The new PSA screening recommendation is not just a recommendation

What has mostly been neglected by the press in reporting the latest pronouncement of the USPSTF is that their conclusion that PSA measurements should not be done to screen men for prostate cancer is much more than a recommendation. Before the passage of ACA  it was merely a recommendation  but now the rules of the game have changed.

Dr. Rich at The Covert Rationing Blog  gives us his excellent analysis of the the panel's recommendations and the data they emphasized as well as the data they underplayed.Here is a quote from that commentary that explains why what the panel at the Task Force says really matters.

Obamacare, which is now the law of the land, makes the USPSTF the final arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). Only those that have achieved a grade of A or B by the USPSTF will be covered. And if you believe you will be able to purchase for yourself PSA screening (or any other medical service which Obamacare has decided not to cover) you have not been paying attention. Perhaps you can do so today (if you’re not on Medicare or Medicaid), but probably not for long.

  So CMS (Medicare and Medicaid ) will not pay for the tests.How long will it take private insurers to follow suit?The question remains can you pay for the test yourself.It is not clear that you cannot but I share Dr.Rick's concern  that prohibiting private choices paid for with private money for health care issue may become illegal.

Cato has recently published their report on economic freedom.  Freedom fans will not be pleased with the falling economic freedom indicators in the U.S. noted in their report. Health care freedom is incompatible with the vision that medical progressives have for the U.S.,namely that medical care is too important to be left in the control of individual physicians and individual patients. From the perspective of the progressives, Obamacare is a great step forward and has been heralded by certain medical organizations as promoting social justice while loss of  individual freedom to make one's health care choices seems to be part of the price of that "justice".

Two great blog commentaries on "Diagnostic skepticism" and why we are seeing less of that?

Dr. RW Donnell in this blog commentary  outlines some of the factors that are impeding  the diagnostic skepticism that traditionally internists had drummed into their heads during their training period.  Dr. Donnell carried forward and expanded comments made by Dr. Robert Centor in his recent blog offering.

Guidelines,the worse aspects of EMRs,time pressures and the metrics by which hospitalists are too often graded are some of the factors that make it more difficult than it used to be to  ask  "what else could the diagnosis be".

Have we seen the last of the CLASS act fraud?

The CLASS Act was a long term care plan appended to Obamacare to give the impression that the total cost would be less than one trillion dollars,which was a slight psychological barrier to its passage.It was a spending program that magically would reduce the defect.It was purported to contribute some 80 billion to the projected health care savings that the Obama health care plan would bring about.

See here for the economist Alex Tabarrok's commentary on this fraud that contributed to the passage of Obamacare. Now, the Secretary of HHS has admitted the plan can't work and will be dropped,but even later breaking news is that the White House hints maybe not yet.

Thomas Szasz's "define or be defined" and Physicians morphed in to health care providers

The husband and wife physician writing team of J. Groopman and P. Harztband make strong points in their commentary found in the Perspective section of the October 13,2011 issue of the NEJM. The title is The New Language of Medicine.

They relate certain changes in language related to health care to the movement to industrialize and standardize health care. These changes include the word "consumer" or "customer" for "patient" and lumping doctors,nurses,PAs,and NPs together under the designation of "health care provider".

The relationship and interaction between physician and patient fades out and is minimized by referring to the generic "health care", as if is in the words of the authors " fundamentally a prepacked commodity on a shelf that is "provided" to the "consumer".

What happens to considerations about the physician-patient relationship when you speak about providers and consumers.

Thomas Szasz wrote brilliantly about the power of language.

"The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?...[the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed."

In short, define or be defined. There was a time not long ago when physicians in many ways defined their role.Their role was to act as a fiduciary to their patients to follow Hippocrates's game plan namely,to do no harm and act in the interest of their patient.Now their role is being redefined as in part acting as stewards of resources.Yes, it has been members of the medical profession,largely a small group of internists, who have helped considerably in this effort to redefined medical ethics and have been able to implant those views in the medical school and post graduate curriculum. While I would not impugn the motives and sincerity of those physicians who have promoted that view and value system,I cannot resist applying the venerable Mafia Rule. Follow the money.Who gains from transforming physicians into health care providers and tasking them with saving money for the health care collective?

