Sunday, November 29, 2009

More wealth for everyone

(HT Steve Horwitz via Carpe Diem)

In the US, wealth is increasing at every income stratum. But, as all of our fathers told us as we were growing up, money doesn't grow on trees. Best we learn just what conditions promote prosperity and well-being before voting on the current health-care and climate change legislation. We stand on the precipice of self-destruction.

More from Carpe Diem:
The reasons for the significant improvements in living standards for all Americans (at all income levels) include innovation, technology improvements, supply chain efficiencies, increases in productivity and other market-driven efficiencies that drive prices lower and lower year by year, measured in what is most important: our time, and the amount of labor it takes to earn the money to purchase household appliances and other goods and services.

Bottom Line: As much as we hear about declines in median income, economic stagnation, the disappearance of the middle class, falling real wages, increasing income inequality, the data tell a much different story: The rich are getting richer and the poor are getting richer.

Wealth is not the problem.

Wealth is the solution.

Saturday, November 28, 2009

Hide the Decline

If you haven't heard about Climategate, you aren't paying attention. But then, if you thought the "science is settled" and that there is a "consensus" agreement on anthropogenic global warming, you haven't been paying attention either. If you get you information from Wikipedia, I can understand why you might not be aware of scientific work that challenges the conventional "wisdom." The recent bruha over the science only confirms the importance of keeping science separate from politics and political funding--but the "truth about climate change science" is irrelevant in deciding the proper role of government in climate matters.

You can read about how their goose is cooked while I cook a turkey today (for a second Thanksgiving, as there is so much to be thankful for one wasn't enough this year.)

On a more serious note, a lot more work must be done to carefully read through all the emails, making the best effort possible to not take them out of context. Even then, the exposed emails are not the complete record of correspondence. Private emails contain meaningless venting more often than evidence of criminal activity and conspiracy.

That said, the emails I have read are disturbing and the authors have some serious explaining to do. The authors and the recipients are major players in the Global Warming debate and significant contributors to the IPCC: Michael Mann (the "hockey-stick" guy) James Hansen, Gavin Schmidt, Stephen Schneider (of "being honest vs. being effective" fame), Ben Santer, Tom Wigley. Some of their view point can be read on RealClimate. (Do check the links to these scientists, as some are quire amusing.)

Climategate: The Fix is In Robert Tracinski , RealClearPolitics

Real Climate Spin Marlo Lewis,

Climate Science and Candor WSJ (unedited emails)

Three Things You Absolutely Must Know About Climategate Iain Murray,

And to understand the video clip below, read Mike's Nature Trick Watts Up with That?, and then enjoy:

On a more serious note, here's a Who's Who in Climategate and a few of their quotes:

Wednesday, November 25, 2009

Woe to the people who can not limit the state.

"The state tends to expand in proportion to its means of existence and to live beyond its means, and these are, in the last analysis, nothing but the substance of the people. Woe to the people that cannot limit the sphere of action of the state! Freedom, private enterprise, wealth, happiness, independence, personal dignity, all vanish."

-- Frederic Bastiat (1801-1850) French economist, statesman, and author. He did most of his writing during the years just before -- and immediately following -- the French Revolution of February 1848. Source: Sophisms, 141 (HT Liberty Quotes)

I am currently just posting good quotes to contemplate while I am researching for a detailed post on the number of uninsured Americans. Where does the figure 47 million come from? How much confidence should we place in that number? The size of the problem tells us nothing about the solution, but it does provide a measure by which we can gauge the degree of urgency appropriate to the problem. Stay tuned!

Tuesday, November 24, 2009

Ancient Wisdom

"The object of life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane."

-- Marcus Aurelius (121-180) Roman emperor (161-180)

(HT Liberty Quotes)

Monday, November 23, 2009

Emerson Electric Shrugs

From Manufacturing and Technology News:

Emerson Electric Votes With Its Feet, Saying The Government Is Destroying American Manufacturing Nov. 17, 2009

The federal government is "doing everything in [its] manpower [and] capability to destroy U.S. manufacturing," says David Farr, chairman and CEO of Emerson Electric Co., in a presentation at the Baird 2009 Industrial Conference in Chicago Ill., on Nov. 11. In comments reported by Bloomberg, Farr added that companies will continue adding jobs in China and India because they are "places where people want the products and where the governments welcome you to actually do something. I am not going to hire anybody in the United States. I'm moving. They are doing everything possible to destroy jobs."

In his Powerpoint presentation available on the Emerson Electric Web site, Farr notes that the federal government is damaging prospects for U.S. economic growth with a $1.41 trillion federal deficit (10 percent of GDP); $12 trillion in government debt that will grow to $20 trillion in 10 years; a policy of printing money; a "non-targeted $800-billion stimulus"; bailouts for Wall Street and the automobile companies; the prospect for cap and trade legislation; a "government takeover" of health care to the tune of more than $1 trillion; increasing taxes and regulations; and a "lack of U.S. $ support" for manufacturing. The global stimulus "soon will fade," says Farr.

Emerson Electric did major down-sizing in response to the recession (14% decrease in headcount and shut down 75+ facilities) and plans to build back up over seas, leaving the increasingly interventionist U.S. Government behind, and unfortunately U.S. workers as well.

A few choice slides from his PowerPoint presentation:

Slide #7

Slide #11

Slide #13

Senate Begins Discussion of Health Care Bill that 56% of Americans Oppose

Read about the new Rasmussen Poll.

Also, for a succinct explanation of just what Saturday's vote was all about, read this post by Dr. Paul Hsieh.

Saturday, November 21, 2009

Senate Votes to Start Debate on Health Care

Voting along party lines, the Senate voted tonight to begin debate on the Healthcare bill following Thanksgiving break.

