1. Featured Article: One in Five Mothers Experience Post Partum Depression

Postpartum Depression Epidemic Affects More than Just Mom

A deep despair mars the first year of motherhood for as many as one in five women. Without treatment, postpartum depression can weaken critical bonds between a mother and her child, By Katja Gaschler, Scientific American Mind - March 20, 2008

The psychologist smiles at Manuela, a new mother in her late thirties. "Please play with your baby for two minutes," the therapist instructs her and then leaves the room. Two video cameras film Manuela (which is not her real name) and her three-month-old daughter. In the next room, a split-screen monitor shows the mother's profile on the left and her infant in a baby chair on the right.

At first, Manuela appears to be at a loss for what to do. Then, her face noticeably stiff, she begins to talk softly to her baby. Her baby fidgets, briefly makes eye contact and then turns away. Manuela eventually stops talking and stares into the distance, unsure again how to act. She absentmindedly strokes her baby's foot with one hand. The psychologist knocks on the door; the videotaping is over. The new mother is now on the verge of tears.

Manuela is undergoing therapy at the Clinic for General Psychiatry in Heidelberg, Germany, for postpartum depression, an ailment that has strained her relationship with her baby. Although the vast majority of mothers experience periods of crying and irritability along with concentration lapses and exhaustion, these so-called baby blues disappear within a few hours or days of delivery. But 10 to 20 percent of women in the U.S. develop, in the first year after childbirth, the more disabling despair that afflicts Manuela. These mothers succumb to a deep sadness that, if untreated, may persist for months to years.

Manuela frequently feels exhausted and emotionally empty. When her baby cries, she sometimes wants to flee or hide. She is wracked with guilt because she cannot show love to her daughter. Mothers with symptoms of postpartum depression [see box on page 70] are often overwhelmed by the feeling that they might harm their babies. Although they rarely cause any outright harm, depressed mothers may have difficulty caring for their infants—and that fact can heighten their distress. . .

The causes of the disorder are not fully known, but the dramatic hormonal fluctuations that occur after delivery may contribute to it in susceptible women. A bout of previous depression is a huge risk factor for the postpartum variety, new research shows. Whatever its cause, depression can weaken the nascent bond between a mother and her child, studies suggest, and thereby make a toddler more passive, insecure and socially inhibited—although a child's intellectual development usually remains unimpaired.

Thus, in addition to treating the mother's depression, psychologists and psychiatrists increasingly focus on strengthening the relationship between the mother and her child—for example, by using a video camera to record and analyze their interactions. "We need to change the unfavorable behavioral patterns that develop between mother and child during depression," says University of Heidelberg psychologist Corinna Reck.

Hormonal Havoc
Women seem to be particularly vulnerable to depression during their reproductive years: rates of the disorder are highest in females between the ages of 25 and 45. New data indicate that the incidence of depression in females rises, albeit modestly, after giving birth. In the October 2007 American Journal of Psychiatry, epidemiologist Patricia Dietz of the U.S. Centers for Disease Control and Prevention and her colleagues reported that 10.4 percent of 4,398 mothers had been depressed in the nine months following childbirth, compared with 8.7 percent in the nine months before pregnancy and 6.9 percent during pregnancy. More than half of the women with postpartum depression had also been depressed during or before pregnancy, suggesting that a previous occurrence of depression may be the biggest risk factor for acquiring the illness postpartum. . .

The demands of motherhood very likely play a role as well. Many women feel exhausted from a baby's broken sleep and become overwhelmed by new child care duties. Some may lament the loss of the life they led before having the baby or of their former figure. Women who must endure such stresses on top of marital problems, a complicated birth, job loss or lack of support from family and friends are more likely to succumb to depression.

Broken Bonds
The consequences of depression inevitably reach beyond the mother. In a fog of sadness, a mother often lacks the emotional energy to relate appropriately to her baby. Overwhelming grief prevents her from properly perceiving a child's smiles, cries, gestures and other attempts to communicate with her. Getting no response from mom, the child quits trying to relate to her. Thus, three-month-old infants of depressed mothers look at their mothers less often and show fewer signs of positive emotion than do babies of mentally healthy moms.

In fact, infants of depressed mothers display something akin to learned helplessness, a phenomenon University of Pennsylvania psychologist Martin E. P. Seligman and his colleagues described in the 1960s. In Seligman's experiments, an animal would conclude that a situation was hopeless after repeatedly failing to overcome it—and then remain passive even when it could effect change. A similar passivity characterizes depression. "Sometimes the infants mirror their mother's depressive behavior," Reck says . . .

