A Concise Critique of Obama's "Health Care" Reform

John Hinderaker at the blog Power Line has a concise critique on the fundamenal problems with President Obama's "health care" reform plan. I would love to just quote the whole thing, but such activity is frowned upon in the blogosphere, so I strongly encourage you to go read the whole thing.

For anyone who thinks that this plan is not a back door into a single payer, government-controlled system, take a look at this statement:

What is being overlooked this time around compared to 1993 is this: to prevent "leakage" from the system, draining of supply to other providers of insurance/purchasers of health care services...the "public option" has to effectively outlaw them.

Of course, if other options are outlawed, then only the public option is left -- voila! a single payer system.

I saw this the first time I analyzed his proposals during the campaign. (Which is well before I posted this.) Anybody who believes otherwise is just deluding themselves. Or they are too stupid to be allowed to make decisions for themselves.

The World Moves Right, and the US Moves Wrong

I sit here despondent. I had hopes that the House of Representatives was not this stupid. And it almost wasn't; H.R. 2454, The American Clean Energy and Security Act of 2009, passed by 7 votes, and really only 1 vote, as the 219 votes for the bill was only 1 vote over 50% of the entire House. It seems there were 5 votes not cast.

Meanwhile, the rest of the world is moving away from AGW lunacy. As this editorial in The Wall Street Journal reports, Australia is voting to kill their cap and trade system, the new government in New Zealand has suspended their weeks-old program before it could do any damage. Poland and the Czech Republic both have taken positions opposed to AGW, and even France appears to be appointing a commission (or assigning the task to a ministry) to look at the science behind AGW again.

Here in the US, the tide is turning as well, though you'd be hard pressed to tell from our "objective" news media.

The number of skeptics, far from shrinking, is swelling. Oklahoma Sen. Jim Inhofe now counts more than 700 scientists who disagree with the U.N. -- 13 times the number who authored the U.N.'s 2007 climate summary for policymakers.... A group of 54 noted physicists, led by Princeton's Will Happer, is demanding the American Physical Society revise its position that the science is settled. (Both Nature and Science magazines have refused to run the physicists' open letter.)

Why is this happening?

The collapse of the "consensus" has been driven by reality. The inconvenient truth is that the earth's temperatures have flat-lined since 2001, despite growing concentrations of C02. Peer-reviewed research has debunked doomsday scenarios about the polar ice caps, hurricanes, malaria, extinctions, rising oceans.

In Australia, the credit is being given principally to one man.

Credit for Australia's own era of renewed enlightenment goes to Dr. Ian Plimer, a well-known Australian geologist. Earlier this year he published "Heaven and Earth," a damning critique of the "evidence" underpinning man-made global warming. The book is already in its fifth printing. So compelling is it that Paul Sheehan, a noted Australian columnist -- and ardent global warming believer -- in April humbly pronounced it "an evidence-based attack on conformity and orthodoxy, including my own, and a reminder to respect informed dissent and beware of ideology subverting
evidence." Australian polls have shown a sharp uptick in public skepticism; the press is back to questioning scientific dogma; blogs are having a field day.

Senator Jim Inhofe continues to lead the battle against AGW in the Senate. I heard part of a speech he was giving regarding HR 2454 earlier this week. He rightfully pointed out that the US unilaterally restricting our CO2 emissions (with the subsequent frightful damage to our economy which would ensue) while other nations, particularly India and China, did nothing to restrict their emissions, would mean that our efforts would be in vain. He estimates that what little American manufacturing that still remains would move to China, where they would escape our oppressive taxation, and that the increased number of coal-fired power plants the Chinese would need to power these new manufacturing plants would ultimately lead to an increased global CO2 levels.

Not that it matters that much, since CO2 is not the cause of the warming we saw in the 1990's.

Current observations indicate that the global temperature peaked in 1998 and has been flat ever since, except for a possible trend toward decreasing over the past 18 months or so. If historical trends, revised computer models, and sunspot minimum factors can be trusted, the temperature will definitely be going down in the years to come.

What depresses me further is that when the temperature does come down, these AGW imbeciles will think that The American Clean Energy and Security Act had something to do with it, thereby reinforcing their delusions of grandeur. And then we may never be able to get rid of this piece of excrement.

