Elkhorn Creek Lodge

Socialized Medicine; More Snuffing

Posted in medical by Eugene Podrazik on May 31, 2009

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.

 

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GM; An Abortion Known As “Industrial Policy”

Posted in uncategorized by Eugene Podrazik on May 30, 2009

“What’s good for GM is good….”  You know the rest.  The irony, is that GM and the US government has been bound at the hip for nearly three quarters of a century.  It started with the Wagner National Labor Relations act.  And, ended there.  For this company, in particular, became the vehicle that has been the government-mandated honey pot for the UAW.  

Indeed, with governmental help, GM evolved into a Social Security agency and a Medicare agency; with three out of every four UAW members drawing down on retirement benefits.  It a wonder that GM had any time to make cars.  This charade led to GM’s current business model of manufacturing large cars, SUV’s and trucks to generate the profits needed to subsidize the lush benefits that the UAW now enjoys.  Moreover, the CAFE standards were originally conceived to keep small car production in the US, thereby guaranteeing more UAW jobs.  So, those same said large cars and trucks also had to subsidize small car production as well.

This delicate homeostasis succeeded until energy became politicized by the environmentalists.  The act of pumping gas became political statement.  And, scientific inquiry about global weather patterns became similarly politicized.  

An energy policy designed to create scarcity, to drive up the price of gas, succeeded with four dollar per gallon gas last summer.  And, GM’s balancing act collapsed.  Not that any of this ever had to happen.  Because, most Americans like large cars.  We are, generally, a country that has a very low population density.  Ours is under 100 persons per square mile as opposed to populations densities in the hundreds if not over a thousand persons per square foot in Europe or Asia.  We therefore, on average travel farther for a given trip.  And, given these longer trips will want to carry more.  Hence the need for a bigger car.

Energy policy that abandoned the flat-earth mythology of global-warming (sorry, climate change), could easily provide the necessary gas, well under two dollars per gallon, by off-shore drilling.  Extraction of shale-oil.  Nuclear power.  The energy densities of these sources outstrip all other sources.  It is only because of energy production politicization that “alternative” power sources are remotely economically viable. 

Yes, there are people who live in very congested inner-city areas who would want a very small car.  But, the free market is more than capable of providing such cars.  But, in America, we engage in gigantic carbon-footprint activities such as having, instead of aborting, children and that, with our low population density makes for a demand for larger vehicles–like Obama’s Tahoe.  But, how about letting individuals choose what they want to drive?  I guess not in Obama’s command economy.

So, welcome to the brave new world of econo-boxes.  Mandated by Obama’s acolytes in the EPA and department of transportation.  Actually, the brave-old world of econo-boxes.  Once again, thanks to Reagan and the prosperity his policies engendered, we have a whole generation of people who simply forgot or never experienced the world of the 70’s.  Remember the le Car?  Or, the Gremlin, Pinto or Maverick?  How about the incredibly sexy 1974 Mustang?  Or, a car so bad, it became the official wheels of Wayne’s World–the AMC Pacer.

And, so, the picture at the top of this post is supposed to represent the new, Obama controlled GM (h.t., Drudge).  What we have is a state controlled car company capable of being as innovative as the old Soviet block manufacturers that gave us the Lada or the Trabant.  GM is going to require permanent government subsidies to give away these cars.  Because, for those with some pocket change left after Obama’s systematic looting via taxes, you aren’t going to lay down one penny more on something out of GM.  We’ll also know when some lowly bureaucrat is out an about since they’ll be driving one of those ridiculous GM econo-boxes.  The GSA is going to become the official buyer of all products, GM.  How else to prop up the US Treasury’s investment in GM.

Since, Obama’s GM will keep the Cadillac nameplate, we’ll also be producing the Zil.  So, our solons will be able to look down upon all of us unwashed rubes as they are whisked to their oh so important governmental meetings.  We could even, like in the old Soviet Union, have special lanes reserved for the limousines of the high party big-shots.  

In a way, it’s fitting.  Keep  GM. Because GM has been the province of the government and the UAW since 1935.  Produce exactly the kind of cars that the enviro’s get wet dreams over.  And, keep the UAW as an object lesson, with three retirees for every worker on the line, for the future of Medicare and Social Security.

 

Spilling Secrets

Posted in biden by Eugene Podrazik on May 18, 2009

We learn that our Veep, Joe Biden, spilled the beans on the existence and location of a top-secret bunker reserved for the Vice President at the Vice Presidential residence at the Naval Observatory.  What was disturbing was the dissemination of such information was done at the Gridiron Club in a manner to set up a shot at former Vice President Cheney to create a impression of a “bunker mentality” and thereby Cheney’s off-the-wall policies.

