This is Chapter 7 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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Chapter 7 – Limiting Individual Prerogatives in a Progressive Healthcare System

Of all the seemingly outlandish things I am going to assert in this book – all of which I will fervently desire the reader to, if not swallow whole, then at least take into serious account – the most outlandish of all is probably the one I am addressing in this chapter. Namely, that any Progressive healthcare system will necessarily attempt to curtail the ability of individual Americans to spend their own money on their own healthcare, and thus, will try to limit the most essential freedom of all – the freedom to act to preserve oneself.

To those many readers who at this moment are expressing alarm over my apparent paranoia, I thank you for your concern. But fear not, for if it turns out I am wrong about this (and I sincerely hope that I am), then not only do they have medication for paranoia, but also, I would be permitted to purchase it legally.

Progressives, of course, deny that they have any such thing in mind. And undoubtedly the majority of progressives, and even many actual Progressives, do not. Indeed, I will happily concede it likely that very few Progressives actually start out with this idea.

What I am saying is that limiting this vital individual liberty turns out to be such an essential component of any Progressive healthcare system that the people who run such a system, perhaps despite themselves, will, sooner or later, find themselves acting forcefully to limit it. This is my proposition.

My intention in this chapter is (once again) to present my proposition as a theory. It is a theory that takes into account two things. First, it incorporates the natural and necessary inclinations of the Progressive Program to limit an individual’s freedom of action regarding his or her own health. And second, my theory incorporates objective observations we can make today, relating to actions which Progressives have already taken in this regard. I contend that my theory best explains both of these things. And of course, as always, I invite (and in this case, greatly desire to hear of) any alternative theories that explain these observations better than mine does.

But if my theory is correct, then if we Americans are to avoid severe restrictions on our ability to purchase healthcare services with our own money (and, ultimately, on our ability to expend any individual resources for any individual benefit), such a favorable outcome will only result if we remain vigilant and alert to the aims of our Progressive leaders, and to fight vigorously against their efforts to suppress our liberties, whenever and whereever we find them. It will not result from our complacency, or from placing our trust in the beneficence, the common sense, or the respect for fundamental American precepts, of our political leaders.

The Individual Is The Proper Guardian Of His Own Health

It really ought to go without saying that a person should be able to expend his or her own resources to purchase any healthcare service he or she desires. This is a primary corollary of classical liberalism, and was recognized as a fundamental human right by the likes of John Locke and Thomas Jefferson.

It is also an idea deeply imbedded in American jurisprudence. The great Supreme Court Justice Joseph Story, in his Commentaries on the Constitution of the United States (1873), noted that the individual “is the proper guardian of his own health.” This precept was repeated by Louis Brandeis in 1890, and became the foundation of the Supreme Court’s assertion of an individual right to privacy. In particular, the writings of Story and Brandeis were specifically relied upon by the Court in its 1965 finding (Griswold v. Connecticut) that a right to privacy is not only guaranteed by our Constitution, but is also a right which is “older than our Bill of Rights.” I would like to remind my Progressive friends that it was this very precept that laid the basis for deciding Roe v. Wade in 1973.

Fundamentally, both classic liberal philosophy and the American judicial system have always recognized a liberty to act to preserve one’s own health to be an inherent, inalienable right.

Why Individual Prerogatives Must Be Restrained

Despite this long history in political philosophy and in jurisprudence in favor of such an inherent liberty, it is nonetheless natural and unavoidable for any Progressive healthcare system to strive to limit it. This is because Progressive healthcare systems are necessarily universal.

They are universal in two senses. First, they attempt to cover all people. Second, they purport to cover all healthcare services.

Under Obamacare, for instance, health insurance – which every American is required to have – must cover (as laid out in Section 1302 of the law): ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, pediatric services, and oral and vision care.

Fundamentally, this “universality of features” reflects a particular philosophy. It is, in fact, the Progressive philosophy. Healthcare being an essential component of any ideal society, it is thus necessary to assure that everybody receives everything that is officially deemed to be healthcare. In Section 1302, the Central Authority is telling us, everything will be taken care of for all of us, from soup to nuts. So there is no need to worry our pretty little heads.

But, as always when the Central Authority assumes all responsibility for providing some aspect of security (in this case, healthcare security), it also assumes all control.

Complete central control is necessary not only to assure the societal perfection promised by the Progressive Program. Central control is also the method by which Progressives propose to manage America’s healthcare spending. Which is to say, controlling all healthcare expenditures is essential for the purpose of covert rationing.

Allowing individuals to spend their own money fundamentally undermines a Progressive healthcare system. It implies that the Central Authority is actually not supplying all useful healthcare services (when, by definition, it is), and thus implies that the government is holding back, and indeed, may be engaging in some kind of rationing. Such an implication cannot be permitted.

To say it another way, when individuals are allowed to purchase “extra” healthcare, that’s a graphic admission to the unwashed masses that there is extra healthcare to be had. The real problem is that this behavior raises expectations for everybody, and these higher expectations make it that much more difficult for the Central Authority to ration covertly.

The critical importance of controlling expectations in a Progressive healthcare system is nicely illustrated by some of the problems being experienced by the British and the Canadian healthcare systems. Both of these systems, naturally, initially outlawed private healthcare spending. But unfortunately, the very visible medical progress that continued unabated in the American healthcare system – new drugs, new techniques and new technology – were noticed by Canadian and British citizens, and created new demands upon their respective healthcare systems. Essentially, seeing what was possible, a critical mass of the population demanded some of these medical advances, even if they had to pay for them themselves. Ultimately the authorities were forced to relent, at least to a degree, on their desired restrictions on individual freedom.

Some have argued that such “loosening” of individual restrictions in Great Britain and in Canada proves that any restrictions on individuals simply will not stand – so we Americans don’t really have anything to worry about. For, if such restrictions cannot be maintained in those countries, how will they ever be maintained here? Perhaps. But I would suggest instead that the need to loosen individual restrictions in Canada and Great Britain graphically illustrates the critical necessity, in any universal healthcare system, of managing expectations. It in fact proves that a failure to manage the expectations of the people leads to a loss of control.

Had it not been for the very visible example of advances in American healthcare, citizens of Canada and Great Britain quite possibly never would have agitated for “more.” As it is, thanks to the unfortunate example of the high-cost healthcare their citizens saw in the United States, British and Canadian officials were simply unable to manage the expectations of their own citizenry. (Which means that healthcare officials in those countries were likely among the happiest people, anywhere, when Obamacare became the law in America.)

Once we have a universal healthcare system in America, it will therefore become critically important for the Central Authority to manage the healthcare expectations of American citizens. Fortunately, American healthcare bureaucrats won’t have any annoying, external healthcare systems to worry about, busily spinning out advances in medical technology and thus continually raising expectations. Their job likely will be somewhat easier than it was for their counterparts in Canada and England.

For American bureaucrats, managing public expectations will largely become a matter of restraining individual American citizens from going outside the system, and buying extra healthcare with their own money. And for this reason, restricting individual prerogatives in the United States will be critical, even more critical than it was in our cousin nations. And we should not be surprised if our bureaucrats employ some very devious and even draconian maneuvers to do so.

It’s All About Fairness

The official rationale which the Central Authority will always invoke for taking such restrictive actions will be to achieve “fairness.” Allowing the rich to go outside the system would create an unfair, two-tiered healthcare system, &c. The goal of fairness, as is being taught to every schoolchild, is unquestionably and obviously a righteous one, and indeed, its achievement is a chief responsibility of the Central Authority*. Equally obvious is the fact that its hindrance is always threatened by the greed of a certain kind of person. Therefore, the Central Authority is fully justified in constraining the individual liberties of those enemies of righteousness who would stifle fairness.

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*As I write this, President Obama is campaigning very hard for a special new tax on the very rich. While this is nothing new in itself, what is new is the rationale that is being advanced for this new tax, i.e., “fairness.” The President and his spokespersons have all acknowledged that this new proposed tax would do next to nothing to reduce our deficit, or to create new revenue for the government. Rather, the purpose they articulate for taking the property earned by these very successful people is, quite explicitly, redistributive justice, or “fairness.” This argument, possibly for the first time, explicitly creates “fairness” as a principle goal of taxation, and makes achieving such fairness a chief responsibility of the Central Authority (which is convenient, since the Central Authority also gets to define what “fairness” is). This explicit new principle is readily extendable to government actions outside the tax code – such as healthcare.
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And so, restricting the right of individuals to use their own resources to benefit their own health is something that will always be conducted only for the best of reasons – to achieve the fairest and the most ethical healthcare system possible.

But whatever the reasons Progressives might offer for their actions, and whatever the dictates of classical liberal philosophy or American jurisprudence to the contrary, their attempt to restrict individual prerogatives will become deadly serious, because doing so is essential to their real aims.

Hillary Started It

The natural propensity of Progressives to limit individual prerogatives was manifest as early as 1993, with the Clinton Health Security Act, affectionately known as Hillarycare.

The question of how much individual freedom Hillarycare would permit came to a head in early 1994, just as the debate over this bill was reaching a crescendo, and played a significant role in defeating the legislation. What brought the question to a head was the publication of an article by Betsy McCaughey, entitled No Exit, in (of all places) The New Republic.

Ms. McCaughey, who quickly became for Progressives a sort of practice version of Sarah Palin, was at the time a frequent denizen of Conservative think tanks and an occasional editorialist. But what made her an acknowledged expert on Hillarycare was the fact that she was one of the few people who actually had read the legislation.

No Exit revealed that many of the claims being made by proponents of Hillarycare (for instance, that patients could keep their present insurance; that specialty care would be readily available; and that there would be no rationing) were actually false. Despite the fact that the White House quickly released an official response to Mcaughey’s article insisting that many of her conclusions were untrue, her accusations stuck. And according to many observers McCaughey’s article was at least as influential as the Harry and Louise commercials in turning the tide against Hillarycare. Indeed, the importance of her article was formally recognized when it won her the National Magazine Award for excellence in the public interest.

One of McCaughey’s chief assertions – and likely its most striking one – was that Hillarycare would make it illegal for patients to pay doctors directly, and that doctors could be paid only through the government-sanctioned insurance plans. And of all her claims this one in particular made proponents of Hillarycare angry, because the legislation explicitly stipulated that this was not to be the case. Here is the actual language from the bill: “Nothing in this Act shall be construed as prohibiting…an individual from purchasing any health care services.”

Because one of the main assertions in her highly effective article so obviously ignored this explicit statement to the contrary, for the past 20 years McCaughey has been widely painted in the general media as being totally incompetent at best, and more often as a congenital liar and/or a shill for various components of the healthcare industry. And in 2009, when she performed a similar analysis of the Obamacare legislation (coming to many of the same conclusions), she was for the most part either ignored or ridiculed.

It turns out, however, at least in retrospect, that McCaughey’s analysis of Hillarycare was largely correct.

Hillarycare Is The Model For Obamacare

Before demonstrating how McCaughey was right, I ought to say why spending any time with Hillarycare at this point is still worthwhile. Hillarycare is still relevant for two reasons. First, while Hillarycare itself never became law, many of the provisions of Hillarycare eventually did – and so, we are living under them today. And second, Hillarycare embodies the fundamental aims of any Progressive healthcare system, so understanding the aims of Hillarycare will help us to understand the aims of Obamacare (and whatever Progressive reforms might succeed Obamacare).

When House Speaker Nancy Pelosi famously pronounced that we would have to pass the Obamacare legislation in order to find out what was in it, she did not misspeak. She was not uttering a typical Nancy-ism (such as her contention that paying people not to work is a great stimulus to job creation), nor was she channeling Yogi Berra. She was, in fact, speaking the plain truth, and imparting a nugget of deep wisdom to us in the general public.

I have spent substantial time reading large portions of the 2700-page Obamacare legislation. And having done so, here’s what I can tell you about it.

The Obamacare legislation was specifically designed to be obscure; in fact, it is fundamentally indeterminate in its meaning. It was designed in such a way that the unelected regulators who would later translate it into actual rules, regulations and guidelines (under which healthcare providers can then be prosecuted), would ultimately determine what the bill really said. And until those regulators finish their work, what Obamacare actually says is a matter of debate. So Nancy was right.

This fact explains why none of our legislators bothered to read it before voting on it – except for a few pesky Republicans, who were only trying to make trouble. What’s the point in reading a long, boring document whose actual meaning will only be determined later?

This fact also raises another question. Where did this extraordinary document – whose true meaning was elusive even to the President and the legislators who were promoting it – come from? Who actually put the words to the page, and crafted this remarkable legislation?

We may never know the names of the people who actually held the pens which scratched out the actual words, any more than we will ever know the real names of the individuals who wrote the gospels of Matthew and Luke. But, just as New Testament scholars have been able to trace these two gospels to a now-lost common prior source – the so-called “Q document” – it is not difficult for anyone with a smattering of interest in the art of legislative exegesis to trace the source document for Obamacare.

The Q Document for President Obama’s Patient Protection and Affordable Care Act was Hillarycare.

In preparing to write this book, I decided to go back in time, and re-examine Hillary’s original proposal for fundamentally transforming the American healthcare system. What I found surprised me.

While Hillary’s Health Security Act was widely castigated by contemporaries as being a vast monstrosity of bureaucratic legerdemain, filled with complexity and labyrinthine passages that attempted to hide its true meaning, I found Hillarycare, in comparison to Obamacare, to be a model of legislative brevity and clarity. In fact, I now believe that its very straightforwardness is one of the things that killed it. (And, it seems obvious to me, so did whoever wrote the Obamacare legislation, an individual or individuals who so clearly and so painstakingly avoided making the same mistake.)

For instance, Hillarycare is only 1368 pages in length. How could they be so concise? Even more remarkably, Hillarycare spelled out pretty plainly what it actually meant to do.

For instance, in the Obamacare bill, in order for a reader to assemble the information necessary to determine that the Independent Medicare Advisory Board is actually to be called the Independent Payment Advisory Board (IPAB), and that its “advisory opinions” which are to be submitted to Congress for “consideration” are actually formal dictates which must be followed to the letter, and that it can inflict its cost-cutting mandates to all of healthcare and not just to government programs, one must jump around to numerous distant sections in the 2700-page document, cutting and pasting the relevant sections, jigsaw-like, into a coherent whole. In the Hillarycare bill, in stark contrast, the analogous National Health Board (which, like the IPAB, was to have been an appointed-not-elected Supreme Court of healthcare, beyond which there was to be no appeal, no revision, and no repeal) is presented in an entirely straightforward way, and pretty much all in one place.

Having now immersed myself in the relatively refreshing model of clarity and precision that was Hillarycare, I find it quite likely that the people who actually wrote the Obamacare bill (and may God keep these invaluable artists of legislative lyricism safe, as we will be needing them), simply began with Hillary’s old Health Security Act, disassembled it into various bits, padded each bit with a little more than twice its weight in verbiage, and reassembled the pieces in some nearly random fashion into the exceedingly difficult-to-read document that became Obamacare.

Obamacare’s debt to Hillarycare is obvious. Hillarycare required every American to have government-approved health insurance; it reduced private health insurers to government-directed utilities, whose products, rates, and profits were to be controlled by the feds; and it created omniscient and omnipotent panels which were to hand down dictates to “let doctors know” what services they may or may not provide and under what circumstances. This should not be surprising, since any Progressive healthcare system will ultimately have the same goals, and will likely discover similar pathways toward achieving those goals.

Hillarycare and Individual Prerogatives

So: if Hillarycare is to a large extent the model for Obamacare, and indeed, if it is a model for Progressive healthcare systems in general, then what did it have to say about the ability of individual Americans to use their own resources for their own healthcare?

Progressives have told us (and have spent nearly 20 years castigating Ms. McCaughey for telling us otherwise) that the answer is obvious – the bill says in plain language that “nothing in the bill should be construed as prohibiting an individual” from purchasing healthcare services. What could be clearer?

I humbly suggest, and ask the reader to suspend disbelief long enough to consider, that when an act of legislation makes an unprovoked, blanket assertion like this, apparently out of the clear blue, sometimes that assertion is being made in order to distract the overly curious from digging through the bill to find out what it really says, or at least, to create plausible deniability. There are lots of examples where legislation begins by saying, “This legislation does not do X,” and then immediately goes on to do precisely X.

For instance, the legislation that created Medicare contains the following language: “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine, or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services.” (Section 1801, Medicare Act, 1965). This point of law, in light of what Medicare has in fact become, is mind boggling.

Also, in the Obamacare legislation, the introductory language in the section which creates the IPAB (the IPAB being a straightforward and very blunt instrument for rationing healthcare), contains language that prohibits healthcare rationing.

Then there’s the fact that Hillarycare itself, in its section on fee-for-service medicine, begins by establishing a collective negotiation process for determining what fee-for-service doctors may charge (Section 1322, paragraph (c)(2)). But then it immediately goes on to say (paragraph (c)(5)) that “collective negotiations by providers pursuant to paragraph (2) shall be considered as efforts intended to influence government action.” And efforts intended to influence government action is later defined, in the Fraud and Abuse sections of the legislation, as an act of healthcare fraud, and is subject to criminal penalties. To top it all off, the very next section of the bill also prohibits providers from boycotts or even threatening boycotts. So in effect, after asserting that there will be collective bargaining, the bill provides a mechanism for the government to dictate doctors’ fees, without input from doctors, and furthermore, these dictated fees are not even presented to doctors in a take-it-or-leave-it fashion, but rather, in a take-it-or-go-to-jail fashion.

All this, of course, is not to say that the language in Hillarycare denying that the bill has any intention of prohibiting individual prerogatives is itself definitive proof that the legislation intends to prohibit individual prerogatives. All I am saying is that such language, so gratuitously offered, may actually not mean anything at all in particular, and certainly should not be treated as being dispositive. If anything, it should make you want to read the rest of the bill with particular care.

And when we read the rest of the Hillarycare legislation we find (Section 1406, Paragraph (d)(1)) that “A provider may not charge or collect from any enrollee a fee in excess of the applicable payment amount. . .for items and services covered by the comprehensive benefits package.” When we deconstruct this language, we find that a “provider” is any individual who provides health professional services (a definition that includes all doctors); an “enrollee” is any American citizen (since all Americans are required to be enrolled in a government-approved health plan); and the “comprehensive benefits package” covers all healthcare services. So: any doctor who treats any patient in America is bound to the fee schedule as determined by the government. Furthermore, the next paragraph (paragraph (d)(2)) prohibits directly billing the patient for any of these services. The plain meaning of these provisions is that doctors and patients cannot contract with one another legally for the delivery of healthcare services.

The Fraud and Abuse sections of Hillarycare also limit the prerogatives of doctors and patients. For instance, under Hillarycare, some activities which would usually be considered compatible with routine medical practice, even when conducted within the government-approved healthcare system, created opportunities for jailtime for both doctors and patients. According to Paul Craig Roberts, writing in the Washington Times in December, 1993, “Mr. Clinton’s plan turns normal patient advocacy into a federal criminal offense. For example, a doctor who wants an earlier date for surgery for a needful patient can be accused of using wrongful influence and accepting a bribe and sentenced, along with the patient, to 15 years in prison.”

So, on one hand Hillarycare made a very direct, blanket assertion that it did not intend to inhibit individual prerogatives. On the other hand the specific provisions of Hillarycare seem to do just that. It seems likely, then, that the blanket assertion made in Hillarycare that people could buy whatever healthcare they wanted, may just be another example of employing such an assertion for the purpose of providing plausible deniablity that the legislation in fact (and in less plain language) does just the opposite.

Furthermore, the overall effect of the Hillarycare legislation, when viewed from 10,000 feet, was most striking in the detailed and minute control it assumed over each and every conceivable aspect of American healthcare. And when you consider their work product in its entirety, it becomes difficult to believe that the authors of Hillarycare would really countenance individuals going outside the system to buy whatever healthcare they wanted.

To me, this all indicates that Ms. McCaughey was probably right after all.

But since Hillarycare never became law, we can’t really know how its apparent limitations on the freedom of individuals actually would have played out.

Or can we?

After Hillarycare

As I have noted in an earlier chapter, the ignominious defeat of Hillarycare in Congress did not stop the Progressives’ efforts to overhaul the healthcare system. It simply put them on a somewhat slower track.

For instance, large sections of the onerous Fraud and Abuse portions of Hillarycare were cut-and-pasted into the HIPAA legislation which became law a few years later. We saw, in Chapter 3, just one example of how these new anti-fraud provisions were then employed to change routine medical practice into a maze of regulatory booby-traps, punishable by ruining fines and jail terms. Such methods, which were aimed at wrenching the physician’s attention away from what was best for the patient and toward what would best please the Central Authority, were extraordinarily painful for doctors at first, but in the intervening 15 years have come for many physicians – especially the younger ones who never knew anything else – to seem routine and natural. And so, despite the defeat of Hillarycare, the government has succeeded in getting physicians into the correct frame of mind for Progressive healthcare.

