SCOTUS’ Revolution

Okay, here is something different from me. I am writing a book, “The 100 Year Quest,” about how the Progressive Movement has been trying to get its hands on health care for the past century. To get from 100 years ago to today, we have to understand how FDR’s Supreme Court changed the Constitution so that it would be unrecognizable to the people who wrote it. It took them only seven years, from 1937 to 1944. What follows is the chapter dealing with what they did.

It is longer than my usual posts, but you may find it useful.



SCOTUS’ Revolution

From time to time some of us wonder how we got here. We hear quaint expressions like “Freedom of Contract” and ask, whatever happened to that? How is it that two people are no longer allowed to enter into an enforceable contract without running afoul of some governmental restriction?

A recent example is that I can no longer agree to a contract with a health insurance company that does not cover contraceptives. Why? If I and an insurance company are both willing to sign such a contract, how is it that the government says we cannot?

This and many, many more restrictions on freedom came about during a seven-year (1937-1944) reign of terror by FDR’s Supreme Court that shredded all traditional understandings of the Constitution’s limits on federal power. It began with Social Security, went on to eliminate Freedom of Contract, expand the Commerce Clause, and redefine the meaning of insurance, all in the service of the Progressive movement to put an elite bureaucracy in charge of all economic activity in the United States

Social Security. The first and most important decision was affirming the Constitutionality of the Social Security Act. At the time it was enacted it was no sure thing that the Supreme Court would uphold it. It was unprecedented for the federal government to provide such a sweeping social safety net, and several of the key New Deal programs had been thrown out, including the Railroad Retirement Act in 1935, the National Industrial Recovery Act, also in 1935, and the Agricultural Adjustment Act in 1936.

The reversals frustrated President Roosevelt to the point that in 1937 he proposed legislation allowing him to appoint additional judges to all federal courts when there were sitting judges over the age of 70 who refused to retire. This move was widely seen as a political blunder and a power grab at the time, but the mere threat of such legislation served to intimidate judges, including the Supreme Court, into being more accommodating to New Deal Programs. Most notable was Justice Owen Roberts who switched from opposing most New Deal legislation to supporting the programs in the course of a single year. His change of heart was characterized as “the switch in time that saved nine.”

The issues involved in the decision were profound. As Larry Dewitt, historian for the Social Security Administration, wrote in 1999, “The basic problem is that under the ‘reserve clause’ of the Constitution (the 10th Amendment) powers not specifically granted to the federal government are reserved for the States or the people…. Obviously, the Constitution did not specifically mention the operation of a social insurance system as a power granted to the federal government.” The authors of the bill opted to dodge this issue by relying on Congress’ power to tax on one hand and to spend money to “provide for the general welfare” on the other. The authors went so far as to write separate titles keeping the raising of revenue and the spending of money apart, as if they had nothing to do with each other.

The Court eventually accepted this reasoning in Helvering v. Davis (1937), but its decision makes it clear that it did so as a political pretext to address what it called a “nation-wide calamity that began in 1929.” Indeed, the whole episode illustrates the use of political hysteria to achieve a reordering of American society, as in — “never let a crisis go to waste.”

This reordering is reflected in President Roosevelt’s statement, “We put those payroll contributions there so as to give the contributors a legal, moral, and political right to collect their pensions and unemployment benefits. With those taxes in there, no damn politicians can ever scrap my social security program.”

This statement has all the veracity of “if you like your health plan, you can keep your health plan.” Michael Tanner, writing in 1998,  noted that the Helvering v. Davis decision stated that Social Security was not a contributory insurance program. It wrote, “The proceeds of both the employee and employer tax are to be paid into the Treasury like any other revenue generally, and are not earmarked in any way.” Tanner adds, “(I)n the 1960 case of Fleming v. Nestor, the U.S. Supreme Court ruled that workers have no legally binding contractual rights to their Social Security benefits, and that those benefits can be cut or even eliminated at any time.”

The other curious thing about this episode is that the Court accepted that under its “general taxing power” Congress could institute an entirely new form of taxation – the payroll tax. Just a few years earlier, in 1913, the nation thought it was necessary to adopt an amendment to the Constitution (the 16th) to impose an income tax. Apparently the new thinking was that such an effort was too cumbersome for enlightened Progressivism to bother with.