Here again is another manifestation of a patently unserious administration that now thinks that state secrets are not only to pillory former out-of-office figures from the former administration.  Now, these same secrets are to serve as fodder for jest and humorous talking points.  Not once does it seem to occur that people, like Biden, are given a public trust and entrusted to keep this country safe.  And, this means keeping certain knowledge safe; safe for enemies who would use this information to harm our country and its citizens.  

There is a quaint practice, in the Senate, for the Senators to refer to each other as the Senior or Junior Senator from thus and such state.  Not, notice, a reference to a given Senator by his name.  But, this practice points to a fundamental fact that in filling a Constitutionally mandated office, you the individual lose that identity and become that office.  There is not to be a cult of personality, rather you the individual is subordinated to the Constitution and the office and duties that the Constitution mandates.  Your “feelings” and your “empathy” do not matter when wearing the mantle of power as specified by the Constitution.  

Yet, Joe Biden seems to regard those awesome duties as matter of personal choice.   That the person of Joe Biden is more important than the office of Vice President.  This is a man that barely two years out of law school, won an election as Senator.  And, has spent his entire adult working life drawing a paycheck as a US Senator; and now Vice President.  He is so inured to the trappings of power that he no longer has the perspective to understand the need to subordinate his person to the public trust that serves as the source of his power.  But, what perspective does he really have?  None, because his entire adult life has been in the bubble of power and prestige of being a Senator.  Never, ever, having to derive income by holding down a job that actually requires productivity.  

So, Joe Biden the person, now Joe Biden the Constitutional officer, who so regards all this power as his personal entitlement, makes jokes about state secrets.

The Perniciousness Of Evidence Based Medicine

Posted in medical by Eugene Podrazik on May 17, 2009

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.

Knifing Pelosi

Posted in uncategorized by Eugene Podrazik on May 13, 2009

Rep. Steny Hoyer will allow investigations of “torture” to proceed with he inclusion of investigations of Pelosi’s knowledge.  Oh, there are the usual bromides about how the GOP diverting attention from the “truth” to a witch hunt about what the Democrats knew and when.  

The real truth is that Hoyer knows that everyone knew, the practice of water-boarding was very circumscribed and used with specific intent on specific suspects.  And, that specific intent was the fact that there was information, life saving information, that had to be extracted.  Hoyer also knows that this use of so-called torture was not used gratuitously to extract a confession for some Stalin-purge show trial.  

In sum, this subject as a useful weapon against the GOP is kaput.  And, Hoyer knows that too.  So, Hoyer is now going to use this weapon against an equally inviting target–Pelosi.  He’s got a payback to deliver.  Force her out and he’s the speaker.  Hoyer also knows that the minute Pelosi gets sworn in, these hearing are going to turn into the when-did-Pelosi-know hearings.  At this point, it won’t matter if former vice-President Cheney gets arrested with thumbscrews in his back pocket.

And, then the law of unintended consequences kicks in.  First, you can bet that if Pelosi gets called on the rug, she’s going to be sure she’s got as many fellow democrats who “knew” up there with her.  Further, with the long knives out, there’s a very good chance that just about every other agenda on the Hill is going to be dropped.  Especially, if there’s any chance that there’s going to be a shake up in the House leadership.  And, Obama might as well as take his teleprompter to Death Valley to yammer on about having his program priorities delivered to his desk by thus and such a date.

All of which points to the lack of leadership and executive experience of either Pelosi or Obama.  Obama farmed out his agenda to rich dilettante, by virtue of marrying well, whose first act was to come up with a “stimulus” bill that beyond caricatured the “tax and spend” liberal.  Then Obama came up with these torture memo releases with the full knowledge, despite his protestations to the contrary, that his fellow travelers would immediately use them in an anti-Bush show trial vendetta.

All of which, increasingly, will distract from issues that will really make or break Obama’s presidency–putting the country back on track to prosperity.  Executive experience would inform Obama that you need to focus your agenda, sort through all the chaff and distractions to find the real issues that need to be addressed and to pick your lieutenants very carefully.  Of which, Pelosi turned out to be a very poor choice.  Not that I’m complaining that hard.  There’s a very good chance that Obama’s agenda is going down in flames all over informed executive experience that would have told our President that there are somethings you just leave alone.

Socialized Medicine; Stiffing II

Posted in economics, medical by Eugene Podrazik on May 11, 2009

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.

 

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Socialized Medicine; Stiffing and Snuffing

Posted in economics, medical by Eugene Podrazik on May 10, 2009

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.