The Covert Rationing Blog

Government-Run Healthcare “Despite” Obama?

November 6th, 2008 by DrRich

In his campaign, President-elect Obama did not promise or even advocate a universal healthcare system controlled by the government. Indeed, he referred to government-run healthcare as an “extreme” option that ought to be avoided. Instead, he advocated a system in which people who liked their current health insurance would be permitted to keep it, while those who did not have health insurance or who did not like their current insurance would be able to join a new government insurance plan, based on the plan “available to members of Congress.”

Conservatives and cynics, of course, pointed out that such a plan amounted only to a stealth government takeover of healthcare. Since the new government insurance plan would be competing with private insurance, and since the government would be establishing the rules of competition, it would be a simple matter to arrange things so that, before too long, the private competition would melt away.

As a matter of fact, DrRich himself painted such a scenario, and even suggested that the insurance company executives were supporting Obama over McCain during the election precisely because Obama would present them with a graceful (and lucrative) exit strategy. (Mr. McCain’s plan, in contrast, relied on insurance companies to invent the “efficiencies” that would control healthcare costs, as if the insurance companies hadn’t already been trying unsuccessfully to control those costs for 20 years, and were not already completely bereft of useful ideas.)

The fervent wish of the insurance executives, DrRich surmised, was this: Mr. Obama would provide them with one last, huge windfall, in the form of government-provided premiums for some significant chunk of the 47 million uninsured Americans. Then (DrRich went on) a couple of years later and having realized their final gains, they would get out of the health insurance business altogether and let the feds have the whole mess.

But now, things have changed.

Thanks to the sub-prime mortgage crisis and the economic meltdown that has resulted, it will be difficult if not impossible for Mr. Obama to implement any sort of organized healthcare reform, or any other reform that promises to greatly increase federal spending. (Dick Morris points out in a column today that the realities of our current economic situation will serve as a general constraint to the Democrats now controlling the administration and both houses of Congress.)

But if Obama-style healthcare reform is off the table, or even significantly delayed, the health insurance companies are likely to be in deep trouble - and soon.

The market value (i.e., stock price) of these companies completely relies on their continued growth. Through the 1990s and for the first half of this decade, their growth was spurred by the acquisition of public assets (not-for-profit institutions) at a tiny fraction of their real value, and on mergers and acquisitions among insurers. But there are no more non-profits to take over, and these companies have pretty much run out the string on mergers.  So, for the past few years their growth has almost solely relied on their participation in government programs such as the Medicare Advantage Plans (which, by the way, may be going away soon given the recent election results). The entire prospect for future growth (and therefore viability) in the health insurance industry, as DrRich has explained, depends on an Obama-style expansion of government programs that will provide a new stream of insurance premiums.

One sure thing is that health insurance companies have no hope of even maintaining their current profitability, let alone continuing their growth, solely by doing what they are supposed to be doing - by managing the healthcare of their enrollees. (The prospect of having to survive by doing that, once again, is what frightened them so much about the McCain plan.)

Panicked insurance company executives are not in a pretty place. On top of a mounting recession in which their customers (American businesses) are cutting back or failing, and during which their own costs continue to increase at a double-digit rate of inflation, they now have to face the likelihood that in spite of Mr. Obama’s election there won’t be a massive infusion of government dollars into their businesses any time soon. These poor souls are very likely casting about for a Plan B.

And Plan B seems pretty obvious to DrRich. The path has been very recently blazed by others.

Over the last two months it has become obvious that when businesses vital to the public welfare are about to fail, the government has little choice but to take them over. This was the case with AIG, with Fanny and Freddy, and to a lesser extent with several major banks.  We now see the American auto industry lining up for a bailout/takeover. It is easy to imagine the gasping airline companies forming themselves up into the same landing pattern.

So if you are a health insurance executive, you are probably looking at your current broken business model, lamenting that your savior Mr. Obama is probably not going to be able to come to your rescue with the one last windfall he has promised, and observing what is happening with other “vital” American industries in similar straits.  DrRich imagines that these executives have already resolved themselves to a government takeover (indeed, this was the end-game they have long planned once their last Obama windfall played itself out), and that they are merely calculating the right moment for it. How best to divest their stock before hinting that such a takeover is in the works? With careful planning and negotiation, can some of the takeover money be parlayed into executive bonuses, or at least into one last, extravagant junket (a la AIG)? There is no real hurry, after all - whenever the health insurance industry says it just can’t do this any more and that the government needs to take over healthcare, then no matter which other industries the government will have already acquired, what choice will the feds have?

If DrRich is right in such speculations, we may end up with government-run healthcare  sooner than we think, despite the promises and intentions of Mr. Obama, and despite the seeming unlikelihood of achieving organized healthcare reform in the foreseeable future.

DrRich humbly suggests that those who currently own stock in health insurance companies should take note of what happened to the shareholders of AIG and other companies whose demise the feds have recently engineered - which is to say, they were completely wiped out.  DrRich is not really trying to give investment advice here, and admits to being entirely unqualified to do so, as anyone would agree who saw his portfolio. He’s just sayin’.

Posted in Gekkonian Rationing, Healthcare economics, Investment "advice" | 5 Comments »

The Real Reason Americans Have a Right to Healthcare

October 30th, 2008 by DrRich

In recent posts (here, here and here), DrRich has considered the legitimacy and the implications of our recently-announced right to healthcare.

In one of those “meditations” DrRich decided that declaring healthcare to be a right is indeed legitimate, but not because it is the only humane thing to do, or because there is some sort of a natural right to healthcare, but rather, due to the BOSS rule (that is, Because Obama Says So), which is simply another manifestation of the longstanding principle that the sovereign authority gets to declare anything he/she/it wishes to be a right.

At this time, DrRich wishes to drop his usual sarcasm, to the furthest extent possible, and explain why Americans in truth have a legitimate claim to a right to healthcare - even if the electorate (through some unaccountable fluke) should fail to consummate their promised elevation of Mr. Obama, thus, incredibly, negating the BOSS rule.

In short, Americans have a right to healthcare because they’re paying for it.

