Wednesday, September 30, 2009

Political Ego

WASHINGTON -- "My colleagues, this is our opportunity to make history," implored Chairman Max Baucus as the Senate Finance Committee last week opened consideration of his bill. Politicians, in their most self-important moments, see themselves as instruments of national destiny. They yearn to be remembered as the architects and agents of great social and economic transformations. They want to be at the signing ceremony; they want a pen.”

Robert Samuelson, “An Exercise in Ego Gratification,” Newsweek, September 28, 2008

Could it be what drives health reform is ego,

Therefore,consequently,axiomatically,and ergo.

According to Robert Samuelson’s prose flow.

Democrat ego makes them want to run the show,

why to any length they think they can go,

as they try to control all - friend and foe.

That includes the AFL-CIO,

enemies who go blow-by-blow,

or foolishly toe-to-toe,

anybody else who says hello.

Only they are in the know,

have enough knowledge in stow.

They want their destiny to glow,

to have their place in history to grow.

For them there is no quid pro quo,

no living with the evil status quo.

About their victories they will crow,

But it will be up to voters to show,

upon whom destiny's laurels to bestow.

which politicians under the truck to throw,

during the next mid-term election fandango.

Dr. Richard Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic)

The Struggle to be Heard about Health Reform

I am in earnest – I will not equivocate – I will not excuse – I will not retreat a single inch, and I will be heard.

William Lloyd Garrison, 1805-1879

William Lloyd Garrison was a journalist, abolitionist, and social reformer. His mission was to emancipate the slaves and to free up people to speak their minds.

Today Garrison would be a passionate spokesperson for health reform. Americans, particularly patients and doctors, are feeling enslaved by government, health plans, the media, and other members of the reigning establishment.

People are mad as hell, as reflected in national poll averages indicating 64% disapprove of Congress and 54% say the country is headed in the wrong direction, and they aren’t going to take it anymore.

In a book just on the market, What Americans Really Want, pollster and communication expert, Frank Luntz, a University of Pennsylvania and Oxford graduate, says people want to be heard. They are finally being heard, he says, through town hall meetings , tea parties gatherings, and massive marches on Washington by the public and the medical profession.

The masses, at least those in the center, being heard is a good thing. It tells us what concerns ordinary Americans. Among other things, according to Luntz, the center is sending these messages, “All we want is to improve our economy. It’s not about health care or nuclear weapons, it’s about jobs.” To the Republicans he says, “No is not the answer.” To the Democrats, he says, “You can’t get it all in one year.” To all, he says, it’s about the freedom to make your frustrations known.

Health reform bills now percolating through Congress treat doctors as political nobodies. The bills fail to address tort reform, they either ignore or suppress the strengths of consumer-driven care, they play down the importance of health savings accounts, they do not seem to want to tell people what things really cost, they over-stress unproven savings from EMRs, they treat physicians as government surrogates. and they seek to pay doctors as Medicare and Medicaid rates, which doctors say would drive about 45% of doctors out of practice.

Doctors and patients are struggling to be heard. It is not easy. President Obama dominates the media, and it is hard to break through. If you have a dissenting point of view and you write a letter to the editor of the New York Times, your chances of being published are miniscule. I know. I have tried on countless occasions. The liberal media filter is very effective. A recent study indicated the Times referred to liberal blogs 389 times and conservative blogs 18 times. The other side may be equally biased and filtered. Small wonder that talk radio, cable TV, and bloggers to the left and right chatter – and sometimes even matter.

Up until recently, when the voices of August boomed out and began to be heard, public frustrations were kept at bay. Those days are gone. The public is now engaged. The central issues are freedom.

• to speak your mind

• to choose your doctor or hospital

• to have access to care no matter what your age

• to select your own policy no matter who employs you or in what you state you live

• to have a policy that fits your individual needs rather than those of the community at large

• to have a policy regardless of your pre-existing condition

• to retain a policy regardless of expenses of your disease

• to have health-related deductions whether you are in individual, entrepreneur, or an employee of small or large business

• to have the same plans and benefits that federal employees and Congress members enjoy in the Federal Employee Benefits Program, now 49 years in operation and with the choice of 278 separate plans

• to interact with your doctor without fear of federal intervention into the process.

Dr. Richard Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic)

Tuesday, September 29, 2009

Proposed Obama Speech before U.N. on Health Reform

The idea for this blog – a proposed but fictitious speech before the United Nations came from an article entitled “Wanted: A Defender of American Interests” in the September 27 Financial Times, by Christopher Caldwell.

"The percentage of the US population that is uneasy with Mr Obama has grown steadily. Conservatives are rightly outraged by Obama’s obsessive denigration of America and his reliance on mythical international consensus. Caldwell is getting to a much under-discussed aspect of the UN speech. Moderates are a bit nervous that he sounds sophomoric and naive. But Caldwell points to the gap, not between reality and Obama’s worldview, but between Obama’s view of America and Americans’ view of America."

This is my view of how Obama might defend America’s health system.

Good evening. Members of the United Nations. You have heard about the health reform debate now being taking place in the U.S. We know we have flaws – including high costs and lack of coverage for all. These flaws need correcting, and we are addressing them. We are not a perfect nation, but we should not let the perfect drive out the good.

Tonight I shall speak of what’s good, unique, and even exceptional about American health care. Despite contrary rhetoric, mine included , we are an exceptionalist nation, the shining City on the Hill - brimming with optimism, innovation, and a full of hope of what’s achievable based on building upon our current system.

As T.R. Reid, a Washington Post journalist, noted in his excellent book, The Healing of America: A Global Question for Better, Cheaper, and Fairer Health Care, America has the best hospitals and specialists in the world, although universal access to the best is sometimes unfair and costs too much.

We are a big-hearted and moral nation. Our nation spends as much of its GDP, outside of private pay, as other countries. We have no age cut-offs for dialysis, for hopeless cases, or for end of life care. We treat all patients who enter our emergency rooms – regardless of ability to pay or citizenship status. We do not allow people to die while waiting for expensive or life-saving technologies. We do not let them die in their beds or on the streets. Though we may, on occasion, be unfair, we are also overly generous, particularly to the elderly, which is the big reason behind our unfunded Medicare deficit.

Critics of our system are fond of citing a World Health Organization study indicating the U.S. ranked 37th among industrial countries. This study based largely on lack of universal coverage and high costs. What those same critics usually fail to mention is that WHO, one of the most respected of U.S. agencies, also conducted a study saying the U.S, ranked 1st, yes, you hear me correctly, number one, among 191 countries in “responsiveness,” defined as dignity, autonomy, prompt attention, quality of basic amenities, access to technologies and social support systems, and choice of providers. Our citizens are more appreciative of our system, and its responsiveness to their needs, than public health critics.

What critics fail to say is chances of survival for those with chronic disease – cancer, heart disease, lung disease, kidney failure, and AIDs – is better in the U.S. than almost anywhere in the world. Critics do not tell you the U.S. has 27 MRIs per million and 34 CT scans per million, compared to 6 MRIs per million in Canada and Britain, and 12 CT scans, and 8 in Britain and Canada. Our survival rates for cancer of the breast, colorectal cancer, and cancer of the prostate are better than elsewhere. More Americans are on statin drugs than in Canada, the U.K., Switzerland, Germany, and Italy, and we have the highest heart attack survival rate, 6%, in thw rold. Finally, we have a lowr out-of-pocket spending, 12.6% of total spending, than almost any other country.

To recapitulate and amplify, here are ten facts, gathered by the National Center for Policy Analysis.

Fact No. 1: Americans have better survival rates than Europeans for common cancers. Breast cancer mortality is 52 percent higher in Germany than in the United States, and 88 percent higher in the United Kingdom. Prostate cancer mortality is 604 percent higher in the U.K. and 457 percent higher in Norway. The mortality rate for colorectal cancer among British men and women is about 40 percent higher.

Fact No. 2: Americans have lower cancer mortality rates than Canadians. Breast cancer mortality is 9 percent higher, prostate cancer is 184 percent higher and colon cancer mortality among men is about 10 percent higher than in the United States.

Fact No. 3: Americans have better access to treatment for chronic diseases than patients in other developed countries. Some 56 percent of Americans who could benefit are taking statins, which reduce cholesterol and protect against heart disease. By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons and 17 percent of Italians receive them.

Fact No. 4: Americans have better access to preventive cancer screening than Canadians. Take the proportion of the appropriate-age population groups who have received recommended tests for breast, cervical, prostate and colon cancer:

• Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).

• Nearly all American women (96 percent) have had a pap smear, compared to less than 90 percent of Canadians.

• More than half of American men (54 percent) have had a PSA test, compared to less than 1 in 6 Canadians (16 percent).

• Nearly one-third of Americans (30 percent) have had a colonoscopy, compared with less than 1 in 20 Canadians (5 percent).

Fact No. 5: Lower income Americans are in better health than comparable Canadians. Twice as many American seniors with below-median incomes self-report "excellent" health compared to Canadian seniors (11.7 percent versus 5.8 percent). Conversely, white Canadian young adults with below-median incomes are 20 percent more likely than lower income Americans to describe their health as "fair or poor."

Fact No. 6: Americans spend less time waiting for care than patients in Canada and the U.K. Canadian and British patients wait about twice as long - sometimes more than a year - to see a specialist, to have elective surgery like hip replacements or to get radiation treatment for cancer. All told, 827,429 people are waiting for some type of procedure in Canada. In England, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.

Fact No. 7: People in countries with more government control of health care are highly dissatisfied and believe reform is needed. More than 70 percent of German, Canadian, Australian, New Zealand and British adults say their health system needs either "fundamental change" or "complete rebuilding."

Fact No. 8: Americans are more satisfied with the care they receive than Canadians. When asked about their own health care instead of the "health care system," more than half of Americans (51.3 percent) are very satisfied with their health care services, compared to only 41.5 percent of Canadians; a lower proportion of Americans are dissatisfied (6.8 percent) than Canadians (8.5 percent)

Fact No. 9: Americans have much better access to important new technologies like medical imaging than patients in Canada or the U.K. Maligned as a waste by economists and policymakers naïve to actual medical practice, an overwhelming majority of leading American physicians identified computerized tomography (CT) and magnetic resonance imaging (MRI) as the most important medical innovations for improving patient care during the previous decade.

