The Perfect Storm?

A reader, GBK, was kind enough to comment on my blog about Ezekiel Emanuel, MD, PhD.

Ezekiel Emanuel is the brother of Rahm Emanuel, and in an act of apparent nepotism, has been appointed by Obama as a "health care" adviser. Ezekiel is a big proponent of H.R. 3200, the Obama/Pelosi bill. Betsey McCaughey is a political commentator who wrote an article published in the New York Post about Ezekiel Emanuel. GBK issued--along with disparaging remarks about the New York Post and Betsey McCaughey--the following challenge to me:

Here is a JAMA article cited numerous times in [McCaughey's] piece. It's a whole 3 pages, but I think you can handle it. http://www.ipalc.org/Healthcare_Policy/The%20Perfect%20Storm%20of%20Overutilization%20(JAMA%202008).pdf.

The gauntlet having been thus thrown, I took the liberty of reading the JAMA (Journal of the American Medical Association) article, which is co-authored by none other than the archangel Ezekiel Emanuel himself.

Ezekiel attempts to place the blame for the "perfect storm" of American Healthcare on doctors and--get this--patients. Doctors, because they try to do everything they can for their patients, and patients, because they demand the best that hi-tech medical care has to offer. In making the case against our existing system, Ezekiel managed to convince me more than ever that we are better off with what we have than with what the Congress wants us to have. Consider these comments by Ezekiel, which he offers as proof that our system is a failure compared to socialist models:

[Compared with their European Couterparts]
Hospital rooms in the United States offer more privacy,
comfort, and auxiliary services than do hospital rooms
in most other countries. US physicians’ offices are typically
more conveniently located and have parking nearby and more
attractive waiting rooms.


US patients utilize many more “new drugs”—
those on the market 5 years or fewer—than patients in other
countries.


This one is my favorite:


Peer recognition goes to the most thorough and aggressive physicians.
The prudent physician is not deemed particularly competent,
but rather inadequate. This culture is further reinforced
by a unique understanding of professional obligations,
specifically, the Hippocratic Oath’s admonition to “use
my power to help the sick to the best of my ability and judgment”
as an imperative to do everything for the patient regardless
of cost or effect on others.
[emphasis added]


Although most physicians are not income maximizers, they knowthat it is better to be paid to do something, and the higher the payment the better.

[What about members of Congress? Do they know this?]


Then there is the patient side. US patients prefer high technology
over high touch.


In normal markets, demand is modulated by cost. But
third-party payment for patients attenuates this control. Although
patients experience deductibles, co-payments, and
other out-of-pocket expenses, health insurance and gov-
ernment programs significantly shield patients’ decisions from
the true costs of health care.

So, by all means, says Ezekiel, lets expand the insurance system; lets let the government get more and more involved; lets take away financial pressures from patients and doctors entirely and let Congress decide who gets treatment and who does not. That will surely help keep costs under control.

Like I said: I read Ezekiel's own words, and I oppose HR 3200 more than ever.


To see an example of a sensible, understandable plan that the government can undertake to improve health care in this country, see my blog 4 Steps and 3 Sentences to Health Care Reform, 2009 Aug. 23.

Ezekiel 25:17

"I will execute terrible vengeance against them to rebuke them for what they have done. And when I have inflicted my revenge, then they will know that I am the Lord."

And it appears the Lord (Obama) has sent the archangel Ezekiel (Emanuel) to exact vengeance upon those who have (a) spent health care dollars, (b) lived too long, (c) had the audacity to think that they could make deeply personal decisions for themselves, without the help of a government employee or program. Don't believe me? Then read about Ezekiel in Deadly Doctors, by Betsey McCaughey, New York Post, 2009 Aug. 17.

Four Steps and Three Sentences to Health Care Reform

Congress has produced a 2000 page mish-mosh that is supposed to be a plan for health care--pardon me, health insurance--reform. It is an incomprehensible monstrosity. Incomprehensible to me; incomprehensible to Ms. Pelosi; incomprehensible to every member of the House of Representatives; incomprehensible to Harry Reid and Chuck Schumer; incomprehensible to the President. I maintain that there is no one, but no one, who comprehends it. There is no group or committee, or even the Congress as a whole, that comprehends it. They are like "All the King's horses and all the King's men" trying to reassemble Humpty Dumpty when it comes to explaining this legislation. Is it any wonder that most Americans have turned against them?

I, on the other hand, can improve our health care system and save money in four simple steps that would require three sentences of legislation.

Step 1: Tort Reform.

Sentence 1: In malpractice cases, non-economic (aka punitive) damages are capped at $250,000.

Step 2: Equalize tax treatment of health insurance premiums.

Sentence 2: All health insurance premiums (not just for employer sponsored plans) are deductible for federal income tax purposes.

Step 3: National health insurance market.

Sentence 3: Health insurance may be purchased across state lines.

Step 4: Close our borders to illegal immigration.

