BobbyG's Binge Thinking

On "Envy"

2012-01-29T18:28:00.000-08:00

So, tonight, I'm watching the SAG Awards on TV with one eye/ear as I tend to other stuff. I just had this tangentially connective thought as I ruminate on the 2012 presidential campaign.

MITT ROMNEY: "This country already has a leader who divides us with the bitter politics of envy. We must offer an alternative vision. I stand ready to lead us down a different path, where we are lifted up by our desire to succeed, not dragged down by a resentment of success."

"The bitter politics of envy?"

Well, apropos of Mr Romeny's facile assertion, the graphic above pretty much sums up my "religious" beliefs, in addition to the "Thou Shalt Not Covet" admonishment of the Ten Commandments. Not that I'd fully assimilated all of that by age 5 or 10 or so. It took a remorse-precipitating, reflective whack upside the head by Kant and others in Grad School to fully drive the point home.

Well, so, yeah, of course, Mr. Romney's comment is the to-be-expected low-road hyperbole characteristic of much of American politics any more. Newt Gingrich and Rick Santorum and others have expediently riffed on this same shallow and dishonest anti-Obama theme ad nauseum as well.

to wit:

(Jan 29th, ABC News) House Speaker John Boehner defended calling President Obama’s economic message “almost un-American,” saying that the president is dividing middle income and wealthy Americans.

On Tuesday before the State of the Union address, Boehner criticized the president’s calls for increasing taxes on the wealthy, telling a group of reporters, “This is a president who said I’m not going to be a divider, I’m going to be a uniter, and running on the politics of division and envy is — to me it’s almost un-American.”

In an interview on “This Week,” Boehner told me, “What I’m talking about here is the politics of dividing America, the politics of envy. This is not the American way.”

Right.

As I watch the latest annual tripartite mutual love feast celebration of the Hollywood gliterati (Globes, SAG, and Oscars), I am struck by the extent to which we, in the aggregate, love our cinema stars and those who produce their works, people who mostly live lives of luxury utterly beyond our comprehension. Yeah, we'd all like to experience such comforts and perks. But, we don't begrudge them theirs.

NOTE: I am more in love with the work they do. It never ceases to amaze me that any film every gets made. The technical, logistical, financial, and ego-management requirements make the mind boggle if you are a diligent student of film at all (e.g., Google "Heaven's Gate").

Mr. Romney, we don't resent "success," we resent those who obtain it via slick zero-sum subterfuge that adds nothing to the advancement of a just, sustainable civilization.

People like you.

A generation passes

2011-11-11T12:16:00.000-08:00

Above: I shot this in March 2007 at the assisted living place in Palm Bay, FL where I'd moved my Ma to in January 2005 after she could no longer safely stay in the house just a couple of miles away, where they'd retired in 1973. In July I moved her to Vegas (I'd moved my late Dad in May that year; he had serious dementia and was already in nursing home care since the fall of 2001).

Below: she managed to clutter up that apartment pretty quick. That ugly roll-out bed couch was my swell recurrent Delta red-eye bunk 'til I moved her and Pop to Vegas.

My Dad came home from the war in Europe (minus a leg) and married my Mom in August 20th, 1944. I was then born in February 1946. Pop died in May 2008. I will miss them both greatly. They were loyal to each other and loyal to me and my sister and all the grandkids.

I owe everything to them.

Above, circa 1974 or so. Below, Mother on her 88th birthday, January 18th, 2010. We took her to Olive Garden in Henderson, "Awlive Gawdin," as she put it in her finest Long Island accent.

That was her last marginally decent year. Below, Mom and Dad visiting at the nursing home where he resided in Melbourne FL prior to my bringing them both to Vegas.

A good, long run, both of them.

UPDATE

We had a celebratory supper Sunday evening at the Olive Garden in Henderson where we'd last taken Ma, for her 88th birthday. My sister Carole read for us a reflection she'd composed.

Marion Elizabeth (Dittus) Gladd,
January 18, 1922 - November 10, 2011
How do you describe the life of your mother when you don’t pay attention to the details while you are a child and it’s all about yourself and not about the person who chose to bring you into this world? After having 5 children, I realized what my mom must’ve gone through raising two children. And she (and my dad) did a pretty decent job when you read about what goes on in families nowadays. I often think -- how did they manage to raise two children who generally are compassionate and reasoned people? It must’ve been their lifelong concern for us and our families. Selfishness was not part of their character when it came to their kids.

My first recollection of my mom was in Morristown, New Jersey (George Washington’s stomping grounds!). I remember her taking me to a birthday party -- I remember being shy and not wanting to go but I didn’t have a choice. I remember kindergarten and her leaving me there and I remember being scared. Never gave one thought to the fact that she was now alone, both children in school. I wonder what that was like for her.

My next recollection was our “farmhouse” in Hanover, New Jersey. What a wonderful home that was -- a big old home, with a wrap-around front porch and a walk-around attic to die for. Interestingly enough, years later as an adult, I was talking to my mom about that house and she said that she hated that house. Once again, what she must’ve given up so Bobby and I could have this interesting outdoors experience -- I think Bobby even built a log cabin in the woods and I remember scooping up frog eggs in this jellylike glob form from the pond in the woods next to our home. And that was the house where I got my first “cat” addiction—our landlord, Mrs. Weber, gave me a cute little black and white kitten and the same day she ran over it with her car! No pets after that one! That’s why I’ve been making up for it ever since -- in fact, Bobby has a bigger zoo than me.

The next move was to Hillsborough right before I started 4^th grade. We moved into a brand new development with the ranch homes and the split-level homes. Already, you knew the people who had split-levels had to have more money -- or that’s how I perceived it. My mom was the typical 50-60’s stay-at-home mom. Little did I know what a gift she gave to me. She made my lunches, she was always there when I got home from school, and I always had a very well balanced meal with the dreaded green vegetables. My mom was a great cook -- and I mean great when I compare it to my paltry cooking skills. And I hated to eat--I didn’t like anything -- I know it’s hard to believe when now there isn’t much I dislike. And both my parents were adamant that we clean our plates. And Bobby always got away with murder at the dinner table—pushing his mashed potatoes out of his mouth to make me laugh -- which I did -- and which I got punished for.

My parents somehow got across to Bobby and I that you don’t get a free ride and you take care of yourself and be kind to others. It was expected that we do well in school. I know I feared both my parents -- but I can’t really remember getting disciplined except for the occasional swat on the behind with the rolled up newspaper -- and that was dad. I don’t remember Mom ever physically disciplining me -- but I knew when I disappointed her and that was enough punishment. Now it’s coming back to me -- mom was not happy when I said “shit” -- which is minor to what I’ve said in front of my kids. And mom never liked me calling her “Ma”. I guess it was considered slang, and not proper.

Growing up, I thought my mom and dad were too strict and too “proper.” I remember having to go to St. Paul’s Episcopal Church in Somerville, New Jersey; Dad never had to go -- and I used to wonder, why did I have to go and he doesn’t? But I never really questioned or fought the idea -- I just obeyed. And mom made sure I had all the fixings for church--dresses and white gloves. And the dreaded hats at Easter!

I always wished my parents had done more fun things with my friend’s parents. Their houses were the fun houses. They had pools -- I wanted one in our back yard—but, no, couldn’t have one because of liability. Something I didn’t understand until I had children of my own. But I spent a lot of time at my friends’ homes. But here’s the kick -- while I was enjoying my free time at their houses away from my “strict” home, their families were falling apart. Little did I know at that time, that what I perceived as “being too strict” was that they were giving me security -- actually life long security.

And then I went off to Bowling Green, Ohio, for college. Once again, it never occurred to me the loss for my mom -- having both her children, who she devoted her life to, moving so far away. And then Dad retired and made the decision to move the both of them to hot and humid Florida. And then my mom rose up out of her compliant 50’s mode, and started speaking up for herself. A lot of fights ensued between the “happy couple” but they miraculously persevered as a couple to become the most unselfish grandparents on the planet.

Mom never gave me raising children advice. I remember when we had our first child David in 1975. And Tony and I knew nothing about raising babies. And mom was just as puzzled as us -- never made me feel guilty if I used a pacifier or picked David up whenever he cried. That was the first time I felt closer to my mom.

My parents never missed one of my children’s birthdays, Christmases, Easter or the first day of school. There was always a check in the mail or a box filled with gummy worms, little Debbies, and all sorts of treats and clothes -- and it really helped us financially since I too was a stay at home mom. I remember in 1989 when April got so deathly ill and Tony had to drive with 4 kids to Ann Arbor. The brakes went on the car and Mom and Dad stepped up to the plate and gave us $2,000 for the repairs (must’ve been a few other things wrong with the bomb!).

I know my mom was the moving force when it came to helping Tony and I. They came for every event in our lives too -- when Tony graduated, when he got his Master’s, when the kids were born, and finally for high school graduations. They always made the effort even if their visits sometimes drove me crazy.

Regardless of all the pain my mom endured in her life, she somehow managed to carve out good lives for Bobby and I -- we wouldn’t be the people we are and we wouldn’t have the loving families we have if it hadn’t been for her love from the first moment we were born. She did a good job and I thank her from the bottom of my heart for what she gave unselfishly to my family and I.

I will miss her silliness, her friendliness, her jokes and her patience. I will never forget the “digitized” TV, the trips to Patrick Air Force Base, the walks on the Officers Club boardwalk, the endless restaurants such as Friendly’s—you know, the one who banished my mom!!! And I remember my mom’s meatloaf -- a recipe I have from her--that I will make when I get home in her honor. Nathan will wonder what is wrong with his mom -- “she’s cooking a meal—really?”

Well, mom, you obviously gave me the gift of gab, so until I see you again—I love you.
Your daughter, Carole Elaine

Wow.

SUNDAY, NOV 20th

They Married in August 1944. Pop died in May 2008, my Ma ten days ago. Feeling rather sad today. Got my Mother's ashes Friday. I just shot that out on my driveway, on a piece of wood on my sawhorses. Good light today with the overcast.

The little blue and red thing beneath this photo arrangement is my "blankee" -- one of the few surviving physical artifacts from my young childhood.

My heart goes out to Steve Jobs' family and friends

2011-10-05T17:19:00.000-07:00

I hope others can step up to fill this void.

To Nevada Governor Sandoval

2011-04-03T19:32:00.000-07:00

Subject: Your proposal to eliminate the UNLV Department of Philosophy
From: Robert Gladd
Date: April 3, 2011 3:11:32 PM PDT
To: president@unlv.edu, neal.smatresk@unlv.edu, regentjamesdean@aol.com, jgeddes@sbcglobal.net, malden@nevada.edu, andrea_anderson@nshe.nevada.edu, william_cobb@nshe.nevada.edu, cedric_crear@nshe.nevada.edu, mark_doubrava@nshe.nevada.edu, ronknecht@aol.com, kevin_melcher@nshe.nevada.edu, jack_schofield@nshe.nevada.edu, michael_wixom@nshe.nevada.edu, michael.bowers@unlv.edu, chris.hudgins@unlv.edu
Cc: dschrade@udel.edu, Jon Ralston , mike.campbell@lasvegassun.com, brian@lasvegassun.com, danny@lasvegassun.com
___

Good day,

I first learned of the Nevada budget reduction proposal advocating the elimination of the UNLV Philosophy Department in the Las Vegas Sun on March 29th in an article by J. Patrick Coolican. I was aghast. I ask that you reconsider, and take this proposition off the table. It could not be more antithetical to the very purpose of an institution otherwise positioning itself as an "Up and Coming Urban Research University" with a goal of attracting excellent faculty and students via whom to help make this state and our world a better place. You have other viable alternatives at your disposal.

Let me first cite a salient excerpt from the March 23rd, 2011 letter from David E. Schrader, Executive Director of the American Philosophical Association:

"The AAC&U has done substantial work surveying the needs of America's businesses. AAC&U data indicate that 81% of employers want universities to place greater emphasis on Critical Thinking and Analytical Reasoning skills. 75% want universities to place greater emphasis on Ethical Decision Making. These are precisely the areas in which philosophy plays the most significant role."

Indeed, and the irony here could not be more acute. That we are now find ourselves in this painful circumstance of acute economic travail, both nationally and in nearly every state, is in large measure the direct result of a political, legal, and economic culture run amuck in Gresham's Law fashion, where -- absent effective and rational regulation driven by ethical acuity -- the Bad inexorably drives out the Good. The examples are by now legion (and dispositive, in my view). I need not cite them, but I do need to emphatically add my voice here for the ongoing -- no, heightened -- importance of critical thinking and ethics coursework offerings at the university level. We have no shortage of trade schools and otherwise career-dollar focused curricula. This is absolutely not the time for retrenchment in the reasoning and ethical arts and sciences.

I am a quantitative analyst and writer of long, broad, and deep experience spanning multiple domains (see www.bgladd.com/papers). I am also a mid-career 1998 graduate of the now-moribund UNLV Institute for Ethics & Policy Studies (comprised of faculty drawn mostly from Philosophy). I count the upshot of my experience there as an invaluable, cherished asset, and simply the best academic dollar value I ever received. It served to appreciably leaven my otherwise native polemical, iconoclastic tendencies with an indelible sensitivity to the continuing challenges posed by the inseparable attributes of both objective analytical reasoning and moral/ethical inquiry. I now try daily to bring these skills to my work in health care information technology as part of the national effort to improve our health care system. I blog about these topics here:

http://regionalextensioncenter.blogspot.com
http://bgladd.blogspot.com (see health care post links in the upper right links column)

I am also a Senior Member of the American Society for Quality (ASQ), a 22 year veteran of that organization, and a person long committed to the ideals, strategies, and tactics of continuous improvement. The organizational literature is by now fairly replete with solid evidence of the significant cost-saving opportunities available to organizations of every stripe, public and private. Systematic, carefully implemented process improvements have repeatedly been shown to result in operational cost savings of as much as 30% or more (and I would speculate that academic institutions in general are in the upper range of quantifiable process improvement opportunity). This is wherein lies your opportunity for sustainable improvement and subsequent institutional budgetary viability (and not just at UNLV).

Let me be clear: I am by no means a reflexive apologist for the administrative or curricular status quo at the UNLV Department of Philosophy nor its parent institution. Nonetheless, what you are proposing will achieve little if anything of long-term benefit while introducing much of real short- and long-term harm. Please reconsider, and strike this proposal.

Thank you for your time.

Sincerely,

Robert E. (Bobby) Gladd, MA/EPS
www.bgladd.com

Las Vegas: The next Anasazi Ruin?

2011-01-29T20:08:00.001-08:00

Lake Mead, which now supplies the Las Vegas Valley with 90% of its water, has dropped 128 vertical feet since January 2000, and is now at roughtly 43% of capacity (I track these data monthly and drop them into Excel, from which I generate the above graph). It came back up 4 feet in December 2010, owing mainly to severe and sustained west coast and Rocky Mts watershed rains and snows, but, will likely again continue to decline. I shot the photos below in June 2009. The lake has dropped another 9 feet net since then.

When my wife and I relocated to Las Vegas in 1992, 1/3rd of the area's water came from the Spring Mountains watershed to the west of the valley, but the western watershed groundwater levels comprising that resource have declined significantly as well (for the most part owing to our sustained drought and -- until recently -- intense population influx). Below, Lake Mead at Hoover Dam during happier hydrological times.

In response to the dramatic lake level decline, the Southern Nevada Water Authority has proffered a plan to construct a pipeline into Lake Mead via which to obtain water from the northern rural ranching and mountain areas of eastern Nevada along the Utah border. But, the political pushback against this proposal has proved quite formidable. Critics call it another "Owens Valley" debacle, arguing that rural Nevadans (and nearby rural Utah residents). should not be sacrificed for the benefit of even more Las Vegas urban growth just to further enrich developers and the gaming industry.

Clark County, NV (the greater Las Vegas metropolitan area) is now home to some 2 million residents.

It is, long-term, an ecologically unsustainable region, and, absent gaming, would likely be another (perhaps slightly larger) Barstow -- one more dessicated, hardscrabble truck and rail stop of 30 to 40,000 people along the route between Los Angeles and Salt Lake City. Everything is brought in here by truck, rail, or aircraft. With the exception of water (for now).

AN EXCELLENT SERIES FROM THE LAS VEGAS SUN

[Click above to go to the story]

"Las Vegas was first settled for its springs, springs that made it an oasis in the desert. Although those springs have decades since run dry, water is still the most import resource to Las Vegas and the dry Southwest.

And by all indications the region is only going to get dryer. Scientists predict devastating effects from global warming, conservationists are calling for a halt to growth in Southern Nevada as a way to preserve supplies and water managers are looking to ever more creative ways to reduce reliance on the overburdened Colorado River. A Colorado River reservoir at Lake Mead is the source of 90 percent of the valley's water supply. Water levels there have fallen steadily for nearly a decade..."
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DESALINATION TO THE RESCUE?

Consider some attributes of sea water.

One acre-foot of sea water (325,851.4 gallons) weighs roughly 1,390 tons and contains about 40 tons of salt, and another 7 tons of lesser chemical constituents. The technologies for transforming salt water into potable fresh water are relatively mundane (albeit energy intensive). A net 96,500 acre-feet of potable desal water (100,000 acre-feet less the brine constituents) could serve perhaps 300,000 household per year. But, beyond the KwH energy cost of production, there would remain [1] the considerable expense of transporting it to the destinations of need, and [2] environmentally benign disposition of the 4.76 million tons of the residual chemicals (mainly salt), which are typically simply slurried back into the oceans proximate to the desalination plants.

