Yet another time bomb in the “stimulus” package, that won’t be debated:
One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Daschle, doctors have to give up autonomy and “learn to operate less like solo practitioners.”
The last entity that I want monitoring my health care is the federal government.
This bill is apparently chock-a-block with stuff like this, each and every one of which should be discussed, debated and if passed, passed on its own merits with its own bill, and has nothing to do with stimulus. This is quite possibly the worst piece of legislation in the nation’s history, and it’s being rushed through with almost no debate, discussion, or even knowledge of its contents by those voting for it. The Founders would weep.
If they vote for the conference product, I hope that Collins, Snowe and Specter all lose their next races, even if they’re replaced by Dems. At least they’ll be honest Dems.
[Early evening update]
(Democrat) Mickey Kaus explains how this bill will roll back, if not completely undo, welfare reform.
This is an excellent idea. The Dartmouth Atlas project has revealed enormous discrepancies between health care practices in different areas, with no basis in science and at great cost in health and dollars. By one estimate, if all doctors and hospitals emulated the practices of their best peers we’d get better healthcare for 30% less money. Reining in health care costs is the key to restraining the growth of entitlement spending, and keeping health care costs from swallowing the rest of the economy.
And as for “won’t be debated” — this was part of Obama’s campaign platform, which was debated for nearly two years!
Seven score and eight years ago, there were some pretty bright Constitutional scholars who had four score and seven years experience with our Constitution. When it came time to write the Confederate Constitution, they made only a handful of changes. (One, of course, was the slavery abomination.)
One of the more interesting was a clause that “Every law, or resolution having the force of law, shall relate to but one subject, and that shall be expressed in the title.”
James Madison missed that one. Dammit.
By whom? All I ever heard about Obama was that he was popular, and … and historic, and… and… and he gives us a thrill up the leg!!! <swoon>
By one estimate, if all doctors and hospitals emulated the practices of their best peers we’d get better healthcare for 30% less money.
Yeah? And what, pray, would be the cost of the coercion and monitoring system necessary to force that emulation? Both in terms of money and in terms of loss of liberty, loss of choice?
There ought to be something like the Second Law of thermodynamics in politics, some observation that a reduction of entropy — chaos, “inefficiency”, et cetera — always requires a free energy (money and/or liberty) cost, to put a stop to this perpetual motion-style foolishness that suggests that “all” we need to do is just “require” this or that sensible behaviour, and, poof, it’ll happen, and we can add the benefit to the plus side of our ledger without having to add any negative cost to the minus side, in defiance of TANSTAAFL and any other rational model of human behaviour.
Hey, here’s an idea, Jim. Property crime costs hundreds of billions of dollars a year. Why don’t we just make it illegal? Imagine the savings!
Also, while we’re at it, the annoying habit of every individual driver on the highway driving his own particular individual speed slows down overall throughput, tremendously so when traffic is heavy. Why don’t we just require everyone to drive exactly the same speed? Problem solved! Imagine the increased throughput on a six-lane interstate when everyone starts driving exactly 65.000 MPH!
People freely choose their major in college, too, and foolishly enough they don’t match it up to the jobs that will need to be filled in four years’ time. Why don’t we just require that everyone entering college pick a major such that the eventual graduates in each field simply match the job openings in each field? Imagine the cost savings, with exactly the right number of doctors and engineers, instead of some annoying stupid surplus of one and deficit of the other.
Isn’t it amazing that earlier generations didn’t think of all these simple, cheap, top-down command regulations of our economy that would make life so much easier? The fools!
…what, pray, would be the cost of the coercion and monitoring system necessary to force that emulation? Both in terms of money and in terms of loss of liberty, loss of choice?
Carl, please.
Jim, like many Democrats, is entirely indifferent to those things, unless they involve the loss of freedom or choice to do things like having overseas conversations with Al Qaeda members.
Choice to kill your fetus? No prob.
Choice to determine your own health treatment, or what school your child will go to? Can’t allow that.
Well, Rand, I’m assuming that Jim is naive, not malign; that, like the audience Hayek addressed in his famous book which you so usefully pointed out, he has become so accustomed to breathing free air that he does not realize it isn’t actually free — that it must be bought and paid for, and the price of liberty is, very often, toleration of the crazy choices of others.