Here's the explanation from Take Back Medicine:
Senate schedule & next steps

The Senate will begin formal debate on the healthcare bill after the Thanksgiving recess. At that time amendments may be introduced as well, which will likely number into the hundreds. Debate will probably take up to 3-4 weeks, so that brings us up to Christmas recess. Even if it passes the Senate then, it would have to be reconciled with the House bill, which is significantly different.

Senate proceedings

First, let's be clear - the vote tonight was only to proceed with formal debate. The bill can be filibustered, and some have indicated that they will do so. That means that the Senate would again have to invoke cloture to end that debate. The votes required for that are 60.
Those votes would come before we even get to a final vote on the bill. So when you hear that the Senate voted to pass the health care bill - THAT IS NOT CORRECT!

On the same page, they posted an interesting piece on cloture. Scroll down (at TBM site) to read the whole article, but here is the brief history which is quoted:

March 8, 1917 Cloture Rule

Portrait of President Woodrow Wilson
Woodrow Wilson

Woodrow Wilson considered himself an expert on Congress—the subject of his 1884 doctoral dissertation. When he became president in 1913, he announced his plans to be a legislator-in-chief and requested that the President’s Room in the Capitol be made ready for his weekly consultations with committee chairmen. For a few months, Wilson kept to that plan. Soon, however, traditional legislative-executive branch antagonisms began to tarnish his optimism. After passing major tariff, trade, and banking legislation in the first two years of his administration, Congress slowed its pace.

By 1915, the Senate had become a breeding ground for filibusters. In the final weeks of the Congress that ended on March 4, one administration measure related to the war in Europe tied the Senate up for 33 days and blocked passage of three major appropriations bills. Two years later, as pressure increased for American entry into that war, a 23-day, end-of-session filibuster against the president’s proposal to arm merchant ships also failed, taking with it much other essential legislation. For the previous 40 years, efforts in the Senate to pass a debate-limiting rule had come to nothing. Now, in the wartime crisis environment, President Wilson lost his patience.

Decades earlier, he had written in his doctoral dissertation, “It is the proper duty of a representative body to look diligently into every affair of government and to talk much about what it sees.” On March 4, 1917, as the 64th Congress expired without completing its work, Wilson held a decidedly different view. Calling the situation unparalleled, he stormed that the “Senate of the United States is the only legislative body in the world which cannot act when its majority is ready for action. A little group of willful men, representing no opinion but their own, have rendered the great government of the United States helpless and contemptible.” The Senate, he demanded, must adopt a cloture rule.

On March 8, 1917, in a specially called session of the 65th Congress, the Senate agreed to a rule that essentially preserved its tradition of unlimited debate. The rule required a two-thirds majority to end debate and permitted each member to speak for an additional hour after that before voting on final passage. Over the next 46 years, the Senate managed to invoke cloture on only five occasions.

Reference Items:

U.S. Congress. Senate. The Senate, 1789-1989, Vol. 2, by Robert C. Byrd. 100th Cong., 1st sess., 1991. S. Doc.100-20.

Also worth reading is an article by Jane Orient, "Forget the Trees; Look at the Forest on Healthcare." Nothing earth-shakingly new, but just a clear and succinct explanation about the Republicans and Democrats quibbling over how they are going to take over medicine, while the real issue is that they shouldn't be involved at all!

Senate Votes Tonight on Healthcare

The Senate vote tonight is a vote to "invoke cloture" on the motion to proceed on the bill. Sixty votes are required.
If the motion does pass tonight, we are likely looking at several weeks of further debate on the Senate floor before a vote on the actual bill takes place.

From Take Back Medicine:

Breakdown of the Senate's schedule for today:

The Senate convened at 9:45 AM est and resumed debate on the motion to proceed to H.R. 3590 (shell for the health care bill) until 8:00 PM. The time will be equally divided and controlled in one hour alternating blocks until 6:00 PM, with the Majority controlling the first hour.

The time from 6:00-6:30 PM will be under Majority control, the time from 6:30-7:15 PM will be under Minority control, the time from 7:15-7:30 PM will be under Majority control and the final 30 minutes will be divided equally between the two leaders with the Republican Leader controlling the first 15 minutes.

At 8:00 PM the Senate will proceed to vote on the motion to invoke cloture on the motion to proceed to H.R. 3590. If cloture is invoked, all post-cloture time will be yielded back, the motion to proceed will be agreed to and the Majority Leader will be recognized to offer a substitute amendment which will be reported be number only.

Please let your Senators know that you do not support government take-over of healthcare. If you are in an area where you do not think your voice will change your Senator's vote, consider writing to a Senator who may still be "on the fence" and let them know that you will financially support their opposition next election if they vote yes tonight. Or choose from the list below:

(via TIA Daily)
Richard Chudacoff of MillionMedMarch helpfully provides contact information for four senators considered to be persuadable on this vote.

Senator Bill Nelson (NE)
Chief of Staff: Tim Becker (
Washington, DC (202) 224-6551 / (202) 228-0012 fax
Lincoln (402) 441-4600 / (402) 476-8753 fax
Omaha (402) 391-3411 / (402) 391-4725 fax

Senator Blanche Lincoln (AR)
Chief of Staff: Elizabeth Burks (
Washington, DC (202) 224-4843 / (202) 228-1371 fax
Little Rock (800) 352-9364 / (501) 375-7064 fax

Senator Mary Landrieu (LA)
Chief of Staff: Jane Campbell (
Washington, DC (202) 224-5824 / (202) 224-9735 fax
New Orleans (504) 589-2427 / (504) 589-4023 fax
Baton Rouge (225) 389-0395 / (225) 389-0660 fax
Shreveport (318) 676-3085 / (318) 676-3100 fax
Lake Charles (337) 436-6650 / (337) 439-3762 fax

Senator Mark Warner (VA)
Chief of Staff: Luke Albee (
Washington, DC (202) 224-2023 / (202) 224-6295 fax
Abingdon (276) 628-8158 / (276) 628-1036 fax
Norfolk (757) 441-3079 / (757) 441-6250 fax
Roanoke (540) 857-2676 / (540) 857-2800 fax
Midlothian (804) 739-0247 / (804) 739-3478 fax

Act now to help preserve freedom of choice in health care!