Under our present system, every person living in the United States is sharing in the cost of healthcare for every person who receives healthcare. Let us list some of the ways in which this is true:

1)    Anyone receiving a paycheck is subject to payroll deductions to pay for Medicare for the elderly and Medicaid for the poor.
2)    Anyone paying income tax is paying higher tax rates to offset tax-deductible health insurance premiums purchased by businesses for their employees. (That is, employer-provided health insurance is subsidized by the taxpayer.)
3)    Anyone buying products in the U.S. is paying higher prices to cover the healthcare costs of American businesses.
4)    Anyone living in America is sharing in the massive societal burden we are creating by allowing healthcare spending to be passed off to future generations, by way of the national debt.

These costs, and more, are borne by everybody living in the U.S.  Since everyone in one or more ways is paying for healthcare, everyone has a just claim - a right - to some of that healthcare.

It is important to notice that this argument for a right to healthcare is fundamentally different from the arguments typically given.  Typically, a right to healthcare takes on the characteristics of an entitlement, a grant bestowed on individuals by society just because of who they are (such as, citizens, people over 65 years of age, etc.)  A right like this - an entitlement - is rarely taken away, or even limited, once granted.  Entitlements are soon seen by their recipients (and by the bureaucracy that administers and regulates them) as something that is owed forever, as a natural, God-given right, which can always be expanded, but never ever restricted.

In contrast, the right to healthcare which DrRich is describing is not “granted” to an individual by a beneficent society because of some inherent characteristic of the recipient, but rather, comes into being solely as a result of their being party to a social contract, under which healthcare is a consideration given in return for certain obligations the individual makes to society.  Those obligations would include paying for the publicly-funded healthcare through taxes, and subjecting oneself to whatever limits to publicly-funded healthcare such a system requires in order to maintain societal integrity.

This kind of contractual right to healthcare would enable us to set necessary limits on what we mean by healthcare. There would no longer be an obligation to provide individuals with every manner of available healthcare under all circumstances, but only to provide individuals with that level of healthcare provided as a public benefit to all other individuals, under the terms of the social contract. (An entitlement, in contrast, generally is an open-ended promise in which “healthcare” comprises anything and everything one might think has any possibility of restoring every bit of health.)

To summarize, as DrRich sees it we have already created an obligation to provide publicly-funded healthcare to all individuals, by virtue of the fact that we have already burdened every individual with the cost of healthcare for anyone who is now receiving it.  We might as well own up to our responsibilities with a formal contract that recognizes the widely-shared cost of American healthcare, that recognizes the right of all Americans to the considerations that arise from this widely-shared burden, and that establishes clear limits to the obligations borne by the parties, limits that are part of any legitimate contract.

Such a social contract will finally give us the framework we need for a public discussion on setting necessary limits on publicly-subsidized healthcare spending.

Posted in A right to healthcare | 3 Comments »

Why Conservatives Shouldn’t Sweat Our New Right to Healthcare

October 27th, 2008 by DrRich

In response to a couple of recent posts (here and here) defending the declaration by President-Nearly-Elect Obama that healthcare is a right, several readers have offered comments indicating that simply declaring healthcare to be a right is not very useful, unless you also clearly say what you mean by “healthcare.”

This is indeed the question. Exactly how much healthcare are you entitled to if you have a right to healthcare?  Do you have a right to certain specified healthcare services, to a certain dollar amount of healthcare per year or per lifetime, to whatever healthcare it takes to achieve perfect health, or to some other limit or non-limit?

The question of limits (whether we should have them or not, and what should they be) has been a central theme of this blog and of DrRich’s book.  To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit healthcare in any way, that everyone is entitled to the very best healthcare, that any bit of healthcare that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the unwealthy, or corporate greed).  2) But against that closely held belief, we must balance the unremitting law of economics which tells us that there is simply not enough money in the known universe to buy all the healthcare that might potentially offer some small amount of benefit to every person.  Healthcare spending has to be limited, or it will become a fiscal black hole.*

Our insistence upon simultaneously balancing these two utterly incompatible factors (the rock-solid belief that there are and can be no limits vs. the unalterable law that limits are unavoidable) requires us to do the necessary rationing of our healthcare (that is, withholding at least some potentially useful healthcare from at least some of the people who might benefit from it) covertly.

So, our entire healthcare system, from all three branches of the government, to health insurance companies, to hospitals, to doctors, to individual Americans (at least when they themselves are not actively patients), are fully and extravagantly and enthusiastically engaged in covert rationing, by a thousand different mechanisms, some of which have been chronicled here.

One reason DrRich is not as reluctant as some to accede to the notion that healthcare is a right is that such a declaration might, at last, move us closer to the day when we will actually be forced to engage in a public discussion of what we mean by healthcare; that is, will move us closer to deciding what should be the limits of healthcare.

Consider: When we have tens of millions of uninsured Americans who don’t have ready access to regular and routine healthcare, then it’s relatively easy to pretend that “healthcare” should include everything we might want it to include.  By using the uninsured as a huge fiscal safety valve for our dysfunctional healthcare system - a valve that can be opened, as needed, to increase the number of people ineligible to consume routine healthcare - we can shore up the fiction that “healthcare” ought to have no limits. (Indeed, steadily increasing the number of uninsured Americans has become perhaps our most effective mechanism of covert rationing). This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits.

But once healthcare becomes a right, then presumably those (currently) 47 million Americans will suddenly have a claim to equal access to whatever it turns out we mean by healthcare.  The severe fiscal stress produced by this sudden influx of entitled Americans will likely force us, finally,  to explicitly define the limits of what we should expect from our healthcare system.

Defining those limits will be extraordinarily painful, and will very probably traumatize our social structure. However, the process is necessary, because if we fail to set those limits the resulting fiscal tsunami - which will utterly dwarf the economic trifle we’re dealing with today as a result of the mortgage crisis - will leave us without any social structure to traumatize.

If declaring healthcare to be a right causes us to engage in this painful exercise now, before it is too late, then DrRich is in favor of it. Even American conservatives ought to be thanking Mr. Obama for doing his bit to bring the issue to a head.

