AMA opposes marriage and "Don't Ask, Don't Tell"

November 10, 2009, delegates to the AMA interim session approved resolutions recommending that the AMA oppose same sex marriage bans, urge redefinition of marriage under federal and state laws. They also recommend the ending of the "Don't Ask, Don't Tell" policy in the military.

"Report 1" - "REPORT 1 OF THE COUNCIL ON SCIENCE AND PUBLIC HEALTH (I-09), Health Care Disparities in Same-Sex Households," is only published in the "members only" access, in advance of publication in a "peer reviewed journal." There is a specific request *not* to publish the report. However, for those of you who would like to review the report, let me know and I'll forward the pdf.

Report 1 tells us that, according to census data, approximately one third of people living in same sex relationships are uninsured, while also noting that slightly less than 1% of the US population lives in same sex households. The Reference Committee report states that "Adoption of this report further strengthens AMA policy in support of issues impacting same-sex households."

The AMA currently recommends that members be aware of and work to prevent possible health care disparities among men and women who live in same sex partnerships. However, by adopting this report, the delegates have now apparently voted to encourage a wide-spread untried and potentially unhealthy social experimentation by calling for the redefinition of marriage on behalf of 0.33% of our population in order to "support measures providing same-sex households with the same rights and privileges to health care, health insurance, and survivor benefits, as afforded opposite-sex households."

Surely, the same goal can be achieved without demanding that all States and the Federal Government change their definition of marriage.  It appears that even the State of Washington, which just voted to afford the same rights of marriage to same-sex couples, did not go far enough to make the radicals happy.



The resolution concerning "Don't Ask, Don't Tell" originally asked that the AMA oppose using any disclosure to a health care professional for dismissal. However, the reference committee recommended and the HOD approved, a substitute resolution that goes far beyond support for patient confidentiality in health care:
"HOD ACTION: Substitute Resolution 917 adopted.
"REPEAL OF “DON’T ASK, DON’T TELL”
"RESOLVED, That our American Medical Association advocate for repeal of “Don't Ask, Don't Tell,” the common term for the policy regarding gay and lesbian individuals serving openly in the U.S. military as mandated by federal law Pub.L. 103-160 and codified at 10 U.S.C. § 654, the title of which is "Policy concerning homosexuality in the armed forces.""

It's getting harder and harder to tell myself that I must continue my AMA membership in order to make a difference with in the organization. I'm beginning to be afraid that by adding to their numbers, I'm part of the problem, rather than a help.

Politics bites science

For a clear outline as to why you shouldn't believe that 45,000 people die each year because they don't have insurance, read the blog entry by John Milloy, publisher of "Junk Science" on last week's report in the American Journal of Public Health.

Forget that the authors are blatantly biased members of the "Physicians for a National Health Plan."

All you need to know is:
# Among the many problems with the study, here are four of the most glaring; all of which will likely be missed by the media:

* The researchers assumed that study subjects lacking health insurance at the time of the interviews did not subsequently gain or regain insurance coverage. In fact, a study subject could have received health coverage the very next day after the interview and this would not have been considered by the researchers.
* The researchers essentially assume that lack of health insurance at the time of interview is the causal factor in the deaths that occurred. No data was gathered to back up this assumption.
* None of the data collected during the interviews, including insurance status, was validated by the researchers.
* The study result is statistically weak. Combined with the peculiar date-of-death cutoff (the year 2000 as opposed to any other year), it raises questions as to whether the study result was produced by “data dredging” – essentially cherry-picking data that provides the desired result.

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.

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."

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.