Wednesday, September 23, 2009

One Size Does Not Fit All

Today I spoke about my book Obama, Doctors, and Health Reform before a local Rotary club. Here is the gist of what I said.

The book is civil. It is respectful but skeptical of Obamacare because of four obstacles: our culture, the complexity of our system, its costs, and adverse consequences of reform.

As I noted in my book, American culture distrusts government, wants prompt access to the best technologies, and believes in equal opportunity but not equal results; our complex employer-based system has been evolving for 65 years and is a whirling Rubik’s Cube with millions of fast-moving, interchangeable parts, and special interests; costs always exceed projections because cost is no object when it comes to people’s health; and any top-down government entitlement program has adverse consequences, such as fraud, abuse, and overuse.

President Obama has another problem. He must promote, explain, and glorify a plan that does not exist. It is a work in progress. He is betting that if he talks about the plan enough, the public will believe it must be true. This does not seem to be working. Today’s NBC Wall Street Journal poll indicates only 39% approve of Obama’s handling of health care.

The book predicts Obama will get 1/3 of what he wants. It ends with a toast to his ambitions and a prayer for his safety. It may be, like Julius Caesar, Obama will bestride the political landscape like a colossus. I doubt this. He is a center-left president trying to govern a center-right country, and that limits his reach.
Our health system’s root problem, as a Minneapolis heart transplant surgeon explained to me, is: “Dick, I’ve never met a patient who didn’t want to live another day.” People know we have the technologies to make this possible. It is politically difficult to dash these expectations.

Title and Which Hunt

My title for today’s talk is “One Size Does Not Fit All.” My message is: Obamacare, conceived of as a homogeneous. standardized, universal care program, the same in all regions of the country, is destined to fail.

We are simply a country which is too diverse, which distrusts big Government, which cherishes individualism, which wants prompt access to the latest in medical technologies, which prefers to make their own health care decisions. This is the culture of our country, and therefore you might call this little talk “A Which Hunt.”


In preparing for this talk, I ran across a little book, The Sir Winston Method: The Five Secrets of Speaking the Language of Leadership.(William Morrow, Inc, 1991)
Sir Winston’s Formula was:

I Strong Beginning

II One Theme

III. Simple Language

IV. Pictures

V. Emotional Ending

Strong Beginning

Sir Winston’s advice is: never, never, never “open” with “It’s a Pleasure” or a Bad Joke. Too prosaic and too inane he says.

Instead, pick out someone in the audience you admire and talk about them. I admire Bill Suits. Everything he represents, if you’ll pardon an obvious pun, suits me just fine. He has shown great courage in fighting Parkinson’s disease. He loves this Rotary Club, and he loves nothing more than telling you a good joke or an entertaining story. You’re a central part of his life.

I know. He drops by my condo at Banbury Crossing every week to tell me about your good work across this community. He tries out his jokes for you on me. We talk about his Parkinson’s disease. As a member of the Medical Advisory Board of America’s Top Doctors, I once even referred him to a neurologist at Massachusetts General Hospital.

We talk politics. To this day, I do not know if he is a Republican or Democrats. He blasts them all, shows no mercy, takes no prisoners. No politician fits into Bill’s suitscase.

Bill shares with me the secrets of Real Estate, e.g. “Get or Buy a lot while you’re young” or “Old Realtors never die, they just give up their lease.”
Bill tolerates me, I think, because I laugh at his jokes and tell him a few of my own.

Please join me in giving a hand to Bill and his long and loyal service to this club.
Bill has asked me to address these questions: what does health reform, Obama-style, mean to the average American – probably higher taxes and more burearacy. To the young and middle-aged uninsured , an individual mandate would mean you will be obligated to pay $1000 for yourself and $3800 for your insuracne’ for the old it will mean some form of rationing.

