Saturday, October 31, 2009

Patient dies after British doctors failed to diagnose broken pelvis in 'chaotic' hospital

A woman who had been run over by a minibus that left a tyre mark across her trousers died after staff at a "chaotic" hospital failed to diagnose her broken pelvis. Susan Haigh, 50, told paramedics she could feel no pain and was able to walk after the accident, but she had actually suffered two fractures and a torn bladder. The injuries were not picked up by medics at Barnsley District Hospital A&E department, South Yorkshire, which was short staffed and in a state of "chaos" when Mrs Haigh was admitted, an inquest heard.

A breakdown in communication meant doctors were not informed that she could have been suffering from serious crush injuries and the tyre marks and blood on her white jeans had not been pointed out.

Mrs Haigh was assessed and then discharged by Dr Jane Brenchley, a consultant, on Saturday May 3 2008, despite protests from her daughters who insisted she was in pain. She was readmitted the next day and rushed to intensive care, but died three days later after medics discovered two pelvic fractures.

The inquest in Sheffield heard that paramedic Andrew Flavell, who was called to the scene of the accident, saw the tyre mark on her jeans and told Nurse Pam Whittaker that he suspected crush injuries when they arrived at hospital. Mrs Haigh was put on a trolley in a corridor and Nurse Whittaker passed on the information to A&E coordinator Tom Holmes, but was only 98 per cent sure she mentioned the tyre mark.

However, details about the patient were not written down because it was not hospital policy at the time. She had also not been properly assessed by a nurse before being seen by a consultant.

Mr Holmes told the inquest that the hospital, which has five nurses and three doctors, was understaffed and on the night in question it was "quite chaotic." "We were busy from the onset of the shift and it just deteriorated," he added. He said that Nurse Whittaker had not expressed any urgent concern for Mrs Haigh and said he could not remember being told about the tyre mark. "The consultant has seen the patient and made the decision. My own personal feeling was that "it's a consultant, things must be OK."

Mr Holmes added that Dr Brenchley, who was on call, seemed "annoyed" at being asked to come into hospital.

The inquest heard that Mrs Haigh, from Goldthorpe, Barnsley, had been involved in a row with a group of women when she fell under the wheels of a minibus during a night out. The back wheel of the bus ran over her legs.


Battles over cost, Medicare loom for House health plan

The House Democrats' health care overhaul bill released Thursday creates a government-run insurance program, provides insurance coverage to 96 percent of all Americans and sets the stage for major battles over politically risky cuts to Medicare, new taxes, high spending and the hot-button issues of abortion and immigration.

The landmark legislation also ensures a fight with the powerful lobby for the pharmaceutical industry by overriding a deal among Pharmaceutical Research and Manufacturers of America (PhRMA), the drug industry trade group; the White House; and a Senate committee to help pay for the $1.06 trillion bill.

"There's a lot of political posturing going on right now," PhRMA spokesman Ken Johnson said. "But unfortunately, many people are unrealistic in their expectations of what our industry can contribute to health care reform" without job losses or a decrease in research and development.

Under the House blueprint, nearly all Americans for the first time would be required to purchase health insurance and most large employers would have to provide it, with tax credits available to low- and middle-income people. The proposal would be paid for through new taxes on individuals making more than $500,000, or couples more than $1 million, hoped-for reductions in Medicare waste and a 2.5 percent tax on medical devices not sold in retail stores. The Congressional Budget Office (CBO) said the bill, estimated to have a gross cost of $1.06 trillion, would reduce the deficit by $104 billion through 2019.

House Democrats put the net cost of their bill at $894 billion Thursday, based on CBO projections that penalties paid by companies that don't offer insurance and individuals who do not purchase coverage will lower the final tab. President Obama had set a $900 billion target for the 10-year cost.

Top Democrats said Thursday that they have the votes to pass the bill, possibly by Veterans Day, and praised the progress made in the House and Senate on Mr. Obama's goal to reshape the health care system.

"Leaders of all political parties, starting over a century ago with President Theodore Roosevelt, have called and fought for health care and health insurance reform," House Speaker Nancy Pelosi said while introducing the bill on the West Front of the Capitol, surrounded by her Democratic colleagues.

"Today, we are about to deliver on the promise of making affordable, quality health care available for all Americans, laying the foundation for a brighter future for generations to come," the California Democrat said.

But there are plenty of obstacles ahead as floor debate is expected to start in a week. Even the size of the bill -- 1,990 pages -- has sparked controversy as Republicans say it symbolizes the scope of Democrats' plans. House leaders said Wednesday that they introduced the bill with the understanding that changes would be made as the process moved forward.

The final House draft -- a merging of three committees' work over the past months -- does not have the so-called robust public option, which was favored by liberal Democrats and would have reimbursed doctors based on Medicare rates plus a 5 percent premium. The more moderate version would allow the Department of Health and Human Services to negotiate rates with providers, as private insurers do.

More here

Health bill: 42 studies, 214 mentions of taxes

House Democrats' health care bill runs to 1,990 pages, costs $1.06 trillion, covers 96 percent of eligible Americans and demands the production of 42 studies on everything from whether post-partum screening should be required to using student loan programs to help recruit doctors.

The studies could be a blueprint for action by future congresses. They include looking at geographic disparities in Medicare, whether more services need to be provided for those who don't speak English and the undercapitalization of nursing homes. But studies are just part of the extensive reach of the measure, which Democrats introduced Thursday.

The word "report" appears 364 times and "tax" is used 214 times -- and while some of those refer to bookkeeping such as tax years, the bill does raise several key levies, such as a "surcharge" of 5.4 percent on individual taxpayers who earn $500,000 or couples with incomes of $1 million.

Rep. Mike Pence, Indiana Republican, said the bill uses the word "shall" 3,425 times, which he said was an indication that a lot of new mandates are being imposed. Among them is a requirement that chain restaurants print directly on their menus how many calories each item contains.

The bill also takes care of some long-languishing measures, such as reauthorizing the Indian Health Service, which has been kicking around for the past decade and was most recently held up by a fight over abortion.

The Congressional Budget Office says the bill will have a gross cost of $1.06 trillion but, with $167 billion in new penalty taxes imposed on businesses and individuals, the net cost is $894 billion. It would mean 36 million more people would be covered than the status quo by 2019, and leave about 18 million without insurance. One-third of those left uncovered would be illegal immigrants.


The Public Option Is Not an Option

Can you imagine the brazenness of President Barack Obama and his cohorts in going so far as to ridicule opponents of Obamacare for rightly pointing out that its ultimate goal is single-payer socialized medicine?

These people are propaganda virtuosos of the highest order. You might expect grand artists of deception just to silently dismiss such claims from critics or, at most, to summarily deny them. But they go further and mock the critics, trying to reduce them to acutely paranoid, tinfoil-hat-wearing, black-helicopter-hallucinating Cuckoo's Nest inpatients.

What better way to distract attention from what is right in front of our faces? It's brilliant reverse jujitsu: using the outrageousness of your own plan to discredit as preposterous the allegations of your opponents about your truly outrageous plan. Shameless!

Obama and his minions are indeed conspiring to foist socialized medicine on this nation through whatever means necessary -- including outright deception over the nature and purpose of the so-called public option. But before presenting proof of that, let me pose a few questions bearing on the likelihood Obama would be involved in such a deception in pursuit of this goal.

Didn't Obama repeatedly threaten to "spread the wealth"? Isn't he deliberately indebting us through government expenditures of borrowed funds not remotely designed to appreciably increase employment? This "stimulus" monstrosity is a massive redistributive scheme not only in its direct transfer payments but also in the confiscatory tax increases it will necessitate to retire the debt it is generating.

Obama is hellbent on passing economically crippling cap-and-tax legislation on the dubious pretense that man-made global warming is leading to an apocalypse. The Heritage Foundation's Center for Data Analysis estimates that this legislation would make the United States some $9.4 trillion poorer by 2035 while moderating temperatures by only hundredths of a degree in 40 years. Obama's former colleague Sen. John Kerry, adding insult to injury, has the audacity to sell this plan as one that would enhance our national security -- security that depends on our economic viability.

Based on those two examples alone, the inescapable conclusion is Obama believes that America's resources have been unfairly allocated under its free enterprise system and that he must preside over an unprecedented correction of this "injustice" through institutional changes disguised as benign measures necessary to stop phantom demons.

But if you're not sufficiently convinced of Obama's Marxist bent to understand he is determined to implement socialized medicine as a means to establishing government control over all aspects of our lives, how about considering direct evidence of the administration's deception concerning the true purpose of the public option?

First, we have Obama's pre-presidential words (in a 2003 speech) on a single-payer system. "I happen to be a proponent of a single-payer universal health care program. ... We may not get there immediately."

Bloggers at Verum Serum have further exposed this "transparent deception" with a video montage of Obama and other leftists -- including politicians, professors and journalists -- speaking candidly about the relationship between a "public option" and a single-payer system.

The videos show Rep. Jan Schakowsky, D-Ill., telling her audience that an insurance company spokesman claimed that a public option would put the private insurance industry out of business and lead to a single-payer system. "My single-payer friends," said Schakowsky, "he was right. ... This is not a principled fight. This is a fight about strategy for getting there, and I believe we will." Professor Jacob Hacker smugly boasts: "Someone once said to me this is a Trojan horse for single-payer. Well, it's not a Trojan horse, right? It's just right there." Health and Human Services Secretary Kathleen Sebelius confesses: "I'm all for a single-payer system, eventually. ... What we have to do, though, is work with what we've got to close the gap." Rep. Barney Frank says a public option "is the best way to reach single-payer." New York Times columnist Paul Krugman believes that a public option would, "in the end, kill the private plan." Presidential adviser Rahm Emanuel, in explaining Obama's apparent flip-flop on the public option, said, "The objective is what's important; it's not the means."

