Posts Tagged ‘Congress’

COMPROMISE—THE ANTIDOTE TO SOLVENCY

February 11, 2018

OK, the title of this rant is an exaggeration; we haven’t been solvent in decades. Still, I’m sick and tired of hearing about the need for our ruling class to “compromise.” What it gets us is a two-year, $400 billion spending bill that increased the federal debt by more than $1 trillion. The bill passed in the Senate 71-28, with 16 Republicans and 11 Democrats voting nay. In the House it passed 167-73 (56%-43%), with 57 Republicans and 119 Democrats voting nay. Rand Paul stood up to protest, and irritated his colleagues. Per Jeff Crouere, writing in an op-ed for Townhall, “Senators of both parties were left fuming, with most of their ire directed toward Paul.”

Well, Paul, I’ll stand with you. Compromise is like telling someone who makes $80,000 and carries $100,000 of debt while spending another $100,000 per annum that he’s really got to cut his spending to $90,000—someday. But for the next couple of years, at least keep it to $110,000, okay?

Everyone agrees we should cut spending. Few believe we must actually do it. It’s too hard.

It’s easier to focus on the reputed imminent demise of the planet than imminent demise of the economy. I’ve heard the arguments that the burgeoning debt is “no big deal” and arguments that it will sort itself out (unfortunately, the living are not the ones that will be doing the sorting). Some believe this can go on forever. While I believe sane people can argue all day where the spending cuts need to occur, the idea that we can drift on into eternity borrowing, overspending and overprinting is delusional, and history bears this out (in case you haven’t noticed, we’re not speaking Latin).

It’s now clearer than ever that there exists not a progressive and a conservative party, but a more progressive and less progressive one.

The definition of insanity is doing the same think over and over again and expecting a different outcome” may be cliché, but America seems to have become yet another poster child for it.

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SMOKE AND MIRRORS: THE HEALTHCARE ACT VANISHING GAME

August 7, 2017

The American public is frustrated. Congress has its lowest approval rating ever. And they just can’t seem to pass a healthcare bill. The only surprise is that anyone’s surprised, and even that should come as no surprise. Let us gaze upon the elephant(s) in the room:

First, almost everyone hates the do-nothing Congress but continues to elect the same career politicians over and over again, pointing the finger at “the other guy.”

Second, everyone wants healthcare reform unless it involves rescinding expanded benefits that the prior legislation meted out.

Third, everyone wants laws that require emergency rooms to provide urgent care irrespective insurance or ability to pay (that’s what a compassionate society does, right?) but no one wants a mandate to purchase health insurance.

Beginning to see a pattern?

Congress can’t fix a system that needs a major overhaul in both the way we think and the way we conduct business until we accept the fact that we need to overhaul the way we think and conduct business. A politician’s lifeblood is votes. Everyone accepts the need for increasing efficiencies and trimming waste and fraud in healthcare, and many embrace increasing competition in the insurance marketplace. Some are convinced a single-payer system is the answer (see below). But it will not be enough. The burgeoning ranks of the elderly infirm with fewer workers to pay for their care doom any of the current plans to failure. For any clear-thinking healthcare worker the trajectory of premiums for Obamacare was inevitable from the day of its conception. Gravity says you go down, and the laws of economics say, “You don’t get sumthin’ for nuthin’, as much as wishful thinking tries to obscure this truth. With bunsiness as usual, the many hidden taxes in Obamacare were insufficient to sustain the mandate of covering all pre-existing conditions and extending insurance for “minors” until age 26, on top of providing mandated non-essential care. And it’s only going to get worse.

What’s the answer? Health care rationing, otherwise called “death panels” by those that want to quash any reasonable discussion of the topic.