A child of a depressed mother may even become more introverted and face a greater risk for social phobia, an extreme fear of social situations, among other emotional difficulties. In 2007 Reck, Moehler and their colleagues reported that in the same 101 mother-infant pairs, postpartum depression at six weeks, four months and 14 months after birth tended to make a 14-month-old toddler more fearful and inhibited as compared with same-age toddlers of healthy moms. Other work suggests that postpartum depression may produce behavioral problems and negativity in children. . .

Meanwhile a mother can take steps to ease her emotional burden by asking for help from family and friends, sleeping more, spending time with her spouse, getting out of the house and putting less pressure on herself. In the end, most mothers who receive adequate treatment—often a combination of psychotherapy, medication and self-help—usually recover completely within about two months of starting treatment, according to psychiatrist Ricardo J. Fernandez of Princeton Family Care Associates in New Jersey. Some mothers even emerge from their cloud of sadness with a new sense of clarity. As one mother said of her depression, "It gave me the impetus to change my life."

Read entire article . . .

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2. In the News: Transparency Is More Powerful Than Regulation

Transparency in health care has been spoken of as a way to reign in healthcare costs. Yet many of us fail to believe this. The modus operendii is that regulations will control costs better than the free marked. We feel that the free market is the most ruthless mechanism to lower any costs and healthcare costs would be reduced in the same manner. If there were no health insurance, most of us understand that we would find the best doctor at the cheapest price we could find. Other doctors who are seeing open appointments in their office schedule would consider lowering their fees to attract more patients. If we all paid to see our doctor, no one would go to a doctor without knowing up front what the charages would be. This is transparency.

Attempts to have hospitals disclose their charges have been unsuccessful. They have negotiated various fees with the several insurance carriers including Medicare and are not inclined to make these public. However, if patients paid in cash, hospitals would have to disclose their fees up front or suffer increasing empty beds which means lost revenue. No one would go to any hospital outside of an emergency with no assurances that they won't be gouged with suprises.

Now Gordon Crovitz comes up with a historical analysis of transparency.

In 1933, newly elected president Franklin D. Roosevelt had to make a tough choice in dealing with the aftermath of the stock-market crash that wiped out much of the equity in American companies. Leading members of FDR's brain trust wanted federal regulators to get the power to make key decisions over markets, such as which companies deserved to be publicly traded. Today, many of President Barack Obama's advisers want unprecedented authority to oversee details of the credit markets, and how banks lend.

FDR decided instead to side with advisers who argued for disclosure as the key operating principle of our markets. Helping markets function better, they reasoned, was a sounder safeguard than trusting regulators to decide.

Supreme Court Justice Louis Brandeis had made the point that "sunlight is the best disinfectant," and the Securities Act of 1933 mandated the information that public companies would have to share. One indicator that disclosure was more important than regulatory power is that it wasn't until the following year that the Securities and Exchange Commission (SEC) was created.

What worked to restore confidence in the equity markets then can help to restore confidence in the debt markets now: more disclosure, aimed at making the terms of debt such as mortgages more transparent. Unlike the case of stocks, under current law no one in the chain of making, insuring and rating debt is required to disclose full terms to regulators or to the market. Instead, debt markets function based on best estimates, with mathematical models determining probabilities of cash flows and defaults.

Ever since the models failed due to an unpredicted bubble, the market has been paralyzed with uncertainty. There is still a wide gap between what banks think their bad debt might be worth and what the Treasury or private investors are willing to pay . . .

FDR was no Milton Friedman, and neither was Brandeis, but they grasped what we seem to be forgetting, which is that markets are too complex for even the most powerful regulators to dictate. Better transparency is the surest way to make markets more efficient and less volatile. Market wisdom results when more people access better information. . .

Read the entire article . . .

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3. International Medicine: Natasha Richardson, 45, died on March 18, 2009, of epidural bleeding.

Natasha Richardson, 45, daughter of Vanessa Redgrave, died on Wednesday, March 18, 2009, at Lennox Hospital in New York after a ski accident on Tuesday, March 16, 80 miles from Montreal while taking a skiing lesson on a bunny slope. She initially turned down medical treatment but an hour later complained of a severe headache and was taken by ambulance to a hospital.

