Federal Judge Rules Individual Mandate Unconstitutional

U.S. District Judge Henry E. Hudson ruled today that the individual mandate of the ACA (a.k.a. ObamaCare) is unconstitutional.

“Neither the Supreme Court nor any federal circuit court of appeals has extended Commerce Clause powers to compel an individual to involuntarily enter the stream of commerce by purchasing a commodity in the private market. In doing so, enactment of the (individual mandate) exceeds the Commerce Clause powers vested in Congress.” from newsok.com

I have previously read that due to the lack of a severablity clause, if any part of the law is ruled unconstitutional, the whole bill will have to be thrown out. Unfortunately, it turns out to be more complicated than that.

Here is the best explanation I have yet come across:

A Guide to Severability and ObamaCare

[T]he lack of a severability clause wouldn’t necessarily result in the overrule the rest of the legislation, which mostly have to do with spending and rationing — the expansion of Medicaid, Medicare cuts, and sweeping regulatory authority — and isn’t wrapped up in the mandate. This has been the Court’s approach to other issues, such as the recent Sarbanes-Oxley ruling, another law which lacked a severability clause, where they invalidated a portion of the law and allowed the rest to stand.

Some proponents of the ACA believe that the health of the individual mandate would move us closer to implementing a single payer system. (See Ezra Klein's article in today's Washington Post.) The danger of this is only too real.

The best way to prevent that from happening is to continue to speak out against ObamaCare as a whole.

Even a Supreme Court ruling that the individual mandate is unconstitutional will not save us from the multitude of other violations of life, liberty and property intimately woven throughout the ACA.

Preservation health care freedom and the sanctity of the doctor-patient relationship requires the complete REPEAL of the ACA, and the extraction of government from the business and practice of medicine.

For more analysis on today's reading see:

Individual Mandate in Heath Reform Law Ruled Unconstitutional by Federal Judge on Medscape.com

ObamaCare Is Unconstitutional by Grace-Marie Turner

Full Text of the Opinion

Health Reform Will Survive it Legal Fight by Eric H0lder and Kathleen Sebelius

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Debt Reduction and Health Care Freedom

Two for the price of one.

With the national debt rising to dangerous levels, serious cuts to government spending are paramount. President Obama’s debt commission has made some interesting recommendations–but even better are the following proposals…

Read more here.

Regulations and Arbitrary Rule

Last month, federal officials granted dozens of one-year waivers that were aimed at sparing certain employers, including McDonald’s, insurers and unions who offer plans that sharply limit the coverage they provide...

Concerned about the potential disruption that would be created by enforcing the new rules, the administration has granted dozens of additional waivers and also made clear that it would modify other rules affecting these policies. Last week, the Department of Health and Human Services issued more guidance, saying it would use a different method of calculating spending for these plans so they would be able to meet new regulations dictating how insurers should use the premium dollars they collect. NYT 11/9/10

This is what was meant when Speaker Pelosi infamously informed us "We have to pass the bill so we can see what is in it." So many details have been left up to regulatory rule making, even if Congressmen had read the bill, there would be no way to know its actual meaning. Far too much was left up to the discretion of yet-to-be-created agencies, and the Secretary of HHS.

And that is the way it has to be. It is the nature of central planning.

Command and control economic planning can not function through legislating. Legislative reaction time is too slow and the decision making process to cumbersome and contentious. The only way to allow for the necessary responsiveness and flexibilit is to delegate a significant portion of the decision making power to regulatory agencies. The broader the regulatory mandate, the more the decisions become sway to special interests and the arbitrary whims of the regulators and rule-makers.

One of the first casualties of regulation is Rule by Law--which is replaced with Rule by Men. The second casualty is usually Equality Before the Law--which is replaced with Rule by Special Favor. This is the nature of central planning, and of the regulatory behemoth which it spawns. Everybody has to follow the rules...except those who Sebelius decides to let off the hook.

Special waivers are now up to 111.

UpDate: Here is the current waiver list.

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White House Healthcare Stories Ignore Hazlitt's Lesson

The ink is barely dry. The electrons have barely been tallied. The lessons of the election have yet to be learned.

Yet, the White House continues blindly down the path of promoting its unwanted, hopelessly flawed health care law by committing the economic fallacy of ignoring what is unseen. (But I guess that goes hand-in-hand with being blind.)

Today I received the following in an email from Nancy-Ann DeParle, director of the Office of Health Reform:

Health Care Updates

Health care is an issue that’s important to all of us and the new health care law is already helping Americans across the country. Visit the 50 States/50 Stories map to find stories of how the new law is affecting people in your area -- people like Jim Houser, who will be receiving a small business tax credit that will enable him to continue providing health insurance to his employees or Adrienne Lowe who can now stay on her parents’ plan after graduating from college. You can also watch as the President makes a surprise phone call to Gail O’Brien who was without insurance when she was diagnosed with lymphoma and has been able to get coverage through the newly established Pre-Existing Condition Insurance Plan.

