European Statism and the Death of the Filibuster

The greatest damage of Obamacare is not the legislation itself, but the destruction of the filibuster.

The United States Senate is a rather unique institution in the annals of parliamentary governance.  It only analogue and, indeed, model is the House of Lords; similarly destroyed by a charismatic socialist.  While parliaments the world over institutionalize the concept of majority rule, the Senate is designed specifically to protect the rights of the individual against the tyranny of the majority.  It was a brilliant concept, one of several in the United States Constitution to “district” elections.  A method of forcing a candidate to win not just a majority vote but a majority of several electoral districts.

Hitler won his election as chancellor.  And, to him went the spoils.  All of them.  Within the paradigm of German governance at the time, what Hitler did to the Jews was ‘legal.’  It was this precise event that our Founding Fathers anticipated in coming up with a bicameral legislature; in particular, the Senate.  For, in general, the best default status, legislatively, is to do nothing.  This may be frustrating to some inspired reformer, but the it is far better to do nothing than to charge off a cliff in pursuit of some ‘brilliant’ (at least in the eyes of the reformer) ‘change.’

And, over it two or so centuries of its existence, the Senate developed traditions and methods of doing business that enhanced it ability to fulfill its role as protector of individual rights.  One of those  tools is the filibuster.  It is but one of a variety of methods to gives, literally, a solitary Senator the power to delay the business of the Senate.  But, the filibuster is the crown jewel of those tactics; to create the need for a supermajority for doing business.  It is a double edged sword, a godsend when you’re in the minority, but frustrating as hell when you’re in the majority.

Last week, in engineering the passage of Obamacare, Obama, Reid and Pelosi threw out the protections of the filibuster.  Arguably, the Democrats, at least until last summer indeed had a mandate to wring the sort of change that Obamacare represents.  Arguably, the GOP perhaps had no right to sit at the table.

But, with the angry townhalls of last summer, the elections of two GOP governors in New Jersey and Virginia (both states carried by Obama in 2008) changed that dynamic.  Finally, the election of Scott Brown to the US Senate, last January gave the GOP the crucial 41st vote.  It is at this point the GOP earned its right to sit at the table of deliberations; particularly over the final shape of Obamacare.

In doing so, this was going to upend the entire health bill if it went through ‘regular order.’  But, Scott’s election wasn’t a bolt out of the blue.  For the better part of six months public polls, two governor’s elections and the town hall protests already tipped off the Democrats that this bill was not wanted and did not carry any mandate with the very people whom Congress is supposed to serve.

So, the philosopher kings in the Democratic congressional leadership with our messiah-complexed president needed a method to shove legislation past all opposition.  The entire exercise of passing the Senate bill in the House and following with a reconciliation bill was to avoid the filibuster and completely circumvent the Senate’s true role of serving as a check, in the name of individual rights, the tyranny of the majority.  It was to lock out the minority’s ability–though supported by a majority of the electorate–to serve in its role to place a significant check on the majority’s will.

The result is the reduction of the Senate to another House of Commons.  A style of governance that flies in the face of the intent of the US Constitution, designed to prevent permanent majorities to develop thereby run rough shod over individual rights.  And, it furthers Obama’s style of governance, honed in Chicago, in which a coalition of a favored 50 percent plus one gets to loot the hard work of the out-of-favor 50 percent minus one.  Maybe there are wiser heads in the Senate Democratic caucus that appreciate the damage that was done because they are going to have to repair the damage before the November 2010 elections.

Because after the mid-term elections filibuster is gone.  I doubt that McConnel, as majority leader, is going to take the likes of Durbin or Schumer at their word that they will respect the filibuster when they get back into the majority.  Reforming filibuster as being proposed by a number of the Democratic Senators is meaningless.  Every legislative road block by the minority will be ‘reconciled.’  But, given the damage of Obama’s policies the GOP is going to have its hands full ‘reconciling’ Obama’s damage out of existance.

Reconciliation Fraud

Reconciliation won’t happen.  It is a fraud; the ultimate bait and switch to allow Nancy Pelosi to whip up enough votes to get the Senate version of health care “reform” through the House and on to the President’s desk.  It is an inducement to get the Blue Dog Democrats to vote yes.  After which, they will be abandoned having served their role as cannon fodder in Obama, Reid and Pelosi’s great cause to recast America as a socialist paradise.

Before any reconciliation bill can even be crafted, the Senate version of health care “reform” must pass the House completely unchanged.  Nancy has no leverage in modifying even the most obscure preposition in that bill.  All she can do is promise is a whole slew of fixes on a companion bill.

But, if she succeeds in scaring up enough votes to pass the the Senate version, a bill will have passed both houses of congress and can proceed to the Oval Office to be signed into law.  At that moment, health care “reform” will be the law of the land.  And, with that presidential signature, all incentive to compromise will evaporate.  Because, for all its “imperfections,” that bill, that law will go a long way to expropriating, banana republic style, one sixth of the economy.  What isn’t directly in the hands of the federal government, will now be tightly controlled by a vast, newly-created federal bureaucracy.  What’s left will be taxed to death by this same said bill.

For the hard left partisans of Obama, Reid and Pelosi, what’s not to love.  More taxes, more government, more regulation.  Even a back door to publicly fund abortions.  Public option?  Who cares.

And, what deficiencies will be corrected?  If anything, sans the limitation of a sixty vote super-majority, a companion reconciliation bill will be used to pile-on.  It certainly won’t be used to “reach across the aisle” in the name of bipartisanship; that was written all over Obama’s face at the health care summit of last week.  Reconciliation won’t be used to reward the Blue Dog Democrats foolish enough to go along and take yet another bullet for Nancy and vote yes.  With back door abortion funding in the Senate bill, what’s the incentive to make Bart Stupak happy?  In fact, Nancy can take huge electoral losses next November.  All she need is to re-elect 218 Democratic representatives and she and her hard-left allies who control the key chairmanships will remain with their power intact.

But, why even bother with reconciliation and give health care “reform” another thought?  Obama, Reid and Pelosi have so much else to do to gin up all sorts of pork laden spending bills to buy votes for the coming November elections.  The Blue Dogs are expendable.

‘Health Care Reform’–Chicago Style

The tired hobby horse of health care reform gets another lap on the race track as Reid schedules a vote in the Senate today.  This is one horse that needs to be retired to the glue factory.  But, as you take this bill in context of Pelosi’s and in the context of the ‘stimulus’ legislation and the Cap-and-trade bill one get a very clear sense of where this is all going.

