Volume 64, No. 12 December 2008
THE MORNING AFTER
Euphoria about "change" explodes across the television
screens and front pages and at least the coastal and heavily
urbanized parts of the land. Huge crowds hitherto a feature of
Third-World but not American politics applaud and cheer. The most
lavish inaugural ball in history is planned.
But the morning after will dawn, when one asks, "Was it
really love?" Is it now This Perfect Day of Ira Levin,
with perfect central planning and ever-present "advisors," quick
to prescribe an extra drug treatment should a disruptive thought
or selfish impulse intrude? Have we perhaps spawned Levin's
Rosemary's Baby, a monster that will destroy its mother?
The seeds of the destruction of the Republic have been
gestating for a long time, long before the current campaign. Will
one final push to burst the fetters of the Constitution ("what
the government can't do to you," as Barack Obama put it) succeed?
Will we all be "citizens of the [One] world," required to perform
"national service," "spread the wealth around," and assure that
every woman immediately gets her "choice" if the choice
is an abortion? Or will Obama, as some media sages predict,
instead "govern from the center," continuing the bipartisan
incrementalism of recent years?
Have we reached the point at which the frog will either get
cooked, or jump out of the pot before the lid clamps down?
Has the Titanic already hit the iceberg? And are we now
planning to drill some holes to let the water out?
What It Means for Medicine
Obama promises, in an October article with his byline
(NEJM 2008;359:1537-1541), that: "Under my plan, if
patients like the insurance they have, they keep it and nothing
changes, except the costs are lowered." That assumes that the
plan is still permitted to exist, with requirements for
guaranteed issue, community rating, "meaningful coverage," etc.
He opposes health savings accounts because "the freedom to choose
magnifies the uneven risks and rewards of today's winner-takes-
all economy" (Cato Briefing Papers #104, 7/29/08).
Also promised: a children's mandate; $10 billion/yr for
health information technology; and funds for care coordination,
exercise, vaccination, anti-smoking, and anti-obesity programs.
His answer to malpractice: preventing medical errors. "I
will also support legislation dictating that if you practice care
in line with your medical society's recommendations, you cannot
be sued" (NEJM, op. cit.).
Obama might adopt the plan being readied by the dying Sen.
Ted Kennedy: mandated purchase, employer payment, HIT, case
management, etc., with a new national Health Insurance Exchange
as the sole source of coverage. In sum, massive government
control over the entire insurance and medical care system. "If
you liked Fannie Mae, you will love this system," writes Greg
Scandlen (Consumer Power Rprt 152).
What about the Money?
The cost of the $700 billion bailout has reached $5
trillion, say some analysts (infowars.net 10/15/08), and
the government will borrow a record $550 billion in the current
11/3/08). Private investors have lost trillions. Where will
Congress find the money to enact new programs, even with grossly
Scandlen suggests that federal expenditures would be limited
at first as the infrastructure is set up, with physicians and
hospitals bearing the entire brunt of "cost-containment."
Could the hidden agenda be drastic cuts in medical spending
through rationing? "Waste, we know you are out there," writes
Henry J. Aaron, Ph.D., of Brookings (NEJM 2008;359:1865-
1867). If spending limits cause withholding of services,
uninsurance would be terrifying, and societal revulsion toward
inequities would threaten the cost-control effort, he states.
Hence the need for compulsory universal care.
Part of the answer to rising costs is something like
Britain's National Institute for Health and Clinical Excellence
(NICE), writes Victor Fuchs (NEJM 2008;359:1749-1751).
Obama, who in the 1990s was a forthright proponent of single-
payer health care, has promised to spend billions on a NICE-
inspired institute, writes David Gratzer (City-Journal
NICE doesn't try to be cruel. "We are trying to
look after everybody," states chairman Michael Rawlins
(NEJM 2008;359: 1977-1981). Patient advocates suggest
that up to 36,000 Britons went blind from macular degeneration
waiting for NICE to approve Lucentis in the name of "fairness"
(Gratzer, op. cit.).
Is There Hope?