Sentence 4: None required. This is already an obligation of our government. Indeed, protection of borders in an inherent obligation of any nation, and does not require legislation.

All it requires is for the Congress and the President to man up, to step up to the plate, to grow a pair, if you get my drift.

The rationale for each of these steps is obvious, and does not require explanation for most Americans. If you are a member of Congress and do not understand, please email me with your questions, and I will have my staff, or a student from the local middle school, send you an explanation.

A Failed Health Care System?

The August 19 issue of JAMA, the Journal of the American Medical Association, reported on mortality from heart attack ( acute myocardial infarction, or AMI). The article compared statistics from 2006 with those from 1995. In a span of only eleven years, there has been a 17% reduction in the death rate within 30 days of AMI. These are nationwide figures. Furthermore, there has been a reduction in hospital-to-hospital mortality, as one can see in the above graph: the bell curve on the left, representing 2006 data, is narrower than on the right. This means that the benefits are across the board, trickling down to both genders and all races and ethnicities.

To be sure, the federal government deserves some of the credit, since (a) the data came from Medicare, and (b) Medicare and the Joint Commission for Accreditation of Hospitals (JCAH) were responsible, in part, for imposing certain standards on the hospital and medical community. Nevertheless, these findings do not represent a health care system in distress; and, although health care in this country is expensive, it appears that we are getting what we pay for.

Plain English, a la H.R. 3200

SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

(a) Accurate and Timely Disclosure-
(1) IN GENERAL- A qualified health benefits plan shall comply with standards established by the Commissioner for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner shall require that such disclosure be provided in plain language.
(2) PLAIN LANGUAGE- In this subsection, the term `plain language' means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing.
(3) GUIDANCE- The Commissioner shall develop and issue guidance on best practices of plain language writing.

I wonder if the liars--uh, I mean, lawyers--who wrote H.R. 3200 could follow their own requirement:

From section 122:

(3) MINIMUM ACTUARIAL VALUE-

(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).

Thankfully, the Speaker of the House, Nancy Pelosi, provides a section by section explanation of the bill. Here is the translation of 122 (3) (A):

Defines the initial essential benefit package as being actuarially

equivalent to 70% of the package if there were no cost-sharing imposed.

OK. Now I get it.

Here are some more examples:

SEC. 135. TIMELY PAYMENT OF CLAIMS.
A QHBP offering entity shall comply with the requirements of section 1857(f) of the Social Security Act with respect to a qualified health benefits plan it offers in the same manner an Medicare Advantage organization is required to comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare.

And Pelosi's translation:

Sec. 135. Timely payment of claims. Applies Medicare’s timely payment of claims standards to the plans offering coverage through the Exchange.

SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

...

(2) TREATMENT OF FAMILY- Except as the Commissioner may otherwise provide, members of the same family who are affordable credit eligible individuals shall be treated as a single affordable credit individual eligible for the applicable credit for such a family under this subtitle.

Pelosi's translation:

None provided

SEC. 301. INDIVIDUAL RESPONSIBILITY.
For an individual's responsibility to obtain acceptable coverage, see section 59B of the Internal Revenue Code of 1986 (as added by section 401 of this Act).

Pelosi's translation:

Sec. 301. Individual responsibility. Cross-references the shared responsibility provision in the Internal Revenue Code where an individual has the choice of maintaining acceptable coverage or paying a tax.

SEC. 244. AFFORDABILITY COST-SHARING CREDIT.
(a) In General- The affordability cost-sharing credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in the form of the cost-sharing reduction described in subsection (b) provided under this section for the income tier in which the individual is classified based on the individual's family income.

Pelosi's translation:

Sec. 244. Affordability cost-sharing credit. The affordability cost-sharing credit reduces cost-sharing for individuals and families at or below 133% of poverty up to 400% of the federal poverty limit as specified in the act.

SEC. 245. INCOME DETERMINATIONS.

...

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

Pelosi's translation:

Sec. 245. Income determinations. To determine income, the Health Choices Commissioner uses income data from the individual’s most recent tax return. The federal poverty level applied is the level in effect as of the date of the application. The Commissioner takes such steps as are appropriate to ensure accuracy of determinations and redeterminations to protect program integrity. Processes are established for individuals with significant changes in income to inform the Commissioner of such change. There are penalties for misrepresentation of income. The Commissioner is required to conduct a study examining the feasibility and implication of adjusting the application of the federal poverty level for different geographic areas so as to reflect the variations in the cost-of-living among various areas in the country.

Had enough? There are 1018 pages in this bill; the last section is number 2531. I find what I have read so far to be incomprehensible for the most part, even with Nancy Pelosi's help in understanding it. This is despite the requirement, cited above, for plain language. It is typical of Congress to apply different standards to the rest of us than they apply to themselves.

Can you imagine the challenge for our dauntless congressmen--not the brightest stars in the firmament, for the most part--to try to understand this thing? Unfortunately, their failure to understand it will not stop them from voting for it.