Archive for the ‘Health Care Madness’ Category
An Open Letter to Senator Lindsey Graham (R, SC)
Senator Lindsey Graham (R., SC)
I think we’re going over the cliff. It’s pretty clear to me they made a political calculation. This offer doesn’t remotely deal with entitlement reform in a way to save Medicare, Medicaid and Social Security from imminent bankruptcy. It raises $1.6 trillion on job creators that will destroy the economy and there are no spending controls.
- Lindsey Graham, 0n CBS’s “Face the Nation,” December 2, 2012
WC’s grandmother used to tell him that if he had a zit on the end of his nose, it meant he had told a lie. Francis Bacon traces the line all the way back to Theocritus.
There are so many lies and half-truths in Graham’s statement that it’s a marvel the zit on his nose in this Reuters photo is so small. You’d expect it would be larger than his nose, blocking his vision. Perhaps the photo was taken before he popped the whopper on national television.
Any blog post that rebutted all the fibs in that single paragraph would be tediously long. After all, it earned the Senator the Washington Post‘s coveted Three Pinocchios Award. But WC will dissect a few of Graham’s Big Lies in a doubtless futile effort to keep the conversation honest.
Dear Senator Graham:
On “Face the Nation” last month, you said that the then-current discussions on solutions to the “fiscal cliff” didn’t “remotely deal with entitlement reform in a way to save Medicare, Medicaid and Social Security from imminent bankruptcy.” As you know, Senator, they aren’t “entitlements” and there is no threat of “imminent bankruptcy.” You are indulging in neocon Big Lies again.
Medicare and Social Security are both insurance programs. They are only “entitlements” in the sense that any contractual obligation entitles a person to performance. By your reasoning, the hefty salary you are paid by American taxpayers is an “entitlement.” WC and his fellow citizens pay premiums their entire working lives for the modest benefits that Social Security and Medicare provide. It’s insulting and dishonest to call the programs “entitlements.”
Medicaid isn’t an entitlement; it’s governmental prudence. Or do you and your fellow neocons intend to turn away health coverage for those who cannot afford it? Isn’t it clear that denying minimal health care to those who need it is contrary to everything America stands for? Because if we don’t turn them away, Americans will pay. Either in a somewhat sensible program like Medicare, or in the form of higher rates for themselves as the hospitals and clinics shift the cost of those who cannot pay. There are only three options: Medicaid, or something very like it; forced subsidization as insurers and medical providers pass the costs of treating the poor on to the rest of us; or turning the poor away at the health care door.
You call them “entitlements” because the term mischaracterizes what they really are in a way that you think is advantageous to you and your fellow neocons. It’s a trick straight out of the Newt Gingrich lexicon. It’s a ploy. It’s an attempt to make cuts seem inevitable, rather than a hard political choice. It’s an attempt to make treating the elderly badly a virtuous deed.
Nor is social security in imminent danger of bankruptcy. It’s fully funded, under existing contributions and existing benefits, through 2023. At least ten years. Imminent is the fiscal cliff. Imminent is the pending borrowing limit. A decade is forever. And there is a known, easily implemented solution to the social security funding shortfall: remove the limits on social security contributions by the wealthy. You claim to oppose it because it is a “tax increase” but your real objection is that it’s a easy fix to your non-crisis.
Medicare is fully funded through 2024. No imminent threat of bankruptcy there, either. And that’s just one part of the overall Medicare system. Congress has eleven years to act. As if there was anyone in Congress who can think and plan eleven years into the future.
So WC would appreciate it if you could stop the political showboating, including your vote against the interim compromise on the morning of January 1 and deal with issues like a statesman. Or at least use the truth instead of lies, false alarms and Newtisms. Call it a New Years Resolution.
Or that zit on your nose is only going to get bigger.
Seriously,
/Wickersham’s Conscience
Problems That Never Really Go Away, v. 1
From the Fairbanks Daily News-Miner, Letters to the Editor, September 13, 1909:
On August 20th, at 10 p.m., John Francis (or Franceses), a man made helpless by paralysis, was laid at the door of St. Joseph’s Hospital. The automobile had brought him down from Engineer Creek. The invalid is an old-timer in the country and has been a woodchopper. His home is in New Jersey, from which place he has been a wandered these last 40 years. He is penniless; his partner, Mr. Campbell, is out on him with $50 or $60 It is hard to tell whether the man will ever recover. Whatever the issue of his trouble, the case apparently is one that is calculated to entail great expenses on the hospital, as the man has no control whatever of the functions of his body, and has to be nursed and waited upon as an infant.
We are ever read to do the part of charity which the means put at our disposal allow, but with the heavy debt on the institution, and the far too great number of non-paying patients, it becomes our duty to ask the Government to come to our aid.
I would wish to know what assistance the Federal Government is willing to give in the present case, either by taking the invalid out ofour hands and having him removed to some public institution in the States, where proper care can be given him, or by defraying some of the of the expenses which out hopital will incur in nursing him.
Very respectfully,
ST. JOSEPH HOSPITAL
Per S. J. Cimont, S.J.
The newspaper reported that Marshall Love said nothing could be done unless the man was adjudged insane.
One hundred three years later, we are still having these debates.
2012 in Review: Examining WC’s Wishes for 2012
Once again, WC opened the year with wishes for the upcoming months. And once again, WC’s wishes and hopes were mostly dashed. But with just a week or so left in 2012, let’s look at the specifics (Predictions in bold face; outcomes indented below):
1. Overpopulation. Among the crises facing the planet is human overpopulation. During 2011, we rolled the odometer over to an estimated 7 billion. To a deplorable extent, especially in the Western world, the rate of population growth is a function of religious teachings. The Catholic church’s and the Latter Day Saints’ crazed obsession with large families would be two examples. When religious dogma have counter-survival effects, it’s past time to change them. WC calls on those latter day saints and infallible pontiffs to have a revelation: that further growth of human populations is terrible, and must be controlled, that more than two chldren is a sin by whatever definitions they use.
Not. Zilch, zero, nothing. Another 180,000,000 babies were born in 2012, more or less. More than half of them will never have enough food to eat. The closest thing to good news is that we didn’t elect as president someone who thinks their god wants them to breed big families.
