Volume 65, No. 9 September 2009


As reported by Sarah Tobianski of ABC News, "What started as a battle of words...when President Obama hit back at Republican senator Jim DeMint of South Carolina for saying health care reform could be Obama's 'Waterloo,' has turned into a fullblown war to rally support and money behind the president's health care policies."

Historical Note

On Jun 16-19, 1815, the Battle of Waterloo put an end to the tyrannical rule of Napoleon, and marked the end of his triumphal return from exile, "the Hundred Days."

Having beaten the Prussians at Ligny, "but not sufficiently," and seeing that Wellington's troops were outnum- bered, weak, ill-equipped, and inexperienced, Napoleon thought "this affair is nothing more than just eating breakfast." Wellington later said, "It was the nearest run thing you ever saw in your life." The British hung on tenaciously, and the Prussians under Blcher attacked Napoleon's right flank. The battle ended in a rout, and as H.G. Wells wrote, "Everyone who had joined [Napoleon] was eager now to attack him."

Organizers Deployed; Congressmen Flee

Having missed their deadline to pass a bill before the August recess, "members of Congress will listen to their constituents and explain reform legislation," promised Speaker Nancy Pelosi (D-CA) and Rep. Steny Hoyer (D-MD) despite the "disruptions." Instead of the expected pep rallies for Obama's Change agenda, town halls featured hundreds of citizens shouting things like "Tyranny!," or "Read the bill!"

An ad by the Democratic National Committee calls such citizens "an angry mob." Congresswoman Gabrielle Giffords (D-AZ) called them "manipulative racists." Other Democrats call them "actors organized by the crazy right wing and the insurance industry" engaging in "un-American" tactics. It's not spontaneous grassroots activism, but organized "Astroturf."

MoveOn.org tells prospective contributors that "right-wing extremists are crashing town hall meetings, shouting down members of Congress, making death threats they even hung [sic] one congressman in effigy." Washington Post business writer Steve Pearlstein accuses dissenters of becoming "political terrorists" bent on preventing consensus.

To "fight back against this disastrous brand of old-style politics," Obama's Organizing for America and others are ramping up their efforts. Ads on Craigslist seek "talented leaders" to work for health care reform for $11-$16/hr. The Administration is recruiting citizen snitches on "fishy misinformation." (Chief of staff Rahm Emanuel is said to send dead fish to his political opponents, notes Greg Scandlen.)

As the Organizer in Chief orders his citizen army to action, the talk could stop, and the violence begin. The first physical aggression was reported when "Purple People" from the SEIU (Service Employees International Union) showed up to protect congressmen from senior citizens and parents.

The SEIU's organizing philosophy is: "[W]e prefer to use the power of persuasion, but if that doesn't work, we use the persuasion of power" (Michelle Malkin 8/6/09). Its intimidation tactics have been explicitly condemned by AFL-CIO president John Sweeney, among others.

The Administration was "[t]hrown off balance by the unexpected rude awakening of the normally silent sleeping public," writes J.B. Williams (Canada Free Press 8/7/09). He recalls that on the campaign trail, the career community organizer said, "I want you to go out and get in their face."

Despite this support, many Democrat legislators are cancelling live town halls and resorting to telephone town halls. As Lee Vliet, M.D., of Tucson, AZ, points out, this not only gives the politician complete control, but eliminates the risk of a YouTube video showing what really went on.

Who Is the Opposition to "Reform"?

At a town hall in Houston on Aug 8, Rep. Kevin Brady (R-TX) told some 500 citizens: "The only thing standing between us and this 1,000-page bill is you."

"Inside the...Beltway, there are only a few good soldiers left standing. Everyone else has sold out or been bought out or bullied out," writes John Goodman. "Yet there is one group that was not invited to participate in the behind-closed-door sessions.... These are the people."

Health insurers aren't paying town hall activists; they paid congressmen, donating more than $19 million since 2007, 56% of which went to Democrats. And they are the likely victors in a battle that could already be over, according to Chad Terhune and Keith Epstein (Business Week 8/6/09).