Fact No. 10: Americans are responsible for the vast majority of all health care innovations. The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other single developed country. Since the mid-1970s, the Nobel Prize in medicine or physiology has gone to American residents more often than recipients from all other countries combined. In only five of the past 34 years did a scientist living in America not win or share in the prize. Most important recent medical innovations were developed in the United States.

In other words, despite serious challenges, such as escalating costs and rising numbers of the uninsured, the U.S. health care system compares favorably to those in other developed countries. In the United States, we are proud of our accomplishments. So are many of you – 400,000 of you come to this country for care you may have difficulty finding elsewhere, and your doctors flock here for advanced training in our leading medical centers. We welcome you. You have much to learn from us, and we from you.

Dr. Richard Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic)

Monday, September 28, 2009

Positive Consequences of An Electoral Defeat after a Reform Victory

In The Health Care Blog, a widely and deservedly cited blog, futurist Joe Flower forecasts,

The way things are trending now, Obama and the Democrats will succeed in getting a reform bill – and it will cost them the Congress in 2010 and possibly the presidency in 2012. Why? Because it will be ineffective in bringing most voters and tangible benefits soon, and ineffective especially at bringing down the cost of health care.

One need look no further than the 3 year old Massachusetts experiment in universal coverage to see the ineffectiveness of Obama-type, i.e., top-down reforms, in satisfying voters and reducing costs.

According to an April 27, 2009 Cato Institute Report, “Massachusetts-like Reforms Increase Costs and Waiting Times,” Massachusetts has experienced a 46% faster health inflation rate than the rest of the nation, waiting times to see a doctor are now 7 weeks compared to 3 weeks for most of the country, and Massachusetts voters are saying, they see reduced quality by 3:1, less affordable care by 31% to 27%, and reform failure by 37% to 26%.

This is not to say Bay State reform has not succeeded in some respects It has reduced the number of uninsured to under 3% - far below the national average of 15%.
But reform has failed to lower costs, pacify voters, and has ushered in talk about health care rationing to stem the inflation tide.

If the Democrats and the President go down, it should not be interpreted as a defeat. Defeat may be a blow to the ego, but Obama will have advanced the reform debate, he will have initiated certain needed reforms, and he will have shown what works – and doesn’t work – in American Democracy and its underlying culture. We will better know the right mix of public policy and marketplace forces, and the limits of left of center governance in a right of center nation.

Sunday, September 27, 2009

On the Importance of Innovation in Draining the Health Reform Swamp

When you’re up to your neck in alligators, it’s hard to remember your original intention was to drain the swamp.


The alligator-draining the swamp metaphor aptly describes a widespread health reform dilemma , viz, that the brute-forces of reality invariably overwhelm lofty, soft thoughts of idealism.

Ideally, of course, health care ought to be a right, everybody ought to have immediate access to care, and it ought not to bankrupt or financially to inconvenience anyone. Ideally universal coverage ought to mean universal access, but because of growing doctor shortages and changing doctor behaviors, such is not the reality on the ground.

So much for dashing of the dream. Now back to sinking in the swamp.

Cynics often compare American politics in general, and health reform in particular, to a swamp. It is low-lying, boggy, teeming with prey and predators, rotting vegetation, stinging insects, snakes, and vermin. It is hot, it smells, and it emits noxious gases. Health care has its own rules for survival, and it is hard to escape from if you’re part of its ecology. It will never be fit for precise cultivation of singly planted crops all arranged neatly in a row and free of weeds.

I have long been aware its Darwinian features. In my book, Innovation-Driven Health Care; Thirty Four Concepts for Transforation (Jones and Bartlett, 2007), I maintained the only way to thrive in the swamp is through innovations, which will vary whether one with individuals organization, and even nations.

It might be ideal, of course, if one big innovation – such a single-payer or all payer collaboration – were to emerge and drain the swamp.

In liberal eyes, draining the swamp of villainous for-profit organizations, or bringing them to the government’s heel or forcing them to pay government prices is the answer.

To conservative minds, the answer, as much as possible, resides in ridding the swamp of governmental rules and regulations.

To me the solution may lies in-between, with say, a universal private payer system with thoughtful government oversight, the situation in the Netherlands and Switzerland and Germany.

After my book was published I interviewed Lyle Berkowitz, MD, who leads the Northwestern Memorial Physician Group in Chicago and the Szollosi Healthcare Innovation Program at that institution, “Fixing Healthcare from the Inside,” Physician Leadership Forum.

His position, then as now, is that the most powerful innovations are most likely to occur and take root within large institutions who have the resources to pursue systematic innovation. The favorite models among policy wonks rare Mayo and Geisinger and in general feature integrated systems with salaried physicians.
Berkowitz has just sent me a copy of the California Healthcare Foundation’s September report “Reinventing Halth Care Delivery: Innovation and Improvement Behind the Scenes” detailing the work of a series of innovation centers based at large health systems, among them, Northwestern Memorial in Chicago, Kaiser Permanente in Oakland, Vanderbilt in Nashville, Geisinger Health in Danville, Pennsylvania, Massachusetts General in Boston, The Mayo Clinic in Rochester, Minnesota; Ascension Health, in St. Louis; Alegent Health in Omaha. They are all part of a loose Innovation Learning Network, spearheaded based at Kaiser.

These organizations differ in their approaches to innovation but focus on such things as facility design, operational efficiency, optimial IT, improved patient experiences, and care quality. Together the organizations form an innovation Learning Network that communicates regularly and meets periodically to share information.

What these big learning organizations generally fail to mention is that innovations are also occurring at a rapid pace among independent physicians. These innovations, often engineered by practice management firms, are happening at the solo and small group level and include such things as- patients creating their own medical histories using computer algorithms before visiting the doctor, doctors making more liberal use of medical technicians for history taking and drug use documentation, practice management and information management techniques to speed patient flow, concierge practices, the dropping of HMOs and PPOs patients, the growing non-acceptance of new Medicaid and Medicare patients, the significant shift towards cash-only practices, and, course, imaginative use of IT technologies.

These changes in practice patterns not have gained much attention, either because they take place in small practices or because they are considered negative individual innovations, outside the conventional big organization or government mainstreams, but collectively when taken together, independent practice innovations represent massive practice innovations that are changing the fundamental nature of medical practice.

Into The Valley of Health Reform

Into the valley of health reform
Bestrode the one hundred senators.
Comprehensivists to the left,
Incrementalists to the right.
Squarely in the middle sat the arcane,
Senator Olympia Snowe of Maine.

Bespoke the comprehensivenists.
It must be done all at once.
Evoked the incrementalists.
No, it must be done one at a time.

Bespoke the comprehensivenists.
We simply cannot wait any longer.
Evoked the incrementalists,
Why not,you've waited a century already.

Bespoke the comprehensivenists.
It must be done right now.
Evoked the incrementalists.
No, it must be done right.

Bespoke the comprehensivenists.
It must be done now or never.
Evoked the incrementalists.
No, now or never is forever.

Bespoke the comprehensivenists.
It must contain federal mandates.
Evoked the incrementalists.
No, not like socialist states.

Bespoke the comprehensivenists.
It must have a public option.
Evoked the incrementalists.
No, that means federal co-option.

Bespoke the comprehensivenists.
Tax the private side to pay for it all.
Evoked the incrementalists,
No, it would be the middle class you tax.

They labored and negotiated
and reacted to the polls,
deep into the day,
and late into the night,
for seven long months.

Both claimed they were voices of reason.
But each feared the next political season.
What would happen in 2010 and 2012?
Would they be put on the political shelve?

What did those public events of August portend,
those tea parties, capital marches, and town halls?
Would their grassroots constituents they offend?
Were they headed for collective political falls?

And so each side labored long and hard
To either muster or stave off sixty votes.
Above all they sought not to be caught off guard,
Before the end of this non-election year,
What they feared was November next year.

Doctor Reece is noted author, blogger, speaker, and health reform expert. His latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic)

Saturday, September 26, 2009

Obamacare and the Doubling Down of Political Bets

As I read about how Democrats and Republicans are negotiating the final Senate Finance Bill on health reform, I am getting the distinct impression both sides are “doubling down,” i.e. doubling their initial bets on the final product.

The Democrat Bet

The Democrats are betting that, by imposing mandates, taxes, and penalties on individuals, businesses, and health plan contents, government can, at long last, beat back the for-profit health industry and control health care.

The definition of the word mandate, “authoritative order or command, esp. a written one,” captures the essence of what’s going on. Democrats are saying, We have the power and the political capital, and By God, we are going to use it - soon, before the end of the year while we still have it – no matter what the consequences, which we will define using our own rosy assumptions.

A Tell-Tale Example

A tell-tale example is the case of mandates pertaining to the contents of health plans – chiropractic care, wigs, autism, in-vitro fertility procedures, massage therapy, and so on. In many states, such as Massachusetts and Minnesota, there are more than 70 of these mandated benefits, the inclusion of which, drives up premiums but assures the plans are comprehensive.

By a vote of 14 to 9, the committee rejected an amendment by Senator Jon Kyl, Republican of Arizona, that would have prohibited the federal government from defining the specific health benefits that insurers must offer. The government would prescribe a minimum package of benefits under all health bills pending in Congress.

A Love-Affair

The Democrats, it seems, have a love affair with the word “comprehensive,” which pleases more of their constituents more of the time but drives up costs.
Republicans are arguing comprehensive benefits, coupled with low-deductible, low-copayment insurance has brought us to where we are today – unsustainable health inflation that threatens to make the nation globally uncompetitive and businesses and individuals insolvent.

If you offer “comprehensive care”, i.e. care covering virtually every possible contingency to everybody, at low cost to everybody without awareness of the true costs , costs will soar.

Obama care simply expands and lock-ins this flawed model and defeats the goal of making health services more affordable for everyone. The Republican Plan, which follows, rests on the bet that Democrats will not be able to get 60 Senate votes to assure government control of the health system.

• allow everyone to purchase health insurance across state lines.

• Give individuals the same tax break that companies get when they supply health insurance for their employees.

• Third, make health insurance portable.

• Companies should help their employees own their own insurance so that it travels with them from job to job, state to state, and is under their control.

• Congress should enact tort reform so that doctors can do what is best for their patients instead of practicing costly legal defensive medicine.

• Let people purchase insurance that meets their needs, rather than requiring intrusive, one-size-fits-all federal government mandates.