Scandlen notes that imposing a Massachusetts-style system on
the whole country is more daunting than putting a man on the
moon, and the whole enterprise could collapse.
Sen. Schumer and Ben Bernanke could be right: paying almost
all bills through credit is the "lifeblood of the economy" of
nonproductive Masters of the Universe. Likewise, funneling almost
all medical bills through third-party payers feeds government and
What if doctors stopped collaborating with the destruction
of medicine? How about some bypass surgery?
Paper money and vapor money are in trouble the prices are
wrong. But, "as serious as this economic crisis is," writes Henry
Maybury, "I have not heard of one instance of real wealth
disappearing. The factories, railroads, skyscrapers, telephone
poles, and lug nuts are still there" (EWR 11-12/08).
X-ray machines, surgical instruments, and libraries are
still there too. In liberty, the love of the art can be
"People will never surrender themselves for a point of
utility," writes Fr. Sirico of Acton Inst. But for deeds of moral
courage on behalf of liberty, a vast army can be summoned.
Economics in Literature
In a 1944 novel by Agatha Christie, Death Comes as the
End, set in Thebes, 2000 B.C., the scribe Hori and a
daughter of the estate have this conversation:
Hori said, "At present a few scribes are all that are needed
on a large estate, but the day will come, I fancy, when there
will be armies of scribes all over Egypt. We are living at the
beginning of great times."
"That will be a good thing," said Renisenb.
Hori said slowly: "I am not so sure."
"Why are you not so sure?"
"Because, Renisenb, it is so easy and it costs so little
labor to write down 10 bushels of barley, or 100 head of cattle,
or 10 fields of spelt and the thing that is written will come to
seem like the real thing, and so the...scribe will come to
despise the man who ploughs the fields and...raises the
cattle but all the same the fields and the...cattle are
real they are not just marks of ink on papyrus. And when
all the records on all the papyrus rolls are destroyed and the
scribes are scattered, the men who toil and reap will go on, and
Egypt will still live."
Renisenb looked at him attentively. She said slowly: "Yes, I
see what you mean. Only the things that you can see and
touch and eat are real . To write down I have
240 bushels of barley means nothing unless you have the
barley. One could write down lies."
"We've lived with government interference so long that we've
forgotten how fast an unfettered economy can get back on its
feet," writes Richard Maybury (op. cit.). "In World War II,
Germany may have suffered more economic damage than any other
country in modern times except Russia. Whole cities were
leveled.... Much of the population was starving, living barely
above the stone age." Ten years later, Germany was one of the
world's leading economies. The Marshall Plan got the credit, but
Germany received only $1.45 billion, compared with $3.3 billion
to Britain which went socialist after the war and did not fully
recover until the Thatcher era in the 1980s.
Doctors Defect in Washington State
According to a straw poll taken by the Washington State
Medical Association, 31% of the state's physicians either see no
Medicare patients or take no new Medicare patients (Puget
Sound Business J 10/242/08). AAPS member Smiley Thakur,
M.D., however, accepts Medicare-eligible patients gladly he just
turns down government money.
"It's sad to lose patients you've taken care of for years,"
he said, as many patients abandoned him. Dr. Thakur is the first
U.S. nephrologist to opt out of Medicare.
Dr. Thakur's article, "Whether to Opt Out of Medicare: How
to Make a Titanic Decision" appears in the winter
2008 issue of the Journal of American Physicians and
"There is a profound ethical reason why an economy governed by free...markets...implies health and plenty, while the
socialist economy means sickness, disorder, and lower
productivity. The liberal economic system releases and utilizes
the extraordinary forces inherent in individual self-assertion,
where as the socialist system suppresses and wears itself out
Wilhelm Ropke, A Humane Economy, 1960
Politicians call bills designed to extract large campaign
contributions from industry "milker bills" or "fetcher bills."