These are just a few of the examples of Americans who are benefitting from the Affordable Care Act. Across the nation, the new law is making health care better for millions of Americans.

The Fifty Stories are only the tip of the ice berg--and unless Obama et al start paying attention to what lies below the surface, our country's finances and health care are headed for the same fate as the Titanic.

What is NOT mentioned, of course, are all the jobs which will NOT be created because labor costs will be too high due to the tax and regulatory burdens the law places on employers and businesses.

Or the medical devices, medicines and cures that will NOT be invented.

Or the aspiring young adults who will NOT choose medicine as a career because of decreasing incomes and job satisfaction---caused by government price fixing, paperwork and billing hassles, --to say nothing of the repeated vilification of physicians as greedy and incompetent (in need of ever more practice guidelines and government oversight.)

Or employers who respond to the law's strong financial incentives to drop health insurance coverage for their employees.

Also not mentioned are the number of insurance companies which must either discontinue significant benefits, (unless they get a waiver) raise premiums or go out of business due to the PPACA.

So don't be fooled when the White House tells stories.

Be sure you understand the lesson that Obama, DeParles and the rest of the White House gang either refuse to understand, or worse, understand but choose to ignore:

This is the persistent tendency of men to see only the immediate effects of a given policy, or its effects only on a special group, and to neglect to inquire what the long-run effects of that policy will be not only on that special group but on all groups. It is the fallacy of overlooking the secondary consequences.

In this lies the whole difference between good economics [or politics] and bad. The bad economist [or politician] sees only what immediately strikes the eye; the good economist looks beyond. the bad economist sees only the direct consequences of a proposed course; the good economist looks also at the longer and indirect consequences. The bad economist sees only what the effect of a given policy has been or will be on one particular group; the good economist inquires also what the effect of the policy will be on all groups.

The distinction may seem obvious...Yet when we enter the filed of public economics, these elementary truths are ignored."

--Henry Hazlitt, Economics in One Lesson

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Health Care Rights and Wrongs

For Patient Autonomy: Repeal ObamaCare

Dr. Alieta Eck of AAPS, and Drs. Pegg, Hansen and Lovett of Docs4PstientCare assisted the Independant Womens Forum in making this commercial prompting voters to ask their candidates to pledge to repeal ObamaCare if elected.

Listen carefully to their message, because it gets right to the heart of the matter: ObamaCare takes control away from patients and doctors and gives it to government bureaucrats. The PPACA may be primarily insurance reform, but whoever controls insurance, controls the payment for medical care and will eventually have to control what gets paid for. That means deciding what your treatment options will be.

The solution?

Repeal ObamaCare.

Restore choice and accountability--for patients, doctors, hospitals and insurance companies.

In a free country, we all have our part to play.

Then, to make sure we don't simply go back to the problems which prompted health care reform, the next steps include:

1. End government policies which give preferential tax treatment to employer-based insurance with first-dollar coverage. Instead, all medical expenditures must have the same tax advantage or disadvantage. This will increase the availability of insurance for individuals, and insurance portability for everyone.

2. Allow insurance companies to complete across state lines. Insurance companies from states with the least intrusive regulations are already less expensive than those in heavily regulated states, so prices for insurance will rapidly drop. (For an Oct. 2010 report on health insurance mandates by state, see here.)

3. Remove legal limits and hindrances to purchasing catastrophic health care combined with a Heathcare Savings Accounts so people can more easily take advantage of this form of insurance which has repeatedly demonstrated its superiority in lowering health care spending and maintaining patient satisfaction. A significant part of the cost problem in health care relates to the perverse incentives which occur in a third-party payer system.

4. Allow balance billing for Medicare to end the massive amount of cost-shifting doctors and hospitals have to do in order to make up for the inadequate payments they receive from the government. When doctors are able see Medicare patients without losing money, the doctor shortage for Medicare patients will disappear.

5. Encourage states to enact real tort reform. Defensive medicine increases testing and procedures and drives up costs.

But first, we have to repeal ObamaCare.

Take the Pledge.

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ACOs Threaten Quality Medical Care

The PPACA is "nudging" doctors out of independent practice and into working as employees of large practice groups or hospitals. This move is occurring because of the bundled payment structure of Accountable Care Organizations (ACOs) which favors "vertical integration" of doctors, hospitals and health plans.

The only problem is that bundled payments are simply capitation rewritten, and employee physicians face divided loyalties between the needs of their employers and the desires/needs of their patients.

This arrangement is especially insidious when coupled with the ethics of "social justice" which gives a physician the moral OK to sacrifice his patients to the "greater good" of society. What is good medicine for the masses is often at direct odds with what is good for the individual patient--and thus, quality medical care suffers.

Resources:

For more on the PPACA effects on private practices see "Killing Marcus Welby: How ObamaCare stifles private practices" by Scott Gottlieb, MD, NY Post 10/18/100

For more on problems with the underlying assumptions for ACO's see "On Being Politically Incorrect and Realistically Correct about ACOs" by Richard Reece, MD at Medinnovation, 10/7/10

For more on the destructive effects of the concept of "Social Justice" on the availability of quality medical care, see Dr. Rich Fogoros at The Covert Rationing Blog.(multiple posts)

See also:'"Deconstructing ACOs" by John Goodman at John Goodman's Health Policy Blog, 8/18/10

September BRP Update

A lot has been happening with the Black Ribbon Project and an update of developments is long over due.

