic Party’s activist wing:

The solution may be corporatism or corporate paternalism--by which I mean the mandatory universalization of private employer benefits. If the politics of ethnic diversity makes movement in a universalist, social democratic direction impossible in the U.S., then the alternative might be to mandate that all employers provide certain benefits to all employees, with no exceptions. The costs of such unfunded mandates might drive some small businesses out of existence. But small-business owners are the most vocal opponents of wage and benefit reform in the U.S. The replacement of Scrooge & Marley by a smaller number of bigger private and public employers who treat Bob Cratchit and Tiny Tim better would not necessarily be a tragedy.

Not a tragedy? Don't be so quick, Democrats. You can’t have it both ways. Stick it to small businesses (through higher payroll taxes, cap-and-trade and union card check) and the assaulted will trim their payrolls until conditions clear, if ever. But if you don't stick it to small businesses, your party’s activist base will go nuts.

You have checkmated yourselves, Democrats.

http://blogs.forbes.com/digitalrules/2009/11/democrats-checkmate-themselves/

[Body-by-Guinness]

Publius vs. Obamacare
Let the Senate be the Senate.

By Rich Lowry

Supporters of Obamacare have their next target for obloquy and shame. It’s the United States Senate, an institution whose villainy will almost match that of the insurers and Fox News if the health-care bill sinks there.

The anti-senatorial campaign is already revving up. Liberal columnist Harold Meyerson stamped his feet in frustration yesterday in the Washington Post at the cussed balkiness of the Senate: “Dithering Heights.” “Proceeds glacially and produces next to nothing.”

This amounts to raging at the Senate for its very nature and purpose. It’s supposed to be slow-paced and unproductive. Everyone has their moments of frustration at the Senate (I’ve had plenty) because it is designed to be frustrating, especially when a majority in the House is electric with ideological excitement. Conservatives spent most of 1995 hurling epithets at the Senate.

So it’s not surprising that the Left is upset at it at a time when “Iron Nancy” is using her solid majority to muscle massive pieces of legislation through the House by a handful of votes. Why can’t the Senate do the same, goes the cry, entirely missing the point. It’s not just that the Senate is built differently from the House: It won’t truly be fulfilling its role in our constitutional scheme if doesn’t deep-six Obamacare.

The Senate exists to keep temporarily enlarged and inflamed majorities from rushing through far-reaching pieces of legislation that don’t command broad and deep public support. In its institutional DNA, the Senate should regard Obamacare the way a cheetah regards a gazelle — prey to be killed.

The Democrats enjoy such a large House majority thanks partly to an accident of timing. The election was held in uniquely disastrous circumstances for the Republicans, in the immediate wake of the collapse of Lehman and the ensuing financial panic. Piled on top of the other causes of Republican woe (some of them quite well-deserved), the crisis allowed Democrats to run up the score. But in a matter of months public opinion began snapping back to its center-right state. So we have a House majority that is caught in amber circa October 2008 when the nation’s mood has already moved on.

Hey, you might say, such is the dumb luck of timing in elections. True. But in their wisdom our Founders devised a check to keep a majority augmented by temporary circumstances from running amok. It’s called the Senate.

The House stands for election all at once, capturing public opinion at one moment in time. In contrast, only one-third of the Senate stands for election at once. Originally, its members were selected by state legislatures, further shielding it from public opinion (a feature done away with by the Seventeenth Amendment, of course). It was supposed to be more elite than the House. And the very fact of its existence, in a bicameral legislature, added complexity to the legislative process.

The Senate is protection against rashness. As the great historian Daniel Walker Howe writes of Publius — the collective author of the Federalist Papers — in his book Making the American Self: “The branches of government he wanted to strengthen were ones he associated with the most rationality: the judiciary, the executive, and the Senate; the elements he wanted to limit he associated with narrow self-interest and the passions: the state governments and all popular assemblies, including the House of Representatives.”

Howe continues, “Of course, factions could be majorities as well as minorities. Indeed, the factions Publius was chiefly worried about were the ones that commanded a majority; minority factions were easily limited. But ‘when a majority is included in a faction, the form of popular government . . . enables it to sacrifice to its ruling passion or interest both the public good and the rights of other citizens.’”

The Senate — among other aspects of our complex government — helps protect us from such abuses by slowing things down, and simply stopping dubious legislation. Here’s Federalist No. 73 (it’s discussing the executive and the veto power, but it’s the sentiment that is important):

The oftener the measure is brought under examination, the greater the diversity in the situations of those who are to examine it, the less must be the danger of those errors which flow from want of due deliberation, or of those missteps which proceed from the contagion of some common passion or interest. It is far less probable, that culpable views of any kind should infect all the parts of the government at the same moment and in relation to the same object, than that they should by turns govern and mislead every one of them.

It may perhaps be said that the power of preventing bad laws includes that of preventing good ones; and may be used to the one purpose as well as to the other. But this objection will have little weight with those who can properly estimate the mischiefs of that inconstancy and mutability in the laws, which form the greatest blemish in the character and genius of our governments. They will consider every institution calculated to restrain the excess of law-making, and to keep things in the same state in which they happen to be at any given period, as much more likely to do good than harm; because it is favorable to greater stability in the system of legislation. The injury which may possibly be done by defeating a few good laws, will be amply compensated by the advantage of preventing a number of bad ones.

This essential wisdom of the Founders is now the Democrats’ enemy. They want to rush because they know their legislation won’t bear long, careful scrutiny; because they know the public will soon demand that they focus on things of more pressing concern (the economy); and because they know it would be folly to keep debating the bill in an election year. So they want to pass major social legislation on basically a party-line vote and forge ahead even though almost every poll shows more people opposing than supporting it. It’s hard to think of major, defining legislation that has ever passed this way.

Liberals recall how long they have talked about national health insurance: No rush here, it’s the work of decades. But this plan has, relatively speaking, been sprung on the American public. Barack Obama did not campaign on huge tax increases to pay for health-care reform, or large Medicare cuts, or premium increases, or even the individual mandate. He talked of health-care reform in the most anodyne way.

If Obamacare is so necessary and wise, there’s no true need to hurry. If it fails to pass the Senate, Democrats should campaign on it around the country. They should keep talking of its wonders, and build up public support for it, turning around the polls. They should enhance their majority in the House and the Senate, bringing new Obamacare Democrats to Washington. That’s how you build toward passing historic legislation in a system such as ours naturally resistant to large-scale change.

Democrats don’t want to do that because, in their heart of hearts, they know they can’t do that. They want to jam it through instead. Here’s hoping the Senate does its proper work and — slowly, frustratingly — assigns the health-care bill to the grave.

— Rich Lowry is the editor of National Review.

National Review Online - http://article.nationalreview.com/?q=OTMwNzg2MzZmNmNjYzE2ZGZkMGMxYmZlMmNlZDFmNjg

[DougMacG]

Very interesting take.  Democrat Senators in red and split states might as well vote yes on the Pelosi-Obama agenda, against their constituents, because otherwise they will be destroyed by their own parties and activists.  That doesn't bode well for defeating the bill.  Voting against health care in the Dem party would be like one of us leaving our country.  They could switch parties but I don't any of them are in a position or interest to do that.

I would not want to be in the situation of these moderates, R or D, trying to figure out what to do politically without having any backbone or principles of their own. 

[ccp]

From everything I have read so far mammograms before age 50 have not been shown to save any lives though this article suggests that one life could be saved in around 1900 of them.  No where does it point out the increased burden from the extra CUMULATIVE dose of radiation that undoubtedly will cause some breast cancers by starting radiation screening at age 40 rather than 50.

Make no mistake about it - this is and has been more of a political decision.  There are potent lobbying groups from the Susan Kormen foundation, NOW and others, primarily womens groups who lobby and claims that breast cancer researched lagged ( because of course most researchers are men and therefore they don't give a hoot about what is mostly a woman's disease and any politician that disputes this is of course going to incur the wrath of woman at the polls.  I always felt groups like the American Cancer Society who support mammos from 40 to 50 were succumbing more to political pressure than to science.

Now of course with the USPSTF new rec. that screening mammos be done in normal risk pts only after age 50 the screams and outcries are all over the news.  It is more obvious than ever health decisions are no longer just that - they are political decisions.

And the questions begs to be answered - WHEN IF EVER IS COST TO SOCIETY AN ISSUE??

So we SHOULD do nearly 20,000 mammograms (1,900 babes screened over ten years) to save one life?
The cost is not an issue??

Well by that logic why do we even do mammograms???  Why not do MRIs which are more sensitive and safer (no radiation) than mammos ( and probably less painful)??

Why not do them every 6 months?  Where do we draw the line???  This is EXACTLY a perfect example of individuals screaming they they want everything done known to man at a cost that is acceptable because why??  Someone else pays for it.

Who if anyone will take the leadership and ask us where to draw the line???

Folks this is one reason we go broke.  No one is addressing this.

http://www.webmd.com/breast-cancer/news/20091116/panel-breast-screening-should-start-50

[Body-by-Guinness]

The Rationing Commission

Meet the unelected body that will dictate future medical decisions.

As usual, the most dangerous parts of ObamaCare aren't receiving the scrutiny they deserve—and one of the least examined is a new commission to tell Congress how to control health spending. Democrats are quietly attempting to impose a "global budget" on Medicare, with radical implications for U.S. medicine.

Like most of Europe, the various health bills stipulate that Congress will arbitrarily decide how much to spend on health care for seniors every year—and then invest an unelected board with extraordinary powers to dictate what is covered and how it will be paid for. White House budget director Peter Orszag calls this Medicare commission "critical to our fiscal future" and "one of the most potent reforms."

On that last score, he's right. Prominent health economist Alain Enthoven has likened a global budget to "bombing from 35,000 feet, where you don't see the faces of the people you kill."

As envisioned by the Senate Finance Committee, the commission—all 15 members appointed by the President—would have to meet certain budget targets each year. Starting in 2015, Medicare could not grow more rapidly on a per capita basis than by a measure of inflation. After 2019, it could only grow at the same rate as GDP, plus one percentage point.

The theory is to let technocrats set Medicare payments free from political pressure, as with the military base closing commissions. But that process presented recommendations to Congress for an up-or-down vote. Here, the commission's decisions would go into effect automatically if Congress couldn't agree within six months on different cuts that met the same target. The board's decisions would not be subject to ordinary notice-and-comment rule-making, or even judicial review.

Yet if the goal really is political insulation, then the Medicare Commission is off to a bad start. To avoid a senior revolt, Finance Chairman Max Baucus decided to bar his creation from reducing benefits or raising the eligibility age, which meant that it could only cut costs by tightening Medicare price controls on doctors and hospitals. Doctors and hospitals, naturally, were furious.

So the Montana Democrat bowed and carved out exemptions for such providers, along with hospices and suppliers of medical equipment. Until 2019 the commission will thus only be allowed to attack Medicare Advantage, the program that gives 10 million seniors private insurance choices, and to raise premiums for Medicare prescription drug coverage, which is run by private contractors. Notice a political pattern?

But a decade from now, such limits are off—which also happens to be roughly the time when ObamaCare's spending explodes. The hard budget cap means there is only so much money to be divvied up for care, with no account for demographic changes, such as longer life spans, or for the increasing incidence of diabetes, heart disease and other chronic conditions.

Worse, it makes little room for medical innovations. The commission is mandated to go after "sources of excess cost growth," meaning treatments that are too expensive or whose coverage will boost spending. If researchers find a pricey treatment for Alzheimer's in 2020, that might be banned because it would add new costs and bust the global budget. Or it might decide that "Maybe you're better off not having the surgery, but taking the painkiller," as President Obama put it in June.

In other words, the Medicare commission would come to function much like the National Institute for Health and Clinical Excellence, which rations care in England. Or a similar Washington state board created in 2003 to control costs. Its handiwork isn't pretty.

The Washington commission, called the Health Technology Assessment, is manned by 11 bureaucrats, including a chiropractor and a "naturopath" who focuses on alternative, er, remedies like herbs and massage therapy. They consider the clinical effectiveness but above all the cost of medical procedures and technologies. If they decide something isn't worth the money, then Olympia won't cover it for some 750,000 Medicaid patients, public employees and prisoners.

So far, the commission has banned knee arthroscopy for osteoarthritis, discography for chronic back pain, and implantable infusion pumps for pain not related to cancer. This year, it is targeting such frivolous luxuries as knee replacements, spinal cord stimulation, a specialized autism therapy and MRIs of the abdomen, pelvis or breasts for cancer. It will also rule on routine ultrasounds for pregnancy, which have a "high" efficacy but also a "high" cost.

Currently, the commission is pushing through the most restrictive payment policy in the nation for drug-eluting cardiac stents—simply because bare metal stents are cheaper, even as they result in worse outcomes. If a patient is wheeled into the operating room with chest pains in an emergency, doctors will first have to determine if he's covered by a state plan, then the diameter of his blood vessels and his diabetic condition to decide on the appropriate stent. If they don't, Washington will not reimburse them for "inappropriate care."

