It is not true that Marie Antoinette said "let them eat cake" when informed that the peasants had no bread. The point of that quote, however apocryphal, isn't to show her as callous though. The point is to show she had no comprehension of the plight of the poor. In the myth she was trying to be helpful by way of suggesting that since cake is like bread if someone is out of bread they can eat cake instead.
In the healthcare debate, with regards to the passage of the Patient Protection and Affordable Care Act of 2010, the debate often centers about people who do not have healthcare. In fact, many of those so described do have healthcare, they do not have health insurance. Those described as lacking care can easily get care, and in many cases do not have to pay.
An unfortunate aspect of the whole Healthcare Reform debate is that advocates of increased government intervention routinely confuse care and coverage. Even after this obfuscation is pointed out, advocates of increased government intervention continue to make the same error. There seems to be no way to shame an advocate of increased government intervention to accurately describe the debate as over healthcare coverage and not over healthcare itself.
And yet, that is the point. Healthcare does become less available the more the government intervenes. "But everyone is covered" does little good if there is nothing the coverage can buy. Many dentists refuse to accept Medi-Medi patients, and more doctors are refusing to do so as well. Massachusetts had to pass a law stating that all Ob-Gyns had to accept the state sponsored insurance. There is a crisis in West Virginia as more and more doctors flee the state due to malpractice lawsuit abuse.
Coverage is expanding, yet what that coverage can buy is shrinking. It leads to the question of what that coverage is supposed to purchase. Is someone in need of a bandage supposed to wrap insurance forms around the injury? Once there is plenty of healthcare coverage and yet no healthcare, perhaps it will be reported that some senior government official will be heard to say "let them eat healthcare."
Showing posts with label Healthcare. Show all posts
Showing posts with label Healthcare. Show all posts
Saturday, June 16, 2012
Friday, May 13, 2011
Rules for thee, not for me
It seems that many of the same organizations that supported the passage of Obamacare are also the organizations that have been
granted waivers to not be subjected to that legislation. It seems rather ironic, because if the people involved in those organizations really believed in the program then they would have no reason to ask for a waiver.
On the other hand, those groups that were not favorable to Obamacare are not being granted any waivers.
In a previous experiment in discussing healthcare reform it was shown that the point of healthcare reform was to force people in to it who didn’t want to be in it. The offer was made that those who oppose healthcare reform would be willing to fund it in exchange for not being part of it. The socialists argue that everyone needs to pay in to it in order for the program to work, so that was given to them. The socialists argue that government healthcare is better, so that was given to them. The price was that those who want a private system get a fully private system, private in every way. The offer was treated with horror.
The previous experiment proved that the whole point of healthcare reform was to force objectors in to a government run system. The current waivers show that the rule is intended only for those who do not want to be in it.
Such blatant hypocrisy can only be the result of a a truly authoritarian mindset where the rules are intended only and completely for political opponents. People are required to either support the ruler and get exemptions or suffer the consequences. By that standard, Obamacare is far more fascist than initially realized.
granted waivers to not be subjected to that legislation. It seems rather ironic, because if the people involved in those organizations really believed in the program then they would have no reason to ask for a waiver.
On the other hand, those groups that were not favorable to Obamacare are not being granted any waivers.
In a previous experiment in discussing healthcare reform it was shown that the point of healthcare reform was to force people in to it who didn’t want to be in it. The offer was made that those who oppose healthcare reform would be willing to fund it in exchange for not being part of it. The socialists argue that everyone needs to pay in to it in order for the program to work, so that was given to them. The socialists argue that government healthcare is better, so that was given to them. The price was that those who want a private system get a fully private system, private in every way. The offer was treated with horror.
The previous experiment proved that the whole point of healthcare reform was to force objectors in to a government run system. The current waivers show that the rule is intended only for those who do not want to be in it.
Such blatant hypocrisy can only be the result of a a truly authoritarian mindset where the rules are intended only and completely for political opponents. People are required to either support the ruler and get exemptions or suffer the consequences. By that standard, Obamacare is far more fascist than initially realized.
Friday, February 25, 2011
Anti-Obamacare Constitutional Amendment
So far twenty seven states have joined in the lawsuit against Obamacare. That is more than a majority, and most of the distance towards the thirty seven states that would be required to pass a constitutional amendment.
The last time a constitutional amendment was almost passed by a convention of the states was the repeal of prohibition. In order to maintain the precedent of constitutional amendments being passed first in congress, the congress acted quickly to pass the amendment before the states would.
Their concern is understandable, if base. The worry was that if the states were to pass the amendment it would be in effect a partial reversal of the trend towards the federalization of political power. This would embolden the states to constitutionally act against the federal government in other ways. Given that President Herbert Hoover was being very activist at the time to fight the Great Depression, sponsoring the programs that eventually were called the New Deal by President Franklin Roosevelt, any measure that emboldened the states against the federal government would be a disaster for federal power. Moreover a constitutional convention could easily go beyond whatever issues initially chartered it.
Given the polarized nature of the congress today, especially given that the Senate is controlled by the same party that passed Obamacare in the first place, it is unlikely that they would defensively pass any constitutional amendment that would weaken that measure. The constitution, meanwhile, forbids tampering with the amendment process.
Twenty seven states is still shy of the thirty seven states needed to call a constitutional amendment. Each additional state is that much harder to recruit. But if that number is reached by states joining the lawsuit then suddenly it becomes easy to call a constitutional convention.
The final problem is what would be the wording of the theoretical amendment. It is far too easy for this to go wrong, just as the congress that passed the twenty first amendment. The best possible outcome is for it to restore proper dimension to the Interstate Commerce Clause. Although Obamacare is a major expansion of the interpretation of that clause, it is a major expansion in the same direction as the previous major extension during the New Deal.
The best wording would be to restore the interpretation as understood by those who wrote it.
1. The federal government does not have the ability to regulate any commerce that takes place entirely in one state, no matter the effect that the intrastate commerce would have on interstate commerce.
2. The federal government does not have the authority to demand or forbid the manufacture, purchase, or sale of any good or service.
It may not be a perfect wording, but it is definitely a great place to start.
