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Volume 59, No. 1 January 2003

SCIENTIA EST POTENTIA

This Latin motto-translated "knowledge is power"-is displayed over the office of Admiral John Poindexter, Director of the Information Awareness Office of the Defense Advanced Research Projects Agency (DARPA), the agency that originally developed the Internet (Wesley Pruden, Wash Times 11/22/02).

One of its databases is the Total Information Awareness System (TIA). The goal is to link databases, such as those under development by the Justice Department to catalog gun owners and compile vehicle registrations, and integrate other data as from credit card transactions, insurance applications, and electronic tags for toll-road use.

"[S]uch a system...will allow someone to build a complete dossier on virtually any person in seconds," stated computer security expert Allen Eagleton (Capitol Hill Blue 11/21/02).

The $200 million initial funding and authority to gather this information without judicial protections is granted by the USA Patriot Act, the Homeland Security Act-and the Health Insurance Portability and Accountability Act or HIPAA.

The most controversial of the Orwellian items floated by the current and former Administrations, a national ID card and the Citizen Corps of spies known as TIPS (Terrorism Information and Prevention System), were disavowed. However, a number of other troublesome provisions were enacted as part of "must pass" legislation that few Congressmen had an opportunity even to read, much less debate.

Under the Homeland Security Act, Special Agents of the Bureau of Alcohol, Tobacco, Firearms, and Explosives (BATF) have the authority to make arrests without warrant for any offense against the United States and to seize property subject to forfeiture. Other Inspector General agents empowered to carry firearms and make warrantless arrests include those of the Departments of Education, HHS, HUD, and Transportation; AID; FDIC; NASA; FEMA; the Small Business and Social Security Administrations; and many more.

Meanwhile, government secrecy increases. The Homeland Security Act creates an additional exemption to the Freedom of Information Act (FOIA) for "critical infrastructure." In ongoing cases, the Justice Department has filed a motion to place an indefinite seal on evidence gathered in a Federal Vaccine Injury Compensation Program proceeding to investigate a possible link between vaccines and childhood autism. All original records and documents used in identifying units and personnel immunized during Operation Desert Storm are still classified (Joint Staff Action Processing Form, Action #J-4A 01206-91).

Immunity and nonaccountability of government and its favored private partners also expands. The Homeland Security Act makes only the United States liable for adverse consequences of "smallpox countermeasures," if and only if given as deemed advisable by the Secretary of HHS, and if and only if the "covered person...cooperate[s] in the processing and defense of a claim." If the U.S. should pay a claim, it has the right to recover the damages plus interest and litigation costs of actions "resulting from the failure of any covered person to carry out any obligation or responsibility" assumed under contract.

Past liabilities, as of Eli Lilly, are also wiped away by a provision on pp. 482-484 of the Homeland Security Act-one for which no one will claim responsibility. This defines as a "vaccine" any ingredient (such as thimerosal) disclosed either on the label or in the product license application for a vaccine. About 800 pending claims could be dismissed.

In war, government is unconstrained by truth, even when testifying under oath. For example, evasiveness and word games characterized congressional testimony by generals defending the Anthrax Vaccine Immunization Program (AVIP) (Heemstra TS, Anthrax: A Deadly Shot in the Dark, 2002). In safety, anthrax compared very favorably with other vaccines, they said. A GAO survey, however, found an 86% rate of adverse reactions, 60% of which had not been reported to military personnel out of fear of ridicule or loss of flight status (Chan, GAO-01-92T).

The "asymmetrical threat" of terrorism is the rationale for "supersnoopers." And war is always a rationale for pervasive government power: whether it's war on terrorists, drugs, organized crime, tobacco, fraud, poverty-or ill health.

Germans now read in Der Spiegel Online "wie die US-Regierung ein engeres Netz von Information aufbauen will als die Stasi je hatte" (how the US regime intends to construct a tighter net of information than Stasi [the East German spy agency] ever had (Schwabe A, www.spiegel.de, 7/22/02).

Even if well-intentioned, the information net will fail to achieve any useful purpose in medicine or economics, exactly because of asymmetry: private, local information tends to be highly useful; centralized, government information nearly useless (Henderson DR, "What the Nobel Economists Missed," Wall Street J 10/12/01). That is why central planning has always led to chaos and widespread poverty.