We’ve always had covert rationing (shhh!). Anyone who thinks a homeless street person gets the same level of care as a movie star or professional ballplayer (or Congressperson, for that matter) is living in a fantasy world. That being said, the excesses in the U.S. system are more enormous at all levels of care than most people realize. I will illustrate with a single example: At a recent meeting I attended there was a discussion about the suitability of placing an artificial valve in a patient that had a critical narrowing of the exit valve of the heart, otherwise known as aortic (valve) stenosis, which kills someone within 1-3 years of onset of symptoms. Until a few years ago, the only treatment was an open heart operation, but innovative minds developed a procedure to place a valve inside the old, calcified valve via an artery without surgery, known as transcatherer aortic valve replacement, or TAVR. This particular patient was in her late 60s to early 70s, had advanced alcohol-related liver disease (but was no longer drinking), and had begun to show signs of reduced blood clotting and fluid accumulation in the belly known as ascites related to her diseased liver. Although her life expectancy from the liver disease cannot be precisely predicted from the information I have, it is not unreasonable to postulate 3-5 years. Her aortic valve disease would probably kill her within 1-2. She was deemed a high risk surgical candidate so is being triaged to TAVR. It is more difficult to find the average cost of the procedure doing an Internet search than a cost-effectiveness figure ($50,000 is considered the benchmark for qualitylife-years gained, or QALY, originally based on hemodialysis figures), but $52,200 ± $28,200 is the estimate I found, representing a purported net loss for the institution (as opposed to surgical valve replacment which supports a net gain). Assuming that this patient has no complications (likely, but certainly not guaranteed), you will reduce her short term risk and improve short term quality of life significantly. However, you now have a patient with another terminal illness (end-stage liver disease) at even higher bleeding risk due to the aggressive antiplatelet drugs needed to prevent valve clots, who will likely live longer to be in and out of the hospital in her final years to palliate her progressive liver disease. (Of course, it is possible that the medications could shorten her life, as liver patients are prone to bleeding for many reasons.) Now extrapolate this example across the country and across different illnesses and medical specialties, and you’ll begin to get a sense of the magnitude of the problem.

So, are these doctors greedy, incompetent, or stupid? Absolutely not. A terminally ill patient with advanced cancer and low life expectancy would never come up for discussion. However, that large (and growing) senior population with serious chronic illnesses we’ve become so proficient at eking every last ounce of life from is a much more difficult decision for doctors. Often, they feel that societal issues should not come between the physician and the patient, and everyone is loathe to place the responsibility for these tough decisions in the hands of the government. The upshot of all this is that we’ve abdicated the responsibility to address this overtly. And no wonder: Opening oneself to the criticism of being an uncaring bean-counter is no more appealing to a physician or layperson than to a politician seeking reelection.

So what can we do?

We can set up committees made up of doctors, clergy, citizens, social workers, economists, and yes, politicians to examine clinical scenarios and/or actual patient cases and determine suitability and feasibility of a particular high-cost interventions, adding into the equation societal and fiscal constraints. (There are those that believe a single-payer system will solve the system’s ills, perhaps by overtly or covertly addressing this; I’m skeptical, but the debate is beyond the scope of this rant). This independent committee approach unburdens the caregiver of the responsibility for factoring in issues extraneous to the patient. However, this concept will not be well received. Consider the outrage engendered by recent British government intervention in its decision to prevent a high risk procedure on an infant afflicted with a congenital ailment. Although in this case I agree with the critics, as it was reported that the funding was obtained by the family from private sources, there are other high-profile examples of widespread censure of attempts to limit life-giving care in patients with poor prognosis (i.e. Karen Ann Quinlan and Terri Schiavo, to name a couple).

So what will we do?

All indications are that we will continue to posture, discuss repealing and replacing or modifying Obamacare, and either do it or not. For me, it doesn’t matter. Without fundamental changes that I believe the American people, at this time, are unwilling to accept, the downward economic medical spiral will persist. The forecast is for increasing debt paralleling that of the greater economy (of which healthcare comprises 18%). Like a junkie needing greater and greater cash infusions, it will need to hit bottom before it changes.

