I have just published the first chapter of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide To Right Thoughts and Right Actions Under Obamacare.”

You can find it here.

This is Chapter 1 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.
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Part 1 – Progressive Healthcare, and Why We Have Chosen It

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Chapter 1 – Run For The Hills, As We Are All Doomed!

I originally meant to call this chapter, “Healthcare Economics,” but I decided that name would frighten people off.

Everyone (that is, everyone with an ounce of common sense) is frightened by economics. Economics is the index case of what happens when you attempt to apply mathematics and the language of science to what is essentially a study of human behavior. (Microeconomics, as I understand it, attempts to study the behavior of one or two guys at at time; macroeconomics purports to study the behavior of everyone, all at once.)

Human behavior will stymie anyone who tries to understand it, let alone predict it, or especially control it. (Even God, according to Genesis, became so frustrated with human behavior that on at least one occasion he was moved to wipe just about everybody out and start over. And all to no avail, one must note.)

And so economists, having dedicated their lives to studying something that intrinsically surpasses all understanding – such that even astrophysicists seem closer to their goal of understanding what happened before the Big Bang than economists are to theirs – are reduced to devising massive, complex and unlikely constructs of mathematical clockwork only they can understand, with which to pummel one another in professional meetings, in peer-reviewed publications, and on CNBC.

Oh, and they also advise our political leaders.

So I have called this chapter by a name that is far less alarming than “Healthcare Economics,” and that I hope will not send readers scurrying away. Besides, the name I have chosen is at least partially true. For it seems reasonably likely that we are indeed all doomed, though heading for the hills probably will not help very much.

Assuming that we can avoid the Really Bad doomsday scenarios that are always out there (collisions with asteroids, nuclear war, electromagnetic pulses, sudden ice ages, &c.), then the thing that is most likely to produce among us the renting of clothes, gnashing of teeth, heaping of ashes upon heads, and other behaviors commonly associated with the End Times, is the fiscal black hole we’ve made of our healthcare spending.

Our healthcare spending is sufficiently out-of-control that it produces a real threat to our survival as a society, and within many of our lifetimes. It was largely the effort to control this runaway spending that led us to adopt Obamacare in the first place, even though Obamacare (as I hope to demonstrate) promises to be almost as destructive itself.

The first five chapters of this book that comprise Part I aim to show how our healthcare system’s dire fiscal problems have led us to choose a Progressive healthcare “solution.” Here in Chapter 1, I will describe the astounding magnitude of our healthcare system’s financial mess, and how we have created it. In Chapter 2 and 3, I will survey some of the incredibly harmful changes we have made to our healthcare system in an attempt to cope with the fiscal mess. These changes have caused so much damage that, when it was time to try to choose among the four possible methods for bringing the costs of healthcare under control (which are described in Chapter 4), we finally acceded to the Progressive solution many of our elected representatives had been pining for for at least 20 years. Accordingly, in Chapter 5 I will discuss the Progressive program in general, and show why control over our healthcare is the lynchpin to the Progressives’ overarching plans for all of us.

The Fiscal Golden Age of Healthcare

Once Upon A Time, when people received a service from a physician, they paid for it themselves. Physicians who wanted to maintain a viable practice would keep their prices within the reach of their patients. And if somebody could not pay they would typically accept a reduced fee, or even a couple of chickens in exchange. During this time, healthcare was not considered a crisis, or a right, or even very important in the lives of most people.

I call this the Lancing Boils And Getting Paid In Chickens era of healthcare. It was the dark age of medicine – there was generally very little a doctor could do for you, other than lance those boils, set some but not all broken bones, and hasten your demise with leeches and bleeding. (At this point we must say a prayer of thanks that Progressives care very little about history, and so are relatively unlikely to re-discover the benefits of leeches and bleeding.) But while it was the dark age of medicine, it was the Golden Age of healthcare finance. Healthcare in those times accounted for none of our (or anyone’s) national, collective debt.

Even when inhaled anesthesia first came into common usage – making various surgical procedures such as appendectomy and Caesarian sections routinely available for the first time – the cost of healthcare was not considered a major societal problem. Somehow, arrangements were made to reimburse doctors for their services, whether through cash payments, barter, or some sort of Victorian E-Z payment plan, thus allowing the patient to avoid destitution, and the doctor to avoid the sundry nefarious activities that have always been available to cash-strapped medics.

Indeed, right up until World War II, when penicillin was discovered, physicians and their skills could offer relatively little benefit for most serious illnesses beyond the surgical variety. As a result, relatively little money was spent on healthcare. And by the traditional means of barter or negotiated settlements, or the more modern means of charity hospitals, hospitals run for their employees by the big railroad and lumber companies, or in the later years, fledgling Blue Cross plans, all the medical services that were considered useful were somehow paid for on an as-you-go basis. There was no fiscal burden placed upon society. And all was well.

Unless you got sick.

The Medical Golden Age

Conservative Americans can rant and rave about it all they want, but the fact is undeniable that the remarkable advances we’ve seen in American healthcare over the past 50 – 60 years were ushered in by a new fiscal era – an era in which we began to pay our healthcare costs collectively.

This new era was begun during World War II, when companies began offering health insurance to their employees in order to attract workers during the wage controls then in effect. Health insurance proved so popular that Congress changed the tax laws to make the insurance premiums paid by employers tax-deductible so as to encourage the practice, and before very long virtually every company provided health insurance to their employees as a matter of course.

The tax-deductibility of employer-provided health insurance was the game-changer. Healthcare costs suddenly were no longer borne entirely by individuals, or by individual businesses who paid the insurance premiums. Instead, they were distributed among the American taxpayers, whose taxes had to make up for the insurance deductions taken by businesses. So-called “private” health insurance became publicly subsidized.

The public funding of healthcare advanced by a giant step with the institution of Medicare and Medicaid in 1965, which amounted to direct public funding of healthcare for a large proportion of the population. So, by 1970, most of American healthcare was paid for by the taxpayer either directly, or indirectly through subsidized private insurance. We had largely collectivized the financing of our healthcare.

While most of my Conservative friends would like to think otherwise, when you look at the big picture it becomes apparent that this collectivization of healthcare financing has not been the unmitigated disaster they like to claim. There have been substantial benefits, and chief among these is the incredible progress we’ve made in medical learning and medical technology over the past half century.

In fact, this taxpayer subsidization of healthcare catalyzed an incredible golden age of medicine.

It turns out that, the moment everything that is deemed “healthcare” is “covered” by taxpayer-supplied or taxpayer-subsidized health insurance, and therefore payment is guaranteed for virtually any medical product by the full faith and credit of the United States government, a huge amount of investment money suddenly appears to fund research and development in every aspect of medicine you can imagine. And the next thing you know, you’ve got medical progress.

Medical entrepreneurs figured out in about a minute and a half that to be successful, all they had to do was to come up with a product that offered a measurable benefit to some group of people with some illness – no matter how marginal that benefit might be, or how expensive their product – and they were certain to have a ready market for their product and a customer who would pay the going rate without complaint. The more products you could develop, the greater your profits. And so R&D budgets went through the roof.

An utter explosion in medical progress, virtually all of it arising in the United States, began in the 1950s and 1960s, and really accelerated in the 1970s when Medicare was up and running full-bore. With a bit of sputtering, it continues until this day. Except for the Manhattan Project and the moon shot (whose fruits medical researchers strongly relied upon in doing their work), the kind of concentrated scientific effort that was applied to advance the science of medicine during this interval is unsurpassed in human history.

And like the Manhattan Project and the moon shot, it was ultimately funded by the taxpayer.