If you need more proof, you can read a short history of the public option on "Tapped," The American Prospect's leftist blog, which traces the genesis of the public option idea as a means to get to single-payer. Because single-payer wasn't politically feasible if directly proposed, the public option was crafted as a compromise that would eventually lead to single-payer. "Ideally, it would someday magically turn into single-payer."

Apart from Obama's statist ideology and the evidence of his true aims, our common sense tells us that a "public option" backed by a government-stacked deck against private insurance companies -- which Obama hasn't demonized for nothing -- will eventually bury private health insurance companies. Let's wake up!


Obamacare: Startling New Revelations Scare Public

First, we learned that a $500 billion cut in Medicare will dramatically affect the quality and quantity of healthcare available to America's senior citizens. Grandma's access is being slashed to add illegal immigrants and twenty-somethings into the insurance system. However, this revelation pales in relation to what we heard this week.

Here's the latest shock: Average current health insurance premiums with likely triple under Obamacare. The new data comes from a well regarded, state-by-state study conducted for WellPoint, Inc. The most dramatic premium boosts will hit young people. These are the actual individuals that often opt out of insurance plans now.

Reaction from the Obama White House was swift and harsh. Linda Douglass, Obama's healthcare spokesperson, had the audacity to compare the health insurance firm with tobacco companies. Since the White House refuses to argue the facts, they instead turned to using one of their favorite tactics, which is demonizing any voices of dissent.

The reason for the dramatic insurance premium increases is the result of Obamacare regulations. First cause is the mandate that insurance companies take any customer. Insurance traditionally is an actuarial business that rates different customers based on risk factors. This is the reason a driver aged 19 with two speeding tickets pays more for auto insurance than a customer aged 35 with no speeding tickets. Nineteen-year-olds have more accidents. Therefore they pose more risk.

Traditionally, health insurance companies charged customers with risk factors and chronic illness more than young, healthy 19-year-olds. Obamacare stands the concept of insurance on its head. Since an insurance company will be forced to sell to any sick patient, the incentive to buy insurance when you are healthy decreases. Why not wait until you are sick; get cancer, diabetes or some other severe illness before you buy? To circumvent this problem, Obama is riddling the program with police-state mandates on healthy, younger citizens. Perverted, negative incentives such as threats of large fines and even prison time will hang over young people's heads to force them to join and stay enrolled in Obama's healthcare scheme. Does this sound like America to you?

Democratic leaders in Congress are seeing support slip through their fingers because Americans are learning that they will end up paying more for less-adequate care. The beneficiaries of this plan are still lobbying hard. Big business will likely dump most of their current employee-based plans and pay the less expensive tax. Big unions are facing the reality that they are going to be bankrupted by their generous membership health plans. Many want to dump their responsibilities on the new government option recently revived by Senate Majority Leader Harry Reid, D-Nev. AARP is salivating at the money they will make selling new, bigger Medicare-gap plans after the current program is gutted.

These powerful lobbies are the driving force for change. Individual family finances will pay the higher costs and see no benefit.

There is still time to kill this wrongheaded plan and replace it with reforms that will truly work. Selling insurance across state lines will increase competition and lower prices. Tort reform that eliminates outrageous judgments in malpractice cases will get lawyers out of medicine; this will result in eliminating billions currently being spent in the name of defensive medicine.

Insurance can work, but the costly mandates and regulations already choking the healthcare system are a big barrier to cutting costs. Free markets deliver to Americans consumer goods, groceries, veterinary services, and even plastic surgery at affordable prices with little government meddling. Let the free market price and correct the distortions currently in the health care system.

Government has bankrupted Fannie Mae, Freddie Mac, Social Security, Medicare and the U.S. Postal Service. Let's not let the politicians destroy the greatest healthcare delivery system in the world.


Friday, October 30, 2009

House Dems reach deal on key health care elements

House Democrats reached agreement Wednesday on key elements of a health care bill that would vastly alter America's medical landscape, requiring virtually universal sign-ups and establishing a new government-run insurance option for millions. House Speaker Nancy Pelosi planned a formal announcement Thursday morning in front of the Capitol. Lawmakers said the legislation could be up for a vote on the House floor next week.

The rollout will cap months of arduous negotiations to bridge differences between liberal and moderate Democrats and blend health care overhaul bills passed by three separate committees over the summer. The developments in the House came as Senate Majority Leader Harry Reid, D-Nev., tried to round up support among moderate Democrats for his bill, which includes a modified government insurance option that states could opt out of. Reid met Wednesday with Arkansas Sen. Blanche Lincoln, who faces a potentially tough re-election next year.

The final product in the House, reflecting many of President Barack Obama's priorities, includes new requirements for employers to offer insurance to their workers or face penalties, fines on Americans who don't purchase coverage and subsidies to help lower-income people do so. Insurance companies would face new prohibitions against charging much more to older people or denying coverage to people with health conditions.

Pelosi has also said the bill would strip the health insurance industry of a long-standing exemption from antitrust laws covering market allocation, price fixing and bid rigging.

The price tag, topping $1 trillion over 10 years, would be paid for by taxing high-income people and cutting some $500 billion in payments to Medicare providers. The legislation would extend health coverage to around 95 percent of Americans.

Republicans criticized the bill even before it was unveiled. "Americans' health care is too important to risk on one gigantic bill that was negotiated behind closed doors," said Rep. Dave Camp, R-Mich. "The Medicare cuts will hurt seniors, the tax increases will kill jobs and the government takeover of health care will increase premium costs."

One change expected to be revealed Thursday is that some of the provisions of the bill, which were set to take effect mostly in 2013, have been moved up so Americans would see the benefits of the legislation more quickly, according to Pelosi spokesman Nadeam Elshami.

"I'm pretty confident that we've got the right pieces in place," said Rep. George Miller, D-Calif., chairman of the Education and Labor Committee, one of the three panels involved in writing the bill. "We can quibble over parts of it, but the fact is when you're taking a 60-year-old system that grew up in a rather haphazard fashion and you're trying to bring some coherence to it, these are sort of the things you have to do at the beginning of that process."

Plenty of work remains to be done before a bill could land on Obama's desk - and there's still no guarantee that Congress can complete the legislation before year's end, as the president wants. If Obama does sign a health overhaul bill, he will have bucked decades of failed attempts by past administrations, most recently by former President Bill Clinton in the 1990s. House leaders hope to finish the bill before Veteran's Day, Nov. 11. The Senate is aiming to start debate sometime in the next several weeks.

Bills passed by the House and Senate would have to be merged before a final product could be sent to Obama, and there are a number of differences between the two chambers that would have to be reconciled. Among them are the different approaches to the public plan. The House does not include the opt-out provision for states, and it has more stringent requirements for employers. The Senate would use a tax on high-value insurance plans to pay for the bill, an approach that the House version doesn't have.

In the end, Pelosi, D-Calif., and other House leaders were unable to round up the necessary votes for their preferred version of the government insurance plan - one that would base payment rates to providers on rates paid by Medicare. Instead, the Health and Human Services secretary would negotiate rates with providers, the approach preferred by moderates and the one that will be featured in the Senate's version. That marked a defeat for liberal lawmakers, who argued for months that a public insurance plan tied to Medicare would save more money for the government, and offer cheaper rates to consumers. Moderates feared that doctors, hospitals and other providers, particularly those in rural states, would be hurt, and in the end they looked poised to prevail, despite constituting a distinct minority in the 256-member House Democratic caucus.

Some liberals were prepared to accept the negotiated rate structure. Others were still withholding support, even while pointing to Reid's inclusion of a government insurance plan in the Senate bill as a victory in itself. "We were laughed at in August. Who would have thought that the Senate bill would have a public option?" said Rep. Lynn Woolsey, D-Calif., a co-chair of the Congressional Progressive Caucus. Woolsey was noncommittal about whether progressives would accept the negotiated rates. "This is not walkaway time and it is not acceptance time," Woolsey said.

Members of the progressive caucus, along with lawmakers from the black, Hispanic and Asian-Pacific American caucuses, were scheduled to meet with Obama at the White House on Thursday, she said.

The legislation would set up a new purchasing exchange where small businesses and individuals without affordable health care options could shop for and compare insurance plans. The new public plan would be one offered in the exchange, and it would be optional; an analysis by the Congressional Budget Office of early versions of the bill said that the public plan would be expected to cover 9 million to 10 million people by 2019. The House plan also envisions a significant expansion of Medicaid, the federal-state health care program for low income people.

Democratic leaders still faced disputes over prohibiting taxpayer money for abortions and health care for illegal immigrants, issues they hoped to resolve after the bill's unveiling.


The real costs and benefits of Obamacare

As individual citizens and taxpayers read the various healthcare bills that their legislators have not read, it becomes very clear that there are many losers in the Administration's healthcare reform plan. And it is experience with previous government healthcare programs shows that proponents of new government programs will misrepresent the cost to the public to get programs approved.

For example, when Medicare was proposed in 1965, the projected cost in 1990 was determined by the Johnson Administration to be 12 billion dollars. The real cost in 1990 was 107 billion dollars. The cost was underestimated by a factor of 9 to obtain passage of the legislation. Imagine what the real cost of healthcare reform would be in 10 years if the CBO estimate of 1.2 trillion dollars is equally under estimated. Clearly the American taxpayers are losers in this legislation.

The Medicare experience shows that when inexpensive medical coverage is offered, utilization increases. The only way to prevent greater utilization is to impose rationing. If Obamacare is to have any hope of containing costs it will have to limit care to those that use healthcare most extensively. Since more is spent on healthcare in the first and last years of one’s life than all the years in between, seniors will have rationed care.

