Is the "social justice" of ABIMF and ACP what John Rawls had in mind?

The stated reason for the existence of the American Board of Internal Medicine Foundation (ABIMF) is to further medical professionalism.,the three principles of which are patient welfare,patient autonomy and social justice. By social justice they seem to mean the " just and cost effective distribution of finite [medical] resources ".

The Choosing Wisely campaign is promulgated by ABIMF and in its original version was an seemingly innocent and well intentioned suggestion that physicians and patients have a frank discussion about medical procedures and treatments to the end of trying to minimize those that might be wasteful and/or harmful. Of course,everyone want to do away with waste and harm.but it is morphing into something much more than that. Suggestions are being made and gaining momentum that lists should be made of those procedures and treatments that are "low value" which will be defined as falling below some threshold of quality adjusted life years (QALY) per amount of money. A figure  of  $150,000 per QALY is being proposed.Further, there are suggestions that CMS enforce the dictates of the Choosing Wisely campaign.

Note-if it is "determined" that something's value is  "low" i.e  if less than some dollar amount per QALY then physicians should not recommend that procedure and third party payers might just not cover it. So patients dependent on third party payers to obtain  that procedure would not receive it while more affluent folks who  are free to pay for their own treatments would be able to obtain this so called  low value procedures.

Social justice is a slippery term and its ambiguity may serve promotion of a given social movement  but it is generally recognized to be redistributive justice.Rawls said that redistribution would be acceptable only if the most disadvantaged members of society would benefit.

If the plan to suggest that "low value" treatment should not be done, then no one should receive it , at least in theory. But in practice it may well mean that those who cannot afford to pay for it on their own would not receive it, and such a group certainly would include the most disadvantaged members of society. Not a very Rawlian outcome.

Further, Rawls did not support decisions made on utilitarian grounds. The cost effectiveness analysis of the QALY calculus is clearly based on the dictum greatest good for the greatest number. Rawls believed that this approach did not support the autonomy,the individual rights and dignity of the individual.

Dr. Christine Cassel and Dr. Virginia Hood,both leaders of  the American College of Physicians spoke of "parsimonious care". Social justice a la Rawls would champion more care for the most disadvantaged .Parsimonious care is less care for everyone in theory but in practice the affluent may get it anyway. so who gains from that? Third party payers comes to mind.The ACP and ABIMF and others are going on a full court press to convince physicians that they are population doctors and to conserve resources they should follow guidelines. This will achieve the re-defined, non-Rawlian , social  justice imperative that they have said is required of physicians .Adherence to guidelines it is argued will improve the health of the collective though some individuals will suffer but the bottom line of the third party payers and ACOs will not suffer  and the medical elite mandarins will also do well.

Minor spelling,grammar and punctuation changes made on 7/11/14.

Another chapter in the never endling clash between the collective and the individual regarding health care

The following comments were inspired by this insightful and very well written commentary by Margarit Gur-Arie entitled "Is the Nuremberg Code Obsolete?" After reading about where the cronies at IOM and the ideologues at Hasting Institute want to take us, I have to shout "It sure as hell better not be obsolete and do you people even know anything about the events that took place in Europe (or Macon county,Alabama for that matter)  in the 20th century and why we have the Code in the first place."

One of the more troubling developments in recent years in medical care is the seemingly increasing acceptance of the notion of the importance of the health of the collective even if sometimes to the determent of the welfare of the individual and that the latter seem to exist for the welfare of the former.

One of the latest twists here is that some are arguing that certain types of clinical research can be done without getting consent of the participants or even informing them about what it going on.

Quoting Gur-Arie:

" The Office for Human Research Protections (OHRP) held a public hearing in August 2013 regarding the nature of informed consent for randomized clinical trials...., two very distinct opinions regarding consent emerge from reading the various testimonies before the committee. The traditional opinion argues that there is a difference between treatment and research and that informed consent is required for both, including study of “standard care” interventions, CER and QI; that randomization always deprives research subjects of the judgment of their physician and that these issues are governed by law (e.g. the Constitution and such). The progressive view, presented by testimony from members of the Institute of Medicine (IOM), its Clinical Effectiveness Research Innovation Collaborative (CERIC), NIH and other research establishments, posits that randomization of “standard care” interventions poses no additional risks to patients, since doctors’ decisions are essentially like flipping a coin anyway, and therefore patients in this new learning system may be subjected to randomized CER and QI experiments without explicit consent and with minimal, if any, information (e.g. “something posted on the door”)."

 Related is this Hasting Center  report which speaks of   (with my bolding):

"The obligation of patients to contribute to the common

purpose of improving the quality and value of clinical care

and the health care system.

Traditional codes, declarations,

and government reports in research ethics and clinical ethics

have never emphasized obligations of patients to contribute

to knowledge as research subjects. These traditional presumptions

 need to change. Just as health professionals and

organizations have an obligation to learn, patients have an

obligation to contribute to, participate in, and otherwise facilitate learning.

This obligation is justified by what we call a norm of

common purpose. This norm of common purpose is similar

to what John Rawls calls the principle of the common good."

Wow, here is a group composed mainly of several ethicists from Johns Hopkins who presume to define an obligation for everyone and redefine the ethics of medical research, a goal they openly admit to in the first paragraph of their report.Everyone has an obligation to work for the common purpose of better health care.

Once all the health care providers and all the patients work together to participate in and gather the data about various medical tests and treatments the very smart people will be able to analyze it all and determine what is best for the collective. Utopian health care is within the reach of the  very smart people with ideas.

More internists are failing the MOC exam-why could that be? Resistance to ABIM's MOC grows.

Why are more internists failing the Maintenance of Certification (MOC) exam? Kevin Pho on his medical blog offers two suggestions. See here. One reason is what I call the economically driven bifurcation of internists into hospitalists and officists and the disuse atrophy of hospital care skills in the office bound docs and the lack of familiarity with the preventive care changes and routine treatment of non acutely ill patients on the part of the hospitalists. If you don't treat respiratory failure,sepsis and acute heart failure on a regular basis you might just not do as well on the boards. The second reason Pho suggested is that the hassle factor in office care is now so high , with insurance,computer,and quality measures documentation  ever increasing that the fire in the belly to try and keep up with everything may be burning too low to try and keep current on conditions  you no longer are called upon to manage.

The suggestion that there should be one test for the hospital based internist and another for the officist has some merit but what about the dwelling number of dinosaurs who still try to do both. Of course that group is rapidly dying out.

