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Volume 65, No. 4 April 2009
The defining issue for Americans is freedom: not
equality, efficiency, quality, power, security or even
prosperity. Freedom, Henry Grady Weaver's "mainspring of human
prog-ress" did lead to unprecedented wealth, but it was not for
wealth that early American settlers left behind a relatively safe
and comfortable life to face a wilderness. They fled tyranny and
sought the freedom to worship and to live according to their
conscience, and to follow their own dreams.
The word "freedom" occurs but once in Barack Obama's
booklet, A New Era of Responsibility: Renewing America's
Promise it's what American troops are defending. America's
"legacy," defined by Obama, is "misplaced priorities" not
freedom. The government must "lead the way" not individual
Americans. While "choice" occurs 14 times, three as "tough
choices," Obama has already started the process of overturning
the Provider Conscience Clause, which defends the freedom of
physicians not to be compelled to participate in actions they
believe to be unethical or harmful.
Government Supervision Guaranteed
Stating it was time to "boldly" rebuild the nation's
"foundation," the economy's Architect-in-Chief released a budget
that was not just a budget, but a "blueprint for our future"
(Daniel Henninger, "A Radical Presidency," Wall St J
2/26/09). It will work, Obama says, in "dramatic ways that will
upset the status quo" (AP 3/1/09). It includes a $630 billion
"down payment" on fundamental health care reform.
Fixing the economy demands immediate health care reform, as
"skyrocketing health-care costs have threatened the stability of
families, businesses, and our economy as a whole," write Senators
Baucus and Kennedy (Wall St J 2/26/09).
After Daschle's fall, Ezekiel Emanuel, M.D., brother of
White House chief of staff Rahm Emanuel, is a rising star.
"Health Care Zeke" will set priorities. As chairman of the
bioethics department at the NIH, he focused on resource alloca-
tion rationing, as in a pandemic (Science 2006;312:854-
855). In his 1992 book The Ends of Human Life: Medical Ethics
in a Liberal Polity, he describes his ideology as "comm-
unitarian."
Emanuel's recent book Healthcare, Guaranteed: a Simple,
Secure Solution for America, an expansion of an earlier
article with Victor Fuchs (N Engl J Med 2005;352:1255-
1260), proposes vouchers for 100% of Americans to purchase the
federally approved "standard" health plan of their choice.
Receipts from a dedicated value-added tax (VAT) would set the
global budget. As in Daschle's plan, a Federal Health Board
modeled on the Federal Reserve system, and an institute to assess
the value of various treatments would oversee it all.
The key objective: "fragmented care must be replaced
by coordinated care." Our present nonsystem had no
designer. It is "chaotic," "unstable," "driven by thousands of
small physician practices,...a remnant of the horse-and-buggy
era, ill-suited to the twenty-first century." It lacks oversight
of physicians Lyndon Johnson had to promise that Medicare and
Medicaid would not interfere with physicians' decision-making
authority in order to get the programs passed.
Most interestingly, Emanuel opposes single payer because it
would lock in a fee-for-service system and make it impossible to
change the way care is delivered. Also, extensive monitoring
would be impossible if administrative costs were limited to 3 4%.
There would be queues, and physicians in private practice would
feel obligated to help their own patients!
The problem, in a word, is freedom. And one big obstacle to
sweeping changes is the James Madison Rule of
Government: checks and balances. When the short window of
opportunity opens, reform must be rammed through before the
losers can mobilize to thwart it. Never mind the devilish
details: "God is in the essentials!" proclaims Fuchs in the
foreword.
We Are All Socialists Now
This title appeared on the cover of the Feb 16 issue of
Newsweek magazine, with the Communist handshake symbol.
As the lead article noted, the share of American GDP spent by
government is now only 8 points below that in France.
"[T]he socialist bogey-mantra has made a full-scale return
after a long stretch of relative dormancy," writes Mark Leibovich
(NY Times 3/1/09). But now that the horrors of Communism
have been largely forgotten, "it is a less potent slam than it
once was."
