Community For Better Health Care

Vol VIII, No 21, Feb 9, 2010


In This Issue:

1.                  Featured Article: Change You Can Believe In Needs a Government You Can Trust

2.                  In the News: Babies With Ambiguous Genitalia

3.                  International Medicine: Paying More, Getting Less: 2009 Report

4.                  Medicare: Medicare Free For All: Medicare in Free Fall

5.                  Medical Gluttony: Medical Futility

6.                  Medical Myths: Nationalized medicine will reduce medical errors

7.                  Overheard in the Medical Staff Lounge: What Does Obama Care Mean?

8.                  Voices of Medicine: An Important letter to the American Medical Association

9.                  The Bookshelf: Spiritual and Medical Perspectives on Euthanasia and Mortality

10.              Hippocrates & His Kin: What's the current cost of purchasing a vote in Congress?

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

Words of Wisdom, Recent Postings, In Memoriam . . .

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The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 7th Annual World Health Care Congress will be held April 12-14, 2010 in Washington D.C. For more information, visit The future is occurring NOW.

Keep in touch with evolving healthcare by subscribing to HPUSA . . .

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1.      Featured Article: Change You Can Believe In Needs a Government You Can Trust

Lack of trust in government killed Obama's health care reform

By David J. Gibson, MD & Jennifer Shaw Gibson

A year ago, it appeared that America was heading into a new era of progressivism.  The party of government, the Democrats, had just experience two successive election cycles where their party had attained overwhelming control of both the Senate and the House of Representatives.  They had also successfully elected a President whose activist credentials were impeccable.  What happened? 

We rediscovered the fact that America does not trust the competence of its governments at both the federal and state levels.  Our governments have consistently demonstrated their inability to manage the health care entitlement programs the taxpayers have previously entrusted them to manage.

President Obama on September 9, 2009 claimed that his administration could eliminate $500 billion in fraud fund diversion over the next ten years without taking a single treatment away from a single Medicare patient.  So, why hasn't the federal government produced this savings before?

In 2010 the Medicare and Medicaid Programs are projected to generate over $817.7-billion in spending ($499-billion for Medicare and $319.7-billion for Medicaid).  If one takes the most conservative estimates for fraud diversion within these programs (10%), the current annual loss will be over $81-billion with the actual loss more likely to be twice that amount.

Over the next decade, if one assumes a growth in cost at 5-percent which is roughly the projected rate of inflation within health care and further assume that the Medicaid program will not be expanded as is currently called for within the reform initiative before Congress, the cost for these programs will be over $13-trillion.  That will translate to over $1.3 trillion in losses to fraud.  Using current recovery statistics, less than 0.55-percent, the government will retrieve less than $71.5-billion.

The fraud problem is readily fixable but it will require a proactive, data mining approach, rather than the current reactive, law enforcement approach.

The electorate has reasonably concluded that before they entrust the government with expanded responsibilities for health care, the government needs to demonstrate it capability and objective credibility in efficiently managing the current programs for which it is responsible.  The place to start that effort is by eliminating fraud within the massive social welfare programs now in place.

David Gibson is the president of Reflective Medical, a health care software development company. Jennifer Gibson is an economist specializing in evolving health care markets as well as a futures commodity trader specializing energy.

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2.      In the News: Babies With Ambiguous Genitalia

Going beyond X and Y By Sally Lehrman 

Babies born with mixed sex organs often get immediate surgery. New genetic studies, Eric Vilain says, should force a rethinking about sex assignment and gender identity.

When Eric Vilain began his medical school rotation two decades ago, he was assigned to France's reference center for babies with ambiguous genitalia. He watched as doctors at the Paris hospital would check an infant's endowment and quickly decide: boy or girl. Their own discomfort and social beliefs seemed to drive the choice, the young Vilain observed with shock. "I kept asking, 'How do you know?' " he recalls. After all, a baby's genitals might not match the reproductive organs inside.

By coincidence, Vilain was also reading the journals of Herculine Barbin, a 19th-century hermaphrodite. Her story of love and woe, edited by famed social constructionist Michel Foucault, sharpened his questions. He set on a path to find out what sexual "normality" really meant--and to find answers to the basic biology of sex differences.

Today the 40-year-old French native is one of a handful of geneticists on whom parents and doctors rely to explain how and why sex determination in an infant may have taken an unusual route. In his genetics laboratory at the University of California, Los Angeles, Vilain's findings have pushed the field toward not only improved technical understanding but more thoughtful treatment as well. "What really matters is what people feel they are in terms of gender, not what their family or doctors think they should be," Vilain says. Genital ambiguity occurs in an estimated one in 4,500 births, and problems such as undescended testes happen in one in 100. Altogether, hospitals across the U.S. perform about five sex-assignment surgeries every day.