You can just to a little transport arithmetic starting with a gallon of fresh water (post-desal processing) at 8.35 lbs: equivalently ~1360 tons per acre-foot. Use the rough rail freight shipping estimate of a nickel per ton-mile. Haul it 300 miles. About 20 grand, plus the cost of desal production. Pretty expensive alternative to the natural (and, of late in the west, chronically inadequate) hydro cycle.

Given that pipeline pumping of desalinated water several hundred miles up to higher elevations such as Las Vegas (2,160 ft above sea level) is a non-starter (as would be the use of rail tank cars; we don't have enough for just this singular "rolling pipeline" purpose), trade-off/diversion proposals have been floated in recent years in which Nevada would fund additional desal capacity in California in return for diversion of an equivalent volume of downhill-flow water from the Sierra Nevada range watershed inventory. But, myriad California agricultural, environmental, and energy concerns have thus far sufficed to stifle such initiatives.
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BARCELONA'S DROUGHT

News from May 2008:

Spain's worst drought in decades has forced the city of Barcelona to begin shipping in drinking water in an unprecedented effort to avoid water restrictions.

For the first time ever, tankers began to deliver desperately needed drinking water to the parched region of five million people. Incredibly, Spain has seen almost no rain in the last eighteen months. Water levels have dropped so low in local reservoirs that a long forgotten medieval village has emerged from beneath a rapidly drying lake.

Sixty six tankers are expected to deliver water over the next few months. Meanwhile the Spanish government appears to have given up relying on rainwater. They are now constructing a desalination plant that will supply 60 billion litres of water a year to the parched region.

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More to come...

This is not a Black Swan

2010-06-07T20:53:00.000-07:00

I am aghast, angry, and depressed over the events in the Gulf of Mexico that began with the catastrophic, tragic fiery destruction of the British Petroleum Deep Water Horizon oil drilling platform and the unimaginably horrific deaths of eleven of its workers.

This will very likely turn out to be far and away the most severe man-made environmental calamity of my lifetime. The Gulf of Mexico (and perhaps far beyond) faces biological and economic ruination that may well be at this point beyond human capacity to truly remediate.

"Act of God"? As more than one fatuous politician has lamely proffered? No "God" that I would care to consort with or submit to. Forget it. This was the culmination of a series of acts by identifiable men (All of them by now all suitably lawyered up).

WELL, PERHAPS A "BLACK SWAN" EVENT?

Citing Nassim Nicholas Taleb:

What we call here a Black Swan (and capitalize it) is an event with the following three attributes. First, it is an outlier, as it lies outside the realm of regular expectations, because nothing in the past can convincingly point to its possibility. Second, it carries an extreme impact. Third, in spite of its outlier status, human nature makes us concoct explanations for its occurrence after the fact, making it explainable and predictable. I stop and summarize the triplet: rarity, extreme impact, and retrospective (though not prospective) predictability...

Notwithstanding my extreme affinity for the philosophical/theoretical/empirical insights and works of Taleb, I would have to seriously demur were anyone to argue Black Swan here. To wit:

First, it is an outlier, as it lies outside the realm of regular expectations...
Second, it carries an extreme impact.
Third, in spite of its outlier status, human nature makes us concoct explanations for its occurrence after the fact, making it explainable and predictable.

Only the second of these proffers legitimately obtains here.

"Black Swan" is an analogy, perhaps to the point of metaphor. So, let me offer another.

RUSSIAN ROULETTE

Six chambers, one live round. Place your bet, load the weapon, spin, place the business end of the barrel against your temple, pull the trigger. The probability of blowing your brains out in the wake of each attempt is one in six. Would you do it?

Of course not (unless you're suicidal). The negative "expected value" (obliteration) -- i.e., probability times the "payoff" -- remains essentially "infinite" irrespective of the well-below 50/50 (1/6th) nominal, non-accruing independent "chance" (a concept which utterly explains fear of flying).

Now, assume the revolver has not six, but, say, 10,000 chambers. Moreover, the barrel is pointed not at your temple but at beaches, marshes, pelicans, turtles, shrimp, shrimpers, and the rest of the inhabitants of a region writ large.

Place your bet. By the time you "lose," you will have made plenty of bank. Unlike those uninvolved in the game.
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"Years of Internal BP Probes Warned That Neglect Could Lead to Accidents"

A series of internal investigations over the past decade warned senior BP managers that the company repeatedly disregarded safety and environmental rules and risked a serious accident if it did not change its ways...

No, this horrific event fails Black Swan postulates 1 and 3 above. It may indeed have been "outside the realm of regular expectations," but only to the conveniently, expediently dilettante executive mind. And (3), there is nothing to "concoct" here. There exists a record -- one that points to criminal negligence. (see 2 - "extreme impact").
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For now, consider an earlier post of mine. We have alternatives. BTW, I am in fact a "Drill, Baby, Drill" kind of guy.

No need to idle all those drillers. There's plenty of heavy industrial work to be done.

UPDATE

This is hard to watch.

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MORE TO COME

Opportunity for collaboration? ASQ and the RECs

2010-05-18T19:40:00.000-07:00

On March 2nd, 2010 I returned to work with my twice former employer HealthInsight, the highly regarded long-standing not-for-profit Medicare QIO (Quality Improvement Organization) serving the states of Utah and Nevada in the wake of their being awarded a federal "Regional Extension Centers" (REC) contract by the U.S. Department of Health and Human Services (HHS) as part of the Obama administration's stimulus funding initiative to spur the widespread adoption and "meaningful use" (MU) of health information technology (HIT).

It is a most ambitious, pedal-to-the-metal, high-velocity program (unrealistically so, say some of its critics), one whose goal is to bring the vast majority of medical providers into the digital information world, a world the rest of commerce finds at once unremarkable and indispensable.

Above, the still-predominant information storage and retrieval model for medical information. It is functionally untenable. Prohibitively expensive in ways significantly under-appreciated. It is dangerous. It could cost you your life in an exigent circumstance. It cries out for extinction. Yes, conversion will be difficult, and exasperatingly rife with logistical and legitimate, vexing policy problems.

Nonetheless...

I have been writing a bit about this on one of my other blogs. See "Irrespective of national health care policy reform legislation, the medical sector is going full-steam-ahead HITECH," initially written prior to the passage of the Obama "Health Care Reform" legislation (with updates still to ensue, mostly pertaining to the complex data security issues bearing on patient privacy).

ASQ

The American Society for Quality. My wife and I have been members since the mid-1980's. We live and breathe "quality" concepts and issues, having both come together out of the same legacy-era "quality control" paradigm. We have both served as Examiners for our Nevada state-level Baldrige Award assessments (ASQ administers the national Baldrige program). My friend and ASQ colleague Fred Schwager and I co-founded the Nevada Quality Alliance (NvQA.org), which administers the Nevada Baldrige model program.

When I returned to work, I renewed my optional special interest sub-membership in the ASQ Health Care Division. Shortly thereafter, I had the fine fortune to strike up an internet and phone conversation with the Chair-Elect of the Division, Dr. Joseph Fortuna. Joe is an enthusiastic supporter of the REC effort, and was intimately involved in DC legislative support for health policy reform.

We share some concerns, which we have by now discussed at some length; e.g.,

Critics bemoan a lack of prior HIT deployment and QI experience among some REC awardees (as well as the heterogeneity of business models);
While 60 REC contracts have thus far been awarded, with the newly chartered RECs frantically ramping up to meet the rather compressed Stage One Meaningful Use incentive payment timelines, both the requisite Meaningful Use reporting criteria and the EHR (Electronic Health Record) certification regulations remain unresolved at this writing. The cart is seriously out in front of the horses in many respects;
Notwithstanding that HHS is spending hundreds of millions of dollars on REC contracts, physicians and hospitals are not required to engage REC services in order to qualify for federal incentive payments. Consequently, RECs are having to spend significant time and money hawking their services (the polite term being "enrollment." I did not know when I signed on that I would be required to do what amounts to hastily and minimally trained cold-call sales). Moreover, REC services are not fully subsidized, the upshot of which is often skeptical "we'll pass" pushback, especially in light of the hyperbolic claims of virtually all major EHR vendors "guaranteeing" that their products will get the provider to MU (with the glossed-over disclaimer, well down in the fine print "When Used As Directed");
- At this writing, the aggregate Final Rule for MU criteria is still under HHS consideration, with myriad professional stakeholder groups arguing for relaxation of both the compressed compliance timelines and the all-or-nothing approach, countered by a broad array of equally vocal consumer/patient advocacy organizations arguing for MU criteria adoption "as-is" as set forth in the Interim Final Rule.
  
  I would have added another MU criterion: require working with the RECs as a condition of incentive money eligibility;
The relatively sparse per-provider federal REC funding may force the RECs to focus simply on assisting their client physicians with hitting the MU criteria in pursuit of the incentive reimbursements -- to the practical exclusion of broader and more sustainable, internalized quality improvement efforts;
There is to be a "Health IT Research Center" funded by HHS and intended to "gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support. The HITRC will build a virtual community of shared learning to advance best practices that support providers’ adoption and meaningful use of EHRs."

It is not even slated to be up and running until FY2012.

Notwithstanding our concerns, we see potential opportunities for win-win synergistic REC-ASQ collaboration via which to help improve health care.

THE ASQ HEALTH CARE DIVISION "MARSHALL PLAN"

Dr. Fortuna is a Champion of the ASQ "Marshall Plan."

"...In different areas of the country, ASQ members, under the leadership of the ASQ Healthcare have teamed up with the local healthcare community and medical organizations to help improve healthcare delivery. Being that we are all stakeholders in this system and that there is much opportunity to apply quality and lean methodologies, this is a great place for ASQ members to use their skills for the betterment of the system. The focus is on primary care doctor offices..."
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Click the link, Read all of it. An extremely worthy volunteer effort with the potential to deploy a large number of experienced QI professionals in pro bono service to the healthcare community in a manner complementary to and reinforcing of the work of the RECs.

The Regional Extension Centers could certainly benefit from the help, and ASQ in return would be made visible to a large source of potential new members, given the projected HIT-related and health professions employment growth across the decade.

I would also favor inviting several other ASQ Divisions to collaborate: Biomedical, Software, and Service Quality.

There is a lot of experience and relevant expertise upon which to draw. I would even surmise there might be interest and value adding input from and collaboration with the ASQ Quality Management and Statistics Divisions.
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"LEAN? THAT MAY BE OUT OF OUR SCOPE"

Such was a reaction from one of my skeptical HealthInsight HIT Adoption Support team members during a recent meeting in which I'd recommended that we consider deploying aspects of "lean methods" for workflow analysis and re-design, as proffered most recently in the new Quality Press book "Lean Doctors." He didn't say so explicitly, but his implication was clear: in light of our finite FTE resources and the huge scope of the project, our necessarily circumscribed task will be to drive providers toward MU and the incentive money riding on it [PDF], period. Point taken, to an extent, but, it should be equally clear that I don't regard the MU goal contractual imperative as inexorably being at odds with the utility of lean re-design tactics. Neither do I buy the implicit, gauzy HHS assumption that clinicians hitting the MU targets amid the money chase constitutes focused, adequate, and lasting healthcare QI of the kind we are incontrovertibly in need of.

This (highly recommended) book rightly points out, ever so politely, that the term "workflow" -- particularly in the medical setting, can be seen as having become something of a cliche, i.e., there's typically very little in the way of smooth "flow" in the daily "work," which is more aptly typically characterized as a series of "push" processes rife with bottlenecks caused by lack of coordination and waste. Any method that can demonstrably abate that simply has to be worthy -- whatever you choose to call it.

In the words of the publisher's blurb, Lean Doctors posits

"six proven “success steps” for implementing lean in any healthcare environment:
Create physician flow
Support physician value-added time
Visually communicate patient status
Standardize everyone’s work
Lay out the clinic for minimal motion
Change the care delivery model
"Why go through such a transformation? Because it works. Tell a doctor that he can see the same number of patients, offering the same high quality and personal care, and have an extra 90 minutes at the end of his clinic day – and that means something. Tell the staff that they can look forward to actually ending on time, with satisfied patients, no backlog, and having focused their attention completely on quality patient care – and they will listen..."

"They will listen." Really? Making that sale is perhaps not as easy as it might appear. But, in my view, such is our mandate, given that the elimination of process flow roadblocks and the waste they comprise cannot but provide, among other QI benefits, the availability of the requisite time for MU compliance.

A useful quote from the text for now:

Lean is a science for creating flow in a system—whether of a physical product or of a service. In healthcare, this would mean that we aim to create patient flow, without wait times, through any given area. As we focused on patient wait times in the clinic we found that no other metric brought the varied root causes of inefficiency so clearly into focus. When patients were moving through the process promptly, a lot of things were going right. However, when patients waited in the exam rooms or waiting rooms or at supplying processes, then any one of a great number of things could be going wrong...

And, one more:

As you consider undergoing a Lean transformation process at your own practice or clinic (or hospital or larger healthcare setting), you might think that a minute shaved off here and a minute saved there does not seem worth much. Change is difficult, time-consuming, and cumbersome. So why would you literally analyze every step a nurse takes? Why take the time to have technicians or nurse practitioners describe in detail the reality of their jobs, when you need them to simply get the work done? Why? [again] Because it works...

Color me a believer, based on what I have thus far learned. However, our REC reality may be that we will largely be limited to predominantly a prescriptive/advisory/auditing role. We will necessarily be developing SOPs via which to guide clinicians and their staffs toward accurately and routinely documenting in their EMR systems the structured data required for their MU Stage 1 attestations (and eventual data reporting). The current draft of MU criteria contains 25 outpatient items, many of which require numerator and denominator data for calculating percentages that must meet or exceed MU thresholds, e.g.,

1.01 Computerized Physician Order Entry (CPOE): Use computerized CPOE for at least 80% all orders (e.g. medications, consultations, labs, diagnostic imaging, etc.);
1.02 Medication Interaction/Contraindication Checks: Enable functionality in EHR for automated drug-drug, drug-allergy, and drug-formulary checks;
1.03 Patient Problem List: Maintain an up-to-date problem list of current and active diagnoses (recorded as structured data) based on ICD-9-CM or SNOWMED CT® for at least 80% of all unique patients;
1.04 E-Prescribing: At least 75% of all permissible prescriptions written are transmitted electronically (eRx) using an EHR;
1.05 Active Medication List: Maintain an active medication list (recorded as structured data) for at least 80% of all unique patients;
1.06 Active Medication Allergy List: Maintain an active medication allergy list (recorded as structured data) for at least 80% of all unique patients;
1.07 Patient Demographics: Record demographic data (including preferred language, insurance type, gender, race and ethnicity coded by federal guidelines, and date of birth) as structured data for at least 80% of all unique patients;
1.08 Vital Signs: Record and chart vital signs (including height, weight, blood pressure, calculated and displayed BMI, plotted and displayed growth charts for children) for at least 80% of all unique patients;
1.09 Smoking Status: Record smoking status for at least 80% of all unique patients 13 years old or older;
1.10 Lab Results: Clinical lab results captured as structured data for at least 50% of all labs ordered...

...and so forth. SOPs driving toward uniformly capturing such subsequently queryable information will necessarily be EMR platform-specific, and will comprise substantial work to derive and implement. Consequently, I may in fact be asking too much to insist on inclusion of "Lean" principles in our REC workflow re-design effort during this initial phase.

But, before I leave this issue (regarding which I welcome commentary/feedback), consider a few screen clip excerpts from a recent Lean project study posted on the ASQ Healthcare Division web page:

While I know that a lot of QI has gotten a sometimes deserved rep of being "soft" touchy-feely dubious flip-chart fad-of-the-moment social "science," the outcomes here are expressed in (verifiable, I assume) bottom line "hard dollar annual savings" on the order of $90k.

Annual.

Now, consider: the maximum HHS MU physician incentive payments are $44,000 over 5 years for Medicare providers and $63,750 over 6 years for Medicaid providers.

Think about that, in the context of leaning up one process at a net of 90 grand a year.

The basic issue, visually:

More to come...
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Irrespective of national health care policy reform legislation, the medical sector is going full-steam-ahead HITECH

2010-03-17T19:39:00.000-07:00

While I've continued to closely follow the dismaying -- albeit admittedly "realpolitik" -- end-game developments in the increasingly acrimonious "health care reform" national political debate since I quit blogging about it in November, 2009 (with snide demagogues now largely in charge of national discourse on the topic), I'd intended to move on next to "drought and western states water policy," regarding which I've culled a ton of technical information and have some arguably value-adding ideas to proffer.

However, I've just been re-hired by my former employer (the not-for-profit Utah-Nevada Medicare QIO) as a Project Coordinator for Health Information Technology (HIT) in the wake of their being awarded the HHS contract to become one of the CMS "Regional Extension Centers" (RECs) under Title XIII of the 2009 Obama Stimulus legislation, ARRA ("American Recovery and Reinvestment Act"), i.e., the ARRA "HITECH" Act ("Health Information Technology for Economic and Clinical Health").