Over 1000 ribbons have been distributed, with orders pending for several hundred more.

Bumper stickers with 3 different slogans are now available to donors upon request.

One BRP supporter was using a Post-It note to send a short message to her doctors. Included with every bill she paid was a note saying “Thank you. Health care is not a right.” To make the task easier, and to spread the word about the BRP, we designed the pre-printed pads shown below. The pads have 50 pages each and are also available to donors upon request.

A new tri-fold pamphlet is almost complete. The pamphlet introduces the Project and offers suggestions on how the Black Ribbons can be used to focus attention on the fact that quality medical care requires freedom of choice. If you are interested in receiving pamphlets to hand out, email your request to BlackRibbonProject@gmail.com.

Here's a preview of the pamphlet (click to enlarge):

This month, I have had several opportunities to promote the Black Ribbon Project.

At a fund raising diner for John Dennis (running for Congress against Nancy Pelosi) I met the leaders of several organizations who support the repeal of ObamaCare.

Last week, I presented The Black Ribbon Project to the 67th annual meeting of the Association of Physicians and Surgeons. My talk was well received and I was able to distribute many ribbons and almost 20 bumper stickers. In addition, the board of AAPS voted to send a Black Ribbon and business card to each of their new members.

This coming weekend, I'll be in Washington DC at a conference of the American College of Surgeons to help staff an informational booth for Docs4PatientCare --which will include pamphlets, pins and other materials from the BRP. ACS has officially announced its opposition to the new health care control law, so I'm expecting a warm reception. I'll also participate in a special physician's forum on the impact of the Accountable Care Act (a.k.a ObamaCare) organized by D4PC and the Heritage Foundation. I look forward to meeting the leadership of D4PC, who have been enthusiastic supporters of the BRP. Docs4PatientCare will also be sending a Black Ribbon to each new member of their organization.

In addition to the above, I have mailed letters of appreciation accompanied by a complimentary Ribbon to several physicians who are speaking and writing in defense of health care freedom. Recipients include the following:

Dr. Lee Hieb, practicing orthopedic surgeon, President for AAPS, author of article in Human Events 10/08/08 “No Barak, Medical Care is NOT a Right.”

Dr. Jack Cassell, practicing urologist, famous for the sign he put on his office door after passage of ObamaCare

Dr. Milton Wolf, practicing radiologist and cousin of President Obama who is speaking out against ObamaCare; blogs at The Wolf Files

Dr. Marcy Zwelling, practicing internist, for participating in a panel discussion at Stanford University: “The Federal Government or Free Market: Which Can Offer the Most Compassionate and Effective Health-Care Plan for America?”

Dr. Reed Wilson, practicing cardiologist, for participating in a panel discussion at Stanford University: “The Federal Government or Free Market: Which Can Offer the Most Compassionate and Effective Health-Care Plan for America?”

Dr. Jane Orient, practicing internist and managing editor J Am Phys Sur, for her multiple articles and speeches promoting private medicine and the Hippocratic Oath. Latest article: “ObamaCare”: What Is in It”

Dr. Saul Greenfield, practicing pediatric urologist, for his 09/07/10 WSJ Op-Ed, “In Defense of Physician Autonomy.”

If you have suggestions for individuals you think deserve a letter of appreciation, please pass them along either in the comments or by email.

It's a been a busy month---and I am looking forward to October being even busier!!

Beth Haynes, MD

The Real Reason Medical Costs Are Rising

If a doctor misdiagnoses the cause of a symptom, his treatment will not help and will likely make things worse.

If a President misdiagnoses the cause of rising health care costs, his solutions will not help, and will likely make things worse.

This is the situation we currently have with ObamaCare.

The new health care control laws are constructed on the belief that the large numbers of uninsured along with profit-driven behaviors of hospitals, doctors and insurance companies are the cause of run-away spending and cost increases. For these reasons, the new law concentrates its efforts on mandating insurance coverage and increasing government control over the private medical decisions made between patient and physician. Attempting to increase access, the law lowers or eliminates a patient's out-of-pocket payments, increases mandated benefits by third parties (both governmental and private) while simultaneously reducing payments to doctors and hospitals.

This analysis has it exactly wrong.

The numbers of uninsured are the result not the cause of rising costs. Patients are insulated from the cost consequences of their medical care while doctors, hospitals and insurance companies are blocked from competing on price and quality. This hinders innovation and interrupts the normal market signals to increase supply and decrease cost.

The REAL cause of spiraling health care costs is our current third-party payment system and the consequent economic separation of consumer from payer (and of effort from reward.) This disconnect is enhanced under ObamaCare. In "The Prognosis for National Health Insurance," Dr. Arthur Laffer (of Laffer Curve* fame) refers to this separation as "the health care wedge."

