What next for health reform?

July 26th, 2014

It looks to me that the Supreme Court will have little justification for continuing the Obamacare program as it exists. The Halbig decision should kill it off. It is clear that the IRS subsidies to federal exchange subscribers are illegal.

The only statement anyone has found in the legislative history that addresses this point comes from the Act’s lead author, who affirmed that Congress did intend to withhold tax credits in federal Exchanges. During a September 23, 2009, mark-up of his bill, which ultimately became the PPACA, Senate Finance Committee chairman Max Baucus (D-MT) refused to consider a Republican amendment regarding medical malpractice on the grounds it fell outside the Committee’s jurisdiction. Sen. John Ensign (R-NV) protested, asking how Baucus’ bill could do other things that lie outside the Committee’s jurisdiction, like direct states to create Exchanges. Baucus responded the bill creates tax credits, which are within its jurisdiction, and makes eligibility for those tax credits conditional on states creating Exchanges. Conditional necessarily means that Baucus intended to withhold tax credits in states that did not create their own Exchanges.

I just don’t see how the Court can ignore that history. The political left has been on a rant about Congressional intent since the decision was announced.

Read the rest of this entry »

An Update on Medical Reform

July 21st, 2014

Cash medical practice or, in the phrase favored by leftists critics, “Concierge Medicine,” seems to be growing.

Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.

The article suggest that all these doctors choosing to drop insurance and Medicare are primary care. Many are but I know orthopedists and even general surgeons who are dropping all insurance.

The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.

Read the rest of this entry »

Is Israel winning the Global War on Terror for us ?

July 12th, 2014

Update: From Instapundit

UPDATE: Question: Come a real confrontation with Obama — which seems possible — could the Israelis flip and ally with Putin? The Soviets backed the Israelis pre-1967, and right now Putin’s siding with Assad against the Islamists. Israel would be a game-changing ally for Russia in the Middle East, especially with all the traditional Arab powers looking shaky — not only in terms of military assets, but more significantly in terms of intelligence assets.

Interesting as a game changing gambit although unlikely. Not even Obama is that stupid.

Hamas has attacked Israel, first with the kidnapping of three teenagers, now with rockets aimed, for example, at Tel Aviv and its airport.

GAZA: Islamist Hamas’ armed wing has warned airlines that it intends to target Israel’s Ben Gurion International Airport with its rockets from Gaza and has told them not to fly there, a statement by the group said Friday.

So far, Israel’s Iron Dome antimissile system has been successful in intercepting those that are a risk to populated places.

Israel’s astonishingly effective Iron Dome air defense has prevented Hamas from killing Israeli Jews and spreading terror in the civilian population. Ironically, though, the better Iron Dome works, the less sympathy the rest of the world has for a nation that remains under rocket attack.

That sentiment is to be expected as even the Presbyterian Church is anti-Isreal.

David Goldman, who has been writing as “Spengler” for years, reports on the situation in Israel.

the thumbnail version is that Hamas is making a demonstration out of weakness. Money is tight, 44,000 Gaza civil servants haven’t been paid for weeks, and the IDF did significant damage to its infrastructure on the West Bank after the kidnapping-murder of the three yeshiva boys. Netanyahu will look indecisive and confused, because he has to deal with an openly hostile U.S. administration on one side and his nationalist camp on the other. Time, though, is on Israel’s side: economically, demographically, strategically. The proportion of Jewish births continues to soar. The fruits of a decade of venture capital investing are ripening into high-valuation companies. And the Arab world is disintegrating all around Israel’s borders.

Israel has been in mortal danger for 50 years. They have survived and thrived. The Arab countries are collapsing into chaos. Iran is still a threat but its demographic future is grim.

There will be no Intifada on the West Bank: the Palestinian Arabs are older, more resigned and less inclined to destroy their livelihoods than in 2000. Syria and Iraq continue to disintegrate, Lebanon is inundated with Syrian Sunni refugees (weakening Hezbollah’s relative position), and Jordan is looking to Israel to protect it against ISIS. Egypt is busy trying to survive economically.

