Throw’n Out Bodies Just t’Cut Down on the Drag?

Critics of the Town Hall Protesters like to accuse them of being ill-informed. They complain about socialized medicine, but they're all on Medicare! Never mind that it's no contradiction to want to keep a paycheck coming but also think that further government expansion might be a bad idea.

But it is clear, to me and to the editors of the Washington Post, that the White House has been just as guilty of peddling disinformation with less excuse.

[I]t is disappointing, to say the least, to see Ms. Pelosi and other Democrats revert to round-up-the-usual-suspects demagoguery. President Obama has been more restrained but hardly more accurate; in a news conference last month, he inaccurately complained about insurers making "record profits, right now." In fact, among U.S. industries generally and other parts of the health sector in particular, insurers are not particularly profitable. The latest Fortune 500 ranking of most profitable industries has pharmaceuticals third, medical products and equipment fourth, and health insurers down at No. 35. Drugmakers reported a 19.3 percent profit margin; insurers, 2.2 percent.

More fundamentally, the Obama administration is peddling health reform as an everybody-wins scenario in which no one, except perhaps the wealthiest of the wealthy, has to sacrifice anything. We recognize that selling dessert is easier than selling spinach, especially when the other side is falsely claiming that your food is poisonous. But if health reform passes and starts bringing down costs, it is going to pinch some patients who have become accustomed to getting every test or procedure they want. At that point, Mr. Obama might wish he had done a little more to prepare people for the changes.

The President has a somewhat larger staff than your average Town Haller. He has no excuse for not knowing the truth.

The Post is right about the basic problem, but isn't being very explicit itself. What is it about healthcare reform that is so unpalatable? Another piece in the WaPo by Charles Lane zeroes in on Sec. 1233

which would pay doctors to give Medicare patients end-of-life counseling every five years -- or sooner if the patient gets a terminal diagnosis.

Lane notes that, contrary to some conservative propaganda, there is nothing sinister about this. But why, then, do the Democrats not want to talk about 1233?

Perhaps because, at least as I read it, Section 1233 is not totally innocuous… Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they're just trying to facilitate choice -- even if patients opt for expensive life-prolonging care. I think they protest too much: If it's all about obviating suffering, emotional or physical, what's it doing in a measure to "bend the curve" on health-care costs?

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive -- money -- to do so. Indeed, that's an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.

So as Lane explains it, Section 1233 provides incentives for Doctors to provide patients with "end-of-life counseling." Doctors may initiate the counseling, and if a patient agrees a decision to end care can be signed right then and there. If counseling patients about end of life decisions is part of the process of "bending the cost curve" down the road, well…

The problem is that government, a party interested in reducing overall costs, will be recruiting doctors to make a case. Paul Krugman thinks that private insurance is bad because the insurance agent has an incentive not to pay for your treatment. But surely a government trying to get control over costs has an incentive not to pay for a lot of folks' treatment and one way of reducing payments is to get more of them to go more gently and more importantly earlier into that good night.

Now something like this may be unavoidable. An aging population and the growth of medical technology are what is driving up total healthcare costs. Anyone who does not know this is ignorant about the issue. Both public and private insurance may have to simply refuse to pay for treatments that would extend the life of an elderly person several years into the future. I am not passing judgment on that, I am just noting that it may be a fact. See Peter Singer's piece on this, in the New York Times (hat tip to FS). 

But you can understand why Obama doesn't want to talk about it. According to the WaPo, not exactly a Republican rag, the President isn't being candid about healthcare reform. So let's not pretend it's just Town Hall mobs who get the story wrong.

Comments

[FascistSocialist]

This post is so riddled with inaccuracies I don't even know where to begin! I guess I'll just start at the top and work my way down. It is 1:00 am when I'm starting this, insomnia and all that, so bear with typos and silly sentences.

"In fact, among U.S. industries generally and other parts of the health sector in particular, insurers are not particularly profitable."
Obama was referring to the recent record earnings report of UnitedHealth.
http://www.marketwatch.com/story/unitedhealth-earnings-rise-boosts-outlook
- Tuesday said second-quarter net earnings rose to $859 million, or 73 cents a share, from $337 million, or 27 cents a share, in the same period last year.