(Correction: Deleted sentence which erroneously stated that filibuster would be prevented by passage of tonight's motion.)


Mammograms: The Road to Rationing?

Four days ago, the New York Times reported on the updated recommendations for breast cancer screening as announced by the United States Preventive Services Task Force (USPSTF), an "independent panel of experts" commissioned by the Agency for Healthcare Research and Quality (AHRQ), a division of the Department of Health and Human Services.

New analysis of existing research led the task force to change their previous recommendations for breast cancer screening. In 2002, the USPSTF guidelines called for "screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older." The new 2009 recommendation for mammograms states: "For women aged 40-49 years, do not screen routinely. Individualize decision to begin biennial screening according to the patient's context and values."

Not all screening that is technologically available is cost effective. At some point, the benefit to be gained is outweighed by the costs, whether you measure the costs in terms of physical resources, negative side effects, price in dollars, or even just the time involved to have the test performed. Medical research is constantly advancing the base of data from which we evaluate this cost/benefit ratio. An analysis which provides us a more accurate assessment should be welcomed with cheers. Instead, this pronouncement has triggered an angry controversy. Why?

The ruckus is the result of the degree to which government mandates effect our health-care options. New recommendations from a government agency will in all likelihood have significant effects on reimbursement policies for government-financed medical care and quickly followed by reverberations throughout the private insurance industry.

From the NYT article:

The guidelines are not expected to have an immediate effect on insurance coverage but should make health plans less likely to aggressively prompt women in their 40s to have mammograms and older women to have the test annually.

Congress requires Medicare to pay for annual mammograms. Medicare can change its rules to pay for less frequent tests if federal officials direct it to.

Private insurers are required by law in every state except Utah to pay for mammograms for women in their 40s. But the new guidelines are expected to alter the grading system for health plans, which are used as a marketing tool. Grades are issued by the National Committee for Quality Assurance, a private nonprofit organization, and one measure is the percentage of patients getting mammograms every one to two years starting at age 40.

That will change, said Margaret E. O’Kane, the group’s president, who said it would start grading plans on the number of women over 50 getting mammograms every two years.

It is no idle concern that these recommendations will be adopted and enforced by the government. Provisions within the Medicare Improvements for Patient and Providers Act of 2008 (MIPPA) grants authority to HHS to use USPSTF recommendations in determining Medicare coverage. As experience with DRGs demonstrated in the post, how goes Medicare, so follows private insurance.

The recent drive for increased government control of payment for medical care (HR 3962) only heightens concern that what starts out as a simple dissemination of knowledge and informal recommendation will turn into legal mandates and rationing. A closer look at the full report from the USPSTF, and criticisms raised by other informed institutions, further increases suspicions that politics inordinately influenced the work of this "independent panel."

First, a little back ground on the disease of breast cancer.

According to the USPSTF's own article published in the Annals of Internal Medicine, breast cancer is the "most frequently diagnosed non-cutaneous cancer and the second leading cause of cancer deaths among women in the Untied States." A woman in her forties has a 1 in 69 probability of developing breast cancer. The risk increases to 1 in 38 in her 50s, and up to 1 in 27 in her 60s. In 2008, over 250,000 women were diagnosed with breast cancer, and just over 40,000 women died of this disease. Additionally, as the American Cancer Society points out, 17 per cent of breast cancer deaths occur in women diagnosed in their 40s.

The benefits

Developing breast cancer is a real and significant health risk for women in America. Early detection is known to improve survival. Routine mammography, instituted in 1990, has contributed to a 30 per cent reduction in the breast cancer mortality rate. Even the USPSTF report recognizes that annual screening of women in their forties will reduce breast cancer deaths by 15%--but it still concludes this reduction does not warrant routine, annual mammograms.

Here's some numbers presented in the study:

For women in their 50's, 1339 individuals must be screened in order to save one life. For women in their 40s, 1904 must be screened. An additional 565 women aged 40-49 must be screened in order to obtain equal life-saving results as for women in their 50s. Lives can be saved by earlier and more frequent screening...but is this benefit worth the cost?

Maybe. Screening costs money, resources and time, and is not risk free.

The harms

What "harms" did the task force look for? The task force ran no studies of their own but performed an extensive review (a meta-analysis) of the literature. Below is a brief summary:

1. Radiation exposure and risk of causing cancer
(No studies were found that looked directly for an increased risk of breast cancer due to the radiation exposure of mammography. Studies of other types of radiation exposure demonstrate a clear connection between high-dose radiation exposure and breast cancer, but inconclusive results for low-dose exposure. Mammograms are considered a low-dose radiation exposure.)

2. Pain during the procedure ("but few would consider this a deterrent from future screening.")

3. Anxiety, distress and other psychological responses. (Important to note but difficult to translate into policy decisions due to their subjective nature.)

4. Over-diagnosis (Studies were "too heterogeneous" to provide statistically significant results.)

5. False-positive results leading to additional imaging and biopsies; false-negative results leading to missed diagnoses.

Let's take a closer look at the findings for false-positives as this "harm" is the only one with measurable consequences and appears to have significantly influenced the task-force's evaluation of the cost-benefit ratio.