The Republican bet is – if the Democrat plan goes down, perhaps we can start over and come up with a badly needed sensible reform that benefits everyone.

Thursday, September 24, 2009

Ten Reasons for Compromising on Health Reform

In a September 23 piece, David Brooks, a New York Times columnist, gives these reasons for compromising on the Baucus Health Bill.

First, something is going to pass; the only question is its nature.

Second, whatever passes will be based on the Baucus bill. If Obama was really a socialist, he wouldn’t be pushing the least liberal of the alternatives.

Third, the left is in an uproar over the bill. That should tell you something.
In politics you don’t get to choose your options, you only get to select from the available options.

Fourth, Republicans have all along said that the bill should not make our fiscal situation worse. The Congressional Budget Office says the Baucus bill is deficit neutral over the first 10 years and would save money over the next 10. The C.B.O. number may not take into account the various political inevitabilities. Still, that’s pretty darn impressive.

Fifth, the bill, as currently constituted, forces many Americans to pay for their health care. This is a step toward a consumer-driven system, and not the only one in the bill.

Sixth, the bill would lead to widespread coverage. Republicans let Democrats do most of the talking about this, but it is a social good, as anybody who has seen the anxiety of the uninsured knows.

Seventh, there will now be a major tussle over the shape of the bill. Liberals are going to try to pull it to the left, by increasing subsidies and reducing the revenues, making it less fiscally sound. If Republicans sit out the fight, then the liberals will surely succeed and we’ll be back where we were a few months ago, on the path to fiscal suicide.

Eighth, Obama has at least signaled a willingness to look into tort reform and other issues Republicans care about. This is an opening they should try to drive a truck through.

Ninth, the Baucus bill does have some reforms like comparative effectiveness research and bundling that really could lead to some gradual progress toward a sane health care system.

And tenth, the bill also taxes employer health benefits. This too could move us gradually to a less distorted system

Wednesday, September 23, 2009

A Pair of Crystal Balls

I have a pair of crystal balls. I do not say this to imply I lack manhood. Or that my predictions for the future are fragile.

I say it because I feel crystal clear about two of my frequently voiced personal prognostications:

One, that the doctor shortage will precipitate a monumental political crisis because baby boomers, who are accustomed to having things their way, suddenly find in 2011 that they will be having a hell of a time finding a doctor;

Two, by 2013, or thereabout, that Obamacare, if it goes through as Obama wants it to, will result in another political crisis - perceptions of decreased quality, concern over exploding premium costs, and a revolt on the part of seniors, young people, and the business community because on increased costs secondary to individual mandates, business mandates, and increased taxes on the middle class.

These crises will be made worse by a widespread revolt of doctors, who will protest they cannot make it on the basis of Medicare and Medicaid rates. As a forerunner of the doctor revolt, we shall see events like the MillionMedMarch, scheduled for October 1 in John Marshall Park in Washington.

As these events unfold, it will become increasingly clear, my two crystal balls forecast, that doctors are essential for the delivery of health care and that consumers will demand access to a personal doctor, not some surrogate.
To reinforce the message contained in my crystal balls, I reprint the following article from the New York Post by Marc SiegelM.D, a New York City internist, who more than 50% of doctors no longer accept new Medicaid patients and 28% don’t take new Medicare patients. It may be the government could mandate that doctors accept patients covered by government, but that would be a form of tyranny.
September 23, New York Post

Why Doctors Hate Obama Care


TWO-thirds of doctors "oppose the proposed health-care plan," reports an Investors Busi ness Daily/TIPP poll. Almost half would "consider leaving their practice or taking an early retirement" if "Congress passes its health-care plan." Many of my colleagues feel like we're already struggling -- nor are we prepared to take care of tens of millions more patients.

An Association of American Medical Colleges survey predicts a doctor shortage of 150,000 (at current rates of population growth) by 2025 if universal health insurance is adopted. The doctors we do have would be overwhelmed with far more patients than we could realistically take care of. We'd have to work under huge time pressures, and the service we could deliver would decline.

Those who didn't quit would have to learn to "game" the new system by seeing more patients, doing more procedures, providing less care per patient and becoming less accessible for health-choice discussions.
Is this what President Obama has in mind when he promises that everyone will get to keep his or her doctor?

All the current health-care bills are unfair to doctors. Even Sen. Max Baucus' "moderate" bill (like the other bills) includes cuts to Medicare and Medicaid that would directly affect hospitals and doctors: How far does Congress think it can cut our reimbursements before compromising care, if not driving us out of business?

More than half the nation's doctors now don't accept Medicaid, a 2005 Community Tracking Physician survey found. The Medicare Payment Advisory Commission reported this year that 28 percent of Medicare patients looking for a primary-care doctor had trouble finding one. This scarcity will only get worse if reimbursements are cut further and more doctors opt out.

For those who stay in, it will be harder to practice the more services are cut. Baucus even proposes doing away with Medicare payments for motorized wheelchairs. How am I going to help my paralyzed patients then?

Nor are Baucus' "co-ops" much improvement over the "public option" of the House bills. Consider the existing paradigm of a health co-op: Group Health, the Seattle outfit with half-a-million patients. It's known as "Group Death" by many patients and doctors, for its low-quality care and long waits.

Nor do any of the bills provide anything to address the issues that infuriate doctors about the current system: No tort reform or any other real effort to address outrageous rates for malpractice insurance. (Many surgeons and obstetricians pay more than $100,000 per year.) No mechanism to screen out nuisance lawsuits before they can be brought; no penalties for frivilous suits, even though doctors end up winning the vast majority of cases that go to trial.

The American Trial Lawyers Association -- big donors to the Democrats -- have vetoed any such relief.

In short, doctors fear "health reform" because it's not really about health care; it's about catering to the prejudices of the politicians and the lawyers who've already made such a mess of our health-care system

One Size Does Not Fit All

Today I spoke about my book Obama, Doctors, and Health Reform before a local Rotary club. Here is the gist of what I said.

The book is civil. It is respectful but skeptical of Obamacare because of four obstacles: our culture, the complexity of our system, its costs, and adverse consequences of reform.

As I noted in my book, American culture distrusts government, wants prompt access to the best technologies, and believes in equal opportunity but not equal results; our complex employer-based system has been evolving for 65 years and is a whirling Rubik’s Cube with millions of fast-moving, interchangeable parts, and special interests; costs always exceed projections because cost is no object when it comes to people’s health; and any top-down government entitlement program has adverse consequences, such as fraud, abuse, and overuse.

President Obama has another problem. He must promote, explain, and glorify a plan that does not exist. It is a work in progress. He is betting that if he talks about the plan enough, the public will believe it must be true. This does not seem to be working. Today’s NBC Wall Street Journal poll indicates only 39% approve of Obama’s handling of health care.

The book predicts Obama will get 1/3 of what he wants. It ends with a toast to his ambitions and a prayer for his safety. It may be, like Julius Caesar, Obama will bestride the political landscape like a colossus. I doubt this. He is a center-left president trying to govern a center-right country, and that limits his reach.
Our health system’s root problem, as a Minneapolis heart transplant surgeon explained to me, is: “Dick, I’ve never met a patient who didn’t want to live another day.” People know we have the technologies to make this possible. It is politically difficult to dash these expectations.

Title and Which Hunt

My title for today’s talk is “One Size Does Not Fit All.” My message is: Obamacare, conceived of as a homogeneous. standardized, universal care program, the same in all regions of the country, is destined to fail.

We are simply a country which is too diverse, which distrusts big Government, which cherishes individualism, which wants prompt access to the latest in medical technologies, which prefers to make their own health care decisions. This is the culture of our country, and therefore you might call this little talk “A Which Hunt.”


In preparing for this talk, I ran across a little book, The Sir Winston Method: The Five Secrets of Speaking the Language of Leadership.(William Morrow, Inc, 1991)
Sir Winston’s Formula was:

I Strong Beginning

II One Theme

III. Simple Language

IV. Pictures

V. Emotional Ending

Strong Beginning

Sir Winston’s advice is: never, never, never “open” with “It’s a Pleasure” or a Bad Joke. Too prosaic and too inane he says.

Instead, pick out someone in the audience you admire and talk about them. I admire Bill Suits. Everything he represents, if you’ll pardon an obvious pun, suits me just fine. He has shown great courage in fighting Parkinson’s disease. He loves this Rotary Club, and he loves nothing more than telling you a good joke or an entertaining story. You’re a central part of his life.

I know. He drops by my condo at Banbury Crossing every week to tell me about your good work across this community. He tries out his jokes for you on me. We talk about his Parkinson’s disease. As a member of the Medical Advisory Board of America’s Top Doctors, I once even referred him to a neurologist at Massachusetts General Hospital.

We talk politics. To this day, I do not know if he is a Republican or Democrats. He blasts them all, shows no mercy, takes no prisoners. No politician fits into Bill’s suitscase.

Bill shares with me the secrets of Real Estate, e.g. “Get or Buy a lot while you’re young” or “Old Realtors never die, they just give up their lease.”
Bill tolerates me, I think, because I laugh at his jokes and tell him a few of my own.

Please join me in giving a hand to Bill and his long and loyal service to this club.
Bill has asked me to address these questions: what does health reform, Obama-style, mean to the average American – probably higher taxes and more burearacy. To the young and middle-aged uninsured , an individual mandate would mean you will be obligated to pay $1000 for yourself and $3800 for your insuracne’ for the old it will mean some form of rationing.

Let’s look briefly at the neighboring state of Massachusetts – which enacted Obama-like reforms 3 years ago According to an April 27, 2009 Cato Institute Report, “Massachusetts-Like Reforms Increase Costs and Waiting Times,” in that span the number of uninsured have dropped from 8% to 3% at these costs - a 46% faster rate of costs compared to the national average, increased waiting times – 7 weeks compared to other parts of the country, increased costs to the state of $88 million a year, and voters saying the following - reduced quality by 3:1, less affordable care by 27% to 21%, and 37% to 26% saying reform has been a failure. Finally, state officials are recommended fee-for-service be eliminated and care be rationed by paying for episodes of care on a budget.

One Theme

The central theme of my book is: no size fits all in our individualistic American society. Medicine is practiced in different ways across this vast land.
I came here from Oklahoma, which is just to the right of Atilla the Hun and cowboy entrepreneurship is the order of the day. There I started a health care newspaper, founded an organization called the National Physician Hospital Organizations, and developed a computer algorithm to measure the health of Oklahoma state employees.

