Saturday, November 30, 2013

some of the week that was in the commentary regarding the magestic unfolding of Obabacare

1. Don Boudreaux , economist from George Mason University, blends the history of the Plymouth Colonies,Thanksgiving, the purported right to health care, ACA  and the incentive problem with his typical trenchant style , See here.

Referring to a recent article suggesting a significant increase in the numbers of Medicaid patients resulting from implementation of Obamacare would aggravate the already problematic doctor shortage , Professor Boudreaux said :

"This historical experience [ referring to the Plymouth colony's failed experiment in communal ownership] contains a lesson for health care.  The problems highlighted in your report – a surge in health-care consumption along with a shortage of health-care resources – is a predictable result of turning health care into a common-property resource.  Consumers have fewer incentives to consume it wisely while physicians and other health-care providers have fewer incentives to supply it in quantities sufficient to meet all of the demands for their services."

 The colonists in Massachusetts figured it out in the 1600s what  finally hit the leaders in the USSR when that  failed economic experiment imploded in the early 1990s.

Communal ownership of health care resources is a theme that the medical professional elite has put forth for some time, perhaps beginning with the lame analogy between health care resources and the so called  tragedy of the commons the coining of which is typically  attributed to  Garrett Hardin in a 1968 article.Later Dr Howard Hiatt wrote in the New England Journal of Medicine in 1975 : " the total resources available for medical care can be viewed as analogous to the grazing areas on Hardin's common."

 The absurdity of this analogy was dealt with in some detail here but the notion of medical care as a common property issue has flourished in the medical policy literature and gave birth to the meme
popular in progressive medical thought leader circles that physicians have an ethical duty to be stewards of the [mythical]  medical resources.To promote this stewardship theme and to to conserve these limited common resources  appears to be the reason for existence of the American Board of Internal Medicine Foundation  with its" choosing wisely" campaign which in turn is well funded from the Robert Wood Johnson Foundation.It should not go unnoticed that one of the authors of the New Medical Professionalism which promotes social justice as a ethical imperative  is current leader of the RWJF amd she was at the time of that pronouncement was sent forth.

2.The related topic of appropriateness guidelines is discussed by Dr. Westby Fisher in his blog "DrWes" . He traces the origin of that movement to the Rand Corporation in the broader theme of  the tension between the medicine of the individual and the medicine of the collective..See here.

quoting Dr.Fisher:

"Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.
Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment "appropriateness" using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as "Appropriateness Criteria®" or "AUC®" by our own medical professional organizations."

I did not realize that the organizations of cardiologists were as aggressive as the ACP and the ABIMF in their efforts to institutionalize guideline medicine  and  minimize the individual physician patient decision making process.

3.Dr. Robert Centor, one of my all time favorite medical bloggers, opened the can of worms of IPAB , a topic that had become somewhat dormant. He expressed support for IPAB and this was meet by several letter writers voicing the opposite view.See here. For those of us who believe that Public Choice theory is largely correct and worry about regulatory capture and cronyism  ,there is much to worry about with IPAB.

 4.More and more economists and others have been writing about what they believe to be the very  real possibly of the insurance exchanges,critical to the viability of Obamacare,entering into some type of Greek tragedy death spiral. Seth Chandler,a law professor who is a specialist in insurance law at the University of Houston Law school does a great job of very detailed and nuanced analyses of many of the incredibly complicated and complex details of that law and of the still emerging regulations that further define its operational meaning makes predictions iffy since may change tomorrow. See here for Prof.Chandler's blog.
Even NPR seemed to recognize that some called a death spiral could actually happen.

Friday, November 29, 2013

Do the new medical professionalism and new ethics conflict with the notion of "rule of law"?

Both the new medical Professionalism and the current rendition of the ethics of the American College of Physicians have added to the long standing ethical precepts of  patient welfare and patient autonomy the ambiguous notion of "social justice".I use the term "ambiguous" because in neither proclamation do the authors clarify exactly what they mean by social justice.Later writings by the ABIM foundation,an organization closely linked to the ACP seem  to equate social justice to conservation of medical resources which seems to me to be at best an idiosyncratic use of the term.

