1. Featured Article: Pulling it together by Drew Altman, PhD, www.kff.org

What Do We Want Health Insurance To Be?

Trends in the health insurance marketplace show substantial growth in high deductible health plans, especially among smaller firms, where 35% of workers are now covered by plans with a deductible of $1,000 or more. That's according to our recently released employer health benefits survey, which we have been conducting now for ten years. The majority of these plans are simply high deductible health plans; only a minority are so-called "consumer driven" plans with savings accounts. The percentage of workers in firms with high deductible plans has almost doubled in the last two years.

There are several important messages here. First, while enrollment in plans with savings accounts is growing modestly, the larger trend is simply towards more bare bones high deductible plans with no savings accounts or consumer-driven features to help employees cover out-of-pocket costs. Second, the health insurance people get from smaller employers, if they get it at all, increasingly looks very different from the coverage workers get from large employers; it looks much more like the insurance people get in the non-group market. A recent analysis by our researchers showed that people in the non-group market shouldered 43% of their health costs out of pocket compared to 22% for people in employer plans. Third, people are paying more for their health care at the worst possible time, when their wages are flat, energy and food prices are up, 401ks are falling, and many face problems paying the rent or mortgage or credit card debt. Small wonder so many Americans in our tracking polls name paying for health care and health insurance as one of their top economic problems.

For as long as I have been in the health care field, there has been debate between experts about how much health insurance people should have. Some -- typically conservatives -- argue that we are over-insured, and that if people saw more of the costs of health care themselves they would consume it more prudently, use less health care overall, and we would spend less on health care as a nation. They also believe that making more bare bones options available in the market will enable more people to afford coverage. The liberal view is generally that if people paid more of the cost of health care they would be even more exposed than they are today to financial hardship, access would suffer, and low-income people and the chronically ill in particular would be hit the hardest. They also believe that offering less comprehensive insurance options will split the risk pool further, driving up costs for those who remain in more traditional comprehensive plans. . .

Ultimately the comprehensive versus less comprehensive insurance question frames a fundamental tradeoff that is almost never stated clearly in public debate, perhaps because it is regarded as too stark for the public to digest.

Do we want and can we afford to provide subsidies to make more expensive comprehensive coverage, from preventive to catastrophic care with more modest out-of-pocket costs, affordable for people who are already struggling from the burden of health care costs?
Or should government subsidies and tax policies encourage less comprehensive and somewhat cheaper insurance with higher deductibles, higher out-of-pocket costs for routine care and back-end catastrophic protection?

Answering this question explicitly would force us as a nation to more clearly point out who would win and who would lose if we move further in either direction. The answer also will frame broader discussions about how the nation will attempt to contain health care costs and whether we want to do it primarily by influencing demand using insurance as a lever or by other means.

Currently, the marketplace is edging towards less comprehensive coverage as employers, especially smaller employers with few other options, seek to reduce their health premiums. The question is whether we will have a national discussion of what we want health insurance to be, or if this fundamental question will remain the elephant in the room in the health reform debate that we never really talk about.

To read the entire report published 9-30-08, go to www.kff.org/pullingittogether/093008_altman.cfm.

A GLIMPSE INSIDE STATE GOVERNMENT Because health care costs rise faster than virtually anything else in a state budget Medicaid spending rises faster too, even if no changes are made to the program. Enrollment also goes up in a weak economy. This simply reflects Medicaid playing its vital counter cyclical role as a safety valve when the economy falls off, but it also means more spending. Here is how it works at the state level. In a weak revenue year when the economy is bad, budget increases for Medicaid just to maintain the current program can easily consume more than a third of the new money available in a state budget. A lot of state government is an annual contest for these new resources, and this can instantly make you the least popular person in the governor's cabinet or with the state legislature. A single program and a single state department can only win just so much of the new money on the table each year, because other priorities are important, and other departments have influential constituencies too, often more influential. This means that there will not be enough money to address other critical health and social services priorities, from reducing waiting lists for community services for the mentally ill and developmentally disabled, to adequately funding state institutions, to paying child protective services workers a living wage, to funding state Head Start programs, to paying for services for homeless families, to providing child care so women on welfare can work, and much more. If you run a state umbrella agency as I did, the truly agonizing decisions are these tradeoff decisions because in state government decisions about Medicaid and SCHIP spending, especially in "bad years", occur in the context of a host of other underfunded and unmet needs. For governors, who also need to worry about funding secondary and higher education, and corrections, and the environment and the state police and much more, the tradeoff decisions are even broader and more difficult.

-- Published June 11, 2008 at www.kff.org/pullingittogether/061108_altman.cfm.

* * * * *

2. In the News: Pennsylvania Is Driving Its Doctors Away

Blame Gov. Rendell if you can't find a physician. By FREDERIC JARRETT, WSJ,

Pittsburgh

Gov. Ed Rendell is holding the legislature, physicians and patients of Pennsylvania hostage. His ransom is a universal health-care program that he wants to create and force doctors to pay for.