False-positives occur more frequently in women aged 40-49 (97.8 per 1000 women per screening round) vs. 86.6/1000/round for women aged 50-59 years. This led to more frequent "additional imaging" in the younger age group (though fewer biopsies), increasing the number of tests and thus the expense of detecting each additional case of cancer. The category "additional imaging" includes tests widely varying in cost and time. It could simply refer to one additional x-ray or to obtaining an ultrasound, or it could indicate referral for the more involved and expensive procedure of contrast MRI. These tests were not distinguished in the paper so there is no way to tell what proportion of the "additional images" were simply a single extra mammogram view. This omission severely hinders the ability to discern just how burdensome "additional imaging" is and undermines the value of this finding.

The benefits not accounted for

Another very important limitation of the task forces' review is their use of mortality as the only end-point for assessing benefit. No effort was made to consider the increased morbidity and disfigurement, or the increased cost (either in money or in personal suffering) of therapy necessary to induce cure following delayed diagnosis. Mortality does provide a more easily determined objective end point than measuring for morbidity. However, it is curious that the pain and suffering resulting from delayed diagnosis was ignored but the pain of the mammogram procedure was taken into account.

Professional Criticisms

The new USPSTF recommendations do provide useful information to consider when weighing the personal cost-benefits of obtaining breast cancer screening. Two important professional organizations, The American Cancer Society and the American College of Radiology, have released statements (here and here) strongly disagreeing with the task force's conclusions. This is all part of healthy and necessary debate which should be encouraged.

American College of Radiologists (ACR) claims that the USPSTF report is seriously flawed:

Ignoring direct scientific evidence from large clinical trials, the USPSTF based their recommendations to reduce breast cancer screening on conflicting computer models and the unsupported and discredited idea that the parameters of mammography screening change abruptly at age 50. In truth, there are no data to support this premise.


The task force commissioned its own computer models that had never been subject to critical peer review, ignoring previously published computer modeling studies and direct scientific evidence from large clinical trials that contradict their conclusion. The recommendations also ignored peer reviewed journal articles that critiqued studies on which their recommendations rely. They did not consider literature that didn’t evaluate mortality as an endpoint.

Notably, the USPSTF does not even mention the actual published data from Sweden and the Netherlands that directly show what happens when new therapies and mammography are introduced into the population. These studies demonstrate that it is mammography screening and not new therapies or practices that are responsible for most of the decrease in deaths over the past 20 years.

And elsewhere, an ACR statement confronts the unspoken implications of the task force recommendations:

Although USPSTF states that their recommendations were not motivated by cost savings, based on the above, we cannot help but draw the conclusion that the taskforce recommendations amount to rationing on the basis of financial costs. The USPSTF’s analysis evaluates the number of lives lost under a variety of screening scenarios and then blatantly recommend the most “efficient” (i.e. less expensive) screening interval, not the one that saves more lives. Not only are these numbers based on the lowest estimate of benefit, but they have no meaning for the women being screened. Each woman has a single screening study each year regardless of the yield of cancers. Numbers only suggest the relative “cost” of curing a cancer by early detection and the USPSTF has, arbitrarily, decided that the cost of saving women ages 40-49 is too high. (Emphasis added.)

It is this real and reasonable fear of government limitations restricting or even prohibiting free choice in medical decision-making that has many clinicians alarmed.

Dr. James Thrall, chair of the American College of Radiology Board of Chancellors, stated in his initial response:

I am deeply concerned about the actions of the USPSTF in severely limiting screening for breast cancer. These recommendations, in combination with recent CMS imaging cuts, jeopardize access to both long proven and cutting-edge diagnostic imaging technologies. Government policy makers need to consider the consequences of such decisions. I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives.

From Dr. Phil Evans, M.D., president of the Society of Breast Imaging:

The USPSTF recommendations are a step backward and represent a significant harm to women's health. To tell women they should not get regular mammograms starting at 40 when this approach has overwhelmingly been shown to save lives is shocking. At least 40 percent of the patient years of life saved by mammographic screening are of women aged 40-49. These recommendations are inconsistent with current science and apparently have been developed in an attempt to reduce costs. Unfortunately, many women may pay for this unsound approach with their lives. (Emphasis added.)

From Otis W. Brawley, M.D., chief medical officer, of the American Cancer Society.:

The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions. (Emphasis added.)

This table (see pg 35 AHRQ Evidence Synthesis) summarizes the current recommendations of various professional medical organizations for breast cancer screening for average-risk women:

Task-force Study vs. Task-force Recommendations

Perhaps most telling, however, are the details mentioned in the "Limitations," "Future Research" and "Conclusions" sections of the Systematic Evidence Review Update for the USPSTF
published by the task-force itself. The different tone and the overall impression one gets from these sections of the report emphasizes the danger of drawing conclusions from press releases and "executive summaries." The full story is so much more complex. It is worth quoting those sections at length:

Breast cancer is a continuum of entities, not just one disease that needs to be taken into account when considering screening and treatment options and when balancing benefits and harms. None of the screening trials consider breast cancer in this manner. As diagnostic and treatment experiences become more individualized and include patient preferences, it becomes even more difficult to characterize benefits and harms in a general way. Many patients would consider quality-of-life an important outcome, although it is a more difficult outcome to measure and report in trials...
No screening trials incorporating newer technologies [digital mammography and MRI] have been published, and estimates of benefits and harms in this report are based predominantly on studies of film mammography. No definitive studies of the appropriate interval for mammography screening exist, although trial data reflect screening intervals of 12-33 months...

Additional research on benefits and harms of mammography screening with quality-of-life outcomes, as well as morbidity and mortality outcomes, would provide further understanding of the implications of routine screening...

Our meta-analysis of mammography screening trials indicates breast cancer mortality benefit for all age groups from 39-69 years, with insufficient data for older women. False positive results are common in all age groups and lead to additional imaging and biopsies. Women age 40-49 years experience the highest rate of additional imaging whereas their biopsy rate is lower than older women. Mammography screening at any age is a trade off of a continuum of benefits and harms. The ages at which the trade-off becomes acceptable to individuals and to society are not clearly resolved by available evidence. (Emphasis added.)

