Bush and Kerry, healthcare foes (warning - this link will give you the latest Kondracke column - thus if you are reading this in the future, you will have to search back through his columns to find this particular column).

If you or a loved one suffers from cancer, heart disease, diabetes or another dread disease — or you fear you might contract one — you have a hard choice when you vote for president this year.

President Bush is cutting the budget for medical research that might find a cure for your disease. At the same time, the Democratic frontrunner, Sen. John Kerry, D-Mass., wants to strangle the revenues of the pharmaceutical companies who'd develop a medicine to treat you.

Between the two of them, they're a deadly duo. And Sen. John Edwards, D-N.C., would be little better. He's joining in his party's jihad against drug companies.

The remainder of the article argues that Bush is worse because of the proposed NIH budgets.

Disclaimer: I receive NIH funding and AHRQ funding.

Wow, this is a really tough issue. I am reminded of the famous George Bernard Shaw quote (often attributed to Winston Churchill) - "We've already established what you are, ma'am. Now we're just haggling over the price.". We know that we cannot increase the NIH budget by 100%. Our challenge is to understand how much we should increase that budget.

Supporting the NIH is akin to motherhood and apple pie. One can always stand on the high moral ground when criticizing the President's NIH proposal. The question becomes not the NIH budget per se, but the NIH budget in the greater context of the overall budget.

I would love to see NIH increases and AHRQ increases. Our research group would have better funding odds. Our fellows would more likely have successful research careers. And even more important, our contributions (and the contributions of similar groups around the country) would improve our overall health status.

Read the article and perhaps you can decide (just on this issue) whose approach would benefit the common good. I fear that I cannot tell.

I often rant that each party has good and bad proposals related to health care. This article reinforces my beliefs.

2 Cancer Drugs, No Comparative Data - this title is misleading, because the drugs are really anemia drugs, used both with cancer patients and with Chronic Kidney Disease patients.

Medicare officials sought the study, hoping to see if Aranesp, a drug made by Amgen that costs about $1,300 a vial, is superior to Johnson & Johnson's Procrit, an earlier version of the drug that costs $470 a vial. The federal Medicare program spends more than $1 billion a year on the two drugs, which stimulate the bone marrow to produce red blood cells in patients who have become anemic during treatment for kidney disease or cancer.

We (physicians) have no way to choose between two similar drugs (and these drugs are just variants of each other) unless we have head-to-head comparisons. I have repeatedly ranted on this subject. For physicians to control pharmaceutical costs, we must do the right studies. The study which CMS wants is the right study. Congress should not prevent important medical research.

I hope that we can overcome the pharmaceutical industries meddling so that we can do good comparative studies. Interestingly, the health insurance industry wants these studies. Thus, the Republicans have two major support groups at odds over this provision.

I hope that Congress revisits this issue. Perhaps this article and more like it will help everyone understand the importance of doing this type of research.

This article does not explicitly address medical issues. However, I believe it does a nice job emphasizing the costs of any benefit. One can take these principles and apply them to malpractice suits, drug benefits, marijuana laws, and many other issues that we address regularly. Goodies cost us

There are no two ways about it: There are benefits from all the costly federal, state and local regulations imposed on American businesses. But we must also acknowledge our federal, state and local regulatory agencies have no jurisdiction in India, China, Southeast Asia and Latin America. That means for many products and services, people who are far less productive than we, in a physical sense, can beat us in the global marketplace.

We all can agree there's no benefit that's worth any cost. If that weren't true, we'd do nearly anything that has a benefit, and that would include mandating a 5-mile-per-hour speed limit. Why? The benefits would be enormous in terms of the tens of thousands of highway fatalities and injuries avoided. We don't have a 5-mile-per-hour speed limit because we have decided its benefit is not worth the enormous cost.

No free lunch. Someone has to pay.

Or how inconsistent our politicians are. This column documents the Democrats' inconsistency on Medicare. I am not implying that the Republicans are any better when it comes to the political process. Patient welfare will always remain secondary to political gain. Medicare hypocrisy

What's wrong with the new Medicare bill? Nothing that a little honesty couldn't cure. A recent Wall Street Journal article suggests that the problem is not so much the substance but the failure of Republicans to rise up in defense of the measure. Since the day the bill was passed, Democrats, labor unions and seniors from retirement villages have been holding rallies and press conferences to scream about how the law is either "scamming" seniors or cheating them out of more generous private-sector coverage in order to pay off "Big Pharma and insurance companies."

They are also annoyed that the drug benefit only pays for half of all drug costs and begins two years from now — not immediately. They want the pharmacy benefit management companies in the law to be replaced by Medicare price controls and a national drug list. Some disgruntled Republicans aren't helping matters much by saying "I told you so" after learning that the Bush administration's estimate of adding a drug benefit to Medicare exceeded the Congressional Budget Office (CBO) number by more than 25 percent.

To paraphrase Mark Twain, let's get the facts straight and then distort them as we please. As an article in Health Affairs reports, the president "proposed an outpatient prescription drug benefit to be offered under a new voluntary Part D of Medicare ... Medicare would pay half the cost of covered drugs ? The drug benefit would be administered by a [private] pharmacy benefit manager." To help seniors maintain more generous private-sector coverage, "the president's proposal had incentives for employers to keep [drug coverage]. Medicare would pay employers 67 percent of the premium subsidy costs it would have incurred if retirees had enrolled in Part D instead."

Sound familiar? This proposal was supported by virtually every Democrat. But it wasn't President Bush's plan; it was Bill Clinton's. And it had three big differences. First, it was scheduled to kick in four years after it was to pass in 1999, not in two as the Bush plan anticipates. Second, it covered a lot fewer people. And third, the Clinton plan didn't cover catastrophic drug spending; it capped government spending at about $2,500 per senior with some adjustment for inflation. The Bush plan covers all drug costs over $3,000 a year.

I hope you read that excerpt and the remainder of the article. The Medicare bill is flawed. Virtually every bill passed by Congress is flawed. We can always find and exploit the flaws.

What we should (and apparently never will) do is to evaluate the pros and cons and weigh them to decide on whether a bill is worthwhile. I believe that on the whole (the forest view) this is a good bill. If I focus on trees, of course I see some that should be cut down.

Frist Expects Congress to Try to Expand Health Coverage

Dr. Frist, a principal architect of the new law to provide prescription drug benefits to the elderly, accused Democrats of waging "huge campaigns to discredit" the law. He expressed concern that their criticism might sway voters.