Their commentary closes with:

"We believe doctors and nurses,and others engaged in care should eschew the use of such terms (consumer,health care provider) that demean patients and professional alike and dangerous neglect the essence of medicine."

Amen.

Obamacare-A great opportunity for Medical Hubris

In 2005, I outlined a few thoughts about what I would include in a lecture to medical students about hubris and the practice of medicine. See here. At the time, I had no idea about the surge of exuberant hubris that the next few years would bring although I should have because of the strikingly hubristic five part series in JAMA which was a plea for utilitarian planning for allocation of health care resources.

Hubris is defined as excessive pride or self confidence.From Wikipedia we read that the word implies an overestimation of one's own competence and capabilities particularly as exhibited by someone in a position of power. In Greek tragedy it leads to nemesis, or the end result of harm or ruin. However,in the context of public health expert advice and edicts, it seems to be the beneficiaries of the edits that run into harm's way and not the expert.

Several thinkers have issued warnings to those who would take portions of the scientific wisdom of the day and go forward with hypertrophied self confidence and idealistic certitude to make the world (or their little sector of interest) better.

Boris Pasternak said; " What is laid down, ordered, factual is never enough to embrace the whole truth.Life always spills over the rip of every cup." The medical elite in the public health sector who would tell everyone how to eat, or treat all folks with a given medical condition think "Well, not my cup" and charge ahead as if the concept of unintended consequences had never been formulated and that individual variation , personal circumstances and values would not have to be contended with and progress in medical knowledge would be frozen in time so as to not make necessary changes in their determinations.

Morton Hadler ( J.O.M.,Vol 31, pg 823,1989) spoke of various categories of truth including the distinction between scientific truth and clinical truth,the latter informed in part by the former and is determined by the joint efforts of the physician and the patient.

Karl Popper said "We know a great deal but our ignorance is sobering and boundless.All things are insecure and in a state of flux."

Ian Stewart and Jack Cohen in their book "Figments of Reality" spoke of "what science offers is not facts but understanding, not answers but contingency plans"

Those type comments could be considered life advice to the newly minted practitioners of various discipline, and in particular, in this commentary to medical doctors.

The type of hubris often seen in novices is typically what I am calling the more benign form and is often cured by experience and seeing highly regarding paradigms and treatment plans replaced by others often 180 degrees from the discarded notion.This is what I call Type 1 hubris. It is an unwarranted and persistent belief in the correctness and permanence of contemporary consensus views.It is a failure to realize they are working with concepts that are often more contingency plans than permanent solutions.This type of hubris often dissipates as the practitioner gains more experience and sees the various ways disease patterns play out and how patient's disease scripts differ from the text book. Aristotle spoke of phronesis or practical wisdom which is the result of combining the lessons of experience with empirical knowledge (episteme) and technical knowledge (teche).

However, there is a second type of hubris, a more dangerous form, logically named Type 2. Type 2 includes the over blown pride and hypertrophied confidence in one's beliefs and idealistic certitude as is found Type 1 but in addition includes the internalized imperative to to bring about widespread practice (s) consistent with their version of current medical wisdom or truth. Starkly put" I'm know what should be done,everyone should do it " and when someone with Type 2 hubris is in a position of power ",let's make them do it".

The five part series of articles published in JAMA in 1994 by David Eddy is , in my opinion,a candidate for the most hubristic series ever published in a major medical journal.Reference is "Rationing Resources while Improving Quality", Eddy, DM, JAMA,1994:272,817-824)

Eddy's answer to the problem of how to save resources while improving quality was to employ the utilitarian maxim/imperative strategy to do the greatest good for the greatest number or make the herd healthier along some metric even though some cows might be worse off.The herd here was a medical collective such as a HMO.This also applies to the ACOs put into play by Obamacare to the extent those entities based as they are on an Underware Gnome type plan will survive .

Dr. Don Berwick speaks of the need for "leaders with ideas" and the need to replace the physician-patient "dyad" with a group outcome oriented decision process authored by the wise leaders with ideas. ( You have to worry when someone talks about "dyads"). Those views conform with the Progressive Medical Axiom of " medicine is too complex and too important to be be left in the hands of the individual physicians and patients."

