Obamacare's Sobering Vocabulary Lesson

Over the last three years, America has been embattled in a health care reform debate, ranging from the legislative debates to the townhalls and Tea Parties and later on to the actual vote and bill signage and Supreme Court decision. In reality though, we were never really discussing health care reform; we were discussing health insurance reform. The difference is huge and will become more and more evident as time progresses. More Americans may receive health insurance coverage as Obamacare is implemented, but that doesn't mean that they will receive health care. We need to look no further than Medicaid to see the failures when government gets involved in health insurance and health care. Medicaid has been in place for nearly fifty years, but has the potential to greatly expand in states that choose to do so. However, Medicaid is also illustrative of how health care reform is a complete misnomer.

The New York Times finally highlighted the burgeoning doctors' shortage on Sunday. Even prior to Obamacare's passage, a doctors' shortage was anticipated. However, the shortage of doctors more than doubles with the implementation of Obamacare. What do doctors' shortages do? As the NYT story notes of current doctors shortages (emphasis added):

Experts describe a doctor shortage as an “invisible problem.” Patients still get care, but the process is often slow and difficult. In Riverside, it has left residents driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.

Yes, the New York Times would follow up a sentence that notes patients would receive care by noting that the doctors' shortage would influence them to forego care hoping that their readers would miss their attempt at nuance. Medicaid, though, adds an additionally wrench in the physician shortage, as the NYT goes on to say:

Moreover, across the country, fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008, making it hard for the poor to find care even when they are eligible for Medicaid. The expansion of Medicaid accounts for more than one-third of the overall growth in coverage in President Obama’s health care law.

If there is already of shortage of doctors and  Medicaid patients are hard pressed to find a physician that will take them as a patient, where is the reform of health care? It's almost as if the government has offered to give the entire country their own car, but only gave everyone a set of keys. One of the main reasons that doctors aren't accepting new Medicaid patients is due to reimbursement rates, which Obamacare is supposed to increase. However, while President Obama was attempting to offset the financial aspect of care on the backs of the taxpayers through projected reimbursement increases, he neglected to address tort reform, which would have decreased medical malpractice insurance for doctors, while only negatively affecting ambulance chasers and the Democratic politicians to whom they donate, not the taxpayers.

Since Medicaid is partial state funded, there is a state specific aspect of this too. Take Illinois for example, where in FY2012, Medicaid was underfunded by $2.1 billion dollars . Additionally, even if funding stayed flat as Governor Quinn projects, payment to providers is projected to average nearly a year's delay by FY15. The state is already $8 billion behind on their bills overall, prompting the state comptroller to provide emergency funding to a mental health facility reliant on Medicaid funding to prevent the agency from closing its doors.  The expansion of Medicaid as Obamacare is implemented is supposed to make matters worse. Although the Supreme Court decision allows the states to decide whether or not they are going to expand Medicaid, true to form, Illinois Governor Pat Quinn has already indicated he will. With a growing doctors shortage, a limited number of doctors accepting Medicaid, and the potential for facilities to close due to delayed payment, it would be a miracle if a Medicaid patient even got into the doctor!

Let's pretend though that a new Medicaid patient was able to get into the doctor, but they have a rare illness or are extremely sick and require a great deal of medications. Well, Illinois Medicaid has stated that they now will limit patients to 4 brand name drugs. This comes after last year, when Illinois cut availability of brand name psychiatric drugs. Fifteen other states have limits on brand name prescriptions as well. To be sure, there are a great deal of generic medications, but there are still situations where there are no generics available. Essentially, this is drug rationing.The implementation of Obamacare, which is predicted to double the number of Medicaid recipients in Illinois over the next ten years, will only exacerbate the problems already in place.