Michael Jackson Did Not Die of a Cardiac Arrest!

This drives me nuts! I mean literally insane! And that's not a good thing when you're already postal.

The news media is reporting today that Michael Jackson died of a cardiac arrest. This is not the first time I have seen this on the TV or in the newspaper. Unfortunately, I have even seen it listed as the cause of death on death certificates, put there by professionals who really ought to know better.

Nobody dies of cardiac arrest. Cardiac arrest is a mechanism of death, it is a definition of death, but it is not a cause. Saying Michael Jackson died because of cardiac arrest is equivalent to saying Helio Castronevas won the Indy 500 because he crossed the finish line first.

Of course, Helio did win the Indy 500 because he crossed the finish line first, but that's because crossing the finish line first is the definition of winning. Similarly, Michael didn't die of cardiac arrest because cardiac arrest is the definition of death. (Or at least one definition of death, the one that is most incontrovertible.)

Cardiac arrest is caused by something else. That something else could be a coronary thrombus, a primary ventricular arrhythmia, anoxia, penetrating trauma, or any number of things. But there is a something else, and that something else is the cause of death.

If anyone out there knows of someone who is dead and has not had cardiac arrest, please let me know. I've been looking for something unique to write up in a medical journal.

Before anybody throws a brain death case at me, do note that when you take a brain dead patient off life support, they progress to cardiac arrest. I also do not want any references to your favorite zombie movie, unless you have access to the actual zombies.

Michael Jackson experienced cardiac arrest and now meets the definition of being dead. But that is not what killed him. We must all wait for the autopsy results to find out what that something is.

Fire in the Sky

We're going off on a science jaunt today.


Courtesy of the London Daily Mail Online come these pictures (only one shown here; more at the link) of a volcanic eruption as viewed by the astronauts aboard the International Space Station. Scientists are theorizing that the hole in the clouds was caused by the shockwave of the initial eruption, but I'll opine that the real cause is the heat of the volcanic plume evaporating the clouds as it passes through -- quite literally fire in the sky.







In other space news, the Japanese lunar probe Kayuga was crashed into the Moon June 11, ending its two-year mission of making high definition maps of the lunar surface. One of its last photos is below. Video of the crash, as well as a video of a high-def Earthrise, is available here. Amazingly, Australian astronomers actually got pictures of the flash of the crash on the moon, also at the link above.







Addendum 6/27/09 -- Here is a link to a NASA video of the volcanic eruption above. It almost has a 3-D effect to it.

http://earthobservatory.nasa.gov/images/imagerecords/38000/38985/sarychev_oblique_final_H264.mov

It runs in Quicktime and takes a little while to load.

President Obama Takes His Plan to the New Digital Airwaves

President Obama went on TV tonight to promote his bastard child of a "health care" reform package. It covered 90 minutes of television, minus commercials, during which little was said that you couldn't have learned from doing a little rudimentary web searching, or even just an occasional visit to the Drudge Report.

I must admit, it was not as much of a puff piece as I thought it was going to be. Charlie Gibson and Diane Sawyer actually asked some real questions regarding some of the problematic issues with Obama's plan. Mind you, they weren't real tough questions, but they were specific questions about the deficiencies of the plan, such as how it is to be paid for, why a public plan wasn't going to just outcompete the private plans in the Exchange, and the like. They even allowed a question from John Sheils, senior vice president of The Lewin Group, a health care policy research and management consulting firm, who estimated that up to 70 percent of those with private insurance would end up on the public plan. (Just as I predicted last October in Presidential Politics 2008: Health Care Proposals.)

The major theme of Obama's discourse was weaseling out of the tough questions and going back to his talking points, which don't sound like they have changed much since the campaign last fall. For example, AMA President J. James Rohack, MD asked a pertinent question about how this plan was going to guarantee that medical decision making was going to be left to the doctor and his patient and not by some governmental overseer whose main concern would be bean-counting. Obama replied by going off-question to his talking points about how the Exchange would operate. Furthermore, in answering the question from John Sheils, he avoided the intent of the question by going into nitpicking about how there would be a firewall to prevent individuals from choosing the public option over their employer-provided plan, ignoring the obvious fact that the question was about preventing employers from dropping their coverage for their employees in lieu of the public option as it will likely save them (the employers) money -- just as I outlined in my previous post.