And the more I read and hear about the absurd hoops internists are expected to jump through to try and satisfy the ever onerous non-test aspects of the ABPM's MOC process, the happier I am that I retired.See here for a great presentation of the clown-designed MOC program authored by the leadership at the American Board of Internal Medicine (ABIM).

I am pleased to see that there is at least some organized,as well as much unorganized, effort to resist or maybe even boycott the latest MOC affront imposed by the well paid folks at ABIM. See here and here. Further, mega kudos to Dr. Paul M. Kempen for his efforts to resist the MOC movement. Read what he has to say here. See here for Dr. Wes Fisher's comments re the big business that testing physicians has turned into.

Also of interest are the questions posed by Dr. Marc S. Frager to Dr. Richard J. Baron as well as Dr. Barron's reply.See here.

If you want to sign a petition to urge the ABIM to rescind their latest edicts regarding MOC ,go here. 

It is easy to find much anger and indignation directed towards the ABIM and recent revelations about possible conflicts of interests regarding its leadership has fanned the flames even more.

Adam Smith's Men of Systems and the progressive medical elite

Adam smith spoke of the men of system- men with a dangerous mixture of hubris and naivete  who presumed to know what is best for every one  and how to plan to bring that optimal state into being.

The following commentary highlights the views of some physicians who might be considered the medical men of system.

The following quote from Drs Don Berwick and Troyen Brennan in their appropriately named book, "New Rules" captures the essence of the fundamental nature of how men of system would arrange medical care.
 
"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making

 

Dr. Robert Berenson strikes a  seemingly different but clearly related note in a commentary in the Annals of Internal Medicine , 1998,pg 395--402.  in which he promotes the health of the collective rather than the individual patient :

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group while Berwick and Brennan talk about dissolution of the physician patient relationship and moving the locus of medical decision making  away from the physician and his patient to a reliance of authoritarian rules.

More recently Berenson has this to say:

 "we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now"

A series of articles in JAMA in 1994 (Rationing Resources while improving Quality) by Dr. David Eddy also recommended a utilitarian type medical care structure in which funds would be  spent on medical tests and treatments that were most likely to benefit some majority subset so that in the aggregate there would allegedly be a greater good for the greatest number.

Dr. John Benson is the former CEO of ABIM and ABIMF and had this to say recently on the ABIMF's website:

"  ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, for candidates for certification or the ABIM's Maintenance of Certification to even be allowed to take the tests they would have to recite,perfectly, the catechism of the brainchild of ABIMF ,the "Choosing Wisely" guidelines.

This alone, in my opinion,should qualify Dr. Benson for membership,along with the aforementioned doctors,in the Medical Men of System hall of fame.  

The recommendations of Berwick,Brennan,Berenson and Eddy were met by some vocal resistance as least as documented by letters to the editors in JAMA and the Annal of Internal Medicine . These authors were advocating a paradigm shift ,arguing for a 180 degree reversal of traditional medical ethics for which , I believe, physicians at the time were not ready and I hope are not ready now but...

But there is another way to gather support for a sea change in medical ethics and practice behavior,one that will also bring about greater concern for the collective and aggregate outcomes and that will to a large and ever increasing degree move the locus of medical decision making from the individual dyads to a central decider .

This other way is to nudge physicians and later shove them a bit into the acceptance of the notion that physicians have a duty to work for social justice and to act as stewards of the nation"s finite medical resources.To strive for social justice is a political position, one that does not necessarily have any professional links. To declare, or assert gratuitously , as was done the in the  publication known as the Medical Charter that physicians have an obligation to strive for social justice represented a audacious move,one that I am afraid has been at least nominally successful.

To close with a quote from Adam Smith's "Theory of Moral Sentiments" :

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own,"


addendum: Minor editorial changes made 9/12/14

Breaking news-OBM discovers economics prinicple of "incentives matter"

Several of my favorite economists have said that the real good stuff in economics is revealed in the econ 101 courses. One of the secrets revealed is that "incentives matter".

Milton Friedman said most of economics could be boiled down to two thoughts; 1) there is no free lunch 2)demand curves slope downwards which simply means people tend to buy more if something costs less and tend to buy less if something costs more.

Another principle is that generally supply curves slope upward which means that someone will tend to supply more of something if the price increases and tends to supply less if the price is lower.

The Chicago economist Casey Mulligan has been making that point for some time  in regard to certain aspects of Obamacare.Obamacare provides subsidies for folks when their income falls below a specified threshold.If they work more and earn more and exceed that threshold  they loose that subsidy.Hence the incentive to work less.In other words, less labor will be supplied if the effective pay is less which is what happens when someone works more and loose a subsidy so your net income falls. As Mulligan says you can decrease employment by changes in the supply side as well as by changes in the demand side.

The downward sloping demand curves notion enters into the Obamacare employment issue as well. If an employer has to provide health insurance or be fined if he employes more than 50 people the incentive is to keep his employee count under that number because the cost of hiring the 51th person is too high. He will tend to hire fewer employees when the cost of hiring increases.

See here for a WSJ article on Prof.Mulligan and his work and comments and how OMB finally caught on.

Is this what ABIMF"s Choosing Wisely is really all about?

Dr. John Benson Jr, Emeritus President  of the American Board of Internal Medicine Foundation,makes it clear  what direction he wants the Choosing Wisely  (CW)  Campaign to go. See here for his comments.

 Dr. Benson begins his policy prescription with a gratuitous assertion which seem to be a favorite technique of the folks at ABIMF. (Their mother-of-all gratuitous assertions was that physicians were stewards of medical resources.)

 "The prospect of health care consuming 20% of the GDP by 2020 is unconscionable so corrective actions have enormous urgency."  

This recent commentary from The NEJM seems to share some of Dr. Benson's views which is basically "If you people do not do what we know is right someone needs to make you do it". He speaks of penalties.

He wants the CMS to enforce the  Choosing  Wisely 's wisdom.The NEJM article speaks of linking compliance with MOC ( Maintenance of Certification)as well as tying CW recommendation to CMS actions.

Quoting Dr. Benson:

"The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in." ( He does not explain the ominous reference to the year 2020).

He continues

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."  (note the current President of ABIM and ABIMF is Dr. Richard Baron who left a post at CMS through the revolving door to assume his duties at ABIM and ABIMF)

and it gets worse

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC." (Maintenance of Certification)

So, a candidate for ABIM certification would have to properly quote the Choosing Wisely catechism before he even gets to take the certification of MOC examination.