As Hayek so usefully pointed out, well-meaning social planners begin by wishing merely to extend the wisdom exhibited by the few to everyone. If a some people manage to live to old age comfortably merely by choosing not to smoke, eating right, getting their exercise, marrying the right person, buying the right stocks, and making sensible choices with their sensible doctor over the decades — well, why not all? Why continue to let people overeat, smoke, marry partners with whom they’ll merely fight all the time, lose their money in pyramid schemes, and see charlatans and quacks to fix what ails them? It seems so…wasteful, not to mention inhumane and unfeeling.
These are not new thoughts; Hayek thoroughly addressed their dominance among the social planners of the 30s, and brilliantly pointed out how the logical — inevitable — endpoint of their drive was not Annares in The Dispossed, a fictional utopia, but in fact Nazi Germany, the fascist hellhole.
I generally try to use the same cautionary arguments Hayek used, such as:
(1) Remember the problem of defining terms, that one man’s “waste” is another’s “vital investment,” and one man’s “charlatan” is another’s “visionary,” et cetera.
(2) Remember the problem of unintended side effects in a poorly-understood complex system, such as asking yourself what behaviour you will incentivize if you tax the ants to bail out the grasshoppers.
(3) TANSTAAFL. The price of efficiency in any complex machine is rigid conformity and predictability in the behaviour of its components. The choice before you is to be a free man in a messy, badly-coordinated, inefficient society, or to be a programmed worker ant in an efficient, clean, powerful society. There is no third choice except in fantasy free lunch land, where you can always have your cake and eat it too.
What greatly mystifies me is that none of these arguments would be strongly contradicted in the personal lives of any of us. We recognize their force and truth. Everyone, for example, who has experience as head of a household including teenagers or even several housemates recognizes the tradeoff between orderliness and efficiency and someone being a ruthless dictator. Everyone who tries to help a friend with a drug or alcohol problem, or whose choice of mate or career has gone sour, recognizes how difficult it is to know what kind of intervention will have only the intended, good effect, instead of unanticipated and possibly very bad effects.
And yet, somehow when we move from the personal to the global, from dealing with five people we know to 300 million we don’t, we revert to the simplest and most naive notions of our adolescence, when we were sure we could better organize the world by merely sitting down and thinking hard for a while. We forget all the hard practical lessons life has taught us about dealing with other people and become starry-eyed goofballs who see other people as simple chessmen we can move about with ease and confidence. Very strange.
I’m assuming that Jim is naive, not malign; that, like the audience Hayek addressed in his famous book which you so usefully pointed out, he has become so accustomed to breathing free air that he does not realize it isn’t actually free — that it must be bought and paid for, and the price of liberty is, very often, toleration of the crazy choices of others.
Well, you’re a lot more generous than I am with trolls.
First, the bill cited is the 2nd of 7 versions of the bill. Since I haven’t had time to see what the final version says, I shall merely comment on version 2.
Second, the bill (here, section 9202) actually calls for:
1) generation of a report TO CONGRESS with recommendations.
2) EXPLICITLY forbids implementation of technology unless it’s approved.
3) DOES NOT mandate any action by physicians.
What the Bloomberg opinion piece has done is co-mingled a bill directing the development of a plan and Daschle’s book.
In other words, Betsy McCaughey (author of the Bloomberg piece) needs to get her facts straight.
And this is where in reality we lose the universal in universal health care. Universal health care just emphasizes the majority of health care in the general practice areas of out patient and preventative care. The hospital systems themselves often suffer major budget shortfalls in a universal care system. On the general practice side of things you can most definently stretch your dollar per patient costs much further. Not only because the general practice side of health care services more people to amortize those costs but the type of illness and treatment is less specialized as well. It is when you get sick that the specialized equipment and doctors need to intervene and that is when the per patient costs go up dramatically.
So, the answer for some is, just don’t let people get sick with good genera practice and surely the hospital costs will go down. Now everyone just has to cooperate and not get sick. If you don’t cooperate with your general practice guidelines then your likely to get sick and therefore you should be punished for not doing your part for the greater good.
