1.
Featured Article:
The Future of the American Idea, November 2007 Atlantic Monthly
With this issue, [The Atlantic Monthly]
turns 150 - declining, with respect, the "battered," still aspiring
to the magical. What, beyond the patient commitment of its owners, can account
for this longevity? Consider The Atlantic's passage: through a permanent
revolution in technology, from the telephone, to the practical fountain pen, to
the radio, to the note pad, to the television, to the Internet; through
financial crises, beginning in 1857 with what The Atlantic called a
national "flurry" over credit (or liquidity, to use the
present flurry's term); through national arguments over slavery, suffrage,
evolution, immigration, prohibition, anticommunism, civil rights, feminism, gay
rights, evolution and immigration (again); through the international contests
of ideology that defined the last century and into the new contest that so far
is shaping this one. How has The Atlantic endured? More to the point,
why? To read more, please go to www.medicaltuesday.net/index.asp.
We may be able to spot a clue in the arguments.
Unlike other publications, The Atlantic wasn't created to track a
particular identity found on a map - Hollywood's glamour, New York's
sophistication, Washington's power, Silicon Valley's imagination. It wasn't
yoked from birth to a particular industry or technology, like the automobile or
the computer. The Atlantic was created in Boston by writers who saw
themselves as the country's intellectual leaders, and so its scope from the
start was national, if rather theoretical. It was founded on an encompassing
abstraction, expressed in the words that appeared in the first issue and that
appear again on the cover of this one: In politics, it would "honestly
endeavor to be the exponent of what its conductors believe to be the American
idea." That sounds pretty good. But those first conductors - among them
Lowell, Ralph Waldo Emerson, Oliver Wendell Holmes, Henry Wadsworth Longfellow,
and Harriet Beecher Stowe - did not explain what they meant, not exactly. What
or which "American idea"? The answer must have seemed obvious to
them: In literature, they wanted to provide a platform for an emerging American
voice; in politics, they had a cause – abolition - that gave granite definition
to the American idea as equality, at least among men. One can easily imagine
that beyond abolition, agreement would quickly break down. Only reluctantly did
Lowell finally agree, in 1859, to publish an essay called "Ought Women to Learn the Alphabet?"
Today, our national facts would seem
radically strange to Lowell - machines that can listen in on millions of
telephone conversations, city-killing weapons that can fit inside satchels,
tools that can pluck cells from embryos and hone them to fight disease - but the
reference points for debate would seem quite familiar. What American faction,
what American, doesn't embrace both the revolutionary message of the
Declaration of Independence and the restraining message of the Constitution?
Our endless quarrels are over what these messages mean, over how the ideal
should be made real. It is the endlessness of the quarrels - the elusiveness of
the American idea, the tantalizing possibility of its full realization - that
has sustained The Atlantic. Through the decades, The Atlantic has
argued; over time, its writers have been found on both sides of some questions,
as, without regard for party or clique or convention, the magazine has
struggled with the great perplexities of the day. (This by turns fractious,
forceful, and witty history is anthologized in a new collection of Atlantic pieces - called, as it
happens, The American Idea - that Doubleday has just published.)
Only a magazine devoted to understanding change could have thrived through so
much of it. Only a magazine that constantly questions its own assumptions about
the American idea could remain true to that idea's potential. That, surely, was
the founders' original intent. (The image they selected for The Atlantic's
first cover, pictured on the preceding page, is of John
Winthrop, he of the "City upon a hill.") While we celebrate the magazine
this month with glances
back at the archive, we honor it more by continuing to turn
our gaze ahead, with pieces like Walter Kirn's romp through the multitaskers' labyrinth, Robert D. Kaplan's report on the decline of American might, and Caitlin Flanagan's essay on Hillary Clinton.
To mark this anniversary, we also invited
an eclectic group of thinkers who have had cause to consider the American idea
to describe its future and the greatest challenges to it. We provided little more
charge than that, beyond asking that they accomplish this feat in 300 words or
so. (It should be noted that Judith Martin - Miss Manners - delivered precisely 300, one of them whoops. Her old colleague Tom Wolfe, who happens to differ with Martin on one
point of historical interpretation, returned again and again to the library,
revising his piece until it reached 2,100 words.) We asked artists to perform
the same feat with a drawing or a photograph.
In the
pages that follow, George F. Will rings an alarm over the danger inherent in embracing a
singular American idea, but many of the contributors agree on a rough
definition of the idea itself - the easy part, as John Hope Franklin suggests. Yet has this idea been put into practice
or not? Is it more threatened by Americans' faith in God or by their
secularism? By Islamic fundamentalism or by our response to it? By poverty,
racism, celebrity, the gobbling up of natural resources? Will science and the
entrepreneurial spirit carry us through? Should we rejoice on this anniversary,
or should we be angry? What follows is a wise, amused, pained, and impassioned
cacophony, and, in sum, a statement of the sustaining value of The Atlantic,
its commitment to the open mind in pursuit of an idea whose realization was
partial and fragile 150 years ago, and still is.