2. A second great crisis facing humanity is anthropocentric climate change. The way things are going, to paraphrase Pratchett and Gaiman, we are going to scourge all intelligent life from the planet, leaving nothing but dust, cockroaches and fundamentalists. The time for denying man-caused climate change is past. Can we at least shift the debate about how to deal with it? And can all the global warming-denying politicians who have sold their small, dark, crabbed souls to the fossil fuels industry have a look in the mirror and ask themselves, “Do I care about my gtandchildren?” There will come a day when fossil fuel lobbyists and the politicians they have purchased will be held in the same contempt as Congressmen who defended slavery, or claimed tobacco was harmless. Why not now?
Not. Zilch, zero, nothing. The single glimmer of good news was some movement by U.S. energy consumers from coal to natural gas, an accident of the fracking epidemic. But fracking carries its own, very serious environmental consequences. Some wind turbines are installed, but the tax credit that encouraged them appears to be a victim of the fiscal cliff. More importantly, the climate change deniers haven’t shut up. Did WC mention we set a new record for minimal sea ice in the Arctic Ocean in 2012?
3. The health care crisis facing facing America threatens to sink the economy of our country. The Affordable Care Act remains the only half-way comprehensive solution presented. The need for health care is not going to magically vanish if Medicare and Medicaid are repealed. Passing a reduced amount of money out as vouchers isn’t going to reduce spending or lower costs. It is absolutely clear that traditional capitalist solutions are an abject failure in controlling costs. We’ve been trying it for the last 50 years and it has gotten us where we are. The neocons have to come up with specific, functional proposals to fix a real crisis, or shut up. Not more of the same. Real solutions.
Maybe. A mixed result. The Affordable Care Act was upheld by the U.S. Supreme Court, to the horror of the Act’s critics and gnashing and wailing of Fox News. But the SCOTUS gutted some critical Medicaid provisions, and the largely Republican governors are slow-rolling the health care exchanges that would help implement the law. They don’t have a good reason. They just don’t want President Obama’s law to work.
4. Despite the Republican presidential wannabes’ lies, distortions and self-deception, President Barack Obama as a national leader is vastly superior to Mitt Romney and all the Not-Mitts. Despite the protracted and concerted efforts of the Republicans to blow up the economy rather than allow him to effect reasonable repairs, the economy has improved. He has done more to slap down Islamofacsist terrorism than his predecessor managed with two land wars in Asia, up to and including the assassination of bin Laden and the liberation of Libya. He has gotten us out of George W. Bush’s disastrous, ill-conceived and unnecessary war in Iraq. He has stopped and repudiated the use of torture as an instrument of national policy. He has enacted the first real health care reform in the United States since Medicare. He has saved the plutocrats from their own greed and folly. And he has done all this is the face of an unscrupulous U.S. House that would tear the country to shreds if it had its way. Re-elect him. And while we are at it, pitch the Teabaggers out of the U.S House.
Maybe. President Obama was re-elected, whatever Dick Morris may think. Integrity still matters. Yes, the House is still dominated by teabaggers who refuse to come to grips with reality. Or learn from their mistakes.
So it’s another disappointing year. As was the case for 2011, none of WC’s wishes came completely true, but as of year end perhaps two are partially so. Two failed completely. Better than 2010, but still a disappointment to WC. Maybe next year.
The Commerce Clause and Fungal Meningitis
The ongoing tragedy of death and severe illness from fungal meningitis dramatically illustrates the danger of Neocons’ narrow view of the Commerce Clause of the U.S. Constitution. It’s a perfect example of why a broader, not narrower, interpretation of the Commerce Clause is critically important.
A “compounding pharmacy” in Framingham, Massachusetts has been identified as the source of fungus-contaminated steroid solution. The steroid solution is intended to be and has been injected into patients’ spinal columns. When contaminated by fungal spores, fungal infections can lead to life-threatening infections in the spinal cord canal and brain. At least eleven persons have died.
Compounding pharmacies, like New England Compounding Center, the suspected source of the contaminated vials of steroid solution, are unregulated by the federal government. The absence of regulation results from a poorly drafted federal law and the U.S. Supreme Court’s blinkered interpretation of the that statute. In 2002 in Thompson v. Western State Medical Center, the U.S. Supreme Court found that the Congressional restrictions on commercial speech – advertising – by compounding pharmacies was unconstitutional, and through out not just the speech limitations but the entire body of federal law regulating “compounding pharmacies,” outfits that assemble known drugs. So regulation is left to the state level and is woefully ineffective. Congress has not been able to get its act together to adopt new laws.
As a result, outfits like New England Compounding Center manufacture drugs, ship them into interstate commerce, and are almost completely unregulated. The butcher’s bill for the fungal-contaminated steroid vials so far:
| State | Case Count | Deaths |
| Florida | 4 | |
| Indiana | 12 | |
| Maryland | 8 | 1 |
| Michigan | 25 | 3 |
| Minnesota | 3 | |
| New Jersey | 1 | |
| North Carolina | 2 | |
| Ohio | 1 | |
| Tennessee | 39 | 6 |
| Virginia | 24 | 1 |
| TOTALS | 119 | 11 |
The toll will undoubtedly get worse. Fungal meningitis can take as long as 30 days for cause symptoms, and is notoriously difficult to treat.
In the absence of federal regulation, and in the face of individual state’s inadequate resources to regulate, there is no effective oversight. Instead, there’s the post hoc remedy of product liability regulation. New England Compounding Company is itself effectively dead. All of its products since the start of the year have been recalled. Plaintiffs’ lawyers are lining up and the usual Chapter 11 bankruptcy will probably ensue. It’s the moral equivalent of leaving the hung corpse hanging from the tree to rot, as a warning to others. But there’s no evidence that the hanging corpses deterred criminals and there’s no evidence other unregulated compounding pharmacies would – gasp – reduce profits by imposing FDA-standard self-inspection. Anyone who thinks self-regulation works is invited to read Upton Sinclair’s The Jungle as remedial homework.
Nor is there any way that a state like Tennessee – the state with most case counts and deaths so far – can police drugs entering that state.
In any sensible view of the world, outfits like New England Compounding Center, which “compounds” some 2,400 different drugs and distributes them in at least 13 different states, is a drug manufacturer, and not you neighborhood pharmacy assembling a special version of a drug for you because you have an allergy to the standard filler. But after the regulatory cloud from Western State Medical and Congress’s inaction, everyone pretends it isn’t in the business of manufacturing drugs and therefore is unregulated by the FDA.