Similarly, the downfall of Hillarycare did not deter ongoing efforts by Progressives to limit the freedom of individuals to purchase their own healthcare. These efforts necessarily had to be relatively subtle, and accordingly have been marked by subterfuge and clever legal posing. But their aim cannot be plausibly denied.

Limiting The Rights Of Medicare Patients

Lest I mislead readers into thinking that I’m blaming only the Clintons for starting all this, I will point out that the first major effort to limit the ability of Medicare patients to purchase healthcare services outside of Medicare was effected by government bureaucrats during the administration of George Bush 41.

In 1991, Medicare administrators published a “carrier bulletin” warning physicians that direct-pay agreements between Medicare patients and doctors (even non-participating doctors) were strictly prohibited, unless the contract was initiated solely by the patient, and even then, the rate of payment for any such direct-pay agreements must be those rates set by Medicare, and further, that any such direct-pay agreements were still subject to all Medicare rules and regulations. Medicare added that if the patient at some later time became dissatisfied with that (patient-initiated) contract, Medicare would severely (and retroactively) sanction the physician. The clear aim of this new policy was to deter any direct-pay agreements, whatsoever, between Medicare patients and doctors, and thus, to limit the patients’ ability to spend their own money on their own healthcare.

When a group of physicians and their patients sued Medicare in 1992 to prevent this odious new policy from being implemented (Stewart et al. v. Sullivan), the government took the position that the plaintiffs could not prove that Medicare had really promulgated this new policy after all – since they could not “prove” that the carrier bulletin had been initiated by the Secretary of HHS. The judge agreed with the defendants over this legal technicality, and after implying that if Medicare had actually implemented such a policy (which at the time could not be “proven,”) it would indeed unreasonably limit individual rights, threw the case out in a summary judgement for lack of “ripeness.”

Then, having successfully dodged this challenge on a legal subterfuge, Medicare immediately (and cynically) rendered this very policy official, in its entirety, by formally changing its Medicare Carriers’ Manual.

But the Feds were still not satisfied. The new, restrictive policy technically still allowed for private-pay contracts, as long as the patient initiated them. So the Clinton administration engineered an amendment to the Balanced Budget Act of 1997 – Section 4507 – which prohibited any self-pay contracts whatsoever between Medicare patients and their doctors for medical services which are covered under Medicare. Under Section 4507 – which is still the law today – if a doctor provides even one self-pay medical service to a single Medicare patient, that doctor is punished by complete banishment from the Medicare program for at least two years.

The federal government was eventually challenged again in court over Section 4507, but that lawsuit was also thrown out in a summary judgment (United Seniors Association et al. v. Shalala). The rationale the government offered to the court for its actions in this case is instructive: “. . .what you will have is a system whereby the rich can buy what they want and those many beneficiaries who are on fixed income will not be able to afford those services.” So again, the interest of collective “fairness” was invoked to justify a law which stifles an individual’s fundamental right to purchase medical services he or she determines to be necessary for his/her well-being.

There are several legitimate reasons a Medicare patient might want to self-pay for a medical service that is covered by Medicare. If Medicare “covers” heart valve surgery, for instance, a patient might want to pay for a new, minimally-invasive surgical approach that is inadequately reimbursed by Medicare, rather than the big, open-heart surgery that Medicare reimburses fully. Or, one might want to self-pay for “covered” psychiatric care, or for treatment for a venereal disease, in order to keep embarrassing or harmful medical records out of government-controlled databases – that is, for privacy reasons.

Furthermore, it is important to recognize that just because a healthcare service is “Medicare-covered” does not mean that it will be covered for a given patient. Whether a specific individual is covered is often determined by a “medical necessity” ruling, made by a bureaucrat. Section 4507 essentially precludes a patient’s ability to purchase a denied (but “covered”) medical service, no matter how badly they want it, or believe they need it.

One can argue, and with some merit, that at this juncture denials of medically necessary services by Medicare have been relatively judicious, and therefore that the “Section 4507 rule” has not had much of an actual impact. In fact, it is likely that most Medicare beneficiaries do not even know that this rule exists.

But while its impact might be relatively small so far, the Section 4507 rule has now been in place for 15 years – it is very well-established. So, once Medicare begins reducing reimbursements to physicians and hospitals to the point where they can no longer afford to offer certain “covered” services to Medicare patients (and Medicare has just recently begun doing so, specifically, for some cardiac imaging studies), patients who need those services will be left out in the cold. Services which are officially covered by Medicare, but which are reimbursed at such a low rate that they cannot actually be provided to them, will become unavailable even to Medicare patients who are willing and able to pay for them.

It is conceivable that some older people who understand the implications of Section 4507, and who want to receive a covered-but-denied medical service, might decide to drop out of Medicare altogether so they could legally purchase that desired service. But this is something Progressives do not like either, because allowing patients to drop out of Medicare threatens to create an unfair, two-tiered healthcare system.

And this is why, also in 1993, the Clinton administration promulgated a rule in its Program Operations Manual System (POMS) to prohibit Medicare-aged Americans from forgoing Medicare. The rule implied that no elderly person could drop out of Medicare unless they also gave up their Social Security benefits, and repaid any Social Security benefits they had already received.

Recently, this POMS rule was challenged in a lawsuit filed by three elderly Americans (one of whom was Dick Armey) who wished to drop out of Medicare in favor of self-purchased health insurance, without having to sacrifice their Social Security benefits.

But in the summer of 2011, Washington DC District Judge Rosemary Collyer ruled for the defendants and upheld the POMS rule. So: elderly Americans do not have the right to drop out of Medicare and purchase their own health insurance, unless they also forgo and repay all Social Security benefits.

Interestingly, in 2009 Judge Collyer had denied a motion by the Obama administration to dismiss the suit, and in her denial pointedly noted that “neither the statute nor the regulation specifies that Plaintiffs must withdraw from Social Security and repay retirement benefits in order to withdraw from Medicare.” Her preliminary ruling thereby confirmed the plaintiffs’ main contention. So most observers had assumed that the judge’s final ruling would also be in favor of the plaintiffs.

It was not. In her final ruling in 2011, Judge Collyer found a new interpretation of the Medicare statute itself that upholds the POMS rule. The Medicare statute, she finally determined, specifies that people who are entitled to Social Security are automatically “entitled” to Medicare, and therefore if one elects to receive the Social Security payments one is owed, one must also accept Medicare. She flatly rejected the notion that when Congress says “entitled” it is implying anything optional, as in, “You can have it if you want it.” When you’re dealing with Medicare, she said, “‘entitled’ does not actually mean ‘capable of being rejected.’” So, when Congress creates a new entitlement, Congress actually means you must have it – that it’s mandatory. Judge Collyer ended her ruling by sympathizing with the plaintiffs (or laughing at them – I cannot tell for sure): “Plaintiffs are trapped in a government program intended for their benefit.”

The apparent change in Judge Collyer’s reading of the Medicare statute between 2009 and 2011 is disturbing. What made her originally read the plain language of the Medicare statute just like any literate American would, but then two years later read it as if she had to twist it into a presupposed “right” answer? We likely will never know what induced this marked shift.

It is instructive that the Obama administration would go to such lengths to prevent old people from dropping out of Medicare. Medicare is not only in the red, but is a great fiscal threat to our national well-being. One would think they’d welcome the idea that some of our elderly might want to pay for their own health insurance, and thereby save Medicare a lot of money. But instead, the administration fought the idea tooth and nail, to the point of articulating absurdities that even the judge could not refrain from mocking. One of the Obama administration’s arguments, for instance, was that the plaintiffs were lucky to receive such a boon as Medicare, and therefore suffered “no injury” by having to accept it. The judge responded in her ruling: “The Secretary extolls the benefits of Medicare and suggests that Plaintiffs would agree they are not truly injured if they were to learn more about Medicare. . .The parties use a lot of ink disputing whether Plaintiffs’ desire to avoid Medicare is sensible.”

So as it now stands, seniors (unless they are rich enough to also walk away from Social Security altogether) must accept Medicare. Admittedly, for most elderly Americans this is not a big deal – of course they’re going to accept Medicare. But, as we have seen, current law already makes it nearly impossible for patients on Medicare to self-pay for denied medical services. Once you are on Medicare, you will get the medical services the Central Authority approves for you – and nothing more. In the not-too-distant future, this restriction is likely to become much more apparent to Medicare recipients than it has been to date. When and if the day comes when we would like to buy ourselves some medical care which the Central Authority would rather we did not have, Old Farts like your author will find that we are “entitled” neither to pay for our own healthcare, nor to drop out of the government program that so restricts us.

Preventing Doctors From Adopting Direct-Pay Practices

Disturbed by the destruction of their professional autonomy, and by their inability to advocate for their individual patients, for the past decade more and more doctors have been dropping out of the “system,” and establishing practices under which they are paid directly by their own patients. By eliminating the pressure from insurers and the government to make the patient’s best interest a secondary concern, direct-pay practice immedidately restores the classic doctor-patient relationship, and therefore restores professional integrity – and so it is a menace to Progressive goals.

Unfortunately, direct-pay practitioners have a serious public relations problem. Part of the problem, to be sure, was caused by these doctors themselves. The first few to set up this new style of practice unabashedly catered to rich patients, and to attract the rich, referred to themselves as “concierge” practitioners. This name (and its elitist connotations) have been forcibly affixed to all direct-pay practitioners, even as this style of practice has evolved into a much more democratic form. Today, more and more doctors are starting direct-pay practices which are easily affordable to anyone who can afford a cell phone or cable TV contract. This evolving variety of direct-pay practice is actually not so radical as Progressives would have you believe. It is the way doctors practiced medicine until very recently. It is, in fact, the way Dr. Welby practiced medicine.

While many direct-pay practices offer patients certain benefits they usually cannot get from primary care doctors who remain in the approved system (such as phone and e-mail access, same-day appointments, appointments lasting as long as necessary instead of the allotted 7.5 minutes, &c.), the fundamental benefit, to both the patient and the doctor, is that it restores the classic doctor-patient relationship. The physician’s primary obligation is no longer to the 3rd-party overlord, or to the Progressive ideal of social justice, but to the patient.

And while critics (who abound) attack direct-pay practitioners for their elitism, laziness, and greed, their real issue is that direct-pay practitioners are acting as if their primary duty is to their individual patients, and not to “social justice.” It is for this reason that direct-pay practices are a deadly threat.

Having gained nearly complete control over the behavior of primary care practitioners, it is critical for Progressives to shut the door to any alternative forms of primary care. Direct-pay practitioners are a menace because they threaten to raise the expectations of both doctors and patients. Perhaps, doctors might tell themselves, there really is a way to maintain our professional autonomy within the healthcare system. Perhaps, patients might tell themselves, there really is a way for me to have a personal advocate watching out for my interests when I have to interact with the healthcare system.

The issue, as always, is one of “fairness.” It is not fair for rich people to be able to buy “extra” access to their doctors, since it will create a condition of inequality. The policy director for the AARP (an organization that is ostensibly intersted in the best interests of older Americans) has said that direct-pay practices creates “the prospect of a more explicitly tiered system where people with money have a different kind of insurance relationship than most of the middle class, and where Medicare is no longer as universal as we would like it to be.” It is apparent that, to assure fairness, no patient should have email or cell-phone access to their doctors, or same-day appointments – or to a true professional advocate who is dedicated to their own individual interests, instead of the competing interests of the whole.

The attacks on direct-pay practitioners have followed the usual scheme Progressives follow when they discover an idea they need to suppress. First, they were ridiculed. “For a Retainer, Lavish Care by ‘Boutique Doctors,’” said a headline in the New York Times in 2005. Then, they were demonized, widely attacked for their elitism, for catering to the frivoulous desires of the rich, and for their lack of fundamental medical ethics. In this latter effort, it was not difficult to find fellow physicians – generally, from the medical organizations which promulgated the New Medical Ethics (see Chapter 3) – to lead the attacks. There are countless examples. I will give just two.

Anthony DeMaria, then President of the American College of Cardiology, criticized the practice of direct-pay medicine in an article in the Journal of the American College of Cardiology in 2005, saying, “Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality.” So, direct-pay physicians improve the quality of healthcare only for only some patients (i.e, for their own patients), and so have no place in the healthcare system.

In a 2002 article in the New England Journal of Medicine, Troyen A. Brennan M.D., J.D., and M.P.H., really gets to the point. Referring to direct-pay practices as “luxury primary care,” he notes that “traditional medical ethics is rather poorly equipped to address issues related to luxury primary care.” That is, while “traditional” medical ethics always places the individual patient first, that kind of thinking is now outmoded. “(M)ost ethicists now agree that the financial structure of health care is an important subject for ethical consideration. Access to health care, in particular, is a salient ethical issue.” Direct-pay practitioners threaten (by their elitism and the limited size of their practices), to limit access to primary care, and thus are in fundamental violation of medical ethics.

The argument here, for those who missed it (advanced by fellow physicians no less), is that, of the two competing ethical precepts now established by New Medical Ethics (i.e., the physician’s obligation to the individual patient vs. the physician’s obligation to society), clear primacy is to be given to the physician’s obligation to society. Physicians must (like it or not) place the needs of society above the needs of the patient – and participate in covert bedside healthcare rationing. Physicians who take the only path remaining to them that allows them to make the individual patient their primary obligation are to be castigated as ethically deficient.

When ridicule and demonization fail to suppress their opposition, Progressive dogma indicates it’s time to resort to force. The first pass in this regard, of course, is always to render the opposition illegal. (Actual violence is reserved for criminals who persist in their misbehavior, despite more polite efforts to get them to behave lawfully.)

Making direct-pay medical practice illegal has not been accomplished yet, but clear efforts have been made in this regard. Noting with alarm the rise of direct-pay primary care, numerous Congresspersons have issued statements of concern, suggesting that perhaps Congress should “look into” the propriety of such activities.

Indeed, the first step by Congress has already been taken. In 2003, as part of the Medicare Prescription Drug, Improvement, and Modernization Act, Congress directed the GAO to study and report on the effect of direct-pay practices on Medicare patients. The GAO did so in 2005, and a fair paraphrase of its report is as follows: “The practice of direct-pay medicine is not currently a threat to Medicare patients, because the direct-pay movement is not large enough yet to have an impact. If it does begin to have an impact on Medicare patients, action will have to be taken.” That is, direct-pay medicine was considered OK in 2005 not because it was inherently an ethical and legal form of medical practice, but simply because there were not enough practitioners at that time to bother about. The clear implication is that Congress stands ready to pass laws outlawing – or, at least, severely limiting – direct-pay practices, as soon as those practices begin to “impact” the system.

A follow-up report was done in 2010 which showed a 5-fold increase in the number of direct-pay practices since 2005. It is not yet clear what actions the Feds may take – the numbers are still quite small – but leaders of MedPac (a commission that advises Congress on Medicare) has publicly expressed alarm that this new phenomenon appears to be growing rapidly.

Certain state governments are not waiting for Congress to ban direct-pay practices. The state of Maryland and a few others have taken the creative position that, because many direct-pay practices work on a retainer basis, they meet the definition of a health insurance company. And as a health insurance company, to be considered legal entities, they have to have millions of dollars set aside to pay for unforeseen “claims.” (Interestingly, the lawyers in state legislatures who are advancing this argument have never suggested that the same rules be applied to attorneys, who also often work on a retainer model.) According to the Baltimore Sun, the state’s stance in this regard has already successfully caused several primary care physicians to abandon their plans to become retainer practitioners. This interesting pathway to banishing direct-pay practices is being taken up by other states, as well. In early 2012, for instance, the state of Oregon also began requiring direct-pay physicians to register their practices with the state insurance commission.

Less devious (but more draconian) is the action that was proposed in the state of Massachusetts (whose universal healthcare system, we’ve all heard, is a preview of Obamacare circa 2015). A bill was introduced in 2009 in the Massachusetts Senate which would require doctors, as a condition of their licensure, to accept payment rates as determined by the government. The bill has not become law in Massachusetts (not yet, anyway), but its introduction illustrates the tactics which are being entertained to make direct-pay practices completely impracticable, if not illegal.

Since medical licensing is controlled by the various states, it would take 50 bills like the one proposed in Massachusetts to really get rid of direct-pay healthcare. But there are ways for the Central Authority to accomplish this goal much more expeditiously. Now that the federal government directly controls all student loans, for instance, it would be a simple matter to make student loans for medical students contingent on agreeing to become primary care doctors working strictly within the government controlled system, or to offer loan forgiveness for doctors who agree to do so, or to rescind favorable re-payment conditions (retroactively, and decades after the fact, if necessary) for doctors who go to a direct-pay model later in life.

Even without taking such action, the Central Authority may already have poisoned the water for direct-pay practices. Attorneys representing direct-pay practitioners think they have discovered a potentially fatal problem within Obamacare. Under this law, apparently only physicians enrolled in Medicare can order durable medical equipment or home health services for Medicare patients. Worse, the language of Obamacare may award to the Secretary of HHS the authority to expand this limitation to all other medical services they might order. If direct-pay physicians are banned from ordering any medical services for their patients, it is difficult to see how their practices can remain viable.

Direct-pay practices are the last, best hope for patients who want their own individual interests looked after, and for their doctors who want to practice their profession ethically. This is why Progressives are determined to terminate them with extreme prejudice.

What Do Contraceptives Have To Do With All this?

In early 2012, 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 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, felt betrayed.

Some felt personally betrayed. Cardinal Timothy Dolan had met in the Oval Office with the President in November 2011 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, Cardinal Dolan said after the President’s directive on contraceptives, “seems to be at odds with the very assurances that he gave me.” (This is as close as a Cardinal may come, when speaking of the President, to saying, “He lied to me.”)

Progressives were delighted with the new rule, which put the principles of religious belief into their proper place. Conservatives, however, along with Catholic leaders and leaders of other religions, expressed outrage at the President’s directive, which was a clear assault on religious freedom in America.

The President was ready for them. Supported by his allies in the American media, he portrayed objections to his new directive as a “Republican War on Women.” It is instructive to consider the basic premise of this War on Women, to wit: By objecting to the new directive, Republicans are saying that women should not have access to contraceptives.

This twist of logic seems completely absurd, from almost any perspective.

Almost.

If there is one aspect of healthcare services to which American women have plenty of access, regardless of their income levels, it is contraceptive services. That is why we taxpayers fund Title X Family Planning Services, and also why we fund Planned Parenthood. And for any woman who does not wish to avail herself of this taxpayer-funded access to contraception, Walmart sells birth control pills at $10 for a month’s supply. There is no lack of ready access to contraception.

Indeed, if Republicans really wanted to prevent women from having contraceptives, objecting to the President’s new directive would not be of any material help whatsoever in accomplishing such a goal.

But there is, in fact, one perspective from which blocking the President’s directive would indeed limit womens’ access to contraceptives. If one approaches the issue from this perspective – and only if one approaches it from this perspective – then the idea of a War on Women makes logical sense. Furthermore, when we listen to the passionate, heart-felt and indeed almost tearful arguments that are being made by Progressives against the heartless Republicans – vociferously denying that Republicans care anything about religious freedom or constitutional authority, and insisting instead that they only want women to be denied contraceptives – it seems plain that this is, in fact, the perspective which Progressives must necessarily hold.

That perspective is: Anything that constitutes healthcare MUST be provided by government-approved insurance products, since if it is not provided by government-approved insurance products, one cannot legally acquire it.

So, in fact, the controversy over whether religious organizations must provide insurance that covers contraceptives boils down to the notion that people should not have to – and indeed should not be permitted to – purchase healthcare services on their own.

The President’s directive on contraceptives, therefore, seems to have been 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.

Women must be provided contraceptives without paying for them NOT because there are so many women going without them today, due to insufficient access. 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.

Summary

My main point, once again, is that the Central Authority has a deep and abiding need to limit our individual prerogatives when it comes to our healthcare, and has been acting on that need for a long time. The basis for these limitations on our individual liberties – the principle of social justice – has already been established, and has survived court challenges.

Extending these limitations on personal liberties to Obamacare, and broadening their usage, will not require any major changes in direction, or principles, or policy, but will merely require an expansion of already existent – and even “venerable” – rules, rules which have been an established part of Medicare for many years.

Such restrictions by our government on such fundamental individual liberties are a very big deal indeed, and, in fact, signal an end to the Great American Experiment.