The last time a constitutional amendment was almost passed by a convention of the states was the repeal of prohibition. In order to maintain the precedent of constitutional amendments being passed first in congress, the congress acted quickly to pass the amendment before the states would.
Their concern is understandable, if base. The worry was that if the states were to pass the amendment it would be in effect a partial reversal of the trend towards the federalization of political power. This would embolden the states to constitutionally act against the federal government in other ways. Given that President Herbert Hoover was being very activist at the time to fight the Great Depression, sponsoring the programs that eventually were called the New Deal by President Franklin Roosevelt, any measure that emboldened the states against the federal government would be a disaster for federal power. Moreover a constitutional convention could easily go beyond whatever issues initially chartered it.
Given the polarized nature of the congress today, especially given that the Senate is controlled by the same party that passed Obamacare in the first place, it is unlikely that they would defensively pass any constitutional amendment that would weaken that measure. The constitution, meanwhile, forbids tampering with the amendment process.
Twenty seven states is still shy of the thirty seven states needed to call a constitutional amendment. Each additional state is that much harder to recruit. But if that number is reached by states joining the lawsuit then suddenly it becomes easy to call a constitutional convention.
The final problem is what would be the wording of the theoretical amendment. It is far too easy for this to go wrong, just as the congress that passed the twenty first amendment. The best possible outcome is for it to restore proper dimension to the Interstate Commerce Clause. Although Obamacare is a major expansion of the interpretation of that clause, it is a major expansion in the same direction as the previous major extension during the New Deal.
The best wording would be to restore the interpretation as understood by those who wrote it.
1. The federal government does not have the ability to regulate any commerce that takes place entirely in one state, no matter the effect that the intrastate commerce would have on interstate commerce.
2. The federal government does not have the authority to demand or forbid the manufacture, purchase, or sale of any good or service.
It may not be a perfect wording, but it is definitely a great place to start.
Friday, April 09, 2010
Who will be betrayed?
Now that healthcare reform has passed, the onerous task of finding out what is actually in it has begun. But some parts are already known. There is a provision that people must either carry insurance or pay a fine, but the fine is lower than the price of an insurance policy. This is coupled with a prohibition against denying anyone who has a pre-existing condition.
Politicians are convinced this will cause everyone to carry insurance for their own good. Economists are convinced that given the nature of the incentives people will only carry insurance when they actually need it and will prefer to pay the fine the rest of the time. Politicians are shocked when economists tell them that people may deliberately opt to not carry insurance given the nature of the incentives.
The situation is completely unsustainable. One way or another something has to give. The question is what exactly will give? As long as the situation continues as designed then the insurance companies will lose money. Who exactly is congress planning on betraying?
At first people will pay the fines rather than carry the insurance. At first the insurance companies will lose money. Then they will petition congress to raise the fine above the cost of an insurance policy. Then one of two things will happen.
One option is that congress will comply with the wishes of the insurance companies and raise the fines. This will cause people to actually try to contest the validity of the fines in court. This will lead to the argument that by paying the fines before they went up people had agreed to the validity of the fines. Those who had not contested the fines in previous years will have their standing questioned. Perhaps congress will, when raising the fines, enact legislation that anyone who had willingly paid the fine in previous years without complaint have no standing in the future.
The other option is that congress will keep the fines low in spite of the complaints of the insurance companies. Perhaps, adding insult to injury, they will raise the fines but still keep them lower than the cost of an insurance policy, directing yet more money that “should” have been going to the insurance companies to the government. This will bankrupt any company that is offering health insurance and direct even more people to a government healthcare plan.
Neither option is attractive, and it is difficult to say which option is worse. But given the current situation as designed in the healthcare reform bill those are the two possible futures.
Politicians are convinced this will cause everyone to carry insurance for their own good. Economists are convinced that given the nature of the incentives people will only carry insurance when they actually need it and will prefer to pay the fine the rest of the time. Politicians are shocked when economists tell them that people may deliberately opt to not carry insurance given the nature of the incentives.
The situation is completely unsustainable. One way or another something has to give. The question is what exactly will give? As long as the situation continues as designed then the insurance companies will lose money. Who exactly is congress planning on betraying?
At first people will pay the fines rather than carry the insurance. At first the insurance companies will lose money. Then they will petition congress to raise the fine above the cost of an insurance policy. Then one of two things will happen.
One option is that congress will comply with the wishes of the insurance companies and raise the fines. This will cause people to actually try to contest the validity of the fines in court. This will lead to the argument that by paying the fines before they went up people had agreed to the validity of the fines. Those who had not contested the fines in previous years will have their standing questioned. Perhaps congress will, when raising the fines, enact legislation that anyone who had willingly paid the fine in previous years without complaint have no standing in the future.
The other option is that congress will keep the fines low in spite of the complaints of the insurance companies. Perhaps, adding insult to injury, they will raise the fines but still keep them lower than the cost of an insurance policy, directing yet more money that “should” have been going to the insurance companies to the government. This will bankrupt any company that is offering health insurance and direct even more people to a government healthcare plan.
Neither option is attractive, and it is difficult to say which option is worse. But given the current situation as designed in the healthcare reform bill those are the two possible futures.
Saturday, November 14, 2009
One Healthcare Reform
Proponents of the current healthcare reform proposal in congress like to accuse critics of not offering any alternatives, of only opposing without offering anything. While that accusation is completely not true, it serve proponents of the fascist system well as a big lie, just as calling it socialist instead of fascist serves as another convenient lie.
Rather than dissect any particular part of the fascist bill, a refutation of the false charge that critics offer nothing is also useful. The reason the proponents say that critics offer nothing is because only big government solutions are allowed to be considered. Anything else is not a "constructive proposal" and thus they can get away with that big lie.
In spite of the psychological block against small government proposals being considered, it is always useful to suggest as many small government solutions as possible. That way the next time someone says that critics of fascist health care never offer solutions the critics can respond with "look at all the solutions I've offered that you refuse to consider."
Given the large number of problems, any single solution fails to address the full problem and appears short sighted. But one aspect is all that can be addressed at once.