Which takes us to the Neocons and their narrow view of the Commerce Clause in the U.S. Constitution. An originalist like Justice Antonin Scalia (yes, he was in the majority in Western State Medical) would argue that because the Constitution is silent on interstate shipment of compounded drugs, the federal government has no jurisdiction. Paul Ryan would take us back to the narrow, long-rejected view of the 1930′s. His idol, Ayn Rand, would reject any government oversight of the manufacture of medicines. But two conclusions can be drawn from Food & Drug Administration regulation of medicines.
First, it works pretty well. Yes, the FDA has let some bad stuff slip through, but overall things are much better than the unrestricted, free market days when poisons, narcotics and patent nostrums could be sold without regulation. The FDA is the best means we’ve found so far to the problem of protecting the public from the toxic combination of rampant capitalism and bad medicine.
Second, and more importantly, no one has a better solution that works as well, let alone better. Free market nut jobs who would allow the industry to regulate itself have forgotten, or are ignoring, or are utterly ignorant of history. We tried it. It didn’t work.
All of which is why a broad interpretation of the Commerce Clause, allowing the federal government to regulate companies like New England Compounding Company, is critically important. Lives depend on it. Indeed, WC would argue lives have been needlessly and senselessly lost because Congress has failed to act.
Stale Waffles: The Mitt’s Latest Flip-Flops on Issues
A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines.
- Ralph Waldo Emerson, “Self-Reliance“
The Mitt did the Sunday talk show circuit. And it’s pretty clear he is reacting to polls and not principles. Again. Still.
Remember when The Mitt was going to repeal “Obamacare”? Appearing on “Meet the Press,” The Mitt announced:
I’m not getting rid of all of health care reform. There are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage.
WC is amazed that The Mitt isn’t so dizzy he staggers…
Remember when Romney was going to balance the budget? Not so fast. Now The Mitt says he would seek to balance the budget in 8 to 10 years, perhaps after his own potential presidency would end. Any attempt to do so in a first term, The Mitt said, would have “a dramatic impact on the economy — too dramatic.” Simpson-Bowles, anyone?
What we are watching is The Mitt caught between his extremist Tea Party base and the need to attract the votes of the sane majority. The ones in touch with reality. The ones who don’t think government employment grew under President Obama (what Paul Krugman calls the Zombie That Ate Paul Rand’s Brain). The ones who understand trickle down doesn’t.
It is appalling that so many citizens are willing to even consider re-electing the horse thieves and clowns who wrecked our economy just four years ago. But perhaps The Mitt’s shift back to the middle is a dim recognition on his part that the electorate’s memory isn’t quite so short.
Flaks and Health Care: Lessons on the Economies of Scale
Last week, WC wrote an analysis of an opinion essay by Department of Administration Commissioner Becky Hultberg. Well, more likely by some assistant. The issue was whether Alaska’s employees and retired employees should be shipped stateside for medical treatment. WC was not kind; the Commissioner’s essay was a textbook example of logical fallacies. AKM at The Mudflats was kind enough to post the essay as well, giving WC a lot of additional readers. Among those additional readers, apparently, was someone in Commissioner Hultberg’s office.
Because a modified version of the same essay appeared in the Fairbanks Daily News-Miner on Sunday, August 4.
The new version removed the ad hominem fallacies but left in the non sequitur fallacy. The new version also recasts the Commissioner’s trial balloon as a wholly voluntary program. Whatever that means.
But the Commissioner’s revised essay still demonstrates an apparent ignorance of economics, including economies of scale. The laws of economics apply to health care, after all. The Commissioner says,
We have documented many examples of medical procedures performed in Alaska that are charged at several times the rates of those performed in the Pacific Northwest. While we recognize that costs will be higher in Alaska, they cannot be double or triple the costs in the regional market.
Let’s try a hypothetical and see if the Commissioner is right.
Assume there is an expensive piece of diagnostic equipment. Assume it’s very useful, even life-saving, in emergency diagnoses. It has the potential to save a dozen or more lives a year in interior Alaska. Assume the machine is only useful in the few hours after an accident or injury, to diagnose what is wrong. For convenience, we’ll call this hypothetical gadget a Hultberg Machine.
Assume the Hultberg Machine costs $500,000. Assume it has a maintenance cost of $100,000 a year. And assume it will be obsolete and have to be replaced in five years. So the total cost of the Hultberg Machine, over it’s useful life, is $1 million. That total cost has to be repaid in patient fees over the useful life of the machine.
In Seattle, the Hultberg Machine might get used twenty times a day. In Interior Alaska, it might get used twice a week. Ignoring operating costs and indirect costs, how do the charges for the use of the Hultburg Machine pencil out in Seattle and in Fairbanks?
In Seattle, the $1 million dollar lifetime cost of the Hultberg Machine gets amortized across 36,500 patients, for a cost of $27.40 per patient.
In Fairbanks, with a much lower usage rate, the Hultberg Machine gets amortized across 520 patients, for a cost of $1,923.08 per patient.
So on WC’s little hypothetical example, the unit cost of using the Hultberg Machine in Fairbanks is about seventy times higher than in Seattle. Not “several times higher,” it’s seventy times higher. Ordinarily, another economic law, the law of supply and demand, would dictate that increased competition would lower the price, but increased competition – two Hultberg Machines in Fairbanks – would simply increase the price, not lower it, because the constraint is demand, not supply. Note also the risk of artificially increased demand, where the Hultberg Machine is used inappropriately simply because it is available.
Shipping patients to the Lower 48 isn’t workable; this is an emergency diagnostic tool, after all. Do we sacrifice the dozen lives that might be saved and not have a Hultberg Machine in Fairbanks? Do we make the conscious decision to let patients die who might be saved? Do we create the kind of de facto “death panels” that former Governor Palin fantasized might exist?
WC’s point is that many of the profoundly difficult questions in U.S. health care policy involve the hard laws of economics. While the Commissioner’s revised essay removes the personal attack on Shannyn Moore, the complaints about higher costs in Alaska betray a very worrying ignorance of economics and avoid the real issues and challenges in health care. What health care can we afford to provide? Who decides?
