Pew Research Center:  The Big Questions

 Do Obama’s failures outweigh his accomplishments?  And who will prevail  on health reform -    Republicans,  Democrats, or Independents,   millennial voters  (18-34 year olds) or perennial voters (those above 35)?

I awoke this morning asking these questions,  in the wake of  Supreme Court Justice Antonin Scalia’s death and the impending battle to  nominate this successor?

For guidance, I turned to the Pew Research Center, who has conducted two major sets on polls on these matters:   “Overwhelming Share of Republicans Say Obama’s Failures Outweigh His Achievements” and “A Deep Dive into Party Affiliation.”

On January 21, 2016, Pew Addressed the failures versus achievements issue.

Overall, among the general populace,  39% said the failures outweighed the benefits while 61% said the opposite along party lines.

Among Republicans and Democrats it was lopsided.

Republicans,   5%, 88%

Democrats,  74%, 19%

Independents,  36%,  52%

I am assuming these same percentages  apply to health reform.  Keep in mind, however, that 39% of Americans now say they are independent while 32% declare themselves Democrats compared to 23% avowed Republicans.   This is largest percent of independents since Gallup began polling on the issue.

Which brings me to the millenials, aged 18 to 34, the largest demographic segment at 25% of the population.  

Who will they vote?  Well, according to an April 17, 2015 Pew Report,  “A Deep Dive into Political Affiliation,”  51% of the Millenials  are Democrats and 35% Republicans.      And,  in separate polls,  in keeping with the revolution against the Washington establishment,  46% of  illenials ways they will vote for Bernie Sanders while 35% will opt for Trump.

To me these percentages all come down to time-worn political issues:  the idealism of youth vs. the realism of the seasoned,  the upper classes vs the lower classes,   the affluent vs. the working and poorer classes,   the inequalities of capitalistic blessings vs. the miseries of socialistic economic stagnation. 

Will voters choose to follow the America model of  egalitarianism, liberty, or individualism , or the European model  of equality for all, to-down  control,  and collectivism?

The jury is still out.  But according to Charles Murray of the American Enterprise Institute,  the American model not longer holds the  upper classes,  who look with condescension at those below them,  and this in the working classes who look with contempt at those above them.  Where the millienials fit into this growing gap may determine the next election and the future of health reform.

Electronic Health Records Marriage Vows May End in Divorce

I’ve been thinking  of electronic health records  and their mating with physicians  compared to  the Catholic marriage vows,  which  I have taken and which, as you know,  go like this, “” to have and to hold, from his day forward, for better, for worse, for richer, or poorer, in sickness and health, until death does us part.”

The U.S. health system has imposed a  similar marriage vow  between physicians and the Internet.   The vow aims to improve the system in sickness and health, until  death does  the physicians and the Internet  part. 

This is inevitable,  as Alfred Chandler, Jr. (1918-2007),  Professor of History at Harvard Business School and Johns Hopkins University,  observed,  “All I know is that the Internet will transform the world.”   And indeed it has.  

But as a latter day historian of the Internet,   Silicon Valley-based   Andrew Keen, expresses in his 2015 book  The Internet Is Not the Answer (Atlantic Monthly, 2713, 2015),  the Internet may not be the key to a successful digital marriage.    A reviewer of the book says “It  is a packed compendium of the ways digital life casts aside basic human virtues in favor of a rapacious winner-take-all economy.” (Michael Harris,  “Book Review, Washington Post, January 2, 2015).

The physician-computer marriage, like most marriages, may end in divorce.    This is what  is occurring with the marriage of electronic health records with physicians.  The two are proving to be incompatible.   EHRs,  physicians in the main agree,  distract from patient care,    are clinically dysfunctional ,   create  unnecessary overhead expense , and do not improve quality of care.   EMRs, to use Health Information Technology lingo, are not  “meaningful”,   which is why, in the face of massive physician protests, that CMS has abandoned its “Meaningful” EHR stage 2 and 3 programs.

In the Medinnovation and health reform blog, I have written over 50 blog posts questioning the value of EHRs.    Here are 7 of them, which you may read by going to Medinnovation and Health blog post,  and typing in the title in the search box.