One of the problems with the current system is that the patient is not the customer. When a doctor treats a patient, the patient isn't the customer. The insurance pays for the visit, and so the insurance is the customer. And who is the insurance company's customer? Since most people get their insurance through their employer, the employer is the customer and not the employee. It is true that sufficient employee complaints can cause an employer to switch companies, but the customer of the insurance company is the employer.
For a truly responsive insurance company, the patient needs to be the customer of the insurance company. For truly responsive health care, the patient needs to be the customer of the doctor. The only remaining question of this particular solution is how to make it possible. As proponents of fascist health care are quick to point out, the average person cannot afford a catastrophic illness.
The first part of the solution is to transfer the tax incentive for the purchase of health insurance from the employer to the employee. That way, unlike the Obama plan, people have a positive encouragement to purchase insurance instead of a punishment for failure to purchase insurance. Persuasion always being preferable to force, encouraging people to purchase insurance instead of punishing them for failure to purchase insurance is a better solution.
To make insurance affordable enough for a person to purchase it, the price needs to be brought down. That can be done through coercion or through encouragement. To do it through encouragement the best way to do it is through removing the rules that prohibit insurance companies from competing across state lines. Putting individual insurance policies in the hand of the customers while simultaneously increasing the number of companies and policies available, while giving people a tax break for purchasing insurance, will drive down the cost to the point where most people can afford it.
Another way to make insurance affordable is to remember that insurance is supposed to be for the unusual event. The way health insurance currently operates is absurd - it is comparable to using automobile insurance to pay for basic tune-ups, or even to pay for putting gas in the car.
Analyzing a standard insurance statement or doctor's visit statement, one finds that in general a large portion of a standard bill is an insurance negotiated adjustment. Another large portion is the patient co-pay. The smallest part is the payment the insurance company makes to the doctor. Ask most doctors what their cash price is and it turns out it is actually lower than the stated price for a visit.
People need to pay directly for office visits, and a good way to do that is through tax deductible healthcare savings accounts. But not the HSAs currently in use, that have an end of year use-or-lose for the funds. What is needed is a roll-over HSA, that allows people to put in more funds than needed while healthy so that the funds will be there many years later when people need more healthcare funds. This is similar to using a retirement savings account. In order to encourage use of a roll-over HSA account funds put into it should be tax free, just as in the current annual HSA.
That will give our current healthcare system another thirty years of operation before it gets as bad as it currently is.
Rather than dissect any particular part of the fascist bill, a refutation of the false charge that critics offer nothing is also useful. The reason the proponents say that critics offer nothing is because only big government solutions are allowed to be considered. Anything else is not a "constructive proposal" and thus they can get away with that big lie.
In spite of the psychological block against small government proposals being considered, it is always useful to suggest as many small government solutions as possible. That way the next time someone says that critics of fascist health care never offer solutions the critics can respond with "look at all the solutions I've offered that you refuse to consider."
Given the large number of problems, any single solution fails to address the full problem and appears short sighted. But one aspect is all that can be addressed at once.
One of the problems with the current system is that the patient is not the customer. When a doctor treats a patient, the patient isn't the customer. The insurance pays for the visit, and so the insurance is the customer. And who is the insurance company's customer? Since most people get their insurance through their employer, the employer is the customer and not the employee. It is true that sufficient employee complaints can cause an employer to switch companies, but the customer of the insurance company is the employer.
For a truly responsive insurance company, the patient needs to be the customer of the insurance company. For truly responsive health care, the patient needs to be the customer of the doctor. The only remaining question of this particular solution is how to make it possible. As proponents of fascist health care are quick to point out, the average person cannot afford a catastrophic illness.
The first part of the solution is to transfer the tax incentive for the purchase of health insurance from the employer to the employee. That way, unlike the Obama plan, people have a positive encouragement to purchase insurance instead of a punishment for failure to purchase insurance. Persuasion always being preferable to force, encouraging people to purchase insurance instead of punishing them for failure to purchase insurance is a better solution.
To make insurance affordable enough for a person to purchase it, the price needs to be brought down. That can be done through coercion or through encouragement. To do it through encouragement the best way to do it is through removing the rules that prohibit insurance companies from competing across state lines. Putting individual insurance policies in the hand of the customers while simultaneously increasing the number of companies and policies available, while giving people a tax break for purchasing insurance, will drive down the cost to the point where most people can afford it.
Another way to make insurance affordable is to remember that insurance is supposed to be for the unusual event. The way health insurance currently operates is absurd - it is comparable to using automobile insurance to pay for basic tune-ups, or even to pay for putting gas in the car.
Analyzing a standard insurance statement or doctor's visit statement, one finds that in general a large portion of a standard bill is an insurance negotiated adjustment. Another large portion is the patient co-pay. The smallest part is the payment the insurance company makes to the doctor. Ask most doctors what their cash price is and it turns out it is actually lower than the stated price for a visit.
People need to pay directly for office visits, and a good way to do that is through tax deductible healthcare savings accounts. But not the HSAs currently in use, that have an end of year use-or-lose for the funds. What is needed is a roll-over HSA, that allows people to put in more funds than needed while healthy so that the funds will be there many years later when people need more healthcare funds. This is similar to using a retirement savings account. In order to encourage use of a roll-over HSA account funds put into it should be tax free, just as in the current annual HSA.
That will give our current healthcare system another thirty years of operation before it gets as bad as it currently is.
Sunday, September 20, 2009
Government disease
On Lew Rockwell, one of the writers compared government to a drug on the grounds that the more government we have the more people desire yet more government. With any normal product, people eventually get sated and fewer and fewer people desire to have greater and greater quantities of given goods.
On Liberty for All, one of the writers noted that the more chaos the government creates, the more people see it as the only way to avoid chaos, because without government there would be chaos.
Libertarians, whose political philosophy starts with trying to expand the rights of the individual and therefore have less government as a consequence, are accused of having a hatred of government as a starting point.
Whenever a libertarian exercises his right to try to improve the government by reducing the size and scope of the government, those who prefer larger government offer the spurious argument "move to Somalia", although curiously the argument that those who enjoy large government should move to Cuba is never considered. The argument "move to Somalia" is quite spurious since Somalia actually suffers from government just like other countries do - every time the Somalis start to rebuild some country sends in a "peacekeeping force" to destroy everything that was built up and try to impose a government that the Somalis don't recognize. Eventually the "peacekeeping force" leaves, the puppet government collapses, and the rebuilding resumes.
