Veterans Affairs Secretary Eric Shinseki has resigned in the wake of the waiting times scandal. But the problems at the VA go much deeper than a single man. His eventual successor will have his hands full dealing with the toxic combination of problems that fueled the crisis: a shortage of doctors, perverse incentives, and a widespread culture of dishonesty. And these problems could affect the rest of America under ObamaCare…
The first two of the three factors are already in play under the Affordable Care Act (aka “ObamaCare”) and there are troubling early indicators that the third may take root as well. If this happens, Americans had better watch out.
I discuss the bureaucratic hurdles that USAF veteran Robert LeChevalier had to endure when diagnosed with glioblastoma multiforme (a very malignant brain tumor). Fortunately, he and his wife Monica Hughes have a lot of grit and tenacity.
Monica also posted this photo, which I used in the Forbes article with her permission: “Here are the 58 claims denials, totaling $250,000 of emergency care, that we have received by the Veteran’s Administration. Excuse? Robb was too healthy. He hadn’t sought any care at the VA in the prior 5 months. Really.”
That’s the question American physicians are grappling with. The New York Times recently reported on a growing debate within the medical profession as to whether doctors should make treatment decisions in the best interests of their individual patients — or if they should limit care to save money for “society.”
This would represent a seismic shift in standard medical ethics. Traditionally, a doctor’s primary ethical duty is to the patient. Patients literally put their lives in our hands, trusting that their physician will always act as their advocate. But with health care costs currently consuming 18% of the US economy (and an enlarging share of government budgets), some doctors are openly calling for fellow physicians to limit their use of more expensive tests and therapies to save money for “the larger society.”
As Dr. Martin Samuels (chairman of neurology at Brigham and Women’s Hospital in Boston) warned in the Times piece, doctors risk losing patients’ trust if they say, “I’m not going to do what I think is best for you because I think it’s bad for the health care budget in Massachusetts.”
We don’t expect our lawyer to balance our legal interests against saving money for “the court system” or our real estate agent to balance our housing preferences against what’s best for “the regional housing market.” Shouldn’t our doctors adhere to the same code of ethics?…
I also discuss how this conflict of interest will worsen under ObamaCare as well as how adapting an idea by UCLA law professor Russell Korobkin may help avoid this problem and protect the doctor-patient relationship.
Is it fair to ask a patient to pay $6 for emergency medical care? Or are patients entitled to free medical care whenever they need it? That’s the question Australian government officials are currently grappling with.
As the Australian health care unfolds, there are two lessons for Americans — one political and one philosophical.
I discuss how government-mandated electronic medical records are hampering doctors’ ability to practice and resulting in medical errors. I also discuss 4 concrete steps patients can take to protect themselves.
I didn’t mention this in the Forbes piece, but there was a terrific drawing in the Journal of the American Medical Association from a couple of years ago by a 7-year old girl depicting her recent doctor visit. Even young children understand the effect of electronic medical records on their care:
No one was more surprised than the physician himself. The drawing was unmistakable. It showed the artist — a 7-year-old girl — on the examining table. Her older sister was seated nearby in a chair, as was her mother, cradling her baby sister. The doctor sat staring at the computer, his back to the patient — and everyone else. All were smiling. The picture was carefully drawn with beautiful colors and details, and you couldn’t miss the message…
Do you trust your doctor? Most patients assume their doctor is working in their best medical interests whenever he or she orders a diagnostic test or recommends a particular treatment. Customers might wonder whether an unscrupulous auto mechanic is being truthful when he recommends a brake job or a new transmission. But most patients trust that their doctor isn’t recommending unnecessary surgeries merely to line his pockets.
The vast majority of doctors take their ethical responsibilities very seriously. Prior to ObamaCare, only a relatively few “bad apples” have chosen to compromise their professional ethics for financial gain. However, ObamaCare creates new ethical conflicts for doctors. We’ll examine some common physician conflicts of interest before and after ObamaCare, and discuss how patients can best protect themselves…
Prior to ObamaCare, physicians faced perverse incentives for overtreatment. Physicians might also be tempted to pad their income through inappropriate self-referral or business relationships such as “physician owned distributorships”.
After ObamaCare, physicians will face perverse incentives for undertreatment, especially with “bundled payments” and government “appropriate use criteria”. The new “narrow networks” required by many ObamaCare exchange plans will exacerbate these issues:
To cut costs, many ObamaCare exchange plans also require “narrow networks” of providers, where patients may only receive treatment from a short list of approved hospitals and doctors. President Obama has repeatedly promised, “If you like your doctor, you can keep your doctor,” but many patients are learning the hard way that this isn’t true.