The Clintons' proposal to impose price controls on pharmaceutical
and other medical enterprises brought in unprecedented levels of
contributions. The most egregious example of regulatory blackmail
was the Community Reinvestment Act (CRA), featured during
Clinton's 1999 "Poverty Tour." Before granting NationsBank
permission to merge, it had to promise $150 million in low-
interest loans in areas chosen by the Administration, probably
corresponding to areas where votes were most needed (Thomas
IT at a Standstill in NHS
Rollout of the flagship 12 billion Pound information technology
system has been halted by the British National Health Service.
"This huge centralised project has been a shambles from the
start," said Liberal Democrat health spokesman Norman Lamb
(Daily Telegraph 10/28/08). Conservative shadow health
spokesman Stephen O'Brien said that the "hugely expensive"
program was "desperately behind schedule"; that suppliers were
"deserting in droves"; and that "frontline professionals" were
"voting with their feet and insisting on local solutions" (E-
Health Insider 10/28/08).
WWW I in E-Stonia?
Estonia is one of the most web-dependent places on earth;
its parliament considers Internet access to be a "fundamental
human right." For 3 weeks in the spring of 2007, its commu-
nications infrastructure was crippled by what has been called
"Web War I," "Cyberwar I," or a "cyber-riot." It is thought that
the attack was launched by Russian nationalists unhappy about the
relocation of a Soviet-era war memorial.
While "cyberwar doesn't make you bleed, it can destroy
everything," said Ene Ergma, speaker of the Estonian parliament.
Estonian President Toomas Hendrik Ilves warned that the attack
might be a test run for something much worse, like the 1936 tests
of German Stuka bombers in Spain.
The U.S. considers cyberwar a threat to national security.
The Pentagon was forced to disable a system serving the Dept. of
Defense after the Chinese military hacked into it. A Cyberspace
Command is being set up, and the U.S. Air Force is working with
industry to develop weapons for disrupting an adversary's
information system (Fraser Forum, September 2008). Will
the Dept. of Homeland Security's "information highway patrol"
keep our electronic medical records safe?
Feb 6-7, 2009. Workshop, board meeting, Dallas, TX.
Sep 30-Oct 3, 2009. 66th annual meeting, Nashville, TN.
Medicare Patients Sue to Opt Out
Three seniors who want to provide their own hospital
insurance and avoid Medicare's rationing, loss of privacy, and
stifling rules are suing for the right to refuse Medicare Part A
without losing their Social Security benefits, or to disenroll
without having to repay all the benefits they have already
received. Brian Hall et al. v. Michael Leavitt, et al.,
was filed Oct 9 in the U.S. District Court for the District of
Hall, a retired federal worker who contributed to a health
savings account throughout his career, also complains that if he
is required to take Medicare, he will no longer be allowed to
make contributions to that account (WSJ 10/27/08).
The relevant policies were implemented by the Clinton and
continued by the Bush Administration. Plaintiffs ask the Court to
void POMS HI 00801.002, POMS HI 00801.034, and POMS GN 00206.020
because they violate the U.S. Constitution, and because their
implementation without required notice and comment violated the
Administrative Procedure Act.
If just 1% of seniors turned down Part A, taxpayers would
save $1.5 billion/yr immediately and $3.4 billion/yr by 2017.
Rep. Sam Johnson (R-TX) has introduced the Medicare
Beneficiary Freedom to Choose Act, which would allow seniors to
forgo Medicare Part A without penalty, and contribute tax-free
dollars into a Health Savings Account.
"It's sad that people who want to make their own health care
decisions feel like they have no other option than to sue the
federal government," Johnson said (Daily News 10/22/08).
Social Security is tied to Medicare for the same reason that
the 1990s Congress barred seniors from supplementing their
government care: to avoid a "two-tier" system. "Equity trumps
freedom even if it means poorer care" (WSJ, op. cit.).
