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Fear and Loathing over the Stimulus Bill

CapitalThe reaction in certain quarters to the healthcare reform provisions of the stimulus bill now clearing 
Congress lays bare the nature of opposition to the forthcoming fight for real change in healthcare: It will be viciousness at the top of the lungs.  It will be a scorched-earth campaign.  Its main weapon will be fear. It will be unencumbered by any actual knowledge, subtlety, awareness of history, or access to the thoughts of people who actually know what they are talking about.  Its fury will be unloaded not just in service of narrow and inflexible political nostrums, but in the service of sectors of the industry which fear that a truly efficient and effective healthcare system would cripple their profit margins.

The fulminating rages across Rush Limbaugh's radio rants, Matt Drudge's blog, the editorial pages of the Wall Street Journal, and commentaries issued by conservative think tanks, all echoed around the blogosphere. The connections and logical leaps that they consistently make are rather startling to anyone who has been working on the systemic problems of U.S. healthcare for the last few decades. The prime targets of this offensive are comparative effectiveness research, to which the bill allocates $1.1 billion, and help for digitization. The federal government already pours over $300 million per year into comparative effectiveness research – using powerful medical and statistical techniques to determine the most effective and least costly ways to treat disease – through the National Institutes of Health and the Agency for Healthcare Research and Quality. But to Limbaugh and company, actually finding out what works and what doesn't automatically means having committees of government bureaucrats tell your doctor what to do. Research equals socialism. In this frame, digitization, which seemed to work out okay in airport kiosks, grocery stores, and the ATM down at the bank, means something entirely different in healthcare.  It means the end of all medical privacy, all ability to choose, and all security in one's access to healthcare.

The irony is that these folks are all about the free market, about choice, about one of America's great skills, shopping. But Americans, and America, are truly dismal shoppers when it comes to healthcare, because we have no idea what we are buying. Neither we nor our proxies (the government, health plans, employers) have any clue what actually will keep us healthy or cure us, who is really good at it, or what it will really cost. As situations go, this is double-plus ungood.

The really sad irony is that we already have, in our system as it works today, every bad outcome these folks are imagining.  We already have bureaucrats telling the doctors what they can and cannot do, and telling consumers what doctors they can go to, they're just private bureaucrats working for health plans, informed more by the balance sheet than by effectiveness studies. We already have people's private medical records being used to deny them coverage – by everyone except the government.  We already have healthcare rationing, we just do it by ability to pay, by whether you still have a job, and by whether you have been visited by the dread "pre-existing conditions." With our current patchwork of plans tied to employment, many with very high deductibles and co-payments, many subject to rescission when they are most needed, most immune to lawsuit under ERISA, no American under the age of 65 can feel secure in their access to healthcare.

There is a good chance that this toxic brew will be effective.  Comparative effectiveness research in political methodology shows that fear and ignorance are a powerful combination when administered in high enough doses. As the debate over the actual healthcare reform bill moves forward, we can expect massive volumes of this combination to be dumped on the public, and on those of us who have been trying to roll this boulder up the mountain for a long, long time.

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  1. My question is this..If the goverment is going to help people with their healthcare costs who cannot afford it (medicaid) and if the health reform bill passes and more people must be helped in order to have insurance, many of those people choose to spend their money on non-life saving medicines but refuse to pay for the ones they really need. Also, why should people go to jail for not being able to buy health insurance but we are keeping and at many times giving free healthcare to illegal immigrants. Many parts of the bill could be good, but also very scary. But yes, we would be able to buy our own insurance with private money. Isnt that what a lot of people do now anyways?

  2. How to buy prescription drugs…? My doctor prescribed vicodin for a while back, my back hurts, I think it is a great help, but in my country it is difficult to find, it is paramount to have my information on it and found information about findrxonline.com the medicine, because it provided me.

  3. is better than trying to navigate the Soviet bureaucracy here in the United States.
    ————–
    And getting government involved is supposed to improve this? We do have socialized medicine run by the government. It’s called the VA and it is terrible.

  4. I am a Finn living in the United States and here is my situation: at home in Finland I have the choice between
    a) Almost-free national health care.
    b) Immediate access to any private doctor in any specialty (you can usually get an appointment same day), for a fraction of the cost of same in the US.
    c) Immediate access to emergency health care.
    The health care is some of the best in the world. Just one statistic off the top of my head is infant mortality – next to nothing in Finland, whereas the US is something like number 18 globally.
    ———
    But we have a different system of government by design. In order for someone to have access to all that ‘free’ health care someone else has to pay. To force someone else to pay is to steal their justly acquired property by force. IOW, it steals my liberty.

  5. I’d just like to know where the Constitution authorizes any of this? And please, don’t say “promote the general welfare.” The Constitution lists specifically what government can do to promote the general welfare. Nowhere does it say anything about health care.

  6. Apologies if this double posts as my first attempt seems to have disappeard in the electronic black hole.
    Nate, your math is a little sparse.
    The Y in your calculation is made up of P(profit) at each level of the chain. So included in Y is P+P+P+P+P. That determines an X that is about twice what other countries pay. In a single-pay system the X is also made up of P but it’s small p as the components are regulated. P can also be eliminated from the insurance part along with a smaller A (administrative costs).

  7. Spike- what I am saying is this: if YOU want to turn your health, and that of your family’s, over to some ‘data mining software’ and a complete reliance on available evidence for every possible diagnosis you could have, by all means it should be your right to do so.
    Just do not coerce and compel the rest of us to be a part of that system.
    Joe- then shame on you for not recognizing the policies being promoted today are the same fallacious ones that characterized the stagflation of the 1970s and the Ted Kennedy driven HMO Act of 1973.

  8. Nate, your math is a little sparse.
    Profit is extracted at all levels of the chain. To get to Y you need to add profits (P). So Yt(total) equals P+P+P+P+P+P. The X then is inflated far beyond what is sustainable and hence why we pay twice as much as other industrialzed countries.

  9. Ok, it appears we accept that healthcare isn’t a “right”. Didn’t see a response to who might be forced to provide it… which begs the next question:
    Under what circumstance is it ok to forcibly take from one what was justly acquired to give to another? Perimeter defense comes to mind… but doesn’t that sort of benefit everyone equally? Not to mentioned being a basic requirement of continued existence?
    I would expect of a truly enlightened society (one that actually learns from history) a better grasp of the utter infeasibility of forced, collective redistribution to be a catalyst for human “progress” and a far greater appreciation for the limitlessly effective, focused, and agile capabilities of the worthwhile charities of human sp1rit.
    Don’t have any friends that might be there in your hour of need? Sad. Might want to make some. Could try going to “chirtch” (just a thought, G@d forbid).
    So what does it matter which method, mechanism, treatment, weighting, formula, program, qualification, or policy framework is used? It isn’t opposition to the fight for real change in healthcare… it’s opposition to the WRONG change in healthcare – which is the same opposition applied to the broader set of false premi(ses), straw arguments, and mis-guided euphoric/social consciousness/can’t we all just get along that brought us to this question.
    ps – misspellings courtesy of a filter that apparently doesn’t like this kind of talk.

