nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Wednesday, November 12, 2008



No jokes in this one…well, maybe a little irony…and only one topic.  If you’re not up for some serious thinking on a complex issue, give it a miss.  Next issue I’ve got a couple of doozies for your entertainment.


U.S. Rep. Henry Cuellar expects Barack Obama to pass legislation within the early months of his presidency that will ensure that an extra four million children receive health insurance.

Cuellar said that, of the four million extra kids that will receive coverage under CHIP, about 500,000 live in Texas and many of those are from the border, reported the Rio Grande Guardian. Cuellar said CHIP was important to him because he authored the legislation - HB 997 - that set up a pilot program in Laredo back in 1997, when he was a state representative. The pilot program was so successful that it became a model for the whole state, the Guardian noted. The 110th Congress tried to expand CHIP but fell about 13 votes short of overriding President Bush's veto. Cuellar said the bill was postponed until next March, and that he was confident the new president "will be willing to work with us," the Guardian added.
Rio Grande
Guardian, November 6, 2008

AMA, other physician groups hopeful President-elect Obama will make healthcare reform a major priority.


Modern Healthcare (11/6, Lubell) reports, "Physician organizations appear confident that President-elect Barack Obama (D) will make healthcare reform a major priority, although his interests in resolving Medicare payment issues are less clear." According to AMA president Nancy Nielsen, M.D., Ph.D., "Obama 'has proposed a serious framework for health system reform in 2009, and made it a central issue in his campaign." Dr. Nielsen added that "the AMA shared Obama's focus on expanding health insurance coverage and choice through income-related federal subsidies," and the group looks "forward to continuing to work with him and the new Congress toward reform." She also noted that "bipartisan efforts will be an essential building block for comprehensive healthcare reform."


Doc D:  Healthcare reform proposals need some close scrutiny.  The Republican party proposals focused on market competition along with tax measures to increase affordability, allowing more people to be able to buy healthcare coverage.  This is more of the free market same-old-same-old.  The best that can be said is that it would give “some” of the uninsured a chance to be covered, and that costs, while continuing to rise, would rise a little slower.  Ultimately, it would only delay the worsening crisis. 

The Democratic platform, on the other hand, concentrated on the “Pie in the Sky” approach (see here, or  the emphasis was on coverage for the uninsured, the most clear of which was that for all children.  Costs were dealt with by “cutting taxes” and reduced administrative overhead, primarily from the adoption of electronic health records (EHR).  Actually, the reduced taxes would be in the form of a rebate, like we got this year (what insanity was that, with a big budget deficit already?), and NOBODY I know except Obama advisers thinks that EHR’s are going to save much money: it will take many years even to adopt a universal standard for health records. Right now there are a hundred software systems, none of which can talk to each other.  So, will the administration and Congress plan to nationalize another chunk of the healthcare market, with no realistic way to pay for it?  Does this sound familiar?

Let me recap some things I’ve shown in previous letters:

  1. 75% of the federal budget is “transfer payments:” This part of the budget is unalterable.  The Big Three that account for most of this spending are:  Medicare, Social Security, and Welfare.  With current revenues, all three will be bankrupt eventually.  Where’s the money going to come from to pay for the Big “Four”, with the addition of another healthcare benefit?
  2. The “47 million uninsured” figure everybody tossed around didn’t stand up to scrutiny.  It included 20% who were below the poverty line, and were already potentially covered, and it included everybody who made enough not to need coverage.  See the data here.  The most recent update (2007) says that the no. of uninsured has fallen by 1.5M.  Still a problem we need to fix, but not as advertised.
  3. The Clinton administration balanced the budget.  Hoo-ray.  But, most people don’t know that $160B of the $200B deficit reduction came out of Defense: reduced manpower, cancelled equipment replacement, and the like.  Those tanks and planes are wearing out, and there’s nothing in the pipeline to replace them.  You need at least a decade of lead time to develop and procure things like this.  ANOTHER big bill that will be forthcoming, and will cause a lot of finger-pointing.
  4. Employers say that their biggest cost is Labor, and the fastest growing part of that is healthcare.  Tax increases on businesses, and increased employer healthcare requirements (as proposed), will reduce capital for (1) growth, (2) hiring, and (3) salary increases.  In a time when we expect layoffs due to the financial crisis, this could aggravate rising unemployment.
  5. The federal deficit had been falling in the last three years and until the mortgage brouhaha, was projected to be about $100B.  Now it’s projected to double from the current $200B (even before the financial bailout).  The President-elect’s often repeated claim about the war costing “$10B a month” sounds like a lot of money to you and me, but doesn’t even raise a blip on the GNP graph, and wouldn’t pay for a single domestic program, if recouped.  All of Defense spending is only 3.5% of the federal budget (30% in the 50’s).
  6. Massachusetts, which passed a near-universal coverage law last year, is seeing acceleration in healthcare costs and increasing waiting times.  While the advocates still continue to make happy talk about bringing in the unfortunates who were not covered before, the dirty little secret is that they plumped a whole bunch of people into the system without any way to pay for it, and without considering whether there were enough doctors and clinics to absorb the increase.  This is what happens when you concentrate on Coverage, and disregard Cost, Access, and Quality.
  7. The proposal to expand CHIP included those children in some states who were in families at 300% of the poverty line.  Covering children is a good thing, but this was a transparent effort at national child healthcare.  It would cover all the families except those who are wealthy.  Why couldn’t they just say so?
  8. Fewer applicants to medical school, more doctors retiring early, and very low percentages of medical students who want to go into Primary Care…all spell a big problem on the horizon.  What good does it do you to have healthcare coverage, when nobody is there to take care of you when you need it?


So, what are we facing?  The biggest danger, as I see it, is that we will adopt a major overhaul in healthcare without consideration for ALL the major elements that need to be addressed:  Coverage, Cost, Quality, Access…a four-legged stool.  The administration will likely pursue the traditional Democratic line:  a nationalized program on the European model.   First, get everybody inside the tent with coverage, then introduce the “sacrifice” the President-elect has talked about:  either we raise revenues or we ration care.  Revenue will come from us, the citizens, either through the businesses that provide us with our livelihood or directly through taxes, or fees, or surcharges…or even a VAT like Europe has.  Rationing is the major road that Europe took:  philosophically, they said that ALL the citizenry will share in reduced availability of care, so that it evens out across the board.  If the radiation therapy unit you are using to get your cancer treatment goes on the fritz, you wait until it’s fixed (a real case from a patient I know).  To be fair, some people will disagree with me on this, and say that these are just temporary imbalances in the resourcing of their system…but the data says that everybody waits.

If I’m right, this is a MAJOR change to how we view well-being.  Traditionally, we have valued the individual highly, as against valuing the group (the European model).  We just need to be sure that’s the change we want.

In closing, my guess is that the incoming administration will do one of two things:

  1. They will do a “Hilary”.  There will be an early, big push to get a major healthcare overhaul pushed through, because they know that the clock is ticking on the traditional six-month honeymoon period.  The danger is that it will be just a push to “cover” people, and not reform of the system.  Beyond the honeymoon peeriod, people will begin to say “wait a minute…we wanted change, but this is not the change we thought we were getting.”  Sadly, some new faces will be in town, but it’s the same old political process.
  2. They will be so encumbered with the financial crisis that they will back off on major healthcare reform for one-to-several years, incurring the risk that down the road there will be less punching power to effect change.  At some point, disenchantment sets in, and Congress may flow back toward the Republicans, as has frequently occurred in the past.  The most that can be accomplished in the short term is some improvement in CHIP or the like.

Option 2 is more likely.  There’s some evidence that this could unfold this way.  If you looked at the election results closely, the country voted for a liberal president, but on the ballot resolutions voted conservatively:  one gay-marriage ban didn’t pass and one state did adopt assisted suicide, but elsewhere most proposed gay-marriage bans, affirmative action restriction/elimination, and the like passed.  To me, this means that the election WAS about change, just not a specific change.  The voters are progressive on economics, but conservative on social issues.  Where “Change” bumps up against this polarity, the fur will fly.

Doc D

Opinions are entirely my own.  Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), and AMA Morning Rounds (© U S News Custom Briefings).  As always, you may share this column, with appropriate attribution (above) included:  I just ask that you not forward my email address.  I don’t care to argue with wacky strangers.




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