For most physicians, the Type 1 hubris wears off or withers away after the realities of a few years of clinical experience bump up against the overly simplistic concepts of the novice. Type 2 is what we need to worry about and to fear those leaders in positions of authority (or advisers to those in power) who never caught on to the Hayekian notion of "how little men know about what they imagine they can design..." But no matter, being a public health expert or a medical planner means you have never say you are sorry.

With Obamacare and IPAB's unprecedented powers as well as CMS's control over Medicare,there are great opportunities for leaders with ideas and the requisite amount of hubris to do unprecedented damage to the practice of medicine.


Minor syntactic,spelling and punctuation change made 8/18/14. 

More worrisome news about hazards of long term marathoning

I have written before about the troubling reports of certain test results following endurance events.

There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.

One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.

Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.

Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary disease but could this be an instance of " too much of a good thing".See here for that study.

Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.

If Health care planning is like green energy planning, hold on to your seats

In this article in Investor Business Daily we see how well government planning is working out in the Green area.

Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.

On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.

And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??

Medical decision making moves to Washington

Every time I re-read a section of Thomas Sowell's Knowledge and Decisions I am more impressed with how brilliant it is,how filled with insights and how well written .

A central theme of the second half of the book is described by Sowell in this way: (my bolding)

Even within democratic nations,the locus of decision making has drifted way from the individual,the family and voluntary associations of various thoughts and toward government.And within government, it has moved away from elected officials subject to voter feedback,and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

The ACA (Obamacare) represents a major shift in the locus of decision making regarding medical care. One could consider Obamacare the poster child for that concept. Of course, the locus has already been shifted to a major decree away from the the individual physician and individual patient ( the "dyad" in Don Berwick's quirky terminology ) by the hegemony of third party payers and the virtual single-payer status of government finance health care administered through CMS (Medicare and Medicaid).


A major theme of the first half of his book is the following. One should analyze the decision making processes of institutions in terms of the incentives faced,the constraints in place and the likely outcomes and  whether the decision makers are immune from  or influenced  by  feedback mechanisms .Do not look at the "hoped for results" or the mission statements but rather at the mechanics of the decision making process.

Consider those mechanics in the context of ACA and how the myriad details which will make the lofty goals operational will be determined. Various governmental agencies and panels will deliberate and churn out the pages of rules and regulations that physicians and patients will have to live with. For the most part these rules makers will be immune from meaningful feedback but they will will not be immune to lobbying efforts by various special interest groups during the rule making process.

Consider the mechanics of the Independent Payment Advisory Board ( IPAB) and how decisions will be made by its fifteen member presidential appointed panel and how lobbyists for various special interests will target this group and likely their efforts will be proportional to the power that IPAB has been given.

Addendum: Minor stylistic changes made 9/25/14

Victor Fuchs solves the "doctor's dilemma"-appropriate care is cost effective and ethical too

Victor R. Fuchs,Economics Professor Emeritus at Stanford, wrote a Perspective commentary in the August 18,2011 Issue of the New England Journal of Medicine entitled: The Doctor's Dilemma-What is "Appropriate" Care ?

The dilemma he describes is the following;

"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"


Fuchs tell the readers if all the physicians in a given health care collective practice (as in HMOs and now Accountable care Organizations) cost effective medicine the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.

I believe Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit some may be harmed.

In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .

The basis of Kant's ethical precepts was the categorical imperative which is:

"Act only according to that maxim whereby you can,at the same time, will that it should become a universal law."

In other words, a person acts morally when he acts as if that conduct were establishing a universal law governing others in a similar situation.


I find it interesting and puzzling that Fuchs uses a Kantian based ethical argument to support cost effectiveness based decisions in health care as cost effectiveness analysis is typically justified using a consequentialist type argument. Philosophical support for the notion of resource allocation based on the best bang for the buck is supplied by this outcome based school of ethics.

Kantian ethics, on the other hand, is duty or rule based ,an approach called deontological in the literature of ethics.Kant believed that the individual should be considered an end in himself not as a means to an end. In the medical collective the individual's interests are subjugated to the aggregated good of the group;the individual functioning as a means to achieve the greater good of the collective whether or not a particular member of the collective enjoys the benefit.