Health-care reform debates often center on how to make insurance affordable for patients. But in Pennsylvania we've had to confront how to make malpractice insurance affordable enough to keep doctors in the state.

Six years ago, prior to Gov. Rendell assuming office, Pennsylvania addressed that issue by passing tort reform. It also created M-Care (Medical Care Availability and Reduction of Error), a supplemental malpractice insurance program that every doctor in the state must pay into, but which pays malpractice claims that exceed the required basic liability coverage. M-Care replaced a state fund designed to pay judgments in excess of physicians' liability coverage.

The tort reforms have reduced the number of suits filed by preventing venue shopping, and by requiring an expert to certify the legitimacy of a malpractice suit. But they have not significantly reduced malpractice premiums. M-Care has helped lower the total burden only because the legislature has abated the supplemental premium in its entirety for high-risk specialists (neurosurgeons, orthopedic surgeons, obstetricians and general surgeons), and by half for all other physicians. Premiums for some specialties had risen to as high as 55% of a doctor's annual income. The reformed system came with a public benefit -- before receiving the subsidy a doctor had to promise not to move to another state within the next year.

M-Care was able to abate its premiums because there is a surplus of more than $500 million in reserves in a separate retention account (funded by a tax on cigarettes and fees on some traffic violations) that is growing by about $15 million a month. Money in the retention account is used if and as needed to abate physician premiums in M-Care.

Enter Mr. Rendell. He was a supporter of M-Care abatements in 2003. But now he's desperate to punch his health-care reform ticket by creating a universal health-care program, in hopes of landing a cabinet post if Barack Obama is elected president. He wants a program that would provide health insurance to individuals whose income is less than 300% above the poverty level, and to fund it he proposes raiding the surplus in M-Care's retention fund.

The governor calls his program "Cover All Pennsylvanians." It will increase the cost of practicing medicine, make health care more expensive, and drive doctors out of the state.

And that will only continue a trend that M-Care may have slowed down, but hasn't stopped. The state Department of Health reported earlier this year that the number of practicing physicians in Pennsylvania is down 6% from a few years ago. Younger doctors just are not as willing to settle down in a state where liability payouts are twice the national average and physician income is 44th out of the 50 states. Today, about 7%-9% of our doctors are under 35. A few years ago, the number was 15% and in some specialties more than 40% of the practicing physicians are more than 50 years old. And less than 80% of physicians with active licenses are engaged in patient care.

Newly minted doctors educated here are setting up their practices elsewhere. In 1992, 60% of residents stayed in Pennsylvania when they finished their training. Now only 20% do so. . .

Pennsylvania's physicians are willing to provide health care for those who can't afford it. More than 90% of us accept Medicaid despite reimbursements that are obscenely low and have not been raised since 1989. But what I, and other doctors, object to is being extorted to fund the governor's sociopolitical agenda.

I hope the legislature resolves this unseemly debacle appropriately by directing M-Care to start spending its funds on the program's stated purpose (cutting the cost of liability insurance) before year's end.

But in the meantime, if you are a woman with a high-risk pregnancy who is unable to find an obstetrician in the rural areas between Philadelphia and Pittsburgh, or if you can't find a neurosurgeon on trauma call in the two-hour drive from Pittsburgh to Erie, call Mr. Rendell. He can tell you about his plans to "cover all Pennsylvanians."

Read the original at http://online.wsj.com/article/SB122488988370268531.html?mod=todays_us_opinion

Dr. Jarrett, a vascular and general surgeon, is a clinical professor of surgery at the University of Pittsburg.

Hillary Clinton, Edward Rendell and Barack Obama.

* * * * *

3. International Medicine: Is Government Medicine Coming to America?

The Europeanization of America: What's ahead if Obama becomes president. WSJ, By Pete DuPont

Barack Obama is likely to become the next president of the United States.

Six weeks ago John McCain was leading Mr. Obama. But according to RealClearPolitics, as of yesterday Mr. Obama led in the national polls by just under 8% and in the Electoral College by 306 to 157 (a majority is 270). Throughout his campaign Mr. Obama has successfully presented himself as a careful and sensible person and was recently endorsed by Christopher Buckley, son of the late William F. Buckley, as having a "first-class temperament and a first-class intellect."

But Mr. Obama will most likely be our most liberal public policy president since Franklin D. Roosevelt. Since President Bush is not popular (his approval rating is at 25%, with 71% disapproving), Mr. McCain has not run an inspiring campaign, and most people have declining confidence in our economic and financial system, voters have simply decided it is time for change. Gallup reports that just 7% of Americans are satisfied with the way things are going, so voters seem to have concluded that they will take a chance on Mr. Obama, whatever his policies may be.

The only organization with a worse rating than the Republican president is the Democratic Congress—14% approval, 75% disapproval. But there, too, the Democrats will gain strength. They are expected to increase their majority in the House, and current polling shows that in Senate races Democrats will increase their members from the current 51 (including two independents who caucus with the Democrats) to at least 57. They may even achieve the 60 votes needed to overcome a filibuster.