Some of Vilain's work has helped topple ancient ideas about sex determination that lingered until very recently. Students have long learned in developmental biology that the male path of sex development is "active," driven by the presence of a Y chromosome. In contrast, the female pathway is passive, a default route. French physiologist Alfred Jost seemed to prove this idea in experiments done in the 1940s, in which castrated rabbit embryos developed into females.

In 1990, while at the University of Cambridge, Peter Goodfellow discovered SRY, a gene on the Y chromosome hailed as the "master switch." Just one base pair change in this sequence would produce a female instead of a male. And when researchers integrated SRY into a mouse that was otherwise chromosomally female, an XX fetus developed as a male.

But studies by Vilain and others have shaped a more complex picture. Instead of turning on male development directly, SRY works by blocking an "antitestis" gene, he proposes. For one, males who have SRY but two female chromosomes range in characteristics from normal male to an ambiguous mix. In addition, test-tube studies have found that SRY can repress gene transcription, indicating that it operates through interference. Finally, in 1994, Vilain's group showed that a male could develop without the gene. Vilain offers a model in which sex emerges out of a delicate dance between a variety of promale, antimale, and possibly profemale genes.

Because researchers have long viewed the development of females as a default pathway, the study of profemale genes has taken a backseat. Over the past few years, though, geneticists have uncovered evidence for active female determination. DAX1, on the X chromosome, seems to start up the female pathway while inhibiting testis formation--unless the gene has already been blocked by SRY. With too much DAX1, a person with the XY complement is born a female. Vilain's group found that another gene, WNT4, operates in a similar way to promote the formation of a female. The researchers discovered that these two work together against SRY and other promale factors. "Ovary formation may be just as coordinated as testis determination, consistent with the existence of an ovarian switch,' " report geneticist David Schlessinger and his collaborators in a 2006 review in the journal Bioessays.

Lately Vilain has been exploring molecular determinants of sex within the brain and whether they may be linked to gender identity. Despite classic dogma, he is certain that sex hormones do not drive neural development and behavioral differences on their own. SRY is expressed in the brain, he points out, suggesting that genes influence brain sexual differentiation directly. His lab has identified in mice 50 new gene candidates on multiple chromosomes for differential sex expression. Seven of them begin operating differently in the brain before gonads form. Vilain's group is testing these findings using mice and is collaborating with a clinic in Australia to study expression patterns of the sex-specific genes in transsexual people.

This work, like much of Vilain's efforts, treads on fairly touchy ground. He copes by sticking to his findings conservatively. "You also have to be aware of the social sensibilities," he explains. Accordingly, he has come to agree with some gender activists that it is time to revamp the vocabulary used to describe ambiguously sexed babies.

At the 2005 Intersex Consensus Meeting in Chicago, he stood before a group of 50 geneticists, surgeons, psychologists and other specialists and argued that terms such as "hermaphrodite," male or female "pseudohermaphrodite" and "intersex" were vague and hurtful. Instead of focusing on a newborn's confusing mix of genitals and gonads, he urged his colleagues to let the explosion of new genetic findings point toward a more scientific approach. Rather than using "hermaphrodite," for instance, he recommended referring to a "disorder of sexual development" (DSD) and applying the more precise term of "ovatesticular DSD."

Although the attendees eventually concurred, not everyone likes the new terminology. Some who prefer "intersex" feel that a "disorder" is demeaning. Milton Diamond, who studies sex identity at the University of Hawaii, complains that it stigmatizes people who have nothing wrong with their bodies.

But the decision to change nomenclature realizes a 15-year dream for Cheryl Chase, executive director of the Intersex Society of North America (ISNA). Chase has fought for years against secret, rushed surgeries intended to comfort parents and adjust anatomy to match an assigned social gender. Recalling how a doctor once called her "formerly intersex," she hopes physicians will begin to see mixed sex characteristics as a lifelong medical condition instead of a problem to be quickly fixed. "Now that we've accomplished the name change, culture can accomplish a little magic for us," she predicts. . .

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3.      International Medicine: Paying More, Getting Less: 2009 Report.

Ontario, New Brunswick on pace to spend half of all revenue on health care by 2014; four other provinces expected to hit 50 per cent by 2034
(November 30, 2009)

TORONTO, ON—Provincial spending on health care continues to grow faster than provincial revenues, with six out of 10 provinces projected to be spending half of all available revenue on health care by 2034, according to a new report from the Fraser Institute, one of Canada's leading economic think-tanks.

Ontario and New Brunswick face the biggest crunch, where health expenditures are on pace to consume half of total provincial revenues by 2014 or earlier. 