One needs to understand, in Chicago, that all the named purpose of any public institution is always the secondary purpose.  The primary purpose for all Chicago public functions and agencies is that of graft, corruption and vote buying.  Chicago, with its machine is the most obvious example of machine politics that plague governance of much of the northeast and, of course, California.

Indeed, over the years, as the cost of such vote buying has grown so has the cost of government.  And, corruption is expensive.  I remember, as a kid, the big debate over the establishment of a state income tax in Illinois.  It was to ‘more equitably’ gather tax dollars to replace such things as property tax revenues.  Well, some 30 year later, Illinois is saddled with an income tax, property taxes that are literally a whole order of magnitude greater than mine in Wyoming and sales taxes just shy of ten percent.

Indeed, the function of governance is an annual exercise in scraping enough revenue to pay-off all co-opted interest groups necessary for that fifty percent plus one to keep the Chicago machine in power.  Moreover, governance to actually benefit its citizen–such as economic growth and jobs–are mere distractions.  Governance becomes an exercise in constant intrusions into the business and the private lives of people, otherwise competent adults.

Once upon a time, Northeast Illinois, the Chicago area, used to be a powerhouse of economic growth.  Steel, the Stockyards, railroads.  Now, what economic activity still remains stems from the fact it can extort rent by virtue of its physical location.  New York state was the same way, truly the Empire State.  Kodak, Westinghouse, IBM, Corning, Xerox and so on.  Most of those industries have moved on.  Factories shuttered, waiting to be turned into tres elegant loft apartment instead of factories generating wealth, jobs, opportunity and wealth.  But, the power class doesn’t care.  So long as there is something to tax and so long as there are enough votes to get to fifty percent plus one, the downward spiral of once great regions continues unabated.

Aside from coming up with new ways to gin up more revenue to tamp down another ‘crisis’ to close yet another multi-billion budgetary gap are a bunch of generally rich, out-of-touch legislators who pursue agendas that saddle the average taxpayer with even more burdens.  While they, by virtue of personal wealth, shielded by trust funds, vote on legislation with intended and unintended consequences that will never touch their priveledged lives. Pelosi married well, she has access to personal wealth to buy her way out of any medical rationing; the lush congressional health plan helps as well.

Governance becomes the personal hobby horse of these same said elites to pursue personal conceits with the power and revenue of government to supercharge their agenda far beyond their wildest dreams when they concocted them in their respective college midnight dorm-room bull sessions.  California, with its imploding fiscal crisis, wants to regulate large screen TV’s.  Never mind that this will be just another business and job killing venture that will have Californians buying those TV’s out of state instead of locally.  Chicago seems to have debates over whether it will allow a Walmart to build within the city limits.  (Jobs?  New tax revenue?  Less on the welfare rolls?  What’s not to like?  Oh!  Pissed off Unions.)  New York City, amid its fiscal floundering, sees the need to regulate trans-fats at restaurants.  Remember the great foie gras ban in Chicago; got anything better to do?  Functions and decisions that otherwise competent adults used to do for themselves are political.

So where do we stand with Chicago-style governance?  The track record since January of this year is tax and spend.  In matters not what the bill’s title said; beneath the title on bills that go on for over a thousand pages on average, have nothing but monies spent for every liberal wish since the last time the Democrats controlled all three branches of government with the majorities they have now in the first two years of Carter’s presidency.

First was the ‘stimulus.’  The point was to bolus a large infusion of money into the economy immediately.  And, had Rahm Emmanuel’s need to “never let a crisis go to waste,” that stimulus might have worked.  But, it merely put most of the money into 2010 to buy votes.  And, to set the stage for ‘health care reform.’

Then came ‘tax and cap.’  It was originally intended to be a cash cow of taxes to fund Obama’s socialist remake of America; and at the same time create a never ending source of money to fuel machine style elections for a Democratic machine in Washington D.C.  As if it weren’t already apparent that climate change was a fraud, it is a fraud.  But, that never mattered, it was the ultimate tax since it was geared to tax carbon dioxide and methane (alleged ‘greenhouse gases’).  Carbon dioxide and methane, fancy terms for what you breathe out and what you fart, respectively.  A tax on basic bodily functions.

But, tax and trade, as the bottomless cookie jar, fell short of its promise when the Democrats could figure out how not to tax Democrats.  So, the tax angle, which was the real purpose of this bill became a means to create bureaucracy to distribute largess and government jobs.

And, now the latest, we have two bills, one in the House and one about to be debated in the Senate, that are notable for taxes.  Taxes on Cadillac health plans, surtaxes on the ‘rich,’ elevated Medicare payroll taxes, again on the ‘rich.’  Mandates to buy insurance or pay a fine (or go to jail).  If the coercion isn’t on your wallet, it’s literally on your person.  There is the creation of all sorts of new regulatory agencies (more government jobs) to ‘reform’ health care.

My job as a physician is, ultimately, to sit down with my patient and try to find the best course of action to preserve my patients health and well being.  It’s that simple.  Yet, in this mass of thousand-page bills were is the simple concept of getting a patient and doctor to sit down and decide what is really best for that patient’s well being?  Obviously of no political value.

Mammograms And Rationing

The U.S. Preventive Services Task Force (USPSTF) steps up to the plate, swings and whiffs.  In the face of other recommendations, it recommends that screening mammograms be started for women above the age of 50; instead of the current practice and recommendation of starting at age 40.

And,

“While the bills are still being drafted and debated in Congress, health insurance reform legislation generally calls for the task force’s recommendations to help determine the types of preventive services that must be provided for little or no cost. The recommendations alone cannot be used to deny treatment,” he wrote.  (white house deputy communications director Daniel Pfeiffer; see above link)

And, from HHS Secretary Sebilius,

“The U.S. Preventive Service Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government.” (see above link)

Of course.  And, of course.  The 900 pound gorilla that are the proposals of Obamacare will just docilely let doctors and their female patients make that mammogram decision on their own.

It’s probably true that there’s probably valid science behind the recommendation.  Some of my gynecological colleagues seem to think so.  It’s probably true that no, absolutely no, considerations of money were brought into the final decision.  But, it would be nice to know who sat on that panel and who paid them.  Full disclosure of funding is now standard by any presenter at any medical meeting for purposes of continuing medical education.