"Democrats right now are out banging this thing and using very partisan criticism, trying to tear it down, because they see that it is a huge leap forward," Dr. Frist said.

Mr. Bush takes credit for adding drug benefits to Medicare, a goal that long eluded Democrats. But Democrats are determined to turn the issue to their advantage by highlighting what they see as defects in the law.

"This is an opportunity for Democrats, but they must seize it and work to define the terms of the debate," says a memorandum for Congressional Democrats by Al Quinlan, president of Greenberg Quinlan Rosner Research, a political consulting concern. "It is critical to engage aggressively and not allow Bush and the Republicans to shape the dialogue."

To win the debate, the memorandum said, Democrats should "define the current law as unacceptable, not as something that can be fixed." Though "voters start with a slight inclination to support the law," it continued, they swing decisively against it when they are told that Medicare beneficiaries will face high out-of-pocket costs, high drug prices and gaps in coverage.

I worry that the politics of health care will undermine real progress. The Democrats do not seem to care whether this law helps some patients. They will not admit that having a drug benefit, even with some gaps, trumps having no drug benefit.

They see any law purely for its political ramifications. But then the Republicans are no different here. Politics trumps the common good at all times. In years past, the Congress and Senate understood compromise. The two parties worked together to at least try to craft positive legislation.

The Medicare bill is not perfect. But then neither am I, or you. Frist is right that we should watch what happens for a year or two prior to making more radical change (because this law is radical change).

Yesterday I linked to Sydney Smith's piece on Edwards. One of my most frequent commentors - Bernie - had this to say:

I read the article you linked to and it had lots to say about defensive medicine as a consequence of malpractice litigation and little to say about Senator Edwards' supposed misconduct as a malpractice lawyer. Unless you assume taking malpractice cases is prima facie evidence of moral depravity, I have yet to see how any of these opinion pieces impeaches Senator Edwards' character.

Bernie and I often disagree - and we both give and take arguments well. I really have not problem with his character, rather his apparent philosophy scares me. Rangel has a great post on this - How Edwards and his ilk are destroying America Quoting from Rangel-

Despite such manipulation of the court system, as repulsive as it is to rational, thinking Americans who have a sense of fairness and justice, a surprising number of people feel that this kind of behavior is perfectly acceptable as long as there is a sense that some type of "justice" has prevailed. This mentality goes along with the commonly held idea that things are not supposed to go wrong without someone else being responsible for causing it. This is a mentality that trial lawyers like Edwards have successfully cultivated over the last 40 years. Americans are more suspicious about big government, big business, industry, and professionals like their own physicians. If something goes wrong then someone is to blame. Call the lawyer!

Obviously, physicians and lawyers view the world through different prisms. (Well maybe not all lawyers, but likely most trial lawyers). These prisms differ due to a fundamentally different motivation for our professions.

Physicians have the patient's well being in mind as a first priority. We "adjudicate" information to try the best known therapy for our patient. We espouse evidence based medicine as our goal. New studies change our practice (the recent data on HRT represents a study which has caused a sea change).

We often will consult a colleague if we believe that the colleague can add valuable insights into our patient's care.

The job of the trial lawyer is to win the case for his/her client. Some lawyers take cases to change policy. But most cases are chosen for monetary benefit. The underlying principle is to win.

There are exceptions to this generalization, however, it is not the lawyer's job to worry about the health care system. He/her will often put the client's interest above the greater good. That is the nature of the lawyer/client relationship and of trial law in this country.

I believe that lawyers like John Edwards undermine our medical system. They can ignore data, science and greater good, and they do regularly. They are doing their job - and Edwards does that job well.

I admire his skill, but I disdain what his cases do to our health care system. I do not blame him, but I do not want someone with his attitude about the law as my president.

We need tort reform, and not just in medicine. With Edwards in power any hopes of reform would vanish. The court system, as used in this country, does not protect the public good. It does not evaluate the scientific evidence as scientists do.

We need a change, and since Edwards represents the current sorry state of affairs, he scares me.

Despite New Law, the Fight Over Medicare Continues

Democrats, denouncing the arm-twisting tactics used to pass the bill in the House, vowed Monday to rewrite the law to reduce the role of private health plans, to increase drug benefits and to authorize the government to negotiate drug prices.

Unless we elect a Democratic majority in the House and Senate, I doubt that they will get their wish. I would like to see some slack in negotiating drug prices. It sure works for the VA system.

Our legislative process has great flaws. The bills they construct make a camel look normal. Almost any observer can find flaws with any bill. Each bill contains something which makes great sense.

Most of you know the expression - there must be a pony in here. Perhaps this is the pony. Rural Doctors Welcome Medicare Overhaul

The Medicare bill before Congress contains help for rural health care providers that would significantly strengthen service in those areas, hospital administrators and doctors say.

The centerpiece of the huge Medicare bill is a prescription drug benefit for older Americans, but the measure also would boost payments to doctors and hospitals in rural areas by $25 billion and rework a reimbursement system they say is outdated.

"The bottom line is that there have been some very damaging provisions in Medicare for many years for the way rurals are paid, and this erases most of them," said Dr. Wayne Myers, president of the National Rural Health Association.

The government has used different rates in rural and urban areas to determine the size of checks sent to hospitals that treat Medicare patients. The formulas date to the 1980s and were based on the belief that medical treatment is less expensive in small cities and towns.

Many lawmakers and hospital administrators say that no longer is the case as hospitals everywhere compete to recruit doctors and pay the same for high-tech equipment.

"The costs (in rural areas), believe it or not, are also very high, and in many cases higher than in cities," Sen. Max Baucus, D-Mont., said on the Senate floor Friday.

The bill reduces the extent local wages factor in the formula that determines what a hospital gets paid from Medicare, which would raise the reimbursement rate in rural areas, said Myers, a former official with the Health and Human Services Department's office of rural health policy.

It also would eliminate a provision that set the hourly rate of a rural doctor lower than an urban doctor's for cost-reimbursement purposes; raise payments in regions that are short on physicians; and increase how much rural hospitals can be reimbursed for treating uninsured patients.

These provisions have great importance. They are long needed and very welcome. Keep searching, there may be more ponies.