I had always though that insurance was just that, for a rainy day. Not to build pillars a mile high to try and keep the sky from falling.
I think calling these people well meaning it a fallacy. What in fact has happened is there is some number crunching going on again, and the numbers look dismal. Their solution is to limit the health care your mother and father will be authorized to receive under Medicare. The reasoning is simple if mom and dad die sooner their monies can be used to extend the Ponzi scheme that is the Social Security System. They are kicking the can down the road long enough for the baby boomers to die. You will see their handiwork when your loved one enters the system. As Minnie Joycelyn Elders said years ago it is the duty of the elderly to let go. (paraphrase) This is nothing short of genocide.
> And as for “won’t be debated” — this was part of Obama’s campaign platform, which was debated for nearly two years!
I note that this stuff was so ubiquitous that Jim doesn’t bother to provide a link.
There’s a good reason why. Said links usually go to something unrelated or in opposition.
And then there’s the whole “this is a stimulus, not an ordinary spending bill” thing. Health care, of course, belongs in the latter, not the former. That being Obama’s position until someone points out what’s in the bill.
The Obama health care plan (the subject of 20 primary debates, and countless articles) is at:
http://www.barackobama.com/pdf/HealthPlanFull.pdf
According to the HTTP headers that file was last modified October 30, 2007.
It states:
Obama will
establish an independent institute to guide reviews and research on comparative
effectiveness, so that Americans and their doctors will have accurate and
objective information to make the best decisions for their health and well-being.
This should be about as controversial as keeping statistics on traffic accidents. But no, here in loony land it’s evidence of imminent genocide!
What does Barack’s Health Care Plan have to do with a the economic stimulus? If it is a great plan that’s worth while doing, why note put it in a separate bill (preferably its own bill) and let everybody see it?
Ah, Jim. So, you’re OK with selective service registration — because there’s no actual draft? It’s OK for the government to listen in to your phone calls — provided they don’t take notes, and promise not to act on what they learn? It’s OK for the government to review what books are in your library, and publish a list of the recommended Correct Thinking books — because it’s just a suggestion, fer crissake?
Have you thought this carefully through? What will be the response of insurers when they review the list of “best practises?” Suppose the list says breast cancer surgery should be given within 6 weeks of diagnosis. Are they going to say, well gosh, we’ve been in the habit of paying to have it within 2 weeks, so we’re all set. Or will they say, gosh, looks like we can lighten up, extend things out to 6 weeks because the official government report backs us up?
So then your doctor says, shit, you need this surgery right now, but the insurer denies coverage. You appeal — you lose; after all, there’s that government report. How could the government be wrong? So you sue — and you lose, again. How can the government be wrong? WTF do you know?
I know, I know, you have a solution to this problem. If the government advisories are going to be so badly misused, why, there’s no other solution than to stop making them advisory. We need government to just take over these decisions, so there’s no chance of the advisories being misused by naughty private concerns. That is, as always, the solution to the problems government creates is still more government, more coercion.
This is why Hayek called it the road to serfdom. It’s paved with good, noble, kind-hearted intentions. It’s hard to reverse course. Each step seems, as you say, so very reasonable and mild.
What the Bloomberg opinion piece has done is co-mingled a bill directing the development of a plan and Daschle’s book.
Er…what you’ve overlooked, Chris, is that Daschle was Obama’s choice to lead health care reform.
That is, another way to put what you’ve said is that McCaughey observed that what the Obama government has actually put into legislation looks a lot like Step 1 of a plan laid out in a book by their favored leader of health care reform (Daschle), and she then points out what Daschle says Step 2 is going to be.
You think it’s just Chicken-Littleism to warn folks about Step 2, because so far only Step 1 has been enacted? I’m as wary as the next guy about unwarranted paranoia, but this seems a little too placid and trusting.
Carl,
You don’t need hypotheticals. Look at what happened with the Community Reinvestment Act. To Jim, I say there is no such this as a suggestion from the government. See above.
Carl – Daschle’s book is not Obama’s health care plan. Obama’s plan, as noted by Jim, starts with studying how we can provide health care better.