·         “Limits of Technology – A Data-Doubting, Technologically -Incorrect Tale”,  September 17. 2007

·         “Mandatory Electronic  Health Records – The Right Thing to Do?”,  November 15, 2007

 

·         “Electronic Medical Records – The EMR Funk,” March 31, 2008

 

·         “Data Use and Misuse – Contrawise, Confessions of a Data Contrarian,” August 6. 2008

·         “Unnatural Human Communication – The Main Barrier to Electronic Medical Records,"
April 27. 2010

 

·         “Meaningful Use – Clinically Useful or Bureaucratic Boilerplate, “ July 24. 2010

 

·         “The EMR Absurdity,” December 29, 2015
 

Sometimes, even in the face of most noble and well-intentioned of vows, divorces ensue  after a trial run, in this case a 7 year marriage initiated by a $30 billion 2009 Health Information Technology  Stimulus designed to improve health care and advance reform.

Standardization of American Health Care: The View from Boston

Michael Porter, PhD, MBA, of Harvard Business School, Stefan Larsson, MD, PhD, of the Boston Consulting Group. And Thomas Lee, MD of the Harvard Business School, all in Boston,  writing in the New England Journal of Medicine,  also in Boston,  proclaim  in the Journal,  that “The arc of history is increasingly clear  health care shifting from the volume of services delivered to the value created for patients, with “value” defined as the outcome achieved relative to costs, (“Standardizing Patient Outcomes Measurement,” NEJM,  February 11, 2015­.

The authors assure us that “..the feasibility of outcomes measurement is now clear, and broad adoption of the standard sets is beginning.”   They have a table showing that for standard sets of measurements have already been achieved 10 conditions in 2013,  7 more were completed in 2015,  8  done in 2014 await final approval , and 15 are under consideration for 2016 and beyond,  which together will cover about 45% if disease burdens in the U.S. and other advanced countries.

The authors complain that previous work on standardization has been slowed  “dramatically” by different approaches by various organizations, by teaks of existing measures and risk factors, and by sensitivities to physicians concerns.

I am aware Boston is full of advocates for measuring outcomes through use of EHR data and  that it  runs to brains behind the Obamacare  to standardize care,  and somehow, given enough data on mortality, and patient-reported and clinician reported health status,  that  it can  standardize  and systematize care for all patients and all physicians so that one-size-fits- all treatments can be achieved across the population and so that one can achieve the maximum outcomes for the minimal cost.

“Universal measurement and reporting of outcomes won’t happen  overnight,” say the Bostonians, “ But we believe that agreeing upon and implementing respected standard sets of outcome for each medical condition is a practical and decisive step in accelerating value improvement in health care.”

Put me down as dubious.  Information technologies have their limits, and that,  I believe, is the situation  here.   Human beings and their illnesses are too variable  to be reduced to optimal standardized outcomes.

Two  Health Care Alternatives

What’s the alternative?  That’s the perpetual question asked when faced with difficult questions.

After writing over 4000 blogs and six books on health reform over the last 10 years,  I have come to the following conclusion.

There are two alternatives.  Why don’t we stick with both? Progressives could keep their piece of the health care cake, while conservatives could retain their slice.

·         Top-Down Government-Driven  Care

One is top-down government care as exemplified in Medicare and Medicaid.    These two programs now cover 125 million Americans (55 million in Medicare, and 70 million in Medicaid), and they are certain to grow as our population ages and if our economic growth remains stagnant.   I would  not include the PPACA (Patient Protection and Affordability Care Act), or ObamaCare,  in this alternative, because it has neither protected the majority of Americans nor made their care more affordable.   The PPACA, however,  has lowered the uninsured rate to 9.1%. That’s  a good thing.   Medicare and Medicaid has done well  for  the old and low-income  income patients,  have been established for 50 years, and are politically popular  and impossible to end.  Let’s keep them largely intact. My only suggestion for maintaining their sustainability  is that we edge up entry into Medicare by 2 years or so, and hand over Medicaid management to the states, each  of which has a unique set of problems. 