  10. Hello Nate,
    I think you may have a Freudian slip in your algebra up there. If you look at your assumptions:
    X=T and U>Y
    then T-U=Q MUST be smaller than X-Y=Z.
    Since Q denotes the waste in a public system and Z the waste in a private system, I must conclude that your math agrees with my logic, even if you do not 🙂
    Have a good evening….

  11. I am a Finn living in the United States and here is my situation: at home in Finland I have the choice between
    a) Almost-free national health care.
    b) Immediate access to any private doctor in any specialty (you can usually get an appointment same day), for a fraction of the cost of same in the US.
    c) Immediate access to emergency health care.
    The health care is some of the best in the world. Just one statistic off the top of my head is infant mortality – next to nothing in Finland, whereas the US is something like number 18 globally.
    In the US, I have access to one bad doctor (only one near me who was accepting new patients and accepts my insurance), no emergency access to speak of (7 hours wait for a few stitches), and whenever I do manage to get an appointment with a doctor, the only thing they are interested in is convincing me I have something that needs constant “monitoring” – meaning, constant milking of my insurance company. The healthcare facilities have a distinctly Soviet appearance (my doc’s office has mildew everywhere!), not the state-of-the-art gleam I am used at home. I have yet to locate an OB-GYN that will take me as a patient, and have forked over untold amounts of money to Planned Parenthood for health care my insurance is supposed to cover.
    The result? I visit private doctors on my trips to Finland for my regular checkups. I get state of the art care and 50 euros for an uninsured, private doctor’s visit is better than trying to navigate the Soviet bureaucracy here in the United States. I get my health care when I want it, and who I want it with.
    Americans: missing out big time. And dying from preventable diseases. Darwin award, anyone?

  12. Clarification…. Usually, in a setting such as this BLOG, this type of question is just ignored (in the BLOG). In this setting, “Experts” commenting in most blogs seem to usually be well-intended, but have little to no concept as to how their proposals are typically not possible or practical for the majority of medical practices (i.e. 1 to 3 clinicians). They are often in error, yet seldom in doubt. Their “deer in headlights” response to questions is a frequent give-away as to their lack of perspective in the settings a majority of care is delivered. The evidence is that attempting to generalize what has worked for larger practices (i.e. the 30%) generally fails in smaller ones (i.e. the 70%). Few “experts” understand this reality based on the evidence. Sad, because I think most of them seem to want to see the same end results that most patients would prefer (e.g. less waste, better information, and better care based on the evidence). I typically deal with dozens of physicians in more typical practices (i.e. smaller practices) every week. The vast majority I speak to feel the same way and desire less waste, want better information, and crave the information that would facilitate their efforts to deliver better care. However, the previous “experts” have created a system that does not allow this to happen.

  13. Margalit Gur-Arie
    “The math is very simple: there is X amount of money going into the system. There is Y amount of money spent on actual care delivery and administration. There is X-Y=Z amount of money leaving the system in the form of profits extracted by insurance companies. We can save Z amount of money if the “for-profit” notion is eliminated.
    A bit simplistic? Maybe, but true in principle.”
    Actually it’s very untrue in principal, your missing most of the equation.
    For Profit system
    X-Y=Z
    Public system
    T-U=Q
    T=Amount of money going into system
    Y=is amount spent on care
    Comparison
    X=T
    U>Y
    Q>Z
    True you can save Z if you eliminate profit but if you replace it with a public system you will spend Q which is greater then Z. In your ideological hatred of insurance companies you just wasted billions in tax payor dollars. The increased fraud and waste in public plans alone exceeds insurance carrier profits.
    If you really cared about saving money you would be fostering competition in private insurance to drive down profit and admin cost. Before the government started pushing people into HMOs and advocating for a couple large national carriers there was considerably more competition.
    You would also reign in government regulation. In the stimulus bill there is assistance for COBRA premium payment. OK idea, could be done better and cheaper but it’s only tax payor money but the provision requires everyone that terminated since 9/08 be sent another COBRA notice. Besides giving the struggling post office business this is a huge waste of money. How about if someone wants it they request it instead of mandating tens of millions be spent mailing another letter.

  14. Maggie Mahar is on a roll over at HealthBeat Blog. With last week’s Reinhardt/ Aristocracy/Fairness articles and two this week on comparative effective resesarch,as a journalist, she is articulating our best hopes for US health care reform.
    Peter Orszag as head of OMB is defintely key.
    Dr.Rick Lippin
    Southampton,Pa
    (Charter “Hadlerian”)

  15. When will the discussion get to the evidence of what actually works within the highly fragmented, widely dispersed,small medical practices that actually deliver the 70% of health care in the U.S.?
    Usually, in a setting such as this, this type of question is just ignored. In person, the asker nearly always is left with little more than a “deer in headlights stare.”

  16. Both sides deal in demonization and hyperbole, Joe, this post really did not move the conversation forward.
    With the average age of a member of the AAFP over 50 and 1/3 of all board certified family physicians “certainly” or “almost certainly” going to stop practice in 5 years, there will be no one to provide care, so the point is moot. Hope you know a doctor, cause the ship is made of iron and it most certainly will sink.

  17. > essentially no-bid contracts to manage the health of 300,000,000 Americans is divided between a handful of private contractors is the future under your scenario, no matter how idealistic you want to be.
    Dr. Novak, this is called “making stuff up.”
    And for the second time in this discussion, you have lectured someone else not to call names or use other rhetorical devices – and for at least the second time, you have implied that I have less standing to discuss how to organize healthcare because I am not a practicing physician. Healthcare is, I think we can all admit, an extraordinarily complex system, something that might require some considerable expertise and experience to understand. Being a physician certainly gives one certain valuable perspectives and insights, and I am always eager to hear what doctors have to say about their own experience. At the same time, I first began writing about healthcare, and interviewing doctors and hospital executive and other leaders in healthcare, when Jimmy Carter was president. My clients have included everyone from little six-bed hospitals and private doctor groups to the WHO, the DOD, and the governments of Canada, the UK, and China.
    So perhaps we can leave aside the question of who has standing to comment on this extraordinarily difficult problem, and focus on what actually works, and what we have evidence for.

  18. Yes Eric, I’m sure you are way more well-equipped than data-mining software at keeping 10,000 diagnoses straight, evaluating based on all relevant variables like severity, gender, age, race, BMI, previous medical history, etc., and coming up with the perfect treatment protocol for every patient you see. A few journal articles and you intuitively know what billions of CPU cycles could only guess at.
    My question is: can doctors who aren’t as brilliant as you do it?

  19. This notion of something having to be a “right” before it can be placed at government funding’s feet always concerns me. Is it truly American to deny a public good until a piece of paper says you have to offer it?
    Nonhetheless, health care is not a right. It is not a human right, it is not a constitutional right. No-one has the “right” to health care.
    But society providing health care to all is simply a demonstration and embodiment of the civilization. As a society, we choose to make sure our fellows, our neighbours are healthy. Nye Bevan says it best:

    “The same story is now being unfolded in the field of curative medicine. Here individual and collective action are joined in a series of dramatic battles. The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility that they should be made available to rich and poor alike in accordance with medical need and by no other criteria. It claims that financial anxiety in time of sickness is a serious hindrance to recovery, apart from its unnecessary cruelty. It insists that no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means.

    Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide. But private charity and endowment, although inescapably essential at one time, cannot meet the cost of all this. If the job is to be done, the state must accept financial responsibility.”

  20. I find it very disturbing that it appears we are only headed toward more waste of tax dollars. I have advocated interoperable medical records and incorporation of best medical practices based on evidenced-based medicine for years. I had hoped that we would soon be able to redirect tax dollars away from worthless medical treatments. I find it disturbing that it appears that any savings on worthless medical care will are only to be redirected toward a boondoggled plan that will either be a major hassle or outright rejected by a majority. Will the “experts” ever learn this sort of change has to be participatory and can’t be forced?

  21. ¡¡¡…Margalit Gur-Arie…!!!
    ***Standing ovation***
    ►►►LOUD CHEERS◄◄◄
    (…prolonged applause………)
    Uh, what she said.

  22. I find it very disturbing that people aren’t concerned that comparative effectiveness isn’t the norm.
    If I have a health problem why would I want the less effective treatment, even if it costs more or is newer?

  23. Margalit Gur-Arie : It is simplistic but true in principle. But being democratic state we have the freedom to STATE-ments.

  24. If a democratic state has an obligation to defend its citizens from bodily harm caused by terrorist attacks, criminal behavior, contaminated food supply and unproven drugs, then the state has a similar obligation to defend its citizens from bodily harm caused by disease and ailment. And yes, I know that some disease is brought on by personal life style choices, but not all. People cannot “opt-out” of national defense by hiring a private army.
    Healthcare is, or should be, a right in an enlightened state.
    As to the centralized repository of medical records, it would probably make no difference if we didn’t have to deal with private, for-profit, insurance companies and all sorts of risk management for exclusionary purposes.
    The math is very simple: there is X amount of money going into the system. There is Y amount of money spent on actual care delivery and administration. There is X-Y=Z amount of money leaving the system in the form of profits extracted by insurance companies. We can save Z amount of money if the “for-profit” notion is eliminated.
    A bit simplistic? Maybe, but true in principle.

  25. Joe– not a straw man argument if you are the patient…
    There are literally tens of thousands of diagnoses (I will point you to the impending ICD-10– the ‘coding book’ for diagnoses that will have 200,000!!!)
    Inter-person (patient) variability is huge… look for my post on determining ‘outcomes’ for something as simple as a broken wrist as just one example.
    There are ground rules already– there are also a fair number of not so good doctors AND and fair number of disinterested patients— it is no longer possible to say that it is hard to find out information about diagnoses on one’s own.
    We can go back and forth on this, but my guess is you do not take care of patients, talk to families, fill out disability paperwork, on a regular basis— a central planning solution— where essentially no-bid contracts to manage the health of 300,000,000 Americans is divided between a handful of private contractors is the future under your scenario, no matter how idealistic you want to be.
    And I hope you have taken the time to read the entire portion of the law dedicated to health IT and the rulemaking authority given to the unelected Director HIT and HHS secretary under this bill. True, there is no ‘unifying’ law tying it all together (have no fear, that is coming)— but the authority is there now.
    There is a difference between Wells Fargo having my records and a warrant being needed by the gov’t to get them and the law which specifically gives HHS and ‘researchers’ access to your health information. (again, read the bill)
    Maggie- no name calling, please. If you believe I misquoted you, just say so– but why not let the readers make up their own minds by reading your post.
    Also— your arguments are really excellent ones for wholesale medical liability reform- do you support that as part of any health reform package?
    and by the way, bloodletting still IS the treatment of choice for a couple of conditions, and leeches HAVE made a comeback as part of the treatment after certain soft tissue and plastic surgery procedures…

  26. This discussion has wandered pretty far afield from the stimulus bill. Probably because we can all agree that healthcare in this country is broken, but we don’t have a clear picture of where we want it to end up. There are two threads that run loud and clear through the arguments above: One side wants to preserve choice and one side wants to set controls that prevent “market” forces from trampling over the patient. Ultimately, I don’t see these as diametrically opposed. I think we should be aiming for choice within the context of substantially more complete access to information – for both consumers and medical professionals.
    Let me lay my biases out on the table. I’m a healthcare business analyst and many of my clients are health plans. To that end, many might view me as part of the problem (every dollar I earn from health plans is not spent on patient care). I’m also a patient with a chronic condition – one that my health plan/employer would love to deny coverage for without some form of regulation, I’m sure. I also have substantially liberal leanings and tend to believe in caring for the weak and not letting the few get rich at the expense of the poor.
    In theory, I’m a fan of socialized medicine. I do believe that basic healthcare is a right – just as much as I believe basic education and basic nutrition are rights. I’ve lived in a place where access to none of the above were available and the conditions were appalling. I will grudgingly acknowledge that defense must also be a right. But without a reasonably educated, basically healthy population, I don’t know what we have to defend (if anyone can explain to me why it’s more important to teach high school students advanced trigonometry in lieu of personal finance, nutrition fundamentals, and some degree of social decency, I’m all ears).
    But I don’t think socialized medicine makes sense in this country. Not under the control of this government – and I don’t mean this administration. I mean this government that is subject to the swings and whims of an overly bipartisan political system with shifts in power every 4 to 8 years.
    So what does choice in the context of information mean? It means that, yes, we do need to collect and centralize people’s health information (I know that’s not what the stimulus bill is proposing, but if we’re going to fund comparative studies can we please acknowledge that this is a more cost effective way to do this in the long run?). And we need to have an information system that allows doctors and patients to understand and have access to the treatments that are most likely to result in the best, most cost-effective outcomes. We also need to allow those patients that deviate from the average to explore alternative treatments with their care providers. Maybe the patient will need to pay a little more for those treatments – there’s no way to be totally “fair” here. Maybe instead of investing time and energy into administrivia, (tax)payers and advocates for the outliers can push for better collection and analysis of information so we won’t just know that a treatment works for 80% of the population, we’ll know ahead of time which 20% it won’t work for.
    Medicine will remain an art informed by science. But it’s about time we apply science and analytics to the practice of medicine and not just the research (or the underwriting models). Let’s stop throwing privacy demons up to justify ignorance. And let’s also stop pretending we have a market economy with rational actors in healthcare. We don’t and we won’t. But we can’t keep banging our heads against the same walls and expect our headaches to go away.