A few more observations:

President Obama used the Mayo Clinic as an example of a system that is able to provide care in a more cost-effective manner, primarily by reductions in duplicative testing. Of course they can do that! The Mayo Clinic is a giant group practice, complete with a unified record system that all members of the group can access. We doctors not in that kind of a practice could do that too, if it were not for pesky little things like state and federal privacy laws, not to mention HIPAA. And lest we forget, the Mayo Clinic is in Minnesota, a state that has been dominated by managed care for decades, forcing the Mayo Clinic to develop its efficiencies simply in order to survive. (A medical version of Darwinian survival of the fit.) I do give kudos to ABC for airing that they have been receiving emails using the Mayo Clinic as an example of how the free market can provide less expensive, high quality care if only given a chance, and that more government intervention was not needed.

Obama dodged the partially formed question about the 99 year old mother who got a pacemaker after one electrophysiologist turned her down due to her age. She is now a 105 year old mother and still going strong and enjoying her life. Obama wants medicine to be evidence-based; that's what his Office of Comparative Effectiveness Research is all about. There is no study on the effectiveness of pacemakers in 100 year old people. If one were to be performed, I'd wager that it would show little or no benefit of using pacemakers in 100 year olds, because the mortality rate at that age from all causes would likely mask any beneficial effect provided by the pacemaker. EBM would likely have led to this woman not receiving a pacemaker, and Obama knows this; that's why he looked so uncomfortable answering the question. And this extraordinary woman would have come to a premature end. This did not happen because the patient/family and their doctors were allowed to make a decision in contradiction to EBM, suspecting that in this one case EBM did not apply. They were right -- but only because they were free from government interference in making that decision. Under Obama's plan, they would not have been so free.

Obama also gave a list of things he thinks will free up money to pay for this monstrosity:
1. Preventive health care -- nope, this will cost more in the long run. Only politicians think this is a cost saver.
2. Improved efficiency of health information technology -- not yet proven; and if it can, it will only be after privacy rules have been relaxed, which no one seems to want and which the stimulus bill actually made more stringent.
3. Eliminating all of the paperwork and bureaucracy -- in a government system??? ROTFLMAOF!
4. Evidence-based care -- again, there's no proof that this will reduce costs, and every likelihood to suspect it may increase them overall.
5. Changes in reimbursement -- A-ha!! Here it is! The only one on the list that he can guarantee will save money, because it's the only one that is directly controllable. Of course, changes in reimbursement must in this event mean lower reimbursements, to doctors, hospitals, et cetera. And as reimbursements go down, so does the supply of doctors overall, as older practitioners retire, and fewer young people enter the medical field. And as the supply of doctors goes down, so does your chance of getting an easy appointment, followed by waiting lines, followed by rationing.

I hope that this little spectacle tonight has the opposite effect from what was intended. I hope that those watching now have more questions and are more critical of what is about to be done to them. Time will tell.

The End of Prosperity is Coming

The House of Representatives votes Friday, June 26, on H.R. 2454, The American Clean Energy and Security Act of 2009. This is the euphemistic name given to the carbon cap and trade tax bill that will increase the energy bills (electric, gas, gasoline, coal) of all Americans, as well as increase the cost to the consumer of everything that requires energy in its manufacture or delivery to market, which of course means the cost of literally everything.

This will lead quickly and irrevocably to a massive downturn in the economy right when we don't need it the most.

As I said in the title, the end of prosperity is coming. The first arrival announcement will be this coming Friday, assuming this bill passes. I have faith in the Democratically controlled Congress to always do the exact wrong thing, so its passage is assured.

I implore you to call your Congressman and Senators and demand that they vote against this bill. After it has been killed, then they need to burn the body and scatter the ashes. (You see, the bill is printed on paper, and burning it will release CO2 into the atmosphere and ...... oh, forget it. If you have to explain a joke......)