So, bear with me. This is important stuff. Indulge me this coda. It bears to a significant degree on national health policy broadly going forward, given the undeniable importance of timely, appropriately available health data as a core component of effective care. And, the first round of this particular initiative has now been launched and will go forward for at least the next four years** independently of the outcome the current contentious national health insurance reform legislation heading for its final House and Senate showdowns.

(** Assuming the Republicans don't regain control of Congress via this year's mid-terms and thereafter see fit to cripple or asphyxiate the HITECH program.)

"HITECH" - HEALTH INFORMATION TECHNOLOGY
FOR ECONOMIC AND CLINICAL HEALTH

The HITECH goals are to [1] facilitate widespread adoption of electronic medical records systems across the nation (given that health care providers still lag far behind the rest of commerce in the use of digital information technology), [2] guide clinics and hospitals toward using the systems fully, in a "patient-centered" manner (known as "meaningful use"), and [3] assist with the deployment of widespread appropriate, secure sharing of electronic health information through which to improve personal and public health.

ANALOGY

Cheryl, Nick, and I went to to the UK and France in 2004 for 16 days, mainly to go see Lance Armstrong win le Tour #6 in Paris. Which he gloriously did.

I booked and paid for the airfare, hotels, B&Bs, and EurRail passes in advance online. Without adverse incident. I used my credit union debit card multiple times while in the EU, for cash, car rentals, and restaurant meals, etc. All without incident.

Ongoing, like most of you, I routinely buy books and other products from Amazon.com and myriad other mainstream eCommerce sites. Without incident. I increasingly do most of my banking online, including most of my bill paying. Securely, without incident.

I bought my late cat Max's insulin and ancillary diabetic feline supplies online via PetMeds.com (he had a better health plan than do I, LOL). Without incident.

And so forth. You know precisely what I'm talking about. Simply put, absent being "wired" across myriad domains, civilization could simply no longer function. To close the loop on this analogy, the fact that health care continues to operate largely on paper simply means that it cannot function effectively. At root, health care is about making frequently maddeningly complex decisions -- usually under intense time pressure --, based on the best and most comprehensive available information. Most clinicians today still frequently lack such fingertip access.

OK, TO BE FAIR, I'VE INDEED SUFFERED AN INCIDENT

It was relatively banal. We awoke one morning in December 2007 to find that someone had commenced a wild holiday shopping spree in Paris via our credit union debit card. It had nothing to do with our prior EU trip, but, rather owed to my a couple of years thereafter having bought a pair of shoes in Henderson, NV at the DSW "Discount Shoe Warehouse." They subsequently got hacked, with my card number acquired amid the aggregate ePirate booty.

The credit union's fraud indemnity insurance covered the bogus $600+ accruing charges, and shut the card down forthwith, promptly issuing us new ones. Without further problems.

HACKING YOUR ONLINE MEDICAL RECORDS

In the 2009 survey summary depicted above, ~3/4 of the respondents (76%) recently expressed it to be "somewhat likely" (35%) to "very likely" (41%) that "an unauthorized person would get access to your medical records" were they to go digital and subsequently become accessible "online."

Well, while that's probably a rational concern to a point, having worked in credit card risk management (where the fraudster probers were/are 24/7 relentless and insidiously ingenious), I would observe that the Bad Guys are far, far more interested in getting directly into your financial accounts -- for what ought be obvious reasons. Yet most of us engage in a gamut of online financial transactions routinely, absent major widespread adverse consequence.
___

HIT concerns

There are basically three levels of present and emergent online HIT concern. First, even in the circumstance where a particular medical practice's electronic records system (the EMR, a.k.a. EHR -- or, even simply a front/back office non-clinical "Practice Management system") may be confined totally in-house, it remains -- just like your internet account at home -- vulnerable to hacking should there exist an internet connection up and running amid the onsite network, even if not in any way directly interfaced with the clinical system.

Second, if a clinic opts to contract with an internet EMR "hosted service" -- a.k.a. the "ASP" or Application Service Provider model, wherein the practice simply avails itself of the web browser-based input/output screen array comprising the remote EMR, with transactional data being stored on and pulled from "secure" offsite servers, one still must address, among other risks (such as 'net outages), possible encryption-surmounting hacker vulnerability concerns (an endlessly moving target, that).

Finally, we come to the mostly nascent "HIEs" -- Health Information Exchanges (existing today in wildly varying degrees of planning or operational maturity, and comprising the bigger-picture end goal of the REC effort). The national goals here are twofold: [1] enabling patients to accord health care providers of any stripe authorized access to pertinent elements of their clinical histories anywhere/anytime as either exigent/acute or routine needs dictate, and; [2] the "blinded" reporting of clinical information of interest and need to various medical authorities, both for public health surveillance and outcomes research.

The "HIE"

a.k.a, the "Regional Health Information Organization (RHIO)." As I mused in my prior post:

"A fully integrated, electronic health information exchange is essential to ensuring that high-value health care is delivered to the right patient, at the right time, and in the right setting." Yes, of course... These things go the acronym "RHIO" or "RHIE" ("Regional Health Information Organization/Exchange"). The Utah Health Information Network (UHIN) stands as a fairly mature example here. During my last QIO tenure, I sat on the Steering Committee for a southern Nevada RHIO startup attempt. I recall the fractiousness of the proceedings, given the disparate interests of the various for-profit and non-profit interests. We still don't have one in Nevada. I applaud these efforts, but they remain fraught with technical and policy difficulties...

That was several years ago. It does not appear that all that much has changed. The technical (e.g., "data mapping" standards for seamless "interoperability") and policy challenges (e.g., data security, HIPAA privacy compliance) remain many and complex.

I continue to be concerned with the sometimes contentious, duplicative attributes of much of this HIE thinking and effort (i.e., primarily the potentially heterogeneous "regional" aspect).

And, that drives me back to ruminating on my bank risk management days.

THE BUREAU PULL

During my credit card bank risk department tenure, I was involved with vetting applicants for appropriate risk-assessed revolving credit line assignments, and for passing judgment on existing customers' requests for "CLIs" -- credit line increases (or a variety of account forebearances), the latter based on a mix of their current FICO scores and internal account performance histories.

Like any credit grantor, we had essentially instant authorized access to the financial "health histories" of both prospective and existing customers. The first step in consideration of an initial or secondary credit request was the "hard pull" (a.k.a. "bureau pull") from one or more of the three credit reporting agencies: Equifax, Experian, or TransUnion.

THE CREDIT FILE "DATA MAP"

Credit applicant bureau files arrived as legacy platform (mainframe) encrypted export data that, once unlocked, simply comprised variable-length ASCII files containing fixed-position row/column headers denoting each subsequent sequential following data element (with the respective data types and field lengths defined by a standard "data dictionary" - i.e. "data maps" guiding the import conversion specifications). Such files are necessarily "variable length" owing to the fact that every person's credit history differs, both in length of history and relative periodic intensity of activity and breadth of credit utilization.

A bit of relatively unremarkable programming, and the import "data map" routines are done.

How a person's health/medical transactional history differs materially in concept from that escapes me. For example, a core HIT industry consensus standard -- HL7 -- exists for interoperable transmission of medical information messaging. It simply specifies a "data map" wherein health data elements are identified by their relative position within an ASCII file, each datum preceded by a coded identifier readable by an HL7-enabled destination interpreter, e.g.

"HL7 messages are in human-readable (ASCII) format, though they may require some effort to interpret.

Each message consists of one or more segments. A carriage return character (\r, which is 0D in hexadecimal) separates one segment from another. Each segment is displayed on a different line of text."

This is all rather Old School, actually.

To be fair, data in individual medical files extend beyond the IT-mundane alphanumeric items comprising credit bureau compilations, principally with respect to bandwidth-intensive graphic imaging files, e.g., x-ray and other scans (PACS output), EKG graphs, and so forth. However, such imaging data might simply be be made effectively accessible via secured proxy hyperlink reference (thereupon downloadable as needed) rather than traveling pixel-by-pixel with the textual/alphanumeric data constituting the bulk of transactional health records.

In sum, there seems to exist a functionally mature mega-scale infrastructure already in place, one that securely and efficiently manages perhaps close to 200 terabytes of data ongoing, 24/7, capable of near-instant accessibility/turnaround.

PUSHBACK?

It almost writes itself. Beyond the turf-protective antipathy likely to be voiced by existing regional HIE organizations that have labored mightily to date, credit reporting firms are far from the most beloved of corporate entities. Everyone seems to have his or her pet horror story (as do my wife and I). Widespread, chronic inaccuracies in consumer financial information are bad enough. Trafficking in error-ridden personal medical data would be orders of magnitude worse, sometimes lethally so. Also, we are unhappily witness to ongoing "mission creep" as bureau pulls get used to vet people for decisions having nothing directly to do with the properly limited legitimate purpose of creditworthiness evaluation: Hiring decisions, apartment rentals, actuarial model insurance policy rate setting, etc**.

** Not to mention the poignantly hyperbolic cast of derisive Palinistas and indignant fellow traveler Tea Baggers who reflexively see "Federal Death Panels" lurking behind every tree stump, shrub, USB port, and T-1 line (particularly when the cameras are rolling), and who will no doubt breathlessly spin HIE data distribution as inexorable grist for exactly that.

Nonetheless, those are policy issues that can be reconciled legislatively and via subsequent regulation (to the sufficient satisfaction of the sane, in any event). My speculation goes to the availability of an extant but possibly overlooked yet scale-and-technology viable digital infrastructure that might expedite the goal of universal, standarized HIE.

Perhaps neither Equifax, Experian, nor TransUnion would have any interest in getting involved in HIE (What would be the viable business model? What is the quantifiable fair-market value of timely access to individual and aggregate health information?). I simply don't know. But, it's a question worth asking, in light of their long experience dealing with secure, large-scale transactions of highly sensitive data.

THE HIT DATA SECURITY/PRIVACY ISSUES

Coming shortly. Google "Latanya Sweeney" and "Deborah C. Peel" for starters. If you take everything these two prominent critics have to say at face value, you'll be anxiously aching to get off the wire (and the wireless) and off the grid and off to the far reaches of some inaccessible somewhere that no longer exists.

Stay tuned...
___

DISCLAIMER: I composed the foregoing wholly on my own time and my personal computer at home. The views proffered are expressly my own as a concerned and active citizen/taxpayer, and in no way reflect any policy views of my employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the new work with which I am now charged.

Public Optional

2009-08-23T22:17:00.000-07:00

[Last updated Nov. 19th 2009]

To use an aviation analogy, we have turned from the downwind vector and are now (Aug 23rd) in mid-approach "base leg" on this policy reform flight prior to turning 90 degrees into the turbulent fall 2009 headwinds of final approach and (crash?) landing of "health care reform" legislation. I will add a few more observations, and recap central points and issues I've addressed in my prior three posts before moving on to another topic (drought and water policy).

"PUBLIC OPTIONAL"

I am really sick of hearing about the "public option" wrangle 24/7 in the media these days. I am increasingly skeptical of its inclusion of any final legislation that may or may not reach the President's desk, and likewise skeptical that it would comprise much of an improvement even should it pass the Congress (and, it looks increasingly to me like a slickly orchestrated "misdirection" strategy). Without a "public option" (our having taken Single Payer off the table a priori), it is difficult to see what "health care reform" would truly amount to. But, then, "public option" as currently proffered (e.g., H.R. 3200) merely looks like -- as I've said before -- [1] corporate welfare ("Play or Pay" forcing everyone to buy health insurance policies under threat of tax penalty for non-compliance), and [2] outright "welfare" (means-tested government subsidy for health insurance "affordability").

The sarcastic title of this post simply alludes to the very real political fact that, to the extent that the priorities of key legislators align with true needs of the aggregate public (e.g., universal access, better clinical quality, and restraint on cost), they will work for such things, but, the overriding, never-ending imperative of most lawmakers seems to be simply that of re-election. And, for the Legislative Branch (in particular the House**), there's only one viable source of effective campaign funding -- special interest money. This is beyond debatable, and is not exactly news. You might be able to mount and sustain a viable Presidential campaign on broad-support grassroots small-increment donation money -- as Obama obviously did -- but this is simply not the case for Senators and Representatives. It has been recently reported that there are today six health care industry lobbyists in place for every member of Congress. The money is flowing generously, and the backroom special interest pleading is in high gear.

[**] It has long been noted that roughly 80% of a Representative's time is spent on campaign fundraising, given the short 2-year re-election cycle. In the House, staff do nearly all of the actual legislative detail work, with the elected official mostly just stopping in for "drive-by" votes.

So, your interests as a citizen are "optional."

A couple of headlines today:

"OK, so, how much is AHIP Job?"

This one is blanketing the TV channels of late. AHIP (American's Health Insurance Plans) is the lobbying organization for the private health insurance industry. From their March 2009 "Board of Directors’ Statement on Setting a Goal to Achieve a More Affordable and Effective Health Care System" -

Health care reform has eluded our nation for nearly a century. But today, a broad consensus is emerging that comprehensive reform of the system – that covers all Americans and provides safer and more effective care – is possible if the growth in health care costs can be brought under control. Health care costs are rising at an unsustainable rate and adding a burden on families and small businesses, and hampering our competitiveness as a nation...

Can't argue with that: universal coverage improved quality, cost containment. Recall the opening words of my May 25th post, "The U.S. health care policy morass":

Some reform advocates have long argued that we can indeed [1] extend health care coverage to all citizens, with [2] significantly increased quality of care, while at the same time [3] significantly reducing the national (and individual) cost. A trifecta "Win-Win-Win."

Note the soothing v/o in the AHIP PSA above: "...If everyone's covered, we can make health care as affordable as possible (0:14)...and the words 'pre-existing condition' become a thing of the past (0:19)..."

Laudable, without a doubt (notwithstanding the red-flag weasel phrase "as affordable as possible").

Again, citing the AHIP Directors' Statement:

Health plans are doing their part by pioneering disease management and care coordination programs; promoting prevention, wellness and early intervention; and implementing innovative payment strategies that reward performance and outcomes. We are committed to working with the Administration, Congress and other stakeholders to advance strategies that promote effective, efficient, and high-value health care.

So, assuming this is not simply finely crafted rhetorical lorazepam PR spin, the AHIP membership in fact regard themselves as indispensably embedded, value-adding, necessary clinical adjuncts, rather than the bloodsucking, obscenely profitable (and otherwise ruinously expensive), paper-pushing, value-hampering, care-denying intermediary parasites their political adversaries claim them to be., e.g., liberal OpEd writer Chris Hedges:

The real debate, the only one that counts, is how much money our blood-sucking insurance, pharmaceutical and for-profit health services are going to be able to siphon off from new health care legislation. The proposed plans rattling around Congress all ensure that the profits for these corporations will increase and the misery for ordinary Americans will be compounded. The corporate state, enabled by both Democrats and Republicans, is yet again cannibalizing the Treasury...

...The Democrats are collaborating with lobbyists for the insurance industry, the pharmaceutical industry and for-profit health care providers to craft the current health care reform legislation. “Corporate and industry players are inside the tent this time,” says David Merritt, project director at Newt Gingrich’s Center for Health Transformation, “so there is a vacuum on the outside.” And these lobbyists have already killed a viable public option and made sure nothing in the bills will impede their growing profits and capacity for abuse.

A commentor on Salon.com notes:

A Broken Process

As I've said before; our political system is not capable of dealing with long term complex issues. Between entrenched special interests that fight to maintain the status quo, a legislative branch beholden to those interests, a political culture that only looks as far as the next election cycle, a fundamentally broken news media, an ignorant misinformed and unengaged electorate and a host of other problems it will be miracle if US makes to the half century mark as anything other than third rate power with most of its citizens living in abject poverty trying to get buy with crumbling infrastructure and a collapsing environment.

A skeptical commentor in my local paper observes:

Trust in government must be earned. The 'government' programs called Social Security and Medicare have been headed for insolvency for years. What have our representatives done about that? Nothing. We have needed real immigration reform and a sane immigration policy for years. What have our representatives done about that? Nothing. I could go on but you get the point. Health Care insurance needs reform and it will not be reformed without some government action. That said, it is possible for the present system to be reformed by legislation and not replaced by a full government program if our representatives took some tough action. But just like Social Security, Medicare and Immigration, either nothing gets done or what is done is overkill or ineffective or both. I feel both shame for my government and fear of my government and in my estimation I have good reason...our government has done such a poor job for so long on so many big issues I don't have much belief in them at this point.

An even more skeptical commentor writes to my other local paper:

It is important for all of us to realize that the health care legislation currently being hotly debated is not about insuring the uninsured, reducing health care costs, etc.

This legislation is all about power -- greatly expanded power for the Obama administration, for Speaker of the House Nancy Pelosi and for Senate Majority Leader Harry Reid.

The federal government and the unions already effectively control the American automobile industry. The government has recently gained great power over the financial institutions of the United States.

Renewable energy regulations give the government a lot of power over utilities. If the cap-and-trade legislation passes the Senate, the government will totally control the production of energy in this country.

If the proposed health care legislation passes, the federal government will control one-sixth of the U.S. economy. President Obama's appointed czars and other unelected bureaucrats will control the health care system in the United States, maybe not in the next year, but certainly within the next five years.

Make no mistake, this health care legislation is all about power.

That is why President Obama, even in the face of stiff opposition from some of his own Democrats, refuses to give up his demand for a government-run health care system to compete with the private sector.