Proceed to the
collection of essays. Proceed to the Atlantic www.theatlantic.com/doc/200711/intro.
* * * * *
2.
In the News:
Organ Transplants from an Ill-Informed Malpractice Attorney
Edwards and Organ
Transplants By SCOTT GOTTLIEB, WSJ, January 11, 2008
Campaigning in the primaries, former Sen. John Edwards
is leveraging the tragic story of Nataline Sarkisyan -- the 17-year-old
California woman who recently died awaiting a liver transplant -- to press his
political attack on insurance companies and argue for European-style,
single-payer health care. But the former trial lawyer, accustomed to using
anecdotes of human suffering to frame his rhetoric, is twisting the facts.
Organ transplantation, like many areas of medicine, provides a poor basis for
his political thesis that single-payer health care offers a more equitable
allocation of scarce resources, or better clinical outcomes.
Late last year, Ms. Sarkisyan developed liver failure,
apparently a result of blood clotting that stemmed from the high doses of
chemotherapy and a bone marrow transplant she had received to treat relapsed
leukemia. She was put on life support as her doctors at the University of
California-Los Angeles tried to get her a new liver, and asked CIGNA, the
insurer that was acting as administrator to her father's employer-provided,
self-insured health plan, to pay for the transplant. CIGNA deemed the
transplant unproven in its medical benefit and ineffective as a treatment. It
recommended that her father's employer not cover the procedure.
After an appeal, CIGNA hired an oncologist and
transplant surgeon to review the case. According to CIGNA, these experts agreed
that the transplant exceeded appropriate risk-taking, with little support from
existing medical literature. . . . To
read more, please go to www.medicaltuesday.net/news.asp.
CIGNA never reversed its administrative decision. But
after significant pressure from the California Nurses Association, a powerful
union lobby -- and legal threats -- it made a clumsily-announced concession, a
one time "exception" to pay for the transplant itself, despite
sticking to its judgment that the procedure constituted an experimental use of
a scarce organ. But CIGNA's concession came too late. The same day it was made
Ms. Sarkisyan was taken off life support and died. . .
Mr. Edwards seized on the case. "We're gonna take
their power away and we're not gonna have this kind of problem again," he
said on Dec. 21. "These are living and breathing examples of what I'm
talking about and there are millions more just like them," Mr. Edwards
told reporters on Jan. 6. An edited video of his attacks on CIGNA has posted on
YouTube.
Research provides little support to Mr. Edward's
underlying premise that single-payer health-care systems would do better. On
balance, data suggests that in the U.S. transplant patients do quite well
compared to their European counterparts, with significantly more opportunities
to undergo transplant procedures, survive the surgery, and benefit from new
organs.
Some of the best data pits the U.S. against the U.K.
and its National Health Service. A study published in 2004 in the journal Liver
Transplantation compared the relative severity of liver disease in transplant
recipients in the U.S. and U.K. The results were striking. No patient in the
U.K. was in intensive care before transplantation, one marker for how sick
patients are, compared with 19.3% of recipients in the U.S. Additionally, the
median for a score used to assess how advanced someone's liver disease is, the
"MELD" score, was 10.9 in the U.K. compared with 16.1 in the U.S. --
a marked gap, with higher scores for more severe conditions. Both facts suggest
even the sickest patients are getting access to new organs in the U.S.
On the whole, the U.S. also performs more transplants
per capita, giving patients better odds of getting new organs. Doctors here do
far more partial liver transplants from living, related donors, but also more
cadaveric transplants (where the organ comes from a deceased donor). In 2002 --
a year comparative data is available -- U.S. doctors performed 18.5 liver
transplants per one million Americans. This is significantly more than in the
U.K. or in single-payer France, which performed 4.6 per million citizens, or in
Canada, which performed 10 per million. . .
These findings aren't confined to transplanted livers.
A study in the Journal of Heart and Lung Transplantation compared statistics on
heart transplants over the mid 1990s. It found patients were more likely to
receive hearts in the U.S., even when they were older and sicker. The rate was
8.8 transplants per one million people, compared to 5.4 in the U.K. Over the
same period, about 15% of patients died while waiting for new hearts in the
U.K. compared to 12% in the U.S. In 2006, there were 28,931 transplants of all
organ types in the U.S., 96.8 transplants for every one million Americans.
There were 2,999 total organ transplants in the U.K., 49.5 transplants for
every one million British citizens.
What about Mr. Edwards's implicit thesis, that U.S.
organ allocation is dictated by someone's ability to pay? When it comes to
livers, the majority of U.S. transplants are for chronic liver disease, usually
resulting from hepatitis C or alcoholism. These are diseases disproportionately
affecting lower-income Americans who predictably comprise a comparatively
higher number of people getting new organs.
Ideally, everyone who can benefit from an organ
transplant would receive one, especially a young patient like Ms. Sarkisyan.
