Platonic Medicine and the ACA with its IPAB

 A recent commentary by one of favorite bloggers,Dr. Robert Centor, spoke favorably about IPAB, one of many,many provisions of ACA.See here.I made a brief reply to his entry. I recalled this earlier blog entry and if Dr.Centor's comment stirs up much furor  I want to add this earlier blog post to the kerfuffle.Originally published  6/22/11 and now submitted with little editing.

I had been sketching out some comments about what I was going to call "Platonic Medicine" referring to the "leaders with ideas" who will lead the way to transform medicine based on the underlying premise that "medicine is too complex and important to be left to the individual physician and the individual patient" and therefore it should be controlled and directed by the wise medical elite who will determine the collective utility of a given approach and its value.I have commented before about Don Berwick's advocacy of that view.

However, someone had written something in that regard better than I could.See here.

Hat tip to the Pacific Legal Foundation who filed a friend-of-the-court brief to challenge the constitutionality of IPAB on the grounds of violation of the non-delegation doctrine and for the above mentioned link which alerted  me to Jost's frightening comments.

It turns out that an outspoken advocate and supporter of Obamacare,law professor, Timothy Jost has already praised that legislative act in part because of what the IPAB will provide. He said:

A board of “Platonic Guardians” to govern the health care system or some aspects of it. The cost of health care is spinning dangerously out of control…. [O]ur traditional political institutions—Congress and the executive administrative agencies—are too driven by special interest politics and too limited in their expertise and vision to control costs. Enter the Platonic guardians…an impartial, independent board of experts who could make evidence-based policy determinations based purely on the basis of effectiveness and perhaps efficiency.

Incredibly Jost is asserting that this board will be immune to the influence of special interests and will make decisions rationally and in a proper evidence based manner.From what planet will these board member be chosen? Philosopher kings in charge,what could go wrong with that?

The PLF commentary pointed out that a Platonic government was definitely not what the founding fathers had in mind and Jefferson and associates were not big fans of Plato.

In the commentary that I was considering I thought perhaps calling the panel members Platonic Guardians would earn me the accusation of being overly dramatic and hyperbolic, but now we see an IPAB advocate using the same characterization and believing that to be a very good thing.

Dictating the coverage to control the cost for Medicare and Medicaid may not be enough for the medical Platonic elite as is illustrated by this quote from Dr. Robert Berenson:

"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".

I wonder who the "we" is that Berenson references.

Finally, another chilling quote from Mr. Jost:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Yeah, it just might be.

Why is there a shortage of certain drugs?

When faced with a shortage in some good or services a good first guess as to what might be going on is to see if there are price controls at work?

Go here to read a detailed analysis by John Goodman of what factors are at work in the ongoing shortage of over 200 hundred medications. It turns out that at least a contributing factor to the shortage is price controls which are part of a 1992 Federal 340B drug rebate program to certain medical facilities.

Another, perhaps more important governmental factor is at work in the form of the the output controls put in place by the FDA which limits the production of product by drug companies and diminishes their ability to quickly react to market conditions with increased production.

No, price controls are not the entire explanation but government price controls and other regulatory actions impeding market process are playing a role. The situation is more complicated that the two factors mentioned above and some of the other contributing factors are discussed here. But,as the various shortages play out, I'll be it won't be long until we hear that the free market has failed again and more governmental controls are necessary to protect the public.

Peripheral arterial disease (PAD) and smoking, now there is a real relative risk

While I thought there was little doubt remaining about the relationship between cigarette smoking and PAD, a recent study published in the Annals of Internal Medicine (see here for abstract) provided more convincing data, this time in women. Yes, cigarettes are bad for women's peripheral arteries as well.

This study from the Women's Health Study generated some robust, relative risk numbers.I am not talking about the puny 1.2-1.4 relative risks (RRs) we often see in the typical data dredging articles and certainty not the ridiculous RR of 1.01 (not a typo) that was the alleged increased risk of death from vitamin E use.See here for that silliness.

