Monday, August 31, 2009

Bob Dole on the health care battle

Bob Dole has some good advice for Barack Obama.

In The Washington Post this morning, Dole writes: "Obama's approval numbers would jump 10 points if Americans knew he was fully in charge." That's surely true.

And, of course, if Obama proposed a popular plan--a Serious Medicine Strategy, that would defeat a disease that people fear and want to see cured--his approval numbers would jump 20 points.

Sunday, August 30, 2009

"Cold Souls," "Taboo Trade-offs," and Serious Medicine

The new Paul Giamatti movie, “Cold Souls,” raises interesting points about Serious Medicine. Roger Ebert gave it three stars, and The New York Times called it “flat-out funny.” But from a Serious Medicine point of view, “Cold Souls” deserves to be taken seriously, as it illustrates dilemmas that we have seen, and that we will continue to see, in medical/scientific research.

“Cold Souls” is a comedy, albeit a black comedy, taking inspiration from, most obviously, Nikolai Gogol’s 1842 novel, Dead Souls. But what “Cold Souls” is, most of all, is thought-provoking. It gets us thinking about the Promethean, even Faustian, possibilities of medical technology.

Indeed, as medical science has climbed the grand staircase of advancement over the centuries, every step has been controversial, and some steps have been missteps. Once upon a time, dissection was controversial. So were vaccines. Today, we struggle with tough ethical issues, such as malpractice and organ harvesting, while terrible visions of Dr. Mengele and Dr. Kevorkian continue to haunt us.

But the enormous expanse of medical science has guaranteed that another group, economists, will try to fit it into their own Procrustean Bed of economic analysis. Yup, economists are always trying to boil health and medicine down to mere numbers. And while anything that costs trillions of dollars, worldwide, can and should be subjected to rigorous scrutiny, health-care economists will almost always be regarded skeptically, even hostilely, by their fellow humans. Why? Because, as Jim Woodhill has argued, health care is not an economic good--or at least it’s not an economic good in the sense of that widgets, or pork bellies, are an economic good. And so to apply economics to health care is also to apply “the dismal science” to some of the deepest impulses of human nature.

Indeed, economic analysis of medical science quickly brings to mind the phrase “taboo trade-off.” That phrase, “taboo trade-off” was coined by the University of California’s Philip E. Tetlock in his “Thinking the unthinkable: sacred values and taboo cognitions,” published in Trends in Cognitive Sciences in July 2003.

Tetlock makes the distinction between “taboo trade-offs,” which can’t be thought of as economic, and “routine trade-offs,” which can. As Tetlock explained, there’s a distinction to be made between “taboo trade-offs (which pit sacred values against secular ones) and routine trade-offs (which pit secular values against each other).”

Any attempt to apply economic accounting to health care is usually seen as “hard-nosed,” at best, and “cold-hearted,” at worst--it stumbles over people’s sense of taboo, also known as their deep-seated sense of right and wrong. Such concerns don’t stop economists from doing their thing, of course. In fact, morality-based criticism of economics only encourages some economists, such as the “freakonomics” crowd. Those who love to shock will relish the prospect of shocking further.

But for the overwhelming number of people, in any country in the world, the putative monetary value of a life is a great example of a topic which is, and should be, taboo. So is trafficking in human organs. Such discussions and transactions go on all the time, of course, but people don’t like them, and frequently, the transactions are illegal.

And yet for reasons that introduce us to the full complexity--or, if one prefers, perversity--of human nature, some health-care economists, even those inside the U.S. government, seem to revel in taboo talk.

A case in point is Ezekiel Emanuel, the special White House adviser on health care policy. By his own account, Emanuel has written more than a million words on health-care topics, which led The New York Times to summarize his career as having built “a reputation for pushing limits while exploring uncomfortable life-and-death issues in starkly academic terms.” Translation: Emanuel did a lot of taboo trade-offing.

So is it fair to call Emanuel a “deadly doctor” or even, “Dr. Death”? Well, fair or not, it’s too late. Emanuel has delved into the realm of taboo trade-offs, and it has cost not only him dearly, but also the Obama administration, which has seen support for its health-care plan plummet amidst accusations of “death panels.”

“Cold Souls” makes no reference to 2009 politics, but it, too, thrives in the realm of taboo trade-offs, albeit mostly for laughs. The film presumes that it is possible, scientifically, to extract a soul from an individual, and then, furthermore, to implant that soul in someone else. And yet the film is wrapped up in science, and pseudo-science; the device that does the soul-extracting and soul-implanting looks a lot like an MRI machine.

So, according to the film, out of such dark and weird science has emerged a transnational underground railroad of soul-trafficking. And yet the film always bears in mind the humane point that such “body part” trafficking is taboo--or at least it should be taboo.

So where does “Cold Souls” leave us? The precise notion of soul-trafficking aside, it leaves us with the uncomfortable feeling that edgy medical-trafficking is a) a bad idea, and b) inevitable. If something can be thought up, it will eventually get made. And if something gets made, it will eventually get trafficked, at least by some, in a harmful fashion. So just as there are never any final victories in the anti-crime work of policemen, prosecutors, and prison guards, neither will there be any final victories in efforts to stamp out bad medical ethics, and even evil medical ethics. We can try, we must try, and we will try, but the best that we can look forward to is a long twilight struggle, waged on the ramparts of human decency.

In the endless struggle to help people, the vast majority of doctors and medical scientists are great allies--heroes, in fact. And for the good doctors in the vast army of health-betterment, Hippocrates is the guiding general, the man whose Oath binds medical professionals to the light side. But sadly, not every medical doctor, or scientist, will be a trustworthy and loyal soldier in this great army. And the unrestricted free market, abstracted as it sometimes is by greed and amorality, is an uncertain ally.

“Cold Souls” is funny enough to make us laugh, but creepy enough to make us think.

Bill Bradley Puts Forth a Thoughtful and Constructive Suggestion on Health Care

Former Senator Bill Bradley (D-NJ) writes in the New York Times today, offering a "grand compromise" on health care:

The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care.

Universal coverage can be obtained in many ways — including the so-called public option. Malpractice tort reform can be something as commonsensical as the establishment of medical courts — similar to bankruptcy or admiralty courts — with special judges to make determinations in cases brought by parties claiming injury. Such a bipartisan outcome would lower health care costs, reduce errors (doctors and nurses often don’t report errors for fear of being sued) and guarantee all Americans adequate health care.

It will be interesting to see if anyone picks up on this idea. Conservatives should come to realize that some sort of mandate is inevitable. If you need car insurance to get on the road, you should have health insurance before you get into public places. And liberals should come to realize that trial lawyers, in their current form, are the antithesis of every honest egalitarian value that the left holds dear.

Saturday, August 29, 2009

Jacob Weisberg, T.R. Reid, and Serious Medicine Strategy

Jake Weisberg, the always thoughtful writer-turned-editor at, wrote a thoughtful piece on health care last month that I belatedly just read. It starts out as a review of T.R. Reid's new book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, to which Weisberg adds plenty of his own thinking:

In his new book The Healing of America, the journalist T.R. Reid employs a clever device for surveying the world's health systems: He takes an old shoulder injury to doctors in various countries. In the United States, a top orthopedist recommends a major joint-replacement operation, costing tens of thousands of dollars. In France and Germany, general practitioners offer him the same surgical option, at little or no cost, but steer him instead toward a regimen of physical therapy. In Britain, the doctor is unimpressed with his injury and tells him to go home. In Canada, he is offered a place in line, where he will wait a year just to consult a specialist. In India, he is sent to an ayurvedic clinic, where he is treated, quite effectively, with herbs, massage, and meditation.

