I’ve been at a conference on disease management for diabetes where there was an interesting talk from Brian Klepper at the Center for Practical Health Reform. I don’t know much about the Center, (here’s a PDF) but it’s positioning itself as a neutral forum for reform based on the principles that Arnie Milstein’s been espousing — using process technology to reduce health care costs.

Klepper is a pessimist and an optimist. He believes that the sky is falling and quickly. He notes that the acceleration of employers dropping coverage (67 to 63% from 1999 to 2002) is speeding up. He also had another chart showing that only 45% of employees got their coverage from their employer anymore. Plus as cost sharing of premiums is heading up as less is being offered, cost per unit of benefit is increasing. The result is that even in employer coverage, people are being priced out of the market. The impact on providers is that bad debts are rising very fast.

He reasonably thinks that Medicaid is heading to block grants, and that Medicare is heading to defined contribution. So no more money from the government. Meanwhile as private health care funding is half of all income for the system, a 5% of fall in private coverage leads to a 2.5% contraction in actual revenue. This is what’s causing a spike up 10% nationally in hospital bad debt (in a surge of people showing up at EDs who don’t have the means to their deductibles or co-pays). This is showing up first in safety net institutions, such as Grady hospital in Atlanta which last year said that they will no longer admit indigent patients. A few years back community hospitals were at 12% margins–now most are losing money or making 1-2%. But they’re building like crazy and may not be able to service the debts they’re incurring. Meanwhile half of all bankruptcies are caused by medical bills and 1 in 7 families have problems paying their bills. And worse, 2/3 of those have insurance.

In other words there is going to be a net outflow of money from the system leading to a collapse. That’s where I think Klepper’s overly pessimistic. I think that the economy can keep pumping money into health care for a decade or two before we get anywhere near that point.

He says that the health care has refused to do what it takes to limit costs. I’d agree there. Where he’s an optimist is that Klepper thinks that this is the tipping point that will push all the players in the system to sit down and agree a way that will lead to their survival.

But given what he believes, Brian has 3 questions

1. What changes must we make to overcome these problems?2. How do we overcome the special interest gridlock?3. How do we avoid working on the wrong things? (e.g. working on the uninsured rather than the underlying costs that cause uninsurance–although again I think this is the wrong way around).

Brian believes that the only common ground is to get people to act for survival for the sake of their own self-interest. So the crisis has to be very, very visible. He thinks it will be and that all players (including suppliers, physicians and employers) will look for a neutral ground to solve the problem.

How is CPHR going to solve this?They have 3 major principles1) Retool American Healthcare enterprise with standardized management tools, such as–compatible IT platforms–transparency in performance accountability–evidence-based medicine–evidence-based management–pre-market national technology assessment–changes in reimbursement to move to P4P–process changes throughout system

2) Establish a national floor of basic coverage that everyone will get

3) Fix health care liability (but that must include quality and error prevention)

5 phases to the CPHR plana) Show that the system is unsustainableb) Establish a neutral coalition platformc) Outreach and mobilizationd) Develop content and consensus on actione) Coordinate the content through policy adjustment

Brian believes that they’ve achieved 1 and 2. I’m by no means sure, but the effort is worth watching and supporting, faute de mieux.

After this talk there was an interesting conversation among the audience about how long the system can sustain now. I think it can go on for a long while in this mess, but in the room 3-5 years seems to be the consensus. Brian thinks that he can get changes made within that time by setting the right folks up in a political environment where they’ll overcome their opposition. That’s why I think he’s an optimist. I don’t see any initiatives on Capitol Hill that will address any of these problems quickly. Perhaps the CPHR might create some.

In my less than glowing reviews of the Bush Administration as a whole I reserve a special place of opprobrium for Condi Rice. This is partly not really her fault. I turned up at Stanford in 1989 to do a one year masters in Poli Sci wanting to take a class on Soviet affairs (remember that?) and found that the Stanford professor who specialized in Soviet affairs had taken the year off. Yup, because Condi had decided to have fun somewhere else I had to get up early every Friday and take a rickety old bus to Berkeley to take a similar class there. So as well as being a completely incompetent National Security Adviser — "I believe the title was ‘Bin laden determined to attack in the US’ but it was a historical document" — she’s also directly responsible for me having to wake up early, often hungover as Thursday was sorority girl drinking night, when I was a young grad student. Yesterday Condi was getting what passes for a reaming these days from a mostly compliant bunch of Dems (well done Kerry and Boxer for voting ‘Nay’) in the Senate as she advanced up to and beyond the level of her own incompetence to Secretary of State. Good grief.

Meanwhile, to end my political rant and return to healthcare, down the hall in the Senate a much more agreeable bunch was giving plaudits to the soon-to-be former governor of the nation’s most conservative state as he takes over Tommy Thompson’s job at HHS.