Here are the age adjusted incidence numbers for symptomatic PAD

0.12 never smoked
0.34 former smoker
0.45 smoked less than 15 cigarettes per day
1.63 smoked greater than 15 cigarettes per day

1.63/0.12 =13.6

You are not likely to see RRs greater 10 from the typical data dredge and the WHS data also demonstrated a dose-response effect.

So, how large should a RR be before one worries about it or seriously believes we may have a causal relationship?

Sackett ,of McMaster EBM fame, asked one of the giants of epidemiology that question. Sir Richard Doll said that if the RR were 20 or greater that would be almost sufficient to indicate causality.Sackett was not quite that cautious and indicated that a RR of greater than 3 was "convincing".

Some courts use a RR greater than 2 to reach the threshold of "more likely than not".This is the current level of proof in most tort cases.

Michale Thun, who at the time was vice-president of epidemiology and Surveillance at the American Cancer Society, said:

With epidemiology you can tell a little thing from a big thing.What's very hard to do it to tell a little thing from nothing at all.

With cigarettes and PAD, we have big thing and we will not likely see battling statisticians debating the data. However, we did see that when Nissen's NEJM article claimed a RR of 1.43 for of Avandia and heart disease and we will likely get to see another again with the current breaking news of a RR around 1.4 with Actos and bladder cancer.

Independent Payment Advisory Board (IPAB)-what could go wrong with that?

The IPAB which was inserted into Obamacare at the last minute without anything approaching proper legislative review and contemplation establishes a 15 member panel appointed by the President which will beginning in 2014 ( if a cost limit trigger is met) have unprecedented power to control medical spending in the country with almost no significant or likely effective congressional oversight.

Now what could possibly be wrong with that?

James Madison had some thoughts about that.He was concerned about what he referred to as "factions' which today would be thought of as special interest groups.Special interest groups have developed a potent skill set to influence government bodies to focus benefits on themselves while the cost are diffused.

In general, the founding fathers of the country has some thoughts about what could be wrong with that sort of entity.They tried to design a government not so that wise leaders could do great good but rather one that would limit the damage done by fools,thugs and would be despots who might(most assuredly would) find their way to influential posts in government.

Their wisdom seemed brushed aside as the view of a benevolent and wise government assumed the default position as it was persistently promoted by a cadre of progressive minded academia intellectuals and high school civics texts which visualized a government that would wisely recognize problems,devise safe and effective solutions and then without special favors execute remedial plans marvelously bereft of significant unintended consequences.

Fortunately, James Buchanan and Gordon Tullock resurrected Madisonian wisdom, enlarged upon it and explicated the theory of public choice which basically asserts that government officials and bureaucrats display the same characteristics as other humans, namely a proclivity to look after their own self interest. They definitely had some thoughts about what could possibly go wrong with something like  IPAB.

The economist, George Stigler,who did much to develop the concept of regulatory capture might have some to say about what could go wrong with the IPAB.Governmental agencies and organizations can be subject to the influence of the very groups that they are  nominally created to regulate and control .

Mafia dons and wise guys alike know the explanatory value of the "follow the money" and could explain simply what could go wrong with the IPAB.

Big Pharma had supported the passage of ACA but it is hard to believe that their support would have been forthcoming had they realized what IPAB would be.They certainly recognize the danger now.

The American College of Physicians (ACP) also supported Obamacare but now express opposition to the IPAB section "as written".Although (unfortunately in my view) they do not recommend repeal of IPAB but instead want certain changes that would make the entity acceptable.See here for ACP's position which objects to the exemption of hospitals and hospices from IPAB's edicts until 2019,the absence of primary care physicians on the panel,the lack of a mechanisms for significant congressional oversight and for preserving quality while decreasing costs.

So, much can go very,very wrong with IPAB but it gets even worse. Go here to read a recent commentary by George Will which discusses the chilling thought that the IPAB may not be stoppable. It may well be " entrenched".