I agree with this editorial. O Canada, O cannabis

This is a bill that everyone can (and will) criticize. If you are interested here are some links with selected quotes. 6 Democratic Candidates Attack Medicare Measure

"This is a Trojan horse bill," General Clark said. "It's got provisions in it to undercut Medicare. I think the American people want their representatives and their association to stand up and be counted for senior citizens, and that means rejecting this bill."

The debate offered a hint of the fault lines likely to emerge as Democrats struggle to position themselves on an emotionally charged issue that carries great weight with their constituents. The bill includes provisions intended to inject market forces and more competition into Medicare, which Republicans say will lead to better, more cost-effective care. Many Democrats condemn such efforts as tantamount to privatizing the program.

But the bill, which would create the largest transformation of Medicare in its 38-year-history, would also significantly increase spending on the program and offer a prescription drug benefit that many Democrats had sought for years.

Incremental medical repair

Conservative lawmakers who were balking over the bill said it did not go far enough in the direction of true privatization reform to yield the kind of savings that would make it more affordable. Liberals, such as Sen. Ted Kennedy of Massachusetts and several Democratic presidential hopefuls, think it goes too far, sticking the nose of privatization under Medicare's tent that they warned would eventually destroy the fee-for-service nature of this virtual government monopoly.

In a stunning political split among the Democrats this week, the powerful 35 million-member AARP (which lobbies for America's retirees) embraced the GOP's compromise. AARP policy director John Rother said he was won over by the added subsidies the bill would give low-income Medicare patients, plus incentives aimed at keeping employers from abandoning existing drug coverage for their retired workers.

Endorse Medicare

On the liberal side of the ledger, USA Today notes that "Sen. Edward Kennedy, D-Mass., and other critics are denouncing parts of the new plan as a $12 billion slush fund for private insurance companies to lure seniors out of traditional Medicare. But they offer few alternatives other than open-ended spending."

But conservatives are no better when they claim that an experiment falls far short of real reform, since the time limit dooms the proposal to failure. They forget that in 1996, welfare reform legislation,whichMr. Kennedy also strongly opposed, was offered as a five year experiment requiring re-authorization. What conservatives did was to insure that welfare reform worked and when re-authorization time came, to improve and refine the policy.

Medicare Monstrosity

Instead, Republican negotiators, joined by Democratic Sens. John Breaux and Max Baucus, went behind closed doors and decided to use the public's demand for drug coverage as an opening wedge to change Medicare. The shame of it is that Republicans and Democrats in the Senate had already reached a real compromise. The bipartisan proposal, crafted in cooperation with Sen. Ted Kennedy, was inadequate. Yet it was better than this bill. It passed the Senate overwhelmingly because it left the larger Medicare issues open for real debate later.

But House conservatives weren't willing to go that far. They want medical savings accounts, a tax cut for the wealthy in disguise, and they insisted on experiments with privatization.

But if privatization is such a good idea, why do the private insurance companies need such big subsidies to enter the Medicare market? The bill includes $12 billion for what Kennedy calls a "slush fund" to subsidize the private insurers. That's not capitalism or competition. It's corporate welfare.

The debate is interesting. The Democratic candidates have sided with Ted Kennedy in attacking the bill. The NY Times (not known as a conservative bastion) has endorsed the bill. AARP (which many consider pro Democrat generally) has endorsed the bill. Everyone dislikes something about this bill. This bill is clearly a compromise. So I leave you with two quotes about compromise:

A COMPROMISE is the art of dividing a cake in such a way that everyone believes that he has got the biggest piece. (Ludwig Erhard - a German politician)

The COMPROMISE will always be more expensive than either of the suggestions it is compromising. (Arthur Bloch)

Wow! Medicare for the Fiscally Healthy

ith the government wallowing in deficit spending, it is understandable and even encouraging that Congressional Republicans are thinking about requiring high-income retirees to pay more for their Medicare coverage. This rare nod toward fiscal reality arises as the G.O.P.-led Congress attempts to deliver on campaign pledges to provide a Medicare prescription drug program.

Legislators are looking for ways to soften the financial blow of the 10-year, $400 billion drug plan now on the table. This page has questioned whether the country can afford to add new entitlements to Medicare at all, given the size of the federal deficits swollen by the Bush administration's ill-advised tax cuts. If Congress is intent on going ahead, there will certainly have to be other savings made.

Many Democrats, but not all, warn that the Republicans are venturing onto sacrosanct ground in proposing such a basic change in Medicare, a highly popular program that has always been equally available to all retirees.

But upper-bracket Americans have enjoyed disproportionate benefits under the Bush tax cuts. They can easily afford to pay the premium increases being considered for the top 2 percent of beneficiaries: individuals earning over $100,000 a year, and couples more than $200,000, in retirement. Even the possible tripling of annual premiums, to roughly $2,100, for the richest retirees would still make Medicare a bargain.

Well said, and correct logic!!!

The Health Insurance Crisis

Even most experts were surprised by the sharp jump in the number of Americans lacking health insurance last year. The latest Census Bureau figures show that the number of uninsured jumped by 2.4 million, the largest increase in a decade, bringing the national total to 43.6 million uninsured in 2002, or 15.2 percent of the population. The ranks of the uninsured have increased by 10 percent over the past two years, with the likelihood that things may get worse this year.

The lack of health insurance, a problem once confined mostly to the poor and nearly poor, has reached into the lower middle classes, most notably to those earning $25,000 to $49,999 a year, and even to some above $50,000. It is a problem that needs to be addressed by Congress and the administration, which have thus far sat mostly on the sidelines.

Several factors are driving the expanding crisis. The number of unemployed Americans keeps growing in this jobless recovery, thus depriving many people of the opportunity for employer-provided health insurance. Even many full-time workers ? an astonishing 20 million last year ? lack health coverage.

Many employers, both large and small, are cutting back on the health insurance they provide, either by dropping it entirely or by making it harder for employees to qualify. Some are requiring much higher contributions from workers, so many workers are dropping coverage rather than paying amounts they consider unaffordable.

Underlying the problem is the still-unsolved issue of escalating health care costs, which leave employers struggling to find a way out and individuals staggered by premium increases.

The NY Times takes the easy road - let big government provide a solution. As usual, those who favor big goverrment show little understanding of the crisis, they just want Congress to solve (put a bandaid on) the problem.

Health care costs may or may not be escalating out of proportion. We must relate cost to value. We need to understand where the money goes.

Health care costs increase for many reasons. Some costs increase because newer technology makes diagnosis more reliable. More reliable diagnoses allow us to better target therapies.