As in the last week hints have been emanating from the Rove White House about figuring out a way to cut Medicaid — presumably because its recipients can’t afford to buy seats at today’s inaugural — the conversation in the confirmation hearings somehow turned to block grants. Sates’ rights-loving Republicans approve of block grants as they give states the ability to do what they like, and Leavitt did some of what he liked in Utah–basically using the Oregon formula of giving worse benefits to more people. Of course block grants also do something else, in that they theoretically stop states gaming the system to get more matching Federal dollars. New York has been the master at this forever and there are going to be some Medicaid cuts there soon anyway. (For much, much more on that see the excellent Health Signals New York).

Leavitt was at pains to deny that he’s ever heard of such a thing.

Leavitt was asked repeatedly about block grants and avoided answering directly several times. When pressed hard, he finally replied, ‘I know of no block grant proposal that would come to you.’ But at other points in the hearing, he mentioned that he was not yet privy to all White House plans and on several occasions he differentiated between the core Medicaid population that states must cover by law, and other ‘optional’ groups that states can choose to incorporate.

Bush a few years ago proposed what was essentially a block grant system that would apply to the optional groups. That was controversial even among congressional Republicans, and many Republican state governors also oppose it.

Of course what’s really fiction is that any cabinet secretary would be privy to any information at all about policy that might affect their area of authority. And you don’t just have to look at the treatment of Paul O’Neill. In fact look no further than the words of Leavitt’s predecessor, (and I assume for a few more minutes) current HHS secretary Tommy Thompson, who was also a Republican governor. Here’s what Thompson said after he quit about the small matter of the biggest legislative change to Medicare in 20 years.

In response to a question after his resignation speech, Secretary of Health and Human Services Tommy G. Thompson said, "I would have liked to negotiate" or bargain with pharmaceutical companies over the price of prescription drugs.

Thompson also said this:

"Out here, in this department, you get an idea and you have to vet it with all the division heads and the 67,000 employees. … then it goes over to the supergod in our society, and the supergod is. … the White House Office of Management and Budget. And they turn you down nine times out of 10, just to show you who the boss is. Then it goes to the young intelligentsia of the White House, who don’t believe that anything original or good can come from a cabinet secretary. And if you do get by them, it goes to the president. And if the president does agree with it, it goes on to the Congress, and if Congress ever does pass it, it’s time to retire."

So frankly I don’t doubt that Leavitt is telling the truth, I just don’t think that the Rove/Norquist Administration has yet told him what’s he’s selling. And it’s clear that like a fresh young car salesman he gets no choice of the options he’s offering the bemused customer standing in the dealer’s lot. I’m sure he’ll look forward to deferring to his manager.

It is though somewhat all of a moot point. Medicaid is a disaster. It has been continually forced to pick up all the expansion of coverage thrown at it from both the first Bush Administration (that’s daddy, not the last 4 years), then Clinton’s CHIP program, then the abandonment of health coverage from employers in the last recession. And increasingly it has had to do this on less money as states went into deficit big-time in 2001.

Don’t forget that Medicaid is three and a half programs masquerading as one. It’s pays for poor moms and kids, it pays for nursing home care for the spend-down elderly and disabled (and for their Part B premiums for Medicare), and it provides the DiSH payments to big inner city hospitals. And most of the money (about 70%) goes to the long term care for the elderly and disabled. There’s not enough money in the system to fix it by moving people into different programs, and the whole thing ought to be wrapped into some kind of universal coverage program for the working poor.

But pigs will not be flying anytime soon, so Medicaid is all there is to prevent even more kids being thrown out of health insurance and even more destitute seniors being thrown, literally, out on the street. So for that reason, despite the terrible margins on the business associated with it, the maintenance of Medicaid is of interest to lots of players in the health care sector from nursing home operators, to safety-net providers, to pharma companies, to a sub-set of health plans. And to anyone concerned that we may not be treating our most vulnerable citizens very well.

Meanwhile, apparently some other chump who couldn’t manage his way out of a paper bag is also getting a renewed contract for his job today. I need to get better at screwing up as it seems to be what Americans like to reward.

Ever since Bush claimed his "mandate" (meaning he actually got more votes than the other guy in this election), we’ve been hearing a little too much about social security reform. As San Francisco standalone journalist Chris Nolan points out in her blog Politics from Left to Right, the real "reform" in question is the de-linking of social security payments from wages to inflation, which will eventually reduce the value of the benefit. The privitization thing is just a sop to Wall Street.

Turns out that the Brits did this delinking a while ago and then privatized a segment of their state pensions by paying such huge bribes in tax incentives that it actually cost the government money. Then because interest rates dropped well below the levels at which the private plans had forecast their investment returns in the 1980s, they don’t have enough to pay the pensions at the rate that those few who stayed behind in the government plan (called SERPS) are getting. Not a pretty picture, and one well described in this article from the American Prospect, which though it appears in a lefty journal is written by a Financial Times reporter.