Before that I was in Minnesota for 25 years, where the average sized group is 150 doctors, and the Mayo Clinic reigns supreme. There I served at editor-in-chief of the state medical journal for 15 years and came to know the Minnesota Way of medical practice – Consensus Medicine with constant access to coordinated care. It is sound approach, and I endorse it.

Now I am in Connecticut, where the average group has 3 to 4 doctors, and Yankee privacy and Yankee ingenuity are greatly admired. I remember an ad of about 20 years ago, which read, “What weighs 3 pounds and wakes up at 6AM?” The answer was: The Yankee Brain.

Based on these regional experiences, I do not believe you can standardize and homogenize medical practice into integrated groups following rigid protocols, practicing strictly scientifically-based medicine, and being directed and judged by computer algorithms devised by geeks bearing formulas.

The aim may to limit treatment to the “best practices,” but there is a hooker. Patients rarely feel they are overtreated, and lawyers agree with them. Think of a 4year old child who falls and hurts his head and is a little woozy. Science-based medicine says this child should not get a CT scan. The parents and the suit-conscious ER doctor will think differently.

Nor do I think the Dartmouth approach, advocated by Peter Orzag, Obama’s budget chief. of forcing the high spending Medicare cities, such as Los Angeles, spend the same amount of money as the low spending cities, such as Rochester, Minnesota, will work because of profound socioeconomic differences and costs of doing business. Poor, sick uninsured Hispanics who have delayed treatment simply cost more than uninsured Scandanavian-Americans who have taken care of themselves.

Nor do I foresee using statistical averages, assembled by some Comparative Effectiveness Institute, to dictate what tests to order or what procedures to do in every doctor-patient encounter.

Simple Language

Churchill said, “Short words are best and the old words when short are best of all.” In short, prefer the Anglo-Saxon to the Latin, the active to the passive, the direct to the indirect, the concrete to the abstract, common language to the grammatical correct.

Once, after he spoke, a nit-picking bureaucrat confronted Churchill and pontificated, “Prime Minister, I was shocked in your speech you actually ended a sentence with a proposition.” Churchill replied, “This is pedantic nonsense .. up with which .. I shall not put.”

When it comes to health reform, remember that the only tools available to Government to reduce costs are: one, paying doctors and hospitals less, rationing, and imprecise language. Government tends to express itself in indirect and euphemistic language, sometimes referred to as jargon, unsustainable growth rates for going broke; pay for performance, value, and outcomes as a means of telling doctors what to do; and as far as rationing goes , comparative effectiveness and coordinated, integrated, and bundled care, or QALY for quality of life years left to indicated what procedures can or should be done for a person of your age.

In Britain, the NHS has a department called NICE (National Institute for Comparative Effectiveness). NICE’s job is to deny paying for treatments that cost too much and have a low QALY. Needless to say, cancer patients who need some high-end drug for a potential cure don’t find NICE to be very nice.


Churchill loved memorable visual images, particularly of animals of make his point. He called Hitler a viper, a snake, a guttersnipe, a crocodile, a hyena. He said the dictator who rides the tiger dare not dismount, for the tigers are getting hungry. When told his fly was open, Churchill said, “ Never fear. Dead birds do not drop out of their nests.”

In health reform, we have another set of animal images – Blue Dogs for moderate or conservative Democrats who fear the electorate will turn them out in November 2010; RHINOs (for Republicans in Name Only), Elephants who suffer from bureaucratic elephantiasis; Donkeys who turn into stubborn mules capable of only saying “No,”, Bearish Bears, who never saw a stimulus package they didn’t like, and Angry Bulls, like Rep Wilson of South Carolina, who carry their china closets with them.
If you like animal metaphors, here’s a dozey from Senator Judd Gregg (R) of New Hampshire, “A public plan is essentially a stalking-horse for a single payer plan. It is more than a camel’s nose under the tent. It is the camel’s neck, and probably front legs, under the tent. There is no way the private sector can compete.”
Here is another, from Thomas Sowell. Of the Hoover Institute,

A dog with a bone in his mouth looked into the water and saw his reflection. He thought it was another dog with a bone in his mouth-- and the other dog's bone looked bigger than his. He decided that he was going to take the other dog's bone away and opened his mouth to attack. His own bone fell into the water and was lost.
Today the President of the United States is telling us that he will take that other dog's bone away.. He will take the bone away from doctors, hospitals, pharmaceutical and insurance companies, and most of us will end up with worse medical care than we have available today. We will have opened our mouth and dropped a very big bone into the water.

An animal that works as a metaphor for Obamacare is the python, an enormous snake that either crushes its prey or swallows them whole. Th python has an enormous appetite and can swallow whole industries, like automobiles, energy, and education, or health care industries whole- crushing each before swallowing.
The Obamacare python prefers whole industries to satisfy its appetite. With health care, the python already has Medicare, Medicaid, and the VA in its gut, 100 million Americans in all, but it is hungry for more. The next big gulp may be the 78 million baby boomers who will qualify for Medicare in 2011. A smaller bite will be Medicare Advantage plans, which cover 22% of the Medicare population. After that, using the Public Option, as its bait, he may be able to gulp down up to 111 million more now in private plans.

Emotional Ending

Up until now, emotions have been on side of liberal Democrats, who are full of self-righteous, and sometimes justifiable, indignation about the cruelties of capitalism and patients falling through the payment cracks. Democrats have a moral cause, universal care for all in the name of fairness. They have harbored this concept for nearly 100 years. They see it as their crown jewel and their reason for being. They feel they are near their goal.

President Obama is quite adamant on our national moral lapse and sees our concern about costs as a defect in our national character. Furthermore, he states emphatically and emotionally, “I will not sign it if its adds one dime to our deficit, now or in the future.”

But as poet Robert Frost might say, President Obama has miles to go and promises to keep and is deep in the woods on the health reform issue. Obama critics note that is foolhardy to make long-term promises on how government will spend on health care, which, until now, have always been underestimated. You will notice his promise leaves it open for future presidents to add a dime or two to our deficit.

The countervailing emotions did not really surface until August, when hundreds of thousands of frustrated Americans swarmed into town hall meetings, gathered in tea parties, and marched on Washington to express their fears about losing care as they know it and of saddling the nation with debt, as on conservative commentator remarked, “ from sea to shining sea as far as the eye can see.”

Among other things, Americans at the grassroots fear reform will divest them of their current plans, will ration their care when they grow old, will burden themselves with higher taxes, and their children and grandchildren with unmanageable debt.

Whether these emotions will turn the tide against government controlled care is unknown. The choice of the right health system os not an easy choice. It is an emotional and moral choice. As Churchill observed, “The inherent vice of Capitalism is the unequal sharing of blessings, the inherent virtue of Socialism is the equal sharing of misery.”

But as Sir Winston observed, “ You can always trust the Americans. In the end they will make the right choice, after they have eliminated all the other possibilities. “

I suspect what we’re seeing is the start of a long debate. Or, as Churchill might say of the health care debate, “Now this is not the end. It is not the beginning of the end. But it is, perhaps, the end of the beginning.”

Monday, September 21, 2009

Fox News and the Obama Henhouse

President Obama knows the lesson of the fox and the henhouse. Don’t let the fox guard the henhouse . The fox, in this case Fox News , will then be in the position of exploiting its position and raiding the White House, pardon, the henhouse.

In his weeklong blitz to persuade the American people of his own position on health care, Obama appeared on 5 talk shows on Sunday and the David Letterman show on Monday, but not on Fox News. He was scornful of Fox News, but filled with charm, explanations, and definition in the other venues.

Our philologist-in-chief told George Stephanopoulus that the $3800 to be imposed on a family of four as a result of individual mandates was not a tax.

Opined Obama, “No, that’s not true, George For us to say that you’ve got to take responsibility to get health insurance is obviously not a tax increase. What it’s saying is, that we’re not going to have other people carrying your own burden for you anymore. This levy, don’t call it a tax, is for your own good.”

In other words, when you’re using your own money rather other People’s Money, it’s not a tax.

It’s probably a good thing, Obama didn’t invite Fox News into the henhouse. Fox might have feasted on these juicy hens.

• Why is the $35 billion Democrats propose to levy on insurers for “Cadillac health plans” not a tax?

• How do you plan to pay for the $800 billion cost (Baucus) to $1.6 trillion cost (OMB) without raising middle class taxes when you run out of rich people to tax?

• Why would a $1000 penalty on young people for not paying for health insurance not be considered a tax?

• Why are the penalties to be imposed on businesses who do not cover employees not a tax?

• Why do you think the $190 billion you propose to levy on hospitals, insurers, medical device makers, and drug manufacturers will not be passed on to consumers”? Are these levies not really disguised taxes?

• In your campaign, you promised not to tax the middle class to pay for health care. How are you going to honor that pledge if cost overruns occur to pay for your health plan?

• Millons of people showed up at tea parties, town hall meetings, and the march on Washington to protest your health care policies. What kind of people are these? What motivated them?

And so on. Maybe Letterman can pose these top ten questions to President Obama.

10. You are suffering from underexposure. Do you consider this appearance your final chance to say what you really think.

9. Explain why you regard Fox news, which regularly swamps it competitors in the ratings and has a vast audience, as simply right wing media tool?

8. Why are you here?

7. You are going to appear on ”Oprah” next week. That’s important because you and Oprah feel many Americans are hapless victims of American capitalism. Who are this week’s victims, and how do you and Oprah, as certified millionaires and billionaires as beneficiaries of American capitalism, plan to help them?

6. Why have your plans for health reform dropped to the low forties in terms of voter approval?

5. Why will your plans to cut $500 billion out of Medicare will not affect seniors?

4. Why does ACORN (American Community Organizers for Reform Now) have no connection with your activities as a Community Organizer? Don’t your share the same philosophies?

3. Will you please repeat your claim that, under your administration, the economic crisis is almost over even in the face of 10% unemployment?

2. Some cynics have said your new slogan is: "Yes, we can -- with enough taxpayer money." Why are they wrong?

And the No. 1 reason Obama should appear on David Letterman's "Late Show:"

Now, here tonight, you will finally get a little air-time to talk about health care reform, a little-noticed topic of your first few months in office and on which you have had too few opportunities to elaborate on his position. Tell us. What is the American people don’t understand?