Some costs increase because new medications allow us to improve quality of life or even quantity of life. Some costs increase because patients demand more care. Some costs increase because the cost of doing business increases: government regulations always cost money, malpractice insurance costs, higher salaries for employees (supply and demand for nursing staff).

So the question we should ask as a society is what health care we want, and is it worth the money? Should we expect health care expenditures to increase or not? Can we develop more reasonable governmental regulations? Can we control liability costs?

Solving the health insurance problem should require a careful analysis of all costs. We should better understand why health care costs increase every year.

Unfortunately, I am skeptical that Congress will address this issue intelligently. They rarely show common sense when passing laws which have impact on health care. Why should we expect better now?

Besides Prescription Drugs

MEMBERS OF CONGRESS are pretending that the Medicare bill, currently bogged down in conference negotiations, is simply about prescription drugs. Not quite. Both House and Senate versions of the bill contain provisions designed to help particular companies and congressional districts, benefiting everyone from Weight Watchers International to marriage therapists to doctors in Alaska. The legislation also contains measures to shore up rural health care, adjust doctors' pay and patch up bits of the Medicare system that don't work. And it has new rules allowing the re-importation of prescription drugs from Canada and elsewhere. Some of these measures are justified, some not.

The most expensive provision in the House bill would create "health savings accounts" -- in effect, tax shelters. While it is a good idea, in principle, for people both to save for health care costs that health plans don't cover and to manage some of their health-care money themselves, this is an extremely expensive program. The cost to the budget is more than $170 billion over 10 years, which comes on top of the $400 billion that the bill is already going to cost -- and this at a time of soaring budget deficits. The creation of costly health savings accounts should be considered as part of a fundamental restructuring of health care, not tacked on as an afterthought.

Regular readers know that I favor health savings accounts. I would like to see a tighter linkage between the patient and health care cost decisions. While I have written often about this concept, Robert Prather - Insults Unpunished - has written even more often. For a feel for this issue check out - Health Care Costs Yet Again.

I believe that the Washington Post has this issue wrong. In the meantime, I do not expect any compromise on these issues. We will go another year with politicians dancing their dance. And our single payor system for the elderly gets more unfair to both patients and physicians.

Political Debate Looms Over Obesity

Even fat is the stuff of politics in Washington. And with obesity a growing health problem, lawmakers, lawyers and activists are lining up the way they do for most issues: on two sides.

The left's view is that the food industry and advertisers are big bullies that practically force-feed people with gimmicks and high-calorie treats. They say Ronald McDonald is the cousin of Joe Camel.

The right's argument has been dubbed: You're fat, your fault. They say people can make their own choices about food and exercise.

``I don't think people want to go back,'' says Tomas Philipson, a University of Chicago economist. ``They'd rather be fatter and richer.''

The debate has spilled over into public policy, with proposals for a junk-food tax, limits on food advertising, demands for more details on labeling and lawsuits against food manufacturers. Several states are considering limits on sweets sold in schools; Some are debating whether to force chain restaurants to list nutrition information on menus.

Sen. Mitch McConnell, R-Ky., recently introduced a bill that would prevent people from suing restaurants and food manufacturers for making them fat. Similar legislation has been introduced in the House.

The stakes are high. Some 300,000 Americans die prematurely each year from being overweight. It's the leading lifestyle-related cause of disease and death in the United States after smoking.

Apparently, the obesity lawsuits captured political attention. As a libertarian, I believe that each individual must take responsibility for his/her own actions. Thus, I cannot support suing over obesity. The article seems balanced and presents both sides.

Back from my beach hiatus, I browse the NY Times quickly and find! Congress Weighs Drug Comparisons

Over fierce resistance from the drug industry, Congress is moving to authorize research that systematically compares the effectiveness and cost of top-selling prescription drugs.

Proponents say that if Medicare is to spend $400 billion on new drug benefits over the next 10 years, it should have objective, reliable information about which medicines are most effective.

"Often there are a number of competing drugs to treat the same condition," said Senator Hillary Rodham Clinton, Democrat of New York, a leader of bipartisan efforts on the issue. "But which is more effective? Oftentimes we just do not know."

The House voted last month to provide $12 million to the Public Health Service to conduct "research on the comparative effectiveness" of prescription drugs. The money was in an appropriations bill for the fiscal year that will begin on Oct. 1.

Drug companies say they fear that such studies will be used to restrict patients' access to medicines perceived as too expensive. But supporters of the research say it will improve the quality of care. Doctors, patients and insurers need help in making informed choices, said Representative Doug Bereuter, Republican of Nebraska.

Representative Nancy L. Johnson, Republican of Connecticut, said the proposal was "absolutely key to reducing the cost of drugs."

"There are many expensive products on the market that are no better than aspirin," said Mrs. Johnson, the chairwoman of the Ways and Means Subcommittee on Health. "We need to be able to demonstrate that and provide senior citizens and all Americans with that information so they can choose the most cost-effective, medically effective pharmaceutical for their particular needs."

Researchers said they might address questions like these: How does Lipitor stack up against Zocor for lowering cholesterol? How does Prilosec compare with Protonix for ulcers and heartburn? How do the long-term effects of Vioxx and Celebrex compare with those of older drugs for arthritis, like Motrin and Naprosyn?

Mrs. Clinton and Representatives Tom Allen, Democrat of Maine, and Jo Ann Emerson, Republican of Missouri, have proposed spending $75 million on comparative studies by the National Institutes of Health and the federal Agency for Healthcare Research and Quality. The studies would focus on drugs widely used by Medicare and Medicaid beneficiaries.

Mr. Allen said, "Our proposal would ensure that doctors and patients have credible, unbiased information, as an antidote to the claims made in so many pharmaceutical TV commercials."

As expected, the pharmaceutical companies oppose this plan. Their rationale is incomprehensible.

With studies comparing various drugs, federal officials could make "simplistic, one-size-fits-all decisions about which patients should have access to new medicines," the industry said.

The Pharmaceutical Research and Manufacturers of America also made these arguments:

¶The federal studies would almost surely influence private insurers. "As a result, the government's cost-based decisions about medical access would be imposed on many patients in both public and private health plans."

¶Cost-effectiveness studies show which drug works best, on average, for large numbers of patients, but the studies often overlook the value of specific medicines for individuals or subgroups, like racial minorities. "Different people need different medicines" because they respond differently.

