Catch 22 in Britain

Woman too fat for operation is too thin for weight loss surgery. Expect similar bureaucratic catches to affect YOU under Obamacare

A woman who was considered too fat for a hernia operation has now been told she is not heavy enough to be given weight loss surgery. Jo Thompson, who is 5ft tall and weighs nearly 18 stone, has found herself in the Catch 22 situation after years of failed dieting. “I have always had a problem with my size,” she said today. “I have tried every diet going to lose weight. “In the last two years I’ve cut down on my portions, and although I can’t afford to go to the gym I do a lot of walking.”

Miss Thompson, 37, from Parson Cross, Sheffield, recently complained to her doctor about heartburn and indigestion. He referred her to a specialist at the city’s Royal Hallamshire Hospital, telling her he thought she needed a hernia operation. However, the consultant there said she was too big to undergo the procedure and instead recommended the gastric bypass. This, he said, would help her lose weight and thereby ease the hernia problem.

“But when I saw another doctor I was told I could not have the bypass surgery because I am not heavy enough. “It’s a crazy situation and I just don’t know what to do. I’m not obese enough to have a gastric bypass, but I’m too big to have the hernia operation. Miss Thompson, whose body mass index is 46, went on: “It seems I must reduce my body mass index to 40 to have the hernia operation or increase it to 50 to have gastric bypass surgery. It’s a crazy situation and I seem to be caught in the middle”.

The refusal by staff at Royal Hallamshire to carry out the bypass operation while Miss Thompson’s BMI remains below 50 has been criticised by a specialist health group. Dr Matt Capehorn, of the National Obesity Forum, said: "Under National Institute for Clinical Excellence (NICE) guidelines, patients who have unsuccessfully tried other weight loss methods should be considered for surgery if their BMI is above 40. "Sheffield NHS have been very short-sighted in their view of the funding for this operation because the surgery would pay for itself within three years.” He added: “They are not following NICE guidelines and are therefore leaving this woman in a state of limbo."

A spokesman for NHS Sheffield confirmed that the trust had turned down Miss Thompson’s request to have the operation. Its criteria on the issue had been set by the Yorkshire and Humber Specialised Commissioning Group and was therefore in line with the rest of the county. The procedure was always used as a last resort “because it is a very serious operation.”

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Australia: Ambulances sit waiting for hours before public hospitals can take patients from them

Too bad that patients arriving by ambulance are generally seriously ill

MORE patients than ever are waiting over 30 minutes in ambulances "ramped" outside busy Queensland public hospitals because doctors and beds are not available. State Government figures reveal a 26 per cent increase in the number of sick and injured people being forced to wait before being seen by an emergency department doctor. Queensland Ambulance Service staff reported waits of three to four hours were not uncommon before they could hand over a patient.

In 2007-08, the cumulative hours spent waiting in the back of an ambulance were 10,528 across the state's 27 public hospitals. That jumped to 13,269 in 2008-09. Brisbane experienced the biggest jump, from 3879 hours to 5823 – a 50 per cent increase.

Opposition emergency services spokesman Ted Malone described the waiting as disgraceful and said it was costing taxpayers millions of dollars every year. "The Bligh Government's own statistics prove just how serious this issue has become," Mr Malone said yesterday. "Public hospitals have been in crisis for years and I have repeatedly questioned the Bligh Government to detail the costs of hospital ramping. "Emergency Services Minister Neil Roberts has arrogantly brushed my questions aside and refused point blank to detail what the considerable cost is to the QAS."

Mr Malone said the union representing ambulance officers had kept a tally of hours spent ramped outside southeast Queensland hospitals. He said Mr Roberts should have access to the information, but suggested it would embarrass the Government. "This is a critical issue and Queensland taxpayers deserve to know what the dollar cost of ramping is to the QAS," he said.

The Liquor Hospitality Miscellaneous Union said that on one day in September, 11 ambulances were ramped at Logan Hospital for more than two hours.

In an answer to an Opposition question, Mr Roberts said the average off-stretcher time across Queensland was 13 minutes. He said 92 per cent of all patients were in hospital beds within 30 minutes and it was not possible to work out the cost of what officials termed "access block".

