A Brief History…

A year ago, I wrote several posts on what I considered a useful model for reform of the US system. The present debate seems to be focused on everything but a viable model for reform. The Obama/Baucus plan that is slowly emerging from the Senate finance committee seems to be vague and there are aspects that seem to represent politics and nothing else. The “white paper” seems to be mostly propaganda and lacking in concrete proposals. It does point out that France spends about half of what we do on health care (page 15 chart)/ per capita with excellent results. Baucus’s “vision” continues the usual blather about providing everyone care at less cost.

It contains six “elements” that typically lack focus.

1. Individual Responsibility. Covering all Americans means the enrollment of every individual in some form of health care plan, private or public.

OK, I agree with that.

2 Strengthening the Employer-Based System. We must ensure the continued viability of the employer-based system — the principal source of health coverage
for most Americans — to allow workers to keep the insurance that they currently
have and value.

This is bogus. One of our problems is the employer-based system but, for Democrats, this means exempting union plans from any controls on utilization.

3. Guaranteed Access to Affordable Coverage for Individuals and Small
Business.

This is the entire problem misrepresented as a factor. It is THE PROBLEM !

Here Baucus comes up with one concrete proposal.

the Health Insurance Exchange — will connect individuals and employers to insurance offered at local, state, regional, or national levels. Insurers offering coverage through the Exchange would need to meet certain requirements established by a new Independent Health Coverage Council.

This is basically what the Clinton Plan was about. It is too vague to even know what they are talking about. Presumably this is the “co-op” concept we have heard about.

4. Strengthening Public Programs. Existing public programs represent an effective and efficient way to increase access to coverage and decrease the number of
uninsured.

The existing public programs are certainly not efficient and Medicare is losing doctors at a rapid pace as they try to cut the budget by stiffing providers. Medicare will be out of funds in less than 10 years.

Offering individuals approaching age 65 the chance to buy into Medicare early and eliminating the requirement that disabled individuals wait two years to enroll in Medicare would ensure coverage to populations that the private market is under-serving.

These statements represent a big reason why Medicare is bankrupt. Adding beneficiaries without new funding is a terrible way to do business.

5. Focusing on Prevention and Wellness. Increased access to preventive care and wellness is another step that could be accomplished in the short term.

This is an old canard that has been proven to be ineffective in controlling costs. Early diagnosis in breast cancer will improve survival but whether it saves money is another matter.

Increasing the availability and effectiveness of primary care coverage could create a national
focus on maintaining wellness, rather than treating illness — which would improve
quality and reduce costs across the health care system.

This is utter bullshit but sounds good. The fatal flaw in the Canadian system is the emphasis on primary care with severe rationing of specialist care. Politics goes for the visible benefit and the long term benefit often is ignored.

6. Addressing Health Disparities. In our current health care system, racial and ethnic minorities disproportionately lack ready access to high-quality medical care.

This is standard political speech but means little. The urban underclass is the source of our poor life expectancy and child mortality figures but to expect that these people will take advantage of better access to care is naive and is the usual political pablum offered to rube voters.

None of this suggests that a useful plan will emerge from this committee.

My suggestions, which will go nowhere but which are based on 40 years of practice plus a graduate degree in health economics, are as follows.

1. The employment connection with health insurance must be broken. This can be done by forming large funds, like pension funds, to which employees can transfer their insurance plans. The Employer should be happy to do this as the plans will then be funded by payroll deduction, as they are now. The employer will no longer be expected to manage the plan. The same insurance company ASO (Administrative Service Organizations) that manages the employer plan can submit bids to manage the new funds. If the employee loses his job or changes jobs, the health plan remains the same.

2. Like in France and in Medicare, the fund will pay 80% of the approved charges for approved procedures and services. This will not be the total payment as co-pays and balance billing will be added. It does provide catastrophic insurance, which is what insurance should be.

3. Private insurance plans, chosen by the individuals, will contract with funds and the individuals to cover the remaining 20%. The same companies that provide “MediGap” insurance for Medicare beneficiaries could enter this market. For the poor, government subsidies can fill this gap.

4. The insurance funds will pay on a national fee schedule, which will be negotiated with provider organizations like hospital associations and medical associations. This fee schedule will resemble the indemnity-style health plans that were still around when I began practice. This pays a flat fee for each service. “Usual, customary and reasonable” fee payments have led to fee inflation and moral hazard. The flat fee will be on the low side but no lower than Medicare fees and without the hassle. The doctor can negotiate a higher fee with the patient and fees should be posted in the office. This is the only way we will ever get a market in medicine. The greatest benefit of such a system will be the open disclosure of charges. Only when prices are known can we have a market.