"The health care wedge is one way of thinking about government involvement in the economy. When the government or a third party spends money on health care, the patient is not. The patient is then separated from the transaction in the sense that the costs are no longer his concern. This separation--how far the supplier and consumers are separated from one an another--is what the economic wedge is measuring."**

Multiple segments of the new health control law aggravate this wedge: removal of co-pays, caps on the portion of premiums paid by the insured, government subsidies, price controls on provider payments, mandated benefits, and much more.

On the consumer side of the market, the wedge diminishes consumers' incentives to monitor costs...On the supplier side, doctors and other medical providers receive no incentive to provide higher quality services for less cost.

President Obama has no excuse for failing to grasp this vital connection. His Council of Economic Advisors stated in their June 2009 report, "The Economic Case for Health Reform":

There is well documented evidence that individuals respond to lower cost-sharing by using more care, as well as more expensive care, when they do not face the full price of their decisions at the point of utilization.

Americans have progressively been paying less and less of the costs of their personal medical care. In 1960, patients directly paid for almost 50% of their medical care. Today, out-of-pocket payments for patients in the private sector are only slightly more than 10% of the total cost for the medical care they receive.

"Accelerated medical inflation, consequently, is strongly correlated with a growing separation (wedge) in the medical market between doctors and patients."

What are the forces which cause this "wedge"? The primary forces are government actions themselves: rising government expenditures on health care, insurance mandates and regulations which favor third-party payment systems and "protect" patients from the financial consequences of their actions, cost-shifting due to medical welfare and entitlements programs, price controls integral to Medicare and Medicaid, to name just a few.

But it is not just the cost of medical care which is affected.

In the case of health care, the wedge also separates patients from doctors in determining what type of care should be provided. Decisions are made by government, insurers, and judges deciding medical malpractice liabilities.The government, lawyer, and third-party wedge in our current health care system causes [both] higher costs and diminished efficiency.

Additionally, as health care costs rise and government increasingly foots the bill, the damaging effects spill over into the wider economy leading to slower economic growth, rising tax burdens, as well as lower wages and standards of living.

The acceleration in health care costs needs to be brought under control. Because Obama has misdiagnosed the cause, the measures enacted in the new health care control law push us in exactly the wrong direction. ObamaCare increases the health care wedge, bolstering incentives to consume medical goods and services without the ability, let alone the requirement, to consider cost, efficiency or quality.

Laffer concludes this excellent article with a list of suggestions for a patient-centered health care reform which would remove the artificial and destructive incentives government currently has in place and "empower the patient and doctor to make effective and economical health policy choices":

1.Remove the tax advantage for employer-based health insurance by giving the tax deduction to individuals

2. Remove limits and disincentives on Health Savings Accounts

3. Allow interstate purchasing of insurance

4. Reduce [or preferably eliminate] mandated benefits that insurers must cover

5. Eliminate unnecessary scope-of-practice laws to allow non-physician health professionals practice to the extent of their education an d training

6. Reform tort liability laws.

Although written before the final passage of the health control law, this article provides an excellent analysis of the economic and governmental forces which created our current situation and explains how Obama's policies will only make things worse. I encourage you to read the whole 24 page paper.

Government has much to gain by following this key principle of medical ethics:

First do no harm.

*For a more humorous explanation of the Laffer Curve, you may enjoy watching this video clip by San Jose State University student, Gregory Downs, one of a series of ShortHand Politics clips he is producing to try and engage college students in economic ideas.

**All quotes are taken from Laffer's article.

The ACA is destroying independent medicine

A few months ago, I had dinner with a couple from Pennsylvania. Knowing the husband was a physician, I asked what type of medicine he practiced.

He replied, "I am a dinosaur. Something that hardly exists anymore: a family practice doctor in solo practice."

In addition to being a primary care physician in a small town, he is a small business owner, doing his best to survive in an era of increasing government demands both on his business and on his practice of medicine. Solo and small group practice is becoming less and less financially viable within the third-party payer system.

For years, this doctor saw many Medicaid patients, willingly accepting payment less than his cost of providing care because of his loyalty to these individuals and his interest in offering charity care. Recently, he regretfully had to inform these patients he would no longer be able to be their doctor. Not because of the inadequate "reimbursement," but because of the onerous and expensive regulations Medicaid required. He provided the following example:

In order to provide immunizations for children on Medicaid, he could not simply have a special shelf in his office refrigerator. Medicaid required he purchase an entirely separate refrigerator in which to store the shots. This was in addition to reams of paperwork accounting for the purchase and use of the immunizations for Medicaid recipients.

Squeezed between falling payments and rising costs, the solo and small group practice of medicine is indeed endangered. More and more physicians are flocking to large group practices, frequently as employees. Maybe this is a good thing. But maybe not. However, patient demand is not the driver of this change, but rather the increasingly expensive government mandates placed upon the practice of medicine.

Dr. Richard Reece, physician, author, and health care policy commentator, has a recent blog post on the effect of the ACA on physician employment. He summarizes the findings of a recent survey, "Physician Alignment in an Era of Change."