If Democrats impose such a commission nationwide, it would constitute a radical change in U.S. health care. The reason that physician discretion—not Washington's cost-minded judgments—is at the core of medicine is that usually there are no "right" answers. The data from large clinical trials produce generic conclusions that rarely apply to individual patients, who have vastly different biologies, response rates to treatments, and often multiple conditions. A breakthrough drug like Herceptin, which is designed for a certain genetic subset of breast-cancer patients, might well be ruled out under such a standardized approach.

It's possible this global budget could become an accounting fiction, like the automatic Medicare cuts Congress currently pretends it will impose on doctors. But health care's fiscal pressures will be even stronger than they are today if ObamaCare passes in anything like its current form. And that is when politicians will want this remote, impersonal and unaccountable central committee to do the inevitable dirty work of denying care.

The only way to take the politics out of health care is to give individuals more power to control medical dollars. And the first step should be not to create even more government spending commitments. The core problem with government-run health care is that it doesn't make decisions in the best interests of patients, but in the best interests of government.

http://online.wsj.com/article/SB10001424052748703792304574504020025055040.html

[Body-by-Guinness]

Health 'Reform' Gets a Failing Grade
The changes proposed by Congress will require more draconian measures down the road. Just look at Massachusetts.
By JEFFREY S. FLIER

As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade.

Instead of forthrightly dealing with the fundamental problems, discussion is dominated by rival factions struggling to enact or defeat President Barack Obama's agenda. The rhetoric on both sides is exaggerated and often deceptive. Those of us for whom the central issue is health—not politics—have been left in the lurch. And as controversy heads toward a conclusion in Washington, it appears that the people who favor the legislation are engaged in collective denial.

Our health-care system suffers from problems of cost, access and quality, and needs major reform. Tax policy drives employment-based insurance; this begets overinsurance and drives costs upward while creating inequities for the unemployed and self-employed. A regulatory morass limits innovation. And deep flaws in Medicare and Medicaid drive spending without optimizing care.

Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true. The various bills do deal with access by expanding Medicaid and mandating subsidized insurance at substantial cost—and thus addresses an important social goal. However, there are no provisions to substantively control the growth of costs or raise the quality of care. So the overall effort will fail to qualify as reform.

In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it. Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction. The true costs of health care are disguised, competition based on price and quality are almost impossible, and patients lose their ability to be the ultimate judges of value.

Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern.

In effect, while the legislation would enhance access to insurance, the trade-off would be an accelerated crisis of health-care costs and perpetuation of the current dysfunctional system—now with many more participants. This will make an eventual solution even more difficult. Ultimately, our capacity to innovate and develop new therapies would suffer most of all.

There are important lessons to be learned from recent experience with reform in Massachusetts. Here, insurance mandates similar to those proposed in the federal legislation succeeded in expanding coverage but—despite initial predictions—increased total spending.

A "Special Commission on the Health Care Payment System" recently declared that the Massachusetts health-care payment system must be changed over the next five years, most likely to one involving "capitated" payments instead of the traditional fee-for-service system. Capitation means that newly created organizations of physicians and other health-care providers will be given limited dollars per patient for all of their care, allowing for shared savings if spending is below the targets. Unfortunately, the details of this massive change—necessitated by skyrocketing costs and a desire to improve quality—are completely unspecified by the commission, although a new Massachusetts state bureaucracy clearly will be required.

Yet it's entirely unclear how such unspecified changes would impact physician practices and compensation, hospital organizations and their capacity to invest, and the ability of patients to receive the kind and quality of care they desire. Similar challenges would eventually confront the entire country on a more explosive scale if the current legislation becomes law.

Selling an uncertain and potentially unwelcome outcome such as this to the public would be a challenging task. It is easier to assert, confidently but disingenuously, that decreased costs and enhanced quality would result from the current legislation.

So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.

Dr. Flier is dean of the Harvard Medical School.

http://online.wsj.com/article/SB10001424052748704431804574539581994054014.html#

[ccp]

Of course the parade of women on the news networks, who have had breast cancer parading, and with their anecdotal stories mostly explaining their outrage at the recent task force recommendations which are just that - recommendations based on the data.
One woman this morning agreed and actually commended the USPSTF for their courageous decision only to be questioned with disbelief from the CNN announcer.

Question to all here:

Would anyone want to say no to a mob of angry women about the advisability of mammos between 40 and 50, OR is it easier and more politically expedient to just say OK - we rec. mammos between 40 and 50?

Based on any numbers I have read we could just as easily be causing just as many breast cancers with the additional 5 or 10 mammograms in a person's lifetime then we *may* be saving.  I admit it seems hard to believe but if we are saving so many lives who come we can't prove it with hundreds of thousands of people in the studies?

No one wants to be called sexist, a murderer, a piece of dirt who just wants to save money while many women die needlessly because heartless insurance companies don't want to pay for the mammograms.

So we have been paying for them even when the science doesn't show evidence they help more than they harm.

FWIW there is similar controversy with prostate cancer screening.

And by the way my mother and aunt both had breast cancer.

[Body-by-Guinness]

http://reason.com/blog/2009/11/18/harry-reid-happy-with-cbo-scor
Reason Magazine


Harry Reid Happy With CBO Score He Worked to Guarantee He'd Be Happy With

Peter Suderman | November 18, 2009

Ezra Klein is reporting that Senate Majority Leader Harry Reid has seen the CBO scores for the Senate's health care bill, and is "very pleased." Of course he is: It's doubtful that we'd be getting a score today if he weren't; according to one of Klein's recent posts, the reason we didn't see the score last Friday, as originally expected, is that the CBO's numbers came back to Reid, but weren't what was hoped. As a result, the bill, according to Klein, was "tweaked and trimmed until CBO [gave] Reid the answer he's looking for." Indeed, this is often how the scoring process works: Legislators work closely with CBO to push and pull at various elements of the bill until the CBO's math produces the desired result. So given that Reid knows exactly what it will be in advance (he sees preliminary numbers), can choose to release the score or resubmit again, and has been working with the CBO to make sure the numbers are to his liking, it's hardly surprising to see that, on a high profile bill like this, Reid is happy with the result.

[Body-by-Guinness]

Second post:

That Darn Mandate
Shikha Dalmia, 11.18.09, 12:01 AM ET
ObamaCare has nothing going for it anymore. With unemployment touching double digits, its economic timing is bad; with polls showing tanking support in every group outside of the narrow sliver of die-hard liberal reformers, its political timing is bad; and with the Center for Medicare and Medicaid Services last week saying that it'll add billions to the already out-of-control deficit, its fiscal timing has gone from bad to awful.

So how are Comrades Pelosi, Reid and Obama able to march ahead with their grand designs undeterred? One reason is that Republicans have done precious little to seize the moral high ground from them. By insisting on the removal of the public option--instead of the individual mandate--as the price of doing business, Republicans have missed a major opportunity to put Democrats on the defensive and change the terms of the debate.

Republicans threw down the gauntlet on the public option--a government-funded, Medicare-style insurance plan that will compete with private insurance--in a June letter to Obama. "Washington-run programs undermine market-based competition through their ability to impose price controls and shift costs to other purchasers," they said. "The end result would be a federal government takeover of our health care system, taking decisions out of the hands of doctors and patients and placing them in the hands of a Washington bureaucracy."

True. But the problem is that Democrats don't need the public option to engineer a "federal takeover of our health care system." All they need is the power to force Americans to purchase insurance.

A mandate will fundamentally alter the relationship between Americans and their government. Instead of the government being accountable to them, they will become accountable to their government. No less than the Congressional Budget Office--a non-partisan government agency--once admitted as much. "A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action," it noted. "The government has never required people to buy any good or service as a condition of lawful residence in the United States."

If the government can force Americans to buy coverage on the threat of fines or even imprisonment--an option that Nancy Pelosi has pointedly refused to rule out--every other government diktat becomes small potatoes by contrast. In fact, it becomes necessary. If uninsured Americans must buy coverage, why shouldn't other Americans be taxed to subsidize them? Why shouldn't the insurance industry be required to sell them coverage? Why shouldn't government set insurance prices to ensure affordability? Why shouldn't doctors and hospitals be asked to charge only "reasonable" rates--or offer only government-sanctioned treatments? Nothing about ObamaCare fundamentally changes so long as the individual mandate remains intact.

Therefore, instead of wonkishly droning about the public option, Republicans should counter Democrats' grand appeals for "universal coverage for all" with equally grand appeals for "medical freedom for all." They should stand together on the Capitol steps and issue the health care equivalent of Reagan's Berlin Wall ultimatum: "Mr. President: Tear up this mandate."

During the campaign, Obama himself successfully stopped poor Hillary dead in her tracks by reminding voters at every turn of her tyrannical plans to force them to purchase coverage. So why aren't Republicans doing the same to Obama?

The main reason is that they themselves are deeply conflicted about the mandate. On the one hand, every Republican on the Senate Finance Committee voted against it--except, of course, for Maine's Sen. Olympia Wavering-Heart Snowe. On the other hand, many Republicans, led by their intellectual lights at the conservative Heritage Foundation, among others, have long accepted--no, championed--the notion that unless people are forced to carry insurance, freeloaders who land in emergency rooms will cripple the health care system. Legislate personal responsibility, in other words. It was a Heritage plan for forced coverage that formed the blueprint for the Massachusetts universal care debacle that the then Republican Gov. Mitt Romney enacted.

Thus Republicans have no leg to stand on now that Obama, pulling one of his many switcheroos, has embraced the individual mandate. Heritage folks are trying to pull their own switcheroo by opposing Obama's mandate, saying what they had originally proposed for Massachusetts was not really a mandate but actually a self-insurance scheme under which an uninsured person would have to post a personal bond before being treated in an emergency room.

But countering mandates with bonds doesn't exactly make for a rousing rallying cry. Indeed, both ideas are based on the mistaken diagnosis that the central cause of our health care woes is the cost of uncompensated care that the uninsured get. The fact of the matter is that this care accounts for no more than $40 billion of the country's $2.26 trillion health care bill--or less than 3% of total health care spending. This is less than what department stores lose to shoplifting every year. Several private hospitals that I visited in India last month make a fraction of the profits that American hospitals do but still reported treating up to 10% of their patients for free.

The mandate barring American hospitals from denying treatment to anyone who lands in emergency--the root of the supposed freeloader problem--certainly imposes a heavy burden on some hospitals, especially in inner cities. But it is far from clear that it forces American hospitals as a whole to provide more charitable care to the uninsured than what they would have without it. It would certainly be worthwhile at some point to consider policy options to replace this mandate with mechanisms to strengthen voluntary charity by hospitals and others. In the meantime, however, there is zero evidence to suggest that this mandate is imposing a crippling enough burden on hospitals to warrant mandates on everyone else as well.

The Republican strategy for defeating ObamaCare consists of notifying: seniors that they will face rationing and loss of private Medicare options; the uninsured that they will face fines and possibly jail; the young and healthy that they will have to subsidize the old and sick, etc. Alerting Americans to the personal dangers they will confront under ObamaCare is certainly a legitimate part of the political process.

However, the downside of a strategy based entirely on fear is that even if it succeeds now, it won't help to define the proper terms for a genuine solution in the future. For that, Republicans have to offer a principled critique of ObamaCare that delineates the sharp moral choices that Americans face. The current health care battle is the domestic policy equivalent of the Cold War. Democrats are on the side of command-and-control mandates that deprive individuals of choice. Republicans should position themselves on the side of market-based solutions that empower--not enchain--patients.

Shikha Dalmia is a senior analyst at Reason Foundation and a bi-weekly Forbes columnist.

http://www.forbes.com/2009/11/17/obamacare-health-democrats-republicans-opinions-columnists-shikha-dalmia_print.html

[Crafty_Dog]

"However, the downside of a strategy based entirely on fear is that even if it succeeds now, it won't help to define the proper terms for a genuine solution in the future. For that, Republicans have to offer a principled critique of ObamaCare that delineates the sharp moral choices that Americans face. The current health care battle is the domestic policy equivalent of the Cold War. Democrats are on the side of command-and-control mandates that deprive individuals of choice. Republicans should position themselves on the side of market-based solutions that empower--not enchain--patients."

EXACTLY SO.

[Body-by-Guinness]

Reid Health Bill Perpetuates the $1.5 Trillion Fraud
Posted By Michael F. Cannon On November 19, 2009 @ 9:05 am In Health, Welfare & Entitlements | Comments Disabled

Senate Majority Leader Harry Reid (D-NV) has finally unveiled his massive 2,074-page health care bill [1].  The Congressional Budget Office reports [2] that the insurance-expansion provisions would cost the feds $848 billion over 10 years.  To raise those funds, the bill would tax [3] wages, medical devices, prescription drugs, sick people, health insurance premiums (twice), HSAs, FSAs, HRAs, and — why not? — cosmetic surgery.  The remainder would supposedly come from $491 billion of Medicare cuts, even though Medicare’s chief actuary says [4] such cuts are “unrealistic” and “doubtful.”  But don’t worry.  Somehow, this thing’s gonna reduce the deficit.