The Social Security decision was only the first of a flood of Supreme Court decisions in the short seven-year span of 1937 to 1944 that would completely reorder American society and the Constitution itself. The current devotion to the principle of stare decisis is often cited by today’s Progressives to protect these decisions, while such devotion would have been denounced as reactionary in 1937. Some of the other revolutionary decisions from this era included:

Elimination of Freedom of Contract. Article 1, Section 10 of the Constitution states, “No State shall… pass any Bill of Attainder, ex post facto Law, or Law impairing the Obligation of Contracts….” The courts have never found this to be an unlimited right of contract, but there was an ongoing dispute over when a state’s policing power could override the due process clause of the Fourteenth Amendment in regulating contracts. Law professor David E. Bernstein writes that in the late 19th and early 20th Centuries “The Supreme Court gradually accepted the notion that liberty of contract was an enforceable constitutional right under the due process clause.” Progressivism and the rash of labor law regulations in the 20th Century eroded this protection. Bernstein writes “By 1934, a majority had formed willing to broadly expand the ‘affected with a public interest’ doctrine to the point where just about any regulation of prices was constitutional.” After 1937, the Roosevelt Court eliminated virtually any limitation on the government’s power to violate contracts.

Interstate Commerce. Article 1, Section 8 of the Constitution reads, “The Congress shall have the power… to regulate Commerce with foreign Nations, and among the several States, and with the Indian tribes.” It would seem this applies to goods and services passing between jurisdictions, not within the jurisdiction. But the Roosevelt Court decided otherwise.

The most famous, and outlandish, case here was Wickard v. Filburn, decided unanimously in 1942. In this case, an Ohio farmer who was growing wheat for his own consumption exceeded the quota set by the Agricultural Adjustment Act of 1938. Filburn argued that Congress had no jurisdiction over what he did on his own farm, since his wheat never left his farm and was not used in “commerce.”  The Court reasoned that by growing his own wheat, Filburn was failing to buy wheat that might have been sold across state lines, so his activity affected interstate commerce, and could so be regulated.

While this case is the one most often cited, it is far from the only decision between 1937 and 1942 to expand the concept of what can be regulated by the federal government under the Commerce Clause. Writing in the Marquette Law Review in 1945, Joseph Ziino provides quite a laundry list, including –

  • NLRB v. Jones & Laughlin Steel Corp (1937). A company not engaged in interstate commerce was found in violation of the National Labor Relations Act because “the local business of the corporation substantially affected interstate commerce.”
  • Santa Cruz Fruit Packing Co. v. NLRB (1937). While 37% of its products were intended for interstate commerce, the products had not yet been actually shipped. The Court ruled that the Feds could regulate them well before the commerce actually took place.
  • Sunshine Anthracite Coal v. Adking (1941). The federal government could regulate the price of coal that was not sold across state lines because the price in one state affected the prices in other states.
  • Mulford v. Smith (1939). A tax was applied to tobacco that exceeded the production quotas. “Congress may tax any activity to promote and foster commerce.”
  • United States v. Darby (1941). Congress could regulate the wages, hours and working conditions of workers in a local lumber mill because the products might be shipped in interstate commerce.

Insurance as Commerce. For most of American history insurance wasn’t considered “commerce” at all, let alone interstate commerce. Commerce was defined as the buying and selling of goods by merchants, according to David Kopel and Rob Nateson in the National Law Journal. This understanding was the basis for a Supreme Court ruling in Paul v. Virginia in 1869, and was repeatedly affirmed over the years. But this understanding was turned on its head in a narrow four to three ruling in 1944 in United States v. South-Eastern Underwriters Association. The case ruled that the Sherman Anti-Trust Act applied to the insurance industry and that fire insurance companies were subject to Federal regulation under the Commerce Clause.

Chief Justice Stone wrote a strongly dissenting opinion that relied on the traditional understanding of the word “commerce” and argued that Congress was well aware of this understanding when it passed the Sherman Act, so did not intend for it to cover the insurance industry. Plus, he argued, the states are well equipped to regulate insurance, while the federal government has no such experience or expertise. The ruling, he said, would “loosen a flood of litigation” and cause great disruption in an otherwise stable industry.

