25 Years for Pleading Not Guilty
Even the prosecutors who obtained a 25-year prison sentence
for pain patient Richard Paey concede that he doesn't deserve it.
Still, it's his own fault, they say, for insisting on his
innocence and not taking a plea bargain. "All we wanted to do was
get him some help," stated Assistant State Attorney Mike Halkitis
(Jacob Sullum, reasononline 4/23/04).
Now in a wheelchair with a morphine pump, Paey at one time
took Percocet. When he had trouble finding a new doctor, he used
undated prescription forms from his previous physician, who
denied authorizing them. Under Florida law, Paey is a drug
trafficker of the worst sort, even though he never sold a single
pill, because he illegally obtained more than 28 grams of
painkillers containing oxycodone. The mandatory minimum sentence
is 25 years. (See News of the Day Archive for 3/9/04 at www.aapsonline.org.)
Pfizer Unit Pays $430 Million
Although physicians are permitted to prescribe drugs for
off-label uses, pharmaceutical companies are forbidden to promote
use of their product for any but FDA-approved indications. In a
qui tam action, Warner Lambert was accused of violating the
Federal Food Drug and Cosmetics Act and defrauding state and
federal Medicaid by promoting the use of gabapentin (Neurontin)
for attention deficit disorder, migraine, restless legs syndrome,
bipolar disorder, and amyotrophic lateral sclerosis. The fine is
second only to that paid by TAP Pharmaceuticals in the Lupron
case (BNA's HCFR 5/26/04).
Correspondence
A Model Waiver Form. In order to play in an annual
charity basketball event, participants (or their parents) must
sign a waiver form. This is published in a full-page newspaper
ad. Since the inception of the tournament in 1997, 10,000 persons
have signed this form. In it, they agree to hold tournament
sponsors harmless for any injury associated with the event. They
agree not to sue and to indemnify anyone for all costs if they do
sue, and also bind all heirs and assigns by this waiver.
Now that physicians and charity basketball players find
themselves playing on the same court, patient waiver forms may
become the only option compatible with economic survival in the
era of falling fees.
By the way, the whole concept of informed consent came from
the Nuremberg trials, in which 16 of 23 Nazi doctors were found
guilty, and seven sentenced to death.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Preventing Physician Ownership. Stark-like referral
prohibitions are generally not limited to Medicare. They
selectively prohibit physicians from investing in medical
facilities while permitting anyone else to do so. Such rules are
pushed hard by the American Hospital Association and its state
affiliates. If hospitals can prevent physicians from competing
with them, they will gain enormous control over their medical
staff and will not need to listen to physician requests for
better equipment, better nursing staff, better OR schedules, or
charges that accommodate price-conscious patients.
Donna Kinney, Texas Medical Association
Why Ban Self-Referral? If you're good at what you do
and open a hospital to give the kind of care you think your
patients deserve, why shouldn't you refer your patients there?
Nothing concentrates the attention like having a reputation and
cash at stake when you are trying to lure customers who can take
a hike if they don't like your service. If there is a concern
about conflict of interest, require disclosure.
Linda Gorman, Independence Institute
Absence of the Market. The two major sectors of the
economy of which we have said "the rules of the market don't
apply here" education and health are the two most dysfunctional
sectors. Is there any correlation?
Sean Parnell, Heartland Institute
Some seem to see medicine as an issue that transcends all
the rules of the universe because of the nobility of its very
existence. This is apparently why reasonably intelligent folks
persist in trying to rearrange the Titanic deck chairs.
Frank Timmins, HealthBenefitsReform group
Let the Customer Choose. I have no problem with kiosk
medicine even though it does compete with my practice. A kiosk
manned by a nurse practitioner in a grocery store in a nearby
city charges $5 less than I do. Let the patient decide whether,
in a particular situation, board certification in emergency
medicine and internal medicine is worth the additional $5. No
need to protect the producers.
Robert Berry, M.D., Greeneville, TN
Command and Control. Powerful interests are indeed
trying to control physician behavior by fiat: have panels of
experts develop practice protocols and enforce them on all
clinicians, by payment restrictions, malpractice suits, and
licensing. This is not a paranoid fantasy. It is quite literal.