Of course, that $848 billion only accounts for part of the federal government’s share of the tab.  There is other new federal spending.  My read is that the CBO estimates $998 billion of total new federal spending — though I’ll be waiting for former CBO director Donald Marron [5] to provide a more authoritative tally.

And then there are costs that Reid and his comrades have pushed off the federal budget.  For example, the $25 billion unfunded mandate that Reid would impose on states.  Total so far: just over $1 trillion.

But the biggest hidden cost is that of the private-sector mandates.  In both the Clinton health plan [6] and the Massachusetts health plan [7], the private-sector mandates –- the legal requirements that individuals and employers purchase health insurance [8] –- accounted for 60 percent of total costs.  That suggests that if the Reid bill’s cost to federal and state governments is $1 trillion, then the total cost is probably $2.5 trillion, and Harry Reid — like House Speaker Nancy Pelosi — is hiding $1.5 trillion of the cost of his bill.

Without a cost estimate of the private-sector mandates, Reid has not yet satisfied the request made by eight Democratic senators [9] for a “complete CBO score” of the bill 72 hours prior to floor consideration.

Fortunately, by law, the CBO must eventually score the private-sector mandates.  When that happens, the CBO will reveal costs that the bills’ authors are trying to hide. When that happens, the CBO will present the new federal spending on page 1, new state spending maybe on page 10, and the cost of the private-sector mandates on page 20 or something.  Democrats will tout the figure on page 1.  But the bill’s total cost will the sum of those three figures -– a sum that will reveal the costs that the bill’s authors have been hiding.

The House passed its bill without a complete CBO score.  The Senate should not follow suit.

I’ve written previously about this massive fraud here [10], here [11], here [12], and here [13].

(Cross-posted at Politico’s Health Care Arena [14].)

Article printed from Cato @ Liberty: http://www.cato-at-liberty.org

URL to article: http://www.cato-at-liberty.org/2009/11/19/reid-health-bill-perpetuates-the-1-5-trillion-fraud/

URLs in this post:

[1] 2,074-page health care bill: http://democrats.senate.gov/reform/patient-protection-affordable-care-act.pdf
[2] reports: http://bit.ly/UCAIk
[3] tax: http://jct.gov/publications.html?func=startdown&id=3635
[4] says: http://bit.ly/3DmEEJ
[5] Donald Marron: http://dmarron.com/
[6] Clinton health plan: http://www.cbo.gov/ftpdocs/48xx/doc4882/doc07.pdf
[7] Massachusetts health plan: http://www.cato.org/pub_display.php?pub_id=10488
[8] that individuals and employers purchase health insurance: http://www.cato.org/pub_display.php?pub_id=10576
[9] eight Democratic senators: http://blog.sunlightfoundation.com/2009/10/07/eight-senators-want-the-public-to-read-the-health-care-bill/
[10] here: http://www.cato.org/pub_display.php?pub_id=10439
[11] here: http://www.cato.org/pub_display.php?pub_id=10631
[12] here: http://www.cato.org/pub_display.php?pub_id=10944
[13] here: http://www.cato.org/pub_display.php?pub_id=10959
[14] Health Care Arena: http://www.politico.com/arena/healthcare/

[Crafty_Dog]

Guidelines Push Back Age for Cervical Cancer Tests

New guidelines for cervical cancer screening say women should
delay their first Pap test until age 21, and go for screening
less often than had been previously recommended.

Read More:
http://www.nytimes.com/2009/11/20/health/20pap.html?emc=na

[ccp]

What can I say?  For anyone who works hard and keeps getting robbed by the government this should be infuriating.  But it doesn't matter because the number of people who are on the receiving end of government dole outs keeps rising and they certainly don't give a crap.  This makes me wish there were enough people who are willing to stand up and just say enough and simply not pay their taxes.  What are they going to do arrest 100 million people.
We just keep getting robbed more and more.  There is no end in sight.
Obama has hated America as it was and barely still is for 200 years.  So now I can hate what he is turning it into.
In his mind that is justice.
I can only hope we kick this guy out of office in time and can restrict his power next year in the elections.

***ABC News' Jonathan Karl reports:

What does it take to get a wavering senator to vote for health care reform?

Here’s a case study.

On page 432 of the Reid bill, there is a section increasing federal Medicaid subsidies for “certain states recovering from a major disaster.” 

The section spends two pages defining which “states” would qualify, saying, among other things, that it would be states that “during the preceding 7 fiscal years” have been declared a “major disaster area.” 

I am told the section applies to exactly one state:  Louisiana, the home of moderate Democrat Mary Landrieu, who has been playing hard to get on the health care bill.

In other words, the bill spends two pages describing would could be written with a single world:  Louisiana.  (This may also help explain why the bill is long.)

Senator Harry Reid, who drafted the bill, cannot pass it without the support of Louisiana’s Mary Landrieu.

How much does it cost?  According to the Congressional Budget Office: $100 million.

Here’s the incredibly complicated language: 

SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR CERTAIN STATES RECOVERING FROM A MAJOR DISASTER.

Section 1905 of the Social Security Act (42 U.S.C. 1396d), as amended by sections 2001(a)(3) and
2001(b)(2), is amended— (1) in subsection (b), in the first sentence, by striking ‘‘subsection (y)’’ and inserting ‘‘subsections (y) and (aa)’’; and (2) by adding at the end the following new subsection:

‘‘(aa)(1) Notwithstanding subsection (b), beginning January 1, 2011, the Federal medical assistance percentage for a fiscal year for a disaster-recovery FMAP adjustment State shall be equal to the following:
‘(A) In the case of the first fiscal year (or part of a fiscal year) for which this subsection applies to the State, the Federal medical assistance percentage determined for the fiscal year without regard to this subsection and subsection (y), increased by 50 percent of the number of percentage points by which the Federal medical assistance percentage determined for the State for the fiscal year without regard to this subsection and subsection (y), is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year after the application of only subsection (a) of section 5001 of Public Law 111–5 (if applicable to the preceding fiscal year) and without regard to this subsection, subsection (y), and subsections (b) and (c) of section 5001 of Public Law 111–5.

‘‘(B) In the case of the second or any succeeding fiscal year for which this subsection applies to the State, the Federal medical assistance percentage determined for the preceding fiscal year under this subsection for the State, increased by 25 percent of the number of percentage points by which the Federal medical assistance percentage determined for the State for the fiscal year without regard to this subsection and subsection (y), is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year under this subsection.

‘‘(2) In this subsection, the term ‘disaster-recovery FMAP adjustment State’ means a State that is one of
the 50 States or the District of Columbia, for which, at any time during the preceding 7 fiscal years, the President has declared a major disaster under section 401 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act and determined as a result of such disaster that every county or parish in the State warrant individual and public assistance or public assistance from the Federal Government under such Act and for which— ‘‘(A) in the case of the first fiscal year (or part of a fiscal year) for which this subsection applies to the State, the Federal medical assistance percentage determined for the State for the fiscal year without regard to this subsection and subsection (y), is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year after the application of only subsection (a) of section 5001 of Public Law 111–5 (if applicable to the preceding fiscal year) and without regard to this subsection, subsection (y), and subsections (b) and (c) of section 5001 of Public Law 111–5, by at least 3 percentage points; and ‘‘(B) in the case of the second or any succeeding fiscal year for which this subsection applies to the State, the Federal medical assistance percentage determined for the State for the fiscal year without regard to this subsection and subsection (y), is less than the Federal medical assistance percentage determined for the State for the preceding fiscal year under this subsection by at least 3 percentage points.

‘‘(3) The Federal medical assistance percentage determined for a disaster-recovery FMAP adjustment State under paragraph (1) shall apply for purposes of this title (other than with respect to disproportionate share hospital payments described in section 1923 and payments under this title that are based on the enhanced FMAP described in 2105(b)) and shall not apply with respect to payments under title IV (other than under part E of title IV) or payments under title XXI.’’.****

[Body-by-Guinness]

Welcome to the Vast Right-Wing Conspiracy
A team of NPR reporters unearths the truth about health care.

By Stephen Spruiell

In May 2008, Chicago Public Radio teamed up with National Public Radio (NPR) to produce an episode of the show This American Life called “The Giant Pool of Money.” The episode garnered widespread praise and won several awards for explaining the subprime-mortgage crisis with clarity and concision. It was such a success that NPR created a podcast, Planet Money, featuring the same team of reporters and producers. Planet Money covered the financial collapse last fall and continues to file jargon-free reports on the economy three times a week. 

A few weeks ago, that crew put together another big project, this time a two-parter of This American Life and several subsequent podcasts devoted to the subject of health care. As in “The Giant Pool of Money,” the reporting was clear and even-handed. The team’s correspondents sought out industry professionals, economists, and patients. (They ignored politicians, by and large.) They surveyed the history of the American health-care system and drew some conclusions about why it has so many problems. And, if you’re someone who expects a certain amount of leftishness from NPR, those conclusions might surprise you.

1. Medical-malpractice lawsuits drive up the cost of health care. The first episode began by defining the problem: The average cost of a health-insurance policy for a family of four doubled between 2000 and 2007, host Ira Glass said, and it is projected to double again in the next seven years. Health-care costs are spiraling out of control, eating into the wages of those who have insurance and making it harder for the uninsured to buy it. Why? The answer is complex, but one of the problems the NPR team identified is that doctors practice what’s known as defensive medicine. That is to say, they order tests and perform procedures that their patients might not need, out of fear that otherwise they might get sued.

The NPR team produced several stories on how defensive medicine drives up costs, including one about a doctor named Dan Merenstein. As a third-year resident, Merenstein counseled a 53-year-old man on the benefits and risks of getting a PSA screening (a common test for prostate cancer). Merenstein told his patient that he thought the risks outweighed the benefits: False positives are common, follow-ups invasive and potentially harmful. The man declined the test.

The man was later diagnosed with a fatal prostate cancer, a kind that early detection probably would not have helped. He nevertheless sued Merenstein and his residency program. The plaintiff’s lawyers argued that Merenstein shouldn’t have given the man a choice on whether to have the test. “The jury . . . rejected the idea of following the guidelines based on evidence,” Merenstein said. “They took this approach that this thing called evidence-based medicine is just a way to save money, just a way to ration care.”

The verdict left Merenstein alone, but found his residency program liable for $1 million. He told NPR that it’s hard not to see patients as potential plaintiffs. He says he still counsels patients on the potential drawbacks of the expensive, not-always-necessary screening, but he admits that he gives patients a little push by telling them that most people do get the test.

2. Insurance companies are not evil. This summer, amid all the town-hall pushbacks against Obamacare, Nancy Pelosi lashed out at private insurance companies: “They are the villains in this,” she said. “They’ve been immoral all along in how they have treated the people. . . . You know, the litany of it all.”

Many mainstream reporters know the litany of it all, or at least they think they do. But NPR actually probed this received wisdom, and found a lot of holes. For instance, a former insurance executive named Wendell Potter had a conversion experience and now goes around the country talking about all the bad things insurance companies do to save money. Potter is fond of telling one story about how Aetna purged 8 million people from its insurance rolls and subsequently saw its stock price go up. Taking away people’s coverage for profit: proof positive of insurance-company greed.

“The truth of the story,” producer Sarah Koenig explained, “is a little more complicated, a little less Machiavellian.” In 2001, Aetna was losing $1 million a day. Aetna did two things to turn the company around: It raised premiums, and it pulled out of markets where it did not have a large presence. It turns out, the less competition an insurance company faces in a particular market, the cheaper it can price its products, and the lower premiums are for the insured. Why? Because insurance companies have to wield a lot of clout in order to bargain effectively with the large health-care provider groups in a given area.

Obama says, “One of the best ways to bring down costs, provide more choices, and assure quality is a public option that will force the insurance companies to compete and keep them honest.” But if the public option would actually weaken dominant players in the insurance market and concentrate more pricing power in the hands of provider groups, it would drive health-care costs up.

3. Our reliance on third-party payers is at the heart of the problem. So if insurance-company greed isn’t to blame, what does ail our health-care system? NPR’s reporting points to what economists call the “third-party-payer problem.” As David Goldhill pointed out in a must-read article for The Atlantic earlier this year, you don’t get the bill for your medical care. Someone else gets the bill, and that distorts incentives for payers, providers, and consumers of health care.

The NPR team put together a couple of stories that illustrated this problem, but the most succinct explanation came from Adam Davidson and Alex Blumberg in a segment on the history of American health care. “We the consumers are totally separated from the cost of what we’re consuming,” Davidson said. “We get tests and procedures we don’t need because, well, why not? We’re not paying for it a la carte. Our employers are paying for part of it, our government is paying for part of it through . . . tax incentives.”

How did we end up with such an inefficient system? Prior to World War II, health insurance existed, but most people paid for medical care out of their own pockets. The government instituted price and wage controls during the war, but placed no controls on benefits, so companies turned to benefit packages as a means of competing for workers.