Congress largely agreed with the Chief Justice and immediately (on January 25, 1945) enacted the McCarran-Ferguson Act to return to the states the sole power to regulate and tax the insurance business.

Still, the precedent had been set, and this one ruling empowered Congress to directly regulate insurance whenever it chose. It has frequently made use of the power in the years since.

This series of cases set the stage for an entirely new American governance having little to do with the system established by the Founders. It was a revolution as profound as that of 1776, only no one sets off fireworks to commemorate the occasion.

Consumers in Charge

PricewaterhouseCoopers has issued a report on a survey conducted by its “Strategy&” subsidiary (formerly Booz and Company). The survey of over 2,300 U.S. residents is a hearty endorsement of consumer empowerment, so much so that the report’s first paragraph states –

“There’s a new boss in U.S. healthcare: the survey of 2,339 U.S. residents by Strategy&. The research paints a clear picture of a population displeased with its overall healthcare experience — and with rising expectations for transparency, value, and customer service, as well as a willingness to seek healthcare services from less traditional sources. The healthcare market as we know it is being upended, and the consumer is in the driver’s seat.”

The report has a lot of lessons for the next phase of health reform efforts. In particular –

People like shopping on Exchanges. They like private exchanges better than public ones – 73% said they are likely to stay with the coverage they selected on a private exchange, vs. 57% who said the same about a public exchange. Of course, staying with your current coverage may not be a good thing if the cost changes substantially, as seem to be happening on the public exchanges. While the bureaucrats are encouraging people to look around for the best deal each year, they seem to ignore the real problems with doing so – changing insurance plans every year is extremely disruptive to families and continuity of care. Under Obamacare, it means learning all over again what benefits are covered, what providers are included, what drugs are covered, how to file a claim, how to appeal a denial, how to locate customer service, and so on.

People are ready to try non-traditional sources of care. The report says –

“Consumers, particularly younger ones, increasingly expect healthcare to work the way other digital markets work, with user-friendly interfaces, clearly options designed to meet their needs. Their other buying experiences have made them more savvy and skeptical, and they want to know what they’re getting before they spend.”

Health care services are woefully behind in the transition to digital. While 80% of consumers said they would like digital services to help manage their care, only 23% said they currently have that.

The report also suggests that non-traditional providers such as retail firms like Target and tech firms like Google and Amazon have the potential to take “significant market share” as “consumers associate them with efficient, effective, and delightful customer experience.

Age cohorts make a big difference. Obviously younger people are more comfortable with a digital world than older people are, but the differences go well beyond that –

 “Half of those younger than 25 would go to a shiny new hospital for care as opposed to an older, drab one, even if the new one was scored lower in national rankings; only 16 percent of those older than 65 felt the same way. In attitudes toward telemedicine, the generational divide is just as wide: More than four in five respondents younger than 35 said they embraced care provided via virtual marketplaces, whereas 47 percent of senior citizens “hate” the idea.”

More important for Obamacare, younger people consider “price to be paramount in their decision-making..” while the elderly are “largely unmoved by price variations…” This suggests Congress made a very big error in limiting age differentials in premium pricing and getting the young to subsidize the elderly – the older people don’t care that much about price, but the younger ones care a whole lot.

Overall this report is just another rock on a growing mountain of evidence that Americans are no longer content to be passive recipients of whatever the health care establishment wants to do for (or to) them. They want to be in control of their health care as they are in every other aspect of their lives.

Price Transparency Works

The Journal of the American Medical Association (JAMA) has just published a new study on the ability of price transparency to lower costs.

The study, by Christopher Whaley et. al., was very large, involving over 500,000 individuals in 253,000 households. They were covered by 18 large self-insured employers, which adopted the Castlight Health price transparency platform sometime between 2010 and 2013. The employers represented a wide range of industries and offered a variety of health benefit designs. Every state in the country was represented.