The medical technology that has been developed since the 1950s has done immeasurable good. Uncountable heart attacks and strokes have been prevented or aborted; cancers have been cured or beaten back; people who formerly would have been crippled can conduct normal daily activities without assistance; and some scourges of mankind (such as smallpox and polio) have been nearly vanquished altogether.

But there is a problem. Coincident with this explosion in medical progress has been an explosion in medical spending, spending to such a degree that, unless we bring it under control, we are headed for societal chaos.

The Magnitude of the Problem

A fundamental principle in economics is that when we are buying consumable products that we are consuming ourselves – like Caribbean cruises, sports cars, ice cream, or healthcare – we should spend no more on those products than we individuals are able to pay ourselves.

I realize that by adding healthcare to this list I have probably angered a lot of readers. But I assure you that I am not making a political statement here; I am simply stating an economic principle, which (as is the unfortunate case with principles) is inherently true even if inconvenient.

It is certainly true that some societies, including ours, have decided to purchase some of these consumable products (healthcare, for instance) collectively, so that individuals don’t pay for them at all. And the collective purchase of consumables constitutes a somewhat different situation that I will address in a moment.

But for consumable products that everyone agrees ought to be paid for by the individual (let’s just take Caribbean cruises as a relatively non-controversial example), the individual must arrange to cover the cost. The reason for this principle is obvious. If individuals could arbitrarily decide to go on a cruise whenever they’d like, but leave the cost to others who have no say in whether the cruise takes place, the economic system would soon collapse.*

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*Like most laws, principles, and ethical mandates, this one can be systematically violated by certain, small, well-defined groups of people without crashing the whole system, as long as the rest of the population (for whatever reason) decides to overlook, tacitly approve of, and pay for the irresponsible behavior of this elite group. I am referring, of course, to our political leaders.
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But what about those societies which have decided to collectively purchase certain products and services (like healthcare) that are consumed by individuals? It turns out that these societies must operate under a very similar economic principle: A society should spend no more on products which are consumed by individual citizens than it can pay without incurring long-term, multi-generational debt.

In the United States as we have seen, we have decided to pay for healthcare collectively. Whether your healthcare is provided directly through government payments or through tax-deductible insurance premiums, to a great extent society is collectively footing the bill.

This would not be a problem, economically, if we were doing it on a pay-as-you-go basis. But we’re not. We’re running a huge national debt today, and largely because of healthcare obligations that debt will reach stupendous proportions in the foreseeable future.

Reasonable people can argue over whether having a large national debt is good or bad, but the answer lies at least partially in what it is that the debt has been incurred to pay for.

The ability to borrow money, and carry debt, is important to a vibrant economy. Individuals can borrow even large amounts of money as long as they promise to pay it back and their credit rating is sufficiently high. But if a person fails to pay back what they owe according to a predetermined schedule, society takes steps to stop further borrowing and to force them to repay. If they get in too deep, society ushers them into bankruptcy, and allows them to slowly make themselves whole again. But society does not allow them to simply keep borrowing indefinitely.

This is because individuals die. If we were to allow individuals to simply accumulate as much debt as they want until they die, leaving it to somebody else to pay it back, the economic system would soon disintegrate. So before people can borrow money, they need to demonstrate their ability to repay it, or to have their estates repay it upon their death. In this way there is a natural limit to how much individuals can spend on consumable products in their lifetime.

Societies, like individuals, must borrow no more than they can eventually pay back. The difference is that, unlike individuals, society lives “forever.” That is, the accumulation of debt that cannot be paid off in a single generation is not necessarily alarming, because society will “always” be there to pay it off.

As it turns out, the ability to accumulate even huge amounts of debt is vital for complex societies like ours, as it permits us to maintain a buffer for economic stability, to smooth out boom-bust cycles, and to maintain reasonable predictability, stability, and steady growth. The ability to carry multi-generational debt enables the government to borrow the money it needs to make multi-generational investments, things like building up the nation’s infrastructure, providing for national defense, advancing medical research, and engaging in other forms of non-commodity spending that will allow society to progress, to grow stronger, and to steadily improve the lives of successive generations of its citizens.

The “right” kind of long-term national debt, then, is a chief enabler of economic growth and prosperity, an investment in the nation’s future. It is appropriate to ask future generations of Americans to share the financial burden of that debt, since they will reap the benefits of the investment.

Things go very wrong, however, when we burden society with the “wrong” kind of debt, the kind that represents an open-ended promise to purchase products and services that are consumed by individuals, such as healthcare. There are two problems with this kind of debt.

First, this kind of debt is not an investment in the future, whose fruits will be realized by our children and grandchildren, and whose returns will more than compensate for the overall debt obligation. Instead, it benefits only the individuals currently alive who are the direct recipients of the consumable services, leaving no direct benefits but only an ever-increasing debt burden to those who will be left paying the bills decades later.

Second, while there is a natural limit on how much an individual can spend for products and services they consume during their lifetime, once the responsibility of paying for those consumables shifts to society there is no longer such a natural limit (since societies live forever). The debt can now be borne by multiple generations. Because there is no longer an inherent limit to what an individual can consume, and because it is to the advantage of present and would-be officeholders to eliminate any remaining arbitrary limits, individuals are eventually encouraged to consume as much as they want. And without these limits (whether natural or imposed by rules) the provision of such services to individuals rapidly becomes an entitlement, whereupon the natural checks and balances that (in past times, at least) apply to other parts of the federal budget are no longer available.

When society faces an accelerating debt burden that is completely open-ended and is not subject to normal checks and balances, that society is dealing with a “disproportionate economic variable” (DEV) – that is, an economic obligation that grows without limit and completely out of proportion to the growth of the overall economy. Healthcare spending, which unrelentingly consumes an ever-increasing proportion of our GDP, is such a DEV.

DEV’s are inherently destructive to a society, and for that reason they are typically rare. Indeed, in viable societies the only commonly encountered DEV is wartime spending, where a disproportionate amount of a society’s wealth must be spent in the violent struggle for survival (or, alternatively, in the violent struggle to take away valuable resources of the opponent in order to power future growth, in which case war is analogous to a high-risk start-up). Indeed, the disproportionate spending in wartime is tolerable only because war itself is temporary. It should be noted, however, that one reason war is temporary is that in a prolonged war, a runaway DEV can cause a country to spend itself into oblivion. (See: the multi-decade Cold War and the demise of the Soviet Union.)

Until the time we began to collectivize our healthcare expenditures, healthcare spending in the United States acted like any well behaved economic sector. That is, until the 1950s healthcare spending remained at a steady 4% of the GDP. But by 1960, healthcare spending had become a DEV. Healthcare spending was at 5.3% of the GDP in 1960, 7.3% in 1970, 10.2% in 1980, 13% in 1993, 14.9% in 2002, and 17.6% of the GDP in 2009.

We already cannot afford to pay-as-we-go for all the healthcare we’re consuming. Instead, we’re violating that economic principle I mentioned earlier, and accumulating massive amounts of federal debt to cover the cost ($16 trillion at last count, enough that we’re already flirting with fiscal brinkmanship), which we are leaving to future generations to figure out how to pay off. And it’s about to get much worse.

Assuming we survive credit downgrades, the European debt crisis, oil disruptions in the Middle East, and other more routine difficulties, the most immediate fiscal threat to our economic survival becomes apparent when you think about all the expensive medical technology we’ve managed to accumulate over the last 50 years, and imagine applying it to our rapidly aging population, that is, to the baby boomer generation – which (I can personally assure you) is planning to make exuberant use of all this stuff. The magnitude of this problem is actually pretty easy to estimate.