This is no different that my dealings with managed care back in its height in the mid-90′s.  I remember one incident where I was counseling a go slow approach for a series of medical tests only to have the patient challenge me on the basis I was shilling for the insurance plan by making that recommendation for a slower approach to treatment.  I was, in fact, trying to counsel not to pushing a surgical decision until we had exhausted all reasonable non-surgical options.  But, like our current congress, any remote affiliation with an insurance company destroyed all credibility.  That’s why I like to work for myself, in my own practice.  There is not even the appearance of working for anyone but my patient–I know, very quaint.

You also have to shake your head at this arrogant tin-eared administration in launching its first rationing recommendation on an incredibly emotionally freighted subject like breast cancer.  Not to say that this is all pure emotion, since breast cancer is the number two killer of women in this country.  Should have stepped off with, say, vaccinations of delta smelt.

So, you have the debut of health care rationing.  First, it demonstrates how political and how politicized every medical decision will become.  Instead of a physician and his patient quietly discussing the pro’s and con’s of a mammogram screening at 40, we will now have those heretofore decisions now shouted out in every congressional office in Washington, D.C.  Personal medical decisions will now be poll-driven by senators and congressmen fearful of losing the next election.

Whatever the merits, this decision will be shortly rescinded.  Probably, as a clause inserted in one of the health care reform bills now swirling around the halls of congress.  But, given the rank dishonesty underlying the push for ‘health care reform,’ whatever merits there may have been for this new mammogram recommendation will now be lost in a federal government that has no credibility.  That’s what happens when you try the bait-and-switch tactic of “never letting a crisis go to waste.”

Then, the tort bar will weigh in.  Which decision will sway a jury?  The USPSTF recommendation of mammograms over 50 or the American Cancer Society’s recommendation of mammograms at age 40, reiterated in the maw of this controversy.  Chances are that half of the jury will be women; and, women suffering from breast cancer make sympathetic plaintiffs.  Will congress be willing to protect physicians by making the USPSTF binding in any tort action?  Again, of course.

Welcome to the new world of identity politics.  Every disease will now have to have a lobby.  And, disease management will now hinge of who can deliver the campaign cash and stuff the ballot boxes on election day.  ACORN and mammograms anyone?

The AMA’s Acid Test

Now the Democrats are dangling the promise of averting planned Medicare reimbursement cuts before the AMA in return for support for “health care” reform. And, we shall see if the AMA will truly stand by our nation’s physicians and the finest health care system built by their hard work. Or, will they fall for the fraud.

Even if the “cuts” are restored, we still have a system that so grossly underpays that physicians will still need to cost shift in order to break even. Further, this “restoration” will only avert a cut in reimbursement from the current levels. Levels so bad that seniors are having trouble, even under the current reimbursement rates, finding physicians in the first place.

Also, in many respects, the Democrats aren’t really giving anything away.  Seniors vote and any Democrat should know a political third rail when they see one; after all they made Social Security one such.  The net effect is that those Medicare reimbursement rates were going to be raised back (er, maintained) to their current levels anyhow.

Ultimately, the only answer is “no.”  No, because this whole process of reform is a lie and fraud.  Baucus’ plan was supposed to be paid in part by a 500 billion dollar reduction in Medicare.  The 247 billion dollars to be “restored”  is half of the money slated to “pay” for health care “reform.”

The docs at the AMA should look to the object lesson of the insurance companies.  They signed on to “reform” under the supposition that community ratings and no pre-existing conditions would be offset by a robust mandate to sign up young uninsured persons.  But, when someone’s constituency got stepped on the mandate got watered down and the insurance companies got stuck with adverse selection nightmare that will, frankly, bankrupt them.  The insurance companies no longer had anything to lose by releasing the PriceWaterhouseCooper study.  They’re screwed anyway.

Ultimately, the real goal is a banana-republic style expropriation of one sixth of the economy.  It say no is to stay free.  Accepting the Medicare bribe is just negotiating the terms of your serfdom.

The Fraud of Bacus-care

Smoke, mirrors and accounting slights of hand and we have health care “reform” for only about 829 billion dollars.  It conveniently comes in under under Obama’s price tag of 900 billion dollars.  Wow.  Bacus may look and talk like Montana, but he’s been in Washington much too long; and gone totally native.  Because while 829 billion dollars is a real saving compared to 900 billion, here in fly-over land, 829 billion dollars is still a lot of money.

But, this is all a wink and a nod to sell a very expensive new entitlement that will cost far more than the 829 billion dollar loss leader.  This will be an entitlement that will grow to consume the federal budget and, indeed, the economy to transform America into a no-growth, no-job zone like everyone of Europe’s nanny states.  England, France and Germany used to actually be major players on the international stage.  But with social welfare, with “universal” health care leading the way, so consuming every mark, franc and pound (sorry, euro) there’s no money for the real priorities of a nation-state such as defense.  No, with universal health care coverage brought to you by the snuggle bears of Health and Human Services, we won’t have to worry about Afganistan, Islamo-fasism or the war on terror.  We simply won’t have the money to fight.

Let’s go through the fraud.  First, Obama will sign anything, something that carries the label of “health care reform.”  For all of his new found fiscal rectitude, he’ll sign if it cost ten bucks or ten trillion bucks.  Since the Bacus bill is only the skeleton for the final reform, we can more than expect the price to go up.  But, fear not, whatever the price, we can depend on an immediate loss of any fiscal scruples on Obama’s part.

About 500 billion dollars will come out of Medicare “savings.”  Like that’s going to happen.  Say what you will about making the wealthiest senior generation in the history of mankind footing more of the bill, they vote.  Expect, after a proper chastising at the polls in 2010, Congress to come back and restore every penny of Medicare.  You’d think, after the Democratic Party made Social Security the “third rail” of politics, that Bacus would recognize a third rail when he saw one.

Then, we have the taxation of the so-called Cadillac health plans.  This was supposed to raise some serious money.  I’ve read somewhere as much as 200 billion dollars.  Well, my dynamic scoring scores this income stream at zero.  You can expect every health insurance plan to carefully calibrate premiums to fall just under the limits of $8000 and $21,000 for individuals and families, respectively.  And, big labor hasn’t weighed in yet.