  27. Whoever wrote that doctors should be relied upon to present patients with all treatment options so that they can make “informed choices” is naive.
    I am the wife of a prostate cancer survivor who writes a blog about this for a non-profit organization (“Living with Prostate Cancer”, prostatecancerblog.net). I am aware, for example, that the National Comprehensive Cance Center, a consortium of the top cancer hospitals in the country, recommended in its “Practice Guidelines” last year that doctors thoroughly educate their newly diagnosed PCa patients about ALL the treatment options available (including “watchful waiting”), and allow the patients to choose. In practice this never happens.
    The reality is that almost all patients diagnosed with PCa are pushed into one-size-fits-all surgery — usually robotic laparascopic prostatectomy (which, incidentally, has not proven superior to the old-fashioned kind, although it is more expensive). These men, many in their 40s and 50s, will very likely be left impotent, and maybe incontinent. Yet there is no good evidence that RP prolongs life.
    No wonder there is so much resistance to “evidence-based medicine”.
    Leah
    prostatecancerblog.net

  28. Let’s not mistake the stimulus bill for healthcare reform. Digitizing records is not reform. We’re not going to spend our way to reform, unless that spending funds an initiative aimed at changing the unhealthy ways of the American public. If I had $50 billion to spend on healthcare reform, you can bet every penny would go to reversing the alarming chronic condition trends that we’re experiencing. You will not find a better ROI than that, guaranteed.

  29. thanks for your comments. But what is so wrong with Obama and letting him have some leeway just like we did with Bush?

  30. Dr. Novack wrote: “…sometimes the most conventional treatment is NOT best and will NOT produce the best outcome… there used to be the concept of giving patients options, explaining the risks and benefits of different choices and letting the patient decide…You all seem rather against this…”
    Straw man argument. No one that I can see is saying that doctors and patients should not be allowed to choose the best treatment. But there need to be some bounds, some incentives to pay attention to what the best evidence shows. Why don’t doctors do bloodletting, as they routinely did 200 years ago? Why don’t they whip out every kid’s tonsils, as they did when I was a kid? What happened to the idea that radical mastectomy was the gold standard treatment for breast cancer? What about the fad for high-dose chemo and bone marrow transplants for breast cancer, all before studies showed little benefit and great risk? What about all the routine things that are still done that have shown little benefit in studies (like routine episiotomies, brain bypass surgery for patients with warning signs of stroke, or HRT to prevent a second heart attack in women)? What about the hundreds of thousands of spinal fusions still being done, not for tumors or spinal fractures or congenital problems, for which the surgery shows great benefit, but for chronic back pain, for which repeated studies show little long-term advantage over non-surgical techniques?
    What do we do with such information? Do we just shrug our shoulders and do nothing about it? Do we wonder whether such over-treatment with unproven or even disproven therapies has anything to do with the fact that we spend roughly twice as much per capita as every other major, medically modern economy, whether socialized or mixed, for worse outcomes, and still can’t seem to afford to offer even basic care to all Americans?

  31. Boy is this unsettling. I just started tracking The Healthcare Blog and thought I was really into a great source of professional information. Instead, one mention of the stimulus bill and all I see is a bunch of medical professionals carping and fighting among themselves in a catfight no better than a comment thread at Kos’ or Malkin’s places.
    As a layperson looking to health care professionals for advice I am neither impressed nor encouraged.
    I’m not without bias. My attitude about insurance companies was poisoned many years ago when I discovered that their business was tracking actuarial tables and peddling a product calculated to do a lot more than insure me against liability, property loss, injury, whatever… Over and above the actual costs of insuring a risk group, they must also pay an administrative cost which includes not only keeping a database but rewarding outstanding sales people, brokers and executives more handsomely than other competing insurance companies, they are also expected to generate enough income over and above that to insure that shareholders receive dividends. Oh, did I mention the lawyers? Don’t get me started.
    But as I said, I’m biased.
    So when now I come to the stage in life when my wife and I are trying to make sense of a bewildering array of supplemental insurance plans to go along with our Medicare benefits, I find that the insurance industry has now grown to the point that a variety of Medicare Advantage plans is kidnapping beneficiaries from the system to be enrolled in yet another measurable risk group in yet another form of managed care.
    Here’s the odd part: unlike the old medigap policies these so-called “advantage” plans have lower premiums. Huh? Yes, and depending on what county you live in, the premium might be ZERO! What’s that all about?
    Heck if I know. All I can figure is that they are being paid by Medicare so much that they are awash in money. Either that, or they are able to “manage” the care of their population so well that is costs less for some reason. The devil in me wonders if that reason might be rationing what they offer their clients. Or kickbacks from drug companies. They must be doing well because with all this economic crisis I’m not hearing anything about health care insurance companies having any problems.
    Something is very, very wrong with this picture, folks.
    I sincerely hope it’s worked out in a gentlemanly manner, but I’m not seeing much of that the closer I look. All this carping about record-keeping makes me want to puke. Hell, if they want to deny coverage to someone the insurance companies seem to have no problem uncovering the most obscure piece of trivia from someone’s medical history. I bet everyone reading this knows anecdotal evidence of what I just said, but I doubt anyone would admit to it on the record.
    Credit card companies, banks, and retailers have data galore about all of us. I can go on line and for about thirty-five dollars can find out more about someone than they know about themselves, including their mother’s maiden name and the names of their pets.
    Every time I fill up my tank using a credit card I wonder why, after all these years, the card company hasn’t lost track of a single digit of a transaction. But NO, buddy. They always appear on my monthly bill. I went to Staples a few weeks ago and used my credit card to make copies on their copier which was equipped with a credit card terminal. I had a line item on my Mastercard bill the next month for seventeen cents!
    Come on, ya’ll. Get real. i know medical records are a different creature. I know if you have an STD you don’t want your spouse to find out, or if there is reason to believe you might be dead in two years you don’t want the life insurance company to find out… especially after you’re dead, because if you knew that and failed to reveal it that might be fraud. Well I don’t really give a crap about all that. All I want is better health care at more reasonable rates.
    One more thing before I end this rant. As a food service manager I employed several thousand people over the last thirty or so years. I found our long ago that ordinary people from other countries often return to their home countries for medical care because they get it so economically that they can afford to make a round trip, see their friends and family while they are there, and still come out better than if they had done it in America.
    Likewise, one of my post-retirement jobs was in a hospital where I learned the term “medical tourism.” When I heard it I thought it meant rich foreigners, probably loaded with petro-dollars, coming to America for medical care. Wrong! I’m sure readers of this thread, being in the profession, already know that medical tourism means Americans going elsewhere, notably India or Thailand, to get expensive procedures done at rates so low that they can include the costs of travel and lodging and still come out ahead.
    Does any of you even care about what was once called a good bedside manner? Or the privacy concerns of HIPAA that so obsessed the workplace where I spent five years? This comment thread is a very public place to be airing your dirty laundry. And as a consumer (Remember me? Does my opinion really mean anything?) I am very unimpressed.
    If there is one take away from all this it would be the following:
    ►Providers deliver health care. They are the professionals and that is their mission.
    ►Administrators and insurance companies do not deliver health care. Their mission is to manage it based on costs.
    There is a symbiotic, incestuous relationship between health care and insurance companies that serves shareholders, executives and other non-medical professional quite well. The system operates at the expense of quality health care to a population badly in need of it and health care professionals who deserve better compensation and resources than they are being allowed, in order to do a better job of what they do well. I heard one politician state it well who said “We have the best health care system in the world and the worst possible way of paying for it.”