Information overload and government secrecy will even impede the apprehension of real criminals. An alert trucker captured the D.C. sniper after information was strategically leaked from a specific, limited, privacy-protected database-car license plate numbers. In the meantime, the TIPS-like hot line was overwhelmed with 70,000 false leads (CDT Policy Post 10/25/02). TIA will have an inherent error rate orders of magnitude larger than the number of terrorists in the world.

The federal government and corporate entities covet data from TIA-especially from medical records: for "planning"; "quality" monitoring; and ferreting out noncompliance with rules, such as vaccine mandates. All this knowledge will indeed give them unprecedented asymmetric power over their subjects.

But it is truth that leads to freedom. And without freedom, who can seek and find the truth?


Health Crimes

"If government is responsible for healthcare, then unhealthy behavior is a crime," is "an interesting statement today by a Washington State law professor," posted to the HealthBenefitsReform Yahoo discussion group on Dec. 7.

In 1999, the American Public Health Association asserted that 48% of the determinants of disease were now due to "behavioral lifestyle," 25% to genetic constitution, 16% to environment, and 11% to lack of access to medical care. The "great moments in public health" have evolved from sanitation in the 1910s to polio vaccine in the 1950s to seat-belt laws in the 1980s and tobacco taxes in the 1990s. Visionaries predict: "2020s: The U.S. conquers fat. Millions lose weight and regain energy and vitality as as states pass fat taxes and levy fines on overweight people" (Arizona Health Futures, Fall 2002).

Minnesota leads the way in collecting the necessary information-for "research." The Health Department wants a database to track every doctor or hospital visit, and an administrative law judge ruled that the department has the power to collect the data. Two attempts to repeal the enabling legislation have failed. Twila Brase, R.N., of the Citizens' Council on Health Care ( www.cchc-mn.org) is prepared to try again (Star Tribune 12/3/02).

 

Minimum Data Set (MDS)

The MDS for Nursing Home Resident Assessment and Care Screening presented at the HHS Advisory Committee on Regulatory Reform in March has 500 items. The highly paid professionals who fill it out claim that it is responsible for great improvements in the quality of nursing home care.

Michael S. Smith, M.D., of Tucson presented a form he used successfully as director of a subacute/nursing facilty. It has 13 items, easily completed by minimally trained personnel.

 

Remember the Clinton Health Care Task Force

As AAPS pointed out when the bill was introduced, HIPAA was imported almost word for word from the Clinton Plan. A key role in the Task Force that drafted the plan was played by information technology companies. Working Group 19 was called "Administrative Simplification."

Proposals for a Bush version of a "health care overhaul" were drafted by a Committee of the Institute of Medicine of the National Academy of Sciences (see p. S1), four of whose 16 members were prominent participants in the Interdepartmental Working Group led by Ira Magaziner (Robert Berenson, Karen Davis, William Sage, and Marla Salmon)-see the Clinton Task Force records posted on www.aapsonline.org.

As Uwe Reinhardt said, "I have been predicting that the Republicans will try to steal the Democrats' thunder" (Waldholz M, posted to HealthBenefitsReform 11/20/02).

 

It's the Process

Whatever you think of thimerosal, and even if Senators keep their promise to repeal the "Lilly provision," the process that turns Congress into a secret cabal is a clear and present danger to the security of the Republic. During the bill-drafting process, Washington's special-interest "alchemists work their black magic to turn legislative gold into self-preserving lead" ( www.ariannaonline.com/columns/files/120402.html).

 

Cut Medicare More, Doctor Urges

In a letter to Senators Boxer and Feinstein, Tom LaGrelius, M.D., president of the California chapter of AAPS and the only geriatrician in a city of 500,000, urged them to vote against H.R. 5063, which would have increased Medicare fees.

"Medicare, the second biggest Ponzi scheme in the world (Social Security being the biggest) will bankrupt the U.S. government sooner or later....

"Doctors who do not like the low fees Medicare pays have a simple solution. They can quit! The more doctors who do that, the better.... Already 20% have quit."

Dr. LaGrelius reports that his 93-year-old father is delighted with the excellent care he receives from his opted-out internist. Last year, he was seen often and hospitalized once. The total physician's fees: $900.

Dr. LaGrelius is planning to opt out "before HIPAA compliance becomes a bigger issue in April." Several of his Medicare patients suggested the idea independently, and 8 out of 10 are willing, even eager, to see him opt out.

"The 65 to 85-year-old population is the richest demographic subgroup in the country. Their care is paid for through a tax on poor workers who will never see benefits after the Ponzi scheme goes down. That is outright theft."