Entrenchment refers to one legislative body passing a law that contains provisions that prohibit later legislatures from repealing the law.

Can a legislative body really pass a law that contains a wording to prohibit further changes in that law?Is the IMAB really an immutable entity?

Eric Posner discusses it here and, as best I can translate it from the legal dialect academic lawyers speak into everyday English is that the Supreme Court has decided that they cannot allow that but as with anything that might be litigated there are at least as many sides to the issue as there are interests who can loose or gain from a decision and Supreme Courts sometimes change its mind.

It is hard to find a better summation that the one penned by Mr. Will in his above cited recent column:

"The essence of progressivism, and of the administrative state that is progressivism’s project, is this doctrine: Modern society is too complex for popular sovereignty, so government of, by and for supposedly disinterested experts must not perish from the earth. "

And the corollary for progressive medicine is that "medical care is too important and complex to be left to the individual physician and the individual patient."

minor editorial changes and typo correction changes made 8/17/14.
more corrections made 11/29/14

Harvard economist expresses concern over plans for IPAB

When a main-stream, Harvard economist expresses concern about a entity created by the enormous health care bill (ACA,Obamacare) known as the IPAB, it should evoke more wide spread concern about the wide reaching aspects of the legislation.

Professor Greg Mankiw has written with alarm about what a progressive think tank has proposed regarding the IPAB. See here for his commentary but I believe there is more to worry about than a proposal in regard to the IPAB. Mankiw references a proposal by the Liberal Center for American Progress to allow the IPAB to control the expenditures of private health insurance plans not just those expenditures regarding Medicare and Medicaid.

From what I understand the IPAB already has been given that power by Obamacare.

Dr.Richard Fogoros writing in his blog The Covert Rationing Blog explains how the IPAB was created and what it is authorized to do beginning in 2014. His reading of the statute indicates that this presidential appointed panel already has the legislative authority to limit expenditures by private health insurance companies. His analysis also describes how difficult it will be for Congress to over ride the panel's edicts. See here for his comments.

Remember the notion that "more [medical care] is less " and harmful as well -Guess what

Dr. Buz Cooper sticks a dagger in the heart of the non-sense that claims more medical care is harmful and less care is better. See here for his take on the latest study from the Dartmouth group which seems to contradict the mantra they have been selling to the gullible and to the progressive planners for years.

Dr. Cooper sums it up this way:

"Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE."

Isn't this what common sense would suggest?

Being a (public health) expert means never having to say you are sorry

One of the continuing pleasures of following and sometimes participating in the world of medical blogging is the enjoyment of watching some bloggers who regularly hit things out of the park. I am thinking particularly about DrRich (aka Dr Richard Fogoros of the blog " the covert rationing blog") and his recent commentary about public health efforts that go wrong,sometimes badly so,and how the experts cram their previous advice down the memory hole and go on with their latest recommendations . See here for his latest and then here for an earlier spot-on critique of our public health brothers and their follies .

Public health experts enjoy a decision making advantage over the medical doctor who has to often take aggregate data-such as randomized clinical trials but often less reliable data) and then attempt to apply that to the individual patients sitting in his office.All the public health expert has to do is to look at the aggregate data and base recommendations on that while the practicing physician realizes that lying under the summary statistics are individual patients some of whom may will benefit from the proposed treatment while others are unaffected and still others are harmed. Life in the dealing with real patient trenches is more complicated ,nuanced and reality based than in the offices of the academic public health experts who can base their conclusions and recommendation on the utilitarian imperative .

DrRich talks about public health experts " displaying every ounce of the overblown self-confidence traditionally enjoyed by the expert class operating within our Progressive
institutions "

The public health experts share the following view with " leaders with ideas " who vie for the position of architect in the redoing of American health care :

The basic tenet of what I call the medical progressive is that:

health care is too important (and too complicated) to be left to the individual physician and her patient.

