The best name yet for Obamacare-TNRKMA (turkey ma)

High fives to the endlessly insightful blog of John Goodman for what I believe is the best designation yet for PPACA which is also known as Obamacare.

I quote his introduction to the new name,TNRKMA.(The Thing that Nobody Really Knows Much About.)

'...what should we actually call this thing? That is, the Thing that Nobody Really Knows Much About (TNRKMA). At this blog, we have followed the convention of calling it “ObamaCare,” but that could be considered derisive. There is always “health reform,” but this bill will almost certainly be reformed many, many times, even before all of the original provisions are enacted.

On balance, I’m inclined to go with the acronym, TNRKMA — which is pronounced “Turkey Ma” (mother of all turkeys), with the N silent, or simply “Turkey,” for short.'

I tend to prefer the simpler designation, "turkey".Read his entire blog here.

Business Roundtable suffers buyer's remorse with Obama care, will AMA, ACP, etc. be next ?

This article, from the WSJ, tells a precautionary tale that has been told many times in the past.It is a narrative with apparent deal-making,double cross ,doing what seemed expedient and the regrets of buying a pig in a poke.

The prominent business organization, the Business Roundtable, provided valuable support to the Obama administration in regard to the health care bill. Their support, according to this article, was based on the fear that the Obama administration would push forward with a tax on US corporations who have overseas operations. Now Mr. Orszag tells the group that the administration will go ahead with the tax anyway but by the way thanks for your help with the health care bill.

The folks at BR are now realizing what they "gained" from their earlier support .

"Roundtable President John Castellani, ... We stuck with that majority "through trying circumstances," even "alienating many of our traditional colleagues," and what did we get? They keep "vilifying" the private sector! And taxing it, and empowering unions, and ignoring trade. "The time has come for a new course," declared Mr. Castellani, a mere 18 months after Democrats announced plans to tax companies, empower unions and ignore trade."

Several professional medical organizations, including the AMA and the ACP, also supported the health care bill. Both have been rightly critical of the tardiness exhibited by Congress to fix the SGR but ,so far, I have heard no denunciation of the many provisions of Obama care that delegated unprecedented power to the HHS and other government entities and will exert increasing hegemony over the practice of medicine. Rather we have heard self congratulatory comments about furthering social justice which along with having a "seat at the table" may have been all organized medicine received for their support.

h/t to Wolf Files:12% Pure Hope for the link to the WSJ article.See here for his comments which close with this:

"It was the perfect execution of manipulative divide and conquer by a power-hungry government that sees the private sector as its adversary. And the proverbial man who sat idly by as the king ran over all others because it didn't affect him directly is now left without friends to defend him as the king comes knocking on his door."

Laymen find notion that more care and more expensive care can be worse as counter intuitive

A recent publication in the publication "Health Affairs" has evoked comments and some concern from advocates of comparative effectiveness research and admirers of the Dartmouth Atlas. See here for full text (pdf). A survey of "consumers" found a level of skepticism that is alarming to those folks who are in the business of claiming to know what aspects of medical care should be offered.

The idea that more care and more costly care gives inferior results to less care and less expensive care seem to be inconsistent with one's experience in a variety of areas. Many would relate to the experience of having a fly by night craftsman using cheaper materials doing a shoddy job at painting the house or doing household repairs. Few people believe that a cheaper car is better than an expensive luxury car. Think of a Mercedes versus those jokes made in Russia sold as cars. Most dental patients accept the notion that a root canal treatment followed by a crown is better than a dental extraction though the latter is much cheaper.

In the sixties what passed for treatment of acute myocardial infarction was cheaper than the much more effective and life saving treatment available now. In that instance more is better.

Until hip replacements became available patients with severe degenerative arthritis of the hip could look forward to years of limited mobility and pain. Now their lives are clearly improved but at a monetary cost considerably greater than the pain pills. In that instance more is better.

HIV-AIDS has been transformed from a rapidly debilitating and fatal illness to a chronic controlled illness with often very good quality of live.In that instance more is better.

I could easily generate a number of instances in which certain tests or procedures or medication use was/is not reasonably indicated and in the cases more is not better and I would agree that sometimes it is worse.

Surely, sometimes more is better and sometimes it is not. It is a more a matter of case law than the application of a universal general principle that cheaper is better. It is an empirical question regarding the particular intervention and the particular outcomes of interest. Sometime it may be but often the opposite seems to be the case. Many people seem to believe the lay adage that you get what you pay for even if that is not always right.

It is interesting that much of verbiage saying that more is not better comes from the progressive side of the spectrum of ideas and they will have their work cut out for them to disabuse the less informed of the naive notion that less is often not better.