Israel is becoming a huge economic success under Netanyahu. Just think of our future had we elected his friend, Mitt Romney.

Obama promised a “pivot to Asia” but Israel may in fact be the one doing the pivot, leaving us in the dreary Socialist past.

Richard Fernandez notes that in the view of the world press and elites being rich makes you “white.” Everybody knows that white people, even if they are Asian like John Derbyshire’s Eurasian children, are the root of all evil.

Read the rest of this entry »

New developments at the hospital where I used to practice.

June 27th, 2014

When I moved to Orange County in 1972, I joined a friend from my surgery residency in practice at a new hospital that had opened a year before. It was called “Mission Community Hospital,” and was owned by a group of doctors with one of the partners an owner of the new development of Mission Viejo. His name was Richard O’Neill and his family had developed Mission Viejo from part of their huge ranch.

The hospital was small with 110 beds total and the staff was made up of young doctors who had recently finished their training like me. The owners were mostly older doctors and practiced in another area of the county. Some of them we would not have allowed on the staff if they had applied. They largely left us alone and over a period of a few years we developed what we thought was the best hospital in Orange County.

Mission Hospital in 1975.

Mission Hospital in 1975.

This is what the hospital looked like in 1975. The swallows used to nest in that entry area. To the right of the entry, there was a doctors’ parking lot and, for a while, the hospital paid a kid to wash our cars. Tom and I always tipped him extra. The food in the doctors’ dining room was free and good and I got a bit pudgy. The hospital went to considerable trouble to make it friendly to doctors and we responded.

Read the rest of this entry »

Iraq Collapses

June 13th, 2014

The Iraqi collapse we are seeing on TV has been predictable and is related to the Obama decision to leave with no residual US presence. The reasons why the Iraqi army is dissolving are well known.

iraq humvee

An Iraqi Hummvee.

A retired US general tells the story.

The day the U.S. forces left – because of the desire of our people and our politicians, but also because Prime Minister Nouri al-Maliki refused to sign a required and critically protective Status of Forces Agreement – the Iraqi Army began to deteriorate.

There were myriad reasons for this, besides our departure. Even before the U.S. forces left, American-trained leaders were being replaced with more and more “favored” officers from sects, tribes or families linked to the government. They weren’t chosen for their competency, a big mistake.

This is the history of Arab armies.

In my final tour, between 2007 and 2008, our soldiers did a great job reducing attacks in the north. I was able to observe and compare the capabilities of the four divisions of the Iraqi Army with the many units of the Kurdish pesh merga.

While both groups were becoming increasingly professional and capable, the connection between the pesh merga and the Kurdish government officials and Kurdish population was positive and vibrant. The same cannot be said of the Iraqi triad.

Beyond that, I also had the chance to engage with government officials, police, academics and doctors, lawyers, and women’s groups. The people we met were unfailingly professional and kind. And, almost universally, the Arab Iraqis and the Kurdish Iraqis were vocal in their frustration with the lack of action by “those in Baghdad” to attend to the matters of government: security, economic growth, services.

The attempt to “build a nation” in Iraq was possibly a worthwhile effort but it was abandoned too soon and cannot be revived.

Afghanistan will be even worse as it is far from the sea and evacuation will be much harder for the last US forces to leave.

Lord Elphinstone learned just how difficult it could be.

The Afghans launched numerous attacks against the column as it made slow progress through the winter snows of the Hindu Kush. In total the British army lost 4,500 troops, along with 12,000 mainly Indian camp-followers. The final stand was made just outside a village called Gandamak on 13 January.[3]

Out of more than 16,000 people from the column commanded by Elphinstone, only one European (Assistant Surgeon William Brydon) and a few Indian sepoys reached Jalalabad.