"..to demonstrate to men how little they really know about what they imagine they can design.

This F.A.Hayek's quote was directed to the central planners who believed they could control an economy from a governmental perch and did not need the knowledge derived from competition of a price driven market.The problem of knowing what and how much everyone should and should not eat is of a different sort but Hayek's words can function as a much needed counterpoint to their hubris .

Is WHO's "World Health report 2000" the worst study ever?

After reading the commentary (see here )by Dr. Scott W. Atlas I would give that publication my vote as the worst or darn close to it. Dr. Atlas is a Senior Fellow at the Hoover Institution and is chief of neuroradiology at the Stanford University Medical Center and has a long list of scientific publications to his credit.

It is amazing how often sound bites from that study are quoted not only by the main stream media but also recited as gospel by medical researchers often in the boiler plate introductions to what otherwise would legitimately pass for a scientific publication.

How many times have we been told that something must be done about the U.S. health care system because although the U.S. spends 16 % of its GDP on health care it ranks 37th (out 191 countries) in something the WHO staffers called "overall performance".

Dr. Atlas said the the WHO publication " ranked countries according to their alignment with a specific political and economic ideal-socialized medicine-and then claimed it was an objective measure of "quality" ".

Quality,which is always a usefully ambiguous concept, was in the view of the report's authors the degree to which a country had distributed wealth and centralized administration of health care.

Atlas explains that 62.5 % of the overall performance index created by the report to rank countries was an assessment of one particular concept of equality and not about health care outcomes at all.

Quoting Dr. Atlas :

In fact, World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all.

Read Dr. Atlas's commentary for more details of the methods used by the WHO staffers to achieve this propaganda masterpiece. I expect politicians and policy wonks with a particular agenda to quote the WHO's factoids but it is embarrassing to see medical researchers use the bogus material from the report as fillers and appropriately politically correct genuflexions to the notion of social justice in their publications.

Can this really happen in the U.S.?

This commentary is fairly far afield from the areas of my usual writing but the facts are so egregious and frightening that I had to say something. The topic is civil forfeiture. I defer to the excellent commentary on this subject by one of my favorite writers,Dr. Donald Boudreaux who is trained in economics and the law having a PhD in the former and is teaching at George Mason University.See here.

The case he discusses and the subsequent decision of the Supreme Court can fairly be described as mind-boggling , the dictionary definition of which is "intellectually or emotionally overwhelming".

In regard to the case,Bennis versus Michigan,Boudreaux and his co-author, A.C. Pritchard, said in part the following:

[the Supreme Court's decision] allows government to impose huge costs on people never charged with criminal wrongdoing"

Those of us who,probably against all reason,still think that the Supreme Court will overturn Obamacare find little hope that the supremes will do the right thing after one reads their decision in this case.

A slightly positive note is this was a five to four decision by the court and one of the dissents was penned by Justice Kennedy who is generally thought to be the possible swing vote when the health care bill gets to the court. Maybe he will do the right thing again.

Will the over crowded ERs generated by Obama care reflect social justice

As the facts continue to flow out of various analyses of Obamacare and we learn that it will not keep the nation from "going bankrupt"and (shockingly) it will actually cost money and that various elements of it have to be postponed or exemptions for certain provisions have to manufactured to avoid voter push back in 20122, advocates are running out of justifications and may have to fall back on their claim of furtherance of social justice.

Some Democratic Senators and several spokesmen for medical organizations risked shoulder injury so exuberant were their efforts at self congratulation when the bill was signed into law.To be able to discern what the results would be in a bill so long, dense and ambiguous regarding details would require analytic ability not yet achieved by any creature who evolved on this earth.In fact, the details of the bill had not yet been written as the particulars were in numerous instances delegated to government entities for rule making some of which were yet to be formed.