Freedom vs. Coercion
The people's decision "will determine the ultimate fate of
Freedom and Truth in this Nation," wrote the AMA in 1950, on an
effort to pass compulsory national health insurance. That would
be "the most sweeping attempt yet made in this country toward
central control of the personal lives of Americans" (pamphlet
titled "The Voluntary Way Is the American Way").
"The only guarantee...is guarantee of a new payroll tax the
eventual amount unpredictable," the AMA warned.
To sacrifice freedom to authority in government-controlled
medicine "borrowing the unsuccessful systems of foreign
countries" would be the "greatest error in all history." Noting
that Lenin had proclaimed socialized medicine to be the "keystone
in the arch of the Socialist State," other areas of American life
might soon be socialized also, the AMA wrote.
Advocates, then as now, used "distorted evidence, juggled
statistics, and false logic." Reaching out to patients with the
facts, physicians played a major role in defeating socialized
medicine. The threat that they would refuse to participate in
Medicare won the "guarantees" of physician autonomy.
Where do physicians stand on freedom today?
The Obama budget proposes to pay for the $630 billion "down
payment" on reform with $318 billion in new revenues from taxing
the "wealthy," and the rest in "savings": $20.5 billion from
"aligning incentives toward quality," $287.4 from "promoting
efficiency/accountability"; and $8.1 billion from "encouraging
shared responsibility" (Obama, op. cit.). This translates to:
competitive bidding for Medicare Advantage plans; increased drug-
company rebates for drugs sold to Medicaid patients; and flat
fees for first admission and 30-day follow-up for Medicare
patients, to avoid payment for readmissions (Washington
Post 2/25/09).
Obama asserts that medical costs cause a bankruptcy in
America every 30 seconds. That would be 1,051,200 per year. The
total number in 2007 was 822,590, of which 5% were due to medical
costs, according to a Univ. of California study (CPR
#167, 2/25/09). It is not the AMA that has disputed such figures
(see AAPS News, October 2008).
At the Mar 5 Health Care Summit, AMA President Nancy Nielsen
agreed that health reform is the "linchpin of economic recovery."
Obama alleges that premiums have increased four times faster
than wages in the past 8 years. Actually, they have stabilized in
the past 5 years at a 6% increase, while wages increased 4%,
notes Greg Scandlen. Moreover, companies adopting consumer-
directed coverage are seeing premiums increase at a slower rate
than wages or inflation (CPR #167).
Obama declares that the cost of health insurance is a major
reason for small businesses to fail and corporations to ship jobs
overseas. Actually, notes Greg Scandlen, it's a major reason for
business to stop offering coverage. Moving abroad has more to do
with taxes, regulations, and wages (ibid.).
Nielsen said that doctors resist government control, but if
the specialty societies write the protocols, that is not
government control. The AMA is "here to be partners."
If everybody is not in the system, reform will fail, said
Steven Udvarhelyi of Independence Blue Cross, warning against
allowing "opting out" provisions for business or individuals.
"Falling short of 100% is unacceptable," states Emanuel,
although he would allow the "rich" to buy a "platinum" plan, with
after-tax dollars, after everybody had a plan as good as
congressmen now have. He quotes Jonathan Gruber's analogy that
well-insured Americans are like people on a comfortable boat in
the middle of the lake. Someone says, "Okay, everybody off the
boat. We'll move you onto a new boat with the uninsured and
Medicaid recipients, but don't worry, it'll be nice enough."
Emanuel rejects Massachusetts-style mandates or other ways of
plugging the cracks to avoid dealing with this problem.
Apparently, he wants to blow up the boat.
"There is nothing more difficult to accomplish...than
to initiate a new order of things. The reformer has enemies in
all those who profit from the old order and only lukewarm
defenders in all those who would profit from the new order."