CNBC Takes on the "45 Million"

As I have covered before, the oft-quoted figure of 45 million uninsured is a complete fabrication. Certainly one would expect a conservative blogger to explain this as we head into the muck of "health care" reform, but I never expected to see it on the Obama-worshipping Peacock Network.

So imagine my surprise as I sat in the doctor's lounge at lunch today and saw this report on CNBC:

http://www.cnbc.com/id/15840232?video=1158405259&play=1

Fox Business has covered this as well. But Fox News covering this is no big surprise. (The links to the Fox videos are harder to get to. Go to www.foxbusiness.com/video/index.html and in the video search box [the one above the video list] type in "uninsured". From the resultant list watch the videos entitled "Is the Number of...." and "Study: 25-75% of....")

The important thing to note is that these reports, citing different studies and surveys, all reach the same conclusion -- the number of the truly uninsured is around 8-13 million. Not even close to 45 million.

In a semi-related video from last fall, a study by the Harvard School of Economics indicates that the overcrowding in our nation's emergency departments comes not from the unwashed sea of the uninsured but rather from the insured, most of whom are either seeking medical care at a time that they won't miss work or are trying to avoid paying an office co-pay. This video is on the Fox Business site, on the Uninsured search list, and is entitled "Uninsured not Res...."

Trying to Comprehend President Obama's Fantasyland

President Obama gave his speech before the AMA House of Delegates today. I can only hope the delegates gave as warm a welcome to his statements as I did when I read them this evening. (Hint: they'd be warmer on Pluto.) Let's go through the speech with a little contemporaneous editorializing on my part, shall we?

"Today, we are spending over $2 trillion a year on health care – almost 50 percent more per person than the next most costly nation. And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren't any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do. "

Of course, much of the reason for this is because of the heterogeneous nature of our population, and the higher levels of poverty here than in, say, Sweden. It has to do with a lot more than dollars spent on "health care". (More on why I am putting that in quotation marks later.) If you were to compare our system to say, Mexico and not Canada, or Zimbabwe rather than Japan, our system would seem to prove that spending more on "health care" does make us healthier. But it would be an unfair comparison, just as comparing us to Canada, Japan, Sweden, etc. is an unfair comparison. There are actually no other countries that really could serve as an adequate comparison to the USA.

"It is unsustainable for Americans like Laura Klitzka, a young mother I met in.... Our costly health care system is unsustainable for doctors like Michael Kahn in.... Small business owners like Chris and Becky Link in Nashville are...."

I hate this oratorical technique. Picking random, supposedly real (I suspect that they really are real, however; it would be too easy to prove otherwise to risk making these people up) people who have fallen on hard times to "personalize" the crisis is a common technique of the socialist left. What they don't do, however, is back up their example with statistics showing how common this one individual's particular problem is. It pulls at your heartstrings without giving your brain a handhold on the problem, thus motivating you to accept the proffered solution without a lot of thought. That's why I hate it so. It offends the logical scientist in me. And it's pretty hard to offend me.

"If we fail to act, one out of every five dollars we earn will be spent on health care within a decade. In thirty years, it will be about one out of every three – a trend that will mean lost jobs, lower take-home pay, shuttered businesses, and a lower standard of living for all Americans. "

Naturally not taking into account that as the "health care" spending increases, the "health care" industry will expand, providing new jobs as others are lost. This is especially true as more and more of those dollars will be government dollars and not private-industry dollars. But politicians of both parties never consider a job gained in an industry they don't care for as a job gained.

President Obama then spends the next several paragraphs demonizing the opposition forces that have so far stood in the way of "health care reform", an excellent example of setting up the straw man he will later (not in this speech but in the days and weeks to come) use to try to marginalize those (like the AMA even!) who oppose part or all of his plan.

"Despite this long history of failure, I am standing here today because I think we are in a different time. One sign that things are different is that just this past week, the Senate passed a bill that will protect children from the dangers of smoking... "

Mark my words. This piece of legislation will be ruled unconstitutional. Because it is. I am a rabid anti-smoker and one would expect me to actually be in favor of this regulation. But if it subverts the Constitution, well, then, we need to find another way. Let's not set that precedent.