The study suggests that Prince Edward Island will likely reach the 50 per cent point within 10 years, followed by Nova Scotia in 15 years, Manitoba in about 17 years, and Quebec in 25 years.

"Health spending has increased at an unsustainable rate in the majority of provinces over the past decade," said Brett Skinner, Fraser Institute Director of Bio-Pharma, Health, and Insurance Policy and lead author of Paying More, Getting Less: 2009 Report.

"Unless provincial governments can devise a better way to finance health care, they will be forced to either hike taxes, expand rationing of medical goods and services, or make extensive cut backs in other government programs."

Paying More, Getting Less: 2009 Report is the Fraser Institute's sixth annual report on the financial sustainability of provincial public health insurance. The peer-reviewed study makes projections using Statistics Canada data on the most recent 10-year trends for provincial government health expenditures and total available provincial government revenue from all sources.

Skinner points out that while the 10-year trend confirms the urgency of the sustainability problem, more recent one-year trends are even more concerning.

"Over the past year, health spending in Ontario is on pace to consume 50 per cent of total available revenue in the province by the end of next year," he said.

The report points out that some provinces have tried to address the sustainability problem by raising tax burdens. Skinner argues that this approach is misguided.

"Tax hikes reduce economic growth in the long run, resulting in job losses and increased demand for government spending on employment insurance and social assistance programs. Attempting to drive long-term revenue growth through tax increases is futile, and if introduced at this time, would only further delay economic recovery from the recession," he said.

The report also chronicles how provinces have tried to cut health spending using blunt, centrally imposed rationing. Provincial governments are increasingly forcing Canadians to accept less from public health insurance by reducing the supply of physicians and nurses, allowing hospital infrastructure to deteriorate, and refusing to cover new medical technologies. All of which contributes to long wait times for health care services, Skinner notes.

"Despite these misguided efforts, health spending is still growing faster than the ability of government to pay for it."

The report concludes that Canada's current public health insurance system is simply not financially sustainable through public means alone and recommends several changes: . . .

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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

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4.      Medicare: Medicare Free For All: Medicare in Free Fall

Medicare at 55 by Andrew J. Rettenmaier and Thomas R. Saving

Brief Analyses | Health No. 682 Tuesday, December 15, 2009

A proposal to allow 55- to 64-year-olds to buy Medicare coverage is gaining traction in the Senate deliberations on health care reform. What will this mean for Medicare's finances? How much will it cost to buy the coverage? How will this expansion affect the labor force participation of older Americans?

How Much Will It Cost to Buy Into Medicare? Proponents of the change say that new enrollees will be charged a premium that reflects the total cost they will add to the Medicare program. Since Medicare often pays providers less than private payers, Medicare premiums could be lower than private insurance premiums in principle. However, Medicare coverage is less complete than what most Americans expect from health insurance. That is why so many seniors pay a second premium for MediGap insurance. Unless this Medicare expansion is heavily subsidized the odds are that very few uninsured near-elderly will opt in.

If Medicare Coverage Is Subsidized, Will the Currently Insured Near-Elderly Drop Their Private Insurance to Enroll? As of 2008, 12.5 percent of 55- to 64-year-olds were uninsured, representing less than 10 percent of all uninsured. To induce this uninsured group to voluntarily buy into Medicare, the premiums would have to be subsidized in some way. But these subsidies would also make Medicare attractive for those who currently purchase their own private insurance

Are the Uninsured Near-Elderly More Likely to be Unemployed or to Have Low Family Incomes? How does the labor market activity of the uninsured members of the targeted age group differ from those who have insurance coverage? Figure I shows how labor force participation and family income vary by type of insurance coverage for the 55 to 64 population. Among the uninsured in this age group, about 57 percent are in the workforce and 22 percent have family incomes of $60,000 or more. More of those who purchase their own insurance work and they have higher earnings, but they account for just over 7 percent of the targeted population. The 60 percent of this age group covered by private employer-based insurance have the highest labor market participation rate - almost 80 percent - and 55 percent are in families with income of at least $60,000.

Are the Uninsured Near-Elderly More Likely to Be in Poor Health? The uninsured among the 55- to 64-year-old population is the target of the proposed Medicare extension. Those who are less healthy may not be able to find affordable health insurance. Figure II compares the health status of this age group by insurance coverage: 

·                     Individuals with employer-provided or self-purchased health insurance report the best health, while 64 percent of those covered by Medicare and/or Medicaid report fair or poor health. 

·                     By contrast, 76 percent of the uninsured people in this age group report that their health is good, very good or excellent, and 24 percent report fair or poor health.

Thus, the evidence suggests that uninsured older Americans are not uniformly in low-income families nor are they uniformly in poor health. 