When I have expressed this conclusion in the past, many critics have admonished me that I make far too much of it, and that our government, in its benign wisdom, is just doing what’s best for us. I beg readers to forgive me if I see, in such a reply, even more evidence that the only nation in the history of mankind to be founded on the principles of individual freedom is well on the way to abandoning those exceptional principles, for the sake of the same, soothing-but-empty blandishments that have been offered, throughout human history, by well-meaning people who end up producing – or becoming – tyrants.

This is Chapter 5 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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Chapter 5 – A Practical Theory Of The Progressive Program

My goal in Part I of this book has been to describe the sorry state of the American healthcare system pre-Obamacare. Before moving on to Part II – which will attempt to show why “fixing” the problem by instituting Progressive healthcare reforms is exactly the wrong thing to do – it occurs to me that I ought to explain exactly what I mean by “Progressive.”

What I have done so far in this regard – which has consisted of offering unflattering innuendoes, casting negative aspersions, remarking snidely, and quoting from Ayn Rand (who I think was brilliant in characterizing the diagnosis, but whose prescription – unfettered and godless self-interest – I find a little disturbing) – has not exactly constituted an exercise in probity and precision. In this final chapter of Part I it is my intention to remedy this shortcoming.

To really understand where our healthcare system is headed, and for that matter where our society is headed, we need to understand Progressives and the Progressive Program.

I have personally found this understanding hard to come by. This is because Progressives, and especially American Progressives, have always been a bit enigmatic about their real goals. In my view their behavior tends to be persistently, almost defiantly counterproductive to the rights Americans traditionally hold dear, and which the Progressives themselves insist they revere – in particular, our inalienable rights to life, liberty and the pursuit of happiness.

Even a superficial analysis of the words and deeds of Progressives should reveal that, their protests to the contrary notwithstanding, they never really bought into the “inalienable” thing. It is quite apparent, to anyone who cares to look, that for Progressives such “natural rights” can and must be abridged whenever it is necessary to achieve some higher goal.

Since the behavior of American Progressives is so often inconsistent with the values they (most of them, at least) insist they love as well as any American, I concluded long ago that they must either be prevaricators or self-deluded when it comes to telling us what they are really up to. Either way, if we want to know what they really think, and what their agenda really is, we’ll have to figure it out for ourselves.

And perhaps we’d better do just that, since it is looking a lot like the Progressives are going to be running things around here for a while.

I am not a political scientist. But I am a scientist. And for a scientist, one useful way to learn about any kind of system is first to make as many observations as you can about that system, then devise a theory to fully explain those observations, and then apply that theory to attempt to predict future behaviors of the system. As you observe how your theory is working, you can then go back as needed and readjust it to comport with your new observations. Repeat until done.

When you get to the point where subsequent, otherwise-difficult-to-explain behaviors have become predictable, your theory is reasonably likely to be in the ball park.

And so, I am going to present a theory of Progressivism. It is a theory that I have found useful in explaining many of the otherwise confounding and enigmatic behaviors which Progressives habitually display. I am not claiming that this theory is absolutely correct, merely that it is useful in practice. Since it is a theory whose value you can assess objectively with your own observations, its practical value should not depend on my own character, morals, intelligence, or psychological status, all of which have been impugned by readers of my blog in the way of proving that my theory cannot have any merit. (Simple observation suggests that Progressives generally allow only three possibilities when somebody disagrees with them – you can be crazy, stupid or evil. Their prescribed remedy – therapy, education, or elimination – depends on which of these possibilities they finally settle upon. My theory, obviously, will have to explain this behavior, too.)

You may not like this theory. A lot of people don’t. But the thing about the scientific application of theories is that if you are going to make any, well, progress, you cannot simply write off or ignore theories whose implications you do not happen to like. Whichever theory is currently the best at explaining the known facts necessarily takes precedence, until such time as you can devise a new or adjusted theory that explains those facts even better.

I would welcome hearing about such a theory. In the meantime, here’s mine.

A Hopelessly Abbreviated History Of Progressivism

When I began my study of Progressives, I honestly did not know where to begin. So, like Descartes before me, I decided to proceed from the simplest and most irreducible of truths. Namely, that Progressives are really, really smart. We know this because all the best professors in all the best Ivy League schools are Progressives.

From this simple truth we can deduce that, whatever it is that Progressives are actually up to, it must have its roots in the writings of The Philosopher.

And sure enough, it was not at all difficult to discover the roots of Progressivism within the teachings of Aristotle. Aristotle tells us that man is innately a political animal, an animal with an inherent propensity to gather into increasingly complex communities. The essence of man, according to Aristotle, is society.

The formation of complex societies is what defines mankind; it is what differentiates man from the rest of the animal kingdom. Hence, because man is defined by society, society is inherently on a higher plane of importance than the individual. Individuals are entirely beholden to and dependent upon and subservient to the society to which they belong. Indeed, they are defined as individuals by their place and status within that society. Without society, a man is just an ape with better thumbs.

And so the precedence of the collective over the individual is not something we can simply choose to accept or reject; it is the very essence of mankind. It is nature. It is just the way it is.

Aristotle, as we can see, is a great friend to the Progressives.

The general idea that mankind is essentially a creature of society, and that the worth of the individual is defined by his/her worth to their society, is thus a very old idea, and in fact has been the normal way of looking at the relationship between individuals and society throughout most of history.

This really started to change just a few hundred years ago, when humanists began to cautiously explore the radical notion that individuals (rather than the collective) constitute the fundamental unit of humanity. The new humanist heresy – which declared the innate and irreducible worth of the individual and began to celebrate individual “autonomy” – came to be called “liberalism.” Classical liberalism stressed individual freedom of thought and action, the right of private property, individual responsibility, free markets, and the limited power of the state. Classical liberalism reached its zenith a mere two and a half centuries after its painful birth, with the Declaration of Independence and the Constitution of the United States. The formation of a new nation whose government was explicitly established on the grounds of classical liberalism is what I’ve been calling the Great American Experiment.

The Great American Experiment, so far at least, appears to be a once-in-a-species event. So if we’re about to abandon it, I would caution that perhaps we should first really think about it for a while.

In any case, even in America the collective countercurrent never really went away. And it never will, if only due to its extraordinarily deep roots in the history of men. And so, after only a century or so of relatively unfettered capitalism (the natural economic system of classic liberalism), during which the industrial revolution had been whipped to new heights, leading to unimagined progress and economic growth but also, alarmingly, to the creation of a large new underclass of hopelessly poor and horribly oppressed urban dwellers, collectivist thinkers were stirred to new action.

In some countries the “action” consisted of violent revolutions and all the bad stuff that typically follows such things. In the United States, the collectivist movement followed a much more prudent, much more practical, much more gradualistic approach.

Taking its cue from the industrial revolution, which by radically transforming the modern world had graphically introduced the idea of “progress,” and fascinated by the ideas of Darwin (which suggested not only that a system could be steadily and unrelentingly directed toward some state of “perfection,” but also that the very nature of things seemed to dictate that it should be so), the new collectivist movement at the turn of the 20th century adopted the name “Progressive.” To Progressives, classical liberalism has always been an aberration. Despite what America’s founding documents might say, society takes precedence over the individual. It takes this precedence by way of the very essence of mankind, as was taught by The Philosopher, and so it cannot be otherwise.

(Within a couple of decades, “Progressives” had gotten such a bad reputation that they brazenly began referring to themselves as “liberals,” usurping the terminology from a philosophy that was nearly its opposite, as if to convince the public that they actually held to those foundational American precepts of individual liberty, limited government, &c. But true to form, by 2008 they had pretty much trashed the name “liberal” as well, at which time Hillary Clinton famously declined to call herself a liberal any longer, and insisted instead that she was a “Teddy Roosevelt Progressive.” It is therefore in deference to Ms. Clinton’s explicit instructions that I am using that original terminology in this book.)

The Progressives, following unrelentingly their steady, Darwin-inspired evolutionary-not-revolutionary approach, have made astounding strides. Today they are on the verge of rendering their Program irreversible. And taking over the healthcare system will likely lead them to the final victory for which they have striven, so patiently and for so long.

The Progressive Program

Progressivism is a political movement whose premise is that the society of men can be perfected, and therefore it is the highest duty of any “good” society to constantly strive toward that achievable state of perfection. And so the Progressive Program – the thing that makes Progressives progressive – is to develop the perfect society. This program is not optional; it is dictated by the nature of mankind. It is therefore “right,” and objecting to it is therefore “wrong.”

The perfect society has three fundamental requirements. First, it must meet all the basic needs of the individuals within that society (such as food, clothing, shelter, sanitation, and health), without which individuals will always be tempted to engage in the counterproductive behavior of striving for things. Second, the social and economic benefits of society must be fairly distributed among all people. Therefore, there must be social justice – there must be no big winners or big losers. Big winners are an especial problem, because the presence of big winners just encourages greed and self-aggrandizement on the part of others, and will discourage citizens from dedicating themselves to the good of the whole. Third, once perfection is finally achieved, the social order must be of such a nature that it can persist, theoretically forever, without fundamental change. Indeed, the very notion of perfection implies that any change, of any type, is bad, since it will necessarily constitute a movement away from perfection. (This means, of course, that once the Progressives reach their goal, they will need to change their name. Of necessity they will become Conservatives.)

The perfect society therefore requires that people be granted “rights” to things – food, clothing, shelter, healthcare, &c. These rights obviously do not come from any Creator – so where do they come from? They can only come from a Central Authority – from the sovereign entity within a society that has the ultimate authority (backed by the legal use of violence or the threat thereof) to distribute the fruits of the society in such a manner that all those rights can be realized.

Progressives love to grant new rights to everyone, because each time they do, the Central Authority accrues that much more power over the behavior and the property of individuals.

The perfect society demands social or redistributive justice in all areas of social and economic endeavor, even in areas that have not yet been defined as a formal “right.” Once again, only a strong Central Authority can determine what is fair or not fair, and can have the power to affect the appropriate redistributions it determines are necessary to achieve such fairness. The aforementioned creation of “rights,” of course, will guarantee that such a powerful Central Authority will have been established, so that social justice can progress steadily forward.

The perfect society requires complete stability. This would include (at a minimum) a stable population size, the preservation of natural resources and the earth’s environment (indeed, when one hears the word “sustainability,” one is usually listening to Progressive gospel), the careful management of the economy, and the careful control – if not suppression – of unplanned innovations.

This latter refers both to material (or scientific) innovations, and innovations of thought, either of which will always threaten hard-won societal stability.

Achieving the perfect society being the paramount work of mankind, any method which may help in achieving this perfection is to be embraced; none discounted out of hand. The only considerations one must make in choosing methods of action are: Is this method practicable? And: Is this method more likely to be successful, or counterproductive?

These two questions fully define Progressive ethics.

And finally, the Central Authority exists purely to grant essential rights to the people, to determine what is fair and then act to effect that fairness, and to establish the executive structures needed to achieve and maintain societal stability and sustainability. Therefore, by definition, as long as its actions are directed in these ways, it is an inherently ethical entity and must be regarded as such; and further, resistance to it is (equally inherently) unethical.

That’s it. That’s my theory of the Progressive Program. If you object to it, then, despite whatever personal shortcomings, sins, and wants you may perceive in your humble author, you are obligated (by all that is righteous and good) to postulate your own theory of Progressivism that explains, at least as well as my theory does, all of the following phenomena:

Rule By Experts

Despite its lip service to the contrary, Progressivism is not egalitarian. It simply cannot be.

For, while Progressivism is not by definition a system of rule by the elite, in practical terms it can only end up this way. Progressive leaders (themselves being quite elite) are never slow to perceive this truth.

It works like this: The duty of mankind is to strive for the perfect society. The chief tool by which mankind is to achieve this program is man’s intellect and logic. It is axiomatic that only a minority of people will have the intellect and logic necessary to direct the Program of mankind.

Therefore, Progressivism ultimately relies on an elite corps of individuals – formally called “experts” – to guide our progress toward the perfect society. The perfect society will not just happen, it must be engineered by those who are expert enough to know what to do, and who are gifted enough to lead.

Those leading experts, the rare individuals without whom we will never achieve our state of perfection, are to be carefully nurtured and valued by society. Because their work is so critical to the essential Program, the elite must be removed from worry over the mundane necessities of life. That is, providing the leadership class with certain luxuries and privileges, and even freedom from having to follow all the rules that apply to the masses, is therefore not hypocrisy, but is an essential good. It redounds to the benefit of the Program, and therefore, to everyone.

This is why Progressive leaders habitually accept special privileges and perquisites that would make the King of Siam blush, and they do so with an air of matter-of-factness and entitlement that is impressive to behold.

The Duty of We the People

Just as it is the sacred duty of those who have been blessed with the intellectual tools to lead us toward the Promised Land, it is no less the sacred duty of the rest of us – we in the unwashed masses – to do whatever it is that the experts determine is best. The determinations and directives which the experts hand down may apply to all people, or they may be specifically directed toward you or me (which indeed would be a very great honor for us, would it not?) Either way, it is our duty to comply with all central directives, for the greater good of the whole.

This explains why Progressives express such indignant wrath over the Tea Party. Tea Party enthusiasts insist that their own individual autonomy must remain paramount, and utterly deny that they have any duty to comply with the Progressive Program. This attitude, of course, makes members of the Tea Party stupid, crazy or evil. And, because the Progressive-in-Chief happens to be an African American who is acting within the prescribed range of behaviors for African Americans, it also makes them racist. (More on this latter point shortly.)

Progressives vs. progressives

Progressives (capital P), as I use the term, are the thought leaders of Progressivism. They are the experts, the leadership class. They are the political leaders, the academics, the authors, the bureaucats, and the pundits and spokespersons who set the agenda, make the decisions, form and transmit the message, and pass the judgments that make the Progressive engine run. They are the ones who know the way to the perfect society, and are driving us to it.

On the other hand, progressives (the “small-p-progressive,” the rank and file, one-of-us progressives who spend their lives toiling away within the general population), who form the large majority of American progressives, are basically just nice people. For the most part progressives honestly believe that their political philosophy is the right philosophy, the fairest philosophy, and innately the kindest and most humane political philosophy there can be. They are not trying to drive society toward perfection as much as they are merely aiming for more fairness in the distribution of the good things that come from being in a society in the first place.

Small-p-progressives do indeed tend to look at non-Progressives, and especially Conservatives, as being driven chiefly by vice – usually selfishness and greed – and so are subject to being induced to states of great indignation and anger (by Progressives) against specific non-Progressives, and can often be mobilized to action against same.

So, within the great unwashed masses, progressives are seen by Progressives as the ones who bathe at least weekly.

The Fundamental Flaw Of Progressivism

The fundamental flaw of Progressivism is the same as the fundamental flaw of all collectivist political systems. Namely, Progressivism ultimately relies on all members of society to subsume their own individual needs to the needs of the collective. That is, the Progressive Program requires a fundamental change in human nature. And alas! This change will never be forthcoming.

All ideal political and economic systems – including capitalism – eventually founder on the shoals of human nature if certain adjustments are not made. However, collectivist systems are especially vulnerable to human nature. Unlike capitalism (which incorporates, utilizes and makes the best of the individual’s innate self-centered nature), collectivist systems require the complete suppression of man’s natural impulses (again, unless you are lucky enough to be amongst the leadership class). So collectivist systems are rapidly and deeply challenged by human nature. It is their fundamental flaw.

This fundamental flaw will almost always lead to great frustration on the part of the leadership of any collectivist system, dooms their attempts at societal perfection, and finally results in tyranny or anarchy. This is why, while collectivist systems often sound quite attractive to the inexperienced youth or their unaware elders, collectivism always tends to end badly.

So, despite their frequent hymns of praise to the worthiness of the common man, Progressives invariably develop an underlying contempt toward the unwashed masses. It is not difficult to spot this contempt if you are alert to it.

Managing the Unwashed Masses

Instead of surrendering to the inevitabilities of human nature, Progressives will instead try to “manage” the unwashed masses.

Now, for your typical American progressive, getting people to go along with the Progressive Program will be a simple matter of education. The Progressive Program is so obviously Right, and anything else so obviously Wrong, that anyone can see it with a minimum of instruction. These progressives believe this because it is how they themselves were won over.

But the Progressives – the elite class of leaders, who have probably been to Harvard – understand that education (i.e., indoctrinating the public to the great benefits of the Progressive agenda), only goes so far. It does indeed get you a substantial number of believers (probably 20 – 25% of the population), but it still leaves you with a very large proportion of the people who will only go along to the extent that they themselves benefit.

And so Progressives attempt to control the unwashed masses by means of pacification (i.e., attempting to meet all their basic needs, so as to eliminate their impulse to strive). This helps quite a bit – in fact, it is one of the main strategies of the Progressives for controlling the people.

Unfortunately, even this does not work in a substantial number of people. Some people, no matter what kind of indoctrination you provide for them, or what benefits and entitlements you may offer them, will simply refuse to place the needs of the collective above their own.

In other collectivist systems we have seen around the world, the utter frustration that develops on the part of political leaders because of this innate human recalcitrance seems nearly inevitably to lead to coercion, intimidation, peer-pressure, and, ultimately, violence*. When the expediency of violence is finally reached, you inevitably end up with the tyranny or anarchy I mentioned earlier.

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* According to R.J. Rummel in his book Death by Government, during the 20th century the world’s governments killed four times as many of their own people, on purpose, as were killed in all wars combined.
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In the United States, while the frustration of our Progressive leaders with us folks is often palpable, and while their growing contempt for us occasionally breaks through the surface, so far wholescale violence has been avoided. I think this is at least partially because of a unique invention of American Progressives – Diversity.

The Importance of Diversity

“Diversity” was once merely a pleasant feature of some population or group, a nice-to-have, a quality that implied a certain open-mindedness, an acceptance of different kinds of people, or thoughts, or music preferences. In recent years, however, Diversity has been transformed into the Uber-Virtue, the highest virtue of all, the virtue from which all the other subsidiary (formerly cardinal) virtues must necessarily spring. Today, when planning any new endeavor, no matter of what type or for what purpose, your chief and overarching consideration must be – can only be – to achieve Diversity.

How did it get to be this way?

It all comes from the Progressive Program, which, again, is to create the perfect society. The Progressive elite know just how to do this, of course, but individuals within every population throughout human history have insisted upon acting in their own self-interest, which is counterproductive to the collective goal. In many places which have made similar efforts to perfect human societies, such individual recalcitrance has been dealt with by means of concentration camps and pogroms and the like.

“Diversity” is a much kinder and very much gentler approach to curing the problem of individualism. With a critically important goal like that, Diversity has naturally assumed a primary place in our society.

Specifically, the doctrine of Diversity defines the range of permissible behaviors and thoughts – Right Actions and Right Thoughts – for a given group of people within a society. Diversity informs you of how to be a legitimate and accepted member of your group.

The numerous celebrations of Diversity we see all around us invariably turn out to be strategies to reinforce those allowable ranges of thought and behavior. In this way, members of a particular group can be individually celebrated as embodying the characteristics assigned to the group. Conversely, those who begin behaving and thinking outside the allowable range can be quickly identified and dealt with, either through correction (which brings them back into the group), or through vilification (which completely marginalizes and devalues them within society). So, for instance, Al Sharpton and Jesse Jackson are celebrated individuals, whose accomplishments nicely reflect their assigned group identities. In contrast, Clarence Thomas and Thomas Sowell are not celebrated by Progressives, and indeed are castigated as abominations, because their individual accomplishments do not reflect their assigned group identities.

This concept, I believe, also helps us to understand what Progressives mean by “racism.” Racism is when you criticize a person, for any reason, who is acting entirely within the expected range of behaviors of their assigned group. On the other hand, it is not racism – and indeed, it is strongly encouraged – to criticize a person who is acting outside of his/her allowable range of behaviors. So criticizing Louis Farrakahn for calling Jews devils is racist. Saying anything nasty about Thomas Sowell, for any reason whatsoever, is perfectly acceptable.

Similarly, the concept of Diversity helps us to understand why it is laudable for Progressive commentators to say extraordinarily vile things about Ms. Palin and Ms. Bachman (and their children); but it is the height of sexism (sexism being a mortal sin) for Conservative commentators to say equally vile things about Sandra Fluck (the Georgetown law student who voluntarily testified before a Congressional subcommittee in early 2012 to ask for free contraceptives). I was raised in an era when it was unacceptable to say such horrible things about any woman, and believe Mahar, Letterman and Limbaugh all ought to be ashamed of themselves. But by the lights of Progressivism, since those Conservative women are acting well outside the bounds of acceptable behavior for their group (i.e., Women), making defamatory statements about them (and theirs) is no less than they deserve. Ms. Fluck, needless to say, was acting in precisely the prescribed manner, and so any negative statements (vile or not) about her are entirely verboten.