AAPS Principles of Medical Ethics state: "4. The
physician should not dispose of his services under terms
or conditions which tend to interfere with or impair the
free and complete exercise of his medical judgment and
skill or tend to cause a deterioration of the quality of
medical care."
In 1965, many physicians recognized that
Medicare would lead to such conditions, and that
Medicare could be stopped if physicians declined to
participate. The AMA board, however, committed to a
policy of "constructive advice and guidance." Although
the threat of nonparticipation dominated the June House
of Delegates meeting, no action was taken. Therefore, a
special meeting was called in October by petition of
delegates from state associations, led by Francis Davis,
M.D.
The anger surging through the House was
expressed by E.S. Rifner, M.D., of Indiana (Frank
Campion, The AMA and U.S. Health Policy Since
1940): "We feel let down, bewildered, shocked
and dismayed as we attempt to assess the probable
damage of the collusion between the ruthless power of
Federal Government and organized medicine."
The House applauded, though Rifner had
virtually accused the AMA leadership of treason.
However, outside legal counsel A. Leslie Hodson said that
a resolution recommending that physicians refuse to see
Medicare patients would violate antitrust law. AMA
President Appel said that even if legal the resolution
would be "unwise." Americans expected the doctors to be
good losers. Though the president got a chilling
reception, the next day delegates endorsed a policy of
working with HEW. Dr. Davis reports that the bylaws
were changed so that a special session could never again
be called.
Note: Physicians do not need to refuse to
see patients, only to decline to accept government or third-
party payment.
At the Summit breakout session chaired by Zeke
Emanuel, Sen. Robert Bennett (R-UT) said he was a
cosponsor of the Wyden Healthy Americans Act
(AAPS News, February 2007). He said change will
be "wrenching" if we do what we need to do. But
Republicans need to "get over their opposition to
universal coverage," join hands with Democrats, and,
"like Butch and Sundance," jump off the cliff together.
[Recall that Butch Cassidy and the Sundance Kit were
bank/train robbers who landed in the river and lived to
steal again.]
Reactions to the summit (video, press release,
and member comments) are at
www.aapsonline.org. Post your views also!
Jun 5-6, 2009. Workshop, board
meeting, Dallas, TX.
Because of reports that medical centers and staff
were under increasing pressure to perform abortions
despite federal laws prohibiting discrimination against
those who refused, the Bush Administration issued a
regulation requiring agencies to certify compliance or risk
losing federal funds.
AAPS comments supporting the "Provider
Conscience Clause," posted at
www.
aapsonline.org/ethics/foc.php, state:
"Medical professionals should not fear the loss of their
ability to practice their profession if they decline to
participate in procedures...they believe to be harmful or
unethical."
Some state officials, Planned Parenthood, and
the National Family Planning and Reproductive Health
Association filed several lawsuits seeking to overturn the
regulations. AAPS filed suit to intervene to defend the
rules, emphasizing the broader context of physicians'
conscientious objection to many procedures beyond
abortion and sterilization, for both religious and other
reasons, such as involuntary psychiatric treatment.
Just before the government's response was due,
the Obama Administration filed a proposed rule for
completely rescinding the Provider Conscience Clause. A
30-day public comment period opened Mar 5. The
Department of HHS intends to "review this regulation to
ensure its consistency with current Administration
policy." Concerns include access to services and
disproportionate impact on underserved areas.
Apparently, the "right" to certain services
implies a duty for professionals to provide
them, despite their objections.
Among the "Rules of Civility" studied by
George Washington was: "Labor to keep alive in your
breast that little spark of celestial fire called
conscience" the innate understanding of moral right and
wrong that is assumed in the Declaration of
Independence and is the foundation of our nation.
Extinguishing that spark, writes Mary
Davenport, M.D., plants the seeds for mass liquidation of
the largest generational cohort in American history, the
Baby Boomers. They will be the first Americans to be
denied available, effective life-saving treatment on the
basis of cost (American Thinker 3/3/09).
The concept of conscience is mocked, writes
Davenport, by University of Wisconsin law professor R.
