Qualify for government subsidy: become a(n involuntary) unionized government employee

 Next up: doctors, section 8 housing owners, ????? Grocery stores, drug stores???

A year ago in December, Ms. Berry and more than 40,000 other home-based day care providers statewide were suddenly informed they were members of Child Care Providers Together Michigan—a union created in 2006 by the United Auto Workers and the American Federation of State, County and Municipal Employees. The union had won a certification election conducted by mail under the auspices of the Michigan Employment Relations Commission. In that election only 6,000 day-care providers voted. The pro-labor vote turned out.

Many of the state's other 34,000 day-care providers never even realized what was going on. Ms. Berry tells us she was "shocked" to find out she was suddenly in a union. The real dirty work, however, had been done when the state created an "employer" for the union to "organize" against.
Of course, Michigan's independent day-care providers don't work for anybody except the parents who were their customers. Nevertheless, because some of these parents qualified for public subsidies, the Child Care Providers "union" claimed the providers were "public employees."
Michigan's Department of Human Services then teamed with Flint-based Mott Community College to sign an "interlocal agreement" in 2006 establishing a separate government agency called the Michigan Home Based Child Care Council. This council was directed to recommend good child-care practices—and not coincidentally, to serve as a "public employer." Although the council had almost no staff, no control over the state subsidies and no supervision of the providers' daily activities, it became the shell corporation against which the union could organize.
Thus the state created an ersatz employer and an ersatz "bargaining unit" against which what was essentially an ersatz union could organize.
Today the Department of Human Services siphons about $3.7 million in annual dues to the union—from the child-care subsidies. The money should be going to home-based day-care providers—themselves not on the high end of the income scale. Ms. Berry now sees money once paid to her go to a union that does little for her. She says she is "self employed and wants nothing to do with the union."

No Connection - Hasting Center Essays Miss the Mark

The Hasting Center has published an online collection of essays called"The Values and Health Care Reform Connection" allowing the public to comment on health care and "American Values." You have to admire the awareness of the academics - not only have they noticed that the conservative, pro-life, religious “American” is concerned with values, but they are trying very, very hard to appeal to those of us with a Judeo-Christian background. I’ve only skimmed a couple of the essays so farm but I have found a glaring inability to stay on task or a basic lack of understanding of the world view of the intended target, uh, audience.

For example, in “Stewardship: What Kind of Society Do We Want?,” Len M. Nichols misses the mark in spite of peppering the essay with terms like “stewardship,” “abundant life” and “covenant” and appeals to the writings of John Locke and Thomas Jefferson.

 (Skip over the use of a faulty, biased 2009 Institute of Medicine report on the consequences of lack of universal health care insurance in the U.S., already thoroughly debunked by Steven Malloy’s “Junk Science” blog.)

In his appeal to “American Values,” Nichols attempts to define “stewardship” to include a “covenant” as a duty of property owners to ensure that the poor have food to eat. He refers to the book of Leviticus and Jewish Law that land owners leave “the corners” of their fields for the poor to glean, rather than going back to harvest all that is there.  While noting that the rule was propagated the “other books that Moses wrote,” Nichols explains that only adult males could own land "in ancient Palestine." He would have been better off referring to the “Torah” or “the Law,” which was given by G_d, not Moses, and to the Nation of Israel, since there was no “Palestine” at that time.

Nichols almost persuades me that he “gets it” in his discussion of the basis for rights: the belief that humans are created in the image of G_d. However, he asks what good is the right to life or the pursuit of happiness without access to essential health care and quotes Jefferson’s comparison of liberty with health. He does not seem to understand that both Locke and Jefferson described these as negative rights: the right not to be killed, and the right not to be enslaved or have ‘the fruit of one’s labor” forcibly taken. In other words, no one has the right to cause another to be sick, but there is no right to medicine or medical care.

Nichols does not resort to the usual call for Christians to remember the Good Samaritan. In fact, he turns to an argument that might be more appealing to Libertarians, whom he calls “a tiny group of argumentative people.” His discussion of rights and stewardship by is converted to support for the rationing of health care, noting that Leviticus does not require the landowner to bring the poor person home and cook him a meal. In this, too, he demonstrates his lack of understanding of the Judeo-Christian world view. The covenant to care for the sick and poor is between individual believers and G_d. Government hasn’t proven itself to be trustworthy enough for me to assign my duty to G_d over to its stewardship.

?No self breast exams?

The recommendation *not* to teach exams throws the whole report into question for me. If we are changing the frequency of mammograms, should we also change the recommendation to do self exams? Won't the first change the effectiveness of the second?


In the news, the report by the Agency for Health Care Research and Quality. The "conventional wisdom" about breast cancer screening was turned on its head - or, at least tweaked, this week.

I think we might have been over doing the mammograms ("MMG"), but the old recommendation to do a "baseline" MMG between 35 and 40, with self exams each month and MMG each 2 years from 40 to 55 and then one a year or each 2 years according to risk, made sense to me.

What I absolutely don't get is the recommendation to stop teaching self exams. Teaching self breast exams received a "Grade D" recommendation - meaning there's no empirical evidence that the procedure is "effective." In other words, it has "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The practice would be "discouraged" -- considered bad medicine, and actually put the doctor at risk for criticism. It most certainly won't be paid for.

There's a reason to find masses: it will change what we do, we have treatment that we can and should do for positive changes. Any mass that's fast growing and lasts over a month is highly suspicious and any mass we can feel should be biopsied. Even though the sensitivity may be low (compared to MMG), patients who do regular exams have been proven to be more likely to find masses earlier and smaller than the doc would at an annual exam, and it's non-invasive, cheap, and accessible. Teaching the self exam gives me something to talk about while I'm doing my own exam of the patient and is an opportunity to explain what I've written, above.