To help pay for inclusion of the uninsured into healthcare, taxes will be levied on businesses that provide healthcare coverage to their employees and responsible individuals that purchase their own coverage. So clearly, small businesses and responsible individuals do not benefit from this reform.

However, there are groups that do benefit from this legislation. Those groups have “contributed” significantly to the Obama administration and the legislators drafting Obamacare.

In some ways, hospitals will benefit from not absorbing the cost of providing medical services to the uninsured. And this can be a significant cost especially if there is a large illegal alien population. But at the same time, Obama has promised to reduce Medicare/Medicaid spending on hospitals.

Pharmaceutical companies will have a new taxpayer-funded market for their products. In early March they met with the Obama team to negotiate support for the bill in exchange for more generous prescription drug reimbursement, which will undoubtedly cause costs to rise even faster.

Not to mention, insurance companies support this legislation because it will force 30 million young and healthy people to by insurance. This is almost half of the current uninsured and represents a profitable untapped market for insurers, making a massive government-granted cartel.

However, perhaps the largest beneficiary of this legislation is not quite so obvious. The Service Employees Union International (SEUI) contributed 60 million dollars and thousand of hours to the Obama campaign. Their purple shirted members have attended August town hall meetings to support Obamacare through intimidation and violence.

The real prize in this legislation is the ability to organize 7.5 million new government employees that Obamacare will create. The National Health Service (NHS) in England employs approximately 1.4 million workers in a country with a population of 60 million. The voting power of those workers effectively thwarts any NHS reform efforts in that country.

The SEUI has used threats and intimidation to pirate nurses and other service workers from other unions in California. It has used taxpayer funds fraudulently provided by ACORN programs to enrich its bosses and diverted member dues to subsidize ACORN’s supposedly non-partisan voter registration programs. In testimony before the Pennsylvania Legislature it recently admitted to knowingly organizing and collecting dues from illegal aliens. It has also been one of the most vocal advocates of Card Check legislation that would replace secret voting on union representation with public intimidation.

In the healthcare debate, if those wearing purple win, the American taxpayer, small business owners and senior citizens will lose.


“Public option” is a gimmick that won’t improve healthcare

In the Washington Post, Robert J. Samuelson explains in the “Public Plan Mirage” how the so-called “public option” contained in congressional health-care reform bills is just a gimmick: “It pretends to control costs and improve access to quality care when it doesn’t.” Steve Chapman wrote earlier about the “‘Public Option’ Health Care Scam.”

In other news, a study by PriceWaterhouseCoopers found that the provisions in the Senate health care “reform” bill sponsored by Sen. Max Baucus (D-Mont.) would add $1,700 a year to the cost of family coverage in 2013 and $600 for a single person. By 2019, family premiums could be $4,000 higher and individual premiums could be $1,500 higher.

CEI’s Greg Conko calls the Baucus bill “worse than the disease.” In a recently-released paper, “A Cure Worse than the Disease: Obama Care Won’t Cut Costs, But May Cut Quality,” Conko notes that most of the alleged cost-cutting measures in the Baucus bill merely shift costs from the federal government onto the states or private payers, without reducing long-term health care inflation. The only measures that could conceivably reduce the annual rate of growth in health care costs would erect government barriers between patients and their doctors, while jeopardizing long-term medical innovation.

A new study by the Oliver Wyman consultancy found that provisions contained in the health-care reform bills, like guaranteed issue and community rating mandates, would drive up premiums by 50 percent for individual policies and 19 percent for small group plans.

A study from the Independence Institute says that ObamaCare would drive up inflation and medical-care costs, while shrinking the economy.

As CEI’s Conko notes, many states have highly concentrated markets. In Hawaii, Rhode Island, and Alaska, for example, 95 percent or more of the health insurance market is served by just two insurers. But Obama and congressional Democrats oppose letting insurers compete across state lines, blocking competition that could make health insurance cheaper. Other countries with cheaper health insurance permit insurers to compete nationally.

ObamaCare would raise taxes. It would also explode state and federal budget deficits, and would actually cost $2 trillion — far more than its promised $800 billion price tag. It also ignores needed reforms that would actually reduce the costs of health care, like steps to reduce the cost of defensive medicine, which wastes $200 billion annually. And it contains special-interest pork, like racial preferences.


The malpractice problem

We can't have health care reform without tort reform

The extra imaging study, the extra day in hospital at the end of an admission, the repetitive laboratory testing, the admission to the hospital to be "sure" about the diagnosis are all inherent in the culture of American medical care. The avoidance of litigation has become ingrained into all aspects of medical care. Since physicians are not liable for the increased costs of care but are liable for any error or missed diagnosis, it would be foolish for them to act in any other fashion. The costs of this mindset cannot be easily assessed by surveys.

No one can identify how the current health care bills being debated and apparently continuously modified in Congress will reduce the cost of health care. They may produce a reduction in insurance premiums for some, but just paying less for health care does not magically produce a diminution in the actual cost of health care. The latter would only occur if there were large profits in the overall health care enterprise that could be trimmed without changing the basic character of the system. But no one has identified such profits. The president points to for-profit insurance companies, but for-profit insurance companies only make up 25 percent of the system and they are not that profitable, ranking 85th among all U.S. industries. "Reform" will redistribute the money, not reduce the overall cost. This is pretty much what the American Health Insurance Plans study, so denigrated by the president, concluded. Unless the costs of health care fall, lowering insurance payments in one segment of the populace will inevitably cause an increase for some other group.

There is much that can be done to make our system more efficient. Tort reform is a great place to start. Medical errors are common and fairness demands that compensation be paid when someone is injured. However, the price for the current system is enormous. The view from the left is that the direct costs of the current malpractice system -- the actual payout of dollars in lawsuits -- are pretty minimal compared to overall health care spending. The indirect costs, the use of tests and procedures to avoid lawsuits, are also said to be overstated in studies, as those who answer surveys about this issue are assumed to be biased. The view from the right is precisely the opposite and ascribes an important component of health care spending to malpractice costs. This view also blames the lawyers.

The experience in Texas, where there is a law capping payments for pain and suffering to $250,000, suggests some benefit. For example, as reported in the Wall Street Journal, malpractice suits have been dramatically reduced. The year before the caps on pain and suffering payments took effect, there were over 1,100 medical liability suits filed in Dallas. Only 142 cases were filed in 2004. In addition, there was a surge of physicians entering Texas to set up practice as malpractice premiums fell by about 50 percent. Texas also is actually a state with low health care spending. According to the National Center for Policy Analysis, although Texas is fifth highest in Medicare spending per capita, it is 43rd in per capita spending for the state's entire population. Whether the malpractice caps in Texas account in any way for these data is uncertain but the pattern is encouraging.

More here

The big “single-payer” lie

Scan the history of government programs. The scope and costs usually grow much larger than originally projected. Moreover, ham-fisted government intervention distorts markets, causing shortages or excesses of supply, leading to high prices for goods that should be cheap, and so on.

When the problems pile up one can either repeal the controls or heap on more controls. Guess which “solution” politicians tend to prefer.

Regarding medical care, the politicians’ answer to decades of government bungling is more bungling: regulation, subsidies, rationing, mandates and a new “public option” in health insurance to squeeze out private plans.

President Obama and other public option advocates promise, on stacks of Bibles, that this is not “somehow a Trojan horse for a single-payer system.” But they’re lying. Go to YouTube. Watch the videos of Obama and congressmen explicitly admitting their goal of a single-payer system. Just two years ago, Obama was saying, “But I don’t think we’re gonna be able to eliminate employer coverage immediately. There’s gonna be potentially some transition process. . . .”

That’s how we lose our freedoms. Not all at once, but a slice at a time.

Oh, and about employer-provided medical insurance. That’s a clumsy institution that exists because of World War II wage controls. We do have to transition out of that system. But we should “transition” towards more freedom, not less.


Why government health care keeps falling in the polls

The health-care debate is part of a larger moral struggle over the free-enterprise system

Regardless of how President Barack Obama's health-care agenda plays out in Congress, it has not been a success in public opinion. Opposition to ObamaCare has risen all year. According to the Gallup polling organization, the percentage of Americans who believe the cost of health care for their families will "get worse" under the proposed reforms rose to 49% from 42% in just the past month. The percentage saying it would "get better" stayed at 22%.

Many are searching for explanations. One popular notion is that demagogues in the media are stirring up falsehoods against what they say is a long-overdue solution to the country's health-care crisis. Americans deserve more credit. They haven't been brainwashed, and they aren't upset merely over the budget-busting details. Rather, public resistance stems from the sense that the proposed reforms do violence to three core values of America's free enterprise culture: individual choice, personal accountability, and rewards for ambition.

First, Americans recoil at policies that strip choices from citizens and pass them to bureaucrats. ObamaCare systematically does so. The current proposals in Congress would effectively limit choice across the entire spectrum of health care: What kind of health insurance citizens can buy, what kind of doctors they can see, what kind of procedures their doctors will perform, what kind of drugs they can take, and what treatment options they may have. Meanwhile, ObamaCare would limit the ability of people to choose affordable insurance coverage through less-comprehensive, consumer-driven insurance plans. And it wouldn't allow Americans to shop for better health-care plans from out-of-state carriers.

Second, Americans believe we should be responsible for the consequences of our actions. Many citizens bitterly view the auto and Wall Street bailouts as gifts to people who took imprudent risks, imperiled the entire economic system, and now appear to be walking away from the mess.

Similarly, Americans are cold to a health-care system that effectively rewards individuals for waiting to get insurance until they get sick—subsidizing their coverage by taxing those who responsibly carry insurance in good times and bad.

