Volume 65, No. 11 November 2009
GOING FOR BROKE
Going broke is not altogether bad, in the view of former
New England Journal of Medicine editor Arnold Relman,
Without a dramatic political awakening, "the current slide
of the system toward bankruptcy will continue," he writes. "That
decline, however, might ultimately cause a disaster that would
generate popular demand for real reform" (N Engl J Med
2009;361:1225-1227). Such reform would include a central public
agency that controls total medical expenditures and prevents
physicians from keeping any net income.
We need to "get past denial" and move toward "fundamental
reform," write Sutherland et al. of Dartmouth (N Engl J
Med 2009;361:1227-1230). This means radical change in
payment and delivery systems for example, implementation of a
1933 recommendation to use integrated delivery systems. While
some believe this to be impossible "until the older generation of
physicians retires," the shift could proceed much more rapidly,
as physicians become more dissatisfied with the status quo, and
with the implementation of previously unavailable computer
technology, suggests Francis J. Crosson, M.D., vice-chairman of
the Medicare Payment Advisory Commission (MedPAC) (N Engl J
Congressional proposals are just a beginning.
The Baucus Not-a-Bill and the CBO
The CBO (Congressional Budget Office? Can't Bank on It?) has
miraculously managed to score a bill without having legislative
language. Coming up with a price tag of just under $1 trillion
over 10 years is said to be a "green light." The $829 billion
cost projection is uncheckable, as it is largely based on private
conversations, writes Ernest Istook (Newsmax.com
10/9/09), and comes with an admitted caveat of "substantial
uncertainty." CBO claims the bill will knock an average $8
billion (0.5%) off the annual deficit of $1.4 trillion.
They "claim we're saving $81 billion by spending $829
billion," said Rep. Eric Cantor (R-VA) (SFGate.com
The CBO assumes that Medicare SGR physician pay cuts will
occur in 2012 and omits costs imposed on states and the private
sector through mandates. The real cost would be more than $2
trillion, writes Michael Cannon (Cato 10/8/09).
Who Goes Broke?
Under the Baucus plan, families could be forced to spend up
to 19% of their income on "health care costs," regardless of how
much care they use (Wash Post 10/13/09). Penalties for
those who don't buy insurance have been halved from up to $3,800
per family (for now), and phased in more gradually. Those who
failed to pay the penalty could be charged with a misdemeanor and
fined $25,000 or jailed for one year, according to a handwritten
note Sen. John Ensign (R-NV) received from Joint Committee on
Taxation Chief of Staff Thomas Barthold.
The owner of a hamburger franchise with 250 employees
calculated that a proposed mandate would cost him $1,000,000 a
year, driving him out of business.
Drug and medical device makers are expected to pay $180
billion, including $29 billion from not being allowed to deduct
this "fee" from their corporate taxes (WSJ 10/0/09).
The "mother and father and crazy uncle of unfunded mandates"
will break 50 state budgets by expanding Medicaid (WSJ
9/28/09). The cost to California was estimated to be $8 billion
(San Diego Union-Tribune 10/8/09).
Like the Tariff of Abominations of 1828, the favoritism in
the Baucus bill pits states against each other in a hurtful and
divisive way. Senators seek a higher threshold for the 40% excise
tax on insurance premiums in New York and Massa-chusetts; a $1
billion tax credit for New Jersey drug firms; and special favors
for Harry Reid's Nevada (WSJ 10/8/09).
Insurers are rethinking their support as they calculate how
much the Baucus bill will add to premiums (49% in the individual
market) and costs. Reducing the noncompliance penalties means
that they won't get as many reluctant new customers as they were
counting on (WSJ 10/13/09).
Who Reaps a Windfall
Besides exemptions from provisions that limit or tax their
health benefits, and a $10 billion bailout of insolvent union
plans, unions count on increased power and forced unionization of
health workers. In 2004, Obama vowed to paint the nation purple, the
color of the Service Employees International Union (SEIU). What
will Detroit-style labor relations mean in hospitals? In the
1970s, orderlies belonging to 1199 sat idle while patients not on
their route could not get to needed procedures for hours.