An interesting parallel to this current day notion of there being too much spent on medical care ( not care for too many but too much care for some) is the economic nonsense that was spun out by the early Roosevelt administration. Their early theory as to why there was a recession/depression was that there was an overproduction of goods. Therefore,farmers had to cut back on production as did manufacturers. Interesting argument that the government tried to sell-people going hungry and the claim that farmers had to grow less.

Dr RW gives his take on this topic here and DB gives his here

I quote Dr.RW:

The Dartmouth Atlas was spun far beyond what the evidence supported, for political ends. That’s where the problem lies, not with the project itself. The data need to be viewed within the limitations of the methods. The findings are relevant. The sheer enormity of the variation in cost says deviation from best practice is widespread. Many questions remain unanswered. One is why? What external factors drive the variation? Another is in what direction? The popular assumption is that the error is in the direction of over utilization but it could just as easily be the other way around. After all, that’s what the best quality data we have and a sampling of public opinion say.

DB's headline got it right: "Sometimes money buy better care"

To avoid confusion let me say that I am not against comparative effectiveness research.There are many instances of it being done now and previously without a governmental agency being put in charge of it.I am quite concerned with the power that a governmental CER agency will have and afraid that the well known phenomenon of regulatory capture will happen there.On the basis of the article it looks like a number of "medical consumers" also have some concerns.

Is refusal to accept government price controls "price fixing"

According to this article in the Christian Science Monitor, the Justice Department says it is -at least in regard to as physicians.

This governmental action seems to go past earlier efforts by the Federal Trade Commission who previously considered effort by groups of physicians to band together to try and increase their bargaining position with third parties as violating antitrust laws. See here for my 2007 commentary on one such case. Now physicians seem to have another governmental entity with even bigger teeth ( potential criminal penalties), the Justice Department, to content with as they deal with third party payers in and out of government.


Here is a quote from the CSM article describing the nature of the teeth"

"This is another reason why the DOJ’s presence in a physician case is more disturbing than the normal FTC case. The DOJ has a number of “tools” the FTC does not, including the self-granted power to award amnesties from criminal prosecutions to the first “conspirator” to step forward and provide evidence against one’s competitors.

A doctor that feared prosecution could seek amnesty — and provide the Justice Department a blank check to rummage through his files and private communications. And if that doesn’t work, the DOJ can always seek wiretaps of physicians’ phones and computers, a power awarded the DOJ during a 2006 renewal of the PATRIOT Act. The potential exposure of your physician’s confidential records — including your medical records — is limitless ."

As long as insurers set the prices for medical services and the FTC and now the Justice Department prohibits physician groups from fairly negotiating for fees, efforts by physicians to support and take part in P4P programs in the hope that the downward spiral of fees for primary care will be halted will be less effective than rearranging deck chairs on a sinking ship.More and more "going Gault" seems to be the way to go.My take on medical going Gault is to have a retainer practice and do not deal with insurers in and out of government.Unfortunately this seems feasible only for primary care docs.I don't see that arrangement viable for surgeons and procedurists.


H/T to Medical Pastiche.See here. See also here for a discussion of this recent development in limiting the ability of physicians to negotiate with third party payers from the blog " Road to Hellth"

Composite endpoints in clinical trials can be very misleading

The blog commentary by Dr. David Rind discusses the issue of composite end points in clinical trials and in particular the CREST trial which compared carotid endarterectomy with carotid stenting. See here.

The end points in Crest were periprocedural stroke,myocardial infarction,death or ipsilateral stroke occurring within four years after the procedure. Since both procedures are really done to decrease the risk of stroke in a patient with carotid stenosis, why not just compare the rate of stroke occurring in the two treatment groups over a several year period following the procedure? That would appear to be the key outcome of interest. Well, the more invasive endarterectomy procedure might be more likely to cause operative or post op problems than the catheter based treatment so some measure of that needs to be included in the accounting.

Basically end composite outcomes are done because the difference between two competing therapies is thought to be so small that a very large number of patients would be needed to provide a clinical trial that has sufficient ability or power to detect a difference between the two treatments. This has been particularly evident in regard to the treatment of acute myocardial infarction as treatments have continued to decrease the mortality of acute MI and incremental changes in benefit become smaller as therapies improve.

So what could be wrong with the composite approach?

CREST illustrates what could be wrong. Here the stinting group had fewer myocardial infarction with more strokes. So the trade offs appears to be more strokes with stints and more MIs with surgery. This could be interpreted to mean that the two techniques are quite equivalent but they differ in the adverse effects but are the two adverse effect equivalent? Most folks would say no since surviving a stroke can be much more devastating and life altering that a survived heart attack.

