In Defense of Kevin, MD

Posted on July 22, 2009
Filed Under General Rationing Issues |

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DrRich notes with some consternation that his friend, Kevin Pho, is taking quite a bit of heat over at KevinMD for throwing in with the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association, in support of the House Healthcare reform bill (H.R. 3200). DrRich got to know Kevin a few days ago at the Putting Patients First conference in Washington, DC, and found him to be every bit as thoughtful, articulate and smart as anyone reading his blog might expect. DrRich finds him to be an entirely honest person. He is in nobody’s pocket. If Kevin is supporting H.R. 3200, the one thing DrRich is sure of is that he has good reasons for doing so.

As readers of this blog will know, DrRich has not had a dog in this fight. The battle over healthcare reform, as it is now framed, is not a fight about good vs. evil, or freedom vs. oppression, or budgetary restraint vs. profligacy. This is simply a fight about who - the private sector or the government - gets to control covert rationing. And covert rationing corrupts everything it touches no matter who is controlling it, and patients* are screwed, no matter who wins. So when it comes to the Republicans vs. the Democrats, here DrRich can only say: A pox upon both your houses.

There is much to despise both about H.R. 3200 itself, and about the manner in which its supporters have jumped on the bandwagon. But DrRich does not find that any of these negatives are material enough to unduly influence our decision about whether to support it.

For instance, H.R. 3200 is a budget-buster. Even the Democrat-appointed CBO officials admit (as reluctantly as one might think) that H.R. 3200 will accelerate (rather than reduce) the cost of healthcare, and will cost at least an “extra” $1.5 trillion over the next decade. This indeed would be a significant problem if the U.S. were otherwise solvent.

But DrRich must note that we’ve already committed to spending in excess of $50 trillion over the next few decades on Medicare and Medicaid, a value so absurd that it utterly precludes our survival as a viable society. Against this backdrop, an extra trillion or two can have no measurable impact - except perhaps to cause us to focus a few years earlier on the fiscal black hole we’re heading towards, which conceivably could be a good thing.

Then there’s the now-famous “page 16″ problem, picked up last week by Investor’s Business Daily, where H.R. 3200 (on page 16) shows, in plain language, how (while not outlawing it outright) the bill nonetheless intends to regulate private health insurance out of existence.

But DrRich has pointed out on several occasions that the insurance companies are really just looking for an exit strategy. The only potential difficulty “page 16″ may pose to them is a slight bit of embarrassment should they have to explain (say, to their shareholders) how they can support a plan that so openly spells out their own doom.

And of course, there’s the unseemly and revealing rapidity with which the above-named physician organizations endorsed H.R. 3200. The AMA et al. released letters expressed their “unqualified support” for the massive bill immediately upon its release. Why, a full two days later, when Rep. Paul Ryan spoke at the Putting Patients First conference, the very morning the House Ways and Means Committee had voted to send the bill to the floor, he complained that the bill had been shoved out the door before any congressperson had had a chance to read it in its entirety. So, one can only surmise, certainly nobody at the AMA, ACP, etc. could possibly have read the bill, either, before their enthusiastic public endorsement of it.

One must admit that this looks pretty bad, and that the only conclusion a reasonable person can reach is that the physician organizations endorsed the bill with such alacrity not because they agreed with (or even knew) what was in it, but because the fix was in. What that fix consists of will only be determined in the future, when we see what develops. (Certainly it’s more than just dropping the SGR formula, since Congress each year votes to abrogate the SGR formula anyway. As a former member of one of these physician organizations, DrRich can only assume the physician leaders must have held out for a much better “fix” than that.)

But DrRich reminds his readers that actually reading complex legislation such as this is not all it’s cracked up to be. This is because nobody can say what the words actually mean, even after careful study. For instance, the “page 16″ verbiage, which seems pretty straightforward to DrRich, is claimed by an authority as high as President Obama himself not to say what it seems to say. The point of this kind of legislation is not to advance transparency or to promulgate straightforward laws or systems, but to pass a bill that can be handed off to nameless regulators and bureaucrats, who can then translate the language in their own ways, multiplying and complexifying the verbiage by geometric proportions into innumerable rules, regulations, guidelines, opinion letters, etc., all of which have the force of law to back them up, in order to advance the cryptic and fluid aims of the ruling party of the day. And this legislation, by its sheer mass, seems sufficient to accomplish that much, whatever it actually says. And tinkering with it in this way or that will not appreciably change the bottom line.