Wage and price controls made the third-party-payer system possible, but a different policy set it in stone: a change in the tax law allowing employers to deduct the cost of health benefits from their taxes. After the IRS ruled that employers did not have to pay taxes on health benefits for their workers, the proportion of the population getting health insurance through their employers went from 9 percent in 1940 to 63 percent of the population in 1953.

4. Obamacare won’t fix it. The NPR team did not come right out and say it, but its reporting points to this conclusion. Alex Blumberg put it this way:

Markets are usually really good at controlling costs. When they work best, products come into existence like cell phones or stockings, they start expensive and then they get cheaper and better. But markets don’t guarantee that everyone can afford the things they need. Government can be good at that, ensuring universal access. But when you’re paying for everybody, it’s hard to control costs.

For [economic historian] Melissa Thomasson, she says that either extreme — a competitive market system where consumers know what price they’re paying and what they’re getting, which would drive the cost of health care down, or a government-run system which would cover everyone — would be better than the accidental mixture that we have today: a really expensive system that doesn’t cover us all.

Obamacare would pour even more cement over this broken system. It’s not a single-payer system that would cover everyone and control costs through price controls and rationing. Nor is it a market-oriented reform that would empower consumers by equalizing the tax treatment of health insurance and reducing the role of government in the market. Instead, it makes health insurance mandatory for everyone. It bends the cost curve up by subsidizing insurance without putting any real cost-control measures in place. And it creates a public option that would weaken the power of insurance companies to bargain with hospitals for better rates.

Democrats have accused conservatives of spreading fear and misinformation about their health-care legislation. They might want to look into this new and most insidious propaganda arm of the conservative movement: NPR.

— Stephen Spruiell is an NRO staff reporter.

National Review Online - http://article.nationalreview.com/?q=ZDlhOWMxMWM0NjI0Y2RmYTUwNzQ4YmJjMTIyYTA5MWE=

[Crafty_Dog]

About the best that can be said about the Senate health-care bill that Harry Reid revealed this week is that it's marginally less destructive than the House monster. By a hair. Its $1.2 trillion cost (more like $2.5 trillion if you discount the accounting gimmicks), multiple and damaging new taxes, and new regulations will make health insurance more expensive for most Americans while reducing the quality of medical care.

We'll dissect the damage in the days to come. But for today let's focus on the damage the bill would do to consumer-driven health plans—the kind that give individuals more control over their health dollars and insurance choices. The 2,074-page bill crushes them with malice-aforethought.

Start with its attack on flexible spending accounts that are an important part of many employer plans. Flex accounts let employees set aside some portion of their pre-tax pay for out-of-pocket costs or medical services that their insurance plan doesn't cover, such as a child's orthodontics or testing supplies for diabetics. The Reid bill caps these now-unlimited accounts at $2,500 per year and imposes new restrictions on qualifying medical expenses, raising some $5 billion by exposing income above the non-indexed cap to taxes.

Democrats say flex accounts encourage wasteful spending, because an arbitrary "use it or lose it" rule doesn't allow balances to roll over year to year. But they really hate them because they give consumers a more active role in managing spending, instead of having the government decide.

The Reid bill also assaults health savings accounts, or HSAs, which allow individuals to accumulate tax-free funds for future medical expenses when coupled with low-premium, high-deductible insurance. The Reid bill changes tax provisions to make HSAs less attractive, but the real threat comes via increased regulation.

These insurance products will likely be barred from the insurance "exchanges" that will demolish and supplant today's individual market. Employers will also find them more difficult if not illegal to offer once the government has new powers to "define the essential health benefits" that all plans must eventually offer. Plans that focus mainly on catastrophic health expenses, instead of routine procedures, aren't generous enough for Democrats.

Liberals claim people who choose these options aren't helping as much to finance a common pool and may encourage adverse selection if too many young or healthy people opt out. While all insurance involves some degree of risk-sharing, Democrats want to impose true social insurance a la Europe by obliterating the flexibility of insurers to design products that are tailored to suit different individual needs.

In fact, about 40% of tax filers with HSAs earn under $60,000, according to the IRS. The Employee Benefit Research Institute reports that 4% of adults with private insurance have an HSA this year—up from 1% in 2006—and about 9% are enrolled in some form of consumer-directed health plan. It also found that beneficiaries are evenly split between those with health problems and those without.

The Blue Cross Blue Shield Association, whose members dominate the HSA market, says that enrollees are more likely than those with traditional insurance to be better consumers. They're more likely to track expenses (63% to 43%), save for the future (47% to 18%), and search for information on physician quality (20% to 14%). They're also more likely to participate and see results from wellness programs like weight loss, fitness and smoking cessation. This makes intuitive sense: They've got skin directly in the game.

David Goldhill, a media executive, recently wrote in the Atlantic Monthly that if a 22-year-old starts at his company today earning $30,000 and health costs grow at 3%, by the time he retires he'll have paid out $1.77 million in premiums, lower wages, out-of-pocket costs and both sides of the Medicare payroll tax.

If all that money were instead available via an HSA, including by borrowing against future contributions, "wouldn't you be able to afford your own care?" Mr. Goldhill asks. "And wouldn't you consume health care differently if you and your family didn't have to spend that money only on care?"

This is precisely the future liberals fear because it would make health care less susceptible to political control. The Reid bill makes it impossible for people to choose better reform alternatives, the ones that can only be discovered through innovation and competition in a dynamic marketplace.

Not that any of this seems to matter at this stage of the health-card debate. The polls show the public opposes the Democratic bills, President Obama is below 50% job approval in the Gallup poll, and business and medical providers are increasingly horrified at what reform will do to consumers and patients. But so what? This is about putting government in charge of health care, whether Americans like it or not.

[Boyo]

I have a question...

What happens to a religous hospital ,once a govt run healthcare sysytem is in place, when they refuse to perform abortions?The Roman Catholic Council of Bishops have said they will not kill the unborn or euthanise the elderly and now with the Manhattan declaration being signed by religous leaders from around the country ....are battle lines being drawn? And what ever happened to the seperation of church and state thingy ,guess that only works one way.

Boyo

[Crafty_Dog]

The Manhattan Declaration has the potential to become something important in taking a stand against the arrogance of liberal fascism.

[ccp]

A shining example of Washington corruption and how our government is totally out of control.  Use my tax dollars to bribe a Senator to vote for a bill I don't want.  Obviously this has been going on forever.  Any Consititutional protection against this?  I guess not or we would have seen it by now.   

By Dana Milbank
Sunday, November 22, 2009
Staffers on Capitol Hill were calling it the Louisiana Purchase.

On the eve of Saturday's showdown in the Senate over health-care reform, Democratic leaders still hadn't secured the support of Sen. Mary Landrieu (D-La.), one of the 60 votes needed to keep the legislation alive. The wavering lawmaker was offered a sweetener: at least $100 million in extra federal money for her home state.

And so it came to pass that Landrieu walked onto the Senate floor midafternoon Saturday to announce her aye vote -- and to trumpet the financial "fix" she had arranged for Louisiana. "I am not going to be defensive," she declared. "And it's not a $100 million fix. It's a $300 million fix."

It was an awkward moment (not least because her figure is 20 times the original Louisiana Purchase price). But it was fairly representative of a Senate debate that seems to be scripted in the Southern Gothic style. The plot was gripping -- the bill survived Saturday's procedural test without a single vote to spare -- and it brought out the rank partisanship, the self-absorption and all the other pathologies of modern politics. If that wasn't enough of a Tennessee Williams story line, the debate even had, playing the lead role, a Southerner named Blanche with a flair for the dramatic.

After Landrieu threw in her support (she asserted that the extra Medicaid funds were "not the reason" for her vote), the lone holdout in the 60-member Democratic caucus was Sen. Blanche Lincoln of Arkansas. Like other Democratic moderates who knew a single vote could kill the bill, she took a streetcar named Opportunism, transferred to one called Wavering and made off with concessions of her own. Indeed, the all-Saturday debate, which ended with an 8 p.m. vote, occurred only because Democratic leaders had yielded to her request for more time.

Even when she finally announced her support, at 2:30 in the afternoon, Lincoln made clear that she still planned to hold out for many more concessions in the debate that will consume the next month. "My decision to vote on the motion to proceed is not my last, nor only, chance to have an impact on health-care reform," she announced.

Landrieu and Lincoln got the attention because they were the last to decide, but the Senate really has 100 Blanche DuBoises, a full house of characters inclined toward the narcissistic. The health-care debate was worse than most. With all 40 Republicans in lockstep opposition, all 60 members of the Democratic caucus had to vote yes -- and that gave each one an opportunity to extract concessions from Senate Majority Leader Harry M. Reid.

Sen. Ron Wyden (D-Ore.) won a promise from Reid to support his plan to expand eligibility for health insurance. Sen. Ben Nelson (D-Neb.) got Reid to jettison a provision stripping health insurers of their antitrust exemption. Landrieu got the concessions for her money. And Lincoln won an extended, 72-hour period to study legislation.

And the big shakedown is yet to occur: That will happen when Reid comes back to his caucus in a few weeks to round up 60 votes for the final passage of the health bill.

Republicans also knew that a single defection would kill the bill, so they tried to pressure the holdouts. "That's what we've got to choose today: Do we choose life or do we choose death?" declared Sen. Sam Brownback (R-Kan.). "We just need one vote, one vote on the other side."

But Landrieu had already made up her mind. She went to the floor during the lunch hour to say that she would vote to proceed with the debate -- but that she'd be looking for much bigger concessions before she gives her blessing to a final version of the bill.

"My vote today," she said in a soft Southern accent that masked the hard politics at play, "should in no way be construed by the supporters of this current framework as an indication of how I might vote as this debate comes to an end." Among the concessions she'll seek: more tax credits for small business and a removal of the version of the "public option" now in the bill.

That turned all the attention to the usually quiet Lincoln, who emerged from the cloakroom two hours later to announce her decision. Her attire was school-principal prim -- blue suit with knee-length skirt, orange silk scarf tied tightly at the neck -- and she was clearly uncomfortable in the spotlight. She spoke with the diction of somebody giving a dramatic reading, and she stumbled more than once as she read, botching the crucial line: "I will vote to support, of, the, the, will vote in support of cloture on the motion to proceed to this bill."

She argued, a bit too strenuously, that "I'm not thinking about my reelection" in 2010. All the same, she made clear that Democratic leaders would have to give more if they want her to vote yes as the health-care debate continues. Specifically, she demanded removal of the public option. "I am opposed to a new government-administered health-care plan," she warned, further cautioning that "I will not vote in favor of the proposal . . . as it is written."

By the time this thing is done, the millions for Louisiana will look like a bargain.

[Body-by-Guinness]

A video from Reason-TV:

[youtube]http://www.youtube.com/watch?v=3E29LD98ruo&feature=player_embedded[/youtube]

[ccp]

Commentary Mammogram advice based on science

Breast Cancer
Hospitals and Clinics By Miriam Alexander
 
December 4, 2009

We at the American College of Preventive Medicine support the updated United States Preventive Services Task Force recommendations on breast cancer screening. On Nov. 17, the task force released recommendations that women age 50 and older should have screening mammography every two years, and women in their 40s should decide whether to have screening mammography on an individual basis after talking with their doctors. Since then, misinformation and conspiratorial rumors have been rampant, including allegations that the task force is a mechanism for government or insurance industry cost-cutting at the expense of women's health.

Much of the response by media, pundits and policymakers is a result of two converging factors. The first is a lack of understanding about how the task force operates and how to interpret its findings. The second is a politically charged environment generated by the health care reform debates.

Let's set the record straight: The task force is not a government body. It is an independent panel of health care professionals, mostly primary care physicians - pediatricians, family physicians, internists, obstetricians and gynecologists - many of whom teach at prestigious academic medical centers. To characterize the task force as a collection of stooges for the insurance industry is simply disingenuous. In fact, the task force does not consider cost as a factor in making its recommendations. It conducts rigorous evaluations of the evidence to provide primary care clinicians with evidence-based guidance on using patient-directed clinical preventive services.

The task force concerns itself with clinical services aimed at patients who are healthy or do not have symptoms; it therefore deals with screening to detect early disease in which treatment or intervention will make a difference in ultimate health outcomes. The recommendations are not intended for people who are already ill or have symptoms. We agree with the task force that the tolerance for risk vs. the benefit of any service delivered in an asymptomatic population is different than in individuals who may already be ill.

Any competent doctor will tell you how important it is to consider both the benefits and the drawbacks of any treatment or screening service that they offer. The task force, using rigorous methodologies, examines the scientific evidence for preventive services. It carefully weighs the benefits and the drawbacks before making its recommendations - based on what's best for whole populations, not each individual.