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Defeat Obamacare in Detail

Harry Reid can pass a bill in the Senate that has no public option or an easy opt out, shallow subsidies for the uninsured, a low total cost, weak penalties for not having insurance, no coverage for abortion and no general tax increase (except for the premium and medical device taxes). And Nancy Pelosi can pass a bill in the House (on final passage) that has a public option with no opt out, steep subsidies for the uninsured, harsh penalties if they don't buy insurance, a higher cost, full abortion coverage and a surcharge income tax increase. The question is: Can either one's bill pass the other's chamber? Probably not. So here's how all this is likely to unfold:

Pelosi's bill is dead on arrival in the Senate. Reid is going to have to give up his insistence on the public option and pass a bill in the Senate very much like the Max Baucus bill that came out of the Senate Finance Committee. After extensive negotiations with his liberal wing on the one side and the moderates in the Senate on the other side (led by Joe Lieberman), he will eventually strike a deal.

He'll let the bill pass with no public option or with a generous opt-out provision. Meanwhile, he will placate his liberals by telling them that the final version that the conference committee will report back to the Senate will have a robust public option, not to worry. (Just as Pelosi told her liberals that the final bill would not ban payments for abortions, not to worry.)

After weeks of negotiations, the Senate will probably pass its version of the bill as a Christmas present to America. But ... in the course of all of these negotiations, Barack Obama and the Democrats are going to look worse and worse, more divided and less focused on the ultimate objective. Public antipathy to the bills will mount, and the worst-case scenario of each possible variation in the legislation will spark its own storm of opposition. By the time the Senate acts, the feminists will be angry, the uninsured will be angry, the senior citizens will be angry and the fiscal conservatives will be angry. Support for the bill will drop week after week during November and December.

By the time Congress reconvenes in January to wrestle with the two competing versions, support for the bill will have dwindled to a perilous point. This reduced level of support will just serve to make senators and congressmen more intransigent in the negotiations. Since the bill will need 60 votes in the Senate after the conference report, Lieberman, Maine's Olympia Snowe and Susan Collins, and a handful of other moderates will each have a veto. And, collectively, the liberals in each chamber will have onem as well. Weeks and months of wrangling will ensue. The result could be the defeat of the bill or its amendment in positive ways (for those opposed to it).

Our task is to reduce public support for the bill by publicizing its provisions, notably:

1. The $400 billion cut in Medicare.

2. The inevitable scarcity that will result from the addition of 35 million new patients with no new doctors or nurses.

3. The fine on the uninsured of 2.5 percent of their income if they don't buy insurance.

4. The high cost of these mandatory insurance policies ($15,000 per family).

5. The low level of subsidy available for the uninsured (only after they pay 8 percen to 12 percent of their incomes).

6. The likelihood of a $1,700 increase in the average family's premiums.

7. The possibility of up to five years in prison for failing to buy insurance or pay the fine.

8. The taxation of medical devices like pacemakers, wheelchairs, prosthetic limbs, hearing aids, etc.

9. The tax on sick people (increasing the threshold for deducting medical expenses from 7.5 percent to 10 percent of income.

10. The additional fiscal burden on the states of the increase in Medicaid eligibility.

11. The 40 percent tax on health insurance premiums that will effect households earning more than $75,000 by the fifth year of the plan.

We can still win this fight!

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CMS: House health bill will hike costs $289B

The House-approved healthcare overhaul would raise the costs of healthcare by $289 billion over the next 10 years, according to an analysis by the chief actuary at the Centers for Medicare and Medicaid Services (CMS).

The CMS report is a blow to the White House and House Democrats who have vowed that healthcare reform would curb the growth of healthcare spending. CMS's analysis is not an apples-to-apples comparison to the cost estimate conducted by the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) because CMS did not review tax provisions, which help offset the price tag of the Democrats' measure.

However, the CMS analysis clearly states that the House bill falls short in attaining a key goal of the Democrats' effort to reform the nation's healthcare system: "With the exception of the proposed reduction in Medicare... the provisions of H.R. 3962 would not have a significant impact on future healthcare cost growth rates."

Republicans immediately seized on CMS's conclusions. The long-awaited report should serve as a "stark warning to every Republican, Democrat and Independent worried about the future of this nation," Ways and Means Committee ranking member Dave Camp (R-Mich.) said in a statement on Saturday.

Though House Republicans pressed to have this analysis completed before the lower chamber voted on the Democrats' sweeping healthcare reform bill last week, it was not ready until late Friday. Chief CMS Actuary Richard Foster, who prepared the report, recently told The Hill that he and his staff had only a few days to review the bill before it was voted on.

Brendan Daly, communications director for Speaker Nancy Pelosi (D-Calif.), said, "The report shows that our health reform bill will extend the life of the Medicare trust fund by five years -- significantly longer than any proposal in recent years," adding, "Medicare actuaries estimate $100 billion more in savings than CBO from Medicaid and Medicare."