But with more patients than available organs, some form of allocation procedure
involving administrative judgments is inevitable. In Ms. Sarkisyan's case, that
judgment was made by CIGNA, in an advisory capacity to her father's employer, interpreting
the terms of the employer's health-insurance contract. In the U.K. and other
European systems -- and in the U.S. single-payer system favored by Mr. Edwards
-- those judgments are made solely by a government agency. The available data
suggests that the government allocation procedures do a somewhat worse job, as
far as health outcomes are concerned, than private allocation procedures in the
U.S.
As in all events, the inevitable trade-offs and
ethical dilemmas cannot be wished away. Our system in the U.S. for allocating
scarce resources remains imperfect. But taken as a whole, statistics show that
organ access, our willingness to transplant the sickest patients, and our
medical outcomes are among the best in the world. Probably superior to the single-payer
systems that Mr. Edwards would have Americans emulate -- and certainly better
than the facts that Mr. Edwards wants us to believe.
http://online.wsj.com/article_print/SB120001235968882563.html
Dr. Gottlieb is a practicing physician and resident
fellow at the American Enterprise Institute.
* * * * *
The GOP's Prescription for
Health Care By GRACE-MARIE
TURNER January 29, 2008
Health care has been a sleeper issue in the Republican
presidential primaries. But as we heard in President Bush's State of the Union
address last night, the GOP does have ideas -- big and transformative ideas
designed to energize the free market to target many of the problems that plague
our health sector.
The leading Republican candidates all have announced
plans that would give more power and control to individuals over their health
care and health insurance, breaking the employment-based coverage lock. That's
a far cry from the proposals of the Democratic presidential candidates. While
they talk about patient choice and private insurance options, their remedies
rely on a much bigger dose of government. . . . To
read more, please go to www.medicaltuesday.net/intlnews.asp.
The GOP candidates want to boost options for
individually-owned health insurance, and they would change federal tax policy
to create new deductions and/or tax credits for health insurance. Lower income
people, especially the uninsured, would get new subsidies to purchase private
insurance.
The candidates would allow people to purchase health
insurance across state lines, and they would give states new incentives to fix
problems, especially regulations and mandates, that have helped make health
insurance so expensive in the first place. They believe that bringing millions
of new buyers into the health care marketplace will expand competition and
force insurers and providers to offer more affordable options.
The similarity among Republican candidates'
health-care principles is such that they often sound like they have the same
speechwriter:
- Rudy Giuliani: "I believe we can reduce costs,
expand access to, and improve the quality of health care by increasing
competition. We can do it by increasing health-care choices and affordability,
and by empowering patients and their doctors, not government bureaucrats."
- Mike Huckabee: "I advocate policies that will
encourage the private sector to seek innovative ways to bring down costs and
improve the free market for health-care services. We can make health care more
affordable by making health insurance more portable from one job to another,
and making health insurance tax deductible for individuals and families as it
now is for businesses."
- John McCain: "It is good tax policy to take
away the bias toward giving workers benefits instead of wages. It is good
health policy to reward having insurance no matter where your policy comes
from. To use their money effectively, Americans need more choices."
- Even Mitt Romney, who led the enactment of a
universal health plan for Massachusetts that expanded the role of government in
the health sector, now says: "The federal government needs to loosen
regulations on the nation's health-insurance providers, increasing competition
and thereby lowering patient costs. The right answer is less government, less
regulation, more individual responsibility, and more of the market dynamics
that propel the rest of our economy."
While there are differences in implementation, Messrs.
Giuliani, Huckabee, McCain and Romney all start with proposals to reform the
generous but invisible tax provision that ties health insurance to the
workplace. The U.S. offers a generous tax break worth more than $200 billion a
year to those who get health insurance through the workplace. Any amount of
income that workers receive in the form of health insurance is excluded from
federal and state income and payroll taxes.
This provision, which dates back to World War II, has
cascaded through the economy for 65 years to create a system in which more than
160 million people get health insurance through the workplace.
But today, when four in 10 workers change jobs every
year, tying health insurance to the workplace isn't working for tens of
millions of Americans. Further, because the full cost of job-based health
insurance is invisible to most workers, they have incentives to over-consume health
services and to demand more expensive health insurance, driving up costs for
those trying to buy coverage on their own.
While the Republican presidential candidates don't
want to blow up the employment-based system, they all want to give people the same
tax benefit when they purchase a policy on their own as when they get it at
work. This was also central to the health-reform proposals President Bush
outlined last night.
The Democratic candidates would lock in the
employment-based system with requirements for most employers to pay for
coverage. In addition, Hillary Clinton and John Edwards would impose an
"individual mandate" in which the federal government would require
everyone to have health insurance.
None of the Republican candidates supports an individual
mandate. Barack Obama is the outlier among the Democrats -- a major point of
contention among them -- because he supports a mandate for children to get
health insurance but not everyone. "The reason Americans don't have health
insurance isn't because they don't want it, it's because they can't afford
it," Sen. Obama says.