I want to emphasize the beauty of this formulation. It allows Progressives to make passionate and heart-felt – but highly selective – charges of racism, sexism, homophobia, &c. against their adversaries, while engaging in precisely the same behavior themselves, and without being in the least bit hypocritical. Hypocrisy is when one espouses certain principles, but then acts in a way that violates those principles. But the actions of Progressives in making charges of racism &c. are entirely consistent with their Diversity dogma, right down the line, and hence do not constitute hypocrisy.

To a great extent the potential worth of an individual in society is pre-determined by the group to which the individual belongs. People belonging to White Male, for instance, appear to have lesser intrinsic value to the ultimate goal of societal perfection than people belonging to Hispanic Female, even if they are particularly exemplary members of the White Male group.

Therefore, while individuals within Progressive societies can achieve a certain level of importance, individual importance is merely of tertiary concern, rather than primary or even secondary concern. Individuals can become officially “important” only if their importance reflects the essence of their assigned group; and the importance of the assigned group (the secondary concern), in turn, is proportional to its ability to advance the Progressive Program in general (which, of course, is the primary concern).

In summary, Diversity is critical to Progressivism because group identity is the best available mechanism by which the Progressive leadership can attempt to control and direct individual behaviors without resorting to violence. It is, in fact, a brilliant invention.

I know it is easy to become confused about this, since classically “diversity” means something other than “conformity.” You may find it helpful to remember a general rule about Progressives: If you want to know what Progressives are really up to, listen to what they say and then look to see if their deeds are actually working toward the opposite thing. Frequently you will find that they are.

Progressivism and Religion

Progressives have a natural aversity to organized religion. This is for three reasons. First, most major religions find a higher authority than the enlightened leadership the Progressives propose to create for us. Second, most religions are too concerned with some sort of afterlife, and insufficiently concerned with creating paradise right here on earth. And third, the major religions stress individual conscience and individual salvation over collective priorities.

Apparently realizing that abolishing religion is far too difficult a task, Progressives have adopted the long-term strategy of infiltrating and co-opting religious establishments, and by means of introducing new ideas – such as “group salvation,” and the concept of social justice as a religious imperative – rendering religion, this “opiate of the masses,” less incompatible with the Progressive Program.

Progressives do find certain religions more acceptable than others at various times. Such partiality certainly does not appear to depend in any way on the precepts or beliefs of any particular religion, but rather, on whether temporarily showing sympathy for it might in some manner advance their Program.

Good and Evil In Progressivism

In a similar vein, Progressive intellectuals are known for asserting that there are no absolutes, and so there is no such thing as inherent good or inherent evil, or inherent right or wrong. So, for instance, being against gay marriage because you believe it is “wrong” on religious grounds simply does not signify.

This general attitude toward good and evil is easily explained by the simple fact that true Progressives deny any authority, any arbiter of values, that is above their own enlightened leadership. Saying that something is intrinsically “good” or intrinsically “evil” clearly implies such a higher authority, and so, such statements must be delegitimized.

In general, this kind of moral relativism in Progressive thought holds up quite nicely, except in one area. That is the area of Progressivism itself. Because the Progressive Program is the innate agenda for mankind, there indeed exists a standard by which one can (and must) determine good and evil.

“Good” is anything which advances the Progressive Program; and “evil” is anything which threatens it.

Anyone who doubts the existence of good and evil within the Progressive Program need only observe the scores of behaviors and figures of speech which are condemned as unrelentingly evil by Progressives, with all the wild-eyed fervor of a Jonathan Edwards.

Accordingly, individuals who hinder the Progressive Program are a danger to mankind’s very essence. They are evil, and must be rehabilitated or eliminated.

Progressivism and Environmentalism

Radical environmentalism and the Progressive Program are not perfectly compatible with one another. But they are close.

Radical environmentalists believe that humanity is a plague upon Planet Earth. Everything man has done since the day he first learned to cultivate crops (and thus for the first time became a different kind of animal) has been bad. And anything which delays, halts or reverses the sins mankind has perpetrated upon sacred Gaia, since that day he first departed from Nature, is a good thing. So the radical environmentalists tend to favor strong central governments which (with the help of their Progressive allies) they can influence to control the destructive behaviors of individuals.

Progressives are certainly on board with controlling man’s effect on the environment, but (in most cases) they are not in favor of returning mankind to a hunter/gatherer condition (since most Progressives do not view this condition as the embodiment of a perfect society). Rather, they view the environmental movement – in particular, the Global Warming Theory – as a good way to get the populace to grant sweeping new powers to the Central Authority, which they can then use to carry out their Progressive Program. So Progressives have completely embraced the Global Warming Theory, chiefly as a means to their own political ends. Accordingly they have awarded it the status of Progressive Dogma, pronouncing man-made global warming to be “settled science.” They suppress any efforts to study it further, and declare anyone who dares question it to be the moral equivalent of a Holocaust denier.

This is really too bad. I suspect that global warming is occurring, and I will even concede that human behavior may be playing a role. So I am saddened that this scientific question has been declared off limits, and has been absorbed into the Progressive Program in such a way that we are not allowed to find out what’s really going on. It leaves people like me (who think the Progressive Program is deadly) little choice but to oppose the environmentalist and global warming agenda.

Progressivism and the Intrinsic Value Of Human Life

Progressivism by definition values the individual primarily (and often, solely) as a function of their value to society. True Progressives do not impart any real, intrinsic value to human life itself.

Most Progressives are reluctant to say so publicly, and it is likely that most small-p-progressives value human life as much as anyone else. But it does indeed appear to be a regular and recurrent theme of the Progressive Program to devalue human life.

Progressives will justify their belief that late-term abortion, near infanticide (killing babies who are born alive after a botched abortion), frank infanticide (proposals to allow parents to kill their recently born children if they decide they would rather not have them*), or performing involuntary euthanasia on sick people, are reasonable options by the simple expediency of re-defining what it is to be “human.” If you are truly “human,” they will say, then of course they sanctify human life. It’s just that they reserve the right to determine who is and who is not truly human, based on arbitrary and moveable criteria.
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*Giubilini A, Minerva F. After-birth abortion: Why should the baby live? Journal of Medical Ethics. March, 2012.
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The most visible example of the Progressive attitude toward the sanctity of human life is seen by their support of eugenics. Since World War II, openly espousing eugenics has become unfashionable, for obvious reasons. But eugenics, historically, has been inherently bound to Progressivism. The idea is easy to understand when you consider that, one way or another, a perfect society will require far more perfect citizens than we have today. Indeed, the seething contempt with which Progressives regard the current genetic pool that comprises the unwashed masses is often difficult for them to suppress.

To a large extent, modern Progressivism was born as an offshoot of Darwinism. The idea that society could be perfected, and the idea that mankind could be perfected, were two sides of the same coin. And early Progressives unabashedly embraced both of these ideas, such that the idea of “culling the herd” became extraordinarily attractive to them – and they said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger (the founder of Planned Parenthood) are only the most well-known Progressives who publicly extolled the idea of eugenics.

One can argue, of course, whether the recent Progressive support of such activities as late-term abortions, or creating human embryos for experimentation, are partially aimed at desensitizing the public for future efforts to “guide” a more favorable genetic makeup for the population. Either way, I believe it will be useful for us to keep in mind the historic propensities of Progressivism in this regard.

It is the Progressives, after all, who, in our new healthcare system, will be determining who gets what, when and how.

Progressivism and Animal Rights

This one, I’ll admit, has been a puzzle to me. How can the same people who celebrate the right to late-term (or even post-term) “abortion” become so very exercised at the thought of mistreating a dog, or using cute bunnies for medical research, or the death of a snail darter?

I have come to the conclusion that it’s related not so much to a desire to elevate animals to the status of humans, but rather, the opposite – to help finish the job of reducing the status of individual people to that of any other animal. Again, such a diminished view of human life will come in handy as Progressives are deciding how to distribute healthcare resources.

Progressivism and Politics

Under the Progressive Program, as Aristotle says, mankind is essentially a political animal. In fact, the Progressive Program (in general) can only be achieved by political action. This means that politics – and to be clearer, political control – is the fundamental work of Progressives. Without politics, without political control, there is nothing. To lose political power is oblivion.

Not all Progressives, of course, run for elective office. Many more of them go into “public service,” wherein they spend their entire careers becoming deeply imbedded into the multitudinous governmental bureaucracies, in all three branches, and at all levels.

For Progressives, politics is everything, the essence of human behavior. And it is worth any cost, any desperate measure, to maintain political control. Indeed, to fail to lie, cheat and steal in order to keep political control would be unethical. This is why they think any proposal that would limit their ability to commit what most Americans would consider election fraud is immoral, and must be indignantly put down.

This attitude toward politics is in stark contrast to the attitude of non-Progressives, and especially of Conservatives, for whom government (and therefore politics) is merely a necessary evil, with which one must occasionally contend when it cannot be avoided. For most Conservatives politics is an afterthought.

What this means of course is that Progressivism has progressed continuously, for over a century, despite the fact that a majority of Americans still appear not to subscribe to their Program. Even in those intervals where Conservatives roust themselves into action, and take temporary control of the Presidency or a house or two of Congress, the deeply-imbedded Progressives are still there, busily gumming up the system at every level, until such time as their leaders again are in the ascendancy.

Progressivism and the Great American Experiment

Unlike any other nation in the history of mankind, the United States was not founded because of geography, race, religion or ethnicity. It was founded on an idea. It was founded on the still-radical idea that individual autonomy – the individual’s God-given right to life, liberty, and the pursuit of happiness – is the chief Fact of humankind, and that the only legitimate role of government is to create an environment in which individuals can enjoy those rights to the fullest extent possible.

One can see immediately that the Great American Experiment – which awards primacy to individual autonomy – is fundamentally incompatible with Progressivism. But because a majority of Americans still like the ideas expressed in the Declaration of Independence, the Progressives need to play their cards close to their chests. They need to proceed carefully – but relentlessly.

By slowly re-interpreting the Constitution, and slowly addicting a critical mass of Americans to an array of government programs, Progressives are certain they will ultimately prevail. They have been at it for over 100 years, and have come a long way.

I personally cannot tell whether or not we have already passed the Event Horizon, the point beyond which restoring the Great American Experiment will become impossible. But we are at least very close.

In fact, one plausible theory for President Obama’s headlong pursuit of healthcare reform (and other policies which tend to anger the majority of Americans), is that he sees America as being at the very cusp of that Event Horizon. One, last, great push – Obamacare – will sufficiently expand government control – and government dependency – to render the Progressive Program irreversible, whatever might happen in the next election or two.

In any case, whether the President’s gamble pays off or not, the Progressive assault on the Great American Experiment has at least placed it in mortal jeopardy, and mankind’s one (and possibly only) shot at creating a society in which individual rights are paramount is in grave danger of oblivion.

Progressivism vs. Socialism, Communism, and Fascism

To this point I have avoided directly comparing or contrasting Progressivism to the more commonly discussed economic and political systems of Socialism, Communism, or Fascism. And actually, I would have preferred to leave it this way. As I have said, I am not a political scientist, and so I am not as interested in relating Progressivism to these other -isms, as much as I am in simply characterizing the behavior of the people who will actually be running my life, and the lives of my family and loved ones.

But I know from experience that if I do not directly address this topic, readers with a certain frame of mind will be dissatisfied with my theory of Progressivism, no matter how well it predicts the behavior of Progressives.

So I will do my best, very briefly, to place Progressivism into its proper place relative to these other major political/economic systems.

Progressivism falls into the larger category of collectivist systems. That is, it is a political system in which individual rights and individual freedom of action are subservient to the needs of the collective, and whose chief goal is to run things for the optimal benefit of the collective whole.

Also within the category of collectivist systems are Communism, Socialism, and (some authorities maintain) Fascism.

Communism (the kind that has actually existed in various countries, not the impossible kind which Marx described) is a system in which all property is owned by the state, which in theory acts as a proxy for the “people”. The job of the state is to arrange things so as to achieve a reasonably high and reasonably equal level of “good” for everyone.

Socialism is a much broader and much less restrictive form of collectivism, since, while the state may own all or much of the property, socialism is also fine with a certain species of private ownership. Under socialism, individuals or private organizations may own even large amounts of property, but their control over that property – what they are permitted to do with it, or how they may dispose of it – is largely controlled (or “regulated”) by the state. The state also reserves the right to decide when somebody owns too much property, and has the authority to “redistribute” some or all of it, to further the goals of collective fairness (i.e., social justice).

Under Fascism, individual freedoms are also subservient to the collective goals, and the state has the right to confiscate private property any time it deems it desirable to do so. This (and the fact that Nazis referred to themselves as socialists) causes many authorities to classify Fascism as a collectivist system. But Fascism differs greatly from Communism and “real” Socialism in that the overarching goal of the latter two systems is to achieve a reasonably high and reasonably equal level of good for everyone, whereas the overarching goal of Fascism is to establish a certain faction of the population (an ethnic group, or the party) as a master race, and anyone else who is suffered to continue living as subservient peoples. So Fascism is collectivist only in the narrow sense that by the “collective” you are referring only to the favored group.

Given these constructs, Progressivism is a species of Socialism. As I have just defined Progressivism, it is in fact a fairly uniquely American form of Socialism. It is a harder-edged, more muscular form of Socialism than, say, European Socialism.

European Socialism has been the most successful form of collectivism to date. In particular, unlike other collectivist systems we have seen around the world, it has not led to violent suppression of the people by the Central Authorities. I believe this is largely because of the history of Europe – centuries of monarchies and non-mobile societies in which status was related to birthright, culminating in two extraordinarily destructive wars that deeply and directly affected virtually every member of society. This history rendered the idea of socialism (subsuming individual freedom – which had never amounted to all that much anyway – for the promise of stability and security) quite attractive to most Europeans. When Western European countries adopted Socialism, their leaders could afford to be open an honest about what they were attempting to do. And Socialism was broadly embraced by the people, to a large extent, with open arms and a sense of relief. Even today, with the European debt crisis (which is the other end-result of collectivism) threatening to wreck the entire system, most Europeans still love their brand of Socialism, and the relative (though temporary) security it has brought them.

In contrast, American Progressives have the difficult task of having to upend – as surreptitiously as possible – a foundational philosophy that is the polar opposite of collectivism; a system founded on the inalienable rights of the individual, in which the chief job of the government is to provide national security and a reasonably level playing field on which individuals can compete – and otherwise stay out of the way. It is a system that most Americans still like, and do not want to end. So the Progressives’ task has been monumentally difficult. They have had to carry out their Program without being able to say openly what their Program is really all about. Even now, when they are on the verge of success, their success relies largely on the fact that most Americans don’t realize what is about to be taken away from them.

Having to operate in the milieu of the Great American Experiment has made American Progressives – the ones who are really running things, not the large majority of progressives – hard-edged and realistic. They are not immersed in the usual bright-eyed idealism that characterizes most Socialists who first ascend to political victory. American Progressives don’t expect things to go smoothly. They have had, of necessity, to be cagy about what they were doing. They had to prevaricate. And they realize that most Americans are only slowly awakening to the realities of Progressivism. Progressive leaders know they will have to use coercion, cajoling, bribery, threats, selective prosecution, intimidation, and lots and lots of smooth talk to maintain their newly-won positions. American Progressives know what they are up against, and promise to be relatively ruthless, relatively merciless, in consolidating their authority. They have worked long and hard for this opportunity and will be ready for it, and they will be very formidable indeed.

I realize that this synthesis of Progressivism will be highly objectionable to many progressives, who honestly believe that their political philosophy is simply the fairest one there can be. To these, some of whom I have counted among my closest friends, I beg only three things. First, please take an objective look at the history of collectivist systems in the world during the last hundred years. Second, try to articulate, with an equally objective view, exactly how my synthesis is mistaken, and specifically, how it fails to explain the actual behavior we see from American Progressives. And third, ask yourself whether you are really prepared to assist in scuttling the Great American Experiment.

In any case, if there is going to be a fight to slow the march of Progressivism, it will have to be on the battleground they themselves have chosen, and on which their forces already have been fully arrayed. That battleground is our healthcare system.

This is Chapter 3 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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Chapter 3 – The Cowing of the Medical Profession

“Did you really think that we want those laws to be observed? We want them broken. You’d better get it straight that it’s not a bunch of boy scouts you’re up against . . . The only power any government has is the power to crack down on criminals. Well, when there aren’t enough criminals, one makes them. One declares so many things to be a crime that it becomes impossible for men to live without breaking laws. Who wants a nation of law-abiding citizens? What’s there in that for anyone? But just pass the kind of laws that can neither be observed nor enforced nor objectively interpreted and you create a nation of law-breakers.”

- Floyd Ferris, bureaucrat – Atlas Shrugged

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The doctor who tells his patient to open wide and say moo is, in fact, projecting.

For the once proud, once ethical medical profession has been officially broken and domesticated. This, of course, is incredibly sad for the profession.

But it is life-threatening for patients.

And while it began a long time ago, the gradual destruction of the medical profession became a headlong rush in the 1990s, and ended with a final, formal capitulation in 2002. To be sure, doctors did not go voluntarily, but were coerced – by both the avaricious insurance companies and the ruthless government – to sacrifice their professional autonomy for the sake of their personal comfort and safety. The coercion was intense, but still, their resistance was remarkably feeble. In the end they did not fight as they might have to protect either their profession or their patients’ welfare. When the time came they chose not to defend their professional integrity with their lives, their fortunes or their sacred honor.

It is a sorry tale, but it must be told.

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After the collapse of the Clinton healthcare reform plan in 1993, both the triumphant HMOs and the beaten-back government plotted their moves. For the insurers, the pathway seemed open and clear. For government policymakers, chastened as they were, the pathway forward seemed no less clear – but it would have to be negotiated in a somewhat less open manner than they had originally hoped.

When these two powerful entities sat down in their respective bunkers to figure out next steps, they each came to the same conclusion: At the end of the day, the key to controlling the healthcare system was to control the behavior of physicians.

This became apparent the moment the accounting experts from the HMOs and various government agencies studied the matter in order to determine where all their money was going. What they saw horrified them.

They saw, 1.5 million times per day, a single doctor sitting down with a single patient, and – just between the two of them – deciding which extraordinarily expensive healthcare resources they would like to consume for the possible benefit of that individual patient. And, once reaching a decision, the doctor then would calmly scribble something on a prescription pad, or write a line in a hospital chart, and instantaneously all the resources of the massive, mindless healthcare system would heave into action, bending to the doctor’s will. And, seeing all this, the HMO executives and the government policymakers, separately but with equal fervor, each sat up and cried, “My God! They’re spending MY money!”

Something had to be done to get these doctors – the engines of all healthcare spending – under control. The strategies the insurance industry and the government used to control the behavior of doctors were quite different from one another – but both were effective. And as a result of these efforts, as we enter the era of Obamacare, the Central Authority will find the medical profession to be quite compliant and docile to its needs. To be sure there will be a bit of whining from physicians, and expressions of dissatisfaction and similarly ineffectual complaints, but these are easily dealt with. Doctors will not pose any real obstacle to Obamacare. They have been fully domesticated.

What The HMOs Did

HMO executives, being businessmen, set out to control doctors the only way they knew how – by attacking them in their wallets. Promise them riches beyond belief (or at least the wherewithal to make a decent living) if their behavior pleases you, but make sure they know that destitution awaits if they should displease you.

It did not take long for these smart business experts to figure out that to control the physicians’ wallets, you need simply take control of the flow of their patients.

Doctors in the early 1990s were used to getting their patients by the hard work of establishing their professional reputation, and relying on referrals from appreciative colleagues and by word of mouth. When the HMOs suddenly moved in, before physicians ever realized what was happening, that model disappeared virtually overnight.

Under the HMOs, insurance products no longer covered patients for whichever doctor they chose to see. Instead, in exchange for reduced premiums, their health insurance covered them only if they received their care from doctors who had been admitted to the HMO’s “physician panel.” Doctors all over the land quickly learned that patients they had cared for, sacrificed for, and worried over for years, and who (they thought) regarded them as part of their family, dropped them like a hot potato the moment they had the opportunity to choose a health insurance plan which was marginally cheaper, but which did not include them on its panel of physicians.

And it quickly dawned on doctors that, if they were going to maintain themselves in anything like the style to which they had become accustomed, they needed to get on every panel of every HMO that served their area. It was the only way to allow all their patients to continue to have access to them.

But once doctors were “captive,” (i.e., completely dependent upon their position on HMO panels for their livelihood), the game was was all over except the shouting. Physicians were cooked virtually before they knew what had happened to them.

At first, the HMOs were happy to have all physicians on their panels. This is because at first, the HMOs’ major priority was signing up just as many patients as they could – so including as many doctors as possible on their physician panels was an important aspect of recruiting subscribers.

