THE NEW MAD LIBS SUPREME COURT GAME

Mad Libs is a venerable game that’ s been around for a long time, since I was a kid. So has the Supreme Court. I just didn’t know that they were both games. So let’s play [cue the honky-tonk clown music]:

The Supreme Court ruled today on a case ________ President

                                                                prep.

_____________ regarding ______________.

proper name                      proper noun

The Court, in a ____ to ____ decision ___________

                       #          #                        verb

________________ was ___________ because

proper noun                        adj.

the president was a(n) ___________ man.

                                           adj.

Game 1: against, Trump, DACA, 5, 4, rescinding, DACA, illegal, orange

Game 2: for, Obama, Obamacare, 5, 4, rescinding, Obamacare, illegal, charismatic

Game 3: against, Trump, LBGTQ, 6, 3, applying, Civil Rights Act 1964, legal, orange

Fun, wasn’t it? Well, perhaps a bit boring with seemingly predetermined outcomes once the president’s name is entered, but there’s a bonus: We’ve all learned that any of us can judiciate (my word, I claim dibs) as well as the top lawyers in the country without the expense and tedium of 4 years of law school and interminable internships. All it takes is a bit of ideology, and the absence of a spine.

It’s not really judiciating, but legislating from the bench. But no one really cares, do they, if it’s an issue the Court comes down on our side for, right? For instance, some may be surprised to learn that I have no desire to deport Dreamers. I even foolishly thought the Democrats were going to give Trump the measly $5 billion for the wall to resolve the issue for once and for all, until I realized that handing Trump any win and removing from the table a handy issue for labeling him was far less beneficial politically than helping a group too long in limbo. So Obama legislated (real word, sort of) by executive order with his famous phone and pen after saying it was illegal for him to do so. Trump foolishly thought he could undo the illegal order with another order rescinding it, which is legal, but the Court majority, not one to let messy legal issues get in the way of determining policy, said, “uh, uh,” you didn’t give the required notice or some such claptrap that Obama should have done as well (if this confuses you, it’s because you have a brain, almost as dangerous as a spine; ditch it).

As for LGBTQ rights, again, it doesn’t matter that the law clearly didn’t address this, limiting itself to sex discrimination. But since the Congress hasn’t done their job and legislated (remember that word?) on it, the same effect could be achieved by… judiciating!

By changing the definition of the word “tax,” they were able to save the well-loved and super-effective system of Obamacare and—wait for it—judiciate from the bench!

Pretty soon, we can get all our legislation from the Court. There are enough laws on the books to recycle for the remaining life of the country and we can abolish the Congress entirely, which is exceedingly expensive in this time of rampant debt and does nothing useful, anyway. What’s that, you say? What if the unelected Court decides against your pet issue? Life is tough, get a spine.

SMOKE AND MIRRORS: THE HEALTHCARE ACT VANISHING GAME

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.

DOC-IN-A-BOX

A small study, unlikely to garner much media attention, may be one of the first salvos in the war against medical waste.

Recently published in Circulation: Cardiovascular Imaging, the trial studied the impact a web-based computer program might have on decision-making in the emergency room. About 500 patients presenting with chest pain or a sensation of shortness of breath, something doctors call dyspnea, were randomized to an active group that had a computer gauge their medical risk and prescribe the necessary testing. The doctors in the control group decided in the usual fashion, without computer help. The investigators found that the program lowered the patients’ radiation exposure (i.e., fewer tests) without a significant difference in the rate of return to the emergency department for care or occurrence of adverse events.

Watching the geometric progression of technological evolution, it seems inevitable that someday the line will be crossed where computers become more accurate diagnosticians than people. Whether you believe that day is 25 years away, 50, or 100, is irrelevant. The importance of this study lies in the fact that, properly applied, even present-day computer programs have the potential to cut waste (and increase patient safety).