Why am I writing about social security in a health care blog? Good question. My primary focus on health insurance is that it ought to be a form of social insurance because the payments required for it are very uneven (some people are sick–others are not). Theoretically you might be able to design a largely private pension/savings system that might actually work and not compound social inequality. We already have private pensions from both employers and 401K and other plans for individuals that provide some mechanisms for savings and retirement. So there is the basis for a mixed public-private system–not unlike in health care.

Furthermore the separation of social security from general taxation is mostly an accounting sham which also allows the those earning substantially more than $87,000 a year to pay a proportionately lower share of their income in tax than those earning less–something that is clearly regressive but explained away by the concept that it’s a savings plan. So I’m not against reform per se, especially if the tax inequity was changed.

However, Paul Krugman in his latest NY Times op-ed lays out clearly that the attempt by the Bush Administration to privitize social security is going to cost a whole lot of money while these individual accounts are set up. And that lack of money is going to add to the deficit, which in the end will require less money to be spent on other things as we instead spend money servicing the national debt. What are those other things? Well, apart from servicing the debt Federal and state governments really only spend money on three things–defense, education and health care. Guess which one of these will get cut first.

Furthermore, the diversion of tax revenues into private accounts leaving a shortfall in the overall amount needed for keeping current benefits in social security has an eerie parallel in the diversion of money from the health insurance risk pool to HSA accounts. And in one more parallel, I have an HSA account with less than $2,000, and I pay a fee of $20 a year to manage it. Not a huge fee by any means, but assuming that it’s related to costs, I suspect that’s a much larger cost than what the government pays to manage social security accounts. In fact the management fees on British private pension accounts were so high the industry was forced into a huge settlement with its customers.

So as we head towards a self-funded, individual insurance funding future, there must be strong questions asked about the impact on health care, and society’s ability to pay for what’s needed for its less wealthy citizens.

Apologies to faithful THCB readers. The crunch continues (yesterday was the first day I’ve skipped in quite a while) and I can’t spend much time today writing up the blog, but there are lots of interesting pieces for me to point you towards. So please go take a look at these.

• There is a great interview from Bob Galvin at GE with Don Berwick, the doyen of healthcare quality improvement in Health Affairs. You owe it to yourself to take the 10 minutes to read the whole thing, but as the abstract says "Donald Berwick, founder of the Institute for Healthcare Improvement, supports performance incentives for hospitals and health systems. But expresses skepticism about the value of pay-for-performance schemes for individual doctors and nurses and emphatically condemns increased patient cost sharing as an appropriate tool for increasing the efficiency of the health care system." Berwick thinks that money isn’t enough and that a national move to transparency and individual accountability will inspire the correct response from ego-driven providers. Fascinating stuff, most of which rings true for me.

• On the pharma side, the NY Times reports that 10 big pharmas are joining the Together Rx Program and are adding their prescription drugs at low cost to the generics already in the program. Methinks all that criticism is working. Meanwhile Forbes has an excellent pair of articles–one on reforming the FDA, particularly pointing out its underfunding in the wake of the explosion of new pharma products out there, and one an interview with Marcia Angell in which she predicts that big pharma will become simply marketing machines (which is what some of us think they already are!).

• The token moderate Democrat on the NY Times Op-Ed page, Nicholas Kristoff, decries the state of health care for the poor noting that we are now below Cuba in terms of infant mortality. There are some counter arguments to this (in terms of our efforts to keep low weight babies alive that don’t get counted as full term deliveries elsewhere), but overall it is a condemnation of the outreach the care system does for poor mothers. Kristoff’s article Health Care? Ask Cuba notes that "In every year since 1958, America’s infant mortality rate improved, or at least held steady. But in 2002, it got worse: 7 babies died for each thousand live births, while that rate was 6.8 deaths the year before." It’s not pleasant reading.

• Finally, the latest spending numbers are out — and getting reported more quickly these days. It used to be that you had to wait for a couple of years but CMS released the new numbers for 2003 yesterday, only 12 months after the year ended. And although overall growth moderated a little to 7%, it’s still in the zone of where it’s been for several years now. Here’s the full CMS article in Health Affairs and here’s the Boston Herald‘s take on it. In days of yore I got pretty buried in those numbers as part of a 10 Year Forecast I co-authored back in the late 1990s. The way they are put together is interesting, and what they say is also interesting, so I’ll add a deeper explanation to my to-write list.

For now happy reading and I’ll see you tomorrow.

The Commonwealth Fund has sponsored one of Harris Interactive’s periodic surveys of health care experts and influencers (and no they didn’t ask me what I thought!).