• 74% [of hospital CEOs] plan to employ a greater percentage of physicians over the next 12 to 36 months.
• More than 70% say they have received increases in requests [from] physician groups for employment.

He concludes the post stating:

I spoke to John McDaniel, founder and CEO of Peak Performance Physicians, a practice management firm in New Orleans, and he pointed out to me that what’s driving hospital physician employment is not only anticipation of lower reimbursements under reform but the mounting costs and complexities of doing business.

Complexity per se is not the problem doctors are currently facing. Medicine and business are replete with complex problems which must be faced and dealt with on a daily basis. The problem is that far too much of the complexities doctors must deal with are the constantly shifting mandates and regulations which substitute the plans and values of the politically powerful for the plans and values of patients working privately in conjunction with their doctors.

Will the system of employee-physicians that is emerging be superior to the independent private practice of medicine? It depends on your criteria for judging.

If the goal is to meet the individual medical needs of patients according to their personal priorities, offered on a voluntary basis by physicians whose primary focus is the welfare of the patients he treats, then the ACA pushes us in exactly the wrong direction.

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In Defense of Physician Autonomy

Dr. Saul Greenfield, pediatric urologist and professor of medicine, wrote in the Sept. 7, 2010 WSJ:

In recent political debates, the autonomous physician has been portrayed as a problem to be solved, an out-of-control actor motivated by greed---and a major cause of rising health-care costs...

Physician autonomy is a major defense against those who comfortably sit in remote offices and make calculations based ont concerns other than an individual patient's welfare. Uniformity of practice is a nonsensical goal that fails to allow for differing expression of disease states.

this is not to say that critical research, randomized controlled trials, literature meta-analysis an guidelines are not necessary and useful. They are all essential...But we must recognize that many physicians will often make decisions that deliberately do not conform to "community standards"---and that patients will be better for it.

Dr. Greenfield correctly points out that quality medical care consists of physicians applying their independent assessments to the unique circumstances of each individual patient. Without autonomy, this goal can not be achieved.

Read the rest of what he writes "In Defense of Physician Autonomy."

ACA intentionally undermines the Doctor-Patient relationship

The new healthcare law has multiple provisions which disrupt individualized decision-making between the physician and patient. This is no accident. It is by concerted design.

Dr. Donald Berwick, the new head of CMS, wrote the following on the doctor-patient relationship:

“Today, this isolated relationship is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized, individualized decision making.” (emphasis added)

from New Rules, by Donald Berwick

Dr. Zeke Emmanuel and Nancy DeParle want and expect the new law eliminate solo and small group practices. Along with Dr. Robert Kocher, they wrote the following in an article in the August 23, 2010 issue of the Annals of Internal Medicine:

"To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put into motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups...

The health care system will evolve into 1 of 2 forms: organized around hospitals or organized around physician groups...Only hospitals or health plans can afford to make the necessary investments in technology and management skills."

Other revealing quotes from Dr. Berwick include:

"I can not believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for the leaders to do."

and

"I would place commitment to excellence--standardization to the best-known method--above clinician autonomy as a rule for care."

These health care policy makers believe the source of our health care problems stem from the autonomous decisions made by the private doctor-patient team, working together in the best interest of the individual patient.

They are wrong.

They have forgotten that the best interest of the individual patient is the purpose and standard of medicine--both morally and practically. The health of the nation depends on the sum of the health care provided to individuals. Nothing more or less.

Medicine for the masses is meaningless if the lives and health of individuals are sacrificed to the "common good."

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UPDATE 9/28/2010:

Worthwhile related posts at Retired Doc's Thoughts:

Physician fiduciary duty-a thing of the past?

Crisis in medical professionalism

What is the fate of the doctor-patient relationship in a Donald Berwick designed health care system?

Socialized insurance IS socialized medicine

“Socialized insurance necessarily leads to socialized medicine, and if the government controls well over half of the insurance sector through Medicare and Medicaid, and tightly regulates the rest, it is only inevitable that it will also seek to control how health care is bought and sold.”

— David Dranove on ObamaCare, at The Health Care Blog

The more the government controls health care delivery, the more it will have to control medical decisions themselves, which means less control for is left to individual doctors and patients.

Proponents of the ACA continue to claim that it is NOT "socialized medicine." The desire to distance the law from this term is because it is well known that socialized medicine does notimprove quality and access and does reduce individual freedom. Tthe essence of socialized medicine is centralized government control for the purpose of creating material equality by taking from some to provide for others--and that is exactly what the new law is designed to do.

Let's call it "socialized medicine"---because that's exactly what it is.

HT John Goodman's Health Policy Blog.

A Letter to all who are Patients

Thousands of physicians will be distributing the following letter to their patients in the next few months and weeks. Speaking up about the detrimental effects of the new healthcare control law is becoming an important part of attending to the health and welfare of patients.