The Measure of Value
As reformers demand paying doctors for "value" rather than
for work done, the unit of value is increasingly in doubt. The
implications of thresholds for subsidies and taxes depend on the
value of the dollar and they are not indexed for inflation. The
U.S. appears to have a de facto weak-dollar policy. On Oct 2, the
dollar hit a 14-month low against other currencies. Measured in
euros, the U.S. per capita GDP is down 25% since 2000. Investors
have been playing the weak-dollar trade for years, diverting
dollars into commodities, foreign currencies, and foreign stock
markets: "the Third-World way of asset allocation." Experts
suspect the Administration plans to escape the debt burden by
devaluation (WSJ 10/8/09).
In 2009, about 40% of individual income tax payments will go
for debt service (WSJ 10/20/09). Still, Congress is
hurtling toward an unaffordable universal entitlement.
The Long-term Strategy
Savings from delivery-system reform are speculative and
slow. U.S. budget projections indicate explosive increases in
borrowing and debt-service costs, "which could cause lenders to
lose faith in the nation's repayment capacity," writes Henry J.
Aaron, Ph.D., of Brookings. "Prospects are so bleak that not
even...the worthy goals of health care reform justify
increasingly perilous budget deficits." Since the reform agenda
may be beyond immediate political reach, it is "essential to
identify elements of the full plan that would set the stage for
later reforms" (N
Engl J Med 2009;361:937-939).
Doing the Math
- 800 gal/y: gas used by clunker (12,000 mi @ 15 mpg)
- 480 gal/yr: gas used by newer car (12,000 mi @ 25 mpg)
- 224 million gal/y saved (700,000 cars 320 gal/y) =
- 5 million barrels of oil = 5 hrs of U.S. consumption
- $350 million saved (5 million barrels $70/barrel)
- $3 billion in taxes: $8.57 spent per dollar saved
"Will we get just as good a deal from centralizing our
medical system?" asks Dave Johnson.
A Precedent: Got Milk?
The federal government has interfered in the milk marketing
system since 1937, notes Dr. Lawrence Huntoon. The federal milk
marketing orders system was put in place to assure an ample
supply of milk at affordable prices. As with the CPT coding
system, the government set classifications for milk products.
Dairy farmers were lured into the system via promises of adequate
minimum prices, rather like promises made to physicians to pay
for services to Medicare "beneficiaries." Dairy farmers are
having trouble making ends meet, and the American Farm Bureau is
calling for market-based reform.
The "Woodwork Effect"
Arizona Governor Jan Brewer complains that the Baucus bill
would require actual enrollment of all who are income-eligible
for Medicaid, costing the state $4 billion in 5 years. The state
has to pay now if eligibles end up in the emergency room, but
since Arizona's Medicaid is set up like an HMO, it has to pay a
monthly fee to providers for all enrollees, whether they use any
services or not (Ariz Daily Star 10/8/09).
Eliminating Profit Won't Pay the Bill
The greatest problem with our third-party payment system is
the illusion that somebody else can pay the cost, writes David
Goldhill. He calculates that all the profits of the "famously
greedy health-insurance companies" would pay for 4 days of
medical care for all Americans. Adding in the profits of the "10
biggest rapacious U.S. drug companies": another 7 days.
All profits of all American companies wouldn't
buy even 5 months of care (Atlantic, September 2009).
Leave your health care to bums...what do you get?
Another day older and deeper in debt!
Saint Baucus don't you tell me what insurance is for
You sold your soul for a CBO score.