Such “narrow networks” also mean that many doctors will lose long-standing relationships with patients they’ve seen for years. Instead, doctors will be increasingly reliant on the government-run exchanges for new patients. This will create a powerful incentive for physicians to adhere to any treatment guidelines mandated by the government or by government-approved insurance plans.
I also discuss several ways patients can protect themselves from these old and new physician conflicts of interest.
A new national initiative launched [November 19, 2013] by the Institute for Justice seeks to make sure the government stays out of some of the most personal decisions people make every day: What we eat and how we get our food. This nationwide campaign will bring property rights, economic liberty and free speech challenges to laws that dictate what Americans can grow, raise, eat or even talk about.
To kick off the initiative, IJ is today filing three separate lawsuits challenging Miami Shores, Florida’s ban on front-yard vegetable gardens; Minnesota’s severe restrictions on home bakers, or “cottage food” producers; and Oregon’s ban on the advertisement of raw–or unpasteurized–milk. Each case demonstrates how real the need for food freedom is in every corner of the country.
“More and more, the government is demanding a seat at our dining room tables, attempting to dictate what we put on our plates, in our glasses and, ultimately, in our bodies,” said Michael Bindas, an IJ senior attorney who heads up the new initiative. “The National Food Freedom Initiative will end government’s meddlesome and unconstitutional interference in our food choices so that Americans can once again know true food freedom.”
IJ is challenging Miami Shores’ front-yard vegetable garden ban in state court on behalf of Herminie Ricketts and Tom Carroll, a married couple who grew vegetables on their own property for their own consumption for nearly two decades before Miami Shores officials ordered them to tear up the very source of their sustenance or face fines of $50 per day. Learn more about their case: www.ij.org/FlVeggies.
Minnesota allows food entrepreneurs to make certain inherently safe foods–such as baked goods–in home kitchens, but it: (1) prohibits their sale anywhere other than farmers’ markets and community events; and (2) limits revenues to $5,000 per year. Violating these restrictions can lead to fines of up to $7,500 or up to 90 days in jail. IJ is challenging these restrictions under the Minnesota Constitution on behalf of cottage food entrepreneurs Jane Astramecki and Mara Heck. Learn more about their case at: www.ij.org/MNCottageFoods.
In Oregon, it is legal for small farmers to sell raw milk, but they are flatly forbidden from advertising it. If they do advertise their milk, they face a fine of $6,250 and civil penalties as high as $10,000–plus one year in jail. IJ is challenging this ban under the First Amendment on behalf of farmer Christine Anderson of Cast Iron Farm. Learn more about Christine’s case at: www.ij.org/ORMilk.
These three cases raise important constitutional questions that show how meddlesome government has become in our food choices: Can government really prohibit you from peacefully and productively using your own property to feed your family? Can government really restrict how many cakes a baker sells and where she sells them? Can government really ban speech about a legal product like raw milk? The answer is no.
IJ’s President and General Counsel, Chip Mellor, said, “For 22 years, IJ has been on the forefront of protecting Americans’ property rights, economic liberty and freedom of speech. With our National Food Freedom Initiative, IJ will now bring that experience to bear in the most fundamental area–food–so that Americans can be truly free to produce, market, procure and consume the foods of their choice.”
If you care about your access to foods of your own choosing and the rights of food producers to engage in voluntary trade, please consider donating to IJ! IJ is extremely effective and principled in their advocacy of liberty, and I know that my donor dollars are going to very good use.
P.S. With this initiative, the Institute for Justice is tackling a really important and growing aspect of statism in a way that resonates with ordinary Americans. They’re doing so on the basis of sound principles and facts, and they’re likely to effect change through the courts and public outreach. In contrast, ARI’s only activity in this area has been a series of propagandistic blog posts in defense of GMOs by an astrophysicist without an adequate understanding of relevant principles of biology. Basically, ARI’s approach seems little better than what Christian Wernstedt satirized here: The Tragedy of Milkia®: The Luddite Attack Against Industrial Dairy Progress. For this reason and about a hundred others, I’m glad that my donor dollars have long gone elsewhere, particularly to IJ.
My basic theme is that we need to legalize real “catastrophic-only” insurance, free of government mandates. More broadly, instead of debating which new government entitlements to create, we should be vigorously debating which freedoms to restore.