Let’s look briefly at the neighboring state of Massachusetts – which enacted Obama-like reforms 3 years ago According to an April 27, 2009 Cato Institute Report, “Massachusetts-Like Reforms Increase Costs and Waiting Times,” in that span the number of uninsured have dropped from 8% to 3% at these costs - a 46% faster rate of costs compared to the national average, increased waiting times – 7 weeks compared to other parts of the country, increased costs to the state of $88 million a year, and voters saying the following - reduced quality by 3:1, less affordable care by 27% to 21%, and 37% to 26% saying reform has been a failure. Finally, state officials are recommended fee-for-service be eliminated and care be rationed by paying for episodes of care on a budget.

One Theme

The central theme of my book is: no size fits all in our individualistic American society. Medicine is practiced in different ways across this vast land.
I came here from Oklahoma, which is just to the right of Atilla the Hun and cowboy entrepreneurship is the order of the day. There I started a health care newspaper, founded an organization called the National Physician Hospital Organizations, and developed a computer algorithm to measure the health of Oklahoma state employees.

Before that I was in Minnesota for 25 years, where the average sized group is 150 doctors, and the Mayo Clinic reigns supreme. There I served at editor-in-chief of the state medical journal for 15 years and came to know the Minnesota Way of medical practice – Consensus Medicine with constant access to coordinated care. It is sound approach, and I endorse it.

Now I am in Connecticut, where the average group has 3 to 4 doctors, and Yankee privacy and Yankee ingenuity are greatly admired. I remember an ad of about 20 years ago, which read, “What weighs 3 pounds and wakes up at 6AM?” The answer was: The Yankee Brain.

Based on these regional experiences, I do not believe you can standardize and homogenize medical practice into integrated groups following rigid protocols, practicing strictly scientifically-based medicine, and being directed and judged by computer algorithms devised by geeks bearing formulas.

The aim may to limit treatment to the “best practices,” but there is a hooker. Patients rarely feel they are overtreated, and lawyers agree with them. Think of a 4year old child who falls and hurts his head and is a little woozy. Science-based medicine says this child should not get a CT scan. The parents and the suit-conscious ER doctor will think differently.

Nor do I think the Dartmouth approach, advocated by Peter Orzag, Obama’s budget chief. of forcing the high spending Medicare cities, such as Los Angeles, spend the same amount of money as the low spending cities, such as Rochester, Minnesota, will work because of profound socioeconomic differences and costs of doing business. Poor, sick uninsured Hispanics who have delayed treatment simply cost more than uninsured Scandanavian-Americans who have taken care of themselves.

Nor do I foresee using statistical averages, assembled by some Comparative Effectiveness Institute, to dictate what tests to order or what procedures to do in every doctor-patient encounter.

Simple Language

Churchill said, “Short words are best and the old words when short are best of all.” In short, prefer the Anglo-Saxon to the Latin, the active to the passive, the direct to the indirect, the concrete to the abstract, common language to the grammatical correct.

Once, after he spoke, a nit-picking bureaucrat confronted Churchill and pontificated, “Prime Minister, I was shocked in your speech you actually ended a sentence with a proposition.” Churchill replied, “This is pedantic nonsense .. up with which .. I shall not put.”

When it comes to health reform, remember that the only tools available to Government to reduce costs are: one, paying doctors and hospitals less, rationing, and imprecise language. Government tends to express itself in indirect and euphemistic language, sometimes referred to as jargon, unsustainable growth rates for going broke; pay for performance, value, and outcomes as a means of telling doctors what to do; and as far as rationing goes , comparative effectiveness and coordinated, integrated, and bundled care, or QALY for quality of life years left to indicated what procedures can or should be done for a person of your age.

In Britain, the NHS has a department called NICE (National Institute for Comparative Effectiveness). NICE’s job is to deny paying for treatments that cost too much and have a low QALY. Needless to say, cancer patients who need some high-end drug for a potential cure don’t find NICE to be very nice.


Churchill loved memorable visual images, particularly of animals of make his point. He called Hitler a viper, a snake, a guttersnipe, a crocodile, a hyena. He said the dictator who rides the tiger dare not dismount, for the tigers are getting hungry. When told his fly was open, Churchill said, “ Never fear. Dead birds do not drop out of their nests.”