Why studying how to provide health care better would be controversial is beyond me, unless of course there are /cue H. P. Lovecraft/ “things which Man should not know.”
By this slippery slope argument virtually anything the government does is a step towards serfdom. So they shouldn’t inspect meat, because the next thing you know they won’t let you sell meat with e-coli. Oh wait, now they’re doing that too! That must mean that they’re going to start inspecting my fridge to make sure I don’t eat more than 4oz of beef per day — run for the hills!
Giving patients, doctors, and insurance companies more and better information about what actually works is an unambiguously good thing. There has to be a better way to keep the big bad government from infringing on personal health care choices than to insist we remain ignorant of which treatments are effective.
Jim – I came back here to make that argument and see you’ve beaten me to it.
No, not virtually everything the government does, Jim. Just quite a lot. That’s why it’s dangerous stuff, like any powerful drug or explosive or giant standing army, and so forth. Huge concentrations of power are inherently dangerous, like cocked guns, and should be handled with extreme respect.
Should the government collect and publish information? Maybe yes, maybe not. My point is not that it never should. My point is that it is should never be undertaken lightly — and certainly not buried in the middle of some totally different must-pass bill, as if secretly, as if people might object if they saw it. That doesn’t seem like even its proponents are confident it is uncontroversial.
I’m sure you can think of lots of information that you’d prefer the government not gather and publish, even if some of it would be economically useful, if you put your mind to it. For example, it’s certainly possible for the goverment (for a small fraction of the $800 billion or $1.5 trillion or whatever it’s presently flinging about with gay abandon) to run genetic screening tests on every single American, looking for all the little bumps and wiggles in the genetic code that suggest you’ll live long, or not, you’ll get cancer, or not, you’ve a susceptibility to heart disease, or not.
They could put all that information together into a nice database, accessible — of course! — only to authorized people, such as health insurers, physicians….mmm, maybe military recruiters….”vital industry” employers, public-safety agencies, maybe. I’m sure that would generate substantial savings and efficiency in our health-care spending.
I mean, if Kaiser dumps everyone from their rolls who has a genetic predisposition to early heart disease, imagine how much money they’ll save! Indeed, we’ll save money as a society, overall, because those folks won’t get any insurance, and the first time they’ll rack up any medical costs at all is when they present to the ER with their first heart attack. Since about 30% of them will arrive asystole, the only real cost is refrigeration for their morgue slab.
Giving patients, doctors, and insurance companies more and better information about what actually works is an unambiguously good thing.
No doubt. Now, as a homework exercise, go sit down and write out, in one page only, a watertight definition of “what actually works” when it comes to medicine. When you’re done, send it on over to the NIH. They’ll be able to stop these enormous expensive repeated epidemiological trials, and the endless snarly journal debates about the meaning of the results. We’ll all finally agree on what heart-healthy diet “actually works”! No more fat wars!
There has to be a better way to keep the big bad government from infringing on personal health care choices than to insist we remain ignorant of which treatments are effective.
Sigh. Right to the opposite extreme, huh? If government doesn’t do it, it remains undone. Makes me wonder how you can tie your shoes in the morning, given that President Obama is probably too busy to send you a tweet explaining how.
Look, do you not think patients and physicians are extremely interested in “what works”? Do you not think they eagerly seek out such information, and are willing to pay good money for it? Do you not think there exist organizations that earn that money by providing it? Journals, clearing houses, professional organizations? Even, at the extreme, fringe-group websites where crazies gather to swap stories of how thimerasol causes autism, or colon cancer is the result of eating too much processed cheese, or being anal probed by aliens too often?
The difference between these organizations, e.g. between the American Heart Association and CURE magazine on the one hand, and the Federal government on the other, is. first, that they live and die by how well they do their job, as measured by the people who are directly served, the patients and doctors. If the AHA diet guidelines are fraudelent and sucky, and a competing organization gives better ones, the AHA stops earning money and dies. Try getting a government agency that does a sucky job to close up shop.