David McKalip, M.D., apologies to Merle Travis, 1946
New Officers Elected
At the 66th annual meeting in Nashville in October, George
Watson, D.O., assumed the office of president, and the following
officers were elected:
President-elect: Lee Hieb, M.D., of Logan, IA
Secretary: Charles McDowell, Jr., M.D., Johns Creek, GA
Treasurer: R. Lowell Campbell, M.D., Corsicana, TX
Directors: Richard Amerling, M.D., New York, NY; Alieta Eck,
M.D., Somerset, NJ; Wayne Iverson, M.D., San Diego, CA; W. Daniel
Jordan, M.D., Atlanta, GA; and Tamzin Rosenwasser, M.D.,
Insurance Rescission on a National Scale
Reformers cite heart-rending anecdotes of sick patients who
lost coverage when they needed it most, suffering or even dying
because of delays and uncertainties about treatment. This may
happen because of alleged fraud lying about a pre-existing
condition. Sometimes insurers may act indefensibly. But Congress
is not proposing better enforcement of contractual rights quite
the contrary. While Americans may cheer requiring coverage of
pre-existing conditions at least until they find out the effect
on premiums the proposal that Peter Orszag calls "the most
important game-changer" in the fight to control costs constitutes
rescission for millions at a time. This is the Independent
Medicare Advisory Commission (IMAC), which would apply
comparative effectiveness research to deny coverage, in a process
modeled on the UK's National Institute for Health and Clinical
Excellence (NICE), writes David Gratzer, M.D. (FrontPageMag.com 9/16/09).
For a one-minute video on the public
airplane to Healthyville and other
ObamaCare short takes by the Independence Institute, see www.i2i.org.
Forget the Uninsured
While most arguments for reform start with the number of
uninsured, they quickly shift the focus to everybody else,
observes John Goodman. None of the bills in Congress deals with
the short-term uninsured. Tests for eligibility and subsidies all
assume that people have stable incomes, though fluctuating income
is typical of uninsured and indeed many low-income families
Deficit to Bottom in 2012
According to a CBO analysis of the Obama budget, the ten-
year low of $658 billion would be reached in 2012, with increases
without end thereafter (CPR #197).
Feb 5, 2010. Thrive Not Just Survive
workshop, Houston, TX
Feb 6, 2010. Board of Directors meeting, Houston, TX
Sep 15-18, 2010. 67th annual meeting, Salt Lake City,
Be Vaccinated or Else
The swine flu pandemic may be the pretext to implement state
emergency powers acts. The governors of Massachusetts and
Pennsylvania, for example, appear to have the power to order mass
vaccinations, under pain of forced relocation or imprisonment.
The police apparently cannot restrain people to inject them
without consent, but can forcibly remove them from their homes
and confine them with other refuseniks in group facilities thus
exposing them to influenza. Authorities are virtually immune from
accountability for harm they cause.
The Iowa public health department, whose policy is posted as
a model by the CDC, has the authority to forcibly confine people
to a quarantine facility if they simply have contact
with a person who has H1N1 influenza.
The New York Department of Health (DOH) has recently passed
a regulation requiring all medical staff and allied health
personnel employed in medical facilities to have seasonal
influenza immunizations every year by Nov 30. Currently, more
than 90% of confirmed influenza cases are caused by H1N1 virus,
but seasonal flu could emerge later, say public health officials.
The H1N1 requirement will depend on vaccine availability and DOH
priority guidelines. The only exceptions are documented severe
prior reactions to vaccine.
To decline vaccine at a facility in Sacramento, physicians
must sign a form acknowledging the "fact" that their refusal
endangers the health of their patients and the community.
We know of no studies of the prevalence of viral
shedding by asymptomatic vaccinated or unvaccinated persons, nor
could the public health director in Pima County (AZ) cite any.
In the past, the majority of health workers have declined to
take influenza vaccine. Most could change their minds and clamor
for vaccine if influenza turned out to be more widespread or
severe than anticipated.
A protest movement is posting signs around Phoenix, AZ:
"Support first responders that say NO to mandatory shots."
"While nurses protest at the state capitol, another
unintended consequence of New York State's bold attempt to claim
ownership of people's bodies has arisen," writes Lawrence
Huntoon, M.D., Ph.D. "Some volunteer workers may leave the
hospital rather than submitting to mandatory vaccination."