It is precisely this frequently heated divergence of characterization that comprises the core of the health care policy reform issue soon to resolve itself one way or another, for better or worse.
___

"OK, so, what exactly is AHIP Job?"

From the March 2009 AHIP Directors' Report:

What Our Community Brings to the Table

Health plans offer strategies and tools to consistently improve quality and drive down the cost of care delivered to patients across all care settings:
Tools to Coordinate Care Across a Variety of Settings for Specific Patient Populations: Health plans have a wealth of administrative and clinical information which can be integrated to help clinicians have a comprehensive view of a patient’s clinical history. For instance, plans may evaluate this [sic] data to identify preventable medical errors, providing clinicians with this information to address gaps in care and help make efficient, informed patient-care decisions.

Incentives for an Interconnected Electronic Health Care System: A fully integrated, electronic health information exchange is essential to ensuring that high-value health care is delivered to the right patient, at the right time, and in the right setting.

Clinical Decision-Making Based on Best Evidence: Health plans encourage clinical practices that rely on best data and best evidence. A strong base of evidence can help evaluate whether the costs of services, devices, and drugs are commensurate with the value of care delivered.

Innovative Payment Models That Drive Real Delivery System Change: Health plans have experience with and are committed to innovative payment models that reward improved clinical outcomes and overall health status, and optimize the patient experience, such as an enhanced medical home, paying for episodes of illness, and shared risk models that promote comprehensive care management.

Benefit Design: Plans can implement benefit design strategies to encourage consumers to choose the safest, highest quality and most cost-effective drugs, devices, and procedures. These strategies include offering lower cost sharing for those procedures and technologies that are proven to be the safest, higher in value and lowest in cost.

Administrative Efficiencies: Health plans, in concert with providers and consumers, can drive down administrative costs and by doing so, improve efficiency and care delivery.

Mostly all high-mindedly Mom & Apple Pie laudable, no doubt. The foregoing, however, do beg a few questions. First, if the AHIP membership is equipped with and savvy with "strategies and tools to consistently improve quality and drive down the cost of care," then why the evolved crisis nearly everyone agrees is extant? Why the pressing, politically front-burner imperative for comprehensive reform? Why do we see chronically suboptimal, uneven outcomes quality, and cost escalation running three times the rate of inflation -- in particular when concomitant with the AHIP membership's enviable, ever-increasing profits? What have they been doing with all of that money?

Asked and Answered.

Feeling the reform heat, are we?

[1] "Health plans have a wealth of administrative and clinical information which can be integrated to help clinicians have a comprehensive view of a patient’s clinical history." Really? I would take issue with this with respect to private, and most notably, employment-based coverage. "Plan-hopping" has become a commonplace, as bottom-line anxious employers increasingly shop the most affordable benefits plan du jour. As I noted in a prior post, during my last two-year job tenure, my employer switched plans THREE times. I had no say in the matter, and was not consulted in advance. Each time, my personal "administrative and clinical information" became the private HIPAA-firewalled "business intelligence data" of the new vendor. Seamless ongoing longitudinal "continuity" of my "patient history" may have a nice ring, but it is not the predominant reality -- except, I should note, for those covered under Medicare or the VA, i.e., the public entitlement de facto "single payer" programs.

[1.b] "...plans may evaluate this [sic] data to identify preventable medical errors, providing clinicians with this information to address gaps in care and help make efficient, informed patient-care decisions." Well, that is precisely the type of analytic data-mining work I did during my two tenures with the Medicare QIO. It is also the type of extensive outcomes research performed by the CMS Agency for Healthcare Research and Quality (AHRQ). A salient -- no, critical -- difference is that entitlement beneficiaries are not put at risk of coverage exclusion/"rescission" that is increasingly common within the for-profit actuarial insurance model.

[2] "A fully integrated, electronic health information exchange is essential to ensuring that high-value health care is delivered to the right patient, at the right time, and in the right setting." Yes, of course. Again, see my foregoing comments in response to [1]. These things go the acronym "RHIO" or "RHIE" ("Regional Health Information Organization/Exchange"). The Utah Health Information Network (UHIN) stands as a fairly mature example here. During my last QIO tenure, I sat on the Steering Committee for a southern Nevada RHIO startup attempt. I recall the fractiousness of the proceedings, given the disparate interests of the various for-profit and non-profit interests. We still don't have one in Nevada. I applaud these efforts, but they remain fraught with technical and policy difficulties [a], difficulties that would be significantly abated under a universal coverage "social insurance" paradigm (be it a "Single Payer" model or one more akin to a "Swiss Model").

[a] The private sector "EMR" (Electronic Medical Records) industry -- regarding which I am thoroughly evangelistic -- has been in high gear for a number of years and has matured greatly, but it has nothing to do directly with the health insurance industry, except to the enervating extent that the latter significantly complicates the work of the former. An integrated EMR is one wherein the front office (demographic & scheduling), mid office (the clinical/patient encounter and historical record), and back office (billing and admin) functions are synch'd (with automated CPT/ICD-9 encounter coding linked with the front and back office functions). The focus, though, ultimately remains that of reimbursement, i.e., the back office imperative of billing -- having to deal with the hundreds of 3rd party payers, each with their own proprietary submissions forms, policies, and procedures. This adds nothing substantive to improved actual health care effectiveness. Single Payer would simplify this aspect of health information technology immeasurably, enabling software developers and their end-users to focus more on leveraging the EMRs for better care.

[3] "A strong base of evidence can help evaluate whether the costs of services, devices, and drugs are commensurate with the value of care delivered." Again, no argument with that ideal. However, again, it begs the question of efficiency and effectiveness, when health care data constitute in large measure the proprietary "business intelligence" of competing for-profit actuarial model enterprises. By contrast, the research initiatives of public entities such as AHRQ (a) suffer from no such potential profit-model conflicts-of-interest, and (b) are already focused on patient populations with the higher levels of utilization experience (increasingly so as the population ages).

[4] "...innovative payment models that reward improved clinical outcomes and overall health status..." It's called "P4P" (Pay for Performance), already long a front-burner priority within CMS. Nothing exactly "innovative" about it -- it's called "evidence-based medicine," i.e., "science," which results in "clinical practice guidelines" (which, it should be noted in fairness, is derisively referred to by numerous skeptical docs as "cookie-cutter medicine"). I find it the height of hypocrisy that this is touted as a virtue by the likes of AHIP while it is also attacked by reform opponents as looming, ominous "death panels" and "federal health/lifestyle police" if undertaken by the public sector.

[5 & 6], OK, what, precisely, have you been waiting for? AHIP claims that their membership "can" do these things. The for-profit private sector evidence to date seems to infer the opposite.
___

MENDACITY OF THE DAY

"And you know what public option is? It leads to single-payer, completely government-run health care system and no choice. And we want to preserve choice for our people."

- Senator Charles Grassley (R-IA), Des Moines Register, 09/25/09
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Main Entry: op·tion
Pronunciation: \ˈäp-shən\
Function: noun
Etymology: French, from Latin option-, optio free choice; akin to Latin optare to choose
Date: 1593
1: an act of choosing
2a: the power or right to choose: freedom of choice

Not exactly the sharpest knife in the drawer, this man. Beyond the patent lexical contradiction, it's undergrad sophomoric Slippery Slope Fallacy 101.

First of all, we have had Medicare in place for 44 years now. And, guess what? This government entitlement beneficiary cohort also can and does avail itself of private sector "Medi-Gap" insurance coverage. And, guess what? The Evil Government-run agency Medicare itself touts these policies on its website:

Medigap (Supplemental Insurance) Policies

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs...

In addition to Senator Grassley's transparent Slippery Slope rhetoric, he also commits the "False Dichotomy" appeal. Some germane thoughts from a blog post on the "Swiss Model" by Dr. Steve Blevins:

The Swiss system works by regulating commercial insurance. People buy insurance directly from insurance companies, so businesses are out of the loop. Everyone must carry insurance, and those who don’t pay a penalty.

The government subsidizes the cost of insurance for low-income individuals (about one-third of the population). The affluent are not subsidized. (Contrast that with Medicare, which covers everyone over the age of 65, including wealthy people who don't need government assistance.)

In Switzerland, insurance companies must provide basic insurance to all recipients and cannot deny coverage on the basis of poor health. Premiums are not affected by health status. "Basic insurance" is defined by government, which decides which drugs, lab tests, and devices will be covered. Deductibles and premiums are tightly regulated and cannot exceed certain limits. Insurance companies cannot profit from the basic plan, though they may profit from supplemental insurance...

I, for one, would oppose any type of "single payer" reform plan, such as "Medicare For All" that did not permit ancillary supplemental "private option" choices according citizens the freedom to buy coverage beyond that provided by a public program (as in the Swiss system, and as we already unremarkably seen with widely available "Medi-Gap" insurance here). As I have stated before, notwithstanding, for example, that we take basic police and fire protection as a tax-funded given, people are quite free to buy all the additional enhanced private sector protective products and service their wishes dictate and their financial resources can sustain.
___

"Why We Need Government-Run Universal Socialized, Call It Whatever You Want Health Insurance"

LOL. This is pretty interesting.

CONTRARIAN VIEWS

I will give voice herein to an articulate and representative two ("representative" in the non- angrily shouting banal bumper sticker "Town Hell Meeting" sense).

First, the libertarian arguments of Whole Foods CEO John Mackey, whose recent Wall Street Journal OpEd unleashed a torrent of contentious debate (much of it quite hostile, and which included calls for a boycott of his company).

While we clearly need health care reform, the last thing our country needs is a massive new health care entitlement that will create hundreds of billions of dollars of new unfunded deficits and moves us much closer to a complete governmental takeover of our health care system. Instead, we should be trying to achieve reforms by moving in the exact opposite direction-toward less governmental control and more individual empowerment...

...Many promoters of health care reform believe that people have an intrinsic ethical right to health care -- to universal and equal access to doctors, medicines, and hospitals. While all of us can empathize with those who are sick, how can we say that all people have any more of an intrinsic right to health care than they have an intrinsic right to food, clothing, owning their own homes, a car or a personal computer? Health care is a service which we all need at some point in our lives, but just like food, clothing, and shelter it is best provided through voluntary and mutually-beneficial market exchanges rather than through government mandates. A careful reading of both The Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter, because there isn’t any. This “right” has never existed in America...

Then there's David Goldhill's thoughtful Atlantic Monthly essay "How American Health Care Killed My Father."

I’m a Democrat, and have long been concerned about America’s lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system—largely problems of incentives—our reforms won’t do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy...

I would exhort everyone to closely read and assess these two arguments. I will detail my own reactions shortly.
___

JOHN MACKEY, OR "HELL HATH NO FURY LIKE THAT OF AN EX-LIBERAL"

It's difficult to accord much credence to a man who transparently engages in vague and broad-brush Straw Man framing right at the outset. To wit: "Many promoters of health care reform believe that people have an intrinsic ethical right to health care - to universal and equal access to doctors, medicines, and hospitals."

Many? Who, in the mainstream forefront of the policy debate, exactly? Maybe some far-left fringe elements within the "Comrade" contingent, for whom "Property" remains "Theft," but his implicit charge of incipient "Communism" -- "how can we say that all people have any more of an intrinsic right to health care than they have an intrinsic right to food, clothing, owning their own homes, a car or a personal computer?" -- is merely the sophomoric Straw Man tactic (wherein you disingenuously "knock down" a spurious, inflated characterization of a position with which you disagree). Conflating health care with the panoply of consumer products is simply dishonest, a red herring means of rousing peoples' ire at the thought of undeserving "Moochers," in order to poison the well.

How can we say that people have an "intrinsic right" to military defense, or to police and fire protection, (or to safe food and water, or to otherwise safe products that won't electrocute us when we plug them in)? Well, we simply say it. And then we codify it. And, then, having codified it, we don't lie awake nights worrying that everyone will demand a Special Forces FOB dug into his or her front yard, or an occupied Metro PD Black & White, an ambulance, and a hook & ladder truck parked at the curb 24/7.

"A careful reading of both The Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter, because there isn’t any." Really? So,

The 1776 observation "We hold these truths to be self-evident, that all men are created equal" was intended to exclude fundamental aspects of successful living such as viable health?
the Preamble phrase "promote the general welfare" is nothing more than vapid, gratuitous filler?
That Article I, Section 8 of the Constitution -- "provide for the common Defence and [again] general Welfare of the United States..." (a.k.a. "the Commerce Clause") -- well, they really didn't mean it. Neither did they mean the subsequent declaration providing the Legislative Branch the authority to "make all laws which shall be necessary and proper for carrying into execution the foregoing powers, and all other powers vested by this Constitution in the government of the United States, or in any department or officer thereof."

Silly me.

Move over and make room, poignantly foaming "Birthers," and "Deathers." Here come "The Tenthers"!

...all part of a movement whose members are convinced that the 10th Amendment of the Constitution prohibits spending programs and regulations disfavored by conservatives. Indeed, while "birther" conspiracy theorists dominate the airwaves with tales of a mystical Kenyan baby smuggled into Hawaii just days after his birth, these "tenther" constitutionalists offer a theory that is no less radical but infinitely more dangerous.

Tentherism, in a nutshell, proclaims that New Deal-era reformers led an unlawful coup against the "True Constitution," exploiting Depression-born desperation to expand the federal government's powers beyond recognition. Under the tenther constitution, Barack Obama's health-care reform is forbidden, as is Medicare, Medicaid, and Social Security. The federal minimum wage is a crime against state sovereignty; the federal ban on workplace discrimination and whites-only lunch counters is an unlawful encroachment on local businesses.

Tenthers divine all this from the brief language of the 10th Amendment, which provides that "the powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." In layman's terms, this simply means that the Constitution contains an itemized list of federal powers -- such as the power to regulate interstate commerce or establish post offices or make war on foreign nations -- and anything not contained in that list is beyond Congress' authority...

I guess by such "logic" the United States Air Force must be disbanded. The Constitution speaks explicitly only to the establishment and sustenance of an army and navy.

Speaking of the Navy, a bit of Sept 1st blog news...

BACK TO THE MACKEY PLAN

I will mostly just excerpt his eight points below. For the full text of his OpEd, click here.

Remove the legal obstacles which slow the creation of high deductible health insurance plans and Health Savings Accounts...
Change the tax laws so that that employer-provided health insurance and individually owned health insurance have exactly the same tax benefits...
Repeal all state laws which prevent insurance companies from competing across state lines...
Repeal all government mandates regarding what insurance companies must cover...
Enact tort reform to end the ruinous lawsuits that force doctors into paying insurance costs of hundreds of thousands of dollars per year...
Make health care costs transparent so that consumers will understand what health care treatments cost...
Enact Medicare reform: we need to face up to the actuarial fact that Medicare is heading towards bankruptcy and move towards greater patient empowerment and responsibility.
Permit individuals to make voluntary tax deductible donations on their IRS tax forms to help the millions of people who have no insurance and aren’t covered by Medicare, Medicaid, SCHIP or any other government program.

Some of his proffers make good sense, in the abstract. Some require verification to determine whether he's just gilding the lily, and some are questionable.

[1] What exactly are the "legal obstacles" to the creation of high deductible plans? He does not say, and I'm not aware of any. Perhaps a coupling of high-deductible "catastrophic coverage" plans and tax-deductible Health Savings Accounts (HSAs) can be of benefit to those for whom they are economically practicable, but they won't be of much help to those at the lower socioeconomic margins of society (and/or the un- or underemployed), which brings us right back to health care as a disparate economic "privilege." Perhaps at a lower aggregate cost, but disparate nonetheless.

[2] End employment-based vs "private" tax deduction discrimination for health plans? In principle, I would have to agree. My concern here is more general. For example, certain costs associated with my residential mortgage are "deductible." I have to assume, though, that this "tax benefit" may be in fact chimerical, i.e., its "value" is directly (if subtly) reflected in the market value of my property. I tend to view a lot of this "deductibility" idea as a Zero Sum Game.

[3] "Buy anywhere" and "portability"? Again, in principle, I cannot take issue with this -- provided that we don't end up with the bulk of insurance companies ending up nominally chartered in the least-regulated states. There is little mystery regarding why major bank credit card operations seem to be mostly chartered in South Dakota.

[4] Government mandates on what insurance "must cover"? I'm not at all persuaded that this is a serious problem. Moreover, insurance regulation is a state-level patchwork. I'm not aware of any overarching "federal primacy" law mandating the specifics of insurance coverage.

[5] Tort reform? I have two words: "Loser Pays." Look it up.

[6] Price transparency? Here, Mr. Mackey, David Goldhill and I could not agree more. Details when I get to the Goldhill article (which is much more nuanced and detailed).

[7] "Medicare reform"? Mr. Mackey offers up no clue as to what he means by this. The fact that Medicare has prospective unfunded liabilities cannot be disputed, but, that is a problem for Congress. I tire of critics conflating Medicare administration with its congressional funding. Moreover, what, precisely, Mr. Mackey, is the putative financial "responsibility" of a retired fixed-income Medicare beneficiary?

[8] Voluntary tax deductions for donations? Again, this already exists, and truly only serves to nominally financially benefit those who can afford to make the donations. How that will materially abate the aggregate problem of health care financing for those at coverage risk escapes me.