Down the road there will be a situation in which this justice will be quite visible.That will play out in the emergency rooms across the country. The rich and the poor alike, those with insurance cards and those without will wait together as increasingly overworked and overstressed ER docs ( and their physician extenders) try and cope with the infusion of 30 plus million more insurance card holders into the health care system. Everyone waiting together to be screened by the NP or PA or as things evoke a NP assistant will give a lovely portrait of the wisdom of the central plan for [almost] everyone having nominal access to medical care but operationally finding little of it.

Social justice typically means redistribution and accordingly to CMS czar Dr. Donald Berwick good medicine must mean redistribution . Easier access to health care will be redistributed and diluted so that everyone gets to wait and wait and everyone's quality of care goes south.

For those of us who hope that having a retainer doc will help, and I think it will, here is a sobering thought and something else to worry about. With more vertical integration of medical care and the latest acclaimed saviors of medicine (the ACOs) becoming prevalent and perhaps dominant, will independent retainer docs even be allowed to admit and treat patients in a hospital or will her patients also end up in the increasingly long lines in the ERAs and the retainer physician unable do anything about it.Is there really anyway to escape from the clutches of Obamacare? Will it all be up to Justice Kennedy? Will it even be possible (i.e. legal) for someone to purchase health care outside of the centrally planned system? If you have not worried about that issue before I suggest you visit this and other commentaries by DrRich.

Here is a commentary from NPR on what ER docs think will happen when millions ( about 34 million) of new folks get an insurance card to show the clerk in the ER. Let us see-increased demand and no significant increase in supply combined with the already in place price controls in Medicare just might mean shortages , long lines, and decreased quality of care.You think.

The semi-secret RUC is getting less and less secret

The RUC (more formerly known as the AMA/Specialty Relative Value Update Committee) up until recently has been an obscure creature of the AMA about which little was known and even less was written about. Thanks to a number of physicians,including Dr. Roy Poses, more and more information of the composition of that group is being revealed. See here for Dr. Poses's latest revelations about the current members of the RUC and and some of their relationships which might represent conflicts of interest.

Not only are we treated to looking behind the curtains but there is an organized effort to opt out of the RUC influence. See here for information about the "Replace the RUC" effort.

Dr Poses raises several of the unanswered questions regarding the RUC. The one that interested me for some time is this. Why was there and is there so little outcry about the central governmental management of physician's fees, i.e. price controls.? (If there is anything Keynesians and non-Keynesians agree on it is that price controls lead to shortages and decreased quality) Could part of it be that the AMA whose brainchild we are talking about kept the whole process obscure and largely behind the scenes?

How bad is the Supreme's denial for expedited review of Obamacare?

According to David Catron the news is really bad for those of us who still hold out some hope that Obbamacare will be stopped by the Supreme Court. Here is his commentary in the American Spectator. While the issue(s) crawl though the courts, the "leaders with ideas" are cranking out rules and regulations for the statute's implementation.

Meta-analysis fails to show all-cause mortality benefits to statins in primary prevention

A 2010 meta-analysis by Dr. KK Ray et al ( see here for full text) in the Archives of Internal Medicine stirred a bit of interest and commentary as it failed to show an all-cause mortality benefit from statin use in the setting of primary prevention in patients with elevated risk factors for coronary artery disease.

A few context setting comments are in order. First, it is well established that statins are clearly beneficial in secondary prevention of coronary disease. In patients with proven coronary artery disease few would disagree with statin use.Its efficacy and safety have been demonstrated in several of the well known so-called landmark statin trials.

Second, the argument is strong for the conclusion that statin use in primary prevention results in a decrease in cardiovascular (CV) deaths. The authors of the Archives article make their position clear in that regard when they say in their comments sections "the benefits of statins in CV deaths are unequivocal based on primary prevention data from the CTT meta-analysis." The Cholesterol Treatment Trialist Collaboration or CTT was published in Lancet in 2005 ( see here ) .

So, the issue that Ray and his fellow authors addressed was not do statins reduce CV mortality in primary prevention but do statins reduce all cause mortality and their data analysis lead to the conclusion it does not.