On its face, the reformers' promise to provide health insurance to nearly all, regardless of pre-existing conditions, is appealing. But as most instinctively realize, if people don't have to worry about carrying insurance until they need it, many won't buy it. Already, the Census Bureau tells us that 21% of the uninsured are in households earning at least $75,000. Although there are certainly plausible reasons for this in some cases, this phenomenon will worsen under ObamaCare.

Third, ObamaCare discourages personal ambition. The proposed reforms will institute a set of government mandates, price controls and other strictures that will make highly trained specialists, drug researchers and medical device makers less valued now and in the future. Americans understand that when you take away the incentive to make money while saving lots of lives, the cures, therapies and medical innovations of tomorrow may never be discovered.

Yet we are told this is all for the best. In his commencement speech at Arizona State University earlier this year, Mr. Obama told the graduates not to "fall back on the formulas of success that have been peddled so frequently in recent years": "You're taught to chase after all the usual brass rings . . . let me suggest that such an approach won't get you where you want to go."

Crass materialism is indeed a tyranny that can lead to personal misery. But most Americans believe it's up to individuals, not a nannying government, to decide what constitutes too much income and too much ambition.

An April 2009 survey conducted by the polling firm Ayers, McHenry & Associates for the conservative nonprofit group Resurgent Republic asked respondents which of the following statements about the role of government came closer to their view: (a) "Government policies should promote fairness by narrowing the gap between rich and poor, spreading the wealth, and making sure that economic outcomes are more equal"; or (b) "Government policies should promote opportunity by fostering job growth, encouraging entrepreneurs, and allowing people to keep more of what they earn." Sixty-three percent chose the second option; just 31% chose the first. This is consistent with nonpartisan surveys showing that most Americans think our increasingly redistributionist government is overstepping its bounds. For example, a September 2009 Gallup Poll found that 57% believe the government is "doing too much"—the highest percentage in more than a decade. Just 38% said it "should do more."

We will continue to hear both sides of the health-care debate argue about particulars of insurance markets, the deficit impacts of reform, and the minutiae of budgetary assumptions. These arguments, while important, do not address the deeper issues involved.

The health-care debate is part of a moral struggle currently being played out over the free enterprise system. It will be replayed in every major policy debate in the coming months, from financial regulatory reform to a cap-and-trade system for limiting carbon emissions. The choices will ultimately always come down to competing visions of America's future. Will we strengthen freedom, individual opportunity and enterprise? Or will we expand the role of the state and its power?


Thursday, October 29, 2009

British doctors engaged in ‘slow euthanasia’ for patients with terminal illnesses

Patients with terminal illness are being heavily sedated by doctors before their deaths in a form of “slow euthanasia”, research suggests. A poll of nearly 3,000 doctors found that almost one in five had administered infusions of drugs to keep patients unconscious for hours or days at a time.

In appropriate doses, sedatives and strong painkillers are considered a valuable way of easing the pain and anxiety of patients who are dying with conditions such as cancer. But 18.7 per cent of British doctors polled said they used drugs to invoke “continuous deep sedation” in a dying patient, a practice which in other countries is seen as an alternative to legalised euthanasia.

GPs and hospital doctors who are not palliative care specialists were more likely to report using high doses of sedatives or painkillers to keep patients asleep, leading to calls for all doctors to have mandatory training in the care of dying patients. Guidelines for care at the end of life emphasise that doctors should always act in a patient’s best interests and act within the law, which prohibits euthanasia or actively helping someone to die.

The study, published in the Journal of Pain and Symptom Management, also found that of the sample of 2,786 doctors, those who strongly supported the legalisation of assisted suicide were nearly 40 per cent more likely to employ continued deep sedation than the average. By contrast, doctors who reported strong religious beliefs or who actively opposed changing the law were less likely to report sedating patients before death.

In most cases sedation was used for between one and seven days or less than 24 hours. But in a significant minority of patients — 8 per cent — doctors reported sedating patients for more than a week before they died.

Clive Seale, a professor of medical sociology who led the study at Queen Mary, University of London, said that deliberately keeping patients unconscious until death was controversial, with some physicians viewing it as a form of “slow euthanasia”. “Sedation in itself not directly kill a patient, but it does put them to sleep and is associated with other things such as the withdrawal of fluids and ventilation,” he added. “In this country it can be seen as a form of treatment to relieve intractable suffering but in the Netherlands and Belgium, doctors also see it as an easier alternative to legalised euthanasia.”

Most doctors who sedated patients reported using midazolam, a drug which in high, continuous doses can cause loss of consciousness and memory loss. But nearly a quarter of those surveyed also reported using only opiate painkillers such as morphine or medical forms of heroin to sedate patients, which experts said suggested they misunderstood the effects of the drugs.

Rob George, of the Association for Palliative Medicine, said that rather than deliberately acting to bring on a patient’s death, some doctors may be misreporting the effect of the drugs. “Some doctors who are not specialists may be confused and incompetent in using these drugs but the study suggests they are misunderstanding what they are doing as well. "Dying patients are more likely to be drowsy or asleep in their final days and doctors might assume wrongly that this is a result of medication. “It does not mean that they are hastening a patient’s death. But we do have ample evidence that many doctors do not know what they are doing when it comes to palliative care, and whether or not [dying patients] get good control of their pain and symptoms is a lottery.”

The National Council for Palliative Care, which funded the study with medical charities, estimates that 300,000 people die each year without getting the specialist care and pain management they need. Simon Chapman, director of policy at the council, said that sedation was recognised as an appropriate part of end of life care for some patients.

An official for the Patients Association said: “There is no doubt that the vast majority of patients’ families who contact us after a death do so because they are haunted forever by watching their loved one not have the necessary care, including sedation. “It is imperative that everyone considers making a living will to make your views about end of life care clear and understood. “At the moment you have more training in pain relief as a vet than a doctor.”


Half of British doctors 'too busy using computers to look patients in the eye'

America's got some great things to look forward to under Obamacare!

Nearly half of GPs claim they are too busy to look patients in the eye during consultations, according to a shocking poll out today. A survey of family doctors found that 38 per cent are unable to give patients enough eye contact because they are spending so much time tapping information into their computers to meet Government targets. They say a third of their time with patients is spent on paperwork or data inputs - meaning there is less time to listen to patients.

Although the average length of consultations has increased in recent years, GPs are now working an average of seven hours a week less since a lucrative new contract negotiated in 2003.

The study also showed that half of GPs say their primary care trust did not actively support their practice in offering high-quality patient care, and 27 per cent said they were ‘actively obstructive’.

Last night critics said doctors would be able to spend more time with patients if they worked a bit longer.

The survey of 600 GPs in Pulse magazine found the computer-based work - such as the recording of data to meet Government targets - has left doctors struggling to deliver patients' personal care. Much of the information they are forced to input leads to bonus payments under the performance-related part of their contract.

The poll found that 38 per cent of GPs said they were unable to give patients enough eye contract during consultations. They said that just over half of each consultation - 55 per cent - is now spent speaking to patients and addressing their needs, while a third is spent on paperwork and data input.

Almost all - 97 per cent - said consultations had become more complex and intense over the past five years, with three quarters saying complexity had 'greatly increased'. Although the length of consultants has been increased to an average of 11 minutes, the GPs surveyed said they really needed 14 minutes to give the best service to their patients.

Dr Robert Baker, a GP in Swanage, Dorset, told Pulse that the bureaucratic burden was affecting the doctor-patient relationship. 'I could do with being split in two to manage prevention and curative aspects; both of which I am expected to address, for multiple systems, in 10 minutes,' he said. 'The demands of the patient's agenda, the Government's agenda and the requirement that everything I hear, say and do must be meticulously recorded make for an extremely crowded consultation.’

But Vanessa Bourne, of the Patients Association, said: 'GPs are the gatekeepers to all other healthcare. Patients must be able to trust that an accurate diagnosis is being made. At the very least that means having a proper look at the patient. 'If PCTs are to blame for the wrong priorities in a consultation, then patients risk being shortchanged twice over - once by their GP and again by the PCT. ‘For over a quarter of GPs to feel that their PCT is being “actively obstructive" tells patients that urgent action is needed.’

Richard Hoey, editor of Pulse, said: 'GPs' consultations with patients may have got a little longer, but they've failed to keep pace with the steep rise in computer work and the growing complexity of cases, as patients are managed in the community rather than in hospital. 'With 101 things to squeeze into a consultation, it's the personal elements that are being squeezed out - and that includes the real basics such as making eye contact with the patient.'


Reid's public option plan splits Democrats

Senate Democrats remain divided over Majority Leader Harry Reid's plan to establish a national health insurance program run by the government, signaling that Capitol Hill leaders could have a difficult time scraping together enough votes for passage. Sen. Joe Lieberman of Connecticut, an independent who typically votes with Democrats, became the first to declare that he would join a Republican filibuster to block passage of a bill that enacts a national public option. But he left room for negotiation, saying he doesn't oppose state-based programs or cooperatives.

Other moderate Democrats in both the House and Senate remain skeptical of plans to establish a government insurance program over concern that it would add to the federal deficit and increase private insurance rates, but didn't go so far as promise to block it. Many are waiting to see the details in the text of the bill, which hasn't been released yet.

Mr. Reid's announcement Monday that he would pursue a public option in his health care reform bill re-energized liberal Democrats, who say the plan is the only way to drive down costs and truly reform the nation's health care system. But all 40 Senate Republicans are expected to vote against the bill and any procedural votes required, meaning Democrats would need to keep all 60 of their members within the fold to overcome a filibuster.

Mr. Reid, Nevada Democrat, told reporters he thinks Mr. Lieberman and other Democrats will come around. "There are a lot of senators, Democrat and Republicans, who don't like part of what's in this bill," Mr. Reid said. "We're going to see what the final product is. We're not there yet."