I know this is a pretty grim, some might say pessimistic, prediction. And there is always the chance that the exponential advance of technology may save us by completely changing the face of medicine. Unfortunately, we don’t have a lot of time.

The truth is, elephants in a small room make quite a mess.

WE THE PEOPLE

January 7, 2013

I caught a snippet of a commentator interviewing a talking head, probably a politico. After lambasting Congress, she asked if he thought, ultimately, that the American people were responsible for the poor shape we’re in. I waited for the usual response, and wasn’t disappointed: No, we can’t blame the folks for the failings of the legislators.

It’s very unpopular (duh) to criticize the electorate, and no politician will cross that line; it’s like signing your own pink slip. But I’m not running for office, so I can afford to state the obvious: We’re a democratic republic, and we elect and re-elect the people who are failing us. Albert Einstein is quoted as saying the definition of insanity is doing the same thing over and over again and expecting different results. I suppose, then, we’re insane.

It’s true that in a country as large as ours with widely disparate views, it’s unfair to paint everyone with one brush. Perhaps a better term would be schizophrenic. It all comes down to the same thing: in the net, as a nation we continue to behave irrationally when it comes to our economic survival.

In the people’s defense, for decades we’ve done the same things with ups and downs and eventual recovery, so one might argue our profligate spending, unbridled borrowing, massive governmental expansion and its attendant “quantitative easing,” works. It’s easy to forget the government, in its protective financial bubble, is now an even larger part of the total economy. The debt and the corresponding interest payments are larger than they’ve ever been. The entitlements are bigger than ever with fewer workers per recipient. Most importantly, the culture has changed from one of deploring government charity to expecting it. But you can put a lot of layers of spackle and paint over a large, sturdy house like the U.S. and keep it looking quite spiffy until the moment the termite-ridden support beams give way.

In the 1980s Carter’s disastrous policies brought him the boot. In 2012, Obama’s ineffectual leadership under even more dire circumstances bought him four more years.

Money, the Prozac of the progressive era, whether you print more of it or steal it from a few wealthy people, ain’t gonna cut it for much longer. We need a good shrink.

Let’s start with the government.

WELCOME TO THE SANDBOX

November 20, 2011

We’re told that if the “super committee” (a misnomer if ever there was one) appointed by Congress fails to come up with a plan to right our listing economy by next week, automatic, Draconian cuts will take effect. Of course, in typical ruling class fashion, they don’t take effect until 2013, coincidentally after the presidential election. But life is full of coincidences, isn’t it?

Reports are that the “supermembers” (my term—remember you heard it here first) are no closer to reaching consensus than on day 1, and this should come as no surprise to us. Ideology always trumps common sense. Like children squabbling in a sandbox, the left has drawn a line in the sand—no increased taxes on the rich, no cuts. The right panders to its ideological base: no increase in taxes; show me the cuts. While they wallow in this sandy quagmire they ignore that it’s actually quicksand, and it’s taking us all under.

In the early ‘90s Canada faced a similar debt crisis and a liberal government reversed it with a policy of spending cuts and tax increases with a ratio of seven-to-one, as summarized in a brief analysis by the National Post. While these analysts are pessimistic about the success of such an approach in our much bigger, and the world’s much sicker, global economy, I posit that the alternative, wallowing, guarantees failure. An intervention along Canadian lines is our last, best hope for a turn-around. Like everyone else (except most of those unfairly benefitting), I favor closing tax loopholes and “making everyone pay their fair share”, but this will barely shave a sliver off the deficit gap. While I don’t think tax increases are especially wise in dealing with what is predominantly a spending rather than a revenue problem, it is abundantly clear that an approach similar to Canada’s is what is needed to resolve the political/ideological deadlock. And we’ll need cuts to at least 2005 spending levels. We’ll need to preserve funding to critical services like our national defense, (although we can probably shave 15 or 20% off from waste, fraud and inefficiency alone), and we need a balanced budget amendment and overarching tax reform. We have to demand tough spending cuts to justify tax increases, not in a milksop 1:1 fashion.