Although many  would consider social justice to be something along the lines of  " trying to help the less fortunate " or at least a sincere concern for the disadvantaged, many equate social justice to re distributional justice and that  seems to be a widely accepted meaning. Against the first informal definition few would raise objections but there is a long history of political economic thought in opposition to the second including principles prominent  in the founding of the United States and dates back at least to John Locke and others typically characterized as classic liberals.

So what does the quest for social justice have to do with the rule of law?

According to some,most notably,  F A Hayek, social justice in the sense of distributive justice is inherently incompatible with the rule of law.Basically this is because the progressive philosophical position which include efforts to bring about social justice favors  efforts to redistribute resources or services to lessen inequality along some purported  axis while the rule of law proposes treating everyone the same and promotes the rule of law as opposed to the rule of man. The progressives  oppose treating everyone the same because treating unequals equally likely results in no lessening  of the inequality which is the "polar star" of the progressives much as liberty could be said to be the polar star of the classic liberal thought, now referred to as libertarianism.

Hayek speaks of social justice a being "devoid of specific meaning " but "fraught with insinuations" that are dangerous and erroneous. He believed that people who use the term do not know themselves what the mean by the term.

To Hayek justice referred to a process while the progressives  (on modern liberals) consider justice as a result. Hayek favored a society in which coercion was limited as much as possible  and believed human freedom was dependent on general rules that carved out domains of activity that were exempt from government power.

The classic liberal view point  strands in clear opposition to the  view espoused by the modern liberal  also known as progressive. If there is a cogent argument for the proposition that a physician must adhere to the progressive view and act accordingly to be considered ethical it has not been made. Rather certain organizations- most prominently The American College of Physicians and the American Board of Internal Medicine Foundation- have gratuitously asserted that support of social justice is a fundamental precept of medical ethics and medical professionalism.These advocates have attempted to make a political goal ( redistribution and social justice) an ethical requirement of physicians.

Dr Thomas Huddle of the University of Alabama Medical  School said:

"Advocacy on behalf of societal goals... is inevitably political".
and
" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Dr Huddle co-authored the following along with Dr. Robert Centor:

..we should not assume that the pursuit of social justice is an integral aspect of physician identity,despite numerous assertions to that effect.We contend that social justice is a civic virtue that makes its claims upon physician as citizens.If we are obligated to further health care access for every member of society,we have that obligation as members of society,not as physicians.Promoting nonprofessional virtues or ethical imperatives is not the province of professional ethics.

So, in answer the the question posed by the title-yes. Would physicians hung up on the archaic notion of the rule of law be considered unethical?

 Minor changes ,word order and spelling, made on 7/31/14 and again on 8/15/14 and 8/31/14.

Monday, November 25, 2013

More emerging aspects of the great kaleiscope of the Obamacare debacle

1. Contrary to the silly claim made in the even sillier comparison between Obamacare and Katrina  that " at least Obamacare  did not kill anyone ", well it just might. See here. for economist John R Graham's discussion about ACA and the median voter. He references the WSJ article about Edie  Sunby whose medical insurance policy was cancelled after the insurer has paid out 1.2 million dollars for treatment of her rare cancer.Apparently her options to purchase insurance now does not include plans that provide care at the specialized institutions necessary for her treatment.Maybe that is not a matter or life and death but then again..

2. Reports suggest that the health care insurance policy cancellations seen so far are just the tip of a very large iceberg .Is the 100 million more cancellations  projection from AEI just predictable  anti-Obamacare spin and Casandra talk or are they on to something.Seth Chandler from the University of Houston, in his new blog, provides a detailed and nuanced analysis. His bottom line seems to be is maybe 15 million is a more realistic guesstimate.See here. Professor Chandler's legal analysis may well be correct in saying that many small employers will be impacted by the law and the fall out would be more policies cancelled. The big but here is that so far in regard to Obamacare the administration has seen fit to delay execution of various aspects of the law when that is the politically advantageous thing to do.There is an election in 2014 and one does not have to be excessively cynical to think that they will do everything they can to postpone what ever they can to try and salvage the 2014 election.