Opting Out of TRICARE
In response to a recent member's question, Dr. Lawrence
Huntoon sent a Jul 22, 2005, letter from Karen Marlowe, TRICARE
Provider Data Management, of HealthNet:
"This is to acknowledge your recent request to no longer be
an Authorized TRICARE Provider. We have changed the status of
your record in our database to Inactive effective...the date your
request was received by this department. Please be aware and
advise your staff of the following:
"1. By electing to be an inactive provider (Non-
Authorized), you may not provide services to a
"2. A sign must be posted in your office that indicates
that you are not a TRICARE Authorized Provider. The
sign must specifically state Non-Authorized rather
"3. If you have a TRICARE beneficiary that you elect to
treat by mutual agreement anyway, prior to treatment,
you must specifically advise the beneficiary that you
are not an Authorized Provider. You must have the
patient sign a statement that they were informed of
this, that they will be solely responsible for the bill
and that neither the beneficiary nor the provider will
submit a claim for the services to TRICARE. Thus, the
beneficiary is exempting the provider from the Balance
Billing rules for the specific treatment episode of
"4. We suggest that you have ALL patients sign the mutual
agreement, so you are protected from a beneficiary who
fails to inform you of their TRICARE eligibility and
submits a claim.
"5. If you treat a TRICARE beneficiary without the mutual
agreement, you are bound by the Balance Billing Act,
even if you choose not to accept assignment. And your
status would again be updated to Active in our Provider
database. Failure to comply with the Balance Billing
rules would subject you to being sanctioned by all
Federal government programs."
AAPS Supports Freedom of Conscience
Together with Family Research Council and others, AAPS filed
comments in response to a proposed rule, "Provider Conscience
Regulation" 73 Fed. Reg. 50,274 (Aug 26, 2008), that would deny
federal funding to institutions that punished medical
professionals for refusing to participate in abortions.
The right to obtain a certain service does not impose an
obligation on others to provide, promote, or pay for it, AAPS
argues. The freedom from discrimination on the basis of one's
moral beliefs is at least as important as the protection of other
civil rights. "If HHS [Dept. of Health and Human Services] had
not taken up the cause of the conscientious-objector Ob/Gyn
community, those physicians would face daunting economic pressure
to conform their conduct to quasi-official coercion."
Comments are posted at www.aapsonline.org .
Although the incoming administration is strongly committed
to removing all limitations on the one choice, there is
substantial evidence that abortion is often not a free choice. A
former abortion clinic security guard testified before the
Massachusetts legislature that women were routinely threatened
and abused by men outside the clinic to be sure they kept their
abortion appointment. A survey showed that 64% felt pressured by
others, and 84% felt they were not given enough information to
make an informed choice. There have been no federally
funded studies of abortion's impact on women. The rate of
immediate, potentially life-threatening complications, according
to some sources, is startling: 10%. The all-cause death rate for
women was 3.5 times higher after abortion than after giving birth
2009 OIG Work Plan: "A Return to Hard Ball"
Already scores of providers have had their Medicare licenses
suspended, data mining is rampant, and there is a discernable
increase in search warrants. Agents knocking at your door could
represent the FBI, Postal Service, BATF, and the IRS.
Medicare Compliance Alert offers 18 tips on how to
handle a search, including making your own inventory of the items
seized instead of signing the agent's. If you don't cooperate,
agents have axes to break open locked files. Usually they arrive
early in the morning, secure all entrances and exits, cut off the
phones, and attempt to interview employees on their way to work
(MCA 11/3/08). Advice not given by MCA: Quit.
Now. Other reasons: Recovery Audit Contractors (RACs) "will get
you every time for technical errors." You could have 3 employees
working full time to copy thousands of documents. "There is no
data point that will exonerate someone." Some contractors, though
they have little understanding of Medicare rules, commonly find
provider error rates of 100%. The government makes billions of
dollars from bounty-hunting contractors (MCA 10/6/08).
Viciousness Escalates. I recently heard from a
neurosurgery resident who had a loaded gun held to his head (and
to his sister's head) by a medical school security guard as they
sat in his sister's car on a public street. Although he was
unarmed and had threatened no one, he was treated like an armed
terrorist. The security guard had been ordered to pick him up and
bring him in. With five other neurosurgery residents from the
same academic institution, he was sent to a "retraining center"
for "disruptive physicians." He was terminated from the program
and is without income. He is living in a room provided by another
physician whom we have assisted.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
History Lesson. The Soviet Union was founded on liberal
principles. The world was going to be remade, and they were
going to lead the way. The problem was that there was no room for
disagreement. Anyone who disagreed was, by definition, an evil
person. When coercion did not work, capital punishment, which was
initially banned, was brought back.