The population was split into two groups – those who searched the Castlight platform prior to getting services, and those who did not. Each searcher could get estimates of personalized out-of-pocket costs based in their own plan design. They could also get non-price information such as provider qualifications and patient satisfaction ratings. The services studied were limited to three frequent but elective categories – lab tests, advanced imaging (MRIs and CT scans), and clinician office visits. The two populations groups could be compared both before and after the Castlight platform became available to them.

The results were interesting.

Before either group had access to the price transparency platform, the study group (those who eventually became searchers) had higher costs than the control group in two categories – 4.11% higher for lab tests, 5.57% higher for imaging, but 0.26% lower for office visits.

After the search tool became available, the study group’s costs went down – 16.93% lower than the control group for lab tests, 14.97% lower for imaging, and 0.76% lower for office visits. These are for situations where the patient had cost sharing responsibilities. When there was no cost sharing, the results were 14.13% lower for labs, 13.63% lower for imaging, and 2.26% lower for office visits.

Looking at both the before and after comparisons, the savings were significant — in the 20% range for labs and imaging, but not as much for office visits.

The study authors did not look at other metrics, such as health outcomes or patient satisfaction. But they did test for selection. The two groups were nearly identical in age, gender, health condition and use of services. The control group had slightly higher household incomes than the study group ($75,233 vs. $73,149) and somewhat higher medical spending ($559 vs. $495) in the year prior to access to the search program.

These are not “set the world on fire” results but they are significant. They illustrate that, given the tools and the incentives, health care consumers will indeed shop around for value, which means not just price but also quality and convenience. Importantly, the search for value seems to continue even when the financial incentive is taken away. The authors write –

“We also demonstrated that payments for claims, even without cost sharing, were lower for those who searched than for those who did not. This result may be in part due to inertia because clinician choices when employees must pay a deductible might persist even after they have reached the deductible and have little or no cost sharing.”

In other words, economizing behaviors continue even after the cost sharing is ended. This helps answer one of the objections critics have made about Health Savings Accounts. They have stipulated that having a high deductible may lower spending, but once the deductible has been met, they say, people will go wild consuming care that is suddenly free to them. That sounds plausible, and even I have been puzzled that HSA programs seem to save money across the board, not just on the lower cost services. Apparently thrifty habits persist.

Now, of course, our friend Uwe Reinhardt weighs in with a one-page commentary in the same issue of JAMA. Uwe is losing his touch. He starts right out with –

“Citizens in most economically developed nations have health insurance coverage that results in only modest cost sharing at the time health care is used. Furthermore, physicians, hospitals, and other clinicians and entities that provide health care within most systems outside the United States are paid on common fee schedules uniformly applied to all clinicians, health care organizations, and insurers.”

Of course, according to OECD, the United States has one of the lowest rates of OOP payment in the industrialized world (see chart below).  And I am astonished to learn that Uwe is now a fan of fee-for-service payment. So am I. It will be nice to have an ally in academia. He goes on to complain of “cost shifting” by employers, but as an economist he surely knows there is no cost shifting, or more accurately all health care spending is already cost-shifted. Every penny the employer spends on health care is a penny taken out of wages. Employers concern themselves only with total compensation – the more they spend on paying for health services, the less they have to spend on take home pay.

OECD OOP cropped

But the most important error he makes is supposing that health care consumers need to have price transparency before they are allowed to control their own funds. That is exactly wrong. The reason we don’t have price transparency is because of third party payment. Consumers don’t know what things cost and don’t care because they are not paying the bill directly. The only way transparency will ever happen is when consumers demand it, and they won’t demand it until they control the money.

Meanwhile, the evidence is piling up that when people can control their own funds they do a very good job of using the money wisely – far better than any third party payer has done in the past fifty years.

Another Side of Atul Gawande

I’ve been pretty hard on Dr. Atul Gawande over the years.

During the Obamacare deliberations he wrote an article in the New Yorker about McAllen, Texas  that became mandatory reading in the White House. It purported to show that for some unexplained reason McAllen had much higher costs than other locations in the United States. This was evidence, the White House said, that physicians are greedy and need to be controlled by bureaucrats. It was a poorly researched article that relied solely on Medicare data and failed to account for unique conditions in that city. As it turned out, when you include non-elderly spending, McAllen isn’t particularly costly and the area has an extreme shortage of physicians, so people tend to go to the emergency room instead.