Rind put it this way:

Composites can quickly get you into trouble, though, if you combine events of very different importance to patients. Sometimes this appears to have been done with the intention of obscuring the real outcome of a trial or to make a therapy look far better than it really is.

A recent commentary in JAMA also discussed the composite outcome issue and warned readers to beware of a" bait-and-switch" type phenomenon. See here. The following is the authors' final paragraph.

Readers of randomized trial reports must understand both the reasons for and pitfalls of choosing to combine clinical outcomes. Examination of the relative importance, frequency, and consistency of effect size across the components of a composite outcome are important steps in the interpretation of information derived from trials. But it is equally important to be aware of a potential bait and switch strategy. In some cases, readers and authors of reports of randomized trials may wish to weight each of the outcomes by an importance factor, similar to the way quality of life is measured.¹⁰ In other cases, they may wish to point out that even though a randomized trial was designed to detect a difference in the composite outcome (because the vast majority of the effect is on one component, typically the least severe), the trial has mainly showed the effect on surrogate outcomes and not definitive ones.

P4P(Pay for performance) harmful effects may impact surgeons as well-I am shocked,shocked

This paper (see here) regarding P4P and its impact on surgery or the lack of it for the obese patient has received at least two appropriate commentaries in the medical blog world. DrRick (see here) and Robert Centor (see here)have highlighted the article pointing out yet another example of the unintended consequences of P4P.

The main point is that if surgeons or the institutions in which they practice are penalized for certain surgical complications or length of stay in the hospitals it is likely that when possible surgeons just might tend to avoid elective surgery in patients who are in a group likely to have a higher than average complications rate.Such a group is the obese.

Goodhart's Law which indicates that when a measure become a target it looses the characteristics that made it a valid measure is a valuable insight capable of explaining a lot of behavior. One of my favorite examples is the ill fated " four hour pneumonia rule.See here and here. Teaching to the test and treating the chart are phenomena in same general category.These things are so common and predictable that maybe we should not call the consequences unintentional. The planners ( at least some of them ) must have it figured out by now but just do not care.

Physicians have been criticizing the P4P nonsense for years now but the caravan moves on.Here are some comments I made in 2008 with reference to an excellent essay on the subject by the prolific Dr. Roy Poses.

Medicare and Price controls -one more time

I harp on the theme of the effect of the price controls on physician's fees in regard to Medicare several times. It is good to see someone else playing that song. See here.

Price controls equals less and poorer quality medical care and PPACA , in part, through the agencies and panels it establishes will only make worse.

For another glimpse back into Economics 101, read this commentary by yet another articulate, thoughtful, EP cardiologist-blogger who talks about the decreasing supply of primary care docs and the soon to be ( well, by 2014) increase in demand for medical services plus the additional factor of more docs likely to be on salary and the likely incentives that will bring.Further, the increasing shortage of medical providers is not just in primary care.See here.

More on freedom to purchase one's own health care

See here for a interesting review of aspects of the history of health care insurance in the U.S. from Peter Zavislak at the blog Medical Pastiche. Note carefully what almost happened with Hillary Care .More detail on one important development in the history of US health insurance,namely the RBRVS, can be found on Doug Perednia's blog, The Road To Hellth, See here.

This is what Thomas Sowell had to say about what was being planned for America's health care by Hillary and friends in the update to his 1980 masterpiece, Knowledge and Decisions.

....[the]1993 attempt to have the government take over the entire medical sector of the country-an attempt spearheaded by people with neither medical training, hospital management experience,nor expertise in pharmaceutical research or even in the running of a drugstore.

Note what was contained in the Hillary care plan. Here are Zavislak's words on that:

Clinton Era – Attempted passage of Universal Health Insurance Plan Fails. IF it had passed, it would have been illegal to use one’s own private funds to pay for services NOT covered by this plan!!

This was a close call apparently largely averted by in fighting among Democratic party factions but this time we have a home run for those who believe that medical care is too important to be left to the individual physician and the individual patient that was made to happen by some folks with the same qualifications as described above by Sowell as well as some folks who actually went to medical school.

No, PPACA does not contain words that explicitly prohibit private transactions between physicians and patients ( as Hillary wanted) but see here for Dr. Richard Fogoros's presentation of his concerns about that possibility arising out of the recently passed health care reconstruction.

Will Obama care lead companies to drop their health care plan?

An analysis published in Fortune ( see here ) makes a strong case for many employers to do just that."If you like your health care plan you can keep it"). Note to the leaders at AMA and ACP -can you say unintended consequences? On one of the other hands,could it be that the plan was to do that all along?