Obamacare may end up technically providing some form of "health insurance" to the majority of Americans. However, if past is prologue when it comes to government's role in medicine, this will not be legitimate health care reform, as people who now may not have health insurance or health care may inevitably end up with health insurance, but with delayed or non-existent care and limits on what medication they may receive.Of course, this is not what was promised by President Obama. Julia may get her free birth control, but she will likely have a heck of time scheduling an appointment for a doctor to prescribe it for her. Moreover, this is being done on the backs of the American taxpayer, or in the case of Illinois, the $2.1 billion Medicaid underfunding  came on the heels of a 67% state income tax increase and a more than 40% increase in state corporate taxes. This is the kind of newspeak that has become commonplace in the Obama administration, but hopefully proponents of government intervention in medicine will learn a sobering lesson. Health care and health insurance are not synonymous. Crossposted here and here.

Death Panels--Turning Patients into Algorithms

Over two years ago, in the heated discussions leading up to the passage of Obamacare, Governor Palin rightfully categorized a key aspect of the legislation--the "death panel".  More and more evidence of such rationing continues to become evident day-by-day. In her initial post, Governor Palin rightfully highlighted President Obama's healthcare adviser, Ezekiel Emanuel and his advocacy of a "complete lives system" that would ration care to those who are capable of being productive in society (i.e. those who are disabled, have special needs, or who are elderly would be less likely to receive needed care). Controversial former Medicare commissioner nominee Donald Berwick willingly admitted that he considered rationing to be necessary component of healthcare. Congressional Democrats have even recognized that the Medicare Independent Payment Advisory Board is an effect a rationing board that essentially redistributes the health of Medicare recipients. The FDA has also skirted the thin line between being a regulatory agency and a rationing board when they took cost into consideration in their approval process for a breast cancer drug, rather than sticking to their role of evaluating safety and efficacy of drugs.

Eyebrows have been raised also with reports released in the past few years from the US Preventative Task Force suggesting changes to the normal breast cancer and prostate cancer screenings. Those who disagree with the task force's findings are critical of the fact that they do not include radiologists and oncologists as part of their group as this may indicate that the appropriate expertise is not being utilized. Supporters of the findings think that this is beneficial as it removes the potential of bias from those who may benefit professionally from the status quo or increased frequency in screening recommendations. Those on both sides of the issue are addressing the wrong problem.

Dr. Richard Ablin,the physician who developed PSA testing for prostate cancer, is now saying that routine testing is "a public health disaster". Yes, PSA screenings can detect cancer when it is treatable, but that also must be weighed against unnecessary treatment and surgery if the test results in a false positive. The psychological effect must also be taken into consideration for those who tested positive, but were actually negative. Sometimes very old patients are treated for cancer with treatment regimens that are very painful and uncomfortable in and of themselves, and some would have likely have died of natural causes prior to the cancer itself killing them. Similar issues can occur with breast cancer. There is a concern that too frequent of mammographies has the potential to cause cancer itself. There's also the psychological concern that arise with the worries of yearly examinations among other problems.

The true problem is the burgeoning influence of the government in these screenings and the shrinking influence of individual patients and physicians. The recommendations of such a government commissioned panel as the US Preventative Task Force has the potential to create a precedence for influencing what both private and public insurers cover and at what ages and frequencies they cover screenings such as mammograms. In the United Kingdom, their universal health care covers mammography for women aged 50-64 years of age every three years. Prior to the most recent US Preventative Task Force recommendations, women in the United States were recommended to receive mammograms on a yearly basis from age 40 and up, which is still what is generally adhered to. In the UK, breast cancer  mortality rate of 26.2 per 100,000 while it was 23.5 per 100,000 in the US for an 11% difference in mortality. Although not all factors can be effectively evaluated, earlier and more frequent screening likely played a role in making survival better for American women than UK women.