Will Subsidized Medicare Insurance Induce the Near-Elderly to Drop Out of the Labor Market? An unintended consequence of the proposed change is its impact on the labor force participation of the 23 million baby boomers between 55 and 64 who currently work. While health insurance coverage should be portable from job to job, the lack of portability because of the present tax treatment of health insurance appears to influence the timing of retirement: 

·                     Social Security's early retirement age is 62 and 40 percent start claiming benefits at this age. 

·                     But there is a second spike at 65, the age of eligibility for Medicare, when 34 percent join the Social Security rolls.

This suggests that many older Americans continue to work until they are eligible for Medicare benefits.

Could the New Program Add to Medicare's Unfunded Liabilities? Given that a significant portion of individuals wait to claim Social Security until they are also eligible for Medicare, the structure of the new reform, particularly the subsidy rate, will determine how many workers will exit the labor force if their continued work is not required for health care coverage.  Such a drop in labor force participation will reduce both tax revenue and output. The ultimate costs of the reform are therefore more than just the subsidy per capita multiplied by the number of people who buy into Medicare. Further, subsidy rates in Medicare have a history of growing. Initially, Medicare's Part B premiums paid by enrollees were to cover 50 percent of the program's costs and taxpayers were to subsidize the other 50 percent, but within 17 years of Medicare's passage taxpayers were subsidizing 75 percent of the cost. However the cost is accounted for, this Medicare expansion would likely add to the program's unfunded liabilities.

Conclusion. These are some of the foreseeable consequences of extending Medicare to the 55- to 64-year-old population. If the proposal does not include generous subsidies, the uninsured probably won't find it attractive. However, even without subsidies it may induce some current workers to retire early. But if the proposal does include large enough subsidies that make it attractive for the uninsured to voluntarily buy-in, then the costs of covering the uninsured will rise. In addition, the subsidized Medicare will make early retirement much more attractive for the currently insured working population. Thus the expansion of Medicare to the 55- to 64-year-old population is likely to be expensive and counterproductive. 

Andrew J. Rettenmaier and Thomas R. Saving are executive associate director and director, respectively, of the Private Enterprise Research Center at Texas A&M University and senior fellows with the National Center for Policy Analysis

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Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony: Medical Futility

An effort to provide a benefit that reason and experience suggest is highly likely to fail and in rare exceptions cannot be systematically reproduced. –L. Schneiderman, N. Jecker, A. Jonsen

The Medical Grand Rounds at the University of California at Davis recently was given by Emeritus Professor of Ethics titled: "Where Oh Where Has Futility Gone"

This is a topic that has been discussed in Medicine for more than two decades as the reference below indicates. Because of legal ramifications, physicians listening to lawyers rather than their own ethical judgment, it has been difficult to contravene until recently. As more data has become available, physicians have been able to make their own decisions in concert with the patient or his/her family or those in charge based on rational judgment.

Dr. Jonsen cited data that more than 800 patients given bone marrow transplants who had underlying liver and lung disease requiring a minimum of four hours of ventilator care had zero survivors. Thus the BM transplant can be categorized at Medical Futility before implemented rather than afterwards when failure becomes obvious. This averts the anguish that family members are subjected to and the painful discussion revolves around the decision to turn off the ventilator and watch a loved on die.

In my professional experience, when patients and families have agreed that it would be inappropriate and futile to intubate, I would rush to the patient's bedside to control the rush to start life support and stand with the family at the patient's bedside between the patient and the mechanical devices which were rushed in to begin the "futile effort." The respiratory therapists sometimes seem to be pleading to allow them to start life support. This effort was sometimes so aggressive that if I moved to the foot of the bed, the therapist would rush in to begin heroic and futile efforts.

This was not fully understood until a Respiratory Therapist mentioned to me in private that I had just cheated the hospital out of a lot of money. How much? He stated that the charge for the set up was $500 and he thought it was about that much for each additional half hour. Did I cheat the hospital out of $24,000 a day? One therapist could manage two patients in the ICU on ventilators. Were they really getting $48,000 return on one employee's work? That was not a bad one-employee return on a $17 an hour (the RT pay rate at that time.) hospital cost. This of course, could never be corroborated since hospital charges are not published or made apparent.

Dr. Jonsen also cited data on occasion where medical futility for the patient is appropriate. A woman who was near term in her pregnancy suffered a massive stroke. There was no hope of recovery. However, the decision was reached by the medical team, in concern with her husband, to keep this brain dead woman on life support until she could be delivered of her child. Since the fetus was viable, this was accomplished and a healthy baby was delivered from a dead mother.

Medical Futility: Its Meaning and Ethical Implications. By L. Schneiderman, N. Jecker, A. Jonsen, Ann Intern Med 1990; 112:949-54.