¶Federal studies could stymie "incremental innovation." The government often does not appreciate the value of the incremental benefits of a new drug over existing treatments, but a series of modest gains can produce a major improvement ? a much safer, more effective medicine.

Sometimes an idea makes great sense. This idea fits that category.

Medicare Robbery

But the conference now is faced with the need to square the square, keeping on board both Senate Democrats who want to spend even more money and House Republicans who want an even bigger role for the private sector. A few weeks ago, all players involved were talking optimistically of finishing the conference by the end of this month. Now some are talking about September -- or later. Myriad squabbles will doubtless break out over precise numbers, levels of benefit and how much cash should be spent to encourage private insurers, who, so far, have shown little interest in participating in any of the new roles the bill designs for them. Lobbyists have persuaded Congress to add on a wealth of provisions, benefiting groups ranging from rural ambulance services and Alaskan doctors to the weight-management industry. They will no doubt try to add more.

Yet behind the squabbles lurk deeper issues. Of these, perhaps the one that has received the most attention is Medicare's universality. Many Democrats and some Republicans consider this to be Medicare's central attraction. It is a program, they say, that gives the same benefits to everybody, rich or poor, and therefore receives universal political support. To preserve this universality, many are fighting against a provision in the House bill, for example, that calls for people with incomes above $60,000 to pay a larger share of their drug bills. They object on the grounds that nobody should be treated differently.

This kind of thinking helps to illustrate what has gone so deeply wrong with the bill, a piece of legislation that seems to be oblivious to its long-term consequences. In practice, the refusal to countenance any means-testing will set in motion a vast transfer of wealth, from the pockets of America's poorer children -- who will eventually be working adults -- to America's wealthier elderly. The desire to maintain political support for Medicare is understandable, but the zealous opposition to any reform that would provide fewer benefits for the rich is profoundly misplaced. It guarantees the swindling of a generation that cannot vote in order to benefit a wealthy constituency that can.

I agree with the Washington Post. I should not receive the same benefit as someone with little retirement income (I assume that my retirement savings will provide a better than average lifestyle). We should help the needy, but getting older does not necessarily imply neediness.

I would guess not. The current bills are huge, technical and significantly different. It appears that House Republicans and Senate Democrats are digging in their heels. Compromise Seen as Harder to Find on Medicare Drugs

Differences between the Senate and the House bills have become more apparent in the two weeks since the competing versions of the legislation were adopted. Now conservative House Republicans and Senate Democrats are issuing ultimatums, threatening to oppose the final legislation if it does not address their concerns.

...

Many Republicans say such competition is essential if Medicare's costs are to be brought under control. But Democrats say the competition and the higher premiums could be devastating to the oldest and sickest beneficiaries, who are most likely to stay with the traditional program.

...

The Senate and House bills have significant similarities, often overlooked in the debate over the most contentious provisions. Both bills are officially estimated to cost $400 billion over 10 years. Both rely on private insurance companies to deliver drug benefits under Medicare, starting in 2006. Both call for drug discount cards, to help the elderly in 2004 and 2005. And both increase Medicare payments to doctors and hospitals in rural areas.

Much of the recent maneuvering is simply an effort to lay down markers for the approaching negotiations. But nobody is sure how much is positioning and how much is nonnegotiable principle.

"The question is: what is the deal killer in the Senate, and what's the deal killer in the House?" said a House Republican strategist. "It's not clear what the walk-away point is for either side. It's just not clear."

I would like to see a good bill. But my limited observation does not suggest that either side has a good bill. I believe that an error of commission would harm us more than an error of omission. We do not need a bad bill. We have enough of those already.

I think the Democrats just get too much money from the trial lawyers. Short of Votes, Senate G.O.P. Still Pushes Malpractice Issue

A bill that would impose strict limits on jury awards in medical malpractice cases ? a central element of President Bush's plan to revamp tort law ? appears headed for defeat in the Senate. But the majority leader, Bill Frist, intends to introduce the measure on Monday anyway, forcing a vote that could be used against Democrats in the next election.

The bill, similar to one the House passed in March, would limit awards for pain and suffering to $250,000.

The bill has no Democratic sponsors, and Republican leaders, including Dr. Frist and Senator Mitch McConnell, the Republican whip who will manage the bill on the floor, concede they do not have the 60 votes needed to overcome a filibuster.

"It's going to be difficult," Mr. McConnell said.

A vote could occur as early as Wednesday. But proponents say that even if they lose, as expected, the issue is not dead for this Congress.

Instead, Dr. Frist, who has made malpractice changes a signature issue, hopes the vote will force lawmakers to take a stand. That would expose them to more pressure from lobbyists, and might yield a compromise later in the year.

So we have a national problem (admittedly worse in some states than others). We may have no acceptable solution. The politics are bothersome.

With medical liability premiums rising and some doctors leaving their practices as a result, proponents of malpractice changes say caps on jury awards are necessary.

Doctors, insurers and business groups, all of whom contribute substantially to Republicans, are lobbying heavily for the bill.

But opponents, mainly trial lawyers and consumer groups and the Democrats they support, say the bill, modeled after a California law, would deprive malpractice victims of their day in court without solving the insurance problem.

They say the $250,000 cap is too restrictive.

"We have tried during the first six months of the year to see if we can't build a bipartisan consensus on this, and thus far have been unsuccessful," said a spokesman for Senator Frist, Bob Stevenson. He added, "We view this as a long march, and this is the beginning of it."

That march may well extend until the next election, in 2004. Some Democrats ? who complained that Dr. Frist is circumventing Senate procedure by bringing the measure up for a vote before it has been considered in committee ? said he is using the vote to generate a political issue for Republicans.

Republicans made it clear that they intended to use the vote against Democrats.

"Women are having trouble finding obstetricians to be able to deliver their babies," said Senator John Ensign, Republican of Nevada, the chief sponsor of the measure.

"In states like Nevada, doctors are leaving in droves, and that kind of scenario is repeating itself over and over around the country," Mr. Ensign said. "As voters become aware of it, I think you're going to see the change of minds of senators who may now be against it. We bring it up for a vote now, and it may cost them in the next election."

Relief From High Drug Costs

Senate committees will take up two bills this week that could help many Americans cope with the ever-rising cost of prescription drugs. With both parties looking toward the 2004 elections, the chances are improving for useful drug legislation to be approved by Congress and signed into law by President Bush.