UnitedHealth, highly praised by Blue Dog Democrats, is probably the biggest winner. This leviathan is already enmeshed in the lives of 70 million Americans. Its Ameri-Choice unit, whose revenue increased 34% last year, is the largest contractor administering Medicaid. Its OptumHealth unit is in great demand as government and big employers try to curb costs by supervising patients more aggressively. Proposed legislation could benefit its Ingenix data-crunching unit. UnitedHealth also owns Lewin Group, whose data is routinely cited by Republicans Orrin Hatch and Eric Cantor.

Although he is a proponent of a government-run competitor, Tom Daschle sells political tips to UnitedHealth.

Contrary to the Democrats' claims, only 25% of voters strongly support the reform effort, while 41% are strongly opposed, writes Scott Rasmussen (Wall St J 8/7/09).

Napoleon may have miscalculated, and there may be a Wellington and a Blcher. It could be a close battle.

Sarah Palin Denounces Government Takeover

Former vice-presidential candidate Sarah Palin, who just stepped down as governor of Alaska, remarked:

"As more Americans delve into the disturbing details of the nationalized health care plan that the current Administration is rushing through Congress, our collective jaw is dropping, and we're saying not just no, but hell no.

"The Democrats promise that a government health care system will reduce the cost..., but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost."

It would be "a point of no return for government interference in the lives of its citizens," she added.

The elderly and the disabled would suffer most.

Law professor Harold Pollack posted a "have you no decency" entry on the New Republic blog, about Palin's use of the term "death panel," in quotation marks, for the bureaucracy that will make decisions based on value to society.

In fact, notes law professor William Jacobson on the Legal Insurrection blog, the term is an apt one for Ezekiel Emanuel's concept of a priority curve based on a "complete lives" concept.

And it's perhaps even more descriptive of the ideas of Peter Singer of Princeton, who writes: "what better say of deciding what treatments people should get than by comparing the QALYs [quality-adjusted life years] gained with the expense of the treatments?" (New York Times Magazine 7/19/09). Recall that Singer would allow killing of "defective" infants.

Washington Post editorial board member Charles Lane admits that concerns about the bill are well-founded: Section 1233 "addresses compassionate goals in disconcerting proximity to fiscal ones." While end-of-life consultations are not mandatory, doctors have an incentive to insist on them, and the legislation lists what topics doctors "shall discuss" (Steven Ertelt, LifeNews.com 8/10/09).


Questions on White House Reports?

In a letter to Barack Obama, Sen. John Cornyn (R-TX) asks: "How do you intend to use the names, email addresses, IP addresses, and identities of citizens who are reported to have engaged in 'fishy' speech?" Also, "Do your own past statements qualify as 'disinformation'?" for example, a report on Obama's 2003 statement supporting a universal single-payer system.


Why Not Deregulate?

Private health insurance in America is extraordinarily expensive because of regulatory requirements, writes Thomas DiLorenzo. The quickest way to make it affordable would be to completely deregulate the industry, as by repealing costly mandates, and allowing a free market to develop.

"Politicians don't want to do it, of course, since they would then no longer be able to extort campaign 'contributions' from all those special-interest medical care/service providers. They prefer to lie about the 'evil, capitalist health insurance industry' instead" (lewrockwell.com 8/9/09).

According to the American Academy of Actuaries, savings from consumer-directed health care could be as much as 12% to 20%, with a lowering of future trend rates by 3% to 5% compared with traditional plans. It is already "bending the cost curve" (Consumer Power Report 8/7/09).

It is not, however, owned by UnitedHealth.


AMA's Waterloo?

Even if ObamaCare doesn't break the Administration, it could well devastate the AMA. Individual members are dropping out, and local, state, and specialty societies are voicing their dismay at the board of trustees' endorsement of H.R. 3200. At this writing, answers to the question "should doctors dump the AMA?" on www.aapsonline. org are: yes, 1,246; no, 49; not sure, 38. There are 107 comments posted.