John Mackey clearly and unapologetically regards heath care as a privilege, one based substantively (beyond adequate financial resources)
on one's own "lifestlye" diligence:

...every American adult is responsible for their own health. Unfortunately many of our health care problems are self-inflicted with over 2/3 of Americans now overweight and 1/3 obese. Most of the diseases which are both killing us and making health care so expensive-heart disease, cancer, stroke, diabetes, and obesity, which account for about 70% of all health care spending, are mostly preventable through proper diet, exercise, not smoking, minimal or no alcohol consumption, and other healthy lifestyle choices...

i.e., get off your butts, go to the gym, and then shop for groceries at Whole Foods on your way home. Problem solved." I posted my reaction to that in another blog comment:

I saw that assertion and then went at looked at WHO (World Health Organization) data for the European nations last night. Guess what? Similar prevalence of these same suboptimal "lifestyle" conditions, yet they STILL somehow manage to significantly outperform us on a broad array of health metrics -- at roughly HALF our per capita spending.

While it ought be a Blinding Glimpse of the Obvious that we, of course, should tirelessly exhort and rationally incentivize healthier living, it does not axiomatically follow that such measures will alone suffice to replace affordable health care access. Genetic and environmental factors alone may well serve to negate for many the most "circumspect" of "lifestyles" as currently favored by those bent on patronizingly lecturing everyone else. Consider the apt observation of Dr. Rahul K. Parikh:

I agree we need to pay for cost-effective prevention options...But it's a tough fit because that's not going to end disease in America. And as long as people continue to get sick, they will face the problem of an inadequate insurance system and an out-of-control medical system. As one intelligent commentator pointed out, every one of us is eventually going to get sick, face a traumatic injury or an unexplained illness. Every one is going to die, and many will face agonizing end-of-life medical choices -- no matter how healthful their lifestyles.

When any of that happens, they deserve a well-functioning and reasonably priced sick care system. The last thing a sick person needs is a lecture on how they ate wrong and failed to get enough exercise in the months and years leading up to the acute event."

THE DAVID GOLDHILL ARTICLE

This one, "How American Health Care Killed My Father," deservedly got a lot of national attention.

ALMOST TWO YEARS ago, my father was killed by a hospital-borne infection in the intensive-care unit of a well-regarded nonprofit hospital in New York City. Dad had just turned 83, and he had a variety of the ailments common to men of his age. But he was still working on the day he walked into the hospital with pneumonia. Within 36 hours, he had developed sepsis. Over the next five weeks in the ICU, a wave of secondary infections, also acquired in the hospital, overwhelmed his defenses. My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy...

...My survivor’s grief has taken the form of an obsession with our health-care system. For more than a year, I’ve been reading as much as I can get my hands on, talking to doctors and patients, and asking a lot of questions.

Keeping Dad company in the hospital for five weeks had left me befuddled. How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient’s room? Considering the importance of a patient’s frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient’s care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?...

...I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value.

These are the impersonal forces, I’ve come to believe, that explain why things have gone so badly wrong in health care, producing the national dilemma of runaway costs and poorly covered millions. The problems I’ve explored in the past year hardly count as breakthrough discoveries—health-care experts undoubtedly view all of them as old news. But some experts, it seems, have come to see many of these problems as inevitable in any health-care system—as conditions to be patched up, papered over, or worked around, but not problems to be solved...

Again, I commend this thoughtful, detailed article to everyone. He accurately notes something I have long been concerned with:

How often have you heard a politician say that millions of Americans “have no health care,” when he or she meant they have no health insurance? How has a method of financing health care become synonymous with care itself?

The reason for financing at least some of our health care with an insurance system is obvious. We all worry that a serious illness or an accident might one day require urgent, extensive care, imposing an extreme financial burden on us. In this sense, health-care insurance is just like all other forms of insurance—life, property, liability—where the many who face a risk share the cost incurred by the few who actually suffer a loss.

But health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We’ve become so used to health insurance that we don’t realize how absurd that is. We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and deliveries are predictable many months in advance, yet they’re financed the same way we finance fixing a car after a wreck—through an insurance claim...

Yes. As I've noted before, while I have car insurance and homeowner's insurance, etc., I regard them simply as necessary (required, really) hedges against potentially bankrupting disaster, and I fork over my premiums sans significant complaint for the benefit of the contractual indemnity while being also perfectly happy to never have to file a claim. On the other hand, some sort of health care service is something most of of are going have have to seek out eventually (increasingly so as we age). Navigating an entire life without encountering one or more serious accidents or illnesses is overwhelmingly unlikely. And, while a prudent lifestyle comprising, among other behaviors, habitually healthy nutritional regimens and exercise diligence is of course to be encouraged and incentivized, the extent and impact of random malignant events beyond our control looms chronically larger than it does with respect to other aspects of economic life. We are nearly all at risk of medical malady to a far greater extent than some care to admit.

The question then becomes one of how best to address the risk? Mr. Goldhill joins the chorus of critics who claim that we must all become "smarter consumers" of health care goods and services. Arguing for price "transparency," he complains:

...try discussing prices with hospitals and other providers. Eight years ago, my wife needed an MRI, but we did not have health insurance. I called up several area hospitals, clinics, and doctors’ offices—all within about a one-mile radius—to find the best price. I was surprised to discover that prices quoted, for an identical service, varied widely, and that the lowest price was $1,200. But what was truly astonishing was that several providers refused to quote any price. Only if I came in and actually ordered the MRI could we discuss price.

Several years later, when we were preparing for the birth of our second child, I requested the total cost of the delivery and related procedures from our hospital. The answer: the hospital discussed price only with uninsured patients. What about my co-pay? They would discuss my potential co-pay only if I were applying for financial assistance...

I have had similar experiences. It is maddening. Imagine going to a restaurant and looking at a menu that had no prices therein, to then be informed that you had to order first before the price was revealed. Imagine going to the auto repair shop, only to be told that they'd tell you what your transmission repair would cost only after you signed the work order. Absurd.

David Goldhill:

Keeping prices opaque is one way medical institutions seek to avoid competition and thereby keep prices up. And they get away with it in part because so few consumers pay directly for their own care—insurers, Medicare, and Medicaid are basically the whole game. But without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will...

...It’s astonishingly difficult for consumers to find any health-care information that would enable them to make informed choices—based not just on price, but on quality of care or the rate of preventable medical errors. Here’s one place where legal requirements might help. But only a few states require institutions to make this sort of information public in a usable form for consumers. So while every city has numerous guidebooks with reviews of schools, restaurants, and spas, the public is frequently deprived of the necessary data to choose hospitals and other providers.

'How often have you heard a politician say that millions of Americans “have no health care,” when he or she meant they have no health insurance?"'
-David Goldhill

Sometimes it's not easy to determine the difference, even if you're not a politician. I am 63. I am overdue for a colonoscopy. My wife and I were both laid off, me in 2007, she in 2008. We then lost our COBRA coverage and went for an anxious time without any insurance. Finally, she found another job, and I am now covered under her employer-provided health plan (while her coverage is part of her compensation, we pay for my coverage).

I saw my primary care doctor earlier this year. He gave me a referral for the colonoscopy. I called to schedule. The first -- and I mean first -- four words I heard in reply to my inquiry were "who is your insurance?"

Not "what is your name?" Not "what is your age?" Not "How are you today?" Not "do you have any family history of colorectal disease?" Not "thank you."

"Who is your insurance?"

I provided the requisite information, and we scheduled my consult, six weeks or so out.

The morning of that 1:30 pm consult, the phone rang. "Mr. Gladd, we're very sorry, but we just found out that we do not in fact take your insurance" (Great West/CIGNA).

The caller magnanimously told me "you won't be charged for today if you have to cancel."

A quick Google search tells me that the average cost of a colonoscopy is approximately $3,100.

I canceled, and until I can find a specialist who does take my coverage, I am "without [this aspect of] health care," given that I don't have a spare $3,100 in the bank. Perhaps the likely delay of several months will be of no clinical consequence to me. One hopes.
___

"Talk to the Invisible Hand"
"The promises and perils of treating patients more like consumers."

In light of the Goldhill lament, an interesting and cautionary tale.

Five years ago, former President Bill Clinton developed chest pains caused by blockages of several coronary arteries. After going to a small hospital near his home in Chappaqua, N.Y., Clinton had further tests at nearby Westchester Medical Center, where cardiologists suggested that he undergo surgery at Columbia-Presbyterian Hospital in New York City. Clinton's condition required a complex procedure called coronary-artery bypass grafting, in which blood vessels are harvested from the patient's legs or chest and sewn around the heart to "bypass" the blocked arteries.

It's hard to imagine a savvier, better-connected health care consumer than the former president. But consider this: Beginning in 1991, state health officials in New York began releasing hospital- and surgeon-specific death rates from heart surgery. Anyone can see them online. At the time of Clinton's surgery, the most current report showed that Columbia-Presbyterian had the highest death rate of any of the 35 hospitals doing bypass surgery; it was twice the expected rate (about 4 percent instead of 2 percent, a margin not explained by random chance). Clinton's surgeon was the chief of cardiothoracic surgery, a man named Craig R. Smith. Among the four surgeons at Columbia-Presbyterian who performed more than 100 bypass surgeries each year, Smith had the worst mortality rate. (After the procedure, notably, Clinton suffered a complication requiring yet another major surgery.) According to the New York Times, there was "no indication that the Clinton family was aware of the state report."

Mortality statistics from heart surgery accurately predict future death risks (both for hospitals and individual surgeons) and also catalyze targeted improvement efforts. But Clinton isn't alone in overlooking them. Studies show that most consumers don't bother looking for this information; physicians also wrongly dismiss the statistics and fail to inform their patients about their existence.

Advocates for consumer-driven health care often claim that patients should have "some skin in the game" by sharing decision-making power for their medical care. This depends on patients making informed decisions about their care based on quality and price—but as the case of Bill Clinton demonstrates, even the brightest, most educated people don't always do that reliably...

Excellent brief article by Darshak Sanghavi on Slate.com. He continues:

In short, the usual rules of the marketplace seem not to apply to health care. When left to their their own devices, buyers ignore product quality, fail to value goods properly, and overpay vast sums. (Weirdly enough, they're also happy as clams with the results.) Yet every health reform bill with a chance of passing involves significant cost shifting to patients. Like it or not, patients will have to be better consumers. That's why it's critical now to fix the failures of the market before we throw open the gates for business.

To continue with my restaurant menu analogy, given that there are tens of thousands of ICD-9 and CPT codes pertaining to health care goods and services, an individual health care "shopper" would face a "menu" the size of the Manhattan phone book.

Multiple "phone books," actually. Perhaps they'd be more like the venerable Sears or J.C. Penney catalogs, replete with color-coded "Good/Better/Best" options for your meds or hip job or bypass or MRI.

David Goldhill again:

The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.

A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance...

...How would we pay for most of our health care? The same way we pay for everything else—out of our income and savings...

...Today, insurance covers almost all health-care expenditures. The few consumers who pay from their pockets are simply an afterthought for most providers. Imagine how things might change if more people were buying their health care the way they buy anything else. I’m certain that all the obfuscation over prices would vanish pretty quickly, and that we’d see an end to unreadable bills. And that physicians, who spend an enormous amount of time on insurance-related paperwork, would have more time for patients...

"Imagine how things might change if more people were buying their health care the way they buy anything else."

That would be a sweeping and difficult, if perhaps abstractly laudable, social experiment. But, as I write this update to this post (having just watched much of the contentious Nov. 7th House H.R. 3962 debate on CSPAN), the political momentum seems to be marginally heading the other way -- a worrisome way, in my view. But, much remains in flux, and the only thing of which I can be certain is a further ramping up of the already overheated, increasingly inane rhetoric.

FINAL APPROACH

The legislative debate now moves to the much less populist, much more patrician U.S. Senate.

NY Times
November 9, 2009
Obama Presses Senate to Act Quickly on Its Health Bill

By SHERYL GAY STOLBERG
WASHINGTON — The White House, growing concerned that the Congressional timetable for passing a health care overhaul could slip into next year, is stepping up pressure on the Senate for quick action, with President Obama appearing Sunday in the Rose Garden to call on senators to “take up the baton and bring this effort to the finish line.”

Mr. Obama’s remarks came just 14 hours after the House narrowly approved a landmark plan that would cost $1.1 trillion over 10 years and extend insurance coverage to 36 million uninsured Americans; the president called it “a courageous vote.” But the votes had barely been counted when the White House began turning its attention to an even bigger hurdle: getting legislation passed in the Senate.

In the Senate, where proposals differ substantially from the House-passed measure on issues like a government-run plan and how to pay for coverage, the bill is stalled while budget analysts assess its overall costs. The slim margin in the House — the bill passed with just two votes to spare, and 39 Democrats opposed it — suggests even greater challenges in the Senate, where the majority leader, Harry Reid of Nevada, is struggling to hold on to all 58 Democrats and two independents in his caucus.

Mr. Obama has staked his domestic agenda on passing comprehensive health legislation, a goal that has eluded presidents for decades. While Democrats were forced to make major concessions on insurance coverage for abortions to win House passage of the bill, they were nonetheless ebullient on Sunday, with many saying the vote gave them momentum to push the bill forward.

“For years we’ve been told that this couldn’t be done,” Mr. Obama said in the Rose Garden. Of the American people, he said, “Moments like this are why they sent us here.”

But for all the exultation, there was a sense inside the White House and on Capitol Hill that the hardest work is yet to come. The House debate highlighted the pressures that will come to bear on senators as they weigh contentious issues like federal financing for abortion, coverage for illegal immigrants and the “public option,” a government-backed insurance plan to compete with the private sector...

Those on the activist progressive left are unhappy on a number of counts. Jane Hamsher:

I was on Democracy Now with Dennis Kucinich this morning talking about the health care vote.

Kucinich voted against the bill after they didn’t allow a vote on his amendment to allow states to create single-payer health care systems...

...It was hard to be happy about the passage of the health care bill on Saturday given the incredible blow to women’s rights that it represents...

...A public option was never anything more than a stepping stone to Medicare for all, a foothold in what would have otherwise been nothing more than a huge transfer of wealth to the insurance industry (which is still by-and-large is). But it’s going to take a lot more political organizing on the inside before any real headway can be made on that front, and we’re working on that now.

"A public option was never anything more than a stepping stone to Medicare for all..." Well, this is precisely the objection of the reactionary right, which gets derided as a slippery slope fallacy. The whole acrimonious "government takeover of health care" objection.

One concludes we should simply be grateful for not yet having been forced under the oppressive heel of government takeover of military, police, fire, and food safety services.

THE STUPAK AMENDMENT: A POISON PILL?

Monday, Nov. 9th: The media are ablaze with firestorms concerning the inclusion of the Bart Stupak [D-Mich] anti-abortion amendment in H.R. 3962.

In an interview with ABC News's Jake Tapper, President Obama said he did not support any change in current abortion laws through the health care bill -- an implicit rebuke to the House for passing an amendment that could considerably restrict women's access to abortions. The president said that he doesn't want to change "the status quo" one way or another.
TAPPER: Here's a question a lot of Senate Democrats want to know. You said, when you gave your joint address to Congress, that under our plan, no federal dollars will be used to fund abortions. This amendment passed Saturday night which not only prohibits abortion coverage in the public option, but also prohibits women who receive subsidies from taking out plans that -- that provide abortion coverage. Does that meet the promise that you set out or does it over reach, does it go too far?

OBAMA: You know, I laid out a very simple principle, which is this is a health care bill, not an abortion bill. And we're not looking to change what is the principle that has been in place for a very long time, which is federal dollars are not used to subsidize abortions. And I want to make sure that the provision that emerges meets that test -- that we are not in some way sneaking in funding for abortions, but, on the other hand, that we're not restricting women's insurance choices, because one of the pledges I made in that same speech was to say that if you're happy and satisfied with the insurance that you have, that it's not going to change. So, you know, this is going to be a complex set of negotiations. I'm confident that we can actually arrive at this place where neither side feels that it's being betrayed. But it's going to take some time...

It will be (depressingly) interesting to see how this plays out. It may in fact drown out all other major points of contention (cost, coverage, public option, etc) and may comprise the effective torpedo below the waterline the GOP has been searching for as a weapon to finally sink the reform effort and hand the President a major political defeat heading into the congressional mid-term election period.

Strange Bed Fellows:
Health Care Reform and the Stupak Amendment
- Michelle Kraus, Huffington Post

How did women’s reproductive rights become the bargaining chip for health care reform in this country? Federal funding for clinics is essential to the future of women’s reproductive rights and health. The Stupak Amendment slams women back to a time of unsafe abortions. What is the President thinking? Didn’t we fight this battle before and wasn’t it put to rest decades ago? And what alliances were forged that put women’s reproductive rights into play yet again? There is something very odd about this dilemma. It causes one to ponder how we got here and why. Realistically, health care reform has become very nasty business fraught with religiosity, prejudice, hatred and fear mongering. It has become the divisive issue that the Iraq War was in 2002, 2003, and 2004. Either you are with us or against us – clear and simple. Partisan lines were drawn again, and GOP support was withheld in the landmark bill passed in the House on Saturday evening.

Yet somehow, women’s reproductive care became the oil thrown on an already smoldering fire...

BTW, I have previously written at some considerable length on the seemingly intractable reproductive rights issue. Apparently, "conservatives" are 100% for "choice" and against "government control of health care decisions" except where it bears on womens' reproductive rights.