But once this initial sign-up phase was over, the HMO executives no longer had use for all those doctors on their panels. Some were expendable. They let their doctors know it by terminating a few of them from time to time, apparently arbitrarily and without explanation – leaving the surviving doctors to guess the reason for it.

But since doctors are generally pretty smart, they were good at guessing the heart’s desire of the HMO executives.

It should be obvious that HMO executives would be anxious to get rid of doctors who spent a lot of their money, and retain the ones who did not. To distinguish between the two, HMOs set up “performance standards.” These standards, following the usual fiction, were billed as “quality” measures, but in general they actually seemed aimed at determining how much money various doctors were spending. Often, something like 10% of the physician’s annual reimbursement was held back as a “withhold,” payable to the doctors only if they met the published performance standards. Doctors who failed to meet performance standards not only did not get the rest of the money they had earned, but worse, were in danger of being cut loose from the HMO’s panel altogether, thus jeopardizing their livelihood.

This system quickly got physicians into the right frame of mind, and focused them quite nicely on whose interests they actually needed to keep at the forefront when they were making clinical decisions for their patients. It also prepared them to put up with more of the HMOs’ new management techniques.

Once each quarter, some men in dark suits would come to visit. They were “practice consultants,” and they were there to help. The practice consultants would use data the HMO had accumulated to assist the doctor in re-titrating his or her decision-making processes, in order to guarantee they were practicing medicine to everyone’s best advantage.

For instance, the practice consultants might say, “Dr. Smith, we notice that the patients in your practice cost our HMO an average of $342 each last quarter. This is unfortunately higher than the target we set for you of $315. We are distressed to have to mention that this puts you in some jeopardy regarding your “withhold,” and possibly of further action as well. But we are here to help. Let’s see how we can do that. Ah! Here’s something. Notice that you sent four patients last quarter to Cardiologist Jones, and Cardiologist Jones spent an average of $4300 doing whatever it is he did to evaluate and treat those patients. And you sent three patients to Cardiologist Wilson. And she only spent $2100 per patient. That is quite a difference, isn’t it, Dr. Smith? Hmm. Well, Dr. Smith, you know we would never tell you how to practice medicine – you’re the doctor! – but we thought you might find this cost differential interesting, as you decide where to refer your next patient.”

And while Cardiologist Jones and Cardiologist Wilson have entirely different areas of expertise, which Dr. Smith had formerly taken into account when deciding where to refer his patients, his new-found wisdom now dictates that it might be best if Cardiologist Wilson would become his new go-to cardiologist for all cardiac-related problems his patients might have. And Cardiologist Jones, when he notices a marked decrease in his referrals during the following quarter (since the men in suits visited lots of primary care offices in the area), will probably never know that he (as well as many patients) has become the victim of trickle-down covert rationing.

Another common methodology to improve the quality of care, in a manner that would save the HMO money, was to institute Pay for Perfomance programs. P for P initiatives provided primary care doctors with a checklist of 10 or 12 items that they would need to accomplish during each patient visit, if they would like to be paid. The checklist consisted mainly of things that everyone would have to agree are useful – things like checking and discussing blood pressure and cholesterol levels, and reviewing their dietary and exercise habits, smoking habits, &c. There would be nothing on the list that anyone could possibly object to. However, the lists were so constructed that it was impossible to complete them in less than 10 minutes or so. And that, too, would have been fine, except that in order to meet the patient load the HMOs required, doctors needed to see a patient every 12.5 minutes. And here you can begin to see the true brilliance of P for P.

P for P saw to it that the routine health maintenance stuff got done each and every visit. But P for P also saw to it that there would be little or no time for “ad libbing,” that is, for the patient to bring up new, potentially-expensive medical issues, or, if the patient managed to blurt something out, for the doctor to adequately assess it. At best, the patient would have to reschedule another visit, for perhaps a month or two later. By that time the problem might be resolved, or might have run its course. Or perhaps something else might happen to make the new medical issue, well, moot.

Severely limiting the doctor’s face time with patients, then carefully scripting, down to the minute, what is to take place during that limited time, creates an opportunity for real cost savings. This is the kind of benefit you get when you apply modern management techniques to a trade whose processes really hadn’t changed much since the Middle Ages.

Through these and other creative applications of business principles, in a matter of a couple of years the HMOs owned doctors, lock, stock and barrel. And to make it official, in the middle years of the 1990s (once doctors realized that being retained on HMO physician panels was a matter of life or death), HMO executives invented the “gag clause,” which they added to the doctors’ contracts when it came time for renewal. Gag clauses said something like this:

“The physician agrees not to take any action or make any communication or representation to patients or patients’ families, potential patients or potential patients’ families, employers, unions, the media, or the public that would tend to undermine, disparage, or otherwise criticize the healthcare coverage provided by [insert name of HMO here]. The physician further agrees to keep all proprietary information such as payment rates, reimbursement procedures, utilization-review procedures, or other processes and procedures related to billing, collection, or review, strictly confidential.”

Agreeing to keep such potentially vital information from their patients – information which might materially affect a patient’s decisions regarding his or her own healthcare – was of course a direct violation of medical ethics. Medical ethics, however, had long since gone by the boards. The moment they had acceded to “performance standards” that enticed them to withhold medical services – and also acceded to sundry other coercions which HMOs had dreamt up to make sure physicians answered to their needs instead of their patients’ – doctors had already become deeply complicit in bedside healthcare rationing, essentially, rationing by omission. The gag clauses just put it in writing. So, apparently believing they had no good options, and already having lost the professional integrity which they ought to have held dear, doctors signed contracts by the thousands with gag clauses in them.

After a few years the gag clauses were noticed by “patient advocates” and other species of troublemakers, and strong objections were raised to them. The objections were based on the notion that it’s not nice for HMOs to gag physicians from telling their patients things that they ought to know. So, gag clauses were finally removed from HMO contracts.

But the damage had been done; the essential point had been made. When HMOs had asked doctors for a declaration of fealty that superceded all pre-existing professional obligations, doctors gave it, and with barely a protest. Whether or not gag clauses continued to appear in the contracts was immaterial. Once a dog learns to heel you can get rid of the leash, and the dog still heals just fine.

What The Government Did

The defeat of the Clintons’ healthcare reform plan certainly set the government policymakers back. The Progressives’ plans for a government takeover of the healthcare system, all in one grand campaign, had been foiled. But Progressives always take the long view, and they were undismayed. They quickly regrouped, and began stealthily instituting as much of the defunct Clinton plan as they could, piece by piece, through various laws, budgets, executive fiats and riders on Congressional bills.

Like the health insurance companies, Progressives in the government also recognized that it was imperative for them to gain control of the behavior of doctors. Hillary probably had said it best: “The problem with our healthcare system is too many greedy doctors using too much expensive technology.” So the name of the game was controlling the greedy doctors, the decision-makers on the ground.

The methodology they employed to do so was fundamentally different from the methods used by HMOs. HMOs naturally concentrated on controlling physicians by the power of economics, through simple threats to their livelihood. But as Ayn Rand taught us so many years ago, the power of the government over its citizens derives from regulatory (ultimately, prosecutorial) intimidation.

There is no need for the government to go all Robespierre, however. Actual bloodshed can be minimized. The Feds can usually get the effect they need by sending in the regulators – always backed by the threat of legal violence, of course – to harass a few people, ideally for what appear to be entirely arbitrary reasons. This action always proves wonderfully intimidating to the rest, and is an effective way to focus people’s attention on that which you would like them to focus.

I will be devoting much of the rest of this book to the abuse of government power with regard to healthcare, and don’t want to get too distracted by that topic here. So I will simply describe a single foray the government made in the time frame we’re talking about – the late 1990s – aimed at teaching doctors what is expected of them, and letting them know who they really work for. By doing so, I hope to make a bit more understandable why the medical profession made a complete and disastrous capitulation in 2002.

The E&M Guidelines

During the second Clinton administration, a new set of tortuous documentation requirements were imposed on American physicians by our government. The E&M guidelines, for “evaluation and management,” apply to the documentation that physicians are obligated to provide in support of their Medicare billing. The E&M guidelines, first instituted in 1995 and revised in 1997, were part of the Clintons’ great healthcare fraud reduction initiative. Ostensibly, the new, very strict documentation requirements would reduce the opportunity for fraudulent billing.

However, the E&M guidelines were, from the very beginning, a Regulatory Speed Trap of the first order. Regulatory Speed Traps work like this:

1) Over a long period of time, regulators will promulgate a confusing array of disparate, vague, poorly worded, obscure and mutually incompatible rules, regulations and guidelines.
2) Individuals or companies which need to provide their products or services despite such hard-to-interpret regulations, will necessarily render their own interpretations (usually with the assistance of attorneys, consultants, and the regulators themselves), and will act according to those interpretations.
3) By their apparent concurrence with, or at least by their failure to object to, such interpretations of the rules, the regulators over time allow de facto standards of behavior to become established.
4) When it becomes to their advantage, the regulators will reinterpret the ambiguous regulations in such a way that the formerly tolerated de facto standards suddenly become grievous violations.
5) Regulators aggressively, but selectively and arbitrarily, prosecute newly felonious providers of those products or services.

The E&M guidelines are so convoluted as to be unworkable in any objective way. Through their utter opacity and complexity, only partially reflected by the 48 pages of dense prose that comprise them, the E&M rules (for “rules” is what they are) in fact greatly magnify the doctor’s opportunity for making inadvertent documentation errors, and thus of producing a “fraudulent” bill.

Under the E&M rules, writing what used to be a simple progress note in a patient’s chart requires the physician to assemble a complicated set of “elements” from Column A and Column B, as from a Chinese menu, for each of four subject areas of the patient “encounter” – the history, the physical exam, the assessment, and the plan. Then somehow, one must translate the result (which reads like – and often is – a computer-generated form letter) into a billing code.

Despite the morass of confusion caused by the E&M guidelines, any failure to follow them to the complete satisfaction of the Central Authority is a priori evidence of Medicare fraud or abuse. And therefore, the E&M guidelines assure that with each and every patient encounter, the thing that will be foremost in the physician’s mind is not the needs of the patient, but how to fill out the complex documentation in such a way as to avoid the appearance of committing a crime.

In practical terms, this means filling out the documentation so as to blend in with the masses, so that one’s records will be passed over by the sharp eyes of the greedy forensic accountants (who are paid by commission for detecting instances of substandard documentation, now construed as “fraud or abuse”), or even worse, by the sophisticated software now being deployed to detect ever-more nuanced gradations of “outliers.”

The bottom line is that virtually any doctor who uses the E&M guidelines, and virtually all doctors do, are always guilty of healthcare fraud. It’s just a matter of who gets investigated.

Even if this documentation mess resulted in a straightforward means of determining proper billing codes (which it does not), it results in a medical progress note that is virtually undecipherable. This means that when another doctor (or even the same doctor on a different day) tries to read the progress notes to figure out what’s been going on with the patient (which used to be the point of medical progress notes, before they became primarily a vehicle for auditors), they cannot. Compliance with the E&M guidelines often actively confounds patient care.

The E&M guidelines were recognized immediately by doctors as a complete abomination. Indeed, the great hue and cry from angry physicians caused the Secretary of HHS to appoint a special commission to review the E&M guidelines in 2001. The special commission reviewed the evidence and concluded that indeed, the E&M guidelines were entirely counterproductive to patient care. In June, 2002 the commission voted (20-1) to recommend abandoning them altogether.

But HHS declined to follow the recommendations of its own commission, instead leaving the E&M guidelines in place “temporarily,” and vaguely promising to revise them “soon” in order to make them less dangerous to patient care – knowing full well that the saurian lassitude of the bureaucracy would easily outlast the fleeting indignation of the medical community. And, as the bureaucrats predicted, there has not been any substantial noise from doctors about revising these guidelines for several years now. A whole new generation of doctors has been weaned on them, and does not know any better. The E&M guidelines have become as permanent as the IRS.

(This simple example ought to teach us how difficult it will be to roll-back any of our new healthcare reforms in the future, even ones that are officially deemed to be harmful.)

Not only has HHS failed to take (or, alternately, succeeded in not taking) the steps it promised to take to revise the E&M guidelines, they also have vigorously pressed forward with audits and prosecutions for the federal crime of healthcare fraud, based on physicians’ inadequate compliance with them.

In a well-publicized test case, instituted by the government shortly after the E&M guidelines were first implemented – apparently to let doctors know they were deadly serious about this – criminal charges were brought against a Montana family doctor, alleging medical coding violations. But the government’s own expert concluded that the prosecutors were holding the doctor to standards that were not yet in force at the time the bills were submitted, and that the government was applying its new rules retroactively. The expert was so disturbed by his findings that he even offered to switch sides and testify for the defendant. Unfazed, the government simply switched tactics, dropping criminal charges and instead initiating a civil suit against the doctor for $37 million – which is way more money than the average family doctor has on hand. The defendant, breaking from the usual pattern, fought the government instead of settling. And after a long, long time, she was finally cleared – but not before she had spent over $300,000 out-of-pocket in legal fees.* Nonetheless the Feds had made their point to the physician community, loud and clear: We intend to vigorously prosecute physicians for violation of these guidelines, whatever you may think of them, and whether we’re acting fairly or unfairly.

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*Paul Rosenzweig, Senior Legal Research Fellow, The Heritage Foundation, testimony on “Sentencing and Enforcement of White Collar Crimes,” Subcommittee on Crime and Drugs, Committee on the Judiciary, U.S. Senate, June 19, 2002, p. 9.
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Every doctor in America suddenly realized just how serious the Feds were about enforcing these ridiculous, clinically counterproductive coding guidelines.

Frightened by the prospect of prosecution for Medicare fraud, many doctors adopted the tact of systematically “downcoding” their Medicare bills, figuring that they are unlikely to be brought up on fraud charges for underbilling. And normally one might think that the Feds would consider this a victory, since it would result in their keeping money they should be paying out. But the Feds’ purpose here was only secondarily to save money. Their primary purpose was intimidation – showing those doctors who’s the boss. So Medicare let doctors know that systematic downcoding may also be considered a fraudulent act, since it shows contempt for the law, and doctors suspected of doing so will be audited.

Because of the clear and present danger the E&M guidelines pose to every doctor, a multi-million dollar industry has sprung up to help physicians better comply with these coding guidelines. Physicians across the country are spending the time and money allotted for their continuing medical education learning to become better accountants, rather than better physicians.

Which brings me to a very interesting point about the E&M guidelines: It is not actually possible to follow the E&M guidelines accurately.

It turns out that coding correctly is impossible. This was proven in a formal study conducted a few years after these guidelines were instituted. A group of government-sanctioned coders took a sample of typical doctor-patient visits, coded them according to the E&M guidelines – and they all got different answers. If government-approved coders, using the government’s own guidelines, cannot figure out how to arrive at what prosecutors will always insist is the singular correct answer, then what hope do mere doctors have? (The results of this study were published in the Annals of Emergency Medicine in September, 2002.)

Obviously, then, since there is no “right” way to comply with the coding rules, all a doctor needs in order to become guilty of abusive billing, if not outright fraud, is for the fickle finger of the Feds to point his way, and initiate an audit. Violations are virtually guaranteed to be found during any audit. So what we’ve got here is a well-documented, openly acknowledged, published-in-peer-reviewed-literature Regulatory Speed Trap.

Here’s what happens to doctors who are suspected of committing coding abuse (which is to say, to any doctors who are visited by Federal auditors):

1) A small sample of their patients’ charts is audited.
2) The coding error rate (which is determined by the auditor) will be calculated for that sample, then that error rate is applied by extrapolation to every Medicare bill the doctor has submitted for the past 6 years (the statute of limitations).
3) For each violation in coding the doctor is estimated to have committed during those six years, the doctor must pay: a) triple the amount of restitution, plus b) $11,000.00 per coding violation.

It is not unusual for audited doctors to be hit with hundreds if not thousands of coding violations over a 6-year period, and the fines will almost always amount to well over 7 figures, if not 8. However, if it’s just abuse the doctor has allegedly committed and not fraud, often the Feds may offer a settlement deal in the low 7 figures.

And here’s what happens if the coding violations are judged by the auditor to be fraudulent (which involves the determination of intent, and therefore, unfortunately, often appears a somewhat arbitrary designation):

1) All the above.
2) Jail

And, as we have seen, if you somehow escape being convicted on criminal charges, the government still has the prerogative to come back at you with civil charges, where the burden of proof is lower.

Any doctor who has come anywhere near such a process wishes fervently for the good old days, when it was only the HMOs making your life miserable. Yes, HMO executives can be nasty sons of guns. But they can only decide not to pay you what you are owed, or perhaps throw you off a panel. They cannot decide to wipe out your life savings, take your professional license, or put you in jail.

The Feds know that the E&M guidelines are harmful to patient care. Their own commission came to that very conclusion in 2002. The Feds know that failing to comply perfectly with the E&M guidelines in each and every case does not really indicate fraud and/or abuse, but is the necessary outcome when you institute a complex set of rules that not even the government’s own approved coders can interpret.

That the Feds continue to impose the E&M guidelines on physicians, despite the harm that they know this causes, tells us something very important about their underlying motives. When you are in the business of covertly rationing healthcare, controlling the behavior of physicians – getting them under your thrall – is Job One. And as George Orwell observed for us, when you want to control the behavior of some people, a critical step is to control the mode, the rules, and even the very language of communication.

That physicians continue to comply with such oppressions, despite the harm they know this causes, and (with notable exceptions) without serious complaint, tells us something important about them, too.

What The Doctors Did

Despite the intense, unrelenting attacks against them by the health insurers and the government, it remains striking how completely physicians capitulated to the pressure and abandoned their professional responsibilities, and how quickly they did it. And in doing so, physicians threw away two thousand years of tradition, jurisprudence and ethics.

Medicine was one of the three original professions, the other two being the clergy and attorneys. Today, anyone working in any area of endeavor, as long as they have sufficient expertise that that somebody is willing to pay them to do it, calls themselves a professional. So we have professional hairdressers, chefs, sanitation workers, hit-men, and athletes. And by this definition, I suppose doctors can still call themselves by that name as well.

But by the original definition of the word, they gave up that privilege in 2002.

Originally, the term “professional” was defined not merely by somebody’s knowledge or expertise, but rather, by the special quality of the fiduciary relationship they had with their clients – a relationship marked by an absolute duty to place the needs of the client ahead of the professional’s own personal interests, or the interests of any third party.

In the case of physicians, this relationship is called the doctor-patient relationship.

To really understand what the doctor-patient relationship is supposed to be like, it is quite sad that today it might be necessary to have a look at a different profession, one whose members are often despised by physicians, but one that has managed to hang on to its professional integrity to this day – namely, the lawyers.

Say you are arrested for robbing a bank. Say the arrest was not unexpected, since you actually did rob a bank. Say that while you didn’t actually mean to do it, you shot a teller in the process, and the teller subsequently died. And finally, say you were caught red-handed.

Given this series of unfortunate circumstances, what rights can you expect?

It turns out that under the law, you have many rights. Despite the overwhelming evidence against you (the surveillance tapes, the eyewitnesses, the being-caught-at-the-scene-with-the-smoking-gun-in-your-hand, &c.), you have the right to a fair trial; you have a right to be considered innocent until a jury of your peers declares you guilty; and you will have the right of appeal (assuming you won’t like the verdict). But more importantly than anything else, you have a right to counsel, to an advocate, a knowledgeable professional who is obligated to defend you to the limits of her abilities, and to fully protect all of your interests under the law.

Society recognizes that the legal system is a morass of rules and regulations that ordinary citizens cannot hope to navigate on their own. Society acknowledges the need for any citizen caught up in the complex legal system to have a personal advocate who will hold that citizen’s interests above all others. Even when the accused party is as obviously guilty and as deserving of punishment as you obviously are, most of us would shudder to think of the abuses that would occur if people (even the likes of you) had to face a hostile legal system without the guidance of their personal attorney.

When you are sick, you are no more capable of navigating the complex healthcare system than is the accused felon of navigating the complex legal system, and you are no less in peril if you run afoul of that system. And your need of a personal advocate, a professional whose job is to protect your interests against the conflicting aims of a hostile healthcare system, is no less acute.

When you are sick, you should be entitled to at least the same protections as when you rob a bank. And this is what the doctor-patient relationship is actually for.

In recent years the “doctor-patient relationship” has been taken in hand by certain “experts,” who (in the way of teaching doctors to work more “effectively”), have reduced the whole thing to a series of tricks from the interpersonal-relationship trade. These may include looking your patients in the eye; displaying sympathetic expressions (practicing with the use of mirrors may be necessary); nodding as they speak (with all the sincerity of a Dr. Welby bobble-head); freely showing them your emotions (even if you have to manufacture them); remembering their birthdays and childrens’ names (yet another benefit of computerized medical records), and similar strategies for convincing patients that they have your full attention, and that nothing can be more important to you at this moment than their welfare. Such techniques are designed to get your patient’s thinking to the right place – which is to say, to get them to understand without too much fuss or muss why the efficient course of evaluation and treatment you have selected for them (with the kind assistance of various government expert panels) is the correct one.