The perverse relationship some people have to the government is revealed in the healthcare debate. The current system in the United States is already largely a government system, as over half the dollars spent on healthcare are spent by the government, and the rest are heavily regulated. Given that state of affairs, and that the current system has serious flaws that are crying out for reform, the only proposals that are considered as part of the debate are those that advance the government. A public option is proposed to allegedly increase compeition, when allowing insurance companies to compete across state lines and forcing states to reconginze medical licenses from other states would actually do the job without increasing the size or scope of government. But when that is mentioned in debates proponents of government medicine fail to notice that it was mentioned. They do not argue against it, they do not say it is wrong, they do not say their plan is better. They simply do not respond to it at all.
There are so many ways in which the government is responsible for the current broken system that it would take many analysts reporting from many different angles to cover them all - the entire libertarian blogosphere. But those who are addicted to government will never see that their own addiction causes the very chaos that they want their drug to cure.
On Liberty for All, one of the writers noted that the more chaos the government creates, the more people see it as the only way to avoid chaos, because without government there would be chaos.
Libertarians, whose political philosophy starts with trying to expand the rights of the individual and therefore have less government as a consequence, are accused of having a hatred of government as a starting point.
Whenever a libertarian exercises his right to try to improve the government by reducing the size and scope of the government, those who prefer larger government offer the spurious argument "move to Somalia", although curiously the argument that those who enjoy large government should move to Cuba is never considered. The argument "move to Somalia" is quite spurious since Somalia actually suffers from government just like other countries do - every time the Somalis start to rebuild some country sends in a "peacekeeping force" to destroy everything that was built up and try to impose a government that the Somalis don't recognize. Eventually the "peacekeeping force" leaves, the puppet government collapses, and the rebuilding resumes.
The perverse relationship some people have to the government is revealed in the healthcare debate. The current system in the United States is already largely a government system, as over half the dollars spent on healthcare are spent by the government, and the rest are heavily regulated. Given that state of affairs, and that the current system has serious flaws that are crying out for reform, the only proposals that are considered as part of the debate are those that advance the government. A public option is proposed to allegedly increase compeition, when allowing insurance companies to compete across state lines and forcing states to reconginze medical licenses from other states would actually do the job without increasing the size or scope of government. But when that is mentioned in debates proponents of government medicine fail to notice that it was mentioned. They do not argue against it, they do not say it is wrong, they do not say their plan is better. They simply do not respond to it at all.
There are so many ways in which the government is responsible for the current broken system that it would take many analysts reporting from many different angles to cover them all - the entire libertarian blogosphere. But those who are addicted to government will never see that their own addiction causes the very chaos that they want their drug to cure.
Saturday, September 05, 2009
A fully private healthcare system
Although it appears that Obama may be dumping the public option (for now) many of his supporters both in and out of government are still pushing for a taxpayer funded public option. Allegedly this public option would be a Government Sponsored Enterprise, after the fashion of such success stories as FNME or FDMC. It is called "alleged" because no part of the upcoming healthcare bill that will eventually be voted on by either the House or the Senate has actually been finalized.
On a libertarian internet site (probably on Lew Rockwell but the original reference cannot be located), someone suggested that he would support the public option – including a 15% tax increase - in exchange for the private option actually being private.
The private system would be completely private. It would not be regulated in any way. It would be free of all FDA regulations, DEA regulations, and medical licensing. Anybody can be a healthcare practitioner, and can prescribe any medication. But any prescription would be considered nothing more than advice since no medications would be controlled.
So as an experiment, this idea was run by several supporters of socialist medicine.
Theoretically there should be no reason for them to oppose it. They get everything they allegedly want - full government run medicine with all the controls, paid for by those who do not want government medicine. They get free healthcare paid for by their opponents. They get all the controls they say people need. They get all the licencing, all the regulations, and all the restrictions they say people need. And they get to have those who prefer a private system pay for their public system.
The suggestion was greeted with horror.
For some reason, even though the suggestion gave them everything they say they want, they didn't want it.
They were obsessed with the question of how someone in the private system would know which medicines to take. It was suggested that people in the private system would go to any fraud who claims to be a doctor, and only wanted the medicinal freedom in order to "pop pills". Such arguments would indicate that advocates of socialist medicine need the government to prevent them from going to frauds and would need the government in order to not "pop pills".
It seems that the argument in favor of Socialist medicine is more than simply an attempt by the advocates of that system to have "free" healthcare. There is for some strange reason a desire to ensure that everyone else is in a controlled and regulated system as well, a desire to control and regulate everyone else.
On a libertarian internet site (probably on Lew Rockwell but the original reference cannot be located), someone suggested that he would support the public option – including a 15% tax increase - in exchange for the private option actually being private.
The private system would be completely private. It would not be regulated in any way. It would be free of all FDA regulations, DEA regulations, and medical licensing. Anybody can be a healthcare practitioner, and can prescribe any medication. But any prescription would be considered nothing more than advice since no medications would be controlled.
So as an experiment, this idea was run by several supporters of socialist medicine.
Theoretically there should be no reason for them to oppose it. They get everything they allegedly want - full government run medicine with all the controls, paid for by those who do not want government medicine. They get free healthcare paid for by their opponents. They get all the controls they say people need. They get all the licencing, all the regulations, and all the restrictions they say people need. And they get to have those who prefer a private system pay for their public system.
The suggestion was greeted with horror.
For some reason, even though the suggestion gave them everything they say they want, they didn't want it.
They were obsessed with the question of how someone in the private system would know which medicines to take. It was suggested that people in the private system would go to any fraud who claims to be a doctor, and only wanted the medicinal freedom in order to "pop pills". Such arguments would indicate that advocates of socialist medicine need the government to prevent them from going to frauds and would need the government in order to not "pop pills".
It seems that the argument in favor of Socialist medicine is more than simply an attempt by the advocates of that system to have "free" healthcare. There is for some strange reason a desire to ensure that everyone else is in a controlled and regulated system as well, a desire to control and regulate everyone else.