Whatever your view of Obamacare, it is evident that universal coverage and no exclusions for pre-existing conditions are good things. It is also evident that good things come at a cost. The only immediate way to get a good thing at no cost is by removing fraud and waste. Having practiced in the medical field for decades, my impression is that there’s probably a lot more waste than fraud. Figures of 20-30% of our medical care dollars have been bandied about, which jives with my admittedly subjective impression.

Eventually, the march of technology and knowledge will lower costs in other ways, by allowing more effective treatments and perhaps even curing chronic illnesses that, at present, we can only effectively manage to the point of bankrupting the health care system. In the meantime, it behooves us to put a lot more effort into studies like the one above, the primordial germ of artificial intelligence, that will ultimately make my job obsolete.

Someday, perhaps sooner than we think, the only “doc-in-the-box” you’ll ever need will be attached to a touchscreen with circuits linked to what is now known as the “cloud.”

THE OTHER SIDE OF THE STORY

As per my last rant, Forbes magazine’s critique by Chris Conover of Steve Brill’s investigative report on health care pricing appeared early this month in parts one and two. It centers on the premise that Brill obfuscates issues enough that his piece might be interpreted as making a case for a single-payer health system. Salient points of Conover’s “counter-attack” follow:

• The claim that U.S. outcomes are no better and often worse than in other countries is exaggerated. When adjusted for violent deaths that have nothing to do with health care, the U.S. ranks #1 in life expectancy at birth, and the figures for infant mortality distort the issue as well. Adjusted for length of gestation, the U.S. ranks second, third or fourth against European nations. Cancer patients live longer in this country than any other, we screen more people, have lower smoking rates and, despite our smaller size, produce more top medical and pharmaceutical innovations.
• The claim that the U.S. spends 27% more than other countries is refuted with the assessment that, when broken down into regions such as states more comparable to the size of European nations, “U.S. health spending is almost exactly where it is expected to be, given U.S. GDP per capita.” Conover does add that he is not implying that there is no waste in our system.
• The assertion that drug prices here are 50% higher on average than other developed nations is true for those still on patent, but we pay less for generics and over-the-counter products. These account for 70% of the volume but only 20% by sales. The argument that government monopoly or removal of patent protection should be used to lower prices will destroy the incentive for research and innovation; the return on investment for drug research is 18%. The CBO concluded that negotiating drug prices for Medicare would result in negligible savings over what is obtained under current law for covered Part D drugs.
• Excess prices don’t equate to excess profits. Inpatient hospital care generates an average operating profit margin of 2%; the 11.7% Mr. Brill cites is too high. The profits in the health services sector are in the middle of the pack (or lower) compared to other industries.
• Medicare administration is not more efficient than private health insurers. Private insurers spend 9.2% rather than 22.5% of each health care dollar on claims processing. Medicare also doesn’t have to pay for as many functions, such as marketing and provider rate negotiations, inflating the private insurers’ costs by one-half. Also, the patient population using Medicare uses costly services more so its administrative expenditures will necessarily be a smaller percentage of the total. Conover maintains that the “handcuffs” Congress has itself placed on Medicare points to the fallacy of a public health care system being inherently better, and he reminds us that every dollar Uncle Sam gets carries the burden of shrinking the economy by 44 cents (he doesn’t mention that we borrow 40% of this).
• Less consequential issues are Brill’s exaggeration of the personal bankruptcy figure related to medical bills (Conover says it is less than half the figure claimed), that the charity care Brill claims is based on chargemaster prices is not accurate, and that the argument that there is less fraud in the Medicare that the private sector is false.

Mr. Conover states, “What makes good for politics far too often is not good policy,” and concludes, “Mr. Brill has nicely codified much of what is wrong with American health care. He arguably has shown just how inadequately Obamacare addresses the myriad of problems he identified.  But unfortunately, he also has contributed to some of the very same misconceptions that resulted in Obamacare, a very misguided prescription for what really ails the American health care system.”