To My Patients,

Section 1311 of the new health care legislation gives the US Secretary of Health and Human Services and her appointees the power to establish care guidelines that your doctor must abide by or face penalties and fines. In making doctors answerable in the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions. This new law politicizes medicine and in my opinion destroys the sanctity of the doctor-patient relationship that makes the American health care system the best in the world.

In addition to also badly exacerbating the current doctor short age, the law will bring major cost increases, rising insur ance premiums, higher taxes, a decline in new medical techniques, a fall-off in the development of miracle drugs as well as rationing by government panels and bureaucrats like passionate rationing advocate Donald Berwick forcing delays of months or sometimes years for hospitalization or surgery. Finally, studies show the legislation will adversely affect the elderly, the poor and rural residents.

Despite countless protests by doctors and overwhelming public opposition -- up to 60% of Americans opposed this bill -- the current party in control of Congress pushed this bill through with legal bribes and Chicago-style threats and is determined now to resist any “repeal and replace” efforts. This doctor’s office is non-partisan -- always has been, always will be.

But the fact is that every Republican voted against this bad bill while the Democratic Party leadership and the White House completely dismissed the will of the people in ruthlessly pushing through this legislation. In the face of voter anger some Democratic candidates are now trying to make a cosmetic retreat, calling for minor modifications or pret ending they are opposed to government-run medicine. Once the election is over, however, they will vote with their party bosses against repealing this bill. Please remember when you vote this November that unless the Democratic party receives a strong negative message about this power grab our health care system will never be fixed and the doctor patient relationship will be ruined forever.

I will be glad to discuss this with you at the end of our consultation.

Your Doctor

A message in consultation with Docs4PatientCare - a 501(c)6 national organization of of concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship, promotes quality of care, supports affordable access to all Americans, and protects patients’ personal health care decisions. Learn more online at www.Docs4PatientCare.org

Good Medicine Requires Freedom

Autonomy--one of the pillars of individual rights--is also a central principle of biomedical ethics and an essential ingredient of the doctor-patient relationship. Doctor and patient form a partnership of autonomous individuals--united in the goal of promoting the patient's health.

Autonomy includes the freedom to choose who your doctor is, and how you will pay for the doctor's services. The new health care control law (PPACA) severely reduces our autonomy by restricting the choice of payment methods to those pre-approved by government.

Efforts are on-going in multiple states to preserve freedom of choice in health care by resisting the federal mandate to purchase health insurance. In addition to a number of Health Care Freedom Initiatives (both legislative and ballot initiative,) many state attorneys general have filed lawsuits questioning the mandate's constitutionality.

Colorado has an interesting approach, which you can learn about through the links provided by Dr. Paul Hsieh at Freedom and Individual Rights in Medicine. Although federal law trumps state laws, states are not without power against the federal government. Read more here, and here, and here.

Good medicine is not simply a set of pre-defined protocols. Decisions must ultimately be made according to each individual's unique circumstances and values. Doctors must be free to advise patients of the full range of options--and patients must be free to choose.

UPDATE 8-21-10: as of May, 2010, 20 states had filed suit.

Social Justice and Medical Ethics

The AMA is actively working in conjunction with Association of American Medical Colleges to inculcate young physicians with the ethics of "social justice."

Since 2005, the "Initiative to Transform Medical Education" has been working to correct what it views as deficiencies in the current training of physicians. These include an over-emphasis on the ability to acquire knowledge and problem solve-- to the detriment of "caring." Traditionally, physicians have expected to be autonomous decision-makers--but according to the Initiative this clashes with "increasing requirements...to be more accountable to various constituencies, including...the public, payers and government." Although physicians are recognized as "prepared to do what they believe is best for individual patients... [t]hey are not...prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless." The solution proposed for allocating finite resources is John Rawls' principle of social or "distributive" justice.

"Social justice" is a euphemism for economic egalitarianism--and since people do not naturally come by equal wealth, "social justice" requires taking from some to give to others. "Social justice" is thus in direct conflict with the principles of equality before the law and the individual right to private property. "Social justice" also requires that a physician NOT advise his patients solely based on what is in the patients own best interest. He must instead somehow "balance" the patient's interests with those of the rest of society.

The concept of "social justice" has now been incorporated into several official statements of medical ethics. The Physician's Charter of the American College of Physicians now states:

[C]onsiderations of justice must inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate. More than ever, concerns about justice challenge the traditional role of physician as patient advocate.

The Council of Medical Specialty Societies ethics statement includes the following:

The ethic of medicine must seek to balance the physicians' responsibility to each patient and the professional, collective obligation to all who need medical care.

Not only is this new ethic altering the curricula of medical schools to emphasize "social justice," but admission requirements will also be changed--deemphasizing a background in the sciences and MCAT scores. It is hoped that the selection of more "altruistic" and less competitively driven applicants will result in a larger number of residents opting for a less prestigious and less remunerative career in primary care.

This shift away from academic excellence and autonomy in the doctor-patient relationship toward serving the needs of society follows directly from centuries of medical ethics disavowing the legitimacy of physician self-interest. This error is compounded by a claim of moral superiority because "medicine is a profession not a business."