 

HIPAA Report from HHS

As reported at a Dec. 10 meeting of NCVHS, 550,000 HIPAA extensions were filed. Estimated costs for compliance with the transaction standards varied enormously: 11,000 estimated >$1 million; 8,000, $0.5-$1 million; 28,000, $100,000-$500,000; 111,- 000, $10,000-$100,000; 196,000, <$10,000; 189,000, unknown. HHS was astonished that anyone would choose to be uncovered, including a large oncology practice, which is returning to paper claims. More public education will help people see the light, it thinks; but it's having trouble explaining the regs at the required sixth-grade reading level.

 

Collaborators

The AMA and its partner HIPAAdocs Corp. plan to profit from the HIPAA regulations. They offer on-line compliance tools to members for a "discounted" price of only $600 for a solo or two- doctor practice, or up to $1,700 for ten or more doctors. Nonmembers pay more.

 

AAPS Calendar

Jan. 31, 2003. Board of Directors, San Antonio, TX.
Feb. 1, 2003. San Antonio mtg with Bexar County Med Soc.
Sept. 17-20, 2003. 60th annual mtg, Point Clear, AL.
Note date change to avoid conflict with Rosh Hashanah.
Oct. 13-16, 2004. 61st annual mtg, Portland, OR.


Replies Filed in HIPAA Privacy Rule Case

In its November reply to the AAPS appeal of AAPS, Congressman Ron Paul, et al. v. U.S. Dept. of HHS, et al. (No. 02-20792) to the Fifth Circuit Court of Appeals, U.S. attorneys argue that the Fourth Amendment is not violated.

"[T]he only part of the Privacy Rule that affirmatively mandates disclosure of a patient's private information" is the enforcement provision requiring cooperation with an investi- gation to determine compliance with the Rule [emphasis added]. A physician might decide to honor a patient's request not to release information for other purposes, except those required by other laws-but is under no obligation to do so.

Moreover, argues the Department of Justice, even if a hypothetical future search did violate the Fourth Amendment, the only remedy would be the invalidation of the search at issue, not overturning the Privacy Rule.

The AAPS reply brief contends that the Privacy Rule "exposes personal medical records to broad mandatory and permissive disclosures to government, without any meaningful safeguards protecting their confidentiality."

The district court essentially ignores the Supreme Court precedent in Whalen v. Roe, which found: "[T]he Constitution puts limits not only on the type of information the State may gather, but also on the means it may use to gather it. The central storage and easy accessibility of computerized [medical] data vastly increase the potential for abuse of that information, and I am not prepared to say that future developments will not demonstrate the necessity of some curb on such technology."

The Privacy Rule commands essentially unlimited means.

AAPS also challenges the government's assertion that the Regulatory Flexibility Act (RFA) is purely procedural.

The RFA "requires more than a perfunctory invocation to justify the onerous new regulatory burdens." Small medical practices have "no realistic way to comply...and remain in business." As John Lumpkin, M.D., M.P.H., Chairman of the National Committee on Vital and Health Statistics (NCVHS), to Secretary Thompson: "[P]roviders may drop out of the system of providing care to indigent patients because they cannot afford to absorb the costs of complying with the Privacy Rule.... Millions of health care workers will need to be trained in the next few months, but there is a dire shortage of expertise, materials, and funding."

Attempting to assert that paper records preserved in small practices are in the "interstate stream of business" is "akin to the Federal Communications Commission attempting to regulate all actions of any individual who ever placed an interstate telephone call," AAPS argues.

Briefs are posted at www.aapsonline.org . AAPS thanks the American Health Legal Foundation for its support.

 

OCR Guidance on Privacy Rule

On Dec. 3, the Office of Civil Rights (OCR) posted 123 pages of "guidance" at www.hhs.gov/ocr/hipaa/privacy.html, to "communicate as clearly as possible the privacy policies contained in the Privacy Rule." The replies to the Frequently Asked Questions appear to have been coordinated with the Dept. of Justice's responses to the AAPS lawsuit. For example:

"Q: Does the HIPAA Privacy Rule require my doctor to send my medical records to the government?" (p. 115)

"A: No.... This Rule does not require or allow any new government access to medical information, with one exception: The Rule does give ... (OCR) the authority to investigate complaints that Privacy Rule protections or rights have been violated, and otherwise to ensure that covered entities comply with the Rule."