I leave it to the reader to decide who is right. There are many known problems with a single-payer system, and we ignore them at our peril. The truth is that our current, unsustainable system through indirect subsidies has helped many of the single-payer systems overseas to function at diminished cost. Like our economy, the medical marketplace is, to an extent, a global one. However, the uniqueness of medical care is that much of it is essential rather than discretionary, and creating the ideal, a marketplace with free competiton, is not always feasible from the standpoints of logistics and optimal health care delivery. We need a hybrid approach. I’ve given my opinion of the needed fixes in past rants.

Mr. Conover feels that Obamacare is a “misguided prescription for what really ails the American helath care system,” and that “[u]ntil we get the diagnosis right, we have no reasonable prospect of getting off the wrong track we’re now on thanks to the Affordable Care Act.” I agree. And I’d like to add that until the American public becomes more informed and begins making the right demands of its ruling class, the patient we call our health care system will remain as what we physicians term a “failure to thrive.”

IF THE GAME’S FIXED, BREAK IT

Last rant I discussed Steven Brill’s important piece on another critical aspect of our health care system’s malaise. Here’s what he recommends to change it:

1. Tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them. They have increasing leverage as they consolidate lab work and doctors’ practices and will drive insurance premiums up.
2. Tax hospital profits at 75% and have a tax surcharge on all non-doctor hospital salaries that exceed a certain amount (he offers $750,000 as a reasonable figure). He estimates this would save over $80 billion a year.
3. Outlaw the chargemaster, the “retail” price list with the obscenely inflated charges.
4. Amend patent laws to prevent pharmaceutical firms from exploiting the monopoly these laws give them, or set price limits or profit-margin caps. Reducing prices to conform to other developed countries, he argues, would save more than $25 billion a year.
5. Tighten further what Medicare pays for CT and MRI scans and cap what insurance companies can pay for them, as well as profits on in-house lab tests.
6. Embarrass Democrats into stopping the fight against medical-malpractice reform and provide safe-harbor defenses for doctors.

Tongue-in-cheek, he adds that we could limit administrator compensation at hospitals to 5 or 6 times the salaries of the lowest-paid physician, require the drug companies to post a notice of the gross profit margin on the drugs’ packaging and the salary of the parent company’s CEO (as well as their website).

He summarizes Obamacare as “doing some good work around the edges of the core problem,” but reminds us that ultimately it will raise, not lower, costs. In essence, you can’t get something for nothing, even if that something is a laudable goal.

Mr. Brill concludes that “…we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.

“We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.

“And we’ve allowed those on the island and their lobbyists and allies to control the debate….”

Where do I, the free market capitalist guy, come down on these suggestions? Because I don’t see free market forces operating in many areas of our health care playing field I’ll give a thumbs up on #1. I don’t trust the government with #2; giving them more money to waste is like handing a loaded pistol to a 2-year-old. Let’s have Medicare actually negotiate with drug and device companies like they do elsewhere, along the lines of #5, and get the lobbyists out of the equation. As an erstwhile affluent nation, I think that subsidizing the world made sense, but not to the extent that we’ve done it, and we certainly can’t continue this behavior while we’re borrowing 40 cents on the dollar. Two thumbs up on #3. Require the uber-wealthy from overseas to make a donation if they want to utilize our specialty health care institutions, or get their care at home. I’d prefer that #4 be handled, as previously stated, with hard-ball negotiations, à la #5. And I’d prefer to limit upper management salaries through market forces, though a mechanism to tie compensation more closely to performance is sorely needed. Even in the private sector, I’ve seen the sky-rocketing CEO salaries that appear to be more a form of racketeering than a function of the marketplace. Success should be well-compensated but coupled with real-world performance. Having the heads of corporate governing boards determine compensation willy-nilly is tantamount to letting the wolves guard the henhouse (sound familiar?—it’s what the ruling class has been doling out for themselves for years).