So where is the new Obama administration likely to take us? Seven things seem certain:

§ The U.S. military will withdraw from Iraq quickly and substantially, regardless of conditions on
the ground or the obvious consequence of emboldening terrorists there and around the globe.

§ Protectionism will become our national trade policy; free trade agreements with other nations will be reduced and limited.

§ Income taxes will rise on middle- and upper-income people and businesses, and individuals will pay much higher Social Security taxes, all to carry out the new president's goals of "spreading the wealth around."

§ Federal government spending will substantially increase. The new Obama proposals come to more than $300 billion annually, for education, health care, energy, environmental and many other programs, in addition to whatever is needed to meet our economic challenges. Mr. Obama proposes more than a 10% annual spending growth increase, considerably higher than under the first President Bush (6.7%), Bill Clinton (3.3%) or George W. Bush (6.4%).

§ Federal regulation of the economy will expand, on everything from financial management companies to electricity generation and personal energy use.

§ The power of labor unions will substantially increase, beginning with repeal of secret ballot voting to decide on union representation.

§ Free speech will be curtailed through the reimposition of the Fairness Doctrine to limit the conservative talk radio that so irritates the liberal establishment.

These policy changes will be the beginning of the Europeanization of America. There will be many more public policy changes with similar goals - nationalized health care, Kyoto-like global-warming policies, and increased education regulation and spending. . .

These are Mr. Obama's plans. Meanwhile, congressional Democrats would increase spending for their own interests and favorite programs. More important, the Congress will consider itself more important than a freshman president who has never held an executive position, so they will do what they want and he will have to go along with most of it.

What can the Republicans in Washington to do to avoid the Europeanization of America? The obvious answer is to win some elections two years from now to reduce the congressional power of those who favor it. But in the meantime they need stronger, better leadership of their minority party.

Then they need to make the case against each of the issues noted above; why they would be a mistake, what their cost would be to the economy, jobs and people and their families, and what would be a better approach. They will not win all the fights, but on protectionism, higher taxes and broader government regulation they can win the support of a great many Americans. And that might keep America from becoming Europeanized and our people from losing their money, their jobs and the market freedom of our country.

Read the entire report at http://online.wsj.com/article/SB122504438328069963.html.

Government Medicine does not give timely access to healthcare, it gives access to a waiting list.

* * * * *

4. Medicare: The Only State Universal Child Health-Care Program In The Country Vanishes

Hawaii's Hard Health Care Lesson, by Grace-Marie Turner, New York Post, October 27, 2008

Hawaii just had a vivid lesson in health-care economics, learning that if you offer people insurance for free - surprise, surprise - they'll quickly drop other coverage to enroll.

As a result, Hawaii is ending the only state universal child health-care program in the country after just seven months.

The program, called the Keiki (Child) Care Plan, was designed to provide coverage to children whose parents can't afford private insurance but who make too much to qualify for other public programs (such as Medicaid and Hawaii's State Children's Health Insurance Program). Keiki Care was free for these gap kids, except for a $7 office-visit fee.

But then state officials found that families were dropping private coverage to enroll their children in the plan. "People who were already able to afford health care began to stop paying for it so they could get it for free," said Dr. Kenny Fink of Hawaii's Department of Human Services.

In fact, 85 percent of the children in Keiki Care previously had been covered under a private, nonprofit plan that costs $55 a month.

When Gov. Linda Lingle saw the data, she pulled the plug on funding. With Hawaii facing budget shortfalls, she realized it was unwise to spend public money to replace private coverage that children already had.

Yet Lingle is facing a political firestorm in the state from critics who say that she's denying children health insurance - notwithstanding the fact that children in Hawaiian families earning up to $73,000 a year are eligible for Medicaid.

All this is a lesson for political leaders in Washington who are drafting plans now to expand SCHIP to children in families earning up to $82,000 a year or more. That expansion would wind up doing what Keiki Care did: mainly crowd out the private coverage that millions of middle-income kids already have.

During last year's Washington debate over expanding SCHIP, many politicians took a principled stand against expansion of the program into these middle-income families. They supported President Bush's veto because they feared that expanding coverage to children in higher-income families would largely just crowd out existing private insurance.

Plus, two-thirds of kids who lack health insurance are already eligible for government help through either SCHIP or Medicaid. The opponents of expansion said Congress' first priority should be to make sure these poorer, uninsured children are taken care of.

States have struggled to get these children enrolled. If there is a stampede to cover higher-income kids, the poorer kids will likely continue to get left behind.

The Hawaiian debacle should also be a caution to Barack Obama, who wants to mandate that all children have health insurance. This would plainly not only require penalties for those who didn't comply but also new programs to help parents get their children covered. The risk of crowd-out will be great.

MIT economist Jonathan Gruber says his studies "clearly show that crowd-out is significant" - on the order of 60 percent. In other words, SCHIP coverage replaces private health insurance 60 percent of the time, and the rate will be greater if we extend eligibility to higher-income families.