Ray analyzed data from 11 randomized clinical trials of patients with what they considered to be high risk for coronary artery disease ( 244,000 patient years). Big numbers for patient years tends to give credence to findings but the key thing here is that in these trials the follow-up period was only 4-5 years as is typical of clinical trials. In patients with increased CV risk -as opposed to patients with proven CAD-the ratio of CV deaths to total deaths is relatively low particularly in a 4-5 year time frame. So that it is not surprising that all cause mortality may not be decreased, which is what Ray demonstrated.

Both the editorialist in the Archives and a subsequent commentator in a Update section in the April 5, 2011
Annals of Internal Medicine seem to conflate failure to show decrease in all cause mortality in a short observation period with overall lack of benefit. Ray and co-authors do not deny benefits in terms of decrease in C-V mortality.
.

Major cuts in Medicare Advantage postponed until after election

Remember how we were told that if ACA ( Obamacare) were not passed the country would "go broke". Obamacare would reduce the deficit. One of the cost saving mechanisms contained in the bill was a major reduction in Medicare costs including significant reductions in Medicare Advantage (MA).This was supposed to bolster the long term solvency of the entire Medicare program. Now the Obama administration has decided to postpone saving the country from going broke until after the election and actually spend a little more money of the MA program.Why? To avoid a voter push back from looming cuts in Medicare Advantage seems the obvious answer . AARP can't be happy with that. See here for more on AARP.

See more about the Medicare Advantage ploy from Black Ribbon Project blog here. Also I commented on this egregious political play before.

Another alleged cost saving proposal included in Obamacare was the Community Living Assistance and Support Act (CLASS).

Early on, opponents of the health care bill insisted that its provisions were not fiscally sound and were placed in the bill to give the illusion that Obamacare would cost less than the magic one trillion dollar price tag. The plan was to front load the plan with premiums without any benefit payments for a number of years. It was advertised as a mechanism to decrease the federal deficit by 86 billion over a ten year period. Now even with the deck as rigged as it was it will not work . The Secretary of HHS has admitted that.

More and more elements of the Obamacare monster bill seem to be either unraveling completely or postponed until after the 2012 election.

Still more data on adverse and beneficial effects of statins

Here is a recent article in the BMJ detailing the absence of numerous adverse effects of the statin class of drugs and the occurrence on a few beneficial effects. The article mentions cataract as a complication of statin therpay , an adverse effect that was of concern in very early animal work by Merck but about which I had stopped worrying until the BMJ article. In fact, there was this study from 2010 which claimed the opposite, i.e . a decrease in the risk of cataracts from statin use and this 2003 fairly large case-control article that found no effect in regard to cataract.


For a while those who read or skimmed medical literature were treated to an array of articles that claimed numerous effects of the statins that were not just further evidence of the pleotrophic effects of statins but were really just short of miraculous. I wrote about some of those claims here. Most of those claims did not pan out. Another claim,that of the statins causing an epidemic of heart failure made by Dr. Peter Langsjoen ( see here),does not appear verified by the BMJ article.

Federal Judge" Entitlements" are mandatory-people are trapped [in Medicare]

Regulations put into place during the administration of Bill Clinton prohibited folks from opting out of Medicare part A unless they agreed to forgo their social security payments ( and pay back whatever SS funds they had received).

It seemed to take a long time for someone to challenge this rule but someone finally did and the federal judge presiding over the case has now rejected the case with an appeal pending. Here is a link to the decision by the US District Court Judge Rosemary M. Collyer.


Her convoluted and self-contradictory reasoning (see here) concluded that this entitlement ( to Part A) is mandatory .To some the notion of a "mandatory entitlement" may seem Orwellian but at least the judge did offer some interesting comments in her written opinion that suggests lawyers even when they become judges might retain a sense of irony.

For example Judge Collyer said in her conclusion:

Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole...