Consider: All the people who will constitute our population of Old Farts for the next 30 years (a group which already claims your humble author as a proud member) are alive today. We can count them. We can also enumerate the quantity of many of the various illnesses and ailments they will suffer – the strokes, heart attacks, heart failures, Alzheimer’s disease, hip replacements, cancer, drooping body parts and ED – with fair accuracy. And we can estimate reasonably closely (if our leaders succeed in stifling medical progress, and therefore medical technology is held at its current level) what kinds of drugs, devices, nursing care and other expensive medical appurtenances they will require. And with this information we can add up all the sums and multiply all the multipliers to estimate what it’s all going to cost us.

Indeed, the GAO has done this. It’s looking like it will cost $30 – 40 trillion over the next several decades, just to cover the medical entitlements which we have promised current and not-too-distant-future older Americans, Americans who have themselves been paying taxes for many years, and who have arranged their affairs according to the expectations created by those promises.

That’s way more money than it will take to cause societal collapse.

Can’t We Just Eliminate Waste and Inefficiency?

In Chapter 4, I will talk about the four ways that are available to reduce this dangerous level of healthcare expenditures. You may be surprised to learn that none of these four methods is to eliminate all the waste and inefficiency in our healthcare system.

I am in favor of eliminating waste and inefficiency, of course, and I applaud most efforts to do so. But eliminating waste and inefficiency did not make the list of four for a simple reason. It will not work. That is, even if we somehow got rid of all the wasted healthcare expenditures taking place today (and there truly is a tremendous amount of it), that won’t be enough to rescue us from economic oblivion.

This is not a pleasant thing to hear, nor is it a common thing to hear. Indeed, it is a central assumption of all of the healthcare reform plans ever proposed that we can get our spending under control simply by eliminating – or at least substantially reducing – the vast amount of waste and inefficiency in the healthcare system. Conservatives propose to do this by incorporating the efficiencies of the marketplace, thus eliminating the waste and inefficiency imposed by government bureaucrats. Progressives propose to do it by adopting and enforcing strict, top-down regulations (ideally, through a single-payer system which employs the officially-perfect wisdom of various expert panels) that will control the wasteful and inefficient behaviors of greedy and/or ignorant healthcare providers. But one way or another, schemes for reforming healthcare all propose to bring spending under control by eliminating waste and inefficiency.

Another way of describing what all the reformers across the political spectrum are telling us is: There is so much waste in the system that we can avoid healthcare rationing by getting rid of it. Most Americans believe this. Most policy experts believe this. They have to believe it, because nobody wants to even think about healthcare rationing.

But this is unfortunately false. No matter how much waste and inefficiency you think might be gumming up our healthcare system today, there’s not enough to explain the uncontrolled rise in healthcare spending we have been seeing for decades, and therefore, not enough to allow us to avoid rationing altogether in any economically feasible, publicly funded healthcare system.

To understand why this is the case, we must first recognize the fundamental problem with our healthcare spending. The real problem is not simply that we’re spending a lot of money on healthcare, or even that we’re spending a larger proportion of our GDP on healthcare than any other country. If that’s all the problem was, we could with modest difficulty adjust the rest of our spending to accommodate it, and get our national budget under control that way.

Rather, the real problem is that our healthcare expenditures for decades have been growing at double digit rates, several multiples faster than the overall inflation rate, and each year consumes an ever-greater proportion of our national spending. Unless this disproportionate rate of growth is stopped, eventually healthcare spending will cannibalize our entire economy. (What will really happen, of course, is that the debt we are accumulating to pay for our healthcare will grow to the point of producing societal upheaval, sending us back to a more typical era for mankind, where healthcare is a little-thought-of luxury, and not a necessity or a right. This will happen well before healthcare consumes 100% of the economy.)

To reiterate, it’s not the amount of spending on healthcare that is creating a fiscal crisis, it’s the rate of growth of that spending.

Once we understand the problem – that it’s the rate of growth of healthcare spending that threatens our society – then demonstrating that waste and inefficiency cannot possibly account for that rate of growth is a matter of simple mathematics.

There are only two things that can possibly account for the excessive growth rate of our healthcare expenditures. Either it is caused by unrelenting growth in wasteful spending (as we are assured by our political leaders), or it is caused by unrelenting growth in useful healthcare spending. If it is the latter, then in order to get spending under control in a collectivized payment system we must cut back on or ration useful healthcare. This is why we all fervently pray, and most of us choose to fervently believe, the excess rate of growth must be caused by wasted spending.

This desired conclusion, unfortunately, leads to mathematical absurdities, and therefore (for anyone who eschews magical thinking) turns out to be utterly false.

I am going to show you some data from a spreadsheet. My spreadsheet illustrates what would have to happen in order for wasteful spending to account for our current level of healthcare inflation. The spreadsheet is based on the following four assumptions:

Assumption 1) The annual growth rate of spending on useful healthcare (discussed further below) is economically well-behaved. That is, it matches the rate of overall inflation. The spreadsheet therefore assumes a 3% annual inflation rate for useful healthcare spending.

Please note that this is the very assumption which politicians invoke whenever they say that all we need to do to control healthcare costs is to eliminate waste and inefficiency. In fact, the whole point of this spreadsheet is to test the logic of this assumption. For, if useful healthcare spending is not economically well-behaved, then eliminating all the wasteful spending would still leave us with disproportionate healthcare inflation.

Assumption 2) 25% of healthcare expenditures at Year 1 of this spreadsheet are wasteful. I have picked 25% arbitrarily, a value that happens to fall within the range of popular estimates. As it turns out, the initial value we choose for the level of wasteful spending at Year 1 in this spreadsheet has very little influence over the outcome. So if you don’t like this number, feel free to pick your own.

Assumption 3) The annual rate of growth of overall healthcare spending (i.e., healthcare inflation) is 10%. This is a rough average of what we have actually seen for the last few decades.

Assumption 4) Total healthcare inflation is the sum of healthcare inflation due to the growth of “well-behaved,” useful healthcare spending, and the healthcare inflation accounted for by spending on waste and inefficiency. Given that the inflation rate for useful healthcare spending is 3% (Assumption 1), this spreadsheet simply calculates the cumulative annual inflation rate for wasteful spending that would be necessary to account for an overall rate of healthcare inflation of 10% (Assumption 3).

Before I show you the spreadsheet, we should discuss the difference between “wasteful” and “useful” healthcare. In actual practice, this is not a distinction which is straightforward. It depends, for one thing, on who gets to define “wasteful.” If I’m a 92-year-old man who gets a $12,000 stent procedure to eliminate my angina, I and my doctor might consider it money well-spent, while you might consider it wasteful.

But for the purposes of this present analysis, I am defining “wasteful” healthcare in the way our politicians define it – or at least in the way they want us to think they are defining it. That is, wasteful healthcare is completely wasteful – it is a totally useless expenditure, and is no more beneficial than flushing money down the toilet. In contrast, useful healthcare is that which is likely to provide at least some of its intended benefit to patients.

Any other definition of useful vs. wasteful healthcare would require us to place a value judgment on just how much benefit a healthcare service must provide before we consider it to be useful, and thus worthy of paying for. Another name for such a process is “rationing,” and we all know that we’re not going to do any rationing. No, sir.

So, the definition we must use for “useful” vs. “wasteful” healthcare, by process of elimination, can only be the definition I have just laid out.

Here is the spreadsheet:

Year	Index of overall Dollars Spent per year	% wasteful spending	% of annual increase due to useful spending	% of annual increase due to wasteful spending
1	100	25%	-	-
5	146	42%	18%	82%
10	236	59%	13%	87%
20	612	78%	7%	93%

We can immediately see several things. First, as expected, the amount of money we’re spending on healthcare, assuming a rate of healthcare inflation of 10%, is doubling roughly every 8-9 years. It’s this growth rate that threatens our survival as a society.

