Tuesday, July 26, 2011

Free-Market Capitalism and Death Panels: The Musical

How long ago it seems. While we await the final negotiations in Washington to figure out some solution to the budgetary battles--which will likely produce a bill, endorsed by the President, that will be either "very right" or "extremely right" but will somehow be billed as "centrist"--we at the Billy Rubin Blog are feeling nostalgic tonight for those heady days of the summer of 2009, when a health care bill was slowly working its way through Congress.

Remember that? What passed for reasonable dialogue got hijacked by a very noisy rabble of Know Nothings, a group for whom the descriptions "willfully ignorant" and "anti-intellectual" are taken as praise, who screeched at town hall meetings and demanded that "government get its hands off my medicare". But the meme that took the cake at the time, the Chant Of Nitwits as it were, was that somehow the government was secretly planning to arrange "Death Panels," and the paranoia from the imbecilic mob sent the few remaining sensible Republican politicians running for cover and pandering to save their souls (as Chuck Grassley of Iowa did here).

Between the media, who largely buy into the myth of false equivalence that every story must have two equally valid sides and thus reported on the protests without pointing out the basic stupidity of the protesters, and the politicians, too many of whom were spineless in shouting down the nonsense, the silliness carried the day. The Obama administration backpedalled in the Public Relations game, giving up ground to its political foes (sound familiar?), and the consequence was that the country ended up with two presents. The first was a not especially progressive healthcare bill. The second was the Tea Party.

Which brings us up to the present, more or less. So what did ever happen to the Death Panels? Well, they never left, argues the massively awesome blog Health Care Renewal. HCR links Bloomberg News reporter Peter Waldman's investigation into the for-profit hospices now littering the landscape. It makes for grizzly reading. For instance, Waldman relates the story of former social worker Misty Wall, who alleges in a lawsuit against Gentiva Health Services, Inc. that she was "assigned to convince people who weren't dying that they were." (A spokesman for Gentiva said that the allegations predate Gentiva's ownership of the hospice at which Ms. Wall worked. She was fired from the hospice in 2005 for refusing to continue such practices.)

Perhaps even more troubling--and that is saying something--are the allegations that for-profit hospices gave "financial kickbacks" to "referral sources" (in English, that usually means money to doctors) and tied employee bonuses to "enrollment goals". This easily has the potential to induce some employees to move the goalposts a bit and encourage hospice for some patients inappropriately. How's that for a "Death Panel"?! No grim bureaucrats in Washington doling out the Number of The Beast, but rather a "Death for Dollars" in which the most successful recruiters walk home with a tidy cash sum at the end of the day, along with the corporation supervising it.

One notes more than a touch of righteous indignation as HCR writes,

There has been a lot of blather from politicians in the US about "death panels" in debates about health care reform. Many such politicians seem worried that the US government has or will have death panels under the new health care reform legislation. We have criticized that legislation for not addressing many important health care problems. No one, however, has convincingly demonstrated how its provisions would convene "death panels."

I couldn't agree more.

Lest I am misunderstood, hospice has been a tremendous step forward in American medicine. It allows people to die in greater comfort and with greater dignity than before. We need hospice, which is precisely why we shouldn't sully it by making it the object of some corporation's greed. But if people don't want their government involved in their health care, the business of dying will be overseen by for-profit businesses, and the Death Panels will be convened in elegant board rooms with oak tables, plush carpeting, and executives enjoying record salaries. Sound appealing?

Saturday, July 16, 2011

The Budget "Crisis" and Medical Residencies

Among the more amusing tidbits of news that came out of the state government shutdown in Minnesota were pieces like this in which certain voters expressed outrage over the stalemate and demanded their elected officials to just "get things done". "They could have talked more, but they get their feelings hurt a little bit, and act like a bunch of little kids," said one frustrated citizen.

Umm....no. What we witnessed in Minnesota, and what the media is playing up in Washington at this moment, is not merely a bunch of squabbling children, even if there are some childish antics involved. The problem, in Minny as in Washington, is that you have genuinely, truly divided government, with huge blocs of both parties with irreconcilable views about the proper function and structure of government, and to expect them to arrive at agreements on operating costs totally misunderstands the ideology of these blocs. You can't simply expect them to "go and get it done" because there's no consensus on even the most basic roles of government.