Saturday, August 15, 2009
End of life medical care
It is true that there needs to be a reform of end of life medical care. Unfortunately for the country the reforms originally poffered under one of the five competing and not thoroughly defined plans promoted by President Obama offered exactly the wrong reform.
End of life counseling, death with dignity discussions and other such means aimed at helping seniors plan for the ultimate end, or even panels that decide the life value of the care and thus cut off care as some describe (and may or may not have been in any one of the five plans) are not the answer that is needed. Those reforms mean more regulation and more bureaucrats, which will ensure that the care fails to offer any actual concern for the people involved.
The problem lies not in the absense of government, but once again in government involvement.
It is well known in the medical profession that the most expensive treatments are almost always the end of life care, whether the patient be 30 or 90. The patient will start to suffer from what medical professionals call "TBF", short for "Total Body Failure." At that point there is no care that is cure. All the care will do is extend life for a few more hours, or perhaps even minutes.
But when a patient is experiencing TBF, generally the family says "Do what ever it takes to keep (him) alive." The Doctor's hands are thus tied, by law, to fulfill the wishes of the family and spend hundreds of thousands of dollars for a few more hours of life.
The one thing the doctor cannot do, without risking a malpractice suit and possible license revocation, is to say "there is nothing more I can do, so I will do nothing more." He is forbidden to say that.
Since the family is not the one paying the final bills, they belong to the patient himself, the patient's insurance if available, and probably medicare and medicaid, the family has no reason to worry about the cost of these extra hours. The bill is paid for by everyone else, either the hospital or insurance company absorbs the cost and passes it along to everyone else, or the taxpayer absorbs the cost and passes it along to everyone else.
One simple way to substantially reduce the cost of medical care is would be to reduce the regulations that forbid doctors from making this determination, but that would be opposed by statists because that would be doctors instead of bureaucrats making the decision, and that ould be less regulation instead of more. But, unlike the end of life counseling preferred by statists this would actually work.
End of life counseling, death with dignity discussions and other such means aimed at helping seniors plan for the ultimate end, or even panels that decide the life value of the care and thus cut off care as some describe (and may or may not have been in any one of the five plans) are not the answer that is needed. Those reforms mean more regulation and more bureaucrats, which will ensure that the care fails to offer any actual concern for the people involved.
The problem lies not in the absense of government, but once again in government involvement.
It is well known in the medical profession that the most expensive treatments are almost always the end of life care, whether the patient be 30 or 90. The patient will start to suffer from what medical professionals call "TBF", short for "Total Body Failure." At that point there is no care that is cure. All the care will do is extend life for a few more hours, or perhaps even minutes.
But when a patient is experiencing TBF, generally the family says "Do what ever it takes to keep (him) alive." The Doctor's hands are thus tied, by law, to fulfill the wishes of the family and spend hundreds of thousands of dollars for a few more hours of life.
The one thing the doctor cannot do, without risking a malpractice suit and possible license revocation, is to say "there is nothing more I can do, so I will do nothing more." He is forbidden to say that.
Since the family is not the one paying the final bills, they belong to the patient himself, the patient's insurance if available, and probably medicare and medicaid, the family has no reason to worry about the cost of these extra hours. The bill is paid for by everyone else, either the hospital or insurance company absorbs the cost and passes it along to everyone else, or the taxpayer absorbs the cost and passes it along to everyone else.
One simple way to substantially reduce the cost of medical care is would be to reduce the regulations that forbid doctors from making this determination, but that would be opposed by statists because that would be doctors instead of bureaucrats making the decision, and that ould be less regulation instead of more. But, unlike the end of life counseling preferred by statists this would actually work.
Friday, July 17, 2009
Public and Private Competition
One way those who want to "improve" the free market do so is by introducing competition in the form of a government program or agency that duplicates work done outside the government. Usually those in the afflicted field would be surprised to know that the field doesn't currently have competition. But in order to correctly analyze the claim, it is good to look at fields where the government directly competes with private enterprises.
First and foremost on any list of government activities that compete directly with private endeavors is education. At one time education was largely private, and to a great extent taxes were not used to pay for education. Yet education was available at all levels, although non-compulsory, to the point where religious groups were even offering free education to the poor. But government sponsored education has only increased. Since it is paid for by taxes the direct consumer does not directly pay for the education and therefore mistakenly considers it free.
As a result, private schools have diminished in number. While they generally provide a much higher level of education, only those who are either make major sacrifices or are wealthy can take advantage of the better education offered.
The second endeavor to be examined is in delivery of the mail. Libertarians are generally familiar with Lysander Spooner's attempt to deliver first class mail, and how the Post Office used legal coercion to shut it down. Package delivery still has private competition in the form of UPS or FedEx.
The prices for package delivery by the USPS are lower than UPS or FedEx, due to undercutting. The low price is supported by raising the rates on first class mail. Even with that undercutting those who can afford it (and in this case many but not all can) prefer to use FedEx or UPS. What makes the USPS special among cases of comparing private and public offering of services is that the user does pay for the service directly. But even then the USPS is subsidized by the Federal Government.
Another is the providing of security. It is well known that the rich do have private security in private communities or residences that respond quickly in the event of a disturbance. Those who are of average means can afford to defend themselves by the purchase of a firearm. Those who cannot afford any better rely on the police, who arrive after a crime has already been committed to make the report and try to apprehend the criminal. The rich have proactive protection, the middle class can protect themselves, and the poor have no protection.
The building of roads has been entirely taken over by the government to the point where many cannot imagine it being any other way. In the former Soviet Union people could not imagine how shoes could be distributed if the government did not do so, and wondered if those who thought a free market in shoes meant that only the rich could get shoes. There is nothing to compare the building of roads to, given that the ability of government to force everyone to pay and offer the resuliting roads for "free" has completely driven private roads out of business. Those toll roads that are managed by special grants from the states do not count as they are not free market but are corporatism.
In every case except the Post Office, the ability to force payment into the program, combined with while offering the service for "free" has driven competition out of the market for all but the very wealthy. The same is true to a lesser extent for the Post Office. This has resulted in only the wealthy being able to truly afford high quality goods or services.