  32. Good job poking the hornet’s nest, Joseph! Health “reform” really touches all the main nerve trunks. . .
    You are correct about comparative effectiveness- it has powerful industry opponents, not merely libertarian physicians and the black helicopter people. The antibodies against a more scientific approach to coverage and payment decisions are clearly aimed at how this research is used: a national health board or something like it that draws upon the research to make Medicare coverage and payment decisions.
    The right over-reacted here, as Joe has suggested, and a lot of the pundits sounded really shrill and foolish. Their first salvo will give advocates for a more thoughtful approach to medical technology policy some clues about where the rifle fire is going to come from when they attempt broader health reform.
    Just because so many of the conservative talking points on the health reform components of the Stimulus bill are “simply and provably not true” does not mean that they will not deliver the usual rabid mob to the gates of Congress when the larger issues are actually being considered. Conservatives remember that the botched Clinton health reforms delivered them a Congressional majority in 1994, and sense there may be an opportunity to pull themselves out of the ditch.
    I think they have underestimated the depth of the ditch as well as how much credibility they’ve lost.
    The Obama administration clearly had the bit between its teeth on health reform when it hit Washington, and has been harmed in a major way by the failed Daschle nomination. The loss of Daschle has left a major gap in the “care and feeding of large egos” necessary to accomplish health reform. He was clearly going to chair all the key meetings, and now it’s not obvious who can do that effectively Not a job for a Governor, I”m afraid. And no CMS Administrator, no Assistant Secretary for Health, no ASPE, no CDC- and it’s almost March already. It will take a new health team until fall to get moving. And in the meantime, we’ll have a brutal budget battle over health spending priorities.
    Obama is now spending a ton of the political capital he had intended for health reform on its larger and, frankly, more urgent economic agenda (and learning valuable lessons about how easily he can lose control of agendas to a bitterly polarized Congress). We’ll see how many chips they have left to spend on this issue in six months time.
    The above posts clearly evidence a poisoned battlefield, and arms are stockpiled for a long and ugly conflict. It is sad how little chance there is likely to be for reasonable people and ideas to be heard. Most people seem already to have made up their minds, and they don’t even have a policy framework to react to. Lots of anger, lots of shouting, lots of empty slogans.
    No trust, no faith, no honest dialog- no reform.

  33. J Bean,
    “Not one single (meaningful!) Democrat has proposed that there be a universal access solution that doesn’t permit the purchase of additional private insurance or to opt out of a public insurance in favor of private.”
    This is incorrect. Many of Dem has suggested Medicare for all and you are not allowed to opt out of Medicare without losing your SS. Even if you have private insurance and the means to pay they won’t let you just pass on it. There has been a couple lawsuits over it.
    This fact sort of kills the liberal argument of trust us we don’t intend to do anything unsavory, you already are. Starting with Medicare then to Ted Kennedy in 1973 till today Democrats have 50 years of failed healthcare policy. Any smart person wouldn’t trust Liberals to take out the trash when it comes to Healthcare, you’ve screwed the system to bad already.
    When Ted Kennedy passed the HMO Act did he intend for them to kill people? Ops it happened not what we meant to do not our fault is the standard responce.

  34. > dragging conservative talk show hosts into this argument as evidence that political conservatives think “research equals socialism” is taking it a bit far don’t you think?
    No, I don’t, since that’s what they are saying, as is the Wall Street Journal, and conservative think tanks and columnists. The genesis of this article was an email of a blog someone sent me the other day, which included this sentence: ‘That Stimulus Bill being passed by Congress has our “nationalized healthcare” system within it. It explicitly provides for a system where the national government will be telling YOUR doctor what he can do, and what he can’t do with YOUR health.’
    Of course, the Stimulus Bill says no such thing. It provides money for researching comparative effectiveness – and the final version of the bill explicitly precludes the federal government from dictating any clinical actions. It provides that a government panel shall coordinate standards for interoperability for EMRs – something government panels working on the National Healthcare Information Infrastructure have been dealing with for a long time. As noted above, there is nothing there about a centralized government database of all citizen’s health records, nor about a panel of bureaucrats somewhere removing all decision-making from doctors. Nothing. The conservative talking points on this are simply and provably not true.

  35. Before I am thrown into the bag of just being another physician that is only looking after the best interests of physicians, let me make one thing very clear. I support the creation of a saner form of health care rationing than what we now have. Any different choices we make with rationing are going to be opposed by large groups of patients and physicians. However, any changes should at least be acceptable to a majority of patients and the physicians that DO deserve their patient’s trust. Where is the evidence that the advocated approaches to a shared information system will be submitted to this type of assessment? Is this even perceived as being necessary?

  36. This may be a minor point in all the “Don’t Tread On Me, You Socialist” versus “Healthcare for All, Immunizations Not Guns” high-minded principled shouting, but I don’t understand exactly how an government-sponsored comparative effectiveness board translates into rationing by bureaucrats.
    Are physicians and clinical experts not allowed to work for the federal government? Why do we assume that these “bureaucrats” commissioning the studies, sorting through the evidence, and issuing guidelines are NOT going to be doctors? The institutes comprising NIH are run largely by academic research physicians, and last time I checked, private health systems and academic medical centers were quite happy with the grants they receive and how they are disbursed. No one calls that “research rationing.” In fact, private medical centers get upset when the NIH budget is cut. But NIH grants are supplemented by private (pharma) research studies! OK, so we’ll let private insurance stick around for a while as an opt-out – they just have to play by the same effectiveness rules.
    I think it would be a real missed opportunity if physicians didn’t a) sense that sweeping cost control is coming one way or the other, and b) line up to be part of the group that MAKES the rules, since they will almost certainly have to abide by them. You can continue to exhaust yourself fighting individual insurance companies’ schemes to deny payment one at a time, or you can grab a seat at the table to make the ultimate rules.
    Physician leaders might be better off not worrying about rationing – instead, they should act rationally in their own best interest over the long term.

  37. Somebody, please help me understand how/when this centrally planned system of shared personal health information will be allowed to pass a sniff test by patients and the physicians that are deserving of their patient’s trust. Otherwise, how can we expect this to succeed? Admittedly, centralized planning that overrules the preferences of patients and physicians was largely followed in the U.K. with disastrous results (except for a handful of IT vendors). Are the central planners thinking this shared information system can simply be forced onto patients and their physicians? If so, Lenin would be proud. At least health care may have a different flavor and a different set of “winners.” Will patients ever win?