Nice examination of the salient issues here in the L.A. Times:

Also, the NY Times chimes in on its Opinion Page (11/09/09):

...The restrictions would fall on women eligible to buy coverage on new health insurance exchanges. They are a sharp departure from current practice, an infringement of a woman’s right to get a legal medical procedure and an unjustified intrusion by Congress into decisions best made by patients and doctors.

The anti-abortion Democrats behind this coup insisted that they were simply adhering to the so-called Hyde Amendment, which bans the use of federal dollars to pay for almost all abortions in a number of government programs. In fact, they reached far beyond Hyde and made it largely impossible to use a policyholder’s own dollars to pay for abortion coverage...

One last take on the issue for now (click the image):

At this point, I would think, it's too early to conclude what will be the upshot with respect to any final bill. Expect more nasty, counterproductive hyperbole, I suppose.

NOV 12TH UPDATE

Well, this is just a tad inconvenient. From the Think Progress blog:

IOKIYAR, 'eh?
___

For now, I return to my initial thoughts when I commenced this series back in May. Can we

[1] extend health care coverage to all citizens, with
[2] significantly increased quality of care, while at the same time
[3] significantly reducing the national (and individual) cost?

Is there even -- yet, at this late date -- overwhelming public consensus that such are worthy and necessary national goals? If so, how do we get there in the most effective manner? Comprehensive federal legislation? Incremental federal and state legislation (e.g., incremental regulatory/tort/market reforms)? Unfettered competitive free-market initiatives, perhaps coupled with expansion of Health Savings Accounts (HSAs) and regulation anew only in areas of "price transparency" ostensibly enabling citizens to become more astute health care "consumers?"

HEALTH CARE "COVERAGE"

It's obvious that the overriding U.S. political focus remains that of private for-profit health care "insurance" regulatory reform, with lobbying entities such as AHIP battling tooth, claw, and checkbook to preserve their members' core commercial advantage while paying P.R. lip service to actual reforms of significant benefit to the public.

I put the word "insurance" in quotes in recognition of the the observations of critics such as David Goldhill (and, going all the way back to my May 2009 post, Malcolm Gladwell), as we're really properly talking simply about 3rd party remittance intermediaries, not indemnity "insurance" in the otherwise accepted meaning of the term. Meaningful discussion of of this differential policy nuance is by now pretty much off the public/political radar.

Attention of late has turned to (weak?) threats of removing the health insurance industry's anti-trust exemption, concomitant with proposals to enable consumers to buy health insurance across state lines. A recent graphic posted on HuffPo readily illustrates the problem.

In a number of states your choices are limited to those of a few large players such as Anthem/Blue Cross, United Heath Group or CIGNA, etc. Removing the industry's anti-trust exemption might well force true downward price pressure competition into the industry.

Which is precisely why the AHIP membership will fight this to the legislative death. The mainstream media are increasingly ablaze with the requisite fear-mongering.

More on this from the Denver Post:

Health insurers' antitrust exemption becoming a focus of reform debate
By Jennifer Brown
The Denver Post, 11/12/09

Dr. John Bender, a family physician in Fort Collins, says his power to negotiate with health-insurance companies packs the might of a tiny bug: "We are like gnats to them."

About half of Bender's patients have either Anthem Blue Cross Blue Shield or United Healthcare — the two companies that hold 53 percent of the market in Colorado — so losing either contract could push him toward bankruptcy.

It's forbidden under antitrust law for doctors to collude about rates and demand that insurance companies reimburse them more for their work. But in what some argue is lopsided policy, insurance is one of the few industries exempt from federal antitrust laws that prohibit price fixing and "bid-rigging," the practice of unscrupulous brokers ensuring that favored insurers get contracts.

A major goal of national health care reform is to spur competition in the insurance industry. Reform advocates argue competition would drive down costs. Among the latest proposals up for debate in Washington: yank the antitrust exemption in place since 1945.

The health-insurance industry argues that it is not engaging in anticompetitive conduct and that the exemption doesn't shield such conduct anyway.

Health insurance is regulated by state insurance commissioners, so repealing the federal antitrust exemption would do little more than undermine the current regulatory structure, said the industry's national trade organization, America's Health Insurance Plans.

Democratic lawmakers pounced on the antitrust exemption soon after insurance companies pulled support for leading reform proposals. Insurers, who had cautiously supported reform throughout the past year, released reports this fall predicting that health care premiums would rise even faster than they do now under current reform plans.

"It's just political battling back and forth," said John Soma, who teaches antitrust law at the University of Denver's Sturm College of Law. "The power of this insurance lobby is just awesome."...

Click the link above to read the entire article. A subsequent salient point therein:

Regulation of anticompetitive behavior among insurers is weak in most states, Balto said. A recent Center for American Progress survey found no antitrust actions brought by state insurance commissioners and that about one-third of the states "brought no significant consumer protection actions."

Health insurers don't need the antitrust exemption now because the market isn't competitive, Balto said. But after health care reform, new companies or cooperatives will emerge and the country will need to prevent the four or five dominating insurers in a given area from colluding to kill off new competition, he said...

AGAIN, ON "CHOICE"

I would commend to everyone an instructive book "The Paradox of Choice" by Barry Schwartz. Additionally, Thaler and Sunstein's excellent "Nudge" is usefully illuminating in the context of this topic.

It is particularly hard for people to make good decisions when they have trouble translating the choices they face into the experiences they will have...

Take the problem of choosing a mutual fund for your retirement portfolio. Most investors (including us) would have trouble knowing how to compare a "capital appreciation" fund with a "dynamic dividend" fund, and even if the use of those words were made comprehensible, the problem would not be solved. What an investor needs to know is how a choice between those funds affects her spending power during retirement under various scenarios -- something even an expert armed with a good software package and complete knowledge of the portfolios held by each fund can have trouble analyzing. The same problem arises for the choice among health plans; we may have little understanding of the effects of our selection. If your daughter gets a rare disease, will she be able to see a good specialist? How long will she have to wait in line? When people have a hard time predicting how their choices will end up affecting their lives, they have less to gain by numerous options and perhaps even by choosing for themselves...

...people may most need a good knowledge for choices that have delayed effects; those that are difficult, infrequent, and offer poor feedback; and those for which the relation between choice and experience is ambiguous. A natural question is whether free markets can solve people's problems, even under such circumstances. Often market competition will do a lot of good. But in some cases, companies have a strong incentive to cater to people's frailties and exploit them.

Notice first that many insurance products have all of the fraught features that we have sketched. The benefits from holding the insurance are delayed, the probability of having a claim is hard to analyze, consumers do not get useful feedback on whether they are getting a good return on their insurance purchases, and the mapping from what they are buying to what they are getting can be ambiguous. But the insurance market is competitive, so a natural question to ask is whether market forces can be relied upon to "solve" the problem of fraud choices.

...There is a general point here. If consumers have a less than fully rational belief, firms often have more incentive to cater to that belief then to eradicate it...

The foregoing speak directly to my own dubiety with for-profit market-based "choice" driving, to the virtual exclusion of all other considerations, health care policy reform. Every marketing, legal, and otherwise corporate bureaucracy dollar devoted to the concoction of, hawking of, and administration of excess, inscrutably byzantine (and frequently spurious) "choice" is a dollar unavailable for actual clinical care.

But, as my former QIO Senior Medical Director Dr. Brent James would often say, "every misspent dollar in the health care system goes into someone's paycheck."
___

SOME DEMOGRAPHIC IMPLICATIONS

Recall from my initial post on this topic which commenced on May 25th a simple, broad, and bracing statistical revelation set forth by AHRQ:

How Are U.S. Health Care Expenses Distributed?
A Small Proportion of the Total Population
Accounts for Half of All U.S. Medical Spending

As policymakers consider various ways to contain the rising costs of health care, it is useful to examine the patterns of spending on health care throughout the United States. In 2004, the United States spent $1.9 trillion, or 16 percent of its gross domestic product (GDP), on health care. This averages out to about $6,280 for each man, woman, and child.

However, actual spending is distributed unevenly across individuals, different segments of the population, specific diseases, and payers. For example, analysis of health care spending shows that:
Five percent of the population accounts for almost half (49 percent) of total health care expenses...
...[while] half of the population spends little or nothing on health care...

And, the rest of us move up and down somewhere in between from year to year. It should be obvious that the highest expenditure cohort is -- unsurprisingly -- generally correlated with advanced age (as I have come to know all too well via the course of my next-of-kin duties concerning my aged and ailing parents). Now, consider a summation of some data I just culled from a U.S. Census Bureau database.

Click the graph to enlarge. It depicts relative percentages of our population in five-year age increments (dark blue line) along with projections going out 25 years (2024, light blue line), and 50 years hence (2049, red line). I drew in a vertical black line to demarcate the +/- age 60 threshold. You might think of these as simple current and forecast "survival curves" indicative of our graying population, i.e., relatively more people will be alive in the 60+ group going forward. Increasingly so with the advance of time.

Sometimes, a data table is more illuminating than a graph. While the foregoing illustrates shifts in relative age-strata percentages, we must be even more concerned with the impact of growing population in actual enumerative terms. Below, blended projected U.S. population growth (both sexes, all races) 25 and 50 years out respectively.

Most noteworthy here is that, while our population is projected to increase by perhaps 42% by 2049, the age 60+ cohort -- precisely the demographic accounting for a hugely disproportionate share of health care expenditures -- is predicted to double.

The most excruciating of economic and ethical choices inescapably await us. And, while much of the public continues to sleepwalk into this morally daunting future (abetted by the well-funded stultifyingly fear-stoking fallacies of corporate status quo interests), we really don't have the luxury of time to continue to kick this policy can down the road. Sadly, it appears to a worrisome degree that that is precisely where we're headed at best.

Health insurers could bypass some key reforms
By David S. Hilzenrath
Washington Post Staff Writer
Friday, November 13, 2009 4:54 PM

Nobody wants to spend a lot of time, energy -- and taxpayer money -- and end up back where they started. But that's what could happen with one of the principal elements of health reform, the so-called exchange or gateway.

Legislators are designing this new insurance marketplace to protect consumers from many of the pitfalls and inequities in the current system. But even as they focus on the details of how the marketplace will work, senators have indicated that they would allow insurers to continue operating outside it, much as the health insurance lobby has sought.

One of the Senate bills would preserve the possibility that insurers could tailor policies to draw healthy individuals out of the new markets, leaving coverage less affordable for those who stay behind.

"It's a leak in the system," said Karen L. Pollitz, a professor at Georgetown's Health Policy Institute. "It returns you to problems that we have today."

Senate bills guarantee that certain basic reforms -- such as requiring insurers to accept people regardless of preexisting medical conditions and banning annual and lifetime limits on coverage -- would apply both inside and outside the new markets for individuals and small businesses. But that would not be true for a host of other requirements that should help consumers compare health plans on an apples-to-apples basis and force insurers to compete more directly on price.

For example, the bill written by the Senate health committee would not require insurers operating outside the marketplace to provide standardized disclosures about what they cover.

It would not prohibit health plans outside the exchanges from using marketing practices that discourage the seriously ill from enrolling, nor would it demand that they offer "a wide choice" of medical providers -- including "essential community providers . . . that serve predominantly low income, medically-underserved individuals," as the bill prescribes for insurers inside the exchanges.

Perhaps the sharpest dichotomy is that, under the health committee proposal, certain standards governing the nature and extent of covered benefits would apply only to policies sold inside the exchanges.

All of those factors contribute to the possibility that insurers might offer cheaper, less comprehensive policies outside the exchanges and entice healthier people to leave the new markets. That would leave the exchanges responsible for sicker people who are more expensive to insure.

Similarly, outside the exchange, the bill drafted by the Senate Finance Committee would not regulate the marketing of individual coverage, nor would it require that health plans be rated based on quality and price...

The image above (from a Nov 15th HuffPo article) says everything. Nothing new, either. Recall from my July 9th, 2008 post "Privacy and the 4th Amendment amid the 'War on Terrror'."

"INTELLIGENT MAIL"?

I had to laugh when I found out about this one. Amid the recommendations of President Bush's Postal Reform Commission was one advocating the implementation of what they called "intelligent mail" as yet another "tool" for combatting terrorism. Ostensibly driven by anxieties regarding toxic "anthrax letter" incidents, the idea was to require verified sender and recipient ID for every piece of USPS mail...

...given my chronic and tedious inclination for looking under the hood, I reviewed transcripts and supporting documentation of the Postal Commission hearings. Therein I found a document supporting "intelligent mail" proffered by Pitney-Bowes, one of the vendors salivating over the prospect of getting the contract to implement such a system.

Well, guess, what? The section of the Postal Commission's final report advocating implementation of "intelligent mail" was lifted nearly verbatim from the Pitney-Bowes proffer...

Different day, same, M.O. Bidness as usual within DC and the halls of Congress.

"Public Optional"

___

"CREATION SCIENCE" COMES TO HEALTH REFORM

This is rich:

Health bill foes solicit funds for economic study
By Michael D. Shear
Washington Post Staff Writer
Monday, November 16, 2009

The U.S. Chamber of Commerce and an assortment of national business groups opposed to President Obama's health-care reform effort are collecting money to finance an economic study that could be used to portray the legislation as a job killer and threat to the nation's economy, according to an e-mail solicitation from a top Chamber official.

The e-mail, written by the Chamber's senior health policy manager and obtained by The Washington Post, proposes spending $50,000 to hire a "respected economist" to study the impact of health-care legislation, which is expected to come to the Senate floor this week, would have on jobs and the economy.

Step two, according to the e-mail, appears to assume the outcome of the economic review: "The economist will then circulate a sign-on letter to hundreds of other economists saying that the bill will kill jobs and hurt the economy. We will then be able to use this open letter to produce advertisements, and as a powerful lobbying and grass-roots document."...

I have just a couple of brief reactions.

To the (debatable) extent that conventional "economics" can be considered "science, "this is classic "junk science" (as is the poignant "Creation Science"), wherein you start with an a prior conclusion and then work backward, picking off and retaining only "evidence" that supports your ideological conclusion;
While the relative socioeconomic impacts of various flavors of national health policies around the world have been studied in detail for decades, given that we as yet have no firm final reconciled House-Senate legislative proffer, this "study" would necessarily be entirely speculative -- and, the thrust of that speculation is, of course, already known. This would be nothing more than one more latter-day exercise in partisan fig-leafery posing as economic "research."

SPEAKING OF "STUDIES"

Uninsured ER patients twice as likely to die
New study highlights disparity of care for those who don't have coverage CHICAGO [AP] - Uninsured patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance, according to a troubling new study. The findings by Harvard University researchers surprised doctors and health experts who have believed emergency room care was equitable. "This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States," said senior author Dr. Atul Gawande, a Harvard surgeon and medical journalist...

...The researchers couldn't pin down the reasons behind the differences they found. The uninsured might experience more delays being transferred from hospital to hospital. Or they might get different care. Or they could have more trouble communicating with doctors.

The hospitals that treat them also could have fewer resources.

"Those hospitals tend to be financially strapped, not have the same level of staffing, not have the same level of surgeons and testing and equipment," Gawande said. "That also is likely a major contributor."...

CONCLUDING REMARKS

While I will continue to follow the legislative developments as this policy fight draws to a close, let me end where I began back in May. Can we, via federal legislation

provide health care coverage for all, with
improved levels of quality, while concomitantly
reducing health care costs?

Incontrovertibly laudable goals, one would think, but the skeptics remain many and loud (many of them simply rigid ideologues, most of them comfortably and hypocritically secure in their own amply feathered nests). I have tried through this series of posts to shed detailed light on the various core aspects and issues from all of the serious contending perspectives. As I follow the "final approach" debate these day, I hear this or that argument and think "yeah, I already covered that," so it's time to move on.

What are the options going forward?

Do nothing;
Further de-regulate free market health care, with legislation perhaps limited to expansion of things like Health Savings Accounts (HSAs), tort reform, and permitting consumers to buy insurance across state lines;
Health insurance reform containing a "public option" via which to put countervailing pressure on health coverage costs;
Health insurance reform based more or less on the "Swiss Model";
One or another of the "Single Payer" variants -
- "Medicare for All";
- UK Model National Health Service (true "government run health care");
- "Canadian" style Single Payer Model (essentially just "Medicare for All").

Possible outcomes this time around? Option 1 remains a serious possibility ("...hand the President a serious political defeat heading into the mid-terms.."). Option 2 is politically DOA right now, as are options 4 and 5. So, in my view only one or another inscrutably complex version of option 3 is likely to pass should the entire effort not fail. To date I see nothing to materially abate my concern that we will not accomplish much of truly transformative, socially beneficial substance that gets us anywhere near goals 1, 2, and 3.

Where do I come down? Net, (and guardedly), "Single Payer / Medicare for All" (all not otherwise covered by the active DOD or VA systems) But, I could live with a "Swiss Model" system, perhaps to exist alongside our current long-functioning single payer systems -- (VA and Medicare) -- the latter perhaps expanded to permit lower age enrollment as a de facto "public option" without being structured as means-tested "welfare" with a wasteful "corporate welfare" "affordability eligibility" vetting process. (And under that scenario I would subsume Medicaid under Medicare, and do away with the former).

I won't be holding my breath.