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Medical Gluttony thrives in Government and Health Insurance Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6.      Medical Myths: Nationalized medicine will reduce medical errors

AAPS Myth 15. Nationalized medicine will reduce medical errors, improve care, and save lives.

Based on 173 deaths in the Harvard Medical Practice study, and extrapolating to the entire U.S. population, the Institute of Medicine (IOM) has been claiming for almost a decade that as many as 98,000 Americans are killed by medical errors every year.

Moreover, it is asserted that Americans have only about a 50/50 chance of receiving "proper health care."

The proposed solution: electronic records with constant surveillance of compliance with government-approved protocols. The IOM claims that its methods could reduce errors by 50% over 5 years.

The IOM's definition of error, the assumption that a death was a result of the error and would not have occurred anyway, and its guesstimate of the number of deaths all lack independent confirmation. The IOM number is three to seven times higher than a 1998 estimate by the National Safety Council.

Although the IOM analysis is uncritically accepted by the AMA and other influential bodies, there is no evidence at all that the proposed solution would result in any improvement in mortality or other patient outcome measurements. More likely results are:

·                     Choice of therapies not embraced by mainstream medicine would be much curtailed. Nutritional approaches, long-term antibiotics for Lyme disease, chelation, hyperbaric oxygenation, acupuncture, prolotherapy, treatment for multiple chemical sensitivities, and other innovative, nonstandard, or "alternative" modalities could become unavailable.

·                     Intensified oversight and rigid protocols might make physicians even less likely to provide adequate relief for chronic pain. National electronic databases of prescription drugs would facilitate stigmatizing patients who use controlled substances whether for pain or mental health reasons.

·                     Patients' freedom to decline "recommended" therapy—such as vaccines and psychotropic drugs—would be threatened as doctors feared being penalized as "outliers."

·                     "Recommended" therapy has possibly done more harm than medical errors, and more rapid and widespread adoption could amplify the harm resulting from a misdirected "guideline." For example, more than 50,000 individuals are estimated to have died from encainide (Enkaid) and flecainide (Tambocor), used as directed to treat abnormal heart rhythms, before their adverse effects were recognized (Kilo CM, Larson EB. Exploring the harmful effects of health care. JAMA 2009;302:89-91). A trial of aggressive blood sugar control was stopped because the "common wisdom" was apparently wrong: more patients died from the "improved" treatment (Couzin J. Deaths in diabetes trial challenge a long-held theory. Science 2008;319:884-885).

·                     Guidelines focused on cost control would deprive patients of newer, more effective drugs. Oncologist Karol Sikora states that thousands of premature deaths result from the British National Health Service's restrictions on new drugs through its National Institute of Clinical Excellence (NICE) (Union Leader 5/12/09).

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Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7.      Overheard in the Medical Staff Lounge: What Does Obama Care Mean?

Dr. Rosen: What do the doctors in our hospital think of Obama care?

Dr. Yancy: Not much.

Dr. Paul: It really doesn't make any difference what we think here at lunch. It's coming and we can have our unions negotiate the terms.

Dr. Yancy: So you think we'll all be union workers?

Dr. Paul: Certainly. Just like everyone else.

Dr. Dave: I don't follow you Paul. It looks like unions are losing clout and membership all over the country. You want to be like them?

Dr. Paul: The union man has a carefree life. He doesn't have to sweat the decisions. He just has to read the rulebook and follow along.

Dr. Edwards: You would be happy to do that?

Dr. Paul: Who said anything about happiness? You look rather down in the mouth yourself. You must not like our current system.

Dr. Edwards: Can't say as I do.

Dr. Paul: So you don't like free-market health care, do you?

Dr. Edwards: We don't have free-market health care by any stretch of the imagination. We have government-dictated healthcare.

Dr. Paul: So if the government is dictating to us, why not be on the same level with forceful negotiation.

Dr. Edwards: I don't think union leaders would understand practice issues any more than the government does at this time.

Dr. Paul: They don't have to. They just need to whip the membership into shape and bulldoze those that don't want to go along out of the way.

Dr. Rosen: So you think that's what an advanced society has evolved into? Sounds more feudal to me than a freedom-loving and kind society built on the Golden Rule.

Dr. Paul: I know it's difficult for a non progressive. But you'll get use to it. Then we'll all be in it together and we'll cooperate much more than we are doing right now.

Dr. Edwards: I get the impression cooperation for you is that we're all in the same pot and fighting a common enemy and it will be us fighting each other.

Dr. Paul: But we will know who the villain is. It may be the government, but we'll have power to strike, withhold care, not furnish coverage and go home at 4:30. And enjoy the good life.