In the House, conservative "Blue Dog" Democrats have been skeptical of the plan's cost and another group of 40 pro-life Democrats say they will block the bill from getting to the floor unless they are promised a chance to debate their proposal to ban government funding of abortions.

House leaders are trying to determine whether they have support for a "robust" public option, which is favored by liberals and reimburses doctors based on Medicare rates, plus 5 percent. There is wider support for a public option that negotiates its own rates with health providers, but it saves less money.

House Speaker Nancy Pelosi of California encouraged Democrats to come together to support the bill in a caucus meeting Tuesday and told members she expects the bill to be released this week, with floor debate beginning next week.

In the Senate, Democrats are already crafting alternatives in case their proposal to allow states to "opt out" of the public plan doesn't do enough to generate moderate support. Sen. Thomas R. Carper of Delaware is floating an "opt-in and opt-out" alternative that would only establish the public plan in states with expensive insurance rates or little competition and later allow other states to join or leave the program. "There's some senators, Democrats, who aren't going to vote for a public option in all 50 states," he said, calling the opt-in and out-out plan, "more acceptable to some of our centrists."

Republicans have pledged to vote against the reform plans if they include a public option, arguing that the proposals would drive up costs for people who already have health insurance and lead to a government takeover of the health care system. "We know that it will include a half a trillion dollars in Medicare cuts," Senate Minority Leader Mitch McConnell of Kentucky said of the pending legislation. "We know it will include $400 billion in new taxes. And we know that independent - independent groups taking a look at the effect on the insurance market have indicated that insurance for the 85 percent of Americans who have insurance - health insurance is going to go up."


Constitutionality of health overhaul questioned

On top of all the other obstacles facing President Obama in his quest to pass health reform is this one: Does the U.S. Constitution allow the government to require uninsured Americans to buy medical insurance or impose a tax penalty if they refuse? Congress has never before required citizens to purchase any good or service, but that is what both House and Senate health bills would mandate.

While this debate has been overshadowed by other issues involving the plan's nearly $1 trillion cost and its government-run option, the constitutional argument strikes at a pivotal part of the health care plan's finances. To make a government-run health care plan work, the nation's largely uninsured young adults would need to be covered to help subsidize medical care for older and typically less-healthy Americans, legislators say.

House Speaker Nancy Pelosi dismissed the complaint Thursday when she was asked by a reporter if the Democrats' health reform proposal was constitutional. "Are you serious? Are you serious?" Mrs. Pelosi replied.

But House Minority Leader John A. Boehner said the argument could not be ignored. "I'm not a lawyer, and I'm certainly not a constitutional lawyer, but I think it's wrong to mandate that the American people have to do anything," he told reporters at his own press briefing last week.

The question of the mandate's constitutionality "hasn't been part of the public debate, but the legal community has been debating it. It's been on all the legal blogs," said Michael Cannon, director of health-policy studies at the libertarian Cato Institute. He said "the Constitution does not grant Congress the power to force Americans to purchase health insurance."

In 1994, the nonpartisan Congressional Budget Office noted that a "mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action." "The government has never required people to buy any good or service as a condition of lawful residence in the United States," the CBO said. The statement was part of an analysis of then-President Clinton's ill-fated health care reform plan, which also required that all Americans purchase health insurance plans.

More here

Fraud plagues government health care

Two recent headlines convey a disturbing contradiction: "Medicare fraud: A $60 billion crime" ("60 Minutes"), and "Reid to announce push for public option" (Politico). The former is the latest in a long parade of similar articles about Medicare, the government's biggest health care program. The latter updates liberal Democrats' continued effort to expand government health care despite its long and dreary record of waste and fraud.

Indeed, Medicare corruption has been so extensive for so long that the terms "federal health care spending" and "waste, fraud and abuse" are virtually synonyms. In May 1986, for example, Department of Health and Human Services Inspector General Richard Kusserow reported that in the prior six months 65 people were convicted of attempting to defraud Medicare, Medicaid or Social Security, with savings of more than $50 million as a result. During his long tenure as the department IG from 1982 to 1991, Kusserow unearthed hundreds of millions of dollars in fraud and helped gain convictions of thousands of people.

Nothing much has changed in the 23 years since Kusserow's 1986 report. Last Sunday, "60 Minutes" broadcast a devastating segment featuring a depressing progression of government and private lawyers, law enforcement officers, auditors, investigators, and people convicted of Medicare fraud explaining why and how ripping off Medicare has become one of the easiest and most profitable crimes in America.

One of the criminals explained that Medicare management was so lax that he got $150,000 by claiming reimbursement 10 times for a "gas-powered prosthetic arm." The same criminal said there are "thousands" of companies in the Miami area being paid for such fraudulent claims every day. A lawyer with extensive experience defending those accused of Medicare scams told "60 Minutes" that Medicare fraud is bigger than the drug trade in South Florida.

Predictably, Attorney General Eric Holder told "60 Minutes" the government needs a bigger budget and more employees before it can stop the fraud. But HHS has worked for more than two decades to clean up Medicare fraud and currently has more than 63,000 employees. If, after working all those years -- with the Justice Department, FBI and state authorities -- HHS still can't stop Medicare fraud, why is hiring more people and fattening up the department's budget going to do the trick?

Kusserow told the San Francisco Chronicle in 2003 that every time the government nailed one abuse, three new ones soon took its place. We hear a lot these days about companies that are "too big to fail." We should worry even more about government that has grown too big to do anything but fail.


Wednesday, October 28, 2009

Many fake doctors in Pakistan

Most English-speaking countries have recruited substantial numbers of doctors from Pakistan and many of those in Britain's NHS have been found to be poor performers. Could the report below be relevant to that? Australian bureaucrats have certainly often been very lax in checking the credentials of overseas doctors

SOME 70,000 quacks with bogus medical degrees are said to be endangering lives across the country. But the recent news of a fake doctors’ recruitment scam at the District Headquarters Hospital in Rawalpindi raises new concerns about the infiltration of such charlatans into our public healthcare institutions. Several senior health officials have already been arrested for the hiring of at least four people — three of them brothers — whose medical certificates were found to be bogus. One was taken on by the hospital as a neurosurgeon no less. While all those found guilty ought to be prosecuted and punished, more comprehensive preventative measures are also in order.

For starters, the Pakistan Medical and Dental Council could ask all public and private hospitals in the Rawalpindi-Islamabad area to send a list of their doctors for verification. The PMDC needs to introduce a multi-tiered checking and monitoring system which should include routine degree verification in all hospitals. Fake doctors are either not registered with the PMDC or hold phoney registration certificates, and as such unqualified doctors can be weeded out without harassing genuine practitioners. Hospitals which fail to verify credentials with the PMDC before hiring new doctors should be appropriately penalised. Detecting fake doctors requires diligent regulation as well as public awareness and prompt reporting by medical professionals who are suspicious of a colleague’s credentials. Not many people perhaps know that the PMDC’s website allows the general public to check if their doctors are registered with the council and are thus licensed to practise medicine. The PMDC and the health authorities should encourage the general public, through advertisements and posters, to be involved in exposing fake doctors in this manner. After all it is the public that will benefit most, in terms of safer healthcare, by the eradication of bogus physicians.


A cure worse than the disease

With Democratic support coalescing around Sen. Max Baucus’s (D-Mont.) health care reform proposal, passage of a comprehensive overhaul now appears more likely than ever. One reason is the Congressional Budget Office’s (CBO) preliminary cost estimate for the bill suggesting that it would cost $829 billion over the 10-year budget window, but actually reduce the federal deficit by $81 billion.

On paper, the plan looks affordable, because it contains several features intended to reduce long-term health care costs. However, there is good reason to believe these proposals will not cut costs substantially, and could reduce the quality of care for patients. Most of the alleged cost-cutting measures merely shift costs from the federal government onto the states or private payers, without affecting long-term health care inflation. The only measures that could reduce the annual rate of growth in health care costs would erect government barriers between patients and their doctors, while jeopardizing long-term medical innovation.

Bringing millions of currently uninsured Americans into public or private health plans will not be cheap. That is why White House Chief of Staff Rahm Emanuel has said that the administration’s first priority is “getting health care costs under control.” And, in an August New York Times op-ed, President Obama wrote that the Democratic proposals “will finally bring skyrocketing health-care costs under control” by cutting “hundreds of billions of dollars in waste and inefficiency in federal health programs like Medicare and Medicaid.”

In order to keep the bill’s reported net costs down, Sen. Baucus’s plan relies on $397 billion of new taxes and other expected revenue and on accounting and cost-shifting gimmicks. For example, to help increase health care coverage, the bill would expand Medicaid eligibility, a move that shifts an estimated $33 billion of spending to the states. The CBO’s analysis notes this, but because it is not a federal expenditure, does not account for it in the bill’s budget score.


American healthcare fascialism

Some time ago I invented the phrase "fascialism" to describe the American system of political economy. Fascialism means an economy is part fascist, part socialist. Economic fascism has nothing to do with dictatorship, militarism, or bizarre racial theories. Fascism is a brand of socialism that was the economic system of Germany and Italy in the early 20th century. It was characterized by private enterprise, but private enterprise that was comprehensively regulated and regimented by the state, ostensibly "in the public interest" (as arbitrarily defined by the state).

Socialism started out meaning government ownership of the means of production, but it came to mean egalitarianism promoted by "progressive" taxation and the institutions of the welfare state, as F.A. Hayek stated in the preface to the 1976 edition of The Road to Serfdom. The problems of the American healthcare system are caused entirely by the fact that the government subjects the system to massive interventions, some of which are fascist in nature, while others are socialist.