I have yet to dig into the survey but the experts believe that the most important priority for Congress is dealing with the uninsured. So it sounds to me as if either they asked the experts what they thought ought to be the main priority of the nation regarding health care or what they hoped to be the priority of the nation. Because this nation, or at least its government, seems to have a lot of priorities in spending its money at the moment and covering the uninsured does not make the list. Unless of course you’ve really bought into the kool-aid that Association Health Plans and tax credits for those on minimum wage are going to solve the problem.

Those of you who think I’m an unreconstructed commie will correctly suspect that I’ve always discussed Marxism in my health care talks. You’d be amazed at how many audiences of hospital administrators in the mid-west know nothing about the integral essentials of Marx’s theory of history. And I really enjoy bring the light to them, especially when I manage to reference Mongolia 1919, managed care and Communism in the same bullet point.

While I’ve always been very proud of that one (err.. maybe you have to be there, but you could always hire me to come tell it!), even if I am jesting, there’s a really loose use of the concept of Marxism in this piece called A Prescription for Marxism in Foreign Policy from (apparently) libertarian-leaning Harvard professor Kenneth Rogoff. He opens with this little nugget:

"Karl Marx may have suffered a second death at the end of the last century, but look for a spirited comeback in this one. The next great battle between socialism and capitalism will be waged over human health and life expectancy. As rich countries grow richer, and as healthcare technology continues to improve, people will spend ever growing shares of their income on living longer and healthier lives."

Actually he’s right that there will be a backlash against the (allegedly) market-based capitalism — which has actually been closer to all-out mercantilist booty capitalism — that we’re seen over the last couple of decades. History tends to be reactive and societies go through long periods of reaction to what’s been seen before. In fact the 1980-20?? (10-15?) period of "conservatism" is a reaction to the 1930-1980 period of social corporatism seen in most of the western world. And any period in which the inequality of wealth and income in one society continues to grow at the current rate will eventually invite a reaction–you can ask Louis XVI of France about that.

But when Rogoff is talking about Marxism in health care what he really means is that, because health care by definition will consume more and more of our societal resources, the arguments about the creation and distribution of health care products and services will look more like the arguments seen in the debates about how the government used to allocate resources for "guns versus butter" in the 1950s. These days we are supposed to believe that government blindly accepts letting "the market" rule, even if for vast sways of the economy the government clearly rules the market, which in turn means that those corporations with political influence set the rules and the budgets (quick now, it begins with an H…). That’s how defense has always been and how pharmaceuticals will increasingly be. Rogoff recognizes the centrality of this argument in his description of what’s wrong with American health care:

Part of the rise in U.S. healthcare costs stems from the breakdown of the checks and balances that more centralized systems provide. (For example, Americans are several times more likely to receive heart bypass surgery than Canadians, where the procedure is reserved for extreme cases. Yet several studies suggest that patients are no worse off in Canada than in the United States). And even the most fanatical free marketers recognize that healthcare is different from other markets, and that the standard supply-and-demand principles don’t necessarily apply. Consumers have poor information, and there is an obvious case for greater government involvement than in other markets.

But he then goes on to say that the much greater spending seen here as compared to Canada and the UK creates both a terrible service level (and by implication quality level) and diminishes innovation in health care services. And if all countries squeezed profits in the health sector the way Europe and Canada do, there would be much less global innovation in medical technology.

Today, the whole world benefits freely from advances in health technology that are driven largely by the allure of the profitable U.S. market. If the United States joins other nations in having more socialized medicine, the current pace of technology improvements might well grind to a halt. Even as the status quo persists, I wonder how content Europeans and Canadians will remain as their healthcare needs become more expensive and diverse. There are already signs of growing dissatisfaction with the quality of all but the most basic services. In Canada, the horrific delays for elective surgery remind one of waiting for a car in the old Soviet bloc. And despite British Chancellor Gordon Brown’s determined efforts to rebuild the country’s scandalously dilapidated public hospital system, anyone who can afford to go elsewhere usually does.

His conclusion is that because for the sake of social equity government intervention in the system is warranted, the health sector will be a "battleground" between capitalism and socialism through this century. If you get past his mis-use or mis-understanding of the terms "capitalism" and "socialism", the point he’s making is quite interesting. It does though suffer from a typically Amero-centric bias. Rogoff assumes that the extra spending on health care in America leads to better services and by implication better quality. But that’s an old chestnut. By that measure the higher spending in Canada (11% of GDP) should lead to a better system than in France (9%) or Germany (10%). But in those two nations access to drugs and technology is much greater than in the UK or Canada, and things like waiting times are comparable to the US — in fact in Australia and New Zealand they’re better than they are here. A few years back The Economist said that the Swiss system (again several percentage points cheaper than here) was better than the American on an absolute level. Furthermore recent studies of international care quality suggest that particularly for primary care, the US is results-wise(at best) in the middle of the pack. All of those nations have a heavier proportion of government funding of health care spending than in the US, and all of them spend a whole lot less money. Note that the US government spends more per head (and damn nearly as much as share of GDP) on health care as the whole of the UK.