How about a tax on durable medical goods and devices.  Who uses such things as artificial hip and knee replacement?  Pacemakers?  Wheel chairs?  The same said seniors who are going to clobber the Democrats in 2010 over Medicare.  Another 30 billion dollars or so that are purely mythical.

So, what you have is a massive benefit cut for seniors.  And, we haven’t started to account for the most spoiled generation, the boomers, who will be joining demanding, with a capital “D,”  services as Medicare beneficiaries.

And, after looting the seniors, you have a bill that amounts to a huge middle class tax.

In some respect, it’s good that the Democrats have the majorities that they now possess.  Because they, in their arrogance, thought they somehow knew better and could in a mere six months remake the finest health care system on earth.  That they had answers and solutions, that somehow eluded the millions of professional that populate the health care system, that only they could see.  Of course its a creaky system; how could it be otherwise in dealing with the health needs of 300 million Americans.  So, we can now sit back and see the Democrat philosopher-kings, lead by Obama, Reid and Pelosi, come up with something better that the worker bees in the trenches are just too stupid to see.

Go ahead vote that bill.  And, better yet, do it in the dark of night before any has a chance to read it.  That bill will provide 1000 plus pages of GOP campaign material for 2010 and 2012.

Aging Hippies and Congressional Leadership

The headlong, damn-the-torpedoes approach to health care “reform” is a function of democratic congressional leadership in the hands of a bunch of aging Woodstock era hippies.  Much of the top leadership hails from the early 1970′s, especially from the class of 1974; Democrats elected at the height of the Watergate scandal.  Many of these were the hippies or fellow travelers who were going to carry the revolution to the establishment by working “in the system” and thereby undermine the “system.”

But, their 30 year journey was greatly frustrated by a misalignment of stars.  The last time the Democrats held the balance of power as they do now was in Jimmy Carter’s first two years (1977-78).  At that time these hippies were much too junior to exert much influence in the House and Senate.  And, so the dream to radicalize America fizzled.

But, now comes the next opportunity.  But, for the leadership, their last opportunity since many of them are in their 70′s and will literally be pushing up daisies  when the next opportunity comes around.  So, we see the most heavy handed legislative pushes on record to move health care “reform,” cap and trade and card check to remake America as some socialist utopia.

True to their boomer roots this leadership will push this agenda forward with out the slightest care about the consequences and damages their children and grandchildren will have to bear.  They care not a whit for unintended consequences since they will live their remaining years on a lush congressional pension and then be dead shortly thereafter.  They have exempted themselves from the maw of rationing that will be unloaded on the rest of America thanks to their socialized medical monstrosity.  And, they will be able to avail themselves of what was once the finest medical system on earth before their “reforms” grind American medicine into the socialized mediocrity that now graces England and Canada.

Reid plans to jam health care reform through on reconciliation or some other obscure parliamentary trick to side it through on 51 votes.  This will in effect kill the filibuster and turn the Senate into a more grandiose version of the House. Frankly, Reid has the votes; it only takes 51 votes to kill the filibuster right now.  But, once that rule is gone, it’ll never come back.  But, what does Reid care that he’ll turn the deliberative functions of the Senate into an over-glorified student senate.  He’ll be departed from the scene; hopefully as soon as November 2010.

And, this same leadership is fighting to jam this bill through before anyone has a chance to read it.  This may give Reid, Pelosi and company some cheap thrills.  But, it’ll be murder for their party.  Because the Republicans, going into 2010 and 2012 will have over a thousand pages of selective quotes from that unvetted bill to bludgeon the Democrats. Remember, the actual reform doesn’t take place until 2013.  So, the actual vote buying potential of this entitlement will not be around until after the 2010 mid-term elections.  Nor the 2012 presidential election.

To hell with all of you left on the Titanic, suckers, I’ve already got my place on the lifeboat.

Socialized Medicine; More Snuffing

Let’s start with Clive Cook’s commentary about medical care in the US being far too expensive for the results is obtains; as compared to statistics of such things as longevity when compared to other countries around the world.

The cost differential is the cost of treating patients out on the margins.  But, before we discuss that more specifically, we need to explore some fundamental concepts that animate our attitudes about the worth of the individual.  The United States and its founding documents–Declaration of Independence, Constitution, Bill of Rights–reflect the highest attainment of the ideals undergird the amalgam of concepts and ideas that we call Western Civilization.  And, on its own as well as part of that amalgam is Judeo-Christian morality.  These ideas and the institutions that they spawned all have a common thread of elevating the rights of the individual and preserving those rights.  

These are moral precepts based on a God that created man in His own image, gave him the knowledge to know Him and the free will to acknowledge God.  This is the God of the Ten Commandments; rules that supersede any majoritarian or human authority.  This is a God that will require every human to stand alone, at the final judgement, and be judged worthy of Heaven on his actions alone.  No Nurembergian “collective guilt.”

It is with this in mind, we have developed a sense of individual worth through the ages that is designed to protect those rights conferred upon the individual by his Creator.  And, our secular institutions reflect that philosophy.  Trial by jury of one’s peers; so as to check the power of governmental authority.  The jury stands as the highest officers of the court, who’s decision is final.  Not guilty will stand regardless of the case the state may have made.  Rule of law.  Due process.  Presumption of innocence.  The burden of proof on the accuser, not the accused.  A Constitution and Bill of Rights that acknowledges and secures right; not grants them. 

This commitment to the individual is reflected in all our activities, economic and otherwise.  It is reflected in our medical care and medical system.  Is it more expensive than any other country in the world?  Heck, yes!  But, that’s American Exceptionalism.  Besides, for all the blathering about how much we spend, as a percentage of GDP, on medical care, I’d rather have 84 percent of the American economy than, say, 95 percent of the Canadian economy.

But, medical care today is being fought on the margins.  Just like the defense of our rights secured by the Bill of Rights.  All the easy stuff has been done.  The big gains in life expectancy and infant mortality rates came largely because of public health measures.  Public sanitation; sewers and clean water.  Immunizations.  Better nutrition.  

Medical progress is now being made into rarer disorders.  And, in pushing the frontiers in the care for the critically ill.  Or, neonatology.  It is reflected in the medical economic fact that eighty percent of a group of insured persons consume only twenty percent of the benefits paid out.  And, the sickest twenty percent consume the other eighty percent of those benefits. 

The most expensive year of your life, medically, is your last year of life.  As is your last hospitalization.  About thirty to fifty percent of Medicare dollars fund this phenomena.  

