Thursday, November 19, 2009

High dropout rates undermine stupid British plans for degree-only nursing

Plans to make nursing a degree-only profession could be thwarted by the high number of students who drop out before finishing training, the latest figures suggest. More than half of students on some nursing degree courses do not graduate because of pressures of time, money and the academic standards demanded. The figures, obtained using the Freedom of Information Act, show wide variations in attrition rates among England’s 10 strategic health authorities.

At one university, in the North West, 51 per cent of students fail to complete its degree programme in adult nursing. The highest attrition rates in London, the South West, West Midlands, Yorkshire and the Humber show more than a third of students dropping out.

The Department of Health is so concerned about the problem that it ordered an annual report on dropout rates from university nursing courses, Nursing Attrition National Aggregate. However, it has not published the findings.

The figures, obtained by Nursing Standard magazine,dropouts are even more common. One university lost 78 per cent of students on a children’s nursing degree course, and more than 54 per cent of students on a mental health nursing course failed to graduate.

The findings come a week after The Times reported on government plans to require those wishing to become a nurse to have a degree. Supporters claim that the move, which will be enforced from 2013, will improve the quality of patient care and raise the status of nursing.

Critics suggest that the changes will create an elitist profession and scare off recruits with the prospect of a long and expensive period of study. There are also concerns that some nurses would be “too clever to care” and refuse to carry out duties such as washing and feeding patients and helping them to the lavatory.

Norman Lamb, the Liberal Democrat health spokesman, said that the dropout rates cast degree-only plans into disarray. Concerns have also been raised about the millions of pounds of taxpayers’ money, given in bursaries, wasted on courses that were not completed. “These figures appear to massively undermine the Government’s new plans for nurses,” he said. “Such high dropout rates suggest there is something seriously wrong. Ministers are burying their heads in the sand by refusing to publish their own report into quit rates.”

Nursing education specialists said that financial difficulties and the high number of mature students who juggled families with their studies were among the main reasons for dropping out.

Nurses, who make up the largest part of the NHS workforce, now require the minimum of a diploma — a nursing course lasting two or three years — for trainee nursing positions. Under the new rules, candidates will require a degree in nursing or equivalent international qualification. The courses, lasting up to four years, will meet standards developed by the Nursing and Midwifery Council, the professional regulator.

Peter Carter, general secretary of the Royal College of Nursing, which helped to draw up the degree-only plans, said that losing potential nurses was “an entirely unnecessary waste of people who are willing to learn and want to care”. He added: “Of course, some people will not be suited to the demands of nursing, but with rates as high as 78 per cent, something is seriously wrong with the support offered to the nurses of the future. Financial support is very important but it is not the only kind of support that needs to be on offer.”

A Department of Health official said that an incentive scheme to pay universities with low attrition rates would start next year.


Is Obamacare Like Mandatory Auto Insurance?

Teaching introductory logic for ten years made me vividly aware of the low average quality of reasoning among college students. It also showed me how little improvement can realistically be accomplished by only one semester’s training in the art of thinking clearly. By all rights, then, I should have severely pessimistic expectations about public discourse in this country. Nevertheless, whether I suffer from my own strain of bad induction or just unquenchable naïveté, pandemic outbreaks of illogical memes still catch me by surprise.

That’s why I’ve been so shocked at the widespread assertion that a national mandate requiring individuals to carry health insurance is legitimate (and even Constitutional) because we already require everyone to purchase auto insurance. There’s just one small error this idea seems to forget: the federal government does not actually have a law requiring individual drivers to carry such insurance. Only states do.

And since federalism is at the center of the Constitutional concerns surrounding Obamacare, I find it stunningly bold to claim the federal government has authority for a project because of something similar the states currently do. The argument seems to be, “Congress can do it because it’s just like something else that Congress doesn’t do.” Now, obviously, if we were debating whether individual states could mandate health coverage, at least the levels of government being analogized would be the same. But the leap from what states do to what Congress can do betrays vistas of ignorance concerning our system of government. A college freshman would be embarrassed to make such a weak argument, yet members of Congress have said precisely this.