Although she was only an hour ambulance ride away from Montreal, the world's second largest French speaking city, two days later she was taken to the United States to the New York Lennox Hospital with emergency life saving surgery not having been done in Canada.

An autopsy of the actress Natasha Richardson on Thursday indicated that she died of a brain hemorrhage caused by "blunt impact" to her head, according to the chief medical examiner for New York City. The official cause of death was an epidural hematoma. A hematoma is a collection of blood, and epidural in this case refers to the space between the skull and the dura. If surgery is performed quickly, it may be possible to save the patient's life, doctors said.

If the accident had happened in the United States, she may also have died. However, all the reports fail to recognize the deficiencies of Canadian Medicare. Superior care is available in nearly every city in America. Ms Richardson had her warning when the headache occurred one hour after the accident, which normally alerts any physician to an impending catastrophic bleed requiring immediate burr holes in the scalp to drain the blood before it compresses the brain and possibly craniotomy. This was not done during the two days in Canada despite being within one hour via ambulance ride to hospitals in a world-class French Canadian city, several times larger than Sacramento.

In Sacramento, a city of less than one million and two million in the metropolitan area, all four Mercy Hospitals, all three Sutter Hospitals and all three Kaiser Hospitals, and UC Davis Medical Center would have been able to save her life. Montreal surely must have even greater capability. Yet, her family chose to delay treatment and leave Canadian Medicare for care available universally in America.

The news accounts focused on safety measures and helmets. These are excellent comments for the future of others. None seemed to be focused on what was really necessary to save her life after the accident. Perhaps no one wants to admit that we have the number one world-class healthcare that half of the country thinks needs improving. However, they are talking about payment reform, not healthcare reform. Even though the World Medical Association rates America behind Columbia in care, we have never seen anyone flee American Care for that available in Columbia. The rating agencies never rate anyone without socialized medicine as having appropriate care. Hence, the falsely low standing of America noted in these prejudicial polls. (If you would flee from America for better care elsewhere, give us your story at the blog above and we'll publish it.)

Universal availability of care saves more lives than universal access. America has universally available care. Canada has universal access to a waiting list. Care may never be rendered. In this case, it was tragic.

Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html

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4. Medicare: The Massachusetts Debacle Coming to Your Neighborhood

NATIONAL HEALTH PREVIEW: THE MASSACHUSETTS DEBACLE, COMING SOON TO YOUR NEIGHBORHOOD

Praise Mitt Romney, says the Wall Street Journal. Three years ago, the former Massachusetts Governor created the "universal" health-care program that the White House and Congress now want for the entire country. It is proving to be instructive, as Romney's foresight previews what President Obama, Max Baucus, Ted Kennedy and Pete Stark are cooking up for everyone else.

In Massachusetts's latest crisis, Governor Deval Patrick and his Democratic colleagues are starting to move down the path that government health plans always follow when spending collides with reality -- i.e., price controls. As costs continue to rise, the inevitable results are coverage restrictions and waiting periods. It was only a matter of time, says the Journal.

They're trying to manage the huge costs of the subsidized middle-class insurance program that is gradually swallowing the state budget, says the Journal:

• The program provides low- or no-cost coverage to about 165,000 residents, or three-fifths of the newly insured, and is budgeted at $880 million for 2010, a 7.3 percent single-year increase that is likely to be optimistic.

• The state's overall costs on health programs have increased by 42 percent since 2006.

Like gamblers doubling down on their losses, Democrats have already hiked the fines for people who don't obtain insurance under the "individual mandate," already increased business penalties, taxed insurers and hospitals, raised premiums, and pumped up the state tobacco levy. That's still not enough money, says the Journal.

Which brings us to Washington, where Obama and Congressional Democrats are about to try their own Bay State bait and switch: First create vast new entitlements that can never be repealed, then later take the less popular step of rationing care when it's their last hope to save the federal treasury, says the Journal. . .

Source: Editorial, "National Health Preview: The Massachusetts debacle, coming soon to your neighborhood," Wall Street Journal, March 27, 2009.

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Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5. Medical Gluttony: Obtaining an extra $600 Opinion on the way to a $125 Office Visit

A patient came in today with an upper respiratory infection, with a two-day history of cough with minimal expectoration. Last evening she decided that she would go to the emergency room to make sure all was well. She obtained a cursory evaluation, tests were ordered and the nurse told her two hours later that she could go home. She complained that she had not been told what was wrong with her and the doctor interrupted his emergency schedule to inform her that nothing was found and went back to his emergency.