The most important bill, to be considered by the Senate Finance Committee, would add a prescription drug benefit to the Medicare program for elderly and disabled Americans. This is a badly needed benefit that would drag Medicare into the modern age by including drug coverage alongside the traditional hospital and medical coverage.

Some patients need a prescription drug benefit. We should take into consideration ability to pay. If not, any plan could have major financial implications on Medicare.

Congress continues to work on providing a prescription drug benefit. We all want such a benefit, but many worry that we cannot really afford that benefit. As usual Robert Prather has weighed in - There Ain't No Such Thing As A Free Lunch (TANSTAAFL). Now I know that TANSTAAFL comes from a science fiction book, written by Robert Heinlein. It should become a widely used phrase.

Robert Samuelson, who is always refreshingly honest, says flatly that a prescription drug benefit for Medicare is a bad idea. I agree. My solution, as I've said numerous times, is to provide Medical Savings Accounts (MSAs) coupled with catastrophic care insurance for hospitalization. The MSAs could be used to buy drugs, but would also cover doctor's visits, blood tests and the like. Insurance would only be used for emergencies, as it was originally intended.

Social Security has an unfunded liability of $8.7 trillion in 2002 dollars and Medicare has an unfunded liability of $5.9 trillion in 1999 dollars. Together they represent more than our annual GDP. Nothing less than radical reform of both systems is required or the burden placed on future workers will be crippling. Adding a prescription drug benefit will only add to an already tremendous problem.

The Republicans are being dishonest but are trying to add a cheap version of the drug benefit. The Democrats are being even more dishonest in saying they can provide universal care and the drug benefit and pay for it by simply repealing the Bush tax cuts. As Samuelson points out, the real cost of the drug benefit doesn't kick in until 2011 and the projections currently being used only account for two of those years. Nor does it include the inevitable increase in demand for prescription drugs because they will now be "free".

Read his full entry and especially the comments. Prather speaks logically - this means he is unelectable - but I admire his reasoning.

We have followed this story closely for several months. This link summarizes the final bill - $15 Billion AIDS Plan Wins Final Approval in Congress

Congress and the President are now focusing on a Medicare drug benefit. We should all view this debate cautiously. Pharmaceutical costs have a major impact on the sick. Without a drug benefit, only the wealthy can afford our many medication advances. We all agree that we would like to provide a benefit to all Medicare beneficiaries, however, we also must consider the fiscal viability of any such plan. Herein lies the debate, which the NY Times outlines well - Bush Drug Proposal in Medicare Plan Faces a Stiff Battle.

As Congress begins drafting Medicare legislation, one of the most contentious and politically explosive issues is whether the same drug benefits should be available to all.

The Bush administration and many of its allies on Capitol Hill say they want to use prescription drug benefits as an incentive to encourage older Americans to enroll in private health plans. People who stay with the traditional, government-run Medicare program would receive only modest drug benefits, while those who join private plans would be rewarded with much more extensive coverage.

White House officials and Republicans in Congress say the private plans would be more efficient than Medicare's lumbering bureaucracy. But the idea of using drug benefits to entice elderly people into those plans is in trouble on Capitol Hill.

Democrats are almost universally opposed to the effort, which they deride as a move to privatize Medicare. More ominous for the administration is the opposition of many Republicans, including several moderates who bucked the White House on tax cuts and several powerful lawmakers from rural states.

The debate is gaining urgency as Congress begins an intensive six-week drive to pass Medicare legislation, potentially one of the most significant domestic policy bills of the legislative session and one that is already behind schedule because of the struggle over tax cuts.

I personally am conflicted over this issue. Sorting out the pros and cons is, at least for me, dizzying. I do understand both sides of this issue, and can make a strong case either way. I could also attack each position.

The cost of prescription benefits will become staggering. How we pay for that benefit will, unfortunately, impact how we pay for the rest of health care. We should follow this debate and watch how the politics unfold. The process makes me uneasy.

Found this link thanks to Jane Galt - Asymmetrical Information. Premium Blend: Why is it so difficult to provide universal health care?

...the core economic issue: It's the rising cost of health care that has left some 41 million Americans without health insurance today. For the last 30 years, health-care costs have been rising 6 percent to 8 percent a year—more than double the inflation rate in the rest of the economy—because demand keeps outstripping supply. Moreover, the forces behind this exploding demand cannot easily be changed or affected. As people's real income rises, they expect more medical care; our society is aging, so people need more care; and with new technologies treating formerly intractable conditions, people want more care.

In practice, almost everyone, insured or not, has access to health care, especially in emergencies. Insurance affects how much people actually use health services: The access of the uninsured involves inconveniences and costs that encourage them to underconsume medical services, sometimes with grim results. By contrast, people with insurance often have such broad access that many overconsume those services. These consumption patterns drive the price increases that ultimately shrink insurance coverage. Still, it's hard to blame Gephardt or Dean for skipping past the cost issues, since every effort in the last 30 years to stem those costs—creating Medicare and Medicaid, wage and price controls, government threats of strict cost containment regulation, and the rapid spread of managed care—has failed. Anyway, who gets elected president by telling people that their health-care costs will soar so long as everybody has access to the most expensive forms of care?

The problem lies not in people's natural desire for the best (and most expensive) care, but in the way our health-care market operates—especially the weakness of the market forces that normally slow high inflation. That makes health care a prime example of what economists call "path dependency," where pivotal events from long ago shape a sector's development more than normal competitive forces. Health care's path began when employers in World War II, desperate to attract workers without breaching wage controls, first offered health insurance as an untaxed fringe benefit. This approach took strong root, because tax law requires that firms providing any tax-free form of compensation have to offer it to all their employees.

Over time, these beginnings brought most people into an insurance system that insulated them from the full cost of each treatment; they also left government as the insurer for everyone outside the work force, notably retirees and the poor. All insurance markets are subject to "moral hazard," where the small personal cost of using the insurance—a co-payment in this case—encourages people to overuse it for minor complaints. The hazard is intensified in the case of health care, because people don't pay for the insurance directly. To be sure, working people ultimately pay for their coverage in lower and slower-rising wages, but the cost of premiums is still subsidized by its tax-free treatment; and since employers write the checks for us, we don't even feel the pinch directly when premiums go up. (Imagine how much less coverage many would accept if we all had to write annual premium checks for $4,000 or $5,000.) These hazards are even greater in public-sector health care, where the retirees and poor people consuming most of the services don't bear most of the taxes financing them.