Minority Leader John Boehner (R-Ohio) highlighted the CMS report on Saturday in a written statement. "This report once again discredits Democrats’ assertions that their $1.3 trillion government takeover of health care will lower costs, and it confirms that this bill violates President Obama’s promise to ‘bend the cost curve.’ It’s now beyond dispute that their bill will raise costs, which is exactly what the American people don’t want."

Republicans predicted that if the CMS numbers were available last Saturday when the House voted on the Democrats' healthcare bill, the measure would not have passed. “This report confirms what virtually every independent expert has been saying: Speaker Pelosi’s healthcare bill will increase costs, not decrease them. I hope my colleagues in the Senate heed CMS’ findings and refuse to rush ahead until any bill under consideration can be certified to actually reduce healthcare costs," Camp said.

According to the 31-page report, the House-passed bill would increase costs, cut Medicare and expand Medicaid. “In aggregate, we estimate that for calendar years 2010 through 2019 [national health expenditures] would increase by $289 billion," the report notes. "About three-fifths" or more than 60 percent of the uninsured would gain coverage by an expansion in Medicaid eligibility.

Medicare would be cut by "more than one-half trillion dollars ($571 billion), ... possibly jeopardizing access to care for beneficiaries," according to the report, and smaller companies would be "inclined to terminate their existing coverage."

Camp said that the nonpartisan analysis demonstrates that the Democrats' bill "does the opposite of everything they've been wanting to do" in terms of reducing overall health costs. He added the CMS report shows that "this is not healthcare reform, this is entitlement expansion."

A Democratic aide said the CMS and CBO findings are not that different: "While the actuaries do not show tax increases, adding those amounts from JCT would also illustrated that the proposal reduces the deficit over the next 10 years."

In an interview with The Hill on Saturday afternoon, Camp pointed out that CMS actuarial numbers were cited by Democrats back in 2003 during the Medicare prescription drug debate. CMS estimated at that time that the GOP-crafted Medicare bill would cost more than $550 billion over 10 years while CBO estimated its pricetag at $395 over the same period. The CMS cost estimate did not emerge until after the final conference bill was approved by Congress.

CMS's findings are not binding on Congress, however. Congress must abide by CBO and JCT estimates.

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Health cooperatives: Fast lane to nationalization

Of the 1,990 pages in the healthcare reform bill passed by Congress Saturday night, page 206 is especially touted – and little understood. That's the page that creates a federal Consumer Operated and Oriented Plan (CO-OP) to establish not-for-profit, member-run health insurance cooperatives.

Supporters say these health cooperatives, or HCs, will reduce costs by giving smaller buyers of insurance (such as small businesses) the ability to act as a large buyer. HCs will level the playing field, giving the "little guy" much more leverage to negotiate lower prices. They won't. What they will do is put the United States on a track toward nationalized healthcare even faster than the government-run insurance plan called the public option.

The reason HCs won't lower costs has nothing to do with politics or economics but a simple error of logic called the "fallacy of composition." Senators should take a refresher course in logic before they review page 206 and the rest of the legislation in coming weeks.

What, exactly, is a fallacy of composition? The basic idea is that if something is true for the part, it is not necessarily true for the whole. For example, if the Red Sox improve their batting average next year, they'll probably win more games. But if all major-league baseball teams improve their batting average next year, will all teams win more games? Of course not.

Yet proponents of HCs are making a similar mistake in judgment. Their fallacy results because market power is a relative concept. The advantage of being a large buyer comes at the expense of small buyers, so it is a fallacy to expect that any benefit currently derived from large buyers can be enjoyed by everyone if everyone becomes a large buyer.

Suppose, for example, that a pencilmaker sells one pencil per month to 10 separate buyers. Each pencil costs $1 to make and overhead is $10. The pencilmaker needs at least $20 in revenue per month to stay in business, so the average price per pencil must be at least $2.

Now suppose some buyers form a cooperative and use their newfound market power to negotiate a price below $2. To continue generating $20 in revenue, the pencilmaker must now charge the remaining buyers more than $2 because overhead has to be paid by someone.

If the remaining buyers also form a cooperative they may to able to negotiate the pencil price back down to $2, but only if pencil buyers in the first cooperative experience a price increase. Once everyone is large, the advantage of being large disappears.

Similarly, if "Jane" switches from a non-HC plan to a HC plan, she will probably get to pay a lower premium because the HC plan can negotiate lower reimbursement rates. But that also means that she will now be contributing less to her healthcare providers' overhead expenses than before. This forces them to make up the difference by charging non-HC plan patients more.

So if we reform the system to make small buyers large ones, then as the number of small plans declines, the large plans will run out of small plans to shift costs to, so the benefit of being large will disappear.