Ideal preventive care for healthy individuals should "do no harm," as is stated in the Hippocratic Oath. Mammography may lead to harms such as false positives and subsequent unnecessary tests and biopsies. Furthermore, though unquestionably able to pick up true disease that needs treating, mammography also detects certain breast cancers will never spread and will never cause signs or symptoms. Our challenge in the medical community is that at the time of diagnosis, we do not know which cancers will lie dormant or regress and which will go on to cause significant suffering. We therefore move forward on treating essentially all cancers detected. A recent study suggests that 1 in 3 breast cancers detected on screening results in unnecessary surgery, chemotherapy and/or radiation therapy.

This recommendation also has nothing to do with health care reform. The task force voted on this recommendation more than a year ago - before the current administration took office and before health reform became a centerpiece of public policy. This recommendation is not about rationing, health care costs or politics. It is all about making intelligent decisions from a scientific perspective as to what works and what does not, and weighing medical benefits against negative outcomes.

As preventive medicine physicians, we support the value of mammograms for early detection of breast cancer. We know mammography screening saves lives. But it is important for women to be informed about the risks and benefits and make their decision in conjunction with their doctors. Let's not politicize this issue and these recommendations. Too many lives are at stake.

Dr. Miriam Alexander is president-elect of the American College of Preventive Medicine. She is on the faculty at the Johns Hopkins Bloomberg School of Public Health and is director of the school's General Preventive Residency Program. Her e-mail is mhalexan@jhsph.edu.
Copyright © 2009, The Baltimore Sun

[Crafty_Dog]

Blue Cross Blue Patients
Another study predicts higher insurance prices..ArticleComments (5)more in Opinion ».EmailPrinter
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. Text  .Another day, another study confirming that ObamaCare will increase the price of health insurance. The Blue Cross Blue Shield Association has found that premiums in the individual market will rise on average by 54% over the status quo, which translates into an extra $3,341 a year for families and $1,576 for singles. The White House denounced the report as a "sham" before it was even released, which shows how seriously it takes such concerns.

The Congressional Budget Office also found this week that ObamaCare will boost premiums in the individual market by as much as 13%. But the White House called that a triumph because the higher costs will be offset by taxpayer subsidies that will be transferred to the federal balance sheet.

The Blue Cross study is in fact more precise than CBO's because it is based on real market data, rather than modeling assumptions. The association mined the actuarial data from its six million individual or small-business policies, nearly one-eighth of those sold in the U.S.

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The $1.9 Trillion Gimmick
The WellPoint Revelation
.Lo and behold, Blue Cross found costs will rise if Democrats force insurers to cover anyone who applies and then limit how much insurers are allowed to charge based on age or health condition. Economists call this adverse selection; people will wait until they're sick to buy coverage, and the Democratic rules make it perfectly rational for them to do so.

"And you can bet as we continue to make progress," communications director Dan Pfeiffer wrote on the White House blog, "the insurance industry will continue to try and distract and misinform because they know their very profitable status quo is in grave danger." He must be referring to the industry's overall profit margin of 2.2% in 2008.

The reality is that all health-care costs are ultimately borne by consumers, whether through more expensive premiums, lower wages or higher taxes. The regulatory schemes favored by Democrats can't change that law of economics but they will ensure that insurance is even more costly than it is today.

When that day comes, the political class will of course blame the insurance companies, and all of the current White House denials will fall down the memory hole.

[G M]

http://hotair.com/archives/2009/12/07/california-moves-to-ration-mammograms/

California moves to ration mammograms
posted at 10:12 am on December 7, 2009 by Ed Morrissey


ObamaCare advocates claim that putting government in charge of health care coverage and treatments won’t result in care rationing, while its opponents say rationing will be the inevitable result.  The latter can point to California as evidence for their position.  Facing enormous budget shortfalls, the state has ended subsidies for mammograms for poor women between 40-50 years of age, and will also freeze enrollments in a breast-cancer screening program for its Medicaid recipients:
The eligibility age for state-subsidized breast cancer screening has been raised from 40 to 50 by the California Health and Human Services Agency, which will also temporarily stop enrollment in the breast cancer screening program.
Advocates for low-income women, whose health care the department helps pay for, say the cuts put a two-tier system in place that is based on money rather than medical standards.
The cuts will greatly harm the clinic’s mammogram program, said Natasha Riley, manager of Vista Community Clinic’s Breast Health Outreach and Education Program.
The clinic and others like it in San Diego County provide reduced-cost care, mostly to low-income people, with money from the state and some private donations.
“More than 50 percent of the women we give breast exams and mammograms to are in their 40s,” Riley said. “The majority of our current breast cancer survivors are women in their 40s.”
The state followed the recommendation of the US Preventive Services Task Force, which claimed that regular mammograms created too much anxiety for women between 40 and 50.  It also linked the decision to declining revenues from tobacco sales — no, really — which cut into funding for anti-cancer screening programs:
In its announcement, the state said the cuts were needed because of a projected budget shortfall for the California Department of Public Health, and from declining revenue from tobacco taxes.
However, it did not say how much money it expected to save.
Gee, what else have we built on the shifting sands of tobacco taxes?  I wonder how the S-CHIP program is faring these days.
This is a great example of the difference between static and dynamic tax analyses.  The former predicts a revenue from a tax that assumes that the tax won’t change the environment which produces the revenue, while dynamic tax analysis accounts for behavior changes when tax policies are applied.  In this case, it’s actually worse; the tobacco-tax advocates argued both that increased taxes would discourage smoking while relying on a constant increase of revenue from the boost in tobacco taxes.
And now what we get is rationing, because the government created these programs based on rosy revenue projections that can’t be met.
Given Carly Fiorina’s recent statement on her experiences with breast cancer, I asked her campaign for a reaction to this decision:

“This is an example of what happens when the government’s role in healthcare decisions grows and the role of doctors and patients diminishes. With more government involvement cutting costs becomes paramount over quality of care. This situation underscores what is so critically wrong with the health reform legislation making its way through Congress now. It increases the role of government in our healthcare which is a recipe for higher taxes and lower quality of care.  Instead, Carly believes any reform to our healthcare system should be focused on market-based reforms that prioritize quality of care and increasing access and choice.”— Julie Soderlund, Deputy Campaign Manager for Communications

[ccp]

I am not sure I get the just.  Why should insurers pay for a test that is unproven to have value?

A mammogram is only a couple hundred dollars - if women want it why can't they pay for it?

Or pay for the cadillac insurance that would cover it?

There are woman who are at higher risk who might benefit from it but not woman of avergae risk.

GM you are using this for political purposes.

I don't agree.

It was pure politics that led to mammograms before 50 to be approved by some groups years ago. 

It continues to be a political football.

Who are the powers to be who decided it is ok to have mammograms every 1 to 2 yrs is a great idea?

Why not MRIs every one to two years?  They are better tests than mammos and don't cause cancer like the radiation spewing mammograms?  So they are too costly yet mammograms are acceptable cost?

Who decided this?

My pointy is someone has to make these decisions or we all go broke.

[G M]

Just pointing out how gov't healthcare works. Rationing is inevitable.

[DougMacG]

"It was pure politics that led to mammograms before 50 to be approved by some groups years ago. "

I don't know enough to argue statistically, but know kids who grew up without a mom because of breast cancer in her 40s, and just lost a friend to colon cancer prior to his first recommended screening also.  I don't know the answer but I do know that the latest word from the best professionals in the world on matters like these changes over time.  Which brings us to your other point:

"A mammogram is only a couple hundred dollars - if women want it why can't they pay for it?"

Close to my view, get the cost of all healthcare down and let people decide how much of it they want.

New jewelry, Mammogram? New jewelry, Mammogram? I can't decide.  Maybe the government knows better.  Maybe I can buy the frivolous and get the entitlement free...

[DougMacG]

CCP, My favorite analyst might well be Scott Ott over at Scappleface  We report, You decipher
--------
Obama Brings Afghan Strategy to Health Care Reform
by Scott Ott for ScrappleFace

(2009-12-02) — President Barack Obama announced he would apply his Afghanistan war strategy to domestic health care reform.

“It’s important that we seize the initiative,” the president said, “and put the resources in place so that we can withdraw them in 18 months, leaving the uninsured with the capacity to take care of themselves, to buy their own health insurance on the open market.”

The president said he’ll commit 30,000 new bureaucrats to this effort, who will begin deploying in early 2010, to train the uninsured in how to buy health insurance, and to equip the unemployed to find work, or to start businesses, so that they, too, can buy health insurance.

The president said the entire objective of his health care reform plan is to “hand over responsibility to the people, and then get our government forces out of their lives as quickly as possible.”

“This effort must be based on performance,” said Mr. Obama. “The days of providing a blank check are over. And going forward, we will be clear about what we expect from those who receive our assistance.“

[ccp]

Hi Doug,

"I don't know enough to argue statistically, but know kids who grew up without a mom because of breast cancer in her 40s, and just lost a friend to colon cancer prior to his first recommended screening also.  I don't know the answer but I do know that the latest word from the best professionals in the world on matters like these changes over time."

Breast cancer before age 50 is not rare.  ie the parade of woman telling us their stories on the news.

I agree with you -

That said, no one thinks they should all get cancer and die just to save a few bucks.

Yet -
if doing mammograms were saving lives before age 50 then why is it so hard to show the benefits?

It seems against common sense to think that it doesn't catch some cancers earlier than otherwise would be found and hence earlier treatment and hopefully earlier treatment means less deaths.  I even ask myself how could it not save lives?

Yet the studies fly in the face of expectations.  And we see little comment on the cancers all the extra radiation may be causing.

We do this a lot in our society.  We aggravate and make the majority pay for the few or even rare problems that occur.  Get a couple of outbreaks of salmonella and we get the calls the FDA is not doing their jobs, we are all at risk of dying.  And yet there are millions of eateries all over the US who have no problem.
We all cater to those with disabilities.
We sue and torture pharm companies for the rare side effects of drugs.

Where does it end?

We expect perfection from our police officers.   

We are expecting perfection in every corner of our society.  The cost is obvious.  We are all forced to pay for every little ditsel of imperfection.  And we go broke.

Thanks to the liberals who see financial opportunity with every "cause" they can uncover from under every rock.

[Crafty_Dog]

Some correspondence amongst friends:
========================

One very easy solution to this type of problem is to change the tax laws. Take away the huge incentive for everyone to get their insurance from their employer, and people would end up getting their own policies from day one. They could keep these policies forever, as long as they paid for them. Nobody would lose his coverage because he or she lost his job. You could even buy insurance against losing your job, so that your insurance premium would still be paid. There is absolutely no reason I can see for the US government to reorganize the entire healthcare system in order to address the problems that a relatively small number of people like this have.

========================

Yes, yes, yes.


And given this kind of freedom, people would tend to actually buy "insurance" -- protection against catastrophic medical bills -- instead of prepaid medical plans. With people actually paying for their own routine health care, they would take an interest in the cost of diagnostic medicine and many of today's abuses would disappear.
===========================

Your similar suggestions -- to focus on the insurance portion of an extended equation -- is a good first step... but only that, a first step.


Look there is so much (what's the word I want here: collusion? No, too emotional. Games-playing? How about...) linkage between vendors: insurance companies, doctors, government, and employers. Whether the issue is capitation counts (gee, tell me again why the doctor fails to respect MY time), balance billing, negotiated prices, the bottom line (pun intended) falls to that constituency left out of the loop: patients (consumers).


Some additional steps to your first step:
1) Abolish the AMA. Its primary purpose (though it will claim otherwise) is to limit the number of doctors and thus drive up, or provide a floor, on doctors' pricing. Let the winds of competition flow through that guild.
2) Reform the tort laws. However, make transparent (public) claims against the doctor for malpractice, whether arbitrated, mediated, or heard in a court.
3) Doctors MUST provide transparent pricing. Place prominently a placard that betrays prices for many common procedures. (No different from pricing at auto repair shops -- even though that is a sham.)
4) End the cozy relationship between the ethical and proprietary drug manufacturers and doctors. Really, how many scandals can one profession endure before consumers cry, "Enough!" (Well, apart from the Catholic church.


Some flesh on my bullet points:
Patient A requires a procedure. Dr charges $1,000. Patient A has insurance so he or she pays a co-pay, insurance company pays its portion of a negotiated amount between, simplistically, Dr A and the insurance company. Balance is either billed to patient or 'eaten' by Dr A.  We all are savvy to the fact that in any 'negotiation' you inflate your price to settle on a lower, perhaps more realistic charge, and everyone leaves the table happy: doctor, insurance company, and consumer... Right? Now consider Patient B, who requires the same procedure, but because he lacks insurance he must pay 100% of the Dr's inflated $1,000 fee. Hmmm. I understand that volume offers discounted pricing, but the assessed cost is not a true cost; instead it is a sham between doctor and insurance company as opening offer in a negotiation. Even so, this result on its face sure argues for single payer as one option among many.