Finally, if we’ve decided we want everybody covered for all pre-existing conditions in perpetuity, let’s decide to go broke or make the hard rationing decisions that go along with it. Because, short of really, really, excising fraud and waste, the money has to come from somewhere. And a printing press or a Chinese bank will get you only so far.

Next: Forbes contests Brill as a shill

TOUGH LOVE

Now that the season of love and giving is coming to a close, I can once again revert to type and foray into the world of what will be as opposed to what we all wish it would be.

The Affordable Care Act, more colloquially known as Obamacare, has promised us more coverage for more people, both highly laudable offerings that may have contributed to his return to the Oval Office. In an era of shrinking revenues and ballooning debt, how is this possible? I’m going to prognosticate.

The healthcare world of the not-to-distant future will, by necessity, implement the following changes:

1. Comorbidity, i.e., the number of severe, chronic medical conditions, will determine whether or not a procedure or treatment will be a covered benefit. Age will be one of these comorbidities, but not the sole one, unless things become pre-cataclysmic. No percutaneous valve replacements for a 91-year-old grandfather with diabetes and kidney disease.
2. Medical care for prisoners will be titrated to the offence. Rapists, child molesters and serial killers with no longer be escorted by two highly paid guards for diagnostic testing and expensive surgery so that they can be housed for a few more decades at great taxpayer expense. When things get bad enough, single murderers will find themselves in the same boat. When things get even worse, attempted murderers may succumb to the same fate.
3. Drug addicts will be denied care for ongoing abuse. When things get worse, tobacco abusers better watch their backs.

Of course, before any of this occurs we will have to bring the economy to its knees. Our dysmorphic view of how a compassionate society is defined (and the powerful trial lawyers lobby) will fight these kinds of changes to the very end. All of the above, to some extent, should have been implemented years ago, but we tend to be a much more reactive than proactive culture. Perhaps it’s human nature, wanting to put off the suffering for as long as possible, even if it means an even worse fate down the line. Maybe it will take an intervention, like falling off the fiscal cliff or banging our skulls against the debt ceiling.

Tough love hurts.

MULTIPLYING DAVIDS AND SHRINKING GOLIATH

The ideological divide in this nation seems to sharpen as the presidential election draws nearer. My views on individual responsibility and small government are known to my readers, but often lost in the anti-government rhetoric is the reminder that the absence of government is not the answer—that’s anarchy.

The truth is, there is an essential role for government in society but in the tangle of its myriad unnecessary interventions its primary functions become diluted out and it loses its way. It seems others have noticed. Here’s a reference cited in the ACC News Digest:

Economists Suggest Minimal But Important Role For Government In Healthcare.

Modern Healthcare (9/6, Evans, Subscription Publication) reports on a recent article published in Health Affairs, which suggests a minimized, but productive and important role for the Federal government in supporting the private healthcare market. The authors, economists Aparna Higgins and Neeraj Sood, argue that “to best promote healthcare delivery and payment reform, the public sector should fund research, provide access to capital, work closely with the private sector and limit its regulation to address ‘market failures’ such as monopolies.”

Unfortunately, our present government paradigm consists of trying to regulate anything and everything it can get its clumsy hands on. In the process it fails to restrict monopolies not only in the health care sector but in the economy at large. When the inevitable collapses loom they’re “too big to fail” and require taxpayer resuscitation. And with Obamacare, the government is getting a step closer to co-opting the health care economy.

Government isn’t the best instrument to rectify all ills; it’s a club, not a scalpel. Some of you may recall one of the center posts of my proposed solution to the health care crisis was a program administered by medical professional societies (not government regulators) to apprise physicians of their individual utilization statistics relative to their peers in an effort to curb unnecessary ordering of tests. I maintained most physicians would be motivated to self-correct. Here is an excerpt from theheart.org referencing a study that showed a decline in cardiac imaging studies over the past decade: Patrick White, the president of MedAxiom, a company that specializes in collecting cardiology practice data stated, “Physicians are competitive. So if we put data in front of them showing them that they’re performing below the median, sometimes below the 75th percentile, they are very motivated to make improvements.”