Second, in order to account for this unsupportable growth in healthcare spending by invoking waste and inefficiency, the proportion of healthcare spending that is caused by waste must increase to ridiculous proportions very rapidly, such that (for instance) by the 10th year we will have more than doubled (59%) the proportion of all healthcare expenditures that are wasteful; and by the 20th year, nearly 80% must be wasteful.

Similarly, the proportion of the annual increases in healthcare spending that would have to be due to waste and inefficiency rapidly climbs to equally ridiculous proportions. By year 5, wasteful spending will have to account for 82% of the annual increase in healthcare expenditures, and that proportion continues to climb, eventually approaching 100%.

To me, these numbers seem absurd on their face. But if you still need to be convinced, consider that in real life, runaway healthcare inflation has already been taking place in the United States for decades – so our position on such a spreadsheet would not be at Year 1; we are much closer to Year 50. And no matter what value for wasteful spending we might have plugged in at Year 1, by Year 50 wasteful spending would have to be well above 80%, and more likely approaching 100%. In order for waste and inefficiency to account for the situation in which the American healthcare system finds itself today, therefore, one would have to believe that virtually all healthcare spending is wasteful. (And if you believe that, then solving the crisis would be a simple matter of discontinuing all healthcare.)

Now let us illustrate the same point in a slightly different way. This time, let’s pretend that as recently as 2009, when President Obama was inaugurated, our healthcare system was 100% efficient. That is, only three years ago there was no waste whatsoever. Then let’s allow that the remaining three assumptions given above are still operative. The following table results:

Year	Index of overall Dollars Spent per year	% wasteful spending	% of annual increase due to useful spending	% of annual increase due to wasteful spending
2009	100	0%	100%	0%
2010	110	7%	30%	70%
2011	121	15%	28%	72%
2012	133	17%	26%	74%

We can see from these results that, even if only three years ago we had a completely efficient healthcare system, in order for waste to account for the excess growth in healthcare spending we’ve experienced since that time, then after just three years as much as 74% of today’s annual increase in spending has to be due to waste and inefficiency.

Any way you cut it, the spreadsheet leads to nothing but absurdities. Assumption 1 – that useful healthcare spending is economically well-behaved – therefore cannot be true.

Wasted spending may and likely does account for a significant proportion of our healthcare expenditures, but it simply cannot account for the sustained, disproportional growth in healthcare expenditures that threatens to collapse the system.

So yes, by all means, let’s try to eliminate waste and inefficiency from our healthcare system. But if we hope to survive as a culture, we will, at the same time and as an entirely separate endeavor, have to figure out how to get the growth in useful healthcare spending under control.

Summary

It is critical to understand that a fundamental, nearly intractable, doomsday-magnitude fiscal problem with our healthcare spending preceded Obamacare, and continues today. That fiscal problem will remain whether we proceed with Obamacare or not. Simply striking it down in the courts or repealing it will not help fix the underlying problem.

Open Wide And Say Moo! – The Good Citizen’s Guide To Right Thoughts and Right Actions Under Obamacare

OK. The first, irreversible step has been taken. (Nothing after you hit the “send” button is reversible on the Internet.)

I have posted the first installment of my latest (but, I hope, not my last) project, which is to say, composing a new book (of the above title) in real-time, on-line, chapter-by-chapter, until I finish or am hauled off by the fates (or something).

For a full explanation of what this is all about, read this.

So without further ado, here is the first installment: the Introduction.

Open Wide And Say Moo! – The Good Citizen’s Guide To Right Thoughts and Right Actions Under Obamacare

This is the latest version of my ongoing, on-line project, which is to say, composing a new book (of the above title) on-line, in real time. Chapters will be added just as quickly as I can produce them, and revisions to past chapters will be made continuously.

Here is a clearer explanation of what this project is all about, and why I have embarked upon it.

Comments regarding this ongoing work are fervently sought, and deeply appreciated.  I will incorporate them in my continuous quality improvement procedures for this effort. Please leave your comments here.

Open Wide And Say Moo!

Introduction

Part I – Progressive Healthcare, and Why We Have Chosen It

Chapter 1 – Run For The Hills, As We Are All Doomed!

As I was sending in the (finally!) completed manuscript of the 5th edition of my textbook of electrophysiology last week, I was interrupted by two thoughts.

The first was that, while I enjoyed writing this book, I did not have as much fun as I had with the first four editions. Oh sure, I still entertained myself by trying to embed as many jokes, innuendos, double entendres and other amusements as I could into the text (95% of which, as always, will be caught and removed prior to publication by the editors – who are up to my tricks). But still, writing about cardiac electrophysiology is necessarily a desiccating endeavor. I guess I’ve gotten used to the free-reign style of writing I employ here at the CRB, and perhaps it’s ruined me for writing textbooks, at least as far as my own enjoyment is concerned. Sure would be fun to write a book in the style of this blog.

The second thought came to me as I pressed the “send” button, thus instantaneously zapping all the text, tables, and illustrations that comprise a medical textbook to the publisher. Even as recently as seven years ago, when I did the 4th edition, the process involved bundling up three copies of a thick manuscript, and three glossy prints each of all the illustrations, tables, etc., into a bulky package, and hauling it to the US Postal Service for (eventual) delivery.  How the world has changed in so short a time! (I sez to myself.) No need to do things the old way anymore.

Ruminating on these two thoughts for a matter of mere hours, I called an audible on my plans (such as they were) for my immediate future.

I’ve been thinking for more than a year that I need to write another book on American healthcare. It would be a book about what Obamacare expects (and will demand) from all of us citizens. I believe that if we Americans understood what really is to be expected of us from now on (instead of believing the soothing prevarications and wishful thinking commonly thrown our way), then we would do something about it. But Life got in the way, and I have not done much more than think about such a book.

My failure to act creates a seemingly insurmountable problem. The message I hope to convey, if it has any legitimacy at all, is most pertinent right now, before the November election. Given that I have not begun my book, the time frame appears difficult.

Indeed, as anyone who has published a book knows, unless you are writing about last week’s celebrity kidnapping or, perhaps, a Whitney Houston bio (in other words, unless you are writing about recent events so momentous that the usual chains of publishing protocol must be rent asunder to accommodate you), the time that elapses between the conception and the publication of a book is usually measured in years.

But, as I have noted, things have changed. So I have decided to try taking advantage of some of these changes, to try something a little different.

I am going to attempt to write my book right here, on this blog.

This is what I propose to do. Working as quickly as I can (while still fulfilling all my commitments to the various enterprises which are actually paying me to do things), I will compose my new book in real time, on line, here on the CRB. Quite simply, as I finish each chapter I will post it here.

The chapters I put up here will be a work in progress, essentially a draft. I reserve the right to change what I have written at any time, as much as I think I need to. I make no representations regarding how often I will post chapters, or even whether I will be able to carry this project to completion in a reasonable time, or at all. (I’ve never written a book like this before – I doubt many have – and I don’t really know that it’s feasible.)   I risk making a great fool of myself, but acquaintances would tell you that such a result should not create too great an additional burden for me.

I am sure regular readers will recognize large parts of this book as I post it, because I intend to incorporate themes – and even text – from some of my blog postings from the last five years. But I hope that presenting those words and themes in the more coherent and more logical form of a book will give them new life, and possibly extend their meaning.

Because this will be a work in progress, I invite (beg) comments and criticisms from all (or, as the case may be, both) of you.  I promise to consider every comment seriously (as indeed I always do), and I will undoubtedly incorporate many of them into the revisions I’ll be making all the time.

Once I decide that the book is finished, I will plan to publish it in electronic book form (Kindle for sure, maybe Nook) under my own label. Unless this occurs by Labor Day at the latest I will consider the entire effort an abject failure. If by some miracle the book does well in electronic format, I will plan to seek a real publisher in the future.