Universal coverage in any form is an increasingly elusive goal. Several states (including California, Pennsylvania, Illinois and Wisconsin) have attempted major efforts to advance toward health coverage for all citizens. All have had to turn back because the costs were prohibitive.

Massachusetts enacted a universal-coverage law in 2006 - but state officials no longer claim that achieving that goal is even possible. The law's backers had insisted that universal coverage was imperative to get costs under control - yet the state faces serious budget shortfalls even after imposing new fees and taxes and getting an extra $21 billion from the federal government to try to balance the program's books.

Health reform is a tricky business; any change can bring unintended consequences - especially if lawmakers don't get the incentives right.

That's why Hawaii had to say, "Aloha," to its Keiki Care program twice in just seven months.

Grace-Marie Turner is president of the Galen Institute, a research nonprofit focusing on free-market health reform. Read more at www.galen.org/

Read the original at www.nypost.com/seven/10272008/postopinion/opedcolumnists/hawaiis_hard_health_care_lesson_135426.htm.

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

- Ronald Reagan

* * * * *

5. Medical Gluttony: It May Represent Desperation

One morning when I was in the US Air Force working in the internal medicine clinic, a call came in about 11 AM from the operating room asking me to come to the OR in all haste to manage a cardiac arrest. The chest had been opened and the surgeon was vigorously compressing the heart. I managed the monitoring equipment and ordered the intravenous infusions to restore cardiac activity. The heart was responding and the surgeon was preparing to close the chest. I sent a message to the clinic to reschedule all my routine appointments. Rather than go to the mess hall for a lunch break, I would see any emergencies at that time. When I arrived about 12:30, who was there for me to see rather than have lunch?

I found the cancer, heart, diabetic, and emphysema patients had all been rescheduled for later in the week. The patients with backache for 20 years, neck pains for 15 years, abdominal pains for 10 years, and arthritis for decades were all waiting for me to take care of the crises in their lives. Their charts were all two to four inches thick. They all had the necessary tests done several times over and nothing that was reversible could be found. They were very disappointed when I reviewed the extensive charts revealing that all the necessary tests had been done repeatedly. Yet they all had a crisis in their lives they thought I could take care of in a few minutes on that day on an emergency basis and restore their health. However, they all had permanent impairment and were unable to accept the fact that numerous physicians had advised them that their back, neck, and arthritis would never function as new or that the abdominal pain was chronic but could be controlled with the medications they were already getting yet refused to take because they didn't want treatment, they wanted cure.

What went wrong? Practicing medicine is a very difficult profession. It's hard to clinically ascertain where each patient is at in his or her thinking during the appointed allotted time. If the physician doesn't connect with the patient, the patient will not accept or even hear what is said. Some of us are more successful with some types of patients and others of us are more successful with other types of patients. When the trust connection cannot be made, the patient should take some responsibility to be frank with the doctor and perhaps make a change in physicians.

In the military, it may be hard to choose a personal physician. But there comes a point, after numerous tests have been done several times, that one must disengage from frequent medical calls. This may also be difficult to do because the visits are free and can go on for 20 or more years during a military career. Many of these charts represent a medical cost equal to a luxury car or to a home. It is indeed unfortunate that in health care one can utilize this degree of resources without significant responsibility. One presidential candidate wants to extend the amount of irresponsibility while the other candidate wants to reign in some of these costs. Future financial consequences don't matter in the heat of the campaign. The fact that all entitlements are facing an endpoint doesn't register with all Americans. The fact that government medicine causes multi-year waiting in many countries doesn't register either. They all think there are hidden government resources that still can be tapped. That's only because of dishonest politicians who don't speak truthfully to their constituents. We can't entirely blame a president with 25 percent approval rating when all spending bills originate in Congress with a 14 percent approval rating. The least we can do is to keep Congress, which 75 to 86 percent of us don't trust, from writing more medical laws and regulations. We must vote these incompetent folks out of office.

Don't let Congress determine our health care needs. They don't understand them.

* * * * *

6. Medical Myths: Debunking Myths of the Emergency Rooms

The uninsured are not responsible for overcrowding in the nation's hospital emergency departments; rather, insured patients represent the majority of the increased use of the nation's emergency departments over the past decade, says a new study published in the Journal of the American Medical Association.

Even medical researchers get that wrong, say the study's authors, who reviewed work in medical journals and found three common misconceptions about the uninsured and their use of emergency departments. Those myths are:

The uninsured use the emergency department for non-urgent care.
They are the leading cause of ER crowding.
They use the ER disproportionately to their share of the population.

In fact, researchers found:

A higher proportion of patients with public insurance, such as Medicaid and Medicare, use emergency departments than the uninsured.
Yet, the uninsured do represent a large percentage of patients in some hospitals where the surrounding city has high levels of uninsured residents.
Uninsured patients are less likely than insured patients to visit the ER for non-urgent problems; that's partly because it costs patients so much more to go to the ER than to other types of care.
The number of visits to ERs nationally rose 19 percent from 1995-2005, even as the number of hospital ERs fell by nine percent.