5. Balance billing, the charging of an agreed upon fee over and above the insurance payment will be permitted. If someone wants to see the best surgeon or internist in town, they will be expected to pay accordingly.

6. Patients will be expected to pay doctors for services at the time of service and they may seek reimbursement from the plan for covered services. This is why posted charges are important. France has a program where very large bills need not be paid first. The out-of-pocket payment can be capped.

7. Community clinics and HMOs will be permitted to do business as they do now with the insurance fund negotiating a rate of payment for coverage. The subscriber may be expected to pay extra for services not covered by the plan.

8. Drugs will be covered but co-payments will be expected for non-generic drugs. This will be far less expensive for younger patients but Medicare Part D has cost much less than expected.

9. Payments from the plan will be limited to services accepted as scientifically valid by evidence-based medical guidelines or other scientifically based guidelines.

10. A program to forgive medical student loans in return for adhering to the national fee schedule will be developed and extended to future medical students. Eventually, this should result in very low medical school tuition.

11. Ideally, Medicare, Medicaid and workers compensation should be brought under the fee schedule and the program of management of the health plans.

There has been some recent talk about “green shoots” of a possible recovery appearing. The contraction of the economy is estimated at about 2.6% negative. That doesn’t sound all that bad. On the other hand, tax receipts are crashing with a 25% decline compared to last year.

July 2009 will probably come in at 90% or worse compared to July 2008, because July 2008 had over $13 billion in stimulus payments, which Uncle Sam (erroneously, in my opinion) treated as negative receipts instead of outlays. August 2009, vs. August 2008 will be worse than July, because August 2008 stimulus payments were barely $1 billion. September 2009 vs. will probably be even worse than the previous two months, because that month is heavily influenced by corporate income and non-withheld tax receipts, which as you can see above have fallen far more than the overall average. Also note that August and September of 2009 will show year-over-year declines for the second straight year. Monthly year-over-year receipts from economic activity increased for an almost unbroken string of four years up until August of last year, when the recession as normal people define it began.

The facts of these shocking drops in revenue are not being reported even though the Democrats are planning a spending binge that is using estimates of revenue that are out of date.

This is going to get ugly.

The Honduran coup has focused attention on Obama’s problems with foreign relations. After standing aside during the Iran insurrection, allegedly on the grounds that we had a “history” there, he immediately seems ready to barge into the Honduran crisis without any hesitation.
Spengler, in the Asia Times, discusses just how dangerous this is.

Obama doesn’t want to betray the United States; he only wants to empower America’s enemies. Forcing Israel to abandon its strategic buffer (the so-called settlements) was supposed to placate Iran, so that Iran would help America stabilize Iraq, where its influence looms large over the Shi’ite majority.

America also sought Iran’s help in suppressing the Taliban in Afghanistan. In Obama’s imagination, a Sunni Arab coalition - empowered by Washington’s turn against Israel - would encircle Iran and dissuade it from acquiring nuclear weapons, while an entirely separate Shi’ite coalition with the North Atlantic Treaty Organization would suppress the radical Sunni Taliban in Afghanistan and Pakistan. This was the worst-designed scheme concocted by a Western strategist since Field Marshal Bernard Montgomery attacked the bridges at Arnhem in 1944, and it has blown up in Obama’s face.

Obama’s imagination is the most dangerous factor in American foreign policy since 1900.

The recent passage of the “Cap and trade” bill, a modern example of the Smoot-Hawley tariff that brought on the Great Depression, raises once again the theory of anthropogenic global warming. That is the theory that human activity, principally through the production of CO2 by the burning of fossil fuels, has caused global warming. There is no other reason for this massive attack on our economic system except the validity of this theory. Al Gore says the debate is over but others disagree. What does the Environmental Protection Agency say ?

The EPA was recently tasked with producing a report that would justify regulation of CO2 as a harmful substance. The report was produced but, because it did not find evidence that CO2 is harmful, the report is being suppressed by the Obama administration. Remember how Bush was accused of manipulating science for political reasons ?

The information about suppression of the EPA report has not appeared in the media. I wonder why ?