It would be a huge mistake, freezing into place the medicine of
2004 and inhibiting any further innovation.
Greg Scandlen, Galen Institute
The Data Base Trap. You won't see a "single database"
of auto manufacturers, not even in Germany. Putting all
physicians (and their patients) into such a database is a
mechanism for totalitarian control. It must be fought at all
cost.
Jack Tidwell, M.D., Columbus, GA
Licensure Board Actions. The California Medical Board
spends 35% of licensure fees on social programs for which they
have no mandate, such as forgiving indebtedness to place doctors
in downtown Los Angeles. If you doubt that the Board is violently
anti-doctor, read the monthly Bulletin to see the inconsequential
matters for which doctors have been censured.
Herbert Rubin, M.D., UCLA
Separate and Unequal. Every form of taxation involves
the creation of two classes: taxpayers and
taxreceivers. How can one measure the cost to the
grandkids and compare it to the benefit received by Grandma?
Robert P. Gervais, M.D., Mesa, AZ
"Liberal" Thought. You will remember from gross anatomy
that liberals lack a corpus callosum. Thus, one side of the brain
is unable to communicate with the other. I once asked a liberal:
"Then you think that the rich can pay 100% of their income in
taxes?" He said, "Absolutely. They can well afford it." I decided
to push the point further: "Do you think the rich can pay 200% of
their income in taxes?" He responded, "Absolutely. They can well
afford it." I think liberals have been taught from their youth
that the rich have hundreds of times more money than you can ever
discover, and that there are simply no limitations on what they
can be forced to pay.
Del Meyer, M.D., Carmichael, CA
Legislative Alert
The Presidential
Election Issue:
Health Care or Tax Cuts
The Nominating Conventions will soon be upon us, and the
Presidential race will be underway in earnest. The key domestic
policy issue will be Government-managed and financed
health care or tax cuts. Or, we would say: more government
or more freedom. No matter how you slice, dice, or phrase it,
that's the basic choice facing voters, according a leading
analysis of the coming Presidential contest in the June 28th
edition of The Washington Post.
The Post reporters have got the basics right. They
note that Kerry has a health care plan estimated to cost between
$653 billion and $950 billion over the next ten years. Ken Thorpe
of Emory University says that Kerry's plan, a complicated and
multifaceted thing, would yield a net increase of insurance
coverage of about 27 million Americans. (This does not include,
of course, any of Senator's Kerry's more expansive proposals for
Medicare.) Kerry would pay for his basic health care expansion by
rolling back Bush's tax cuts for all families with an annual
income of more than $200,000, raising the two top tax rates of
33% and 35% to 36% and 39.6%, respectively, reversing the Bush
tax cuts on capital gains and dividends for upper-income
families, and preserving the estate tax. The total tax increases
would amount to $860 billion over ten years, according to
analysts with Brookings and the Urban Institute.
Bush, on the other hand, is committed to making permanent
"an array" of federal tax cuts already enacted by Congress,
amounting to $990 billion over the next ten years. Bush has also
proposed a more modest program of refundable tax credits worth
$90 billion over the next ten years, with an estimated additional
increase of 2.5 million Americans getting coverage. Of course,
Bush has also signed into law a massive expansion of the Medicare
entitlement for prescription drugs, expected to cost, on the
Administration's own estimate, an additional $540 billion over
the next ten years.
Medicare: It's Unofficial!
Robert Novak, one of the best reporters in Washington,
writes this explosive little paragraph in a piece on the
President's domestic policy: "Senior administration officials
privately admit that last year's prescription drug bill was a
disaster substantively and politically. The golden opportunity
for Medicare reform was squandered. Although the need for basic
change along market-based lines persists, nobody has the will to
revisit this issue anytime soon" (Washington Post,
6/14/04). Clip that for the permanent file.
Here is another question: Did those same unnamed senior
administration officials feel the same way last year, and did
they convey their reservations to the President before or during
the November debate on the Medicare drug entitlement? The truth
will out. Someday.