Liberals who move to totalitarian means do so out of
frustration with people who block their better world. Before he
was Stalin, Josef Vissarionovich used "Koba" the name of the
Georgian Robin Hood, as his Communist nickname.
My wife, who grew up in the USSR, says: "We were willing to
try for 70 years and shoot 22 million people to prove socialism
doesn't work, so why is the U.S. intent on trying it?"
Edward Dee Hinds, C.L.U., Paso Robles, CA
Soviet Story. The Latvian film maker for this
grisly film which I hear has played in the European parliament
but not here takes the position that Hitler learned the
technically difficult task of disposing of millions of dead
bodies from Stalin. He was reportedly burned in effigy in Russia.
It is remarkable how people think that socialism is benign,
and that something is wrong with people who warn about it.
Speaking of which, when I hear the "seat at the table" line,
I think of Molotov and Ribbentropp at the table, carving up
Poland. Alas, our profession has more than a few docs who
consider themselves so clever as to move the line a few miles one
way or the other, so they keep their view property while millions
are sent to the gas chambers.
Russell W. Faria, D.O., Kent, WA
The Plan. Funny how the U.S. government thinks in terms
of five-year plans like Mao's "Great Leap Forward." U.S. politi-
cians are generally out of office before the 5 years are up, and
they don't have to deal with consequences.
Greg Scandlen, Heartland Institute
Effects of SCHIP. Since SCHIP pays at the Medicaid rate
(less than cost), shifting kids from private to state coverage
increases financial stress on physicians and hospitals and
reduces access to care. This may explain why the director of
Indiana Family and Social Services said, in a letter to
Health Affairs, that his conviction about SCHIP is
almost religious. There is no, that is no, as in NO data
showing that the program produces actual benefits for children.
Also note that the SCHIP reauthorization does not require real ID
for enrollment. At the time real ID went into effect, Medicaid
caseloads started falling. Finally, what sense does it make to
tax a poor family more heavily so that a family with an income up
to $80,000 can have the government provide insurance for its
Linda Gorman, Ph.D., Independence Institute, Golden,
Insurance: No. I'm a child and adolescent psychiatrist.
I've never participated with insurers since finishing training in
1988. I agree that the concept and function of insurance is
beneficial. However, "health insurance" as we know it today...is
a parasite ...holding little value for the [medical] industry or
the common citizen. At this point, I don't think the health
insurance identity can change its identity and be tamed. It is
both too entrenched and too enmeshed with political leaders. The
campaign managers of both Bush and Gore campaigns were top health
insurance financial executives....
Scott Hagaman, M.D., past president, MedChi
Addiction Cure. Society is addicted to entitlements.
The government is the dealer, and the payment is the vote. As
long as the addict is willing to buy, the dealer is willing to
provide. The only real cure is when the dealer no longer has any
product to provide.
Frank Timmins, Dallas, TX
Indentures. Canada tells doctors they are in private
practice only so the government doesn't have to pay
their overhead. The Physicians Master Agreement between the
Queen and the British Columbia Medical Association (www.health.gov.bc.ca)
shows what doctors can not do. Once they pass the daily
allowed total, fees are discounted 100%! American doctors have no
clue how bad it is working in socialized medicine. They see the
bright side one place to bill, less worry about malpractice. What
frustrates Canadian doctors most is lack of tools to heal.
In Canada, the best medical minds are veterinarians. Who
wants to work in a system so restrictive you can't even use
stents! Some Canadians who can't get medical care resort to
seeing veterinarians and paying under the table. Still, people
accept the high taxes and poor service there's nothing they can
do about it anyway and think Americans are evil.
Ralph Weber, C.L.U., Paso Robles, CA