Furthermore, let us not dismiss the fringe groups, because they may not actually be wrong. At one time the notion of washing your hands before surgery was dismissed as crazy old-woman superstition. In a free system, the cranks have their chance. If, over time, their information, initially dismissed by Professionals and Those Who Know Best, proves to be right — they win, they get bigger, they become influential, by the votes (and dollars) of millions of patients. They don’t have to wait for the Secretary of HHS to make an official decision that the cranks turned out to be right after all.
There’s a role for government in dissemination information, particularly when it comes to information about which people are naturally secretive, e.g. preventing fraud. I would welcome a strong push for the government to publish information about treatment fraud, on which people waste gazillions of dollars. But information about what actually works when it comes to medicine — this is not something anybody conceals. Doctors, patients, medical companies, all are as eager as possible to share this information. There’s no obvious need for government to step in, take over. You might as well argue government should step in and take over the dissemination of information about online porn. Not necessary.
Obama’s plan, as noted by Jim, starts with studying how we can provide health care better.
Yeah? Define “better.” Do you suppose we’re talking about research into whether chemotherapy agent A achieves longer remission than B. Of course not. That’s NIH money, plain old research money. Nothing controversial there.
What they’re talking about is, how can we make health care cheaper, and not cheaper for the people who are actually sick, but cheaper for the rest of us, who are partly subsidizing that care. They’re talking about how I can spend less money paying for your Lipitor, or your wife’s breast cancer surgery. Starting to get a tiny bit worried yet? You sure you want me involved in your family’s treatment decisions? Because that’s where we’re going here.
It sounds like you’ve bought into their fantasy, specially prepared for you, that in today’s world the big driver for expensive care that doesn’t do very much is, oh, I don’t know, some evil cabal of Big Pharma, greedy doctors, and uninsured illegal aliens in ERs. The poor middle-class patients — on which the overwhelming bulk of health care costs are spent — are just dupes. The doc and HMO simply insist they get this Very Expensive Test or Treatment, and what do they know? So they go along.
Along will come the government and tell you hey! you can chill! You don’t need that test, or treatment. It won’t do you any good, and the needles hurt. Whew! you’ll think, and get dressed and go home, happy.
This is not reality. Reality is that the driver for Very Expensive Tests and Treatments is patients It’s the cancer patient whose metastatic disease has stopped responding to treatment who says gee, doc, do I just have to give up? Isn’t there something else we could try? And the doc says, well, the statistics suck for this one new — very expensive — drug used off label, but it probably wouldn’t harm, so…and off we go.
Or it’s the very anxious mom and pop arriving at the ER. Two year old junior just fell down the steps, hit his head, and was knocked unconscious for two seconds. Threw up once, but now he seems fine, if a little cranky and woozy.
The triage nurse suggests they just go home, watch for alarming symptoms, go see the pediatrician in the morning. The kid doesn’t necessarily need to have a head CT, because probably he doesn’t have a brain bleed that will kill him or turn him into a vegetable unless he gets immediate surgery. Do Anxious Mom and Anxious Pop wipe their brows in relief? Whew! Thank God we’re able to save some money! Let’s go home! Or do they frown and kinda insist that junior be put in line for the CT scanner?
Now you can suggest that there be built in some kind of restraint here, that people should not order up the most gold-plated super-cautious, life at any price medical care all the time. But we’ve rejected the obvious solution to that problem, which is to have everyone pay the true cost of their medical care, and let them balance the care against the impact on their wallet, with the best care rationed to those willing to fork out the most money.
So what’s left is government coercion. It’s not going to happen by gentle persuasion, by mere kindly advisories from Uncle Sam. It’s going to happen only by force, by the kind of official NO YOU CAN’T that will have people in psychic agony, because they’re sure the treatment denied to Aunt Carol could have cured her, given her an extra year, reduced her pain, whatever. And, the limitations of human intelligence being what they are, they’ll be right, in many cases.
That’s the road the Obama people, including Daschle, want to go down. We’ll see how many follow them, and whether they do it with eyes open, or with sugar plums dancing around their bedazzled eyes.
Carl:
On the one hand you say that doctors and patients already have a burning desire to know what works, and so the government doesn’t need to systematically collect that information. On the other hand you’re certain that doctors and patients won’t actually do what works without the government forcing them to. That’s a strange mental model for how the world works.