TV is incessantly blaring these days with well-funded anti-reform ads replete with the ominously sneering baritone voice-overs gloomily intoning the terrible job-killing, economy-wrecking upshot of passage of health policy reform, given the estimated federal price tag. Intentionally glossed over, of course, is that fact that the money will have to be spent one way or another, and, by all accounts, absent some sort of mandated restraint, we are on course to national financial ruin. The for-profit actuarial model, applied to health care, contains the toxic seeds of its eventual destruction, and left to continue largely unabated, will be a principal factor in that national ruination.

The shallow, media-fueled antipathy toward "government" (emblematically characterized by the "Teabagger" movement), to me, speaks to a broader concern; the still mostly inchoate anxiety increasing numbers of us are feeling that the world has gotten too complex and unmanageable, and the favored U.S. sociopolitical perch of our lifetimes is inexorably attriting away.

It is not a baseless concern. We comprise roughly 5% of world population, while consuming 25% of its resources. As climate scientist Tim Flannery observed in his book "The Weather Makers,"

In 1961 there was still room to maneuver. In that seemingly distant age, there were just 3 billion people, and they were using only half of the total resources that our global ecosystem could sustainably provide. A short twenty-five years later, in 1986, we had reached a watershed, for that year our population topped 5 billion, and such was our thirst for resources that we were using all of Earth's sustainable production.

In effect, 1986 marks the year that humans reached Earth's carrying capacity, and ever since we have been running the environmental equivalent of a budget deficit, which is sustained only by plundering our capital base. The plundering takes the form of overexploiting fisheries, overgrazing pasture until it becomes desert, destroying forests, and polluting our oceans and atmosphere, which in turn leads to the large number of environmental issues we face. In the end, though, the environmental budget is the only one that really counts...

...By 2001 humanity's deficit had ballooned to 20 percent, and our population to over 6 billion. By 2050, when the population is expected to level out at around 9 billion, the burden of human existence will be such that we will be using -- if they can still be found -- nearly two planets' worth of resources." [pp. 78-79]

As I wrote in a prior post in response:

We can choose to continue to drill, mine, cut down, and grind up the planet in pursuit of short-term business-as-usual, unevenly distributed consumerist comforts, but the day of tragically harsh mass reckoning draws ever closer. The lessons to be drawn from Jared Diamond's "Collapse" are compelling in this regard. There is no shortage whatsoever of constructive and remediative work to be done in support of a sustainable and broadly prosperous future for all of humanity. But, let's not kid ourselves that an unregulated "invisible hand free market" alone will suffice to insure its emergence. Recent economic history alone refutes that assertion.

Complicating this unsustainably destructive "consuming the future" market ethos, consider this: In this decade, more than 40% U.S. corporate profits have come from the "financial services sector," with perhaps 3/4 of those "profits" accruing from iterative, non- tangible-value-adding, grotesquely leveraged "fee income" that fueled the recent economic bubble and caused the current recession.

Let me repeat what I wrote a few days ago (scroll back up a bit):

"The most excruciating of economic and ethical choices inescapably await us. And, while much of the public continues to sleepwalk into this morally daunting future (abetted by the well-funded stultifyingly fear-stoking fallacies of corporate status quo interests), we really don't have the luxury of time to continue to kick this policy can down the road. Sadly, it appears to a worrisome degree that that is precisely where we're headed at best."

I would love to be wrong. I would love to hear from others, too. I certainly don't have all the answers.
___

CODA: MY PRIOR HEALTH REFORM POSTS

___

EPILOGUE

Harry Reid has released his compromise Senate draft, H.R. 3590.

Our private, for-profit health insurance system, designed to fatten the profits of private health insurers and Big Pharma, is about to be turned over to ... our private, for-profit healthcare system. Except that now private health insurers and Big Pharma will be getting some 30 million additional customers, paid for by the rest of us.

Upbeat policy wonks and political spinners who tend to see only portions of cups that are full will point out some good things: no pre-existing conditions, insurance exchanges, 30 million more Americans covered. But in reality, the cup is 90 percent empty. Most of us will remain stuck with little or no choice -- dependent on private insurers who care only about the bottom line, who deny our claims, who charge us more and more for co-payments and deductibles, who bury us in forms, who don't take our calls.

- economist Robert Reich

BREAKING: Foreign born Radical Communist Obama wants to kill Grandma and Grandpa

2009-07-30T20:38:00.000-07:00

FROM "BIRTHERS" TO "DEATHERS"

Sometimes you just have laugh, notwithstanding the lack of actual humor in the circumstance. I recently had my bit of Photoshop fun with this inane "Birther" thing (regarding people who continue to increasingly insanely claim that Barack Obama was not really born in Hawaii to an American citizen mother and, consequently, cannot be our legitimate President).

Click to enlarge.

Now we get to put up with the equally idiotic "Deathers," people who claim that health care reform will result in forced euthanasia of the too-costly, expendable elderly, e.g., GOP House member Virginia Foxx of North Carolina:

and the unbelievably hokey Family Research Council's "After A Government Health Care Takeover":

LOL. In terms of "acting," next to them, Harry and Louise look like Oscar nominees.

BTW, Mrs. Foxx and FRC, my personal, actual "pro-life" bona fides are succinctly documented here.
___

OK, back to serious health policy reform discussion. It takes something less than rocket scientist acumen to ascertain that health care expenditures are to a significant degree correlated with age. As I noted in a previous post, my health care CQI mentor Dr. Brent James long ago pointed out that, on average, roughly 80% of a person's lifetime health care expenditure comes during the last six months of life. I would today call that A Binding Glimpse Of The Obvious.

Consider the following graphic, from UCSC:

31 nations, rank-ordered, high to low (L-R) in terms of "average life expectancy" as a function of per capita cost expressed in currency-adjusted "International Dollars" (Note: I drew the black "trend line" through the chart in Photoshop. Eyeballed it -- not having access to the underlying data -- and I tried to visually ignore the U.S. "outlier"). What is noteworthy here? Well,

the life expectancy range, or "spread," is about 5% from the highest to the lowest (Japan to Portugal);
The United States ranks near the bottom, notwithstanding far and away the highest per capita cost (again, as we have discussed before, roughly 2x the otherwise average);
cost, while a salient contributory factor, is nowhere near determinative; e.g., Cuba's spending is nil relative to ours, all the while their having essentially the same average life expectancy. Moreover, Japan, ranked highest in life expectancy, appears to be around the average in terms of per capita expenditures. Myriad other elements are clearly at play. In general, one needs to be aware of the post-hoc, ergo propter hoc fallacy ("correlation=causation"). This very graphic refutes it -- i.e., given U.S. expenditures, Americans ought easily all survive into our 90's and beyond, given the money spent;
just for a thought, visually take out the extreme high/low cost outliers of the U.S. and Cuba in your mind's eye, and then also visually "connect" my informal trend line from Japan (highest longevity on the left) to Portugal (lowest, on the right). The "slope" -- which would pretty much run through the center of the amended distribution -- would be close to flat, i.e. the correlation would be next to nil.

What can you rationally take away from the foregoing? [1] Older people cost more to care for (duh, hel-LO?); [2] Other nations do it far more efficiently and effectively overall -- and without having to resort to heartless, whiney "Kill Grandma" canards.

Spare me.
___

CANARDS UPDATE

"When the government gets involved in health care, things go rapidly downhill."

- Standard GOP obstructionist talking point.

OK. Here's the relative distribution of private vs. public health care expenditures since 1997:

Roughly half of health care expenditures (45% vs 55%) have been publicly funded across this period. I was going to graph it, but it's pointless, the trend lines are flat. You can see that right there in the table. [Source: HHS (pdf), click the image to enlarge]

Below, for historical context. In 1960, 3/4 of NHE were "private." Medicare came to the sociopolitical landscape in 1965, and subsequently, as the population has aged, the relative proportions have indeed shifted inexorably in the direction of public funding.

The point? We have had Medicare for 44 years. It works (and is going to have to continue to do so, as its share of the patient population grows with the incipient huge eligibility wave of the Baby Boom generation). We have had a Veterans' Administration since 1930. It works. No, neither or them perfectly. But they effectively serve their intended functions. Which is that of serving their beneficiaries, rather than the portfolio accounts of for-profit stockholders.

A FEW PERSONAL OBSERVATIONS ON THESE "BURDENSOME ELDERLY"

I have quite a bit more than just a passing familiarity with health care costs. I have been studying many of the issues professionally since 1993 (see my prior posts), when I took up my first tenure as an analyst with the Nevada-Utah Medicare QIO, where much of my work initially involved analytical data mining of the Part-A acute care hospitalization claims databases (today known as the CMS ISAT data).

Then, in the spring 1996, I was summarily thrown into the world of the medically indigent as next-of-kin caregiver to my terminally ill daughter, Sissy. Later that year, my then- 80 yr old Dad came to the brink of dying from heart valve failure. An aortic valve replacement and bypass would forestall his demise.

Sissy died in 1998 in the wake of a horrific and expensive struggle against metastatic liver cancer (paid for mostly by federal and California taxpayers via Medi-Cal). Notwithstanding that we were not legally on the hook for Sissy's expenses, still, we wearily shlepped back to Vegas from Hollywood in the summer of 1998 tens of thousands of dollars in debt in the wake of the experience.

Several years later -- the day after the 9/11 terror attacks in 2001, to be precise -- my Dad, who'd never fully recovered cognitively from his heart surgery, keeled over at home in Florida in cardiac arrest. EMTs revived him, and, after several week in acute care, he was transferred to a nursing home, where he would subsequently languish for years in an increasingly befuddled, often shit-and-urine-soiled state of dementia.

Fast-forward to 2004, where my Mother, then 82 and increasingly enfeebled, would spend most of the fall in revolving-door acute and rehab unit care (and I would spend much of my time on the Delta red-eye from Vegas to Melbourne). An attorney drew up the papers appointing me her Attorney-in-Fact, and I would subequently end up increasingly running most aspects of her logistical and financial life. In December of 2004, doctors would forestall her demise via a pacemaker implant. She'd gotten so wobbly from her increasing cardiac instability that she'd become a constant, serious fall risk. She'd already had one hip replacement. Another fall might well kill her.

In 2007 I moved them both to Las Vegas, Pop to a nursing home, and Ma into assisted living. She lasted all of 9 days. Fell while in the bathroom, and was transported to nearby St. Rose hospital, whereupon she suffered a recurrence of the enervating C-diff infection and UTI that had kept her in Florida hospitals most of the first six months of 2007. She spent the remainder of the year in and out of hospitals and rehab facilities.

My requisite POA pen ever at the ready.

She never made it back to assisted living (I wasted ten grand on that Quixotic effort; her remaining furnishings and effects we'd shipped from Palm Bay and lovingly moved into her new apartment now sit in a storage unit a few blocks from my house). Mother is now bedridden and wheelchair-bound in a nearby nursing home. Private pay (Medicare does not pay for long-term care). I now cut a check for about $6,300 a month on her behalf. She's now 87. I sit with her nearly every day, ongoing.

Dad finally died last year, just shy of his 92nd birthday, and five months after I'd spent close to $4,000 in legal fees to obtain Legal Guardian status, owing to my concern that my POA on my Ma would die with her, and he had no legal cognitive ability to grant me POA on him (she had it on him, but it was non-transferable to me).

Just one personal story. And, I have not the slightest doubt that I'm in extensive company (increasingly so). The ethical issues and quandaries pertaining to the just allocation of health care resources are myriad and maddeningly complex (I addressed that two posts ago in citing the 1994 works of Elhauge and Dr. James). These serious sociopolitical issues deserve orders of magnitude higher-level policy discourse than those proffered by the ignorant, cynical likes of a Virginia Foxx or a Family Resource Council.

My kin have undoubtedly "cost the health care system" millions during the past dozen years or so. How much of that went into actual necessary clinical care and its requisite support services, and how much went into the multi-million dollar compensation packages of for-profit "health care" executives, I have no formal way to calculate. But, look at the "Cost of a Long Life" graphic above.

What would you estimate?
___

AUGUST 11th UPDATE

Sometimes, the sheer willful, unreflective ignorance just leaves you shaking your head. I just saw this photo over at Jon Taplin's blog. It's of a piece with the recent rantings of the numerous "Town Hell" shouters angrily crying 'keep your government hands off my Medicare.'

Well, sir, perhaps because

He's not a Canadian citizen, and,
in addition to his generous insurance provided by the federal employee health insurance program he has as a member of the Senate, he's a MEDICARE BENEFICIARY!

___

RAGING SOCIALIST RANT

"The discoveries of healing science must be the inheritance of all. That is clear. Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion. Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available."

- Prime Minister Winston Churchill, March 1944, arguing for the establishment of a British National Health Service.

Doing some basic health care reform math

2009-07-01T20:54:00.000-07:00

This is a short follow-up to my prior lengthy post "The U.S. health care policy morass." (Cross-posted at Open Salon.)

Some necessary basic arithmetic

The image above is taken from a quick Excel spreadsheet I put together and uploaded here. You can download it and play with it as you wish. The user input cells are the 1st, 2nd, and 6th respectively ("Total Population," "Total Current Expenditure," and "Pct spending reduction."

[NOTE: to speculate on the effects of spending increases, simply enter a negative decimal fraction, e.g., enter "-.25" to see the upshot of a 25% increase, and so forth.]

In my lengthy post "The U.S. health care policy morass," I cited some aggregate health care expenditure data proffered by the bipartisan National Coalition on Health Care.

In 2008, total national health expenditures were expected to rise 6.9 percent -- two times the rate of inflation. Total spending was $2.4 TRILLION in 2007, or $7900 per person. Total health care spending represented 17 percent of the gross domestic product (GDP).

I roughly estimated the 2007 figure up in the spreadsheet to $2.55 trillion for 2008. The rest is simple long division and percentage math. Nothing fancy.

As I've observed in comments elsewhere, some analysts have argued that we can in fact cover everyone, with materially better outcomes, and save perhaps 30% in the process. Even so, do the per capita math (sit down first). 2008 estimated U.S. "health care" spending ~= $2.55 trillion. Divide by a 307 million U.S. population. Decrement by 30%. You still get more than $5,800 per year per person. And, substantially more if you restrict the gross "population" figure to only adult civilian non-institutionalized, i.e., those actually or potentially on the hook for payment. Now, of course, Congress is not buying the "save money" part. The draft Senate bill only speaks to reducing "the growth in spending" (link to that 852 page draft legislation document in my prior blog post appendix). So, re-do the math. Give yourselves more heartburn.

Recognizing that it's never going to be allocated strictly "per capita," (e.g., just look at the monthly "family of 4" data), then the essentially zero-sum game becomes deciding who (individually) or which socioeconomic strata have to pay proportionally more. It's worth noting that, even were we to somehow miraculously cut the NHE (National Health Expenditure) by 50% [1], the resulting aggregate amount would still be more than twice our military budget.

[1] Take out the military and those incarcerated or otherwise institutionalized, ratcheting down the population to, say, an even 300 million, enter a 50% aggregate cost reduction; you still would have more than $1,400 per month for a family of four. If you further deduct an estimated "retired" subset cohort from among the 39 million people over the age of 65 -- those who would now be almost exclusively recipient-beneficiary health care system users rather than tax/premium contributors, the per capita numbers worsen concomitantly, rather dramatically so.

I'm not making any of this up. This is just grade-school arithmetic based on some published national numbers, along with some readily adjustable Excel "what-ifs?"

A big problem.
___

JULY 22nd UPDATE

Well, I watched the President's much anticipated "health care news conference" tonight. Not much really new there. He still claims that he and Congress must -- and will -- get health policy reform legislation agreed to, passed, and signed into law this year.

A core theme in all of this remains "making health care affordable" -- both for individuals and for the nation, given its impact on both personal and public budgets.

What do we mean by "affordable"? Who decides? I simply decide for myself that I cannot afford a Lexus or Dom Pérignon champagne, or caviar, or vacations in Monaco, etc. Others with more substantive financial assets decide otherwise, as is their free choice. But, what about health care insurance? Many people today "decide" that they cannot "afford" it (should it not be provided as part of their employment compensation). Meaning that their own value preferences dictate that they allocate their finite financial resources toward other freely chosen ends (this usually pertains to younger, healthier people).

But, now, we're being told that we all have to contribute in some fashion. No more "free riders," because, should you get seriously injured or ill and have no coverage, society will in fact be picking up your tab.

Stipulated. That is unlikely to change materially, should you find yourself in life-threatening circumstances and bereft of resources.

It's also increasingly increasingly argued of late (albeit not universally) that health care is a fundamental "right." Now, as a matter of long-settled law and policy -- as I pointed out in my prior post -- access to health care is indeed a "right," but it is a "right of last resort," a contingent, means-tested safety net "right" that comes with economic destitution (or close enough to it).

And, as of now, once you reach the age of 65 (I'm 18 months out), it becomes simply an "entitlement" right in no way contingent on personal income or net worth -- i.e., Medicare.

But, now, we're being told that we all have to contribute in some fashion

Well, consider military defense, and police and fire protection. We regard those without a second thought as basic "rights,"[**] and we assume that our various tax contributions suffice to provide them. Taxes may go up or down, defense, police, and fire department budgets may rise or fall, but we don't expect an annual arithmetic average "per capita" bill from the government for them. You earn more, you pay more. Justifiably so, it is argued, because you have more to lose (whether that should properly be progressively so is another argument for another topic).

** And, we readily recognize that those with sufficient means and desires can freely purchase enhanced protections via private security services and/or moving to more affluent areas -- e.g., gated communities -- that accord greater protective amenities.