And health care economics affect all non-trivial aspects of Alaska’s health care. WC is old enough to recall when health care services weren’t available in Alaska. WC, for example, had to go to Seattle in 1968 to have impacted wisdom teeth extracted; the procedure wasn’t available in Fairbanks. If Commissioner Hultberg ships patients to Seattle for removal of wisdom teeth because the cost is 30% lower, the law of supply and demand will inexorably drive up the cost in Alaska.
The health care mess is big, complex and filled with ethical and economic pitfalls. It’s not a place for someone who claims – twice now – that health care costs “cannot be double or triple the costs in the regional market.” The claim betrays a profound ignorance of the underlying issues. And a serious unawareness of the Law of Unintended Consequences.
Flaks, Facts and Intelligent Debate: Health Care in Alaska
Back on July 21, 2012, Shannyn Moore wrote a heartfelt essay on the State of Alaska’s reported consideration of the idea of sending some state-insured retirees outside for medical treatment. Moore is her mother’s primary support. That support would be missing, Moore pointed out, if her mother had to go Outside for treatment.
In an attempted response, Commissioner Becky Hultberg of the Alaska Department of Administration wrote a Compass piece for the Daily News. Well, she is supposed to have written it. We’ll have to hope it was her press aide, who has since been disciplined. Because as a response to the issues Moore raised, it was an embarrassing failure.
Shannyn Moore doesn’t need WC’s help in defending herself. She is perfectly capable of dealing with her critics. In a phrase, WC pities the fool. But as an exercise in logical fallacies and deception, the essay credited to Commissioner Hultberg is worth study. She begins,
It’s unfortunate when we debate without facts — and even more unfortunate when incorrect statements can mislead people. Such is the case with Shannyn Moore’s column last Sunday on state health care plans, in which she claimed that retirees and employees will be forced to leave the state for care.
So the Commissioner opens with a classic ad hominem fallacy. An attack on Moore, rather than addressing the issues. Not a strong start, if you value logic, informed debate and critical thinking. The Commissioner continues,
Ms. Moore is absolutely incorrect. The state has no plans to force retirees and employees to travel for health care, and never said it did.
Well, then at a minimum the State of Alaska is sending mixed signals. There are many reports that the State is considering Outside treatment plans. In fact, in another classic fallacy, the Commissioner next nearly admits that the State is considering that very idea. She says,
Over the past decade, however, the cost of these plans has soared. In 2001, the annual cost of state employee and retiree health care was about $280 million. By 2011, that grew to about $630 million and the unfunded liability for retiree health care ballooned to $4.1 billion.
WC sees the distinction now. Commissioner Hurtley very nearly admits the State is considering shipping its insureds Outside to save money, but isn’t yet planning to do so. But wait. Moore never claimed that State was planning to do so. She said the State was threatening to do so. So we have a classic straw man fallacy. WC hasn’t gotten to a post on the straw man fallacy. So many fallacies. So little time. Briefly, the fallacy occurs when an opponent attacks a position a person hasn’t taken. Commissioner Hurtley attacks Moore’s claim that the State plans to ship patients outside. But Moore never claimed that was the State’s plan; she claimed that State was considering the idea. Which it is.
The Commissioner continues,
Health care costs are more than doubling every 10 years, while the oil production that pays for most of these benefits is declining at a rate of 5 percent to 7 percent annually. The long-term sustainability of these health plans is in jeopardy. As commissioner of the Department of Administration, my job is to address that problem.
Every thinking Alaskan needs to study the report the Commissioner alludes to in saying costs are doubling every decade. But the claim that oil production is declining is largely irrelevant. Oil revenue is increasing or level. It’s pretty much a non sequitur fallacy to raise it here. WC looks to the government to control costs regardless of the levels of state income. We can have a separate debate about oil field production and the Commissioner’s boss’s plans to cure frostbite by rubbing snow on the frozen area. But not here.
The Commissioner continues,
My department is examining both the patient and the provider side of the medical economics equation, looking at what adjustments can be made to reduce the rate of cost growth while maintaining quality coverage. This is a highly complex area, and there are no easy solutions.
Platitudes. Public relations white noise.
On the patient side, we are establishing a culture of wellness and personal responsibility for health as a workplace value. While in some cases patients are unable to control their health condition, for most, lifestyle choices and behaviors have health consequences that drive costs. We are working to provide our members with resources, education and incentives to do their part in improving their overall well being.
By taking personal responsibility, costs can be reduced and quality of life improved. Among the resources introduced this year for active employees are Weight Watchers at Work, tobacco cessation and free preventive care along with new tools to help people with chronic conditions manage their health. We hope to introduce similar offerings to the retiree population.
The State is late to the wellness party, but exactly how does this relate to the cancer treatments that Moore wrote about? And the Commissioner implies that wellness services are available to all Alaskans for whom the State provides medical services. Actually, it’s less than 9% – it’s current state employees only. Retirees, Medicaid and Medicare beneficiaries aren’t eligible.
On the provider side, we recognize the excellent medical provider community we have in Alaska. We want this community to be successful, yet we need to work on containing costs.
We have documented many examples of medical procedures performed in Alaska that are charged at several times the rates of those performed in the Pacific Northwest. While we recognize that costs will be higher in Alaska, they cannot be double or triple the costs in the regional market. I have started discussions with representatives of the provider community over the course of the past year, and those discussions will continue.
Perhaps if Commissioner Hurtley had a bit more schooling in economics and understood the economies of scale, she wouldn’t claim surprise that costs for medical services at, say, Norton Sound Regional Hospital are two or three times higher than in Seattle, Washington. Hospitals demonstrate economies of scale. Add construction and energy costs in Bush Alaska, and the difficulties recruiting good physicians in rural Alaska, and of course you have multiples of base costs. The ISER report is pretty clear about this. If we are going to provide health care across the state, we are going to spend multiples of stateside costs. The Commissioner shouldn’t pretend surprise.
The Commissioner then confesses,
We are exploring extending travel benefits to members for certain procedures. Elsewhere in the country, employers have found success through regional “centers of excellence.” These programs identify quality medical providers, both in and out of state, and establish discount contracts with them. We seek quality and value. Our members deserve no less. Alaskans are no strangers to medically necessary travel, but access to out-of-state centers of excellence would be a voluntary option if the overall cost of the procedure and travel is equal to or less than the local cost. This choice will benefit all Alaskans.