OK, now that's interesting. The world is, well, multicultural. Different peoples do things differently. But then Weisberg both agrees and disagrees with Reid. Weisberg is willing to accept some of Reid's critique, but not Reid's solution:

America's system has become wildly unfair and expensive. In fixing it, Reid says, we should follow other countries where health care is fairer, cheaper, and produces better results. He's right that we can learn much from practices elsewhere—why, for instance, can't we have those nifty smart cards the French use instead of paper records? But the lesson I took away from Reid's book was somewhat different: Health care systems are not just policy choices but expressions of national character and values. The alternatives he describes work better than ours not just because they're well-designed and competently managed but because they reflect the expectations and traditions of their societies.

And then Weisberg goes further, channeling an argument made more than 20 years ago by James Fallows, a patron saint of thoughtful liberalism:

America's evolved, undesigned system is also an expression of our culture at its best and it worst. Health care in the United States is innovative, entrepreneurial, expensive, litigious, and wasteful. It is decentralized, driven by self-interest, excellent at the high end, and increasingly unequal. It resists acknowledging trade-offs or limits and is characterized by shocking gaps in basic care. As we plunge into a long-overdue comprehensive overhaul, it's useful to think not just about how we can build on what works in this hodgepodge but about how we can bring health care into better alignment with our own national identity. In reforming our system, we need to create something that is "more like us," in the phrase of the journalist James Fallows—not more like what the French, Finns, or Swiss have, as appealing as that might sound.

We Americans have the system we have because we are who we are. That's not nationalistic chest-beating, that's just anthropological observation. America is different because it is, well, different. And as we have seen yet again in 2009, attempts to remake the United States in the image of the European Union are perpetually popular among the chattering classes, and perpetually unpopular among the mass of ordinary Americans, the kind of folks who are more likely to take their cues from Oprah Winfrey or Sarah Palin than from Gloria Steinem or Gail Collins.

Weisberg, a thoughtful liberal himself, clearly sympathizes, viscerally, with Reid and his why-can't-we-be-like-Sweden ethos. But intellectually, Weisberg is smart enough to see that the Sweden-ification of the U.S. is not about to happen:

We might as well admit that we're going to continue spending more of our national income on health care than anybody else. We are a rich country, we want the best treatment available, and we're prepared to pay for it.

Weisberg seems to regret this spending, as he goes on to make a pitch for the Wyden-Bennett health care bill. I, too, think that Wyden-Bennett is a pretty good idea. Wyden-Bennett is not Serious Medicine, but if it helps Americans build themselves a safe and secure platform of Routine Medicine--which I think Americans should expect--then that Routine Medicine platform could become the launch pad for Serious Medicine.

Thus the one point I would add to Weisberg's review of Reid's book. America, in all its high-tech--or, if you prefer, "gold-plated"--glory, does spend a lot of money on health care. And for that money, we get the best Serious Medicine in the world. That's why the fatcats of the world tend to come here.

The Serious Medicine Strategy argument is that the influx of fatcats could be augmented by inviting in less fat cats, followed by skinnier and skinnier cats. Not to come and live here, unless we want them to, but as patients at our great hospitals and clinics. And then, furthermore, let's figure out how to export our Serious Medicine overseas--and not just the pills and machines, but the holistic services themselves.

In the SMS reckoning, all those expenditures we make--totaling 17 percent of GDP--should be thought of as an asset to be leveraged, not as a liability to be squelched. If we saw the trillions we spend on health care as an asset, we would see that the rest of the world, over all, pretty much aspires to the same "gold plating" that we enjoy. To be sure, the health care elites in those countries might be horrified at this American-ization of their health care systems, but the masses of folks in China and India and everywhere else seem to show a great interest in enjoying the benefits of a consumer society. If they like our Kentucky Fried Chicken, they will like our treatments for obesity. And health care, of course, is a great consumer good--the ultimate consumer good.

So if we wanted to, we could do a lot more to sell Serious Medicine to the world, and we could invite the non-terrorist populations of the world to come here, if they could afford it, to consume Serious Medicine. (And if, as a matter of charity and/or national strategy, we wished to donate Serious Medicine, that would be fine, too.)

If America could be the hospital to the world, in the way that, say, New York City, LA, Philadelphia and Houston (as well as more out-of-the-way places, such as Rochester, MN, home to the Mayo Clinic) are hospital-cities to America and the world, then nobody in the U.S. could legitimately complain about how much we spend on health care as percentage of GDP. It would all be to the good. Indeed, it would be a great industry for us. Better health and a stronger economy: a win-win.

That's the American Way. That's being more like us.


According to the latest Washington Post/ABC poll, just 46 percent of Americans approve of Barack Obama's handling of health care, compared to 50 percent who disapprove. That's a deficit of four points, compared to an approve/disapprove surplus of 28 points, as recently as April.

And that latest poll is more than a week old. Almost certainly, Obama's numbers have deteriorated further.


Barack Obama's overall job-performance rating: Approve 50, Disapprove 43, according to Gallup.

Not good for eight months in to a presidency.

Friday, August 28, 2009

For the Sake of Our Health, Let’s Practice Prevention, Not Ideology--And Not Bean Counting

An ounce of prevention is worth a pound of cure, as Benjamin Franklin said.  One of the strangest debates around health care reform is over whether or not prevention saves money.   Of course it does.  

But George Orwell was right when he said, “To see what is front of one’s nose needs a constant struggle.”   So I’ll spell it out, for the benefit of skeptics, who come in two forms: ideologues and bean counters:

Keeping Americans healthier means we wouldn’t require as much medical care.  Without as much medical care, we don’t spend as much on medical care. 

On top of that, being healthier means we’re more productive, and we need to be a more productive to turn the economy around and compete with the rest of the world.  Yes, such prevention might require an upfront investment here and there, but it’s worth it, even if we don’t see the benefit right away. As the great French economist Fredric Bastiat observed, there’s a useful distinction to be made between “what is seen, and what is not seen.” As he wrote in 1848:

This difference is tremendous; for it almost always happens that when the immediate consequence is favorable, the later consequences are disastrous, and vice versa. Whence it follows that the bad economist pursues a small present good that will be followed by a great evil to come, while the good economist pursues a great good to come, at the risk of a small present evil.

Interestingly enough, Bastiat illustrated his point with an analogy from... preventive health:

The same thing, of course, is true of health and morals. Often, the sweeter the first fruit of a habit, the more bitter are its later fruits: for example, debauchery, sloth, prodigality. When a man is impressed by the effect that is seen and has not yet learned to discern the effects that are not seen, he indulges in deplorable habits, not only through natural inclination, but deliberately.

Bastiat rightfully belongs in the pantheon of free-market economists, and yet his wisdom derives from that most marvelous of tutors--common sense.

And yet in a way that Orwell would have recognized, if not appreciated, some ideologues have staked out positions that put them crosswise of the age-old wisdom of prevention--wisdom, of course, updated for our technological time. An ideological case in point is one Zachary David Skaggs, health policy analyst for the right-leaning Liberty Coalition, who whose article in The Washington Examineris boldly entitled, “Preventive medicine doesn’t work.” 