In health reform, we have another set of animal images – Blue Dogs for moderate or conservative Democrats who fear the electorate will turn them out in November 2010; RHINOs (for Republicans in Name Only), Elephants who suffer from bureaucratic elephantiasis; Donkeys who turn into stubborn mules capable of only saying “No,”, Bearish Bears, who never saw a stimulus package they didn’t like, and Angry Bulls, like Rep Wilson of South Carolina, who carry their china closets with them.
If you like animal metaphors, here’s a dozey from Senator Judd Gregg (R) of New Hampshire, “A public plan is essentially a stalking-horse for a single payer plan. It is more than a camel’s nose under the tent. It is the camel’s neck, and probably front legs, under the tent. There is no way the private sector can compete.”
Here is another, from Thomas Sowell. Of the Hoover Institute,

A dog with a bone in his mouth looked into the water and saw his reflection. He thought it was another dog with a bone in his mouth-- and the other dog's bone looked bigger than his. He decided that he was going to take the other dog's bone away and opened his mouth to attack. His own bone fell into the water and was lost.
Today the President of the United States is telling us that he will take that other dog's bone away.. He will take the bone away from doctors, hospitals, pharmaceutical and insurance companies, and most of us will end up with worse medical care than we have available today. We will have opened our mouth and dropped a very big bone into the water.

An animal that works as a metaphor for Obamacare is the python, an enormous snake that either crushes its prey or swallows them whole. Th python has an enormous appetite and can swallow whole industries, like automobiles, energy, and education, or health care industries whole- crushing each before swallowing.
The Obamacare python prefers whole industries to satisfy its appetite. With health care, the python already has Medicare, Medicaid, and the VA in its gut, 100 million Americans in all, but it is hungry for more. The next big gulp may be the 78 million baby boomers who will qualify for Medicare in 2011. A smaller bite will be Medicare Advantage plans, which cover 22% of the Medicare population. After that, using the Public Option, as its bait, he may be able to gulp down up to 111 million more now in private plans.

Emotional Ending

Up until now, emotions have been on side of liberal Democrats, who are full of self-righteous, and sometimes justifiable, indignation about the cruelties of capitalism and patients falling through the payment cracks. Democrats have a moral cause, universal care for all in the name of fairness. They have harbored this concept for nearly 100 years. They see it as their crown jewel and their reason for being. They feel they are near their goal.

President Obama is quite adamant on our national moral lapse and sees our concern about costs as a defect in our national character. Furthermore, he states emphatically and emotionally, “I will not sign it if its adds one dime to our deficit, now or in the future.”

But as poet Robert Frost might say, President Obama has miles to go and promises to keep and is deep in the woods on the health reform issue. Obama critics note that is foolhardy to make long-term promises on how government will spend on health care, which, until now, have always been underestimated. You will notice his promise leaves it open for future presidents to add a dime or two to our deficit.

The countervailing emotions did not really surface until August, when hundreds of thousands of frustrated Americans swarmed into town hall meetings, gathered in tea parties, and marched on Washington to express their fears about losing care as they know it and of saddling the nation with debt, as on conservative commentator remarked, “ from sea to shining sea as far as the eye can see.”

Among other things, Americans at the grassroots fear reform will divest them of their current plans, will ration their care when they grow old, will burden themselves with higher taxes, and their children and grandchildren with unmanageable debt.

Whether these emotions will turn the tide against government controlled care is unknown. The choice of the right health system os not an easy choice. It is an emotional and moral choice. As Churchill observed, “The inherent vice of Capitalism is the unequal sharing of blessings, the inherent virtue of Socialism is the equal sharing of misery.”

But as Sir Winston observed, “ You can always trust the Americans. In the end they will make the right choice, after they have eliminated all the other possibilities. “

I suspect what we’re seeing is the start of a long debate. Or, as Churchill might say of the health care debate, “Now this is not the end. It is not the beginning of the end. But it is, perhaps, the end of the beginning.”

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