Meanwhile, the debate on how much the taxpayers will pay is
just getting started. One very big estimate is that of Professor
Laurence Kotlikoff, chair of the Department of Economics at
Boston University and coauthor of The Coming Generational
Storm. Kotlikoff estimates that the "present value" of
promised Medicare benefits is $73.6 trillion, seven times
the current GDP and 14 times the official U.S. debt. (The
"official debt" doesn't count unfunded liabilities.) The
"present value" of the future payroll taxes amounts to $12
trillion. What to do? Kotlikoff writes, "Historically, we've
used general revenues to cover the gap between Medicare's
expenditures and receipts. But continuing to do so will require a
50 percent immediate and permanent hike in federal income taxes.
Alternatively, we can wait and raise taxes by an even larger
percentage in the future. Tax hikes of this magnitude would
severely damage our economy."
In other words, we are not going to "grow" our way out of
the problem. Since nothing can be done about the demographics and
business as usual won't work in the future, Kotlikoff thinks that
the best way out is to "voucherize" the entire Medicare program,
with a fixed government contribution adjusted by the Medicare
patient's medical condition. Care delivery would be secured
through private sector options.
Remembering Ronald Reagan
The pomp and pageantry of Ronald Reagan's funeral last
month was more than appropriate. It was the response of a great
nation in mourning for an increasingly beloved leader. Looking
back on Ronald Reagan is powerful reminder to ordinary Americans
of what real leadership means. Reagan not only changed America;
he changed the world.
For doctors and patients, Reagan's health policy themes were
familiar, if unfulfilled. Reagan had faith in private medicine,
and he warned, repeatedly, of the threat that government programs
posed for American medicine. But on the details of federal
policy, the Reagan record was mixed. In 1983, he embraced the
Prospective Payment System (PPS), originally developed by
researchers at Yale University, as an answer to rising Medicare
hospitalization costs. But recall the context of the Reagan
initiative: the Carter Administration was pushing for price
controls on hospitals. The PPS system was sold by the Reagan team
at HHS as an attempt to inject an element of "fiscal
conservatism" but it turned out to be nothing more than another
federal price-control mechanism.
Likewise, Reagan signed the Medicare Catastrophic Coverage
Act of 1988 into law. Originally promoted by the President as an
attempt to provide peace of mind for America's seniors through
the addition of a modest catastrophic benefit to the Medicare
program, the House and Senate bills became a twin engines of a
massive Medicare benefit expansion, including the addition of a
controversial and costly Medicare prescription drug benefit. Even
though the benefit was "self financing" in the sense that the
Medicare beneficiaries were going to pay for the new benefit
Reagan officials at HHS correctly warned Congress of the
exploding costs of the drug benefit and the practical
difficulties of the government administration of such a thing,
noting that it would require the doubling of Medicare claims and
the monitoring of all those new claims. But Congress, and its
enablers in the AARP, ignored these reservations, and insisted on
including the big benefit expansions. They thus passed it by
overwhelming margins in the House and Senate, and Reagan signed
the final bill into law. It turned out to be a huge political
mistake. The actual and projected costs soared, and seniors, who
were paying for the new benefit, staged a massive political
revolt. In 1989, less than a year after Reagan left office, the
Congress repealed the law, by equally lopsided margins in the
House and Senate.
On a positive note, the Reagan Administration firmly opposed
the Resource-Based Relative Value Scale (RBRVS), rejecting it as
bad policy. That bad policy was then being promoted by the House
Ways and Means Committee as the basis of a new Medicare payment
system combined with price controls. The first Bush
Administration acquiesced.
Politics of Prosperity
Reagan will not be remembered for health policy, but
rather for a dramatic economic revitalization at home and
international victory in the Cold War. When Reagan took office,
Americans were suffering under a savage inflation, a serious
economic slowdown, and declining income. The prime rate was 19%,
home mortgage rates 14.7%. By 1992, the prime rate was 6%, and
mortgage rates 8%. In 1981, he presided over the largest budget
and tax cuts in modern history. The overall result was that his
policies crushed a raging inflation that was killing the
prosperity of the country and destroying the lives of millions of
Americans, including those who were living on fixed incomes. He
stayed the course with his fiscal and tax policies, worked very
closely with the monetarily conservative Federal Reserve Chairman
Paul Volcker, and these combined fiscal and monetary policies
soon lifted the country out of a serious recession. Raging
inflation was dead.