Infanticide is still practice in many portions of the world.  In many of these societies, poverty so rampant, that resources aren’t available to try to salvage these “defective” babies.  Even in the case of a cleft lip/palate baby.  These are otherwise fully functional humans; but the care, rehab and surgery to repair these deformities is enormous.  The US doesn’t fare well in statistics regarding infant mortality rates since we count premature babies in our statistics of live births.  While the field of neonatology has made great strides in salvaging many of those babies, many, more than full term infants, still die pushing up our infant mortality rates. 

To take a completely mechanistic view of human life, to equate life as some many parts that make the machine of society function; you can ask why we keep some many “defective’ people around.  Or, at least, if we don’t immediately discard them outright, why we spend so much in giving them medical care above and beyond those in society who are still working.  Those persons who are still functioning cogs.

All of the above creates hundreds of billions of dollars of temptations to deny care.  Dead people are much cheaper than keeping sick people alive.  In a single payer system this temptation can go unchecked.  Only in a private, market-based system, where 300 million people interact in their own respective self interests do checks exist against such base temptations.

Those temptations are in operation even as we speak.  The British system deny renal dialysis for any over the age of 59.  Your kidneys go out, you die.  Here in America, cigarette taxes are jiggered to maximize revenue, not to discourage smoking.  And, those same said state treasury officials know that smokers usually die at the age of sixty; no state Medicare or Medicaid costs for these folks since they never make it to age 65.  State helmet laws for motorcyclists are being questioned; not wearing a helmet usually kills outright.  That’s much cheaper than surviving and requiring medical care. 

There are lots of illnesses that, at the margins, require very esoteric and very expensive medications.  How about Infliximab (Remicade) for Rheumatoid Arthritis.  It wholesales for about $20,000 per year per patient.  Or, do you just draw the line and let them become cripples.  The Remicade lobby isn’t very big since sick people, by virtue of their debilities, will have very little economic pull.  In the brave new world of government health care all medical decisions will be political.  The sickest will likely be on the margins economically as well.  Unless you have the cash, serious cash, like the amounts to buy a recently vacated Senate seat from Illinois, you’re not going to get some health care bureaucrat to score you twenty grand worth of Remicade.

It’s very easy to fudge the statistics to truly marginalize the sickest twenty percent, create billions in savings and even show, statically, that our new governmental health care system is superior to the old system.  Stop counting pre-term infants as live births.  With no pre-term infants, it becomes easier to stop funding such care.  Those babies die, but, no one’s counting.

Of course, no health bureaucrat is going to order pulling the plug on granny sitting, comatose, on a ventilator in some intensive care unit if she’s surrounded by tons of loving family.  But, how many old folks live, alone, moldering in some nursing home out on the wrong side of the tracks.  Why bother with that last hospitalization, that last year.  They won’t live long enough to matter as a vote.  No witnesses.  No real advocacy.  As mentioned above that last year, last hospitalization is something like 50 percent of Medicare expenditures.  Over 100 billion dollars per year.  That would go a long way to Obama’s goal of saving one trillion dollars over the next ten year.  So tempting.

Fifty bucks of Pentothal is so much cheaper than 100 thousand dollars of hospice care.  And, in Oregon, assisted suicide is legal.  So tempting.

 

The Perniciousness Of Evidence Based Medicine

Here, from Hugh Hewitt is the outline of Waxman’s health care reform bill.  I’d like to specifically comment on the provision for “evidenced based medical practices.”  And, to comment on how pernicious a practice that can be.  Medicine in not pure science, rather it is more like engineering.  It is a reflection that the human body is too complex to accurate model on the lab bench and expect those results from the lab to work in the day to day real world.  

The best examples of this concept can be drawn from the world of engineering.  One can create a small chemical reaction on the lab bench and prove out that a certain new material can be made, say a plastic.  It can then be determined that this new material will have thus and such properties.  And, those properties can be deemed desirable enough to make in large quantities for commercial purposes.  But, miniscule variables, to small to be detected on the lab bench because of the small quantities involved, now become major problems in creating the same material on an industrial scale as you scale up from making a few ounces of this material to now making hundreds or thousands of pounds per hour of that same material.

One does not create a new aircraft merely by drawing a blueprint and going directly into production.  You create models, test the aircraft in wind tunnels.  Then you hand craft your first full scale model, the prototype.  Then you take that prototype out for a first flight.  Which amounts to taking the aircraft off and landing it.  Just proving that the basic concept works.

Human bodies, like the examples cited above, involve the concept of the “black box.”  Inputs go in and reactions/outputs come out.  We, sort of know what happens inside, but not quite.  Therefore, we carefully tweek the inputs until we get the desired outputs.  Science may give you the ball park figures the basic inputs, but engineering empiricism makes the final adjustments.  At every aircraft plant.  At every chemical refinery.  In every surgical procedure, in every operating room, every day.

The effects of Evidence Based Medicine will be the following.  The most important would be to render vast stores of medical knowledge, knowledge that is the reflection of literally thousands of years of empiric experience, “suspect.”  In fact, going back and instituting double blinded studies to brings this medical knowledge into the evidence based medicine” clubhouse would be immoral and unethical.  

The ancient Egyptians knew that one treated a boil or abscess by incision and drainage.  Penicillin was never involved in double blinded trials for bacterial meningitis.  What was once a disease that had essentially a one hundred percent mortality was now cured by penicillin.  Much of our modern knowledge in handling trauma came from our experiences in handling combat casualties from the Vietnam War.  The appendectomy was invented about 120 years ago and has been a well established procedure for the once lethal disease, appendicitis.  

And, now we’re going to double blind all of the above?  Of course the all-wise solons who will run Obama care will avoid the bad publicity of denying antibiotics for bacterial meningitis sans a double blinded study.  But, in the name of cost containment, there are a lot of more obscure treatments and diseases that can be denied for that reason.  Because, absent the imprimatur of “evidence based,” these treatments can be denied because they are “experimental.”

The fact is that double blinded studies forever run against the constraint that you are purposely denying a potentially life-saving treatment to one half of the cohort you intend to test for efficacy of some new treatment.  And, unless you truly do not know which alternative is indeed better, you are embarking on an unethical and immoral practice of medicine.  Further, you must have provisions to break into the blinded study should you discover, mid-study, that one group is indeed benefiting.  Yet, with hundreds of billions of dollars at stake, there will be plenty of temptation to start to cut ethical corners.