This effort is the latest step in decades of research. One of the pioneers of the field recently retired; here’s a profile that gives some background:
http://dartmed.dartmouth.edu/winter07/html/braveheart.php
There is resistance to doctors, nurses and hospitals changing the way they do things. Not because they’re evil, but because they learned to do things that way for good reasons, and there’s a natural resistance to change, especially when it’s demanded by some outside agent who can be dismissed as not really understanding “the way we do things here.” But the result is things like decades going by with millions of children getting their tonsils removed for no valid medical reason.
To overcome that resistance to change you need well-done research that is well-funded and disseminated with credibility. You can’t count on the drug companies or medical device companies to do it — they won’t typically publish research that doesn’t support use of their products. You can’t count on doctors and hospitals — who wants to cooperate with a study that might conclude that one’s competitors are doing a better job? And the American Heart Association? We should rely on hundreds of separate, under-funded, disease-specific charities — charities with strong ties to drug-makers and researchers in their fields?
All your reasons for not having the government do this apply equally well to not having the government inspect meat.
They way I see it is that either we end up with this body rigidly enforcing a planned directive for all health care providers to follow. In which case your lucky if your needs are met by what is perceived to be the right and necessary course of medical treatment. Otherwise, falling outside of this area of planned health care your left paying out of pocket.
Or, this review body will spend all this time and money “investigating” the current state of health care only to come back sometime later and say, “Everything looks good” and shrugs their shoulders. At which we are then left wondering, could this possible be the most expensive ‘thumbs up’ ever purchased in the history of man.
Per this article:
“The National Coordinator of Health Information Technology [agency referenced in the article] is not a new bureaucracy created in the stimulus. Bush signed it into office in 2004.”
The National Coordinator of Health Information has no regulatory authority to control treatment. Their mission is:
“helping the private sector move your medical records from manila envelopes to computers, and trying to help the private sector settle on a single standard so the records can be shared among different providers. That way, if you have an emergency and are taken by ambulance to the hospital, your primary care doctors can e-mail them your information immediately so you don’t die from a drug allergy they didn’t know about.”
Also, “As for McCaughey’s broader claim, nothing in the bill, nor in the structure of the federal government, gives the Secretary of Health and Human Services the capacity, funding, authority, or mandate to monitor the medical profession’s treatment decisions and decide if they’re appropriate. “
Oh, right, Chris, a spin-doctor for the other side says don’t worry, there’s nothing to see here, move along. Now I feel better! Goodness, how naive is your target audience? Are they the kind who feel that if it’s called the “Department of Defense” it can certainly never be used to wage aggressive war? Or that because it’s called a “tax cut” it can’t actually be a welfare payment? Or that a “Fairness Doctrine” can’t, by definition, ever be unfair?
The rule in military planning is you watch what the enemy does and what is in his interest and what his capabilities are. You most certainly don’t simply take his assurances of his benevolent intentions at face value.
There’s zero doubt that the long-term intentions of this crowd are nationalized health care, with the Feds calling all the shots. So a good default response, if you don’t like that end, is to simply assume that anything they propose, and certainly anything they try to sneak into a massive must-pass unrelated spending bill, is heading in that direction, whatever bland assurances they might pass out to pacify the gullible.
Does that mean one opposes everything that has anything to do with medical care, if it’s proposed by Democrats? Well, that’s not a bad action guide, if you don’t have time to do better. But if you do, then, sure, if there’s some strongly compelling necessity for a measure proposed by national health care zealots, and you’re sure it’s harmless, then it could be supported.
This measure fails all of those tests, so far as I can see. It’s not necessary, it’s certainly conceivably related to making nationalized health care closer, and one can readily imagine all kinds of unintended harm, depending on how it’s implemented. So, thumbs down.
If the Democrats want to be trusted a bit more on health care, at least by those of us who loathe nationalized health care like we loathe cancer and leprosy, and for much the same reasons, then they can passionately denounce nationalized health care, and start acting like they despise it. Then I’d trust them, a bit, maybe. At least as far as I ever trust lawyers.
Carl Pham – sorry, but I have chosen not to deal with your irrational paranoia.