Cui bono

This brings us back to the original question: Are the benefits worth the cost?

That depends on how you answer the questions: Of benefit to whom? Of cost to whom?

And that is the entire crux of socialized medical care.

In a system dominated by third-party payers, cost is distributed beyond those who directly benefit. At least with private insurance, an individual still retains a significant degree of choice: How much coverage am I willing to pay for? Which plan will I choose to participate in? In contrast, the more government steps in to regulate insurance and medical care (or even go so far as to provide payment and/or care directly) the more those decisions must and will be taken away from the individual patient and shrink toward a one-size-fits-all policy.

The more that "society" picks up the tab, the further removed the real-life effects on the individual patient will be from cost/benefit calculations, and the less the unique circumstances of the individual most affected by the decision will determine the decision.

Medical research and analysis is fluid and rapidly changing. Attempts to legislate standards of care are slow, cumbersome and unable to account for individual variation. Government-controlled medicine must lead to unnecessary delay in implementing the latest knowledge. Lives will be lost and suffering will be increased while Congress or some bureaucrat work to catch up with medical progress.

Additionally, it is dangerous for government to step between a patient and his doctor, especially for critical life-and-death decisions. Yet, if government is paying for medical services, the requirement of protecting taxpayer money demands that it do precisely that. Recommendations from government-sponsored panels must always be suspect of putting budget needs before patient needs--its part of their job!

Fortunately, there is an affordable alternative to government-guaranteed medical care that preserves individual choice, protects the patient-doctor relationship, allows for a quick response to advances in medical knowledge and technology, encourages innovation, personal responsibility and the efficient use of resources: the free market1. And for those unfortunate few who are hit with disaster above and beyond their ability to provide for themselves, history has shown this country to have the most generous people in to the world.

This week's announcement of the new breast cancer screening recommendations from a government-sponsored review panel set alarm bells ringing: Watch out for rationing! Whether or not the fears are justified in this particular instance, the fears are definitely justified by the accelerating trend toward greater and greater government control of medical care. Let's hope that Congress starts listening to its constituents and allows medical care to return to a private matter between patients and their doctors.

Update 11/24/09 WSJ has an editorial which makes many of the same points as here, but without the detailed analysis. A Breast Cancer Preview


1. Much has been written on free market solutions to the rising cost of medical care. See my current reading list for books which address this topic. Brief papers include:
Cannon, Michael "Yes, Mr. President, A Free Market Can Fix Health Care", Cato Policy Analysis No. 650, Oct., 2009
Friedman, Milton "How to Cure Health Care" Hoover Digest, 2001, No. 3
Whitman, Glen and Raad, Raymond, "Bending the Productivity Curve: Why America Leads the World in Medical Innovation" Cato Policy Analysis No. 654, Nov. 2009
Conko, Gregory and Klein, Philip, "Political Malpractice: Health Insurance Misdiagnosis and the Destruction of Medical Wealth" CEI
Issue Analysis 2009 No. 5


Bourque, Steven "Just Take the Blue Pill, Lady" One Reality
Nov.17, 2009

Kolata, Gina "Panel Urged Mammograms at 50, Not 40"
NYT, Nov. 17, 2009

Mandelblatt, MD et al., "Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms," Ann Int Med, 2009;151:738-747

Nelson, Heidi D., et al., "Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force, Ann Int Med 2009;151:727-737

Nelson, Heidi D., et al., "Screening for Breast Cancer: Systematic Evidence Review Update for the U.S. Preventive Services Task Force," AHRQ Publication No. 10-05142-EF-1, Nov. 2009

USPSTF, "Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement," Ann Int Med, 2009;151:716-726

USPSTF, "Screening for Breast Cancer: Recommendations and Rationale," 2002 statement

American Cancer Society Responds to changed to USPSFT Mammography Guidelines

"Detailed ACR Statement on Ill Advised and Dangerous USPSTF Mammography Recommendations"

"USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year"

Thursday, November 19, 2009

The Legal Plunder of Healthcare

Originally posted May 15, 2008 at RedPlanetCartoons with the following quote by Frédéric Bastiat, 1850

“The war against illegal plunder has been fought since the beginning of the world. But how is… legal plunder to be identified? Quite simply. See if the law takes from some persons what belongs to them, and gives it to other persons to whom it does not belong. See if the law benefits one citizen at the expense of another by doing what the citizen himself cannot do without committing a crime. Then abolish this law without delay … If such a law is not abolished immediately it will spread, multiply and develop into a system.” –from The Law

Wednesday, November 18, 2009

An elaboration on the meaning of Selfishness

(The following is my response to a comment1 on my recent post The Virtue of Selfishness.)

Many proponents of the morality of rational egoism strive to reclaim the term "selfishness" as a virtue. From the perspective of most other moral theories, including today's most prevalent--altruism--selfishness is condemned as the heartless consideration only of oneself, and usually characterized as attending only to the immediate and obvious effects of one's actions.

It is crucial to note, however, that proponents of rational egoism also condemn myopic attention to only oneself, especially when divorced from the wider implications of one's actions. This myopic self-centeredness is not what is meant by their use of the term selfishness.

How can we move beyond these semantic disagreements? We obviously need two separate terms: one to designate myopic self-centeredness, and another to designate the selfishness of rational egoism. One step toward clarification might be to explain why proponents of selfishness view it as a reasonable term to signify rational self-interest (see below). An even better place to start, however, is to ask and then answer the more fundamental questions: What is the purpose of morality? Why are moral principles even necessary?

The entire question of morality arises from two facts of human nature:
1) Our existence is conditional.
2) Possessing freewill, we must choose between alternatives.