Wow! There’s a keeper: “preventive medicine doesn’t work.” One might be tempted to think that Skaggs was a victim of an oversimplifying headline writer, but sure enough, as one reads the article Skaggs genuinely seems to think that “over-diagnosis” is a greater danger than under-detection. And, he says, “hundreds of studies” back him up. To which we might begin by asking, “Danger to whom?” And then note that “hundreds of studies” proved that man couldn’t fly--until he did. Perseverance is a virtue in medicine, just as it is in engineering. The danger that seems to animate Skaggs is the “danger” that we might spend too much money, trying to be safe, rather than sorry. (Interestingly enough, Skaggs’ argument overlaps with the argument made by some on the left as well, including Shannon Brownlee of the New America Foundation, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.)

It’s right and proper to scrutinize all tests and procedures for overuse, as well as outright theft and fraud, and improvements can always be found. But in medicine, small is not beautiful. The cost of underconsumption of health care is obviously vastly greater than the cost overconsumption. If you overconsume, you most likely will have spent too much. But if you underconsume, you most likely will get sick and die. A simple Pap smear--a piece of preventive medicine that’s been continuously improved over the last 80 years--can cut deaths from cervical cancer by as much as 99 percent. And today, having passed over the "cost hump" on Pap smears, women live longer, and we spend less on cervical cancer. That’s a true win-win. Of course, the bean-counters don’t see it that way, but I am getting ahead of myself.

Sticking for the moment with Skaggs and his right-leaning neo-Luddism, we might note that the list of life-saving preventive medicines goes on and on. But it always helps to know what the problem is. Quick! Is that a migraine headache, or a cerebral aneurysm? Is that a stomach ache, or a burst appendix? Is that heartburn, or a heart attack? And, oh, by the way, is that rodent over there a harmless omnivore, or is it carrying bubonic plague? We can quickly see that a key difference between First World countries and Third World countries is that the former suffer from the mild maladies of health care overconsumption, while the latter suffer from the deadly epidemics associated with health care underconsumption.

And did I mention swine flu? The work of the Centers for Disease Control and the Public Health Service is expensive, and it might not even succeed in staving off an epidemic. But in light of estimates that the H1N1 virus could hospitalize up to 1.8 million Americans and kill 90,000--and with memories of past influenza epidemics that killed tens of millions still lingering in our historical consciousness--how many Americans want Uncle Sam to give up work on a vaccine? Or to stop spending money on related public health measures?

Carelessness about key health questions takes you to a dead end. Not just intellectually, but literally. And while yes, it might seem cheaper, according to a certain ruthlessly cold-hearted calculus, to see some people die off and not run up health care bills, that calculus is usually yet another example of Bastiat’s seen vs. unseen dichotomy. Most people with serious illnesses end up in the hospital sooner or later, and that costs money. And yet the even larger loss is not only to the individual and his family, but to society, in terms of lost income and productivity. Conservatives are right to worry about the Nanny State, but they should also consider the cost of the ICU State. And the Morgue State.

But there’s another belief system, too, working against the idea of prevention. That’s the faith in bean-counting as an end in itself--in defiance, once again, of common sense. One bastion of bean-counting is the Congressional Budget Office (CBO) , which has relentlessly insisted that prevention cannot be “scored” as a savings in any health care plan.  

The CBO, it seems, cannot "do the math" to figure out how prevention saves money over time. Okay, fair enough, the CBO can't know everything. But in the meantime, just because the CBO doesn’t know how to account for something, that doesn’t make the thing not exist. The physical world existed before we had numbers to enumerate it.

We all know there are limits to CBO’s sensibilities.  For instance, as Louis Woodhill has pointed out, under the current CBO rules of “static analysis,” if we proposed a huge tax on lima beans--say, 12 trillion percent--CBO would score it to show we could balance the federal budget.  Of course, that doesn’t mean it would, since in reality people would stop eating lima beans because the new tax would mean that the cost has gone through the roof, all the way to Pluto.
The proposals in the current health reform bills, in the House, and  in the Senate, aren’t talking about screening every American for obscure diseases featured only on episodes of "House." They’re focused on fighting health problems that are rampant in America–such as obesity and smoking –with proven, evidence-based disease prevention programs.  And since nobody seriously argues that more smoking and more obesity would be good for our nation’s health, or our overall well-being, it’s worth combating those public-health problems.  But with all the hand-wringing over the details of paying for health care, we’ve lost sight of the fact that any good effort to reform health reform care should actually try to improve the health of Americans.  

The research shows that starting early--like way before someone has advanced diabetes or late-stage lung cancer--is critical not only to the survival of the patient, but also to the biggest monetary savings. Targeting these problems means helping people quit smoking, eat more nutritiously, and get more exercise, which often don’t even involve going to the doctor’s office.  The New York Academy of Medicine has identified dozens of low-cost programs around the country that have shown real results in reducing smoking rates, limiting diabetes, improving nutrition, and increasing exercise, which then in turn reduce rates of disease.

Such wellness in turn reduces health spending.  These results quickly add up:  A recent studyby the Trust for America’s Health shows that an investment of $1 in evidence-based disease prevention programs in communities can lead to $5.60 in health care cost savings.  No doubt those calculations can be disputed here and there, but the intuitive truth of prevention--going back way before Ben Franklin--is so obvious that no amount of number-crunching can make the obvious gains disappear entirely. It’s simply cheaper to have a lumpectomy than a radical mastectomy.

Speaking of lima beans, no one’s going to make you eat them.  There are people who worry that talk of prevention is just an attempt by government to control what we eat or to force us to exercise.  And while there are some in the public-health world who would love to impose "fat taxes," or even go further, toward fat-prohibition and other kinds of draconian health mandates. Those are fights for the future. But in the meantime, we are free to be more healthy--or not.

Just last week, a new study from Finland found that men who jogged or exercised fairly intensely for at least 30 minutes a day had a 50 percent reduction in their risk of dying prematurely from cancer. Sounds like a good deal.

As Washington debates the minutiae of health care dollars and cents, we’re missing what’s clearly common sense.  Better health is a good thing; it would be worth investing in even if it didn’t save money.  But it’s clear that lots of prevention efforts have the added bonus that they do save money.  And thus the double bonus: Americans would be more productive and in better shape, physically and economically, to compete with the rest of the world.  

Wednesday, August 26, 2009

Edward Kennedy, 1932-2009

Sen. Edward Kennedy, who died last night, published an opinion piece in Newsweek on July 18; most of the piece was dedicated to
the cause of national health insurance, but note the emphasis, here, on Serious Medicine--chemotherapy, proton-beam radiation therapy, and so on.

Now I face another medical challenge. Last year, I was diagnosed with a malignant brain tumor. Surgeons at Duke University Medical Center removed part of the tumor, and I had proton-beam radiation at Massachusetts General Hospital. I've undergone many rounds of chemotherapy and continue to receive treatment. Again, I have enjoyed the best medical care money (and a good insurance policy) can buy.

Sadly, Serious Medicine didn't work in the case of Teddy Kennedy, but as the late senator from Massachusetts once said, "The work goes on, the cause endures, the hope still lives, and the dream shall never die."

Tuesday, August 25, 2009


Howard Dean Speaks--So Does The Audience. Dean Tells a Whopper.

The audience, more hostile than not, seems to be trying to chant its way through Dean's talk. If I didn't know better, I would say that the chanters are trying make Howard Dean lose his cool.

There's a ruckus on the floor. I think it's Randall Terry, the anti-abortion activist. Dean just sat down, and Jim Moran is back at the podium.