Furthermore, overcrowding in ERs has many causes such as patients being unable to be moved from emergency departments if other parts of the hospital are full or don't have enough staff. And people with insurance often go to the ER for problems that could be handled in a doctor's office because they face long waits to see their own doctor -- or need help after-hours, say researchers.

Source: Julie Appleby, "Study tries to debunk myths of ERs, uninsured," USA Today, October 21, 2008; based upon: Manya Newton, et al., "Uninsured Adults Presenting to US Emergency Departments: Assumptions vs Data," Journal of the American Medical Association, Vol. 300, No. 16, October 22/29, 2008.

Source: www.ncpa.org/sub/dpd/index.php?Article_ID=17171

For text: www.usatoday.com/news/health/2008-10-21-ermyths_N.htm

For abstract: http://jama.ama-assn.org/cgi/content/abstract/300/16/1914

For more on Health Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=16

* * * * *

7. Overheard in the Medical Staff Lounge: Will The Next President be Qualified?

Dr. Rosen: Are you ready to vote tomorrow?

Dr. Ruth: Not really. I don't like either candidate.

Dr. Milton: I'm voting for McCain. He's got the leadership experience and has been in the trenches of life and will be a real powerhouse.

Dr. Edwards: But I'm not so sure that Palin could run the country if McCain kicked the bucket.

Dr. Michelle: Looks to me that she's got more governing experience that all three of the other candidates combined.

Dr. Ruth: I just can't see her as a serious Vice President.

Dr. Yancy: She's much more serious than Joe Biden. He's the one that's a joke.

Dr. Michelle: Carly Fiorina said she couldn't run Hewlett Packard?

Dr. Yancy: Horse of a different color. None of the other three candidates could run Hewlett Packard either.

Dr. Ruth: What job is she qualified for?

Dr. Michelle: The governor is a logical pre-step to the vice-president's slot.

Dr. Sam: Senator Obama is the most inexperienced person of the four. Not only is he inexperienced, he is not qualified.

Dr. Ruth: How's that?

Dr. Sam: With his connections with Rev Wright, Bill Ayers, Acorn and the Radical Muslims, he is unable to get a security clearance to work for the FBI or the CIA. And he wants to be president and run these organizations for which he's unqualified?

Dr. Ruth: That's scary. Now you see why I'm not sure who to vote for. Maybe I'll just go to work and bypass the polling place.

Dr. Rosen: The whole election is rather scary and all at once it's upon us. Wish we had a few more weeks to sort all these things out.

Dr. Sam: There are really a lot of issues that have come in out in recent weeks that need digesting.

Dr. Milton: The issues have been there for weeks if not months. They just haven't been emphasized by the liberal press. They are readily known to those that listen to the Fox news reports or to Michael Medved's talk show.

[Editor's note: These newsletters are written approximately one week prior to the headline date. The staff discussions on the final day may still be of interest.]

* * * * *

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

VITAL SIGNS - Journal of The Fresno-Madera And Kern Counties Medical Societies

Kenya and Tanzania Medical Safari by Sergio Ilic, MD

To celebrate our 40^th wedding anniversary on December 15, my wife and I took a Safari trip to Africa. Things were made easier thru Professional Travel Abroad, a Florida company that specializes in foreign travel and gives you the opportunity to earn some CME credits when you visit hospitals and doctors as part of the tour.

We flew to London and from there to Nairobi, the capital of Kenya. We were the only ones on that trip, so it became a private safari for us. When we asked why, we were told that most of the other people had cancelled their trips because of the presidential election. We became a little concerned, but thought, hey, what could happen? It's just an election. Being from Chile and having experienced political turmoil during the Allende era, we felt there was nothing to be afraid of - and there we went.

Luckily the trip was fabulous, and we did not have any problems whatsoever. The election was the day before we departed from Nairobi back to the US. Everything was calm until the next day when they announced the results of the election and confirmed that the incumbent president had won. The election was clearly stolen, and everything broke loose after that with the consequences well publicized in the news.

The trip could be divided in three aspects. The first is the political one, and I'll not comment more on that.

The second is the tourist aspect of it. Most of you already know enough about the wild animals, the marvelous views of the African wilderness and jungles, beautiful blue skies, spectacular sunsets, torrential rains and thunderstorms and the sensation of grandeur and peacefulness of the land and feeling of communion and togetherness with the animals. The lions and elephants are not afraid of the vehicles or the people in them. At times they were so close to our jeep that one could touch the back of the lions going by. They look majestic, powerful and… very tame. Gazelles, zebras, wildebeest, hypos, rhinos, giraffes and others are not that friendly and don't get too close to the jeep.

The third aspect of the trip was the medical part. Some of the cities in Kenya and Tanzania are surprisingly modern with high-rises and beautiful neighborhoods, but at the same time there are huge slums where the poverty is striking. The first thing that calls one's attention is the number of people that are walking toward the city. The guide explained that they are people looking for a job that lasts one day. The next day the same thing happens again. There are buses, but people are so poor, they can't afford the fee, so they walk.