It seems to be a matter of doing the math. For example, the article says ATT now spends about 2.4 billion per year in health care costs and if they drop coverage and pay the penalties they will pay out 600 million.So if companies go that route, who pays for at least some of the cost of the shift to the exchanges.The government does in the form of subsidies which will invalidate the accuracy of the alleged savings from PPACA which has already been shown to be a bogus projection.

Did the brilliant planners in the administration and congress not see this coming or maybe that was the plan all along.Was the plan really to get employers out of the health care insurance business and move everyone over to the exchanges wherein insurance companies can be made to fail by the government setting the rates too low and and coverages too broad and then coming to the rescue with a single payer which is what Obama said he wanted all

Dr. Paul Hsieh makes the case here for a scenario in which the health care insurers tank and the government rides in and saves the day.

When you see how IPAB will cut costs, you will want to thank AMA and ACP for their roles in support of PPACA

Yes, the tittle is sarcastic. Go here to read a clear explanation of how exactly the Independent Payment Advisory Board (IPAB) will limit Medicare costs. In a nutshell, Medicare will reimburse physicians and other providers less. The bill is structured so that is about all it can do.

With more stringent price controls that IPAB will generate we will see an even more critical shortage of primary care physicians and a further decrease in quality of primary care. Did anyone at AMA or ACP read that part of the bill?

Another well recognized effect of wage-price controls is the development of a black market which we have not seen so far in health care but see here for how that might play out.

It gets even worse because the IPAB will also through administrative actions of the HHS secretary act to control the rise of private medical costs not just those controlled by CMS.See here.

H/T to John Goodman's blog ( see here ) which is a seemingly inexhaustible source of important information regarding health care economics and the effects we can expect from Obamacare.

Important series of blog posts on Individual prerogative to purchase health care

Earlier I had cited the first in a series of posts by DrRich of the Covert Rationing Blog concerning the issue of
of the future of the right of an individual to purchase his own health care. See here for the fourth and final post from which one can link to the first three.

In light of the numerous reassurances that PPACA is not a government take over and that one's access to medical care will not be limited it is enlightening to think back to 1965 and the Medicare law which clearly stated :

....that nothing in the new law “shall be construed to preclude [an individual] from purchasing or otherwise securing protection against the cost of any health services.”

DrRich then describes in detail the limitations contained with the Medicare system that already restrict private arrangements between Medicare patients and physicians who participate in Medicare.Understand this mean limitations on the individual to purchase certain medical test or treatments or procedures. I quote


... amendment to the Balanced Budget Act of 1997 - Section 4507 - which prohibited any self-pay contracts whatsoever between Medicare patients and their doctors for medical services which are covered under Medicare. Under Section 4507, which is still the law today, if a doctor provides even one self-pay medical service to a single Medicare patient, that doctor is punished by complete banishment from the Medicare program for at least two years.

The entire four part series is important and I urge followers of this blog to read it and take part in the discussion.

One group who loses from PPACA-those folks on Medicare Advantage

Patients enrolled in the Medicare Advantage ( MA) program will loose under PPACA.

The Chief actuary of CMS in his Jan 10, 2010 letter ( see here) estimated that enrollment in the MA program would decrease from the current 13.7 million to 9.2 million by 2015, a decrease of 4.5 million due to changes in the MA program as outlined in section 3201 of PPACA. Other estimates are significantly higher -up to 7 million.

The displaced MA patients can go to regular Medicare but they will need to buy Medicare supplement policy to approximate the coverage they received in their MA plan. I don't see the AARP, who supported the health care bill, complaining about that as they will be available to act as broker for those deals and they supported passage of PPACA. Many of the current MA patients signed with MA because they decided they could not afford the medicare supplement policies.These folks will have more out of pocket payments now if they still cannot afford the extra insurance.

So, for some of the MA patients there will be either the increased cost of a Medicare supplement or paying the 20% typically not paid for by Medicare out of pocket or simply forgoing some medical care.

If one accept accept a utilitarian perspective, then throwing some under the bus to get more to ride inside is might be considered acceptable figuring that more folks are helped than those who are injured. Leaders and spokespersons for AMA and ACP have expressed pride in their roles in supporting a bill that they characterize as furthering "social justice". Millions of seniors will be forced out of Medicare Advantage with the associated financial loss and many more Medicare seniors will have decreased access to primary care physicians as the insurance exchange,newly insured compete for a shrinking population of primary care physicians for which PPACA offers no substantive solution. A insurance card is not equivalent to medical care. If the thought leaders in AMA and ACP think past stage one and consider the longer term effects of the health care bill, will their claim of furthering social justice be validated? I would enjoy hearing what they would say.