I think it’s the same training they give annuity salespersons.

Obviously, none of that has anything to do with the real doctor-patient relationship. The real doctor-patient relationship is a sacred covenant, one which is formed when a patient goes to a doctor for help, and the doctor agrees to give that help. Under that covenant, the patient agrees to take the physician into his confidence, and to reveal to her even the most secret and intimate information related to his health. The physician, in turn, agrees to honor that trust, and to become the patient’s advocate in all matters related to his health, placing his personal best interest above all other considerations. This strong relationship of mutual trust is what patients have always expected, what most doctors have striven for, and what everyone else (medical ethicists, professional societies, and those who enforce the law of the land) have traditionally agreed – and even demanded – must be the standard.

And for over 2000 years, the precepts of medical ethics were aimed squarely at guaranteeing the integrity of that relationship. Fundamentally, these ethical precepts held physicians to the high standards of behavior embodied in the classic doctor-patient relationship, and further, gained physicians admittance to the small society of “professionals.”

Unfortunately, by the late 1990s, perceptive physicians noticed a big problem. Namely, thanks to the various perfidies being visited upon them by HMOs and the government, doctors could no longer act in accordance with their fundamental ethical precepts. They were being pressured to place the vital interests of the insurers and the government ahead of the vital interests of their patients. They were coerced into violating their sacred duties under the doctor-patient relationship. And, as we have seen, doctors gave in to that pressure.

Soon, influential thought leaders in medicine and medical ethics expressed alarm at what was going on. Clearly, they said, something needed to be done about it. And they decided to act.

But the action which the medical thought leaders finally took was not to fight back against the pressures being placed on physicians to violate their most fundamental ethical principles. Instead, the medical thought leaders launched an effort to change the precepts of medical ethics, to make medical ethics comport with the actual behaviors which modern doctors were being coerced to adopt.

Changing millenia-old ethical precepts proved to be surprisingly easy. This is because it is surprisingly easy today to find respected ethicists who will sanction just about any nefarious activity you can think of, as long as that activity furthers some higher cause which is to their liking. These ethicists are called utilitarians.

The solution to the physicians’ ethical dilemma was initially proposed as early as 1998, in an article by Hall and Berenson in the Annals of Internal Medicine (volume 128, p 395) which stated: “It is untenable for the medical profession to continue asserting an idealistic ethic that is contradicted so openly in clinical practice. . .We propose that devotion to the best medical interests of each individual patient be replaced with an ethic of devotion to the best medical interests of the group. . .”

This influential article, among other things, led to the formation of a commission to formally study the issue (the issue, again, being that if it becomes difficult to follow ethical precepts, then one ought to go ahead and change them).

This effort was led by the American College of Physicians, the main professional organization of experts in internal medicine, and this organization was quickly joined by virtually every other major physician organization in the world. Physician-leaders completed their ethical overhaul of the medical profession impressively quickly, and published it in 2002. They called it “Medical Professionalism in the New Millennium: A Physician Charter. “(Annals of Internal Medicine, February 5, 2002). With its publication a two-thousand-year tradtion of medical ethics was ended. It is the suicide note of the medical profession.

The innovation of the Millennialists was to proclaim a new ethical precept: the precept of Social Justice. The precept of Social Justice charges physicians with effecting “the fair distribution of healthcare resources.” That is, it renders it ethical for doctors to decide which patients ought to get those limited resources, and which ought not to get them; it specifically and directly justifies covert bedside rationing by physicians.

The reason this new ethical precept was deemed necessary is explicitly because doctors cannot any longer adhere to the old ones. (“It is untenable. . .to continue asserting an idealistic ethic,” according to Hall and Berenson. “Indeed, the medical profession must contend with complicated political, legal, and market forces,” according to the Millennialists themselves.

Ostensibly, the precept of Social Justice gives doctors who are too introspective (admittedly, not a big problem with many of us) an out when they find themselves having to place the interests of payers ahead of the interests of their patients by, say, failing to mention certain medical options that might be available. “Sure, I’m violating classic ethical principles,” they can now tell themselves, “but I’ve got to do that to honor this new one.”

The bottom line is that, having been coerced by the the insurers and the government (both of which control the doctors’ professional viability, and one of which also controls their status regarding incarceration vs freedom) to place the payers’ needs ahead of the needs of patients, doctors found themselves in utter violation of their fundamental ethical precepts. The proper response of physicians (and their professional organizations such as the ACP) would have been to reassert those ethical obligations, to push back against the payers, and enlist the cooperation of their patients (who, after all, have a particularly vital interest in the matter) in doing so. Instead, they have taken a path of lesser resistance, re-defining medical ethics to comport with their new, coerced behavior.

What Does This “New Ethics” Do To the Doctor-Patient Relationship?

The addition of the precept of Social Justice to the ethical obligations of the physician renders the classic doctor-patient relationship inoperative.

The New Ethics breaks the covenant from the outset. It renders “ethical” the divided loyalty of the physician. Today, when patients go to a doctor for medical advice, they do not know – and cannot know – whether that advice is being given to advance primarily the patient’s own well-being, or the well-being of the society that desires a “fair distribution of healthcare resources.”

With the formal adoption of this New Ethics, patients essentially have been cut loose, and set adrift to fend for themselves in an increasingly hostile healthcare system, without being able to rely on the kind of personal advocate they’ve been conditioned to expect, the same kind of advocate an accused murderer is still granted without question or hesitation. What’s worse, nobody has told patients that they have been abandoned in this way. They think their doctor is still working for them.

Less obvious, but no less profound, are the consequences this New Ethics has on the profession of medicine. Abandoning their primary obligation to the individual patient means that physicians have committed the “original sin.” They have abdicated their traditional, ethical, and legal roles as patient advocates; they have broken a sacred pact. They have fully compromised themselves as professionals; indeed they have become professionals in name only, and not in fact. And as a result, to their utter frustration, they find themselves standing naked before their enemies, the very insurers and regulators who forced them to abdicate their sacred obligation in the first place.

And it is in this utterly subservient position that we find our doctors – our protectors, our advocates – when Obamacare comes to town.

Podcast:

A few years ago, one of the Ladies on the View (DrRich does not recall whether it was Rosie or Whoopie or Joy or Daisy May) “proved” that George Bush was responsible for the collapse of the World Trade Center (and not the heat generated by all that burning jet fuel), when she proclaimed that “steel does not melt.” The audience went wild with approval.

DrRich, however, was puzzled. All those years ago, when America still had lots of steel mills and DrRich used to work in one of them, he could swear that once every six hours a massive door would open on the open hearth furnace, and molten steel would flow out of it. In fact, one of DrRich’s jobs was to advance a long-handled ladle into that molten stream of new steel to acquire a sample for analysis. He would be willing to attest under oath (say, to a Federal grand jury) that the steel in his ladle was in liquid form. So, unless DrRich’s Old Fart memory fails him, steel actually does melt, as long as you can make it hot enough.

The thing about conspiracy theorists, however, is that they are never deterred by facts. And if DrRich had actually sent Whoopie (or whoever) a letter explaining her mistake, as he had thought about doing, it would not have caused her to say, “Oopsie.” She simply would have shifted to another “fact” proving that Republicans (and not Islamists) had knocked down those buildings.

The other thing about conspiracy theorists is that their methods know no party lines. Whatever their political affiliation they are usually whack-jobs. And on the opposite side of the political spectrum, the birthers – who are convinced that President Obama was not born in the USA, but instead was born in Indonesia, or Kenya, or Mars – have displayed no more reasonableness than the Ladies on the View.

So, when one thinks about it, the truly puzzling thing about the birther controversy is not that the birthers won’t give up, no matter what evidence is placed before them. That’s just what conspiracy theorists do. What’s really puzzling is why President Obama and his legal team fought them for so long before they actually produced definitive evidence of his American birth.

Astute readers might respond, “You just answered your own question, DrRich. Conspiracy theorists don’t go away just because you have the facts on your side. Even a time machine that deposited them into the birthing room in Honolulu would not have deterred them. And indeed, when Obama finally produced his birth record, the birthers immediately found six ways to show it had been Photoshopped. Giving conspiracy theorists the real facts does not end the conspiracy theory.”

Very true. (DrRich is proud to have readers like you.) The President had no hope of making the birthers go away by releasing his birth documents. But by not releasing these right away, and instead letting the matter fester for several years, he just made more problems for himself. By fighting the birthers all that time, and running up hundreds of thousands of dollars in legal bills doing it, all he accomplished was to waste a lot of money, and to raise questions among millions of more reasonable Americans who are not given to conspiracy theories.

DrRich believes he has a possible answer to why Mr. Obama stonewalled for so long on his birth records. It may be that he was signalling to his Progressive followers his baseline contempt for the Constitution.

The birthers, as misguided as they were, were raising a constitutional question. For, if Mr. Obama had been born outside the U.S., he could not legally serve as President under the Constitution*.

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*DrRich, for one, thinks this is a rather silly feature of the Constitution, which he believes Mr. Madison inserted into the document for the sole purpose of disqualifying Alexander Hamilton for the job.
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Typically, therefore, inasmuch as a constitutional question is by definition an important one, one might expect that President Obama would have produced the definitive documentation right away, to resolve the matter once and for all. And, as it turns out, he easily could have done so.

But he chose not to. He chose to let the question fester and grow, for several years, before finally putting an end to it. It’s almost as if he was saying: It’s just a constitutional question. I will actively fight against having to acknowledge the legitimacy of my presidency under the Constitution, because to do so would be to acknowledge the importance of the Constitution. And that would be beneath me, and would be at odds with my real agenda.

This message must have offered much succor to nervous Progressives, who had watched him solemnly take the Oath of Office, and had listened to his public words.

Very few Progressives – much less the President of the United States – are willing to say publicly that the Constitution is a major impediment to their program, and that one of the absolute requirements for achieving the Progressive program is to nullify the underlying thrust of the Constitution.

For indeed the Constitution is an impediment, since it firmly establishes the primacy of the individual, and severely limits the government’s ability to control the property or the behavior of individuals – both of which are critical to the Progressive program.

Mr. Obama has said so himself, publicly, before he became President. He has indicated that the chief flaw of the Constitution is that it places limits on the power of the government, and thereby prevents the government from acting to assure redistributive justice.

You can listen to him say it himself on You Tube, here.

Mr. Obama is right about the Constitution, of course. For indeed, if the Constitution granted the government the power to affect redistributive justice, it would have had to make the government all-powerful, and to make all property communal property, controlled by that government. But the founders, having just fought a war with the world’s greatest power to guarantee the autonomy of individual Americans, were disinclined to write a Constitution that immediately nullified their great victory for mankind. So the Constitution simply does not suit the Progressive agenda.

After just two years, President Obama apparently found that he had no further need to continue the charade with the birthers. He has by now, of course, amply demonstrated that the Constitution will not be an impediment to him. He has created scores of hand-picked, unelected Czars who began setting national policy and running much of the government, in independent fiefdoms, answerable only to him; he has unilaterally cancelled contractual obligations to bondholders when “negotiating” with car companies; in addition to the auto industry, he has essentially nationalized the banking industry, the insurance industry, and student loans (and thus, colleges), and of course, the healthcare industry; he went to war in Libia without even a nod to Congress; he allows his DOJ to selectively enforce or ignore laws depending on who has broken them; and he inserted an individual mandate into his healthcare reform plan, which, if upheld by the Supreme Court, will give the government unlimited authority to control the economic activity of individual Americans.

And that’s why it eventually became OK for the President to release his birth records. American Progressives, by that time, had been suitably reassured regarding his stance on the Constitution.

But thanks to the birthers, the President had a convenient way of signalling his attitude toward the Constitution, well before he had had the opportunity to demonstrate it overtly through his Presidential actions.

DrRich will only remind his conservative friends that, once a President has taken over private industry, made the Congress (the people’s branch of government) nearly irrelevant, promulgated the individual mandate, &c., the fact that the Constitution has in it some verbiage about the Presidency being limited to two-terms ought not to be given much weight.

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Some of DrRich’s conservative friends become quite exercised when they hear news commentators in the major media favorably contrasting the Occupy Wall Street movement with the Tea Party.

The Tea Party, the news readers intone, is a phony “movement” dreamed up by the Koch brothers to embarrass our first black president and to consolidate their own wealth, for which they recruited hordes of superstitious, back-woods, gun-toting, ignorant, NASCAR-loving, Bible-thumping, bigoted Ma and Pa Kettles to gather on the Mall, along with their Fox News cheerleaders and their country music stars, in a futile attempt to intimidate the enlightened leaders of the Democratic party into abandoning their program of good works. The Occupy Movement, in contrast, is a spontaneous uprising of innocent and right-thinking citizens against the tyranny of the Republican-controlled Wall Street fat-cat oligarchy, and their noble efforts have been explicitly blessed by such luminaries as Obama, Biden, and Pelosi.

Conservative Americans have a different perspective: The Tea Party was a completely spontaneous expression of public disapproval of a federal government run amok, and its gatherings are notable for its respectful, clean, polite, hard-working, law-abiding participants. The Occupy Movement, in contrast, is a contrived, Soros-funded attempt to undermine the American system, and, as one might expect from such a travesty, the Occupadoes are filthy, lawless, selfish, lazy and unappreciative of the blessings of America, which they themselves (judging from their smartphones and college degrees) have demonstrably received.

What conservatives and progressives seem to agree upon, in the matter of the Tea Party vs. the Occupy Movement, is that one is disruptive and disreputable, while the other is enlightened and constructive. They simply differ on is which is which.

For the benefit of his readers, DrRich would like to point out that, despite the foregoing, the Tea Party and Occupy Wall Street actually have a fundamental similarity between them. They are both middle class movements which are motivated by a conviction that the American system is moving in the wrong direction, that a major feature of that “wrong direction” is that an elite few have gained power that has enabled them to block the upward mobility that is supposed to be a part of the American compact, and that a fundamental change is in order. The solutions they advocate are very different from one another, of course, but their problem statements are very similar. And, most significantly, they both arise from the middle class.

At least since around 1500 AD (since the time when we can say that a middle class was present in most Western societies) the true revolutions – rapid, fundamental changes in the political system (not merely in who is leading the political system, but in the system itself) – have come to pass only when the middle class has finally become sufficiently aroused to demand (or at least tolerate) radical change. The American revolution, the French revolution, the Cromwell revolution (and the subsequent restoration), the Iranian revolution, the Nazi takeover of Germany, the fall of the USSR, various Mexican and South American revolutions, and virtually every revolutionary political upheaval one can think of in the last 500 years occurred only when the middle class had finally had it.

Political leaders instinctively understand that they can treat the poor and downtrodden as badly as they want to, and they will never rise up. (This is where John Brown got it wrong.) And so, from the political standpoint, while it might be worthwhile stirring up the emotions of the poor (at least in a democracy), in general the actual needs of the poor can be safely ignored.

But the needs of the middle class must be seen to, at all costs.

This is why Democrats (and their supporters in the media) were so unreasonably critical of the Tea party movement when it first presented itself, painting it as violent, unAmerican and racist, despite the fact that no objective evidence supported any of these charges. They were frightened nearly unto death by the implications of such a widespread middle-class expression of dissatisfaction with the direction the country is going – a direction that had been manifest for decades, but which was greatly accelerated during the first years of the Obama Presidency.

And it explains why Republicans were so quick to identify with the Tea Party (even though the mainstream Republican party is actually quite suspicious of it).

And so, when the Occupy movement finally appeared – a different middle-class movement sporting a redistributive agenda that is in line with major elements of the Democratic party – our Democrat leaders could not contain their delight. This, despite the rather odious and “non-traditional” behavior of the Occupadoes, including their public defecation, urination, fornication, rapine, drug use, property destruction, &c, that, in more normal times, would have politicians of both parties lining up to vilify them. Democrats reassure themselves that, while the Occupadoes might be dirtbags, if we play our cards right they can become OUR dirtbags.

Smart politicians in both political parties recognize the potential for real revolution in both of these movements – to reiterate, that both arise out of the middle class, and both are demanding fundamental change – and they understand the need to co-opt the one, and suppress the other.

And so the battle lines are drawn. The Tea Party agenda, which is often unfairly summarized in diminished form as “smaller government and lower taxes,” actually is fighting to restore the Great American Experiment, as articulated in the Declaration of Independence and the Constitution, whereby the autonomy of the individual is paramount. Under the GAE, the chief job of the government is to protect the citizenry from foreign aggressors, to grease the skids of a free economy, and to allow free Americans to strive as they will, and in doing so, the government may utilize only its very few, explicitly enumerated powers, and otherwise must stay out of the way.

In contrast, the agenda of the Occupy Movement is a levelling one. The fruits of America should be distributed equitably, so that there are no longer haves and have nots. Obviously, the only entity that can accomplish this feat is a strong, all-powerful Central Authority, which can confiscate the property of the “greedy” and award it to the “deserving.” Fundamentally this means that all property, in fact, is the government’s. To the Occupy supporters, while few of them will come out and say so, the Constitution is not a sacred document, but rather is an unfortunate and obsolete impediment to progress, a document that must be undermined and replaced.

To brush off either of these movements would be a mistake. Each of them is firmly grounded in the middle class; each of them discern a fundamental problem with the American system that can no longer be ignored; and each of them have already taken to the streets demanding that solutions cannot wait, and that action must be taken now.

But the two solutions being demanded by these two movements are not merely different; they are polar opposites, and are deeply irreconcilable.

Our political leaders have likewise taken sides, and the sides being irreconcilable, we can expect no cooperation or compromise between their two camps, at least not until we have another election in which the great, seething, conflicted middle class has an opportunity to say which of the two movements they have now spawned actually holds the key to their hearts.

This is a blog about the American healthcare system, and DrRich has not been bashful about expressing his belief that Obamacare – whatever good elements it may contain – is fundamentally a vehicle for undermining the autonomy of individual Americans, and handing to the government the authority to determine who in this country will get what, when and how. Until the last few months DrRich viewed the fight over Obamacare as the proxy fight for the real, underlying, fundamental question – the question of what kind of country we will be from now on.

But between the Tea Party and the Occupy Movement, DrRich has come to believe we no longer need a proxy. It looks more and more like we will have this fight out in the open, and instead of settling it with the kind of sneaky legislative legerdemain that brought us Obamacare, perhaps it will be decided by an actual election.

But whether it is decided by an election, a coup, or an exhausted capitulation, the fate of American healthcare – and everything else American – will ride on which of these two movements eventually predominates within the middle class.

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DrRich has long argued that a non-negotiable necessity of Obamacare will be to gain complete control over the behavior of American physicians. Most of the important medical decisions which doctors make – the ones that cost the government the most money – will be forcibly centralized. That is, panels of experts will determine which services are to be delivered to which patients under which circumstances, and doctors who fail to follow the experts’ dictates, in all their particulars, will be prosecuted as criminals.

This is more than just a matter of cost management. Placing control of most important decisions into the hands of sanctioned experts is a central tenet of the Progressive program. Centralizing decisionmaking – rather than leaving it in the hands of individuals, who will always operate for their own selfish benefit rather than for the benefit of the collective – is the principle mechanism by which the Progresive program (i.e., achieving the perfect society) is to be realized.

In recent years, growing numbers of doctors who recognize that their independence is quickly being taken away, and that the principle ethical precept of their profession (i.e., to always act for the benefit of their individual patient) is quickly being converted into a mortal sin, and that their own professional organizations are acquiescing with these changes, are realizing that the only way left open for them to retain some of their professional autonomy and professional integrity is to opt out of the system altogether, and begin contracting directly with their patients for medical services.

While the trend for doctors to opt out has not yet become widespread enough to have reached the consciousness of the broad public, it has certainly grabbed the attention of our Progressive leaders. For autonomous physicians pose the greatest possible threat to Obamacare, or to any Progressive healthcare system. And Progressives simply cannot abide these physicians who establish direct-pay practices.

So it has never been a question to DrRich whether our Progressive leaders will act to stop direct-pay medical practices. The only question has been how they will do it.

Over the past couple of months, DrRich has developed a theory about this. He hopes his theory is wrong, but he fears it is not.

DrRich believes that the medical profession is about to become nationalized, and doctors will become government employees, just like the airport security screeners. Furthermore, the mechanism by which they will become nationalized is the very same mechanism by which the airport security screeners were nationalized into the TSA, an event which occurred, DrRich reminds his readers, with barely a peep of protest from American conservatives, or anybody else. That is, it occurred precipitously, out of dire necessity, due to a grave national crisis that seemed to leave us little other choice.