The first hospital we visited was in Tanzania, a small town of about 20,000 people. It's run by missionaries, and the building is nicely kept. It has about 70 beds, a small operating room, lab and a pharmacy that ran on donations, so there are only essential medications. Basically they treat OB-GYN problems, AIDS, TB, and appendectomies and C-sections. Everything else major has to be transferred to larger cities that are several hours away. The families of the patients have to provide care and cook for them. The kitchen is a building with small walls, no windows and basically opened to the outside. There are no stoves, so each family had a fire going to cook on. There was an entrepreneur that was selling vegetables, some eggs, but no meat. They had small fish resembling sardines, which were covered by thousands of flies that did not seem to bother anyone. The relatives slept in tents or under the stars.

The second hospital was in Kenya with about 100 beds and run by the state, so they have more resources. We had an informative conversation with the matrons and nurses about domestic violence and female "mutilation" as it is called, which causes severe problems to the women for intercourse and especially for delivery, which have tremendous lacerations with massive bleeding, ending in a high proportion of maternal deaths.

At first the matrons and nurses were reluctant to talk, but the fact that my wife and I were the only ones there did help. After they started talking there was no stopping them. The interesting thing is that there is a lot of pressure from the mothers and grand mothers to have their daughters circumcised. Even more interesting is the fact that if the girls had not been, they asked for it in their early teens, otherwise the boys would not look at them and they could not marry. If the girl doesn't marry, the survival becomes very difficult since middle and high school education is practically non existent in most of the country.

The final hospital we visited is in another similar size town and run by missionaries. Again, the major and most common diseases are AIDS, TB and OB-GYN problems. I was greeted warmly by the general surgeon as soon as I told him I was an Orthopaedic Surgeon. He had a patient that was hit by a vehicle and had sustained a segmental fracture on the left femur. He wanted me to help with the surgery. Of course I said no problem. He told me they had everything that could be needed for the surgery. I became worried when I saw the patient lying on the bed with no traction of any kind and in significant pain with any motion. When we went to see the OR, it had poor sterile conditions, as one could almost get to the OR table with civilian clothes. They had no instruments, no fracture table that could function properly and no blood available. They did have a C arm that was working well, but I did not test it. There were no power instruments and limited sizes of nails, plates, screws etc. I thought, my God, this is going to be difficult, but somehow we can do it. The surgeon told us to go and tour the hospital while he did a quick appendectomy.

Once we got back to the OR, we were told that the autoclave had broken down and that there were no sterile instruments or clothes anymore. The only man who knew how to fix it was sent on an errand. We were told that he would come back later and fix it. When he came back, it was discovered that the problem was major and that they wouldn't be able to fix it for five days or longer. I was also told that even if they could fix it the next day, no one could come and help us because it was going to be the 25^th of December, and most of the personnel were off. I left feeling bad for the patient and the doctor, but there was nothing that we could do. . .

In summary, I felt that the visits to the hospitals provided some sense of reality to the trip. The tourist is pampered and the food was excellent. We stayed in beautiful lodges (first class beautiful hotels) and given any little thing that we wanted, so one believes that everything is fine, but it is not. The main problems are lack of good education, stable jobs that pay well enough and the tremendous amount of corruption and diseases. The result of all of these is a significant amount of poverty with a real disparity between the minority elite ruling party, no middle class, and no real opportunities for better jobs or education, all of which produces a lack of upward mobility from the poor class. It makes you appreciate how easy we have it here at home even during these more difficult times. We live in the land of opportunities, which are here for us to take.

To read the entire article, go to www.fmms.org/pdf/JUL08_VS_FINAL.pdf.

Read Vital Signs table of contents at www.fmms.org/webpages/archives.asp.

To read more VOM, please go to www.healthcarecom.net/voicemed.htm.

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

* * * * *

9. Book Review: Who Moved My Cheese? An A-Mazing Story

Who Moved My Cheese? An A-Mazing Way to Deal with Change in Your Work and in Your Life by Spencer Johnson, MD, G. P. Putnam's Sons, Penguin Putnam Inc, New York (www.WhoMovedMyCheese.com), © 1998 by Spencer Johnson, M.D., ISBN: 0-399-14446-3, 95 pp, $20.

"Life is no straight and easy corridor along which we travel free and unhampered, but a maze of passages, through which we must seek our way, lost and confused, now and again checked in a blind alley. But always, if we have faith, a door will open for us, not perhaps one that we ourselves would ever have thought of, but one that will ultimately prove good for US." A. J. Cronin

Who Moved My Cheese? is a story about change that takes place in a maze where four amusing characters look for "Cheese" - cheese being "a metaphor for what we want to have in life," whether it is a job, a relationship, a big house, freedom, health, recognition or spiritual peace.

The imaginary characters are the mice, "Sniff" and "Scurry," and the little people, "Hem" and "Haw." They "represent the simple and the complex parts of ourselves, regardless of our age, gender, race or nationality."

We may at times identify with "Sniff who sniffs out change early, or Scurry who scurries into action, or Hem who denies and resists change as he fears it will lead to something worse, or Haw who learns to adapt in time when he sees changing leads to something better!"