Mandatory vaccination is an assault on liberty, writes
attorney Jonathan Emord. It subjects "the vast majority to a
bodily intrusion that can have severe side effects for the sake
of a minority why are or may become ill." Ordinarily, the state
has to meet a heavy burden of proof to deprive a person of
liberty. With vaccines, the government need only show a
reasonable relationship between a means (vaccination) and the end
(reducing the risk of disease). It does not need to show that
less intrusive means were unavailable or inadequate. "Recognize
that vaccination is one of the most extreme examples of prior
restraint in the law" (NewsWithViews.com 10/12/09).
Also see News of
the Day, www.aapsonline.org.
Nurses Charged with Felony for Malicious Report
In Winkler County, TX, a district attorney has indicted two
nurses for filing a malicious complaint against a physician with
the Texas Medical Board. The physician complained to the
Sheriff's office about harassment. The TMB and the nursing
association protested, arguing that people should be allowed to
file TMB complaints with impunity. The trial scheduled for
September has been postponed; a new date is not yet set.
Dr. Becker Entitled to Jury Trial
About 12 years after abuse of neurologist Taj Becker, M.D.,
by the Utah Medicaid Fraud Control Unit began, the U.S. District
Court for the Central Division in Utah has ruled that defendants
failed to show that they were entitled to absolute immunity
(Becker v. Kroll, Case No. 2;02-CV24 TS). A 4-day jury
trial is scheduled for February (see AAPS News, October 2007, and aapson-
Too Much Care Is "Fraud"
An ad in the Buffalo News reads that "many health
care fraud victims have been subjected to unnecessary or unsafe
medical procedures." Insurers mean to control the definition of
fraud, writes Dr. Huntoon. They have long been filing anonymous
complaints with medical boards against physicians who dare to
provide care the insurer does not wish to pay for. The ad now
goes beyond that clandestine tactic to a bolder tactic of
establishing the link between insurer-defined medical necessity
and fraud in the minds of the public. We are beginning to see the
interlocking tentacles of top-down control of medicine fascism.
Among the sponsors of the ad are insurers caught using the
fraudulent Ingenix data base to cheat patients out of proper
payment for out-of-network treatment.
Seniors May Be Able to Opt Out
There is no law or regulation compelling seniors to withdraw
from Social Security and repay retirement benefits in order to
withdraw from Medicare, ruled U.S. District Judge Rosemary
Collyer. Plaintiffs Brian Hall, John Kraus, and former House
Majority Leader Dick Armey are challenging a a Clinton
Administration rule that bars them from keeping coverage they
prefer to Medicare. The Obama Administration filed a motion to
dismiss on the grounds that plaintiffs had failed to exhaust
administrative remedies. The judge rejected it, noting that one
plaintiff had sought an administrative hearing but had received
no response from the Social Security Administration for 3 years;
such a remedy is "futile," she said.
"A three-year wait is precisely the kind of bureaucratic
hassle, or deliberate stonewalling, that government is famous
for," opined Wall Street Journal editors. "The response
of the Obama Administration to this lawsuit is revealing about
its principles, as opposed to its rhetoric," which claims that
the "public option" wouldn't be coercive (WSJ 10/4/09).
Citizen Sues to Stop National Health Database
In June, a citizen filed a class-action lawsuit against HHS,
seeking an injunction to stop implementation of the national
health database concealed in the American Recovery and
Reinvestment Act of 2008 (ARRA or the "Stimulus Bill"). The suit
argue that ARRA provides $22 billion to create a computerized
system that "will by design violate the civil rights of every
person in the United States" (Complaint, Heghmann v.
Sebelius, et al., U.S. District Court for the Southern
District of New York, 09 CV 5880). Additionally, it states that
"penalties administered or threatened by the National Coordinator
will deter the Plaintiff's health care providers from going
beyond the electronically delivered protocols...."
The lawsuit calls attention to ARRA's infringements of
personal freedoms, writes Twila Brase (www.cchconline.org).
What Seniors Say About Doctors. A survey done by the
AMA, AARP, and ANA showed that "87% [of persons aged 50 and
older] said it is very or somewhat important for physicians to be
paid adequately so doctors can continue to accept Medicare
patients" (AM News 9/28/09). Note that the flip side of
that survey result is that there are 13% who really don't care
whether the doctor is adequately paid. Some seniors apparently
believe that the government should force doctors to work without
adequate payment, i.e. as a government slave.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Enforcing a Mandate. A problem Massachusetts faces is
people paying the penalty for not having insurance, then buying
insurance when they get sick, and dropping it after they recover.