"So let me begin by saying this: I know that there are millions of Americans who are content with their health care coverage – they like their plan and they value their relationship with their doctor. And that means that no matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what's broken and build on what works."

Yet earlier he said:

"Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients. "

But isn't it the "health care" plans that he is going to allow us to keep if we like them the very plans that are running the systems that are forcing the doctors to spend "20 percent of each day" doing these non-medical tasks he lists above? How are we going to get rid of these administrative hassles if we don't change the system that creates them? I point this out not because I am championing Obama's reforms, but to point out the hypocrisy in his statements. These two positions are contradictory and cannot be reconciled. The only way to remove these hassles is to abolish them and replace them with something else, and the only something else that he is considering is his 'new public option', which can only provide this 'relief' if it becomes ever-expanding. So when Obama says:

"Now, I know there's some concern about a public option..... What are not legitimate concerns are those being put forward claiming a public option is somehow a Trojan horse for a single-payer system..... So, when you hear the naysayers claim that I'm trying to bring about government-run health care, know this – they are not telling the truth. "

he is either stupid, naive, trying to pull an entire sheep-herd's worth of wool over our eyes, or he is just out and out lying.

"The question now is, how do we finish the job? How do we permanently bring down costs and make quality, affordable health care available to every American? "

The answer is, you can't. Quality costs money. Just try to build a Lexus for the costs of a Honda Fit. It can't be done. It can't be done in the automotive world, and it can't be done in "health care". One dollar can only buy so much, and when it's used up, another dollar will be needed if you want to do more. I will be the first to admit that there are some wastes, inefficiencies, and outright fraud in the "health care" system. But there aren't enough to pay for the kind of changes President Obama is proposing, especially if he insists on keeping it budget-neutral. We in the medical profession hate the term 'budget neutral'. Every time it is used in altering Medicare payments, we end up getting paid less.

"First, we need to upgrade our medical records by switching from a paper to an electronic system of record keeping. "

The research on whether this will actually lead to improved quality, much less lower costs, is so far equivocal. The most well-done study to date suggests that the electronic records introduce as many errors as they eliminate; they are just different kinds of errors. And in Medicare's own pilot program for pay-for-performance (another example of governmental oxymoronic double-speak), the practices using paper records met more of the quality benchmarks than did the practices using electronic record systems.

"You shouldn't have to tell every new doctor you see about your medical history...."

No competent doctor should accept at face value anything he sees in a chart, paper or electronic, that is not hard, objective data. To do otherwise risks compounding someone else's errors. Though I hate to admit it, there are too many practicing physicians whose documentation skills are deficient.

"The second step that we can all agree on is to invest more in preventive care so that we can avoid illness and disease in the first place."

This deserves more space than I can allow here, but very briefly, the only kind of so-called preventative care that saves money is vaccinations. (This can be amply demonstrated by economic modeling.) Increasing what we currently call preventative care is a good thing. It will make people healthier to a degree (and this statement gets awfully close to why I'm putting "health care" in quotes). But it will cost more. It will not save money.

"That starts with each of us taking more responsibility for our health and the health of our children. It means quitting smoking, going in for that mammogram or colon cancer screening. It means going for a run or hitting the gym, and raising our children to step away from the video games and spend more time playing outside."

The socialist proposing that individuals actually take personal responsibilities for their own actions and lives? How very conservative of him! This is one of the few lines in the speech I can wholeheartedly concur with. It is also the very crux of the problem we are dealing with, which neither Obama's or anybody else's "health care reform" ideas will actually impact in any meaningful way.

"Our federal government also has to step up its efforts to advance the cause of healthy living. Five of the costliest illnesses and conditions – cancer, cardiovascular disease, diabetes, lung disease, and strokes – can be prevented. "

Obama has now led us deep into the interior of his Fantasyland. PREVENT diabetes? PREVENT cancer? PREVENT cardiovascular disease and strokes? These are all heavily influenced by genetics, and though each are impacted by lifestyle choices, to claim that by modifying those lifestyle choices we can prevent any of them is hysterical. Certainly we will be able to mitigate against the genetic risks and reduce the incidence rates of these diseases, but prevent them? Never. Not in this century. Maybe not in this millennium. Lung disease, namely COPD and lung cancer, will be the most modifiable through smoking elimination. But not asthma, which for all intents appears to be an autoimmune disease for which, like all other autoimmune diseases, we have pathetically few treatments and no options for mitigation, much less prevention.