3. Has Obamacare violated the primary rule of redistributional politics? The rule is: diffuse the cost and focus the benefits of  any redistribution scheme. With ACA many folks are getting the bill and realizing who is paying for it.See here for comments regarding this rule violation from the blog Pileus who raises the question has the Obama administration's hubris been so great as to think they need not heed this fundamental law. Speaking of law violation it may be that the administration plan of "fixing" the clown car health care website by putting more programmers and very smart people on the project  violate Brooks's law that states:"adding manpower to a late software project makes it later".

4.This is not a new thought but it needs to be repeated. Obamacare is the biggest example of crony capitalism ever. Think about it. Everyone  (almost except ,for example, the Amish) is forced to buy the health care insurer's product,and if someone can't afford the government will provide a subsidy. And if that was not enough ACA provides various safeguards to the insurers that minimize any losses they may incur in the exchanges in the form of reinsurance and risk corridors. See here for details of that.What do you expect when a former VP from Wellpoint was hired by the Obama administration to help write and then to help implement the law. See here for details about Elizabeth Fowler and what executive position she now has in a health care related company.

5.I wonder if many members of the American College of Physicians have embraced the college's program for helping patients sign up for the exchanges.Maybe it is more successful than the government website.See here.

6.United Health cuts thousands of physicians from its roster , See here. This is mostly from their Medicare Advantage Programs which have already or will soon experience cuts from Medicare. You may remember that this funding mechanism for Obamacare was postponed until after the last national  election to avoid the wrath of medicare voters being manifest as votes for Republicans.

Sunday, November 17, 2013

Medical Insurance cancellations-A feature not a bug of Obamacare

Those who believe it is a feature argue something like the following:

Part of the funding for Obamacare was supposed to come from forcing young,healthy people to purchase more expensive insurance so that older,less healthy folks could have their insurance subsidized. This was an essential part of the redistribution of the law thought necessary for the economic viability of the insurance exchanges. It was thought to be politically expedient to claim that no one would loose their insurance and no one would loose their doctor so  the plan could be sold to the public.With the outcry from many of those who in fact did loose their plans, it became politically expedient to postpone or pretend to postpone those cancellations for at least some of those people until the next Congressional election,whether the President has the legal authority to do so or not .

Those who believe it to be a bug and therefore fixable argue the following;

Well, I guess no one actually believes that but the House of Representative has passed a bill with the apparent assumption being that it is a bug and we can fix the problem by not allowing insurance companies to cancel policies  because those polices do not meet the law requirements .But if the cancellations are a feature and necessary for the success of the insurance exchanges, the administration cannot allow that bill to become law and the President has threatened to veto .I wonder if any of the representatives who voted for the abolition of the  cancellations or the Senators who are proposing something similar think they are fixing a bug or realize the entire economic survival or the bill is at stake or do they just think that is politically expedient.

"The curious task of economics..."

Thursday, November 14, 2013

More Obamacare "Social justice": cutting subsidies for charity medical care

Dr John Goodman's website explains what is happening. See here. Less money will be paid by the government to hospitals that provide medical care to indigent patients.

A number of well known hospitals ( e.g. Parkland in Dallas,Grady in Atlanta, etc) provide much medical care to indigent patients. The federal government through the Centers for Medicare and Medicaid have provided significant subsidies under a program referred to disproportionate share payments.

One of the mechanisms devised to fund the health care transformation known as ACA is to make significant cuts in this program.

Quoting from a recent  ( see here) NYT article:

“We were so thrilled when the law passed, but it has backfired,” said Lindsay Caulfield, senior vice president for planning and marketing at Grady Health in Atlanta, the largest safety-net hospital in Georgia.
 
 As Obamacare unfolds we are seeing more than a little backfiring.

 And this quote from my favorite Louisiana economist, Dr. Don Boudreaux writing in his blog  " Cafe Hayek"

" In the 18th century, Adam Smith launched the discipline of economics by explaining that intentions are not results, and that the complexity of a real-world economy nearly always overwhelms and confounds the hubris-intoxicated “man of system” who aims to improve matters through government intervention."