The penalty was set low $900 probably so that the bill would
pass. You can always raise it later. Now the monthly penalty is
half the lowest available Connector policy. If it is too high,
you run the risk of bankrupting a lot of younger people, or of
encouraging people to skip filing taxes. Or you might get a bunch
of people suddenly converting to Christian Science, as there is a
religious exemption. The form for the hardship exemption is now
13 pages long.
Linda Gorman, Ph.D., Independence Institute, Golden,
Primary Care. When I was a child, the newly minted
general surgeon in our area did house calls. When I was a teen,
he no longer did house calls, but he was still our family doctor.
Before third-party payment and the exponential increase in
costs, specialists also did primary care. If patients were put
back in control of their medical dollar, many specialists would
find out that primary care was where the money is, and would
brush up on their generalist skills. In a free market, primary
care would rise to the top of the cost-effectiveness heap, and
the problem of too little primary care and too much speciali-
zation would be solved. The three-legged stool of price, quality,
and accessibility can only be balanced when the free market
allows people to make their own choices.
Alieta Eck, M.D., Somerset, NJ
No Risk-Rating, No Choice. If you want guaranteed
issue, no limits on pre-existing conditions, and severe rating
restrictions, you must remove choice. Too much reliance on
pooling does little good without appropriate risk classification,
as better risks will reduce participation or leave the pool. If
you choose to pool many people together regardless of the
risk/cost they represent, you must mandate participation with
little or any choice of benefits or anything else.
Mark E. Litow, F.S.A., Brookfield, WI
Why Small Employers Pay More. As Obama said, small
businesses have to pay more for health insurance. That's because
of the "other SGR": small group reform, which passed in the
1990s. Every insurer must issue insurance to any employer with
fewer than 51 employees on a guaranteed-issue basis, and cannot
hike premiums based on claims experience. If ObamaCare passes,
large businesses and individuals will also have to pay more.
Ralph Weber, C.L.U., Paso Robles, CA
Sham Peer Review of Whistleblowers. The U.S.A. is
becoming a perfect anti-meritocracy like the U.S.S.R. Oligarchy
rules by the spurious supremacy of the unqualified the factory
worker was more powerful than the engineer, and the opinion of
the hospital orderly counted more than that of the physician.
This was mere illusion in that the Communist Party elite was the
only supreme class. The "protection of the little guy" con is
very effective. It is refreshing to see some fighting back
against this scheme in Winkler County (see p 3).
Walter Borg, M.D.
Why We Dropped Medigap. In 1993, my wife had bypass
surgery that cost $50,000. The Blue Cross Medicare supplement
paid about $800. We had paid in about $3,000 per year for several
years. In the 15 years since then, we would have paid $45,000 in
premiums had they stayed at the 1993 level.
Curtis Caine, M.D., Brandon, MS
Let Government Cut Doctors' Pay! With cuts to doctors'
Medicare and Medicaid fees scheduled for 2011-2012, there will be
no doctors accepting these patients. I believe this is the time
for all doctors to submit their resignation to CMS. We can start
working directly for patients sooner rather than later. That's
the best thing that could happen for American medicine.
Marcy Zwelling-Aamot, M.D., Los Alamitos, CA
Networks Control Doctors. These days, it would be wise
to avoid insurance contracts for closed networks. It might even
be wise not to have expensive insurance for doctors' vis-
its which, after all, cost about as much as a tank of gasoline.
Richard Swint, M.D., Paris, TX
Defending Liberty. My first American ancestor arrived
in Jamestown in 1608. My ancestors fought in the American
Revolution against tyranny and taxation without representation.
Now it is my turn to fight the 21st century tyranny of government
owning our health choices. It is not for government to say, "You
cost too much. Die and get out of the way." I have signed the
Physicians' Declaration of Independence....
Lee Vliet, M.D., Tucson, AZ