Senator Burris, for instance, recently told CNS News that it’s okay to make individuals purchase health insurance because, “Under state law, we have every one required to have automobile insurance … so, that’s the same thing proportionally to automobile insurance. I mean, it’s comparable.” The good news here, of course, is that the former Illinois Secretary of State (hence, overseer of the DMV) rightly situated the law at the state level. The sad news is that this United States Senator has taken an oath of office to uphold a document he apparently has not read. But perhaps we can forgive his lapse, seeing as how he’s the Senatorial equivalent of a baseball September call-up put into office by a now-deposed criminal of a governor. What excuse do his colleagues have?

See, in some sense, those of us who live in states (like Illinois) which require minimum coverage might understandably forget that not all things “the government” requires are things “the national government” requires. But I’m especially surprised that inhabitants of New Hampshire and Wisconsin haven’t immediately exposed this line of reasoning since their states have no such requirement at all—a barely publicized truth which underscores the fact that there is no national car insurance law.

Still, let’s put aside the equivocation between federal and state authority and investigate whether the analogy would hold even if mandatory auto insurance actually were a federal law. In so doing, I must apologize in advance for marching over slightly more well-traveled territory.

The reason states require car insurance is because of the risks to other people and their property which driving so obviously entails. The underlying legal basis here is tort law, which holds me liable for any harm I cause to others. Since driving increases both the likelihood and extent of such torts, mandatory insurance (or proof of financial ability to pay in New Hampshire and Wisconsin) “insures” that I can restore my victims to wholeness. In a world without car insurance, every accident would lead either to a court ruling or a settlement. Insurance payouts are rooted in this and are simply a more expeditious way of resolving torts. But in basing health insurance on this model, I’m naturally led to ask about the underlying rationale. Whom, exactly, should I have sued when I caught the flu or broke my leg falling down the stairs if I hadn’t had health insurance?

Unless I was deliberately coughed upon or pushed, there is no one to blame. So there simply is no parallel with tort law to draw upon here. Moreover, the two possible types of auto insurance which would fit fairly well with a health insurance mandate (collision and medical payments) are specifically not ever required by the states.

Additionally, you should note that no state requires you to have liability insurance until you positively engage in some enhanced risk activity, like driving, performing surgery, or opening a restaurant. Even though any of us at any time could harm another person (bicycling, playing softball or even just tripping on a crowded escalator), no one is required by law to carry bodily motion insurance.

Taken together, all of this means that, far from being a good example to draw upon, current auto insurance laws are actually quite a robust counter-analogy to mandatory health insurance because the two are so starkly asymmetrical. The similarities between the two types of insurance seem to begin and end with their shared name.

But wait, there’s more. One of the most debated aspects of current health care reform proposals is the “public option,” or government delivery of health insurance. Once again we find a glaring disconnect in the comparison with auto coverage. Although 47 individual states make insurance a precondition of driving (Virginia will allow you to simply pay a $500 annual fee in lieu of having it), no state to my knowledge actually supplies the required insurance to anyone. Geico, Allstate, Country Companies and State Farm do not have to compete with “Vermont Casualty Group” or “The Florida Collision Underwriting Consortium.” Thus, if auto insurance is a good object lesson, it seems to urge us to specifically not involve the federal government as a provider.

Is there anything else we can learn from mandatory car insurance to guide us in the current debate? One thing is that the presupposition behind such mandates (where they exist) is the recognition of driving as a privilege rather than an entitlement. Driving prohibitions can’t be litigated as deprivations “without due process of law” because there is no fundamental right to endanger others through the operation of a motor vehicle. But what privileged behavior am I engaging in before I must carry health insurance? I must breathe.