Quoting the NEJM article by Dr N.E. Morden and her co-authors from Yale and Harvard:

"..physician-endorsed low-value labels will probably be leveraged to these purposes. [cost containment and quality measures]...We believe that if such efforts are designed and applied carefully they should be embraced as a promising method for reducing low-value services."

...linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification act activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low value service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."


Remember the CW campaign,which was very low key in 2009. was just to get a dialogue going   so that  the physicians could explain to their patients how at least some of these tests and treatments really don't need to be done because they may be wasteful and sometimes harmful. In 2012 the program was ramped up as the ABIMF "invited various medical professional societies to take ownership of their role as "stewards of finite health resources". And now , in 2014 the movement to give the CW recommendations teeth is ramping up.


The coercive recommendations of Benson and the authors of the NEJM article are in the tradition of those who believe that medical care is too important ( and complex) to be left to the short sighted individual patient and her knowledge and the wisdom challenged physician health care provider.They seem to march to the drum beats orchestrated by  Dr. Don Berwick (the temporary head of CMS) and  Dr.Troyen Brennan (the current executive VP of CVS Caremark) who said in their book, New Rules:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines...

 
Berwick and Brennan must be pleased as largely through the efforts of ABIMF and ACP much has been accomplished   in the reformulation of  traditional medical ethics. Those organizations  have shaped the narrative to emphasize the bogus stewards-of- resources concept while letting the fiduciary role of the physician to the patient fall  quietly down the memory hole.Unfortunate  the leaders of other medical professional societies have swallowed the bait.

The progressive medical elite who hold positions variously at major medical societies and medical certification boards ,some of whom rotate through various government medical agencies and sometimes private third party payers, have not been shy about what they want to happen.For those of us who believe that the patient is best served by a physician acting as fiduciary to the patient and advocating for him have much to worry about.

 Addendum:Minor editorial changes to correct some grammar and spelling done on 6/8/2014 and again on 7/23/2014.

Say it isn't so Joe, Medical "thought leaders" might have conflict of interests

 The issue of possible conflicts of interest (COI) has arisen in regard to both the National Quality Forum,  (NQF) and the popular UpToDate.

 This article in the Journal Of Medical ethics discusses that issue in regard to the popular UpToDate which on its web site describes its self as "premier evidence-based clinical decision support resource". The journal article has this to say regarding several sections of UpToDate comparing it to another rival medical resource:

"All articles from the UpToDate articles demonstrated a conflict of interest. At times, the editor and author would have a financial relationship with a company whose drug was mentioned within the article. This is in contrast with articles on the Dynamed website, in which no author or editor had a documented conflict. We offer recommendations regarding the role of conflict of interest disclosure in these point-of-care evidence-based medicine websites."  It should be noted that the journal authors did not review all of sections but selected ones that involved subjects for which treatment was controversial and/or involved recommendations for specific treatments that wee provided by a single supplier.

Much more has been written about possible COI regarding the NQF.

Details regarding Dr. Charles Denham can be found in this article in "Modern Health Care. Quoting that article:
"

"Dr. Charles Denham, co-chair of NQF's Safe Practices Committee in 2010, received $11.6 million from San Diego-based CareFusion to promote the company's ChloraPrep line of skin-preparation products. Denham's committee at the NQF also recommended surgeons use ChloraPrep products to prevent surgical infections, the NQF said."

Dr.Christine Cassel,currently CEO of NQF left little doubt about her assessment of Denham actions saying simply "He lied" when he mislead the NQF regarding his possible COI and business interests. Dr. Cassel was not affiliated with NQF at the time of the allegedly kickback  related activities.

Ironically enough now Dr Casell has the spotlight on her in regard to possible COI  regarding her role at NQF. ProPublica takes up that issue here. I say ironically because one aspect of Dr.Cassel's academic reputation has been in the field of medical ethics.Dr. Cassel has written and lectured extensively on medical ethics, authored or co-authored several publications in the field including "Ethical Dimension in Health Professions" and completed a fellowship in bioethics.

 So what is it that Pro Publica finds of concern in regard to Dr. Cassel's role at NQF. It is in regard to other compensated positions that she holds.For example Dr. Cassel is a board member for Premier Inc with a reported compensation  of  $ 235,000 and stock.Does a board member of a corporation not have a fiduciary duty to the corporation.?

Since she has earned the title of expert in the field of medical ethics it seems astonishing to me that she apparently does not consider it an ethical breach to play a leadership role in the NQF and to  receive compensation  from two organizations that could profit ( or loose) based on some recommendations made by that organization. Two ethicist interviewed by Pro Publica seem to disagree and Dr Roy Poses ( see here) who is absolutely untiring in his efforts to point out issues of COI in health care has this to say regarding Dr. Cassel's dual roles:


"However, in my humble opinion, the issue here goes even beyond a blatant and undisclosed conflict of interest.  That a top steward of a big for-profit health care corporation could simultaneously be the top leader of an influential non-profit health care quality improvement organization suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improving health care.

 As ProPublica put it,
Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious.'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'

Update: 2/27/2014 Dr Cassel has resigned from her posts at Premier and  Kaiser.

Obamacare may decrease employment but at least more folks can "pursue their dreams"

The situation involving recent projections about job loss and Obamacare from the Congressional Budget Office and the White House's reaction to it falls under the joint headings "you can't make this stuff  up" and  You gotta be kidding me"
Yes, the White House really said that now people will be able to pursue their dreams,which is one way of considering  having no job,and those blessed with less work can spend more time with their family as well as having the opportunity to retire early.


See here for Avik Roy's comments regarding the CBO projection of 2.5 millions job losses and the administration's reaction it which should have destroyed any feeble residue of credibility that Obamacare apologists  may still retain.

 No,CBO is not saying that 2.5 millions folks will be fired but rather there will be "a decline in the number of full time equivalent workers of about 2.0 million in 2017 , rising to about 2.5 million in 2014."

Basically the CBO says Obamacare will decrease employment by the millions.Here is Avik Roy's explanation of how that might be brought about.

"The new, larger estimate of the law’s negative impact on the labor force derives from three factors: (1) Obamacare’s employer mandate, which will discourage hiring and reduce wages offered by employers; (2) Obamacare’s $1 trillion in tax increases, which will discourage work and depress economic growth; and (3) the law’s $2 trillion in subsidies for low-income individuals, which will discourage many from remaining in the labor force."