It looks like the fuss over the recommendation will be the first test of the realities of "Comparative Effectiveness Panels" which was funded by $1 Billion allocated in the 2009 "Stimulus Package."  Emotions and reactions are high, with Health and Human Services Secretary Sebelius,  Medicare and most insurance companies already reporting that their policies (paying for annual MMG and recommending teaching at doctors' exams) won't change. The Mayo Clinic has absolutely renounced the recommendations.

For more information on the policies of other nations, see this article.

Aristotle ethics, RFK, and health care reform

The Wall Street Journal's daily newsletter by James Taranto, The Best of the Web Today, debunks a quote floating around the Internet to support the "right" to health care paid for by government. The blurb has been attributed to a translation from the writings of Aristotle, a translation from the original Greek by Robert F. Kennedy.

Unfortunately, the first reference to the quote is from 10 years after Senator Kennedy died, is credited to someone else, and the original cannot be found in the existing works of Aristotle.

From an article by Edmond Pellegrino, the last chairman of President Bush's President's Bioethics Council, written in 2008:

In attempts to establish the provenance of the text in question we have conducted an extensive search for its source and original wording. We have not been able to locate it. Our initial curiosity was aroused by several things, including that rights language did not seem to have the Aristotelian context, and health care, as such, was not included in Aristotle's works. We searched Nicomachean Ethics and Eudemian Ethics, and the Magna Moralia without successfully locating the quote. Nor could we find it in other of works of Aristotle: On Length and Shortness of Life, De Anima, Economics or the Fragments. "Rights" language certainly would stick out in Aristotle's virtue-based ethics.

That article by Dr. Pellegrino is available in pdf, here, thanks to the WSJ and Georgetown Bioethics.

Playing doctor with the White House

Who’s playing doctor with the White House: Another example of the lack of openness in the dealings of the Obama Administration

(Informed consent blurb: Organizing for America, etc., along with all the White House websites, are collecting data including email and other information from everyone who visits or contacts their sites. I got a couple of those emails from David Axelrod last month.

Don't worry - they already have my data. I used to email President Bill Clinton at least once a month and ask him to resign for the sake of our daughters – they are about the same age - because he'd set the women's movement back 50 years. He never answered. However, it occurs to me now that maybe that's why I was named to the Bush Administration's National Advisory Committee on Violence Against Women.)

On Thursday, September 17, 2009, I was web-surfing and searching Google news hits on the September 12th March on Washington and health care reform when I found information about a conference call between "Doctors for America," the White House "Office of Public Engagement" and doctors like me who somehow found out about the conference call.

I called in, but wasn't called on to ask my questions, so I re-wrote them as an essay (see below) and emailed it to info@drsforamerica.org I'm also sending the essay to the White House OPE.

When I started writing up my notes from the call, it finally occurred to me that – even though there was no attempt at disclosure - there might be a connection between "Drs for America," "Organizing for America" (whose website address is still "http://www.barackobama.com/ ," the same url once used by - and the remains of - “Obama for America,” the Barack Obama campaign machine.

I was slow to catch on, but I was right: The leadership at Doctors for America is made up of nearly the same roster of men and women who, in 2008, were the leadership of “Doctors for Obama” in 2008. Common names are Vivek Murthy, MD MBA, Mandy Krauthamer, MD MPH, Nikhil Wagle, MD, Alex Blum, MD, and Jay Bhatt, DO MPH

And, I was wrong: there’s a disclaimer at the bottom of the “Doctors for Obama” leadership page that says “Not affiliated with Obama for America.” (Yeah, right.)

In fact, former Obama Administration transition chief John Podesta's “Center for American Progress” funds the group :

May 04, 2009
'Doctors for America' launches

This may not wind up being decisive in the health care fight, but the organizing gap between the two sides continues to widen.
Sen. Max Baucus and the Center for American Progress Action Fund are announcing a new group on a conference call later this morning: Doctors for America, which is a reincarnation of Doctors for Obama, an arm of the Obama campaign that boasted more than 10,000 members.
The question of patients' relationships with their doctors is always a flashpoint in debating changes to the health care system, so doctors are often particularly credible messengers.
Today they'll "release new reports detailing the depth and breadth of America's health care crisis and announce a new effort to amplify physicians' voices in support of health care reform," according to the advisory.
By Ben Smith 11:07 AM

Here's the bio on the President and Co-founder, Vivek Murthy, MD MBA, at the Center for American Progress website:

Vivek Murthy is an internal medicine physician at Brigham and Women’s Hospital and an Instructor at Harvard Medical School. He received his undergraduate degree in Biochemical Sciences from Harvard University, his MD from the Yale School of Medicine, and his MBA from the Yale School of Management. He completed his residency training in Internal Medicine at Brigham and Women’s Hospital. Vivek is the co-founder of VISIONS and the Swasthya Project, international health non-profit organizations focused on HIV/AIDS education and women’s health, respectively. He is also the co-founder and chairman of Epernicus, LLC a web-based professional networking service for individual researchers and scientific institutions. Vivek’s past research has focused on the participation of women and minorities in cancer clinical trials; his current research interests include physician satisfaction and burnout. During the 2008 presidential campaign, Vivek served as a member of the Obama Health Policy Advisory Committee and the Obama New England Steering Committee.