Some liberals find HCs appealing because they believe them to be a first step toward nationalized healthcare. Most conservatives oppose them for that very same reason. Some conservatives, however, find them appealing because they appear to be less risky than having a government-run public option that competes with private policies.

It is true that a public option carries the risk of driving all private insurance out of existence because it can set terms and rates that no private plan can actually compete with. But if a public option plan began to drive private insurers out of business, then it is at least conceivable that political pressure could emerge to correct course.

Once government-supported HCs take effect, however, they would almost certainly mean the end of private plans, because forthcoming insurance regulations will leave non-HC consumers with added costs and subtracted benefits – nudging everyone into HCs. So by establishing HCs as the centerpiece of reform and then regulating them directly, lawmakers may end up providing a faster path to de facto nationalized healthcare than a public option, which is also included in the House bill.

Indeed, what makes the House bill especially galling is that it has both HCs and a public option. Either provision, on its own, would overwhelm private healthcare. That's why voters shouldn't take much comfort in the speculation that the Senate might exclude a public option. If the Senate's version of the bill includes a provision for HCs, then reform would ultimately nationalize healthcare in America.

Those who are serious about making sure everyone has health insurance need to stop adding more layers of complexity to an already complex system.

The solution is to abolish Medicare and Medicaid, abolish the favorable tax treatment of employer-provided insurance, impose a one-price rule on procedures, and issue a voucher to every single American citizen. The creation of a voucher program would certainly take less than 1,990 pages of legislative language. This will solve the problem of the uninsured completely, immediately, and permanently in a transparent way that works with, rather than against, competition. The big losers will be special interest groups because a transparent voucher system will rob them of their ability to manipulate the system. They know this all too well, which is why they oppose it.

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Insurance perks for healthy habits spur opposition

Who could object to rewarding people who quit smoking, lose weight or start to exercise? The American Cancer Society and the American Heart Association, for starters. Some companies now charge lower insurance premiums to workers who meet benchmarks for healthy living. The Senate's health-care overhaul legislation would expand the trend.

But instead of cheering the proposal, some patient-advocacy and health groups are worried that it would mean higher rates for less-fit Americans, possibly pricing them out of their employers' insurance plans. "It is a way of cherry-picking," said Dick Woodruff, senior director of federal affairs for the American Cancer Society. "We are all for workplace wellness, but when you tie it to the insurance-pricing system, it's a real problem."

Critics of the Senate proposal also say that giving special treatment to those who meet a company's fitness standards could undercut one of the marquee promises of the Democrats' proposed overhaul: preventing employers and insurers from discriminating against people on the basis of their health status and pre-existing medical conditions.

Under current law, companies can discount insurance premiums by 20 percent if employees meet benchmarks for weight, smoking or other aspects of their health. Earlier this year, two Senate committees, as part of the health-care overhaul, voted to allow such cuts to go as high as 50 percent.

Leading the charge for the idea is Safeway, the giant grocery-store chain, which already has adopted an incentive program that includes health-premium reductions. Last year, the company began to offer a 20 percent premium discount to its non-union workers who quit smoking, went on a diet, brought down their blood pressure and cut their cholesterol.

Jo Chiti, a Safeway employee who has lost about 30 pounds over the last year, said she has been swayed by Safeway Chief Executive Steve Burd's argument that health insurance should be more like car insurance. Just as good drivers should be rewarded with lower premiums than reckless drivers, Burd says, people who maintain a healthy lifestyle should pay less for coverage than people who do not.

A lobbying blitz by Burd, who has traveled to Washington 11 times this year, was instrumental in the two Senate committees' decision to include the idea in their health-care bills. Senate leaders are putting together the final version of a bill they will take to the Senate floor. "We believe that personal responsibility and financial incentives are the path to a healthier America," Burd said in a newspaper column.

Critics in the labor movement say the incentive scheme is a backdoor way for companies to cut their costs by driving less-healthy workers out of the insurance group. Indeed, most of Safeway's union workers, who are represented by the United Food and Commercial Workers and make up about 95 percent of the company's workforce, have not embraced the idea in their own health plan, which is established in a multi-employer contract.

What is more, critics worry that the program will unfairly penalize people whose health status is not solely the result of behavior they can easily control, such as a genetic predisposition to obesity or the weight gain that often accompanies smoking cessation.

Ken Schachmut, a Safeway senior vice president, says the company has a system for making exceptions if people bring a physician's note to explain why they cannot safely or wisely achieve the set goals. "We do not discriminate," he said. Opponents hope to water down the Senate provision in the legislative maneuvering ahead.

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