In the moral conflict between the physician's fiduciary duty to do what is right for the individual patient and the imperative to serve the best interests ( by what ever aggregate parameter that is being used) of the group as a whole, would not Kantian rule-duty based ethics support the rule of do what is best for your patient and patient is a singular noun. If Fuchs is suggesting that cost effectiveness analysis should be determinative in medical decisions and that it is justified by Kantian ethics, I suppose the "rule" would be always do what is cost effective.Never mind that pesky notion of a person being considered an end in himself and not as a means.

Once again price control in medicine results in shortages,this time cancer drugs

There has been and continues to be shortages in some of the older well proven cancer drugs. See here for an explanation of what is happening there.

Dr. Ezekiel J. Emanuel blames much of the problem of the 2001 Medicare Prescription Improvement and Modernization Act.

Here is a quote from Emanuel's opinion piece in the August 6,2011 NYT Sunday Review:

The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.

The economist Arnold Kling is fond of saying that they teach all the important stuff in Econ 101 not saving any big secrets for more advance study.I'm fairly sure Econ 101 explains the effects of wage and price controls and that incentives matter.

Aggregate Healthiness, Gross Body Health,Keynesian Medicine

I have ranted and sometime more reflectively argued quietly against the morality of the aggregate as it applies to medical practice. Rules,pay for performance (now re branded as value based purchasing) rely on the statistical aggregates and often overly simplified guidelines. I know, aggregates can be useful in a number of contexts but the individual patient ( what other kind of patient is there?) may have her interest devoured by obsession with rules based on the statistical abstractions.

Here, George Mason Economist,Don Boudreaux, tells a satirical tale about a medical analogue to Keynesian aggregate demand.

No, the fictional gross body health is not exactly what I argue about with the guideline-P4P thrust in clinical medicine but Boudreaux's commentary is worth reading.

MIT Prof discovers people like to spend other people's money

Amy Finkelstein,a PhD economist from MIT,has "discovered" that people when given a card that lets them buy something cheaper than they could otherwise buy more stuff. Thanks Dr. Michel  Accad at the blog, Alert and Oriented,for calling this discovery to my attention.

This link from a news story on the discovery briefly discusses her findings and the mind boggling claim that this finding will change thinking about health care spending. Yeah, it is that old
"demand curves slope downward" thing again. Note: this is not breaking news as her report and news items on it date back to 2007 but I have fallen way behind on my health wonk literature reading.

Here is a quote from the news report:

Already, Finkelstein's analysis is shaking up views across the political spectrum. "This is pathbreaking work," says Joseph R. Antos, a health economist at the conservative American Enterprise Institute. Adds the more liberal MIT economist Jonathan Gruber: "This really changes the whole landscape in the way we think about health economics." 

Wow! The economist ( Gruber)  who advised in regard to Romney-care and Obamacare seemingly was unaware that people tend to buy more of something when it costs less.

Wow again,  path-breaking work.Apparently no one heard or remembered what Milton Friedman had said about the ways people can spend.See here for that concept in Dr.Friedman's own words.The key point here is that when you spend someone else's money on yourself , you are not very careful about how much you spend.

Dr. Finkelstein work supports the notion that health care costs have increased in no small measure because millions of older American have Medicare insurance and they realize that they can get medical services much cheaper than otherwise when they show their card to various health care providers. The fact that some health care wonks thought her findings will change the way people will think about health care policy seems to mean that until now some health care experts believed that demand curves slope upward. Some admirers of Milton Friedman are celebrating the 99th anniversary of his birth. See here. Maybe health care economists might browse through some of his work.Perhaps an econometric demonstration of the absence of a free lunch might be forthcoming.


Addendum: 11/12/14 Minor changes  made re style , spelling  and one factual error in regard to Dr. Accad's first name.

Health Care and Education-the new "commanding heights -"Kling and Schult

An interesting and insightful commentary by Arnold Kling and Mick Schult is found in the Summer issue of "National Affairs" and is entitled "The New Commanding Heights".The title is a play on the title of the book by Daniel Yergin and Joseph Stanislaw "entitled "The Commanding Heights:The battle for the world economy". See here for the Kling essay.