Despite what some commentators have said about the current inter-party spats being just more of the same-old same-old, the different visions being fought over today really are much more substantive than any other political fight since the early 20th century. For instance, Richard Nixon and a Democratic-led Congress, while political foils, really did agree on the basics: yes, Nixon presided over some unpleasantries in Vietnam and Cambodia, and obviously sought to limit government in ways that Democrats didn't. But Nixon bought into the concept that government could play a role in preventing drag on the economy, so much so that he proposed a comprehensive health care bill not dramatically unlike the one the current President finally got passed, the hysteria over which led to the election of a House so radically different in philosophy from Nixon (Richard Nixon!) that he would have blushed. Given the budgetary concessions that President Obama has already put on the table, and his breathtaking capitulations since the arrival of the new Congress, the fact that the House "Hell No" caucus won't budge in the current debt-ceiling discussions is evidence enough that this is not just your ordinary political dust-up.

The point here is: if it really does come to pass that the US defaults because of the political stalemate, don't blame them--because the voters were the ones who put Obama into office, and then two years later not only seated an opposition party, but an opposition who would legislate against the sunrise if the President said, "the sun will come out tomorrow" in his increasingly grating Annie-like naiveté. It doesn't make any sense to elect a Democrat like Obama (even one as willing to adopt right-wing talking points as him) and then vote for Republicans further to the right than what even George W. Bush could have dreamed of. At least the voters of my home state of Ohio were consistent when they seated a right-wing executive and legislature in the most recent elections, and now have a new budget crafted by people with a very particular view of the role of government in the lives of its people. Let's see how that one works out for you guys in the years to come; as Chrissie Hynde of The Pretenders once lamented, "Hey, way to go Ohio."

Anyway, this blog is geared toward commenting on such political machinations in relation to the world of medicine (with a jaundiced eye befitting its name), and needless to say the world of medicine is going to undergo serious revisions if the Tea Party really does get its way and something resembling the Ryan medicare proposal (see here if you want to read warm fuzzies about it, and here if you prefer cold pricklies) becomes federal law. (Side note: I think there's a pretty good chance that our "Democratic" President is going to avert this "crisis" by eventually signing legislation that passes with either zero, or very few, Democratic party votes in the House.) And to that end, here are two stories (NYT and Boston radio station WBUR) discussing the huge impact that deep medicare cuts are going to have on teaching hospitals.

To help lay readers understand the structure, Medicare is the government-run health insurance program for senior citizens. While you almost certainly knew this (though obviously some people are not too quick on the uptake), what you may not have realized is that Medicare is also responsible for financing the postgraduate medical training in the US, which costs, give or take, a little over $6 billion per year, although a proposal that even Obama himself endorses would cut that amount by an estimated 60 percent. The feds don't pay residents directly, but rather pay the hospitals running the programs, which tend to be large, academic medical centers. These places may also get hit by a decreasing NIH budget to fund research at those medical centers, as this November 2010 article indicates current House Whip Eric Cantor's philosophy.

While places like New York and Boston are going to be hit disproportionally by major cuts to the residency training budget, you can bet that smaller places like Peoria, Illinois, with its 10 residencies affiliated with two local hospitals, will smart as well. In fact, as residency programs in smaller, more rural communities tend to serve as feeders of physicians who would otherwise not move to such places, the damage to residency training programs is going to reverberate well beyond the hospital parking lots, and have a good chance of doing so well into the future.

Perhaps this will all work itself out and the changes will benefit everyone; perhaps all that extra money from the taxes that nobody seems to be paying will give taxpayers more money to afford...well, afford something. We shall see, though hope (© Senator Barack Obama, 2008) is becoming as thin as gruel. Dickens would appreciate the consistency.