DrRich believes the outline of the crisis that will justify the nationalization of the medical profession is becoming discernible. He believes the crisis will be precipitated by a provision of Obamacare that, for most observers, has just come to light.

On August 10 Medicare announced that, by March 23, 2013, most American physicians – at least 750,000 of them – will have to recertify their Medicare credentials. Now, for most Americans this prospect does not sound too odious. But be assured that it is.

The Medicare certification process is always a bureaucratic nightmare, and the nightmare will be greatly magnified when three-quarters of a million doctors are recertifying nearly at the same time.

All doctors have gone through Medicare certification at least once, and many have done it more than once. Because several common activities – such as changing your address – trigger the need to recertify with Medicare, doctors go through this process on an average of every decade or so. And most dread the experience.

Certifying requires filling out a 60-page form, a form which is absolutely masterful in combining obtuseness, opacity and redundancy, and then submitting it, along with all sorts of additional documentation, to one of several Medicare administrative contractors. These contractors are famous for their incompetence, their indifference, and their glacial bureaucratic pace. DrRich has experienced the ordeal himself, and knows countless doctors who have as well. The experience is nearly universally painful and expensive.

It is very common – possibly the rule – for submitted applications to be “lost,” at least once. (Officially, of course, the doctor never sent them in.) This event is so routine that doctors know to check with the contractor to confirm that their paperwork has been received. But the contractors have caught on to this gambit, and now refuse to reply to such queries for some specified period, usually for 30 days (at which time, it often turns out, the paperwork has disappeared into the ether). When the doctor finally gets to the point where the contractors will admit to having the documentation, there is another prolonged period of enforced silence, while the contractors painstakingly comb through the documents for misplaced commas, “X’s” typed over the line, or any other trivial excuse for discarding the application and notifying the physician (often, 2 or 3 months after originally submitting it), that they must begin the whole process again, and submit new forms. It is common for the entire process of recertification to take 3, 6 or even 12 months.

And the best part is, during the time the documentation is being reviewed, the physician cannot bill Medicare for any services. So during the recertification process the physician must either stop seeing Medicare patients, or continue seeing them without hope of payment. It is standard to lose at least a month – and very often more – of Medicare income during the recertification procedure.

These cost savings, of course, are why Medicare demands recertification every time you change your address, or add a partner, or sneeze. And this is why a slow, bureaucratic, demeaning recertification process is not only perfectly OK with the “system,” but is lovingly nurtured.

That, DrRich reminds you, is what happens during the typical recertification. The en masse recertification mandated by Obamacare, when 750,000 physicians will be going through this process at the same time, promises to become much, much worse. Doctors certainly believe it will be much worse.

“Tough luck for you doctors,” many loyal readers are now saying, “but what’s that got to do with the TSA-ification of American physicians?”

There are many thousands of PCPs today who are strongly considering opting out of Medicare, or who would like to opt out but they are afraid to take the chance. That is, they’re on the fence.  There are many thousands more who are hoping to retire within several years, and are hanging on almost on a year-by-year basis, waiting either to meet their target retirement funding, or until things get so bad that they just can’t do it any more.

DrRich thinks that a great many of these on-the-fence physicians will be tipped by the prospect of having to recertify for Medicare, especially under circumstances in which the process of recertification promises to be much worse than even the usual stomach-turning process.  If a doctor is thinking about getting out anyway, and now faces the prospect of losing (most likely) several months or possibly a year of Medicare income, then he or she is much more likely to just do it.

If this doesn’t do the trick, then add to it the fact that Medicare reimbursements to all providers are likely to be reduced by something like 25%, when the pre-deadlocked Congressional Super Committee* fails to agree on the necessary budget cuts later this year.  And last Thursday night, when the President announced that the Super Committee will have to find $2 trillion instead of only $1.5 trillion in budget cuts by Thanksgiving (in order to pay for his Jobs! Jobs! Jobs! bill), the likelihood that doctors will take a 25% cut in pay increased even more.

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*The Super Committee is pre-deadlocked because: a) the Republicans audaciously appointed at least one Tea Party supporter to the committee; b) the Democrat leadership (specifically, the Vice President) has identified the Tea Party as terrorists, a designation they have never been willing to assign to any other group, for instance, to Islamic extremists; and c) it is well known that one does not negotiate with terrorists.

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DrRich thinks the Progressives, whether by design or by blind luck, are now precipitating a crisis in healthcare. They are giving American doctors a huge incentive – probably two huge incentives – to opt out of Medicare all at once (instead of opting out gradually, as they are doing today).

If this occurs, the shortage of doctors who accept Medicare will become a hyper-acute problem. Panic will take hold.  The media will decry the crisis, running heart-rending stories about old people dying in their homes because they cannot get an appointment with a doctor, and blaming it all on the abiding greed of physicians (who, after all, probably still owe the government for their education, and hold their professional licences at the pleasure of the state). Medicare beneficiaries will flood their congresspersons’ offices with emails, letters, and their very bodies, demanding immediate action.

The autonomy of physicians may be OK in theory. Classic medical ethics might be a nice idea – a nice-to-have – if you can afford it. The doctors who “opted out” might actually be standing on principle, instead of on greed. But little matter. However you cut it we’ve got a real crisis here. The public’s right to healthcare is being violated. People are dying. The very security of the country is in jeopardy.

Not even conservatives will be able to withstand the tide of public opinion. Something will have to be done to compel doctors to provide that which they owe the public. In the war on illness, doctors need to be good soldiers. So like real soldiers, if they fail to volunteer for duty in sufficient numbers they will need to be drafted – and like soldiers they will need to work for, and receive their orders from, the government.

The politicians will be sorry about this. Nobody wanted it this way, they will say.  A little less greed, a little more compassion, and we could have avoided this. The doctors brought it on themselves, and have nobody to blame but themselves. The welfare of the public must take precedence.

Anyway, that’s DrRich’s theory. With luck, he is wrong. (Perhaps, for instance, many fewer physicians than DrRich thinks are on the fence about opting out.) But if he’s wrong, he’s more likely wrong about what, specifically, will precipitate the crisis that will finally justify taking away what remains of doctors’ autonomy, than he is about the general outline of what the end-game for American doctors will look like.

Progressivism often “progresses” toward its goal not gradually, but in major, discrete leaps – and it usually does so as the result of some “crisis” that causes the people to go along with changes they would never otherwise agree to. Which is why, if you’re a Progressive, a good crisis never goes to waste.

And the requisite “good crisis,” more often than one might think, turns out to be something you can goose along, just when you need it.

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DrRich’s most recent post attempted to show how the creation of the Independent Payment Advisory Board (IPAB) – the panel created by Obamacare that (as President Obama himself indicates) will be primarily responsible for reducing the cost of American healthcare -  nicely illustrates the Progressive mindset. That Progressive mindset, DrRich maintained, is reflected in the degree of power and breadth of control granted to the IPAB, in the coercive process under which the IPAB was created and its powers granted, and in attempts to bind future Congresses from amending those powers.

DrRich did not imagine that Progressives would like his formulation very much. But as always, DrRich offered his analysis in the hope of engaging readers – friend or foe – in a fruitful exchange of ideas.

And accordingly, DrRich is gratified that the venerable blogger Shadowfax has seen fit to offer a pointed (though to be sure, rather brutal) rebuttal. While the nature of his rebuttal does not exactly invite a civil exchange, DrRich (in the spirit of furthering understanding amongst our mutual readers) will attempt to reply in a collegial manner.

Anyone who has read Shadowfax’s post will know that it would be all too easy for a back and forth to descend into heaped vituperations. Shadowfax begins his presentation, after all, with a scathing ad hominem attack on DrRich’s person. He speculates as to whether DrRich is a confabulist or a conspiracy theorist, and proposes, as the qualities which define DrRich, only the following: “laziness, ignorance, misinformation, or untreated paranoid psychosis.” Along the way DrRich becomes also a partisan hack, deceitful, hysterical, and a purveyor of fluff.

For several reasons, DrRich will not respond in kind. First, when he joined his high school debating team in 1965, one of the first things DrRich learned is that when one has induced his opponent into an ad hominem attack, one has already won the debate. Second, by virtue of his original post on the IPAB, DrRich started it – and when one starts it, one invites and ought to expect a vigorous response. Third, DrRich does not take this ad hominem attack at all personally, so does not feel compelled to return the favor. DrRich comforts himself with the knowledge that Shadowfax does not know him personally, and is confident that if he did, he would be entirely won over (as is everyone) by DrRich’s charm, his joie de vivre, his incisive humor, his charisma, and above all, his humility. And finally, DrRich chooses to view this personal attack clinically, as doing so makes it plain that by its very nature, Shadowfax’s reply is itself entirely illustrative of the Progressive mindset. (In other words, Shadowfax has inadvertently succeeded in reinforcing DrRich’s chief message.)

DrRich will return to this latter point in a short while.

For the record, DrRich does not attribute any negative personality or motivational traits to Shadowfax, and indeed, chooses to believe that he is basically a nice person. (Even if he did not believe it, DrRich would not say so. DrRich notes that Shadowfax is the parent of three children, and he would hate to have those tykes see their Dad publicly subjected to personal insults – despite the fact that Shadowfax neglected to consider the fragile sensibilities of DrRich’s own young ones before publicly besmirching his intellect, motives and psychological health.)

To his credit, the bulk of Shadowfax’s rebuttal (after having dismissed DrRich’s person as being beneath contempt) has to do with matters of fact, or rather, with matters of interpretation of fact. For DrRich thinks he and Shadowfax are surprisingly close on the facts themselves. It is in interpreting the implications of those facts that the difference appears.

And here is where DrRich must diverge for a moment to re-introduce his Theory of Progressive Thought. He has explained this theory at some length in the past, and subsequently has further developed it on several occasions. In so doing, DrRich has explicitly insisted that it is just a theory.  It is a proposed framework for explaining the multitude of difficult-to-explain behaviors we have witnessed from Progressives during the last 120 years. In laying out this theory, DrRich has invited one and all to point out its weaknesses, and to suggest a better theory if they have one. Since DrRich himself does not like the implications of his Theory of Progressive Thought – given that Progressives are now running the show – he will, as he has said more than once, be delighted to abandon it for a better theory, should one come to his attention. But in order to be designated a “better” theory, it will have to explain real-world Progressive behaviors even more effectively than does DrRich’s.

Contrary to Shadowfax’s accusations, DrRich does not impute negative motives to Progressives. Indeed, fundamentally Progressives are motivated by a deep desire to achieve societal good. They are dedicated to achieving a society in which all people – whatever their disadvantages and limitations may be – will thrive equally, or as equally as possible. DrRich stipulates that this goal is inherently a good one.

Furthermore, Progressivism being a product of the Age of Reason, Progressives sincerely believe that such a goal is within the reach of mankind. It can be achieved by careful observation, analysis, and rational solutions systematically applied. And therefore it ought to be the goal – rather, it ought to be the duty – of mankind to strive to thus implement effective solutions to society’s problems. And so, Progressives believe that the goal of mankind ought to be to continually progress toward solutions to ALL society’s problems, and hence to strive unrelentingly for a “perfect” society.

And that’s the theory. Contrary to Shadowfax’s accusation, there is no imputation of evil motives in this theory. Indeed, Progressives, as a group, tend to be motivated primarily by compassion for their fellow humans – at least as a starting position.

Unfortunately for everyone, there are two major problems inherent in Progressive thought. First, the rational analyses and the carefully planned solutions to society’s ills which are prescribed by Progressivism are almost always beyond the ken of your average member of the great unwashed. So designing and implementing the Progressive program inevitably relies on a cadre of “specialists,” a class of elites who have the right stuff (the right intelligence, the right education, the right knowledge, the right motivation, &c.) to do the job.

Thus the rational solutions to society’s problems which are offered up by the Progressive program are inevitably to be provided by an enlightened corps of elites, and accordingly, it is the duty of the average citizen (i.e., the rest of us) to cooperate with these handed-down solutions, for the overriding benefit of the whole. Otherwise, the Progressive program cannot succeed.

This fact places Progressivism fundamentally at odds with the Great American Experiment, that is, with a system of government which at its core maximizes the autonomy of we individuals to do as we please, and which allows us to succeed or fail based on our own actions, to the extent that our actions do not infringe on the rights of others. Thus, there is a natural and unavoidable tension between the kind of broad, centrally planned solutions which Progressivism inevitably offers up, and the severely limited sort of central authority provided by our founders.

The second great problem with Progressivism is even more intractable. It is that the kind of societal solutions dreamed up by Progressives invariably require individuals to sacrifice their freedom of action, to one degree or another, for the sake of what the elite planners have determined will benefit the collective – and in so doing, Progressive solutions always seem to require a fundamental change in human nature. That is, the Progressive program requires individuals to subsume their own individual interests to the interest of the collective.

Such a change in human nature will never be forthcoming, and this fact, in the end, will always defeat Progressivism (though often not before a lot of damage is done). Inevitably, the recalcitrance of substantial proportions of the population to their brilliant solutions drives Progressives, once they have been in power for a while, to great frustration, and finally, to drastic repressive action. A history of collectivist governments during the past 100 years amply demonstrates this ugly fact.*

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* According to R.J. Rummel in his book Death by Government, during the 20th century the world’s governments killed four times as many of their own people, on purpose, as were killed in all wars combined.
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With this brief review of DrRich’s Theory of Progressive Thought (and its implications), let us now quickly visit the differences in how DrRich and Shadowfax view the facts as they pertain to the IPAB.

Is the IPAB designed to function as a dictatorial entity? Shadowfax argues that since it will not be utterly impossible for Congress to overturn the mandates handed down by the IPAB, it is therefore not dictatorial. And from a strict definition of the word he is correct. But DrRich holds that the language of the law (which, to halt the IPAB mandates on healthcare spending, requires a supermajority of the Senate to a) block those mandates, then b) come up with its own cost cutting scheme that will achieve equivalent results),  is meant to achieve for the IPAB at least near-dictatorial powers. Even Shadowfax allows this possibility: “The argument is that the IPAB becomes a de facto dictatorial board, because the bar is set too high to override its recommendations. We will see, I suppose.” This unelected panel* of experts will determine who gets what, when and how, and it will be exceedingly difficult (but admittedly not impossible) for Congress to have much to say about it. Therefore, Obamacare explicitly attempts to severely limit the prerogatives of the peoples’ representatives to control the ability of this unelected panel of experts to determine the medical destiny of Americans.

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* Contrary to Shadowfax’s unnecessarily gratuitous implication, DrRich has not referred to the multitudes of expert panels created by Obamacare as “death panels.” To do so would make DrRich seem as unsophisticated as Ms. Palin. Rather, DrRich has referred to them by the much more accurate name of GOD Panels (Government Operatives Deliberating).
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Is the IPAB designed to be an immutable panel? The plain language of the law very clearly attempts to render it exceedingly difficult (if not impossible) to change the IPAB provisions of Obamacare, thus revealing a wish on the part of its creators to render the IPAB an immutable entity. DrRich agrees with Shadowfax that, in truth, no Congress can actually bind all future Congresses down into perpetuity. But the language of the law clearly expresses a desire to do so. Shadowfax makes some sort of argument to the effect that the phrase “It shall be out of order” gives Congress a pathway to changing the IPAB provisions. And it is true that, under Roberts’ Rules, when a chairman declares some procedure to be “out of order,” there are provisions for appealing that ruling and rendering the thing back into order. But this provision is almost exclusively used to determine whether a member can speak or not. In contrast, the immutability language in Obamacare purports to create a LAW (rather than an ad hoc chairman’s ruling), which declares any action to alter the IPAB to be perpetually “out of order.” DrRich can find no parliamentary procedure addressing this remarkable and audacious circumstance.

In any case, even if the immutability language pertaining to IPAB turns out indeed to be something that can be by some manner overcome, as Shadowfax insists, that fact is not obvious. It has also escaped at least some U.S. Senators, who have interpreted the language the same way that DrRich has. And whatever the parliamentary options that may or may not come into play, the clear intent of the language in this provision is to greatly reduce the ability of future Congresses to alter the IPAB provision (if not actually render it immutable). Once again, this attempt is perfectly consistent with the all-consuming desire of Progressives to implement their expert-controlled programs with only minimal interference from the people (or the peoples’ representatives).

Does the IPAB already have the power to restrict private as well as government healthcare expenditures? Here, Shadowfax appears to concede the point, more or less, and adds that the idea “strikes me as a GOOD thing.”  DrRich has described in great detail how and why our Progressive healthcare reforms will inevitably restrict (and is already attempting to  restrict) the ability of individuals to pay for their own healthcare with their own money. And now, the IPAB (this very powerful and nearly-immutable panel of experts) has apparently been granted the authority to take charge of this important goal.

The bottom line, regarding these points of fact, is that DrRich and Shadowfax disagree less on the fact themselves than on the implications of those facts. We differ greatly on whether these features of the IPAB – dictatorial (or quasi-dictatorial) powers, immutability (or quasi-immutability), and the power to restrict private healthcare spending – are good things. Shadowfax explicitly believes that they are.

DrRich’s view, of course, is that these legislated features of the IPAB are perfectly consistent with, and even predicted by, his Theory of Progressive Thought. And that was indeed the whole point of his original post. Furthermore, based on the recent history of collectivist governments and where they invariably lead, DrRich does not believe this to be a good thing.

Before ending, DrRich must return to the ad hominem attack launched against him by Shadowfax which, DrRich submits, also perfectly reflects the Progressive mindset.

Almost invariably, once the Progressive elite have settled upon their scientifically-based, rational, centralized solution to some dire societal problem (such as healthcare reform), their thinking regarding the unwashed masses goes through a stereotypical evolution. At first they always believe (their proposed solution being so scientifically sound, so logical and so well-thought-out), that by delivering a carefully packaged explanation of their solution, the people will enter into paroxysms of delight.  When the people do not react as expected, and indeed express apprehension or anger at what is being proposed, the Progressives will tell themselves that they must not have explained their solution well enough (but what can one expect, after all, when dealing with the great unwashed?) – and then they will arrange to implement the solution anyway (using whatever machinations and maneuverings are necessary to pull it off), confident that once the teeming masses see the incredible benefits that will accrue to them when the program is actually under way, they will at last display those belated paroxysms of delight. But then, when the program is actually implemented and the people are still complaining about it – or more likely, making their complaints more than merely vocal – the Progressives will begin culling out some of the more prominent troublemakers among them and make examples of them. And if that fails to quell the complaints of the masses, the leaders of collectively-oriented governments have been known to move past disappointment and frustration and into a state of wrath – and this (again, DrRich is simply referring to history) is where the real atrocities have taken place.

The evolution of the Progressives’ frustration regarding the public’s acceptance of Obamacare has moved past the “we can educate them” phase, and past the “we’ll go ahead and implement it and then they’ll like it” phase. They will soon be looking for someone of whom to make an example.

Traditionally, they will diagnose such troublemakers as being either misinformed (stupid), motivated by bad intentions (evil), or mentally deficient (crazy). And (again, historically), the solution to which the dissenter is subjected depends on that diagnosis – typically a re-education camp, elimination, or commitment to a state-run mental institution.

DrRich simply notes that Shadowfax has reacted with distressing typicality to a loudmouth who is not going along with the program. He indicates that the only possible explanations for DrRich’s recalcitrance (since a logical objection is not a possibility) are “laziness, ignorance, misinformation, or untreated paranoid psychosis.” That is, DrRich must be stupid, evil or crazy. It only remains for Shadowfax to decide on which of these diagnoses is correct, so that the appropriate final solution can be prescribed.

DrRich stands by his original contention that the salient features of the IPAB, the manipulative and underhanded process which brought it to life, and now, the reaction of Progressives when they encounter people who complain about it, all perfectly reflect the Progressive mindset.

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For some time now, numerous loved ones and dear friends have been advising and occasionally urging DrRich that, perhaps, it has become a bit inappropriate, and even unseemly, for him to continue in his longtime position as President and sole member of Future Old Farts of America (FOFA). For a not unsubstantial interval DrRich ignored this advice, feigning incipient deafness. But finally, after some focused study of that which these days returns his gaze in the mirror, and reluctantly concluding that maybe his loved ones have a point (and not wishing to seem Cranky), DrRich has reluctantly decided to resign from (and therefore disband) FOFA.

DrRich is pleased to announce that he has accepted a new position as President and sole member of Glorious Old Farts of America (GOFA).