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Ken I don't think you read that article on McAllen, Texas by Atul Gawande, nor Shannon Brownlee's book "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer" or you probably wouldn't have highlighted this next section.

"More fundamentally, the Obama administration is peddling health reform as an everybody-wins scenario in which no one, except perhaps the wealthiest of the wealthy, has to sacrifice anything... But if health reform passes and starts bringing down costs, it is going to pinch some patients who have become accustomed to getting every test or procedure they want."

What this statement fails to realize is that less care is more in many cases. Each test and procedure carries with it a risk to the patient. When you are doing tests and procedures that are not necessary you are not only exposing the patient to unnecessary risks but you are also over charging them at the same time. This has been proven time and time again. As an individual patient or practitioner it's hard to know or recognize, that's why we develop guidelines based on science. Patients are typically not doctors or specialists and can not be expected to know what procedures and tests are the best for a given circumstance. And, as we see in the case of McAllen, Texas and countless others, the doctors are either not interested in cost savings/health of the patient (to view the situation sinisterly) or unaware of how profoundly they are affecting the health/cost of care by their actions and are quite shocked when they do find out. (There is a phenomenal example of this in the introductory chapter of Brownlee's book re: tonsillectomies)

Overtreated:
http://www.amazon.com/Overtreated-Medicine-Making-Sicker-Poorer/dp/1582345791
The Cost Conundrum:
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

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I'm wary to jump into the fray on the 1233 discussion, because as you probably haven't, I also haven't read the bill. But, my understanding from attending and viewing multiple discussions on the section in question in town hall meetings and other forums is that the point of the provision is the following:
Right now doctors, hospitals and nurses are reimbursed for procedures. If a doctor consults a patient for 2 hours or 10 hours or 30 hours he can't bill anything even remotely comparable to what he could bill doing procedures for that amount of time.
What this section attempts to do, is permit doctors to provide a valuable service to patients and have it actually be worth their time comparable to other procedures they could be doing.
This is no more sinister than a provision that allows a doctor to spend more time counseling a patient on their weight, smoking, exercise regimen, diet, blood pressure, or diabetes or other chronic condition and be reimbursed for it.
It has to do with promoting end of life provisions that have been pushed for by the federal government for MORE THAN 20 YEARS NOW with absolutely no objection or controversy. To raise such qualms now is just plain odd.

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"An aging population and the growth of medical technology are what is driving up total healthcare costs. Anyone who does not know this is ignorant about the issue."

Again with this Ken? Please, for the sake of my remaining sanity, please, please, please read the two Atul Gawande articles and if you have the time the Shannon Brownlee book. Neither of those factors are primary driving forces when compared to other costs. I don't want to spend a lot of time trying to paraphrase these two excellent writers, but a vain attempt ensues:
Basically, when you have two virtually identical communities and one is paying 100% more (6,000 per person vs 12,000 per person) for care that is statistically WORSE than the cheaper community's care something is at work that is not new technologies and old people. READ THE ARTICLES!!!!!!!!!!!!!!!!!!!!!!!

Anyway, I hope you've enjoyed my rebuttal of virtually everything you've said in this post...

If you've watched any of these town hall disturbances I'm sure you would recognize that they are not objecting objectively. The people who have shown up without prompting get very, very upset with the people who are there yelling, being rude, and disrupting the interaction of the constituents with their elected representation in congress.

Ken... I just don't know, man. Your accusation of the White House spreading disinformation is disinformation itself.

[FascistSocialist]

http://www.nytimes.com/2009/08/10/health/policy/10facts.html

A good source for a quick summary of some of the more volatile "issues". The authors raise a very interesting criticism of Democratic proponents of health care reform that I agree is a valid criticism. Whether it's something that can be realistically addressed or not is another matter. (in the section titled "BLAMING INSURERS")

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The article also has a quote that I quite like in it from the AARP:
"Conservative critics say the legislation could limit end-of-life care and even encourage euthanasia. Moreover, some assert, it would require people to draw up plans saying how they want to die.

These concerns appear to be unfounded. AARP, the lobby for older Americans, says, “The rumors out there are flat-out lies.”"