Notes on the Conference Call

I couldn't catch all the names and I am not very good at telling who was speaking, but did try to take some notes from the opening statements. The quotations are the actual words of the speakers, the rest is my own interpretation and from memory.

The moderators talked about the "public option" as though it's a done deal and strongly pitched it as just a way to provide health care for people who have lost their insurance.

We were told that everyone will be required to have insurance, and that businesses will be asked to "chip in their part."

The White House has a plan to fix the SGR that has been pushed off over and over. In fact, there are plans for a “complete reform of the physician payment system.” without incentives for doing more procedures.

The President has given instructions to begin the medical liability demonstration projects to find a way to decrease defensive medicine while "mitigating risks to patients."

We were told that we are closer than we've ever been to health care reform this year.

The moderators were surprised by the second doctor who said he was from the former Soviet Union and that the public option would soon become the only option. They were adamant that the public option is not a pathway to single payer. (And besides, we all know that being paid by and regulated to the teeth by the government is not at all like working for the government.)

Later, one of the docs who called in asked specifically about the news stories that the public option was finished and the White House representative reminded us that the legislation is not written, yet. He was adamant that we shouldn't rule the public option out and that we should advocate with our patients and fellow doctors for that option.

One doctor asked about the effect on doctors with concierge or boutique practices and the other doctors who "opted out." The answer from one of the men was that these practices were just a reaction to cash pay patients who couldn't afford insurance.

There was a lot of excitement about one doctor's suggestion that doctors be required to give two years to a sort of National Healthcare Workforce. And huffy about the shortage of doctors that a Massachusetts doc reminded them that they'd have if all the uninsured were suddenly looking for primary care.

The woman naturopath was reassured that naturopathic primary care doctors would be evaluated by the same evidence based medicine that the traditional docs were judged by.

My letter to Doctors for America and the White House Office for Public Engagement

I’m Beverly B Nuckols, MD, the National chair of the Family Medicine Section of the Christian Medical Association as well as a member of the AMA, the Texas Medical Association and the American Academy of Family Physicians. I'm not officially representing the above, but I believe that my opinions are shared by a large number of doctors.

Many of my colleagues and I see the Patient Centered Medical Home plans, the protocols at Mayo and other medical centers that have been praised are attempts to model a bureaucratic form of practice for large practices so that they can do what the family doctor does every day.

My experience is that government bureaucracy is not only more restrictive and punitive than private insurers, the clout of the Federal government results in undesired UNINTENDED consequences all across the board. Doctors used to be the good guys, but now we feel as though we are assumed to be guilty of abuse of the system, largely due to Federal legislation and regulation.

These result in time and money spent on our futile attempt to keep up with Medicare regulations in order to avoid charges of fraud, abuse and waste. For instance: HIPPA, National Provider Identification numbers, bullet points and check boxes, E & M’s, procedure and diagnosis codes and qualifiers that change each year, and a whole alphabet soup of regulators.

In addition, government cost control attempts in the '90's actually limited the numbers of graduate medical slots, while encouraging sub specialty growth in relation to numbers of primary care doctors.

Making it all worse is the fact that under current Medicare payment schemes, Family Doctors who provide the same services as sub-specialists are paid less by Medicare.

Like the laws and regulations in the past, this year's “reform bills” and proposals are overly complicated and try to guarantee too much: school based clinics, nutrition data on menus and buffet lines, an overhaul of the federal income tax code, new lists of “enhanced penalties,” taxes, fines and the mixing of all of the above abuses with an overhaul of the Federal Income Tax.

Today’s announcement about the study of liability makes me worry that our Texas laws concerning tort reform will be over come by Federal inertia and interference.

1. Why not just look at Texas’ experience with tort reform rather than wasting time and money on new studies?

2. Is it possible to make the legislation smaller in scope so that it is focused on providing help for those patients and families who cannot afford or access medical care?

3. What plans are there to ensure training and sufficient payment for family physicians and other primary care doctors who are in the best position to coordinate care for our patients in the "Medical Home?"

Edit: added this 4th question that I believe I sent to Doctors for America:

4. Could the fines and mandates be replaced with tax incentives, removal of restrictions on Health Savings accounts, return of the major medical plans and the removal of the barriers preventing patients from owning their own health care insurance?

ABC explains the Obama Administration

ABC News Senior White House Correspondent Jake Tapper has written an article, "When Academic Words Become Political Ammunition," that gives an anonymous "White House official's" rebuttal to the many concerns expressed about President Obama's choices for advisers and "czars" who will affect the shape of health care policies. He attempts to debunk criticisms of the philosophies of Ezekial Emanuel, MD (a bioethicist who is heading the push for control of health care finance and delivery in order to provide universal insurance) and John Holdren, director of the White House's Office of Science and Technology Policy.

The problem is that with Medicare and Medicaid, about half of medical care in this country is already paid for using tax dollars, and we are currently considering expanding tax dollar payment for nearly all health care in the Nation. I disagree with Ezekial Emanuel's position, referenced in the Hastings journal article, "Where Civic Republicanism and Deliberative Democracy Meet," which is linked (in pdf) at Tapper's essay:

Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all - or almost all - available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services un- covered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.

In fact, while we are concerned about the amount of taxes that will be imposed, the Tapper essay points out that we are very much afraid that government interference in health care will result in more limitations, so that none of us will be allowed, much less "guaranteed," to seek medical care that will prolong our lives and make us feel better, unless we are seen as members of a group that is more valuable than others. The examples that Dr. Emanuel gives and our observation of the government pre-paid medical care schemes around the world lead us to believe that, the more health care is financed by tax dollars, the more expensive and rationed it becomes.