One Plan

"Having been in health care policy for a long time, I have read literally hundreds of six-point plans, eight-point plans, and ten-point plans all developed by very sincere and earnest people who think if only the world would do as they say, it would be a better place....

"Unfortunately, that is the same chain of thought that led to Napoleon, Mussolini, Hitler, and Stalin. I'm not suggesting that health reformers are all little dictators (though some would like to be), but the whole notion that a single person, or committee of persons, can sit at a table and plan the future of hundreds of millions of people is offensive to the ideas of human dignity, freedom, and sovereignty.

"So when a colleague suggested that I come up with an alternative, I was reluctant. He told me it isn't enough to be the "Party of No!"... So here is my two-point plan:

"1. Give the money back to the people. 2. Get the hell out of the way." (Greg Scandlen, Opposing Views).


A Modest Proposal

The Obama Administration has announced a new Cash for Geezers program. Every American family will be eligible for a $4,500 rebate for turning in their old entitlement-guzzling grandparents to a hospice program. The hospice dealers will have two days to dispose of the models, so they will never again pollute the environment by emitting a steady stream of CO2 as they exhale. This new program will help combat Global Warming, stimulate the economy, and reduce the federal deficit. Truly a win-win-win program.
Greg Scandlen


Past Is Prologue

The historic "debate" between President John F. Kennedy and Edward Annis, M.D., narrated by Alieta Eck, M.D., is preserved at www.youtube.com/ watch?v=vFesycofKk4 and www.youtube.com/w atch?v=hqVkOlhbsEM.


AAPS Calendar

Sep 30-Oct 3, 2009. 66th annual meeting, Nashville, TN.
Sep 15-18, 2010. 67th annual meeting, Salt Lake City, UT.

An Assault on Citizenship

National health care is the permanent game changer, writes Mark Steyn. Once enacted, it assures that elections are always fought on the left's terms, as the voters identify health as their number one concern.

Ceding responsibility for one's health to government fundamentally changes the concept of citizenship. "If free citizens of the wealthiest societies in human history are not prepared to make provision for their own health, what other core responsibilities of functioning adulthood are they likely to forego?" Steyn asks. They might be trusted to decide what movie to order from Netflix, or what cereal to eat for breakfast, but for how long? "The 'right' to health care elides into the government's right to tell you how to live in order to access that health care." Almost any restraint on freedom can thereby be justified.

Nationalizing health care ultimately means nationalizing your body (www.steynon line.com/content/view/2295/26/).


Everybody In....

Despite "piecemeal reforms," our largely unchanged system remains on an "unsustainable trajectory," writes Michael E. Porter, Ph.D. We need a "comprehensive vision" with "new integrated care delivery systems"; bundled payments; mandatory measurement and dissemination of health outcomes by every provider for every condition; obligatory purchase of insurance so younger, healthier people cannot opt out, bringing in substantial new revenues; and central supervision by perhaps three "independent bodies."

"Unless patients comply with care, even the best doctor or best team will fail [emphasis added]. Simply forcing consumers to pay more for their care is not the answer." But the new system will "enable vast improvements in patient engagement" (N Engl J Med 2009;361:109-112).


Is There a Constitutional Limit?

A government-dominated medical system may be uncon- stitutional, argue David B. Rivkin, Jr., and Lee A. Casey, who worked in the U.S. Dept. of Justice under Presidents Reagan and George H.W. Bush (Wall St J 6/22/09).

The right to privacy, established in the 1960s as in Roe v. Wade, was not abortion-specific, they maintain. What could be more "central to personal dignity and autonomy" than medical decisions? What kind of "undue burden" analysis might the Court require for rationing decisions?