Monday, July 11, 2011

Republican Primary Maneuvering and Hypocrisy About Science, Writ Large

I keep telling anyone who will listen that we all better get used to the phrase "President Bachmann" as the Republican candidate increasingly looks like a not-so-improbable contender for the nomination. Extreme though she may be, she doesn't come with Mitt Romney's troubling baggage of being both Mormon and the former governor of a liberal state whose signature legislation was the passage of a health care law remarkably similar to what nearly all conservatives refer to as "Obamacare"; she doesn't have to resort to a two-step to explain why she worked for President Obama's administration as John Huntsman does; she is a good deal more media savvy than former Alaska governor Sarah Palin; and she isn't Newt Gingrich. I'm no political expert, but in the age of the Tea Party dominated Republican primaries, I see her as having a legitimate shot, with her only substantive competition being former Minnesota Governor Tim Pawlenty, unless current Texas Governor Rick Perry gets into the mix. Maybe I'm misjudging Romney's chances, but I'd call Bachmann the favorite right now.

Representative Bachmann certainly has no fears about wading into controversy, and in doing so making herself a darling of the extreme right. Earlier in the week she became the first candidate to sign a pledge for the protection of marriage entitled "The Marriage Vow: A Declaration of Dependence on Marriage and Family," which as the NY Times noted in a blog post, puts her rivals--at least some of whom do not have such  distinguished marital records themselves--into a tricky position. In a fairly short time, "The Marriage Vow" has managed to generate an uproar over whether or not it explicitly endorses banning pornography (it doesn't, as noted here); its not-so-subtle racism, as discussed here; and its religious fanaticism (see, for instance, here). In short, it highlights all of the qualities most commonly associated with the rightmost wing of the Republican Party, and quite possibly the group best positioned to put a candidate over the top for the 2012 nomination. And Bachmann got there first.

So let me pile on here and point out that one of its additional hypocrisies involves science: as part of the rationale for why the "Institution of Marriage in America is in great crisis," the Vow argues that "[the debasement of marriage continues due to an] anti-scientific bias which holds, in complete absence of empirical proof, that non-heterosexual inclinations are genetically determined, irresistible, and akin to other traits...as well as an anti-scientific bias that holds, against all empirical evidence, that homosexual behavior in particular, and sexual promiscuity in general, optimizes individual or public health." [my emphasis]

There's a lot to unpack in that pile of nonsense but here's a start: whether "non-heterosexual inclinations" are indeed genetically determined is an open question, but to say that those who posit the theory are "anti-scientific" and are making such assertions "complete absence of empirical proof" is patently false. The neuroanatomist Simon LeVay (author of the fascinating tome Queer Science--it proclaims its allegiance right on the cover!) pioneered studies on differences in brain structures between heterosexual and homosexual men, and while I'm skeptical of the results or even the meaning of the findings, there's no question that LeVay's work constitutes science--the empirical testing of hypotheses about the mechanisms of the world. He's hardly the only example, and the literature of scientific publications is rife with tests, theories and arguments about the origin and nature of human sexuality. Nobody's got a definitive answer, but The Vow label of "anti-scientific" is really just tossing out a phrase to make itself seem respectable.

An additional yuck can be had from the fact that the author of The Vow, Bob Vander Plaats, is...well, typically anti-scientific in his fundamentalist Christianity! While running for the position of Lieutenant Governor of Iowa, Vander Plaats endorsed the teaching of "intelligent design" as an adjunct to evolution. As the redoubtable Tara Smith at the blog Aetiology points out, intelligent design isn't a scientific theory at all, something even some of its proponents realize. The casual disregard for critical thought appears to be part and parcel of the document, so a disregard for science shouldn't really be a surprise. Nor should it be a surprise that Bachmann immediately signed on to it.

PS--today's Times has a fascinating article on how some schools (including Billy's medical alma mater, the University of Cincinnati!) have changed their admission interview strategies in the hopes of finding future doctors who are better team players than those who may have stellar grades but are arrogant & condescending (and who in being this way may foster poor communication leading to medical errors). I ran this past a senior colleague who works on a med school admissions committee and he seemed skeptical: "what you do in your life = what you say in a mini-interview; however, grades = long term commitment" was his quick response. Count me tentatively among those hopeful for the new system.