If you were wondering  what the tax increase would be spent you should be reassured that it will all not be wasted as some of it will go to mitigate losses that insurance companies might experience because the plan is not working out quite as projected.See here for what Humana will get so far.In Obamacare's quirky version of social justice all the redistribution does not seem to go to the most disadvantaged making it seem a bit more like crony capitalism.

Are employee wellness programs just silly or can they be hazardous to health?

Leah Binder, writing in Forbes on line ( see here) argues that the answer is "maybe" at least as regards what she calls badly designed programs. She draws from a book from Al Lewis and Kiv Khanna entitled "Surviving workplace wellness".

Practicing internal medicine and pulmonary disease in the late 1970s I had not heard the term "wellness" until I was approached to consult for a large petrochemical company who believed they had a problem with some type of occupational lung disease at one of their facilities. ( The term risk factor was new to me as well)

Later while working part time at that company I sat in on a presentation from a consulting firm who was selling employee wellness programs.They showed slides with huge alleged savings from the detection of early disease in the employees. One cynical older HR person said yes that maybe be true but if we save those lives while folks are working will  we not  be shelling out more money in longer retirement payment because if we have both a health insurance program and a retirement program we will be paying now or paying later.

That argument aside Lewis and Khanna make a persuasive and humorous case for shelving most of what passes for employee wellness programs, which by the way are encouraged by Obamacare giving us reason 962 for never having passed the biggest crony capitalism con job  windfall ever.

The authors tell us that the "sum of value created when an employer plays doctor" can be put in a very small footnote,

stop smoking
eat better
get off your butt

Their analysis resonate with  the impression I had years ago .The difference is they have data to support their conclusions.

So how's that health care insurance for "nearly everyone" working out for you?

Advocates of Obamacare in defense  of it in spite of all the flaws and the ever increasingly list of unintended and intended- but not advertized- consequences ( eg tax payer subsidies for insurance companies  that might loose money on the exchanges) typically fall back on the twin refrains of "health care will be available for nearly everyone" and social justice is being promoted.

Of course, those folks are conflating health care with having insurance but ignoring that for a moment it looks more and more unlikely that the nearly everyone )(usually estimated to be about 30 million) will  actually get the insurance cards . So far  fewer of the uninsured are actually shining up on the exchanges.McKinsey did a study and their analysis indicates that the vast majority of those who are signing up were already insured and only about 11% were moving from the uninsured group to the insured group. See here for some details of that study. If McKinsey's analysis is even close to be correct the 30 million claim will not likely be reached.

As far the social justice argument let me repeat that Rawls defended inequality if it benefited the most disadvantaged in society but while some of that is happening with Obamacare , a significant number are forced into paying more for insurance and often buying benefits which they can never use.

So the plan seemed to be that the young, healthy would sign  up in sufficient numbers to fund the scheme  and the uninsured would rush to the website and sign up since getting those 30 million insured was the purported reason for the legislation in the first place. So far it seems that neither of those things are actually happening in sufficient numbers to   prevent the so called death spiral.More aspects of the Obamacronycare law come to light, one of the most recent  one being the news that HHS is writing or rewriting the details of subsides to bail insurance companies to make them even more generous.

And this quote from Coyote Blog which comments on the fact that many people who are now getting subsidies had insurance before:


"So, we know that 80% of the people are getting subsidized on the exchanges, and now we know that 70-90% of those previously had a unsubsidized policy beforehand.   This means that what the exchanges are doing is NOT insuring the uninsured, but converting people previously responsible for their own health care into government dependents.  The more cynical out there will argue that was the whole point in the first place."


And for  what party will folks dependent on the government likely  vote?

Can widely accepted guidelines be dangerous?

Projections assuming the wide acceptance of peri operative beta blocker guidelines in Europe suggests the answer is a frightening yes..See here for details of what seems to be a candidate for  the mother of all iatrogenic disasters. The authors of that referenced article suggest deaths may be in the hundreds of thousands.Extrapolations are fraught with great mis -estimates but even with assumptions of much less adherence to the guidelines there have to be a large number of patients that died or experienced non fatal strokes in a terribly misguided effort to save lives. Hubris of the medical planners and the danger of excessive faith in the truth producing power of meta analysis and the dangers of guidelines enforcement  are among the windmills at which I  repeatedly joist. 

I shamelessly quote a slightly re-edited comments which I made in 2007 following the disappointing results of the POISE trial that cast an unfavorable light on the use of peri operative beta blockers in non cardiac surgery which demonstrated an increased risk of stroke in the treatment arm of the trial.


"quality measures  often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further if an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition.  I increasingly wonder if those sweeping recommendations should be based to a large degree on meta analyses. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof of efficacy; when you are in the prevention mode, you had better have a much greater level of certainty.

The individual physicians not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty. At least physicians were taught that duty before the days of the New Professionalism as promoted by the ACP with their new ethic and the ABIM Foundation and the Robert Wood Johnson Foundation.See how often you find the word "fiduciary" in the new ethics or the New Professionalism.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. Apparently no one. Being a  public health expert or a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not. Oh well, you can't make an omelet unless...

When guidelines were operationally what they claim to be now suggestions,their benefit and their potential harm was limited. Enter the ever increasing hegemony of the third party payers (government or private insurers ) which  has morphed guidelines into requirements with greatly increased power to do good or harm but with seeming impunity.

(edited on 4/24/24 to correct several spelling and grammar issues)

Are cuts in Medicare (mainly Medicare Advantage) more of the magical social justice of Obamacare?

As this Forbes article by Scott Gottlieb explains,Medicare Advantage programs are in the cross hairs of the Obama administration as ACA continues to roll out benefits for some and just roll over others.

Obamacare is partly funded by cuts to Medicare Advantage,a program popular among low income seniors,particularly those who may not be able to afford the medicare supplements plans.More of these plan members are being shifted to Medicaid, a health care delivery "system" generally perceived as something less than typical care that one obtains under Medicare. If social justice means redistributing stuff around so that the most disadvantaged are benefited. you have to wonder how diminishing the health care for one group of lower income folks to enable another group of low income folks to have insurance cards( not health care but cards) is any type of justice at all. Cuts to Medicare Advanatage had been postponed so that they kick in after the 2012 election, will they be postponed again with the administration's eye on the 2014 elections?