The "Minimum Necessary Standard" does not apply to "uses or disclosures required for compliance with ... (HIPAA) Administrative Simplification Rules" or disclosure required by HHS for "enforcement purposes."

As Jim Pyles of the American Psychoanalytical Association observes: "Whether such information is `pertinent' to compliance is a determination that is solely within OCR's discretion. This provision coupled with `regulatory permission' for covered entities to obtain limitless amounts of personal health information without consent would seem to provide the federal government with unlimited access to the personal medical information of every citizen.

"If the federal government wanted to obtain access to the psychiatric records of a political adversary under this rule, it ... would merely need to conduct a `compliance' review of his health insurer. Even the potential of such an action may be enough to corrupt the political process."

 

AAPS Opposes Cert for CPT-Related Case

The ability of a private entity to lobby the government for adoption of a set of standards, and then to profit from a monopoly on writing the standards, is at issue in the case of Southern Building Code Congress International v. Veeck (No. 02-355) (see AAPS News July 2002). AAPS filed an amicus brief opposing Supreme Court review of a 5th Circuit decision.

The case has obvious application to the AMA's copyright on CPT codes. The AAPS brief notes that "Ambiguities and perpetual changes, which are obstacles to maximizing public compliance, constitute a golden goose for monopolists who can sell explanatory materials and seminars."

AAPS contends that free speech rights are violated when legally required codes cannot be restated for public discussion. The Court has held that "Government by secrecy is no less destructive of democracy if it is carried on within agencies or within private organizations serving agencies."

Of relevance is a letter from Andrea Cooper-Finkle, Office of the General Counsel of the AMA, to the office of AAPS member Wanda Velez-Ruiz, M.D. A letter from the AMA concerning a CPT code interpretation had been submitted with a legal brief appealing a workers' compensation determination.

"This letter," writes Ms. Cooper-Finkle, "contains at the bottom of each page the following explicit language: `The CPT coding information is being provided specifically to you based on the facts and details you provided... Any reprint of all or part of this correspondence, without the express written consent of the American Medical Association, is strictly prohibited' (emphasis mine).

"The inclusion of [the AMA] letter in this Brief expressly violates AMA policy.... We will not respond to your recent letters in light of your violation of this policy."

Edgardo Perez-DeLeon, writing on behalf of Dr. Velez-Ruiz, states: "Please alert the medical community to the conspiracy of silence that the AMA has to let insurance companies [whimsically refuse payment] for services honestly provided.... [W]e asked the AMA how to bill ... according to the AMA's guidelines on the use of the CPT codes,... [but] we cannot support the correct billing with the AMA's opinion because it is secret" (correspondence 11/9/02).


Correspondence

Sympathy, but No Dollars. The Chautauqua County Health Network recently sent a letter requesting contributions to help defray the cost of applying to CMS for designation as a "Primary Health Professional Shortage Area (HPSA)," as grants had not been adequate. I can't help observing the irony: the government helped create the shortage via fixed fees that discriminate against doctors who work in a rural area like Jamestown. Efforts at "correction" would be comical were it not for the problems that government price-fixing causes for patients. As some of the worst famines in the world were created by governments that arrogantly thought that they knew better than the free market how to set prices, one must wonder whether these bureaucrats ever studied any history or economics. While I can empathize with Project Coordinator Stan Lundine's plea, expenses exceeding fees are nothing new to practicing physicians. While adding 10% to Medicare fees in the HPSA may help alleviate the shortage, I don't think it would be proper to contribute to the contorted dance of price-fixing followed by attempts at "corrections."
Lawrence R. Huntoon, M.D., Ph.D., Jamestown, NY

 

Price Controls. As an editorialist noted, "Historically, price controls have had the same impact on the economy that asteroids have had on the earth: The scale of their damage is limited only by their size" (Washington Times 11/19/00). As Citizens Against Government Waste pointed out, in American history the destructive impact of price controls has ranged from abetting starvation at Valley Forge in the 1770s to exacerbating the fuel crisis in the 1970s.
Craig Cantoni, Scottsdale, AZ

 

Government Creates Shortages. In medicine, we have massive government intervention (Medicare, planning, insurance regulations, licensure) and 42 million uninsured. In housing, there is substantial intervention (mortgage interest deductions, Section 8, public housing, zoning and building codes) and who knows how many homeless. In food, there is less intervention (price supports, FDA, food stamps) and only occasional hunger. With clothing, there is no intervention and a surfeit, including cheap, "after-market" clothes. Why is it better for a person to be homeless than to live in a building that does not meet code, or to be uninsured than to have a plan that does not cover mental health or in-vitro fertilization?
Greg Scandlen, Frederick, MD