In 1992, the Hoover Institution published an essay by Milton Friedman titled "Input and Output in Medical Care," in which Friedman documented how, at the beginning of the 20th century, about 90% of all American hospitals were private, for-profit enterprises. State and local governments then began taking over the hospital industry. So, by the early 1990s only about 10% of all American hospitals were private, for-profit enterprises. Socialism characterizes at least 90% of all hospitals. Many other hospitals have received government subsidies, and with the subsidies come reams of regulation, making them fascist by definition.

The effect of this vast government takeover of the hospital industry, Friedman documented, is what any student of the economics of bureaucracy should expect: the more that is spent on hospital care, the worse the quality and quantity of care become, thanks to the effects of governmental bureaucratization. According to Friedman, as governments took over an ever-larger share of the hospital industry (being exempt from antitrust laws), hospital personnel per occupied hospital bed quintupled, as cost per bed rose tenfold.

Friedman concluded that "Gammon's Law," named after British physician Max Gammon, "has been in full operation for U.S. hospitals since the end of World War II." Gammon's Law states that "In a bureaucratic system, increases in expenditure will be matched by a fall in production.… Such systems will act rather like 'black holes' in the economic universe, simultaneously sucking in resources, and shrinking in terms of … production." Dr. Gammon surely knew what he was talking about, having spent his career in the British National Health Service.

"The U.S. medical system, in large part, has become a socialist enterprise," Friedman ended. Friedman also once suggested a syllogism to explain the bizarre spectacle on display today of responding to problems caused by healthcare socialism with even more healthcare socialism. The syllogism goes as follows:

1. Socialism has been a failure everywhere it has been tried;

2. Everyone knows this; and

3. Therefore, we need more socialism.

Layers of regulation plague every aspect of medical care and health insurance in America. In the health-insurance industry, for instance, each state imposes dozens of regulatory mandates on health insurers, requiring them to include coverage of everything from massage therapy to hair implants. The reason for mandates is that the message-therapy and hair-implant industries (and many others) hire lobbyists to bribe state legislators to require insurers to cover their particular practice if they want to sell insurance within a state. Among the states with the largest number of mandates as of 2009 are Rhode Island (70), Minnesota (68), Maryland (66), New Mexico (57), and Maine (55). Idaho has the fewest mandates (13), followed by Alabama (21), Utah (23), and Hawaii (24).

Each mandate increases the cost of health insurance and probably increases the typical health-insurance policy by hundreds, or thousands, of dollars yearly. This is a good example of healthcare fascism.

Government policy in the health-insurance industry applies both the brakes and the gas at the same time. While imposing onerous and cost-increasing regulations, government also limits legal liability in some cases where an insurer refuses to pay for a particular procedure or treatment that costs a patient his life. The state also creates state-wide cartels with laws prohibiting the portability of some aspects of health insurance. (For example, my employer-provided health insurance covers pharmaceuticals in Maryland, where I reside, but not in other states.)

Getting back to pure socialism, Medicare, Medicaid, and the Veterans Administration hospitals socialize a very large portion of healthcare in America, with the same predictable results as the socialization of hospitals: runaway costs for decade after decade, coupled with massive fraud, as is often the case when politicians are enabled to spend other people's money. Even the federal government admits that there is currently about $60 billion in Medicare fraud. Since government always understates the cost of everything it does, it is likely that the real number is at least two or three times that amount.

Having taken over most of the hospital industry, government-run or government-subsidized hospitals have created regional monopoly power for themselves with so-called "certificate-of-need" (CON) regulation. How this regulatory scam works is that an existing hospital in an area will give itself the legal "right" to decide whether there is a legitimate "need" for more hospitals. They have given themselves, in other words, the right to veto new competition in the hospital industry. It is as if the Microsoft Corporation had a legal right to veto new competition in the computer industry.

Not surprisingly, research has shown that CON regulation has increased hospital costs. CON regulation is also used to block competition in various healthcare professions as well, from nursing to home healthcare. (I was once asked to assist several nurses in obtaining a CON license from the Fairfax County, Virginia government so that they could start up their own home healthcare business. The county government was already in the business itself, and vetoed their application, naturally.)

Physicians have long enjoyed a degree of monopoly power derived from state legislatures that delegate to the American Medical Association (the doctors' union) the "right" to limit entry into medical schools through accreditation. Only graduates of accredited (by the AMA) medical schools are licensed to practice medicine. The AMA has used these state-granted privileges to limit both the number of medical schools and the number of medical-school graduates. The reduced supply of doctors drives up the price of medical care and the income of AMA members. Hundreds of other health professions limit entry with the help of occupational licensing regulation, the primary effect of which is to create monopoly profits, not to ensure quality of care.

Government regulation of pharmaceuticals and medical devices, primarily by the Food and Drug Administration (FDA), increases healthcare costs, denies the benefits of myriad helpful drugs and devices, and creates monopoly power. It has literally been responsible for the premature death of thousands of Americans who have been deprived of drugs that were long available to people in other countries.

FDA bureaucrats are extremely risk averse: On the one hand, it costs them nothing personally to delay a life-saving drug for years, if not decades, by demanding test after test. On the other hand, if they permit a drug to enter the marketplace that turns out to be dangerous, it is a public-relations disaster for the agency, which it does not want to be associated with. Consequently, the entrance of new drugs and medical devices onto the market is often delayed by years, costing many lives and inflicting much needless pain on those already suffering, while driving up prices.

The FDA also makes the market for pharmaceuticals less competitive by restricting what advertising may say for myriad drugs — even aspirin. New drugs do consumers no good if they do not know about them. Advertising restrictions imposed by the FDA, therefore, prop up the profits of incumbent drug marketers at the expense of newcomers in the industry and of consumers.

The government's legal system is also responsible for what used to be called "the liability crisis." The genesis of this crisis began in the 1960s. The government courts began accepting the Chicago School Law and Economics argument that assigning all liability in product-liability cases to manufacturers would be a good way to minimize the "social costs" of accidents. Manufacturers know more about products such as medical devices than anyone else, the argument went, so contract law and shared responsibility for accidents with the users of the products were thrown out the window.

So, when accidents occur, slick trial lawyers have had an easy time convincing dumbed-down juries to award millions, or hundreds of millions, of dollars in liability lawsuits. These lawsuits have bankrupted the manufacturers of many medical devices, while convincing others that the devices are too risky to make. The effect on the healthcare consumer is poorer healthcare and higher prices.

There are thousands of other government regulations and controls on all aspects of healthcare, even (or especially) the nursing-home industry. Like most regulation, it has little or no beneficial effect for the public. More often than not, it is part of a cartel arrangement by some group of medical practitioners who are in cahoots with federal, state, or local politicians who are always more than willing to sell their "constituents" down the river for a generous campaign "contribution."

The only sensible approach to healthcare "reform" would be massive privatization of America's socialized hospitals, combined with deregulation of the medical professions to introduce more competition, and deregulation of the health-insurance industry. Free-market competition would produce medical "miracles" the likes of which have never been seen, while dramatically lowering the cost of healthcare, just as it has done in every other industry where it is allowed to exist to any large degree.

This is not likely to happen in the United States, which at the moment seems hell-bent on descending into the abyss of socialism. Once some states begin seceding from the new American fascialistic state, however, there will be opportunities to restore healthcare freedom within them.


Congress' health care bills leave millions uninsured

The high cost of health insurance premiums would continue to put coverage out of reach for millions even if Congress approves legislation President Obama says is intended to ensure "that every American has affordable health care."

The number of people who remain uninsured will depend on how House and Senate leaders reconcile separate versions of health care legislation to arrive at a final bill. The factors include the size of government subsidies to help low-income families pay for insurance and the scope of penalties that would be charged for those who don't buy a plan.

"A lot of this really depends on affordability," said Diane Rowland, executive vice president of the Kaiser Family Foundation. "As they put these bills together, one question is, 'Are the subsidies ... going to be sufficient to make coverage affordable?' "

The non-partisan Congressional Budget Office estimates 17 million Americans would remain uninsured under the Senate Finance Committee's 10-year, $829 billion health care bill. Health experts such as Rowland say that number would include families who earn too much to qualify for Medicaid but not enough to pay for insurance.

Others who could remain uninsured under the Finance Committee bill include people who choose to pay a proposed $750-a-year fine rather than buy coverage and those who are eligible for Medicaid but don't enroll.

Senate Majority Leader Harry Reid, D-Nev., is working behind the scenes to merge the Finance Committee bill with one passed in July by the Senate health committee.

The Finance Committee's bill would expand coverage to 29 million Americans who wouldn't otherwise have it, ensuring that 94% of U.S. residents are covered, according to the Congressional Budget Office. An early analysis found that a proposal being developed in the House would cover an additional 6 million to 7 million people, said Brendan Daly, a spokesman for House Speaker Nancy Pelosi, D-Calif. The speaker is leading negotiations in her chamber to combine three House bills into one.

Details of the House and Senate proposals are evolving. Lawmakers, including Senate Finance Committee Chairman Max Baucus, D-Mont., have said that no matter how the legislation is crafted, not everyone will have coverage. Those who could remain uninsured include:

•Those who can't afford it. All of the health care bills would mandate that individuals have health insurance and would provide subsidies to help low-income families pay for premiums. The Finance Committee bill would allow people to opt out of buying coverage if the lowest-cost plan available equals 8% or more of their income after subsidies.

A Center on Budget and Policy Priorities study estimates a family of three earning $27,465 a year would pay 4.5% of its income for insurance under the Finance panel's bill, more than four times the amount the same family would pay under the health committee's bill. "A family ... at that level is stretching it every day to make ends meet," said Judith Solomon, a senior fellow at the center.