  38. Wow. Lot’s of snide commentary on both sides of the political spectrum…but very valid point underneath it all.
    Joe- I appreciate the entertainment value of your post. Very well written–you truly have an art for provocative verse. However, dragging conservative talk show hosts into this argument as evidence that political conservatives think “research equals socialism” is taking it a bit far don’t you think? The tone that you are invoking however is representative of the fact that in general, conservatives don’t trust big government organizations to make decisions–or even set the guidelines that lead to decisions–that have a limiting effect on individuals’ choices (or our doctor’s choices as the case may be). Look, we all know that this comparative research entity is a page right out of Dacshle’s book (a la the Healthcare Fed). I don’t think anybody argues with the need for this kind of research to drive evidence-based decision making in medical care. The sticking point is where this standards-setting organization should reside. Government is one answer (and the only one currently on the table apparently)…but it’s a point of view that is not favorable among conservatives or the libertarian inclined. Why? Because it essentially puts the responsibility of determining what care get’s delivered (and therefore what care providers are paid for) under the control of the one entity (the government) that already pays for the majority of care in this country. It’s letting the fox guard the hen house. Sure you can argue that “at least it would be standardized”. But you can’t really argue with the obvious conflict of interest here can you? Now, I’m no doctor, but I can certainly understand why doctors feel like they are the ones that should be deciding what the standard of care is–rather than payers (public or private). The next big question is…how are we going to reform our very broken provider reimbursement system? If capitation doesn’t work, and fee-for-service doesn’t work, what will? Just new flavors of both under the guise of “risk adjustment” or “evidence-based”? A topic for another day perhaps…

  39. Unreal,
    Anti-research? How about anti natural laws (say, gravity?). You can prove 2+2=5, but it just isn’t so.
    It doesn’t matter what the “universal” plan is, because central planning is bad… yes, it just is. The eventual outcome is historically bad. Always. The more noble the intention, the worse the unintended consequences.
    Central planning is the antithesis of liberty. Pick one.
    Matt,
    If you think it’s a social good, then YOU pay for it. Goes for public school, medicare, ssn, too.
    Defense? How would you propose to maintain these freedoms without the ability to defend them?
    Tax records? Absolutely. Let each citizen pay an equal share in defense of country and constitution.
    Then debate and vote, in your own state, the balance of social good and liberty. Vote in your own state how much productivity to reclaim from contributors for redistribution. Then let’s compare outcomes.
    BTW – when did healthcare (or any other service) become a Right? And who’s obligated to provide it?

  40. 1. should Americans be allowed to opt-out of having their health records stored in a central government database?
    No such thing exists. So, sure, you can opt-out of it just like you can opt-out of joining the mandatory Mars Colony mission. I think I have a form for that somewhere, I’ll email it to you.
    More importantly, your financial records exist electronically, but are not stored in a central government database. The internet exists, but isn’t run out of a big government base hidden deep in a mountain somewhere. Electronic medical records will be like every other electronic record you have, because the world is full of cheap and lazy bastards trying to get stuff done, not criminal masterminds obsessed with you.
    2. should Americans be allowed to spend their own money to purchase health care services without penalty to the patient or provider?
    It’s your money. Go nuts, dude. But, uh, if you want to buy crack to treat your headache, there are laws against that. Also, if a doctor tells you leeches will cure your cancer, there are laws against that, too. Don’t expect us to tolerate charlatans selling snake oil because you’re wedded to libertarian ideology.
    3. should Americans be allowed to opt-out of a government-run health care plan without penalty?
    Right now, we charge people for Medicare part B, and if freeloaders try to wait until they’re sick before they join, they have to pay higher premiums than people who joined when they were supposed to and paid all along. We’ve done this for about 30 years. Are you saying we should stop that?
    Also, we do the same thing with the drug benefit. Should we stop that, too?
    How do you plan to stop the freeloaders from abusing our tax dollars? “Let them die in the streets” seems a little unrealistic.

  41. Spoken like a true hospital administrator – your point of view is so obvious its like seeing a fastball over the plate thrown at 10 miles an hour.
    The bottom line? Administration would like control of physicians. Anyone look at the latest IRS survey of non-profits? Our CEO alone took in 1.7M for running a hospital system in a dying town with heavy competition. Insanity. And the administration is CONSTANTLY trying to screw docs over every which way – all while having absolutely NO CLUE what they are administrating.
    If you think hospital admins in your own hospital are bad, can ANYONE FATHOM what it would be like to have bureaucrats running healthcare?
    What we need are physician owned hospitals, deployment of free market principles into healthcare by eviscerating 3rd party payors as they currently exist (ie. remove their ability to destroy MD practices) and allow physicians to negotiate as a group with whatever payors arise from the dust.
    ENOUGH already.

  42. Deborah,
    It is different in health care. Name other industries where the government had to fund a company’s switch to electronic. Every case I can think of, the company made the switch to electronic on their own because of the cost savings that IT would afford. If the current health care IT and EMR systems out there were so good economically doctors would be implementing them at a much higher rate. Unfortunately, too many EMR systems aren’t providing those returns for their users. Pouring a bunch of government money into poorly built systems will only exacerbate the problem.
    In the end, I feel that much of this money won’t be spent because doctors will continue to have largely failed EMR implementations using old dilapidated EMR software. Failed implementations means doctors won’t be eligible for the money. The big winner is the “certified EHR companies” that are able to market this well and make a killing off doctors. I certainly hope I’m wrong.

  43. Eric–
    Quoting me, out of context, from a comment on GoozNews is typical, I’m afraid, of the way in which you spread misinformation.
    I am dismayed to see you using THCB as a vehcile for lies and propaganda such as “The endgame of those who want complete government control over your health and mine is clear.”
    To put my comment in context: On Merrill’s post you pointed out that when a person has a colonoscopy, it is possible that his colon will accidentally be punctured–Thus, you suggested, Medicare should pay for virtual colonosopy’s for everyone.
    The risk of a puncture is tiny; every procedure carries some risk. I pointed out that it would make no sense for Medicare to pay for virtual colonosocpies for everyone to guard against the slight risk.
    This would be like saying that Medicaid shoudl pay for a 6 mammograms a year for every women on Medicaid to guard against the chance that a fast-growing tumor will appear and spread in between annual mammograms.
    This does happen– and women (usually young women) die as a result of those fast-growing tumors. But this does not mean that an insurer should be sued beacuse it didn’t cover mammograms more often than annually. Usually annual mammograms are sufficient.
    Bottom line: medical care does not provide absolute protection against death–or a punctured colon.

  44. Sure, there is always something to complain about with any legislation, the Stimulus Bill being no different. And yes, there are some problems with the current language, particularly as it pertains to “meaningful use of certified EHR”. So what is “meaningful” and what is “certified”? Both have yet to be clearly defined and therein lies the challenge – how will this legislation actually be executed? With $19.2B being pumped into HIT, we could easily go down a path wherein we end up with incredibly poor HOT installs as a result of rushed efforts to install the software to capitalize on the reimbursement schedule, which for Medicare is very aggressive. Such “rushed efforts” will likely result in poor attention to workflow and thereby hinder deep and long lasting adoption and use of HIT. There is a very VERY real danger here that we could just make a bad situation worse.
    It will take extraordinary leadership and vision, unfortunately, something we have little of at HHS seeing as we do not even have an HHS designate yet. Just one more reason for deep concern.
    And as for all the incredibly ignorant comments & concerns floating about with regards to digitizing consumer health information, my vote is to let’s get on with it. I want personal control of my records and I want them in a digital format that I can manage myself, thank you very much.