[denature]

I've read 1233 and it still comes across fairly innocuous to me. It's pretty explicit about providing resources for patients to consult. Regardless of how you read the bill, there are no profits given to the doctor to get the patient to end their life early. If the suggestion is that doctors can't resist the call of free money, it would seem to be more profitable just to run a bunch of needless tests, and life-saving activities every couple hours toward the end of someone's life. What's the logic of trusting the doctor on some medical issues but not others? As far as accuracy on record profits, what are the last 5 years of record profits for the health insurance industry? May I assume that you would approve talking points that stated something like profits for health insurers have soared in this decade while consumers have paid more for less coverage, and the number of uninsured has risen dramatically?

[FascistSocialist]

I'm not sure if you're addressing me or Ken with the 2nd part, denature. But the exact quote from Obama's national address on health care was
"Now, you know, there have been reports just over the last couple of days of insurance companies making record profits, right now."
He was referring to that profit report from UnitedHealth that came out, I believe, two days before his national address.

http://www.nytimes.com/2009/07/22/us/politics/22obama.transcript.html?pagewanted=11&_r=1

referring to:

"second-quarter net earnings rose to $859 million, or 73 cents a share, from $337 million, or 27 cents a share, in the same period last year."

Which I would not call inaccurate.

[denature]

The comment was more to Ken. Regardless, I see no equivalence between Obama's statement and organized disinformation orchestrations to prevent health care reform. What Obama implied is largely true--profits are up coverage is down. What deathers imply is largely false--Obama wants to kill old people. If we are actually interested in policy, I do think it would be more relevant to examine the expanded time frame to view the higher profits compared to the diminishing coverage. This illustrates an empirical need for health care reform now. That section 1233 doesn't do the nefarious things implied above is directly contradicted by one of the provision's authors. The provision had republican cosponsors, is endorsed by the AARP, and supported by the AMA. I'm also confused by why deathers get a pass for not knowing the truth, but not Obama since he "has a somewhat larger staff." Not much respect for the individual. No mention of an excuse for congressional republicans for spreading disinformation or the group behind current TV ads. Or an excuse for the pundits, think tanks, lobbyists, or professional spinners sponsoring the recess rallies. Hardly strong praise for the ability of the private sector to arrive at the rational truth.

[lexrex]

lots of long comments, here. i'm still waiting for someone to show me how the federal government has constitutional authority to implement such a program.

the fascist proclaimed, on another post, that it was the commerce clause, but gave no explanation to back it up. can anyone explain how the constitution grants the government such a huge expansion of power? (without resorting to immature name-calling, fascist.)

[FascistSocialist]

I would really rather not derail this conversation, and I hope that Ken Blanchard sticks to the above criticisms. The following post is directed at Lexrex, while I am not a legal scholar nor a constitutional law expert this is my understanding:

"The Commerce Clause is an enumerated power listed in the United States Constitution (Article 1, Section 8, Clause 3). The clause states that Congress has the power to regulate commerce with foreign nations, among the states, and with the Native American tribes. Courts and commentators have tended to discuss each of these three areas of commerce as a separate power granted to the Congress of the United States. It is common to see the Commerce Clause referred to as "the Foreign Commerce Clause", "the Interstate Commerce Clause", and "the Indian Commerce Clause", each of which refers to a different application of the same single sentence in the Constitution."

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The teeth to do anything with the commerce clause is given in the form of the Necessary and Proper Clause.

"The Necessary and Proper Clause (also known as the Elastic Clause, the Basket Clause, the Coefficient Clause, and the Sweeping Clause[1]) is the provision in Article One of the United States Constitution, section 8, clause 18:

'The Congress shall have Power - To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof.' "

Read:
http://en.wikipedia.org/wiki/Necessary_and_Proper_Clause
on the establishment of a national bank and the Supreme Court precedent in 1819 in McCulloch v. Maryland.

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"In addition to these powers to charter and operate federal banks, the clause was linked to the General Welfare clause and the constitutional powers of tax collection and the ability to borrow money to give the federal government virtually complete control over currency."

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A General Welfare clause is a section that appears in many constitutions (including the US Constitution), and in some cases in charters and statutes, which provides that the body empowered by the document may enact laws as it sees fit to promote the well-being of the people governed thereunder. Such clauses are generally interpreted as granting the state a power to regulate for the general welfare that is independent of other powers specified in the governing document.