Since I’m forced to take Congress seriously when they make their arguments, I am driven (sorry) to conclude their use of the auto insurance analogy means they consider some aspect of my behavior to be a privilege rather than a right. The only contenders are existence and breathing. Since they don’t appear to be meta-physicians (sorry again), I have to infer that Congress views breathing as a privilege rather than a right. And since they want to insure all breathers, should I also anticipate the parallel institution of breathing licenses for which we must visit the DMV and pass a proficiency test? Perhaps I should begin studying now. I’d hate to have to refrain from breathing pending a make-up exam.

Furthermore, the actual car coverage levels required by most states are extremely low. Although I suppose some people are satisfied with $25,000/$50,000 coverage (a common benchmark), most drivers understand that $100,000/$300,000 is much more prudent. But if the more robust protections are so obviously smart, why aren’t they required? It’s simple. Because all of the states recognize the need to balance the wisdom of carrying insurance against the restraint all levels of government must exercise when infringing upon the core value of individual liberty.

Since the right to property (in this case to not pay insurance premiums) is so fundamental in our system, it must be violated only for the most extreme of reasons and only to the most humble of extents. Thus, basing health care reform on this same pattern would require at most only some sort of minimum catastrophic coverage. Suffice it to say that current proposals which cover every form of health care down to the most routine are not modeled on the same recognition of liberty and property rights.

So, having taken a more diligent look at whether mandatory automobile insurance justifies the imposition of health insurance, we now have a much better sense of its validity. In order to make the comparison justify current health care proposals, Congress (not the states) would have to currently require that all people (regardless of personal wealth or actual car ownership) owned an insurance policy provided by Congress itself that covered routine maintenance, periodic breakdown, and collision repair to their own cars, even ones they acquire with pre-existing defects (like from a junkyard).

Since not one single element of this hypothetical currently exists, and since breathing is not a privilege, my request is simple. During the two weeks that are fair to allow this column to circulate through society, simply boo anyone who makes the car insurance argument in public. Thereafter, I recommend noogies. It’s what one does to recalcitrant freshmen.


AP Poll: Americans fret over health overhaul costs

It's the cost, Mr. President. Americans are worried about hidden costs in the fine print of health care overhaul legislation, an Associated Press poll says. That's creating new challenges for President Barack Obama as he tries to close the deal with a handful of Democratic doubters in the Senate.

Although Americans share a conviction that major health care changes are needed, Democratic bills that extend coverage to the uninsured and try to hold down medical costs get no better than a lukewarm reception. The poll found that 43 percent oppose the health care plans being discussed in Congress, while 41 percent are in support. An additional 15 percent remain neutral or undecided. "Well, for one, I know nobody wants to pay taxes for anybody else to go to the doctor _ I don't," said Kate Kuhn, 20, of Acworth, Ga. "I don't want to pay for somebody to use my money that I could be using for myself."

There's been little change in broad public sentiment about the overhaul plan from a 40-40 split in an AP poll last month, but not everyone's opinion is at the same intensity. Opponents have stronger feelings than do supporters. Seniors remain more skeptical than younger generations.

The latest survey was conducted by Stanford University with the nonprofit Robert Wood Johnson Foundation. When poll questions were framed broadly, the answers seemed to indicate ample support for Obama's goals. When required trade-offs were brought into the equation, opinions shifted _ sometimes dramatically. In one striking finding, the poll indicated that public support for banning insurance practices that discriminate against those in poor health may not be as solid as it seems. A ban on denial of coverage because of pre-existing medical problems has been one of the most popular consumer protections in the health care debate. Some 82 percent said they favored the ban, according to a Pew Research Center poll in October.

In the AP poll, when told that such a ban would probably cause most people to pay more for health insurance, 43 percent said they would still support doing away with pre-existing condition denials, but 31 percent said they would oppose it. Costs for those with coverage could go up because people in poor health who'd been shut out of the insurance pool would now be included, and they would get medical care they could not access before. "I'm thinking we'd probably pay more because we would probably be paying for those that are not paying. So they got to get the money from somewhere. Basically I see our taxes going up," said Antoinette Gates, 57, of Atlanta.