Dr. Rosen: I guess we'll have to see what BO can accomplish in his second year. Hopefully more than in his first year. Maybe Dr. Paul is correct—his stimulus is working.

Obama Stimulus Program Is Working.

It has created 3 new jobs:
One in Virginia,

one in New Jersey, and

one in Massachusetts.

More to come in Illinois.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8.      Voices of Medicine: An Important letter to the American Medical Association

TO:          Rebecca Patchin, MD, Chair, AMA Board
As you will recall, I and thousands of other AMA members have committed to resign from the AMA the minute Obamacare is signed into law in any form, placing the blame for that debacle squarely where it belongs, in the hands of AMA leadership and its failure to oppose these bills and to promote the AMA House's will.  However it now seems that Obamacare may die, sadly not through any action of the AMA, but at the hands of the MA Senate election, a huge and welcome surprise.  I certainly hope so.  
At any moment though, and until the Congress adjourns at the end of the year, the Senate bill could be passed intact by the House with no other action by the Senate.  Pelosi is determined to do just that, but does not have the 218 votes she needs.  We charge the AMA to make sure that she never does. 
If she does the automatic AMA resignations will flood in I can promise you, starting with mine.  The AMA must make a strong statement that it does not want the House of Representatives to pass the Senate version of the bill at any time.   That is our biggest risk this year.  Please act promptly, frequently and aggressively to prevent this possible scenario.  
In my opinion, AMA must also withdraw its prior support of the bills and insist they be removed from consideration by the House and the Senate in their entirety.  Congress must tear them up and start over with consensus, bipartisan discussions or none at all.  
We need private contracting, expansion of consumer directed health initiatives and HSAs, across state line insurance sales, assigned risk state insurance program expansion, individual ownership of real insurance and tort reform.  We need to stop insuring primary care which is inexpensive, routine and inherently not insurable.  Patients should pay for primary and much basic office specialty care directly.  
We need to make sure insurance is used for its intended purpose, large, unpredictable, unexpected, rare illnesses and injuries.  Our personally owned health insurance policies should sit unused in the bottom desk drawer at home along with our fire insurance policy with the expectation and hope of never having to use them at all.  That is how real insurance works and that is how it is made affordable.  
We need to stop harping on the SGR fix.  The government is broke and may need to ration care by limiting access with these below market public fees to regain solvency.  Doctors got along before Medicare and Medicaid and we can again, if we can balance bill our better off patients.  We can then also take care of the poor getting partial reimbursement from these failed government programs.  
Doctors need to be encouraged and taught how to run direct practices outside or partly outside the failed public and employer based insurance systems as concierge doctors are now doing by the tens of thousands.  These forms of practice need to be endorsed and encouraged by organized medicine right now and with fervor.  It is the only way we will get students again interested in primary care and office practice in general.  
We who believe in these principles will be watching the AMA very closely to see if it now turns in a rational direction.  Dr. Rohack's remarks on balance billing were a small start, but way short of what needs to be said forcefully by the AMA leadership.
Thomas W. LaGrelius, MD, FAAFP

Director, LACMA, President, LACMA-9 (Los Angeles Country Medical Society)

Chair and IPP SIMPD
Keep up the pressure Tom or let's all get out before Obama tells Americans the AMA is Our Voice. 

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about.

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9.      Book Review: Spiritual and Medical Perspectives on Euthanasia and Mortality

DENIAL OF THE SOUL - Spiritual and Medical Perspectives on Euthanasia and Mortality, M. Scott Peck, MD, Harmony Books, New York, 1997, xi & 242 pp, $23, ISBN: 0- 517-70865-5.

Physician, psychiatrist, theologian, and author of the best-seller, The Road Less Traveled, F Scott Peck, MD, gives us an in-depth look at the current euthanasia movement and its origins in the inability of physicians to "pull the plug." Peck states that although Dr Kevorkian gives him the shivers, he must credit him more than any other individual for the genesis of this book. Almost single-handedly over the past five years, Kevorkian has turned the debate over euthanasia into a national issue within the United States.

But Kevorkian didn't inspire Dr Peck to write this book–it was the public response to his behavior. Peck was surprised by the number of people who admire Kevorkian. He was even further surprised by the larger number who, though they feel no affections for Kevorkian, nevertheless deeply approve of what he has been doing in assisting the suicides of those who are ill. Most of all, Peck has been surprised by the huge number of Americans who do not find Dr Kevorkian's work particularly objectionable.

The whole debate is strangely passionless and seemingly simplistic. But the subject of euthanasia is far from simplistic - it involves questions about who, if anyone, has a right to terminate a life; whether it's the same as or different from suicide or homicide; whether it differs from merely "pulling the plug;" and what role does pain, both physical and mental, play in euthanasia decisions. Among the stories he tells, is one about Tony, a patient of his when he was a psychiatric resident. He felt Tony's craziness was organic and referred him to neurology where he was found to have a large frontal brain tumor. The tumor was inoperable and failed to respond to radiation treatment.