The canary in the Mass.coal mine health care is looking bad

See here for comments from Dr. Wes regarding the events as they unfold in the preview to PPACA that health care in Massachusetts is turning out to be. At least, it is possible for physicians to vote with their feet something that will be harder when the entire country becomes Massachusettsasized.

Here is the wording of the proposed law:

Every health care provider licensed in the commonwealth which provides covered services to a person covered under “Affordable Health Plans” must provide such service to any such person, as a condition of their licensure, and must accept payment at the lowest of the statutory reimbursement rate, an amount equal to the actuarial equivalent of the statutory reimbursement rate, or the applicable contract rate with the carrier for the carriers product offering with the lowest level benefit plan available to the general public within the Connector, other than the young adult plan, and may not balance bill such person for any amount in excess of the amount paid by the carrier pursuant to this section, other than applicable co-payments, co-insurance and deductibles.

Does this really mean that a physician accepting a patient in their "Affordable Health Plan" must accept the payment offered as a condition of holding a medical license in Massachusetts? Does that preclude a retainer practice in that state? Maybe the bill will not pass, but the cost overrun problem there begs for legislative action.

A Rand Corporation analysis projected that the cost of medical care was increasing at 8 % faster than the state GDP. Mass. has the highest medical insurance premiums in the country and wait times to see physicians are rising in the state that is said to have more docs per capita than any other state, a situation that might be changed if that bill is signed into law.

Another Medical blogger worried about erosion of physician's duty to the individual patient

I should have noticed Dr. Doug Perednia's blog, Road to Hellth, sooner. See here. I was aware of the "competition "between Dr Richard Fogoros's blog, Covert Rationing Blog and the ACP advocate blog authored by a senior vice president of the ACP for a blog of the year award.

The following is a quote from Dr. Perednia advocating votes for DrRich. Unfortunately, the ACP blog won out.

Dr. Rich's blog has been nominated for an award for the Best Health Policy/Ethics Blog on the Internet. His chief competitor is the blog of the massive and politically powerful ACP - the American College of Physicians. The most important difference between these two competitors is their attitude toward the physician-patient relationship. The ACP has decided to endorse a "new set of ethics" in which "social justice" considerations (whatever the hell they are), should be taken into account along with the personal welfare of the patient when making medical decisions and dispensing medical advice. Specifically, physicians should engage in "parsimonious care", that is designed to minimize the use of medical resources and "ensure that resources are equitably available".

To put it bluntly, the ACP is saying that when you're lying there with a potentially fatal or crippling condition, your doctor has an obligation to think not only about what's best for you, but also about what's best for "society" in terms of what tests to perform, what medications to prescribe and what procedures to undertake. They don't actually say who actually gets to dictate the needs of "society", but it's a reasonable guess that your insurance company, government regulators, Medicare, the AMA or ACP, or some other "official" entity will be making the call. "Normally Mr. Jones, I'd recommend that you get a CT or MRI test to make sure that you aren't having a stroke or a tumor that we would treat immediately, but a 'panel of experts' has decided that it's best for society that we order these tests parsimoniously. So I'm going to have to think about this one for a while. I'm sure you understand. Tell me if you develop any further weakness and we'll reconsider at some point in the future."

I would strongly encourage you to read Dr. Rich's discussions of these differences in perspective and their implications here, here, here and here. I would point you to the ACP's responses to Dr. Rich's arguments, but they've declined to publish any on their own websites.

The issue of the primacy of the physician-patient relationship, the fiduciary duty of the former to the latter and its erosion by the "new" medical ethics has been something talked about much on this blog (see here for a recent comment). I am heartened to see another voice in fray.

CMS actuary's report validates criticism of PPACA-increase costs plus risk of decreased care for seniors

Richard S. Foster, chief actuary for Medicare, issued a report that says in part that PPACA will result in :

Cuts to hospitals that will jeopardize access for seniors.

Costs that will increase from 2010 -2019 but after that may be savings later.

See here for the entire NPR coverage of the report which in part says:

in addition to flagging the cuts to hospitals, nursing homes and other providers as potentially unsustainable, it projected that reductions in payments to private Medicare Advantage plans would trigger an exodus from the popular program. Enrollment would plummet by about 50 percent, as the plans reduce extra benefits that they currently offer. Seniors leaving the private plans would still have health insurance under traditional Medicare, but many might face higher out-of-pocket costs.

In another flashing yellow light, the report warned that a new voluntary long-term care insurance program created under the law faces "a very serious risk" of insolvency."