Sen. Clinton says that the key vision of the Democrats
is to achieve universal health coverage. But that takes her down a rocky road
of mandates on individuals, employers and insurers that squeeze genuine
competition out of the health sector. . .
. . . the contrast between the Republican and
Democratic candidates is stark. Ultimately they break down over whether
individuals or government will be in control of health care in the future. The
choice this election year is real.
Ms. Turner is president of the Galen Institute and
editor of "Empowering Health Care Consumers through Tax Reform"
(University of Michigan Press, 1999). She has advised the Giuliani, McCain and
Thompson campaigns on health care.
See all of today's editorials and op-eds, plus video
commentary, on The Editorial Page1.
http://online.wsj.com/article_print/SB120156877726923875.html
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
* * * * *
4. Medicare: To Every Doctor that Sees Patients with
Payment from the Government
PARK CITY
MEDICAL CENTER, PARK CITY, KANSAS 67219
Dear Doctor: To every practicing physician in
Kansas: January 18, 2008
After all the news coverage of Haysville Doctor
Stephen Schneider, we all have probably thought, "Boy, I'm glad it's not
me!" Not only are the feds after
him, but the trial lawyers, too.
But, what about you and me? With 3,000 pages of Medicare regs and 2,000 pages of HIPAA, ANY
ONE of us seeing Medicare or Medicaid patients could be GUILTY of healthcare
fraud (even though it was UNINTENTIONAL).
And the government is out to collect FINES! . . . To
read more, please go to www.medicaltuesday.net/medicare.asp. !
What is a federal prosecutor? Answer: an attorney with the full backing of
the federal BUDGET and 5,000 pages of laws that are impossible to follow
without numerous unwitting infractions, which the federal prosecutor can build
into a FEDERAL case. And like the
gunslingers of old, each BAD DOCTOR prosecuted becomes a notch on the gun,
bringing publicity to the prosecutor so they can run for office and write more
regulations to entrap you and me. The
federal prosecutor is also a COWARD.
Rather than get the real drug dealers (who threaten to kill the
prosecutor or their family), the prosecutor goes for the easy (safer) mark, the
doctor who keeps enough records to make a case for the prosecutor.
What has Dr Schneider done? He sees the rejects of medicine that WE won't see. The Medicaid folks don't have doctors
standing in line to see people with "the CARD", do they? He sees the people who have had all the
surgeries and epidural steroid injections that insurance would buy, before it
ran out, AND they still have pain. And
he gets duped by the "actors" who have called all of our offices at
one time or another. And the federal
prosecutors have probably sent in some of their own "actors" to
entrap him.
Why does he prescribe so much to so many of these
patients? What would knock you or me
OUT, barely touches the pain of some of these patients.
So, why do WE CRITICIZE OR REMAIN SILENT while the federal
prosecutor CASUALLY goes about her work while a fellow physician is held like a
POW? Yes, it is war. If you take any money from the federal
health programs, YOU are a target.
"But I don't do what he does." Are you certain you have complied with all 5,000 pages of the
minefield we have allowed or legislators and bureaucrats to place into law?
Should the Healing Arts Board do something? Yes!
In the current environment, I am sure that YOU are as afraid to
prescribe CONTROLLED medications for your patients as I am for my
patients. I was glad that Dr Schneider
had THE BALLS to help the people that were OUT OF OPTIONS. The Board should read and reread this
letter, then ask "What can we do to provide pain relief for the people who
have no other place to turn?
How can we work WITH our physicians to provide that
care, KNOWING that some of the "patients" are addicts and dealers,
and how can we COMMUNICATE with one another to IDENTIFY the addicts and dealers
and CUT THEM off?" Let's stop
demonizing physicians, and demand individual RESPONSIBILITY of doctors,
patients, and lawyers.
SURGEONS, how many of your patients, despite your best
efforts, STILL HAD PAIN and you were afraid to prescribe narcotics to control
the pain that surgery did NOT resolve?
YOU should be the most vocal supporters of Dr Schneider, because he was
taking care of many of them (probably most of them).
PRIMARY CARE doctors, Dr Schneider took care of our
patients that we were afraid to give narcotics. We should not criticize him for taking care of the people who
CHOSE to go to a clinic where they COULD get medication. WE should be very vocal supporters of Dr
Schneider.
TRIAL LAWYERS love what the feds are doing. One question. If Dr Schneider is responsible
for Jeff Hambleton's overdose death in Jeff's office, does that mean that the
Hambelton agency is responsible for every drunk who buys a Ford vehicle and
dies in a car crash in the car that Hambleton provided him?
Do YOU, DOCTOR, have any patients with severe,
intractable PAIN?
Of course, we ALL do! Have any of our patients ever
chosen suicide instead of living in constant pain? YES! And many of the
patients seeing Dr Schneider were depressed and probably suicidal. We, and he, can not control what our
patients do, no matter how hard we try.