The health care plans offered by President Obama include a "Public Option" where the Federal Government directly competes with private insurance companies. If history is any indication this will result in only the wealth being able to afford high quality medical insurance. Taxes will be raised to provide the service, and the public will be lied to about how the service is free. Those who advocate anything other than a program which will result in only the rich being able to afford quality insurance will be accused of wanting a program which will result in only the rich being able to afford quality insurance.
I'd like to welcome as readers the Complete Liberty Podcast, as I've just discovered that they've used two of my articles in their podcasts. I'm flattered.
Edited to add:
A critic of this article pointed out that education is somehow disproof of the proposition that public and private competition leads to only the rich being able to afford quality services. What was offered as proof wasn't primary education but colleges, which in the United States are still considered to be very good.
It is true that on the level of Masters or Doctorate the United States is of exceptionally high quality, and in some fields a Bachelor's Degree is worth more than the paper it is printed on. But as is being pointed out on Lew Rockwell's website the cost is becoming prohibitive. Students graduate with many thousands of dollars in student loans just for a Bachelor's, after scholarships and grants. Those who go for even higher degrees finance it almost entirely by borrowing. Education is becoming a way to become an indentured servant of the lending agencies.
It is true that a Bachelor's Degree holder statistically earns more over the course of his life than someone with only a High School degree. It is also true that the costs of paying for that degree are rising to the point where they may be higher than the lifetime earning differential. If that happens than the economic decision would be to forego higher education.
That would mean that thanks to public versus private competition a quality higher education is only the rich can afford.
First and foremost on any list of government activities that compete directly with private endeavors is education. At one time education was largely private, and to a great extent taxes were not used to pay for education. Yet education was available at all levels, although non-compulsory, to the point where religious groups were even offering free education to the poor. But government sponsored education has only increased. Since it is paid for by taxes the direct consumer does not directly pay for the education and therefore mistakenly considers it free.
As a result, private schools have diminished in number. While they generally provide a much higher level of education, only those who are either make major sacrifices or are wealthy can take advantage of the better education offered.
The second endeavor to be examined is in delivery of the mail. Libertarians are generally familiar with Lysander Spooner's attempt to deliver first class mail, and how the Post Office used legal coercion to shut it down. Package delivery still has private competition in the form of UPS or FedEx.
The prices for package delivery by the USPS are lower than UPS or FedEx, due to undercutting. The low price is supported by raising the rates on first class mail. Even with that undercutting those who can afford it (and in this case many but not all can) prefer to use FedEx or UPS. What makes the USPS special among cases of comparing private and public offering of services is that the user does pay for the service directly. But even then the USPS is subsidized by the Federal Government.
Another is the providing of security. It is well known that the rich do have private security in private communities or residences that respond quickly in the event of a disturbance. Those who are of average means can afford to defend themselves by the purchase of a firearm. Those who cannot afford any better rely on the police, who arrive after a crime has already been committed to make the report and try to apprehend the criminal. The rich have proactive protection, the middle class can protect themselves, and the poor have no protection.
The building of roads has been entirely taken over by the government to the point where many cannot imagine it being any other way. In the former Soviet Union people could not imagine how shoes could be distributed if the government did not do so, and wondered if those who thought a free market in shoes meant that only the rich could get shoes. There is nothing to compare the building of roads to, given that the ability of government to force everyone to pay and offer the resuliting roads for "free" has completely driven private roads out of business. Those toll roads that are managed by special grants from the states do not count as they are not free market but are corporatism.
In every case except the Post Office, the ability to force payment into the program, combined with while offering the service for "free" has driven competition out of the market for all but the very wealthy. The same is true to a lesser extent for the Post Office. This has resulted in only the wealthy being able to truly afford high quality goods or services.
The health care plans offered by President Obama include a "Public Option" where the Federal Government directly competes with private insurance companies. If history is any indication this will result in only the wealth being able to afford high quality medical insurance. Taxes will be raised to provide the service, and the public will be lied to about how the service is free. Those who advocate anything other than a program which will result in only the rich being able to afford quality insurance will be accused of wanting a program which will result in only the rich being able to afford quality insurance.
I'd like to welcome as readers the Complete Liberty Podcast, as I've just discovered that they've used two of my articles in their podcasts. I'm flattered.
Edited to add:
A critic of this article pointed out that education is somehow disproof of the proposition that public and private competition leads to only the rich being able to afford quality services. What was offered as proof wasn't primary education but colleges, which in the United States are still considered to be very good.
It is true that on the level of Masters or Doctorate the United States is of exceptionally high quality, and in some fields a Bachelor's Degree is worth more than the paper it is printed on. But as is being pointed out on Lew Rockwell's website the cost is becoming prohibitive. Students graduate with many thousands of dollars in student loans just for a Bachelor's, after scholarships and grants. Those who go for even higher degrees finance it almost entirely by borrowing. Education is becoming a way to become an indentured servant of the lending agencies.
It is true that a Bachelor's Degree holder statistically earns more over the course of his life than someone with only a High School degree. It is also true that the costs of paying for that degree are rising to the point where they may be higher than the lifetime earning differential. If that happens than the economic decision would be to forego higher education.
That would mean that thanks to public versus private competition a quality higher education is only the rich can afford.
Friday, March 20, 2009
Healthcare in the United States
A friend of mine works in medicine, and I told her that if she were to write up commentary on the state of healthcare in the United States I would print it for her. I expected an essay, but instead she forwarded to me two emails she had sent to another organization, the second as an addendum to the first.
To: Department of Health and Human Services
Re: Action plan to to prevent healthcare-associated infections
I am responding as an individual, not representing any organization.
Myself, BS, BSN, MPH, formerly CIC
I currently work as an Infection Preventionist (name recently changed from Infection Control Nurse) in a 500+ bed community hospital. I cover all the intensive care units in the facility, so I am aware of the problems faced on the front line of infection prevention.