*In contrast, our national, de facto declared right to affordable mortgages for everyone, no matter one’s credit risk, will result in some finite, limited amount of national debt, since every home has some finite, limited value. Even if the final cost to society is very, very large, a national right to home ownership in fact results in a fiscal obligation for society that is limited and quantifiable, and in one way or another is therefore ultimately manageable.

Anyone who insists that there must also be similar inherent limits on what we can spend on healthcare should simply consider that once we have artificial hearts, artificial kidneys, artificial livers, and can indefinitely preserve brain function sufficient to, perhaps, plug aged-but-medically-preserved bodies into some sort of virtual reality where they can frolic like virtual children forever (DrRich does not really know what medical immortality will turn out to look like, just that it is the ultimate goal of medical research, as any real American can tell you), then the amount of money we can spend on any given individual’s healthcare becomes limitless.  It is indeed nearly limitless with just the stuff we have today.

Posted in A right to healthcare | 6 Comments »

More Implications of Our Right to Healthcare

October 20th, 2008 by DrRich

Last week, DrRich defended Mr. Obama’s recent declaration that healthcare is a right.  DrRich’s defense was not based on the idea that awarding Americans a right to healthcare is inherently a proper and necessary thing to do, or that a right to healthcare is one of those natural, God-given rights we Americans used to celebrate (like life, liberty or the pursuit of happiness), but rather, that the sovereign authority (i.e., that authority within any society which has the ultimate capacity to force its will by the exertion of violence) can declare anything they wish to be a right. So if Mr. Obama (presumptive President-elect, and soon-to-be wielder of sovereign authority) says healthcare is a right, then it’s a right.

DrRich understands, of course, that our Constitution in its very first paragraph awards sovereignty to “We the People,” and that the rest of the document goes on to specify the limits of governmental authority, and that those limits are most specifically spelled out in the Bill of Rights (which actually does not award rights to the people, the rights of the people being granted by “nature,” but instead explicitly lays out a few of the limits on the government’s ability to intrude on God-given individual sovereignty).

But DrRich has also been taught, by the unambiguous verbiage of our political leaders and by decades of observation of actual governmental actions, that the Constitution is a “living document,” which means that the government may grow its authority as needed in order to deal with perceived social (or financial) crises, or political exigencies.

Simply put, the responsibility for American healthcare, being both a social crisis and a political exigency, certainly fits as one of those items that heretofore has fallen to individuals, but that the government may now choose to take upon itself without violating any really important precedent.

And indeed, it has so been declared.

To his fellow conservative Americans, DrRich wishes to assure that really, this is not such an extraordinary step as many seem to think.

DrRich has heard it said, by those who disparage healthcare as a right, that this is a dangerous step, that, if the government awards Americans a right to healthcare, then what’s to stop the government from also awarding them a right to food, clothing, and shelter (the lack of which would pose a much more dire problem to the vast majority of people than a mere lack of healthcare)?

To which DrRich replies: Where have you been for the past two months?  The housing crisis, the near collapse of our financial markets, and the extraordinary taxpayer bailout that will burden our progeny down through the generations, all amount merely to partial payment for the decision by our duly-elected representatives (and the policies and actions that naturally derive from that decision) that all Americans should have access to an affordable mortgage (or, for that matter, mortgages). That is, we are simply getting a first look at the bill that is coming due thanks to a government-declared right to a house.  And when we are finished, it appears, our government will own the actual mortgages, the government-backed entities (Fannie and Freddie) that support the mortgages, and even large chunks of the banks themselves that do the original lending (several of which, last week, were forced against their will - in a graphic demonstration of the definition of sovereignty - to accept a federal buy-in of their institutions).

So be soothed. The right to healthcare is simply a natural extension of the already extant idea that the government should supply (and control, and therefore, own) all the necessities of life.

There’s a lot to learn from studying societies in which governments have taken on this role. Several such societies have risen (and fallen) just over the past century.  We who worry about the cost of healthcare perhaps can take solace in the fact that, in all of these societies, the notion of “healthcare” quickly came to be seen as the extravagant luxury it has been throughout most of human history, rather than a fundamental necessity.  People enduring famine and exposure (or, at best, inanition) have relatively low expectations regarding healthcare.

In other words, as we look at the real implications of the recent taxpayer bailout of our financial system (engineered by a Republican administration), and at the fact that we are about to elect a Democrat President whose stated aim is to spread the wealth around, a right to healthcare actually becomes a relatively unimportant consideration. Socialism invariably reduces the people’s expectations to the point where it should become relatively easy to pay for our new right to healthcare. So, not to worry.

Posted in A right to healthcare | 6 Comments »

Healthcare Is a Right If the Authority Says It Is

October 14th, 2008 by DrRich

DrRich has been traveling, so he is late to comment on the presidential debate last week in which our presumptive next President declared that healthcare is a right for all Americans. (In contrast, Mr. McCain said healthcare is merely a responsibility, but since he’s only a Senator we can safely discount his opinion on the matter.)

Medical bloggers far more notable than DrRich have since provided commentary on whether healthcare ought really to be called a right.  DrRich particularly recommends posts by Shadowfax and Maggie Mahar, both of whom offer beautifully nuanced arguments which are singularly interesting in that, while both of them are American progressives who favor both universal healthcare and Mr. Obama, neither is quite willing to label healthcare a right.  Presumably, when awarded too (as it were) liberally, the granting of new “rights” raises the hackles of too many people. Rather, after much analysis and thought, they prefer to call healthcare either an entitlement (Shadofax) or a moral obligation (Ms. Mahar).

DrRich, being a relatively conservative American, does not do well with such nuances.  In his simplistic, Palin-esque way of seeing things, nuances (even when he is too thick to follow them) are fine if they draw meaningful distinctions. But they are not so fine when they are invoked chiefly to disguise or confuse.