And all of us, despite our best efforts, have had patients die from
their illnesses, some shockingly sooner than expected.
INSURANCE companies want to control everything. "Send the money to us and we will
decide what we will cover."
LEGISLATORS, your constituents demand more benefits
from government and the insurance companies.
The SMARTEST mandate would be that no insurance policy could be written
with LESS than $1,000 deductible AND a 20% co-pay on everything else. That makes the patient responsible for
ENOUGH of their health care costs that the whole system will become self
regulating, AND the cost of health care will DECREASE!
I do not participate with any insurance company, not
Medicare, not Medicaid. But I see
patients who HAVE those insurance plans, AND they pay cash, check or credit
card for the FAIRLY PRICED services I provide that insurance frequently does
NOT cover anyway. AND, every Tuesday
night I provide FREE medical care through Good Samaritan Clinic, giving three
hours of my time (Many of these patients do not take their FREE CARE seriously
and accept any personal responsibility to improve their own health.). This is what I dreamed of when I applied to
medical school - I am responsible to my patients and they are responsible to
me, with no "third party" dictating what I can or can not do for my
patients. But I don't prescribe
narcotics for chronic pain, because I don't trust the Healing Arts Board or the
federal regulators.
I would be happy to talk with any of you, and I pray God's
blessings upon you.
George R Watson, D.O.
P.S. We all
worked very hard to graduate from medical school. We all had the freedom to choose in what area we wanted to
specialize. If we have NOT had
specialized training in a particular procedure or treatment, let us NOT
criticize a procedure that we have not studied, performed or experienced. Let us respect one another's expertise and
training.
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
I Just Love Being in the Hospital and Getting All Those Tests.
A 73-year-old white male came into the office today in
exuberant spirits stating he was just in the hospital. He said he had little
experience with hospitals before but this was really a plush hotel. He said he
had more tests than he could have imagined in just one day. When he left, the
ER doctor said, "We don't know what you have, but we ruled out all the
important things."
The diagnosis was obvious and required no tests. It
just required a doctor or a family member or a friend to spend five or ten
minutes with the patient, give him a Proton Pump inhibitor, such as Prilosec,
the $5 pill which is now OTC at 50 cents and a Gaviscon tablet, which is OTC at
one cent, see another patient and come back in 20 or 30 minutes to re-evaluate
him to see if he still had a problem. He would have been well. However, the ER
doctor convinced him that his severe substernal burning could be life
threatening and all serious illnesses should be ruled out as possibilities.
My front desk was able to obtain the eleven pages of
testing before his appointment. She also told me that on the phone it sounded
like he just had some severe heart burns. . . To read
more, please go to www.medicaltuesday.net/gluttony.asp..
The eleven pages included two pages of laboratory
reports, all essentially normal. There was a chest x-ray, which was negative.
There were a series of cardiac enzymes all of which were normal. There was a
treadmill stress electrocardiogram, which revealed he was functioning at 7
METs, which is a healthy level. There was a myocardial perfusion study, which
revealed a normal Left Ventricular ejection fraction and normal cardiac
function with normal wall motion, without any evidence that any heart muscle
was ischemic or at risk. The costs were at $thousands.
The reason all these unnecessary tests are done in the
ER is that if the patient is admitted to the hospital they fall under Medicare
Regulations and price controls. The hospitals can, as I understand it,
allegedly get several times as much money by doing these tests in the ER than
if the same studies are done on an inpatient basis.
How can we avoid this 10,000 percent increase in
unnecessary health care costs? As we saw elsewhere in this newsletter, one
party's candidates want to implement controls. However, there is no control
that would prevent this. No reviewer would actively interfere with an Emergency
Doctor's evaluation of heartburns even if camouflaged as chest pain.
Retrospective reviews are regressive, costly, and further reduce health care
quality.
What is the answer? The other party's candidates, as
we saw elsewhere in this newsletter in the article written by Grace-Marie
Turner of the Galen Institute, want to put the decision under the patient's
control. Our colleague from Kansas, also elsewhere in this newsletter, would
increase patient responsibility with a significant deductible and a co-payment
on everything else. He feels this would make health care self-regulating. In
other words, this patient would know from the grapevine that the basic charge
for an Emergency Room visit is $600 or so. With a 20 percent co-payment as
suggested, he would understand it costs $120 to walk in the door. After the
first thousand dollar test, since he is bright enough to understand that 20
percent of the test would be $200 out of his pocket, he would figure out that
he should try a glass of milk or a PPI such as Omeprazole to block the acid
production, and an antacid to neutralize the acid that is burning his
esophagus. The co-payment makes the patient wake up and self evaluate the burn,
makes him more knowledgeable about health care costs, thus saving health care
dollars. In this case, thousands of dollars or an eliminated 10,000 percent
excess cost.