... The report projected that Medicare cuts could drive about 15 percent of hospitals and other institutional providers into the red, "possibly jeopardizing access" to care for seniors.

Not mentioned in this report is another factor that will impact senior's health care-decrease access to primary care physicians (PCPs) as the many newly-insured patients complete for an already short supply of PCPs.

The Chief Actuary for CMS stated that under PPACA the uninsured would decrease from the current 57 million to 23 million by 2019. Of the 34 million newly insured, 18 million will be covered by Medicaid ( eligibility will now be for incomes equal to less than 133 % of the Federal Poverty Level) and 21 million through exchanges, most of whom will receive subsidies, while about 4 million would loose their employer sponsored health plans. Note- that does not quite add up, but the numbers are from the CMS actuary's letter and , I suppose, are close enough for government work.

The 21 million exchange insured patients will be competing with the Medicare patients for what already is a shortage of primary care physicians (PCP). Further, reimbursements are generally about 30% lower for Medicare than private insurance. Follow the money and you will see more and more PCPs opting not to see Medicare patients. Diminished access to care for Medicare patients is a very likely outcome of PPACA and in my opinion will more than offsets the $ 250 made to those Medicare folks who hit the doughnut hole in 2010,future mitigation of the doughnut hole effect and the no co-pay and deductible for Medicare preventive services. Those factors were highlighted in a recent attempt by the ACP to claim that PPACA actually helps seniors. See here for the full comments of Robert Doherty,APC's VP for Governmental Affairs and Public Policy.

Many enrolled in the Medicare Advantage program will loose under PPACA.

The Chief actuary of CMS in his Jan 10, 2010 letter ( see here) estimated that enrollment in the MA program would decrease from the current 13.7 million to 9.2 million by 2015, a decrease of 4.5 million due to changes in the MA program as outlined in section 3201 of PPACA. (Other estimates including the recent report cited by NPR are significanlty higher.)

Medicare Advantage patients losing their plans may revert to regular Medicare, Part B but they will need to buy Medicare supplement policy to approximate the coverage they received in their MA plan. I don't see the AARP-who supported PAACA- complaining about that as they will be available to act as broker for those deals. Many of the current MA advantage patients signed with MA because they felt they could not afford the medicare supplement policies.These folks will have more out of pocket payments now if they still cannot afford the extra insurance.

Social justice to some is achieving the greatest good for the greatest number. ( I realize there are other ways to frame the social justice concept). If you accept a utilitarian approach, then throwing some under the bus to get more to ride inside is probably acceptable. Both AMA and ACP have taken pride in their roles in supporting a bill that they describe as furthering social justice yet millions of seniors will be forced out of Medicare Advantage with the associated financial loss and many more Medicare seniors will have decreased access to primary care physicians raising the question- how just is that.

Social Justice and the Framing of the Healthcare Debate about fairness and individual freedom

Two years ago, I published a blog commentary about what I now call the"social justice revolution" in medicine. I wrote about about what-not too long ago-was a simple two person transaction between physician and patient and some aspects of the path taken to the current situation where a number of major physician organizations ( e.g. AMA,ACP) and medical education bodies ( e.g. ACGME) swear allegiance to the concept of social justice. inculcate trainees with its mantra and charge the physician with a greater task, that of working towards social justice . With the passage of the health care deconstruction-reconstruction bill we see those organizations taking public pride in the role in moving towards the goal of social justice in the area of health care.


Here is what I said then, slightly edited and brought up to date:

In the not too distant past, but well before the current generation of medical students and house officers went to college, a person in the United states might go to a physician with some medical problem and be charged for the medical services and then pay for the service either out of pocket or pay and then file with an insurer to get or all some of that reimbursed. It was a private transaction between two persons in a country in which private transaction between individuals was so normal as to not attract any attention. The ethics or justice of such a transaction was simply not a topic for discourse.

In this not too distant past, the ethics of the medical profession was generally well defined and could be expressed in a few simple sentences and seemed to be firmly imprinted in the physician's mind as part of the transition process from a lay person to a physician.


It was about respect for autonomy, beneficence, and non-maleficence. It was all about the physician and the patient-do no harm, act in the patient's best interest and respect the patient's views and wishes . It was a two party deal, with the physician fulfilling a fiduciary duty to the patient.

The AMA 's 2001 published version of the ethical principles is a bit more detailed but contained little to be contentious about and does not contain the word "justice". More on that latter.