Whatever character we choose to relate to, they all share something in common: a need to find their way in the maze and succeed in changing times. Dr Johnson gives us a real-life example where the principles this individual learns can be used by anyone:

Charlie Jones, a well-respected broadcaster for NBC- TV, reveals that the story of Who Moved My Cheese? saved his career. Charlie had done a great job of broadcasting Track and Field events at an earlier Olympic Games and was surprised and upset when he was removed from these events for the next Olympics and assigned to Swimming and Diving.

He felt frustrated and unappreciated because he did not know these sports as well. He said he felt it wasn't fair! His anger began to affect everything he did.

Then he heard the story of Who Moved My Cheese?

After reading the story, he decided to change his attitude. He realized his boss had just "moved his Cheese." So he adapted by learning the two new sports, and in the process began to feel young. His boss recognized his new attitude and energy, and soon gave him better assignments. He continued to enjoy success and was later inducted into Pro Football's Hall of Fame - Broadcasters' Alley.

Kenneth Blanchard, PhD, who wrote the foreword "the Story behind the Story," has given this book to over 200 people working in his company and lists more than 75 corporations, businesses, universities, the military, hospitals, churches and schools who are using this book. Every company that wants to not only survive in the future but stay competitive, may in the past have wanted loyal employees. Today they need flexible people who are not possessive about the way things are done, understanding that we are living in constant white water with changes occurring all the time at work or in life. This can be very stressful unless people have a way of looking at change that helps them understand it. Enter the Cheese story. . .

To read more of the cheese story and how it applies to health care today, go to www.healthcarecom.net/bkrev_WhoMovedMyCheese.htm.

To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.

To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.

* * * * *

10. Hippocrates & His Kin: May I Order my Own Lab Tests?

A patient came in for an evaluation. She was on a large number of herbs and was monitoring all the vitamin levels in her body. She was concerned because her B12 level had doubled. She was taking B12 supplements and had obtained monthly levels from her previous doctor. She would like to continue doing so. She said her previous doctor had given her blank lab requisitions and allowed her to check whatever test she desired.

I responded that was very expensive. She said that she had high-level PPO insurance. The last set of blood tests, she said, cost her insurance carrier more than $2500. She only did the big thing about every three months.

But that's $10,000 per year. Who's paying for your policy?

It doesn't cost me anything. My employer pays the tab.

With This Kind Of Greed, It's No Wonder Employers Can't Afford To Provide Health Insurance.

Who will be in charge of the FBI or the CIA?

If Senator Obama really isn't qualified to be part of the FBI or the CIA, can he really supervise the top secret aspects of these organizations?

Maybe he can appoint Sarah Palin to the post and let her make the decisions. She'll be capable.

To read more HHK, go to www.healthcarecom.net/hhk2001.htm.

To read more HMC, go to www.delmeyer.net/hmc2005.htm.

* * * * *

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, review how Social Security, Medicare, and Medicaid will use up 100 percent of the Federal Budget by 2050.

• 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, which discusses several current issues.

• 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, be sure to read about the pressing problems that lie ahead -- and the presidential candidates aren't addressing them.

• 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. Be sure to review the current articles listed on their table of contents: www.hiu-digital.com/hiu/200810/.

• 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 new 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. To see if you voted for the correct health plan, go to Your Health, Your Vote.

• Greg Scandlen, an expert in Health Savings Accounts (HSAs) has founded Consumers for Health Care Choices (CHCC). This has moved to the Heartland Institute. His Consumers Power Reports has now also moved to the Heartland Institute. You may want to read the current October 2008 issue.

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News. 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. To help understand our current Economic Downturn, it may be helpful to review our Economic Past.

• 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." This month, read about Arizona's attempt to stop Dr. Statism.

• 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. This month, be sure to read Why employers won't cut and run when individuals own health insurance.

• 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 Failure Of The Regulatory State.

• 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 at www.fraserinstitute.ca/health/index.asp?snav=he. With health care costs no longer sustainable, please read Six provinces expected to spend more than 50% of revenue on health care within a generation.

• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was 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 formerly supported and did extensive research on health care policy that was free market based. - 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 MedicalTuesday will no longer feature them as a freedom-loving institution. Freedom of people doing what is in their best interest is diametrically the opposite of Socialism, people forced into doing what the state desires. www.healthplanusa.net/January08.htm#News

• 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. This month, you may wish to read Jesse Ventura on our Political Parties. 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, which we featured last month; or 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 at www.cato.org/people/cannon.html. This month, select one of CATO's recent OpEds on the candidates' promises and issues.

• 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, war time allows the federal government 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 war time 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 Michael Ledeen, Author, The Iranian Time Bomb on Understanding Iran. The last ten years of Imprimis are archived.

* * * * *

Thank you for joining the MedicalTuesday.Network and Have Your Friends Do the Same. If you receive this as an invitation, please go to www.medicaltuesday.net/Newsletter.asp, enter you email address and join the 20,000 members who receive this newsletter. If you are one of the 50,000 guests that surf our web sites, we thank you and invite you to join the email network on a regular basis by subscribing at the website above.