A few years later he wrote another article in the New Yorker about how marvelously efficient the Cheesecake factory is, and bemoaning that American hospitals can’t do likewise. I posted some comments about how mistaken the analogy is on the NCPA Blog.

So I was prepared for the worst when I sat down to read his latest, an excerpt from his new book published in Slate. It was about end-of-life care, and after Zeke Emanuel’s writing about his determination to die at age 75, I expected to read more about how old folks aren’t worth spending a lot of money on.

In fact, the article is a moving and sympathetic telling of the case of one woman with metastatic ovarian cancer. She is a wonderful, cheerful 72-year old lady with profound problems. Gawande has many treatment options available to him, and he works with her to find the best match of what he can do with her own priorities – fears, hopes, level of comfort.

There are no sweeping generalities, no implicit policy prescriptions, no judgments about her. It is a love story between a caring physician and his patient. She is depicted as a whole person whose emotions are far more important than lab tests. I urge you to read the article for an example of medicine at its best.

This isn’t the first time I’ve encountered this phenomenon – a doctor who is wonderful with his patients who goes completely off the rails when it comes to public policy. Don Berwick is another. As I wrote in another NCPA post about a speech he gave at a graduation ceremony at Yale Medical School —

“Here is a lovely and loving man, someone who treasures the dignity of the people he cares for, who recognizes and honors their humanity and their sovereignty. How could this man be the same one who, as CMS Administrator, advocated locking physicians into an “evidence-based medicine” regimen that treats patients like mere statistics and confines personal knowledge of them to variables of age, race, and gender (like the Dartmouth Atlas does)? How could he push for the adoption of a program that assigns patients to an Accountable Care Organization without their knowledge or consent?”

I’ve written also about Berwick’s fine little book, “Escape Fire”  and been just as puzzled. For example, he writes –

“Interactions … begin with this assumption: The patient is the source of all control. We act only when the patient grants that privilege, each time.

“Control begins in the hands of the people we serve. If we caregivers wish to take it, we must ask. If a patient denies control, then we must accept their will as a matter of right. We are not hosts in our organizations so much as we are guests in our patients’ lives.”

These physicians are at their absolute best when they are dealing with actual patients. They are the epitome of health “care.” But once they sit down to write policy, they turn from Dr. Jekyll to Mr. Hyde. Which reminds me, one again, that for all the talk of Accountable Care Organizations, Bundled Payments, Interoperable Health Records, and Population Health Management, the essential, irreplaceable transaction in medicine is between one doctor and one patient. Nothing else comes close.

Michael Cannon’s Large HSA Proposal

My flippant answer to the problems in health care has always been “give us back our money and get the hell out of the way.” The point is that the supposed expert managers (employers, insurers, government agencies) we have hired to run things for us have completely botched the job and should all be fired. After all, every penny that is spent on health care comes from us and it is all supposed to be spent for our benefit.

But, other than expanding HSAs I haven’t had any real idea on how to make that happen. Somehow I missed a long-standing proposal by Cato’s Michael Cannon for “Large HSAs.” I just recently came across a paper Cannon had published in 2008 that pretty thoroughly explains the idea.

The policy proposal is really pretty simple –

  • Increase HSA contribution limits to $8,000 per individual or $16,000 per family.
  • These contributions would replace the current exclusion for employer-sponsored health insurance, and (like the exclusion) would be free of both payroll and income taxes
  • Remove the requirement that HSAs be tied to a high deductible health plan – or any kind of insurance.
  • Allow HSA funds to be used to buy any kind of health insurance from any source, as well as pay directly for services.

The rest of the paper walks through the consequences of these policy changes – how employers and employees (and the unemployed) would likely react to the new conditions and the effects these behavioral changes would have on health care spending and availability. It also considers the political reactions.

Cannon supposes that most employers would use the money currently spent on benefits to raise workers’ wages, but the employee could then direct that money to be deposited into her HSA up to the limit. The employee could then buy coverage either from her employer or on the open market, or she could save the money to pay directly for care, or use some combination of coverage and cash according to her own preference.