In an interview with Emily Bazelon, Justice Ruth Bader Ginsburg expressed a different view: "Frankly, I thought that at the time Roe was decided, there was concern about population growth and particularly growth in populations we don't want too many of" (NY Times Magazine 7/7/09). Thus, she was surprised that the U.S. Supreme Court barred Medicaid funding for abortions in 1980.

There is the "compelling state need" argument, which Obama's science advisor John Holdren has applied, at least in the past, to coercive population control by an armed international organization, to protect natural resources.

It could be our last chance to choose our destiny "and the right choices could lead to a much better world," he said.

Are there any rights that compelling need or noble intentions do not trump?


Is an Individual Mandate Constitutional?

In assessing the Clinton health care reform proposal in 1993, the Congressional Budget Office (CBO) noted the unprecedented nature of a mandate that required individuals to purchase a specific product. The only analogous mandate was the requirement to register for the draft.

Architects of the Social Security Act, who harbored grave doubts about its constitutionality, settled on the rationale of the taxing powers of the U.S. An individual mandate is not, however, quite the same. Moreover, it might be problematic to use the taxing power as the Constitutional authority, but not call the mandate a tax for purposes of budget scoring rules.

In citing its power to regulate interstate commerce, Congress might have some difficulty explaining how not doing something could implicate commerce.

The mechanism of enforcement could invite even more scrutiny. Identifying and penalizing scofflaws "may require a degree of intrusiveness and bureaucracy that some will find unpalatable," said Sherry Glied, Ph.D., nominated by Obama for an assistant secretary position in HHS. (Peter Urbanowicz and Dennis G. Smith, Constitutional Implications of an "Individual Mandate" in Health Care Reform, Federalist Society for Law and Public Policy Studies; 2009)


Tip of the Month: When a physician's assistant used a physician's NPI, which he had apparently lifted from a job application, to file fraudulent claims for motorized wheelchairs, the physician escaped prosecution because he had not accepted the position, nor given the PA authority to write prescriptions on his behalf. Otherwise, he might have had difficulty defending himself. Physicians are advised to protect their NPIs from identity theft. NPIs are open to the public by internet, but be especially careful when an employee who had access to the NPI leaves. Monitor claims and reimbursements. "Most billing fraud is committed by someone you trust with your NPI," said Susan Miller of WEDI (Medical Practice Compliance Alert 7/27/09). Cancel further use of a number you think has been compromised. [Some physicians who are not HIPAA-covered entities have not obtained NPIs, partly for this reason.]


Bureaucrats Can Overrule Doctors' Orders

The U.S. Court of Appeals for the 11th Circuit overturned a ruling that the state could not reduce doctor-ordered care for a Medicaid beneficiary (Moore v. Medows 08-13926). The state had cut home nursing services for a severely disabled child from 94 to 84 hr/wk. The state of Florida argued: "Treating physicians...cannot be trusted with this sort of decision.... When left to their own devices, they advocate for their patients and deem all manner of unproven, dangerous, ineffective, cosmetic, unnecessary, bizarre, and controversial treatments as 'medically necessary'" (Health Care News, July 2009).


Fraud Enforcement Juggernaut Continues

To help offset the "shocking price tag" of proposed health care reform, sweeping changes were enacted in the Fraud Enforcement and Recovery Act of 2009 (FERA). A flood of new whistleblower actions is expected, and courts will have to revisit prior decisions. Broader classes of defendants and conduct are liable; defenses are weakened. Compliance programs need to be strengthened (HCFR 7/29/09).


County Society Rebukes AMA. All the officers and committee chairmen of the Medical Society of the County of Erie, and delegates to the state medical society, signed a letter protesting the AMA's endorsement of H.R. 3200 with a copy to Nancy Nielsen. Dr. Nielsen is past president of our county society, the "hometown girl that went to great heights" as AMA (now past) president the very one who "engineered" AMA support for H.R. 3200. I think the AMA underestimated the strong opposition to socialized medicine among physicians who actually practice medicine.