Individual costs are rising, but other forces continue to undercut greater price discipline. In most markets, for example, this discipline also depends on people having the information required to judge the value of goods or services before they buy them. In health-care markets, how many people have the information to say no to a more expensive test for diabetes or a treatment for a heart murmur? The norms of the medical profession are supposed to reduce this "agency" problem by aligning a doctor's incentives with a patient's medical interests (especially when the prospect of a malpractice suit reinforces these incentives). But there's no mechanism to align the financial interests of doctors and their patients. So doctors can deliver sound health services in ways that maximize their billings.

When prices rise unusually fast in other markets, people can usually find and substitute cheaper products: Beef prices rise and people eat more chicken, or a real-estate bubble drives up housing prices and people downsize their residential ambitions. That doesn't work nearly as well in health care, when patients are told that the alternative to a costly test or procedure is poor health or even premature death.

Finally, health-care inflation suffers from a classic "free rider" problem. Everyone has a common interest in moderating demand if it will ensure continuing coverage. But no one has an incentive to take the step alone, so no one does.

I hope you read those paragraphs carefully. Shapiro has summarized the dilemma of health care costs beautifully!!

He offers a modest solution, but admits that it is unlikely to work. As long as we have no connection between health care costs and personal expenditures, we likely will have no major health care reform.

Economists cannot tell us how much health care we need . Rather, as a society we determine how much health care we want . Unfortunately, our desires have no relation to what we would spend. The current system has no balances. Universal health care would not improve that problem, it would only shift the locus of control. One need only look to Canada and Great Britain (amongst many) to understand the types of health care cost decisions made in a single payor system.

Our health care insurance system is broken. Perhaps we could look at ways to improve that system, and in some way link behaviors with costs (e.g., smokers and the obese would pay higher insurance) and expenditures with graduated co-pays. Only when each individual starts to understand costs will market forces apply. Without the power of market forces, I suspect that we will be continuing this debate for many years.

Like Jane Galt, I am working through my thoughts on the Democratic health care proposals. In the meantime, read these two posts from her site - HillaryCare, Part II. In this post, she challenges readers

But here's the thing: I'm unaware of any situation in which sick children go without seeing a doctor simply because their parents can't afford it. Poor people have Medicare. Less poor, uninsured people have free clinics, out-of-pocket payments, or the emergency room. The only situation in which I can see this occurring -- that a child goes without a doctor simply for lack of health insurance, rather than because of other parental dysfunction -- is one in which a lower-middle-class family cares more about their credit rating than their child. In other words, it seems vanishingly unlikely.

But perhaps I'm wrong. Can anyone produce evidence -- not anecdotal, "my cousin says. . . ", but real data consisting either of peer-reviewed studies not funded by single-payer advocates, or of personal experience in which you, or a member of your immediate family, did not take a sick child in need of medical attention to the doctor because of the expense? Children with the flu, or other non-fatal maladies for which the only treatment is rest and liquids, do not count. Perhaps in some theoretical medical textbook world, they should see a doctor to ensure that it's nothing serious -- but my mother didn't take us to the doctor for those things, and we had perfectly good health insurance. The pain-in-the-ass factor is too difficult to separate from the expense factor in mild illnesses, so please -- only serious cases.

So Jane instead gets an email example which proves her point. Wow. I just got this amazing response to my post on Dean's health care rhetoric: The response is heartwrenching and finishes with this quote

I don't know if anything I've written above might be of use to you in your coming "pungent words". I have to admit, writing this was at least 20% therapy for me (I've wanted to say these things for some time now - your post just opened the door). But I have a very compelling reason for opposing anything resembling HillaryCare.

I've been through the worst case scenario most HillaryCare advocates like to use as a rhetorical bludgeoning tool - and it convinced me just how wrong they are.

I have been planning to rant about universal health care. As I have been thinking through this issue, I am attracted to this piece by Thomas Sowell. I will quote liberally, because the link is not permanent! "Universal health care"

If there was one defining moment in the debates among an already crowded field of Democrats seeking their party's presidential nomination in 2004, it may well have been when Congressman Dennis Kucinich, pushing for government-provided health care, spoke with obvious disgust of the "profits" of the insurance companies and provoked a burst of spontaneous applause from like-minded members of the audience.

Insurance companies, like every other kind of institution, have to earn money in order to keep functioning. So does every individual who was not born rich. But some people react to the word "profit" with automatic responses, like Pavlov's dog.

While I often have problems with the insurance companies, I do not resent them making a profit. Rather I resent the tactics they use to make those profits.

But, just as there are still pockets of resistance in Iraq and Afghanistan, so there are still holdouts like Congressman Kucinich and like-minded Democrats. Socialism has been discredited as an explicitly avowed belief but it still lives on in a thousand disguises, of which "universal health care" is just one.

Like so many pretty words used in politics, "universal health care" is seldom examined in terms of what its actual track record has been in the countries where it has been tried.

Probably the first country to have universal health care provided by the government was the Soviet Union. After decades of socialized medicine, what was the end result? In its last years, the Soviet Union was one of the few countries in the world with a declining life span and a rising rate of infant mortality.

But that terrible word "profit" had been banished and apparently that is what matters to the true believers.

Not all countries that tried socialized medicine went as far as the Soviet Union. But there has been a whole pattern of problems common to government-controlled medical care systems, whether in China, Britain, Canada or elsewhere. And none of the anti-profit zealots want to talk about any of those problems.

None of those who wants us to move in the direction of Canada on health care ever faces the question: Why do so many Canadians come to the United States for medical treatment and so few Americans go to Canada?

Could it be that we should look at what actually works, rather than what sounds good? Nor should we be overly impressed by words that sound bad, like "uninsured Americans." The bottom line is medical care, not insurance. People without insurance are treated at hospitals all across America every day.

Before we even consider throwing away what works in favor of something that has failed repeatedly, we need to stop reacting to words and start looking at facts. Socialism by any other name is still socialism -- whether it is advocated by shrill zealots like Kucinich or by other Democrats whose words are smoother.

While I will take issue with some of Sowell's arguments, he generally does understand. Our current system is flawed - a problem which I plan to address later this week. Meanwhile, please share your thoughts on this piece.

House Adopts Global Plan of $15 Billion Against AIDS

The House adopted a $15 billion initiative to combat AIDS worldwide today. The vote was taken after conservatives won a requirement that at least one-third of the money promote sexual abstinence before marriage.