What is Mr Edwards' and his party's answer? More
regulations. Eliminate co-payments. Make it free for all. At least until we get
it passed. Thereafter, we can eliminate the rich, decrease payments for the
poor, eliminate certain procedures, just as Massachusetts is already doing for
Romney's socialistic implementation. This is following Canadian, UK, and
European health care restrictions. Why? They are not interested in a freedom
loving independent medical profession judiciously working for the patient. This
would eliminate their populist programs that control the patient and make a
police state with the physician as the scapegoat.
The answer is obvious. Just as we changed political
freedom in this country in 1776 escaping the European way of feudal states and
nobility, we can change the health care of the world by charting a new course
of self-regulating freedom in health care instead of regressing to the
Canadian, British and European deteriorating health care system of controls.
* * * * *
6. Medical Myths: Health Care Reform Will Be Very
Expensive
Health Alert: Subject: Paying for Health Reform Real health reform does not cost money. It saves money. Conservatively, I would guess we could reduce health spending by one-third and raise quality and increase access to care at the same time. That's $7,000 for every U.S. household. Since government spends almost half the money, we could all get an annual economic stimulus check for $3,000 - leaving $50 billion behind for government to mop up any remaining problems. Alas, hardly anyone is in favor of real reform. For a lot of people, reform doesn't even count as reform without sacrifice and atonement. Think of California liberals and global warming. Nothing they do will have any perceptible impact on the climate. But they don't feel good about themselves unless they are enduring pain and discomfort. Anyway, suppose we did need more money to add to our annual $2.1 trillion health care spending spree. Where could it come from?To read more, please go towww.medicaltuesday.net/myths.asp.
In the Democratic primaries, here is the standard mantra: tax cuts for the rich are depriving government of revenue which we desperately need for health reform. All of this is exclaimed with almost religious fervor and a level of hysteria that is hard to top, unless you count this morsel from Paul Krugman in The New York Times: "for 30 years American politics has been dominated by . . .Robin Hood in reverse, giving unto those that hath, while taking from those who don't." Now for an uncomfortable look at the facts. For the past 30 years, there has been no lasting tax cut for the rich. And far from being deprived of revenue, the federal government's share of national income today is exactly where it has been, on the average, for the past 60 years. The penultimate sentence in the preceding paragraph deserves repetition and emphasis: There has been no lasting tax cut for the rich. What we have done, beginning in the Reagan administration 25 years ago, is cut tax rates for the rich. But every time we cut rates, total taxes paid by the rich went up, not down. As Art Laffer explained in The Wall Street Journal the other day, the top 1% of taxpayers are on the wrong side of the Laffer curve, and they have been there for almost the entire sorry history of the income tax. Every Republican tax rate reduction for the wealthiest taxpayers as well as every Democratic one (both Kennedy and Clinton) has led to more revenue for the Treasury. In Clinton's case, approving a Republican capital gains rate reduction (from 28% to 20%) in 1996 is what produced surpluses at the end of his presidency - surpluses that Clinton's own Treasury Department never predicted! Unlike ordinary mortals, the rich have enormous discretion over how they receive their income - as wages, as dividends, as realized capital gains or even as unrealized (untaxed) capital gains. So the way to get the most money out of them is not to push rates up to 70% or 90% (where they once were), but to lower them in order to coax the wealthy into realizing more taxable income. Furthermore, almost every time tax rates for the wealthiest have been reduced, millions of low-income taxpayers have been removed from the tax rolls. So that today almost half the population pays no income tax. The upshot is that virtually every tax change in recent history - whether Democrat or Republican - has made the tax code more progressive. Since noneconomists often wonder whether they are being statistically hoodwinked in these discussions, let us be clear: Over the past two decades the income tax system has become increasing more progressive, no matter how progressivity is measured. So here are the takeaways: (1) government revenues today as a fraction of national income are equal to their historic average, (2) we are collecting more income taxes - both in total dollars and as a percent of the total - from the wealthy than ever, (3) the tax system today is more progressive by far than at any time in modern history and (4) repealing the Bush rate reductions for high-income taxpayers is unlikely to produce any extra revenue for health reform. For Michael Stroup's demonstration that Republican tax cuts have made the income tax system more progressive than otherwise, go to www.ncpa.org/pub/ba/ba606/.
For Steven Moore's demonstration that capital gains rate cuts always produce more capital gains tax revenues go to www.ncpa.org/pub/st/st307/st307.pdf.
For Art Laffer's explanation of all of this, go to www.freerepublic.com/focus/f-news/1959323/posts.
Have a good day, John Goodman, President
National Center for Policy Analysis
12770 Coit Rd., Suite 800
Dallas, Texas 75251 www.ncpa.org
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7.
Overheard in the
Medical Staff Lounge: Insurance Companies Practicing Medicine
Dr. Sam: How
is the insurance company's practice of medicine coming along?
Dr. Rosen:
Medicare, the worlds largest, started to pay in December and gave us a notice
that after December 18 all payments would be electronic.