Innovative Health Reform

Prelude: Commonsensical health reform innovations are: health care tax credits for all, shopping for policies across state lines, freedom to chose policies that fits one’s health needs and one’s purse, health savings accounts with high deductibles for those who want such policies, and scraping of community ratings which force the young and well to pay the same rates as everybody else.

Below, former Speaker of the House Newt Gingrich speaks of another innovation: freeing up doctors and entrepreneurs by not slashing their pay and imposing punitive taxes so they can feel free to innovate.

Wall Street Journal, September 21, 2009
A Growth Vision for Health Reform
Why limit an innovative industry to a certain percent of GDP?

Despite all the well-documented problems with our health-care system, the United States is still the world's leading source of medical innovation. Since 1960, the U.S. age-adjusted death rate for heart disease has declined by 54% due to advancing technology and new drugs. Pacemakers have been transformed. They once required a user to wear a backpack to monitor the device's short battery life. Today, pacemaker batteries last more than seven years and are small enough to install in the rib-cage muscle wall.

Premature babies survive in America to live full lives more often than anywhere else in the world. New drugs now arriving on the market cure once-lethal leukemia. On the horizon there are vaccines to prevent other types of cancer. Modern science and technology offer even more exciting treatments in the future for diseases like AIDS, Parkinson's and Alzheimer's.

Standing in opposition to this world of hope is the vision of reform advanced by President Barack Obama and congressional Democrats. That vision would destroy the economic incentives that drive health-care innovation because it starts with a fundamental conceit: that government planners can spend health-care dollars better than patients and doctors in the marketplace. This planning is the foundation for the arbitrary insistence that spending 17% of our GDP on health care is "too much."

The new bureaucracies that would be set up to reduce health-care spending by slashing payments to doctors, hospitals, surgeons, specialists, drug companies, high-tech equipment makers and others will kill the innovation that has served us so well. The essential incentives for the huge capital investment necessary to develop breakthrough treatments will be gone. And so too will high-paying jobs that these investments create.

Indeed, the plan released by Sen. Max Baucus (D., Mont.) last week would impose new taxes on medical device manufacturers of $40 billion over 10 years. That's more than industry venture capital investment.

We do need basic health reforms. But their focus should be on maximizing patient choice and freeing health-care providers. If we embrace reforms such as expanding Health Savings Accounts, patients and their doctors will, through billions of decentralized decisions, determine the percentage of GDP that should be spent on health care.

We could also expand choice and competition by repealing laws that prevent patients from buying health insurance across state lines. States can follow Florida's example by setting up a Web site that posts real-time prices for medications at different drug stores so customers can comparison shop. The government should make public information collected through Medicare that will allow consumers to see where they can get the cheapest and most effective treatments.

No American should suffer pain, disease or worse because of a lack of health care. We already spend huge sums to help those of modest means through Medicaid and other programs. Reform those programs to create a true health-care safety net. Back it up with state high-risk pools to ensure health coverage for everyone.

That's the American way of reform.

Sunday, September 20, 2009

Beyond Private Health Plan Attacks

It is a socialist idea that making a profit is a vice: I consider the real vice is making a loss.

Winston Churchill, 1874-1965

Profit is not the primary goal, but rather an essential condition for the company's continued existence.

Peter Drucker, 1909-2005

In the health reform debate, private health plans have become everybody’s whipping boy. Private health plans, it is alleged, are bad for your health and don’t offer a good return on your premium money. Besides, most of these plans are for-profit and are beholden to stockholders rather than patients.

Therefore, to reform the system – expand coverage, cut costs, and achieve fairness - one must reform private health plans, by, among other proposals.

• Ending the practice of excluding people with pre-existing illnesses.

• No longer allowing cancelling of policies for those with high-cost disease.

• Eliminating Medicare Advantage Plans, which are said to offer no advantages over traditional Medicare.

• Imposing a 35% excise tax on insurance companies that offer plans that cost more than $8000 for singles and $21,000 for families.
• Limiting tax deductible contributions to health savings accounts and other flexible plans, new and popular products of private health plans.

• Regulate all insurers and compelling them to negotiate with the government to set common payment rules for all.

• Setting up health exchanges so people can shop for the lowest premiums.

• Offering a government public option with lower premiums to insure competition and introduce choice into the equation, and to make private health plans “honest.”

Presumably, all of these proposals will decrease the monopoly or oligopathy powers of health plans, regulate their function, and decrease their “excessive” profits. Also the proposals will offset profits to be gained from bringing into the market new customers through individual, business, and Medicaid mandates.

But, as with anything designed to control health care markets, there are unintended consequences.

• Many with the so-called “Cadillac health plans” are union members, one of the bedrocks of the Democratic party.

• Health premiums are likely to soar, as they have in Massachusetts, because of increased “medical costs,” the main index by which the market judges the stock of health insurers.

• Health insurers, not government, employ most of the talent – executives, medical directors, actuaries, and others – who have been more efficient at controlling costs than Medicare.

One other point, According to Karen Ignagni, who leads America’s Health Insurance Plans (AHIP), the industry has been at the reform table since 2006 with proposals for coverage for all Americans, improving care quality, and bringing down the rate of increase in costs. In addition, AHIP has made these proposals (“Health Insurers at the Table – Industry Proposals for Regulation and Reform,” NEJM, September 17, 2009)
Guaranteed issue- insuring everyone regardless of health status with a guarantee that coverage not be taken away.

Access to essential benefits.

No medical underwriting – same premiums for others of same age with same policy.

• Greater transparency and improved choice.

Limiting the growth of costs.

The AHIP argument is: build on the strengths of the present public-private system rather than dismantling it and replacing it with a government system.

In the end, it comes down to a good cop-bad cop approach, leaving it to the public to decide who is good and how is bad, and who to trust, those proposing a government overhaul or those advocating retention of the best elements of the status quo.

Saturday, September 19, 2009

Does Obama Lie? No, He Does Not - He Elides

Elide (def) – To leave out; suppress, omit, or ignore.

According to Charles Krauthammer, a syndicated columnist and a physician, President Obama does not lie – he elides.

In a recent column, “Does Obama Lie?” Krauthammer had this to say about President Obama’s health care speech before a joint session of Congress on September 15.

1) “I will not sign a plan if it adds on dime to the deficit, or in the future.”“But,” Obama added, “there will be a provision that requires us to come forward with more spending cuts if the savings we promised don’t materialize.”

This is not a lie. This is bait and switch, also known at kicking the can down the road.

2) Then there was Obama’s comment that the current bills do not insure illegal immigrants.

But he neglected to say illegal immigrants are now allowed to take part in health insurance by default because ER staffs are not allowed to ask illegals if they are citizens. After Obama’s talk, Congress quickly changed the language of the bill to require proof of citizenship.

This is not a lie. This is a sin of omission rather than commission and Congress quickly corrected the omission.

3) Finally, President Obama said he would solve the cost problem by “cutting hundreds of billions of waste and fraud” out of Medicare.

Again this is not a lie, but says Krauthammer, an insult to our intelligence. His administration should already be cutting out fraud and abuse without waiting for a reform bill to pass.

No, concludes Krauthammer, “Obama doesn’t lie. He implies, he misdirects, he misleads – so fluidly and incessantly that he risks transmuting eloquence into mere slickness.”

“Obama merely elides, and glides from one dubious assertion to another.”

The Obama Tap Dance

President Obama is from Chicago. Perhaps that’s why his frenzied attempts to sell his health reform plan reminds me of Richard Gere’s tap dancing performance in the movie Chicago.

If you’ll recall, Gere played the role of Billie Bly, a slick high-priced Chicago Lawyer who was defending his client by talking fast while tap dancing around the issues.

This weekend President Obama is appearing on 5 Sunday talk shows – a modern day Presidential record. Why the tap dancing metaphor? The heart of the problem is that he is trying to defend a plan that does not yet exist. That will require some fast talking and fast dancing.

I’m also reminded of the lyrics of the song, “Hey, Big Spender,”

Hey, Big Spender,
The minute you walked into the joint
I could see you were a man of distinction
A real big spender
So good looking, so refined

These lyrics might be changed to read,

Hey, Big Talker,
The minute you walked onto the set,
The nation could see you were a man of distinction
A real big talker
So smooth talking, so refined.

President Obama’s great strength is the power of his rhetoric. He is a magnificent speaker - a great and persuasive talker. But that’s not what’s being tested here. It’s the power and logic of his ideas and policies.

It may be that presidential leadership will prevail. It may also be he is over exposing himself and protesting too much.

As you listen to the President, keep in mind that a June 2009 ABC News/USA Today/Kaiser Foundation survey indicated 89% of Americans were satisfied with their health care and that, according to Obama himself, 281 million of 311 million, or 90%, have coverage. Let’s see how he tap dances around those numbers.

Friday, September 18, 2009

Balancing Health Reform and Medical Innovation

Obsession with the politics of health reform has diverted attention from a huge issue: the decline of U.S. medical innovation.

In March 2009, A coalition of leaders in research, medicine, patient advocacy, academia, education, labor and business leaders anticipated the harmful effects of this diversion. They formed the Council for American Medical Innovation.

"American leadership in medical innovation must be part of our economic recovery plan," said Former Representative Dick Gephardt, a founding member of the Council ,"It has a direct impact on job growth, U.S. competitiveness and the health of all Americans. The future belongs to those who can create and sustain innovation economies, and we must work now to put policies in place that will nurture medical innovation, protect America's ability to maintain its global leadership position and help us find cures."

The other founding members included Dr. Francis Collins, former director of the National Human Genome Research Institute at the NIH; Dr. Edward Benz, CEO of the Dana-Farber Cancer Institute; Billy Tauzin, President and CEO of the Pharmaceutical Research and Manufacturers of America (PhRMA); and Marc Boutin of the National Health Council,. America's future prosperity, they said, will depend on maintaining a lead role in scientific, technological and medical innovation.

Personal Awareness

I am personally aware of this diversion because my two most recent books Innovation-Driven Health Care (Jones and Bartlett, 2007) and Obama, Doctors, and Health Reform (IUniverse, 2009) and my blog address the issue. The slogan for my blog is “Notes of a Medical Innovation Watcher,” but lately all I have talked about is reform.

Obamacare has distracted from innovation by its laser focus on standardization and consistency as a means of system-wide cost control and expanding care to include the uninsured. President Obama rarely mentions innovation as a solution to our health care problems. He focuses instead on savings through prevention, comparative-effectiveness research, disease management, health information technologies, and reduced payments to hospitals and doctors and private Medicare Advantage Plans.