•Individuals and families who choose to pay a penalty instead of buying insurance. The Congressional Budget Office has not said how many people it believes would make the decision, but it estimates the government would collect $900 million in penalties in 2016.

About 48% of those penalties would come from people earning between 100% and 300% of poverty, or between $18,310 and $54,930 for a family of three, according to the budget agency. About 29% of the money would come from people earning more than five times the poverty line.

•People who are eligible for Medicaid and other programs but do not enroll. Marc Cohan, director of litigation for the National Center for Law and Economic Justice, said one reason eligible people do not apply is because of the bureaucracy involved. "A lot of people ultimately throw up their hands in despair and walk away," he said.

Sen. Jim Bunning, R-Ky., criticized the Finance Committee's bill this month for adding "hundreds of billions of dollars more in new taxes ... and yet 25 million people will still remain uninsured." The number includes 8 million illegal immigrants who would not be covered under any of the bills in Congress.


Health reform written behind closed doors

By day, Democrats tout how open they have been while crafting a bill to reform the nation's health care system. By early evening, they're behind closed doors. Three times last week, White House officials went to Capitol Hill to meet in closed sessions with top Senate Democrats to put together a health bill. They left with not much more than a thumbs up or a "we're making progress"-type comment to the reporters waiting outside. It's not exactly the level of transparency that President Obama promised during the campaign, when he said health care talks would be aired live on C-SPAN.

"I'm going to have all the negotiations around a big table," he told a town hall audience in Chester, Va., in August 2008. "We'll have the negotiations televised on C-SPAN, so that people can see who is making arguments on behalf of their constituents and who are making arguments on behalf of the drug companies or the insurance companies. And so, that approach, I think, is what is going to allow people to stay involved in this process."

The small group of White House officials and three senators met in Senate Majority Leader Harry Reid's office three evenings last week to discuss what kind of bill to send to the Senate floor. The negotiation team includes Mr. Reid, Finance Committee Chairman Max Baucus of Montana, and Christopher J. Dodd of Connecticut, who led the work on the Health, Education, Labor and Pensions (HELP) Committee bill.

White House officials seen leaving the meetings include Chief of Staff Rahm Emanuel, Health and Human Services Secretary Kathleen Sebelius, health care "czar" Nancy-Ann DeParle, and Peter Orszag, director of the Office of Management and Budget.

It's hardly unexpected that major legislation on Capitol Hill, particularly on an issue as complex as health care reform, would be done in a small group and behind closed doors. The reform debate is now at a particularly sensitive stage, as House and Senate leaders have to make major political and policy decisions on what kind of legislation to send to their chambers' floors.

But Mr. Obama's campaign promises have provided Republicans and other opponents of the Democrats' reform plans with an easy criticism of how he's crafting the legislation. "They're writing a health care bill in secret, even though the president called for all of this to be out on an open table and have C-SPAN cameras in the room," House Minority Leader John A. Boehner of Ohio said last week. "We're about to significantly alter one-sixth of the economy, and if there was ever a need for transparency it is now," Sen. Mike Johanns of Nebraska warned in a recent Republican address.

More here

Tuesday, October 27, 2009

Incredible stupidity from the Australian medical bureaucracy

Yet another boneheaded and useless attempt at computerization. Britain has spent 12.5 BILLION pounds on their system and it still is not working. Let's hope the Australian authorities stop their nonsense long before that point

A FEDERAL scheme to provide thousands of GPs with communications encryption technology so they can send sensitive health information securely over the internet risks turning into an expensive white elephant because hardly any other health workers can decode the messages. A revamp of federal government incentive payments in August meant GPs must be signed up for the secure communications method known as "public key infrastructure" in order to remain eligible for grants worth up to $50,000 per practice each year.

The idea of the system is that it allows doctors to send sensitive patient data, including referrals and test results, to each other without risk of the information being seen by other people.

But Mukesh Haikerwal, one of the 10 commissioners who wrote the recent National Health and Hospitals Reform Commission report, says the scheme is turning into a "superhighway to nowhere" because hardly any hospitals, specialists or allied health workers have the technology, and they have been given little incentive to adopt it.

"If everybody was connected, it would be a very useful thing to be doing," said Dr Haikerwal, a former Australian Medical Association president who is also a vocal advocate for greater use of information technology in health care. "But it's not (currently useful) -- either you stop the rollout, or you enable everyone to be part of the system. Ninety-eight per cent of us (GPs) are able to send stuff securely, but none are able to receive it in a secure electronic form, and none are able to send us stuff back."

Once GPs have signed up to the scheme, the federal Health Department sends them chip cards that encode a GP's identity, and the readers used to verify the card information and activate the system once a password is entered. Mini chip cards that fit into a USB key that plugs into the GP's computer are also being sent out. The federal Health Department estimates 10,000 GPs are likely to apply for the technology, and says 9000 have done so already.

Medicare sends the necessary equipment free to those who apply, but a Medicare Australia spokesman said the cost of this was commercial-in-confidence. Dr Haikerwal estimated that the cost of extending the technology to specialists could be $7000 to $10,000 a practice for the hardware, software and training, although not all of this would be expected to come from taxpayers.

Dr Haikerwal's concerns were backed by Royal Australian College of General Practitioners president Chris Mitchell, who said there was no point in having a secure messaging system "that allows you just to communicate with yourself".

Stephen Johnston, head of national infrastructure services for the federal government's National E-Health Transition Authority, said the "whole health system has to be connected". "GPs are just one part of the story," Mr Johnston said. "But it won't happen overnight." A spokesman for the Health Department said take-up of the technology was "progressing" and predicted others would come on board steadily.


No health care measure can alter the fact that medical resources are limited

If you've been following the health care debate over the last couple of years, you may have heard the grim tale of Nataline Sarkisyan. Just 17 years old, afflicted with leukemia, she needed a liver transplant, but the insurance company Cigna refused to cover the surgery. After being picketed by nurses and the family, the insurer relented, but too late: She died that same day.

When he ran for president, John Edwards used the girl's experience as proof of the need for reform. Her parents went to Cigna headquarters to charge the company with killing their daughter to make money. Lately, a liberal group called Americans United for Change has used her in a TV spot to dramatize its claim that "if insurance companies win, we lose."

Her case is an excellent illustration of what is wrong with our approach to health care -- but not how Cigna's critics mean. The insurer declined to pay for the transplant because, it said, "the treatment would be unproven and ineffective -- and therefore experimental and not covered."

Nataline's surgeons disagreed, estimating she had a 65 percent chance of surviving six months with a new liver. But Dr. Goran Klintmalm, head of the Baylor Regional Transplant Institute in Dallas, told The Los Angeles Times the surgery was "very high-risk" and "on the margins." Even on the best prognosis, she stood a one-in-three chance of dying -- after undergoing a very expensive operation and taking a liver that might otherwise have gone to someone with a better chance of survival.

Maybe Cigna was mistaken. Maybe not. The problem is that the critics seem to imagine that once we crack down on insurance companies or go to a single-payer government health insurance plan, future patients like Nataline will get anything their doctors recommend.

They won't. No matter how we "reform" health insurance, there will still be close calls, where it's not clear that a costly procedure will actually do any good. There will have to be someone, either in government or in the private sector, to decide which operations and treatments should be covered and which should not. And there will be patients who will die after being refused.

Health care "reform" won't eliminate such incidents and may produce more of them. Despite all those greedy private health insurers -- or maybe because of them -- Americans get far more liver transplants per capita than the residents of Canada, France or Britain.

But liberals are not the only people who fantasize that our health care resources are unlimited. Republicans have accused the Obama administration of plotting to set up "death panels" to ration care for seniors. Former Lt. Gov. Betsy McCaughey of New York called the House Democratic health care bill "a vicious assault on elderly people" that will "cut your life short." Republican National Committee Chairman Michael Steele has taken the same tack. After the administration proposed modest reductions in the growth of spending on Medicare, he did an impersonation of John Edwards.

"We want to make sure that we are not cutting the Medicare program," Steele said. "Anytime you get a body of individuals that go beyond me and my doctor who are going to make decisions about what kind of health care I get, that's rationing of health care." But as long as someone else has to pay for those decisions, someone other than doctors and patients is going to make decisions about what treatments are worth the cost.

As it happens, Washington is not about to get stingy with seniors. The cost constraints in the health care bills moving through Congress would trim total projected Medicare outlays by only 3 to 5 percent over the next decade. A cut of 5 percent in 2019 spending, however, would leave it 80 percent higher than this year.

Ten years from now, even with such "cuts," seniors will have more and better medical options than today. Yet Republicans act as though everyone over 65 will be herded onto an iceberg and pushed out to sea.

What left and right have in common is the delusion that when it comes to medicine, nothing succeeds like excess. But no health care measure can alter the fact that our resources are not unlimited. We may not want to hear it, but no matter what kind of insurance system you have, sometimes someone has to say "no."


End of Life Care Should Not End Life

The subject of how best to honor and care for those facing death due to terminal illness or old age has always been controversial. As talk of "death panels" and "rationing" stirs debate over the government's proper role in health care, two new studies funded by the National Institutes of Health are lending new weight to the argument that, when it comes to providing end-of-life care for the elderly and terminally ill, sometimes less is better. The studies, featured in the New England Journal of Medicine, document how certain medical therapies implemented in the final months of a patient's life often cause emotional and physical stress and pain, effectively negating any positive benefits associated with such treatments.

However, those worried that a government takeover of health care will result in health care rationing in keeping with Dr. Ezekiel Emanuel's "complete lives" theory view these studies with alarm-and for good reason. In a culture where "quality of life" is increasingly viewed as the predominant justification for abortion, assisted suicide, and even infanticide , there is a legitimate concern that these kinds of studies will be used by the government to advance policies that endanger society's most vulnerable members.