The Stanford Encyclopedia of Philosophy says that a right is an entitlement to perform certain actions or to be in certain states, or an entitlement that others perform certain actions or to be in certain states. In other words, a right is simply an entitlement, or an obligation imposed on others, or both.  So, when some insist on calling healthcare an entitlement or an obligation instead of a right, they are merely engaging in soothing obfuscation.

DrRich is sorry to say that the common argument that conservatives like to use against creating a “right” to healthcare - that there is no such thing as a right that imposes obligations or limitations on the individual rights of others - is mistaken.  This is easy to see when one considers certain of the rights that have been legally promulgated during the course of human history, such as the exceptional rights of the aristocracy (especially the divine rights of kings), the unique rights of the clergy, or the special rights of the politburo (or the Congress), all of which clearly imposed more-or-less oppressive obligations on, and limited the individual rights of, the masses.

Where we conservatives tend to get confused is by the notion of natural rights, such as those natural rights to life, liberty and the pursuit of happiness enumerated in our Declaration of Independence. Natural rights are equal rights granted to all people by the Creator (or by “nature”), and cannot be legitimately modified by any mere governmental authority.

Conservatives tend to forget that there is also such a thing as legal rights, which are man-made, created by legislation (or decree, depending on the governmental structure), are not necessarily equally distributed to all people, and are subject to amendment and modification at any time.  In many cases governments will find that, for the overall benefit of the society, or of some subset of society (or even of the governing class), a new “right” will be necessary that produces a limitation on the freedoms or property of individuals within that society, and that those limitations are often not equally distributed.  The progressive income tax, eminent domain, and the military draft immediately come to mind, all of which have been used in countless ways to support innumerable legal rights the government has granted to some or all Americans.

So, DrRich’s message to his progressive friends is: Don’t sweat the “healthcare is a right” kerfuffle. The now-nearly-official right to healthcare is not fundamentally different from other obligations and entitlements that the government has granted to or imposed on American citizens over the years, particularly over the past 70 years.  There is plenty of precedent for it, which should be immediately obvious even to many of us conservatives once you take a second to explain it to us.

So, now that President-Nearly-Elect Obama has decreed it to be so, just go ahead and use the “R” word, and save your nuances for other times when they might be more necessary.

Posted in General Rationing Issues, A right to healthcare | 2 Comments »

Enjoying the Financial Crisis So Far?

September 23rd, 2008 by DrRich

For a while last week, apparently, the American financial system bordered on a complete collapse, one that threatened not only to bankrupt the remaining major investment banks, but that also threatened to freeze all lending and borrowing across the entire American economy. According to some, we were within a day or two of seeing major brand-name non-financial corporations being unable to operate, and all American commerce essentially coming to a grinding halt. Apparently we were about to go, in very short order, from a global economy that functions at Internet speed, to one that works instead on the principle of bartering, if not hunting and gathering.  (At last Mr. McCain’s choice of a running mate becomes clearer.)

And so, on Wednesday evening, stunned congressional leaders listened to Mr. Paulson and Mr. Bernacke tell them that, unless they rapidly passed a massive federal bailout for all the bad loans, then “Heaven help us all.”

The subsequent announcement of the proposed government bailout package has stabilized things for the time being, and has injected sufficient confidence into the financial markets to allow normal commerce (of a sort) to continue. But however this whole mess turns out, whether it leads to another Great Depression, or whether it turns out to be just a really bad quarter, when it’s all over the American taxpayer is going to be saddled with a new debt burden of at least $700 billion, and that some say may reach $2 trillion.  That’s a sizable increase to our total national debt, which today is “only” about $9.7 trillion.  Once they’re old enough to figure out what we’ve just done to them, our children and grandchildren will be pissed.

Even before we reach any kind of resolution of this current fiscal crisis, the blame game has commenced.  It’s too much de-regulation by Republicans vs. too much social engineering by Democrats.  This blame game is potentially a good thing, because unless we objectively assess how this financial crisis happened, we will (as is our habit) devise “solutions” that will just make the next financial meltdown even worse. Unfortunately, the likelihood that we can be objective about assigning blame, especially in an election year, seems slight.

DrRich’s take is that there is plenty of blame to go around. As he sees it, the root of the problem is fourfold:

1)    Our government decided that for purposes of fairness and diversity, mortgage firms should be “encouraged” (and to the government, this means “forced”) to make loans to individuals who, by any reasonable risk standards, simply did not qualify for loans.
2)    The federal reserve made money very cheap, and borrowing relatively easy.
3)    Fannie Mae and Freddie Mac, companies created by government and not subject to normal market forces, bought up the risky mortgages in huge amounts, then repackaged them in complex instruments which it sold to investors all over the world.  Investors (such as the big-name brokerage houses, huge conglomerates like AIG, and the Chinese) bought up the risk-laden instruments, and from them they assembled even more convoluted high-risk investment instruments, which they traded back and forth until nobody knew who owned what, or how much worthless debt everybody had on their books.  This, of course, is where the “free market” went wild, magnifying a very bad problem into an astoundingly dangerous one. The unrestrained wildness was at least partly encouraged by the assumption that, since Freddie and Fannie were quasi-government entities, ultimately the whole mess would be backed up by the U.S. government. (Turns out they were right.)
4)    Mortgage firms, fully realizing that the government really wanted them to lend to unqualified individuals and was happy to buy up all the bad loans they wrote in the process of doing so, nearly killed themselves inventing new and creative ways to entice anybody who could sign a name (and in recent years, not necessarily even their real name, what with the introduction of Alt-A loans - the so-called “liars’ loans”) to take on exotic new mortgages.

So there’s plenty of blame to go around, from the well-meaning but naïve government policymakers who apparently will never “get” the law of unintended consequences; to the Congresspersons of both parties who fought against tighter oversight of Fannie and Freddie (in exchange for major contributions and other perks given to them by F & F) and insisted against all evidence to the contrary that these agencies were fiscally solid; to the arrogant Wall Street magnates who dived head-first into the great feeding trough (whether they were lipsticked-up or not) and allowed their firms to become highly leveraged with disturbingly questionable instruments; to avaricious local mortgage companies who ended up giving houses away and sending the bill to Freddie and Fanny; to the delusional individuals themselves who inexplicably took on hundreds of thousands of mortgages they had absolutely no chance of paying off. All these players should have understood that you can repeal laws of man but you cannot repeal laws of economics, that sooner or later the tipping point would be reached, that the bubble would burst, and that all the players who thought they were winners would suddenly be revealed as major losers.