A patient requires a procedure. His Dr says the cost will be $1,800, but his insurance company will cover only 100% of the first $1,000. Patient is thus on the hook for a balance of $800. With competition comes greater transparency; in such a universe, patients could open his procedure to bids, best price wins. Of course, the doctors (AMA) will warn that quality trumps price... but those same doctors will not, and do not, provide quality ratings in their performance. Why not? Patients (consumers) should trust doctors are well-trained and professional. But, then, why so many malpractice claims...?


I am no fan of the medical-industrial complex (to paraphrase Eisenhower); I make no secret of my feelings in this regard. Whether the issue be the drug manufacturers that hide study results (Vytorin or Zetia, anyone?), doctors who offer zero transparency re their practice and pricing, employers who tweak their company plan to make it affordable (seemingly affordable; most employees -- consumers! -- look only at price and not the lessened coverages, etc, that result from the tweaks and/or the or insurance companies that deny coverage for this or that reason (examples on request), seemingly arbitrarily that smacks of capriciousness.


The oddity for me is that I invest heavily in this sector, especially medical technology, despite my disgust. One of my most profitable positions was/is Intuitive Surgical/ISRG. I ask myself, though, whether in the world I hope for -- complete transparency for and by all constituencies-- such a company would even exist. Oh well, that is not a problem I will ever have to worry about.

[Body-by-Guinness]

http://reason.com/archives/2009/12/10/the-problem-is-cost-of-care
Reason Magazine


The Problem is Cost of Care

Understanding America's dysfunctional health care system

Michael Munger | December 10, 2009

The problem with health care is not that we can’t afford insurance. The problem is that we can’t afford health care.

The U.S. has the world’s most expensive health care, $8,000 per person per year, eating up 16 percent of our GDP. There are many ways of paying these costs, of course, ranging from private insurance such as Blue Cross to public insurance such as Medicare. Many people pay out of their pockets, and local and state taxpayers pick up the rest.

The problem is that health care costs have increased at an annual rate double, or more than double, the rate of inflation for the last two decades. Right now, our attempts at reform are doomed by a law of accounting physics: Insurance can’t cost less than the health care it insures.  That means that subsidizing insurance likely makes the problem worse. 

Consider: I have car insurance. But my insurance doesn’t pay for oil changes.

Instead, I go down to the Happy Lube, without an appointment, get a diagnosis of the needs of my car, and choose services based on a price list published online. Some of these services are complex, and require large expensive machines and equipment. But I don’t have to pay a separate bill, or go wait in another line, at another office or lab.

Now, if I fail to get my car’s oil changed, or to perform other needed services, the engine will be damaged. That’s expensive to fix, but my insurance does not cover the costs. I bear the costs, so I care for the engine.

Health care is a little different. Many of us have “engines,” or other parts, that may not work very well, especially as we grow older. Things happen that may not be our fault, and even if they are we’d like to be able to buy some insurance against the worst consequences, the catastrophic injuries or illnesses that are part of every human society. The problem is that how we pay affects how much we pay.

Again, compare it to car insurance, for two people. Imagine neither of us has to pay for our car repairs, from accidents or engine wear. We can go to the garage as often as we like, and get whatever service we want, for free. The car repair shop can charge our insurance whatever they want, because insurance pays everything. An oil change would bill out at $600; an alignment would bill our insurance $2,200, with another $800 tacked on to pay for micro-digital wheel axis imaging. 

Of course, the services aren’t really free. At the end of every year, we sum the total repair costs for both people, and each of us pays half of that total. 

The cost of that free car care would be enormous, because of all the unnecessary and overly expensive charges. Of course, the government could subsidize the final bill; would that help? The answer is no, for two clear reasons.

First, having the government (meaning taxpayers) subsidize the total would do nothing to reduce the runaway cost increases. Buyers won’t shop around if they don’t know or care about real costs. Subsidies mean I don’t pay if I spend, and I don’t save if I’m frugal.

Second, let’s expand the example from two people (each paying half) to 300 million people getting free care (but paying an equal share of total costs). We have met the public option, and it is us! Once we are all paying ourselves, there is no one else to hit up to help with the costs. We are simply taking each person’s money in taxes, then giving some of it back in subsidies. There is no saving, even to individuals.

The French economist, Frederic Bastiat, diagnosed the problem long ago when he said, “The public option is the conceit that each of us should have free health care at the expense of all of us.” Okay, he didn’t say that, exactly, but it was the same idea.

The solution is out there, but it will require a fundamental change in the way we think. Competition among insurers, without decreases in underlying medical costs, may actually harm people through bad service and arbitrary denial of claims. Instead, we need competition among medical providers, just like oil change services now. LASIK surgery, one of the few areas of medical services open to competition and listed prices, has fallen in cost by 70 percent or more in the last 15 years. And quality has gone up dramatically. Walk-in clinics and fee-for-service arrangements for check-ups, or simple diagnoses like strep throat or  infected thumbs, are already widely available, cost relatively little, and require no appointment.

Subsidizing insurance is a terrible idea. But that is the main focus of the health care reform bills passed by the House, and now being considered in the Senate. Why pin all our hopes on an approach that can’t possibly succeed?

Michael Munger is a professor of economics, and the chair of the political science department, at Duke University. He has written on policy analysis and cost benefit analysis of government programs.

[Crafty_Dog]

By JOSEPH RAGO
Watertown, Mass.

'It's a little bit like talking to a young prince," says Jonathan Bush, chairman and CEO of Athenahealth, a major player in information technology services for physicians, of his recent visits to Capitol Hill. "'So—tell me about this market thing that your people use,'" he says, mimicking the political royalty with a grin and extending his forearm. "'Wait: I must catch my falcon!'"

Athenahealth's headquarters, on the banks of the Charles River outside Boston, is a world away from D.C., and it's clear, as he continues his metaphor, that Mr. Bush enjoys the distance: "And these princes, they mean well and they're lovely," he says, "but they're living in this alternate universe where there's no such thing as a market in health care and they don't understand why one might be remotely useful."

He pauses. "That's weird to me."

Mr. Bush is an outlier in the generally buttoned-down world of the health industry. He's exuberant, hyperactive, speaking in frenetic running monologues; it's not hard to see why the political class might be taken aback: "I still have to keep going to Washington and sucking up," he says, switching metaphors. "Because the problem is when you have a baby with an Uzi, right, they might accidentally mow you down. But here's the thing . . . they're brilliant people. It's just that the idea of a market in health care never occurred to them."

As Mr. Bush sees it, the profound problem with U.S. health care is that there's "no landscape of choices, or choosers." Due to the complexity of America's third-party laundromat for health dollars—your doctor's clerical staff bills your treatment to an insurance company picked by your employer, and it pays him with your money via premiums or foregone wages—"few doctors in America know the actual value of the services they render."

Athena's core business helps them manage their practices and get paid, but the larger purpose of the company, which he and board member Todd Park co-founded in 1997, is to try to shore up health care's resemblance to a normal market. It has grown into one of the country's most innovative health IT firms.

Athena began as a San Diego birthing clinic and floundered because it couldn't cope with back-office volatility. All transactions were conducted on paper. No one understood how to navigate the dense and bewildering coding rules for dozens of different insurers or the fee schedules for government payers like Medicaid. Claims were denied with no explanation or vaporized in purgatory. The clinic went bankrupt in 18 months.

With Mr. Park (who has joined the Obama administration), Athena designed a program to digitize records and automate billing. It now colonizes the wilderness of paperwork and habitual financial chaos that defines running a doctors office, and it is also moving into clinical record-keeping for individual patients. Some 15,000 physicians in 43 states use Athena as a virtual office, a number that is growing at an annual 30% clip.

It is a massive logistical undertaking. Athena's main facility is housed in a decommissioned World War II arsenal on the Charles, where 30,000 pounds of paper is processed every month, most of the tonnage being paper checks. Incredibly, doctors also receive on average 1,185 faxes each month—mostly lab results—and those are handled too.

State Medicaid programs, by the way, are easily the worst payers, according to Athena's annual ranking. In New York, for instance, claims must be tendered on a dead-tree form instead of electronically and in blue ink—black is grounds for rejection—and then go on to spend a full 161 days, or almost a half year, in accounts receivable.

View Full Image

Zina Saunders
 .While streamlining this disorder frees up time for the company's clients to treat patients, it also throws off vast data, which are fed in central servers, aggregated and analyzed. This "athenanet" system is among the few health-tech offerings based on "cloud computing"—in the sense that the applications are accessed on the Web, instead of a computer's hard drive, allowing constant updates and refinements. If a regulation changes or an insurer adjusts a payment policy, it is reflected on athenanet almost in real time; on the clinical side, the program can adapt at the same rapid pace as medicine itself.

Mr. Bush thinks the main benefit is the "collective intelligence" that he is starting to weave together from the 87% of American physicians who practice solo or in groups of five doctors or fewer. "We found one of the last few remaining crowds in health care, which are these independent practices. Now you can argue that this decentralization is not the best thing in the world," but what's most important, he argues, is that "they're still allowed to go and make their own decisions."

In effect, as the network gets bigger, it gets smarter, while opening the space for innovations to feed off one another and spread. There really can be "radical improvement" in health care, Mr. Bush says, but only if there are "radical improvers" able to set themselves apart and lead the forward advance. "No one ever says, 'Here's to the average,'" he declares pointedly.

The Athena model is superior to most electronic medical record systems, or EMRs, which are generally based on static software that are inflexible, can't link to other systems, and are sold by large corporate vendors like General Electric. One reason the digital revolution has so far passed over the health sector is sheer bad product. The adoption of EMR in health systems across the country has been dogged by cumbersome interfaces, error propagation and other drawbacks. In 2003, for instance, Cedars-Sinai in Los Angeles dumped a $34 million proprietary system after doctors staged a revolt.

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CEOs and ObamaCare
ObamaCare at Any Cost
.Athena also stands in marked contrast to most of the wider health-care market, which Mr. Bush argues is homogenized and rigid, and getting more so. The problem is "easily fixed by releasing some power into the arms of consumers and cutting employers and certainly the government out of it," he says, turning to ObamaCare. "Certainly I'm not commenting on the amount of wealth redistribution that we should do as a society. Fundamentally I believe we need some, and whether the amount we're doing today is enough or too much or not enough, that's not my thing. If we feel like rich people should pay more for not-rich people's health insurance, that's fine.

"But just give them the money," he cries. "It's totally inefficient wealth redistribution because they can't get creative with it. They're not allowed by law to get creative with it."

What Mr. Bush means is that the government imposes standardized rules and mandates with no concern for how much they will cost or who will bear the burden. Given the choice, consumers might decide on cheaper policies that cover some services but not others, or decide to run more risk.

Yet for all the talk about expanding coverage, Mr. Bush says the real problem is that "You can't buy what you want." Another way of putting it is that "America will have one car. Everyone will have access to transportation, which means that everyone will have a black Escalade, with spinners. That's it. There's no Hyundais, no bicycles, no nothing."

And it's scandalously unfair. "These poor people who clip the things off the backs of cans to make the tomatoes cheaper are subsidizing the hypochondriac who gets his shoulder done with an arthroscope because it clicks when he serves at tennis."

Under ObamaCare, Mr. Bush says, "everyone is going to get health care according to the wise-men benefit panel, who will tell you exactly what it is, and then they'll run out of money, so every year the wise panel will just squish the benefit a little. People will start to say, well, that's not going to work for me." For this reason he doesn't think central health planning will have any longevity, and eventually people "will start leaking out into the [private] market once we run out of Obama energy."

His company, he thinks, will play an important role in such a world, where individuals would have more responsibility for weighing trade-offs—which, he believes, is the only lasting way to enforce discipline in health spending: "Today it's so complicated that the average consumer—and this is what the academics say—you can't put the average consumer in charge, it's too complicated. Yeah it's too complicated! So let's make it not complicated," he says. Athenanet generates "clean information," the basic price signals about health care that "a regular old consumer could look at and say, 'That's worth it' or 'I'd rather do this one on the other side of Route 128 that does it cheaper.'"

Mr. Bush is less sanguine about the White House cost-control approach of better living through technocracy and "Benthemite micromanagement." As an illustration he singles out the idea of dispensing bonus payments to hospitals that find ways to reduce Medicare spending. If the bonus is higher than what the hospital would have been paid under the status quo, then Medicare is worse off—but if the bonus is less than what the hospital would have earned otherwise, in what sense is it an incentive to change? In other words, "I'm going to give you a dollar bill for every 10-dollar bill you give me?" Mr. Bush asks incredulously.

The irony is that Athena will likely benefit from the Project Mayhem that is about to begin. "It's probably terrible that all this new bureaucracy is being created," Mr. Bush says. "But there's going to be 50 new Medicaid-type plans in these insurance exchanges, run by the same insurance commissioners, these same sort of glazed-over-looking state secretaries of health. You know, just not really the brightest bulbs in the chandeliers of the world. Medicaid, the worst payer in the country by a factor of four! Mother of pearl! So I feel a little bit like a robber baron. I am going to make oil money dealing with them."