The pivotal question is not whether difficult end-of-life decisions must sometimes be made, or whether-as the NIH studies indicate-sometimes the best decision is to forego heroic measures in favor of simply keeping a patient comfortable in his or her final days. The traditions of hospice and palliative care, for example, both work to keep dying individuals in a state of dignity and comfort without resorting to extraordinary, and ultimately futile, measures. The question is who should make these decisions.

Government-run health care has ominous implications because it supplants individual doctor-patient relationships with generalized protocols crafted by bureaucrats who have no way of accounting for the particular needs of the human beings affected by them. These protocols are often drafted with cost-cutting goals and resource management in mind-not the criteria most want at the top of the list when it comes to life and death medical care.

At many hospitals and nursing homes in the United Kingdom, for example, elderly patients deemed close to death are placed in a "care pathway" designed to ease the dying process and conserve medical resources. Once it is determined that a patient is near death, life sustaining fluids and medicines are withdrawn and the patient is placed under heavy sedation. As bioethicist Wesley J. Smith describes it, "the Pathway misuses the legitimate treatment of palliative sedation, and mutates it in some cases into a method of causing death, known as terminal sedation. This means that sedation is sometimes administered, not because the individual patient actually needs the procedure, but because he or she has been reduced to a category member, and that's how members of the category are treated." When this kind of one-size-fits-all approach is employed, casualties are inevitable. One man has already lost his life due to the misapplication of England's bureaucratic approach to end-of-life care.

At the other end of life's spectrum, last month a woman in England was forced to watch her premature infant struggle to survive without medical care for hours before finally dying on the delivery room table. The reason? Doctors told the new mother that "national regulations" prevented them from providing medical care because the baby was born two days too early to qualify for life-saving measures. In Canada, the government recently decided to end funding for a medication that adds an additional nine months to the lives of colon cancer patients. Why? "Clinical" evidence suggested that the additional months of life were not worth the cost of the medication.

In each of these situations, end-of-life decisions were made without the input of, and sometimes against the explicit wishes of, the individuals involved. These treatments are not being employed as one option among many-they are being imposed uniformly as a matter of policy.

Few would deny that some measure of reform is needed in the healthcare arena. Our country is on the threshold of a veritable Senior Tsunami; an enormous age wave is coming. As America increasingly becomes a mass geriatric society, large numbers of the elderly will soon need acute and long term care. Yet, even as the demand for medical care is increasing, Medicare funds are in short supply, and something's got to give .

But if our leaders in Washington are unable or unwilling to come up with a uniquely American solution to this problem, and if the looming healthcare crisis continues to be exploited by leaders on the Left simply as a means to a greater ideological end , there is good reason to fear that the cold comfort of England's "care pathway" approach to end-of-life care may be coming soon to a hospital near you.


Obama Taxes Pacemakers, Heart Valves

The more fiscal details of the health care bills emerge, the more appalling they seem. The Senate Finance Committee bill includes a broad provision taxing all manner of medical devices. This tax includes such frivolous luxuries as pacemakers, stents, artificial heart valves, defibrillators, automated wheelchairs, mechanized artificial limbs, replacement hips and knees, surgical gurneys, laparoscopic equipment and the like. President Obama is planning to reduce the cost of medical care by taxing it!

The most recent Gallup Poll reflected that 49 percent of respondents said they believed that the Obamacare plan will increase their health care costs. Only about 20 percent said it would lower them. It is taxes like these that substantiate this kind of concern.

The origins of this new medical device tax are troubling, as well. The medical device industry had its day at the White House, as did the insurance industry, the drug makers, the nurses and the doctors. In turn, each group heard the White House request that they come up with voluntary cuts in their health care costs and support Obama's proposed changes in return for assurances that Congress would not impose deeper cuts (or, in the case of the doctors, that it would actually rescind cuts already scheduled under current statutes).

But, unlike all these other groups, the medical device industry refused the deal. This posture enraged the tyrants in the White House, who vowed to punish the industry with cuts imposed by Congress. The result was a decision by the revenue-hungry Senate Finance Committee to extract billions in funds from the industry.

The legislation does not work like a sales or excise tax. Rather, it follows the model of the punitive tobacco settlement imposed on cigarette companies in the '90s. It assesses an industry-wide payment that firms must make in proportion to their market share. It bars them from passing along the cost of the assessment by charging more for certain basic products, but allows them to raise the price of others to raise the funds for the fee.

So, the result will be that virtually every piece of advanced surgical equipment will be subject to a price increase to meet the levy from Washington. No matter that these devices often make the difference between life and death and that, in effect, taxing them raises the cost of vital treatments. The vengeful White House will have its pound of flesh from the medical device industry for daring to be independent and refusing to knuckle down to administration pressure.

This tax, imposed in a spirit of haughty arrogance, falls on totally inappropriate objects. Valves, prosthetic limbs, pacemakers, hearing aids and such are essential therapies that make life longer, better and less painful. To tax them makes no sense -- except in the world of sharp elbows and interest group politics that grips this take-no-prisoners and show-no-mercy White House.


House health care bill exceeds $1 trillion

Health care legislation taking shape in the House carries a price tag of at least $1 trillion over a decade, significantly higher than the target President Barack Obama has set, congressional officials said Friday as they struggled to finish work on the measure for a vote early next month.

Democrats have touted an unreleased Congressional Budget Office estimate of $871 billion in recent days, a total that numerous officials acknowledge understates the bill's true cost by $150 billion or more. That figure excludes several items designed to improve benefits for Medicare and Medicaid recipients and providers, as well as public health programs and more, they added.

The officials who disclosed the details did so on condition of anonymity, saying they were not authorized to discuss them publicly.

Some moderate Democrats have expressed reluctance to support a bill as high as $1 trillion. Last month, Obama said in a nationally televised address before a joint session of Congress that he preferred a package with a price tag of around $900 billion.

Obama also said he would not sign a bill that raised deficits, and the CBO estimates the emerging House bill meets that objective. Officials said the measure would reduce deficits by at least $50 billion over 10 years and perhaps as much as $120 billion.

Democrats also said the bill would slow the rate of growth of the giant Medicare program from 6.6 percent annually to 5.3 percent.

"The bill will be paid for over 10 years. It will reduce costs but also will not add a dime to the deficit" in future years, House Speaker Nancy Pelosi, D-Calif., said at a news conference.

Still, Obama's speech provoked enough concern among House Democrats that senior presidential aides were called to a meeting in the Capitol to explain precisely what the president had in mind when he set the $900 billion target.

The figure of $871 billion "is a coverage number. I think the White House has made that very clear. It is a number about coverage," Pelosi said recently when asked about the size of the measure.

Linda Douglass, a spokeswoman for the White House, said, "The speaker is working on a plan that meets with the president's price tag of around $900 billion for health insurance reform and will not add a dime to the deficit."

House Democrats took steps to fulfill another of Obama's goals during the day, announcing their legislation would completely close a gap in Medicare prescription drug coverage within a decade, five years faster than originally contemplated.

In addition, Pelosi said, "as of Jan. 1, 2010, our legislation will give a 50 percent discount for brand-name drugs to recipients in the donut hole and it will reduce the size of the donut hole by $500."

After months of delay, Democrats in the House and Senate are aiming for votes next month on legislation to fulfill Obama's goal of expanding coverage to millions who lack it, banning insurance industry practices such as denying coverage for pre-existing conditions and slowing the growth in health care spending nationally. The House bill will also lift the insurance industry's exemption from federal anti-trust laws, a provision under consideration in Senate negotiations as well.

With time growing short, Pelosi and Senate Majority Leader Harry Reid are struggling independently with the most controversial of all issues involved with health care, proposals for a government-run insurance option to compete with private industry.

In the House, Democrats have tentatively concluded they cannot win passage of the provisions favored by most liberals, one calling for a nationwide government-run plan with payments to doctors and hospitals linked to rates paid by Medicare. It was unclear what fall-back plan was under consideration, but the internal disagreement cast doubt on plans to publicly unveil legislation early next week.

Across the Capitol, Reid, D-Nev., assessed support for a nationwide government-run insurance option that would allow states to opt out of the system. While the plan evidently enjoys a clear majority, it is uncertain whether it can command the 60 votes needed to overcome a threatened Republican filibuster.

Democrats hold 60 votes in the Senate, but one, Sen. Ben Nelson, D-Neb., has spoken out strongly against a so-called public option. A few other members of the rank and file have been non-committal.

One, Sen. Mary Landrieu, D-La., met with Reid during the day and later issued a statement saying she was encouraged that a compromise might be possible. She also added pointedly that she had told Reid about "the unique challenges Louisiana is facing in terms of Medicaid and the special concerns I have about teaching hospitals," a possible signal that easing home-state concerns could influence her vote on the larger, national question of a government-run insurance option.

Also opposed is Sen. Olympia Snowe of Maine, the only Republican this year who has voted for a Democratic-drafted health care bill in committee. As an alternative, she favors allowing the government to step in only if there is insufficient competition in the private insurance industry.

Nor was it clear whether Democrats would be able to enlist additional Republicans. Sen. George Voinovich, R-Ohio, frequently mentioned by Democrats as a potential convert, said in an interview, "We can't afford the health care system that we have right now. And if we can't afford the one we have right now, how are we going to afford another one that's going to cost more money."

For Reid, the question of a government-run option is one of a many thorny issues to be settled before he can bring health care legislation to the Senate floor. He and senior committee chairmen have been meeting with top White House aides in recent days to produce a bill, and hopes of largely wrapping up the work by the end of the week went unfulfilled.