The second factor will be to freeze new treatments, procedures and drugs from ever making it to the market; to the patient.  With the government controlling the purse strings, it will have an enormous financial incentive to not advance medical knowledge.  With money controlled and curtained to test new advances, we have no way to meed the “evidence based” standard.  And, absent that standard, empiric experience gets buried.  Medical advances, for what they will be worth, will be few, highly selective and highly politicized. 

Consider the parachute.  This was a humorous article published in the British Medical Journal in 2003; but a profound commentary on the serious shortcoming “evidence based medicine.”  It pointed out that the efficacy of the  parachute had never been tested in a double blinded study.  And, why not?  People have survived falls from airplanes with out wearing parachutes.  People have died despite the proper use of a parachute.  Do people who choose to wear (or not wear) parachutes self-select?  We have all sorts of variables left unanswered and yet we spend millions of dollars equipping our military pilots and paratroopers with these untested (from an evidence based perspective) devices.  Maybe we should take the advice of the authors and put together a “double blind, randomized, placebo controlled, crossover trial of the parachute” for the advocates of evidence based medicine.  Maybe Obama, with his cool faith in science, can volunteer his administration.

Socialized Medicine; Stiffing II

Here’s the report from the Fox News web site.  And here.  A coalition of health care leaders will present a program to “save” two trillion dollars over the next ten years; thereby making Obama’s health care reform fiscally possible by reducing the up-front costs.  What this really is is crony capitalism.  These players get a place at the table, and a cut in the profits.  In exchange, they will do what everyone in government is unwilling to say–ration.

In going to the nirvana of single payer health care, the government is going to take over the private sector to the tune of one trillion dollars per year.  Of the two or so trillions dollars that make up 18 percent of the GDP, the share that is spent on health care, about 45 percent is already tied up in governmental medical programs.  The rest, in the private sector, is what takes care of the rest of us.  And, through cost shifting and unfunded mandates, props up the shortfalls of the governmental sector.  

There is no such thing as “uninsured.”  Thanks to EMTALA (emergency medical treatment and active labor act), you can walk into any emergency room and must be seen, evaluated and deemed “stabilized” regardless of ability to pay–even if you’re an illegal immigrant.  Whether, you show up for a cold or you show up, flat on your back, having just smeared your face over a mile of interstate after wrecking your motorcycle, drunk.  In fact, so 50 percent of emergency visits are gratis thanks to EMTALA.  The fact is, once the private sector is consumed by the government for matters medical, the government will formally own all of those mandates.  That trillion dollars that will be confiscated by the single payer government program is already accounted for.  It will be a recurring cost, above and beyond the current Medicare/Medicaid tab, forever.

So, two trillion divided by ten means that we have to come up with 200 billion dollars of “savings” for the next ten years.  This is assuming that the profligate spending and loose monetary policy doesn’t ignite a round of inflation like that of the 1970′s.  

What this savings really means is there will be an effort to forgo 200 billion dollars of medical care each year.  For hospitals, forgoing expansions and modernizations.  Forgo new investments in equipment.  And certainly, no acquisitions of technology to push into new treatments; since we can’t have even more cost with even newer medical techniques.

But, I don’t know how our hospitals are going to turn down nurses who want raises to cope with rising tax and inflation burdens.

For the pharmaceutical companies; new drugs cost a billions dollars or more to bring to market.  You can kiss drugs with limited applications goodbye, the so-called orphan drugs.  There have been incredible breakthroughs for myriads of diseases; but at a price.  People griping about these new medicines forget that many have replaced surgery or offered a treatment where heretofore there was none.  Welcome to the brave new world of none.  Most of these big drug companies have their fingers in the manufacture and distribution of generics.  I suspect that emphasizing generics rather than innovation will be the new business model for Barry O’s brave new world of single payer health care.

Insurance companies?  They just hired themselves out as the price enforcers.  They, not their governmental overlords, will take the heat for poor reimbursement rates and care denials.  All to keep our politicians accountability-free.  They’ll make a nice profit at being the fall guy.

And the doctors.  Well, you can get free care right now by walking into any emergency room.  It’s required by law.  You’ll also wait 12 hours to get seen.  Only, now the waiting will extend to every clinic and doctor’s office in the land.  

Ration.  That’s the real deal being cut between these health care players and the administration.  Protected turf in exchange for taking the fall for rationing.

 

Socialized Medicine; Stiffing and Snuffing

A few thoughts about Barry O’s plan to take us to universal health care nirvana.  It’s real expensive.  Now in a the-dog-ate-my-homework moment, we have even newer tax proposals to pay for the monstrosity.  

First the stiffing.  Medical care consumes about 14 to 18 percent of the GDP which works out to about 1.8 trillion dollars annually (these are rough figures).  Already 800 billions dollars are in some way tied up with governmental programs such as Medicare and the like.  So, the question is what to do about the one trillion dollars that still lie in the private sector.  But, the biggest dead beat in the medical system is the government; not the uninsured.  Which means that trillion dollars isn’t just lying around just waiting to be expropriated, banana republic style.  That trillion dollars is already tied up in propping up governmental programs.  

This money, the private sector money, already makes up for shortfalls in the form of cost shifting.  The practice of charging more in other areas to make up for shortfalls in governmental reimbursement.  Moreover, there are any of a number of unfunded governmental mandates regarding requirements of the rendering of care.  EMTALA (the Emergency Medical Treatment and Active Labor Act) requires, regardless of ability to pay, legal status or citizenship, that hospitals provide emergency treatment regardless of ability to pay.  The law provides no mechanism for funding this mandate.  And, something like half of all emergency room presentations go uncompensated.  These costs are written off as bad debt by the hospitals.  Or, these costs are built into general costs and charges of the hospital to make up that shortfall.

And, as big a money loser EMTALA is, it really get expensive when it comes to trauma care where you can run through $20,000 worth of care in the first 2o minutes of presentation.  And, a lot of these folks aren’t just innocent bystanders.  Drunks with jaw fractures who were “just minding their own business” at the local bar.  Or, drunks, laced with other illicit drugs who happened to roll their cars in a motor vehicle accident.  Also, very likely not wearing seat belts.