The double irony is that Athena—while Mr. Bush might not put it in such an impolitic way, but then again, maybe he would—is also showing that the status quo for all its flaws is capable of organic change and real progress without the blunt-force trauma Congress is likely to inflict. Or in spite of it.

Take the nearly $47 billion in stimulus cash the White House has budgeted to prime the pump for health IT adoption. Mr. Bush says he's glad his industry is getting more attention from the bully pulpit, but that "It is kind of too bad that all these software companies that we're really close to putting out of business, these terrible legacy companies, with code that was written in the '70s, are going to get life support. That's why I call it the Sunny von Bülow bill. What it is, basically, is a federally sponsored sale on old-fashioned software."

"It's designed like a box-buying campaign," he continues. "You get this fixed chunk of money for a few years, you get to pay off your EMR, like its a thing. People in Washington think in terms of things that we'll buy and then they'll be there. Buildings. Roads. Tanks. What Lockheed Martin makes. Things.

"And this isn't that. This is a market: its a set of agreements, it's a language. What's needed is a way of exchanging value and making choices, that's ethical—and, you know, nobody, nobody, not nobody, has said a word about that.

Mr. Rago is a senior editorial page writer at the Journal.

[Crafty_Dog]

By SCOTT HARRINGTON
The public is growing wary of the cost of ObamaCare. Yet there is one budget-busting provision that hasn't received the attention it deserves: a new long-term care entitlement.

Known as the Community Living Assistance Services and Supports Act, or Class Act, this entitlement is in both the House and Senate bills and was a top priority of the late Sen. Ted Kennedy. It would provide at least $50 a day toward home or institutional care, equipment and supplies, or home improvements to assist the daily living of those who are enrolled. It is also a significant part of the reason that Democrats claim that ObamaCare is fiscally responsible, but this turns out to be a short-term budget ruse.

The Congressional Budget Office (CBO) projects that the House and Senate health-care bills will reduce federal deficits over the next 10 years by $138 billion and $130 billion, respectively. The lion's share of the savings, $101.6 billion and $72.5 billion, would be realized by the long-term care program.

How can a new entitlement reduce deficits? With budget accounting, the program will pile up more revenues than its costs. But only in the short run. In the long run, it will blow a hole in the federal budget.

Private long-term care insurance works like other insurance policies. Those who buy policies pay premiums over a prolonged period of time. The premiums pay for the benefits they may eventually receive and cover the benefits for those who need immediate care.

To make sure that a premium paid today can pay for a benefit promised for tomorrow, an insurer determines the amount it will need for future benefits, marks that amount as a liability, and puts aside funds to pay for it. An insurer also creates an additional pool of capital to act as a buffer, just in case.

That isn't how the Class Act would work. The House and Senate bills stipulate that premiums would be calculated to cover benefit payments over a 75-year horizon without federal subsidies. And the bills do authorize the secretary of Health and Human Services to adjust premiums and benefits to maintain solvency. But CBO and the Centers for Medicare & Medicaid Services (CMS) have identified parts of the program that will subject it to considerable financial risk.

First, those who enroll would likely be more apt to need care and will be more expensive to cover than those who buy private insurance. To cover its costs, the program would have to charge more than private insurers.

On Friday, CMS Chief Actuary Richard Foster said in a memo on the (less costly) Senate version of the program that premiums would be set so high they would discourage healthier people from buying in. As the healthy stayed on the sidelines, the program would have to charge more to those who did enroll. This in turn would price more people out of the program, risking what the memo called an "insurance death spiral."

Mr. Foster does project the program will lower the federal deficit in its first decade (by $39 billion and $38 billion for the House and Senate bills respectively, much less than the CBO estimates). But neither CMS nor the CBO include in their 10-year projections the program's future liabilities. Of course, that's exactly when the government will have to make good on its promises, putting pressure on the federal budget. Why? Because unlike private insurance, the program won't invest its early surpluses.

Instead the program will hand over its revenues to the feds, who will promptly spend it. In return, the program's administrators would receive federal IOUs, just as Medicare and Social Security do. But these are nothing more than liabilities that have to be repaid, either by taxes or borrowing.

Under the House bill, CBO projects that the entitlement would bring in $123 billion in premiums from 2010-2019 and pay out only $20 billion in benefits. CBO also projects that the Senate's version would generate $88 billion in premiums and $14 billion in benefits.

But in a letter late last month to Sen. Tom Harkin, CBO Director Douglas Elmendorf explained that while the Class Act would likely reduce federal budget deficits during 2020-2029, it would do so "by smaller amounts than in the initial decade."

By the third decade, CBO says the program would pay more in benefits than it received in premiums and what it saved Medicaid (which currently pays for long-term care for millions of elderly). Mr. Elmendorf concludes that "the programs would add to budget deficits in the third decade—and in succeeding decades—by amounts on the order of tens of billions of dollars for each 10-year period." These long-term demands on the Treasury would coincide with shortfalls in Medicare and Social Security projected to be in the hundreds of billions of dollars.

Sen. Kennedy notwithstanding, it is hard not to conclude that a major motivation for the Class Act is to make ObamaCare look fiscally better over CBO's official 10-year budget horizon. Without the new long-term care program, CBO's projected deficit reductions for the House and Senate bills would be $36 billion and $58 billion, respectively, rather than $138 billion and $130 billion. This makes the overall Democratic reform look fiscally more responsible than it really is. The real danger comes after 10 years, when the long-term care program will increase deficits and create even greater pressure for government rationing of medical care.

Mr. Harrington is professor of health-care management and insurance and risk management at the University of Pennsylvania's Wharton School and an adjunct scholar at the American Enterprise Institute.

[Crafty_Dog]

Second entry of the morning

WSJ

=============

ObamaCare's core promise—better quality care for everyone at lower costs—is being exposed as an illusion as it degenerates into the raw exercise of political power. Naturally, the White House and its media booster club are working furiously to prop up this fiasco, especially on cost control.

As Obama budget director Peter Orszag put it at a revealing media breakfast earlier this month, the Senate bill does everything the experts recommend to "get at the underlying drivers of health-care costs." While he admitted that "we don't know enough" to produce results right away, the key is to encourage "continuous improvement" through pilot programs and demonstration projects. Cost containment will actually take "years to decades," Mr. Orszag conceded.

The torch was then passed to Ron Brownstein of the Atlantic Monthly, David Leonhardt of the New York Times and editorial writers for the New England Journal of Medicine, among others. Last week the New Yorker ran a 5,000-word apologia from Atul Gawande, who likewise owned up to the fact that there is "no master plan for dealing with the problem of soaring medical costs," only "a battery of small scale experiments." Keep in mind, this is an argument in favor of ObamaCare.

They might have piped up earlier: What they're finally admitting is that all the grandiose talk about "bending the curve" used for months to sell ObamaCare really comes down to their hope that bureaucratic improvisation will make a difference over the long term. Yet the liabilities of the greatest social spending program in American history will be added to the budget almost immediately, and what happens if Mr. Orszag's technocratic revolution doesn't work as promised? Or rather, when it doesn't?

Forgotten in ObamaCare's march-to-the-sea campaign is that during the transition and early on, the White House was divided on whether to pursue health reform at all. Opponents included Larry Summers, worried about the economy and deficits, and David Axelrod, worried about the politics. Another faction led by Tom Daschle preached from the conventional social-equity church of liberalism.

Mr. Orszag proposed another option, citing academic research observing that as much as 30% of health spending is "waste" that doesn't affect outcomes. He argued the country could save $700 billion a year without harming quality—more than enough to pay for universal coverage.

View Full Image

Associated Press
 
Peter Orszag.
.Thus cost control migrated from Orszag theory to free political lunch. Mr. Gawande wrote an influential New Yorker essay on the topic in June, and the theme shaped both the case for a new entitlement and especially the appeal to potential opponents in business.

But then Congressional Budget Office director Douglas Elmendorf testified in July that "the curve is being raised," given that ObamaCare lacks "the sort of fundamental changes" necessary to tamp down costs. Meanwhile, it became clear that Mr. Orszag's favored research was always more nuanced and qualified than his pose of papal infallibility. One of his main gurus, Jonathan Skinner, mused recently that "the key lesson" from a new study challenging some of his findings "is how little we know about the science of health-care delivery."

Well, sure. A field as dynamic and innovative as U.S. medicine, in which costs are largely driven by new technologies and better ways of caring for patients, is rife with complexities and uncertainties. But no one bothered to strike that note of caution when Washington was hopped up on a cost-control gambit that was too painless to be true.

The new cost-control apologists concede that there isn't any actual plan for controlling costs: Throw enough speculative policies against the wall, they say, and some breakthrough will stick. Yet Mr. Orszag's no-less-confident predecessors spent decades trying to pull down Medicare spending with little to no success. Technocracy rarely if ever works as intended. Mr. Gawande points to the case study of U.S. farm policy, and if politically sacrosanct agriculture subsidies and rural price-supports are the best to hope for, then what's the worst?

More relevant examples include Medicare's "relative value" payment scale, which was designed in 1985 by the Harvard economist William Hsiao to encourage more primary care. That's this year's rallying cry too. "Diagnosis-related groups" were introduced into Medicare in 1983 to alleviate hospital cost growth, and what a monumental success that turned out to be. With only brief periods of relatively slower growth, nominal Medicare spending has risen on average at an annual rate of 9.6% since 1980. Over the same period total Medicare spending has grown 13-fold, climbing from 1.2% of the economy to 3.2% today.

Congress lacks the stomach for serious cost control in any case. One policy Mr. Orszag favors—Medicare penalties for hospitals that re-admit certain patients—is limited to only three conditions in the Senate bill, and the penalties are trivial.

Another—a putatively independent commission that is supposed to enforce cost cutting—is barred from going after costs incurred by doctors and hospitals, which leaves out more than half of Medicare spending. Earlier this year Mr. Orszag got into a heated debate with Henry Waxman over such a commission at a dinner party hosted by Connecticut Rep. Rosa DeLauro, precisely because the House baron enjoys the political power that flows from controlling health spending.

Even if Mr. Orszag's Princeton and Yale Ph.D.s really do cook up some hope-and-a-prayer savings plan, it will invariably offend one constituency or another and Congress will block it. Thereupon the political class will do what it always does when costs run over: Tighten price controls across the board, before moving on to denying patient access to costly treatments that will be defined as "wasteful." That is, ration care.

"Basically everything that has been put forward in health policy discussions for a decade is in this bill," Mr. Orszag said on a conference call shortly before Thanksgiving. He then asked critics pointedly: "What specifically else would you do?"

Hmmm. One liberal sage noted in a 2007 paper that "four decades of empirical research" have shown that insulating people through third-party insurance coverage "from the full cost of health care has been responsible for anywhere from 10% to 50% of the large increase in health expenditures." Ultimately, he concluded, increasing cost-sharing would give individuals a direct stake in more prudent purchasing, as opposed to today's invisible health dollars that vanish as more expensive premiums, foregone wages and higher taxes.

Those are the words of Jason Furman, now the White House deputy economic director who seems to have been put into witness protection. Every serious health economist in the country recommends reforming the tax exclusion for employer-sponsored insurance, perhaps by converting it to a deduction or credit. Cost control will never stick unless it is extricated from politics and transferred to individuals to make their own trade-offs.

Such reforms were ruled out by union opposition, so the Senate gestures at them with a 40% excise tax on high-cost insurance plans, on the theory that two wrongs will make a right. But this untargeted tax will simply raise the cost of coverage for all workers in a given pool—it's too clever by 40%—while doing nothing to stem the distortions from first-dollar, third-party insurance.

No doubt there are efficiencies to be had in health care, and maybe Mr. Orszag has even identified some of them. But all of his bright ideas could be taken for a whirl without adding trillions of new liabilities to the federal balance sheet. And the bad faith of the White House and its acolytes is breathtaking.

The White House hawked a permanent entitlement expansion on flimsy and speculative theories that its own partisans now admit—albeit when it is nearly too late—aren't more substantive than the triumph of hope over experience, while simultaneously writing off the one policy that has been effective in the real world. The cost control mantra of ObamaCare was always a political bill of goods, and its result will be the opposite of its claims: poorer quality care at higher costs.

[ccp]

"Mr. Orszag proposed another option, citing academic research observing that as much as 30% of health spending is "waste" that doesn't affect outcomes. He argued the country could save $700 billion a year without harming quality—more than enough to pay for universal coverage"

LOL if this wasn't such a ridiculous statement.
Just the definition of this word alone:  "outcomes" could stimulate debates that could roar on forever.
Who decides what is the proper "outcome"?

Does he mean death or hospitalization?

Where is the *academic research* on the waste in government?

[Body-by-Guinness]

Morning Bell: The Battle Over Obamacare’s Obituary Has Begun

 Posted December 14th, 2009 at 9.31am in Health Care.

Last month, Speaker Nancy Pelosi (D-CA) rammed through her version of Obamacare almost a week before the agency in charge of running Medicare and Medicaid, the Centers for Medicare and Medicaid Services (CMMS), could issue its non-partisan and independent analysis of the legislation. And for supporters of the President’s plan, it’s a good thing she did. The CMMS report eviscerated almost every single promise the President has made about his health care plan.