The letter reads: "[We have] grave reservations about the recent decision by the AMA.... H.R. 3200...contains many onerous provisions which will lead to a diminution in our ability to care properly for our patients.... The establishment of yet more bureaucratic entities...as [in] H.R. 3200,...will further fracture our system.... Our community wants to...lose the "hassle factor'...and reduc[e] third party interference."
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY


Palin Nails It! Sarah Palin has called the Obama healthcare plan evil. In one word, she summed up the most important problem letting the state (aka politicians and bureaucrats) decide who lives and dies. Meanwhile, most of the Republican pols, think-tankers, and commentators without her [fortitude] debate efficacy, efficiency, and other policy wonk distractions.
Craig Cantoni, Scottsdale, AZ


Please Report Me to the White House. I can't believe what I am seeing on a White House post they want folks to report "fishy misinformation" about the pending healthcare plan. Well here is my "(mis)information": it's euthanasia of our elderly; free abortions; taxing my employer-provided insurance or fining them for not providing it, or me for not buying my own; a council to decide what's necessary and what's not. The plan not only allows the government to access your medical records but your financial records as well....

I'm reporting myself to flag@whitehouse.gov, and I invite you to report me too.... To find the exact blog, go to whitehouse.gov and search on "fishy." Otherwise, it's hidden among the rest of the propaganda there.
Maria Celina Salazar, Albuquerque, NM


To the White House: I would like to self-report: I am quite critical of the unconstitutional takeover, as are my wife and two boys. Nearly all of our family, neighbors, and friends are opposed; some are self-insured and want to keep it that way. We count only four who favor this government confiscation.
Kenneth D. Christman, M.D., Dayton, OH


On the Massachusetts Model. Why did Mass. need a type of reform for "the poor" that other states limp along without, when it has one of the lowest fractions of uninsured? It seems that the fraud in Mass. was such that the feds were threatening to jerk Medicaid funds. Instead of cleaning up, the state said, "Let's paper over the bad things by forcing everyone in the state to throw more money into the payola system we call MassHealth." Romney could've fought it. There's nothing wrong with saying "No" most of the time. It seems to be a primary requirement for raising kids to be competent adults.
Linda Gorman, Ph.D., Independence Institute, Golden, CO


Mandatory Research. Although I do not agree with all AAPS positions and thinking, I was, like you, deeply disturbed by the JAMA article presenting participation in biomedical research as a moral obligation.... Ezekiel Emanuel and his colleagues' position placing "public good" above "individual good" sets a dangerous precedent. Imagine the reaction by Americans to making organ donation a moral obligation! Yet that would probably save more lives than making participation in biomedical research a moral obligation. Another scary thought is to wonder to what extent this type of thinking occurs in Ezekiel Emanuel's brother, President Obama's chief of staff.
Ronald S. Banner, M.D., Philadelphia, PA


Past Results. The guaranteed issue provision in HIPAA has been terrible for small business. In 1996, small-group coverage included 40 million Americans, who had average premiums similar to those in the large-group market. In 2008, only 29.5 million had small-group coverage, with premiums 15-20% higher.... They got HIPAA right if the purpose was to collapse the private market by increasing premiums and decreasing coverage. [And what is the goal of reform? Ed.]
Mark Litow, F.S.A., Brookfield, WI


Sold Out. Washington-based trade and professional associations have sold their souls for a "seat at the table," casting their lot with the most far-left elements in America: SEIU, Families USA, and the Obama Administration. Even Wal-Mart has sold out American business for 30 pieces of silver. We know what eventually happened to Frenchmen who "went along to get along." Like today, the Vichy government argued that they had to be realistic: the Nazis were in power, and maybe by collaborating they could get the Nazis to be less mean.
Greg Scandlen, Heartland Institute


One Word. I was asked by a Congressman what word best describes the plan by Obama et al. The simple, honest, direct, analytical, sad but truthful answer: fascist.
Dave Janda, M.D., Ypsilanti, MI