In addition to the potential for task force  recommendations to turn into government regulations, the influence of comparative effectiveness research provides a potential threat to the patient-physician relationship. When applied on the micro level, comparative effectiveness research is needed and welcomed. Patients and doctors alike want to ensure they are either receiving or administering the most effective treatment for their condition. No one wants unnecessary, ineffective procedures to be performed. However, when the results of such research is applied on the macro level through government regulations, it has the potential to turn patients into algorithms where a patient's demographics, symptoms, and disease are placed into an equation to spit out what is deemed the appropriate treatment.  This is the kind of healthcare system that has been implemented in England through the National Institute for Health and Clinical Excellence  (NICE) which has lead to increased rationing of care, increased wait times, and non-coverage of cancer treatments often basing decisions on a quality of life equation. To be sure, quality of life is important and often more favorable than an increased quantity of life of just a short time. However, the problem lies with who makes this determination. Does a government panel make this decision? Does the influence of government applied comparative effectiveness research play too large a role? Two of the key tenets of bioethics are autonomy and beneficience. When decisions are made by government panels and government implemented algorithms rather than by patients and their doctors, it flies in the face of both of these tenets.

Trying to Put Lipstick on a Death Panel

Governor Palin invoked the outrage of many on the Left with her now famous "death panel" assertion in August of 2009. They claimed that statement of government-controlled rationing was nothing but a hyperbolic lie. Since then, former White House budget adviser Peter Orszag has admitted that Obamacare would sacrifice quantity of care for quality and efficiency, in effect, rationing. New York Times Columnist Paul Krugman has twice admitted that death panels are present in Obamacare. Medicare Commissioner Donald Berwick is upfront with his support for rationing of healthcare. President Obama's deficit commission has suggested the Medicare rationing would be a means of reducing the national deficit.

Depending upon a decision to come today, the FDA may begin to implement a form of rationing by preventing a drug to treat late stage breast cancer, Avastin, from reaching the market based primarily upon cost. The drug was shown to prolong life by an average of 3.5 months, though some survived for years. It was set to be finally approved, but a panel struck down this approval with a 12-1 vote. The drug is rather expensive, but was shown to be effective. An editorial from the Washington Examiner states:

Doctors and patients were then stunned last summer when the ODAC ruled, by a vote of 12-1, that the drug did not produce clinically meaningful results. Why did the panel deny the obvious evidence of Avastin's effectiveness? One member of the FDA's panel, Jean Grem of the University of Nebraska, said, "We aren't supposed to talk about cost, but that's another issue." If the FDA follows through on the ODAC's finding and revokes Avastin's approval, both the government and private insurers will quickly cease paying for its use on breast cancer sufferers.

[...]

Government bean counters were never supposed to determine what your treatment options are, and patient advocacy groups are justifiably outraged. If Avastin and other expensive wonder drugs are denied approval because of costs, proponents of government-run health care will have to no choice but to admit "death panels" have gone from rhetoric to reality.

Sally Pipes writes in Forbes:

Despite all evidence to the contrary, the advisory committee claims its recommendation had nothing to do with Avastin's cost. The FDA's top brass will doubtlessly take the same line and claim that its decision to ratify that recommendation was based solely on the drug's medical efficiency.

The truth is that Avastin is expensive. A year-long supply for breast cancer treatment costs upwards of $80,000.

However, many American women are getting something priceless in return for those dollars: life and vitality. In one clinical trial, nearly 50% of patients receiving Avastin witnessed their tumors shrink. Another study found that patients receiving the drug in conjunction with chemotherapy lived "progression-free" twice as long as patients without it.

[...]

However, if the FDA revokes Avastin's approval, public insurance programs like Medicaid and Medicare could decide to refuse coverage of the treatment. Many private insurers would likely do the same. Indeed, several major insurance companies--including Regence and HSCS--have already reacted to the FDA Avastin debate by restricting coverage for the drug in the treatment of breast cancer.

Of course, doctors would still be able to prescribe the drug "off label." But because patients wouldn't have coverage, the only ones that could still use Avastin would be the small minority that can afford to pay its full price out-of-pocket.