Academic mind experiments that do not draw a line between what is acceptable and what is condemned by the authors understandably will be interpreted by others as at best, neutral, at worst, in support of condemnable acts.

Obama Press Conference Transcript

The transcript of the press conference is on line at the Washington Post.

However, if you want an annotated version, try this blog.

Ann Coulter on government Health Care finance

On the other hand, there's Ann Coulter's take.

Give Ann a chance, here. She makes some very good points.

Addendum -- Including this one:

Now the Democrats want to force us all into one gigantic national health insurance plan that will cover every real and mythical ailment that has a powerful lobby. But if you have a rare medical condition without a lobbying arm, you'll be out of luck.

Governor Jindal reminds us how FEMA helped flood insurance

You may not be aware that the only way to buy flood insurance is through FEMA, the Federal Emergency Management Agency. In fact, the Agency draws the lines for the Flood Plains and so, decides whether you need flood insurance.

Executive Order 12127

President Carter's 1979 executive order merged many of the separate disaster-related responsibilities into the Federal Emergency Management Agency (FEMA). Among other agencies, FEMA absorbed: the Federal Insurance Administration, the National Fire Prevention and Control Administration, the National Weather Service Community Preparedness Program, the Federal Preparedness Agency of the General Services Administration and the Federal Disaster Assistance Administration activities from HUD. Civil defense responsibilities were also transferred to the new agency from the Defense Department's Defense Civil Preparedness Agency.
John Macy was named as FEMA's first director. Macy emphasized the similarities between natural hazards preparedness and the civil defense activities. FEMA began development of an Integrated Emergency Management System with an all-hazards approach that included "direction, control and warning systems which are common to the full range of emergencies from small isolated events to the ultimate emergency - war."

As we learned in 2005, the centralized bureaucracy is not the most efficient method of responding to the disasters of flooding. (It might have helped if the former Governor had allowed earlier response.)

Governor Jindal discusses possible "bipartisan" health care reform measures, here.

Health Care Reform: Tax and Spend (and abortion on tax dollars)

(Editorial correction: Sermo was not begun by the AMA. It is a private group, possibly funded originally by pharmaceutical companies. But, no one there knew the funding source.)
(The vote is now nearly 11,000, and still against the new plan.)

How about a simple solution to the rising government expenditures for health care: don't "force Congress" (See President Obama's press statement video, here. At 6 minutes 40 seconds, he says "force Congress.") to spend more money!

Or, we could try Biden's plan to spend more so we won't go bankrupt as we bankrupt the insurance companies and increase the numbers of people on government-paid health care and increasing mandates that health care funding cover more and more "benefits."

The AMA started a blog-type website that can only be accessed by licensed physicians in the US. 94% of the 2949 docs who have responded to the poll on that site, Sermo, oppose the AMA's endorsement of the current House plan. 96% say that the AMA does not speak for them. The top concerns that the doctors have include interference in the doctor-patient relationship (34%) and malpractice/tort reform (32%).

I've already sent my request to the AMA Board of Trustees to rescind their endorsement. CBS news reports that

"Separately, the White House urged Speaker Nancy Pelosi to toughen the emerging bill so it will hold down the future increases in Medicare payments to doctors, hospitals and other providers. The request, in a letter from Budget Director Peter Orszag, came one day after Congress' top budget official warned that as drafted, the legislation fails to slow the growth in health care costs nationally."

The House Bill still doesn't have a bill number. It's gone from 300 pages to 600 pages, to the current 1018 pages. It's here http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf

All of the Democrat-controlled committees in the House and the Senate have blocked amendment after amendment that would have limited or blocked taxpayer funding of abortion. This is at the same time that the House Finance Services legislation passed, which will allow tax money to pay for abortions in the District of Columbia!

The House's plan will make it impossible to have private insurance if you don't have it at the time the plan passes and those plans will be restricted from changing, except for adding costly benefits that the House mandates. They won't be able to charge anyone any copays for "preventive services" - well child care, physicals and colonoscopies, etc. These requirements will bankrupt the insurance companies.

Everyone who does not have a plan at the time the House "reform" goes into effect will be forced onto the public plan on day one. If they don't sign up, they pay a fine of 2% of their income - this is in addition to the new employer tax and the new "surcharge" tax on the rich - or as Speaker Pelosi says, "a very few people will help with the revenue stream."

(Cross posted to Comal County GOP blog)

$1 Trillion to cover 11 Million people

According to the Associated Press, 37 Million people would remain uninsured under the legislation discussed in Kennedy's Senate Health, Education, Labor and Pensions Committee. If there are 48 million uninsured, now (not, more below), then one trillion dollars to cover an additional 11 million people.

Can you imagine? There's no coverage at all for people who aren't eligible for Medicaid, but who make less than 150 percent of the Federal poverty level ($33,000 for a family of four.)

Of course, some of this cost comes from subsidizing families of four who make $110,000 a year. In fact, 60% of the cost will be in the subsidies for people who make 150% to 500% of the Federal poverty level.

(We won't mention the cost of regulating restaurant menues and forcing the placement of nutrition information on those menues and on notices next to each item on a buffet line. Or the as-yet uncounted costs to the chefs who must calculate and document their recipes in order to know those nutrition facts.)

Daschle/Dole/Baker! Health care on the fast track -along with the entire Nation's finance

Right after this Yellow Brick Award ceremony, I'm thinking that it may save my life for me to learn to use Twitter and Facebook. Now.