So Moore was right. You have to get to the penultimate paragraph of the Commissioner’s essay, but Moore has it right. The State is considering/threatening to ship Alaskans outside for treatment. Excuse me. “Considering extending travel benefits.” There’s an undertaker-class euphemism if WC has heard one. And note the claim of “excellent medical provider community” in the preceding paragraph and now the claim that they are less than excellent? Oh. Cheaper.
The Commissioner concludes,
Sitting on our hands is not an option, but rushing forward without public input is also unwise. We welcome new ideas on how we can slow the growth of these costs to the state while maintaining quality health care. We are engaging with stakeholders across Alaska on our proposals to address this challenge. If you know of a group interested in such a presentation, please contact me — we welcome the dialogue.
But the State – indeed, the Commissioner – is rushing forward. There are “discussions with the provider community.” The State is clearly shopping outside services. And the State doesn’t “welcome new ideas” or your boss would have endorsed a state-sponsored health care exchange which might, you know, increase competition. But WC won’t bring Neocon tropes to the discussion.
And you’ll forgive WC, he hopes, but he’s not interested in a presentation by someone who is so fundamentally dishonest. Someone who, in a brief opinion piece, can create a textbook illustration of multiple logical fallacies. Someone who begins a debate by claiming her opponent lied, and then ultimately admits it is all true. Oh, and remember a state employee was paid to write this thing.
Captain Zero and the Health Care Exchanges
When we last saw Captain Zero, he was muddied and bloodied by his loss in the U.S. Supreme Court. The Affordable Care Act was – Gasp! – constitutional. Captain Zero’s efforts to defeat the Evil Federal Monster had failed again.
Captain Zero had fought the Evil Federal Monster and its Minions many times before. The Endangered Species Act and Cook Inlet Beluga Whales. The Environmental Protection Agency and Greenhouse Gases. The Department of the Interior and its moratorium on off-shore leases following the BP disaster in the Gulf of Mexico. The heroic Captain Zero has been tireless in fighting the Evil Federal Monster.
Completely futile, as it turns out, losing every time, but you have to admit he has been tireless.
But not this time. This time, he has invited the Evil Federal Monster into the governor’s mansion. He’s baked cookies and he’s serving the Monster tea.
The Affordable Care Act requires states to set up health care exchanges. These are intended to be one stop shops, managed by the states or a nonprofit selected by a state, to provide a single point for comparison shopping of health insurance plans. Alaska’s very high rate of uninsured citizens and comparatively few health insurance providers make this a big deal. A carefully designed health insurance exchange might attract more insurers to the Alaska market. More insurers might mean more competition, lower premiums, better coverages and less confusion. It would have involved some work and, yes, some expense, but it carried the potential to provide huge benefits to the Alaska public.
But Alaskans know what Captain Zero does when he fails to get his way: he packs up his marbles and goes home.
Even if it means letting the Evil Federal Monster design and implement Alaska’s health insurance exchange. Because that’s what is going to happen. Rather than develop a state-operated health insurance exchange, Captain Zero has decided to let the federal government do it. Because it might cost the state of Alaska money if the State were to do it and, you know, that would be an unfunded mandate. Oh, wait. Captain Zero already rejected the Federal funding to help set up the health care exchange.
The idea of a cost benefit analysis apparently has escaped Captain Zero, as he scooped up his marbles and ran home.
Captain Zero has surrendered Alaska’s ability to control its health care destiny. It’s a huge chunk of the Alaska economy. According to the University of Alaska Institute for Social and Economic Research,
Health-care spending for Alaskans reached about $7.5 billion in 2010. For comparison, that’s close to half the wellhead value of all the oil produced in Alaska that year. It’s also roughly equal to half the wages Alaskans collected in 2010. (Emphasis added.)
And health care spending is growing, both in amounts spent and as a percentage of the economy. ISER also found
The state’s health-care spending has been rising fast, tripling since 1990 and jumping 40% just between 2005 and 2010—and at current trends it could double by 2020, reaching more than $14 billion.
And Captain Zero’s justification for letting the Feds develop the health care exchanges is that it might cost a little money to set them up? Perhaps $6.7 million. Against a $7.5 billion a year item that’s growing at 8-9% a year? It doesn’t wash, Governor. It doesn’t even pass the red face test. This is about posturing for the teabaggers. This is about sulking because the Affordable Care Act is constitutional. You’ll fight a ridiculous, stupid and losing lawsuit over Beluga Whales to limit federal powers. But you’ll abdicate to the Feds in the multi-billion dollar health care struggles.
To paraphrase Garry Trudeau, “How long does it take to betray everything you’ve ever stood for, Governor?” WC thinks the paperwork alone must be incredible.
Captain Zero and Health Care: Alaska Embarrassed Again
Alaska is among the states with the highest rate of persons uninsured for health care:
Uninsured by State – from Kaiser Foundation
For Alaska’s overall population, we have the 11th highest rate, tied with North Carolina. We’re not as bad a Texas, which is something WC supposes, but we’re still pretty bad.
Because there is no reason for it. Alaska has the wealth and the resources to provide health care for all who need it.
And now Captain Zero, our very own Governor Parnell, the failed co-plaintiff in the court challenge to the Affordable Care Act, is waffling over whether or not to implement the law. California can’t afford state parks; the Golden State has an excuse, at least, for it’s situation. Texas is governed by an idiot clown, Rick Perry, who utters inanities about freedom in rejecting the Affordable Care Act. And betrays a vast ignorance of both how the Constitution works and how the Affordable Care Act works.
But Alaska doesn’t have the excuse of near-insolvency or an idiot Governor. True, Captain Zero has a decidedly mixed record, but he’s not in the same plane of right-wing lunacy as Rick Perry.
And can everyone please remember that savings on Medicaid are a false savings. People still get sick and injured. The absence of health care makes treatment more expensive, not less. And we all pay when folks with no insurance coverage turn up at the emergency room. Seriously, this isn’t complicated. Alaska wins if it opts into the Affordable Care Act. Everything else is particularly stupid politics. Do the right thing, Governor.
Postscript: The Affordable Care Act
So it’s in the hands of the U.S. Supreme Court now. We heard the arguments, heard the querulous questions of the Justices (all those old voices), and listened to the hordes of tea-leaf readers. WC, while he has little confidence in the U.S. Supreme Court, has no idea how it is going to turn out.