The distancing of medicine from business has done both a disservice. In claiming to be primarily an altruistic service, physicians have essentially invited the government to enforce this ideal while simultaneously denigrating the honorable occupations of production and trade. In failing to understand and defend the morality of profits, and the harmony of self-interest which characterize voluntary economic transactions, doctors have aided the enemies of freedom and capitalism-- who are now designing medical school curricula and admission requirements.

Capitalism is nothing more than the individual rights of life, liberty and property as applied to trade. Profits, in medicine as in any economic transaction, are not gained by exploiting patients or customers. Profits are simply the proper reward for successfully offering a value to others which is worth more to them than it costs to produce. In a system of free trade, self-interests are not in conflict--not even between a physician and a patient. In a direct-pay, fee-for-service relationship, it is in the best long term interest of the physician to offer advice and treatment based on the patient's best interest. And, it is in the best long term interest of the patient to only deal with a physician who does!

We can not defend patients' freedom without also defending the freedom of physicians. We can not protect the doctor-patient relationship without protecting the autonomy of both. Freedom of association and freedom to contract are interrelated principles fundamental to a free republic, to capitalism and to the ethical practice of medicine. "Social justice" requires that the individual be sacrificed to the collective. Such an act is as immoral in medicine as it is anywhere else.

"Social justice" claims to be what it isn't-- because true justice will never involve the violation of individual rights. The only way to assure justice and an ethical doctor-patient relationship is through the consistent, proud, principled defense of individual rights. The only way to assure justice and an ethical doctor-patient relationship is through the consistent, proud, principled defense of individual rights. In economics, that means capitalism. In medicine, that means the freedom of choice, not government mandates, for both doctors and patients.

Update 5-21-10 Two other articles on the training of physician to advocate for "health care reform"--by which is meant greater government control.

"Train physicians to participate in health care reform" by Sachiin Jain, Jordan Bolman in Skin & Allergy News, July 2010

"A Plea to Medical Students" by Joseph M Scherzer

ObamaCare Visual Aids

How in the world are we to understand the explicit details of the new 2000+ page health control law, let alone make reasonable estimations of potential unintended consequences?

Although a picture is not an argument, sometimes it's worth 1000 words.

This chart is large and complex, but is reportedly still only about a third of the bill.

(Click on image to go to pdf to enlarge.)

More information here.

Here's a chart which focuses just on one small aspect of the "Affordable" Care Act.

Navigating the Small Business Tax Credit

(Click to enlarge)

A brief introduction to the chart is given by its creator, Committee on Ways and Means member Dave Camp here.

The IRS explanation is here.

And one last one that just attempts to diagram major deadlines:

Implementation Time Line for the ACA by Center for Health Transformation

(Click on the image to go to the PDF to enlarge for details.)

How much will each box cost to implement---both in money and in freedom?

How many new directives in this bill will replace the private decisions of patients and doctors with a bureaucratic decree?

How can a nation of independent, free citizens tolerate this massive invasion into private lives---no matter what the claimed justification?

Answers:

No one know, but too much.

No one knows, but too many.

We can't--if we desire to remain independent and free.

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White House Releases Misleading Ad

Today the White House released an ad campaign featuring actor Andy Griffith, hoping the friendly sheriff from Mayberrry will convince voters that ObamaCare is not the disaster we know it to be. Although technically correct, the ad falsely attempts to reassure Seniors that the new law won’t change Medicare benefits.

As FactCheck.org explains:

So how can the Obama administration claim that “guaranteed Medicare benefits will remain the same”? The answer is that the term “guaranteed” is a weasel word…It may sound to the casual listener as though this ad is saying that the benefits of all Medicare recipients are guaranteed to stay the same — and that may well be the way the ad’s sponsors wish listeners to hear it. But what the administration is really saying is that only those benefits that are guaranteed in law will remain the same…But here’s the catch: The extra benefits generally offered by Medicare Advantage plans aren’t guaranteed by law.

The White House is also counting on people forgetting that the original Medicare legislation made the following “guarantee”:

Sec. 1801: Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee or any institution, agency or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency or person.

In 2002, Dr. Lawrence Huntoon, MD collected more Medicare Myths and Facts including the myths that Medicare has lower administration costs, and that we can count on the government to keep its promises.

For more on the subtle duplicity of the White House ad campaign, read the rest of Mayberry Misleads on Medicare.