That tipping point, it appears, came last week.  And so, the American taxpayers, many of whom take great pains to live within their means and don’t borrow money they cannot pay back, are the only ones left to rescue the greedy and the stupid and the craven.

Assuming our economy does not actually collapse over the next few months, and thus does not wipe out our entire social contract (to the extent that we will have to start all over, and thus render moot any concerns over any future fiscal crises our current social contract promises to bring us), DrRich would like to point out that, compared to what is coming, the economic crisis we are now experiencing is merely a trifle.

The current crisis, DrRich repeats, was brought about by well-meaning government policies that attempted to repeal laws of economics in order to achieve a social good, backed up by government programs that strongly encouraged private companies to behave as if economic laws did not apply.  And now, with the inevitable dénouement, the private companies are being variably liquidated or absorbed or socialized, top executives are being variably rewarded or (one can only hope) jailed, and the taxpayer is being invariably screwed.

Regular readers will recognize in the previous paragraph a description of our current healthcare system - and a description of where it is headed.  Our government has striven to devise policies that will provide unlimited healthcare to all Americans whenever they need it, a policy that requires the repeal of basic economic laws, and one that has resulted in a convoluted system of partly governmental and partly private healthcare that rations healthcare covertly (since the unavoidable limits on healthcare cannot be acknowledged), that eschews transparency, that systematically multiplies waste and inefficiency - and that is inevitably building to a dénouement.

There is one big difference, however. Whereas the newly-burst mortgage bubble has left us with an unfunded liability of merely (we think) something less than $2 trillion, our unfunded liability for Medicare alone, over the next several decades, is estimated to be between $25 trillion and $55 trillion.  Considering the fatal damage our current, relatively trivial financial crisis apparently came within a few hours of triggering, this sounds like a lot of money.

When this massive bubble bursts, not even the stolid American taxpayer will be able to backstop the crash. Unfortunately, heading off this coming healthcare tsunami will require us to acknowledge that healthcare rationing is unavoidable, and to come up with an equitable and efficient way to do it. Since our leaders were unable to make themselves publicly recognize, and take steps to deflate, the equally obvious and much more tractable housing bubble when they had the chance to do so, it is difficult to be optimistic.

So try to enjoy our current fiscal crisis, because some day we’ll look back at it with as much nostalgia as we now do the so-called “crash” of 1987.

Posted in General Rationing Issues, Healthcare economics | 8 Comments »

The Duty To Abort

September 15th, 2008 by DrRich

There are, it would appear by reading newspapers and watching TV, many reasons not to like Sarah Palin, and even more reasons not to approve of her.  Indeed, on the very day Governor Palin was announced as Senator McCain’s running mate, DrRich said to his own lovely bride of these past 35 years, “I hope Ms. Palin has Clarence Thomas’ phone number. She’s going to need some advice.”

Clarence Thomas, of course, is the Supreme Court Justice who is masquerading as an African American (his credentials as an actual black person having been thoroughly and systematically discredited by the diversity establishment, by virtue of his conservatism, during his confirmation “hearings”).

“Why, whatever do you mean?” asked DrRich’s sweet-hearted spouse.

“Just look at her,” DrRich replied. “There she stands: Sarah ‘Jesus, Babies and Guns’ Palin. Why, she’s the embodiment of the rubes Senator Obama talks about, the ones that cling in their misery to their Bibles and their varmint guns, and that keep making babies because they’re just too dim to figure out how to prevent it, and probably even too dim to figure out what causes them in the first place.  In other words, she’s conservative.  So by definition she’s no more a woman than Clarence Thomas is black. If she’s allowed to pass herself off as a legitimate (much less celebrated) embodiment of American womanhood, it will set the Movement back to the days of Ozzie and Harriet. So she’d better put on some thick skin because it’s going to get very nasty and very ugly very quickly.”

All of this, of course, has since come to pass. Why, Wendy Doniger, who is a Professor of the History of Religions at the University of Chicago’s Divinity School, and so who has the formal authority to rule on such things, has even established in her Newsweek blog that Ms. Palin is not actually a woman. (”Her greatest hypocrisy is in her pretense that she is a woman.”)  You can’t actually be a card-carrying woman, you see, and say and do the stuff that Ms. Palin says and does.  Any educated person can see that, and it’s good that the very well educated are taking the time to inform the rest of us.

So, like DrRich says, there are many reasons not to approve of Sarah Palin, some based on facts and some confabulated from a general knowledge of the kind of things primitives like her might believe, and all of them are being well and thoroughly (and desperately) documented for the public record by a panicky media establishment, with every hope and confidence that, once fully informed, no thoughtful person could ever actually vote for one such as she.

But as cynical as he is, and as savage as he expected the attacks to be, there is one criticism being made of Ms. Palin that took even DrRich by surprise.  DrRich refers to the criticism she is receiving for failing to abort the latest addition to her family, her little son Trig, even though she learned while pregnant that he would likely have Down syndrome.

When DrRich was in medical school oh so many decades ago, children with Down syndrome were still largely institutionalized from birth. So when DrRich was being taught about Down syndrome he was shown pictures and movies of drooling children who were unable to speak or communicate meaningfully, and who were unable to feed themselves, use toilets, or interact as humans.

But of course, if you were to place any of today’s Baby Einsteins in such an institution from birth, they would end up much the same way. And once the era of institutionalization ended, and many Down children were raised instead with their families, amazingly we learned just how normal these kids could become.