According to that report, Obamacare: 1) raises health care costs; 2) causes millions of Americans to lose their current health care coverage; 3) forces millions of Americans to pay fines and still receive no health insurance; 4) causes millions of seniors to lose their Medicare Advantage plans; 4) places millions of Americans on welfare; 5) jeopardizes Medicare access for all seniors; 6) worsens health care access for the poor.

This past Friday, CMMS issued another report, this time on Majority Leader Harry Reid’s (D-NV) version of Obamacare and the verdict was in many ways worse: 1) health care costs would rise by $234 billion; 2) 17 million Americans would be forced out of their existing health insurance; 3) 19 million Americans would pay $29 billion in taxes/fines and receive no health care in return; 4) 33% of all Medicare Advantage customers would lose their health care plan; 5)  18 million Americans would be put on welfare; 6) the $493 billion in Medicare cuts would force 20% of Medicare providers to become unprofitable thus jeopardizing access to care for all seniors; and 7) the explosion in Medicaid recipients would exacerbate existing health care access problems for the poor.

The week before the Senate began debating Obamacare, CNN conducted a poll and found that Americans narrowly opposed the plan, 49% to 46%. Now that the Senate has been debating the plan for two weeks, and CMMS has issued two devastating reports on what the impacts of Obamacare would be, opposition to the plan has skyrocketed. This Friday’s latest CNN poll showed 61% of Americans now oppose Obamacare compared to just 36% who support it.

Liberals are is beginning to see the writing on the wall. They know that if Obamacare fails to pass the Senate this year, the battle will be on to explain its failure. For them, the story can not be that President Barack Obama tried to push too ambitious a government health plan. It must be that the President and Congress did not go far enough to the left to satisfy the supposedly government-hungry American people. Hence the left is now attacking the White House and Reid over the public option, the employer mandate, drug reimportation, abortion, and health insurance spending caps.

Obamacare is not dead yet. Speaker Pelosi has signaled that she will quickly pass anything that comes out of the Senate, so Reid could still cave on almost everything and get a terrible bill from everybody’s prospective on the President’s desk by New Years. But Senators thinking about moving quickly should remember that the public strongly opposes this bill, and that opposition is only rising.

http://blog.heritage.org/2009/12/14/morning-bell-the-battle-over-obamacares-obituary-has-begun/

[Body-by-Guinness]

2nd post.

December 14, 2009
A Savings Mirage on Health Care

By Robert Samuelson
WASHINGTON -- We are now witnessing a determined counterattack by the Obama administration and its political allies on the matter of health care costs. Many critics (including me) have argued that President Obama's "reform" agenda wouldn't control rapidly rising health spending and might speed it up. The logic is simple. People with insurance use more health services than those without. If government insures 30 million or more Americans, health spending will rise. Greater demand will press on limited supply; prices will increase. The best policy: Control spending first; then expand coverage.

But the administration insists it can insure most of the uninsured and tackle runaway health spending simultaneously. There's so much waste in today's health care system that both goals can be pursued together, Peter Orszag, head of the Office of Management and Budget, has said.

Two new reports by liberal advocacy groups echo that claim. The first, from the Center on Budget and Policy Priorities, contends that lower Medicare reimbursement rates to hospitals and other providers can pay for about half of the $900 billion or so government cost over a decade of expanded health benefits. Critics (again, including me) have said that Congress would put the Medicare cuts in today and might repeal some or all of them in the future. Nonsense, says the study. Congress has allowed many past reductions in Medicare reimbursements to take effect.

Even more upbeat is a joint report from the Center for American Progress Action Fund (CAP) and the Commonwealth Fund arguing that savings from the bills' cost-cutting provisions have been underestimated. One measure would push hospitals to reduce readmission rates; some "bundled payments" between doctors and hospitals would encourage coordinated care; taxes on gold-plated insurance plans would deter overspending. Health costs would be lower than expected: Medicare "savings" would total $576 billion over a decade (about $200 billion more than estimated by the Congressional Budget Office, which mostly counted lower reimbursement rates); the federal deficit would drop up to $459 billion over a decade; and health care "savings" for typical families would total about $2,500 by 2019.

Who's right? Let's start with the numbers. Unfortunately, the word "savings" is used misleadingly. It doesn't mean (as is usual) actual reductions; it signifies smaller future increases. There's a big difference.

In 2009, national health spending will total an estimated $2.5 trillion, or 17.7 percent of gross domestic product. By 2019, it's projected to rise to $4.67 trillion under present policies, or 22.1 percent of GDP. With CAP's "savings," it rises a little less sharply to $4.49 trillion, or 21.3 percent of GDP, according to Harvard economist David Cutler, the study's co-author who provided these figures. Similarly, family health insurance premiums rise from 19 percent of median family income in 2009 to 25 percent in 2019 under present policies and 23 percent with CAP's "savings."

The point is simple: Even with highly optimistic assumptions, health spending remains out of control. It absorbs more of government, business and family budgets. Higher health spending would put pressure on future budget deficits, already projected to total about $9 trillion over the next decade. If new taxes and Medicare "savings" are real, they could be used exclusively to pay down deficits, not finance new spending.

But many may not be real. Writing in The Wall Street Journal, Dr. Jeffrey Flier, dean of the Harvard Medical School, gave the various health bills a "failing grade" and said they wouldn't "control the growth of costs or raise the quality of care." Quoted in Newsweek, Dr. Delos Cosgrove, head of the Cleveland Clinic, said much the same. Richard Foster, the chief actuary of the federal Centers for Medicare & Medicaid Services, doubts the cost-saving provisions touted by CAP would save much money. He's also skeptical that Congress, facing complaints from hospitals and a squeeze on services, would allow all the Medicare reimbursement cuts to take effect. True, Congress has permitted some reimbursement reductions to occur but has repeatedly blocked the Sustainable Growth Rate adjustment for doctors, which most resembles the new proposals.

Health cost increases might spontaneously recede, but history suggests skepticism. The relentless advances reflect an open-ended insurance and delivery system that gives neither patients nor providers any reason to restrain spending. To attack costs first would be politically challenging. It would require admitting that all good things are not possible simultaneously and that the uninsured already receive much medical care. It would require genuine bipartisanship, not just a scramble for a few Republican votes. And it would require stronger measures to dismantle a fee-for-service delivery system that now rewards more, not better, care. That's a demanding and realistic approach; Obama's is wishful thinking.

Page Printed from: http://www.realclearpolitics.com/articles/2009/12/14/get_real_about_health_costs_99526.html at December 14, 2009 - 04:11:21 PM CST

[Body-by-Guinness]

Why Democrats push health care, even if it kills them

By: Byron York
Chief Political Correspondent
December 15, 2009

To some observers, the Democrats' race to pass national health care seems irrational -- even suicidal. Don't party leaders understand how much the public opposes the bills currently on the table? Don't they know that voters are likely to take their revenge at the polls next year? Given that, why do they keep rushing ahead?

Just look at the RealClearPolitics average of polls, which shows that Americans oppose the national health care bills currently on the table by a margin of 53 percent to 38 percent. That's not just one poll that might tilt right or left, it's an average of several polls by several pollsters. And the margin of opposition seems to be growing, not diminishing. And yet Democrats seem determined to defy public opinion. Why?

I put the question to a Democratic strategist who asked to remain anonymous. Yes, Democrats certainly understand that voters don't like the current bills, he told me, and they are fully aware they will probably pay a price next year. But they have found a way to view going ahead anyway as the logical thing to do, at least in their eyes.

You have to look at the issue from three different Democratic perspectives: the House of Representatives, the White House and the Senate.

"In the House, the view of [California Rep. Henry] Waxman and [House Speaker Nancy] Pelosi is that we've waited two generations to get health care passed, and the 20 or 40 members of Congress who are going to lose their seats as a result are transitional players at best," he said. "This is something the party has wanted since Franklin Roosevelt." In this view, losses are just the price of doing something great and historic. (The strategist also noted that it's easy for Waxman and Pelosi to say that, since they come from safely liberal districts.)

"At the White House, the picture is slightly different," he continued. "Their view is, 'We're all in on this, totally committed, and we don't have to run for re-election next year. There will never be a better time to do it than now.'"

"And in the Senate, they look at the most vulnerable Democrats -- like [Christopher] Dodd and [Majority Leader Harry] Reid -- and say those vulnerabilities will probably not change whether health care reform passes or fails. So in that view, if they pass reform, Democrats will lose the same number of seats they were going to lose before."

All those scenarios have a certain logic (even if the Senate calculation undercounts the number of potentially vulnerable Democrats). But each scenario is premised on passing an unpopular bill that hurts the party. Even if there's a strategic rationale for doing it, why are Democrats dead-set on hurting themselves?

"Because they think they know what's best for the public," the strategist said. "They think the facts are being distorted and the public's being told a story that is not entirely true, and that they are in Congress to be leaders. And they are going to make the decision because Goddammit, it's good for the public."

Of course, going forward has turned out to be harder than many Democrats thought. And now, with various proposals lying wrecked along the road, the true believers are practicing what the strategist calls "principled damage control."

But still, does it make sense? In the end, perhaps the most compelling explanation for Democratic behavior is that they are simply in too deep to do anything else. "Once you've gone this far, what is the cost of failure?" asks the strategist.

At that point -- Republicans will love this -- he compared congressional Democrats with robbers who have passed the point of no return in deciding to hold up a bank. Whatever they do, they're guilty of something. "They're in the bank, they've got their guns out. They can run outside with no money, or they can stick it out, go through the gunfight, and get away with the money."

That's it. Democrats are all in. They're going through with it. Even if it kills them.

Byron York, The Examiner's chief political correspondent, can be contacted at byork@washingtonexaminer.com. His column appears on Tuesday and Friday, and his stories and blog posts appears on ExaminerPolitics.com.

 

 
 
Find this article at:
http://www.washingtonexaminer.com/politics/Why-Dems-push-health-care_-even-if-it-kills-them-8658408-79264542.html

[Body-by-Guinness]

Bland CBO Memo, or Smoking Gun?

Posted by Michael F. Cannon

This weekend, the Congressional Budget Office released “a very strange memo” titled, “Budgetary Treatment of Proposals to Regulate Medical Loss Ratios.”  You wouldn’t know it from the title, but that little memo is the smoking gun that shows how congressional Democrats have very carefully hidden more than half the cost of their health care bills.

First, a little history.  Like both the House and Senate bills, the Clinton health plan would have mandated that individuals and employers purchase private insurance.  In its 1994 score of the Clinton plan, Bob Reischauer’s CBO included those mandated “private” payments in the federal budget –- i.e., as federal revenues and federal expenditures.

And yet, none of the CBO scores of this year’s bills include the costs of similar individual/employer mandates as federal revenues or federal spending.

My read of the CBO’s score of the Clinton health plan is that the private-sector mandates accounted for around 60 percent of the Clinton health plan’s total cost, the remainder being (traditional) government spending.  So how is it that the CBO made the full cost of the Clinton health plan apparent to the public in 1994, but may now be revealing only 40 percent of the cost of the Obama health plan?

For some time, I’ve suspected the answer is that congressional Democrats have very carefully tailored their individual and employer mandates to avoid CBO’s definition of what shall be counted in the federal budget. Democrats are still smarting over the CBO’s decision in 1994.  By revealing the full cost of the Clinton plan, the CBO helped to kill the bill.

Since then, keeping the cost of their private-sector mandates out of the federal budget has been Job One for Democratic health wonks.  While head of the CBO, Obama’s budget director Peter Orszag altered the CBO’s orientation to make it more open and collaborative.  One of the things about which the CBO has been more open is the criteria it uses to determine whether to include mandated private-sector spending in the federal budget.  The CBO even published a paper on the topic.  Read this profile of Orszag by Ezra Klein, and you’ll see that those criteria were also a likely area of collaboration with lawmakers.

The Medical Loss Ratios memo is the smoking gun.  It shows that indeed, Democrats have been submitting proposals to the CBO behind closed doors and tailoring their private-sector mandates to avoid having those costs appear in the federal budget.  Proposals that would result in a complete cost estimate — such as the proposal by Sen. Rockefeller discussed in the Medical Loss Ratios memo — are dropped.  Because we can’t let the public see how much this thing really costs.

Crafting the private-sector mandates such that they fall just a hair short of CBO’s criteria for inclusion in the federal budget does not reduce their cost, nor does it make those mandates any less binding.  But it dramatically reduces the apparent cost of the legislation.  It is the reason we’re all talking about an $848 billion Reid bill, rather than a $2.1 trillion Reid bill.

If someone sold you a house, or a car, or a mutual fund this way, we would put them in jail.

http://www.cato-at-liberty.org/2009/12/16/bland-cbo-memo-or-smoking-gun/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Cato-at-liberty+%28Cato+at+Liberty%29