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.