The term Commanding Heights was used by Lenin in a 1922 speech in which he refers to the dominate industries in Russia at the time indicating that they would be target of the central control of the communists. He gave up trying to control everything so he decided to control the key industries.These included heavy manufacturing,mining,electric generation and transportation.

Kling and Schult contend that those industries are now largely not controlled by the state in the United States and in western countries generally and while these sectors are important they present data showing they are no longer the major growth sectors in our economy.They argue convincingly that education and health care are the growth sectors in the United States.

History has made it clear that markets work. Market economies lead to prosperity,economic growth and innovation while central planning results in dismal and often tragic failures. Lenin promised to do what capitalism did plus eliminating waste, recessions, and inequality:what was produced was mass starvation and mass murder.

However, the authors warn markets advocates against premature celebration. Their thesis is that in the U.S., both in education and medical care, the new commanding heights, governmental controls are prevalent and growing and if the U.S. is to continues to grow and prosper, we need innovation in these areas? How much innovation occurs in government controlled economic sector?

Many (most?) discussions of the medical economy emphasize the overall
cost" of medical care and its growth ( it is a growth sector) and that it is a bad thing. Two comments are appropriate: 1) often overall costs are conflated with government costs ( i.e. Medicare and Medicaid) with overall costs 2) Costs are only one side of the accounting, one person's costs are another's income stream.

Controlling the amount of money that the government spends on health care or farm subsidies or foreign wars is one thing and is well within legitimate government activity, attempting to limit private spending on healthcare or cosmetics or anything other legal activity is quite something else.So with GDP not snapping back to previous more healthy levels do we really want to decrease activity in one of the two major economic growth centers?

Surprise-economic principles apply to old folks and Medicare costs

See here for a report on some data gathering that should be filed under the heading of "very bloody obvious". The link is to the 7/16/2011 blog entry from Dr. Mark J.Perry which tells us 1)Medicare utilization is about 50% higher than private health insurance utilization and 2) why Medicare patients see their doctor so (too?) much. Hint:it has something to do with spending someone's else money and the law of demand.

Economists are fond of saying "demand curves slope downward" which is their jargony way of saying that people buy more when the prices is lower and less when it is higher. Milton Friedman has been quoted as saying that economics is simple- just remember there is no free lunch and demand curves slope downward.

Economists ,for some obscure reason possibly found deep in the history of their discipline, place the dependent variables on the X-axis and the independent variable on the Y-axis. This is just the reverse of the practice of physicists and engineers and most other people who like to draw graphs. So they place price on the Y axis and quantity demanded on the X axis and thus the demand curves slope downward because folks buy more when the price is cheaper.

Medicare patients "buy" more health care because of the way Medicare works they get a really good deal on the price that CMS allows to be charged. It gets better, Medicare generally pay 80% of a significantly lower "allowed price" and many seniors have supplemental insurance which further amplifies the illusion of a free lunch.So,of course,Medicare users utilize more services and the reason is not that fee-for-service doesn't work. Blaming fee-for-service is the current battle cry on many in Congress and many of the organizations who allegedly represent the practicing physicians.

Some would conflate fee-for-service with free markets in medicine but there has been no free market in medical care for many years now (except for a few markets such as lasik surgery and some plastic surgery and much of alternative medicine) and the Medicare system is characterized by price controls and the demand side characterized by folks buying services with someone else's money,both of which are the products of central planning. What could possibly go wrong with that circumstance?

The list of problems in medical practice are not due to fee-for-service but rather what happens in a nominal fee-for-service setting when there are price controls namely shortages,long waiting lines,poor quality and various other forms of rationing by other than prices.As is often the case, the results of central planning are blamed on that heartless,run-away greed all the way down, free market.And as is also often the case the solution is more central planning,which is what Obama care is all about.

More on IPAB and the risk of regulatory capture

See here for a recent report on views of the IPAB.

Particularly interesting were comments of someone who has been there and done things in the setting of a very important and powerful governmental appointed post.

Bruce Vladecks, the former head of CMS under Bill Clinton, had this to say :

"In the short term, it might theoretically work," he said. But the history with other independent regulatory agencies, like the Interstate Commerce Commission and the Civil Aeronautics Board is that over time "the regulated industries tend to capture them; and they tend to do more to protect the regulated industries than they do to protect consumers."