Then the crowd quieted down, and Dean finished talking. That's him, above, next to the red arrow.

Now it's time for Q's and A's. In his first answer, Dean committed something of a howler. He said that the British National Health Service was established by "one of the most conservative leaders, Winston Churchill." Well, no, Dr. Dean, that's simply not a true statement.

The NHS began operations in 1948, when Clement Attlee, prime minister from 1945 to 1951, was firmly ensconced at 10 Downing Street. It is true, of course, that the Tories in Britain have mostly defended the NHS, but that's not the same thing as saying that Churchill started.

"Don't Tread On Me."

At the Reston, VA town hall.

I Think That Jim Moran is Filibustering...

...either that, or he really enjoys hearing himself talk. He is working through all the "myths" about the health insurance bill. He is currently on Myth #9.

That's Jim Moran, next to the red arrow, above.

Jim Moran is Having a Hard Time Up There

Jim Moran, the Congressman representing the 8th District of Virginia, is having a hard time on the podium. He said that he had spent four hours listening to a reading of technical language of the legislation, and the crowd responded, sarcastically, "Awww."

And when he mentioned "the public option," he got about a quarter of the audience on its feet cheering--not a good sign. And when he said the words "Howard Dean," that got more boos than cheers, too.

I can't help but wonder what the reaction would be if he were to say, "I think we should cure cancer." As noted here yesterday, cures are popular. Politics, not so much.

Live at the in Reston, VA Town Hall

Lots of strong feelings here, at this town hall, hosted by Rep. Jim Moran (D-VA), with a special guest, Howard Dean. And a few zanies, too, including this avowed Lyndon LaRouche supporter, pictured above--note the lettering on his sign.

This high school gym is packed, this gym holds 2500 seated, and more standing. And there are still long lines outside. Obama supporters appeared to outnumber opponents--lots of "Yes We Can" chants earlier. But when Moran and Dean walked in, the boos seemed to run about even with the cheers.

Moran is starting out strong. A rabbi gave the invocation, and then a Boy Scout led the Pledge of Allegiance, giving the event the sort of proper solemnity that any civic function should have. But of course, politics and culture always insert themselves--as the Scout led the pledge, conservatives shouted out, extra loud, the words "UNDER GOD," while a few liberals, put their emphasis on "FOR ALL" at the end of the pledge.

Of course, it's different elsewhere in the country. In Arkansas, Razorbacks oppose Obamacare by more than 2:1.

Most trenchant sign here in Reston: "Hurt 100% to 'Help' 5%."

Keep Your Friends Close, And Your Enemies Closer

The Hill's Alexander Bolton writes the story of Howard Dean opposing Obama on dropping "the public option." Proving yet again the wisdom of Michael Corleone: "Keep your friends close, and your enemies closer."

Obviously the Obamans should have made room for Dr. Dean in their administration. The current Health and Human Services Secretary, Kathleen Sebelius, might be a nice enough person, but she is doing them little good.

Live By Words, Die By Words (But What About Deeds?). The Liberal-Left Linguistic Industrial Complex Comes Crashing Down.

So how did Obamacare end up in this much trouble? How could Republicans, plus some radio talkers and some avid townhall protestors, bring the liberal health juggernaut to a screeching halt--or a Titanic-like end? If it's true that journalists write the first draft of history, then The Wall Street Journal's Jonathan Weisman has made a great contribution this morning, taking us behind the scenes, in his news analysis piece, "Obama Allies Find Words Fail Them." Weisman's story is a peek at what we might call the Liberal-Left Linguistic Industrial Complex (LLLIC). The LLLIC, begun with high hopes and at great cost, is now grinding down. As Weisman puts it:

In the rhetorical battle over health care, the forces backing President Barack Obama's overhaul have spent years polling and using focus groups to find the precise language that would win over voters -- an effort that doesn't at the moment appear to be working.

Weisman further notes, "The words had been carefully chosen in an effort to take away the rhetorical targets of health-overhaul foes and replace them with terminology that would bring ordinary Americans on board." OK, from a liberal point of view, so far so good. Having imbibed the lessons of George Lakoff, Drew Westen, et al., the Obamacare forces were ready to fight and win.

So what went wrong? Why is Obamacare in so much trouble? The short answer: The situation changed faster than the Obamans and their carefully chosen words. 'Twas ever thus; as the Prussian military strategist Clausewitz tells us, "No battle plan survives its first contact with combat." When the shooting starts, the fog of war sets in, and an army needs to fall back on doctrine, training, instinct, and luck. Again, the point is not that plans are a bad idea, the point is that plans need to change according to the situation.

And so, as the WSJ notes, the Obamans haven't changed quickly enough. No wonder, because they spent so much time and energy putting it all together. As the Journal notes, the group, which dubbed itself "The Herndon Alliance," included the AARP, the Service Employees International Union, the American Cancer Society, and Families USA, all pitching in to hire high-priced pollsters and consultants. Indeed, as the WSJ notes, the “Herndonians” are so eager to get credit for all their work that they can't resist taking credit, even if the results are, shall we say, less than credit-worthy:

But Herndon members do say they have influenced the lexicon of overhaul advocates."When you've gotten the groups speaking with a similar voice and you've got data to show one phrase works well and one doesn't, that gets into circulation," said Ron Pollack, executive director of Families USA.

Well, that's bad "op sec," operational security. I am willing to bet that most Americans, even those closely following the health care debate, have never heard of The Herndon Alliance--but that could well change today, if maybe Rush Limbaugh or Glenn Beck get hold of this story.

But the larger problem for the Herndonians is that the weight of all their planning and focus-grouping turned into dead weight for the Obamans. It was literally yesterday's news in a fast-changing environment. And so, as the WSJ explains:

Under steady attack from opponents using more-emotional language, some of the president's allies are rethinking the linguistic strategy. "There are emotions on both sides, and some of these recommendations really avoid connecting to emotion in a way that we hoped would bring the temperature down and disarm opponents," said John Rother, executive vice president for policy and strategy at AARP, the giant seniors lobby. "I don't want to second-guess them, but the research is very much a product of where the debate was at the time. Times have changed. Temperatures have gone up."

Indeed, temperatures have gone up. Writing about the thinking of Herndon's strategists, the WSJ observes:

Dr. Crittenden said no one anticipated the charges that the Obama program would include "death panels" or advocate euthanasia. Perhaps more important, said Lake Research head Celinda Lake, no one foresaw the intensity of protests at town-hall meetings.

Famous last words for any bold plan. "No one anticipated." And where did "death panels" come from?

If Sarah Palin had totally made up the line about "death panels," if the entire discussion of euthanasia were a complete fabrication, then it's likely that the anti-Obamacare forces would have been hooted off the stage. But instead, they are winning.

As the University of Pennsylvania's Mary Frances Berry, no conservative she, observed in Politico’s “Arena” section yesterday:

The discussion of end of life consultations, and savings in Medicare and other cost- savings proposals apparently seem scary all taken together. Some people even report experiences with older relatives, who are in nursing homes or assisted living facilities being counseled to make an end of life decision and to sign a form they might not understand.