The most generous interpretation of the comments from spokespeople from AMA and ACP when they lauded ACA as a fountainhead of social justice  is that they were enamored with the purported intentions of ACA and naively believed that intentions equaled results.   




The cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpufThe cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpufThe cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpufThe cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally. - See more at: http://healthblog.ncpa.org/tattering-the-safety-net/#sthash.O6he8bDl.dpuf

Monday, November 11, 2013

Recent Bits and pieces about Obamacare

 Here are few items of possible interest regarding ACA, some fairly trivial,others more significant.


1. Bob Doherty of the ACP blog ACP Advocate takes the difficult-to-defend position that Obamacare is not paternalistic or maybe not at least part of it..See here. Let''s see- we have a law that forces folks to buy a product they may not want and fine them if they don't because it is really for their own good.What definition of paternalism does Mr. Doherty have in mind?  He may have been better off to use the Seinfeld defense and say "not  that there is anything wrong with it".

2.Does Obamacare violate the iron principle of  politics?  See here. That rule is: focus the benefits and diffuse the cost.  In Obamacare we are now seeing focused costs, e.g on . those folks with insurance policies that are now being cancelled and have to pay more for policies that offer coverage they neither want nor need.'The poster child for this type thing is the widely circulated comment to the effect that I was in favor of Obamacare until I got the bill. The authors of the above referenced link wonder if the hubris level of the current administration is so high that they (he?) believed that they could violate that law with impunity.

3.John Goodman asks if the Obamacare bureaucracy become a virtual "deep state" See here. The term refers to the situation that once existed in Turkey in which army had become so powerful if was uncontrollable and unstoppable.Quoting Goodman:

The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf
"The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”

Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance."


4.Does anyone know how many folks will ultimately loss their current health care coverage? If item 3 is true there may be no way to predict unless and until the controlling rules are made by some apparatchik within HHS.No one knows but  here is one recent speculative analysis that projects losses much greater than those affecting holders of individual policies as it may impact holders of some employer plans.Projections are fragile because the Secretary of HHS ( or someone there ) may issue an exception to some and not others at any time.









-
The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf
The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf
The healthcare bureaucracy’s status as a “deep state” is an important factor explaining why ObamaCare is unfathomable. Politicians have little control over this deep state, so they simply grant it more and more power. Philip Klein of the American Spectator went through the law and counted over 700 stipulations which contained the term “the Secretary shall“, over 200 cases of “the Secretary may“, and 139 cases of “the Secretary determines.”
Of course, it is now clear that Secretary Sebelius did not make any serious determinations. Rather, they have been made by many unidentified career agents of healthcare’s deep state, who spend their days responding to lobbyists’ “concerns” about this rule or that regulation, while drafting thousands of pages of impenetrable regulatory guidance.
- See more at: http://healthblog.ncpa.org/the-deep-state-in-american-health-care/#sthash.tSeR6xUi.dpuf

Wednesday, November 06, 2013

Modern legislation as "emergent phenomena" AFTER the bill is passed

One of George Will's more valuable insights is that Congress does not pass legislation anymore but rather passes "intentions". I would add to that the modifier ""purported" to make the designation "purported intentions". Some and often much of actual meat of the bill or the devilish details are filled in later by various bureaucrats and government appointees in various agencies committees and Cabinet posts. The Affordable Care Act and the Dodd-Frank bills are recent egregious examples of that phenomenon.


Many of the actual operational details of both bills are still being written by various governmental entities several years after the President signed them into law.These details are emergent phenomena of the actions and interactions of various agencies as they write the regulations that define bills with varying degrees of influence from various interested parties politely referred to now as stakeholders.

Of course, even as Congress passes intentions some very specific items do end up in legislative acts that favor one or another special interest For example, the big hospital lobby was rewarded for their support of ACA by an exemption for a number of years (I think until 2020) from the edicts of IPAB and also the outlawing of new physician owned hospitals eliminating one source of competition .There may well be other nuggets of pork in the hundreds of pages of ACA that benefit Big Hospitals. The more complex,arcane and opaque the legislation the better is it ,both from the point of view of the law and rule makers and the sp;ecial interests and their lobbyist wise guys.