Weeks later when Peck rotated on the neurology service, Tony, now unresponsive and on a ventilator, reentered his life. He wondered why anyone would decide to place Tony on life support. Was this "heroic" medicine, or just a measure to prolong a life that had lost its essence? Peck asked his chief of neurology at Letterman General Hospital whether this effort to prevent inevitable death was the right thing to do? The Colonel commended him, obtained a portable EEG, and found an occasional distorted brain wave and pronounced that the patient was not yet certifiably brain-dead.

Recalling the anguish of the family in waiting, Peck looked at Tony for the next 15 minutes, cut the levophed drip in half, went to the doctor's lounge, smoked a cigarette, returned 10 minutes later, found Tony dead, and informed the family. As they wept, speaking to each other in Italian, he could not tell whether they were weeping in grief or relief. He concluded, probably both. He, of course, had the presence of mind not to tell anyone about what he had done. . . .

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10.  Hippocrates & His Kin: What's the current cost of purchasing a vote in Congress?

Legislatures favorable to industry interests raise more money to campaign, to conduct polls, to buy ads and get elected. Telecom Immunity: House Democrats who flipped their positions to favor immunity for telecom firms received an average of 68 percent more money from AT&T's, Verizon's and Sprint's political action committees, compared with Democrats who remained opposed to immunity. That's $4,987 to each Democrat who opposed immunity and $8,359 to each Democrat who flipped positions to favor telecom firms. Financial Bailout: House members who voted for the $700 billion bank bailout received 54 percent more campaign contributions from banks and securities firms than House members voting against the bailout. That is an average of $231,877 in bank contributions received by each House member voting "Yes," $150,982 for each member voting "No." Prescription drug imports: In the current health care debate in the U.S. Senate, senators voting to block drug imports from other countries, as drug companies wanted, received an average of $85,779 each from drug companies. That's 69 percent more than given to senators who voted to allow imports.

As long as you have a government for sale someone will be there to buy . . .

It also helps politicians like Dr. John Edwards afford a $1250 haircut . . . David Perel

How big's $1.9 trillion in new spending? Very big, By JIM ABRAMS, Associated Press Writer

A 1.9 trillion-mile trip is about the same as 8 million trips to the moon. And 1.9 trillion feet would take you to the top of 29,000-foot Mount Everest 65 million times, or to the bottom of the 36,000-foot Mariana Trench, the deepest point in the Pacific, about 53 million times.

Unfortunately the $1.9 trillion in new borrowing authority Senate Democrats are seeking for the government won't take us quite that far. That amount, raising the national debt ceiling to $14.3 trillion, may have to be increased again after the fall election.

But 1.9 trillion is still a lot, no matter how you look at it. In dollars, it's almost twice all the money America has spent in military operations in Iraq and Afghanistan since 2001.

That amount would buy about 422 Nimitz Class aircraft carriers, which run about $4.5 billion apiece. It would be enough to provide Pell grants of $5,000 to some 380 million low-income students, a number exceeding the entire population of the country.

The world population is currently about 6.7 billion, so 1.9 trillion people would be enough to populate some 284 worlds.

In terms of time, 1.9 trillion seconds adds up to about 60,000 years. And 1.9 trillion hours ago, or almost 220 million years ago, dinosaurs were just beginning to dominate the Earth.

The US Supreme Court has struck down a major portion of a 2002 campaign-finance reform law, saying it violates the free-speech right of corporations to engage in public debate of political issues. . .

Most Republicans and conservatives were pleased. "This is an encouraging step, and it is my hope that political parties will one day soon be able to speak as freely as other citizen organizations are now permitted," said National Republican Senatorial Committee Chairman John Cornyn, R-Texas.

Conservatives saw the ruling as a victory for free speech, and a boost to political challengers.

"Speech about our government and candidates for elective office lies at the heart of the First Amendment, and the court's decision vindicates the right of individuals to engage in core political speech by banding together to make their voices heard."

--Theodore Olson, who argued the case for Citizens United

"The text and purpose of the First Amendment point in the same direction: Congress may not prohibit political speech, even if the speaker is a corporation or union."

--Chief Justice John Roberts

"With today's monumental decision, the Supreme Court took an important step in the direction of restoring the First Amendment rights of these groups by ruling that the Constitution protects their right to express themselves about political candidates and issues up until Election Day."

Senate Republican leader Mitch McConnell of Kentucky

"Today's ruling protects the First Amendment rights of organizations across the political spectrum, and is a positive for the political process and free enterprise."