While President Obama is planning to take over the entire finance world ASAP, ABC is planning their all-day infomercial for Obama and his push - there is no "plan," yet - for health care "reform" by July 4. No opposing or alternate viewpoints will be allowed. They're even refusing to take a paid-for program in rebuttal, according to the Drudge Report.

ABC REFUSES PAID ADS OFFERING ALTERNATIVE VIEWPOINT FOR WHITE HOUSE HEALTH CARE PROGRAM
ABC is refusing paid ads for its health care program at the White House. Thus they're refusing even a paid-for alternative viewpoint.

Conservatives for Patients Rights requested the rates to buy a 60 second network spot immediately preceding the broadcast of the Town Hall meeting.

While looking for verification of this story, I came across several that report that former Senators Tom Daschle, Bob Dole and Howard Baker are working on a health care "compromise." (Come on! there's a reason they aren't Senators any more!)

See their report, "Crossing the Streams Lines" here.

So, we'll have a Secretary of the Treasury (who claims to be unable to do his own taxes using Turbo Tax) running Wall Street and all the banks. We'll have a known plagiarist and serial failed Presidential candidate (who also can't figure out that gifts and services are taxable) working with another serial failed presidential candidate (who took money for telling the world that he needs a little pharmaceutical help in the bed room) working to reign in the cost of doctors, hospitals, and those pharmaceutical companies. (The third player in the health care waters is Baker, another serial failed presidential candidate. It's just that no one's ever heard of him.)

But don't worry -- even if you are able to vote for a completely new House and a turnover of a good portion of the Senate in 2010, Obama will still run the Census out of his Committee to Reelect the President.

In the meantime, Obama is planning to cut Medicare fees to Hospice, hospitals and doctors while instituting a new tax on health care insurance benefits from employers, according to the Washington Post.

Why not? After all, Daschle had to pay taxes on his limo and driver and Geithner had to pay them on his kids' summer camp!


Addendum after skimming the report:
The "Crossing the Lines" report is full of calls for more regulation with a sprinkling of pablum.

First, they demand that everyone have health insurance. (Could be acceptable if we were allowed to chose between Major Medical and From-First-Dollar. And if it weren’t for the rest of the trash.)

They believe - or at least claim to believe - that it will pay for itself. (Who knew old white haired men could be so funny?)

How will the money be raised?

By a “trigger” to enforce cuts when costs reach a certain point and by not paying for those treatments that are considered less effective.

What are they going to do with all the men and women who insist on antibiotics, today, for their bronchitis? Will they protect the doc when the patient develops bacterial pneumonia?

How about my man in his mid-80’s with a 102 fever in the ER, a bladder infection, multiple falls that resulted in bruises and skin tears, and potassium at 2 (normal is 4)? Medicare would not allow me to actually admit him because he turned out not to be septic by their criteria. He ended up on “Observation” for 3 days while his wife and I tried to find some safe place for him to go after discharge and I tried to get a handle on his potassium. He left for the rehab hospital with a potassium of 2.6. On a heart monitor. Because Medicare rules threaten us with charges of “fraud and abuse.”

How about our local hospice? Obama has announced his intention to cut funding to hospice. I guess there’s not much efficacy in hospice. After all, the hospice patient is, by definition, expected to die within 6 months. However, hospice patients are less likely to present at the ER, with the costs of their care much less than hospitalization.

Force Medicare "reform" without proof that it will work?

The Washington Post reports on the latest findings of the "Medicare Payment Advisory Commission" (MedPAC) today. According to the WaPo, this is a "commission that advises Congress on the federal medical program for older Americans."

In other reports, there is mention that President Obama plans - at the same time - to cut Medicare and Medicaid funding by over $900 Billion dollars, to somehow expand the numbers of Americans who are given "guaranteed health care" under some government "public plan," and to pay for any expansion by taxing insurance benefits given by employers.

And it all has to be done in the next two weeks:

For months, Obama remained on the sidelines of the health-care debate because "he felt it was important to not be too proscriptive," Axelrod said in an interview. "Now we're into a different phase, where decisions are being made very quickly, so it's time to weigh in to a greater degree."

The Obama strategy, articulated in the speech here and in a series of private meetings, is to present each major stakeholder with an enticement in return for a bit of sacrifice.

Again, there's mention of "accountable care organizations," and how to force doctors into them. This time, we do learn that coercion will be necessary to form these organizations and that there's evidence that these sort of interventions don't save money or improve the health care of patients caught up in the schemes. In fact, some of these interventions are now considered wasteful and the first place to cut:

To illustrate what it might take to save Medicare, the commission describes how primary-care doctors, specialists and hospitals could be reorganized into "accountable care organizations" whose members would receive bonuses if the organizations met quality and cost targets. To ratchet up the incentives, health-care providers that fail to meet cost and quality targets could be penalized, the report says.

Even then, any projected savings would be highly uncertain, the report says. What is certain is that Medicare cannot maintain its current trajectory, it adds:

"If current spending and utilization trends continue, the Medicare program is fiscally unsustainable. . . . Part of the problem is that Medicare's fee-for-service payment systems reward more care -- and more complex care -- without regard to the quality or value of that care."

The report underscores the challenges facing President Obama and Congress as they seek to overhaul the health-care economy. The administration has put a spotlight on what it considers wasteful spending, but it has offered sparse details as to how it would change the incentives that produce the waste.