We have airplanes now but the distance to the sea is still intimidating Pakistan is no friend and Russia has no incentive to help. They lost nearly a thousand soldiers retreating to their border.

Medicaid for all.

June 5th, 2014

Obamacare has had its problems in implementation but the real problem is the fact that it has severely distorted the health care market by forcing people into narrow high cost markets that do not reflect the real situation in American health care. I have previously expressed my opinion on how to do health reform.

American health care has been distorted by the type of “insurance” that was brought into effect by employer-based insurance. That is prepaid care, not insurance as we know it in every other market.

The history of American health insurance is greatly distorted.

Now we have this latest iteration of the failure of the Obamacare method and the alternatives.

I have believed for some time that what we see is a system of Medicaid for all. The benefits are skewed by politics and the market mechanisms are crippled. Now we see the situation is even worse.

At least 2.9 million Americans who signed up for Medicaid coverage as part of the health care overhaul have not had their applications processed, with some paperwork sitting in queues since last fall, according to a 50-state survey by CQ Roll Call.

Those delays — due to technological snags with enrollment websites, bureaucratic tangles at state Medicaid programs and a surge of applicants — betray Barack Obama’s promise to expand access to health care for some of the nation’s most vulnerable citizens.

As a result, some low-income people are being prevented from accessing benefits they are legally entitled to receive. Those who face delays may instead put off doctors appointments and lose access to their medicines, complicating their medical conditions and increasing the eventual cost to U.S. taxpayers.

Democratic lawmakers who have promoted the law’s historic coverage expansion are wary of acknowledging problems that hand opponents of the Affordable Care Act another rhetorical weapon, said Robert Blendon, a professor at Harvard University School of Public Health and Kennedy School of Government.

What is going on ?

Meanwhile, Republicans usually eager to criticize the Obama administration or states for implementation problems risk looking hypocritical by showcasing the Medicaid waits. Many oppose expanding the program to people with incomes as high as 138 percent of the federal poverty line, as the law allows states to do, and are loath to demand more efficient enrollment to achieve that goal.

“It’s a total contradiction in terms to spend your public time castigating Medicaid as something that never should have been expanded for poor people and as a broken, problem-riddled system, and then turn around and complain about the length of time to enroll people,” said Sara Rosenbaum, a member of the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Oh OK.

Updated numbers provided by Bataille indicate that the total number of people affected remains about the same as reflected in the document. About 1.2 million have discrepancies related to income; 505,000 have issues with immigration data and 461,000 have conflicts related to citizenship information.

Many years ago, I was still interested in health policy research. I had an office at UC, Irvine and Orange County, where I live, was undergoing a transition from fee-for-service Medicaid (MediCal in California) to a new HMO-based program called Cal OPTIMA. This seemed a good opportunity to study the outcomes in two contrasting systems for the same population. No studies had been done to see how the MediCal Population would repond to the different incentives of fee-for-service and HMO. I developed a proposal to study this transition at a time when databases for both systems were available. The data from the fee-for-service program was still current and the new HMO program would provide the opportunity to see how the MediCal patients fared under the new program. I had obtained the cooperation of the UCI statistics department and had had some experience with this sort of study at Dartmouth where I had recently compacted a Masters Degree program in health policy research.

The Orange County Health Department had hired the recent director of HCFA, the Medicare intermediary. Funding was available from a large endowment fund devoted to the study of low income California residents’ health care. The organization was called “The California Endowment” and was funded when Blue Cross became a for-profit entity and was obliged by the state to donate a large sum to charitable causes.

The proposal is here.

All that was needed was the approval of the Cal OPTIMA program to use their data. All the funding was assured.

They refused. I wonder why ?

Bergdahl, Father and Son.

June 5th, 2014

bergdahl

The world got a little more bizarre this week. President Obama worked a trade that involved releasing five serious Taliban leaders in return for the freeing of an army deserter from Afghanistan. Bowe Bergdahl was a private who seems to have walked away from an outpost in Afghanistan and ended up with the Taliban. There are a number of stories surfacing from other members of his unit about his departure.