Nancy Pelosi was only partially right in her famous statement that we have to pass the bill (ACA) to see what is in it.Actually we only got to see some things in broad general terms and some specifics that typically favor some interest group but have to wait varying periods of time for important elements of the bill that will be written by various governmental entities. Two years later for ACA the details are still gradually being determined and issued as bureaucratic edicts which for the most part are immune from appeal.


Since the much of real meat of the health care legislation is still being written meaning what ACA would do was unknown at the time of the commentary leading up to its passage. How could anyone rationally support the bill.How could medical organizations such as AMA and ACP lobby for the bill when the details that constitute the real effects of the bill were unknown and unknowable.They could likely only support the purported intention of the bill.

The legislative process is a push and pull of various interests and coalitions and horse trading and lobbying and the final bill emerges but the emerging is only begun as some of the particulars will only emerge from the push and pull of various administrative and regulatory entities as they plod along with their various administrative bureaucratic characteristics as they too are influenced by specific lobbying forces.The wheels and levers of crony capitalism do not stop when the president signs the bill.

Thomas Sowell in in his 1980 masterpiece Knowledge and Decisions warns against "characterizing process by their hoped-for results rather than their actual mechanics". Praise for ACA from AMA and ACP because it purportedly furthered social justice lacks basis as no one could know what the end result would be for social justice or anything else as many of the real defining characteristics of the bill were unknown at the time ( and in many regards remains so today).One can argue that giving insurance cards to 30 million people will result in a struggle to find a physician for everyone and in that struggle (as in most struggles) the poor will lose out as it will be the folks with more money and contacts,education and social skills who are in the front of the waiting lines . Giving 15 million people more Medicaid cards out may not be doing any favors to those folks as currently there are far too few physicians who will accept Medicaid patients. Further, as Dr. Scott Atlas has pointed out some studies show that Medicaid patients receive health care inferior to that received by patients who have no health insurance at all.

Dr Donald Berwick,the short lived director of CMS, said that good health care was by definition redistribution. ACA will result in redistribution.Will the poor and uninsured be the recipients of the redistribution or will the recipients more likely be big pharma,big hospitals, big health care insurance and big health care IT?



Monday, November 04, 2013

Are the cancelled health care policies really "substandard" or is that another misleading statement?

The spin being spun by the ACA apologists regarding the hundreds of thousands of medical insurance policies that have been cancelled is that those policies were "substandard" and those misguided policy holders will be much better off because they will be forced to buy the good kind of insurance they should have had anyway if they knew what was best for them and or if those " fly by night" insurance companies had not screwed them over. One commentator had the audacity to suggest that the administration should be bragging about it.

See here for a thoughtful refutation of that simplistic dismissal of what is a really big deal for thousands of Americans who liked their policy but cannot keep them as promised. One site described President Obama's often quote comment in that regard as simply  "misleading" and another as the president simply " misspoke" .The entire run up and sales job for the passage of ACA could generously be described as misleading while one health care blogger suggests that fraudulent  is a more apt descriptor.

Another critique of the "substandard policy" excuse is offered by the economist, Tyler Cowen here.

It is an empirical question as to whether their new, to be purchased plan is better or worse that the cancelled plan. Many opponents of ACA have the quaint view that the individual should make that decision while many proponents of ACA believe that such decisions are better made by experts.The issue is who should make that decision as to what type health insurance a person should purchase. Prior to ACA that decision process also included the prior question of should you buy any at all, most folks have been relieved of having to make that decision.

John Goodman has this excellent summary of what has happened so far  and how the public was mislead about what what going to happen .

Peter Boettke has this excellent commentary in which he has an opportunity to bring out the money quote by FA Hayek. which is :

"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design."
 
Certainly, that would apply to the web site and I afraid  to most of the rest of Obamacare.

Goodman and other economists pointed out from close to day one the problems with ACA  while  the general public was largely kept in the dark by the unrelenting repetition of the major talking points  (you can keep your health care plan, your doctor, etc) by the administration and the echo chamber of the main stream press and the complicit actions of big insurance and the progressive medical elite who manage  the major medical professional organizations. (AMA, ACP etc).