Considering the legislative hurdles that Obamacare put in place for Congress to over ride the edicts of IPAB, capturing IPAB would be prize well worth capturing.

What is the moral case for Obamacare?

Is there one at all?This commentary by the economist John Goodman argues there is none. After Dr.Goodman made his case he invited readers to offer such a moral justification.I could find none in the forty reply to his article.

Several commentators ( including spokesmen for the ACP and the AMA ) claimed that Obamacare furthered social justice. So could that be the moral justification for Obamcare?

In regard to social justice Thomas Sowell said the following:

Their passionate arguments for particular results tend to obscure or distract attention from the question of the social processes by which these hoped-for results are to be pursued.


Goodman,in this most recent cited commentary, and in numerous others posting on his blog gives great detail of the various social process set in motion by Obamacare and the numerous apparently unintended consequences

In short, the various elements of this outlandish long bill do just about anything other than the putative hoped-for results which is "affordable , accessible health care for all" and instead offer a mind boggling array of counterproductive results and bizarre inequities and the frightening promise that many more such dystopian outcomes will arise from the hundreds ( more likely thousands) of pages yet to be written by agencies created by Obamacare and the incredible discretionary powers given to the Secretary of HHS.

Perhaps,spokesmen for the medical organizations who champion (yes, they still support it in spite of the increasing evidence that the bill is a very bad idea) can offer a moral justification .

Meta-analyses-money well spent?

I have blogged more than once ( see here and here )about meta-analyses (MA) and quoted Steve Goodman MD PhD more than once when he said that MAs are just observational studies in which the observed elements are studies. I would add and we just don't know what went on behind the curtain.

They are not super randomized trials as the prefix "meta" might imply but should rightly reside significantly under RCTs in the hierarchy of clinical research methods.

Since the views expressed conform nicely with my biases I was drawn to this commentary by Dr Wes.

"Wise Legislators " pass ACA with IPAB,their "good deed"

Henry J.Aaron,of the Brookings Institute, has written three commentaries in the Perspective section of the NEJM in the last year. He seems to be their go-to guy for IPAB issues.Here is a link to his latest.

He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition to how James Madison thought things would work out.

This is in stark contrast with the friend of the court brief that the Pacific Legal Foundation has filed to challenge the constitutionality of the creation of IPAB. See here for their comments on IPAB and a reference link to their brief challenging IPAB.

Aarons likens the creation of IPAB to the creation of the Federal Reserve which was to be an entity not subject to congressional control.

This may not be the best analogy with the increasing efforts of Congress (and not just Ron Paul ) to at least exert some surveillance of what the Fed does.

July 4th, all about the right to vote or much more than that?

This commentary from the Coyote Blog is good fourth of July reading.

Warren Meyer,a libertarian entrepreneur and prolific writer, who writes the blog as well as being a contributor to Forbes list three principles more important than the right to vote. Here is the first one he discusses:


"The Rule of Law. For about 99% of human history, political power has been exercised at the unchecked capricious whim of a few individuals. The great innovation of western countries like the US, and before it England and the Netherlands, has been to subjugate the power of government officials to the rule of law. Criminal justice, adjudication of disputes, contracts, etc. all operate based on a set of laws known to all in advance and applying equally to all."

Meyer then points out the obvious contempt for the rule of law with the exemptions to certain provisions of the health care law .

More of the "social justice" fallout from ACA

As more and more inequities and unintended consequences of Obamacare are revealed as we learn more and more about the bill,we can see that the social justice Obamacare advocates (you know who you are )boasted about following its passage is a very strange type of justice.

See here for one of the latest revelations about how basically unfair various aspects of the bill turn out to to be. As the AP article explains two families with same income would pay significantly different health insurance premiums to the exchange based on what type of income they receive.This problem seems to be tied to the definition of income used in the statute.

But it gets even worse, more folks become eligible for Medicaid based on the law's wording.

Medicare's top number-cruncher is warning that up to 3 million middle-class people in households that get at least part of their income from Social Security could suddenly become eligible for nearly free coverage through Medicaid, the federal-state safety net program for the poor. Chief Actuary Richard Fosters says that situation "just doesn't make sense."