In fact, there is a strong factual basis in reality for many of the anti-Obamacare accusations, working right there in the Eisenhower Executive Office Building, next door to the White House. Many of the words come from Ezekiel Emanuel, Obama health care adviser (and brother of the White House chief of staff). Responding to his burgeoning legion of critics, Ezekiel Emanuel tells The New York Times:

Maybe if I had been a smarter, more careful thinker about how people could interpret it, I would have qualified it and condemned it more robustly. In my 1.2, 1.3 million written words, you can’t find another sentence that even comes close to advocating that in my voice. When I advocate, I’m not shy.”

Well, there you have it. The Herndon Alliance has its words, all expensively worked and reworked. And Emanuel has his million-plus words. And, as he says, he is "not shy" about what he writes and advocates. In a Googled world, of course, it's just as easy to find Emanuel's words as it is to find the Herndon Alliance’s. And so here we are: A mostly defiant Emanuel and his long, long, long paper trail are an opposition researcher's dream.

Indeed, even the Times allows that Emanuel's writings might be a just a little bit controversial:

As a leading bioethicist at Harvard and at the National Institutes of Health, Dr. Emanuel had a reputation for pushing limits while exploring uncomfortable life-and-death issues in starkly academic terms.

It was great that the Democrats had their expensive plan. But they needed the ability to change it.

And, of course, they needed a better plan, a plan that was more than just words.

The Liberal-Left Linguistic Industrial Complex is a poor substitute for Serious Medicine.

Ezekiel Emanuel in The New York Times this morning

The Times' Jim Rutenberg tries to be nice, but read between the lines of this sentence:

As a leading bioethicist at Harvard and at the National Institutes of Health, Dr. Emanuel had a reputation for pushing limits while exploring uncomfortable life-and-death issues in starkly academic terms.

Monday, August 24, 2009

"Obama Should Focus on HEALTH, Not 'Health Care Policy'"

Just published on's Fox Forum.

"Health insurance reform" failed for both Bill Clinton and Barack Obama, whereas "health" worked for Franklin D. Roosevelt and Richard Nixon. Two very different presidents; but millions of Americans owe their lives to them, and to their good works against polio and cancer, respectively.

"What’s more, health care reform is the Democratic Party’s signature issue. Its wonks have thought longer and harder about it than any other topic." -- Ross Douthat, writing in The New York Times today.

Sunday, August 23, 2009

James Sabin, "Medical Ethicist," As The Grim Reaper. And John J. Pitney Jr., In Defense of Life.

Writing in Politico, Jeanne Cummings illustrates the wide gap between the thinking of the "health care policy" elite and the average American.

Perhaps Cummings didn't set out to let a leading "ethicist" hang himself with his own words, but that's what she did. Cummings reported on the question --a question for "medical ethicists," at least--of whether Sen. Edward Kennedy is getting too much medical treatment in his battle with brain cancer. It seems that James Sabin, a professor at Harvard Medical School and "director of ethics at Harvard Pilgrim Health Care" thinks that Kennedy should show "leadership" and die quickly and quietly and cheaply. Here's an excerpt of Cummings' story:

So, while not critiquing the specifics of Kennedy’s treatment, some medical ethicists said his case shines the light on the cost-versus-benefit questions that need more honest discussion by voters and politicians.

“What messages are being sent by the behavior of people in leadership positions?” said Harvard ethicist James Sabin, speaking of Kennedy.

Sabin recalled the powerful impact on the economic debate of Warren Buffet, one of the wealthiest men in the world, who declared publicly that he ought to pay more in taxes. “If Kennedy spoke of health care choices in the same way, it would be more than mouthing off,” said Sabin, a Harvard Medical School clinical professor and director of ethics at Harvard Pilgrim Health Care.

Given that about a third of Medicare dollars are spent on patients in the twilight of life, Sabin and other experts say a rethinking of treatment for them is essential to reducing costs in the system – a major goal of reform.

The medical choices of the man who has become the face of the universal coverage movement are a delicate subject, particularly with Kennedy’s own health so precarious.

This is, indeed, a delicate subject for liberals, because they know that a) the Kennedy family can afford the best treatment, and will spend what it takes; and b) the Democrats need Kennedy's vote in the Senate to ram through a plan. But even so, Sabin, the "ethicist," can't resist weighing in on the Kennedy case, arguing that Kennedy should go quickly. It would seem that "medical ethicists" can't resist opining, even in cases where their political interests would be better served by keeping quiet.

John J. Pitney, Jr., the Roy P. Crocker Professor of American Politics at Claremont McKenna College, gave SMS this sharp response:

Sabin's message is that Ted Kennedy should pass up life-prolonging treatment and go gently into that good night. The ethicist would applaud if he gave a farewell speech saying "I should die more quickly!" But Americans admire the Kennedys because they fight like hell against illness and injury.

The comparison to Buffet is nonsense. If Buffet gets his way and pays more tax, he's still a billionaire. If Kennedy pulls his own plug, he's dead.

This is the ethics of redistribution applied to life and death. This is the world of Sophie's Choices and overcrowded lifeboats. It's not the world Americans want to live in.

And that's pretty much that. The James Sabins might rule the roost at Harvard, and at "medical ethics" departments and centers and foundations across the country, but the American people reject such cold utilitarian calculus. (And of course, as noted here, "medical ethicists" have a way of changing their mind when it's their own life on the line.) Fortunately, we also have a few Jack Pitneys in the academy, as well, to foster a debate, if not exactly balance.

If the health elites want to continue leading, they should focus on curing brain cancer, not figuring out how to push us toward a convenient death.

Saturday, August 22, 2009

"Obama's healthcare messages are backfiring, strategists say/The president's range of abstract arguments for reform are leaving people confused"

That's the headline atop Pete Nicholas' analysis piece in the LA Times this morning. The piece is worth delving into, because it indicates so much about how the whole debate over health care, on both sides, has gone so wrong.

Let's start by taking a look at that LAT headline again:

"Obama's healthcare messages are backfiring, strategists say/The president's range of abstract arguments for reform are leaving people confused, some Democrats contend."

Note the phrase highlighted above, range of abstract arguments. No kidding! This point became blindingly obvious on August 8, when the Washington Post's Michael D. Shear noted that President Obama had shifted his rhetorical focus from "health-insurance reform," rather than "health-care reform." In other words, Obama went from an abstraction, "health-care reform," to an even greater abstraction, "health-insurance reform."

Which is not to say that health-insurance reform" is not a legitimate issue. But it's just not that engaging to people. When most people thinking about "health," we think, first, of life and death. We think of health and disease, and what's bothering us, and what afflicts our loved ones and friends. And then we might take time to worry about the course of, say, swine flu, or some other epidemic--from HIV to Alzheimer's to obesity--that might threaten large numbers of people. Those are the sorts of health issues that affect us where we live.

The LAT story notes the multiple explanations that Obama has put forward:

For example, Obama has argued that a new healthcare system is necessary to spur an economic recovery. He also has offered up healthcare as an antidote to rising deficits. Earlier this week in a conference call with religious leaders, Obama laid out a "moral" imperative for revamping the nation's healthcare system.

At other points, Obama has portrayed "meddling" insurers as a reason for scrapping the existing system.

"One of the difficulties has been that the explanation has changed," said Howard Paster, a legislative liaison in the Clinton administration. "Originally it was keyed very much to the economy. More recently, emphasis has been placed on issues of fairness and equity. We need to have a consistent set of reasons for doing this."

Note what's missing from this litany: Any sense that the purpose of medicine is cures. The mechanisms of health care delivery are of interest to some, but the question of health cure delivery is of interest to everyone.