The handling of the announcement has drawn considerable criticism from conservatives.

The story of how the Bergdahls ended up at the White House is pure turnip-truck territory. According to Time:

Their presence at the White House on Saturday was the apparent product of coincidence: the couple had visited the capitol for a Memorial Day event and then stayed in town for meetings in Congress. Had they been at home in Idaho when the deal was announced, they likely would not have flown to Washington to appear with Obama—and a key visual element of the drama, replayed endlessly on television, might not have occurred.

Does anyone believe that ?

Where did the Bergdahls stay during their D.C. visit, and who paid? How were they vetted before their appearance with the president — both for security and for political sensitivities — and how long did the process take? Did anybody at the White House know Robert Bergdahl was going to say “bismillah al-Rahman al-Rahim,” along with the “Pashto phrase” that has been getting so much attention?

If anyone is interested, that story should melt quickly like ice cream on a hot day.

The actual story of the Bergdahl adventure has been around for years.

His attitude ?

“The future is too good to waste on lies,” Bowe wrote. “And life is way too short to care for the damnation of others, as well as to spend it helping fools with their ideas that are wrong. I have seen their ideas and I am ashamed to even be american. The horror of the self-righteous arrogance that they thrive in. It is all revolting.”

Bitching by soldiers goes back to Alexander the Great. Not all act on their impulse.

Bowe Bergdahl had a different response. He decided to walk away.

In the early-morning hours of June 30th, according to soldiers in the unit, Bowe approached his team leader not long after he got off guard duty and asked his superior a simple question: If I were to leave the base, would it cause problems if I took my sensitive equipment?

Yes, his team leader responded – if you took your rifle and night-vision goggles, that would cause problems.

Bowe returned to his barracks, a roughly built bunker of plywood and sandbags. He gathered up water, a knife, his digital camera and his diary. Then he slipped off the outpost.

Where was he going ? There are stories that he was not a prisoner but a collaborator.

the Defense Department source confirmed to Fox News that many within the intelligence community harbor serious outstanding concerns not only that Bergdahl may have been a deserter but that he may have been an active collaborator with the enemy…

That is explosive stuff and, so far, is all coming from the right. If these stories are out there why would the White House get anywhere near this thing until it is fully vetted ?

The backlash seems to have taken them by surprise. Now they are even attacking the other members of the platoon. Here’s the thing about Bergdahl and the Jump-to-Conclusions mats: What if his platoon was long on psychopaths and short on leadership?

This is from a minor official in HUD who is an anti-war vet with seeming ambitions to be the next John Kerry.

kerry

Kerry

Friedman

Friedman

Do they look alike ?

Friedman has a point. The final verdict on Bergdahl should come from a court martial. Will he ever face one ?

Have we lost and is this why we lost ?

May 30th, 2014

A new book by a retired army general explains that we lost the Iraq and Afghanistan wars. Why ?

I have had reservations about Iraq for years, at least since 2008.

When President Bush convened a meeting of his National Security Council on May 22, 2003, his special envoy in Iraq made a statement that caught many of the participants by surprise. In a video presentation from Baghdad, L. Paul Bremer III informed the president and his aides that he was about to issue an order formally dissolving Iraq’s Army.

I think that decision probably lost the post-invasion war. The other puzzle that was not explained until the recent book, Days of Fire explained it, was why Bremer was put in place of Jay Garner, who had done well with the Kurds.

Garner began reconstruction efforts in March 2003 with plans aiming for Iraqis to hold elections within 90 days and for the U.S. to quickly pull troops out of the cities to a desert base. Talabani, a member of Jay Garner’s staff in Kuwait before the war, was consulted on several occasions to help the U.S. select a liberal Iraqi government; this would be the first liberal Government to exist in Iraq. In an interview with Time magazine, Garner stated that “as in any totalitarian regime, there were many people who needed to join the Baath Party in order to get ahead in their careers. We don’t have a problem with most of them. But we do have a problem with those who were part of the thug mechanism under Saddam. Once the U.S. identifies those in the second group, we will get rid of them.