So that all tells us one thing. We’re paying a lot more for health care here, but it isn’t necessarily getting us better outcomes, innovation or even services. We might though have nicer waiting rooms and we certainly lead the league in surgeons with Porsche 911s. Therefore it’s a stretch to imply that higher private spending leads directly to innovation and better services, particularly if the system is not set up with either government-based or real market-based co-ercive capabilities to promote efficiency and value for money. And lets be real, the US system is set up to provide revenues and profits for providers and suppliers. It’s a bit like saying Tammany Hall provided the best government services because it cost the most, when huge chunks of the money were getting diverted off into corruption.

Furthermore, it’s also a stretch for Rogoff to suggest that by definition government spending creates lower innovation compared to private spending. After all government spending led to the creation of the Internet and biotechnology. Private spending created reality TV. And despite the fact that there is no private spending on defense, well the boys and girls in the US military are no longer riding around on horses pulling gun carts. Somehow innovation and progress seems to find a way to happen even in government sponsored sectors. And if we want to drag real communists into the equation, the reason that we’re not all speaking German is that Hitler lost WWII to a nation that ten years before he invaded was inhabited by peasants. Yup, unpleasant as it might have been, Stalin’s Great Leap Forward in the 1930s was by far the fastest period of economic growth seen in any nation, probably any time…..just in time to save our arses in 1942-4.

I’m not exactly advocating purges, slave labor camps, collectivization and enforced Ten Year Plans as a panacea for the future of health care (although David Brailer keeps going on about his ten year plan). But the overall point is that greater government involvement in spending and regulation of health care doesn’t necessarily mean the disaster in services and innovation that Rogoff suggests. And there are excellent reasons from the "socialist" angle for greater government involvement in health care than we have now.

The first is the fallacy that there can be such a thing as a private health insurance market with free use of underwriting. Social insurance (or universal insurance), in which everyone pays in and everyone receives at least a basic level of benefits is the only way to get around the problem of the uninsured and the uninsurable. It of course means a relative redistribution of income from the healthy and wealthy to the poor and sick, but in fact that can be budget neutral to the healthy and wealthy if the overall price tag is kept down. That though would require a redistribution of income from the health care sector to the rest of society. Such universal insurance is good enough for everyone over-65 in this country and good enough for everyone else in the developed world, but the concept just can’t seem to get the attention of the American public enough to force it past the "special interests" in Congress. And everyone (apart from actuaries and underwriters and some participants in the system) suffers as a result.

The second is the role of government or someone like it as a clearinghouse of information or as a standards-setting body in a market where information access is very lopsided. Health care is very, very complex and someone has to provide decent information (preferably with some regulatory teeth) so that consumers/patients are not at the mercy of providers and suppliers who know far more than they do and in whom most patients still are forced to place their trust blindly. This is the role of the NICE in the UK, and in theory ought to be the role of the FDA here. Adding an economic element to that role by giving information on value for money would probably be derided as socialism by Rogoff’s "capitalists", but is a rational role for government. And one they are likely to add as spending increases — of course the Brits and Aussies already have done so to some extent, and are linking cost-effective performance to payment.

So overall I don’t think there’s any basis for suggesting that if we have more "socialism" in health care — and by that I’m using Rogoff’s meaning of government spending, regulation and income redistribution — we will necessarily have worse services or lower innovation. Although we may have lower drug prices and a less profitable health care industry. Anyone awake during the last three months of Vioxx breast-beating is becoming painfully aware that expensive "innovation" can be costly for the wrong reasons and actually not be innovative–COX-2s didn’t really do what they were supposed to do (reduce GI problems) but they did cost a lot more than NSAIDs in both money and increased heart disease. But it’s that kind of "innovation" that Rogoff correctly says that Americans are paying more for than anyone else.

However, Rogoff is making a very important point when he discusses the likely trade-offs between basic health care and lifestyle enhancements that will dominate the politics of health care for the next century. We’ve already seen this begin with the medicalization of social afflictions (ugly teeth, small breasts), the medicalization of several "diseases" that aren’t really diseases (impotence, shyness), and the medicalization of old age (osteoporosis, prostate cancer). Now the nano-gurus are discussing the medicalization of death — which will presumably lead to a cure, or at least a delay, for it at a hell of a price.

As more and more health care services become luxury goods, there is a justifiable discussion about what’s a basic necessity and what should someone have to pay for out of their discretionary income. At the moment no-one’s seriously suggesting that your boob job or teeth whitening should be other than an individual expense, or that your cancer treatment is a luxury good to be chosen if your mood and wallet fits. But clearly the middle of that continuum will continue to fill up.