When the patient was seen she was in no respiratory distress with her vital signs stable and she was afebrile. Exam was rather unremarkable except some chest findings consistent with bronchitis. She was given a prescription for antibiotics, which should clear her in a few days.

The HMO to which this patient belongs states that they pay $600 for the average ER visit even though most are considerably more. We have seen statements from the emergency departments that were 10 times that amount. Meanwhile, the same HMO pays us $65 for our $125 office call.

What could change this over utilization of resources and excessive costs? Transparency would help. If the patient knew the charges involved at the registration desk, she may have turned around and waited for her appointment the next morning. If she had known that this was not really the type of consultation she had hoped for, not even three minutes with the ER doctor, she may have reconsidered. If her HMO would have reviewed the case and told her it was no emergency and billed her for the $600 three-minute consultation that was unnecessary, the PR fallout would have been unbelievable.

But none would have come close to the simple mechanism of a significant deductible and a significant co-payment on every healthcare charge. If the patient had to plunk down say 20 percent at the ER registration counter ($120), everything would have been brought into focus and rationale behavior would have ensued. Healthcare costs would have been brought into line at the registration desk without any oversight, mandates, price controls, insurance or government interference. There is nothing more effective than the free market to bring costs into line. But then Congress may have to lay off some of their staff.

Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6. Medical Myths: I have insurance and, therefore, I deserve my electric wheel chair.

A very common concept among patients is that they have insurance and that should settle any issue and cover any desired benefit. The current rage is electric wheelchairs. Patients see their neighbors and friends with these wheelchairs, who they think are less disable that they, so why shouldn't they have one. They come to the doctor expecting the appropriate prescriptions to go out and buy one with their insurance card.

Last week we had such a patient and he had a beauty - a place for his drinks up front and for his groceries in the back. He said he only lives two blocks from the grocery story and decided he no longer needed his car so he sold it. He only would admit that he sold it for more than Medicare paid for the wheelchair.

This is one part of the equation that has never been fully evaluated. Durable medical equipment may replace items such as a car which insurance is not designed to cover.

So how should durable medical equipment be handled? Rather than make the doctor the scapegoat, there is a very simple solution: A co-payment that takes this into account.

We have always felt that durable medical equipment has to have a co-payment of around 40 to 50 percent. Otherwise, everyone wants one. If the co-payment is only 20 percent, this will not be enough of a disincentive. Durable medical equipment always involves the family or significant others. They should always help decide. If it is the spouse, the question is very easy. Is the electric wheelchair important enough to make a $1500 co-payment worthwhile? For that amount of money, the spouse may conclude she can still take her husband in her car and transport him here or there. For only $500, she may enjoy losing the responsibility of her loved one. The decisions are realistic in view of the costs.

Be sure to enroll in our revised sister Newsletter, HealthPlanUSA, coming next month to follow the development of this concept in future months.

Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7. Overheard in the Medical Staff Lounge: Is the Recession Affecting our Practices?

Dr. Milton: Has the recession affected your internal medicine practice?

Dr. Kaleb: Not noticeably yet. Maybe a few are concerned about the co-payment and a few more about their drug co-payments.

Dr. Milton: Are the surgeons affected?

Dr. Yancy: My fees have been so reduced by Medicare and the insurance companies that I don't see how it could get any lower.

Dr. Milton: What about plastic surgery? I would think elective surgery must be hurting.

Dr. Nichols: Well, I can tell you that plastic surgery is really in the pits. There are very few face jobs that are not expensive. The tummy tucks have dropped off. The breast jobs are holding steady.

Dr. Milton: Pediatrics must be holding up. I would think kids will always be brought in by their mothers if they even suspect something serious.

Dr. Paul: I think you're right. We haven't seen much drop off. As we've discussed before, about half of our practice is Medicaid. Even though the government is broke with a multi-billion dollar deficit that is worse than Governor Davis had before he was ousted by Schwarzenegger, we are still getting paid by State of California. But for our private patients, they seem to be coming in less frequently.

Dr. Edwards: Then there are flukes. The HMOs are on a publicity stunt and sending all their patients that turn 50 a letter that they should have a colonoscopy. The Medical Grand Rounds at UC Davis discussed the excess of colonoscopies that were being done in this country. If there is a family history of cancer of the colon, then one might start at age 50. If none, age 60 is early enough. If there is a polyp, the visiting professor suggested an additional one in five years and possibly one in the late 60s when the incidence of cancer of the colon is the highest.