Had Garner continued with that policy, we might have been out of the cities in a few months instead of years, as was the case with Bremer.

Read the rest of this entry »

Is the United States becoming a corrupt enterprise ?

May 22nd, 2014

The activities of the Obama administration have progressed into Mafia territory the past five years. I never thought things could change this fast but it seems I was wrong. The latest example ?

Soon after the US Government sold the last of its stake in General Motors, the company began to announce a huge number of recalls. These safety defects were known for years but unreported until the federal government sold its interests, at a huge loss of course.

Taxpayers, drivers, and investors who assumed the government would never fail to disclose rampant safety problems in a company it owned can rest easy, though. Instead of investigating fatally flawed GM components while the U.S. government was the company’s largest single owner, the NHTSA was busy harassing Toyota — one of GM’s top competitors — for an alleged malfunction that led to “unintended acceleration” in Toyota vehicles. Toyota was fined and eventually bullied into recalling 8 million vehicles over the issue.

Toyota is probably the safest, highest quality auto maker in the world. I drive one and have bought Toyotas for my daughter.

And what was the final result of the NHTSA investigation?

Many drivers may have confused the gas and brake pedals a problem that may account for “the vast majority” of the unintended acceleration incidents the agency investigated, NHTSA deputy administrator Ron Medford said at Tuesday’s NHTSA press briefing.

“What mostly happened was pedal misapplication where the driver stepped on the gas instead of the brake or in addition to the brake,” Medford said.

The Toyota cases were always about driver error, not safety of the auto. Only the trial lawyers and a complacent government permitted this raid on a company to proceed.

Is that the only case ?

Read the rest of this entry »

Global Warming and the Divestment Movement

May 15th, 2014

I have previously posted on global warming, at least back as far as 2007.

If you want to know the costs associated with the “Cap and Trade” system proposed by Kyoto, look at this report. If you can’t decipher the bureaucratic language, here is the conclusion. GDP and consumption impacts in the Full Auction case are substantially larger than those in the Phased Auction case. Relative to the reference case, discounted total GDP (in 2000 dollars) over the 2009-2030 time period in the Full Auction case is $462 billion (0.19 percent lower), while discounted real consumer spending is $483 billion (0.29 percent) lower. In 2030, projected real GDP in the Full Auction case is $94 billion (0.41 percent) lower than in the reference case, while aggregate consumption is $106 billion (0.69 percent) lower, almost twice the estimated consumption loss in the Phased Auction case. A reduction in GDP is called a recession.A reduction that is permanent is called a Depression.

It’s no wonder that nothing was done. First, the risks of serious harm are small. The small amount of warming suggested by more serious studies has nothing to do with the alarmist views.

Now, we have a new strategy. The alarmists are going to try to destroy the fossil fuel industry.

The fossil free movement has spread far and wide on American campuses. Fossil Free Stanford organized in fall 2012 after McKibben visited Palo Alto on his “Do the Math Tour.” Two of the founding members, Michael Penuelas and Yari Greaney, both from the class of 2015, proclaimed their commitment. Greaney held that “our tuition money…is going to support industries that are polluting our future.”

This is standard student radical rhetoric. What is new ?

The students waged a textbook campaign, assembling impressive numbers, soliciting key testimonials, maintaining a respectful tone towards authority while at the same time keeping up the pressure.

The question is really: to what end? The answer is, sadly, self-delusion. No one doubts that Stanford students are smart, but their intelligence is not much of a defense against irrational enthusiasms that can sweep through a community. What the divestment movement has sold to Stanford students is a bit of flummery. When Stanford announced on May 6 that it would divest “direct investments in coal mining companies,” President John Hennessy issued a statement that begins, “Stanford has a responsibility as a global citizen to promote sustainability for the planet…”

Got that? Stanford is no longer a university. It is a “global citizen.” And global citizens, of course, are charged with promoting “sustainability.”