I realize how backward this all is. But (sez I) see how the world has changed in such a short time!

I will end this strange post with a personal note.

I will embark on writing this book despite my better judgment. On two occasions in my career – once as a practicing physician and once as a consultant to a biomedical company – I had very scary and very personal run-ins with officials of the federal government who had the authority (and the desire) to extract large fines and/or lengthy incarcerations from lots of people.  While I myself was not a direct target in either of these matters, and indeed suffered no real damage from either, these episodes were extremely distressing to me, and even life-changing.

I have written about one of these encounters in my temporarily obsolete book, “Fixing American Healthcare” (I’m hoping it will eventually come back in style, thus rendering its current obsolescence obsolete), and here on the CRB. I have not written about the second encounter, which was much more recent. In that second encounter, while I was being interrogated under oath by a prosecutor from the Department of Justice, the opening line of questioning, which lasted far longer than I ever could have imagined, concerned my writings here on the CRB, writings which were not remotely related in any way to the matter at hand. While the line of questioning itself was not particularly intimidating, and even occasionally bordered on expressing amusement (it might have been irony, though I do not expect irony from the DOJ), the message seemed clear: We in the DOJ know who you are, and we know in some detail what you’ve been saying about the government’s role in the healthcare system. And we find it very interesting.

I must have looked as calm and collected as Richard Nixon during the Kennedy debates.

In short, I doubt that such episodes with the Feds are things I could ever get used to, and I would prefer to avoid them in the future if possible.

And so I am ambivalent about the ultimate success of this book. I would be delighted, of course, if the book is successful, as that would indicate that a lot of people will have found it helpful to them, and perhaps some of them will be motivated to affect certain changes that might help all of us. The remote prospect of such an outcome is what compels me to write it.

But I must admit that if this book simply drops into oblivion – which is certainly the more likely outcome – that would be just fine with me. I will be able to tell myself (when what I think I see coming actually arrives), that I did what I could to sound the alarm. I will have done what I thought I must do. And having tried my best, I hope to enjoy my failure (and thus my success in staying under the radar as much as possible) with equanimity. And with an abiding sense of peace I will take my Obamacare medicine along with everyone else.

_____
Here is the up-to-date archive for all the chapters that have been posted so far.

Here is the introduction to my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.

__________

From the Front Matter

“It will be of little avail to the people, that the laws are made by men of their own choice, if the laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood.”

- James Madison, The Federalist #62

___

“The human race divides politically into those who want people to be controlled and those who have no such desire.”

- Robert A. Heinlein
___

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”

- From the ominously titled “New Rules,” Donald Berwick, MD and Troyen Brennan, MD

___

From a recently discovered fragment, attributed by some to Plato:

Meno: This DrRich (whoever he is) has badly mishandled the title of his book. It’s not possible for a person to open their mouth wide while saying moo.

Socrates: It would certainly seem so. But I’ve heard of this DrRich. He is playing with us.

Meno: There’s a message in the title then. That being the case, then obviously he is attempting to draw a comparison between patients and cattle.

Socrates: Yes, it seems to be true. In his earlier writings he has often said that in his land they are establishing a new healthcare system that will treat patients like the interchangeable members of a herd of beeves.

Meno: Well, he would have been better off comparing them to a herd of sheep. After all, one can open one’s mouth quite nicely while saying, “Baaa!”

Socrates: But the fellow is reputed as sly. He chose “Moo” for a reason.

Meno: It doesn’t make sense. No doctor who truly wanted to do a thorough examination of a patient’s oral cavity would ask the patient to purse their lips in such a manner. (Never mind while asking them to make such a demeaning sound!)

Socrates: Precisely. Does it not follow, then, that for some unfathomable reason the doctor does not actually intend to do a thorough examination? But that at the same time, apparently, he wants to pretend otherwise – possibly to himself as well as to his patient?

Meno: You’re proposing that the doctor, by saying “Open wide” as if a full examination is about to take place, is engaging in a purposeful fiction? A fiction which he reveals in the very next moment when he specifies exactly what he means by “wide?” It makes no sense.

Socrates: But doctors do something like this all the time. Has no doctor ever said, “This won’t hurt much,” just before he does something unspeakble to you?

Meno: Certainly. It’s how they earn their drachmas. But my doctor is simply trying to get me to hold still long enough for him to violate my person (only in the most professional way, of course). In contrast, the strange doctor imagined by this DrRich is telling his patient, “I’m going to do an extremely inadequate and cursory examination of your oral cavity, and we’re both going to pretend I gave you the full bore going-over you ought to expect from a competent physician.”

Socrates: Sad, but true. But there’s one more thing – one more particularly disturbing thing – implicit in the doctor’s command to open wide and say moo.

Meno: You mean that, for such a singular and inappropriate command, it is delivered very matter-of-factly?

Socrates: Yes, my young friend. The attitude of supreme confidence this command carries with it is remarkable. The doctor clearly expects that his patient will comply fully with the fiction he is proposing to perpetrate, without protest or complaint, even though compliance is to the patient’s own detriment, and furthermore that the patient will do so with the most submissive of utterances.

Meno: It’s absurd to postulate such a thing. You give DrRich too much credit. I think he is simply an ass, and botched the title of his book.

Socrates: Let us see.
____________

Introduction

The title of this book is not as ill-chosen as you may think at first glance. It is, in fact, a particularly apt illustration of my overall theme.

Under Obamacare, or under any Progressive healthcare system, the Good Citizen must learn to develop the proper mode of thought. When a doctor or some other agent of the healthcare authority informs you with all apparent sincerity that something is true, while their every action indicates that something quite different is true, and you choose to believe what you are told, instead of what your own senses are saying to you, this is called right thinking. Then when you act on what you are told, again in contrast to all the evidence to the contrary, it is called right action.

“Open wide and say moo” is therefore a metaphor that suggests how we as patients are likely to be treated under Obamacare, and it implies how we are expected to respond.

To such an absurd command a skeptic would reply, “What in the hell are you talking about? Do you want me to open wide or not? And what the hell is this ‘moo’ business?”

This is neither right thinking nor right action.

In contrast, right thinking will allow you to process such a request from your doctor in the proper way. You will recognize that the vague command to “open wide” is a mere courtesy. It is a way for you (and your doctor) to pretend that a thorough oral examination is about to take place, and thus to feel better about the kind of healthcare you are about to receive (or give). The real command, you will recognize, is the more specific one, the one that, in essence, defines what is actually meant by “wide.”

And so: Being a Good Citizen (and thus a perfect Obamacare patient), you will purse your lips, just barely wide enough to allow your ObamaDoc (a doctor whose primary interest is in keeping the Central Authority happy) a quick, cursory look at your oral cavity, the kind of look that will certainly preclude discovering anything amiss, and you will simultaneously utter that most placid noise of bovine compliance.

For Obamacare to work, you will need to accept that the quality of healthcare you are receiving is precisely the high quality the Central Authority insists you are receiving, which is to say, the highest quality that can possibly exist – despite the obvious evidence you may notice (if you are of a mind to notice) that it is not.

The people who will run Obamacare, we must realize, will not be lying to us. They actually will believe what they are saying. They fully expect us to believe it, too, and they will become quite exercised if they begin to perceive we do not. Here, an analogy to religion (which will be a recurring theme in this book) is apropos.

When something horrible has happened to you or a loved one, your pastor is likely to tell you that we must all trust that God has a plan, and that in God’s plan what seems very bad to us today must always serve God’s higher (if hidden) purpose. And we must have faith that some day, when it is all done, we will understand that higher purpose, and we will rejoice.