When Down children are raised in the home by loving and caring families, it turns out that most of them become highly functional. DrRich knows people with Down syndrome, and finds them to be good-natured (most of the time), articulate, thoughtful and even witty, and they are not only quite capable of providing for themselves their basic human needs, but also of earning a living.  Above all, they are happy to be alive, and their families are as happy to have them as they are any of their other children and they love them just as much.  Of course, they do have problems, including a high incidence of cardiac abnormalities that need to be surgically corrected, and a relatively high risk of developing leukemia and infectious diseases. But these are fully-realized humans who enjoy their lives and have much to offer.

So if a pregnant woman finds out she is carrying a Down child, she has a lot to think about.  There are a lot of potential problems with these special-needs children, and not every family is prepared to deal with these problems.  But on the other hand, the experience of raising a Down child can be extremely rewarding - for everyone. So as DrRich sees it, the decision to deliver a Down child and welcome him/her into the family is at least a reasonable one, if not a blessed one.

So at first DrRich was a bit puzzled by the criticism being heaped upon Ms. Palin for keeping Trig.  At first, he thought this unreasonable complaint was simply one of the many things being caught up in the pile of indiscriminate criticisms being leveled against her during that first mad rush to discredit her, to shame McCain into dropping her from the ticket immediately. Surely, nobody could really hate her for intentionally delivering a Down child.

But even when the mainstream media realized that it had overplayed its hand a bit, and began to settle down to some of the more reasonable criticisms of Ms. Palin (her inexperience in foreign affairs, for instance, which is every bit as troublesome as Mr. Obama’s), the issue of her having chosen not to abort her Down child did not go away.

The complaints, of course, are couched in terms of concern. A mother with a special-needs child should devote her efforts to the child, so it is clearly inadvisable for such a mother to seek the Vice Presidency. But while they express concern for the wellbeing of the child, their underlying tone is clearly one of approbation, and the criticism rings of false indignation. Since when does the women’s movement become so vociferously exercised because a working mother is not spending enough time with her children, whatever the needs of the children?

Besides, DrRich respectfully reminds critics of Ms. Palin that the Vice Presidency is famously a job with no responsibilities whatsoever (unless the President dies, of course, in which case a new VP is tapped to sit around and do nothing).  In practical terms, being VP is the perfect job for any mother with a special-needs child, and it will certainly allow Ms. Palin to spend more time with her family than she ever could as Governor of Alaska, or even as Mayor of Wasila.  Only being a Senator would approach the suitability of this job for a mother with family responsibilities, judging from  (as demonstrated by Senators Obama, McCain and Biden) the massive amounts of time for which it is apparently perfectly OK not to show up for work. In fact, mothers with special needs-children ought to be harshly and publicly condemned if they do NOT seek the Vice Presidency of the United States.

No, there is clearly something more going on here than mere indignation that Ms. Palin is seeking a job that will take her away from her family.  And gradually, DrRich has figured out what that is.

Ms. Palin had a duty to abort Trig, and she failed to discharge that duty.  By so failing, she has abandoned, by her own choice, any claim she may have had to the title “woman,” and certainly any claim she may have had on the sympathy, much less support, of other women.

It is one thing to deliver a special-needs child who cannot be identified prenatally as having special needs. Women with such children are simply victims of the draw, and are to be pitied and supported in every way possible, with whatever public funds that may require.  Women should not be punished with such an unforeseen and unpreventable burden, foisted on them by chance, or, if there is a God, then by the divine MCP (which is one reason why the notion of a divinity is so abhorrent to so many of the leftward persuasion - if God exists, he’s certainly stacked the cards against everyone except white males).  Such a child is one of the worst things that can happen to an independent, self-actualized, competitive modern woman. Any real woman who cares about the child, who cares about herself, and who cares about doing what’s best for all women would abort that child whenever possible.

The idea that a woman who actually had a choice would cheerfully choose to have a child with Down syndrome seriously undermines the argument.  Such a woman is clearly ignorant or stupid, and must have (through their ignorance or stupidity) bought into the old-fashioned, male-dominant paradigm that we enlightened folks have fought so hard to overcome.  When women like this do their thing in Wasila, Alaska, one merely shakes one’s head at the backwardness of it all, and consoles oneself that, some day, the truth will filter out even to these bush people.

But the idea that a woman, once making such a poor decision, would then not just quietly slink along through her life, privately bearing the burden of her poor choice; the idea that such a woman indeed would allow herself (and even seek) to become well-known, and to run for public office, much less seek the second highest office in the land; the idea that such a woman could become not only popular but publicly acclaimed and even adored - why, such an idea is utterly anathema. This woman calls into question the fundamental tenets of the Movement.

This explains one aspect of the approbation being heaped upon Sarah Palin for choosing to give birth to a Down child. She has made mortal enemies of the extreme women’s movement, and they need to destroy her at whatever the cost.

But another aspect of it (and one that finally resonates with the theme of this blog), is that Ms. Palin is setting an example that, if followed by admiring women, will cost the healthcare system a lot of money. Down children, for a variety of reasons, often need a lot of expensive medical care.  And by actively campaigning to encourage women to abort their babies if pre-natal testing suggests a high risk of Down syndrome (by describing to the stunned mother-to-be the institutionalized Down child of the 1960s, by outlining the horrors of heart surgery and other medical issues that may occur, and by neglecting to mention that Down children most often become completely fulfilled and completely lovable people who bear their trials with grace and humor, and who actually have a lot to teach us), obstetricians in the US, Canada and many European countries have succeeded in sending over 90% of Down pregnancies to abortion in recent years.  Sarah Palin, especially if she remains popular, and most especially if Trig grows up in public view and becomes a beloved example of the potential of Down children, threatens to cause many women to consider their options more carefully. And that will cost society big time, as a prominent Canadian obstetrician has pointed out.

Women who have chosen to deliver their Down babies are today being subtly scorned by society. Women have a duty to their gender and to society to abort those babies, and when they choose otherwise they are displaying serious psychopathology and sociopathy.  It is becoming very difficult for women to do otherwise.

Sarah Palin threatens to change the paradigm. Perhaps she already has. The duty to abort has been hard fought and hard won. Palin has got to be stopped.

And that explains at least some of the passionate attacks from people who, one would think, would normally celebrate the ascendancy of a strong woman who has succeeded at a man’s game while remaining an admirable wife and mother.