Dr. Rosen: I see the GI people are doing simple flexible sigmoidoscopies for those without risk primarily because they can't keep up with all the HMO referrals.

Dr. Milton: It's getting to be a little like in the UK. Procedures are frequently a result of government policies and political directives for healthcare.

Dr. Rosen: If patients only knew what they're going to be getting in the future with further government encroachment, they might be able to prevent it.

Dr. Milton: But it's only human nature or immaturity to continue to think we can get something for nothing.

Dr. Rosen: And a person's healthcare is the most dangerous thing to try to get for nothing.

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8. Voices of Medicine: A Review of Local and Regional Medical Journals

The Recession and its Effect on Healthcare By David J. Gibson, MD and Jennifer Shaw Gibson
Sierra Sacramento Valley Medicine

(This article has been heavily edited for publication. The complete article appears here.)

AMERICA IS IN A SEVERE RECESSION. Last November, the U.S. lost over half a million jobs, the largest one month drop in employment in 34 years. That brought the total jobs lost in 2008 to 1.9 million. A job loss usually means a family will lose its health insurance.

Magnitude of the problem.
We are close to the line that separates a recession from a deflation. America's household balance sheets shed almost $3 trillion in the third quarter of 2008, thanks in large part to declining stock prices. That loss, the largest 3-month drop on record, brings the total loss by U.S. households in 2008 to $10 trillion, or about 10 years worth of equity earnings.

Beyond stocks and bonds, most family wealth is based on real estate. Household real estate assets fell for a 10th quarter out of the past 11 and the net worth of real estate is now down 32 percent since 2005. This is an unprecedented loss of family wealth - almost $6 trillion in real housing wealth in 2008, or on average of $85,000 per homeowner.¹

In addition, retirement accounts have been devastated. Since October 2007, 401(k)s have lost $1 trillion in value - fully a third of the value of all 401(k)s. Another $1 trillion has been stripped from people who lost or changed jobs and rolled their 401(k)s into individual retirement accounts. Millions of others have been forced to make early, so-called hardship withdrawals for unanticipated expenses.

Spending by consumers, which has sustained the economy over the past decade, is in free fall. Most consumer spending has been based on mortgage debt. Mortgage-based debt declined in the third quarter of 2008 by 1.7 percent, the first decline in 25 years, resulting from an end of mortgage equity withdrawals.

The economic damage from prior consumer debt-based spending is becoming apparent. A recent report by New York University Professor Nouriel Roubini indicates credit debt could peak at $3.6 trillion for U.S. institutions.² If this prediction proves accurate, the U.S. banking system is effectively insolvent because it starts with a capital of $1.4 trillion. Thus, the new Obama Administration will have to use as much as $1 trillion in yet uncommitted public funds to shore up capitalization of the banking sector. . .

America's true wealth is based on productivity, not paper derivatives. Here again, the news is not good. After averaging 2.7 percent productivity growth from 1995 through 2002,³ annual growth of productivity in the non-farming business sector has slowed dramatically - to just 1.7 percent in 2005, 1.0 percent in 2006 and 1.4 percent in 2007. At this last rate, it would take nearly 52 years for average living standards to double - versus just 26 years at the earlier rate.

This decline in productivity is reflected in the Labor Department's employment report for December. Employers shed more jobs in 2008 than in any year since 1945. Worse, the pace of job loss is accelerating. In the third quarter of 2008, the economy shed an average of 199,000 jobs a month; in the fourth quarter, 510,000 jobs were lost on average each month. Moody's Capital Markets Group in New York predicts about 2.1 million U.S. jobs will be lost in 2009 with 80 percent of the layoffs by the 4th of July. . .

For the short term, the recession will affect every segment of the economy. For the long term, if we "right size" the country's wealth, we will need to right size all segments of the economy - with serious implications for the health care industry.

Government services.
Even before any new health care entitlement programs and expansions, federal health entitlement programs are an economic disaster. Medicare Trustees note that the program has an unfunded liability of some $36 trillion over the next 75 years. As a percentage of GDP, expenditures are projected to increase from 3.2 percent in 2007 to 10.8 percent by 2082.

The lesson of 2008 may well be that we must ensure that federal, state and local governments renew their focus on cost-effectively achieving their fundamental missions of protecting citizens' safety and security. Government will no longer be able to perform numerous philanthropic and social functions that individuals and private associations can do for themselves.