As I said, I'm no constitutional scholar, and do not claim to be as you seem to. This is just my understanding as informed from basic political science classes and my own meager investigations into the origin of congressional budgetary powers.

[lexrex]

thanks for the response, fascist. you say, "The clause states that Congress has the power to regulate commerce with foreign nations, among the states, and with the Native American tribes."

i'm not sure how my going to see a doctor falls into any of those categories, unless perhaps, i have to cross into another state to do so.

your interpretation, allowing congress to regulate intrastate activity confers the feds with a general power over the whole country. that means it can step in and stop guy from growing his own corn or medical marijuana for his own consumption; it can use tax dollars to fund abstinence programs; it can fund just about anything it wants.

as clarence thomas said in his dissent against the supreme court's decision upholding a federal marijuana prohibition: "If Congress can regulate this under the Commerce Clause, then it can regulate virtually anything," including "quilting bees, clothes drives and potluck suppers." Thus "the federal government is no longer one of limited and enumerated powers."

[FascistSocialist]

Yup, that's basically where we're at. As far as I can tell.

[lexrex]

then why do you suppose the founders put in a commerce clause, at all, if they thought the federal government should have the authority to fund any and everything under the sun? i thought the constitution was written to limit the federal government.

[FascistSocialist]

Well, I can't really speculate on founders' intent, I'm no constitutional scholar and I'm no scholar of the era either.

[KB]

FS: I would like you to consolidate your initial comments to one post. I hesitate to ask this, as your frequent comments make it look like I get more engaged visitors than I really do. But it would make it easier to reply to you. Of course you it is proper to reply to any subsequent post my me or anyone else, especially if they reply to you.

I believe you confessed, somewhere earlier, to being an asshole. If my memory is correct, that's too harsh. You are a blowhard. You can't confine yourself to the argument but have to make useless comments about "refuting everything" I have said. If you have indeed done that, why do you need to say it?

President Obama's statement about record profits was false, or at best unsubstantiated. One business report about stock prices does nothing to confirm it. It was part of the Democrat's demonized the health insurance industry campaign. If the other side did such a thing, you would recognize it in a minute.

I am getting to the New Yorker article that you think is gospel truth. But I don't doubt for a moment that there are serious inefficiencies in the American healthcare system. If we could make the system more efficient, that would free up a lot of money. But not enough money to fix the basic problem. You insist on looking like an ignoramus when you object to my most obvious point: that an aging population and the advance of medical technology are the great engines in the grow of medical costs. Everyone but you seems to know this. It is a challenge for Europe and Japan, where populations are aging much more rapidly than here. Japan has a ministry devoted to population growth precisely because no one can figure out how to sustain a social welfare system with no new workers being born. Am I going too fast for you?

As for the problem of rationing care, which I think we are going to face inevitably, here is one authority I found on the subject:

"a treatment that saves a 90 year old for 1 year and equally saves a 9 year old for 50 years should not be treated equally. In this sense we have to define our value on life at different ages since we MUST put value on human life given the nature of paying for health with finite resources. Right now we have no system to do it, poor people die, wealthy live. That's not palatable for anyone with any semblance of a conscience."

That was, wait a minute! That was you. If you could tone down your bluster for a moment, we might find that we agree about more than one might expect.

denauture: thanks for the comments. Maybe the Washington Post, a solidly liberal paper, is wrong about Obama's statement. It looks to me like they were right. The health insurance industry ain't makin' out like bandits. Obama said that because the Democrats need a villain.

As for 1233, if insurance agencies are suspect because they have an interest in not paying out (as the judicious Krugman has said) then the Federal Government is suspect when it pays doctors to counsel patients about end of life decisions. It has a very strong fiscal interest in seeing as many of them as possible as often as possible pull the plug.

lexrex: I wish I could agree with you. But while I do think there are some constitutional limitations on the powers of Congress to interfere with state prerogatives, there is no barrier to Congress doing something just because the Constitution doesn't explicitly or implicitly authorize it. Maybe there should be. Maybe the Founders intended there to be. If so, they didn't pull it off. There is nothing in the Constitution that stops Congress from creating a Canadian style healthcare system. Sorry.

[A.I.]

Explain please how the Washington Post can be a "solidly liberal" paper and have Fred Hiatt as editor and Charles Krauthammer as a star columnist.