The report identifies some areas that are ripe for savings. MedPAC estimates that the government is paying private Medicare health plans -- which were supposed to save the government money -- much more than it should. In addition, the government could save money by adopting a more streamlined approval process for "follow-on biologics" -- products that imitate biotech treatments already on the market.

Getting doctors to join accountable care organizations may require pressure, MedPAC Executive Director Mark E. Miller told reporters: "If you want people to voluntarily organize, you may want to make sure that the current system isn't as pleasant a place to be."

The model for accountable care organizations resembles that of large, tightly managed physician groups, practices that have been the subject of demonstration projects, and Medicare's experience with those offers limited encouragement, according to the report. Measurable quality improved in the areas of care monitored, such as for diabetes and congestive heart failure. But "whether the demonstration has actually generated savings for the Medicare program is debatable," the report says.

Policymakers hope that money can be saved by better coordinating care. But, according to the MedPAC report, Medicare pilot programs intended to coordinate care for patients with chronic diseases -- programs that involved insurance companies and other private groups -- generally achieved modest quality improvements. Most of the programs cost Medicare more money than it would have spent without them, the report says.

Downgrading American Medical Care

That image above is from a report in the American Spectator by Betsy McCaughey (the former Lieutenant Governor of New York State) on the true cost of medical care in the United States. It demonstrates that Americans still pay approximately the same for combined food and medical care expenses. As food costs less of the family budget, more is spent on medical care. The reason is that food is less expensive, not that people don't buy food because they have to pay for medical bills.

She also points out that our US survival rates for cancer are much better than those in countries that have longer waiting periods and that spend less on health care.

Why the medical home sounds good but won't work

A sister Family Physician says in her blog, "Musings of a Dinosaur,"

It is the source of endless angst among family doctors in solo and small group practice, because the structure of the PCMH excludes us by definition. The PCMH is advertised to work best in large group practices like Kaiser and the Mayo Clinic. All I can say is "DUH!"You know what the PCMH really is? Nothing more than this:

IT'S A WAY TO MAKE LARGE GROUP PRACTICES WORK MORE LIKE A SOLO DOC!!!

I am already performing every meaningful function of the PCMH. So is virtually every physician in solo and small group practice. There is absolutely nothing to be gained -- and a significant amount of money to be lost; this thing is expensive! -- by adopting any of this PCMH shit. Somehow that doesn't seem to stop our Academy from tossing us to the wolves by simply ignoring us.

Trust me, I have no conscience (Again and again, and again)

Siricou Raven, that gadfly of the prolife blogger, says I'm using scare tactics, that the NHS pays for dialysis, and that we pro-conscience doctors are afraid that 'THE GAYS WILL DESTROY MEDICINE!!!!' Oh, and Bush did it!

Well, what do you expect of people who don't have consciences and who are told by the Powers that be that we must violate any oaths we've taken for money and law?

It's not Gays and Lesbians we're trying to protect ourselves and our consciences from - its their lawyers. Beginning in 2005 and through last month, ACOG broke one of the strongest tenets of modern medicine: Thou shalt not put thy colleagues in greater malpractice risk.

The conscience protection ruling is a synthesis of current laws. The synthesis was only necessary because in 2005, the American College of Obstetricians and the American Board of OBGyn turned their quiet attack on pro-life residency candidates (few programs will accept pro-life doctors) into an effort to change laws (lobbying the US Senate) and amended their own ethics policies to put not only ACOG members, but all doctors at risk of losing their certification, their licenses, and increased our lawsuit risk.

Obama, what's-her-name, and Daschle are bought and paid for by Planned Parenthood and NARAL. (Daschle sent out letters against George Bush in '04, on NARAL's letter head. After the SCOTUS allowed the Partial Birth Abortion Ban, Sebelius vetoed 3 separate bills due to their limits on abortion. And Obama made his famous "first thing I do is sign FOCA" speech to PP)

Most people have access to the $4 Walmart drugs. Our little town has 2 low cost clinics, one is free of charge, one has a cost of less than $5. Everyone who can raise the money can have the latest and greatest -- not so in the NHS. A few years ago, it was illegal to sell Tamiflu in Great Britain, because NICE said it was.

Years before that, Dialysis was limited to those under 55 years old. Echoing that, this year, a man in his 50's was told he would not get surgery to stabilize his ankle until he kicked his nicotine habit.
http://www.dailymail.co.uk/news/article-481617/Doctors-refuse-fix-builders-broken-ankle-unless-quits-smoking.html

Our hospital has indigent care, as does our County. We doctors see patients for cash and are aware when their costs are out of pocket. (My phone has a program that has formularies for local insurance plans. The patient and I discuss whether they want the once a day Tier 4 drug, the twice a day Tier 3 or the 4 times a day generic.)

Goodbye Medicare, hello County Clinic

Where is the outrage over the destruction of (what is left of) Medicare and the debt we owe to veterans? I'm afraid that we're not talking about "Medicare for all," or even "Medicaid for all." We're talking about County Clinic for all.

For a look at the proposed cuts in cost for Medicare, take a look a this table.

Consider that "reduce costs for re-admissions" and the "bundling" of hospital and outpatient costs after a hospitalization.

That means that Medicare will only pay a flat fee to the hospital for any hospitalization and follow up care after the hospitalization and will not pay if the patient has to be readmitted for complications or a new illness within a certain period of time. Patients would not be able to return to their family doctor for follow up care, unless the doctor works for the hospital. And there would be a lot of pressure to keep patients out of the hospital.

People who "cost" Medicare the most money would be encouraged to forgo care. I predict a huge push for hospice care for anyone with complicated, chronic diseases. (Or, possibly, a back-alley, underground medical care system for cash and barter. Wonder how long that will be legal?)