Quoting Dr. Gottlieb:

"The net effect of all of these cuts is already expected to shrink the program. The Obama Administration is disproportionately shifting these cuts onto so-called Medicare “special needs” plans. These are Medicare Advantage plans that are specifically designed to enroll patients with certain serious and costly chronic illnesses like diabetes and heart disease. Many of these patients are low income, and dually eligible for both Medicare and Medicaid. "

 We are seeing more strange social justice in the situation in which the program at least nominally designed to help the most sick of those in Medicare Advantage will be cut the most (that is unless the administration decides to post pone it again in the run up to the next elections).

John Goodman also covers this issue here.

"About one of 20 seniors on Advantage had to switch plans because their old coverage was cancelled, but the damage has been particularly acute in a category called special needs plans, or SNPs. More than 1.5 million people were covered by about 500 of these plans in 2013, but the consultants at Avalere Health report that 13% were wiped out."

Being old and sick and poor is becoming more dangerous for some to help pay for insurance cards for some others who may also be sick and poor.   

As 2014 sees Obamacare ramp up,another tip of the crony hat to its "architect" is in order

Of course no one person wrote the bill,it took a small village of cronies to put it together being as careful as they could to make sure that the health insurers were among  the beneficiaries as well as a few other crony beneficiaries.

A health care "reform" bill was constructed that forced large numbers of the uninsured to buy health insurance and included safeguards ( particularly Section 1341 and section 1342) for the insurance industry to minimize losses should the overall strategy ( to get 40% of the newly enrolled to be young and healthy) not work out as projected.

The statute was crafted by the senate finance committee lead by Max Baucus. According to Baucus much credit should be given to one of his staffers,Liz Fowler. Quoting Mr. Baucus;

"“I wish to single out one person, and that one person is sitting next to me. Her name is Liz Fowler. Liz Fowler is my chief health counsel. Liz Fowler has put my health care team together. Liz Fowler worked for me many years ago, left for the private sector, and then came back when she realized she could be there at the creation of health care reform because she wanted that to be, in a certain sense, her profession lifetime goal."

From 2001 to 2005 Ms.Fowler was Baucus's top health care adviser.She left in 2006 to become Vice President of the nation's largest health care insurer  (Well Point) and returned to play a major role in crafting Obamacare in 2008.That's right, an executive at the nation's largest health care insurer helped write the bill that forced folks to purchase the product that company sold. But it gets even better. She was then hired by the Obama administration to help implement the bill and subsequently left to become a vice president at a pharmaceutical company about which Glen Greenwald ( see here) said the following:

"The pharmaceutical giant that just hired Fowler actively supported the passage of Obamacare through its membership in the Pharmaceutical Researchers and Manufacturers of America (PhRMA) lobby. Indeed, PhRMA was one of the most aggressive supporters - and most lavish beneficiaries - of the health care bill drafted by Fowler. Mother Jones' James Ridgeway proclaimed "Big Pharma" the "big winner" in the health care bill. And now, Fowler will receive ample rewards from that same industry as she peddles her influence in government and exploits her experience with its inner workings to work on that industry's behalf, all of which has been made perfectly legal by the same insular, Versailles-like Washington culture that so lavishly benefits from all of this."

Also of interest is she is now also a member of the Institute of Medicine.See here. The IOM is touted as being a disinterested organization of health care experts who will recommend what is right for the health of the nation and its citizens and whose members are not driven by any special interests.

Of course, none of this is a state secret.Many have written about it including Bil Moyers,Mother Jones, the Huffington Post to name a few.

And yet what do we hear from the physician's organizations, particularly the AMA and the American college of Physicians? Why do not they speak out denouncing this massive pork barrel project.? I cannot accept ignorance or naivete as credible explanations.these organizations have their people in Washington who know what is going on.Surely AMA and ACP do not sponsor, condone or take part in crony capitalism.

Even the Daily Kos,which is very pro Democratic Party,says in headlines " Thank you Max Baucus and Liz Fowler for turning the AHC into a Rube Goldberg machine".. (see here.) while ACP continues its defense of the legislation.

Even recently one of their blogs defended  Obamacare as providing affordable insurance coverage to "nearly  all Americans" and of course, furthering  social justice. Apparently " nearly all" means all but 31 million, not counting those who recently lost their insurance.  Social justice typically means redistribution to benefit the most disadvantaged.Yes, some of that occurs with AHC as some folks do gain an insurance card (but not necessarily medical care)but it is hard not to realize how much redistribution might occur from the taxpayers to the insurance companies and Big Pharma. These increasingly lame defenses of Obamacare is getting embarrassing.

The great linguistic coup of 21 th century medical ethics

George H. Smith in his book "The System of Liberty" in the chapter entitled "Liberalism,Old and New" discusses how the concept of liberalism and its advocates were victims of a linguistic coup in the latter part  of the nineteenth century.

 The classic liberals thought of freedom as the absence of coercion.They championed the notion of a limited government whose function was to secure the rights of individuals.Enter a group of thinkers who proposed a " new liberalism" , one that would,in their view, correct this inadequate,limited definition of freedom.To the newcomers liberty without equality was freedom in name only  and true freedom involved equal opportunity and power to enjoy one's life. They wanted to replace the idea of "negative freedom" of the classical liberals with what would become  the focus  of  the welfare state.True freedom in their view was more than mere removal of compulsion or coercion.  The new liberals were paternalistic and believed  the state should do much more than secure the people from internal and external predators but rather protect them from the effects of their own uncoerced actions.The classic liberals defended their position in part by asserting that the new liberalism was old wine in new bottles, with the wine being advocacy for a paternalistic government.The new liberals continued to dispense rhetoric that supported liberty but they had redefined the word liberty.

The new liberals won the day and the old or classic liberals lost much influence  but re-appeared in the 20th century with a new label, libertarian. The new liberals were simply known as liberals and later referred to by some as progressives.

I argue analogously that the traditional ,classical medical ethics and its advocates ( physicians themselves) were victims of a similar linguistic coup. Throughout most of the 20th century and earlier the core of medical ethics was primacy of patient welfare and respect of the autonomy of the patient,the later gradually replacing an older paternalism of medicine.Physicians were considered to have a fiduciary duty to the patient.