This leads me to what has been called the mocha-Frappuchino problem. I read an article once (that I can’t find anymore) that discussed the increase in productivity of the US workforce since the 1930s. It’s doubled. Which means that we could work half the time and have a 1930s standard of living, or we could work as hard as we do now and have more stuff. The author noted that in the 1930s you couldn’t get a Mocha Frappuchino; so you’ve been spending Wednesday 1pm through Friday afternoon working for your Frappuchino (or similarly frothy goods and services).

We’ve always thought of health care as an "essential". And eventually even in the US I believe we’ll figure out a way to solve the problem of creating an equitable and sustainable social insurance model for that "essential". But increasingly, the health care Frappuccino will be paid for and delivered privately, in a separate system. Of course it’s the blurring of those two systems that concerns bleeding heart liberals like me, as that can well lead not as it has done here for the Medicare population, as society giving Frappuccinos to everyone, but instead society deciding to take away essential services from those who can’t afford Frappuccinos.

And that will be the real socialism versus capitalism battle of the next decades.

Well I’ve spent some time emailing with Sydney at Medpundit about her original article and she’s also received support from Enoch at Medmusings and Dr Bob at The Doctor Is In. All three are coming at this (I presume) from a Christian "faith-based" perspective and so there may be no possibility of them agreeing with a secular humanist like me. But let me detail my correspondence with Sydney and make one more attempt.

Last Friday after she had said that the Dutch doctors were the moral equivalent of those committing genocide in Bosnia, the Sudan and Nazi Germany, I called in this post for Sydney to retract her words. My argument was that this was a profound disagreement among well-meaning people, and that equating the Dutch with totally malevolent people was a) incorrect and b) insulting. I also argued that there was no specifically rational or moral difference between ending care and feeding of a terminally ill child causing its death, and actively causing the child’s death by, say, overdosing it with morphine. You could quite reasonably argue that this was kinder for the child as it reduced its suffering. And, as I showed using recent poll data, the former activity is accepted medical practice amongst pediatric specialists in this nation–just as highly regulated euthanasia appears to be becoming in the Netherlands. (As opposed to the unregulated, unstated euthanasia that’s been practiced by many physicians in many countries forever).

Note that I am not trying to convince Syd (or Enoch or Dr Bob for that matter) to change their views. What I am objecting to is anyone saying that  someone who disagrees with them (and acts accordingly) on this type of highly-charged issue is as evil as a human can be–there is no worse crime than genocide. Syd responded:

I disagree. You’re assuming some innate goodness on the part of the Dutch that would prevent them from killing others that they find too much of a burden, and/or some innate evil on the part of the Sudanese and Bosnian Serbs that allows them to kill normal adults they find burdensome. We are equally human and equally subject to moral failings. Once a society has decided it’s acceptable to kill those that are a burden, then any troublesome group is fair game. The only distinction between the Dutch, the Bosnians, and the Sudanese is who they define as a burden. And history has shown us more than enough that that definition belongs to whoever holds political power.

I responded to Syd by saying that "there is one absolute difference. The Dutch physicians believe rightly or wrongly that they are doing what they are doing purely because they are preventing the children from further suffering. They do not believe they are doing it for their own advantage–that’s your (mis)interpretation of their actions. The Sudanese/Serbs/Germans who commit genocide are doing it for their own perceived advantage and have no consideration of any kind for their victims.

There is also one relative difference. If you withdraw care and feeding from a terminally ill child with no prospect of recovery, it will die sooner than if you don’t. If you euthanize a terminally ill child the same is true. It’s a reasonable position to equate these positions morally, and if you do that then many, many physicians (as shown in the poll on my blog) are guilty of the same act. According to your logic, they’re all the same as those committing genocide.

If you cannot logically defend these points you should withdraw your remarks."

Sydney replied:

Active killing is active killing, regardless. The Dutch doctors may tell themselves they’re doing it to end the suffering of the children, but truthfully, there’s no indication that children with neural tube defects have pain just from the defects. They do have long, complicated roads ahead of them, however. The Dutch are making the decision for the children that those are roads best not taken. (According to press reports the physicians make the decision without even taking into consideration the parent’s wishes.) Take it from someone in the profession – doctors make those kinds of decisions most often based on how much of a hassle factor it will be for them, rather than the patient.

Here’s another example. In Germany, before the Holocaust, it became acceptable practice to euthanize mentally handicapped children. The doctors convinced themselves it was OK to do so because the children were too restless and unmanageable. They would put them down to put the "poor idiots" out of their misery. In truth, it was the doctors’ and nurses’ misery that was being eliminated. It wasn’t so much the patient’s condition that was the real problem, as it was the medical profession’s inability to manage their conditions properly.