The health care debate is full of such trade-offs. For example, limiting the premiums that insurance companies can charge 50-year-olds means that 20-year-olds have to pay more for coverage. "These trade-offs really matter," says Robert Blendon, a professor at the Harvard School of Public Health who follows opinion trends. "The legislation contains a number of features that polls have shown to be popular, but support for the overall legislation is less than might be expected because people are worried there are details about these bills that could raise their families' costs." If the added costs _ spread over tens of millions of people _ turn out to be small, it may not make much difference, Blendon said. But if they're significant, Obama could be on shaky ground in the final stretch of his drive to deliver access to health insurance to most Americans.

More than 4 in 5 Americans now have health insurance, and their perceptions about costs are key as Obama tries to rally his party's congressional majority. In the House, Democrats came together to pass their bill. In the Senate, Democratic liberals and a smaller group of moderates disagree on core questions even as Majority Leader Harry Reid, D-Nev., prepares to take legislation to the floor.

The poll suggests the public is becoming more attuned to the fact that in health care, details can make all the difference. For example, asked if everyone should be required to have at least some health insurance, 67 percent agreed and 27 percent said no. The responses flipped when people were asked about requiring everybody to carry insurance or face a federal penalty: 64 percent said they would be opposed, while 28 percent favored that.

Both the House and Senate bills would require all Americans to get health insurance, either through an employer, a government program or by buying their own coverage. Subsidies would be provided for low-income people, as well as many middle-class households. And there would also be a stick _ a tax penalty to enforce the coverage mandate. "I think it's crazy. I think it infringes on our rights as a citizen, forcing us to do these things," said Eli Fuchs, 26, of Marietta, Ga.

Among Democrats, only 12 percent oppose the broad goal of requiring insurance. But 50 percent oppose fines to enforce it.

The poll found a similar opinion shift on employer requirements: 73 percent agreed that all companies should be required to give their employees at least some health insurance. Yet when asked if fines should be used to enforce such a requirement on medium and large companies, support dropped to 52 percent. Uninsured workers are concentrated in small companies.


New CF&P Foundation Study: Government Run Health Care Will Be A Fiscal Train Wreck

The Center for Freedom and Prosperity Foundation (CF&P) today released a paper entitled "Government-Run Health Care Means Higher Deficits and Debt: Realistic Assumptions Show 10-Year Deficits Easily Could Exceed $600 Billion ." Authored by Dan Mitchell of the Cato Institute, the study explains the dangerous fiscal consequences of the House and Senate health care proposals. The study is a companion to a CF&P Foundation mini-documentary video on the same topic.

The paper notes that if current congressional forecasts are modified to be more realistic, deficits and debt will climb by at least $600 billion – and perhaps more than $850 billion – over the next 10 years if government takes over the health care system. Additionally, the paper examines the history of congressional spending projections and finds that almost all federal health care program over the past 50 years has been under-budgeted.

"We are not talking about trivial errors," said CF&P Foundation President Andrew Quinlan. "Medicare was 10 times more expensive than first forecast and a part of Medicaid cost 17 times more than taxpayers were led to believe. No wonder the American people do not trust Congress and its supposed forecasting experts," added Quinlan. The paper makes several key observations:

* Congressional estimates do not properly measure how people and businesses change their behavior in response to government handouts.

* The spending estimates also are far too low because they do not recognize that politicians in the future will be tempted to expand subsidies as part of routine vote-buying behavior, similar to what happened with Medicare and Medicaid.

* If revenues and offsets are 25 percent below the forecast and spending is 50 percent higher than estimated (and that almost surely is still too optimistic), the 10-year deficits will be $602 billion to $860 billion higher

The paper also explains that the federal government has a long history of under-budgeting and over-spending on health care programs.

* The federal government's ability to predict health care spending leaves much to be desired. When Medicare was created in 1965, the long-run forecasts estimated that the program would cost about $12 billion by 1990. In reality, it cost more than $100 billion that year (and now costs $500 billion).

* Medicaid was also created in 1965 and was supposed to be a very small program with annual expenditures of about $1 billion. It has now become a huge $250 billion entitlement.