Shayvitz Blog

In a September 18 The Health Care Blog, Dr. Daniel Shayvitz, health care consultant and co-founder of the Pasteur Project, a program to educate Harvard medical students for the future, has captured the essence of the reform vs. innovation problem,

“Our healthcare system is now facing a problem that has plagued business leaders for years: how do you balance consistency and innovation?

The drive for consistency in health care is based upon the fundamental observation that physicians across the country treat similar medical conditions in dramatically different fashions. Sometimes, these different approaches are costly, such as using a more expensive treatment when a less expensive approach might be as effective. In other cases, these practice variations are dangerous – failing to provide patients with treatment the evidence suggests is best.”

“Standardizing the delivery of care -- identifying “best practices,” and then insisting physicians follow these guidelines – could, in theory, save money while improving quality, and is the basis of Obama’s healthcare proposal.”

Obama and his advisors may be right about “consistency and standardization” as a reliable means of achieving “savings and efficiency,” and maybe a more even quality, but consistency and standardization come at a price.

The Price of Consistency and Standardization

From the physician’s point of view, this price includes:

1) being reduced to mere technicians or robots carrying out government policies or blindly following protocols or algorithms of others not present at the patient encounter;

2) losing one’s autonomy to do what one thinks is best based on one’s training and clinical judgment at the point of care;

3) unwanted and usually unneeded interference by corporate or government business interests primarily occupied with saving money based on statistical averages rather than personal nature of the patient’s problems;

4) limiting clinical choices and freedoms of action on the part of both patient and doctor;

5) ignoring the different cultures, practice styles, and different socioeconomic demands and needs in different sections of the country.

A Sharper Point

To put a sharper point on what I’m saying, I do not believe a centralized government can possibly anticipate or dictate what needs to be done or on what is desirable at the point of care using claims or outcome data based on “averages” or by relying on management consistency standards. Medical care is an individual, personal, and emotional thing and does not lend itself to health 2.0 interventions

Shaywitz sums up the problem well,

At some level, standardized algorithms might be good for medicine, reducing the blatant mismanagement of patients by physicians who have not stayed current, and discouraging doctors from reflexively selecting expensive procedures or medications that have been shown to offer little benefit. In simplifying the physician’s decision tree, such guidelines may also enable doctors to spend more time listening to patients, and less time running through a confusing litany of therapeutic alternatives. “

“At the same time, if medicine lurches in the direction of guidelines and algorithms, two important opportunities may be lost:

“- First, we may lose the chance to individualize care; as Steven J. Gould famously wrote, “The median isn’t the message,” and a treatment ineffective for most patients may be enormously useful for some. A key driver of personalized medicine is the urgent clinical need to identify just which patients are most likely to benefit from a particular drug or intervention. “

“Second, we may lose the opportunity to tinker and innovate – so many powerful discoveries originated with a clinician’s chance observation or slight deviation from standard treatment. If the role of physicians is dumbed down to the point where they are simply expected to mechanically execute on established protocols, the ability to intelligently improvise may be curtailed, thwarting medical progress.”

To put it another way, passive or rigid reliance on evidence-based medicine may come at the cost of producing doctors who rely on technologically-generated statistical averages, rather than on the human beings before them. The practice of medicine calls for creativity and innovation and discernment. not blind reliance on computer-generated data.

Thursday, September 17, 2009

Baucus Plan - Malice in Wonderland

Today Max Baucus (D-Montana), Montana senator, and leader of the Senate Finance Committee’s Gang of Six, three Democrat and three Republican senators ,who have spent months laboring to craft a bipartisan health reform bill, released the final version of his bill.

The bill’s contents drew immediate negative responses – from Democratic Senators Jay Rockefeller and Ron Wyden and Dr. Howard Dean, head of the Democratic Party. Nary a Republicans signed on . There was a collective sense that this thing was DOA and this pig wasn’t going to fly, especially among fervid liberals and fuming conservatives. Doom and gloom prevailed on both sides of the aisle.

This response caused me to wonder and to recall two verses from Alice in Wonderland.

“When I use a word,' Humpty Dumpty said in rather a scornful tone, 'it means just what I choose it to mean - neither more nor less.' 'The question is,' said Alice, 'whether you can make words mean so many different things.' 'The question is,' said Humpty Dumpty, 'which is to be master - that's all.”

"The time has come," the Walrus said, "To talk of many things; Of shoes - and ships - and sealing-wax - Of cabbages - and kings - And why the sea is boiling hot - And whether pigs have wings."

The question here is, who is going to be the master - Obama, Democratic liberals, or the Republican opposition?

President Obama has staked his domestic reputation on the success of health reform. He wants to be master of health reform. Many say the Baucus plan achieves Obama’s overall objectives - extending coverage, affordable care, and a major overhaul to achieve “fairness” under government rules and regulations. Obama wants the plan to be “bipartisan,” which I interpret to mean he wants to get one or more Republicans to sign on. Olympia Snowe of Maine is everybody’s token candidate for Republican sacrificial lamb for the Democratic cause.

Republicans, meanwhile, are hoping Obama has met his political Waterloo, has aroused the anti-socialist grassroots, will end his first year in office empty-handed on the health care issue, and will be set-up for defeat in the November 2010 off-year elections.

What Baucus has done, it seems to me, is to throw a lot of proposals on the wall to see what sticks. Baucus is betting the collection of deals Obama has engineered with health plans, hospitals, drug makers, medical device manufacturers, the AMA, unions, business and the “Harry and Louise’ crowd have enough concessions and new protections to keep the “special interests” at bay. At the heart of these deals is the bet that 30 million new customers from the uninsured ranks will bring enough new business to offset news fees of $93 billion to be inposed on these industries.

As the Walrus said, “The time has come to talk of many things, of tax credits for small businesses; prohibiting denial of coverage for pre-existing illnesses; allowing premiums to vary with tobacco use, age, gender; establishing of competition via health exchanges; catastrophic coverage for young adults; individual mandates; business mandates for those with 50 or more employees; limits on HSAs and other flexible savings accounts; and annual fees on profit-making health industries to help fund the whole kit and caboodle.

It’s enough to boggle the mind , goggle the media, toggle the political switches, and boondoggle the health system.

Wednesday, September 16, 2009

Mt. President, I Have Bad News

The bad news comes in two parts:

• The young, aged 16 to 24, who make up about 40% of the uninsured, and who voted overwhelming for you, don’t particularly like the individual mandate in your plan. The law may force them to pay a 2.5% levy on their adjusted income ($1000 for an income of $50,000). This is important because 17.6 million of the 30 million uninsured (your new figure for the uninsured) make $50,000 or more. In Massachusetts, which has a universal plan, and where less than 3% are now uninsured, many individuals have chosen not to participate, and 40% who have bought individual plans have dropped out. Furthermore, costs in the Bay State, already the highest in the land, are rising at 5% to 10%. causing officials to consider paying only for episodes of care rather than paying fee-for-service. If you consider waiting long times to see a doctor as rationing, Massachusetts leads the country in waiting times. The bad news is that not only has the individual mandate and covering the uninsured failed to contain costs, but these young folk are notorious for not voting in off-year elections, like in November 2010, the first broad electoral test of your policies.

• The other piece is bad news is that the old, 65 and older, don’t trust you. This is not new news. Seniors were the only age group to vote for John McCain, by 53% to 45%, the mirror image of your 53% to 47% total electoral margin. Today the situation is even worse among the elderly. Only 35% approve of your handling of health reform, and seniors made up the bulk of those protesting your policies at town hall meetings, tea parties, and the march on Washington. They are leery of the $500 billion you propose to cut out of Medicare over the next ten years. They have the sneaking suspicion Medicare cuts will come out of their care. They know firsthand Medicare has prolonged and bettered their life with striking reductions in deaths from heart attacks, strokes, and cancer. The chances of living longer are greater in America among middle-aged adults and older are greater in America than in other countries. As Fred Barnes, a conservative commentator recently observed. “If you reach 80 in American, most people are dependent on health care. Your chances of reaching 90 are at least as good as and probably better than anywhere else in the world. The older you get in America, the better your chances of getting to 100.”

There’s another problem too. Seniors are concerned about the present and the future. They fear today’s economic situation will spur inflation, eat into their savings, and burden their offspring with unpayable debts. They have benefited from American capitalism, which for them has been a blessing, and fear Socialism, which purports to spread the wealth equally among all, and in the process, taking away from the old and giving to the young. This may be the right thing to do if you subscribe to the collectivist philosophy, but so far the elderly have not bought in.
Finally there is anxiety your reform will ration their care. The old consume a disproportion amount of health care resources. You and many Democrats still claim that our new health-care system won’t feature the kind of rationing in countries like Canada and the United Kingdom. Yet when given the opportunity to add language to prevent the newly established Center for Comparative Effectiveness Research from rationing health-care services on the basis of cost (as a similar commission in the United Kingdom already does), Democrats rejected the amendments during committee markup.

So seniors are wary. They know the National Health Service acts as Britain's national triage service, deciding who is most likely to respond best to treatment and allocating health care accordingly. The NHS sets priorities for those who can benefit most from medical treatment and who is most likely to respond. This is called comparative effectiveness.

Because of rationing among the elderly and cut-offs for expensive care, a crisis is brewing in the UK. British seniors are restless. The Patients Association, an independent charity, is concerned about end-of-life care. The charity reports “a consistent pattern of shocking standards of care” and “appalling treatment.” In the U.K. in 2007 and 2008, 16.5% of deaths occur as a consequence of “terminal sedation.”
You and your followers dismiss concern about reporting of these events as GOP “scare tactics,” and perhaps it is, but, irhgtly or wrongly, the elderly fear you will take “my Medicare” away and to them talk of “death squads,” which you and I know to be inaccurate, is real.

A scarcity assumption similar to the British mentality underlies your proposed health-care overhaul. You have said, "We spend one-and-a-half times more per person on health care than any other country, but we aren't any healthier for it," That may be true for the population as a whole, but not for our seniors. You claimed in your address to Congress last Wednesday that this situation threatened America's economic competitiveness. This rhetoric does not satisfy the elderly. Until now, they have had the best American medicine has had to offer, and they would like to keep it that way.