Alta Charo, J.D., in her article "The Celestial Fire of
Conscience Refusing to Deliver Medical Care" (N
Engl J Med 2005;352:2471-2473).
Charo calls abstaining from counseling or
referring for certain procedures a "privilege." Those who
want to abide by the demands of an outlier conscience
should be willing to pay a price. "To what extent do
professionals have a collective duty to ensure that their
profession provides nondiscriminatory access to all
professional services?" A personal act of conscience might
actually be "an attempt at cultural conquest." Against the
dangers of "unfettered personal autonomy," the collective
must be guarded by government and "major" professional
societies.
By a 58% to 42% majority, Washington State
residents passed the Death with Dignity Act based on the
1997 Oregon law. Despite concern that none of the 85
patients receiving lethal prescriptions in 2007 had a
psychiatric referral, "Oregon's well-documented
experiences are an invaluable resource," writes Robert
Steinbrook, M.D. (N Engl J Med 2008;359:2513-2515).
Others disagree with that statement. The
Oregon Public Health Division (OPHD) "does not collect
the information it would need to effectively monitor the
law and...acts as the defender of the law rather than as
the protector of the welfare of terminally ill patients,"
write Herbert Hendin, M.D., and Kathleen Foley, M.D.
(IL&M 2008;24:121-145).
There are no penalties for noncompliance with
guidelines, and "OPHD has not addressed the issue of
non-reporting." Thus, conclusions are based on limited
data.
One criterion for eligibility is a life expectancy
less than 6 months. The 9-year data suggest that a
significant number of patients live longer than that.
OPHD, however, does not indicate the time interval
between the prescription and death, precluding evaluation
of the reliability of prognosis, and hiding from the public
the uncertainty of prediction.
There is no evidence substantiating the
allegation that patients requesting lethal prescriptions
were receiving adequate palliative care. Compassion in
Dying executives have indicated that the organization has
been involved in 75% of cases, perhaps exerting undue
influence. Patients may not have adequate counseling for
making an informed choice. The Oregon guidebook
stresses that mental health evaluation should focus on
competence, and that the presence of depression does not
necessarily mean incompetence.
Oregon radically altered its rationing priorities
between 2002 and 2009. Life-saving procedures have been
downgraded, and more routine or preventive care moved
to the top. Severe/ moderate head injury moved from #1
to #101, testicular torsion from #8 to #261, and ruptured
spleen from #13 to #178. Bariatric surgery is #33; abortion
#41; treating hemorrhage from a miscarriage #68. Only
the first 503 of 680 listed procedures are paid for (Linda
Gorman, www.ncpa.org/pub/ba/ba645).
Gorman also notes that the NHS National
Institute for Clinical Excellence (NICE) rejected the
advice of its Citizens Council, of whom 21/27 favored the
"rule of rescue." Rather than giving a high priority to
preventing imminent death, NICE must ensure cost
effectiveness and the fairest distribution of health
resources within society as a whole (ibid.).
Whistleblower Protection. The
American Recovery and Reinvestment Act includes
whistleblower protection for employees who reveal
violations of the law related to stimulus funds. The
language is broadly written so that it also protects
whistleblowers who reveal fraud in Medicare or Medicaid,
which receive stimulus funds (BNA's
HCFR 2/25/09).
RAT Board. Virtually unnoticed was
the Recovery Accountability and Transparency Board,
which would oversee inspectors general. The RAT Board
would have the authority to ask "that an inspector
general conduct or refrain from conducting an audit or
investigation." According to Sen. Charles Grassley (R-IA),
the board "strikes at the heart of the independence of
inspectors general." It could dampen the aggressiveness
with which they pursue something that might make the
incumbent administration look bad. Grassley learned of
the provision hours before the vote. It was "snuck in," he
said. Someone said the Obama Administration wanted it,
but no one has claimed paternity (DC
Examiner 2/19/09).