Similarly, when we think we see something terribly awry with the healthcare we or our loved ones are receiving (or not receiving, as the case may be), we will be exhorted to trust that the Central Authority also has a plan that serves a higher purpose. And just as true believers will be rewarded with God’s higher purpose in the end, so will the Good Citizen, by and by, be rewarded by the fruits of the Central Authority’s own supreme plan (as long as he or she does not become too disabled or too dead to appreciate it).

It is critical to understand that Obamacare, or for that matter, any Progressive program for societal improvement, simply will not work without your full buy-in and full cooperation – without your right thinking and right action. For this reason the Central Authority is very, very, very interested in making sure you develop these proper ways of thinking and acting.

Right thinking, in essence, is faith that the enlightened expertise embodied within the Central Authority knows what is best, for us and for all. And right action is complying, without complaint, with that central judgment. (For practical purposes, of course, right action will suffice all by itself, as long as you refrain from expressing too publicly your not-right thinking.)

The utter inability of most people to comply with these simple (but non-negotiable) requirements is precisely why no Progressive program for societal improvement, anywhere, has ever worked well for a very long time.

The closest that Progressive policies have ever come to realizing the universally beneficial ends which Progressives always promise has likely been in the Scandinavian countries. Here, the trauma of the World War II experience, combined with a homogenous population sharing a deeply-felt common goal, resulted in a generation of citizens who were truly dedicated to the attitudes, thoughts, and actions (specifically, working hard and tirelessly for the good of the whole), which were needed to make their collective society a success. Their children’s generation was slightly less dedicated to selfless action for the sake of the collective. Their grand-children’s generation seems far less so. Today, even Scandinavian socialism is fraying, at least around the edges.

Perhaps three generations of Good Citizens is the most Progressivism can hope for, even under the most favorable conditions.

In any case, we in the United States, through our duly elected representatives, are now committed to Obamacare. And if the Supreme Court later this year throws out the individual mandate and drives a stake through the heart of Obamacare, odds are high (as I will explain later) that shortly thereafter we will just end up with Obamacare II (or, more accurately, Hillarycare III).

And given the strong likelihood that we will all be enjoying our healthcare very soon under either Obamacare or its equally Progressive successor, it behooves us to understand what, exactly, our new healthcare system will require from each of us in order to function as it is intended. These requirements, whether we choose to understand them or not, will turn out to have a major influence over all of our lives (and limbs). But by understanding the requirements which are being placed upon us, then we can each decide whether we will be a Good Citizen – or something else. (While it may not always be easy or pleasant – or perhaps legal – there is always a something else.) So, a main goal of this book is to explore the requirements placed upon all Good Citizens by a Progressive healthcare system – what those requirements are, why they are non-negotiable, and what our options may be, as individuals, relative to them.

If Obamacare is a terrible mistake, as I believe it is, when we allowed our leaders to choose it we at least made an explicit recognition that the status-quo is no longer feasible. It is infeasible because our present out-of-control healthcare spending promises to trigger societal destruction within a few decades.

But the cure we have chosen – moving to a Progressive healthcare system – is likely as bad as the disease. I hope to show why this is so, and perhaps to convince a few people that, before it is too late, we ought to explore a different option for bringing fiscal sanity to our healthcare system.

Unfortunately, our window of opportunity to change paths is narrowing quickly. Once Obamacare (or any Progressive healthcare system) moves beyond a certain point, entropy will dictate that it cannot be undone, short of the traditional method for un-doing the various massive, elaborate, Byzantine constructions mankind is perpetually inventing, which is to say, via total societal collapse. So time is of the essence, which is why I have decided to publish this book in real-time, on-line, as I write it.

This book is divided into three parts.

In Part 1, we will discuss how and why it looks (so far, at least) like we are going to end up with a Progressive healthcare system. We will consider the fiscal black hole our healthcare system has become, and show why some fundamental change in American healthcare has been inevitable for years (whether we take purposeful action to effect such change or not). We will have a look at the four ways it is possible to get healthcare costs under control. (Yes, there are four.) (And yes, there are only four.) Of the four, we as a nation have chosen the Progressive solution, since its proponents can always make it sound the least painful. For this reason we will end Part 1 by considering the general Progressive program for societal perfection, a program which will determine the chief characteristics of our new healthcare system.

In Part 2, we will survey what Obamacare will look like once it is fully rolled out. We will examine its basic tenets, and the implications and mechanics of the herd medicine it will impose. We will consider the kinds of things you will experience personally when you seek healthcare (or are ordered to get some) under Obamacare. Finally, we will survey some of the bigger-picture aspects of Obamacare, such as “life-cycle” medicine (i.e., aged-based priorities for healthcare), and how and why Progressives will stifle medical progress.

Part 3 can be entirely skipped by anyone who likes what they’ve read about Obamacare in Parts 1 and 2. (Your right action, in placing this book aside, should go a long way toward paying your penance for picking this book up in the first place.) Part 3 will examine what we can do, as individuals and as groups, to protect ourselves from some of the hazards of Obamacare, to reverse its most odious parts, and even to begin to construct a replacement healthcare system that might avoid the fatal flaws not only of Obamacare itself, but also of the Pre-Obamacare system of healthcare which has led us to it.

None of this, I understand, constitutes a particularly happy message. So I will try to keep it relatively light, employing along the way a bit of irony, sarcasm, wry humor, perhaps some puns (though very few if I have anything to say about it), and in general my sunny disposition. Just keep in mind, amidst all the merriment, that we are still pretty much screwed, unless we decide to do something about it.

I will end this Introduction by inserting a statement that many may consider out of place, and which others may feign not to understand, and which still others may find insulting, but which may come in handy for me, personally, at a later date. To wit: I hereby fully acknowledge that good people can be led astray by Wrong Thinking, and I believe that sometimes, even having passionately expressed such wrong thoughts in word and deed (say, in book form), many of these good people can be brought back into the light, if they are shown sufficient mercy and understanding. I therefore deeply pray, and fervently hope, that when such strayers are brought to judgment, the Central Authority will give strong consideration to attempting their reeducation and rehabilitation, rather than immediately submitting them to the more final penance of auto-da-fe.

Now that President Obama’s healthcare reform has become the law of the land, it is time for us to prepare ourselves for the real fight. Namely, will individual Americans ultimately be restrained, by law or by subterfuge, from using their own resources to pay for their own medical care?  This notion is not as far-fetched as you might think. In this series of posts, DrRich explores this question, and demonstrates just how far we’ve already come in limiting the healthcare prerogatives of individuals.

Limiting Individual Prerogatives:

Part 1: The Real Fight Is Just Beginning

Part 2: Hillary Started It

Part 3: Breaking the Doctor-Patient Relationship

Part 4: Medicare Already Does It

Update: Why Angering Catholics Makes Sense For Obama

During the time DrRich was composing and recording his prior post – published moments ago – President Obama announced his “compromise” to the dust-up with Catholics over mandated contraception/abortion/sterilization services.

DrRich asks his readers to note that the President’s solution to this problem preserves the one and only thing that he truly needs his original directive to accomplish – namely, to assure that women will receive these newly mandated medical services without paying for them.  This is the one point he cannot abandon.

Case Closed.

Podcast:

President Obama unleashed a firestorm when he ordered HHS to issue a directive requiring all organizations providing health insurance to their employees to cover contraception, “morning after” pills, and sterilization procedures.  This directive has stunned the American Catholic leadership, whose support for the Obamacare legislation (they tell us) was predicated on assurances that healthcare reform would never require Catholic institutions to violate their fundamental principles. The bishops, and many American Catholics, feel betrayed.

Some bishops feel personally betrayed. New York Archbishop Timothy Dolan met in the Oval Office with the President in November to discuss this very issue, and was assured by Obama’s own lips that the administration was committed to protecting the church’s principles. This new directive, Archbishop Dolan now says plaintively, “seems to be at odds with the very assurances that he gave me.” (This is as close as an Archbishop may come, when speaking of the President, to saying, “He lied to me.”)