It was not so long ago that people with even mild physical handicaps were treated as non-entities, even in this country. They were often locked away in their homes by their families. That’s still better than being euthanized out of pity, I suppose.

I guess that’s the difference between the two of us. I’m unconvinced that the Dutch doctors kill infants for completely altruistic motives. You are too willing to take them at their word.

I certainly won’t withdraw my remarks.

On a somewhat trite level it’s easy to refute Syd in this particular case. The Dutch hospital has set up a special protocol, consulted parents, judges and lawyers, and invited controversy including attacks like Syd’s from far and wide on the personal morals of those involved and their national character, all allegedly in her view to save themselves from the "hassle factor" of letting, so far, four children die by withdrawing care and feeding. I know in which course lies the "hassle" and it’s not in the withdrawing of care and feeding. Furthermore, Syd has convinced herself that because she’s seen doctors take those type of decisions for reasons of their own comfort–you see it happens here too–that the Dutch doctors must be doing it for that reason. She also hasn’t bothered to try to logically untangle the relative difference between causing death by action and causing death by deliberate inaction. She just says "active killing is active killing". Similarly Enoch says:

I think there’s a huge difference between allowing a person to die off of life support, and actively ending the life of the person. It’s true that it’s an action to take a person off of support, but that’s morally acceptable to me, to remove life support from a terminal incurable process that will inexorably lead to death soon. Removal of life support is completely different from an action promoting and accelerating death and altering the natural course of disease.

None of them come up with a "why" as to there is a difference. In their view it just is (based presumably on their interpretation of their theology), and that’s that.

Sorry guys, but that’s not good enough. You are all supposed to be scientists and scientists are supposed to bring reason and logic to bear on problems. You may well be right, but you have to at least attempt to prove your case.

But it’s accusing the Dutch physicians of moral equivalence of genocide that is not acceptable. Let me give an analogy. A while back there was a huge brouhaha when two of some 1200 amateur made videos commercials submitted in a contest to Moveon compared Bush to Hitler. As soon as Moveon realized this, they took them out of the contest, and they were rebuked (rightfully so in my view) by both the Republicans and the Democrats for not weeding the commercials out earlier (even if hardly anyone saw them). Now, if you really wanted to, you could draw a parallel between Bush and, say, Stalin. Bush has ordered the indeterminate detention without trial of at least two American citizens. Is he as bad as Stalin, who had thousands detained without trial and tortured and killed? The ACLU (of which I’m a member) has vigorously opposed these detentions (and those of several hundred more non-citizens) as being opposed to fundamental human principles of due process (not to mention the Bill of Rights). However, no reasonable person would suggest that what Bush is doing equates him with Stalin, even though indeterminate detention without trial was a hallmark of Stalin-ist totalitarianism. Whether you agree with him or not, Bush (and his administration) seriously and sincerely believe that the relatively limited numbers of detentions carried out are essential to protect the United States and its citizens. No serious historian believed that Stalin’s use of those tactics (and much worse) was anything other than a means of crushing any possible opposition.

By equating the Dutch physicians with the genocide seen in Rwanda, Sudan, Bosnia and Nazi Germany, Syd and the others are doing the equivalent of saying that Bush is the same as Stalin. That’s what’s so offensive.

I tread gently around criticizing Sydney at Medpundit because her blog is so good even if her politics are increasingly "out of the mainstream" and the evidence she uses to support them is often incomplete, nay baffling. (See this piece reviewed by Ross on how Kerry planned to put everyone into Medicaid, although her argument rested on the ridiculous assumption that all employers would simply stop offering health benefits if Medicaid eligibility were expanded–even though there’s nothing stopping them from dropping benefits now, theoretically).

But in her Tech Central Station piece on the euthanasia issue in the Netherlands she has crossed the line and needs to be repudiated. The issue is that some Dutch doctors have decided after consultation with parents and the judiciary to euthanize terminally-ill babies rather than withdraw care and feeding and have them starve to death. It seems to be done with the utmost care and sensitivity:

"It is for very sad cases," said a hospital spokesman, who declined to be identified. "After years of discussions, we made our own protocol to cover the small number of infants born with such severe disabilities that doctors can see they have extreme pain and no hope for life. Our estimate is that it will not be used but 10 to 15 times a year."A parent’s role is limited under the protocol. While experts and critics familiar with the policy said a parent’s wishes to let a child live or die naturally most likely would be considered, they note that the decision must be professional, so rests with doctors. The protocol was written by hospital doctors and officials, with help from Dutch prosecutors. It’s being studied by lawmakers as potential law. Under the protocol, assisted infant deaths are investigated, but so far all of them have been determined to have been in the patients’ best interests.