Attempting to micro-manage details from afar with reams of progressively more complex laws leads only to more effective and ingenious ways to circumvent those laws, at greater taxpayer expense. Given personal responsibility and the appropriate constraints to minimize fraud and abuse, the system will self-correct, assuming a generally moral citizenry that wants to do the right thing.

I hope that’s no longer a pie-in-the-sky assumption.

I HATE TO SAY I TOLD YOU SO …

Well, maybe not. There is a perverse pleasure in seeing one’s assessment, even when it comes to bad news, validated. It’s human nature. To that end I present a recent excerpt from the ACC News Digest that references several sources analyzing our health care spending:

IOM Says US Health System Wastes $750 Billion Annually.

The AP (9/7, Alonso-Zaldivar) reports that yesterday the Institute of Medicine issued a report finding that “the U.S. health care system squanders $750 billion a year – roughly 30 cents of every medical dollar – through unneeded care, Byzantine paperwork, fraud and other waste.” The conclusion drawn is that while both “President Obama and Republican Mitt Romney are accusing each other of trying to slash Medicare and put seniors at risk … deep cuts are possible without rationing, and a leaner system may even produce better quality.” That’s because the IOM’s “one-year estimate of health care waste is equal to more than 10 years of Medicare cuts” under the ACA and “more than enough to care for the uninsured.” The report also “identifies six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion) and fraud ($75 billion).”

The Washington Times (9/7, Cunningham) reports in its “Inside Politics” blog, “The report highlighted flaws that have long plagued the U.S. health care system, which is relatively slow to adopt new technologies, lacks incentives for doctors and hospitals to keep costs down and doesn’t encourage all of a patient’s providers to coordinate care.”

ABC (9/7, Wong) in its “Medical Unit” blog says that “the money squandered on services that failed to improve Americans’ health could have provided health insurance for more than 150 million workers or covered the salaries of all of the nation’s first responders for more than 12 years.” Author Dr. Mark Smith, president of the California HealthCare Foundation, said, “We’re spending money in ways that don’t seem to improve people’s health.”

I began this blog a few years ago with the health care system as its initial focus. My estimates were based on my personal experiences but I suspected, correctly it seems, that my observations were generalizable. There is a silver lining to this bad news: With this much waste, theoretically we can dramatically improve our health care delivery and its cost by waste cutting alone. The devil’s in the details of ferreting out the problems and realigning the incentives.

In early 2010 I whittled down my 15 recommendations for a healthier health care industry to what I felt were the most crucial 5:

1. Tort reform. Without it we’re banging out heads against an endless testing and retesting wall.
2. Increase competition by allowing patients to obtain coverage from out-of-state insurers, possibly in conjunction with nonprofit health cooperatives owned by the patients. Mandatory minimum coverage for those that can afford it has to be part of this.
3. Establish a centralized medical records database.
4. Immediately halt the arbitrary reimbursement cuts (actually, they seem to be based solely on volume and cost, rather than utility and appropriateness).
5. Notify physicians and providers that are utilization outliers (and by that I mean beyond two standard deviations from the mean) of their status, without penalties.

Since then I’ve become less sanguine about the value of tort reform as a means of reducing cost, considering its impact (or lack thereof) in California, where we’ve had it for decades. Its benefit lies in its ability to bolster physician access by limiting the bloated malpractice insurance premiums that drive doctors away from essential specialties. In any case, little has progressed in this arena. Likewise, numbers 2 and 3 have seen little change, although isolated EMRs are springing up like poorly programmed weeds due to government incentives, which is a first step toward more universal connectivity. Reimbursement cuts are proceeding, although haltingly, so as to keep physicians from bolting from Medicare. I haven’t seen even a mention of number 5.

Will Obamacare be the answer? I know people who think so. I’m skeptical that a complex law no one fully understands, and which the legislators haven’t even read, can increase the extent and scope of medical coverage by increasing taxes without further driving us to the brink of bankruptcy, but we’ll see. Unless it’s repealed.