[lexrex]

kb, your concession, allows the government to expand into just about anything it wants. i would venture to guess that 75% of the government's expansion has happened in the last 50-60 years. what did the pre-roosevelt federal government not know that the post-roosevelt federal government knew?

the founders clearly believed that for the federal government to have the authority to do a thing, a power must be delegated to it. what wasn't delegated to it was recognized as something belonging to the states -- i.e., the 10th amendment. even roosevelt, when he was governor in 1930, recognized that "social welfare" was an area in which the federal government "must not be encouraged to interfere."

if it is as you seem to claim, that there need be no explicit or implicit granting of power via the constitution, then there is nothing the federal government may not do, including forcing people to purchase health insurance.

not quite what madison, jay, and hamilton had in mind, i'm sure. you only need to look at the logical and constitutional twists roosevelt had to make, when defending his new deal programs to see that the founders intended a limited federal government.

madison in federalist 45 said, "The powers delegated by the proposed Constitution to the federal government are few and defined." that means that the federal government does not have unspecified and indefinite powers, but specific and limited ones.

he also said in federalist 41, to those who feard an unlimited, undefined power of the federal government, that if that if it were the case then there would've been no need for the "enumeration of particular powers" in article 1, section 8. he argued that the federal government exercising any power not specifically defined in the constitution would've been an "absurdity."

but, i guess we're all captives of the roosevelt-brandeis era of absurdity.

[KB]

A.I.: Until recently the New York Times had Ben Stein on board. Did that make the NYT's a conservative paper? Having a big name conservative as a columnist makes the paper look more balanced, and fame is fame. Fred Hiatt is the editorial page editor, and he is certainly a fiscal conservative. The editor, Marcus W. Brauchli, was pushed out of the WSJ. So, who did the WaPo endorse in the last Presidential election? Barack Obama, "without reservation." WaPo is solidly liberal. But unlike the NYTs, it's not a rag. It tries to be fair, and points out the obvious.

[FascistSocialist]

Ken, you ignore entire arguments and facts that are inconvenient to you and address the rest with partial truths.

People with end of life plans get better quality, often longer life and cheaper care. End of life plans are GOOD. This is why they are pushed by AARP and being supported in this legislation. Your sinister view point on the subject is backed up by nothing other than your desire to score a point against health care reform.

You continually say that Old people and New technologies are THE CAUSE of the rise of health care costs. You keep going back to this and harping on it every time you write about anything related to health care. This is simply NOT the driving factor, as much as it may play a role for say... Medicare... it is not responsible for the outlandish rises in premiums and cuts in private insurance coverage. In fact, it's counter-intuitive to claim that it is responsible (because of weakening coverage and purging rolls). We know where most of the waste (in this country) is: poor care. (which has very little to do with who insures us)

Please read the following quote from Obama's speech (which the article you were referencing was referencing):
"Now, you know, there have been reports just over the last couple of days of insurance companies making record profits, right now."

Explain how this is incorrect please without simply stating that it is. Were there any reports in the last couple days of insurance companies making record profits? Well, wow, yes in fact there were! As I linked to you. What's incorrect about it? Call me a blowhard...

Plus, I only posted 2 comments in a row... and one was further information I saw after posting my 1st comment, I would hardly consider that spamming. I did consolidate all my responses to one post, as you can see.

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Re: the claim in the 2nd section, you seem to have completely misunderstood or simply not understood what I was saying. Savings can be had without rationing care. Savings can be had without rationing care. Savings can be had without rationing care. Savings can be had without rationing care. Savings can be had without rationing care. Savings can be had without rationing care. Savings can be had without rationing care. Savings can be had without rationing care.

At some level rationing is necessary, I see you agree with that, I already knew you agreed with that. The vast majority of cost savings, however, will not be derived from care rationing. (Less care = More health when Less care = the correct care and More health, in turn, = Less care)

[KB]

FS: yes, savings can be had without rationing care, if by "savings" you mean saving money in some places. Whether such savings will bring down total healthcare costs or even make an appreciable difference is another question. What is driving long term increases in healthcare costs is what I say it is: an aging population and increasingly expensive technology. Virtually everyone on both sides recognizes this, and it is a problem across the board for developed nations.