* Medicaid's disproportionate share hospital (DSH) program is a sobering example. Created in 1987 to subsidize hospitals with large numbers of Medicaid and uninsured patients, the programs was supposed to cost less than $1 billion in 1992, but the actual cost that year was a staggering $17 billion.

Executive Summary:

The health care proposals in the House and Senate are bad news for taxpayers and would permanently damage the American economy with more spending, taxes, and debt. While the details differ, both plans add about $1 trillion to the burden of federal spending over the next 10 years according to congressional estimates. Some of this spending is financed with higher taxes, and both plans also promise to finance a portion of the new spending by curtailing the growth of other programs, particularly Medicare.

Supporters of a government take over of health care argue this approach is fiscally responsible because the higher taxes and promises of future spending restraint supposedly exceed the amount of proposed new spending. Making government bigger, however, is not fiscally prudent – especially when the estimates put together by the congressional forecasters are deeply flawed.

In reality, the proposals on Capitol Hill will make government more expensive and increase deficits. Government programs almost always cost more than the preliminary estimates, and projections for health care spending have been notoriously inaccurate. Moreover, tax increases will not collect as much revenue as politicians want because of "Laffer Curve" effects. Last but not least, the promised spending restraint is a farce. If congressional forecasts are modified to be more realistic, deficits and debt will climb by at least $600 billion – and perhaps more than $850 billion – over the next 10 years.


Health-Care Reform: The Government Run Public Option is Rooted in the Intellectual Laziness of Congress and the Administration

Comment below from a practicing physician

Consider the following syllogism:

(1) To ignore (or refuse to consider) alternative solutions to health-care reform* is intellectual laziness.

(2) Other than expanding the government’s role in health-care, (public option, Medicare for all), the US Congress and Administration ignore alternative solutions to health-care reform.

(3) The US Congress and the Administration are intellectually lazy when they fail to consider alternatives to their government expanding health-care reform proposals.

* or any other problem for that matter

What are the purported purposes of the government run public option (GoRPO)?

The administration and Congress are correct when they point out that, to reduce individual costs for health-care and to insure the uninsured, we must have competition among health insurance companies. You’ll get no argument there from me or just about anyone else on this. Many members of congress, with clandestine support from the administration, declare that the only way to achieve these goals is through the GoRPO. That is, the GoRPO with lower insurance premiums because there is no profit motive, will serve as the prime nationwide competitor to all private health insurance providers. What government run program is known for efficiency and cost containment? Having worked for the federal government for 27 years, I can attest to the inherent inefficiencies and wasteful monetary practices. Sure, it would be simple to add another entitlement program further bloating the federal budget with attendant cost escalation (more government run health-care will never be budget neutral; is Medicare?). To expand federal government involvement in our health-care system while ignoring not only failures of state run systems but also the efficacy of alternatives is nothing less than intellectual laziness. Moreover, the intended and unintended consequences have severe repercussions for the future US health-care and the very fabric of US society.

In addition to desiring to insure the uninsured and reduce costs of health-care, a key intended (though rarely discussed) consequence of the GoRPO is the progression to a single-payer (government managed) health-care system for Americans (this has been stated publicly as desirous by some members of Congress). How can this happen? At the present time, the federal government manages or provides insurance for 33% of the US population. It would only be a matter of time, through GoRPO mission creep, that the government will be responsible for over 50% of US citizens. With this majority stake, the federal government will have the power to dictate rates and services for most Americans, effectively controlling all aspects of US health-care.