"A recent article in the New Yorker, for example, showed how McAllen, Texas is spending twice as much as El Paso County...."

Of course let's not mention that McAllen, in the Rio Grande Valley, is one of the four biggest hotbeds of medical malpractice abuse in Texas, which our vaunted tort reform of 2003 has not completely reversed. I have not read the New Yorker article, but I can easily surmise that the increased need for defensive medicine in McAllen is not even mentioned.

President Obama then extols the benefits of evidence-based medicine (without using the term, though he does use that abomination 'best practices') for a number of paragraphs. I will not quibble here. EBM is a good idea. Spending time and money figuring out what currently works best and implementing it as quickly as possible is imperative; it will result in the fastest increases in patient care quality and outcomes of anything else we can do right now in the "health care" system, though it may not save money if it turns out that those 'best' practices cost more in the long run than the less effective things we now do. (My only fear is that EBM could easily turn into a doctrine rather than suggestion, at which point patient care could be threatened. But that again is another rant.) I intend to hold Obama to this one:

"Let me be clear: identifying what works is not about dictating what kind of care should be provided. It's about providing patients and doctors with the information they need to make the best medical decisions. "

"Any legislation sent to my desk that does not achieve these goals does not earn the title of reform. But my signature on a bill is not enough. I need your help, doctors.... That is why I will listen to you and work with you to pursue reform that works for you."

The President then proceeds to push hard on his public option plan, which the very House of Delegates he is talking to has already passed a position statement in opposition to. Gotta give him credit for trying.

"That is why we need to end the practice of denying coverage on the basis of preexisting conditions. "

Hallelujah, baby!! You are preaching to the choir now! Just add universal nationwide community rating to the insurance industry and you are finally on your way to some real beneficial useful reform.

Next we go visit the bank in Fantasyland, where quality is free and we can expand coverage to the "46 million uninsured" while being budget-neutral (and of course thus paying the doctors less). First, we are going to cut Medicare payments while the number of Medicare beneficiaries increases dramatically with the passage of the Baby Boomers into retirement. Then,

"...we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they are not getting the comprehensive care they need."

And why is this? Because current Medicare hospital payments discourage comprehensive care while hospitalized. So what is the proposed solution? (Sorry, you won't find this in the speech.) To refuse to pay for readmissions within 30 days without changing the system that restricts doctors and hospitals from providing the comprehensive care he's calling for! I treat sick patients. I have had many patients readmitted in under 30 days. And it is rarely, or maybe never, because of inadequate care during their first hospitalization. It is because something else happens to them --- they fall and break a hip 3 weeks after discharge for treatment of pneumonia, for example --- or their underlying medical problems are such that the only resolution to the cycle of frequent readmissions is death. This group includes people with end-stage COPD, CHF, cancer, dementia, etc. Some of these people would actually be better served by hospice care, but as I have previously addressed, our society is not quite ready for the option of quickly accepting the end is near.

"Another way we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now because of the large number of uninsured patients they treat. But as the number of uninsured people goes down with our reforms, the amount we pay hospitals to treat uninsured people should go down, as well. Reducing these payments gradually as more and more people have coverage will save us over $106 billion...."

No it won't! It won't save any money. None. Obama's 'reforms' will cover these uninsured patients with insurance paid for out of public money. The 'savings' from the decreased payments to hospitals for caring for the uninsured will be more than taken up by the public costs of providing the coverage for the same people. There's no savings here. It's just a bookkeeping maneuver. And not a very good one at that. See my earlier paragraph. Is he stupid, naive, wool-pulling, or just straight lying?

I can't comprehend Obama's Fantasyland. I live in the real world, where services cost money, quality is not cheap, defensive medicine is a reality, and sick patients are really, really sick. I have no time for the dreams of someone who has spent no time at all working in the "health care" trenches.