Unfortunately, old ways of thinking die hard. For generations, and in both parties, American politicians have gained power by delivering new programs and services paid for with borrowed funds. Initially, these were raided from the Medicare and Social Security Trust Funds. More recently, funding has come from the sale of bonds to foreign investors.

The new Administration has embarked on a long, highly dubious attempt to return to prosperity by throwing hundreds of billions of newly printed dollars at myriad systemic problems in the health care industry, the housing industry, the financial services industry, the auto industry, the Congressional pork barrel industry, and many other enterprises.

But government has no ability to create demand; only the market can. Government does not create wealth, it can only redistribute it. Government does not create jobs; it can only delay the inevitable creative destruction in any free market. Furthermore, government "stimulus spending" inevitably leads to inflation.

The new Administration is signaling it will exacerbate the recession and its attendant problems by trying to hold labor markets of yesterday in manufacturing, health care and government along with their rich benefit structures.

Make-work jobs in infrastructure will not meet tomorrow's needs. In recent years, government statistics show that about 25,000 jobs are destroyed and created every hour that America is open for business. Rapidly evolving markets create dynamic labor markets.

American government at all levels from the local school systems to the federal are bankrupt.⁵ Politicians are good at giving things away. They have no experience in restricting spending and eliminating programs.

Changes for health care.
As the new Administration greatly expands its funding footprint in health care, permanent entitlement costs will be in place without realistic sources for long term funding.⁶ These new entitlement programs would be created using temporary "stimulus funding" based on borrowed money. Private health plans will be driven from the market; and we will be left with a hopelessly underfunded health care system with no options.

So far, we have few details of how health care policy will evolve under the new Administration. However, there are clear indications of Congressional thinking. The Senate Finance Committee is calling for massive increases in both Medicare and Medicaid. This "Baucus Plan"⁷ will add between $200 billion and $300 billion to the $2.3 trillion we spend each year on government paid health care.

Medicare sets standards for 8,000 medical procedures and services at a 2007 cost of some $425 billion for people 65 or older, or about $10,000 per person. Under the Baucus bill, the age for joining Medicare would drop from 65 to 55. A healthcare system serving 44 million people would make 32 million more (4 million of whom are now without health insurance) eligible.

Medicaid will expand to cover every American living in poverty, rather than just the 61 million people it serves today. This could push 7 million people into the government program and add billions of dollars to its cost.

Finally, the State Children's Health Insurance Program, or SCHIP, will expand to cover all children with family incomes less than 250 percent of the poverty level - up to $53,000 for a family of four. That would add millions more people to SCHIP, which today costs $5 billion a year to cover 6.5 million children.

Put all this together and existing health care programs - Medicare, Medicaid and SCHIP - will be expanded, new healthcare regulation for business and individual policies will be established, and America will have a vast new healthcare program run for and largely paid for by the government. With little input from patients or physicians, government will run it, regulate it, supervise its performance, mandate how company participation in it, and somehow come up with more than several hundred billion dollars each year to pay for it all.

All these program expansions represent fixed future spending obligations. Given the revenue claims by existing social entitlements, there is no long term funding for these spending increases. It is difficult to find the pony in all of these data.

With expanding government health care financing, we can expect a decline in payment to providers compared to their rising cost for delivering services. Competing interest groups will clash for a piece of the spending pie. Highly politicized Medicare-like price controls on providers and services will spread to every health funding decision. The result will be rationing and declines in the quality of services.

Meanwhile, outsourcing of high end health care to international markets⁸ is accelerating. There is a clear and present risk that high tech diagnostic and invasive therapy will migrate to international markets.

Formerly this competition came from distant markets in SE Asia and beyond. Now American hospital chains are starting to buy into Mexico. International Hospital Corp. in Dallas has 5 Mexican locations. Dallas-based CHRISTUS Health has built 6 hospitals in Mexico through its partnership with a Mexican chain. Procedures performed cost a third to two-thirds less than they would in America. People are coming from as far away as Alaska for bariatric, plastic and cardiovascular procedures, as well as knee and hip replacements. Many health insurers are adding cross-border facilities to their networks.

The future will unfold in one of two ways. Either we will deliver an affordable health care financing system in the private sector, or we will find health care thrust onto the political appropriating arena.

The former will require a series of dislocating changes. Innovation will become essential. Increased productivity will be the basis for the reward system. Health care labor costs, which are out of control,⁹ will be reduced. Return to an intermediary free market will be unavoidable.