But between now and a decision late this summer or early next fall – at the earliest – WC will leave you with this quote, from David Frum, over at The Daily Beast. If ACA is held unconstitutional, what next?
In that case, Republicans will need a Plan B. Unfortunately, they wasted the past three years that might have developed one. If the Supreme Court doesn’t rescue them from themselves, they’ll be heading into this election season arguing, in effect,Our plan is to take away the government-mandated insurance of millions of people under age 65, and replace it with nothing. And we’re doing this so as to better protect the government-mandated insurance of people over 65—until we begin to phase out that insurance, too, for everybody now under 55.
In the meantime, we are all in stasis, a stasis we can ill-afford, waiting for the Court’s decision. Well, everyone but the health insurance industry, who doubtless will continue to raise premiums.
Yet More Reasons for the Affordable Care Act
The fate of the Affordable Care Act will be handed to the very conservative U.S. Supreme Court this week. There will be three days of oral argument, and then the SCOTUS will take the various challenges to the law under advisement.
This isn’t a surprise. It was a given from the day the bill was signed into law. But there have been a couple of developments since enactment that bear on the SCOTUS’s decision and the climate in which that decision is going to be made.
Historically, citizens have gotten their health care through their employers. But the evidence is overwhelming that employers have been ending health care coverage.
Employer-provided Health Care - Source: Center for Studying Health System Change (HSC)
In just three years, the percentage of employers providing health care coverage declined from 63.6% to 53.5%, a decline of 10%. As the graph shows, most of those folks are now uninsured, or are unemployed or marginally employed and eligible for Medicaid. In all of those case, it’s the U.S. paying for their health care coverage, and not the citizens themselves.
If the key provisions of health care reform are struck down by the SCOTUS, the misery is only going to increase. Because delayed health care means more expensive health care, the costs of health care to the nation, already increasing too rapidly, will accelerate.
While WC hasn’t found data to support this, WC suspects that among employers still providing health care, the quality of coverage is contracting (higher deductibles, bigger co-pays, more exclusions) at the same time as premiums increase at multiples of inflation. For WC’s small company, 20% annual premium increases are the norm. If the SCOTuS kills Affordable Care, we can expect those trends to accelerate, as well.
Those citizens who wax hysterical about the intrusion on freedom, or shriek about mandated coverage: think beyond your own pocketbook for a moment, and consider the economic health of the nation as a whole. This simply cannot go on. It will bankrupt our economy. And if you cannot think beyond your own pocketbook, ask yourself what you will do when your employer pulls the pin on your health coverage, because absent a mandate, it is gong to happen.
We Interrupt These Bird Photos…
To have a brief discussion on politics and evolution.
The Obama administration is drawing a lot of fire for its recent regulation requiring all employers provide health insurance plans that provide free contraceptives. The political reality is that most Americans – and most Catholics – support the idea.
Approval of Free Birth Control by Belief Groups - Graphic by Sarah Kliff
But let’s set the politics aside and examine the biology of the issue. You know, the science?
Any species that engages in conduct that is contrary to the species long term survival is dooming itself. The peacock’s tail: It may be very appealing to peahens, but it’s a serious handicap when you are trying to escape a predator.
Start with the premise that there are a couple billion too many people on the planet. If you disagree with that premise, you are irrational and should skip ahead to the next blog post. Now, if your species is able to develop a tool that allows you to voluntarily control that population, it beyond stupid not to use that technology. It is contrary to the species’ survival; it’s against our collective self-interest.
As the chart shows, Catholics are smarter than their Catholic leadership. They ignore Catholic dogma. Especially American Catholics ignore the prohibition on contraception. Overwhelmingly. Really since contraception became widely available. All those tirades from the pulpit and still something like 85% of American Catholics have used forms of birth control unapproved by the Church.
No, it’s the White Evangelicals who object to birth control, demonstrating that they are not as smart as their leaders, and insist on following contra-survival strategies. They insist upon procreating in the name of their god and exploding the population bomb that imperils the planet. Thats bad enough, But as the Republican’s strategy shows, they insist, in the name Christianism, in imposing their values and their world view on their fellow Americans. Clowns like presidential wannabe Rick Santorum want us to procreate until the poor, exhausted environment collapses under the weight of humanity.
Is this part of the denial of evolution? The rejection of science? For humanity as a whole, it’s a burgeoning evolutionary crisis. Hello?
We’ll now return to your regularly scheduled nature photography.
Eye of Newt: When Newt Supported Health Care
Serious props to Morgen Richmond, who unearthed this clip of Newt Gingrich endorsing the key components of the health care plan he now reviles.
Once again, you can see the litmus test for Newt’s positions is how they benefit Newt. What’s changed since 2009? Nothing. Except Newt is running for an office that requires him to be opposed to a health care mandate…
The Real Problems With Romney: The Lies
Presidential Wannabe Mitt Romney famously said, “I like being able to fire people.” And it is perfectly clear that the quote was taken out of context:
I want individuals to have their own insurance. That means the insurance company will have an incentive to keep people healthy. It also means if you don’t like what they do, you can fire them. I like being able to fire people who provide services to me. If someone doesn’t give me the good service I need, I’m going to go get somebody else to provide that service to me.
But if the media would look a little more closely at Romney’s comment, they’d see an unholy mix of lies, deception and half-truths in the full quote. As well as a glimpse to Romney’s mind-set at this point in the campaign. WC will undertake his own examination.
- Romney seems to be implying that the Affordable Care Act prevents people from firing their insurer. That’s simply untrue. Romney, of all people, knows it is untrue because the Affordable Care Act is based on the Massachusetts health care plan, which was supported and signed into law by Romney. There are lots of reasons why a prudent patient might not want to fire their insurer; some of them are discussed below. But Romney is intentionally misleading voters, and he knows he is.
- Romney seems to also be implying that individuals don’t get their own insurance under the Affordable Care Act. For better or worse, a sole-provder system was never seriously considered. The Affordable Care Act specifically preserves the right of an individual to shop for insurance. Again, this is the Massachusetts plan, the plan Romney sponsored; the plan Romney signed into law. He absolutely knows the Affordable Care Act doesn’t impair patient choice. He’s lying again.