The AMANews reports that coordination of care doesn't lower costs to Medicare, only 2 out of 15 of the model centers cut patients' days in the hospital, and that the coordination is burdensome for small and solo practices. For every 100 patients, we interact with 99 other doctors in other practices. (I knew it was a lot.) (I don't think any of these links require subscription, let me know if there's a problem.)

This is my favorite part from that article:

"It doesn't matter if you back up a truck to their offices and drop off bundles of money," Dr. Norman said. "They don't have the time, resources or expertise right now to put this all in place."

Speaking of "bundles of money," the stimulus has a chunk to support Community Health Centers, as reported by Reuters' Maggie Fox. Will these centers really be open longer hours, as advertised, and will they continue to mandate the hiring of mid-levels (Nurse Practitioners or Physician Assistants), rather than allowing the hiring of physicians with the grants, as currently the case for other Federally funded clinics?

The budget includes plans to pay for the 667 Billion dollar health care for all by cutting payments to “providers” (including doctors and hospitals, pharmacists and wheel chair companies), according to the Wall Street Journal. We're already scheduled to have that automatic “Sustainable Growth Rate” 20% cut in Medicare payments to doctors, next year. Want to bet that the cut won't go through and/or won't be considered part of the "savings"? (And mesh with the President’s plans to cut the deficit.)

That WSJ and the LATimes articles also mention a “public” health care plan, and possible new taxes (on the employer’s portion of insurance payments or a new income tax).

Speaking of which, the Massachusetts mandatory health insurance trial isn’t working - even to make sure that people have insurance or are able to see their doctor in a timely manner - according to the Boston Globe The solution? That old United States National Health Insurance Act, paid for by "a modest progressive tax."

Elections have consequences (abortion, contraceptives, committees)

ABC's This Week with George Stephanopolis ran an interview with Speaker of the House Nancy Pelosi on Sunday, January 25, 2009. The transcript is here.

Stephanopolis allowed the Speaker to gloss over her policy that does not allow debate or amendments from the House floor, or that no Republicans were allowed to see or vote in Committee on last week's SCHIP Bill ("H.R. 2 is rushed legislation by the Democrat Majority that did not hold a single committee hearing or allow amendments to be offered on the bill."), and were only given a summary at 5:30 AM on the day of the vote.

STEPHANOPOULOS: The president has made it pretty clear he wants this to be a real bipartisan effort. Yet House Republicans have said they have been shut out of this process. There were no Republican votes in the appropriations Committee, no Republican votes in the Ways and Means Committee.
PELOSI: Well, because the Republicans don't vote for it doesn't mean they didn't have an opportunity to.

While I believe that true contraception, as in prevention of the union of sperm and oocyte, is ethical, I had planned to move strait to the Speaker's comments about Family Planning funds. However, it appears that the President was listening to the voters, even if the Speaker hadn't.

Posted: Tuesday, January 27, 2009 11:41 AM by Domenico Montanaro
Filed Under: White House, Congress

From NBC’s Mike Viqueira
The provision within the stimulus that would allocate money for contraceptive programs through Medicaid will be pulled out of the package.

NBC News confirms that the president called Henry Waxman, the chairman of the committee that inserted the contraception provision into the stimulus during the mark up last week, to ask him to remove the measure from the bill, according to a Democratic leadership source.

In short, the idea has simply become too controversial. Speaker Nancy Pelosi's defense of the program over the weekend, where she indicated that it would be a money saver, was not well received.

So that provision is out.

Complicating matters, both Minority Leader John Boehner and No. 2 Eric Cantor have told House Republicans that "all Republicans should vote against the stimulus" if it remains "in its current form," according to a GOP leadership aide.

They spoke inside their weekly conference meeting, behind closed doors. Afterward, both men came to the on camera stake out. The House will begin debate on the stimulus package late today, with no votes expected until tomorrow. Debate is expected to begin somewhere close to 5 p.m. ET.

The way your U.S. House works is that anyone who wants to offer an amendment to be considered on the floor has to go to a committee, the Rules Committee, beforehand.

The Rules Committee is a complete and utter tool of the majority leadership. (Emphasis mine, BBN.) It decides which amendments will be allowed on the floor for consideration. The minority is habitually unhappy with the result, as their measures, especially the ones that have a chance of passage or contain some political mischief or "poison pill" language, are barred. The Rules committee meets this afternoon to make its decisions.

So, besides politics, what's all the fuss about?

Part of the problem is the $50 million for the National Endowment for the Arts, ACORN, $200 million for sod for Washington, DC parks, $20 Billion for electronic medical records, and the emphasis on global warming research (with its increased costs for housing, transportation, food production and all aspects of our daily life).

One day after the 36th Anniversary of Roe vs. Wade and as the number of electively aborted children in the United States alone (non-medically necessary, not associated with "rape, incest, or the life of the mother") approaches 50 Million, President Obama overturned the so-called "Mexico City Policy" or "global gag rule." US tax dollars will once again be allocated to organizations that advocate abortion as birth control, and even those that lobby to change the laws of other nations to allow abortion where it is not currently legal. Every news article I've seen conflates the gag rule with limiting non-abortifacient contraception. However, the only restriction is that on abortion.

Another Bill now in the House and Senate, would wipe out abstinence-based sex ed and mandate emergency contraception according to the Rochester, NY newspaper:

* House member Louise Slaughter submitted the Prevention First Act of 2009 (H.R. 463/S.21). In the Senate it was introduced by Democratic Senate Majority Leader Harry Reid.