The LAT observes that the Republicans, in the opposition, have it easier:

Conservative opponents of the overhaul increasingly use a simple, understandable message: Government-forced cost reductions will restrict treatments, imperiling the ill and elderly.

Note that the conservatives/Republicans aren't really talking talking about cures, either. Or course, at this white-hot political moment, the right might think that it is sufficient, and necessary, to simply beat back Obamacare. And so only down the road somewhere will we find out if the Republicans are really interested in cures, aka Serious Medicine, or if they are simply interested in blocking Obama. If the Republicans make that mistake--if they simply mirror the lefty-nerdy abstractions of the Democrats with righty-nerdy abstractions of their own--they will pay a huge political price, too. So the GOP doesn't have to worry about any of that for now, because Republicans are not in power.

But in the meantime, Obama, who does have power, seems determined to push his own bloodless version of "reform." On Friday, the White House issued a statement, following a meeting with Tom Daschle, affirming the President's determination to press ahead with "health insurance reform." The entire statement appears below:

The President invited Senator Daschle to the White House for a quick check-in on the health insurance reform process and to exchange views on the process moving forward. Senator Daschle is one of the foremost experts on health care and on the legislative process, and has been a friend and sounding-board for the President for several years. The two agreed that substantive reform that lowers costs, reforms the insurance industry, and expands coverage is too important to wait another year or another administration, and they agreed to stay in touch over the coming weeks and months as this critical effort moves forward.

Note the words that are used: "health insurance reform process," "legislative process," etc. So while it might seem obvious that Obama needs to do something different, it looks like he came away from his session with Daschle with a renewed determination to do... more of the same. What's that cliched definition of insanity--doing the same thing, over and over again, despite failure that should be obvious?

And we might further note the words not used: "medicine," "research," "cures." Aren't those the kind of words that move the needle of ordinary Americans?

As Lloyd Green observed here at SMS, the American people are coming to think that what the Democrats have in mind is not so much a health program, as it is an income transfer program. The American people want the expansion of health, not the redistribution of health.

To borrow a phrase from Bill Clinton's 1992 presidential campaign, "It's the health, stupid!"

Friday, August 21, 2009

Charles Krauthammer: "The Truth About Death Counseling"

Is the "death panel" real, or not?

A powerful op-ed about Section 1233 of H.R. 3200, from Charles Krauthammer in the WaPo this morning.

Here's his conclusion:

So why get Medicare to pay the doctor to do the counseling? Because we know that if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care, we've nudged you ever so slightly toward letting go.

It's not an outrage. It's surely not a death panel. But it is subtle pressure applied by society through your doctor. And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it's intended to gently point the patient in a certain direction, toward the corner of the sickroom where stands a ghostly figure, scythe in hand, offering release.

Wednesday, August 19, 2009

Life Expectancy Up -- The U.S. Must Be Doing Something Right About Health

Americans are living longer than ever. News from the Centers for Disease Control:

U.S. life expectancy has risen to a new high, now standing at nearly 78 years, the government reported Wednesday. The increase is due mainly to falling death rates in almost all the leading causes of death. The average life expectancy for babies born in 2007 is nearly three months greater than for children born in 2006.

Are we overweight, too many of us? Yes. Do many or most of us not get enough exercise? Yes. But are we still doing better? Yes.

So let's be careful about pulling apart the system we have. Most of all, let's not confuse the minutiae of "health insurance policy" with the bigger picture of the health and well being of Americans. Healthcare "reform" is not an end in itself. One kind of reform might be better, or might be worse, but it is a means to an end. The end is better health and well-being for Americans. The political argument over "health insurance reform" is just that: a political argument--a small subset of the bigger issue.

Fortunately, the American people, in their wisdom, seem to agree: Sticking with what we have now is better than trading it away for a bureaucratic unknown cooked up in Washington DC. Hence the NBC poll showing that a majority of Americans now oppose "the public option."

We can do better still, of course. Much better. But let's build on our strengths, by going forward with Serious Medicine.

"The Death Book for Veterans Ex-soldiers don't need to be told they're a burden to society."

Important piece by Jim Towey in The Wall Street Journal.

Tuesday, August 18, 2009

Amidst All The Political Tumult Over "Health Insurance Policy"--Let's Keep Our Eye on the True Bottom Line: Better Health Outcomes For People

Yes, it's the doldrum-y middle of August, but this is a great season for political junkies. But for those with real illnesses, or who worry about real illness and incapacitation, there's little news to be interested in--other than the usual grim news about the new deaths from swine flu and the hoped-for progress toward a swine flu vaccine,or the threat of new strains of HIV. That's where the real action is.--or, as we shall see, is not.

But in the hurly-burly of thepolitical arena, the White House is reeling from a revolt by liberals over the administration's apparent willingness to abandon "the public option." Meanwhile, a top Blue Dog Democrat says that any health plan will have to be "deficit neutral" (which means, your choice, a) that it won't spend much, b) that it would be coupled with a tax increase, or c) that the future costs will be extremely well hidden.) And Gallup has a new poll showing that conservatives outnumber liberals in every state in the union--even Vermont. And oh yes, there's even a little scandal brewing in the White House--call it "Spam-gate," which has united both Fox News and the American Civil Liberties Union. Those of us who are political junkies think back to 1993-4, when another Democratic White House overreached on health care, and the Democrats lost Congress.

But from a strictly Serious Medicine Strategy point of view, none of this matters too much. To borrow some computer programming lingo, the current political battle is a battle over "inputs" and "throughputs." That is, how much money do we spend in the name of health care (inputs), and how is it spent (throughputs)? So the whole debate over "the public option" is a long debate over throughputs. By contrast, Serious Medicine is about outputs--outcomes. Do people get better? Can they live better and longer?

Serious Medicine is about waging war on Serious Illness. As in, nuking diseases, the way that we nuked tuberculosis, or polio, or smallpox--or, for the most part, AIDS. Medical triumph over those illnesses made life immeasurably better, and longer, for billions of people. (And so it's a shame that we have backslid so much on TB in recent years, and it's an open question what will happen with AIDS, here and worldwide.) Such medical victories require Serious Resources: money, talent, regulatory streamlining, leadership, and a general sense of mobilization. That's how you win a war.

Some, such as Betsy McCaughey argue that the Obama administration is showing its egalitarian impulses here. That is, if the diagnosis of top Obamans, such as Peter Orszag and David Blumenthal, is that health care is too expensive overall, well, one way to reduce the growth of spending is reduce the rate of medical advancement. Hence, keep the NIH under control. Is that an unfair explanation of Obama budget priorities? Who has a better one?

Now of course, some will argue that NIH spending is just another kind of government spending, and that as such, it is mostly wasted. This is a purist argument that most Americans reject--there is a good enough connection between "input" and "output." And so the burden is on the purists to identify another, better, way to move resources into the Serious Medicine sector. But let's never be complacent: If there's a better way to run and fund the NIH, or something different altogether, let's have a debate. If there's a need to look at the FDA and the overall regulatory climate, let's do that, too.

And there's an opportunity here, too, for politicians. Why do all our leaders want to argue about throughputs? Why can't they argue about outputs?

Making our lives longer and better. That's a real bottom line, and we should lose sight of it, even in August.

Monday, August 17, 2009

"We Don't Spend Enough on Health Care"

"We Don't Spend Enough on Health Care/It's crazy to adopt a bean-counting mentality amid revolutionary, albeit expensive, advances in medicine."