And it is in this new capacity that DrRich has become alarmed at some of the dire warnings now being sounded by respected leaders of the Democratic Party, to the effect that the Republicans’ proposed federal budget for fiscal year 2012, released last week by Congressman Paul Ryan (who serves, DrRich believes, as Deputy Whippersnapper of the House Republican caucus), proves that Republicans are trying to kill old people.

Article 3, Subsection 4(D) of the GOFA charter clearly states: “All things being equal, we would prefer that Old Farts not be killed.”

Therefore, as President of GOFA, DrRich feels obligated to make some sort of public response to the Ryan budget, and to our ever-vigilant Democrat friends’ assertion that it is aimed at producing lethal harm to old people. DrRich’s important position in GOFA, of course, means that his opinion on this matter ought to carry serious weight in any high level discussions about this proposed budget.

By carefully studying the thoughtful commentary being offered by GOFA’s Democrat friends, DrRich has ascertained that Ryan’s proposed budget apparently will kill old people by “ending Medicare as we know it.”  DrRich does not find this a compelling argument, since Medicare as we know it is already being ended, by Obamacare, which is now the law of the land. Strangely, Democrat leaders are not claiming that Obamacare also kills old people.

So, as is all too often the case, the logic being offered up for public consumption by our political leaders does not hold up to simple analysis, which places DrRich into the position of having himself to provide the logical analysis of the question at hand.

DrRich, to be clear, frames that question thusly: Which plan for Medicare most threatens to kill old people? And he finds abroad in the land three distinct plans for Medicare: Medicare “as we know it,” Medicare under Obamacare, and Medicare under the Ryan budget. Let us analyze dispassionately how each proposes to kill the elderly.

Medicare As We Know It. Medicare as it is being operated today is generally popular with GOFA’s constituency, and most old people would like to continue things just as they are. And if you are one of those elderly Americans who is above, say, 75 years of age, chances are you would do just fine under Medicare as we know it. That is, odds are that you would live out your allotted years, and finally die from your heart disease or cancer only after enjoying every modern contrivance our healthcare system has devised.

However, if you are substantially younger than that, there is a real chance that your demise will be related to more systematic causes. This is because Medicare, if it were to continue just as it is today, would drive the U.S. into insolvency within a couple of decades, leading to cultural collapse, societal upheaval, &c. Our modern healthcare system (any modern healthcare system), being totally dependent upon a robust, complex, reasonably stable and technologically advanced society, would cease to exist. All of today’s life-prolonging therapies would either become very scarce, or would disappear altogether. And unless there arises out of the ashes a new culture which is centered upon ancestor worship, odds are that what little healthcare is available would not be disproportionally offered to the very old.

As DrRich sees it, continuing Medicare as we know it would ultimately result in most of our elderly dying much earlier than they do today.

Medicare Under Obamacare. Obamacare promises to prevent a Medicare-induced societal collapse by centralizing virtually all healthcare decisions, thus controlling expenditures. Government-appointed “experts” will decide which medical services ought to be offered to which patients, and will publish those decisions as “guidelines” (a euphemism for “directives”), which will be followed to the letter by doctors who wish to continue their careers and stay out of jail.

DrRich has argued herein that such a system will do great harm to many individuals in all age groups, and will effectively end the Great American Experiment. (Unlike some, DrRich would consider this latter result to be a bad thing.) But our question at the moment is more focused: Will old people be killed disproportionally under Obamacare?

DrRich thinks the answer is yes. First, “guidelines” have the most merit when they are applied to patients whose only (or main) disease is the one to which the guideline applies. For patients with multiple serious ailments, or who are beginning to suffer from various motor and sensory disabilities related to aging, the response to (or ability to follow) standardized treatment directives may be far less than supposed. The reduced ability of doctors to tailor therapy to individual needs (without incurring the undifferentiated wrath of the Central Authority) may thus prove particularly harmful to the elderly.

Second, our leadership class has already anticipated that merely centralizing all healthcare decisions will be insufficient to avert a fiscal disaster, and that more stringent controls will have to be employed. While they do not like to discuss such contingencies publicly, when they do, they make it clear that the elderly will have a reduced priority for healthcare services. That is, there will be age-based rationing.

Third, it is plain that Obamacare will attempt to make it illegal for elderly Americans (or any Americans) to go outside the system to purchase their own healthcare. Old farts will get what the Central Authority says they will get, and nothing more.

DrRich believes Obamacare would end up being pretty tough on the elderly, and that many old people will die earlier than they would die today.

Medicare Under The Ryan Plan. The Ryan plan offers to allow anyone who is 55 or older to remain on Medicare as we know it today. For those currently younger than 55, when they reach the age of Medicare they will be given a suite of health insurance plans to choose from, and will be given a certain amount of money by the government to use to support their premiums. This system is quite similar to that currently offered to many federal employees.

The amount of premium support will be based on the wealth of the individual. The poor and the sick, Ryan insists, will get full premium support, and indeed will end up with “better” health insurance than they would get today under Medicare. Wealthier individuals will have to pay a much higher proportion of their own insurance premiums.

The Ryan plan in its current form is little more than an outline, and DrRich would need to see details before feeling warm and fuzzy about it. But fundamentally it takes medical decisions away from a Central Authority and places those decisions back into the hands of patients. Further, it not only allows but insists that people (who can afford it) spend at least some of their own money on their own healthcare. Also, patients under the Ryan plan will be legally permitted – even encouraged – to purchase any additional healthcare they want, any time they choose. This plan restores individual autonomy (and its twin, individual responsibility) to American healthcare.

Undoubtedly, the insurance companies under the Ryan plan would be no less evil than they are today, and would do harm to patients every chance they get. But (as DrRich has amply demonstrated) so will the Feds, and it is far easier and far less dangerous for doctors and patients to fight insurance companies than the Central Authority.*

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*DrRich hastens to remind his readers that health insurance companies will want no part of a plan such as Ryan’s. Ryan’s plan would require these companies to continue operating under their current, broken business model. After fighting so hard for Obamacare (which converts insurance companies essentially to public utilities), the insurance industry will not give up its victory without a fight – especially if doctors keep insisting on publishing articles showing that old farts can do just fine after receiving intensive medical care. DrRich thinks the health insurance industry will watch the progress of the Republicans’ budget proposal carefully, and if they perceive it has any chance of success, will do whatever they need to do to stifle it.
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Would elderly people die earlier under the Ryan plan? Those who are deemed wealthy enough to contribute to their own health insurance premiums, and who as a result choose to become under-insured, may certainly die earlier. DrRich supposes this is what the Democrats mean by “killing old people,” since he can find no other rationale to support such a statement.

The Bottom Line. Ultimately, the worst thing that could happen to us old farts would be for the current Medicare system to continue as it is, without any meaningful fiscal reforms. The two other plans for Medicare both promise to control government expenditures on healthcare, and thus promise to avoid the societal collapse (and mass elderly casualties) that likely would be produced by doing nothing.

Obamacare accomplishes this by placing healthcare decisions into the hands of government-chosen “experts” who will determine the management of individuals from a great distance, and by giving the elderly a lower priority in unavoidable rationing schemes.

In contrast, the Ryan plan proposes to avert catastrophe by placing elderly individuals in the position of having to choose (and in many cases partially pay for) their own health insurance product, and then live with those choices.

Speaking on behalf of the entire GOFA organization, DrRich would rather his fellow old farts die as a result of their own personal choices in a plan like Ryan’s, than die as the first victims of the societal upheaval, or through the tyranny, promised by the other two options.

DrRich trusts that his position as President of such an august organization will render his opinion in this matter dispositive.

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As difficult as it may be for most of his readers to believe, not everyone appreciates the erudite writings or well-reasoned analyses habitually offered up herein by DrRich. And despite the fact that DrRich takes great pains to express himself cordially even when addressing particularly contentious issues, and that he assiduously avoids personal attacks on his opponents, and indeed usually attributes lofty motives to them (focusing instead on their counterproductive methods or naive premises), it is not at all rare for DrRich to be the recipient of some rather negative, even personally hostile, communications.

And of all the topics likely to engender such negative feedback, none gets a more vociferous response than this: DrRich’s contention that among the many mandatory features that will necessarily comprise any Progressive healthcare system, the most obligatory, compulsory, requisite and non-negotiable of all will be the imperative to forbid individuals from having any meaningful control over their own healthcare destiny.

There are two basic reasons individual autonomy in healthcare must be stifled.

First, in order to achieve the most efficient and most effective outcomes within a Progressive healthcare system, all healthcare decisions will have to be made by a Central Authority, wielding its concentrated organizational and scientific expertise to maximize the public good.  Allowing these carefully calibrated decisions to be modulated by imperfect individuals (i.e., by non-experts) will fatally undermine the entire effort.

Second, and far more importantly, when one has at last devised a centrally-controlled, “universal” healthcare system (again, for the purpose of maximizing the public good), then allowing individuals to spend some of their own money on healthcare services that have not been officially sanctioned for them by the Central Authority will wreck the very legitimacy of that system. That is, to permit such individual prerogatives is tantamount to admitting that, perhaps, the Central Authority is actually NOT providing all useful healthcare services to all people (when, by definition, it is). Allowing individuals to purchase “extra” healthcare is a signal to the unwashed masses that there is “extra” healthcare to be had, and that the Central Authority may be holding out on them.

To say it another way, an essential feature of any Progressive healthcare system will be to carefully manage the expectations of the subject citizenry. To have certain subjects running around purchasing extra healthcare will fatally damage those managed expectations, and thus will fatally damage the Progressive healthcare system itself. Hence, it is imperative that individuals be constrained.

This fact has caused DrRich to say, many times, that the real battle over our new healthcare system will be the battle over whether Americans will be permitted to spend their own money on their own healthcare. Left-leaning readers take great umbrage at such a thought, since it is tantamount to accusing them of working toward a great tyranny. Most left-leaning Americans are still Americans, and therefore despise tyranny, and it is perfectly understandable that they would be angered at such an accusation. This is why, DrRich thinks, most left-leaning Americans will themselves be horrified when they at last glimpse where a Progressive healthcare system is inevitably taking us. Unfortunately, DrRich fears, such a realization on the part of well-meaning, left-leaning Americans will come too late to do us any good.

DrRich has attempted to document the efforts of Progressives to limit individual healthcare prerogatives, and while he himself finds the evidence compelling that they are deadly serious about doing so, he apparently has not made the case to the full satisfaction of many of his readers. So let him offer up the latest, particularly compelling, piece of evidence.

Last week, Washington DC District Judge Rosemary Collyer ruled that elderly Americans do not have the right to drop out of Medicare and purchase their own health insurance, unless they also forgo all Social Security payments, and repay the government any Social Security payments they have already received.

The notion that Americans MUST accept Medicare, of course, dates back to the Clinton administration, which in 1993 promulgated a rule in its Program Operations Manual System (POMS) to that effect. (DrRich has described how the Clinton healthcare reform plan intended to aggressively restrict individual prerogatives, and despite the failure of Hillarycare the Clinton administration still took several steps to do so.)  The lawsuit in question was filed by three elderly Americans (one of whom is Dick Armey), who wish to drop out of Medicare in favor of self-purchased health insurance, without having to sacrifice (and repay) their Social Security benefits.

Interestingly, Judge Collyer in 2009 denied a motion by the Obama administration to dismiss the suit, noting that “neither the statute nor the regulation specifies that Plaintiffs must withdraw from Social Security and repay retirement benefits in order to withdraw from Medicare.” Her preliminary ruling thereby confirmed the plaintiffs’ main contention.  So most observers assumed that the judge’s final ruling would also be in favor of the plaintiffs.

It was not. In her final ruling last week, Judge Collyer found a new interpretation of the Medicare statute itself that upholds the POMS rule. The Medicare statute, she now argues, specifies that people who are entitled to Social Security are automatically “entitled” to Medicare, and therefore if one elects to receive the Social Security payments one is owed, one must also accept Medicare. She flatly rejects the notion that when Congress says “entitled” it is implying anything optional, as in, “You can have it if you want it.” When you’re dealing with Medicare, she says, “‘entitled’ does not actually mean ‘capable of being rejected.’” When Congress says “entitled” Congress means you must have it – that it’s mandatory. Judge Collyer ends by sympathizing with the plaintiffs (or laughing at them – DrRich cannot tell for sure): “Plaintiffs are trapped in a government program intended for their benefit.”

The apparent change in Judge Collyer’s reading of the Medicare statute between 2009 and 2011 is disturbing. What made her originally read the plain language of the Medicare statute just like any literate American would, but then two years later read it as if she had to twist it into a presupposed “right” answer? We will never know, of course, but the turnabout seems troubling to DrRich.

It is instructive that the Obama administration would go to such lengths to prevent old farts from dropping out of Medicare. Medicare is not only in the red, but is a great fiscal threat to our national well-being. One would think they’d welcome the idea that some of our elderly might want to pay for their own health insurance, and save Medicare a lot of money. Instead, they fought it tooth and nail, even though the fight reduced them to absurdity. The Obama administration’s chief argument against the lawsuit was that the plaintiffs were lucky to receive such a boon as Medicare, and therefore suffered “no injury” by having to accept it, and so had no standing before the court. The judge herself ridicules the argument of the Obama administration: “The Secretary extolls the benefits of Medicare and suggests that Plaintiffs would agree they are not truly injured if they were to learn more about Medicare…The parties use a lot of ink disputing whether Plaintiffs’ desire to avoid Medicare is sensible.”

So as it now stands, seniors (unless they are rich enough to walk away from Social Security altogether) must accept Medicare. Admittedly, for most elderly Americans this is not a big deal – of course they’re going to accept Medicare. But, as DrRich has pointed out, current law already makes it nearly impossible for patients on Medicare to self-pay for denied medical services. Once you are on Medicare, you will get the medical services the Central Authority approves for you – and nothing more. In the not-too-distant future, this restriction is likely to become much more apparent to Medicare recipients. When and if the day comes when we would like to buy ourselves some medical care which the Central Authority would rather we did not have, we old farts will find that we are “entitled” neither to pay for our own healthcare, nor to drop out of the government program that so restricts us.

And at the risk of angering his readers yet again, DrRich asserts that we are one giant step closer to the day when it will become illegal for all Americans to spend their own money on their own healthcare.

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In an earlier post, DrRich offered several potential strategies for doctors and patients to consider should healthcare reformers ultimately succeed in their efforts to make it illegal for Americans to seek medical care outside the auspices of Obamacare. To those readers who persist in thinking that DrRich is particularly paranoid in worrying about such a thing, he refers you to his prior work carefully documenting the efforts the Central Authority has already made in limiting the prerogatives of individual Americans within the healthcare system, and reminds you that in any society where social justice is the overriding concern, individual prerogatives such as these must be criminalized. Indeed, whether individuals will retain the right to spend their own money on their own healthcare is ultimately the real battle. The outcome of this battle will determine much more than merely what kind of healthcare system we will end up with.

DrRich, despite his paranoia on the matter, is a long-term optimist, and believes that the American spirit will ultimately prevail. So, to advance this happy result DrRich (in the previously mentioned post) graciously offered several creative options that could be employed to establish a useful Black Market in healthcare, which will allow individuals to exercise their healthcare-autonomy against the day when such autonomy again becomes legal. His suggestions included offshore, state-of-the-art medical centers on old aircraft carriers; combination Casino/Hospitals on the sovereign soil of Native American reservations; and cutting-edge medical centers just south of the border (which would have the the added benefit of encouraging our government to finally close the borders to illegal crossings once and for all).

As entertaining as it might be to imagine such solutions, a readily available, though much more mundane, option exists today, which is to say, medical tourism.

Medical tourism is where one travels outside one’s own country in order to obtain medical care elsewhere. It is becoming a booming business. A number of superb state-of-the-art medical centers expressly aimed at attracting medical tourists have been established in the Middle East, Singapore, India, China and elsewhere in Asia. These institutions cater to citizens of the world whose own healthcare systems cannot (or will not) provide in a timely fashion (or at all) the level of care patients may desire. Many of these institutions offer modern hospitals, numerous amenities, luxurious accommodations, attentive nursing care, and top-notch doctors – and they do it all for a tiny fraction of what the same care might cost (if you can even find it) in the U.S. and other “first world” nations.

Obviously, medical tourism is not particularly feasible for medical emergencies such as heart attack or stroke, or for chronic illnesses such as diabetes, congestive heart failure, or Parkinson’s disease, which require frequent visits and long-term management.  What is feasible is to become a medical tourist for those one-time medical services that can be scheduled and planned, for which there is a long waiting period at home, or which is simply too expensive in one’s own country. Such medical services often include coronary artery bypass surgery, hip replacements, knee replacements, and numerous minimally-invasive and not-so-minimally-invasive surgical procedures. In other words, medical tourism to a large extent is something one does for elective (i.e., non-emergency) surgery.

These are the very procedures, as DrRich has pointed out, which are now being covertly rationed in the U.S. thanks to the “never events” policy adopted by CMS and private insurers. As a result, certain categories of individuals may soon find it more difficult to obtain elective surgical services than they might have just a few years ago, and medical tourism may accordingly become a more compelling alternative.

It ought not be a surprise, therefore, that the first organization of American physicians to issue a formal policy statement regarding medical tourism is the American College of Surgeons.

The reaction of American surgeons to medical tourism ought to be obvious. They hate it. Elective surgical procedures – the very procedures for which Americans become tourists – are the bread and butter of most surgical specialties. It pains them to think of their prospective patients going off to Singapore for their lucrative bypass surgeries. American cardiac surgeons, for instance (already underemployed, thanks to American cardiologists throwing stents at every tiny coronary artery indentation they they can justify as a “blockage”), are nearly apoplectic at the idea.

It’s always a delight to read formal policy statements which attempt to disguise an entirely self-serving message as a selfless public gesture. The actual message of the surgeon’s policy statement, of course, is, “We hate medical tourism, and if you do it we’ll hate you,” but they say so on a manner which is designed to be polite, politically correct, non-judgmental, helpful and even friendly.

The surgeons in general have made a good effort, as you can see if you’d like to read the policy statement for yourself. It’s pretty much what you would expect – “Go ahead and have your knee replaced in Timbuktu if you want to. It’s your right, so go ahead and devil take the hindmost. Just don’t come crying to me when things go south a month later.”  They do so, however, in an extraordinarily collegial way.

The artful style of their policy statement aside, DrRich is struck by two aspects of the actual substance of the document.

First, the surgeons begin with a litany of dire warnings regarding all the medical considerations one must take into account before trusting one’s health to foreign medical hands:

“Some of the intangible risks include variability in the training of medical and allied health professionals; differences in the standards to which medical institutions are held; potential difficulties associated with treatment far from family and friends; differences in transparency surrounding patient discussions; the approach to interpretation of test results; the accuracy and completeness of medical records; the lack of support networks, should longer-term care be needed; the lack of opportunity for follow-up care by treating physicians and surgeons; and the exposure to endemic diseases prevalent in certain countries. Language and cultural barriers may impair communication with physicians and other caregivers.”

Obviously, these are all very important considerations. What strikes DrRich, however, is that these are the very same considerations (even the warning about endemic diseases, when one considers the MRSA infections which are secretly “endemic” in some American hospitals) which patients must also take into account before agreeing to receive care in any American institution. It may turn out that these considerations are more an issue in top-notch foreign hospitals than in your average American hospital, but DrRich is not convinced this is the case, and the surgeons do not provide any evidence that it is. In other words, DrRich sees this very good advice as being equally applicable whether one is considering becoming a medical tourist, or just a typical American patient.

Second, and more astonishingly, DrRich notes – not so much with interest, but more with awe – that the surgeons are beseeching their patients to consider just how difficult it might be to launch a malpractice suit against foreign doctors. (DrRich himself does not know how difficult this would be. Given that we are being so strongly urged these days to merge the American legal system with several varieties of international law, it might not be such a big problem.) Indeed, a careful reading of this policy statement reveals that the potential difficulty in suing foreign doctors is offered as the chief differentiator, and thus it has become the primary argument in favor of good-old-American-surgery. The surgeons, in essence, are saying, “Let us do your surgery, because we’re easier to sue if we screw up.”

This, from the very body of American physicians who are most at risk for malpractice suits, and who traditionally have been most vociferous in favor of malpractice reform.

DrRich can only shake his head in wonderment. If medical tourism is viewed by surgeons as such a dire threat that they have embraced, as their chief weapon against it, a celebration of the ease of suing American doctors, why, one can only conclude that medical tourism must have caught on far more than most of us realize.

As an American physician who has always been proud of American medicine, DrRich’s innate tendency is to lament the fact that Americans are finding it to their advantage to travel to Mumbai for their hip replacements. But as a patriot, he celebrates the fact that his fellow citizens are willing to go to such lengths to exercise their individual autonomy. He finds it a hopeful sign.

Our would-be oppressors might find it more difficult to hold us down than they may think.