At the end of the 20th century and the early years of the 21th century a new medical ethics emerged,one in which -while  its proponents claimed nothing had really changed-there was a radical sea-change in regard to the duties of the physician.This was accomplished by nothing more rhetorically solid based  or intellectually justified  than a simple gratuitous assertion.The notion of social justice was simply declared to be part of medical professionalism and medical ethics.The degree to which this bogus concept has been accepted and endlessly repeated in medical publication is a tragic shame.The victims of this linguistic coup are the physicians themselves but to a greater degree the patients are the real losers as they have lost their advocates at a time when they may need them the most.

Obamacare's noble lie meets the iatrogenics of the statute's reality

 Matt Welch, writing in Reason.com ( see here) offers the following concise summary of what is fundamental to making ACA work.

"The estimated scores of millions of eventual health plan cancellations that Americans will soon face are not some weird unintended consequence of Obamacare. They are fundamental to making the law work as written. The Affordable Care Act relies on previously uninsured young people to overpay for coverage they don’t need, and for previously insured adults to pay for health contingencies they will never face, be it childbirth for men or pediatric dental care for grandparents. That is what is supposed to allow more people to be covered and to keep overall rates in check. Since making people’s health insurance more expensive is not particularly popular, Obama lied about it, and not only when he claimed you could keep your plan and your doctor."

It is making some people pay for other people's stuff or in other words social justice. The possibly fatal flaw in Obamacare  is that the payer class is literally getting the bill for this redistribution and they know the bill is being sent to them. This violates the principle rule of redistributional politics which is to focus the benefits and diffuse the cost and don't let those who are paying the cost realize what is happening. Now with Obamacare lots of folks are realizing that are paying for it and they don't like it.

The noble lie,sometimes referred to as Plato's noble lie refers to the situation in which the elite knowingly expresses an untruth  in order to advance an agenda.

The "ball don't lie" expression  is a basketball phrase referring to the  situation in which a foul is called in error and the player awarded the free throws misses. The injustice of the foul is negated by the missing of the free throws.

Jordan Bruneau writing in the blog "Mises Daily" comments on the iatrogenics of Obamacare. The term iatrogenics enlarges the concept of medically induced harm to the more general meaning of unintended negative consequences which harms the very people the act was intended to help. For example, by the end of 2013 there may well be more people losing their health insurance than the previously uninsured who gained a insurance card.Obamacare is the latest poster child of iatrogenics.Rent control,various anti poverty programs and the war on drugs are among some of the numerous government programs that illustrate this principle of negative unintended consequences.

Obamacare was devised with major crony, special interest influences in mind   but poorly crafted,sold to the public by markedly minimizing the projected costs and misleading the public about its negative consequences,rolled out with numerous politically expedient  exemptions to friends of the administration and then  a monumental website failure, and  was soon recognized by millions of people that the law resulted in their loss of insurance and/or significantly more expensive health insurance costs in spite of several ad hoc ,possibly illegal,likely ineffective and possible counterproductive fixes by an increasingly panicking administration .

The ineptitude of the entire project  in its public relations fiasco,its ignoring of the fundamental rule of distributional politics, its ignoring of the rule of law as it executes the law by political expediency   and its world class disjointed complexity resulting in  quotidian unintended consequences brings to mind the following Hayek quote:

 “The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.”

What happens when health care is based on spending other people's money?

Dr. Paul Hsieh answers the question posed in the title in his recent commentary in Forbes. See here.

He outlines four important ominous consequences of basing health care on spending other people's money.

Everyone should read this excellent article in its entirety but let me briefly highlight and comment on the first in the list.

"Doctors will be increasingly expected to save money' for the system ' ."

This is already happening.Various medical professional organizations are re-writing traditional medical ethics, pushing the fiduciary duty of the physician to the patients in the memory hole and substituting the bogus concept of the physician as a steward of society's medical resources. I have ranted about this before but the caravan rolls on and increasingly  the rhetoric  in various medical forums emphasizes saving money for the system. The medicine of the collective is replacing the medicine of the individual. This is being promoted in part by what I have called the progressive medical elite who, to a frightening degree, seem to occupy the leadership position in many influential medical organization . Their unspoken mantra is that medical care is too complex and too important to be left to the individual patient and his physician. Wise leaders with ideas need to be in charge. Of course, it is promoted by the third party payers, private and public who may well consider the medical professional  elite in this ethical paradigm shift as useful idiots.

The notion of "the system" [in regard to medical care] while a rhetorically useful notion for a certain agenda, is basically fallacious aggregating elements that do not belong together. In short, there is no system for health care just as there is no car delivery system or a home building system. It makes no sense to speak of the situation in which someone buys a new car as a cost to the car supply system or a person buying a home as a cost to the home supply system.All of these are transactions in which there are buyers and sellers and exchanges take  place.Mr Jones gets a CT  of  the abdomen.. This is not a cost to any system. It is a cost to Jones and/or his insurance company while to the providers of care it is a payment.. One person's cost is another person's income.To call this a cost to a system is nonsense.Unless all the health care is provided, operated and owned by  a single entity, usually the government., then the services provided  could be considered  a cost to the system.

Who gains from acceptance of this bogus notion of physicians as stewards of some mythical collectively owned medical resources? The third party payers and the medical elite progressives who stand to gain from their position of prestige  as experts and rule makers gain and the rest of us lose.

so why don't we really know about breast cancer screening? Is it really turtles all the way down?

The more I read and the more I think about what I read and the more things seem to change but really stay the same I develop a  renewed sense of just how damn hard is it to figure out what to do or what advice to give in regard to cancer screening as well as other so called preventive measures.

The  verbal scuffles following the USPSTF recommendations on mammograms settled little. The best commentary I have read on this matter is from the amazingly prolific Dr. Roy Poses and is found in this paragraph from his recent blog posting:

One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?

The big clinical questions of which he spoke were:
does screening mammography improve survival
does it improve quality of life
do the benefits outweigh the risk and harms

Yeah, so how come we don't know after all those studies and trials and analysis and meta-analysis.

Part of the evidence that the USPSTF panel used in formulating its recommendations came from a recent meta-analysis. I always cringe a bit when a meta-analysis seems to play an important role in a decision. I am reminded of an commentary by Dr. Steve Goodman regarding what seemed to be dueling meta-analysis regarding the very topic of breast cancer screening.