The legislation focuses on reproductive and sexual health issues, and in some cases reverses Bush administration policies. It provides funding for comprehensive sex education programs, and none for abstinence-only sex ed. Other provisions include mandatory access to emergency contraception for rape survivors, and a requirement that hospital staff provide factual, science-based information on EC, including instructions that it doesn't cause abortions.

The bill would also force health insurers to offer equitable coverage for prescription contraceptives.

And then, finally (from the first link above), Speaker Pelosi on Federally funded contraception for the poor:

STEPHANOPOULOS: Hundreds of millions of dollars to expand family planning services. How is that stimulus?

PELOSI: Well, the family planning services reduce cost. They reduce cost. The states are in terrible fiscal budget crises now and part of what we do for children's health, education and some of those elements are to help the states meet their financial needs. One of those - one of the initiatives you mentioned, the contraception, will reduce costs to the states and to the federal government.

Insurers, you go first

You did know that due to the Social Security Act and the Patriot Act your medical records can be viewed and copied by anyone who claims to be an agent of the Secretary of Health and Human Services, didn't you? Or that those same agents write their own subpoenas? (The best reference is this ACLU webpage, although most of the regulations were there in a weaker form before the Patriot Act.)

Health insurers - the American Health Insurance Plan group and Blue Cross/Blue Shield - said that they would begin covering everyone regardless of pre-existing conditions if the government will mandate the purchase of their products and subsidize Medicaid and SCHIP. And so grows the government ownership of health care.

From what I've seen of mandatory auto insurance, prices don't go down when the government forces everyone to buy a certain product. I don't believe in government mandates as a rule and haven't been favorably impressed with the way government interference in health care, with the creation of HMO's, ERISSA, and the invasion that has resulted in our current draconian Medicare rules and regulations.

Not to mention $2 Billion dollar stock option bonuses and $125 Million dollar salaries, such as those given to William McGuire by United Health Care in the past and the $13 million to $15 million salary of his successor in 2006 and 2007. (For a look at the compensation of the big companies, click on the names of companies at this page.)

I do believe that insurers abuse their ability to refuse or limit coverage and increase fees due to prior conditions. The industry should be able to evaluate the effect of removal of pre-existing conditions by looking at the history of the insured in States like Texas, which do not allow such limitations for most people covered by employers' health insurance. Let us see those numbers and facts and demonstrate your trustworthiness before we even consider using government laws to increase your customer base.

From the press release of the American Health Insurance Plan group:

Health plans today proposed guaranteed coverage for people with pre-existing medical conditions in conjunction with an enforceable individual coverage mandate.

Under the new proposal, health plans participating in the individual health insurance market would be required to offer coverage to all applicants as part of a universal participation plan in which all individuals were required to maintain health insurance.

Health plans also said that premium support for moderate-income individuals and broad spreading of risk was necessary to promote affordability and maintain premium stability in the individual health insurance market.

To ensure that all Americans can access coverage, health plans also reiterated their long-standing support for making eligible for Medicaid every uninsured American living in poverty and strengthening the Children’s Health Insurance Program.

In the interest of showing good will, let the sellers go first.

I'd rather see a law allowing various levels of coverage, including support for Health Savings Accounts (rather than the ridiculous limits on numbers that we currently have) and encouraging more major medical and high deductible plans.

Healthcare lottery

When you buy a lottery ticket, do you choose the cash option with its immediate payout of half the winnings or do you choose the payment of the full amount, doled out over 20 years?

I've found this question to be a good way to help other people understand the difference between conservativism and those who think that someone else can take care of them or the "totalitarian mamas" who believe that they can take better care of us than we could ourselves and for our own good. (Of course, some Conservatives tell me don't gamble, so they never buy lottery tickets.)

It's amazing how many people tell me that they always buy the "cash option." Some say they worry that their families wouldn't get anything if they die before the 20 years is up. Some tell me that they believe they can manage and invest the money to earn more than they would if they wait out the smaller payments. A few tell me that they would rather not have all the money at one time, preferring the guaranteed income over the years or fearing blowing the money.

The latter group never understands why I suggest that their health insurance should be something that they own and control, rather than something doled out by government and their employers.

A "right" is something that we each have without conditions and which we can call on society and government to enforce or punish if someone infringes that right. The right to life is actually the right not to be killed. We expect our fellow citizens to protect us through providing armies and law enforcement, a militia and by allowing self-defense. If another person infringes our right not to be killed, we expect society to punish him.

Last night, Democratic Presidential Candidate Barack Obama stated that health care is a right. I strongly disagree.

"Health" and "health care" are difficult terms to define. Instead of people and their actions, health is threatened by disease, age and injury. If I'm not well, how will society protect my health - and who or what will be held responsible as I inevitably age? If I have a "right" to health care, then I want everything possible to maximize my health. Rights can't be rationed.

What we're really talking about is health care funding. Funding certainly can be rationed. Take a look at Medicare, Medicaid, and the Veteran's Administration.

These systems work fairly well most of the time. However, they rely on limiting the costs of health care. The limitations fail when demand for cutting edge, expensive treatments or emotional arguments override them. That's why Medicare won't pay for a tetanus shot after a dirty wound, but will pay for annual physicals, screening mammograms and prostate specific antigen tests, although there's no evidence that these prolong life.

Or why Oregon Health sends notes telling patients that they won't pay for cancer treatments, but they will pay for assisted suicide.

For more on this subject, here's another opinion.