Later, a fourth major principle was grafted on the the ethical framework. Justice was the new kid on the block. In the beginning, there was more than a little ambiguity in this term as there are more than one definition of justice. It became quite clear what was mean by justice with the publication of the Medical Professionalism in the New Millennium.A Physician Charter.( Annals of Internal Medicine 5 Feb. 2002, vol 136 pg 243-246.)

The justice to which physicians were admonished to strive was social justice. Thomas Sowell makes the distinction between the traditional American society's version of justice and social justice in this way. On the one hand, we have justice as basically applying the same rules and standards to everyone -equality of opportunity or equality under the law. On the other hand, we have the redressing of those inequalities that proponents characterize as the fault of society-equality of outcome. In the latter, whatever characteristics at issue are thought to be unequally "distributed" between various groups (income,medical care,access to swimming pools) should be "redistributed". Whatever may have been distributed by acts of God, accidents of history, an uncaring society , or whatever, to achieve social justice someone or something needs to correct the maldistribution. When redistribution is needed, someone or something has to make it happen and force or the threat of it is required.I am aware of no third way.

Making everything right would appear to be quite a task to assign to busy, practicing physicians so there was little surprise by the results of a survey,that I talk about here, that indicated that concern for social justice did not take up a large amount of a physician's times or enter heavily into his daily clinical decisions and activities.

Not only it is quite a task, proponents of new professionalism tell us in August 2007 JAMA article that after "further reading" of the tenets of the new professionalism they realized that physicians alone could not do it by themselves. So who should do it? We are told it should be a medical societal alliance. My translation is that again we told medicine is far too important to be left to the individual patient and the individual physician and we need more powerful players, probably the government,possibly big insurance and well connected medical academic intellectuals such as those who write such articles to mobilize things and makes the inequities right.

Thomas Sowell writes about a "moralistic approach to public policy" in the concluding section of his book, "Knowledge and Decisions". I characterize the authors of the New Medical Professionalism with their insistence of physician's allegiance to social justice - in a society where there is no dominant secular view of justice at all-as medical moralists.

In Sowell's section entitled "Embattled Freedom" we read ...The desire for freedom and its opposite,power, are as universal as any human attributes....The moralistic approach to public policy is not merely a political advantage for those seeking concentration of power. Moralism in itself implies a concentration of power...The reach of national political power into every nook and cranny has proceed in step with campaigns for greater "social justice".

The recent, at-times heated,discussions (see here for some links) about the ethics of retainer practices illustrate how the concept of social justice as an alleged medical ethical imperative as promulgated by the medical moralists has framed the discussion and attempts to control the dialog.

With the passage of the health care bill and the massive uncertainty about the bill's meaning some fear for the future not only of retainer practices but more broadly of the individual's prerogative to seek out and pay for her own care.

In a world in which talk about equality of outcome and fairness seemed to have achieved a rhetorical prominence and a position allegedly above further discussion, can better or more medical care for those who can afford it be allowed? See here for the beginning of a commentary about that and here for a discussion about the likely origins of the bill.

If and when the option of individual prerogative is excluded it will not be the result of a vigorous national debate but its components will quietly be chipped away by sundry bureaucratic entities that have emerged almost unseen from the seemingly endless,mild numbing and intentionally indeterminate verbiage of the health care bill. To the extent that any debate at all occurs I doubt that those of us who hang on the notion of individual freedom and the right to pay for one's own medical care will find support from the major medical professional organizations who supported the bill

New Health care bill not long enough ? we need more pages ? And are insurers now utilities or not?

Remember, we were told that we must pass health care reform or America will" go bankrupt" and the bill will bend the health care cost curve downwards.The seemingly inexorable increase in health care premiums which proponents used to help pass the bill may not be stopped by the current bill.We were told that the premiums we pay for insurance would go down.But now we are told that the bill really cannot make that happen nor can it keep premiums from going higher.

At least that is the case put forth by a noted Democratic Senator who tells us that we need more legislation to close that "loophole" and control health insurance premium increases. See here.Apparently 2,000 pages was not enough to get it right. After reading the relatively few relevant Google references to this loophole I could not learn what exactly this loophole is.

This is puzzling because I thought Obamacare turned health care insurance companies into utilities (see here) and that they would have their rates set by a federal office of health rate authority acting in conjunction of the state rate setting agencies.

It gets more complicated.See here for an interesting opinion by Richard Epstein, a law professor at University of Chicago.Epstein says that the legislation turns health insurance companies into public utilities. However, while state rate regulators have been instructed through case law by the Supreme Count that the regulation has be done in such a way as to allow market rates of return to the utility and those safeguards appear lacking in the new law.The court has required is that a firm in a regulated market be allowed to recover a risk-adjusted competitive rate of return on its capital investment. This came down in a unanimous 1988 decision ( Duquesne Light Co. v. Barasch). Epstein says that the law bumps up against this decision.