Look at my spreadsheet example above. How many families could be expected to "afford" a monthly health care premium of of $2,769, or even $1,938 a month in the wake of a 30% decrement in annual costs?

THE CURRENT DRAFT HOUSE BILL: "AFFORDABILITY CREDITS"

Having taken a "social insurance" basic "entitlement" model off the table, federal policymakers are now busy hastily constructing yet another inscrutably complex system via which to assess and provide for "affordability." For example, from page 135 of the 1,018 page draft House bill:

The requisite individual "affordable contribution credit" is to be capped at 11% of income for those at a maximum of 400% of the "Federal Poverty Limit (FPL)."

(Click any of these images to inflate them for easier viewing, btw.) That 2nd graphic is from page 137. Let's take a look at the most recent stratified FPL table (just for the lower 48 states and DC; Hawaii and Alaska are perhaps 20-25% higher)

OK, sticking with our "family of 4" meme, 11% of $22,050 divided by 12 months comes out to $202.13 per month ($2,425.50 a year) for a 4-person household with an income of $88,200 (4x the FPL).

A couple of observations:

This look distressingly like "corporate welfare," in that the government will be expected to make up the difference between the "market price" of insurance coverage and your "affordable contribution" (just as is the case with the Federal Employees Benefit Plan) should you not be otherwise covered through your employer (or via your own wealth enabling you to purchase coverage and/or services at retail). Perhaps this explains why "Harry and Louise" are now on board ad nauseum of late touting reform. Forcibly bring in 40+ million new "policyholders," without having to charge them anywhere near full retail, while still making bank via the U.S. Treasury? What's not to love?
It also looks distressingly like -- well -- "welfare," overtly (begging yet again the question of health care as a fundamental "right" like national defense). We will need another numbing federal bureaucracy within which to vet "affordability eligibility" ongoing for millions. And, while some people are inveterate wards of the state, many others move repeatedly up and down in the socioeconomic strata. Eligibility will have to be re-determined at least annually. Take a number. Now serving number 342 at window 8. Provide two photo IDs and your last IRS 1040. No, I'm sorry, we do not recognize Power of Attorney, your mother must come here in person. Yes, I understand that she's bedridden in a nursing home. Sorry. She must appear in person. Two photo IDs, and last Form 1040. No, your place in the queue expires at 5 pm today.

In my prior post I concluded:

We seem to be headed toward an inscrutably hyper-complex re-jiggering of our no-value-adding "health care" paper-pushing industry. I hope I'm wrong.

I'm not yet seeing much to allay that concern.
___

JULY 30TH UPDATE

The draft House bill -- "America's Affordable Health Choices Act of 2009" -- now has a number, H.R.3200. Now, recall my concern set forth just above in the 2nd bullet point:

"We will need another numbing federal bureaucracy within which to vet "affordability eligibility" ongoing for millions. And, while some people are inveterate wards of the state, many others move repeatedly up and down in the socioeconomic strata. Eligibility will have to be re-determined at least annually."

Well, here you go:

H.R.3200, SEC. 245. INCOME DETERMINATIONS.

(a) In General- In applying this subtitle for an affordability credit for an individual for a plan year, the individual's income shall be the income (as defined in section 242(c)) for the individual for the most recent taxable year (as determined in accordance with rules of the Commissioner). The Federal poverty level applied shall be such level in effect as of the date of the application.

(b) Program Integrity; Income Verification Procedures-

(1) PROGRAM INTEGRITY- The Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle.

(2) INCOME VERIFICATION-

(A) IN GENERAL- Upon an initial application of an individual for an affordability credit under this subtitle (or in applying section 242(b)) or upon an application for a change in the affordability credit based upon a significant change in family income described in subparagraph (A)--

(i) the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the information contained in such application; and

(ii) the Commissioner shall use the information so disclosed to verify such information.

(B) ALTERNATIVE PROCEDURES- The Commissioner shall establish procedures for the verification of income for purposes of this subtitle if no income tax return is available for the most recent completed tax year.

(c) Special Rules-

(1) CHANGES IN INCOME AS A PERCENT OF FPL- In the case that an individual's income (expressed as a percentage of the Federal poverty level for a family of the size involved) for a plan year is expected (in a manner specified by the Commissioner) to be significantly different from the income (as so expressed) used under subsection (a), the Commissioner shall establish rules requiring an individual to report, consistent with the mechanism established under paragraph (2), significant changes in such income (including a significant change in family composition) to the Commissioner and requiring the substitution of such income for the income otherwise applicable.

(2) REPORTING OF SIGNIFICANT CHANGES IN INCOME- The Commissioner shall establish rules under which an individual determined to be an affordable credit eligible individual would be required to inform the Commissioner when there is a significant change in the family income of the individual (expressed as a percentage of the FPL for a family of the size involved) and of the information regarding such change. Such mechanism shall provide for guidelines that specify the circumstances that qualify as a significant change, the verifiable information required to document such a change, and the process for submission of such information. If the Commissioner receives new information from an individual regarding the family income of the individual, the Commissioner shall provide for a redetermination of the individual's eligibility to be an affordable credit eligible individual.

(3) TRANSITION FOR CHIP- In the case of a child described in section 202(d)(2), the Commissioner shall establish rules under which the family income of the child is deemed to be no greater than the family income of the child as most recently determined before Y1 by the State under title XXI of the Social Security Act.

(4) STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL- The Commissioner shall examine the feasibility and implication of adjusting the application of the Federal poverty level under this subtitle for different geographic areas so as to reflect the variations in cost-of-living among different areas within the United States. If the Commissioner determines that an adjustment is feasible, the study should include a methodology to make such an adjustment. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate.

(d) Penalties for Misrepresentation- In the case of an individual intentionally misrepresents family income or the individual fails (without regard to intent) to disclose to the Commissioner a significant change in family income under subsection (c) in a manner that results in the individual becoming an affordable credit eligible individual when the individual is not or in the amount of the affordability credit exceeding the correct amount--

(1) the individual is liable for repayment of the amount of the improper affordability credit; and

(2) in the case of such an intentional misrepresentation or other egregious circumstances specified by the Commissioner, the Commissioner may impose an additional penalty.

"Provide two photo IDs and your last IRS 1040. No, I'm sorry, we do not recognize Power of Attorney, your mother must come here in person. Yes, I understand that she's bedridden in a nursing home. Sorry. She must appear in person. Two photo IDs, and last Form 1040. No, your place in the queue expires at 5 pm today."

As I've also stated before: We seem to be headed toward an inscrutably hyper-complex re-jiggering of our no-value-adding "health care" paper-pushing industry.

And, should these provisions survive to become part of any passed legislation, this requisite new "affordability eligibility" bureaucracy will be a big part of it, diverting scarce, precious clinical health care dollars into clerical verification cubicles as "the Commissioner shall establish...for the verification of income for purposes of this subtitle..."
___

IT GETS WORSE

Under this legislation, we've obviously given up on the concept of health care as a "right" in favor of viewing it as a personal responsibility -- enforceable under tax law via IRS scrutiny. You are to be additionally taxed should you not be able to produce documentation of your having "acceptable health care coverage."

TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Shared Responsibility

PART 1--INDIVIDUAL RESPONSIBILITY

SEC. 401. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.

(a) In General- Subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following new part:

`PART VIII--HEALTH CARE RELATED TAXES

`subpart a. tax on individuals without acceptable health care coverage.
`Subpart A--Tax on Individuals Without Acceptable Health Care Coverage
`Sec. 59B. Tax on individuals without acceptable health care coverage.

`SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.

`(a) Tax Imposed- In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of--

`(1) the taxpayer's modified adjusted gross income for the taxable year, over
`(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer.

`(b) Limitations-

`(1) TAX LIMITED TO AVERAGE PREMIUM-

`(A) IN GENERAL- The tax imposed under subsection (a) with respect to any taxpayer for any taxable year shall not exceed the applicable national average premium for such taxable year.
`(B) APPLICABLE NATIONAL AVERAGE PREMIUM-

`(i) IN GENERAL- For purposes of subparagraph (A), the `applicable national average premium' means, with respect to any taxable year, the average premium (as determined by the Secretary, in coordination with the Health Choices Commissioner) for self-only coverage under a basic plan which is offered in a Health Insurance Exchange for the calendar year in which such taxable year begins.

`(ii) FAILURE TO PROVIDE COVERAGE FOR MORE THAN ONE INDIVIDUAL- In the case of any taxpayer who fails to meet the requirements of subsection (e) with respect to more than one individual during the taxable year, clause (i) shall be applied by substituting `family coverage' for `self-only coverage'.

`(2) PRORATION FOR PART YEAR FAILURES- The tax imposed under subsection (a) with respect to any taxpayer for any taxable year shall not exceed the amount which bears the same ratio to the amount of tax so imposed (determined without regard to this paragraph and after application of paragraph (1)) as--
`(A) the aggregate periods during such taxable year for which such individual failed to meet the requirements of subsection (d), bears to

`(B) the entire taxable year.

`(c) Exceptions-
`(1) DEPENDENTS- Subsection (a) shall not apply to any individual for any taxable year if a deduction is allowable under section 151 with respect to such individual to another taxpayer for any taxable year beginning in the same calendar year as such taxable year.

`(2) NONRESIDENT ALIENS- Subsection (a) shall not apply to any individual who is a nonresident alien.

`(3) INDIVIDUALS RESIDING OUTSIDE UNITED STATES- Any qualified individual (as defined in section 911(d)) (and any qualifying child residing with such individual) shall be treated for purposes of this section as covered by acceptable coverage during the period described in subparagraph (A) or (B) of section 911(d)(1), whichever is applicable.

`(4) INDIVIDUALS RESIDING IN POSSESSIONS OF THE UNITED STATES- Any individual who is a bona fide resident of any possession of the United States (as determined under section 937(a)) for any taxable year (and any qualifying child residing with such individual) shall be treated for purposes of this section as covered by acceptable coverage during such taxable year.

`(5) RELIGIOUS CONSCIENCE EXEMPTION-

`(A) IN GENERAL- Subsection (a) shall not apply to any individual (and any qualifying child residing with such individual) for any period if such individual has in effect an exemption which certifies that such individual is a member of a recognized religious sect or division thereof described in section 1402(g)(1) and an adherent of established tenets or teachings of such sect or division as described in such section.

`(B) EXEMPTION- An application for the exemption described in subparagraph (A) shall be filed with the Secretary at such time and in such form and manner as the Secretary may prescribe. Any such exemption granted by the Secretary shall be effective for such period as the Secretary determines appropriate.
`(d) Acceptable Coverage Requirement-

`(1) IN GENERAL- The requirements of this subsection are met with respect to any individual for any period if such individual (and each qualifying child of such individual) is covered by acceptable coverage at all times during such period.

`(2) ACCEPTABLE COVERAGE- For purposes of this section, the term `acceptable coverage' means any of the following:

`(A) QUALIFIED HEALTH BENEFITS PLAN COVERAGE- Coverage under a qualified health benefits plan (as defined in section 100(c) of the America's Affordable Health Choices Act of 2009).

`(B) GRANDFATHERED HEALTH INSURANCE COVERAGE; COVERAGE UNDER GRANDFATHERED EMPLOYMENT-BASED HEALTH PLAN- Coverage under a grandfathered health insurance coverage (as defined in subsection (a) of section 102 of the America's Affordable Health Choices Act of 2009) or under a current employment-based health plan (within the meaning of subsection (b) of such section).

`(C) MEDICARE- Coverage under part A of title XVIII of the Social Security Act.
`(D) MEDICAID- Coverage for medical assistance under title XIX of the Social Security Act.
`(E) MEMBERS OF THE ARMED FORCES AND DEPENDENTS (INCLUDING TRICARE)- Coverage under chapter 55 of title 10, United States Code, including similar coverage furnished under section 1781 of title 38 of such Code.

`(F) VA- Coverage under the veteran's health care program under chapter 17 of title 38, United States Code, but only if the coverage for the individual involved is determined by the Secretary in coordination with the Health Choices Commissioner to be not less than the level specified by the Secretary of the Treasury, in coordination with the Secretary of Veteran's Affairs and the Health Choices Commissioner, based on the individual's priority for services as provided under section 1705(a) of such title.

`(G) OTHER COVERAGE- Such other health benefits coverage as the Secretary, in coordination with the Health Choices Commissioner, recognizes for purposes of this subsection.

`(e) Other Definitions and Special Rules-

`(1) QUALIFYING CHILD- For purposes of this section, the term `qualifying child' has the meaning given such term by section 152(c).

`(2) BASIC PLAN- For purposes of this section, the term `basic plan' has the meaning given such term under section 100(c) of the America's Affordable Health Choices Act of 2009.

`(3) HEALTH INSURANCE EXCHANGE- For purposes of this section, the term `Health Insurance Exchange' has the meaning given such term under section 100(c) of the America's Affordable Health Choices Act of 2009, including any State-based health insurance exchange approved for operation under section 208 of such Act.

`(4) FAMILY COVERAGE- For purposes of this section, the term `family coverage' means any coverage other than self-only coverage.

`(5) MODIFIED ADJUSTED GROSS INCOME- For purposes of this section, the term `modified adjusted gross income' means adjusted gross income--

`(A) determined without regard to section 911, and
`(B) increased by the amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax.

`(6) NOT TREATED AS TAX IMPOSED BY THIS CHAPTER FOR CERTAIN PURPOSES- The tax imposed under this section shall not be treated as tax imposed by this chapter for purposes of determining the amount of any credit under this chapter or for purposes of section 55.

`(f) Regulations- The Secretary shall prescribe such regulations or other guidance as may be necessary or appropriate to carry out the purposes of this section, including regulations or other guidance (developed in coordination with the Health Choices Commissioner) which provide--

`(1) exemption from the tax imposed under subsection (a) in cases of de minimis lapses of acceptable coverage, and

`(2) a process for applying for a waiver of the application of subsection (a) in cases of hardship.'.
(b) Information Reporting-

(1) IN GENERAL- Subpart B of part III of subchapter A of chapter 61 of such Code is amended by inserting after section 6050W the following new section:

`SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.

`(a) Requirement of Reporting- Every person who provides acceptable coverage (as defined in section 59B(d)) to any individual during any calendar year shall, at such time as the Secretary may prescribe, make the return described in subsection (b) with respect to such individual.

`(b) Form and Manner of Returns- A return is described in this subsection if such return--

`(1) is in such form as the Secretary may prescribe, and
`(2) contains--
`(A) the name, address, and TIN of the primary insured and the name of each other individual obtaining coverage under the policy,
`(B) the period for which each such individual was provided with the coverage referred to in subsection (a), and
`(C) such other information as the Secretary may require.

`(c) Statements To Be Furnished to Individuals With Respect to Whom Information Is Required- Every person required to make a return under subsection (a) shall furnish to each primary insured whose name is required to be set forth in such return a written statement showing--

`(1) the name and address of the person required to make such return and the phone number of the information contact for such person, and

`(2) the information required to be shown on the return with respect to such individual.

The written statement required under the preceding sentence shall be furnished on or before January 31 of the year following the calendar year for which the return under subsection (a) is required to be made.

`(d) Coverage Provided by Governmental Units- In the case of coverage provided by any governmental unit or any agency or instrumentality thereof, the officer or employee who enters into the agreement to provide such coverage (or the person appropriately designated for purposes of this section) shall make the returns and statements required by this section.'.

(2) PENALTY FOR FAILURE TO FILE-
(A) RETURN- Subparagraph (B) of section 6724(d)(1) of such Code is amended by striking `or' at the end of clause (xxii), by striking `and' at the end of clause (xxiii) and inserting `or', and by adding at the end the following new clause:

`(xxiv) section 6050X (relating to returns relating to health insurance coverage), and'.

(B) STATEMENT- Paragraph (2) of section 6724(d) of such Code is amended by striking `or' at the end of subparagraph (EE), by striking the period at the end of subparagraph (FF) and inserting `, or', and by inserting after subparagraph (FF) the following new subparagraph:

`(GG) section 6050X (relating to returns relating to health insurance coverage).'.

(c) Return Requirement- Subsection (a) of section 6012 of such Code is amended by inserting after paragraph (9) the following new paragraph:

`(10) Every individual to whom section 59B(a) applies and who fails to meet the requirements of section 59B(d) with respect to such individual or any qualifying child (as defined in section 152(c)) of such individual.'.

(d) Clerical Amendments-

(1) The table of parts for subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item:

`Part VIII. Health Care Related Taxes.'.

(2) The table of sections for subpart B of part III of subchapter A of chapter 61 is amended by adding at the end the following new item:

`Sec. 6050X. Returns relating to health insurance coverage.'.

(e) Section 15 Not To Apply- The amendment made by subsection (a) shall not be treated as a change in a rate of tax for purposes of section 15 of the Internal Revenue Code of 1986.

(f) Effective Date-

(1) IN GENERAL- The amendments made by this section shall apply to taxable years beginning after December 31, 2012.

(2) RETURNS- The amendments made by subsection (b) shall apply to calendar years beginning after December 31, 2012.

What will be the bureaucratic FTE necessarily devoted to determining compliance with the myriad foregoing provisions? How many childhood immunizations, annual checkups, MRIs, arthroscopic surgeries, splints, and rounds of chemo and radiation would these FTE otherwise pay for?
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