Dr. Ruth: I
can't wait to hear?
Dr. Rosen:
You're right. It's now February and we haven't got paper or electronic checks.
We did get a notice to fill out form 855 again.
Dr. Michelle: Isn't
that the one that's about 17 pages long?
Dr. Rosen: At
least. But we've completed it at least three times in the last six months.
Dr. Sam:
Unbelievable bureaucratic drag.
Dr. Edwards: How
can anyone even think of having the government put that kind of drag in all of
health care? . . . To read more, please go to www.medicaltuesday.net/lounge.asp.
Dr. Milton: HMOs
aren't much better. I had a patient with an acute appendix. The kind that we're
use to operating on the same day? It took my HMO three days to approve the
emergency surgery.
Dr. Yancy:
Well, did it rupture?
Dr. Milton:
Amazingly, it did not.
Dr. Yancy: Too
bad. Sorry for the patient but that would have shaped up the HMO.
Dr. Rosen: I
don't think so. HMOs seem to survive almost all lawsuits that would destroy
private doctors.
Dr. Michelle: So
there you see the protection that HMOs gives us.
Dr. Yancy: At
the expense of patients' health and maybe their lives?
Dr. Rosen: They
even seem immune to the loss of life. Remember the Linda Peeno
story. She had a stamp: DENIED. And then a patient died which made her think
beyond her job.
Dr. Patricia: What
about the pharmacies practicing medicine. Those "Dr. don't you know -
" faxes that question most of my prescriptions.
Dr. Dave: Are
you taking the time to educate the pharmacists?
Dr. Patricia: I've
tried. But some of them don't have enough of a command of the English language
to understand what I'm discussing.
Dr. Rosen:
Don't you think that they are being forced to do that by their mandates and
their insurance carriers?
Dr. Milton: I'm
steering more patients to the Wall-Mart, Costco, and Sam's club pharmacies now
that they have more than 300 generic drugs for $4 a month. They are just super
pleased that for $12 they can pick up a three-month supply and not return to
the pharmacy every 30 days.
Dr. Rosen:
Since the patients are paying, they can go early to pick up the refills instead
of a 7-day window.
Dr. Ruth: You
mean they can pick up refills early?
Dr. Rosen:
Certainly. They are paying cash and, therefore, the pharmacies aren't
controlled by the insurance carriers to be watchdogs over what insurance will
cover and pay. That's an easy way to eliminate one mandate.
Dr. Ruth: Why
don't politicians understand that the costs of drugs seem to be decreasing in
the free market environment?
Dr. Rosen: They
have a political agenda of control because health care involves every American.
What a sly way to put a noose around every Americans' neck. And they won't know
what's strangling them until it's too late. Then they will all be at the mercy
of their congressman and senators and no longer have any voice in restoring
their freedom from state-controlled doctors.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
SONOMA MEDICINE, the
Magazine of the Sonoma County Medical Association
Outside the Office: Diving Docs Explore the
Deep, By Paul Johnson, MD
You may have noticed that
practicing medicine these days has become a mighty intense occupation.
Fortunately, dealing with the rigors of the profession becomes easier when I
participate in activities outside the office that engage my full attention and
enthusiasm and that provide different sorts of challenges and opportunities. I
am lucky to have found all of that and more in scuba diving. . .
To read more, please go to www.medicaltuesday.net/voicesofmedicine.asp.
I became a certified scuba diver more than a decade ago. My training began with
a short "resort course" during a vacation. From my first moments at
the bottom of the pool, I realized that scuba diving was something I wanted to
keep doing. As luck would have it, my friend and colleague, cardiologist Steve
Werlin, had just become certified as an open-water scuba instructor through
PADI (the Professional Association of Dive Instructors).
I was among the three students in Steve's first diving class, and in October of
1996 - after completing the last of four open-water checkout dives in Tomales
Bay - I became a certified diver. I was 49 years old, firmly in the grip of
middle age. Incidentally, the two other students in Steve's class, proving they
were considerably smarter than me, did their four checkout dives in the Cayman
Islands.
The ocean covers more than
two-thirds of the surface of the earth. My explorations beneath the waves have
led me to a beautiful and fascinating realm, quite unlike what we observe on
land. They have also taken me to far-flung locations of the planet that I might
not have otherwise considered visiting, such as Indonesia and Papua New Guinea.
But even without the majestic sights and exotic locales, something about diving
itself exhilarates me. Maybe it's the feeling of weightlessness when I hover in
the water column with perfect buoyancy control. Maybe it's the rhythmic,
Zen-like sound of my own breathing, amplified by the regulator and the water.
And maybe it's my sense of gratitude that I have been allowed into such a
special and different world, experienced by such a small fraction of my fellow
human beings.