Life in general, and human life in particular, requires that we achieve certain conditions--or die. The details of those conditions are not automatically (instinctively) known but must be discovered. Moral principles are the fundamental abstractions we must discover (and then choose to use) which serve as guides for our thinking and our actions. The ultimate purpose behind these principles is the preservation and promotion of our lives. This is what is meant by stating that "life is the standard of value." Life is the goal of our actions and thus becomes the standard by which we measure good and bad, right and wrong. "Good" actions promote our lives; "bad" actions are harmful to our lives.

Since life is an attribute of an individual organism (it is the individual that lives and dies), it is the life of the individual which is the relevant moral unit. Each man's standard of value must be his own life--his own Self. This is what is meant by selfishness as a virtue: the recognition that one's own life (self) is the ultimate goal and proper purpose of one's actions. These moral principles are required even when living alone on a desert island. They are not simply rules of social engagement, but the identification of the proper stance we must take toward reality. However, we neither live in isolation, nor simply for the moment. For actions and policies to truly promote our lives, we must take into account their long-term and full-context consequences.

Political rights extend the moral principle of valuing the self and individual life into rules for social engagement. Rights outline the freedoms of action open to individuals in a social context, delineating boundaries which can not be crossed without violating the prime right--the right of each individual to his own life, and only to his own. When this is understood and consistently applied, it is possible to also see why interactions between human beings must be voluntary--and why to initiate force is to violate a man's right to his own life.2

None of this alters the fact that people can benefit greatly from one another--emotionally, materially, spiritually. It does not preclude or prevent positive, voluntary collaboration between human beings: as communities, nations, businesses, families or lovers --provided the interactions are truly life promoting for each individual involved. Selfishness simply points to the fact that each individual rightfully lives for the sake of his own life (self) and happiness. Extension of this understanding of selfishness into social interactions requires prohibiting the initiation of force against others from the realm of morally justifiable actions. (Defining just what is force and elaborating on how to distinguish between its initiation and self-defense are crucial areas requiring clarification, but that task takes us beyond the purpose of this particular essay.)

What is the tool we use to identify and analyze "the good" and attempt to understand and apply it in the widest context possible? Our faculty of reason: the process of observing reality, and then drawing inductive and deductive conclusions based on those observations, checking for consistency (eliminating contradictions) and assuring that we have sufficient knowledge to justify our conclusions.

Are mistakes possible? Of course! The fact of our fallibility, however, does not invalidate reason. The ability to error only magnifies the importance of reason and the need for careful deliberation, to always be vigilant, to constantly check and expand the context of our knowledge.

The fact of our fallibility also does not make selfishness, properly understood, dangerous. That we are creatures of free will gives rise both to the need for moral principles and to the fact of our fallibility. We have choice, and we are not automatized to choose correctly. Choice brings with it the ability to choose wrongly. Those truths do not change that the standard of value (good/bad, right/wrong) must be each individual's own life (the moral principle of selfishness) any more than the fact that errors in calculations can and do occur invalidates a mathematical principle. "Complete rationality of all decisions" is the goal. That there is no automatic guarantee this goal will always be achieved does not invalidate it as a goal.

Selfishness is a virtue because it identifies the individual self as the origin and the beneficiary of moral action. The only kind of "selfishness" which achieves this goal, consistently through time and across all areas of action, is one that is rational. Thus, the concept selfishness as a moral virtue subsumes rationality, and to state "rational selfishness" is to state a redundancy. The essence of rationality is non-contradiction. Applied to the field of ethics, reason leads us to the recognition that all human beings have the same right to life as ourselves.

In conclusion, I think there are good reasons for trying to reclaim the term "selfishness" as a virtue--but I also do not want the discussion distracted away from addressing the underlying meaning and turned into bickering over terminology. I am open for suggestions for a different terminology, one that that adequately captures the difference between selfishness consistent with reason, and the irrational, truncated "selfishness" which fails to include the full context.

Make some suggestions, or better yet, address the concept which underlies the term. Until convinced otherwise, I will continue to advocate for selfishness.

1. from Anonymous1 (10/29/09): Your treatment of the 'full concept of selfishness' implies the complete rationality of all decisions. This is inconsistent with human experience as much research in economics, safety, and psychology is beginning to understand. More often than not selfishness is just that. Selfishness. Fixation on the immediate benefit to one's self without consideration of the long term, even to the detriment of one's self.

2 Ayn Rand goes further and demonstrates the epistemological basis for the evil of initiating force--why man's unique rational faculty is his means of self-preservation and life promotion--and why for proper functioning it requires protecting the freedom to use one's own judgment--why persuasion is the only moral path to changing another man's actions--0r as I have distilled it: Convince me, or let me be.

Monday, November 16, 2009

Reducing Costs (of medical care) through Freedom

Can we restore freedom and cut costs by 50%?

Dr. Jane Orient, MD answers Yes, and introduces how.

A few of the topics she touches upon:

1. The difference between costs and expenditures:
Current health care reform plans will increase costs (extension of third party payer system, increasing government bureaucracy) and will try to control expenditures through wage and price controls, caps on supply and penalties for "necessary services."

2. What is insurance?
Not a guarantee of medical care, mark of civilization, promise to pay for medical care or a method of decreasing costs, but a means to manage risk.

3. On what are insurance premiums based?
Not need, fairness or income but RISK.

4. Insurance is voluntary. Socialized medicine is compulsory.

5. The unnecessary increased in costs caused by government interventions: taxes, bureaucracy, regulations.

6. Examples of less expensive medical care through free market processes.

7. Unfunded Medicare and Social Security liabilities are approaching 100,000 trillion dollars. No debt that size has ever been repaid.