The bottom line is that that trillion dollars in the private sector isn’t free and clear.  Huge chunks of the money are already accounted for and spent to keep Medicare and Medicaid from collapsing.  Trauma and emergency rooms services are, in essence a tax amounting to hundreds of millions of dollars, given gratis but virtue of unfunded governmental mandates.

This trillion dollars is also what brings new innovation to medical care.  Demographically driven medicine, a large part what falls into public health, will no longer yield significant savings or new treatment horizons.  Epidemics of, say, cholera, are largely things of the past simple because we’ve already invested in sewers and municipal water systems.  Vaccines are now common place.  And, so on.  Health Maintenance Organizations (HMO’s) have been playing this worn out turn since the 1930′s without any measurable effect.  

In the same fashion, Obama’s proposal to create some governmental program to “honestly broker” treatment options.  He makes a hypothetical of say Minnesota doctors treating patients of 25 percent less than, say, Florida doctors.  But, these guidelines work except in exceptions.  Which happen just about every time you see a patient.  Moreover, Florida’s residents being, on average, older that those of Minnesota, will likely have sicker patients requiring more resources to obtain a similar outcome.  And, everyone would just be healthier if they would all just exercise, cut those trans-fats and stop sitting in front of computers blogging.  So, shall we have the health police banging on our doors every morning so we get out and exercise.  And, shutter every McDonald’s.  Maybe, in the name of health care savings those Florida residents should do their patriotic duty and just die (more below).

The real frontier is technology driven medicine.  This frontier is hard to predict in terms of breakthroughs; and these breakthroughs create new arenas for medical treatment.  They create more demand.  They create more cost.  Because people actually want this treatment because they want to live and live comfortably.  But, this area will be sucked dry because of the cost and in order to limit care (see, again, below).  MRI scanners have allowed more accurate diagnosis in a myriad of disorders.  Our small town of Casper, Wyoming has four or five such machines.  More that entire Canadian provinces.  But, accurate diagnosis leads to unanticipated demands in whole new arenas of treatment.  Socialism above all requires stasis and ossification.

Then, to, is the fact that much of the medical infrastructure comes from the private sector.  Whether a private doctor’s office or a major medical center.  Governmental medical programs have largely piggy-backed on the infrastructure.  In many respects, governmental medical programs have largely survived because these programs merely make use of capacity at the margins.  Economic medical decision making is first of all, based on the economics of private sector finances.  Only then do you figure out if a given service can stand, economically, on governmental reimbursement.  If new medical initiatives rested on reasonable profits from governmental medical programs, you’d see all sorts of medical construction in our inner cities.

Finally, of course, will be the stiffing of the doctors themselves.  It will be some sort of pressure that will evolve from government fiat and monosopy power as a single payer.  Surgeons and specialties that do procedures can better survive, to a point, because one can be reimbursed both the procedure and the visit.  But, a primary care doctor, without the benefit of procedures, is going to go out of business.  A grim reality even today as Medicare patients are having increasing difficulty finding doctors that will take Medicare.

But, while those “bad” doctors may be everyone’s favorite whipping boy, are you also going to cut reimbursements in the form of salary cuts to our nurses?

The bottom line is that trillion private sector dollars will become a recurrent cost annually.  It might inject some honesty into the system since the unfunded mandates will also become a formal governmental responsibility.  Therefore, each and every year, the federal government will need to raise one trillion extra dollars just to nationalize what we have.  New initiatives?  New coverages?  New innovations?  That’s going to cost extra.

Now the snuffing.  As in killing.  And, this will ultimately be the effect of rationing.  In some fashion, rationing of medical care will result in people dying.  And, on purpose for reasons outlined below. 

Can this really happen?  Well, yes, because is already is in a sub rosa fashion.  The great tobacco settlements were supposed to drive a stake in the heart of big tobacco.  And, those settlement monies were to educate the public to finally put an end to that filthy habit of smoking.  We’ll pass over the fact that humans have been smoking and fermenting just about every plant since time immemorial.  What really happened was that every state in this settlement became a knowing partner in the enterprise of tobacco use because of the tax revenues.  And, states, instead of taxing cigarettes out of existence, tax at a rate to maximize revenue.  Moreover, state treasury officials know that smoking usually kills the smoker of a nice clean heart attack at about age 60; thereby freeing the state of any expense for future state Medicare and Medicaid expenditures.  It’s a wonder that the Social Security Administration isn’t pushing to revitalize smoking habits.

Debates over state motorcycle helmet laws now revolve on the fact that lack of helmet wearing usually results in the motorcycle rider being killed outright.  A much cheaper out come that treating a helmet-wearing rider who survives but with severe, very expensive to treat injuries.

Europe’s experience with euthanasia has already crossed a number of ethical barriers.  Doctors increasingly make decisions out of greater loyalty ”gate-keeping” state medical resources than loyalty to a patient.  Elderly in Holland are afraid to go to the hospital over this very fact.  This fear serves as a great rationing tool since the hospital isn’t expending resources on that patient.  If that patient were to die, all the better, since dead patients are really cheap to treat.

A colleague tells me, that in New Zealand, cardiac surgeons don’t work very hard.  On purpose.  It can literally take months to get a heart operation.  You might even die in the interim.  More bottom line savings.

And, oh, did you know that approximately 50 bucks of Pentothal is a lot cheaper than 100,000 dollars of hospice care?

Rationing is particularly pernicious to American Exceptionalism and a governing philosophy that organizes around the concept of the maximization of individual liberty (the pursuit of happiness).  Yes, as a surgeon, I have participated in the agonizing decision on when to “pull the plug” on a hopeless ill, dying patient.  And, in doing so, have had to face the fact the in this particular case, any further efforts are simply futile.  But, this was a decision entirely made by private parties.  Done only after assuring ourselves that we left no stone unturned.  Done without the intrusion or pressure of outside parties with other agenda, read financial, forcing a decision.  This was a decision with me acting with an overarching philosophy that only the best interest of my patient matters in this decision.

One must understand the tension of medical economics and Judeo-Christian morality that plays in this issue; and how government sponsored rationing will tear down the latter.  In tearing down the latter, to spawn an attitude that runs contrary to the importance of the individual and individual rights.  Those individual rights that are central to this thing we call Western Civilization. 