To summarize:

Is there a loophole in the new health care bill that does not allow the government control over health insurance premiums that the public was promised?

Does the bill in effect turn health care insurers into public utilities? Is that section of the bill unconstitutional?

Do the insurers really want to be utilities? (see here for the argument that they do, and here for the argument that insurers helped to get the bill passed)

Does anyone know what was made into law, including those who voted for the bill and those physician organizations that supported it?

Only the last question has an obvious answer.

On a related note, we are told that insurance companies are already gaming the system set up by the mammoth health care reconstruction bill.See here. Who would have thought?

Thinking beyond stage one in the health care bill.

I wonder if the leadership of the AMA and the ACP have thought much past stage one in the recently passed health care bill. Stage one is in several parts; for starters let us look at individual mandates and subsidies for those who cannot afford it.

While representatives of both organizations publicly take pride in their tireless efforts promoting legislation that provides insurance for many million people (actually that will not happen for 4 years) what about the unintended consequences? Think for a moment about the "mandate" .

John Goodman offers this commentary about the mandate:

The Ever-More-Costly Mandate. President Obama did not create the underlying problem. Health costs per capita have been rising at twice the rate of per capita income for the past 40 years. Nor is this a uniquely American problem. On the average, the same trend is in place for the entire developed world. But here is the bottom line: If you have to buy something whose cost is rising at twice the rate of growth of your income, that mandated purchase will consume more and more of your disposable income with each passing year.

To make matters worse, the normal consumer reactions to rising premiums are going to be disallowed. For example, most people would react by choosing a more limited package of benefits, or going to catastrophic coverage only or relying more on Health Savings Accounts. But these and other responses are limited or barred altogether under the new law.

Everyone (almost everyone, a few such as those with religious objections) will be forced to buy health insurance , a product whose cost so far increases at a rate greater than the rise in incomes.So you will pay a higher percentage of your income every year. So less disposable income for millions including folks who were promised taxes would not be raised.OK Its not really a tax but you still have less money to spend on things of your choosing.

See here for the entire blog entry.

Read further about the subsidies set up by the bill. According to Dr. Goodman's analysis, lower pay employees will want an employer who does not offer insurance while a higher salaried worker would want an employer to offer insurance.Subsidies for the lower group over time must lead to higher taxes. Thinking past stage two will be necessary to sort out what effect(s) that will have on labor markets and productivity and l leave speculation about that to those more adept at economic reasoning than I am.

CFC asthma inhalers not long for the world

Environmentalists can breath more easily with the CFC inhalers banished while some asthmatic and patients with COPD may have trouble adjusted to the new devices. See here for the latest in what inhalers are gone and which one are on the danger list.

Dr. Mintz has some helpful information about various of the products.See here.

I had written before about this issue.See here for some information of the problems that some patients have had changing over from the old HFA units to the newer ones and some links to comments questioning just how much of a problem the HFA units posed to the environment.

I believe this is the first time that the FDA has banned a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. ( Admittedly, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness from what must be a fairly small amount of CFCs would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task, maybe they will do better than.We can hope.

Well, all that concern about the wisdom of eliminating the HFA propelled inhalers will just float away into the environment since it now is a done deal.The dogs bark and the caravan moves on.

So how might section 10320 (of health care bill) be implemented

Section 10320 of the PPACA deals with the control of private health care costs and tasks some federal structure ( probably the Secretary of HHS) to takes action to decrease the growth of private health care cost.See here if you have not heard about 10320.

To control costs you might want data on costs, here is one mechanism by which the federal government could have access to that information. See here a discussion about a bill proposed in the Colorado legislature.It proposes mandatory data reporting and "harmonization" with federal data bases.

In the above link Linda Gorman says this:


"The Commonwealth Fund, AcademyHealth, and the Robert Wood Johnson Foundation are funneling money to efforts to convince state governments to pass laws requiring that all health care providers provide data to state run databases on every health care transaction. The goal is the creation of electronic records that can be used to track the type of medical care provided to each patient and the health behaviors of those judged to need oversight. These state efforts will be the building blocks for the ObamaCare electronic medical records system."

The bill talks about "all payer health claims", so I am assuming that this does not include the reporting by a private physician when she is paid by a patient outside of any insurance program. I hope that is correct. The bill is here for those who might want to figure out what exactly it is proposing.

Update on section 10320: As of 4/13/2010 a Google search for " section 10320" showed only my blog entries , those of DrRich of the Covert Rationing Blog,see here and this commentary.