 

The Unique ID Number. Like HIPAA's privacy regulations, which have nothing to do with privacy, the unique identifier has nothing to do with assuring strangers that you are who you say you are. The real goal of the unique identifier is to correlate all the personal information of each citizen: educational, financial, health, and labor history. Why would any agency desire this information if not to control the citizenry?
Robert P. Gervais, M.D., Mesa, AZ

 

HIPAA Is Not Privacy. From a letter to the President, American Academy of Family Practice: I realize there is little you can do as the head of what used to be a very proactive organization. Might I suggest that October FP Report should not have a headline worrying about missing the deadline for an extension to HIPAA when there is a simple way out of this government chaos that bedevils our lives.... Please note the absurdity of nailing steel doors to our files. HIPAA is not privacy, but stupidity.... It merely builds the vast data base that seems so dear to the heart of the bureaucrat.... Most of us are ashamed that our medical societies are marching down the incestuous pathway instead of joining the AAPS lawsuit.
Tad Lonergan, M.D., Desert Hot Springs, CA

 

The Result of HIPAA. The original proposed rules were generated in response to very rare abuses by insurance agencies releasing information. The rules generated a self- serving bureaucracy and a new industry meant to regulate medical practitioners who did not cause the abuses.... The public is generally not aware that the privacy rules have nothing to do with real privacy protection. The patients are still signing away most of their privacy if they ask for third-party payment.
N. Henry Pevsner, M.D., West Palm Beach, FL

 

Private Sector Must Work Together. [Each discipline needs to address its own ills.] Otherwise, theorizing about the other guy's ox will only assure that the government will confiscate all oxen, declare them to have mad cow disease, and destroy them all. Oxen will be replaced with a government- designed mechanical ox with no flaws. It will not eat grass, it will not work in the fields, it will not give milk, and it will have no practical value, but it will not pollute, it will not make noise, it will look nice and have no diseases: the perfect solution.
Danny M. O'Grady, CLU, Midland, TX

 

The End of Regulation. Medicare creates a corps of folks who make life miserable for doctors in the name of protecting the public treasury. They add cost without value. More doctors drop out, quality declines, and costs rise. The bureaucracy's answer is to add more rules. Soon, the regulators will outnumber the regulatees, the golden goose will be dead, Lenin will get the last laugh, and we can all go back to growing potatoes and herding goats.
> excerpted from Frank Timmins, HealthBenefitsReform


Legislative Alert

It's 1993 Again

The National Academy of Sciences has come out with a major report on the Health Care System, and it has Washington all abuzz. It says that the system is in Crisis and listed the standard catalogue of problems: double-digit cost increases, gaps in insurance coverage, a rising number of the uninsured, medical errors, and soaring medical liability insurance. The 16-member NAS panel made a number of recommendations. According to veteran health reporter Robert Pear, "The tone recalled the alarm and urgency of President Bill Clinton in 1993 and 1994, but the panel proposed a more modest agenda, using the states as laboratories to attack 'disturbing trends' that have worsened in the last two years" (NY Times 11/19/02).

Meanwhile, former Vice President Al Gore has reluctantly concluded that the private health care system is not in the best interest of the American people and has come out for a single- payer system. On Nov. 14, ABC News Notes called Gore's announcement "stunning." Said the ABC writers: "For Gore, this represents a shocking switch. Although many of the people who worked with Hillary Clinton and Ira Magaziner on the Clinton Health Care Plan at the start of the Clinton/Gore Administration were intellectually and morally sympathetic to single payer, it was rejected as being simply too radical and too big a political target." In other words, many of the Clinton team really believed in their hearts and minds in an unvarnished socialist system. Oh really, now. Somehow, we are less than stunned, shocked, or bewildered than the gang at ABC.

Robert Pear is right: the calendar may say 2003, but, in this respect, it's 1993-again. Let's learn from the past.

Six Big Rules for the Next Debate

In the fall of 1993, the Clinton Health Plan seemed to be inevitable, and Congressional Republicans were initially reduced to mumbling something about working with the White House. This time, the political correlation of forces favors personal freedom, patient choice, and free-market competition. But success will depend upon the President and his allies offering credible proposals for reform.