This is what I said about that before with slight editorial reconfiguration:

[An] important Annals of Internal Medicine Articles and related editorial by Dr. Steve Goodman of Johns Hopkins made it clear to me that meta-analyses (MAs) were basically themselves observational studies in which the studies themselves were subjects. He discussed two major MAs on the value of mammograms, one which concluded they were effective and valuable and the other concluded the opposite.The major difference between the studies was their choice of studies to include and to exclude. Both sets of authors maintained their criteria for exclusion were valid and yet they were quite different and resulted in opposite conclusions. Quoting Goodman:

... this controversy shows that the justification for why studies are included or excluded from the evidence base can rest on competing claims of methodological authority that look little different from the traditional claims of medical authority that proponents of evidence-based medicine have criticized.

I have no doubt that the panelists did their work according to generally accepted evidence based medicine "rules of the game". But along the way both within and apart  from the meta-analyses used in their calculus there are many gaps in which subjectivity and yes even personal bias come upon the scene. When human beings approach problems , gather evidence and analyze it is not evidence turtles all the way down, judgment turtles crawl in.I quote Goodman again:

"Controversies like this one about mammography are
likely to appear more frequently as we move toward reassessing
the evidence base after each new study appears
(15). Such reassessments will guarantee that we are often in
a gray zone between moderate and strong evidence, where
scientific judgment can make a critical difference. We must
learn to navigate within this gray zone better. Judgment
determines what evidence is admissible and how strongly
to weigh different forms of admissible evidence. When
there is consensus on these judgments and the data are
strong, an illusion is created that the evidence is speaking for itself and that the methods are objective. But this episode
should raise awareness that judgment cannot be excised
from the process of evidence synthesis and that the
variation of this judgment among experts generates uncertainty
just as real as the probabilistic uncertainty of statistical
calculations."

I am even more cynical-there may not be any way to navigate this grey zone better. There are many more trade offs than there are solutions.

ACA and " improvisational government"

 Daily, both in the main stream press and in the blogger world, more and more ACA bad news is reported and dissected. But the cancelled policies and the sticker shock, and the shrinking of provider networks  and insurance policy formularies may not be the most frightening aspect of the Affordable Care Act.

"... the most harrowing aspect of Obamacare is that it vests political executives and government administrators with sweeping discretionary power, free of conventional checks and balances. It gives federal officials the authority to set insurance prices without any of the economic and legal standards that govern regulation of public utilities...

Collaterally, Obamacare is introducing a new form of government​—​improvisational government, characterized by continuous ad hoc revisions of statutory law by executive decree. This is a reversion to a primitive form that long antedates our Constitution and rule-of-law traditions. Transported to the modern world, it leaves the private sector in a state of constant uncertainty and subjection."

The above quote is from Chris Demuth writing in the Weekly Standard.. See here for the entire article. Forget Rule of Law, Obamacare is being administered by the rule of men often with the driving motivation being political, minimizing or delaying the bill's harmful effects until after the 2014 election. H/T to the economist John H. Cochrane,aka the Grumpy Economist. See here.

ACA could be described as the "improv health care bill".If provision X of ACA stipulates that this or that be enacted as of a date certain, no problem provision X can be postponed ( until after the next election) . If folks are having their insurance policies cancelled, no problem just postpone those cancellations or more recently pressure the insurers to provide free care. for awhile at least.See here for the latest edict from HHS.If the letter of the law of ACA provides subsidies only under the exchanges that states establish, no problem, just provide subsidies for the federally established exchanges as well regardless of what the plain language of section 1311 might say. See here for a recent update on the legal aspects of that issue.

Section 3, clause 5 of the US Constitution  ( [the President shall] " take care that the laws be faithfully executed" might as well never be written.

 The talking point of the administration has changed from " if you like your insurance,you can keep it" to" if you are unhappy with some aspect of ACA we'll change it".

The increasingly  strident defenses raised by die hard ACA advocates ring less and less credible as they continue to claim that ACA provides affordable health care to almost everyone. More and more folks being stung with higher payments and fewer benefits makes the "affordable" claim much weaker and does "almost all " now mean everyone but maybe 31 millions.( For the CBO estimate for those not insured under ACA,see here.). With July 4,2012 census estimate of the US population being about 313.93 million, just under 10% of the population would not be covered, not to mention an unknown number of the young and healthy who choose to pay the fine tax rather than insurance premium as well as those who have lost insurance and choose not to buy or cannot afford a policy to replace it.


".. constant uncertainty and subjection" was not was Madison had in mind but that seems to be the promise of Obamacare.

Individual risk assessment- Is that a concept that resists meaning?

Following the Annals of Internal Medicine's publication of the latest recommendations of the USPTSP regarding breast cancer screening, was an editorial by Dr. Karla Kerlikowske discussing the need for "individual risk assessment" of breast cancer.See here for excerpt, subscription required for full text

Previously it was a commentary in the same journal regarding breast cancer and the need for "better" (more accurate?) risk assessment in the context of whether women in the 40-49 age group should be advised to get a mammogram. I wrote this entry making the claim that at the core it is debatable if the concept of individual risk risk makes any sense at all as opposed to speaking of the risk of an event in a group of people.

Dr. Kerlikowske begin her final paragraph with this sentence:

We can improve primary and secondary breast cancer prevention effectiveness by implementing risk assessment in primary care and mammography facilities and providing tailored recommendations for prevention based on individual risk.

So what is this thing called individual risk and how do we determine it?

What follows is a re-write of my 2007 blog entry on this issue with the addition of skeptical comments by my brother, Jarrad ,who is a radiologist considering retirement.

Risk assessment for various medical conditions has become an everyday part of the activities of primary care physicians. Risk assessment involves the identification of something called risk factors, personal characteristics or test findings that are associated with increased incidence of a given disease. This term was coined by the researchers in the Framingham study when they spoke of factors that were associated with an increased risk of coronary artery disease. As the "practice model" of internist practices changes from hospital based consultation type to office outpatient, more attention is given to preventive medicine which is a world of risk factor identification and risk assessment exercises as well as recitation of various guidelines and targets or as Jarrad says treating folks who have no demonstrable diseases.

Here is an example of risk assessment using the equation from the National Cholesterol Panel's (NCEP) web site.A 67 year old non-smoking man, Mr. Jones,with a history of hypertension under control and systolic blood pressure of 120, with a total cholesterol of 170 and an HDL cholesterol of 75 would have a risk estimate of 9 % according to their risk equation.

This means that if we consider the 10 year health outcomes of 100 men from the Framingham data base with this particular set of characteristics, 9 would have a coronary event. (A so-called hard end point of either a myocardial infarction or coronary death.) Of course, we do not know who the 9 will be until the event occurs and we cannot tell Mr. Jones if he will be one of the nine or not raising the question of in what sense is this number "his" individual risk.