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Minimum Insurance laws and the Uninsured

Although not universally agreed upon, a strong theoretical and empirical connection exists between a legally mandated minimum wage and the rate of unemployment:

When the minimum wage that is legally-allowed increases, so does the number of unemployed.^{1, 2, 3}

A similar cause-and-effect relationship exists between insurance mandates and the uninsured. Understanding the effect of "minimum insurance laws" is complicated by the fact that different mandates have different cost consequences, and each state has its unique mix of mandates. There are four main types of health insurance mandates: benefit mandates (which are not cost equivalent across benefit types), community rating,guaranteed issue⁷, and mandatory insurance. Each of these categories will increase the cost of insurance, but to different degrees. Insurance mandates all raise the price of obtaining insurance, which in turn increases the number of people unable or unwilling to pay the premiums:

When the minimum insurance that is legally-allowed increases, so does the number of uninsured.^4,5,6

1. Mythology of the Minimum Wage http://mises.org/story/2130
2. Minimum Wages and Employment http://papers.ssrn.com/sol3/papers.cfm?abstract_id=961374
3. Minimum Wages http://www.econlib.org/library/Enc/MinimumWages.html
4. Health Insurance Mandates in the States 2008http://www.cahi.org/cahi_contents/resources/pdf/HealthInsuranceMandates2008.pdf
5. Mandated Health Insurance Benefits: Tradeoffs Among Benefits, Coverage and Costs?http://www.kff.org/insurance/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13995
6. The effect of State regulations on Health Insurance Premiums: A Revised Analysishttp://www.heritage.org/research/healthcare/cda06-04.cfm
7. Impact of Guaranteed Issue and Community Rating Reforms on Individual Insurance Markets, 2007 http://www.ahip.org/content/pressrelease.aspx?docid=20794

Previously posted on Wealth is Not the Problem 1/28/10 and on Sermo 4/25/10 (a physician-only online network.)

Health Care Re-education

President Obama and the Democrats have started the Health Information Center which plans to spend $125 Million defending ObamaCare to the American public--a necessary effort because the majority of Americans still do not want this law. This campaign, plus the newly launched HealthCare.gov website, and the email campaigns of Kathleen Selbalius (Secretary of Health and Human Services) and Nancy-Ann DeParle, Director of the White House Office of Health Reform, are all aimed at reassuring citizens that freedom is not being taken away, only the rich will have to pay more in taxes, in the long run all this spending will save us money and reduce the debt, and this law will "strengthen" Medicare.

As Grace-Marie Turner of the Galen Institute points out below, even the National Council on Aging is in on the propaganda act. A recently published survey shows that Seniors have not been fooled into believing the political spin on ObamaCare and answered the questions correctly according to what the law will actually do, and not what the Democrats ridiculously claim it will do.

In order to keep the truth out in front, be sure to give your financial support to your favorite watchdog organization so they have the funds to challenge the audacious claims of the government. A list of suggested organizations is at the end of this post.

More Re-education

By Grace-Marie Turner

(Galen Institute email update. Subscribe here.)

The National Council on Aging got a lot of media attention this week for a survey that was astonishing in its misrepresentation of the facts.

The NCOA asked 636 seniors true or false questions about "the top twelve facts" they should know about ObamaCare. Only 17% knew the "right" answers to half of the questions and not a single person got a perfect score. The news release read: "Most Seniors Misinformed, Unaware of Key Provisions of the Affordable Care Act."

The infuriating thing is that the pollsters and the NCOA got the answers wrong, and seniors were right! With a lawyerly parsing of words, the questions were designed to obscure and even deceive. Here are a few examples:

• "The new law will result in future cuts to your basic Medicare benefits." True or false? By more than two to one, seniors said the statement was true. But the survey said that was wrong.

• "The new law is projected to increase the federal budget deficit over the next ten years and beyond."By more than three to one, seniors said that was true. Wrong answer.

• "The health care reform law will cut Medicare payments to doctors." Seniors said true by three to one. Wrong answer.

The late Sen. Daniel Patrick Moynihan said, "You are entitled to your own opinion, but not your own facts."

A few facts:

• The health overhaul law cuts Medicare by $575 billion over the next 10 years.

• The Medicare actuary says that at least one in six Medicare providers, including hospitals, nursing homes, and physicians, could be operating at a loss by 2019 and could end their participation in the program, and "possibly jeopardize access to care for beneficiaries."

• More than 7 million seniors will lose their Medicare Advantage coverage, and millions more will find access to care restricted. The Congressional Budget Office found that seniors enrolled in Medicare Advantage will lose an average of $800 a year in benefits.

• As Rep. Paul Ryan explained at the Blair House summit in February, "when you strip out the double-counting and ... gimmicks, the full 10-year cost of the bill has a $460 billion deficit. The second 10-year cost of this bill has a $1.4 trillion deficit."

• And the legislation keeps scheduled cuts in payments to doctors, which is why the Congress passed a separate "doc fix" bill in June to keep doctor payments from being cut by 21%.

Seniors know you can't take $575 billion out of Medicare and not have it affect their benefits. Many already are having difficulty finding providers that take Medicare.

NCOA also found that seniors are not satisfied the information they are getting about the new law is "accurate and reliable." Well the NCOA has certainly proved it is not the place to go for reliable information. This survey deserves to be tossed.

It almost seemed like push-polling where the pollsters try to "re-educate" people through the use of survey questions. Seniors get it, but this is unsettling at best.

Organizations to support:

AAPS

Americans for Free Choice in Medicine

Cato Institute

Docs 4 Patient Care

Freedom and Individual Rights in Medicine

Patient Power

National Center for Policy Analysis

The Lucidicus Project