The latter is more likely. Industry inertia and the primacy of parochial interests will oppose dislocating free market changes. Costs will be controlled through shortages. Provider incomes will be dictated. Innovation will be suppressed. Organized criminal activity will increase as more limited funding is diverted into fraud. Americans with resources will seek care in the international markets and our best talent will go offshore.

As government power and resource move further into health care funding, we will find our ability to make our own choices about our lives, our families and the world around us progressively limited. These policies will ensure that more health care decisions are made - and more of our and our children's money is spent - by a progressively smaller group of policy makers who live far from our communities. They will care little about our personal preferences, religious convictions or personal aspirations. None of this could have happened without the failure we have witnessed in the private sector.

It is not a pretty picture.

Read the article . . .

VOM Is Where Doctors' Thinking is Crystallized in Writing.

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9. Book Review: Atlas Shrugged by Ayn Rand is more relevant today than ever.

Is Rand Relevant?

By YARON BROOK

Ayn Rand died more than a quarter of a century ago, yet her name appears regularly in discussions of our current economic turmoil. Pundits including Rush Limbaugh and Rick Santelli urge listeners to read her books, and her magnum opus, "Atlas Shrugged," is selling at a faster rate today than at any time during its 51-year history.

There's a reason. In "Atlas," Rand tells the story of the U.S. economy crumbling under the weight of crushing government interventions and regulations. Meanwhile, blaming greed and the free market, Washington responds with more controls that only deepen the crisis. Sound familiar?

The novel's eerily prophetic nature is no coincidence. "If you understand the dominant philosophy of a society," Rand wrote elsewhere in "Capitalism: The Unknown Ideal," "you can predict its course." Economic crises and runaway government power grabs don't just happen by themselves; they are the product of the philosophical ideas prevalent in a society -- particularly its dominant moral ideas.

Why do we accept the budget-busting costs of a welfare state? Because it implements the moral ideal of self-sacrifice to the needy. Why do so few protest the endless regulatory burdens placed on businessmen? Because businessmen are pursuing their self-interest, which we have been taught is dangerous and immoral. Why did the government go on a crusade to promote "affordable housing," which meant forcing banks to make loans to unqualified home buyers? Because we believe people need to be homeowners, whether or not they can afford to pay for houses.

The message is always the same: "Selfishness is evil; sacrifice for the needs of others is good." But Rand said this message is wrong -- selfishness, rather than being evil, is a virtue. By this she did not mean exploiting others à la Bernie Madoff. Selfishness -- that is, concern with one's genuine, long-range interest -- she wrote, required a man to think, to produce, and to prosper by trading with others voluntarily to mutual benefit. . .

Rand offered us a way out -- to fight for a morality of rational self-interest, and for capitalism, the system which is its expression. And that is the source of her relevance today.

Dr. Brook is president and executive director of the Ayn Rand Institute.

Read the entire article on Ayn Rand . . .

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10. Hippocrates & His Kin: Cost of Long Term Care

In a study reported by the MetLife Market Survey of Nursing Home & Healthcare Costs, 2008, it is reported that long term care averages over $77,000 per year and private insurance and Medicare cover less that three percent of these costs.

Long term care is primarily in the Medicare-age population. If Medicare is unable to take care of people that it's designed to cover, reform should involve shoring up the Medicare deficiencies rather than extending the coverage to age 55 as some propose.

How much cash does it take to stay out of jail?

The man who was facing trial and possible imprisonment told his lawyer, "I know the evidence is against me, but I've got $50,000 in cash to fight this case."

"You'll never go to prison with that amount of money," the lawyer assured him.

He didn't. He went there broke.

Sewer maintenance increased 42 percent in Sacramento.

Increased regulations for maintenance of 1200 miles of sewer pipes, even if only one has lead, will lead to a 42 percent increase in sewer mileage maintenance in Sacramento.

Sewer mandates appear to be nearly as expensive as healthcare mandates.

Looks like increasing taxes will slowly push us from recession to depression.

To read more HHK, www.healthcarecom.net/hhkintro.htm.

To read more HMC, go to www.delmeyer.net/HMC.htm.

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11. Organizations Restoring Accountability in HealthCare, Government and Society:

• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This month, read the informative article Health Care Reform: Do Other Countries Have the Answers?

• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Just released:

Federal Monopoly of Pharmaceutical Regulation and its Deadly Cost.

• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, treat yourself to an article on Government Reform.

• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on the articles on the home page.

• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?

• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education: Should the government do for people what they can't do for themselves?

• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. Read her latest newsletter.

• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read The Historical Perspective of the Current Economic Downturn.

• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section.

• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom loving institution.

• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

• CATO. The Cato Institute (www.cato.org) was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html.

• The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.

• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17^th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read John Goodman on a Prescription for American Healthcare. The last ten years of Imprimis are archived.

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Words of Wisdom

". . . truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it." -Max Planck (1858–1947).

Definitions: Lawyer: He who is summoned when a felon needs a friend. Lawsuit: A machine which you go into as a pig and come out of as a sausage. -Ambrose Bierce, The Devils Dictionary

'Tis easier to make certain things legal than to make them legitimate. -Nicholas Chamfort

Some Recent Postings

Why Government Doesn't Work

Why the Push for Health Care Reform?

A Disingenuous Debate on Health Care Policy

In Memoriam

"Winston tastes good like a cigarette should."

Alan Landers, ex-smoker, died on February 27th, aged 68, From The Economist print edition, March 12th 2009.

BY THE time he posted his last blog, on February 16th, life was getting rough for Alan Landers. Radiation treatment every day for tonsillar cancer was filling his throat and mouth with sores. This made it hard to swallow and harder to speak, though his voice had long ago sunk to a growl since a botched operation on his voice box in 1993. He was totally bald, although he had buzzed his hair off himself, since he was going to go bald anyway.

The worst part wasn't the hospital sessions. It wasn't even the cancer diagnoses, the first in 1987 and the second in 1992 when the doctor had beeped him while he was driving, and he'd pulled off and gone into a 7-Eleven to be told that he had a tumour on his left lung the size of a golf ball.

Mr Landers never had any doubt about who was to blame for his condition. The big tobacco companies had intentionally hooked their customers on nicotine; they had conspired to conceal the fact that cigarettes were deadly; and he had been lured into "the biggest con of the 20th century". To help shatter the illusion that cigarettes were cool he visited schools, testified to Congress and gave public lectures, pulling off his shirt to show the operation scars that wrapped halfway round his back. He was not involved in the $145 billion class-action suit brought by 700,000 Floridians against Big Tobacco in 1994, the one that was eventually thrown out in 2006 after generating enough paper to make a stack five feet high in the Palm Beach County courthouse. But he was one of the 9,000 victims of tobacco who had been given leave to bring his own case, and in April he was scheduled to. He had no doubt the cigarette companies would be only too glad to see him die first, but he was damned if he was going to give them that satisfaction.

His case was all the more powerful because, for a spell in the 1960s and 1970s, he had been the face of Winston cigarettes. Dark and brooding, in a tux and with vaguely Hollywood lights blurring behind him, he was photographed sliding a Winston seductively from its packet. "I won't settle for anything less than taste," ran the blurb. Cigarette reliably in hand, he poured champagne, hugged beautiful women, brought home the Christmas tree. "Winston tastes good like a cigarette should." Where the Marlboro Man juggled cigarettes with a coiled lasso or a horse, Mr Landers tended to kick about in New England snow. But on the back of his smooth smoking, which paid $3,000 a day, he appeared in Cosmopolitan, GQ and Vogue and was the centrefold in Playgirl magazine. He got bit-parts in "Annie Hall" and "America's Most Wanted", lived in Los Angeles, and was treated like a star by his family whenever he came back to Lakeland. . .

He was desperately ashamed that he had ever promoted tobacco. To the end, in a rough and ever-fainter whisper, he condemned it. Whether he could out-argue those clean-cut fireside frolics, with "real pleasure" dangling from his lower lip, he never knew. He hoped so.

Read the entire obituary . . .

On This Date in History - April 14

On this date in 1890, the nations of the Western Hemisphere joined to found the Pan American Union. This is a good day to be reminded of the spirit of the Good Neighbor and to look North and South in our international relations.

On this date in 1865, President Abraham Lincoln went to Ford's Theatre for an evening of relaxation as the Civil War was ending. John Wilkes Booth went to the same theatre that night also. The rest is history.

On this date in 1912, a great new luxury liner, on its maiden voyage across the Atlantic from England to New York, struck an iceberg. The ship was the Titanic. The rest is history, also.

After Leonard and Thelma Spinrad

MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.

MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol VIII, No 1, Apr 14, 2009