This pending FDA decision is only further proof of a government panel making decisions that should be made by a doctor and his or her patient. People are beginning to admit the presence of "death panels" in Obama administration policy, but their presence has been seen for quite a while. Funding for "comparative effectiveness" health care research, determining what treatments are most effective for a given malady, was arguably the most under emphasized part of the stimulus bill. The general concept of "comparative effectiveness" appears benign. as most Americans want to make sure that the receive the best treatment for a disease and do not wish to receive unnecessary, ineffective treatment. Comparative effectiveness research is performed and presented in aggregate, but treatment is performed on individuals. When results are applied to decisions made by government panels, it is just another indication that further government intervention results in less freedom and volitional control to the individual. Last year, the U.S Preventative Services Task Force recommended reducing the frequency of mammograms and the age to begin the screening. The Task Force made this recommendation all while not soliciting the opinion of either a radiologist or an oncologist. While the recommendations were not further pushed by the Department of Health and Human Services, it provides an open door for government panels' recommendations to affect coverage and thus, potential early detection.

Once again, Governor Palin's prescient comment is vindicated. You can put lipstick on a death panel by calling it the FDA, comparative effectiveness research, or the U.S. Preventative Services Task Force, but it's still a death panel.

Cross posted here and here.

Governor Palin's Year of Health Care Rationing Prescience

This past December, Politifact called Governor Palin's "death panel" Facebook post "the political lie of the year". While those of us who understood Governor Palin's statement in context knew full well that she was stating the truth about rationing of care that would occur under a more socialized system of healthcare, based upon the kinds of people President Obama has placed in his administration, it should be quite clear that rationing is a means to the ends of his version "health care reform".

Last night, following the recess appointment of Dr. Don Berwick to head up Medicare and Medicad. Governor Palin tweeted:

Press Corps-pls do your job as Obama sneaks in Berwick appt;pls cover his mission:socialized healthcare&rationing based on"quality of life"

As citizen journalists, let's take a look at Berwick, shall we? In May, I wrote a post for our local 912 Project that partly focused on Berwick:

On April 19th, President Obama nominated Dr. Donald Berwick to be the administrator for the Center for Medicaid and Medicare Services. Berwick has expressed support for the the National Health Service, the United Kingdom's government-run healthcare system that has the UK lagging on breast care survival, heart attack mortality, and life expectancy compared to even other European countries with socialized medicine. You can hear his support for the the NHS in the video below of a 2008 speech in the United Kingdom:

Berwick has additionally expressed support for the UK's National Institute for Clinical Health Excellence (NICE), the entity that determines the "clinical effectiveness" of various procedures and treatments and whether or not a patient should receive such treatment and other standards regarding care. In essence, NICE determines the quantity of care that a patient receives based upon the incurred cost. In the clip above, Berwick favors for UK healthcare system over that of the United States' system as it is now.

Hmm, rationing of care? Support for an entity like NICE? Death panels, anyone? Of course this is not the first Obama administration official to espouse this mindset. Last summer, Governor Palin and Congresswoman Bachmann called out President Obama' s health care adviser, Zeke Emanuel:

The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

Health care by definition involves life and death decisions. Human rights and human dignity must be at the center of any health care discussion.

Rep. Michele Bachmann highlighted the Orwellian thinking of the president’s health care advisor, Dr. Ezekiel Emanuel, the brother of the White House chief of staff, in a floor speech to the House of Representatives. I commend her for being a voice for the most precious members of our society, our children and our seniors.

Both the man who advises the President on health care and the man charged with the duty of overseeing entitlement health care programs that provide for millions of Americans are strong supporters of rationing. It's quite obvious that perhaps in addition to spreading around the wealth, President Obama wants to spread around the health. In addition to these men, former White House economic adviser, Peter Orszag, has said, " the only real solution…is to move toward a healthcare system that is based upon quality and efficiency — not upon quantity.” If a healthcare system is not based upon quantity, then it means that the number of patients who can be treated is limited, rationing. While quality and efficiency are noble goals--you want to make sure that people are well treated and not overtreated--these cannot be goals that take precedence over ensuring that people are actually treated at all.

So nearly a year after the Facebook post heard 'round the world, it's become even more apparent that Governor Palin was extremely prescient about the means to justify President Obama's health care reform ends: rationing. The biggest political lie now? Those claims that Governor Palin lied about death panel!

Cross posted here and here.