The unintended consequences of a GoRPO are numerous and include, but not limited to: cost overruns (as example – the government program Medicare will be bankrupt by 2017; the Massachusetts program is $9billion in debt), rationing (the only way to reduce escalating costs), higher taxes (income tax rates in western European countries range from 40% to 60% for the middle class), fewer new drug and device developments (from a decline in medical research and development – the government will be unwilling to pay for costly new products; e.g. the U.K. refuses to offer certain effective anti-cancer drugs because of cost), reduced citizen productivity (from loss of work while awaiting procedures), slowed or arrested progress in medical advances (e.g. fewer clinical trials testing new drugs or devices), dissolution of the private insurance industry, demise of private medical practices (all health-care providers will essentially be de facto government employees), government will be forced to pay for all medical education as is done in western Europe because individuals will no longer be able to repay loans for their medical education (the President seemed astonished this past summer when a Georgetown University medical student informed him that her debt after graduation will be $300,000), reduced quality of individuals seeking to enter medicine (in the UK for example, many physicians refuse to works nights and weekends), more claim denials (Medicare already denies a higher percentage of claims than any private insurer) and destruction of the medical profession as we know it.

Are there non-governmental alternatives to the GoRPO? Sure there are. We can insure those without access to insurance (6 to 14 million people by most reasonable estimates) by creating a privately managed member-owned pool consisting of the 6 to 14 million combined with employees of small businesses. Furthermore, such a large pool will have substantial clout in negotiating rates with insurance companies, thereby lowering costs. Another way to reduce cost is to allow companies and individuals to select insurance across state lines as is done for auto insurance. This approach will provide the needed competition and reduce health insurance costs. Proof that this is effective already exists. The 9 million participants of the Federal Employees Health Benefits Program have over 250 options from which to select and have enjoyed a lower rate of rise in insurance premiums when compared to the industry as a whole. Lastly, tort reform is an essential ingredient to reduce costs in any health-care reform proposal and must be applied across the country; billions of dollars will be saved annually.

Government intrusion into the American way of life must be the absolute last resort for resolving the issue of health-care reform, not the first solution we consider. An April 1959 memo from the Department of Health, Education and Welfare to congress is germane today: "In our society the existence of a problem does not necessarily indicate that action by the Federal Government is desirable. The basic question is: Should the Federal Government at this time undertake a new program to help pay the costs of medical care…, or should it wait and see [first if other options are effective]?"

How many Nobel Prize recipients in Physiology or Medicine have been from the US? Since 1950, 58%. With a single payer system, future advances may never see the light of day in clinical practice. What nation other than the US can boast being responsible for bringing significant new technologies and drugs from the bench (laboratory) to the bedside (clinic or hospital)? That other nation doesn’t exist. The US has the distinct and singular honor for the primary development of new medical technologies not only for the US but for the entire human population.

The administration and congress have a mandate to establish health-care reform. But we want it done right, the first time. You know, sometimes neither the easy nor the get-it-done quick ways are the right paths. Don’t mess this up. Don’t be lazy.


Harry Reid’s death march

They're calling it the legislative equivalent of the Bataan Death March. Majority Leader Harry Reid says he's willing to force the Senate to work through every weekend in December to get a health care bill passed before the Christmas holiday. "Long nights, weekends -- constantly, from then until right before Christmas, when I think we'll have the votes, hopefully, to pass the bill," is how Iowa Democrat Tom Harkin described Mr. Reid's plans.

But some Senate Democrats are balking not just at such a schedule but at Mr. Reid's demand that the bill be delivered to the floor this week in the absence of final legislative language or a cost estimate from the Congressional Budget Office.

One Senate Democrat who finds herself in political hot water on health care is Blanche Lincoln of Arkansas. She trails some potential Republican challengers in polls and has said she's leery of supporting a procedural motion to bring a health care bill to the floor unless she can see the final bill.

Senators Ben Nelson of Nebraska and Mary Landrieu of Louisiana are also balking at forcing a health care debate so early. On the other hand, Senators Joe Lieberman and Evan Bayh have both indicated that, while they have problems with the health care bill, they will vote with Mr. Reid on a motion to proceed with debate.

Mr. Reid will need every single one of his 60 caucus votes to overcome a filibuster threat, since all 40 Republicans appear ready to oppose the legislation. But 91-year-old West Virginia Senator Robert Byrd is ill and has missed 130 Senate roll call votes this year, so any vote to begin the health care debate may hinge on his availability.


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