What does this" risk "of 9% for Mr Jones mean? Maybe the following mind experiment will shed some light on that. Let's pretend we can clone Mr. Jones and we do so 100 times and consider the question of what will be the outcomes of these 100 Joneses. Will 9% have a coronary artery event or will it be the case that either all will be fine or all will have a coronary event. (My gratitude again to Dr. Goodman and his memorable article in the Annals of Internal Medicine for this line of though that I blogged about here.)

If we believe in medical determinism- that clinical outcomes are determined by a causal chain of events-we believe that either all will be fine or all will have a heart attack. They will all be fine if they and the original Mr. Jones do not posses the factor(s) that sum up or interact to bring on an event or all will have an event if Mr. Jones had-as will all his clones have-whatever factor(s) known and unknown which determine a coronary artery event. If we believe in a cosmic dice roll then some 9% will have an event and medical science will never know ahead of the event who will because it is simply random.

Another consideration is that while we have placed Mr. Jones in this set of men with these particular features , we could have -if we had the data available-place him into a different set or as a member of as many sets as the imagination allows. We might consider him as a member of a set defined by his age, his c-reactive protein value, his performance on a stress test, his calcium score on a heart CT scan and his triglyceride level and if we consider the event rate in a group of men with these features we may well arrive a different value which could be 22%. So what is his risk- 9% or 22% or any of the multitude of other numbers that we could construct in a similar manner and are any of these numbers his individual risk? With the  publication of the 2013 Guidelines from AHA and ACC we have a  new prediction tool.Is the new tool better than Framigham and how do we make that determination? What if the expert panel who uses their new rule give recommendations and risk level cut points that differ from what the old expert panel with their predictions and rules? Doctor,were you wrong then or are you wrong now?

That type of consideration led the imminent German statistical theorist, Richard Von Mises to say in his book " Probability,Statistics and Truth" that it is only possible to speak of probability in terms of a collective (or in more modern terms -a set or a group) and that to say, for example, that a given person has the probability 0.10 of dying in the next year is nonsense. Yet, isn't this is exactly what we do when we we punch in a person's numbers into the Framingham equation and announce to the patient that his risk of a cardiac event in the next 10 years is 9%. ?

Jarrad,offers this: "But wait,if you believe that "determination" of individual risk is nonsense why is it that seemingly there are a number of very useful prediction models used by physicians for such things as risk or likelihood of pulmonary embolus given several clinical variables?In what way does the use of those prediction model equation differ from telling Mr. Jones that he has a risk of 9 % of a heart attack in the next ten years?"

Well,  I'm not sure but  one thing is usually those prediction models classify patients into low, moderate and high risk of the disease at issue and based on that certain further testing is or is not done and those strategies seemed to have been shown to work out reasonably well in clinical trials.Further the determination of risk in general terms ( low, medium, high) has at times been proven to be of clinical value in diagnosing pulmonary embolism or whatever, but telling someone their risk is 9% of a future disease is not per se an actionable item.We can link the numbers to some recommendations for statins or whatever but.... I am not sure there is any practical or useful outcome from that. Trying to figure out the best way to clinically manage someone with a given clinical picture is one thing, advising someone to take or not take statins or  bisphophonates based on some "determination" of her risk based on some expert panel's judgment is another matter entirely.Although I spent a number of years doing just that sort thing for many hours per week,now I am much less certain about the validity of the entire enterprise and whether I was doing my patients good or harm.

Obamacare's chief economist does not raise the important "and then what" question.

In a recent interview Dr. Jonathan Gruber,a MIT economist whose name is closely linked to ACA gave a broad outline of who gains and who looses as the legislation becomes operational. See here for details of the interview in the New Yorker article.

Here is the brief overview.

80% of folks are basically "left alone", as they will keep their employer sponsored medical insurance.
3% loose as they will no longer have their individual policies.
14% are winners as they will now be able to obtain medical insurance.

Since there seem to be many more winners than loosers, from a utilitarian perspective, the greatest good for the greatest number has been achieved  and ACA must be considered a success .After all, you know to make an omelet..

So, he seems to say " not much here to see, move one"

   However, there is much more to it than recitation of the alleged head counts of the various Gruber categories.

Economists such as Walter Williams and Thomas Sowell in talking about the economic way of thinking emphasize the importance of asking "and then what ". For example, if some one praises rent controls as providing affordable housing for the disadvantaged, the then-what question might lead to a discussion of how such measures typically result in a shortage of available housing , lower quality of the housing and possible black market behaviors and non-price based rationing.

Had Gruber asked the and-then what question in regard to ACA he might have begun a discussion about how much policies would cost in each subset-would the 80% be paying more or less and would the coverage be better or worse or unchanged. Or even as some reports indicate  (even one by the CBO) that significant numbers of the " left alone" 80% might loose their employer provided health care insurance although not necessarily for reasons directly related to ACA..See here.

The and then-what question could lead to consideration of the issue: will there be enough physicians to care for the significantly increased numbers of folks who have an insurance card. Will insurance companies be reimbursing health care providers at their current rate? Will insurance plans offer significantly less choice as to providers? Further, rules issued from HHS have put providers on the hook for service charges not paid by insurance after a policy holder defaults on their monthly premiums.See here. How far will the rule makers at HHS go as they are continually modifying the law go to minimize any lose insurance companies might incur in the exchanges? See here for a detailed analysis of some of the efforts from HHS to minimize those potential loses.Basically HHS rules changed the 90 grace period to a 30 day period during which insurance companies were at risk for reimbursement of of services rendered .

This day to day, or week to week, ad hoc, de facto central planning  which  "readjusting" of the provisions of Obamacare  as they were written continues in the rule making offices of HHS regularly shredding what is left of the rule of law. The lobbying and crony capitalism continues long after the president signs the law. The article 11 , section 3 part of the Constitution ( " he shall  take care that the laws be faithfully executed" ) might just as well never have been written.

How will the $ 700 billion cut in Medicaid funding which in part pays for Obamacare impact the care Medicare recipients receive? How will the $170 Billion cut in Medicare Advantage impact the quality of care of care of folks on those plans?

Gruber's discussion ignores the secondary effects and only looks at the head counts of those who keep insurance,those who loose it and those who gain it ignoring the cost and quality of coverage and access to care issues that are the unintended consequences.

You can easily see why the " and then what" question is something ACA apologists would rather not dealt with.