Progressives (who innately dislike organized religion because a) religions find a higher authority than the enlightened leadership the Progressives propose to create for us, and b) religion stresses individual conscience and individual salvation over collective priorities), tend to be delighted with the new rule, which puts the principles of religious belief into their proper place. Their only reservation about this directive is that the backlash might be politically disadvantageous at this particular moment.

And indeed, that backlash promises to be formidable. Catholics are outraged. Despite the fact that Catholics (Progressives assure us) use birth control with as much enthusiasm as anyone else, they find it quite disturbing that the government is willing to direct their Church to pay for something which the Church (whatever the behavior of its members may be) considers a sin. Whatever else this directive may be, it is clearly an attack on religious freedom. Leaders of other religions – evangelicals, Mormons, Jews – have also expressed outrage at the President’s directive, and organized American religions of all types are mounting a campaign to have this rule reversed.

Senator Rubio and other members of Congress find in this directive a constitutional crisis in the making, and are introducing legislation to prevent the government from mandating that religious organizations violate their religious principles.

It is said that Vice President Biden, a Catholic, urged the President not to issue this directive. And several Democrat members of Congress, sensing growing political repercussions, have pleaded with the President to reverse himself on this issue. There is no telling what the President – who has proven remarkably willing to reverse himself on even his most heartfelt promises – will end up doing. But for now he is holding firm. Catholics will have up to a year to “phase in” their capitulation on their religious beliefs, but they still must capitulate.

The most interesting question, to DrRich at least, is: Why did President Obama choose, in an election year, to issue this directive, which he knew without any doubt, from Archbishop Dolan himself if not from other sources, would create huge problems with American Catholics? Catholics make up 27% of the electorate, and almost 50% of American Catholics are of the Hispanic variety, a group which, it is said, tends to take its Catholicism far more seriously than your average non-Hispanic Catholic. The president can ill afford to lose a substantial degree of support from Catholics, or especially, Hispanics. It also should have been plain to him that this directive would raise the specter of the government trampling on religious freedoms for people of all faiths – and with everything else going on, why would he want to add this issue to the mix in an election year? Finally, he had to know that his new rule would (yet again) call into question the degree of respect he has for the American Constitution as it is written.

Despite the fact that he is being cheered on by true Progressives (even causing Ms. Maddow to gleefully invoke, once again, her Amish Bus Driver Rule), the President’s directive, in net, is shaping up to become a major political liability for him, and in a critical election year to boot. And it would have been easy for President Obama – a very smart man – to see this ahead of time. Issuing this directive at this juncture makes no sense politically.

So why did he do it?

The reason DrRich is compelled, once again, to tear himself away from the fascinating re-write of his textbook of electrophysiology, to the point that he finds himself posting more often during his blogging sabbatical than during normal times, is that nobody in the media seems to have figured out the correct answer to this question. And it is important to know the correct answer, because it tells us a lot about the battle that is really shaping up.

The President did not issue this politically counterproductive directive because it was necessary for the health of American women. (One set of healthcare services American women have plenty of access to, regardless of their income levels, is birth control and abortion services. That, after all, is why we taxpayers fund Planned Parenthood.) So to imply, as some have done, that without this directive American women would be falling dead on the streets is just absurd.

Nor did he issue it in order to further weaken religious freedom, or to further undermine the Constitution as our founders gave it to us. These features of his directive, DrRich submits, are merely useful side benefits, and would not have been compelling enough to jeopardize his re-election.

The reason President Obama issued this directive was not to undermine religious or constitutional principles, but rather, to establish new principles of his own that are critical both to Obamacare and to the overarching Progressive agenda.

DrRich has pointed out many times that the real battle we will face as Obamacare is being rolled out is the battle over whether American citizens will retain individual freedom sufficient to be permitted to spend their own money on their own healthcare. Indeed, DrRich has written a series of posts that spells all this out in painful detail. If you need to know why limiting individual prerogatives is so critically important to Progressives, and why Obamacare must be the vehicle for establishing these limitations, simply read the first post in that series.

DrRich understands how paranoid this all sounds at first glance. To see the truth of it, one must take several glances, and observe, over time, the actual behavior of Progressives in the wild.

DrRich hereby asserts that this new directive – which various commentators insist protects the health of women, or undermines religious freedom, or tears down Constitutional guarantees – actually was issued in order to establish, once and for all, the essential set of foundational principles for Obamacare, to wit:

1) The government will determine what constitutes healthcare and what does not.
2) If the government says it’s healthcare, every insurance product must cover it.
3) If it’s not covered by insurance, thou shalt not have access to it.

The first two of these principles are pretty obvious, and constitute, in fact, the overt meaning of the President’s directive. The government has determined that contraception, abortifacients, and sterilization constitute essential healthcare services, and therefore all employers must cover them, whatever their religious beliefs or other sensibilities may be.

But if you listen carefully to the arguments being made by supporters of the new directive, you will hear them saying that it’s critical that women have access to these services, as Jay Carney, the President’s Press Secretary avers, without paying for them themselves.

And that’s what the whole fight comes down to. Women must be provided these services without paying for them.

Progressives pretend they mean by this that many, many women are going without these services today because they cannot afford them, and so we must make sure the services are provided for them free of charge. But of all medical services that exist today, access to birth control and abortion are likely the ones which are most accessible to women of all socioeconomic backgrounds. And if there are women whose financial status still precludes receiving these services (among whom are most likely not the women gainfully employed by Catholic institutions), surely the President can imagine remedies for this situation that do not require taking the kind of extraordinary political risk he has just taken.

No. Women must be provided these services without paying for them NOT because there are so many women going without them today due to the cost to them. Rather, women must be provided these services without paying for them because we cannot allow women (or any patient) to pay for these services (or any service the Central Authority classifies as “healthcare”) out of their own pockets.

All healthcare services must be covered by all insurance products – regardless of which institutions provide those insurance products – precisely because nobody can be permitted to pay for healthcare outside the sanctioned insurance product.

This is the principle which is being established by the President’s new directive. This principle, so critical to Obamacare and to the Progressive agenda, is a principle worth fighting for. None of the other explanations offered by proponents or opponents of the President’s action make any sense. Establishing this critical principle is the only thing that justifies the huge political risk the President is now taking.

And now, retreating back to the far simpler task of explaining the intricacies of cardiac electrophysiology to novices, DrRich helpfully and humbly reminds his readers: I told you so.

As readers can imagine, few things could interrupt my temporary break from blogging – a break in which I have lost myself in the pleasures of figuring out how best to explain to novice readers the differences between the effective, relative and functional refractory periods of cardiac Purkinje fibers, and a host of other fascinating electrophysiologic arcana. With one’s brain wrapped around delights such as that, blogging fades to a barely remembered romp through some distant dreamscape.

One of the few things that could bring me back from these nether regions to the Covert Rationing Blog, if only for a moment, has happened. The esteemed Dr. Robert Centor, affectionately known as DB in the medical blogosphere, has made a comment on one of my posts, and it is a comment that deserves serious consideration. Further, I find I cannot give his comment appropriate justice by simply answering it with another comment. It requires more.

So, we interrupt this hiatus from blogging in order to give the kind of thoughtful response DB’s comment deserves.

I have been a reader of DB’s blog for several years – substantially longer than the nearly five years I have been writing the CRB. I consider DB to be the voice of internal medicine as it should be practiced. DB is a master of cutting through the fluff to get at the root of what is ailing the practice of medicine today. He has substantially influenced my thinking over the years, and many of DB’s writings have validated (in my mind, at least) certain of my syntheses of some key problems regarding the present state of medical practice. Indeed, out of sheer respect for DB I have dropped in this post the rather haughty 3rd person approach I traditionally use herein.