The only thing for certain is that the only road to “something for nothing” is waste management.

THE ARGUMENT IS TAXING

I’m fed up. The media has nothing better to do than bombard us night and day with the tug-of-war between left and right about whether the health care mandate is a “tax” or a “penalty.” If you’re like me, you’ve been rolling your eyes at the distraction and muttering “here we go again.”

My position on the Affordable Care Act, better known as Obamacare or Romneycare super-sized, is simple. It’s another freebie, writ large, with wonderful gimmees such as health coverage without regard to pre-existing conditions and dependent coverage on their parents’ policy until age 26, as well as new coverage for millions of uninsured. Who could be against that? It’s the same song warbled afresh with every social program, just bigger. It will tax us more and almost certainly remain incompletely funded to keep our creditors and bill-inkers in business (see—job creation at work). And now we know it’s constitutional—because five out of nine Chief Justices told us so.

My view on the mandate to buy health insurance is also simple. I worry that the government may see the Court’s decision as license to require the American public to buy other things it deems to be in our best interest, subject to penalties or taxes or whatever you choose to call it. But I also think it’s ingenuous to expect emergency rooms to be legally compelled to provide “free” care to those that can afford to pay but choose to exempt themselves. You see, I don’t want to pay for your health care if you don’t. Call me selfish.

As for you, Mr. Obama: The mandate was not a tax when you needed to sell it to the American people, but was when you needed to defend it to the Court. Now it’s a penalty again. And you, Mr. Romney, are no better. It was a penalty in Massachusetts and before the Supreme Court got hold of it, now it’s a tax, because five out of nine Chief Justices said so, even though you don’t agree with them—so there!

Enough squabbling, children. Let’s get back to business. Republicans, we know how you feel about the ACA—you’ve told us, over and over—and over. We get it. What we need to know is your alternative. Democrats, stop with the tax vs. penalty “it all depends on what the definition of ‘is’ is” arguments, and move on to your next unfunded gimmee. Surely there are more votes out there to be bought and time’s a-wastin’.

It’s all enough to give me a pre-existing condition.

SHELL GAMES

Politics is what it is—a game of perception. It should be clear to everyone at this time that Barack Obama has little to run on going forward, and still the polls are neck-a-neck. He ran on change—transparency, Guantanamo, nixing lobbyists, unification, economic rebound, and all have failed to materialize. Arguably his biggest accomplishment, health care reform, is viewed by more than half of the electorate as a disaster in evolution. So, if you can’t run on your record, you attack your opponent’s true or perceived negatives; distraction is your ally.

Romney presents somewhat of a problem, however. While conservative opponents in the primary months attacked him as being a moderate, this won’t work for Obama’s team. Instead, they have to dredge up all the old conservative stereotypes: anti-poor, anti-women, anti-gay, pro-pollution. Among true believers, it works. Among true believers, it doesn’t matter—it’s the undecideds, the independents that have to be convinced. So they look for dirt. Here’s the challenge for the Democrat party: Romney’s been such a straight arrow that they’ve had to go all the way back to high school when he allegedly was involved in a bullying episode! Election over—Obama 1, Romney 0.

Kidding aside, if you believe character matters, a revealing story about Romney made the rounds not long ago in a paid political ad and on the Internet that has been vetted by Snopes. In 1996, when he was founder and managing partner at Bain Capital, Romney played a central role in organizing a major effort to find a partner’s daughter, going so far as to close the company and fly 50 employees to New York. He is quoted as saying at the time, “Our children are what life is all about. Everything else takes a back seat.”

Let’s look beyond the distractions to the candidates’ characters and the issues. Let’s get the divisive social issues such as abortion and gay marriage off the federal platforms and ship them back to the states, so we can focus on making the country healthy again.

The only one who wins in a shell game is the person shuffling the shells.