Delusions of this magnitude seem to be getting more common. As at Dartmouth, for example.

The activists unveiled a Freedom Budget in February with over 70 specific actions they want the Dartmouth administration to take to address students’ concerns over diversity, perceived sexism and the campus climate for minorities and the LGBT community. Students entered President Phil Hanlon’s office Tuesday afternoon at 4 p.m. asking for a point-by-point response, following what they felt was a half-hearted statement about their budget from Dartmouth a day before finals on March 6.

What do they want ? Why not much, just turn Dartmouth into an insane asylum.

The Freedom Budget’s items include hiring more racial minorities as faculty, implementing more gender-neutral housing and bathroom options, banning the term “illegal immigrant,” evaluating the Greek system’s role in sexual assault, and harsher punishments for those who commit sexual violence.

Stanford assigned another Constitutional Law professor to teach the course that Derrick Bell was teaching. Why should this be ?

Stanford at that time had one of the leading scholars in constitutional law, Professor Gerald Gunther — and Derrick Bell was no Gerald Gunther. A hastily created program of study of constitutional law was then used to teach that subject to students who were not getting what they needed in Professor Bell’s course.

When this clever finessing of the problem came to light, the administration apologized — to Derrick Bell for the embarrassment this caused him.

They should have apologized to the law students for short-changing them with a professor who was not up to the job — and to those who donated money to the university to advance the cause of education, not to allow administrators to play racial quota politics on campus.

As a full professor at the Harvard law school, Derrick Bell was also surrounded by colleagues who were out of his league as academic scholars. What were his options at this point?

Here is one example of the result of affirmative action. What about global warming ?

The orthodoxy of the left is just as powerful. It recently claimed another scalp.

Dear Professor Henderson,

I have been put under such an enormous group pressure in recent days from all over the world that has become virtually unbearable to me. If this is going to continue I will be unable to conduct my normal work and will even start to worry about my health and safety. I see therefore no other way out therefore than resigning from GWPF. I had not expecting such an enormous world-wide pressure put at me from a community that I have been close to all my active life. Colleagues are withdrawing their support, other colleagues are withdrawing from joint authorship etc.

No mercy for those who say the earth revolves around the sun. Anyway, the alarmists have a big agenda.

This is not a single-issue movement. This is a space where environmental justice, climate justice, and economic justice have come into contact. We understand that we will not win the fight against the fossil fuel industry without confronting racism, classism, homophobia, and other systems of oppression in our movement spaces.

My colleagues and I at the National Association of Scholars have been pointing out for some time how fluidly the sustainability movement changes from clean energy advocacy to a hard left agenda on social issues. Official Stanford no doubt brushes aside these elaborations, thinking that it has discerned the core issue: dirty industries that pollute the water, blight the landscape, and foul the air. But the true core issue is the effort of a movement to foster in students a lifelong aversion to Western values.

How well it will succeed in that no one knows, but there is no comfort in the ease with which Bill McKibben in a little less than two years has conjured this movement into existence.

Personally, I see this as another example of how environmentalism has become a religion that tolerates heretics not at all. The similarity to the Puritans is striking, even to the region that has given rise to the leftist ideology.

Joseph Bottum, by contrast, examines post-Protestant secular religion with empathy, and contends that it gained force and staying power by recasting the old Mainline Protestantism in the form of catechistic worldly categories: anti-racism, anti-gender discrimination, anti-inequality, and so forth. What sustains the heirs of the now-defunct Protestant consensus, he concludes, is a sense of the sacred, but one that seeks the security of personal salvation through assuming the right stance on social and political issues.

Environmentalism is but one branch of leftism but is a particularly intrusive one.