Please note that sections 1-4,6 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the research and writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.

Spammator Note: MedicalTuesday uses many standard medical terms considered forbidden by many spammators. We are not always able to avoid appropriate medical terminology in the abbreviated edition sent by e-newsletter. (The Web Edition is always complete.) As readers use new spammators with an increasing rejection rate, we are not always able to navigate around these palace guards. If you miss some editions of MedicalTuesday, you may want to check your spammator settings and make appropriate adjustments. To assure uninterrupted delivery, subscribe directly from the website rather than personal communication: www.medicaltuesday.net/newsletter.asp

Del Meyer

Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608

Words of Wisdom

Passions unguided are for the most part mere madness. -Thomas Hobbes.

Age is an issue of mind over matter. If you don't mind, it doesn't matter. -Mark Twain

In looking for a husband for your daughter, don't ask: "Who'll make the best husband for her?" Ask instead: "For which kind of a man would she make a good wife?" -Old Proverb

Some Recent Postings

AMERICA ALONE, The End of the World as we Know It, by Mark Steyn, www.delmeyer.net/bkrev_AmericaAlone.htm

HEALTH CARE CO-OPS IN UGANDA - Effectively Launching Micro Health Groups in African Villages, by George C. Halvorson www.delmeyer.net/bkrev_HealthCareCo-OPInUganda.htm

A CALL TO ACTION - Taking Back Healthcare for Future Generations by Hank McKinnell www.delmeyer.net/bkrev_ACallToAction.htm

PUTTING OUR HOUSE IN ORDER - A Guide to Social Security & Health Care Reform by George P. Shultz and John B Shoven www.delmeyer.net/bkrev_PuttingOurHouseInOrder.htm

In Memoriam

Edward Albert ("Ted") Briggs, last survivor of the sinking of HMS Hood, died on October 4th, aged 85

TO DIE in a hospital bed was not the end Ted Briggs expected. He thought he had copped it when, at 16 and on Atlantic patrols on HMS Hood in 1939, he looked up to see a black object "as big as a London bus" tumble gently out of the sky and pepper the deck with shrapnel. Or, some months later, when a stick of bombs from an Italian aircraft blew him down the ladder from the flag deck, giving him a cut on the nose that bled like a torrent. Or the moment when, inching out along an upper yardarm to retrieve a halyard (for he was a signal boy), he saw the engine-room safety valves pump out a column of red-hot steam, and expected to be boiled alive.

The life of a boy-sailor on the navy's prize battlecruiser was no cakewalk. . . That was in time of peace. But Mr Briggs knew only two months of quiet before he was ordered to hoist flag "E" and "show up 46": "Commence hostilities against Germany." To read more, please scroll down at www.medicaltuesday.net/org.asp.

He had not joined the Royal Navy to fight. He had joined because, one day in the summer of 1935, he saw from the beach at Redcar in North Yorkshire a long, slim, huge ship at anchor far away. It was the Hood on a visit to Hartlepool. Mr Briggs, a straightforward man, was embarrassed to mention her "beauty" and "grace", but that was what he felt. It was a love affair. He tried to join the navy the next day; a man told him, since he was 12, to come back later. The day he eventually went on board the Hood, at 16 at Portsmouth, was the time he first felt that peculiar mixture of queasiness and wild excitement that assailed him each time he was piped to Action stations and the big guns opened fire.

In his many writings and talks about the Hood, Mr Briggs recalled great happiness on board. Though patrols near the Arctic to intercept German ships brought mountainous seas and soaking, freezing spray, the "mighty Hood" was a vessel on which he felt cared for. He was proud of her and the tasks he did for her: officers' messenger to and from the cabins of the braided top brass, and signal boy, running up the flags as needed and securing them, on the high yardarms, with Inglefield clips.

The Hood was an old ship, rusty and slow, built in 1916 and never properly refitted or armoured since. She performed well in the North Atlantic and the Mediterranean, leading the force that destroyed the fleet of Vichy France at Mers-el-Kebir in 1940 (an action Mr Briggs found "revolting" though, as ordered, he tremblingly clipped up the white-and-red bunting that meant "Open fire"). But her plating groaned in heavy seas, and water sloshed almost continually over the afterdeck. "Briggo" learnt quickly the niceties of crapping without being washed away. But, boy as he was, he fretted about the ship. Well over his head, officers with "scrambled egg" on their chests did not worry until too late about the thinness of her deck-armour.

To read the entire obit, go to www.economist.com/obituary/displaystory.cfm?story_id=12456696 - top.

On This Date in History - November 11, 2008

On this date in 1918, was Armistice Day in World War I, and the guns went silent. The silence didn't last long.

On this date in 1939, Kate Smith sang "God Bless America" which had been written by Irving Berlin 22 years earlier during World War I but had never been sung in public before. The last line of the song refers to our land as "home, sweet home."

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 VII, No 15, Nov 11, 2008