In her introduction she stated:

Medicare costs are skyrocketing and may bankrupt us all; nonetheless, participation in Medicare Part A (for hospital insurance) is statutorily mandated for retirees who are 65 years old or older and are receiving Social Security Retirement (so-called ‘old age’) benefits. Whether Congress intended this result in 1965 or whether it is good fiscal and public policy in 2011 cannot gainsay the language of the statute and the regulations

It seems to me she might have well said, the program is ridiculous but that is the law -get over it.

DrRich takes up this case (see here) in his blog and considers this case in the broader context of his lingering (or growing) concern about the possibility that down the road seniors and others may face a health care system which prohibits the patient from purchasing any health care not approved by the central authorities. See here for his earlier commentaries on the efforts to limit individual prerogatives in obtaining medical care. I share his concern.

Follow the money rule suggests reason for AARP support of Obmacare

The venerable follow the money rule continues to have explanatory power. This time, apply it to AARP's support for the health care overhaul-reconfiguration bill and presto we have a plausible explanation for AARP support for the bill . Simply put, AARP makes a hefty brokerage fee for selling Medicare supplemental policies and Obamacare dealt a blow to the Medicare Advantage programs so that it is likely many senors will migrate from MA plans to traditional Medicare and will likely purchase a supplemental policy the sale of which is a major income stream for AARP.

See here for details about how much money AARP might make as a result of changes brought about by the health care bill that they vigorously supported.

Meanwhile surveys suggest that most seniors believe Obamacare will diminish access to care for them (that they are the Peters robbed to pay Paul) and more entities are receiving waivers from some of the provisions of Obamacare. Things just get better and better.

Earth Day again-time to look at the satellite view of Korea

Rather than encouraging school kids to guilt their parents into turning off the lights for a while to "celebrate" earth day ,my suggestion is for school teachers to assign an essay to their charges. The topic-why is North Korea dark and South Korea lighted as illustrated in this iconic image.

An alternative topic might be what would our lives be without electricity.

Here is an earlier earth day commentary offered as a counterpoint to the usual sanctimonious
earth day platitudes and indoctrination of youth with the secular religion of naive environmentalism with its rituals of turning off lights and mindless recycling.

Finally, here is an essay from the economist Steven E. Landsburg from his book "The Armchair Economist" in which he makes the distinction between the religion of environmentalism and the science of ecology and makes clear my choice of "mindless" to modify "recycling", putting forward the notion that recycling per se is not a moral issue and therefore always right (or wrong) but each case is an empirical one.

Still another argument against P4P

I have based my opposition to P4P in medicine on several lines of argument. These included :

1) It is unethical (see here for the comments of Drs. Edmund Blum and Faith Fitzgerald)

2 ) it often is a disingenuous method to control costs with feigning a desire to improve care

3)Goodhart's Law (see here).

Now the prolific Dr. Doug Perednia offers another reason to oppose P4P. Read about it here ( this is part 2, read Part 1 also). He offers a brief and very instructive introduction to a field of study known as Self-determination Theory (SDT) and relates that to the P4P issue.

SDT is based upon the idea that there are many things that people do not for the promise of external reward, but because of some sort of intrinsic, human desire for autonomy, competence and relatedness.

Including in that category of things people do not necessarily because of carrots and sticks is the practice of medicine.

The theoretical and empirical case against P4P has grown so strong that the only reason physicians and their organizations put up with it must be they just want to go along to get along.

HHS gets more efficient , now giving an entire state an exemption from Obamacare

The task of giving exemptions to aspects of Obamacare company by company might have proved to be to time consuming for the Department of Health and Human services so they are issuing state by state. See here.

The state of Maine was given a waiver,good for three years,exempting health care insurers from the requirement that they spend at least 80% of premium fees on actual patient care. In Maine, at least for a while, 65% will suffice.

Earlier Maine's secretary of insurance has expressed concern that one company,Healthmarkets,Inc, would drop coverage for policyholders and leave the state.See here for some background on that company .