Rule #1: Realize that the Public is Pragmatic and Not Ideological. The American political tradition, epitomized by the Founding Fathers' work at the Philadelphia Convention in 1789, is supremely pragmatic. We want liberty. We want order. So we set up practical mechanisms to ensure both: separate the different powers of government, establish a complicated system of checks and balances, divide the legislature into two houses, and force consensus and compromise in the legislative process.

The American electorate is largely of the same traditional mind and spirit. They see problems, and they want them solved. The test of good government is whether the solutions work to solve what they see as "their" public problems. Defining what works always invites supremely practical questions: How much will it cost me? Will "the solution" inconvenience me, or take away anything that I have? The survey research shows this overwhelmingly with respect to medical issues. If you ask whether we should expand Medicaid to cover the uninsured, the voters will say yes by large majorities. If the question is using tax credits to cover the uninsured through private plans, or expanding medical savings accounts, the answer is also probably yes by healthy majorities. Unlike policy specialists, or folks on the Left or Right with sincere philosophic convictions, voters are not particularly obsessed with the way things are done, so much as whether or not they are done to their satisfaction.

For policy wonks and their friends in Congress, this gets tricky. According to a recent survey by Ayres, McHenry and Associates, 81% of voters are very or somewhat satisfied with their medical coverage. As most seem also to favor major reform, in some vague way, they probably want reform that doesn't disturb them and their relationship with their doctors or their private plans. Likewise, the approval ratings for Medicare, among young and old, are off the charts. But if you ask whether they know a lot about Medicare, they will admit that they don't-by huge majorities.

Congress will certainly address the Medicare drug issue in 2003. In a November 2002 survey, Kaiser Family Foundation found that 9 out of 10 American favor adding prescription drugs to Medicare, but that this drops to a little more than 7 out of 10 when respondents are told that it will increase costs. Traditional Medicare is preferred over private plans by 55 to 36%-a change from March when the ratio was 67 to 26%.

Republicans have an advantage going into the January 2003 session. In a post election USA Today/CNN/Gallup Poll survey, 50% said that the Republicans have a "clear plan" for curing the country's ills, while only 30% said the Democrats do. Interestingly, 54% of the Democrats surveyed said that their party needs to "moderate its liberal image." (That Democratic majority sentiment did not, however, discourage 177 House Democrats from bypassing Rep. Harold Ford (D-TN) and electing Rep. Nancy Pelosi (D-CA) as House Minority Leader.)

On the Medicare prescription drug debate, syndicated columnist Matt Miller observes: "When Bush pounds the podium for a plan that harnesses the private sector and targets America's neediest grandparents, it will sound entirely plausible, even as Democrats cry that the plan was written by Big Pharma to safeguard their evil price gouging. Whatever Democrats do-assent to the GOP measure as a down-payment on a real plan or try to block it-the GOP could score a big political win."

Rule #2: Know the Battlefield. The diverse players include: professional medical and nursing associations; trade associations for hospital officials, insurance executives, research scientists and manufacturers with biomedical, pharmaceutical, and medical technology companies; organizations representing large and small employers; unions; public health officials; and corporate benefits managers. Conflict among private-sector players often degenerates into a form of political cannibalism. But while private-sector players are often divided against themselves, sometimes seeking government micro-management of their competitors, the Left pursues a unified strategic vision, enjoying the sweet advantage of not worrying about how its legislative or regulatory initiatives impacts its profit margin.

Congressional conservatives and their allies in the medical profession and the private sector need to develop a strategic vision based on the centrality of the patient-physician relationship, patient choice, and free-market competition. Congressional conservatives need to unite as a principled and practical voice for free-market policies, playing the role of an honest broker in the debates among the private-sector players, even when principled positions are at variance with the short- term interests of longstanding allies. Many physicians' organizations, for example, view conservatives in Washington as institutional allies. Nonetheless, during the multi-year debate on the "patients' bill of rights," many of those conservatives relentlessly criticized both House and Senate bills for expanding the scope of litigation and federal regulation over the private insurance market, even though the legislation has remained a top priority of many of the leaders of organized medicine.