The concession helped solidify support for a measure for AIDS treatment, research and education that is a priority of the Bush administration, and it resulted in a strong bipartisan vote in support of a social measure in the usually polarized House. The vote was 375 to 41.

...

Advocates welcomed the vote and said the abstinence language would not pose a serious problem. One advocate said the important development was that Republicans were voting for a measure to endorse condom distribution while Democrats backed abstinence programs.

"That is a pretty good start," he said.

Indeed it is!!!

Now it become official. We (the medical blogger community) have been discussing the health care crisis for many months. Today the NY Times declares it so! Health Care Limps Up Political Ladder

They (and the Democrats) rarely look at the true underpinnings of this crisis. We need solutions which diagnose the disease, not those which try to treat the symptoms.

Now it become official. We (the medical blogger community) have been discussing the health care crisis for many months. Today the NY Times declares it so! Health Care Limps Up Political Ladder

They (and the Democrats) rarely look at the true underpinnings of this crisis. We need solutions which diagnose the disease, not those which try to treat the symptoms.

Consistent readers understand that I approach most issues from a libertarian viewpoint. You are entitled to great freedom, but the freedom of your fist ends at my nose. I argue, often without much success, that our war on drugs creates many more problems than it possibly prevents. While I understand the ravages of drugs on our youth and also many adults, the costs of the drug war (not monetary costs, but criminalization of large sectors of society, murders, robbery, etc.) far exceed the costs that would associate with decriminalization. As always, one must choose which costs are worse, costs of omission or costs of commission. We know the costs of the drug war.

This commentary does an elegant job of summarizing the problem. The war on drugs

Prominent drug legalizers or decriminalizers read like a who's who of conservatives: William F. Buckley Jr., Milton Friedman, New Mexico Governor Gary Johnson, Ronald Reagan's Secretary of State George Shultz.

Mr. Shultz, now at the Hoover Institution with Mr. Friedman, is but a recent convert. In 1984, he sang a different tune, declaring: "Drug abuse is not only a top priority for this Administration's domestic policy, it is a top priority in our foreign policy as well."

The background for the Shultz conversion is well-demonstrated in "Bad Neighbor Policy" by Cato Vice President for Defense and Foreign Policy Studies Ted Galen Carpenter, who dwells here on the more than 30 years since President Nixon declared a War on Drugs. Mr. Carpenter tweaks the title of his timely and instructive book in a play on Franklin D. Roosevelt's Good Neighbor Policy for Latin America in the 1930s, as he documents multiple U.S. sins south of the border and comments on our stepped-up war on drugs:

"U.S. officials have bribed, cajoled, and coerced Latin American governments to try to stem the outflow of illegal drugs. The result has been a rising tide of corruption and violence in those countries and a growing dissatisfaction on the part of affected populations with their own governments ? and with the United States. Washington's hemispheric war on drugs is the epitome of Bad Neighbor Policy."

We need rationale in this discussion, but I fear we will only get emotion. Some drugs are deadly, but the drug trade itself is - I believe - more deadly. We need enlightenment here. I doubt that we will get that enlightenment.

Medicare Drug Benefit Plan Is Proposed by 2 Democrats. I have previously ranted that we really cannot afford to provide a complete drug benefit for all Medicare aged patients. Finally, some Democrats agree.

In a break with party leaders, centrist Democrats proposed today that Medicare provide drug benefits immediately to people who have low incomes or high prescription drug expenses.

Members of both parties said Congress could eventually embrace such a plan if lawmakers could not agree on more ambitious proposals to pay drug costs for all Medicare beneficiaries, regardless of income.

The new proposal was offered by Representatives Cal Dooley of California and Rahm Emanuel of Illinois, with support from 16 other House members who call themselves New Democrats.

"Our proposal is fiscally and politically realistic," said Mr. Dooley, a House member for 12 years. It would, he said, provide drug benefits to people with the greatest financial needs.

Mr. Emanuel, a freshman who worked in the Clinton White House, said the proposal provided "a solid foundation on which Congress can build."

Howard J. Bedlin, vice president of the National Council on the Aging, a research and advocacy group, said, "This is not the ultimate solution, but it would be a good start, a potential compromise, that could attract bipartisan support if we find there's not enough money to provide more comprehensive drug benefits."

Under the proposal, Medicare would pay 80 percent of the cost of each prescription after a beneficiary had incurred $4,000 of drug costs in a year.

The $4,000 deductible would not apply to elderly people with incomes less than twice the poverty level. For the poorest among these, the federal government would pay at least 80 percent of their drug costs, and the federal share would decline as a person's income rose toward 200 percent of poverty. The poverty level for a couple is $12,120 this year.

This proposal has the advantage of making sense. We should strive to help those who clearly need governmental help. A $4,000 deductible makes more sense for those with adequate incomes.

This blog will remain 99% medicine. However, I must comment on Daniel Patrick Moynihan.

I generally vote Republican. My political philosophy is best described as Libertarian domestically and neo-conservative internationally. (see Robert Prather to better understand this - Neocons Vs. Paleocons.

Regardless of ones political inclinations, Daniel Patrick Moynihan should represent the ideal in politics. He based his stands on principle and intelligence. Even when one disagreed with him, one had to reconsider ones own position, because he was so damn smart. Read this outstanding tribute from George Will - A Beautiful Mind. Oh, but that we could have the Congress full of his like!

Now official, we will receive a slight increase for each patient visit in 2003. Physicians win Medicare payment relief: With an increase secured for 2003, the AMA will focus on preventing a cut next year.

Physician groups already have begun a push to modify the way payment updates are calculated each year. Sara Walker, MD, president of the American College of Physicians--American Society of Internal Medicine, said additional changes in Medicare policy would be needed for payments to keep pace with increases in practice expenses.

"We look forward to working with the Centers for Medicare & Medicaid Services on implementing the beneficial changes approved by Congress, as well as other changes in Medicare payment policies that may be required," Dr. Walker said. "The goal must be to assure that Medicare patients have continued access to physician services by guaranteeing that Medicare payments will keep pace with the rising costs of delivering care."

Physician groups have urged CMS to exclude the cost of outpatient prescription drugs and clinical laboratory tests covered by Medicare from its calculation of the spending targets for physician services. Physicians argue that they have no control over the price of those drugs and should not be penalized for the rampant inflation in drug costs in recent years.

So this story will continue, but today's chapter has a decent ending.