Modern medicine operates at the margins.  As a volunteer manager of our mutual medical insurance plan, I note, in reviewing our financial data, that 20 percent of our members covered consume 80 percent of the resources (in the form of medical benefits paid out) and the other 80 percent consume on 20 percent of the resources.  In the case of Medicare, we find that your last year of life, your last hospital admission, will be the most expensive.  Some 30 to 50 percent of Medicare expenditures specifically fund these very expensive end-of-life events.  Note, by being on the margins that many of these patients are in no real position to defend themselves.  Their illnesses impair their ability to work with a concomitant income disadvantage.  They are individuals, who if they died, wouldn’t materially affect statistics such as longevity and infant birth rates; especially if you knew how to fudge those statistics.  If you count infant mortality rate as only term babies, the infant mortality rate for premature births never comes on the radar.  You’re only a step away from saving enormous bucks by letting those premies, just, go.  If you’re in the last year of life, on that last hospital admission, national longevity statistics aren’t going to materially change if, you, just, pull the plug.  There’s hundreds of millions of dollars on the line if you do.

On the other hand, there is the temptation to move  into post-Christian (? pre-Islamic) America and abandon the Ten Commandments and their requirement to honor our mothers and fathers.  Well, maybe the ten suggestions.  There is the temptation to abandon the concept that every human is indeed a unique individual, created by God in His own image.  There is temptation no longer respect a life time of work and contributions of our elders and give comfort  and respect in their old age; rather, to discard them with the old Chicago Machine greeting of “Yeah, but what have you done for me lately.”

There is a temptation to embrace your inner socialist and no longer regard each citizen of our republic as a resource and spark of creativity.  But, to regard people as so many parts of a machine that consume food, shelter and create a big carbon footprint.  Machine parts to be discarded and replaced as they are worn out.  It becomes tempting as a “gate-keeper” to dole out medical resources only to repair those “parts” that are still functioning and “worth” repairing.  It becomes tempting to, say, regard every retiree as useless dead weight, past prime and past repair, to be discarded since maintenance now far exceeds the replacement cost.  Especially if your butt isn’t on the line.

It is only that trillion dollars, in private hands, that will effectively enforce the precepts of the sanctity of the individual and stand firm against the financial temptations to cut ethical corners in the name of preserving the public’s” medical resources.

The Sociology of Socialized Medicine

Before we complete the deal, elect Obama, and turn heath care, lock, stock and barrel, to the government consider this. Socialized medicine is the ultimate government give away. And, the ultimate lie because it isn’t free.

Our GDP is about 13.8 trillion dollars for 2007. Medical care accounts for about 14 percent of the GDP. Or, about 1.9 trillion dollars. Medicare accounts for about 5 percent of the GDP; about 700 billion dollars. That means we have to account for about the 1.2 trillion dollar difference between what comes from the government, primarily in the form of Medicare, with what comes from the private sector.  These are rough figures that don’t account for other public medical programs.

But, these figures are here to make a point. And, the point is not to quibble over exact numbers. Rather, the proposed government takeover of medical care is going to cost, in 2007 dollars, on the order of one trillion dollars. Moreover, because the biggest deadbeat in the medical care system is the government, the legally mandated steeply discounted care that is Medicare is covered by cost shifting from the private sector. This is particularly acute in primary care where there is little in the way of procedures to bolster the poor reimbursements of Medicare.

You will not be able to place the entire health care system a Medicare-like system and think that you can extend the current payment system over the rest of the medical care system that will be nationalized. Any nationalized medical system is going to have to cough up something on the order of a trillion dollars above and beyond is spent in the public sector. 

But, this is not a transfer of money from one account to another. It’s not the issue of waking up one morning and finding you’re working for the government whereas you worked for yourself the day before. This is not limited to physicians. This will sweep in every health care worker; nurses, respiratory therapists and on and on. Even the folks in the hospital kitchen. It may be easy, in the court of public opinion, to stiff the physician. But, physician fees only account for twenty percent of the total health bill. You need that trillion dollars unless you think its okay to stiff our nurses and paramedics too. And, again, since the private sector is propping up the public sector you will need that entire trillion dollars.

Now, wither that trillion bucks? Is it simply an even exchange? Less personal expenditures in exchange for a higher tax bill? Of course! Remember, this is supposed to be free. Magically health care will appear and someone else is going to foot the bill. A trillion dollar honey pot. A trillion dollars to be wisely doled out by dispassionate government experts who will insure every dollar is now spent for the best possible care possible. Expenditures can now be rationally applied so that all of the shortcomings of our impossibly broken system can be corrected. And, ACORN hand in hand Freddie and Fannie was going to give everyone a free house.

Of course not. Expenditures will become hopelessly politicized. Every dollar of this trillion dollar transfer will be doled out for maximal political effect. A single payer Health Care System will devolve into a trillion dollar vote buying fraud. This doesn’t begin to start into the issues of funding abortion.

So, in addition to shouldering the taxes that this trillion dollar transfer will represent, those who want real medical care will be forced to develop a new parallel private system. Just like in England. Canada hasn’t developed such a parallel system since it had the US just to the south to prop up their faltering system.

The simple fact is that there will be employees that will have the bargaining power to negotiate better health benefits than the lowest common denominator health system that Obamacare will become. And, Obamacare, al la the Chicago political machine, will fulfill its role as primarily a distributor of graft and favors. Medical care was never the priority. If you want to see the future of medical care for lumpenproletariat just visit Cook County Hospital. 

Now we get to the subject of small business; which includes many medical practices. Obama’s tax proposal to give everyone a tax break under the $250,000 level of course more than implies that those taxes will be borne by those above that level. As has been noted elsewhere, those $250,000 plus kulaks are small business who file 1040′s as s-corporations or sole proprietors. Before we even deal with the nationalization of medical care, were going to, as small businesses, start shelling out a lot more in tax dollars. Physicians have to deal with the business of medicine. Good intentions and the Hippocratic oath don’t pay the rent, electricity and nurses salaries. Recovery out of this latest mess from the sub-prime mortgage mess will be in the hands of job creation of small businesses; including your local doc.    

But, going further, at the stroke Obama’s pen, a whole class of small businesses will be wiped out. Just at a time we’re going to need every penny of economic growth to get out of this economic downturn, we’re going to nationalize the other ten percent of the fourteen percent of the GDP spent on medical care. We can kiss all that entrepreneurial drive good by.  And, we’re going to get the New Deal II with all the bells and whistles we could ever want; including the Great Depression.