That's the header for Craig S. Karpel's must-read piece in The Wall Street Journal this morning.

Sunday, August 16, 2009

Are All "Bioethicists" This Hypocritical? Or Just Daniel Callahan?

Daniel Callahan
has spent a lifetime telling the rest of us to spend less on health care, but when it comes to his own health care, well, that's a different story. We should do what he says, and he will do as he wishes. Got that? It's all in Saturday's New York Times.

For the past 40 years, The Hastings Center, co-founded by Callahan, has been conference-ing and seminar-ing on "bioethics." Plenty of people have thought long and hard about ethics over the past few thousand years, of course, and reached many different conclusions, but the Hastings Center was at the right place at the right time. It fill a perceived need for a "new ethics"--that is, mostly free of religion--to deal with complex medical- and technology-related issues in the 20th century. As the Times' Peter Steinfels writes:

Ever since Mr. Callahan began exploring such themes in books like “Setting Limits” (1987), “What Kind of Life” (1990), “The Troubled Dream of Life” (1993) and “False Hopes” (1998) — all published by Simon & Schuster — he has been unjustly accused of favoring something like Sarah Palin’s imagined “death panels.” In fact, he has been a vocal critic of doctor-assisted suicide and other steps toward euthanasia.

And Callahan's newest book echoes his predecessors: "Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System,” forthcoming from Princeton University Press. For his part, the Times' Steinfels is sympathetic to Callahan's views--as Steinfels disclosed in the Times piece, he once worked at the Hastings Center.

Others have a darker view of Callahan, Hastings, et al. One such critic is Wesley Smith whose book, The Culture of Death, describes how the "bioethics" movement created its own new political culture, and deeply influenced all of health care policy. It is fair to say that overall, Peter Singer, Ezekiel Emanuel, and the bulk of the professional apparatus that deals with "health care policy" share much of this same worldview.

But back to Daniel Callahan. He is an elder statesman now--literally. And now that he has reached the age of 79, the world, and its health care priorities, evidently looks different to him. Here's more of the Times story:

Still, is there a way to “cool our aspirations,” as he puts it, and gain “a more finite view of what health care is about” without somehow institutionalizing that bureaucratically? Mr. Callahan says he is trying to address such questions in a new book, “Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System,” to be published soon by Princeton University Press.

Meanwhile, he suggests that the United States might learn something from Europe, where government budget caps on health care, price controls and far less news media frenzy about medical breakthroughs combine with widespread deference to a more modest view in the medical profession about what constitutes appropriate treatments.

Solutions, he proposes, will involve an interplay between a “well-managed government program” and an “inner spiritual conversion.”

Mr. Callahan, 79, had just returned from the hospital himself. Days earlier, he had undergone a life-saving seven-hour heart procedure. He chuckled at the idea that when the emergency arose, lightheaded and knowing his life could be in danger, he might have exercised consumer choice and “shopped around” for a better deal than the medical center his cardiologist recommended.

And at this point, of course, he could only guess at the total cost of his hospitalization — bigger than a breadbasket, let’s say, and less than $100,000. “As I was in the hospital,” he said, “I thought a lot about this.”

Those last two paragraphs are worth repeating:

Mr. Callahan, 79, had just returned from the hospital himself. Days earlier, he had undergone a life-saving seven-hour heart procedure. He chuckled at the idea that when the emergency arose, lightheaded and knowing his life could be in danger, he might have exercised consumer choice and “shopped around” for a better deal than the medical center his cardiologist recommended.

And at this point, of course, he could only guess at the total cost of his hospitalization — bigger than a breadbasket, let’s say, and less than $100,000. “As I was in the hospital,” he said, “I thought a lot about this.”

A 79-year-old getting an elaborate medical procedure that might have cost upwards of $100,000? Isn't this exactly the sort of over-treatment that the health care rationers oppose? Sure it is. But it's different when it's them.

The Obama Health Care Order

[Editor's Note: This is a guest editorial by Lloyd M. Green, an official in the Bush 41 Justice Department who now lives in a blue suburb. SMS is grateful for any and all commentary, feedback, and constructive criticism.]

The Obama Health Care Order

Remember the phrase “Two for the price of one” from the 1992 presidential campaign? You know, buy Bill Clinton, get Hillary Rodham Clinton, too? That might have seemed like a good bargain in ’92, but by ’93-4, as we saw Hillary in action, pushing her health care plan, it proved to be a much harder sell.

Now the idea seems to be popping up again--and again--as part of the Obamacare campaign.  

But the first time around, back in the early 90s, “two for the price of one” proved to be mostly just a bad joke. Today, in 2009, there’s the potential for tragedy and nightmare.

At a town hall meeting yesterday in Colorado, President Obama summoned the memory of his late grandmother to defend his stance on healthcare. 

That part was planned. What wasn’t planned was the emergence of another family pair, Rahm Emanuel and his suddenly notorious brother, Ezekiel. Rahm, of course, is the White House chief of staff. Ezekiel is a top health adviser. Ezekiel, who has a Ph.D. as well as an M.D., has long been more interested in “bioethics” than in actual hands-on cures. And recently, as his voluminous paper trail has been examined, he has come under fierce criticism, most notably from Sarah Palin, who suggested that all the Ezekiel Emanuels of the world wanted to create “death panels” to euthanize the unworthy. And while “respectable” opinion rallied around Ezekiel, it seems that the country went the other way--Obamacare took a huge hit in the polls.

And so Ezekiel had to go to The Washington Times, a bastion of conservative thinking, and take back some of his words.

It’s a safe bet that neither of the Emanuel brothers read The Washington Times much, if at all. But there was poor Zeke--no doubt under pressure from Rahm--sucking up to a conservative paper, trying to do some damage-control. As Ezekiel told the Times’ Jon Ward, his “thinking has evolved.” Going further, Ezekiel added:

"When I began working in the health policy area about 20 years ago ... I thought we would definitely have to ration care, that there was a need to make a decision and deny people care," said Dr. Emanuel, a health care adviser to President Obama in the Office of Management and Budget, during a phone interview.

"I think that over the last five to seven years ... I've come to the conclusion that in our system we are spending way more money than we need to, a lot of it on unnecessary care," he said. "If we got rid of that care we would have absolutely no reason to even consider rationing except in a few cases."

Ah yes, yet another public figure whose thinking "evolves" when his past thinking proves unpopular.

But what started out as a decent enough attempt at damage-control--if, of course, you take Ezekiel at his word--turned south at the end there. That last line left open a tantalizing dangling and dangerous thread, which Maureen Dowd picked up on in her column today. There is “absolutely no reason to even consider rationing except in a few cases”? What does that mean, precisely? Is Ezekiel now against rationing, except when he is for it? Could it be that Ezekiel is too immersed in his worldview to see that most of the American people see the world differently? In which case, that’s trouble for the O-Team.

But back to the O Man himself. In the case of the President and his late grandmother, his use of a deceased relative as a prop is not wise--especially when the sentiments Obama expressed about her in April 2009 are not the same as the sentiments he is now expressing in August 2009, when Congress is on recess, when his poll numbers are sagging, and when wide swaths of the American public are no longer buying what he is  selling.   

Let go back just a few months.  Back in April, Obama was telling the New York Times that his grandmother, Madelyn Dunham, who died two days before Obama was elected president, had received an artificial hip, notwithstanding the fact that she had been diagnosed as terminally ill with cancer.  According to Obama, Dunham's hip replacement was not necessarily a wise expenditure.  Rather, it raised  "some very difficult moral issues” of  whether “to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill." 