Both the Dutch and philosopher Peter Singer feel that their actions are morally similar to abortion when a foetus has no hope for life. No doubt Syd disagrees with this, and probably (although I don’t know) with the legality of abortion too. Many who share her views on that also disagree with contraception, and even male masturbation as depriving the possibility of life (for a lot more on the social repression of masturbation up to the firing of Jocelyn Elders for mentioning it see here, but be warned there are some graphic pictures).

Disagreement over these issues is bound to happen and be controversial. However, Sydney goes on in her article to equate the behavior of the Dutch doctors, judges and parents as being the moral equivalent of the people who have committed genocide in Germany, the former Yugoslavia and the Sudan. That is a reprehensible thing to say. And there is a shiningly clear difference. The people in the Netherlands are clearly trying to do what they believe to the best thing for the children concerned. Syd may not agree that what they did was in the best interests of the children, but that is what the Dutch believe. I don’t know if Syd approves of the conventional treatment here of withdrawing food and care and allowing terminally ill kids to starve to death, but to me morally they amount to the same thing. Coincidentally, this week’s Pediatrics journal has an article on Do Not Resucitate orders for children undergoing surgery, which included a survey of pediatric surgeons and anesthesiologists. It finds that:

The majority of anesthesiologists (86%) and surgeons (94.7%) were willing to withdraw life support at the request of the family a few days after surgery if a child suffered an arrest in the operating room, was resuscitated, and had an adverse change in quality of life. The majority of anesthesiologists (55.1%) felt that the perioperative period ended when the child left the recovery room, with only 38.2% of surgeons agreeing (P = .0037). Many anesthesiologists (22.4%) and surgeons (39.5%) felt that the perioperative period should be extended until 24 hours after surgery.

Given that withdrawing life support means that the terminally ill child will die, there’s logically little difference between this and the direct euthanizing that’s happening in a few cases in the Netherlands. I’d argue that there’s no real "slope" whether slippery or not between these actions but there is a vast series of huge steps down to genocide. And logically if that’s the case then Sydney’s accusing the vast majority of physicians in this survey of being on the same moral stature as those involved in genocide.

That type of accusation has no place in our relatively civilized corner of the blogosphere, and if Syd won’t make that clear, the rest of us have a responsibility to call her out on it.

Correspondent Atlas (who you may recall is the token right-winger on THCB)   writes regarding my question as to what will turn the tide regarding reform:

The pondering of what might start a proletarian revolution in health care sounds jarringly reminiscent of Lenin’s observation about Czarist Russia: "The worse, the better."

The reality is that most Americans are reasonably fat and happy with their healthcare, which is why the starry eyed Reds of the health care firmament (Dr. Angell et. al.) are always disappointed when the rage at the machine so fashionable among the chattering class don’t resonate with Red-land.

The real power behind the move to give big pharma and the rest of the healthcare sector, as you allude to in your post, is mean old big business–GM and the rest of the Fortune 500. One industrial titan’s revenue is another’s expense, and since big biz picks up nearly half the tab, they are leading the charge behind the scenes to cut that cost through the usual means–get government to pay for it, or outsource it to India.

Government is the other pincer putting the squeeze on the healthcare-industrial squeeze. Those of you who lament Bush II pay close attention and watch how the Administration uses clever cost cutting wolves in private sector sheep’s clothing to penetrate deep behind healthcare-industrial complex lines.

I’ll have you know there are some otherwise reasonably rational Republicans running around Congress waving bloody reimportation shirts. There are cheap votes to be had in this farce, and most of the Chamber will still respect you in the morning.

Most big business would like nothing more than to unload their healthcare costs on the government, which will then either tax and spend until the whole deck of cards collapses, or (much more likely) ration us into a Kafkaesque gulag system ala Great Britain or those envied denizens of the great white north who migrate south like birds in Fall should they actually need healthcare rather than the illusion of it gratis.

Sad but true, there is no free lunch. Would that there were. But no one works for nothing. Not even noble minded authors. And they are far less likely to be sued into oblivion for human faults than big pharma, hospitals, and the beleaguered medical profession, its ranks already projected to fall 20% short of projected demand by 2015.

Even now, why would any intelligent young person choose medicine over law? A good trial lawyer can make more in a year than a good doctor can make in a lifetime? So those who clamor for socialized health will have to rely on scholarly saints in a capitalist world, which will make the queues for healthcare even longer.

Nonetheless, there are legitimate problems that need to be solved and can be addressed without killing the geese that lay the golden eggs. Some of Kerry’s ideas and some of Hillary’s had merit. If we fully funded Medicaid and raised the eligibility limits, possibly by means testing Medicare and Social Security, I think a lot of the legitimately uninsured would be covered. But instead politicians waste time and political capital on stalking horses like reimportation. Let those who are serious–big business, big pharma, big government, organized medicine and hospitals and all the other players, purveyors, and payers–sit down at the table and make great compromises for the good of the people, instead of demagoguing  for political gain. Only serious candidates need apply.