·         Bottom-Up  Market-Driven Care

Here  I suggest a new program. We could call it  FMCACA (Free Market Choice and Affordability Care Act).    It is based on the philosophy of Milton Friedman (1912-2006), who explained, “So that the record of history is absolutely clear.  That there is no alternative way, so far discovered, of improving the lot of ordinary people that can hold a candle  to the productive activities that are unleashed in a free enterprise society.”   This Act would free people to choose what manner of care they desire.   It would consist of these components:  larger risk pools to help lower premiums,  freedom of choice of doctors and health plans, health savings accounts expansion,  universal health care tax credits, portability of plans across states, state flexibility in managing Medicaid populations,  tort reform to lower malpractice expenses,  and less bureaucratic intervention into doctor-patient relationships.    This act would  stand in contrast to top-down government elitist  policies, which advocate,  fixed global payment rates,   control of population health through data monitoring,   alternatives to fee-for-service payments, competitive bidding for all services, centrally controlled, health  exchanges,  one size-fits-all administrative structures for all providers,  full transparency of prices, more care by non-physicians, banning of physician self-referrals,  reducing costs of defensive medicine.     These policies would continue to apply to the Medicare and Medicaid populations.  Unfortunately,  the policies would accelerate physician shortages and limit patient choices and freedoms.

Conclusion

Given these two alternatives, which they will pursue anyway,  Americans should be free to partake in the  most affordable and convenient care, whether that care be centrally planned or  market-driven.

To Conserve, As in Conservatism

To keep from loss, decay, waste, or injury; preserve.

Definition, To Conserve

 I view the word conservative as a derivative of the word conserve. We want to converse our money. We want to conserve our wealth. We want to conserve. We want to be smart. We want to be smart where we go, where we spend, how we spend. We want to conserve our country. We want to save our country. And we have people that have no idea how to do that and they are not doing it, and it’s a very important word and it’s something I believe in very, very strongly.

Donald Trump,  GOP Debate, February 6, 2015

Donald Trump  made a good point in last night’s GOP debate when he traced the derivation of  the noun “conservatism” to  the verb “ to conserve.”

Cast in this derivative light, “conservatism” has merits.

Its aim is “to conserve” what’s good about America and what contributes to its strength as a nation.

Conserving America is best achieved  by conserving.

·          Reliance on  truths of the Constitution with its emphasis and Checks and Balances of three branches of government with freedom of choice and liberty for all. 

·          Preservation  of traditional American values – self-responsibility,  marriage and family,   religious faith, and government for the people, for the people, and by the people. 

·         Equal opportunity for all, as opposed to equal outcomes for all. 

·         The power  of free market enterprise from the bottom-up  rather than on federal coercions  and regulations from the top-down.

 

·         The elixir of economic growth as the best means of lifting the most people up and relieving poverty for most, while providing for those truly in need.

·         The freedoms to speak one’s mind with straight talk, unvarnished truths, without undue concern about political correctness, of fear of offending someone,  somewhere, somehow.

Opioid  and Heroin Addictions and Deaths a Major Political Issue in New Hampshire

What’s the number 1 political issue in New Hampshire  prior to to the February 8 primary elections? 

It’s  the exploding number of deaths from opioid and heroin overdoses.  This year these deaths are on track to exceed 400.  In Manchester, the state’s largest city at 110,000, there have been 700 overdose calls and 85 deaths.  On Manchester restaurant  has called authorities to report 134 customers suffering from overdoses.

Why is New Hampshire the epicenter of narcotic deaths?  No one seems to know.   New Hampshire is a relatively affluent state with a predominantly white population.  Most of the death have occurred in young white men.  Does New Hampshire  have a high number of dealers?  Does the small size of the state make distribution easier?   Most people seem to agree the low cost of oxycontin , priced at $90 to $100 per 30 mg pillm  may contribute?   The increasingly lower price of heroin, coupled with its increased purity and its being cut with the analgesic  Fentangl  may be a factor.

Most politicians agree the solutions  to the growing problem, which  has doubled in scope in the last year,   resides in better treatment facilities and identifying dealers.   Doctors are on the alert and are lessening the number of opioid prescriptions for pain.  But the problem is mainly on the streets,  not from doctor prescriptions,  and from the low costs and high potency  of these drugs.     And there is now no doubt that opioid use often leads to heroin addiction (Wilson Compton, MD,  “Nonmedical Prescription  Opioid s and Heroin Use, “ NEJM, January 14, 2016).