Obama also told the Times that the  “chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health-care out here.”  Obama let it be known that he was no Mr. Softie:   “What I’ve been constantly searching for is a ruthless pragmatism when it comes to economic policy.”  In other words, it might just be worth letting aging cancer victims stagnate until they die.
Obama is now changing his lyrics, but not his melody. Yesterday, Obama used Ms. Dunham to deflect the allegation that Obamacare would lead to government run "death panels."  According to Obama, “We’ve got enough stuff to deal with without having these kinds of arguments.”   After having intimated in April that his grandmother's hip replacement might not have been worth it, Obama decided to go for the heartstrings without actually rebutting the death panel argument.  He said, “I know what it’s like to watch somebody you love, who is aging, deteriorate and have to struggle with that.”   That sounds like a non-denial denial or a poor attempt to change the topic of the debate.
OK, now back to Zeke Emanuel.  In a paper of his published by the Hastings Center--which describes itself as a "nonpartisan, nonprofit bioethics research institute," but is generally regarded as a citadel of “progressive” thinking on bioethics--Zeke appears to advocate denying government assistance to elderly Alzheimer's patients.  According to Emanuel, an "obvious example" of who should not receive government  guaranteed "health services" are "patients with dementia."   Such writings might play in Cambridge, but they won’t play in Peoria.
My takeaway from all this is stark. Under Obamacare, elderly cancer patients better be able to walk on their own.  As for the elderly with Alzheimers--good luck.  It was nice knowing you--now enjoy your brief trip on the outbound ice floe.

In political-theater terms, the Obama and the Emanuel families are simply more bad examples of “two for the price of one.” And yet in larger terms--how these personal and policy choices affect the rest of us--Americans have a right to be scared.

The first time around, Hillarycare proved to be something of a joke. But this time around Obamacare is more serious. From farce to tragedy, it's happened before.

This is the New World Order, Obama-style.

"It saved my life. It was a miracle, you see. I'm serious. It's a miracle."

"It saved my life," says Carol Stubbs, of the Turks and Caicos Islands. "It was a miracle, you see. I'm serious. It's a miracle." Stubbs is a cancer survivor, who came to Miami's Baptist Hospital for life-saving treatment. And she obviously got it--that's her, pictured above.

As reported by NPR's Greg Allen, Stubbs is one of a growing foreigners who come to the US seeking Serious Medicine--and they are finding it. That's not only making them better off, it's making us better off. As NPR's Allen explains:

In 2008, 400,000 people from foreign countries came to the U.S. for health care, spending nearly $5 billion, according to a report by the consulting firm Deloitte & Touche. It's a fast-growing market that's expected to double within the next three years.

Isn't that the kind of stimulus we want? Not the government printing or borrowing money, but foreigners coming here and buying things--in this case, Serious Medicine--and going home happy.

Not only does Carol Stubbs and her family have a happy story, but this is a happy story, too, for the American economy. How many industries do we have left in the US that beat the world competition? Shouldn't we be seeking to expand this industry, not contract it?

And that's why we need a Serious Medicine Strategy.

Saturday, August 15, 2009

"Health Debate Fails to Ignite Obama’s Grass Roots " Like, Duh!

Who could imagine that the battle cry of "health insurance reform" would fail to ignite a political brushfire? And so we see an entropic story unfolding: It's a tale of not only political enervation, but also an epic tale of policy defeat.

And that's what happens when a well-meaning leader follows a bad political model. The American people want Serious Medicine, and they would tolerate a certain amount of arcane process reform if that's what it took to get that Serious Medicine. But make no mistake--they do want the Serious Medicine, even if they can't necessarily articulate what they want. So it's a grave error--not to mention a missed opportunity--to lead with process reform, and to ignore Serious Medicine.

But don't take my word for it: Ask The New York Times. The headline atop Jeff Zeleny's piece in the Times on Saturday is a study in punch-pulling politeness and understatement: "Health Debate Fails to Ignite Obama’s Grass Roots."

But the harsher hard-hitting reality, which is hard to overstate, is captured by the Times' accompanying photograph of a quiet room (see above) used by Barack Obama's group, Organizing For America. Yup, at a time when Democratic clubhouses should be beehives of activity, they are mostly worker-bee-less. And this is in Iowa, the state that propelled Obama to the Democratic nomination last year, by giving him a crucial victory in the Hawkeye State's presidential caucus.

As the Times explains:

More than a dozen campaign volunteers, precinct captains and team leaders from all corners of Iowa, who dedicated a large share of their time in 2007 and 2008 to Mr. Obama, said in interviews this week that they supported the president completely but were taking a break from politics and were not active members of Organizing for America.

Whoa. "Taking a break from politics"? Excuse me, but that's not how political activists operate. They get into politics because they like a campaign, or, if one prefers, a crusade. And they get out when they don't have such an energizing effort to throw themselves into--or when their eager hearts are broken. And yet that's what Obama has given Democratic activists--a heartbreaking, de-energizing argument.

This is the price Democrats are paying for a plan that Mary Frances Berry, a veteran lefty, described as "bloodless." As in, being focused on the pale pastels of financial processes for health care, as opposed to the bright bold colors of an ambitious plan to make Americans healthier, and to help them live longer and enjoy more productive lives.

But such a pro-health plan not what they got in the "health care policy" that was handed down to them from Ezekiel Emanuel & Co. No, Americans didn't get a plan for making health care better. Instead, they got a plan for rationing and income transfers. And the folks didn't like it, because, among other concerns, after TARP and all the bailouts, they didn't think America could afford it.

So that's the main reason why Obama has pretty much dropped the idea of the "public option"; as the President said in May, in a moment of candor, "We're out of money."

But of course, we are out of money for health care because Obama chose to spend that money on other priorities--Tim Geithner's friends. As I myself argued in the pages of US News & World Report back in June, Obama shot his financial wad in the Wall Street bailouts. Given a choice between investment bankers and non-masters-of-the-universe, Obama and his investment-banker-ish advisers chose... investment bankers. Maybe Goldman Sachs and J.P. Morgan can make those grassrootsy phone calls in Iowa.

Such a failure of vision might seem ironic for The One. But Obama was merely reflecting the distilled conventional wisdom of most health care "experts" across the field, and it never seems to have occurred to him to look outside the circle of their wisdom. Big mistake.

So for now, in the meantime, fans of Serious Medicine will just have to wait--wait for a visionary leader who will wrestle with the great issues of medicine and life, not settling for a wonky working of "health care policy."

Obama and his team all failed to grapple--"chose not to grapple" is probably a more accurate sum-up--with any attempt at solving the challenges of premature death and fearful disability. You know, seek real cures. Just like we did with smallpox, or TB, or polio, or any of a hundred other killers. Some would say that fighting illness is not the true measure of "health care policy." And in Washington DC terms, they might be right. But in American terms, they are wrong. The American people want to fight for their own health, not fight for "health insurance reform."

Shrinking away from the true stuff of medicine, the Obamans settled for mere shadows of the more vivid reality, like the prisoners in Plato's Cave. They failed to grapple with the agony and ecstasy of medicine and life. And that's why activists are enervated, not energized.

But if a U.S. leader would take on the fullness of health issues, the way Americans--and people everywhere--experience that fullness, he or she would grab the energies of not only activists, but voters, and victories concerning "process" would fall into his or her lap.