1. Basics: Make sure government agencies at all levels do not impede best practice.
Research has shown that alcohol-based hand hygiene products can improve compliance in intensive care units. (Maury et. al, Am J Respir Crit Care Med Vol 162, pp 324-327). The hospital I work in has had alcohol based hand sanitizer available for over 8 years. We spent time and effort in selecting a product that was acceptable to all involved. The Georgia State Insurance Commissioner is currently investigating removal of foam sanitizers under pressure for a theoretical fire risk. The last time we were forced to remove our current product from the hallways, our cross transmission of MRSA skyrocketed. Replacing the hallway dispensers stopped the outbreak.
2. Partnership of all involved groups: The patient also needs to be seen as a partner in reducing healthcare associated infections.
Transmission of flora within the hospital does cause healthcare-associated infections, but for SSI (surgical site infection), the patient's own flora can be the source. Aside from complying with preoperative showers for elective surgery, patients need to prepare themselves for the surgery by stopping smoking and controlling blood glucose levels. Smoking has been shown to increase SSI. Post-operative glucose control is important in prevention of SSI, but patients who know they are going to have surgery should prepare themselves.
Patients also need to understand that requiring their physicians to prescribe unnecessary antibiotics also contributes to infection with CD (C diff).
Physicians also need to be involved in getting patients ready for elective surgery. The following is a true story. My mother and the brother of a friend of mine both had knee replacements on the same day. It took a long time to get my mother ready for surgery because her surgeon insisted that she see her primary care physician and her dentist for clearance.. She had to be screened for infection--UTI. Our hospital does nasal screening for MRSA and MSSA on all orthopedic implant surgeries. The brother did not have to do any of this. Within three weeks of surgery, my friend told me that her brother had an infection. My mother is now over one year out from her surgery and doing fine. We switched surgeons early in the course of getting her knee replaced because the first surgeon we went to wanted to basically go from his office to the OR without the preparation the second one required.
3. Focus on MRSA: I find this short sighted.
The worst infections in our facility are caused by Gram negative rods (GNR) for which there are no antibiotic treatments. It is much easier to track MRSA and may be easier to put in interventions. However, GNR are a much worse and growing problem.
4. Futility of Care and End of Life issues: something nobody want to discuss as part of the solution. Strong guidelines on futility of care, and decreased payments for care after such a determination is made need to be in place now.
The last three infections I identified (2 BSI and 1 VAP) were all in patients in whom it had been acknowledged that there was no hope of recovery and all medical interventions were futile. DNR discussions had been ongoing with the families for as long as three weeks prior to the infections. All three patients died of their underlying conditions within three weeks of the onset date of the infection. The infection was not the immediate cause of death, even if it might have hastened the inevitable. Physicians discuss the problem openly during our intensive care rounds. The family will be around after the patient's death and might bring a law suit if their wishes (the family's) are not carried out. The wishes are usually expressed as "Do everything for Mama" even if they have been told that everything will not work and that Mama is going to die anyway. We have discussed the reason for families not to withdraw care. Sometimes it is just too soon. It because apparent today that the patient was beyond hope. Sometimes it is the level of education and sophistication of the family. When you talk to them, they are very nice but they just don't seem to understand the issues. Guilt can play a part also. Having neglected Mama for the past year (nursing home patient, living with a friend, not family), the family wants to make amends. We see cultural differences. African American families seem less able to withdraw care. Sometimes we find out that there is a financial reason.. Mama's Social Security check is going into a family member's bank account.
What ever the reasons are, physicians are not comfortable withdrawing care and instituting palliative care measures if the family still states they want everything done, even if it prolongs death and does not lead to life.
5. Payment issues: The assumption appears to be that hospitals control doctors. I wont' even go there.
We ask, we coax, we nag. We already use a Foley catheter reminder sticker for physicians. It is usually ignored, even though it is part of the chart. Some physicians sign the reminder without indicating why the Foley is to continue and without giving an order for its removal. Physicians have not reason to listen. I recommend that payment for physicians whose patients develop a healthcare-associated infection (HAI) also be reduced, just as payments for hospitals are. The payments are reduced to the extent that hospitals used to get reimbursed for care of infections. Yes, hospitals need good systems to ensure timely care, but physicians have to do their part by responding in a timely fashion.
In my introduction, I noted that I was formerly CIC. One of the most important things that you can do is make sure that all front line workers are adequately prepared. I dropped CIC for three major reasons: my current employer does not pay for the test and it is expensive, I do not get any pay differential for it, and CIC ensure entry level competence. I have been in infection control for over 20 years now. I will have to pass the new requirements for getting my NHSN certificate so I can continue to use the CDC computer-based reporting system. Hospitals should be supported in efforts to make sure that employees are qualified.
Addendum.
1. Best practice. The Office of Insurance and Safety Fire Commissioner has denied the request of the hospital that I work in to keep the foam hand santizing product. The reason that is stated is that the "State is bound by contract to meet the requirements of CMS 211, which supersede those of the State of Georgia..." This ruling was given by the Regional Director for CMS.
If CMS will not pay for HAI then CMS must allow the use of the best products to prevent infection. Changing hand hygiene products is not as simple as it sounds. Not only do the products have to work, but the employees must use them. The products must not cause redness, skin breakdown, stickiness or other problems. The hospital did evaluate gels the last time it looked at hand hygiene products. The end users preferred the foam.
2. Please add to your reserach list: the best way to wean a patient from the ventilator. We have six Intensivists. Each has a way to do this. Each tells us the other ways won't work. ATC trials should not be done more than once a day. ATC does not work at all. Do ATC trials three to four times a day before considering extubation. PLEASE HELP. Meanwhile, we are having a difficult time decreasing our ventilator days and getting patients off the ventilator is the best way to prevent VAP.
3. Patient as partner: All patients should know that it is not a good idea to keep drinking patterns a secret. It can be a major problem when a patient comes in for elective surgery and goes into DTs three days post-op. The patient may wind up on the ventilator with central lines and then is at risk for hospital associated infections. DTs prolong stay no matter what.
To: Department of Health and Human Services
Re: Action plan to to prevent healthcare-associated infections
I am responding as an individual, not representing any organization.
Myself, BS, BSN, MPH, formerly CIC
I currently work as an Infection Preventionist (name recently changed from Infection Control Nurse) in a 500+ bed community hospital. I cover all the intensive care units in the facility, so I am aware of the problems faced on the front line of infection prevention.