We have the Obama administration, which was put into office on the pledge and the promise of openness and transparency and full disclosure and a new change in government. And one of their biggest issues is the issue of climate change and whether we should move a massive reorganization of our entire economy because of CO2 emissions.

There is a group within the EPA that’s tasked with doing some of the economic and environmental analysis. And a career scientist in that group prepared an extensive report, close to 100 pages in length, in which he found that there were very serious concerns about going forward with the finding of endangerment. And that’s the substance of this press conference, is how that report was suppressed, censored, prevented from going through the review process.

Well, I guess it’s just not news.

UPDATE: California Congressman Tom McClintock cites an example in our state where a similar bill has deepened California’s recession.

When I was a child in school, we all learned that the Depression was made more severe, if not caused, by the Smoot-Hawley Tariff of 1930. Over a thousand economists signed a petition asking president Hoover not to sign it. Yesterday, the Waxman-Markey bill passed the House by a seven vote margin. It is as destructive of the US economy as the Smoot-Hawley Tariff was. Analysis is difficult because the bill has changed every day to accommodate lobbyists who offer support for a piece of the action. An analysis of its effect on the US economy is here by CATO Institute.

there is one policy nexus where congressional leaders are still doggedly determined to move the country left: energy and the environment. Speaker Pelosi will reportedly allow a vote on the controversial Waxman-Markey “cap-and-trade” legislation at the end of this week.

You heard correctly: progressives have authored a bill that earns the mortal enmity of domestic energy consumers and our most crucial trading partners at the same time. Economy-killing climate policies and a trade war — together at last!

The effect of the bill is a huge tax increase on the American public plus energy shortages for the rest of the century. The blather about “green jobs” is just that, blather.

And just for the sake of discussion, exactly how much global warming will be prevented by this assurance of future trade turmoil? Well, let’s use the federal government’s own model which — we are not making this up — is called MAGGIC (Model for the Assessment of Greenhouse-gas Induced Climate Change). It comes from the National Center for Atmospheric Research in Boulder, Colorado.

Now, let’s be completely unrealistic and assume that every nation that has “obligations” under the (failed) Kyoto Protocol cuts emissions as much as we do. Then the saved warming balloons all the way to 0.14ºF by 2050 and 0.4º by 2100, or 5 and 7 percent, respectively, of the “business-as-usual” total.

The legislation will wreck the US economy and start a trade war as Obama plans to raise tariffs on imports from countries that don’t adopt similar policies (China anyone ?). Fortunately, a wiser Congress can undo much of the damage as the Democrats have cleverly written the bill so none of the provisions, except the spending, take effect until after the 2012 elections.

The bill barely passed and would have been defeated except for eight Republicans. Their names are:

Bono Mack (CA)
Castle (DE)
Kirk (IL)
Lance (NJ)
LoBiondo (NJ)
McHugh (NY)
Reichert (WA)
Smith (NJ)

Without just 4 of these votes, the energy tax would have gone down and months of scheming by Henry Waxman and Speaker Pelosi would have been for naught. Two of them have hopes of a Senate run, I note. Twitter users are already calling them the #capntr8tors…

I think we can do without these people in the next Congress. If you want to understand just how ludicrous this act of Congress is, consider that there is no existing copy of the bill as passed. Not only didn’t they read it, it doesn’t exist. This is how banana republics are governed.

We have another breaking scandal with Governor Sanford of South Carolina, who has been mentioned as a possible presidential prospect. Now, he admits his mystery trip was to visit a woman he is having an affair with in Argentina. What is it with these guys ? At least the Democrats seem to use hookers and interns. That is a short term situation that can usually be covered up unless you are using state funds, or something.

Mr. Spitzer also had prosecuted at least two prostitution rings as head of the state’s organized crime task force.

“This was a sophisticated and lucrative operation with a multitiered management structure,” Mr. Spitzer said at the time. “It was, however, nothing more than a prostitution ring.”

Tell us about it.

Newt Gingrich wrecked his presidential prospects by having affairs and messy divorces. His first wife was ill with cancer when he divorced her. He would be a potential presidential candidate but he is dreaming if he thinks that messy record would not block a nomination. Then we had Ensign’s affair, spiced with some blackmail allegations.

The Democrats are far more tolerant of their politicians. Just contrast the treatment of Mark Foley with that of Barney Frank and Gerry Studds.

Studds continued to be re-elected until his retirement in 1997.