At one time I was a relatively frequent commenter on DB’s blog, and the exchanges that ensued between us have been some of the highlights of my blogging career (such as it is). But two years ago I stopped posting comments on DB’s Medical Rants, and I stopped making any reference here to DB or his blog. I did so for one simple reason.

It was two years ago that I had my public dust-up with the ACP over the issue of medical ethics. It was a dust-up that drew the notice and disapprobation of some individuals quite well placed within the ACP leadership. Knowing that DB is a member of the ACP’s Board of Regents, I feared that if I continued acting as if I were one of his “blogging buddies” it might reflect poorly on him. The ACP (an organization of which I was a proud member for over 25 years, quitting only when they published their New Medical Ethics in 2002) badly needs voices like DB’s. Indeed, the fact that they value his voice gives me hope. So, out of respect for him, and in consideration of what I guessed were his best interests, I stopped interacting with DB and his blog altogether, though I have remained a regular reader. I realize that, realistically, what I may do or not do almost certainly has no effect whatsoever on DB’s relationship with the ACP, but it was something I felt I needed to do.

In any case, that self-imposed avoidance has now been made moot by DB himself.

In his comment DB takes exception to one (or more likely, several) of my recent posts. I will reproduce his entire comment here:

“First, I admit to bias as a member of the ACP Board of Regents.

DrRich (whom I like and admire) has used a technique that we all use. He has established a straw man and beat that straw man into submission.

ACP advocates strongly for high-value, cost-conscious care (HVCCC). In fact a recent Annals article – Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care – http://www.annals.org/content/156/2/147.abstract – very explicitly attacks low value high cost care.

Advocating for HVCCC does not mean advocating for rationing based on cost alone.

As DrRich always states, we have covert rationing and we believe that rationing has no relation to value.

ACP has challenged all physicians to avoid medications and tests that do not have high value. How is that “herd medicine”?

Please review the recommendations in the recent Annals article and tell us where we have developed recommendations for cost reasons only.

I admire your debating skills, but in my opinion you are not addressing the same question that we are addressing. I speak from clinical experience. I see too many tests ordered that cannot help the patient. I see too many treatments that cost too much without a clear advantage over less expensive treatments.

We should strive for high value care for all our patients. We should eschew low value expensive care for most patients (of course one can construct exceptions to this generalization). Let’s not let hyperbole confuse the issue. We cannot afford unnecessary expenses. We challenge you to define unnecessary. I think you can.”

I believe DB has misunderstood my main argument. This is not his fault. I have been accused more than once of being somewhat obtuse. So let me state it very explicitly:

1) It has been determined that individualized decision making by doctors and patients is the problem, and to resolve this problem clinical decisions need to be centralized.*
2) Obamacare renders much individualized decision making illegal, and establishes formal mechanisms for centralized decision making.
3) The ACP’s New Medical Ethics, whether by intention or not, has allowed agents of the Central Authority to argue that individualized decision making is unethical.
4) Centralized decision making will likely yield better results for the collective, better results for the “average” patients, but suboptimal results for people on the wrong side of the distribution curve – and terrible results for people on the tail of the curve. DB himself has written about this tail.

____

* From the book “New Rules,” by Berwick and Brennan:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”

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There is nothing in my argument that says physicians should avoid attempting to practice high-value medicine. Obviously, they should. There is nothing in this argument that says it is wrong or counterproductive for the ACP (or other professional organizations) to devise publications, guidelines, opinions, or any other kind of aid to assist doctors in making appropriate clinical decisions that will minimize waste for society and harm to their patients. Doing these things is good for the healthcare system and for mankind.

What is wrong is a system that says that centrally-generated clinical “guidelines” must be followed to the letter by all doctors for all patients under all circumstances, and that failing to do so is both illegal and unethical.

The document to which DB refers me – an attempt by the ACP to assign values to certain clinical services – is a good one, and I am sure clinicians should find it helpful. I can’t help but believe that he sent me to this particular document because it explicitly calls out implantable defibrillators (the development of which played a significant role in my professional career) as a high-value medical service. That’s very nice.

But this fact leads me to use, as an example of what I’m talking about, the abuse of ICD guidelines by the Central Authority. A year ago an article appeared in JAMA complaining that 22% of ICD implants did not meet the guidelines. That number (which seems about right to me, if guidelines were being treated as just that) was widely castigated as evidence that doctors were engaging in widespread abuse of this expensive medical device. This was followed, 2 weeks later, by an announcement that the Department of Justice was conducting an investigation of guideline violations by ICD implanters. As a first step in this investigation, the DOJ elicited the cooperation of the Heart Rhythm Society – the professional organization of electrophysiologists – and the HRS let out that it was effectively gagged from further comment or action on behalf of its members for the duration of the investigation.

The specific part of the ICD guidelines that produced the majority of the “violations” was not that ICDs were being used in people who did not really need them. Rather, it was that ICDs were being implanted earlier than the Feds preferred for people who, everyone agreed, should have an ICD. That is, implanters were not waiting the full mandated 4 – 6 weeks after a heart attack, or after heart failure was diagnosed, before implanting ICDs in some of their patients. Two points about this: First, there are clearly individuals who should receive their ICDs within the first month of a heart attack or heart failure diagnosis, despite what the guidelines say. (For instance, if the patient also has an indication for a pacemaker – not an uncommon thing – following the guidelines would require first implanting a pacemaker, then, a few weeks later, doing a second invasive procedure to replace it with an ICD). Second, the clinical evidence supporting this 4 – 6 week waiting period is based on two fundamentally flawed studies, and constituted the weakest part of the clinical evidence regarding ICDs, and while it is now apparently considered settled science if not gospel, it was originally considered highly controversial when the guidelines first appeared.

We don’t know what the results of the DOJ’s investigation will be. Perhaps nothing will come of it and no electrophysiologists will go to jail this time.

Here’s what we do know:

- Doctors are expected to follow clinical guidelines to the letter, with every patient, whether it makes sense for an individual or not.
- Doctors who are not following centralized guidelines to the letter are behaving illegally, and the DOJ – that’s the DEPARTMENT OF JUSTICE people, and not HHS or Medicare – will investigate, and at least threaten criminal prosecution.
- Doctors who are not following centralized guidelines to the letter are behaving unethically. (Go back and re-read the commentary from the press and from other physicians, especially physicians who strongly support Obamacare’s centralized decision making, about the ethics of these ICD-guideline-violators.)
- Such legal and ethical intimidation will prevent doctors from “violating” guidelines for their individual patients who are a standard deviation or two away from the mean, and who clearly need an exception.

That’s my argument. The activities of the ACP, vis a vis establishing helpful studies of the relative clinical value of various clinical actions, or even guidelines for clinical practice (if treated as actual guidelines), are to be lauded and not criticized, and I so laud them.

The ACP has not instituted herd medicine, nor advocated it explicitly, to my knowledge. My only criticism of the ACP has to do with their altering the precepts of medical ethics to make it ethically compatible for doctors to go along with herd medicine. The Central Authority on its own volition has taken it the rest of the way – to where it’s unethical NOT to go along with heard medicine. This “adjustment” of medical ethics is just what the Central Authority needed in order to validate its policy of centralized decision making, and the ACP provided it. The glee on the part of the government’s agents in response to the ACP’s New Ethics is palpable.

I still find this a sad, sad thing for the profession, and especially for patients. I also find it very sad for the ACP itself which, by producing the kind of helpful resources to which DB has referred us, would continue to be a great force for good – were it not for this one very basic, very fundamental, very critical, and therefore utterly tragic flaw.