Each day more dire predictions of what is to come float across the media. Today, polls were quoted stating the favorability ratings for the Congress are lower than for polygamy and pornography. As an electorate, we’re the employers. If our employee-leaders can’t do the job, we need to throw them out. Let’s stop allowing them to bribe us with our own debt.

PUNTING THE TOUGH STUFF

September 12, 2011

Cynics say the government doesn’t do anything well, but they fail to give credit where credit is due: No one kicks the can down the road better than our ruling class. If we weren’t running out of road, they’d still be doing it. Lord knows,  at least half of them are still trying.

When it comes to cutting spending they’ve squirmed, squealed and squabbled. When they realized it was only a matter of time before the printing presses would run out of green ink, Congress abdicated its responsibility to a small committee of people that can fight in closer quarters. In fairness, we’ve enabled them; doing what they should do mandates major give-backs by us, things we’ve been granted in return for our sweet votes. Freebies our elected benefactors didn’t have the assets to offer in the first place. But the shiny printing presses were just too inviting. As I’ve said in prior rants, the government is addicted to spending.

The answer is simple, the consequences hard. Instead of endless, fruitless negotiations, we need to cut spending to 2008 levels. 2005 might even be better. There is a glimmer of hope that something dramatic may occur—people in  the electorate and in government are actually talking about the sacred cows, Social Security and Medicare, something that has been termed for decades the “third rail” of politics. Although they still gasp in horror when a presidential candidate refers to Social Security, a program that uses the money of relatively small numbers of players to pay for the burgeoning numbers of older participants, without putting aside a dime, as a “Ponzi scheme.” Oh, well, change comes slowly.

Cutting spending across the board doesn’t mean every governmental institution needs to remain sacrosanct. As crucial to our well-being as each and every agency may seem to the bureaucrats that nurture them, perhaps we can find a few modifications we can live with.

Next: Cutting the fat

HEALTH CARE CRISIS SOLVED!

March 22, 2010

Well, it’s over. These many months of ranting and raving, and all it took was an emergency late-night vote (on a Sunday!) to fix it. Now another 30 million have health insurance, denial of coverage for pre-existing conditions has gone the way of the Cold War, and on top of it all, the deficit will be cut $138 billion over a decade. Oh, and did you know that as a bonus student loans have been shifted to the government as part of the bill? Those students are a pretty healthy lot, so we wouldn’t want them to miss out on the largess.

Now that it’s over, I guess I can retire my keyboard. My fingers are hurting, anyway. Maybe signs of arthritis setting in. No worry, they have to cover it. What’s that you say? Speaker Pelosi announced that “We will be joining those who established Social Security, Medicare and now, tonight, health care for all Americans”? Wait, aren’t Social Security and Medicare going broke? Oh, the health care bill doesn’t ramp up for another 4 years, you say. Uh, wait, isn’t that after the next presidential election? What’s that? I’m being paranoid? Gosh, maybe you’re right. I’m feeling an uncontrollable urge to vote every Congressman and woman out of office.

I hope there’s a provision for free unlimited psychiatric care, no pre-existing conditions excluded.

WHERE’S THE MONEY?

March 8, 2010

As the President and Congress move closer toward passing the unpopular health care reform bill, the New York Times reported last month that “virtually every state is making or considering substantial cuts in Medicaid, even as Democrats push to add 15 million people to the rolls.” The Washington Post reported that “because the program is large and expensive, the spurt in Medicaid caseloads has produced far more damaging effects on state budgets than” food stamps or welfare benefits.” On the cost-cutting side, The Boston Globe editorialized that “Fear of intrusion in the doctor-patient relationship so inhibits insurers that they are shunning one of the most obvious ways to cut medical costs: Avoiding costly procedures when they are proven to do no good.” They cited a 2007 New England Journal of Medicine study which found that “doctors could save $5 billion a year by treating patients with chest pain with drugs rather than surgically inserted stents” which “has been largely ignored.” The Globe suggests that “the government should give the medical profession the impetus to determine the most effective treatments for a range of ailments by establishing committees to determine the best practices.”