Reagan presided over one of the longest periods of sustained
economic growth in the postwar period, creating more than 20
million jobs in the process. It was an economic expansion that
largely continued well into the 1990s, with only a brief downturn
in 1991. Real average income for American households increased by
16.8% from 1982 to 1989. Isabell Sawhill and Mark Condon of the
Urban Institute, no friends of "Reaganomics," found that the rich
got "a little richer," but the poor got richer too. Incidentally,
the share of income taxes paid by the wealthiest 5% of Americans
actually increased, from 35% in 1981 to 44% in 1989. Poverty fell
significantly during the Reagan years, from 35.3 million in 1983
to 31.5 million by 1989, just as it had increased rapidly during
the Carter Administration. On a per capita basis, charitable
giving increased about 4% per year from 1980 through 1989, double
the charitable giving from 1955 to 1979.
The "Reagan Revolution" charged uphill against a well-
entrenched and bitterly hostile Washington Establishment, and its
momentum in the latter eighties eventually slowed. For example,
Reagan led an effort to reduce the size and scope of government,
and reduced federal employment by 100,000 in the domestic
agencies in the first four years. After his big victories in
cutting government spending in 1981, federal employment started
to creep back up, reflecting the pushback by Congress and the
beneficiaries of government programs that accelerated in his
second term. But even during this period of backsliding, Reagan
had established the rhetorical terms of national debate on the
size and scope of government. It is supremely significant that
when President Bill Clinton came into office, he promised to
reduce federal workforce by 100,000, and actually ended up
reducing the total size of the federal workforce (including the
military) by 300,000. Clinton said that the "era of big
government" was over, even though it wasn't. While formal federal
employment may have been reduced, government contractors were
growing in the millions in the Clinton years. Reagan may have won
the rhetorical debate on big government, and Clinton may have
echoed Reagan's rhetoric, but the battle on the ground was lost.
Likewise, Reagan was unable to control domestic spending and
the consequent rise in deficits. With the enactment of The Tax
Equity and Fiscal Responsibility Act (TEFRA) of 1982, Reagan
agreed to raise taxes, but part of his agreement with the
leadership on Capitol Hill was that for every $1 dollar in tax
increases, Congress would cut government spending by $3 dollars.
Congress never honored that pledge and Reagan did not engage in
a "veto war" with House Speaker Tip O'Neill. We continue to run
deficits, not because Americans are undertaxed, but because
Congress overspends. They are spending again with reckless
abandon.
The "Vision Thing"
Reagan had a coherent philosophy of government: He
believed strongly in smaller government, lower taxes, and
individual freedom. He was a champion of traditional moral
values. These were not vague slogans or metaphysical
abstractions; they were a governing philosophy that pervaded the
Administration. At the staff level, this writer knows that the
policy impact was pretty simple. Whatever the issue was before
you, you had to simply ask yourself the question: "Why am I in
this job, and what would Ronald Reagan want me to do?" You did
that. You were not there to fatten your resume, or get
"government experience." You were there to do a job. The key
questions were always: Will this expand or reduce the size of
government; will this help or hurt the taxpayers?
Changing the World
Reagan's biggest success was in foreign policy. Margaret
Thatcher said it best: He won the Cold War without firing a shot.
He had no illusions about either the Soviet leadership or the
Soviet system. He called them publicly an Evil Empire, and he
meant it in Biblical language. Reagan also did not think that the
Soviet system was a permanent fixture, although a lot of people
in academic life and the big think tanks thought that it was here
to stay for a very long time. Right now, a lot of the same folks,
or their ideological heirs, are saying that Reagan did not
deserve credit for ending the Cold War because the Soviet Union
was on the verge of collapse anyway. Really? That was not what
they were all saying then, when the left was routinely denouncing
Reagan's every move as cowboy diplomacy. In hindsight, the views
of Reagan's critics on the subject of the Soviets look positively
clownish or naive. Reagan knew that the creaky Soviet economy
could not sustain a first-rate military program forever. He knew,
and so did Mikhail Gorbachev, that another arms race would run
them into the ground. He was right, his critics were wrong, and
the world was changed forever.
Robert Moffit is Director, the Center for Health Policy
Studies at the Heritage Foundation, Washington, D.C.