Rule #3: Don't Let the Perfect Be the Enemy of the Good. A practitioner of the contemplative life should strive for precise metaphysical distinctions and doctrinal perfection. We, however, are engaged in public policy, in a life- and-death struggle over the future of private medicine. This is not the time for internecine conflict. Important and difficult- but second-tier-issues include: details of "defined contribution" plans; which deductible is best for Medical Savings Accounts; who should finance reinsurance for bad risks; government rules for guaranteed renewability versus guaranteed issue. Although most ordinary folks would not care to follow these debates if we paid them, they still somehow bring out the blood sports among otherwise sane and sensible folks. Imagine the Allied Command in World War II organizing a D-Day style landing on, say, Malta, with heavy casualties, while ignoring the Nazi-occupied coast of France. The best approach to such questions is empirical; let's have demonstration programs to see which prescriptions work, while expanding choice and competition.

Every battle that private-sector players have among themselves constitutes de facto aid and comfort to the Left in its relentless and persistent quest for socialized medicine.

Rule #4: Welcome Every Political Ally You Can Find, Especially Prodigal Sons. Whether it is a leading liberal intellectual at a prestigious university, a college professor otherwise engaged in pushing some weird politically correct agenda, or a moderate Republican or Democrat makes no difference. Nobody has a monopoly on creative thinking. If a person proposes something imaginative or innovative that will advance personal freedom, patient choice, and free-market competition, we should not say to ourselves, it's about time that fellow saw the light! No, we should get out our poms-poms, do handstands, rile up the crowd into an uncontrollable frenzy, and, amidst a deafening roar, welcome him to the team and cheer him on to victory!

Rule #5: Get Ready for the Return of the Clinton Plan. The Wisconsin State AFL-CIO has recently updated its health care reform proposal. After cataloguing the problems with the system, the union analysts noted that there are two ways to control costs and build bargaining power for purchasers: a single-payer system and an "employer-based unified system," which they prefer. The elements should sound familiar: a new Commission to set rules for all employer plans in the state; a common comprehensive health benefits plan for all; financing through an "employer-paid assessment for each employee" (in plain language, a payroll tax), with the amount set by the Commission. In other words, the Clinton Plan.

Various Clintonista apologists, well trained by Spin Central during the 1990s, are trying to re-write history. Their message: Clinton care was not as bad as we all thought it was.

Well, yes it was. The day after Clinton submitted a 1342- page bill to Congress, an unnamed Clinton advisor admitted: "What they did was to take the form of managed competition and filled it up with content that looks a whole lot like a Canadian-style government system" (Steven Pearlstein and Dana Priest, "In Scope and Vision, Health Plan Defines Clinton Presidency," Wash Post, 10/28/93, p. A-16). As the article notes, the Clinton staffer, in a moment of precious honesty, was "deviating from the official White House line." Exactly.

The Clinton Plan was not, strictly speaking, a "single- payer" plan. It was a system of plans, organized into huge geographically based managed-care networks, all under centralized federal supervision. The medical benefits would have been formally comprehensive and regulated in intricate detail, even down to the number of shots Americans would get. It was stunningly coercive, with numerous mandates, particularly on employers, and "premium caps" on health plans. On January 12, 1994, the Clinton White House, in an act of supreme chutzpah, said that these caps were not price controls. The Clinton Plan, in fact, went further than price regulation: it proposed a global budget for all medical spending, a key feature of "single-payer" systems, as in Britain and Canada. Indeed, under the Clinton Plan, the federal government would have had direct control over almost every facet of the financing and delivery of medical services, public and private, through a National Health Board, requiring, according to Laura Tyson, a member of Clinton's Council of Economic Advisers, an additional 50,000 bureaucrats. Later independent analyses put that number closer to 100,000.

Let's get the crucial distinctions clear, between a "single- payer" system, in which the government would control the financing and delivery of all medical services, and the Clinton "multi-payer" system, even more complicated, in which the federal government would control the financing and delivery of all medical services. After all, you don't want to be accused of misrepresenting the former President's plan, just to score points at the expense of the coming clones.

Rule #6: Conservative Sounding Rhetoric Will Often Accompany Collectivist Policies. Consider the phrase "competitive bidding." It has a free-market ring to it, but what exactly does it mean? Setting prices on a competitive model? Or DOD-style procurement? The government could use the purchasing power of the state to secure big economies of scale. Who could be against that? So why not expand this concept to food, clothing and shelter? We could have all these things cheaper than we have them today: uniforms, K-rations, and HUD-style housing. And the taxpayers could save gobs of money as well. And isn't money what it's all about?

Robert Moffit is a prominent Washington health policy analyst and Director of Domestic Policy at the Heritage Foundation.