1. Basics: Make sure government agencies at all levels do not impede best practice.
Research has shown that alcohol-based hand hygiene products can improve compliance in intensive care units. (Maury et. al, Am J Respir Crit Care Med Vol 162, pp 324-327). The hospital I work in has had alcohol based hand sanitizer available for over 8 years. We spent time and effort in selecting a product that was acceptable to all involved. The Georgia State Insurance Commissioner is currently investigating removal of foam sanitizers under pressure for a theoretical fire risk. The last time we were forced to remove our current product from the hallways, our cross transmission of MRSA skyrocketed. Replacing the hallway dispensers stopped the outbreak.
2. Partnership of all involved groups: The patient also needs to be seen as a partner in reducing healthcare associated infections.
Transmission of flora within the hospital does cause healthcare-associated infections, but for SSI (surgical site infection), the patient's own flora can be the source. Aside from complying with preoperative showers for elective surgery, patients need to prepare themselves for the surgery by stopping smoking and controlling blood glucose levels. Smoking has been shown to increase SSI. Post-operative glucose control is important in prevention of SSI, but patients who know they are going to have surgery should prepare themselves.
Patients also need to understand that requiring their physicians to prescribe unnecessary antibiotics also contributes to infection with CD (C diff).
Physicians also need to be involved in getting patients ready for elective surgery. The following is a true story. My mother and the brother of a friend of mine both had knee replacements on the same day. It took a long time to get my mother ready for surgery because her surgeon insisted that she see her primary care physician and her dentist for clearance.. She had to be screened for infection--UTI. Our hospital does nasal screening for MRSA and MSSA on all orthopedic implant surgeries. The brother did not have to do any of this. Within three weeks of surgery, my friend told me that her brother had an infection. My mother is now over one year out from her surgery and doing fine. We switched surgeons early in the course of getting her knee replaced because the first surgeon we went to wanted to basically go from his office to the OR without the preparation the second one required.
3. Focus on MRSA: I find this short sighted.
The worst infections in our facility are caused by Gram negative rods (GNR) for which there are no antibiotic treatments. It is much easier to track MRSA and may be easier to put in interventions. However, GNR are a much worse and growing problem.
4. Futility of Care and End of Life issues: something nobody want to discuss as part of the solution. Strong guidelines on futility of care, and decreased payments for care after such a determination is made need to be in place now.
The last three infections I identified (2 BSI and 1 VAP) were all in patients in whom it had been acknowledged that there was no hope of recovery and all medical interventions were futile. DNR discussions had been ongoing with the families for as long as three weeks prior to the infections. All three patients died of their underlying conditions within three weeks of the onset date of the infection. The infection was not the immediate cause of death, even if it might have hastened the inevitable. Physicians discuss the problem openly during our intensive care rounds. The family will be around after the patient's death and might bring a law suit if their wishes (the family's) are not carried out. The wishes are usually expressed as "Do everything for Mama" even if they have been told that everything will not work and that Mama is going to die anyway. We have discussed the reason for families not to withdraw care. Sometimes it is just too soon. It because apparent today that the patient was beyond hope. Sometimes it is the level of education and sophistication of the family. When you talk to them, they are very nice but they just don't seem to understand the issues. Guilt can play a part also. Having neglected Mama for the past year (nursing home patient, living with a friend, not family), the family wants to make amends. We see cultural differences. African American families seem less able to withdraw care. Sometimes we find out that there is a financial reason.. Mama's Social Security check is going into a family member's bank account.
What ever the reasons are, physicians are not comfortable withdrawing care and instituting palliative care measures if the family still states they want everything done, even if it prolongs death and does not lead to life.
5. Payment issues: The assumption appears to be that hospitals control doctors. I wont' even go there.
We ask, we coax, we nag. We already use a Foley catheter reminder sticker for physicians. It is usually ignored, even though it is part of the chart. Some physicians sign the reminder without indicating why the Foley is to continue and without giving an order for its removal. Physicians have not reason to listen. I recommend that payment for physicians whose patients develop a healthcare-associated infection (HAI) also be reduced, just as payments for hospitals are. The payments are reduced to the extent that hospitals used to get reimbursed for care of infections. Yes, hospitals need good systems to ensure timely care, but physicians have to do their part by responding in a timely fashion.
In my introduction, I noted that I was formerly CIC. One of the most important things that you can do is make sure that all front line workers are adequately prepared. I dropped CIC for three major reasons: my current employer does not pay for the test and it is expensive, I do not get any pay differential for it, and CIC ensure entry level competence. I have been in infection control for over 20 years now. I will have to pass the new requirements for getting my NHSN certificate so I can continue to use the CDC computer-based reporting system. Hospitals should be supported in efforts to make sure that employees are qualified.
Addendum.
1. Best practice. The Office of Insurance and Safety Fire Commissioner has denied the request of the hospital that I work in to keep the foam hand santizing product. The reason that is stated is that the "State is bound by contract to meet the requirements of CMS 211, which supersede those of the State of Georgia..." This ruling was given by the Regional Director for CMS.
If CMS will not pay for HAI then CMS must allow the use of the best products to prevent infection. Changing hand hygiene products is not as simple as it sounds. Not only do the products have to work, but the employees must use them. The products must not cause redness, skin breakdown, stickiness or other problems. The hospital did evaluate gels the last time it looked at hand hygiene products. The end users preferred the foam.
2. Please add to your reserach list: the best way to wean a patient from the ventilator. We have six Intensivists. Each has a way to do this. Each tells us the other ways won't work. ATC trials should not be done more than once a day. ATC does not work at all. Do ATC trials three to four times a day before considering extubation. PLEASE HELP. Meanwhile, we are having a difficult time decreasing our ventilator days and getting patients off the ventilator is the best way to prevent VAP.
3. Patient as partner: All patients should know that it is not a good idea to keep drinking patterns a secret. It can be a major problem when a patient comes in for elective surgery and goes into DTs three days post-op. The patient may wind up on the ventilator with central lines and then is at risk for hospital associated infections. DTs prolong stay no matter what.
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