The bottom line is this. The private sector has had 15 years to try to reduce the cost of healthcare. They have failed, and they have no viable plan for going on from here, and most tellingly, they have no intention of going on from here. So, like it or not, now it’s the government’s turn to covertly ration healthcare.

(DrRich does not like it all that much. As cruel and nasty and lethal to patients as the health insurance industry has been, covert rationing by the government could be worse. The most frightening experience DrRich has ever had in his life was when the federales focused their attention on his medical practice habits in the mid-1990s, in a particularly nasty application of the Regulatory Speed Trap. And while in the end it all worked out just fine for DrRich, he’ll never forget what it was like having the entire weight of the sovereign authority - i.e., that authority which has the ultimate capacity to exert its will by the focused application of violence - bearing down upon him. Government-sponsored covert rationing will be brutal. DrRich will have much more to say about this in the future, should anything like H.R. 3200 become law.)

Now, back to Kevin.

Kevin understands the shortcomings of the pending congressional legislation on healthcare reform. While DrRich cannot say whether Kevin reaches the same conclusions about those shortcomings as he does, it is clear that, at the end of the day, Kevin gives some of the good features about this legislation sufficient weight to overcome the shortcomings. And DrRich agrees with Kevin that some of these favorable features are compelling. These include provisions for health insurance to be made available to most, if not all, of the people who cannot afford it today; the provision for health insurance to be made available to all the people who are blocked from insurance today because of their underlying illnesses; and the provision to prevent insurance companies (if any continue to exist in their present form) from canceling policies of their subscribers who get sick. These are all important provisions that move us toward more equity, and that will aid our fellow patients who (under a private-sector covert rationing paradigm) have been thrown under the bus.

And since we’re going broke anyway, the insurance companies are leaving the business anyway, and the actual meaning of the verbiage of the legislation is merely an intellectual exercise for lawyers anyway, Kevin’s calculus - that the spelled-out gains are a step in the right direction from where we are now - begins to seem quite reasonable. Furthermore, as DrRich has pointed out, there’s no Plan B. We may not have much choice but to embrace (as Kevin urges us) what’s good about Plan A.

The danger, as DrRich sees it, is in finally ceding to the sovereign authority this much control over our economy and our health, and (ultimately), over anything that has any bearing on our health.  This is a very great danger indeed. The risk is an existential one, one we must accept (with a nod to some of its incidentally good features, which Kevin helps us identify) only because there apparently is no other option.

It is a risk which can only be mitigated, DrRich fervently believes, by insisting that our government conduct the unavoidable healthcare rationing openly and transparently, by means of a very public process. As difficult and as ugly as open rationing would undoubtedly be, it (like Kevin says about H.R. 3200) will be better than the alternative.

*Patients are a group among whom DrRich - a refugee now for almost a decade from the practice of medicine - counts himself, and expects to count himself until the inevitable and bitter end. This, despite the fact that leading patients have apparently rejected his application for membership. So DrRich, Hester-Prynne-like, will go about his daily toil, straight-backed and resolved, attempting to alert his fellow patients to the extreme and dire consequences they face with covert healthcare rationing, all the while proudly wearing his scarlet “P” as a quiet rebuke to other, more secret sinners.

Comments

One Response to “In Defense of Kevin, MD”

  1. Joe on July 23rd, 2009 1:26 pm

    It’s been pretty clear to me all along that Kevin sides with organized medicine, so it is no surprise that he should get cozy with the AMA. Much of what Kevin writes is about how to please one’s doctor and what would be great for doctors to have (but not necessarily great for patients). Kevin’s ideas are very aligned with those of stodgy, slow-moving, status qup-supporting organized medicine. I think it is appropriate that he is “taking heat” as you say.

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