Redistribution for Doctors. It looks as
though Baucus and other reform proposals will have a
mythical "cost neutral" face, whereby money will be taken
from those "overpaid" specialists and proceduralists, and
redistributed to primary-care physicians, who are
underpaid because of government price setting.
The "medical home" is another gimmick, like
"primary- care gatekeepers" and capitation, to lure still
more primary-care physicians into supporting socialism.
Government-supervised "evidence-based medicine" will be
mandatory for those in the medical-home model.
The AMA Agenda. The AMA plan is
the Obama plan. It has been carefully built that way in
the House of Delegates and at the board of trustees level
for the past 5 years. The board has chosen not to push for
protecting the practice of private medicine through
balance billing, labeling it politically untenable. But they
have gotten what they really wanted: a coveted seat at the
table at Obama's health-care prom.
While it seems encouraging that there is talk of
paying doctors the $300 billion due them over the next 10
years in Medicare, the key line is this: "Medicare and the
country need to move toward a system in which doctors
face better incentives for high-quality care rather than
simply more care." That means government will withhold
payment if you don't comply with their rationing
protocols. I predict payments to physicians will be cut
close to 40% over the next 10 years.
AAFP Advocacy. The American
Academy of Family Physicians has been advocating for
nationalized medicine for a long time. Browse the list of
403 policy statements on their website. They think that
group visits are "one component of the system changes
needed for the new model of care." The language suggests
they are completely captured by government control
folks: "stakeholders," "social justice," "fairness," "delivery
systems," and pluralistic buzz words abound. There is no
evidence backing their "medical home" idea a campaign
to raise their pay, which government control will crush.
What's Going On? If I were a
conspiracy theorist (I'm not), I'd think that virtually
everything that's happening is a secret plot to destroy
physician autonomy. I think we've taken many small
steps, mostly without underlying intent. If patients really
understood the forces at work, they would stand up in
unison to try to protect physician autonomy. But they
don't.
TPP Is Evil. I don't know about a
"secret plot," but when I was with the Blues, they were
very clear (not secret) that the whole problem was the
physicians.
Remember that third-party payment (TPP) is
different from insurance. Insurance is a two-party
contract between the insurer and the insured. One pays a
premium so the other will pay a benefit when a loss
occurs. This allows the patient to have a direct
relationship with his doctor. TPP gets in the way of that
relationship. The doctor is responsible to the insurance
company, not to the patient. The doctor is paid by the
insurer, not by the patient. High-cost services need to be
paid by insurance. They do not need to be
covered by TPP. TPP is an abomination started by Blue
Cross in the 1930s. It never existed before, and it is the
biggest mistake ever made in medicine. It is
the source of every problem in medicine.
Opt Out. If you don't accept
any third-party payments, you won't have
to balance bill or figure out CPT codes; you won't have
accounts receivable; you'll be paid fairly; your patient/
physician relationships will improve; you will save
administrative overhead; patients will come because of
you, not because Blue Cross sent them;
patients will enjoy confidentiality....
Will Doctors Be Drones, or Opt Out?
Many will remain in the system and use every possible
loophole, then retire, perhaps decades early, to be
replaced by a less efficient system of physicians with an
employee 9-to-5 mentality, supplemented by nurses and
foreign physicians. The only physician association I know
of that fights this "inevitability" is AAPS.
Rush to Treatment Flawed. To the
Wall St J (3/5/09):
[The op-ed by Sen. Baucus and Sen. Kennedy
creates] a sense of crisis in order to push through
(without time for debate, if possible) a radical takeover of
the system....
Putting the government fully in charge...will
lead to spiraling costs, loss of quality, rationing by "cost
effectiveness," long waits for service, and the destruction
of the greatest health-care system the world has ever
known.
...At its core, health care is a personal
relationship between patients and doctors, but our
current system relies on third-party decision-making that
results in lack of accountability, flexibility and efficiency.
Quality, affordable health care can and should be
available to all Americans, but the path to that goal does
not lie through a Washington bureaucracy.
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