The last piece of bad news for you, of course, is that In America, seniors vote in greater numbers than any other population sector in off-year elections. You are going to have to do something to satisfy their apprehension. I am confident you recognize the age gap crisis, which will grow worse when 78 million baby boomers begin to enter the Medicare market in 2011. I am not worried, as your chief-of-staff, Rahm Emanuel, known affectionately at Rahmbo, says, “Never let a crisis go to waste.” Waste not, Mr. President.

Health Reform Bone to Pick

In my last blog, I mentiond that the Senate Finance Committee’s health reform plan (also called the Baucus Plan or Gang of Six Plan) would likely impose annual fees for on insurance companies ($6 billion), medical device makers ($4 billion), drug firms ($2.3 billion), and clinical laboratories ($750 million).

The rationale for these “fees” is a mystery, as well as how they were arrived at. Presumably they are a trade-off for the new customers, i.e., the more uninsured the plan would bring to market, or maybe they are an indirect slam at those “profit-making” entities as political villains and strawmen to be be struck down as targets for easy political victories.

These fees brought to mind an animal fable described by Thomas Sowell, a senior scholar at the Hoover Institute (“Fables for Adults,” September 15, Real Clear Politics).

Fables for Adults
By Thomas Sowell

Many years ago, as a small child, I was told one of those old-fashioned fables for children. It was about a dog with a bone in his mouth, who was walking on a log across a stream.

The dog looked down into the water and saw his reflection. He thought it was another dog with a bone in his mouth-- and it seemed to him that the other dog's bone was bigger than his. He decided that he was going to take the other dog's bone away and opened his mouth to attack. The result was that his own bone fell into the water and was lost.

At the time, I didn't like that story and wished they hadn't told it to me. But the passing years and decades have made me realize how important that story was, because it was not really about dogs but about people.

Today we are living in a time when the President of the United States is telling us that he is going to help us take that other dog's bone away-- and the end result is likely to be very much like what it was in that children's fable.

Whether we are supposed to take that bone away from the doctors, the hospitals, the pharmaceutical companies or the insurance companies, the net result is likely to be the same-- most of us will end up with worse medical care than we have available today. We will have opened our mouth and dropped a very big bone into the water.

Elements of Baucus Health Plan

In next several weeks, Senator Baucus (D-Montana) says he will unveil the much awaited Senate Finance Committee’s plan to control costs, protect consumers against “unfair” insurance industry practices, and put America back on a path towards fiscal sustainability (Max Baucus, “The Senate if Ready to Act on Health Care,” WSJ, September 16, 2009). According to the Kaiser News, here is what we know about the plan will contain;

• Provide tax credits to small businesses that offer insurance at work.

• Prohibit health insurance companies from denying coverage to individuals with pre-existing health problems.

• Allow health insurers to vary premiums based on three factors: tobacco use, age, and family composition.

• Allow states to form compacts with other states to permit for the interstate sale of health insurance.

• Establish state-based health insurance exchanges to help consumers compare insurance plans and costs based on four benefit coverage options ranging from minimum (bronze) to comprehensive (platinum).

• Allow for a catastrophic coverage plan for young adults.

• Require all U.S. citizens and legal residents to have health insurance or pay an annual fine of up to $3,800 per family.

• Require employers with more than 50 full-time employees tp pay an annual fee of $400 per employee, if they do not offer health insurance at work.

• Authorize funding for the Consumer Operated and OrientedPlan (CO-OP) program to encourage the creation of nonprofit, member-run health insurance companies in every state .

• Expand Medicaid coverage to individuals not currently eligible..

• Impose a 35% excise tax on insurance companies and administrators that offer insurance plans that cost more than $8,000 for singles and $21,000 for families

• Limit contributions to Flexible Savings Accounts to $2,000 per year..

• Impose annual fees on insurance companies ($6 billion), medical device manufacturers ($4 billion), pharmaceutical manufacturers ($2.3 billion), and clinical laboratories ($750 million).

There is plenty to chew on here. Much of the plan – individual and business mandates to compel coverage or be fined, annual “fees” (in less polite terms, known as “taxes”) imposed on health insurers, device makers, drug firms, and clinical laboratories to the tune of $ 13.05 billion, excise taxes on high end plans, insurance portability between states and health exchanges in every state.

We shall see if this “plan” passes political muster..

Tuesday, September 15, 2009

Obama's Health Reform Steep Hill Reclimbed

Back in April, 2009, when I was writing Obama, Doctors, and Health Reform, I predicted Obama’s plan would fail to bring about universal coverage.

Here is what I said,

“Debts incurred by the economic stimuli package and staggering federal deficits ($1.75 trillion for 2010 alone) may be too steep a hill to climb for Obama and those who crave universal coverage or single-payer in the near term. Whether the Obama administration will be an epiphany or a Sisyphus in health care is unknown.”

“In any event, under any circumstances, I don’t foresee how Obama in the next few years can create 3.5 million jobs, redesign the health system, save the auto industry, reinvent the energy sector, revitalize the banks, and reform education with one swipe of his magic wand.”

Well, I’m here to report I may have been right, at least if you believe the polls and Susan Page’s USA Today piece today, September 15, , which goes, in part, as follows,

Health care bill has steep hill to climb

By Susan Page, USA TODAY
WASHINGTON — President Obama's long, hot summer is about to turn into a chilly fall.

A USA TODAY/Gallup Poll taken after the president's dramatic address to a joint session of Congress last week shows Americans almost evenly divided over passing a health care bill and inclined to think it would make some of the system's vexing problems worse, not better.

The findings underscore the steep climb ahead for the White House in trying to push a health care plan through the House and Senate during the next few weeks. Some major provisions, including how to pay for it and whether to include a government-run plan as an option, haven't been settled.

The president's speech apparently failed to galvanize public opinion in the way the White House had hoped. While it drew a national television audience estimated by Nielsen at more than 32 million people, there's little evidence in the survey that it changed minds.

The USA Today/Gallup Poll of 1003 adults indicated 50% of adults were for Obama’s health care bill and 47% against. In answer to the question, will it accomplish his goals, that is, expanding coverage to nearly all Americans without raising taxes on the middle class or lowering the quality of care to those who have coverage, 38% said “Yes,” and 60% said “No.”

Obama’s problem depends on whom you ask.

• If you ask T.R. Reid, author of Healing of America, Obama's problem is the failure of Americans to make the right moral choice, and we ought to be ashamed of ourselves (“Universal Health Care is a Moral Choice,” Newsweek, September 15, 2009).

• If you ask George Will. It’s because , after 233 days of his presidency and 122 public statements on health care with countless contradictory shifts in position, no one believes him anymore *”Why We Don’t Believe Obama,” Newsweek, September 13, 2009).

As for me, I believe the health care hill is too steep to climb in light of unemployment, economic, and debt obstacles at the top of the hill.

Monday, September 14, 2009

Partisanship by the Numbers - Estimates of the Size of the Washington Taxpayer March

None of us really understand what’s going on with all these numbers.

David Stockman, 1946 - , President Reagan’s Budget Director

How and why media estimates vary on the size the taxpayer march on Washington fascinates me. Why? Because the estimates reflect media bias.

For example, the New York Times, an acknowledged and proud Obama partisan, puts the number at “tens of thousands” and places the story on page 27 of its September 13 Sunday edition.

The Wall Street Journal, not exactly an Obama enthusiast, puts the number on at 1.5 to 2 million, and then scaled it back to “tens of thousands.” The WSJ added. “A spokesman for D.C. Fire and Emergency Medical Services estimated the crowd at "in excess of 75,000" people. Local and federal law enforcement authorities don't provide crowd estimates.” No surprise considering Democrats dominate D.C. politics.

The Associated Press cited the media-approved “tens of thousands” number.

CNN at first said the number was 1.5 million, then backed down and used the operative “tens of thousands” figure.

ABC said the crowd was 1 to 1.5 million.

British media outlets said 2 million came.

Wikipedia simply said " the number was larger than expected.“

What frustrates me is that, using satellite imagery, which can hone down to 2 square feet, can precisely estimate the exact number? I'm sure they have detailed pictures of the crowd.

Besides the numbers game, there’s another element to media behavior – describing the make-up of the crowd. It is most often said to made up of “conservative activitists” organized by “right wing organizations.” This is an opinion, not on fact, or detailed informtion who were actually there.

I was speaking to two dear friends of mine, both loyal Democrats. I asked one what the taxpayer march and what the hundreds of thousands of protestors at town hall meetings meant. His comment was, if you’ll pardon the expression, a “bunch of dumb shits.”

I put the same question to the other Democratic friend. I threw in the fact that Obama’s popularity on handling of health care reform, has dropped to 50% or less, depending on the poll. His comment was succinct, “nitwits."

These comments reflect a common opinion among partisans in the ruling party, namely that Obama is "smart," that opponents are “stupid,” as the President said of the policeman in Cambridge, Massachusetts. Ssomehow the Democrats seem to think they have some stranglehold on collective wisdom. This may be, but I doubt it. Democrat majorities,their altitude, has affected their attitude.
Don’t tinker, don’t think, don’t resist, just accept what we say. The thought that the tea parties, taxpayer marches, and town hall protests may be a spontaneous grassroots movement bubbling up from below never seems to cross their mind.

I predict this dismissive, condescending, arrogant, and elitist attitude will backfire, as the American people , who have minds of their own, become more alarmed about growing unemployment, the faltering economy, the skyrocketing debt, and concerns about inflation, taxation, and health care rationing for the elderly.

Response to Response to My Latest Blog on Top-Down Vs. Bottom-up Reform

Response to my blog of yesterday.

From Steve:

"I agree with the future shortage issue. The rationing point is a bit complex.
Anyway, how do we resolve Medicare does not pay doctors enough, and often hospitals for that matter, with Medicare going broke? Who do you think is going to successfully address Medicare costs and how? Bottom-Up sounds good, but I do not see how this works in practice. Private insurance has shown no ability/willingness to hold down costs."

"I enjoyed the interview with Dr. Cooper. Penn grad '85 here. Since graduation I have spent time in the military, moonlighted quite a bit and now work at several places in PA. My experience and what I have seen of physician behavior is a bit different than his. I see guys who own MRIs and PT services making self referrals. I see the consultants coming in to make sure we don't :leave money on the table." Yes, most docs remain good guys, but there is a lot more bad behavior, questionable behavior, than he has seen."