Robin Conrad, of the U.S. Chamber of Commerce National Chamber Litigation Center

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11.  Organizations Restoring Accountability in HealthCare, Government and Society:

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports. This month, read the informative Why Massachusetts is not a Model for Health Care Reform . . .

                      Pacific Research Institute, ( Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Just released Deadly Irony: California's New HMO Regulations Versus Single-Payer Health Care, by John Graham . . .

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, treat yourself to an alternative to government bailout . . .

                      The National Association of Health Underwriters, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on Obama Signals a Dangerous 2010 Strategy.

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

                      The Heartland Institute,, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read Act Now to Stop Health Care Nationalization.

                      The Foundation for Economic Education,, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President,  and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education Competition and Entrepreneurship.

                      The Council for Affordable Health Insurance,, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. Read her latest newsletter: Caldara is calling for an amendment to the Colorado Constitution that would opt Colorado out of the onerous health insurance mandates coming out of Washington.

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read What People Mean When They Talk About Freedom.

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at for an overview of the extensive research articles that are available. You may want to go directly to their health research section. This month check out: Statistical analysis suggests that increases in health care spending appear to have no effect on wait times for treatment and may even increase wait times . . .

                      The Heritage Foundation,, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. - However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom loving institution and have canceled our membership and contributions.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

                      CATO. The Cato Institute ( was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at

                      The Ethan Allen Institute,, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime,, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the US News College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read               Adam Meyerson on The Generosity of America at The last ten years of Imprimis are archived.

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Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. We respect copyright as exemplified by George Helprin who is the author, most recently, of "Digital Barbarism," just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

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Del Meyer, MD, Editor & Founder

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Words of Wisdom

"Those who speak most of illness have illness; those who speak most of prosperity have it, etc." - From the movie The Secret

"When it comes to eating right and exercising, there is no ‘I'll start tomorrow.' Tomorrow is disease." - V.L. Allineare

Men also abandoned natural relations with women and were inflamed with lust for one another. Men committed indecent acts with other men, and received in themselves the due penalty for their perversion. . . Although they know God's righteous decree that those who do such things deserve death, they not only continue to do these very things but also approve of those who practice them. -Paul of Tarsus to the Romans: 1:27, 32.

Some Relevant Postings

Why Government Doesn't Work, By Harry Browne

The Recession and its Effect on Healthcare by David Gibson, MD and Jennifer Shaw Gibson

Charity, Altruism and Free-Market Medicine by the late Madeleine Pelner Cosman, PhD, Esq . . .


HealthPlanUSA is now a separate Newsletter devoted to the rapidly evolving field of health plans being promoted throughout the USA. These are dangerous times. Stay tuned to the current issues, which we bring quarterly and will increase as staffing permits. Why not sign up now at

In Memoriam

Miep Gies, shelterer of the Frank family, died on January 11th, aged 100
From The Economist print edition | Jan 28th 2010

BY HER own account, Miep Gies did nothing extraordinary. All she did was bring food, and books, and news—and, on one fabulous day, red high-heeled shoes—to friends who needed them. It was nothing dramatic. But she also bought eight people time, and in that time one of her charges—a teenage girl called Anne Frank, the recipient of the shoes—wrote a diary of life in the "Annexe". In these four rooms, above the office of Anne's father, Otto, where Mrs Gies worked as a secretary, eight Jews hid for 25 months in Amsterdam in 1942-44.

On the warm summer evening when the Franks went into hiding, Mrs Gies took charge. In subsequent months she and her trusty bicycle often carried so many bags of vegetables, bought with forged coupons, that she looked like a pack mule. No one suspected.

Every weekday morning she would climb two flights of stairs to the Annexe and get the grocery list. Every afternoon she would deliver the shopping and stay a while to chat—after composing herself and putting on a cheerful expression. In the cramped, stuffy rooms, made dim with lace curtains tacked across the windows, everyone had to whisper. She kept back the worst news: truckloads of other Jews sent to the camps, shot and gassed, and old friends killed. On their side, the four Franks, three van Pels and a dentist called Dr Pfeffer tried to conceal their tensions from her. Nonetheless, she could often feel "the sparks of unfinished conflicts left sizzling in the air". . .

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On This Date in History - February 9

On this date in 1870, The National Weather Service was established as a unit of the U.S. Army.

On this date in 1773, William Henry Harrison was born. He is the undisputed holder of the record for the shortest time in office of any U.S. President. He was inaugurated on March 4, 1841, caught cold and died exactly one month later.

Moral: Do what you need to do while you still have breath before the winds of life change.

After Leonard and Thelma Spinrad

Always remember that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people's welfare.