Cannon makes the point that not all workers want high deductible health plans, some still prefer HMOS or first dollar coverage. So employers who institute HSA programs under current rules are disadvantaging those employees. The Large HSA would enable even these workers to buy the coverage that works best for them.

I would add a point I have made here repeatedly – that some not-small portion of the population is unable to cope with insurance of any kind. They can’t read or understand the contracts, they may have poor impulse control so find it difficult to make and keep appointments weeks in the future, and so on. For this reason I have favored John Goodman’s universal tax credit idea that would be paid to safety-net providers for those people who do not buy insurance. Cannon’s Large HSA proposal addresses this problem even better – it would enable this population to show up at a clinic when they have a medical need and pay for the service when they consume it.

Cannon also makes the important point that sharing risks between people is not the only form of “pooling” available. It is also possible to “pool” over time – so that the young healthy Greg Scandlen saves money to pay the expenses of the old decrepit Greg Scandlen many years later. HSAs facilitate this kind of pooling.

I’m not going to go into all of the discussions the paper explores here. Cannon considers the varying effects on lower versus higher wage workers, considers the issue of indexing the contribution amount, looks at the possible effects on medical costs, and so on.

He is not proposing this as a panacea for everything in health care. He doesn’t address Medicaid or Medicare, for example. The focus is more on creating a more equitable market for working people.

But this is a serious, innovative idea that deserves more attention than it got when it was first published.


Want to Make a Difference?

By Greg Scandlen

Like you, I have been watching the events unfolding in Madison, Wisconsin with alarm. The thuggish tactics of the union supporters and the Democrat Senators are appalling. Never mind elections, who can yell the loudest?

That isn’t supposed to be how it works in this Republic. This isn’t Greece.  Here you are supposed to make your case to the voters. If you lose, come back in the next election and try again. That’s what the Republicans did with ObamaCare.

Now it is spreading to Ohio and Indiana, and if the unions win, it will become standard operating procedure across the country.

It all underscores how critical the states are to the future of this country. Much of this gets lost in the 24-hour news cycle that focuses much more on Washington and can’t even find Frankfurt, Kentucky on a map – at least not until it blows up. I have a much harder time finding out what is happening in Harrisburg than in Washington.

We have to change that. One of the best ways I know is by getting involved in your local free market think tank.  These folks are making a huge difference around the country. They do the research and present the case to their own legislators about policies that work by empowering citizens.

They deal with a wide variety of issues in addition to health care – school choice, taxes, environment, criminal justice, transportation – pretty much everything a state or local government does. That means the people who run them are spread pretty thin.  They may be expert in a single area, or they may be general economists or political activists. Rarely do they come from the business community, or have hands-on expertise in a field like health care.

You can help. Obviously, donating money to them is always welcome, but offering your own expertise is every bit as important. They need knowledgeable people to help write papers and op-eds, to make presentations at meeting, to testify before the legislature. Even just giving them encouragement can be helpful when the chips are down.

You can find the think tanks in your area by going to the web site of the State Policy Network. They maintain a directory of every free market think tank in America and they provide resources to help the local groups get stronger and better.

Your participation has never been more important.

Vermont to go Single Payer?

By John McClaughry of Vermont’s Ethan Allen Institute

Dr. William Hsaio of the Harvard School of Public Health has just delivered his long awaited recommendations for installing a single payer health care system in Vermont.

Newly elected Democratic Gov. Peter Shumlin has enthusiastically supported single payer and welcomed the Hsaio report. He has hired Anya Rader Wallack, the architect of Gov. Howard Dean’s 1994 health care collapse, to head his “dream team” of health care wizards to implement some form of Hsaio’s recommendations. The Senate is 22-8 Democratic and the House is 102-48 Democrat + Progressive.

At last the great moment has come when, in Hsaio’s words, “Vermont can show the way forward [sic] for the rest of the United States.”

So far as I know there is no indigenous organized opposition to the Shumlin-Hsaio
program. With a Governor and large legislative majorities eager to vote Yes on a package of their own design, every affected group has little choice but to try to cut their own best deal – or, in some cases, begin retirement or relocation planning.