HT TakeBackMedicine

Friday, November 13, 2009

HR 3962: Political Push toward Single-Payer (i.e. Socialized Medicine)

Columnist Terry Jeffery runs the numbers and shows how the recently passed, Orwellian-named "Affordable Health Care for America" sets up financial incentives which will penalize employers who do not drop health insurance benefits to employees. Those workers will then find themselves priced out of the private insurance market leaving them with the "choice" of the "public option."

  • This will happen because HR 3962 makes it significantly cheaper for employers to pay the mandated tax instead of the mandated insurance.

  • Without the employer's contribution toward payment of health insurance premiums, out-of-pocket cost to employees for health insurance will more than double.

  • Families with incomes up to 400% of the poverty level will be eligible for government subsidies---but ONLY if their insurance is purchased through the government-controlled insurance exchanges, which will of course include the "public option" backed with the full force and guarantee of the US Government. Guess which plan will cost less--even though it won't be the best buy for your dollar?

  • Read the 2 page article for detailed examples, and then see if you think this bill will bring us medical care that is either more accessible or more affordable.

    HR3962: If it's so great, why must it be mandated?

    (HT Hot Air via TIA Daily)

    And failure to "participate" criminalized?

    Buy insurance or go to jail.

    • Section 7203—misdemeanor willful failure to pay is punishable by a fine of up to $25,000 and/or imprisonment of up to one year.

    • Section 7201—felony willful evasion is punishable by a fine of up to $250,000 and/or imprisonment of up to five years."

    (from TIA Daily)

    Addendum 11/14/09: source of criminal penalty information: Joint Committee on Taxation Nov. 2009 letter to Rep, Dave Camp of the House Ways and Means Committee.

    Wednesday, November 11, 2009

    HR 3962: Expanding Immoral Medicine

    No citizen would consider it moral to put a gun to his neighbor’s head and demand that he pay for his mother’s medical care -- no matter how much she may need it. It is no more moral when people use the government as intermediary. For the physician, it is impossible to practice moral medicine in a government system, because ultimately at some level a physician will have to choose between doing the best for his patient or acquiescing to the requirements of the state...[T]he moral tightrope has already started here with Medicare. Federal practice guidelines have slowly become mandates. If you do not do what the government has deemed the optimum pathway for care, the hospital will not get paid... [Doctors] are in the position of doing what is best for their patient, or what is prescribed by the state wielding a financial mallet.

    from "Immoral Medicine" by Dr. Lee Hieb. Read the whole article for a sampling of specific examples in support of the above claims..

    Tuesday, November 10, 2009

    20 Years Ago Yesterday

    Berliners sing and dance on the Berlin Wall in November 1989
    to celebrate the opening of the borders of East and West Germany.
    (Thomas Kienzle/associated Press)

    See this and other fabulous photos in a brief photo-essay
    by Time from the 10th anniversary.

    A couple of good reads:
    "After the Wall Fell" by Anne Applebaum: Central Europe's success deserves more attention.

    "20 Years On" by Alvaro Vargas Llosa: There was nothing inevitable about the fall.

    And a video clip:

    Didn't get around yesterday to noting this glorious anniversary--I was too busy yesterday enjoying my freedom. But, it's too important not to note---even if a day late.

    Addendum to Berlin Wall Post

    After publishing my post on the 20th anniversary of the fall of the Berlin Wall, I came across a moving video clip put together by CEI producer Drew Tidwell. I added it to the post but missed the feed-- which doesn't appear to update previously published posts. Didn't want you all to miss this great tribute to freedom fighters so I am adding it again here:

    And a great slide show Berlin Wall: Then and Now (HT Not PC)

    Sunday, November 8, 2009

    5 votes further away from freedom

    Last night, our leaders and representatives in the House of Representatives voted us further away from the rights and liberties which give this country its moral standing.

    220 to 215.

    If this bill passes the Senate, it will be illegal for me to choose to spend my honestly earned money on my child's education instead of government-controlled, government-mandated health insurance. With less money at my own discretion, it will be more difficult to opt out of government schooling and pay for private school tuition. How can this be considered consistent with freedom?

    As a business owner, it will be illegal for me to offer a higher wage to my employee instead of a health insurance plan.

    It will become illegal for me to contract with an insurance company to design a plan which best meets my unique circumstances-- if it does not align with the mandates from Washington.

    As a physician, it will be even more difficult to care for the elderly as cuts in Medicare reimbursements fall even further below the cost of providing that care.

    As a philanthropist, I can not choose how much I can spare or even the causes I wish to support, but will be forced by law into paying for the health insurance of those the state determines require my charity.

    But most distressing of all is the number of people in this country who support this and similar bills. What I can not understand is how my good and honest neighbors, who would never think of breaking down the door to my house and demanding I submit to their idea of appropriate medical care or health insurance--not only do not even blink at the use of the ballot to accomplish that very act -- but self-righteously claim it to be a legitimate form of social interaction.

    To those who think such laws are not only legitimate, but good, I ask, on what grounds do you justify this blatant intrusion into my peaceful and private life? On what basis can you deprive me of the property I have peacefully and honestly obtained? What crime have I committed to be stopped from directing my own life and the use of my own resources in a manner furthers my life, and the lives of those I value, and perpetrates no harm to others?

    The cost of this legislation is said to exceed $1.2 trillion. It certainly does.

    The full cost is includes our freedom.


    Friday, November 6, 2009

    A Letter to My Representative about HealthCare Reform

    Dear Anna Eshoo,

    Thank you for sending me your latest update on health care reform. You seem to sincerely believe that the current proposals before Congress will improve access to medical care, but I must register my strongest disagreement. The following is in response to just one of the bullet points you included in your latest communication.

    You write that the bill will create “a new Health Insurance Exchange, a one-stop comparison shopping marketplace1, including a public option to compete2 with private insurers to help lower costs3 and improve coverage4.”