- Romney implies that the insurance market has no restrictions on entry; that is, that a patient can change insurers without running into financial or other barriers. That might be true if your income if $26 million a year. But if you have a pre-existing condition, you don’t date fire your insurer, because, until the Affordable Care Act, you wouldn’t be able to find another insurer to provide you with coverage. Let’s suppose you’ve been diagnosed with cancer and the insurer you have is screwing you around. Can you “fire” your insurer and “get somebody else to provide that service to me”? Not a chance. No insurer is going to touch you with a barge pole. Sure, if you offer them enough money they might condescend to insure you. But most of us don’t have that kind of money. Romney knows all this. But it serves his purpose to pretend it doesn’t exist; it serves his purposes to lie.
- Many of us – about 45% – as far as WC can tell – get our health insurance through our employer. We have little or no choice in who our employer selects as our insurer. The only way we employees can “fire our insurer” is by quitting our jobs. Of course, Mitt Romney is famously unemployed, and the poor boy has to make do with annual installment payments of $26 million from Bain Capital. Mitt knows employers select insurers, not employees. It’s deeply disingenuous, at best, for him to imply otherwise.
- Romney seems to believe that all insurance markets have as many health insurers as, say, Massachusetts. There are states with smaller populations where there are only a very few insurers. Like Alaska, where Premera/Blue Cross completely dominates the market. You can’t fire Blue Cross, because there is no one else. Sure, you can “fire” Blue Cross, but that’s a false choice because effectively there is no one else. And the Republicans’ claims that state regulators impose barriers to market entry is again, untrue. If there was money to be made, the insurers would be here. And if the Republicans are claiming that the health insurance industry needs less regulation and not more, they are dangerously delusional. And have never had to deal with an Explanation of Benefits, or, as WC prefers, a Nonexplanation of Nonpayment of No Benefits.
So when you really examine that statement giving rise to the quasi-gaffe, it turns out to be more troubling that the quasi-gaffe itself. There’s a conscious , intentional pattern of deception.
And WC won’t even go down the path of quotes taken out of context, or mention an infamous instance of Romney taking President Obama’s words out of context.
And if they’ll lie to you now, how can you trust them if they get elected?
WC’s Wishes for 2012
Despite the wretched outcome of his wishes for 2010 and wishes for 2011, WC will once again set out his wishes for 2012. While it is tempting to moderate those wishes, WC is not inclined to lower his expectations in the hope of greater success. So here they are: WC’s wishes for 2012:
- Overpopulation. Among the crises facing the planet is human overpopulation. During 2011, we rolled the odometer over to an estimated 7 billion. To a deplorable extent, especially in the Western world, the rate of population growth is a function of religious teachings. The Catholic church’s and the Latter Day Saints’ crazed obsession with large families would be two examples. When religious dogma have counter-survival effects, it’s past time to change them. WC calls on those latter day saints and infallible pontiffs to have a revelation: that further growth of human populations is terrible, and must be controlled, that more than two chldren is a sin by whatever definitions they use.
- A second great crisis facing humanity is anthropocentric climate change. The way things are going, to paraphrase Pratchett and Gaiman, we are going to scourge all intelligent life from the planet, leaving nothing but dust, cockroaches and fundamentalists. The time for denying man-caused climate change is past. Can we at least shift the debate about how to deal with it? And can all the global warming-denying politicians who have sold their small, dark, crabbed souls to the fossil fuels industry have a look in the mirror and ask themselves, “Do I care about my gtandchildren?” There will come a day when fossil fuel lobbyists and the politicians they have purchased will be held in the same contempt as Congressmen who defended slavery, or claimed tobacco was harmless. Why not now?
- The health care crisis facing facing America threatens to sink the economy of our country. The Affordable Care Act remains the only half-way comprehensive solution presented. The need for health care is not going to magically vanish if Medicare and Medicaid are repealed. Passing a reduced amount of money out as vouchers isn’t going to reduce spending or lower costs. It is absolutely clear that traditional capitalist solutions are an abject failure in controlling costs. We’ve been trying it for the last 50 years and it has gotten us where we are. The neocons have to come up with specific, functional proposals to fix a real crisis, or shut up. Not more of the same. Real solutions.
- Despite the Republican presidential wannabes’ lies, distortions and self-deception, President Barack Obama as a national leader is vastly superior to Mitt Romney and all the Not-Mitts. Despite the protracted and concerted efforts of the Republicans to blow up the economy rather than allow him to effect reasonable repairs, the economy has improved. He has done more to slap down Islamofacsist terrorism than his predecessor managed with two land wars in Asia, up to and including the assassination of bin Laden and the liberation of Libya. He has gotten us out of George W. Bush’s disastrous, ill-conceived and unnecessary war in Iraq. He has stopped and repudiated the use of torture as an instrument of national policy. He has enacted the first real health care reform in the United States since Medicare. He has saved the plutocrats from their own greed and folly. And he has done all this is the face of an unscrupulous U.S. House that would tear the country to shreds if it had its way. Re-elect him. And while we are at it, pitch the Teabaggers out of the U.S House.
So there you have it: four modest, sensible and practical wishes. WC cautions against holding your breath while waiting to see if they come true.
Happy New Year, everyone.
Dealing with Anecdotes: Canadian Health Care
During the health care debate, and even now, you hear tales of how terrible the Canadian single provider health care system is. How Canadians can’t get treatment and come to the U.S. so they can get the care they need. We’ve all heard the anecdotes.
And that’s what those stories turn out to be: anecdotes. Using three different methodologies, a publication in a peer-reviewed journal, Health Affairs, looked at how many Canadians actually do come to the U.S. for treatment.
Canadians' Health Care in the U.S.
The answer, despite all the stories, is a vanishingly small percentage. And the numbers in this chart include Canadians who required medical treatment while visiting in the U.S.
All of which is why WC puts little credence in anecdotal evidence and more in science. If you hadn’t guessed.
Teabaggery: Just Let ‘Em Die
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In Andrew Sullivan’s apt phrase, “The fish rotted from the head down. Last night, we got a whiff of the smell.” As a matter of raw statistics, at least 13 out of every 100 Teabaggers cheering the death of the hypothetical young man who didn’t have health insurance do not themselves have health insurance. And the 13% rate was in 2008; subsequent unemployment increases will surely have raised that number. The Teabagger crowd lacks the introspection of a rabid skunk or is deluding themselves that they are immune to all disease and accident. It makes WC embarrassed to be an American.