Since Gov. Howard Dean drove out the insurance carriers in 1992 (community rating, guaranteed issue), Blue Cross/Blue Shield of Vermont, the principal beneficiary of that legislation, is the only remaining small group and non group carrier. It is also a ward of the state, and surely sees its future role as administering the Hsaio-Shumlin single payer plan.

The Vermont Congressional delegation – all enthusiastic supporters – held a news conference to announce they would see to it that Vermont gets a waiver from Obamacare to allow it to impose this system ASAP, instead of waiting until 2017 as required by PPACA.

What would help us most is a concise, pungent critique of Hsaio’s report (especially Option 3, the “public/private partnership single payer plan”) by some respected analyst with a PhD in health care economics.

I have the capacity to present a critique of it, but do not have the academic credentials to get serious attention. Furthermore, EAI has long been viewed (and denounced) here as anachronistically committed to right wing free market gospel, and thus irrelevant. (“Freedom? You think that will work?”)

EAI can not identify any 501c4 or business groups who might form a Citizens Committee to Save Our Health Care. EAI does not lobby legislators, other than to put policy briefs in their mail boxes.

I put all this to you so that you will understand that the socialist health care aliens have landed here in Vermont, co-opted the brains of the indigenous inhabitants, and injected a large dose of dangerous spores into the Petri dish. If enacted here, this infection will be heading your way soon.

Your help would be appreciated – even just publicizing this infection.

Krauthammer is Wrong

By Greg Scandlen

A few weeks ago Charles Krauthammer made a splash on Fox News by advising Republicans not to defund ObamaCare. He said:

“I am skeptical about taking away the funds because what it will do, it will poke holes in the system. It will make it more chaotic. It will allow some things to be enacted, others to be more slowly or clumsily enacted. In the end, if healthcare collapses or if it becomes utterly unworkable, the Democrats will have a way of saying ‘well, it was all these injuries inflicted by the Republicans that made it not work.”

But like a lot of political commentators, Mr. Krauthammer is focused entirely on the political shenanigans in Washington. He seems unaware that all across America an awful lot of people are investing a lot of money on what they see as the new opportunities presented by ObamaCare.

Politico reports that on the other side of the continent, in San Francisco, thousands of investors are placing bets on the idea that ObamaCare will be implemented pretty much the way it is. In an article headlined, “Investors See Health Law’s Potential,” they report:

As Republicans push forward on repealing health reform, planning the law’s demise, a different conversation is happening among thousands of health care investors gathered in San Francisco for this week’s J.P Morgan Health Care Conference: how to capitalize on health reform’s new business opportunities.

One example is Aetna, that is salivating over all the new business coming to it in the Exchanges:

Aetna is exploring how to capitalize on the individual market, expected to boom in 2014 when Americans must purchase health insurance or pay a fine. “We have major efforts underway to strategize on how to take advantage of those opportunities,” said the insurer’s CFO, Joseph M. Zubretsky, in a presentation to health investors. “We’re clearly understanding the risks…but with millions coming on to the health exchanges, one needs to not only balance risk but really understand the opportunity for growth that exists in this market place.”

Another is Molina Healthcare that sees major profits in Medicaid expansion:

Molina Healthcare, a company that has a large book of business in Medicaid, listed the millions of Americans who will become newly-eligible for Medicaid as a “health reform growth opportunity” in an investor presentation.

Add to that the millions of dollars being spent by employers, hospitals, drug companies, and physician practices on software up-grades, consulting and legal fees, and conferences to learn how to comply with the new requirements, and we are building an enormous infrastructure of businesses that are quite literally invested in this new law.

Once up and running, these interests will not want to throw away the effort. Even if they opposed the bill originally, they will soon become the biggest defenders of it.

That is why it is absolutely critical that implementation be slowed down in any way possible and as soon as possible. These companies need to understand that it is premature to invest a lot of money in this monstrosity. They need to hedge their bets and wait for the dust to settle. Talking about what we might do in 2013 will not cut it. We have to show them today that ObamaCare is on the ropes.