  45. Thankfully we know from over 30 years of behavior change research that health care rhetoric rarely is effective in changing behavior. It often just serves to support what people already believe.
    If you are afraid of big government or genuinely believe that the “free market” applies to health care you will take Eric’s position. If on the other hand you don’t believe that running a country is the same as running a company you might move in a different direction.
    What might be more effective is to apply some of the tried and true methods of science and influence to the problem. Identify 2 or 3 places where our health care system is working, share the behaviors that work and see if you can replicate it.
    For example. EMR’s Since we all are comfortable being paid electronically, storing our money in brokerage accounts, banks, credit unions and moving it around via Visa or Debit cards or online transactions. So it is easy to envision a national system where we store our medical data in banks that we control and move it based on rules that the government helps put together similar perhaps to the role the Federal Reserve plays or that Visa plays with banks?
    Large systems like Kaiser have already invested in these systems. Not only do patients prefer being able to see their medical records online but its saves money and increases efficiency (when well implemented). In some clinics up to 30% of all visits are now handled via email, opening up longer visit times for people with chronic conditions and giving them more self management tools. Clearly having a system where the savings accrue to the people who provide the care is a model we can replicate.
    Focus on what we know works behaviorally to get the outcomes you want and let go of the bifurcated verbal arguments.

  46. A survey of physicians in the U.K. reveals that a large majority of them would not place their own personal health records into the national system for sharing of personal health information. How are the plans in the U.S. similar to and different from what has occurred in the U.K. in the process of creating a national system of shared information? Randall Oates, M.D.

  47. Thanks for sharing your thoughts Joe. I agree. The Buzz over implications of the Stimulus Bill is deafening.
    Why are there so many comments? Perhaps people fear change. Enabling technologies that move organizations from paper to digital have, in other industries, provided improved efficiencies and workflow, reduced overall costs, and improved effectiveness.
    Would that be different in healthcare? I don’t think so…

  48. Will download and read. Nothing in your original analysis or these exerpts speaks to a single national clinical database. I have both drafted legislation and analyzed it as part of my job history. Where, specifically, can I find the mandate or specifications for a “central government database” for medical records? It almost certainly will not be required by a Federal Co-ordinating Council for Comparative Effectiveness Research.

  49. tcoyote– almost forgot… it is really worth reading the whole law portion dedicated to this… reading primary source data allows one to see through the hype…
    go here: http://thomas.loc.gov/home/approp/app09.html#h1
    then choose the “Bill Text Div A ” tab… key pages
    Page 156—400,000,000 to NIH for comparative effectiveness research
    Page 157 —400,000,000 to HHS for comparative effectiveness research
    PAGE 183—187(top)
    SECTION 804— ESTABLISHES FEDERAL COORDINATING COUNCIL FOR COMPARATIVE EFFECTIVENESS RESEARCH — does not empower FCCCER but does not prevent HHS/CMS from implementing (printed)
    PAGE 286 — BEGINS HITECH SECTION (ONCHIT et al)
    Page 328: (b) FEDERAL INFORMATION COLLECTION ACTIVITIES.-With respect to a standard or implementation specification adopted under section 3004 of the Public Health Service Act, as added by section 13101, the President shall take measures to ensure that Federal activities involving the broad collection and submission of health information are consistent with such standard or implementation specification, respectively, within three years after the date of such adoption.
    NOTE THAT 3 YEARS OF DATA COLLECTION ARE ALLOWED BEFORE A REPORT IS INDICATED FROM THE EXEC BRANCH ABOUT DATA COLLECTION TECHNIQUES, PROTECTION
    Page 369— PRIVACY SECTION BEGINS
    PAGE 392-394 (PRINTED)— where data can be used without patient consent
    End 424

  50. Excellent but depressing post.
    I followed the progress of the stimulus bill with great interest because it seemed like Christmas and your birthday all rolled into one for primary care. So I was very surprised to start getting angry email against it, until I started checking around and realized where people were getting these talking points. Keeping the status quo is so much easier politically than significant change. The physician community is going to be an important target of these tactics. I hope that even as we argue about the details of healthcare reform we can keep our eyes on the big goal and not be diverted from that.

  51. Joe- so sorry to steal your thunder from your post…
    Now that I am back at my ‘home base’ computer…
    a- from Maggie Mahar (http://www.gooznews.com/archives/001330.html)
    “Bottom line: medicine is shot through with ambiguity. Any proceduure carries some risks.
    Some of us will die of risks associated with a
    medical procedure. We cannot eliminate all risks—even if you or I or our loved one happens to be the one person in x,000,000 who succumbs to the risk.
    Your thinking suggests that no one should die–ever. That death is some sort of error that could be avoided if we just used a more expensive medical technology.
    Death is natural and inevitable.”
    As I said in my response… “Thus we have the central planning, money saving doctrine of the future health care elite bureaucracy class.”
    Bev– I am guessing you are a physician? Outcomes cannot be generalized… sometimes the most conventional treatment is NOT best and will NOT produce the best outcome… there used to be the concept of giving patients options, explaining the risks and benefits of different choices and letting the patient decide…
    You all seem rather against this…
    Ravi– a little realpolitik note to you— the biggest health insurers will NEVER be going away— what we learned in our Prop 101 (yeson101.com) experience to put those 3 rights into our state constitution is that the OPPOSITION WAS COMPLETELY FUNDED BY PRIVATE INSURANCE COMPANIES WITH CONTRACTS TO PROVIDE CARE FOR MEDICAID PATIENTS.
    deny it all you want— but as I tell people regularly, “if you like Halliburton, just wait for universal health care” — a world in which a handful of companies each have 400-500 BILLION contracts to manage the regional ‘universal network’…
    Matthew– did I miss it or did you not answer the questions directly.
    Joe— no where do the groups that want national health care (http://www.nchc.org/) ever consider those answers… and I by promoting an enforceable individual mandate as you do in your answer, you are spouting the rhetoric of the health insurance industry… (http://www.ahip.org/content/pressrelease.aspx?docid=25068)
    MG– focus, focus please—this is not the forum for me to raise my issues on those policy areas… and those voting against the bill DID raise those questions (and soon shall everyone else)
    unreal– snarky, but not very amusing… labeling and demagoguery does not play well here— please return to Kos
    again, Joe- sorry to hijack your post…

  52. I believe in universal healthcare and I tell you, it is not. We need to reduce the influence of insurance industry. For this, I proposed a tiered structure at http://blogs.biproinc.com/healthcare/?p=673
    Many people believe that centralized EHR is worth 20 billion…Well it is not. It can be done in less than a billion. And yes, it can be done in such a way tht government does not have access to personal information. User controlled. We have a beta version of this ready – if anyone interested can contact me.
    It is becoming a broken record…but we need healthcare transformation at multilevel and I would start first by looking into poicy and leadership together with wellness.
    rgds
    Ravi
    http://www.biproinc.com/healthcare_services.html

  53. Eric, Am I missing something, but where did this “centralized government data base” come from? My understanding is that the Stimulus Bill created a permanent federal agency, formerly temporary, to harmonize medical records data standards in order to achieve an interoperable electronic health record system nationally. This means that hospitals’ record systems can talk to one another, and physicians to hospitals and vise versa. When we’ve done this, do we have a “centralized government data base”?
    I know you went thru the bill, so maybe you can give me chapter and verse here.