Last week the committee agreed to investigate Massachusetts Democrat Barney Frank, who has admitted that he had an affair with a male prostitute.

OK, just an affair, but then…

After 18 months, Frank says, he dismissed Gobie upon discovering that he was bringing clients to Frank’s apartment. Two years later, Gobie tried unsuccessfully to sell his story to the Washington Post. He then gave the story to the Washington Times for nothing, in hopes of getting a book contract for the male version of The Mayflower Madam. This week Gobie will appear on Geraldo, discussing his prospects for a television mini-series.

That’s called “a skeleton in Barney’s closet.”

Anyway, Republicans have to know they will be crucified if they have these sex scandals. Any Republican who runs for public office, should have the male version of a chastity belt bolted on. Sanford showed appalling judgement and once again, the Republicans succeed in another self-inflicted wound.

UPDATE #3: There is a lot more now coming out about the health insurance market and the role of a “public option.” Here is a lengthy discussion

UPDATE #2: More stories of Veterans Adminstration nightmares to liven up the debate. Also this sort of thing won’t help.

President Obama suggested at a town hall event Wednesday night that one way to shave medical costs is to stop expensive and ultimately futile procedures performed on people who are about to die and don’t stand to gain from the extra care.

He added: “Maybe you’re better off not having the surgery, but taking the painkiller.”

That should help a lot. There is a lot of truth to this and I support effectiveness research and outcomes research but who will be making these determinations ? Barney Frank ?

UPDATE: The Obama plan seems to be on life support, so to speak at this point. Too bad they couldn’t have an honest debate.

There is much discussion of the need for a “public option” to, as Robert Reich put it on This Week today, to keep the insurance companies “honest.” One model that has been used as an example of the success of federal programs has been the Veterans Administration. Many of my friends trained in VA hospitals and were not as favorably impressed. This article might be cause for more caution in touting the VA as a model.

Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records.The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show.

What it has that is troubling is the benefit of self regulation, as is true of many federal programs, especially in medicine. The Navy a few years ago learned it had a heart surgeon who had been run out of every private hospital for incompetence but he found a home in the Navy. The result was five deaths in patients and a court martial.

Cokie Roberts, on the same program, asserted that Medicare is the most popular health plan in the country, however she did not address the fact that it will soon be bankrupt. The fact remains that health reform has to include a free market method to control over use or the regulations will drown doctors and hospitals in red tape. Already, Medicare is seeing physicians dropping out of the program because of bureaucracy and poor reimbursement. Soon the Obama people will make things far, far worse.

I’m glad I’m retired.

By the way, it is now coming out why Michelle Obama got that high paid job at U of Chicago Hospital.

The boy in the news - Dontae Adams - is a Medicaid patient who the hospital treated with painkillers and a tetanus shot but then refused to admit him for surgery. His mother took him on an hour-long bus ride to another hospital that admitted him and performed the face-saving surgery.Dr. Jouriles took issue with a statement made by medical center spokesperson John Easton that “sending Dontae into surgery too quickly would have created a risk for infection.”

Guess who organized the Urban Health Initiative ? Answer ?

Michelle Obama. No wonder she was worth so much money to the U of Chicago.

A few years ago, executives at the prestigious University of Chicago Medical Center were concerned that an increasing number of patients were arriving at their emergency room with what the executives considered to be non-urgent complaints. The visits were costly to the hospital, and many of the patients, coming from the surrounding South Side neighborhood, were poor and uninsured.

So, Michelle came up with a solution to the uninsured, just like her husband.

Michelle Obama, an executive at the medical center, launched an innovative program to steer the patients to existing neighborhood clinics to deal with their health needs.That effort, in time, inspired a broader program the hospital now calls its Urban Health Initiative. To ensure community support, Michelle Obama and others in late 2006 recommended that the hospital hire the firm of David Axelrod, who a few months later became the chief strategist for Barack Obama’s presidential campaign.

So, now we see what The One has in mind for us. They call it “dumping.”

H/t Michelle Malkin.

At BoingBoing, there’s a lot of helpful hints, centered on those who use Twitter. Here’s one:

“Help cover the bloggers: change your twitter settings so that your location is TEHRAN and your time zone is GMT +3.30. Security forces are hunting for bloggers using location and timezone searches. If we all become ‘Iranians’ it becomes much harder to find them.”

For all the tips, please read the whole thing.