The Real Tucson Story

By Greg Scandlen

Dr. Robert Sewell writes a blog post that puts all of the craven political opportunists to shame. Of all the lessons from this tragedy, the least important is the political one. Far more important is the miraculous response of the medical team to an overwhelming crisis. Only, it wasn’t a “miracle.” It was the result of extremely well trained and dedicated personnel at the hospital trauma center. Dr. Sewell writes:

It’s truly remarkable how a civilian hospital and the personnel who work there were capable of shifting gears, becoming a major disaster management center in just a matter of minutes. It’s my understanding that 10 separate gunshot victims arrived at the University Medical Center, and all but one of them survived. The lone exception was nine-year-old Christina Green who had been shot in the chest. Regrettably, nothing could be done to reverse the mortal wound she suffered. As for the others, including representative Giffords, they were quickly and expertly transported into operating rooms where life-saving care was administered.

And he concludes:

Over the last several years the national discussion surrounding health care in the United States has consistently pointed to various statistics suggesting that we have less than quality care at a higher price than elsewhere in the world. Personally I reject that notion and would point to the events of January 8, 2011, in Tucson, Arizona as proof of the exceptional standards of American medicine.

Sure, we could spend less money on health care. Are we quite sure we want to live (or not) with the consequences?

The Holes in our Safety Net

By Marcy Zwelling-Aamot, MD FACEP

I don’t know Congresswoman Giffords or Judge Roll.  Nor am I familiar with any of the other Arizonians who had their lives seized from them when a crazy person shot up the Safeway in Arizona.  That said, I am sickened by the shooting and like others I can’t help but wonder how this can happen.  How did this man get a gun when he was already known to the police in the area? If his gun was purchased legally, shouldn’t that information have been made available to the police when he was arrested?

The media has already started the spin.  Depending on the bias, this tragedy is the result of the argumentative nature of politics today or it is the result of liberal gun laws.

But, as a doctor, I want to know how someone with obvious mental illness escaped the system.  I want to know how it is that society can’t separate the mentally ill from a gun. Where were this man’s parents? His friends? Where were the counselors at the community college where he was dismissed? He was known to the police, albeit for “misdemeanors,” but the police knew he was a problem, and there should have been a means of getting that information into a data base so that 1) he could not get a gun and 2) he was able to get the help he needed.

The purpose of government is to provide a safety net to provide for the welfare and security of the public.  Where was the safety net?  Have we become so politically correct and so insulated from the world, that we let those in need escape the help they need?

The nation is arguing about Obamacare.  Admittedly, I have also been vocal about repealing the legislation because I don’t think it does a thing to help the health of this nation.  It surely doesn’t do a thing for the mentally ill. And I don’t think that Obamacare helps us become more responsible about helping our fellow man or more accountable about our own health.

The stimulus package was responsible for putting billions of dollars into the economy by mandating the electronic health record.  Doctors are mandated to spend tens of thousands of dollars in hardware and thousands in software in order to provide the government with our patient’s most private medical information.  But, the government can’t seem to share information about felons to keep the mentally ill from owning guns.  Shouldn’t this be a part of homeland security?  Perhaps we could divert some of those funds allotted to the additional agents needed for pat-downs at airports to a system where we could improve communication with our law enforcement facilities, our doctors, and our social service systems.

Does it make sense that the government would know this killer’s cholesterol but they can’t protect the public from the ravages of his mental illness? Does it make sense that a doctor is mandated to report the results of his colonoscopy but there is no means to communicate with law enforcement about the risks of gun ownership?

I, like most of America, am frustrated by the argumentative behavior of Congress and the president.  And I have yet to see a productive debate about how we really might utilize our “security net” to protect Americans and that includes an erudite discussion about the health care delivery system’s flaws and proven solutions that might really work.

I would suggest that the lesson we learn from this tragedy is the lesson that the government would do well to concentrate on the business of protecting the public rather than devising a means to invade the sanctum of the patient-doctor relationship.  When Congress gets down to repealing (or not) Obamacare and legislating workable solutions, they should remember that their job is to protect the public pure and simple and they should start with devising systems that secure our safety rather than systems that invade our privacy.