Over the years, Steve and another colleague, general and thoracic surgeon Vince
Frantz, organized Diving Docs, a loose network of people passionate about
diving, the ocean, and travel. Many of the group's members are people we work
with at Kaiser. The network includes physicians, nurses, pharmacists,
psychologists, and our local non-medical friends - but we also number people
like "Jillie" from New Zealand, whom we met on a dive trip. . .
If you are interested in
taking a break from the hectic world of medicine and joining us beneath the
waves, feel free to contact me at pajkotwf@aol.com or Steve Werlin at
(what else?) divingdoc@hughes.net.
To read more about Dr. Johnson's Diving Docs, their
schedules and destinations, go to www.scma.org/magazine/scp/Fall07/johnson.html.
Dr.
Johnson is an internist at Kaiser Permanente Medical Center in Rohnert Park.
* * * * *
9.
Book Review: Code
Blue: Health Care in Crisis by Edward R.
Annis. Regnery Gateway Press, Washington, D.C. 1993, 278 pages.
Doctor Annis opens his introduction describing the two
worlds that physicians live in: The
wonderland of modern medicine, a gratifying and challenging world of
achievement in research, education, and clinical practice; and the faltering
American health care world, which is on the verge of collapse. Not unlike Charles Dickens in the opening to
this Tale of Two Cities: "It was the best of times. It was the worst of times."
Annis gives us many anecdotal insights into the
history of American medicine: Fleming's
discovery of penicillin in England in 1928, that sat on the shelf until
American drug companies developed methods of production in 1943, making it
available to patients; sick England in the postwar era to healthy America; the
high death rate of Europe to increased life expectancy to 68 years in America
in 1949. The high cost of living is
only exceeded by the higher cost of dying.
His chapter on health insurance ("Call the Plumber, We're
Insured!") is a parody on why health insurance is not insurance and,
therefore, cannot work in its current format. To read more,
please go to www.medicaltuesday.net/bookreviews.asp.
Edward Annis, who never chaired a meeting or held an
organized medicine office, was elected president of the AMA at a young age in
an attempt to counter a cunning band of political sophists in Washington,
D.C. He champions the fight to head off
government intrusion between doctor and patient and dispels the myth that a
"managed" health care system would solve America's problems. He feels the problems in health care have a
"Made in Washington" label.
Health care already is the most regulated industry in America,
strangling doctors and hospitals by senseless paper work, counterproductive
bureaucracy, an abusive civil court system, and price controls that are
actually driving prices up. He feels it
should be labeled a crisis in government that can only be solved by less government
interference.
In his final chapter, "What's the
Solution?," Annis gives us his analysis of why third-party systems aren't
working. Clinton's health plan; and two
well-thought-out plans which he feels put the patient back in the driver's seat
– in charge of his or her own money. He
favors "An Agenda for Solving America's Health Care Crisis," by the
National Center for Policy Analysis. . .
Dr. Annis quotes Tom Paine's 1976 Revolutionary Era
treatise, Common Sense, decrying
excessive government, Time makes more
converts than reason. . .
To read the entire review, please go to www.delmeyer.net/bkrev_CodeBlue.htm.
To read other reviews, please go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To peruse reviews by topics, please go to www.healthcarecom.net/bookrevs.htm.
* * * * *
10. Hippocrates & His Kin: Health Care After the
November Elections
Mrs. Clinton has
promised to force nationalized health care down our throats with mandates if
elected. She wasn't able to cram it down in 1992, because she was only a spouse
at that time.
Fellow Americans: What is it about government medicine
that you don't understand?
Mr. Romney implemented government
health care in Massachusetts while governor. Now that state is facing
insolvency within two years and decreasing coverage already. This is even worse
than the Medicare cost projections of 1966.
Fellow Americans: What is it about state medicine that
you don't understand?
To read more,
please go to www.medicaltuesday.net/hhk.asp.
Mr. Edwards had promised real police
state medicine before he left the campaign. Doesn't it frighten you that
someone of national prominence has this degree of disregard for individual
American Freedom? Much of the huge cost of defensive medicine is due to
trial malpractice lawyers like Mr. Edwards.
Fellow Americans: This kind of luck on the campaign
trail is only temporary.
We have had two pictures of Hillary
Clinton in tears in preparation for Super Tuesday this month. Won't that
put a new dimension into politics?
Fellow Americans: Do you really think that tears will
affect Iran or N Korea?
John Kerry has blamed the tornadoes in
the south on global warming. Come on, John, do you really think the planet is
so fragile that a fraction of a degree can upset the cosmos? Have you read Unstoppable
Global Warming by Fred Singer, founding dean of the School of Environmental
and Planetary Sciences at the University of Miami? He states that the earth's
current warming trend is a largely natural occurrence that we can't do anything
to stop, which is not only harmless, but potentially beneficial, and is part of
a 1,500-year solar-driven cycle.
By the time he and Al Gore
figure this one out, we'll be another 15 generations down the road into the
next warming cycle.
To read more vignettes, please go to www.healthcarecom.net/hhkintro.htm.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society:
