ms. think

"Creative Capitalism" is dead and I'm so not sorry

noreply@blogger.com (Paula Hall) — Sat, 28 May 2011 19:58:00 +0000

I just searched for the term "creative capitalism" on Google and Bing. I can't find anything dated more recently than 2008. To which I can only say, from the bottom of my heart, yippee!

To review, "creative capitalism" was big in 2008, when Bill Gates made a speech at the World Economic Forum in Davos. It was so uncreative that, two years later, I can't remember anything about it. The name sounds great. But as I recall, it was only the latest public mea culpa by rich people who believe in altruism and who really, really want people to like them.

A piece by Bill Gates in Time Magazine is still on the web, here. I've blogged about it here. Give this stuff a quick once-over and then never, ever, read anything on this topic again. The concept, mercifully, is dead--at least, in this incarnation.

The new family values

noreply@blogger.com (Paula Hall) — Sun, 22 May 2011 22:25:00 +0000

I just watched an ABC Family channel promo which breathlessly promises a Summer of Secrets and Lies. From the network that boasts that it's "a new kind of family."

I think I'll take the old kind, thanks.

Banning direct-to-consumer advertising violates freedom of speech

noreply@blogger.com (Paula Hall) — Sat, 26 Jun 2010 15:27:00 +0000

Comments on this WSJ Health Blog post about the FDA's proposed new rules on direct-to-consumer (DTC) TV advertising of drugs assert that such direct-to-consumer advertising should be banned. Like practically every call for a ban against direct-to-consumer advertising the comments assume, without arguing for it, that it is in the financial interests of pharma companies and doctors to have consumers getting sick or dropping like flies from taking dangerous or misprescribed medications. Those who clamor for such a ban further assume that there will be no competition between pharma companies or doctors on the basis of quality.

But other industries which engage in direct-to-consumer advertising produce safe products and compete on the basis of quality. Why would pharma companies and doctors be any different? The answer is, they're not any different. Drug companies and doctors profit from selling valuable services and products, not dangerous or worthless services and products.

On the other hand, we do know that individuals don't lose their right to speak freely simply by engaging in coordinated corporate action. Calls to ban DTC advertising are calls for governments to censor corporate free speech.

We're all on the menu

noreply@blogger.com (Paula Hall) — Mon, 21 Jun 2010 12:54:00 +0000

The American Medical Association News reports that Massachusetts physicians and hospitals will likely see pay cuts. That's because the Massachusetts Division of Insurance vetoed 86% of insurers' requests to raise premiums. This despite the following:

A report by the Massachusetts Health and Human Services' Division of Health Care Finance and Policy that looked at spending trends from 2006 to 2009 found more than 88% of premiums collected in Massachusetts are spent on medical expenses, compared with less than 84% nationally. The report also found that premiums increased 12.2% during that time frame, and the increase was caused almost entirely by growth in medical expenses.

And despite the fact that two insurers whose rate increase requests were denied -- two of the largest insurers in Massachusetts -- have first quarter 2010 losses of $51.9 million and $65.2 million.

Both said the losses were from collecting 2009 premium rates and paying out 2010 medical costs. As companies appeal to the state for premium increases, they are required to keep charging at April 2009 rates.

Massachusetts is eating up its insurers to pay for its rights-abridging health care system -- you know, the system that served as the model for ObamaCare. That's because insurers are an easy target, politically. But since Massachusetts insurers are already showing signs of eventually going under, or going AWOL, Massachusetts Governor Deval Patrick "encouraged health plans to revisit their contracts with health care entities as a way of cutting costs." In other words, Massachusetts have officially put doctors and hospitals on the menu. And why not? Another easy target about demogoguery against "the rich."

But after Massachusetts has eaten up all its private insurers, and eaten up all its doctors and hospitals, and ended up with a completely statist heatlh care system (Great Britain, anyone?), who will be left to scapegoat when costs keep spiraling out of control? It will be the taxpayers, you and me. The state will raise taxes and premiums on everyone regarded as better off than the most unfortunate health-care-resource-sucker in the system. Anyone healthy and able to work will be accused of taking more than their fair share every time they see a doctor, because unless they're walking dead it will be argued that they are using resources best saved for the truly needy. Like someone who needs end-of-life palliative care after spending so much time on a waiting list for basic chemotherapy that they're no longer healthy enough to be helped by chemotherapy.

Thanks to ObamaCare, this is the fate that awaits everyone in every state in the nation.

Pockets and Bedrooms

noreply@blogger.com (Paula Hall) — Sat, 23 Jan 2010 14:11:00 +0000

Paul Hsieh has a nice Op-Ed up at Pajamas Media about the meaning of the Scott Brown victory in the Massachusetts special election to fill the Senate seat vacated when Ted Kennedy died. Here's the last lines:

The independents have spoken — and they want the Democrats out of their pockets and the Republicans out of their bedrooms.

Will our politicians listen?

Maybe the policians will listen, but I am doubtful. As Harry Binswanger recently said on his HBL discussion list, the American people as a whole don't agree with Objectivism. This means that Americans are still altruists, still believe we are all our brothers' keepers, and still look to the government as a source of "rights" or "entitlements" for ourselves and our "brothers." I believe there is a growing minority of Americans that is beginning to understand that government's proper function is to protect individual rights, but it's still a small minority. And as long as most Americans believe that altruistic welfare programs and business regulation are constitutional, pressure groups will be in politicians' faces lining up for the government dole, promising campaign funding in return.

And politics is always about getting re-elected.

Although Brown seems better on a lot of issues than most politicians, he's not an unmitigated good. Hopefully, Scott Brown will retain his focus on economic issues, and walk his talk in that respect by consistently voting against taxes and entitlements and business regulation. If he does, and Massachusetts re-elects him, then I'll really feel hopeful.

Government always loses

noreply@blogger.com (Paula Hall) — Wed, 23 Dec 2009 13:11:00 +0000

Let's grant that health care providers are greedy profit-chasers who don't care about providing value to patients. This is only for the sake of argument, because in a free market, in which the only laws regulating businesses are laws against force and fraud, greedy profit-chasing would be synonymous with providing value to patients.

With this assumption in mind, let's turn back the clock to when existing Medicare and Medicaid laws and regulations were enacted. At the time they were enacted, no doubt, policymakers and the voters who think the government is smarter than everyone else by definition probably thought they'd covered everything -- or, at least, that it was better to enact something rather than nothing, and that the "something" enacted would help, not hurt. I mean, NO WAY was it ever the stated intent of any lawmaker or voter to have medical costs spiral out of control, right? And NO WAY policymakers and voters haven't always been aware of, and operating under the assumption that, health care providers are greedy and just in it to make a buck. And, of course, the aim of all government health care policies is to give voters more health care services at less direct cost to voters, meaning policymakers intended for voters to purchase more health care services. The policymakers figured that the laws they enacted would outsmart both health care providers and consumers who might be tempted to "overuse" the health care system.

And costs continued to skyrocket.

But, you say: "the costs skyrocketed because health care providers learned to game the system, to get as much money out of it as they legally could." To which I respond: EXACTLY. Greedy profit-seekers will always be much quicker to find any possibility of profit than government can be to engage in another round of "reform." Every health care provider, and employee of health care provider organizations, can directly benefit from research into the best way to game the system in the way no government fonctionnaire can. And because private decision-making doesn't require Congressional hearings in the House and Senate and cloture debates and amendments and reconciliation committees and avoiding the threat of Presidential vetoes and whatever, health care providers can implement their gaming strategies as soon as they've identified them. And then the health care providers have years of profitting from these strategies, sucking up taxpayer dollars, while lawmakers try to rustle up the political will to do something about it without offending the health care industry lobbyists who are buying them filet mignon.

But all of this is legal. It's GAMING the system, not breaking the law. Health care costs aren't spiraling out of control because of lawbreakers -- they're spiraling out of control because of the actions of law-abiding health care consumers and providers.

Look at the Medicare Prescription Drug Benefit enacted under the most recent President Bush. Costs are spiraling out of control. It's because patients and health care providers figured out how to milk the government cash cow very quickly. Assuming for the sake of argument that more government regulation is the solution to this problem, how long do you think it will take for the government to respond? And then when the government does respond, how long do you think it will take for the potential beneficiaries to figure out how to suck up those new government dollars? Or, alternatively, to decide there just isn't enough profit in health care any more and to start turning away patients and closing up shop?

There is only one option for government if it wants to "win" -- go nuclear, socialize everything outright, and forbid anyone to purchase health care outside of the socialized system. The people on the far left know this, which is why they're desperate to get "single-payer" health reform enacted before their 60-vote supermajority in the Senate vanishes. I would say that, if they succeed, that the joke will be on them. But if they succeed, they will indeed be satisfied, even when the only possible result of socializing medicine occurs -- the destruction of medicine and the complete elimination of access to good healthcare. See my post "Lawmaker, know thyself."

It's an arms race between lawmakers and voters on the one side, and profit-seekers on the other. And in this arms race, the government always loses.

Insanity: doing the same thing over and over again and expecting different results.
- Albert Einstein (attributed)

Lawmaker, know thyself

noreply@blogger.com (Paula Hall) — Tue, 15 Dec 2009 13:21:00 +0000

In our current system, where regulation of business is regarded as constitutional, this is always the message given by lawmakers (a class which includes the voters that elect and tolerate them) to prospective entrepreneurs: "I will allow you to create things that will enhance the value of my life only according to my rules." This works, for the most part, because the most talented producers can figure out a way to make some money even with one hand tied behind their back. And we never learn what we missed by shutting-out of the regulated field the less-talented, but still valuable and productive, entrepreneurs. What values might have been created are lost in the limbo of "out of sight, out of mind."

But what if some entrepreneur simply said, "No, thanks, I don't think I'll make something of value to you on those terms. You'll just have to do without."

First of all, the rule-makers don't acknowledge this possibility. In their experience, people who can make money will always choose to make money; they don't believe that money-makers care HOW the money is made. Lawmakers assume that any "no" is merely positional bargaining, and that all that is needed to get things moving is compromise -- and compromise is all they were hoping for. And in fact, this is how businesses operate today, by means of maintaining relationships with lawmakers and endeavoring to get the lawmakers to point their guns at someone else (see, for example, the use of antitrust laws). Lawmakers do not acknowledge principles; lawmakers figure that a producer will always take the chance to create a million-dollar fortune even if the producer knows that, if things were unregulated, he or she could make ten million. After all, one million is better than nothing! And it's a larger fortune than any lawmaker could ever create.

However, let's assume for the sake of argument that lawmakers have stopped evading facts and have explicitly acknowledged to themselves that producers have free will and can simply say "no." You'd figure this would upset the lawmakers, right? I mean, people need widgets, including lawmakers. No-one wants to "do without" -- isn't that right?

Wrong. We saw the answer to this question in Atlas Shrugged. The lawmakers don't care about making their own lives better. They only care about cutting talented, productive people down to size. The motive is egalitarianism -- equality of result -- no matter how horrible the result.

They do not want to own your fortune, they want you to lose it; they do not want to succeed, they want you to fail; they do not want to live, they want you to die; they desire nothing, they hate existence, and they keep running, each trying not to learn that the object of his hatred is himself . . . .

- The Ayn Rand Lexicon, "Envy/Hatred of the Good for Being the Good"

The response by "reasonable" people to a statement like the quote above from Atlas Shrugged, is: "Don't go to extremes! We need the government to protect us from bad people, but you just want anarchy!"

If this is your objection, I have a thought experiment for you.

Consider a thing, a product, a service, that enhances the value of your life. Let's say it's your iPhone (I have no reason in particular for choosing that example -- I don't own one). Now answer a single question: where did it come from?

Someone invented it, then made it, then offered for sale. You went to work, earned money, and decided to spend some your money on purchasing it.

Unless you made the iPhone yourself, you didn't have a right to a single molecule of that product until you persuaded the person who made it to voluntarily give it to you -- by offering the iPhone producers something they preferred more than hanging on to the iPhone you wanted: your money.

If you don't own an iPhone, but you are glad the thing has been produced and only wish you had enough money to afford it -- and you have no intention of stealing the money in order to afford it -- then I am not talking to you. If, however, you resent this situation; if you think there is something wrong with the fact that whoever chooses to produce a thing owns that thing, and is entitled to retain ownership of that thing until someone persuades him voluntarily to part with it; if you don't think it's fair that someone gets to be rich just because he was able to think up the iPhone, while you weren't able to -- then you are envious, I AM talking to you, and I am describing a matter of fact. An extreme and accurate fact.

I submit that many people will destroy evidence of their own relative incompetence even at the price of wrecking their own lives. They would willingly give up cars and walk to work if they never again had to see a single billionaire chauffered to his private jet in a Bentley. They would smash every iPhone if in return they received a guarantee that everyone else was just as miserable as they were.

I further submit that this motive animates every regulation of business. It is pure resentment that some people are productive and talented enough to provide products and services so valuable that many people are willing voluntarily to pay for them -- and that these producers grow rich as a result of their own competence, effort, and merit.

A preview of life under universal "coverage"

noreply@blogger.com (Paula Hall) — Mon, 07 Dec 2009 13:09:00 +0000

"Hi Mr. Proprietor," said Mrs. Customer. "I'd like to buy some of your latest and greatest health care!"

"So, sorry," he replied. "But I'm afraid I'm fresh out of health care. My customers cleaned me out of my last health care widgets last month."

"Wow! What happened, did you throw a big sale?"

"Not exactly. I was seeing a ton customers for awhile, it was crazy busy and my hours were ridiculous." He yawned and stretched. "I'm actually exhausted."

"Yes, you do look tired," she said, peering closely at his face. "So why do you think there was a run on your store?"

"Well," he began, scratching his chin, "I suppose it all started right after the government gave people those Medicinos -- you know, that special money that can only be used to buy health care. I guess they're kind of like food stamps."

"That certainly makes sense. I mean, I have lots of Medicinos too, a fistful -- and I am ready to spend! When do you think you'll get some more health care in stock?"

"It's not going to happen. You see, the other big reason for the shopping spree is that all the stores had to reduce their prices or we'd get fined by the government. Same thing happened to my suppliers -- all the health care manufacturers were under price controls, supplies were so cheap, it was great for awhile. But there was a run on all their stock, too. I actually tried to offer some of my manufacturers higher prices so I could get stuff for my best customers, but I was told I'd better shut up about that or I'd get arrested for helping my customers 'jump the queue.'"

Mrs. Customer gasped. "That must have been scary!"

"You bet. Actually, this is my last week in the health care business -- I'm opening a computer store in a few weeks."

"You're kidding!" Mrs. Customer exclaimed. "Well, can you refer me to another store nearby that has some good health care in stock?"

"Gee, that's a tough one," said Mr. Proprietor. "Everyone has pretty much sold everything they had and then closed shop. I heard the government tried to offer one of my manufacturers some special subsidies to stay in business but my contact over there said the subsidies came with so many rules -- and such huge penalties for breaking them, even by mistake -- that she just didn't want to deal with it. As a matter of fact, two of my best suppliers told me they're shutting down their health care factories to start manufacturing smart phones and Blu-Ray players."

"Now wait a minute," said Mrs. Customer, frowning. "The whole problem was supposedly that everyone was looking in the health care store windows but couldn't afford to buy anything -- that's why they gave us all these Medicinos. The experts said there were actually too many health care supplies. So somebody around here must still be making and selling health care."

Mr. Proprietor paused for a moment to consider, and then said, "You know, I think there's one store still open -- "

"Excellent!" Mrs. Customer interrupted. "Can you give me directions?"

"Hang on a minute! You might not want to go. It's about 100 miles away and the owner over there is out of stock, too. You'd have to sign up for her waiting list to buy some health care when she gets her deliveries in a few months. She got special permission from the government to jump to the head of the line when the health care manufacturers have more supplies -- but only if she sells her new stock to the really sick people first. You don't look so bad, so I think you'd be pretty far down on her list."

"But I need to buy some health care now! I've been feeling under the weather and there's a bad flu virus going around!"

Mr. Proprietor shrugged. "I don't know what to tell you. I'm in the same boat, I'm really worried -- I have two kids and I haven't figured where to buy health care, either. I suggest you take a few days off work and wait it out -- hopefully, you just have a bad cold. My mother always gave me chicken soup -- don't laugh, it really works!"

Mrs. Customer stared. Mr. Proprietor stared back.

"So," Mrs. Customer finally said, "You're saying there's really no health care around here to buy, and that my best option is to get on the waiting list 100 miles away and hope I can buy some health care in a few months?"

"I think that's about right. There's just a serious health care shortage and I don't really see an end in sight."

"But how can there be no health care to buy?" Mrs. Customer wailed. "After all, I have comprehensive health insurance and can pay for anything!"

It's safer to steal

noreply@blogger.com (Paula Hall) — Thu, 26 Nov 2009 15:49:00 +0000

Imagine you're really, really sick, and you're out of money to pay for treatment. Maybe you lost your job. Maybe you never had one. Maybe you've exhausted all the treatments covered by your insurance policy and have to pay for further treatment on your own.

Whatever. You're out of money and you're still really sick and if you don't find a way to pay for further treatment you'll die.

Obviously, you're not alone on the planet. There are other people around who have money and who don't need what they have as urgently as you need it. In a free country, you would be free to ask them for money. You could campaign for little donations from a lot of people (this is how people justify health care taxes, by the way -- it's only a little bit contributed by a lot of people instead of a lot contributed by patients who actually need the health care). You could approach a rich philanthropist for a donation. You could try to find a health provider who offers free or reduced-fee health care.

In short, in a free country, you would be free to seek charity.

And people would be free to not engage in charity. Some sick people don't want to take the chance of relying on charity, perhaps most. What if you ask, you make your best case, and no-one agrees to finance your health care? Do you just give up and die? And how do you deal with the humiliation of having spent all that time and effort begging for help, begging to stay alive -- and then you fail?

Really, it's much safer to just force someone to give you the money you need. Since this is theft, and most people cannot bear to be thought a thief, particularly when it's a self-assessment, some evasions are in order.

Such as -- it's not my fault if people won't accept the fact that other people need their surplus money. Such as -- it's not my fault if people refuse to agree that morality requires you to spend some part of your life earning money to pay for other peoples' health care. Such as -- I'm not stealing from anybody, I'm just exercising my democratic right to vote for a government that supports the use of tax dollars for health care. Such as -- it's not my fault when the government uses guns to heard recalcitrant taxpayers to jail, because citizens should realize that taxation is the price of enjoying all the benefits of society.

But of course, if it walks like theft and talks like theft, it's theft. As soon as you point a gun at someone who was minding their own business and demand that they give you money, it's theft.

The refusal to rely on charity is, at the end, to believe that it's safer to steal.

Eureka!

noreply@blogger.com (Paula Hall) — Wed, 25 Nov 2009 13:22:00 +0000

I have found it! I finally understand what's wrong with our health care system!

The problem is . . . wait for it . . . we're all paying too much money for a crappy product. The providers are taking advantage of us. They know they have what we need -- health care -- and they're going to charge us an arm and a leg for the poorest-quality product they can get away with delivering.

The obvious solution is two-fold:

1) Health care purchasers must be hard-bargainers on price. That is, offer a take-it-or-leave it price for the services offered for sale.

2) Health care purchasers must control the product being offered for sale. That is, restrict providers to selling only those products purchasers are willing to buy, and at the price purchasers are willing to pay for it.

In practice, given our insistance that the government foot all health care bills, that means that governments must slash the prices they are willing to pay for health care, and health care providers must be restricted to producing only certain products.

That's pretty simple.

Except . . . what if the providers say "No?"

But that's unthinkable, so no-one is thinking about it. The health care services will always be there. Doctors, nurses, care-givers, pharmaceutical company executives and employees, insurance company executives and employees, medical device manufactuer executives and employees, hospital executives and employees, none of these people have any other options open to them but to stay in their current lines of work.

I mean, isn't that true of everyone? No-one has any choice about what they do for a living?

So that settles it. The solution is to make providers take less money for producing more, and we know for a fact that they won't say "no" because they're all locked into their jobs.

Of course, there's the issue that the only way to "make" someone do something is to stick a gun in their face. But we don't have to deal with the issue of pointing guns at health care providers because they'll cave into our demands long before we'll have to unholster our guns. And we've holstered our guns in some really pretty euphemisms that blend in with all the rest of the help-the-less-fortunate rhetoric we're spouting, so it's easy for providers to evade that the guns are there. Plus, we can threaten to stop liking the health care providers unless they look at the situation through altruist-colored glasses, so they'll all rally around the battle cry that capitulation to our demands is the moral thing to do, guns or no guns. In sum, we don't have to worry about our guns scaring the providers out of the health care field because we do a bang-up job helping the health care providers ignore the guns.

No problem.

Not sure why I didn't think of this sooner.

Scapegoating doctors

noreply@blogger.com (Paula Hall) — Tue, 24 Nov 2009 12:59:00 +0000

Now coming to a socialized medical system near you . . . scapegoating doctors.

I wrote a day or so ago that all the problems attributed to fee-for-service payments for health care would resolve themselves if health care consumers -- patients -- were directly responsible for paying for what they purchase. We have fee-for-service problems because, ultimately, it is the government that is paying the fees.

But let me elaborate on that a bit. Government money comes from taxes. To the extent government charges fees for services like the post office, and makes a "profit," it's only because taxpayer money provides the "capital" for such a concern to be in business in the first place.

Unless you're in an explicit dictatorship, money from taxes is dependent on votes. So policitians have to pretty much lie to voters about how much things cost, because voters finance the government with their taxes and in general, when presented with a new tax, tend to throw the bum who suggested or implemented it out of office.

["Uh, where's the part about scapegoating doctors?" -- I'm getting to it.]

In Massachusetts, all taxpayers know that their taxes are supposed to be paying for the health care of every Massachusetts citizen. They also know that the 2006 health system reforms are costing hundreds of millions more dollars than projected. (We're all shocked, I know.)

The regulators are all posturing by saying things like, "we always knew we were in for a two-part process: first, make sure everyone has someone else paying their medical bills, then deal with the explosion in costs that will necessarily follow." (See p. 20 of the Recommendations of the Special Commission on the Health Care Payment System.) As if that's what taxpayers consciously voted for when they were being told that covering everyone would lower health care costs by eliminating the care that providers give to people who can't pay for it. As if any taxpayer who cries "foul" is somehow forgetting the bargain he made. It's insulting.

But I digress. The regulators, in accord with this "process" everyone supposedly agreed to, are now explicitly tackling the skyrocketing costs associated with the plan. So they came out with their Recommendations on how to curb costs.

This is where the doctor scapegoating comes in. The regulators recommend that Massachusetts move to a "global payment system," which is not the dreaded "capitation" system of HMOs past because the regulators insist that it isn't (see p. 29 of the Recommendations). Under global payments, providers would be paid a set fee to handle all of a patient's care for a given time period. So, $20,000 per year to take care of me, let's say. I have no idea if that's a figure that the regulators would come up with, it's totally random. The move to global payments would be accompanied by various measures meant to ease the pain on providers transitioning away from fee-for-service -- but it would also be accompanied by "pay for performance" in some form or other ("P4P" -- see p. 35 of the Recommenations).

P4P means that providers have to achieve certain health care quality outcomes in order to receive their global payment in full.

P4P means that if providers -- DOCTORS -- don't check the regulators' boxes, they won't get paid.

P4P means doctors lose even more autonomy than they have already. It means that when a doctor is trying to diagnose you and to decide on a course of treatment, she has to consult a regulator's list of do's and don'ts or see her compensation go down. Ask yourself if you want a bureaucrat deciding your treatment, or if you want some politician who is answerable to taxpayers to make the decision whether to spend money on your treatment.

P4P is just another way of slashing doctors' monetary and intangible compensation, which means it's going to reduce access to health care in Massachusetts. The doctors who were good enough to make money allowing them to retire, will retire. Other doctors who think they can make enough money doing something else, will do it.

The doctors who are willing to practice under P4P, who are willing to get paid for following instructions instead of exercising the judgment developed by their training and years of experience, are not the kinds of doctors Massachusetts patients are going to want to have. P4P will attract doctors who think that thinking is too hard, who think that they'd rather have a job that doesn't require them to think too much.

And when waiting times go up, quality declines because its delivered by doctor-bureaucrats, and costs continue to spiral because now people are getting sicker, the regulators will blame the doctors.

They'll blame doctors for not producing quality health care for less money and with their brains outlawed.

Doctors, you have been warned. In Massachusetts, you are about to be excoriated for not doing more with less.

Please please please pretty please don't take this lying down. Go on strike.

Here's a good one

noreply@blogger.com (Paula Hall) — Mon, 23 Nov 2009 23:30:00 +0000

Here's another beaut from the Recommendations of Massachusetts' Special Commission on the Health Care Payment System:

Considering a group of 45 core measures that represent the most important and scientifically credible measures of quality, the 2008 National Healthcare Quality Report (NHQR) found that nationally the median level of necessary care received was just 59 percent (AHRQ 2008).

Imagine you're a patient. You're really worried about some symptom or other and you went on WebMD and you're sure it means you have cancer. You insist your doctor perform a test, and she refuses. Your symptoms worsen, you show up the following year, this time your request for a test is honored, you get the test for the more obvious symptoms, and sure enough you have cancer but now it's untreatable and you're terminal. Now I ask ya -- would you give a f*** if the doctor was operating on the assumption there was only a 59% chance that the first time you asked for it, the cancer screening was "necessary?"

Fee-for-service nonsense

noreply@blogger.com (Paula Hall) — Sun, 22 Nov 2009 21:51:00 +0000

I am just beginning to educate myself on the nitty-gritty of the Massachusetts health care system. I have been trying to resist the urge to blog on what I read as I read it, because everything is so new to me – I assume that at some point all this information clong will resolve itself and I’ll have a sense of the essentials of what I want to spend time blogging about.

HOWEVER, I couldn’t resist on this one. So sue me.

The Special Commission on the Health Care Payment System recently published recommendations on, essentially, getting rid of fee-for-service payments for health care (the “Recommendations”). What is really meant by this is: getting rid of fee-for-service payments in a system where payment for health care services by third parties is the only system permitted by law. Everything that the Recommendations asserts is wrong with the fee-for-service model assumes that it is a third party, and not the consumer, paying for the service consumed. NEVER is that assumption questioned; I guess there’s no one at the table in that particular debate who questions the propriety of requiring payment of medical bills by someone other than the patient. At least, no one whose voice is recognized or heard.

I haven't finished reading through the Recommendations yet, so I could be putting my foot in my mouth here. But my blood is up so I don't care. Here’s an excerpt from the Recommendations, purporting to list everything that is so dastardly about fee-for-service – with my biting commentary added.

FFS rewards overuse of services, does not encourage consideration of resource use, and thus cannot build in limitations on cost growth. If the consumer was directly paying the fees for the services he was consuming, you can bet he would be considering the use of his own resources (his money), and therefore wouldn't be over-using anything.
FFS does not recognize differences in provider performance, quality, or efficiency, and thus does not align with evidence-based guidelines or outcomes. If the consumer was directly paying the fees for the services he was consuming, you can bet he would be taking his money elsewhere if he didn't like the service he got. He votes with his dollars, and so do all the other consumers, and the outcome of the "election" is an evaluation of quality. Cream will rise.
FFS focuses attention on prices, not costs, and fees do not relate to the actual cost of providing care. If consumers are paying their medical bills directly, providers will definitely pay attention to cost, which introduces price competition among providers. Which means the providers will be focused on reducing their costs, because it's for damn sure they're not going to get people to pay increased prices. And, in their capacity as consumers of goods they need in order to provide their services, they will in turn be encourging their providers to pay attention to cost.
FFS is complex and difficult to administer given the wide array of individual health care services and changes in health care delivery and technology. If consumers were paying for their own health care directly, they would become expert on the prices charged for the kinds of services they wish to purchase. Since there wouldn't be one purchaser having to figure out how to get the best deal for every bloody patient on the planet, there wouldn't be a need for that purchaser to consider the fees for every possible health care service. Providers would specialize in their own pricing models, and if the pricing models did not deliver quality care at a good price, consumers won't be directly paying those providers.
Multiple payers negotiate different rates for a service, leading to different rates both within and among providers for the same service. These rates are more often based on relative market leverage, not health care value. Again -- if consumers were paying their own medical bills directly, providers would be dealing with the consumers directly. Consumers would have an excellent reason to pay attention to rates, and providers to compete on the basis of rates. Look at it this way -- consumers currently put a hell of a lot more effort into price shopping for cars and DVDs and computers than they do for health care services. What is Consumer Reports for? Is there an equivalent directed to the health care consumer? (Uh, no.)
Varied payment levels for services leads to variation in profit margins across services; variable margins incentivize volume in high profit services, not value. This one is Economics 101. When consumers responsible for paying their own bills want a desirable good that is limited in quantity, they bid up the price -- check out eBay. When the price goes up on something greedy business flood the market to produce that thing, to try to cash in. When too many greedy businessmen are trying to produce the same thing, the price goes down, and consumers have more money to bid prices up for some other product. Because businessmen are REALLY greedy, they're always looking for ways to make more money, so they try to find the products with higher profit margins. Whatever profit margins exist will be exploited. In other words, every niche market will be filled. Look at how many different kinds of cars and computers there are. However, people who want really specialized products, and who are members of really small markets, will not be the first people that greedy businessmen try to serve. But I'm not saying that like it's a bad thing. The niche markets will NEVER get served if businessmen are not permitted to chase profits in the big markets first.
Some highly valued services are not currently recognized in the FFS system and thus not compensated. What "highly-valued" services are we talking about, here? Why are those services not profitable? I think the complaint here is that primary care physicians make less money than specialists. Feature this -- maybe they should. This one is on physicians, and has less to do with third-party payors than on government-backed monopolies on the practice of medicine. To wit -- get rid of government licensing and let nurses and other less-expensive providers take point on primary care. If that happened, consumers who insisted on having a primary care doctor instead of a primary care nurse would be welcome to pay for it, just the way some people pay for Lexuses -- but the people who buy Toyotas would still get to work reliably and on time.
Caregiver incentives are not currently aligned among acute care hospitals, physicians, behavioral health providers, and other providers. Sorry, can't make heads or tails of this one. My guess is that this refers to different fee-for-service payment regulations for various types of providers. If consumers were paying for their own care directly, there would be a single incentive that everyone could understand and line up behind -- the gawd-almighty dollar. The difference would be that consumers, not just providers and the government, would be watching the bottom line as well.

And as it says on my masthead logo: here endeth the lesson.

What IS it about health care?

noreply@blogger.com (Paula Hall) — Thu, 19 Nov 2009 12:37:00 +0000

Many people who argue against a "right" to health care make the following point, in one form or another: there's no "right" to "food," yet people manage not to starve; therefore, people would still be able to get health care if there were no "right" to it.

It is not strictly true that the government doesn't recognize a "right" to food -- what is welfare? But the argument does hold in this sense: whatever "right" to food there is, does not encompass a right to the best, most expensive food available, price no object.

That is what people mean when they mean a "right" to health care. They mean everyone, no matter their ability to pay, has a right to the best health care services currently on the market, price no object. The assertion is that no-one should suffer worse health -- worse to any degree, no matter how infinitesimal -- than some other person, because he cannot afford to purchase services that could improve his health.

Consider a recent blog post at the Ayn Rand Center for Individual Rights:

With insurance covering all kinds of medical services and the premiums paid by someone else, Americans have little financial incentive to curtail doctors’ visits for minor ailments, to question whether a test is worth its cost, or to seek out cost-effective care. Before we buy virtually anything else, we ask ourselves whether it is worth its price and whether there might be a better deal elsewhere. When we go to the doctor, we don’t even see the price until it shows up on the invoice—with all but a small co-pay or deductible (relative to the total bill) paid by the insurer. History has shown that this system increases demand for health care, encourages wasteful consumption and ultimately increases costs for third-party insurers.

What this blog post fails to capture is the life-or-death quality of the choices involved in health care. Perhaps when the issue is whether to see the doctor when you have a runny nose, it would be easy enough to say, nah, it's probably not the flu, I'll spend my money on a new iPod and wait for the cold to go away. But what if the issue is cancer? If a new expensive treatment is available and it has a 1% chance of putting my cancer in remission, do I even consider the cost? If it bankrupted me, would I consider the money spent on the treatment as "wasteful consumption?" What if I were required to consider the cost, because I did not have some third party paying for my treatment, and then saw some worthless playboy trust fund baby suffering from the same kind of cancer and blithely writing a check to pay for the new expensive treatment?

THAT's what it is about health care. An absence of health is an absence of life. An absence of food will ultimately be an absence of life, but coming up with a meal when you're starving is much simpler than coming up with a new cancer treatment that took hundreds of millions of dollars and thousands of hyper-educated individuals and years and decades to bring to market. An absence of food can be remedied by coming up with a few dollars, and with very little input from others. An absence of health care when you're dying of cancer leaves you virtually helpless to remedy the situation without a juggernaut of others' efforts.

All of this isn't to argue to "we should do something about it." Death comes to us all, and if we didn't face the prospect of death, we wouldn't be alive. It is to point out how easy it is to experience a sense of powerlessness and unfairness when you cannot afford some measure that would prolong life -- no matter how misguided or misdirected that experience of powerlessness and unfairness is.

The proper view is to recognize that health care is care by other people, and that to force someone to help you is just as wrong as forcing you to help them. The proper view is to realize that forcing someone to provide or pay for your health care, no matter how badly you need it, is neither more nor less than theft.

The proper view is to ask yourself: If I were dying of cancer, asked my rich neighbor for money to pay for treatment, and my rich neighbor refused, could I shoot him for refusing? Because this is what a right to health care means -- the right to shoot your neighbor if he refuses to give you what you claim to need.

Steal and deal

noreply@blogger.com (Paula Hall) — Wed, 04 Nov 2009 13:13:00 +0000

I'm trying to learn about the nuts and bolts of the health care laws in Massachusetts. Here's an evaluation from Michael Tanner, an analyst at the Cato Institute:

Massachusetts health reformers rejected proposals that would have reduced the rising cost of health insurance, such as eliminating regulations that drive up insurance premiums or those that limit competition in the insurance industry. Nor did they create incentives, such as increased cost-sharing, for consumers to become more value-conscious in their purchasing decisions. Instead, they increased regulatory costs and then simply threw money at the system through subsidies.
(p. 5)

In other words: Massachusetts health care reformers decided that the best way to fix a broken system was to steal people's money (through involuntary taxation of the unwilling at gunpoint), and then pass laws about how they were going to spend their plunder.

Massachusetts is a Medicare access "hot spot"?!

noreply@blogger.com (Paula Hall) — Mon, 02 Nov 2009 12:52:00 +0000

Look at this from American Medical Association's amednews.com:

Access to care for Medicare patients is already at risk in 21 states and the District of Columbia, an AMA analysis found. "Hot spots" are: Alabama, Arkansas, Florida, Georgia, Idaho, Indiana, Kentucky, Louisiana, Massachusetts, Mississippi, Montana, New Mexico, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, West Virginia and Wyoming. The AMA looks at five measures of access problems.

The AMA deemed states hot spots if they had a poor enough showing, based on:

- Practicing physicians per 1,000 Medicare beneficiaries.
- Medicare seniors with incomes less than 150% of the federal poverty level.
- Seniors living in places deemed primary care health professional shortage areas.
- Hospital emergency department visits per 1,000 residents.
- Seniors not seeing a doctor during past year because of cost.

Notice anything funny about that list of states? I did.

The states can be grouped into three general categories: 1) they're in the South, or 2) they're in the middle of nowhere, or 3) they're Massachusetts?

Southern states often have a lower per capita income, and many attract a lot of retirees. One can easily see how these two factors would affect the affordability of and access to medical care. Montana, North Dakota, Wyoming and Idaho are largely rural states that aren't exactly emigration magnets for doctors, which could definitely affect access.

Why is Massachusetts on that list when it's not southern, not poor, not a retirement state, not rural, and filled with medical schools and doctors?

Could it be that our new health insurance system in Massachusetts is raising the cost of and killing access to medical care?

Their own worst enemies

noreply@blogger.com (Paula Hall) — Wed, 28 Oct 2009 13:26:00 +0000

A poll by researchers at Harvard University reports that about three-quarters of Massachusetts doctors favor the new government-mandated insurance system in Massachusetts:

The first broad-based survey of how physicians feel about the Massachusetts experiment shows strong and deep support: 70 percent favor the law; three-quarters want to keep it.
Only 7 percent would repeal the law, and it's hard to find a doctor to say so publicly, says a spokesman for the Massachusetts Medical Society.

I know nothing about this study, so I can't comment on the questions the doctors answered and whether there was built-in bias. But this is so very Atlas Shrugged -- a real-life example of how, in the book, the heroes start out as their own worst enemies.

Hospital governance mandates

noreply@blogger.com (Paula Hall) — Tue, 27 Oct 2009 12:10:00 +0000

This is a 77-page white paper arguing to a quasi-governmental body called The Joint Commission (TJC) that the current form of hospital governance mandated by that body be scrapped. I refer to TJC as "quasi-governmental" because the feds require hospitals to be accredited by the TJC or they can't participate in Medicare and Medicaid, and TJC accreditation is built into most state hospital licensing laws.

The paper's argument is that the current form of governance creates impasses to achieving patient safety and obeying legal safety standards. The TJC-mandated form of governance places authority for safety in the hands of the functional equivalent of a board of directors, but that same board is unable to require changes in provider behavior because the providers (the "organized, self-governing medical staff"), according to the same mandate, are independently responsible for safety and do not have to report to the board on this issue. The result is that government safety standards aren't complied with, exposing the hospital to fines, government and private litigation, and even litigation from the medical staff.

I can solve the problem in one sentence, as opposed to 77 pages: eliminate the TJC mandate and let hospitals freely choose whatever form of corporate governance they think is best. Providers who didn't like a hospital's form of governance would have to leave that hospital and join a medical staff elsewhere, instead of having a legal right to sue the hospital if they don't like being told what to do. Boards of directors could fire physicians who didn't want to comply with safety rules set by the hospital's board. And the decisions of consumers in the market, aided by the research of private accrediting and rating organizations, would provide socially objective evidence of the best form of hospital governance.

As a side benefit, elimination of government-mandated hospital governance structures would go some ways toward eliminating what I think of as "the FDA effect." When the government is put in charge of certifying a product's quality, once that certification has been achieved, the company making the product has no incentive to compete on the basis of quality. All they have to do is say "we're FDA certified!" and consumers, who've been led to think that the government is the only objective evaluator of quality, are satisfied that the product is good. In effect, the FDA standards enforce a quality minimum above which it does not pay to go.

Something similar to this happened in the recent financial meltdown. Financial instrument ratings agencies operated like The Joint Commission of financial instruments, because the government mandated that companies use those agencies to certify the soundness of the financial instruments they wanted to sell. So financial institutions ran around selling their stupid mortgage-backed CDOs (collateralized debt obligations) and other similar instruments in which there was no "there" there, and buyers figured everything was OK because a government-backed rating agency said the instruments were just peachy.

In the case of hospitals and their governing practices, once the imprimatur of the The Joint Commission was eliminated as a licensing requirement, it would open up another way for hospitals to compete on quality. In this case, it is unlikely a hospital would sell its services by saying, "Lookee here, we have a really neat-o governance structure!" But a good governance structure would, among other things, make a hospital nimble in its response to safety concerns -- and a hospital can definitely compete on product safety.

I really think doctors should strike . . .

noreply@blogger.com (Paula Hall) — Mon, 26 Oct 2009 13:06:00 +0000

. . . but I know they won't, because they're too busy appeasing. They're too busy being good little altruists, mouthing all the correct altruist platitudes, so that people will still like them even though they earn a good living.

Doctors have to be educated in the proper morality, and there are people out there working on that already. But that takes time. And meanwhile, practically all politicians and their constitutents are operating on the premise that universal health care is a good thing. As long as people think that, there's little cause for celebration if this or that plan to socialize health care is delayed or fails. People will just try to cook up another means of reaching what everyone seems to agree is a laudable goal.

And of course, the fact that health care professionals deliver this care and are enslaved to the extent the government runs health care is lost. People only talk about insurance, as if the ability to pay for health care would somehow cure the system. They forget the lesson of the countries behind the former Iron Curtain -- money is useless when there's nothing to buy.

The faster people reacquaint themselves with this practical example from communism, the greater chance people will see that the solution to our health care system woes is privatization.

So, how to kill the supply of health care when physicians are just as altruistic as the politicians and their constituents?

What if we got physicians to retire earlier than they'd been planning? Get them to save their shekels and golf? They could plan for an earlier retirement without undeluding themselves about altruism, if that's a prospect they couldn't face. Early retirement is still pretty much a universal value, even to altruists. (I'll table for the moment the prospect of people accusing doctors who retire early of being "selfish," in the smear sense of the term "selfish." It's bound to happen, but that's a topic for another blog post.)

What would happen to our health care system, and at what rate, if doctors retired at a higher rate?

The first thing that would happen, I suspect, is that nurse practitioners and physician's assistants would be more in demand. That's good. I think that they could handle a lot of the general practice work of physicians more economically, and could be doing that right now if it weren't for licensing requirements, which should be abolished.

To the extent surgeons and other highly-paid and in-demand specialists started to retire early, and the queues started forming for all the physicans who deal with terminal illnesses, there would be a shift in focus away from universal insurance and towards universal access. Which means politicians and their constituents would have to start openly calling for the enslavement of physicians. Well, maybe not openly to start -- it would probably start as requiring a period of government service as a condition of being licensed to practice medicine. But even something like a policy intended as a euphemism for slavery would sharpen the focus on the source of medical care: medical professionals.

When more people realize that health care comes from health care professionals -- in other words, from the labor and choices of human beings -- we'll have a better chance of getting it privatized.

The most important people to convince of this fact are the health care professionals themselves, the doctors. And since so many of them don't want to give up altruism, I say let's just get them to save for an early retirement, for a start.

And now for something a little different . . .

noreply@blogger.com (Paula Hall) — Sat, 03 Oct 2009 14:36:00 +0000

This is how I want to eat, forever: "eat healthy food when you are hungry and stop before you're full."

Broken down:

"eat": As in, no starvation diets, or else your body will start acting like it's starving and try really hard to retain weight.

"healthy food": This means as close as possible to Paleo.

"when you are hungry": When your stomach is literally growling with hunger pains, and not otherwise.

"stop before you're full": You can have a snack, just enough to stop hunger pains, or you can have a meal, which is a larger quantity of food that can slake both hunger and appetite. But you can't make yourself uncomfortable from food, and you're not allowed to evade signals that you're physically uncomfortable. This is the hardest part, but if you eat healthy food, your appetite is satisfied much more quickly and you rarely encounter the issue of overeating.

And that's it. I've been eating pretty much this way for just over a month, it's been pretty easy, and I've been losing weight.

That concludes the diet-advice portion of our program.

The Happiness Project: Happiness Myth No. 7: Doing “Random Acts of Kindness” Brings Happiness.

noreply@blogger.com (Paula Hall) — Sat, 26 Sep 2009 15:13:00 +0000

The Happiness Project: Happiness Myth No. 7: Doing “Random Acts of Kindness” Brings Happiness.

I just found this very popular blog yesterday. There is a lot of good practical advice in the blog, but I doubt the author has systematically defined happiness. I surmise this because it appears her blog (and her book) equate morality with altruism. This means she believes that to some extent the achievement of altruistic "values" can make one happy.

Her entry about the utility of performing random acts of kindness in order to bring about happiness is a case in point. She observes that people do feel happy when they anonymously or randomly do someone a random favor, like top off their parking meter. She claims that the satisfaction from this action comes from the sense that you have made someone else happy. But because people are naturally suspicious of the random acts of strangers, it turns out that the beneficiary of a random act of kindness is often not made happy by it. She therefore advocates targeted, non-anonymous kindness, non-random kindness to non-faceless people. Then you are sure of making that person feel better, because they can judge your apparent motives face-to-face, needn't be suspicious, and can simply be grateful. The result is that you are not mistakenly imagining that you've made someone happy, you are sure of it. This act of kindness will bring you true happiness because you truly have made someone else happy.

This is an altruistic interpretation. I don't doubt that generosity/kindness of this kind, the non-sacricificial kind, can make someone happy. I definitely feel a rush of self-approbation when I give up my seat on the subway to someone who clearly needs it, or hold the door open for a woman struggling with a stroller, or let someone merge onto a clogged street from a side street. Gretchen Rubin (the blog author) would acknowledge the pleasure of observing your own virtue, but she misreads the virtue that's in play. The pleasure one receives in such a sitution is, I believe, the observation of your own competence and fitness to achieve values. In other words -- helping someone else feels good because you observe that you have capacity to achieve values in abundance. You have such an abundance of competence that you can spare life energy to assist someone else, out of a general benevolent sense of life, as a result of your assumption that the person you are assisting is has the potential of being a personal value to you.

You exeperience a pleasurable rush of self-esteem on the most basic, metaphysical level.

Compare a random act of kindness to someone you know to be a rotter -- a murderer or a child abuser. You wouldn't do it, or wouldn't feel personal happiness at doing it. At most, you could feel a sort of twisted satisfaction that you are truly turning the other cheek.

But when you help a lady with a baby, take a minute out of your day to help her load groceries into her Volvo, you promote your own value of parenting and acknowledge, in action, your own competence to promote life-affirming values.

Scare tactics

noreply@blogger.com (Paula Hall) — Mon, 21 Sep 2009 12:15:00 +0000

Here's a telephone call I wish I had a transcript of: according to the AMA News, the American Medical Association, the American Nurses Association and the AARP held a September 9 conference call on health reform to address the "lies and myths" and "anti-reform rhetoric." As if someone can't be against increased government intervention in the health care system without being a liar.

I have a question. If the problem is that people need to see a doctor but don't because they're uninsured, what is going to happen when, all of a sudden, the supposed 46 million who are currently uninsured become insured? Are they going to all run to get a doctor? Whose doctor? What I mean is -- is there a provision in the health care reform proposals to, overnight, create additional phyisicians to take these 46 million people as patients? If there are not going to be new doctors (of course -- in fact, greater government intrusion will chase doctors out of the profession), then won't existing doctors have to some how take up the load of 46 million new patients? And won't that mean 1) existing patients will have reduced access to their doctors, and 2) waiting lists?

Oh, wait -- this has already happened in Massachusetts.

And talk about scare tactics -- those who are in favor of socializing medicine even further accuse those for freedom in medicine of being liars. They use smear tactics, not arguments.

If you're deaf, life is harder -- deal with it

noreply@blogger.com (Paula Hall) — Mon, 14 Sep 2009 20:50:00 +0000

I'm sorry, call me what you will. But I find this announcement incredibly annoying. And I think this story is at the heart of what's wrong with the proliferation of "rights."

Under a settlement agreement reached with the U.S. Department of Health and Human Services, deaf patients at the Fort Washington Medical Center in Prince George’s County, Md., will be screened and provided with sign language interpreters whenever interpreter services are necessary for effective communication.

The settlement was negotiated following an investigation by the Department’s Office for Civil Rights (OCR) in response to a complaint from a deaf patient. The man entered the emergency room late one evening accompanied by his 11-year-old son. Although the man and his son requested an interpreter, none was provided, and the medical staff relied on the son to interpret for his father in the emergency room.

Federal laws prohibit discrimination against persons with disabilities, and require entities such as hospitals to provide effective communication for persons who are deaf or hard of hearing. OCR found that Fort Washington Medical Center violated the Rehabilitation Act of 1973 when it failed to provide the deaf patient with an interpreter during his emergency room visit.

The problem with the "complaint" is that it rests on a premise that being deaf shouldn't make a difference in one's life. But it does. Labeling a hospital with the scarlet "D" of "discriminator" doesn't change the fact that to be deaf is to find it harder than hearing people to do business with others. People -- even doctors -- who have a difficult time communicating with deaf people do not thereby discriminate against them.

And I don't see anything in this story about the man's medical care suffering, by the way. If his medical care didn't suffer, this is all about the effrontery of the hospital in not spending money helping this man pretend that he had the misfortune to be born deaf and that some things are harder for him.

Let the excoriation begin.

Are we surprised?

noreply@blogger.com (Paula Hall) — Mon, 14 Sep 2009 12:04:00 +0000

Some states are cutting Medicaid payment rates to doctors. Here's what an Ohio government official said about the expected effects of paying doctors less: he "expects a decrease in physician Medicaid participation . . . because the state's Medicaid pay has not kept pace with physicians' costs."

Health Care "Clarity"

noreply@blogger.com (Paula Hall) — Thu, 10 Sep 2009 15:56:00 +0000

The new issue of The Objective Standard has an article discussing the ideological clarity brought to the U.S. political scene by Obama's unabashed statism. The author argues that Obama's clarity has had an effect on American politics analogous to the effect of the atomic bombs on Japanese leaders. Obama wants statism now, and the atomic bombs showed Japan that destruction was upon them now. Japan responded by surrendering. The author of the article argues that many Americans are responding to Obama by rejecting the leftist agenda. As evidence, the author cites the Tea Parties and recent polls showing Americans rejecting Obama's health care proposals and fearing government intervention in health care. The article concludes with a warning about the danger of Republican capitulation to Democratic policies, but the overall tone of the article is sanguine.

I cannot be so sanguine. I don't think there is a "silent majority of Americans" waiting in the wings to reject Obama in favor of freedom. The polls referred to in the article show a predictable partisan divide. Importantly, they show a religious divide as well. This tells me that opposition to Obama is Republican and religious---in other words, it is not based on a desire for freedom, but on a desire to return to our government's "roots" in Christianity. The opposition is mere knee-jerks against "the other side," with some anti-abortion hysteria thrown in. If Republicans put out the exact same health policy as Obama, their supporters would favor it and the Democrats would denounce it as "free-market."

I have no solution. I fear we will end up with socialized medicine, and that the only hope of getting out of the resulting mess will be the operation beside government medicine of a sort of "black market" in cash-only medical services. Not because everyone will be able to afford the black market rates, but because people will start to call for conscripting doctors, and to outlaw all private medicine. Perhaps at that point doctors will finally go on strike; perhaps they will by that time have heard enough from the good guys at FIRM and the like to realize that doctors are people, too, and like everyone else, have rights.