  54. Not to pile on, but jeepers Eric, get a grip. Rush Limbaugh is an entertainer. He misrepresents Democrats because (in theory anyway) he thinks he is funny (I don’t see it myself). We have centralized credit rating data, centralized tax data, and centralized retirement account data and despite Republican warnings, the black helicopters have stayed away. Besides, I’m not all that certain why allowing other people to know that I have mild intermittent asthma and migraines (not to mention excellent blood pressure and lipids!) would be such a terrible thing.
    Every other industrialized country has some form of universal health care access ranging from “socialized” medicine in Britain to purely “private” insurance in the Netherlands. There is no reason why the U.S. can’t provide the same access in some form. Despite what Sean Hannity says, it’s not going to change American medical care as much as managed care has. Not one single (meaningful!) Democrat has proposed that there be a universal access solution that doesn’t permit the purchase of additional private insurance or to opt out of a public insurance in favor of private. About the worst any one has proposed is that you have to carry some sort of insurance. In most states car drivers are required to carry insurance and there is no reason why everyone shouldn’t be required to carry major medical, either.
    You need to take what Limbaugh and Hannity and Savage and the other right wing radio shouters blather with a grain of salt. Their not spending their free time researching the issues, you know, they pretty much just make up their rants on the spot.
    As far as comparative effectiveness goes, I say bring it on! There are so freakin’ many sources of information that I would be positively relieved if someone smarter than me could take responsibility for sorting out the alphabet soup of competing studies.

  55. Eric
    should Americans be allowed to opt-out of having their tax records stored in a central government database?
    should Americans who spend their own money to purchase defense, police and education services also be allowed to consume publicly provided services of the same type?
    should Americans be allowed to opt-out of a government-run national defense plan without penalty?
    I suspect that changing a few of the terms invalidates much of your argument. Health care provision cannot be legislated purely by private contract. It’s a social good anywhere.

  56. There are plenty of health care-related items though in the stimulus bill though that Republicans have a very valid criticism of though (e.g., increasing NIH research by $10B annually, essentially just plowing more money into Medicaid and COBRA with no real reforms/cost controls).
    I am kind of perplexed why they choose to go for the more low-base arguments but frankly it doesn’t surprise me much. Large part of it is simple inertia of “same old mantra” of “socialized medicine” thrown out their universally to frighten college-educated, independents who largely have abandoned the Republicans in the ’06 and ’08 elections like rats fleeing a listing ship.
    A very valid criticism of the money going to cost-effectiveness research could be:
    1. “How is such a large amount of money going to be distributed and spent to ensure that there is largely meaningful work produced?”
    2. “What types of research are going to be largely funded as the language in the ARRA bill is incredibly vague and nebulous?”
    Those are just 2 examples. Could easily come up with some more but I don’t they get discussed much by the Republicans in a few weeks.

  57. I find it incredibly odd that the same people who are railing about gov’t intrusion into health privacy (besides distorting the issues) are almost universally silent on the NSA activities regarding monitoring American’s electronic communications. Hell, in some cases they unequivocally support it with few checks and balances and little oversight/if any.
    Wouldn’t you frankly be more concerned about a gov’t organization whose sole purpose is intelligence surveillance and analysis, that has tends of thousands of people at its disposal for this very purpose, and have an annual budget that likely easy exceeds $5B? Let’s also not forget that unlike largely theoretical examples of gov’t intrusions into healthcare privacy, US gov’t intelligence agencies has run very sophisticated and lengthy programs on hundreds of thousands of its citizens for prolonged periods of time.

  58. The stupidity of the anti-research crowd knows no bounds. Let me see if I can put follow the thought process…
    1. Government is bad. It just is.
    2. Put me in government, and I’ll prove #1.
    3. OK, OK, so I lost the election. But look at Medicare: what a waste! Let’s get rid of Medicare.
    4. Oops. Can’t do away with Medicare…too popular, and the Medicare Advantage plans aren’t saving money. But let’s at least try to keep it as wasteful as possible. Remember, one man’s waste is another man’s income, and I didn’t go to medical school to drive a piddly 3 series, after all!
    5. Plus, the last thing I want is studies that produce clear answers. Somebody might actually ask me why I ignore them. I mean, all my buddies and I want is to be left along so we can keep practicing faith-based medicine. All that journal reading sure makes my head hurt! But luckily those hot little drug reps can explain it all to me.
    6. A few soothing mantras may help in these trying times:
    “Patients need freedom of choice…especially the freedom to agree with my therapeutic decisionmaking.”
    “Defending a dogma sure beats worrying about population health.”
    “More medicine is better medicine, especially when more medicine is lucrative.”

  59. Previous comparative effectiveness studies have shown such startling results as – gasp – that back surgery and coronary stents do not produce better outcomes than medical therapy in many groups of patients (note: I said many groups of patients, not all patients. These are complex issues.) Has that prevented some orthopedists from operating on every back they see or some cardiologists from stenting every coronary artery they see, for economic reasons? No, it hasn’t. Even Dr. Novack must concede that. Do I want my already-high HSA/high deductible plan premiums subsidizing those docs to ignore evidence-based medicine to keep their incomes up? No, I don’t. Got a solution, doc?

  60. > 1. should Americans be allowed to opt-out of having their health records stored in a central government database?
    Define “health records.” If you mean with their personal identity, sure – though I am unclear why people with such deep concerns about their privacy from government intrusion don’t seem to mention in the same breath the fact that private health plans know everything about your health – in fact, often more than your doctor does.
    If you mean the facts of their clinical situation, shorn of personal identity, no. How cases actually work out, what dosages are effective in the real world, and so forth, is extraordinarily valuable information.
    > 2. should Americans be allowed to spend their own money to purchase health care services without penalty to the patient or provider?
    Sure.
    > 3. should Americans be allowed to opt-out of a government-run health care plan without penalty?
    Sure – but only if they are covered somehow. The whole idea of “insurance” is to spread the risk pool. When it comes to healthcare, we all have bodies. Private health plans’ business plans depend on narrowing the risk pool. This makes our patchwork system unworkable.
    > The endgame of those who want complete government control over your health and mine is clear.
    There is a long series of assumptions and logical leaps between, on the one hand, advocating comparative effectiveness studies and universal coverage of some kind and, on the other, advocating “complete government control over your health and mine.” These two formulations are not equivalent at all.

  61. Joe-
    1. should Americans be allowed to opt-out of having their health records stored in a central government database?
    2. should Americans be allowed to spend their own money to purchase health care services without penalty to the patient or provider?
    3. should Americans be allowed to opt-out of a government-run health care plan without penalty?
    Feel free to answer these 3 simple questions yes or no…
    I am not sure if you actually care for patients, but try looking at the table of contents to the most recent Orthopedic journal (JBJS) — find it through aaos.org.
    Conmparative research already is being done every day.
    I also send you to Merrill Goozner’s blog at gooznews.com. Read the post about comparative effectiveness and, most importantly, regular THCB denizen Maggie Mahar’s response to me.
    The endgame of those who want complete government control over your health and mine is clear.
    That is not a future I want to pass on to my children.

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