DrRich will end by pointing out that the duty to abort disabled children (a duty that, thanks to Sarah Palin, is obvious today for all to see), is really no different than the coming duty to accept assisted suicide or euthanasia.  Observing the attacks on Ms. Palin has made DrRich realize that we are farther along that road than he had thought.

Posted in General Rationing Issues, Medical ethics | 4 Comments »

Is Treating Cancer Worth It?

July 24th, 2008 by DrRich

Yesterday, Jacob Goldstein of the Wall Street Journal Health Blog pointed out the financial dilemma that has been created by evidence that a new cancer drug, Nexavar, is effective in treating liver cancer.

Most liver cancers are particularly impervious to chemotherapy, and until Nexavar came along no chemotherapy had ever been shown to significantly prolong survival. So when Nexavar improved the overall survival of a subset of patients with liver cancer in a well-designed randomized clinical trial (RCT) last year, the FDA (recognizing a true breakthrough when it sees one) quickly approved the drug.

The problem? Nexavar costs over $5000 per month. That, DrRich points out, is even higher than your average monthly health insurance premium. This means that any insurance company (or government) that agrees to pay for Nexavar is going to be out some big bucks.

(The good news for the payers, if there is any good news, is that Nexavar only prolongs survival by an average of three months, and the one-year survival of a population of patients with liver cancer on Nexavar is still less than 50%. Just think of the damage if Nexavar prolonged survival by several years!)

The economic question created by drugs like Nexavar - which result from extremely sophisticated and costly research and development processes, and whose benefits are undeniable but perhaps marginal - is likely to be asked several times over the next few years. We are also hearing those questions expressed, for instance, regarding the drug Avastin, which is used for lung, colon and breast cancer. Like Nexavar, Avastin has clear-cut and undeniable benefits that have been proven in RCTs. Like Nexavar it is very expensive. And also like Nexavar the duration of its benefits are measured in months, not years.

The form this economic question usually takes is: Should we really pay for extremely expensive cancer drugs like this when the expected benefit is so transient? While DrRich does not pretend to have the best answer for this question,* he will make two observations.

First, the reason it is so difficult to answer questions like this is that we in America (citizens, the government, and the insurers) refuse to acknowledge that there are limits to what we should expect from our healthcare system. We expect to receive any bit of healthcare that offers even a possibility of benefit, even if that benefit is likely to be marginal or transient. We expect our researchers to work day and night to cure every disease, no matter how rare, and we become indignant when progress does not seem rapid enough for our particular disease; indeed, death itself is merely a manifestation of insufficient research. In other words, where healthcare is concerned, there are and can be no limits.

Given this “no limits” paradigm, when our society is faced with the inescapable need to ration healthcare, that rationing can only be done covertly. There’s no other way to do it.

And under covert rationing (whose very purpose, again, is to preserve the illusion of “no limits”), there’s simply no mechanism, or even justification, for addressing questions like the one raised by Nexavar and Avastin. Our procedure is: we do the RCT, and if the RCT shows any measurable benefit, we pay for it. End of story.

So the insurers and the feds won’t be able to base their payment decision on some objective and transparent cost-benefit analysis for Nexavar, evaluating where this analysis falls in relation to all the other cost-benefit analyses they perform for all the other forms of therapy. Rather, they’re simply going to have to announce they’re paying for it. They have no other choice, because to do otherwise would question the “no limits” paradigm.

And then they’ll perform the unavoidable rationing by some covert means probably having nothing whatever to do with this particular therapy, or of any particular therapy, but rather, according to whatever means they can get away with, wherever in the healthcare system and with whichever patient that might be. That’s the job we’ve assigned to them. And they’re very good at it.

Second, the financial questions raised by Nexavar, Avastin, and similar therapies point out yet again that the Axiom of Industry often invoked by healthcare policy experts - that is, that improving quality will always reduce cost - simply does not work in healthcare. There are many, many times when achieving the best possible clinical outcomes (i.e., optimizing quality) greatly magnifies the cost of medical care.

The real problem with Nexavar and Avastin is not that their beneficial effect is just transient. That fact, to be sure, gives insurers and commentators a convenient handle, some basis for whining about these drugs that will engender sympathetic murmurs from certain quarters (though, as we have seen, it will ultimately not get them out of paying for them). But it’s not the problem. Indeed, the fiscal challenge for the payers would be much worse if these expensive drugs resulted in very prolonged survival. The real problem is that some of the stuff that works really well in healthcare is just really expensive, you see, because a lot of expensive research and technology went into developing and producing it. It just costs a lot.

So when some expert comes along and tells us that achieving a cost savings resulting from some brilliant new initiative - such as pay for performance, disease management, medical home, etc., etc. - will necessarily and directly yield an improved quality of care from that same initiative, we can immediately dismiss him or her as being either disgracefully ignorant of his or her chosen field of study, or disgustingly deceitful. In DrRich’s experience, the odds of any particular policy expert being disgraceful vs. disgusting is roughly 50-50.

* He does, however, pretend to have a transparent and equitable process for getting to a reasonable answer, which can be found in his book.

Posted in General Rationing Issues | 11 Comments »

Getting Square With the Nurses

July 9th, 2008 by DrRich

Last month, DrRich wrote about how “doctor-nurses” are fixing to displace primary care doctors, and how the noble American Medical Association – champion, as always, of the American PCP – is mobilizing with decisive action to prevent this tragedy from taking place.*

One of the more remarkable responses to this article came in the form of a blog entry by DrRich’s colleague Annie, an entry which was, let’s say, critical.

DrRich is very sorry to have raised Annie’s ire, especially since Annie represents a combination of two of DrRich’s favorite kinds of people – nurses, and students of the Constitution. It is in this latter capacity that she writes for the blog Home of the Brave, a site that, if a bit leftward-leaning for DrRich’s tastes, is nonetheless dedicated to the very worthwhile goal of discussing “U.S. history, the state of the union, the state of the U.S. Constitution.” DrRich even gave top billing to one of Annie’s posts last week in Medical Grand Rounds – her nicely tuned article showing what the Founders might have said about the current sad state of the American healthcare system, an article which he now recommends again to everyone.

