I am with Cassandra on this; if after 8 months in office, the administration still doesn't know why we are in Afghanistan (ie, they have not determined what our goals are from which strategy and tactics should follow) then I would be extremely disturbed to see American men and women remaining at risk without the most strenuous support by their Commander-in-Chief.
Last month a friend who owns a small business confided that his sales were down ~10% but his company is still making a profit because he has cut expenses by 25%. One area cut was instructive. The company's unit in California had 40 employees. The cost of their workman's comp was 3 times more than the total cost of workman's comp for the 115 employees in New York. He closed the California unit, moving 40 workers to the unemployment line and costing California 40 productive tax payers.
A woman who has visited Paris regularly for the last 30 years was astounded at how expensive it has gotten. A continental breakfast of coffee, toast, and a Danish cost $30!
I have spoken to a fair number of people in the last weeks, most of whom are liberals; I have yet to meet someone who thinks the Healthcare reform ideas being bandied about by Congress having anything to commend them.
One particular emphasis of Obamacare that is worth comment. He has made the point that 25% of health care costs derive from treatments in the last year of life. As Richard Fernandez notes, "hopeless" diagnoses are often incorrect and the existence of a "death pathway" under the aegis of the NIH in Britain creates pressure for a self-fulfilling prophecy to increase death rates. During my Medical School training I spent a day at a Hospice Care facility which primarily offered palliation and comfort to terminally ill cancer patients. The Physician who led us on rounds mentioned in passing that almost 10% of their patients actually survived hospice care and went home because they had been misdiagnosed and did not in fact have terminal cancer! Predicting when a patient is gong to succumb and determining when their quality of life has become so eroded that death has become welcome is not a decision I want the government to make for me or my patients. And the idea that most patients do not discuss their treatment options in the last year(s) of their life is simply inaccurate. The problem, from the point of view of Obamacare, is that most people insist on trying all (or almost all) available treatments before accepting that they have passed beyond the possibilities of modern medicine and coming to terms with their impending demise.
One more health care fiction worth reconsidering; from Jonathan Gruber in the Boston Globe comes this old chestnut:
In fact, both sides in this debate need each other. Liberals are right that fundamental cost control can only come from the supply side. Consumers are poor and ineffective shoppers in the medical arena. Ultimately, they will do what their doctors tell them to do. So only by providing the proper incentives for providers can we truly control costs.
Arnold Kling nails one side of this meme:
Needlessly to say, I take strong exception to Gruber's "poor and ineffective shoppers" allegation. Instead I would describe consumers as embedded in an institutional environment that takes away their motivation to compare costs with benefits.
Once upon a time in a galaxy far, far away, patients were passive consumers of health care. They went to their Doctor with a problem and were instructed from on high in a treatment. Patients can still find themselves passive recipients of health care in urgent or emergency situations, however, there is no excuse for patients taking a passive position in re: their chronic or routine health care. We have been told for the last 40 years that patients are no longer subordinate to their Doctors and that medical decisions are collaborative efforts. Patients are expected to get second opinions (and can easily obtain third opinions while educating themselves via the internet.) When I prescribe a treatment course or medication for a patient I offer them various options and explain why I think one option is preferable to another; the cost of the treatment should be simply one data point they need to consider when determining whether or not they wish to accept my recommendation. The idea that patients do not have the autonomy, wisdom, or knowledge to determine their own choices is nonsense. If patients remain "poor and ineffective shoppers in the medical arena", it is their responsibility; certainly the existence of a multi-billion dollar industry in alternative Medicine suggests that a great many Americans, when motivated, do not consider themselves poor and ineffective shoppers in the medical arena."
And just for the record, medical care is not a right. No one has the "right" to my services without my consent.
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