But going beyond the Libertarian clap-trap, the Emergency Medical Treatment and Active Labor Act (EMTALA) was adopted in 1986 to address the problem of “patient dumping.” Simply put, any hospital accepting federal funds (excluding VA, IHS and Shriners’ Children’s Hospitals) are not permitted to turn away emergency patients, regardless of their ability or inability to pay. The hypothetical posed to Dr. Paul can’t happen.
Of course, that emergency room care comes at a price. And since the patient cannot pay, we all get to pay. Hospitals – even nonprofit hospitals – have to make money, so the cost of treating EMTALA patients gets passed along to those of us who do have health care coverage, in the form of higher rates. TANSTAAFL and all that. A great many emergency rooms visits are the result of a failure to obtain basic or preventative care. So in addition to increasing everyone else’s health care expenses by being uninsured, those ER patients often have avoidable emergency conditions.
In a very real sense, the Patient Protection and Affordable Care Act – the much-derided “Obamacare” – is simply a recognition of the insanity of current practices. Instead of dealing with health care at the ER door, instead of waiting until it is a crisis and treatment is more expensive, deal with it earlier.
And those cheering Teabaggers: It’s easy to talk the talk; let’s see the Teabaggers walk to the walk. WC suggests that if the Teabaggers really want a health emergency to mean death for the uninsured, then seek repeal of EMTALA. By all means, let’s go back to the ambulances driving from hospital to hospital, looking for someone to help a critically ill victim. Pile ‘em up outside the ER door to live or die. That’s civilized. You betcha.
History Lessons: Individual Health Insurance Mandates, 1989-2010
The Teabaggers are likely to return to their attacks on the Affordable Care Act when they “return to work” after the summer recess. As a help to readers, WC offers the following handy history of health care laws containing an individual health mandate. What’s interesting about the history of health care mandates is that it primarily a Republican idea. (WC has had to tweak the table to get it to look even halfway decent on WordPress. Sorry for the cramped appearance.)
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In fact, so far as WC can discover, the whole idea of an individual health care mandate originated with The Heritage Foundation, a very conservative think tank in Washington, D.C., in 1989. So it turns out that it’s not the idea of a crazed liberal crowd of Democrats. See Assuring Affordable Health Care for All Americans (1.6 MB) 
, by Stuart M. Butler.
Of course, Republicans can’t be bothered by history, and where it inconveniences them, they ignore it. But still.
Health Care Reform Affirmed
As most readers know, the Affordable Care Act is under sustained legal attack in at least four federal court districts. To this point, the decisions had all been by U.S . District Judges; interesting, but not authoritative.
Today, the first court of appeals decision was announced. While everyone thinks that ultimately the U.S. Supreme Court will decide the constitutionality of health care reform, unless and until the high court does, the federal court of appeals decisions are very important. And not just because the U.S. Supreme Court has to take those intermediate court decisions into account.
The Sixth Circuit out of the midwest ruled the Affordable Health Care Act constitutional today. A three judge panel – two Republican appointees and one Democrat appointee – found unanimously that the Commerce Clause empowered Congress to take the actions that it did. The 64-page opinion is straight up; there’s no legal games being played. The law is held up against precedent and found to be constitutional. It will be interesting to see how the opinions that are expected soon from panels in the Fourth Circuit in Richmond, Va., and the Eleventh Circuit in Atlanta are affected by their Sixth Circuit cousins.
But the first round goes to the rule of law.
The Problem of Judging Risk: A Case Study
Americans are terrible at judging risk. For example, some parents believe that vaccinations in children carries a risk of inducing autism in their children. The science is pretty clear that there is no evidence that exposure to anti-body stimulating vaccines during a child’s first two years creates a risk of developing autism. A study published this month in The Journal of Pediatrics is pretty clear.
In fact, there are no credible scientific studies which document an autism risk with childhood vaccinations. Of course, not being vaccinated carries a risk of infection by childhood diseases that have a known fatality rate. Those known fatality rates are orders of magnitude higher than the minuscule chance of error in the new study.
So why do parents hesitate to vaccinate their kids?
Psychologist Paul Slovic, in a classic 1987 article, championed the idea of risk perception theory. The theory examines the particular approaches and biases people invent to interpret the amount of risk in their environment. Slovic’s article is heavy going, packed with psychological jargon. At the risk of simplification, WC would describe it this way: People tend to be intolerant of risks that they perceive as being uncontrollable, having catastrophic potential, having fatal consequences, or bearing an inequitable distribution of risks and benefits. The higher a hazard scores on these factors, the higher its perceived risk and the more people want to see the risk reduced, leading to calls for stricter regulation.
Slovic compares the risk of nuclear accidents with the risk of automobiles. Because, say, nuclear energy scores high in Slovic’s risk aversion criteria, people fear it, even though in these post-Chernobyl, post-Japanese tsunami days, death by automobiles is three or four orders of magnitude greater. Automobiles, by contrast, are more familiar, the risk seems both familiar and knowable. So a lower risk phenomenon (nuclear energy) actually induces much more fear than a higher risk activity (driving an automobile). The critical thing to understand about Slovic’s theory is that reassuring the public that nuclear energy is safe won’t reduce the perceived risk. At best, it nibbles away at just the fourth of the four factors.
Perhaps that’s what is happening with early childhood vaccinations. Granted that idiots like Rep. Michele Bachmann (R, MN) contribute to the confusion with their ignorant prattle. Perhaps because autism is so scary, and science doesn’t understand well what causes it, and because it can be so devastating, the reaction is unthinking aversion. Like automobile drivers, they incorrectly assess the risk to their children of not getting vaccinations.
Slovic argues that risk assessment and management is a two-way street: just as the public should take experts’ assessments of risk into account, so should experts respect the various factors, from cultural to emotional, that result in the public’s perception of risk. But in a society where, reportedly, nearly half of Americans reject evolution, achieving the first “street” is going to be terribly difficult.
At a time when pertussis – whooping cough – is killing Alaska children, this is not an abstract issue.
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Written by Wickersham's Conscience
April 21, 2013 at 6:15 am
Posted in Commentary, Health Care Madness, Logic and Illogic, Technogeekery
Tagged with Commentary, Health Care Madness, Logic and Illogic, Technogeekery