This public recognition of Annie’s obvious merits, despite the article she had written in response to DrRich’s posting on doctor-nurses, ought to attest to DrRich’s essential fair-mindedness and objectivity. For in that article Annie was less than kind to DrRich’s sensibilities. For instance, referencing DrRich, Annie said,

A few physicians are skeered of a new demon. They’ve got their Salem witch hunter judicial robes on, and they’re ready to order the press, the pyre or just a good old pompous piosity to their screed. What has their panties all in a bunch?

Doctorally educated nurses. I. am. not. making. this. up. They’re afraid of nurses.

What nurse bashing this is and based on what? Fear of competition?

Annie goes on some more about DrRich’s manhood and such (for the record, DrRich does NOT wear panties), but you get the idea.

More relevantly (more relevantly, at least, to everyone else if not to DrRich), Annie’s post points out that: a) nurses with doctorate degrees are not a new phenomenon; b) the vast majority of nurses are not out to displace physicians, or to usurp the title “doctor;” c) since there is an acknowledged shortage of PCPs, surely something has to be done to fill the void, and nurses – working in full partnership with doctors, as always – can help; d) the formidable Mary Mundiger (formidable, at least, to the lily-livered DrRich) does NOT speak for the large majority of nurses; and e) the organization that actually does speak for most nurses is the very reasonable American Association of Colleges of Nursing (AACN).

And the AACN is greatly disturbed by ideas, put forth by misguided paranoids like DrRich, that doctor-nurses may be getting ready to take over for actual physicians, and is distressed by the blowback that has already been experienced by the nursing profession as a result of such ideas. Indeed, Annie points out, the AACN is so alarmed by the resolutions being considered by the AMA (described here) - resolutions that, if passed, would potentially result in sending nurses a strongly worded letter - that it has issued a white paper itself urging the AMA not to take such drastic action.* This white paper passionately expresses

concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates. . .AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses….AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

That is (Annie assures us, and the AACN certainly confirms), nurses, even most of the doctorally trained ones, want to play nice with physicians. And DrRich’s screed on the impending take-over of American medicine by hordes of aggressive nurses is both overdone, and very counterproductive.

In response, DrRich can only offer that he fervently desires that Annie, and any others who may have been offended by his earlier post, go back and read it again, but this time read it keeping in mind the following prompt: Irony. For DrRich’s comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the inevitable encroachment by nurses on what has traditionally been medical turf. DrRich was attempting to be ironic. (A colleague of DrRich’s, reading Annie’s posting, commented that those who miss the poorly-hidden subtleties of irony also may be likely to miss the well-hidden subtleties of difficult medical diagnoses. But this is unkind and likely incorrect, and DrRich chooses not to subscribe to it. Besides, this snide comment presupposes that DrRich does irony well, which may not be a good bet.)

Furthermore, DrRich would like to go on record to say that virtually everything Annie says (except for the personal stuff about his cowardice, Puritanical judgmentalism, exaggerated piety, panties, etc., much of which is simply not true) is pretty much correct. DrRich agrees that the large majority of nurses have no intention or desire to fundamentally displace American PCPs. And DrRich further agrees that doctors who resent nurses because they think they’re after their jobs are badly misguided.

But it’s not because ascendant nurses aren’t about to displace them that they’re misguided. They are indeed about to be so displaced. Rather, they’re misguided because most nurses don’t want any part of it either, just like Annie says.

Anyone who had read DrRich’s earlier articles on the plight of the PCP would understand that he does not consider the prospect of nurses encroaching on the turf of PCPs to be evil or bad, but simply the normal pattern in a modern society wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. DrRich would never bash nurses for simply playing their natural part in the evolution of a technological society. He would sooner criticize a grizzly bear for dining on the entrails of an elk which had died of the mange.

The quotation Annie provides from the AACN white paper, protesting because the AMA is accusing nurses of doing what nurses are, in fact, doing (however involuntarily it may be) is quite telling. The train is leaving the station. The writing is on the wall. While it is clearly not Annie’s intent, or the AACN’s intent, or the AMA’s intent for nurses to replace PCPs, it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

Those doctors who do view the encroachment by nurses as an unadulterated evil deed will see the protestations of innocence by the AACN - while events on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. They will see it as disingenuous at best, treachery at worst. But viewing it this way is simply wrong.

The posting by Annie and the white paper of the AACN are actually indications that most nurses are as apprehensive as are the PCPs they are displacing. And why shouldn’t they be? Look at the new responsibilities and risks the nurses will be acquiring - medical, moral, legal, financial and otherwise. Historical upheavals like this are often unkind to all parties involved, even the supposed “winners.”

If further evidence is needed that DrRich is correct (beyond simply studying the history of technological societies), simply read the July 2008 Update of the Hospital Outpatient Prospective Payment System issued by CMS. This document (if you can get through it) among other things removes language from the Medicare Benefit Policy Manual that had required that “services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician who is treating the patient.” That is, non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient.

CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the PCPs, and the patients, and even the reluctant nurses.

* This is an example of irony.

Posted in Primary Care in America | 5 Comments »

Medical Grand Rounds, Vol 4, No. 41

July 1st, 2008 by DrRich

Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:

Lists of Grievances

Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)

Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.

Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.

The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!

And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.

Inalienable Rights

DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!

The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?

Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.

Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.

The Spirit of the Individual, That Which Made America Great

Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.

Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.

David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.

Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.

Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.

Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.

Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.

Standing Up To Powerful Authorities

Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.

JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.

DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.

The Freedom From Misinformation Act

Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?

Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.

When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.

David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.

And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.

The Obligations of the Individual in a Free Society

Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.

Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.

Tories

Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.

Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.

Picnic Advice, or Don’t Be Stupid

RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.

The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.

What Doesn’t Kill You Will Make You Stronger

Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.

Service and Sacrifice

Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.

The Most Important Aspect of Any Holiday

Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.

Next Week’s Grand Rounds

Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.

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