My response to his reponse

Excellent point about Medicare not paying doctors and hospitals enough yet going broke. The main reason, I think, is that Medicare has no way to control the number of procedures being down in a fee-for-service environment.

Further, Medicare has neither the staff, nor the expertise, nor the political stomach to deny or review requests. To control costs, Medicare simply arbttrarily rachets down fees for doctors , and more and more doctors respond by declining to accept new Medicare patients. Or doctors do more tests and procedures – either to meet patient expectations and to meet their bottom-up lines.

Insurers, on their part, to keep their networks open and to offer needed services, have to negotiate higher fees than Medicare to keep respectable networks of providers.

And so the cycle goes.

Bottom-up means payments refers to services and innovations set at local and regional refers to services and payments in private markets , rather than by what the government dictates from the “top-down” by fiat.

Health costs, in my opinion, will be best controlled and quality maintained by health consumers spending their own money and truly understanding what things cost. This bottom-up approach will vary by region – in California by capitation, in Massachusetts iby budgets for episodes of care, in Pennsylvania by the Geisiinger approach with integrated care coordination with outcome guarantees for some high-ticket procedures. More globally,i.e. nationally, by HSAs with high deductible accounts or by cross-state shopping for the best deal, or by doing away with “community rating” or comprehensive “ standard” benefit plans. The governnment could seize the initiative by opening up FEHBP (Federal Health Benefit Plans) to all rather than just government employees and to national politicians. I would like to point out that “bottom-up” HSAs are working beautifully in Minnesota , not exactly a conservative state, which leads the nation in HSA membership, and where employers have experienced health care cost drops of 30% to 50% in those with HSAs. I would also note another “bottom-up” approach “work-site clinics,.“ These are being set up by half the corporations across the land, with more than employees in one localtion, with 20% to 40% cost savings. I have interviews in Obama, Doctors, and Health Reform with HSA and work site clinic leaders.

Cost control will not be easy, and much of it will be ironic and contradictory, as exemplified by those who say, “ I hate socialism but don’t mess with my Medicare.” Well, someone has to mess with Medicare. It is going to financial hell in a handbasket. To use it as a model for reform defies logic. To save itself, Medicare is going to have to reform, partly by learning lessons from the hated private sector, where costs are going up at a 30% lower rate than Medicare.

Sunday, September 13, 2009

Bottom-Up, Incremental, Not Top-Down, Total Reform

Talk prepared for presentation at the Acton Public Library, Old Saybrook, CT, September 13, 2008, no given because of mix-up in scheduling

There are, it may surprise you to know, more public libraries than MacDonalds. No other civilization, ever, has had anything comparable to our public library system. Free to the public. You walk through the portals of the public library, and you are walking through the portals of freedom.

David McCullough, Historian

I am here tonight to discuss my book Obama, Doctors, and Health Reform.

I wish to thank Jan Crozier, head librarian here at the Acton Library, for setting up this meeting and for reviewing my book for a library association. I am a library junkie. I am deeply grateful for the services you offer here – access to books, computers, magazines, newspapers, videos, DVDs, meeting rooms, and, of course, ubiquitous courteous librarians, always available at our beck and call.

A Running Start

Let me start by saying, as a physician, I support incremental health reform, expanding coverage for the uninsured, and lowering costs. I am, however, dubious about the practicality of top-down total reform that pays for most care, dictates the terms of payment, interferes with the details of the patient-doctor encounter, pays doctors and hospitals at Medicare rates, which are 20% less than the private sector, and tries to completely overhaul 1/6 of the economy. I realize I am making a moral choice, but I do not think we can afford it right now.

Respectful But Skeptical

My book is respectful but skeptical of Obamacare. It begins by saying President Obama has overreached and over-interpreted his mandate. He has bitten off more than he can digest. It predicts the President will get 1/3 of what he wants. It ends with a toast and prayer for President Obama.


My message is ACDF. Government cannot, all at once, Absorb, Control, Dominate, and Finance the financial, automobile, energy, education, and health care industries.

That is not the American Way, as demonstrated by the town hall demonstrations of August and the taxpayer marches on Washington. In President Obama's eight months in office, if you position the U.S. on the capitalist-socialist scale as measured by the percentage of total government money spent compared to Gross Domestic Product, the U.S. has moved from 9th to 3rd among Western nations – from 36.4% to 49.6%, just behind Sweden at 57.0% and France at 54.6%. Grassroots America is concerned we are accumulating debt we can never repay.

That is why the town halls and marches on Washington are important. It is a case of a moral obligation to cover all against a fear of government domination with an encroachment on personal freedoms. It is uncertainty where this country is going, and 60% think we are going in the wrong direction.

To me reform is essential and overdue, but reform should be incremental. It should include, among other things, tort reform with caps on damages, prompt payment, and expert panels to decide what to pay; shopping across state lines for the best plan, similar to the federal health employee benefit plans now available to Congressman and Senators; and bare bones coverage with lower premiums for the young, the healthy, those making $50,000 or more now dissuaded from being insured because of unaffordable premiums; and insurance reforms, such as not excluding people for pre-existing illness or cancelling policies because of high costs.

My biggest fears are limited access to care because of the doctor shortage and expanded coverage, mediocre care, and uncontrollable costs.


I wish to acknowledge the presence of my wife, Loretta, a nurse who graduated from the Massachusetts General School of Nursing, and who deep insight into the problems of doctors and their patients.

I wish to also acknowledge the example set by son. From attending Spencer's poetry readings, I have learned two things: The importance in context and brevity. Spencer by the way, is a nationally known poet, who is candidate for the Episcopalian priesthood at Yale Divinity School.

Spencer’s influence brings to mind this poem,

Seek brevity.
With a touch of levity.
In short, be terse.
For nothing is worse.
Than verbal longevity.

I invite questions after I end my remarks, which will take about 10 -12 minutes.


I am a retired pathologist. Since I retired, I have diversified into writing 10 books and composing a daily blog, medinnovationblog.blogspot. com., which now has 977 entries. The Physicians’ Foundation, a non-profit organization representing 650,000 doctors helped finance the book. I have been interviewed on Royal Dutch TV and CNN about the book.

I have lived in Old Saybrook for 14 years with Loretta and Paris, a French bulldog of impeccable heritage. I love my wife, my dog, this town, and my friends. I meet 2 or 3 times a week at the Rivermart convenience store on Main Street with a dozen or so townpeople to discuss domestic and foreign affairs.

I worked for 6 months to write this 304 page book, which has been out for a month and which can be obtained at,, and, or by ordering through your local book store.

The book represents a doctor point of view and is biased. It is respectful but skeptical of President Obama’s plan for reform. As George Orwell, who has been on my mind lately because of his warnings about Big Brother watching you, every writer, whether he admits it or not, has a political bias which sooner or later shows through.

My bias? I am an unabashed cheerleader for doctors, and I think our input into the reform process has been too limited. I am not a big fan of big government which underpays doctors by 20% on average, threatens to cut their income each year through a SGR (sustainable growth rate formula), and just a month ago arbitrary cut cardiologists’ and radiologists’ fees by up to 50%. It takes 15 years to make a doctor, takes a big slice out or your working years, and often puts your $200,000 in debt before you start practice. And after all of that is said and done, you must deliver the reform, whatever it is.

Unifying Themes

My book has two great unifying themes - one, that the next big health care crisis will be lack of access to doctors as 78 million baby boomers become eligible for Medicare in 2011 and as we expand coverage to the uninsured ; and two, that exploding costs and mounting federal will result in rationing of care, particularly for Medicare recipients. That may be why only 31% of those over 65 approve of President Obama’s handling of health reform.

For what may involve as we evolve towards universal coverage, let’s look at the neighboring state of Massachuetts. Patrick Deval, governor of Massachusetts, who remarked of his state’s universal health plan, now 3 years old, “Universal coverage without universal access is meaningless.” The Massachusetts experiment indicates that without enough doctors to cover the 46 million uninsured Obama proposes to cover, we are likely to have limited access and rationing. Both will first take the form of long waiting times to see a doctor, now 60 days in Boston, twice that of other comparable u.S. cities, and will feature increased costs, already 30% above the national average in Massachusetts.

Let’s also examine the frequently heard statement that the system is “broken.” Mark Twain, who spent much of his working life time in Hartford. When asked about what he thought about Richard Wagner’s music, Twain quipped, “It’s not as bad as it sounds.” Likewise, I do not think President Obama’s characterization that the American health care system is as “broken” as he makes it sound.

In the last 5 months, I have had a heart attack, treated with stents at Yale, and cataract surgery, treated as the Constitution Eye Center in Waterford. In each case, the treatment was superb, and was, of course, covered by Medicare and supplement Blue Cross Coverage. I am fortunate in having insurance, like nearly 230 million insured Americans, and I am satisfied with the care I receive.

Obstacles to Reform

As I say in my book, I see four obstacles to Obamacare.

One, the American Culture, which distrusts Big Government which cherishes individualism, choice, and freedom and which demands choice and prompt access to the best American medicine has to offer. Incidently, the Whord Health Organization recently said the U.S., despite its high costs, ranked number one in the world, in patient “responsiveness.”

Two, Complexity. It is a tough if not impossible job to instantly superimpose a largely government-run system on our current employer-based system on an inefficient public system, in which Medicare and Medicaid costs are rising 30% faster than in private plans, no matter what you hear to the contrary.

Three, Costs. How are we going to pay for expanding coverage for 46 million uninsured without not adding “one dime” to the deficit, which has already doubled in the first 8 months of the Obama presidency. How are we going to cut $500 billion out of Medicare with 78 million babyboomers coming on board in 2011?

Four, Consequences. Dismantling or to use that appalling phrase, “overhauling” the system will have employment consequences. Collectively, health care, with 13 to 14 million employees, is the largest single employer of Americans and constitutes the only growing employment. sector Those health care sector include doctors’ offices, hospitals, home care, and yes, health plans and the agents who sell these plans and the health resource people who administer them.

President Obama Will Get Something

In spite of these obstacles, I predict President Obama will get something, probably about 1/3 of what he wants, including coverage of some of the uninsured, cancellation of current health plan polices of not covering those with pre-existing illnesses or cutting off of coverage for those with high costs, and other things, and things like shopping across state lines and lower premiums for the young. He will not get a public option or individual or employment mandates. For these accomplishments, he should get credit and can declare victory.
Thank you for listening. I now invite questions.