UPDATE: I’ve been waiting for Reuel Marc Gehrect’s thoughts on the events in Iran and they are here. He knows as much about the country as any American, having studied it as a CIA agent and visited, smuggling himself into the country at the risk of his life.

fI’m reading Amir Taheri’s book on the history of Persia and Shia Islam. It is amazing and reads like a novel. The first few chapters are about the origins of Islam and Shia Islam. For example, there was a religious conversion to monotheism prior to Muhammed and the Quran. The saying Allah Akbar! predates Muhammad and was an expression of the monotheism of Arabs who had adopted the basic tenets of Judaism living in Arabia. Muhammad’s father was such a monotheist. They believed that the God of the Jews was superior to the gods of the Arabs. I have long believed that the hostility to the Jews by Islam is due to the failure of Arabic Jews to adopt the new religion of Muhammad.

He describes the major differences between Sunni and Shia which are far greater than the belief that Ali should have been the fourth in line after Muhammad’s death. The Shia raise the role of imams to the level nearly of Muhammad, himself and have a number of beliefs that are clearly in conflict with Sunni Islam.

Thirdly, he points out that Ayatollah Khomeini established a fascist regime that has little to do with either Islam or Iran. The mullahs have grown rich and many of them, like Akbar Hashemi Rafsanjani, a former president and “moderate,” began as middle class businessmen or other non-scholastic origins. They have made a good thing of their sudden conversion to mullahs in 1978.

Many believe Rafsanjani to be the richest man in Iran due to his deep involvement in various Iranian industries, including the oil industry, as well as his ownership of many properties throughout the country. There have also been allegations that some of his wealth has come from arms deals made after the Revolution. His wealth has earned him the nickname of Akbar Shah in Iran. Rafsanjani family own vast financial empires in Iran, including foreign trade, vast landholdings and the largest network of private universities in Iran which are Known as Azad and these have 300 campuses spread all over the country. They do not only have large financial resources but also an active cadre of student activists numbering around 3 million.

The American business magazine Forbes has included Rafsanjani in their list of richest people in the world. In 2003 Forbes described Rafsanjani as the real power behind the Iranian government, and asserted that he “has more or less run the Islamic Republic for the past 24 years.”

Doing well by doing good, some call it.

Taheri’s book also points out that the Khomeini regime has killed hundreds of thousands and many of their victims have been among the senior clerical class. These were the scholars of Islam who opposed Khomeini in his deviations from Islamic principles. The cult around the “holy city” of Qom is also discussed. Near Qom is a smaller city, Jamkaran, where the “12th Imam” is supposed to be “occulted.” This small city has recently become the beneficiary of President Ahmadinejad who has derived his legitimacy for the presidency from a supposed association with the 12th Imam.

One of the first acts of the government of President Mahmoud Ahmadinejad was to donate £10 million to the mosque, to fund plans to turn “the tiny Jamkaran mosque into a massive complex of prayer halls, minarets, car parks and ablutions.”[5] In recent years, overseers of the Jamkaran compound have become sensitive to its foreign images and have restricted foreign press from the main mosque and well.

He also goes into a number of interesting aspects of Iranian history and its relationship to Islam. Contrary to Khomeini assertions, Iran did not adopt Islam voluntarily and there were bloody battles for many years before the war-like Arabs subdued the Iranians. Once in control, they burned Iranian libraries and insisted that the only book that was necessary was the Quran. An Iranian poet commented that he did not see how a people with one book could rule another people with hundreds of libraries.

I am still reading and will add to this post but I strongly recommend this book.

By Brother Bradley J. Fikes, C.O.R.

This is a companion and followup to the previous piece about newspapers and local government.

That piece discussed what happens when newspapers lose track of their ties to the local community. As editors are wont to say, here is the “nut graf”, journalese for the point of the story about a reporter for the Orange County Register and its affiliate local paper, the Saddleback Valley News:

We finally get a local reporter who cares about these local issues and reports the facts. So what happens? The overstaffed and lazy city government calls her in for a “talk” and the reporting stops. This is why newspapers are dying, although on a very small scale. Still, this is where that reporter was learning her career and this is what she learned. What a shame.

The moral of this story is not difficult to understand. A group of concerned citizens, the kind a newspaper should be happy to have, are disillusioned by the newspaper’s neglect of their concerns. So newspapers should concentrate on serving those local citizens and not let things get between them and their readers.

Now take a gander at what the OC Register is looking for in a county government reporter. It’s totally unrealistic, hence this post’s headline.

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