Here is the opening:
The President has proposed a one-year “fix” to deal with the political fallout from his broken promise (or lie), “If you like your insurance plan, you will keep it.” Now it’s, “If you like your plan, you can keep it until after the 2014 mid-term elections. Maybe.”
But the problems with ObamaCare go much deeper than cancelled insurance. As surprising as it sounds, most Americans never had real health insurance to begin with — and were not allowed to by law. And the only cure for our current health insurance mess is to legalize real health insurance…
I discuss the history of how we got into our current mess and some concrete free-market reforms that would move us in the right direction. These include:
1. Eliminate the tax disparity between employer-provided health insurance and individually-purchased health insurance.
2. Eliminate all mandated benefits. Insurers should be free to offer to willing consumers inexpensive policies covering only catastrophic accidents and illnesses.
3. Allow insurers to sell policies across state lines.
Eliminate the tax disparity between employer-provided health insurance and individually-purchased health insurance. This would uncouple health insurance from employment and restore a level playing field to the individual insurance market. Individuals could then purchase policies that they kept even when they changed jobs (just as they already do with their car and homeowners insurance).
Eliminate all mandated benefits. Insurers should be free to offer to willing consumers inexpensive policies covering only catastrophic accidents and illnesses. Insurers would remain free to offer richer policies that covered varying levels of elective procedures (but cost correspondingly more). Customers could purchase whatever levels of coverage they wished from willing insurers based on their own individual needs and circumstances.
Allow insurers to sell policies across state lines. State mandates create 50 separate state markets rather than a single national market. A family insurance plan costing $3,000 in Wisconsin might cost $10,000 in New Jersey because of state regulatory barriers. Allowing interstate competition would quickly drive down prices and help many working families on a tight budget.
I hope Congress can discuss and debate these ideas as a way to truly fix our health care system.
My basic theme is that we must protect the freedoms necessary for the advancement of medical technology.
I start with a pair of vignettes:
How much has American medicine changed in the past 30 years?
Let’s turn the clock back to 1983. A middle-aged man, Dan, is crossing the street on a busy midday Monday. An inattentive driver runs a red light and plows into Dan at 45 mph, sending him flying across the pavement. Bystanders immediately call for help. An ambulance rushes Dan to the nearest hospital. In the ER, the doctors can’t stabilize his falling blood pressure. They prep him for emergency surgery. The trauma surgeon tries desperately to stop the internal bleeding from his badly fractured pelvis but is unsuccessful. Dan dies on the operating table.
The surgeon gives Dan’s wife the sad news: “I’m sorry, but your husband’s injuries were too severe. We did everything we could. But we weren’t able to save him.”
Fast forward to 2013. Dan’s now-grown son Don suffers the same accident. But within minutes of his arrival in the ER, he’s sent for a rapid trauma body CT scan that shows the extent of the pelvic fractures — and more importantly, shows two badly torn blood vessels that can’t be easily reached with surgery.
An interventional radiologist inserts a catheter into the femoral artery in Don’s right leg. Watching live on the fluoroscopy screen, the radiologist skillfully guides the catheter through the various twists and turns of the arterial system and positions it at the first of the two “bleeders.” From within the blood vessel, he injects specially designed “microcoils” into the torn artery and stops the bleeding. He then guides the catheter to the second bleeder and repeats the procedure. Don’s blood pressure recovers. The surgeons now have time to repair Don’s pelvic fractures and other internal injuries.
The surgeons give Don’s wife the good news: “Your husband’s injuries were pretty bad. But we were able to fix everything. He’ll still have to go through recovery and physical therapy. But he should be back to normal in six months”…
Update #1: A great example of medical innovation coming from unexpected places was this 11/14/2013 New York Times article describing how an Argentinian car mechanic saw a Youtube video on how to extract a stuck cork from a wine bottle and realized it could also be used to help extract babies stuck in the birth canal.
His idea will be manufactured by Becton, Dickinson and Company and has already undergone initial successful safety testing in humans. It could save the lives of many babies in Third World countries and also reduce the need for Caesarean section in industralized countries. (Via Gus Van Horn.)
Update #2: For those interested in the real-life technology used in the fictional scenario I discussed, here’s a nice medical slideshow from UCLA interventional radiologist Dr. Justin McWilliams, “Life-saving Embolizations: Trauma and GI bleeding“.