On the personal front, I’ve marveled at the burgeoning age of my patients. A few days ago I saw a 90 year-old, and 84 year-old, and a 94 year-old in succession, and hardly a day goes by now where one of my octogenarians doesn’t present to the emergency room somewhere in atrial fibrillation, a rapid, irregular heart rhythm that is becoming epidemic. The ability to live long enough to glut the health care system is testimony to the success of out ability to manage, and modulate, the many chronic ailments we haven’t yet learned to cure.

While the Democrats argue that, when presented with pieces of the proposed health care legislation (such as immunity from denial of pre-existing conditions by the insurers, and portability of insurance), their constituents give universal approval. This fuels their arguments that the overwhelmingly negative reception by the voters to the legislation is simply a manifestation of the distortion of the facts promulgated by the Republicans. But I think the politicos (intentionally?) underestimate the collective wisdom of the people. The people know in their hearts you don’t get “something for nothing,” and the addition of millions to the rolls will add billions to the cost. They also know that health care reform is needed and inevitable, but the current proposal, as I’m hearing ad nauseam in the media, is “a dog that won’t hunt.”

The only way to get more “bang for the buck” is to change practice patterns, and increase competition. I’ve suggested ways this can be accomplished in prior posts. I welcome other innovative ideas.

Addendum: In my last post I noted that Medicare reimbursement was slated to be reduced by 21% in March 1st. In the interest of full disclosure, this cut has been placed on hold. It has not been repealed. The jury remains out on what the outcome will be.

USED CAR SALESMEN

December 21, 2009

The Senate now has the 60 votes it needs to give us its Christmas morning present, a shiny new, revamped health care system. Ho, ho, ho. I had hoped that something so vast, complex and expensive would have been hashed out in bipartisan fashion over a couple of years with some input by people actually involved in providing the service, rather than as a holiday stocking stuffer, but perhaps I expected too much. Then again, my expectations of our leaders have been steadily declining over the years, to the point that I’ve viewed them as a step above used car salesmen. 

Used car salesmen haven’t had a particularly glowing reputation in the minds of the American people, yet consider this: they hold down a job in the real world economy, have no guaranteed “Cadillac” health care policy, don’t get to tell other people about their carbon footprint without worrying about their own, and can’t force legislation down your throat in the dead of night without even reading it. Perhaps I’ve sold them short. 

So I propose that the American people canvass their neighborhoods for suitable replacements in Congress. I have no preference as to whether you start with Ford (although they have been fiscally more responsible), GM, or even the ubiquitous Japanese carmakers. After all, they’re efficient and profitable, two attributes that would bring a refreshing change to Washington.

AN EARLY CHRISTMAS PRESENT

November 8, 2009

Well, the new health care bill, supported by the AARP and AMA alike, has passed the House. 

I’m disappointed. 

I like the idea of everybody being covered for everything without exclusion of pre-existing conditions by a portable policy that will also reduce the deficit. I just wish it had passed sooner. Just received a bill for a minor infection my daughter had treated in an urgent visit clinic totaling about $1300, of which roughly $900 is for testing. I thought one of the benefits of insurance is that they disallow outrageous charges, but apparently they are only responsible in this instance for a third. It wasn’t an ER visit, but the clinic is affiliated with an ER, so I guess the high fees are secondary to contagion by close proximity, like the swine flu. I didn’t have the right anti-fleece vaccine. 

But that will all be taken care of now. 

Write to your senators. Maybe we can push it though before Christmas. The faster the better. Someone might read the bill in the meantime.