    1. A government-mandated Health Insurance Exchange is not a “market place” but a state-run insurance cartel. A market consists of the exchange of value for value. Governments produce no values. When government becomes involved in economic exchanges, it can only do so by transferring wealth—wealth it must first obtain from those who produce it. A system of wealth transfer is not a market but a Welfare Program. Voluntary welfare programs are called charity and can be accomplished while preserving the sanctity of individual rights. Wealth transfers by the state are achieved only by violating the liberty and property of some for the welfare of others—thus turning the state into a violator of the very rights it was created to protect.

    2. Government cannot be a market competitor. Market interactions are voluntary; government interactions are not. Governments legislate, mandate, regulate, tax, and subsidize—of which entail the use of force. The essence of a market is free and voluntary exchange. To the extent that government controls a segment of the economy, it is a creature not of the market but of the state—which means a creature of coercion.

    Additionally, fair competition requires a level playing field, and a single set of identical rules for all competitors. But a “competitor” that can draw upon the infinite resources of the US national debt to subsidize itself and its “customers,” and at the same time has the power to tax, regulate and otherwise and hobble its “competition” is not competing, but is in fact running the show under the guise of competition. In sports, it’s called cheating. In business, as in government, it’s called extortion or fraud.

    3. Under government-run programs, “costs” cannot be lowered—merely shifted from one set of individuals to another set of individuals. Costs are not lowered by changing who pays the bill. Costs of producing goods and services also do not change simply because the government mandates a specific legal price. Costs, and free market prices, are a function of the supply of and demand for scarce resources with alternative uses. Free market competition, including the inappropriately maligned profit motive, is the only mechanism by which scarce resources can flow to the most efficient providers of the goods and services in greatest demand. All government contributes to this process is to forcefully interject the political goals of some onto others who, if left to their own judgment, would have chosen differently.

    4. A public option can only “improve coverage” for some at the expense of others, and even then, only for the short term. A system which disconnects consumption from payment can only drive demand higher, putting greater and greater pressure on limited supplies, leading either to sky-rocketing prices or government rationing. Under the current proposals, today’s uninsured or under-insured will only gain “coverage” through forced mandate or government largess. Private insurance option will be limited to government-approved plans—further increasing costs and deceasing choice, until affordable only by the very rich.

    Ms. Eshoo, it is indeed troubling that medical care is not affordable for a sizable portion of our population. However, contrary to the proposals you support, I believe that the solution lies with less government, more freedom and real market competition. Regulations which prevent competition across state lines should be abolished. All insurance premiums should be treated equally by tax law. Insurance companies should be free to offer whatever policies people are willing to purchase, and then held strictly to their promises through contract enforcement. Licensing laws for practitioners and medical supplies (drugs, devices, etc.) should be drastically liberalized—if not eliminated-- allowing people to purchase the goods and services they can afford. Fraud, breach of contract and malpractice should be the standards for legal action.

    You have dedicated decades of effort to increasing accessibility to medical care. I hope your devotion to this laudable goal can motivate you to reexamine your basic assumptions, and to consider solutions which will both provide increasingly affordable medical care while at the same time will protect and preserve our inalienable rights to life, liberty and property. A program that violates individual rights is neither compassionate, nor sustainable.


    Beth Haynes MD

    Thursday, November 5, 2009

    Pay the price, or pay the consequence

    Thomas Sowell has an excellent series of articles on "The 'Costs' of Medical Care: Parts I, II, and III.

    A few key points from Part I:

    There is a fundamental difference between reducing costs and simply shifting costs around...Costs are not reduced simply because you pay less at a doctor's office and more in taxes--or more in insurance premiums, or more in higher prices for other goods and services that you buy, because the government has put the costs on business that pass those costs onto you...

    Costs are not reduced simply because you don't pay them...Letting...people die would undoubtedly be cheaper than keeping them alive--but that does not mean the costs have gone down. It just means that we refuse to pay the costs. Instead, we pay the consequences...

    Anyone of us can reduce medical costs by refusing to pay them. In our own lives, we recognize the consequences. But when someone with a gift for rhetoric tells us that the government can reduce the costs without consequences, we are ready to believe in such political miracles.

    From part II:

    Although it is cheaper to buy a pint of milk than to buy a quart of milk, nobody considers that to be lowering the price of milk...

    And from part III:

    One of the strongest talking points of those who want a government-run medical care system is that we simply cannot afford the high and rising costs of medical care under the current system. First of all, what we can afford has absolutely nothing to do with the cost of producing anything. We will either pay those costs, or not get the benefits...

    Economics and politics confront the same fundamental problem: what everyone wants adds up to more than there is. Market economies deal with this problem by confronting individuals with the costs of producing what they want, and letting those individuals make their own trade-offs...That leads to self-rationing, in the light of each individual's own circumstances and preferences. Politics deals with the same problem by making promises that can not be kept...

    The self-rationing that people do when prices are free to convey the inherent impossibility of any economy to supply as much as everybody wants is replaced...with rationing imposed by governemnt, which cannot possibly have the same knowledge of each individual's circumstances and preferences---least of all when it comes to medical care, where patients differ in innumerable ways.

    That's just a smattering of the economic wisdom in Sowell's current series of articles. He also points out the importance of distinguishing medical care from health care, debunks the misleading statement that American medical care costs more but delivers less, and the laughable claim that THIS administration will eliminate "waste, fraud and abuse" where every previous one has failed. He packs a lot in to rather brief essays that are worth the time to read in full.

    I am hoping there will be a Part IV.

    (Update 11/06/09: Multiple typos corrected.)

    Wednesday, November 4, 2009

    Healthcare Morality and Practicality

    The moral and the practical are two sides of a single coin: the coin of human action. A breach in one is a breach in the other. This is because the whole purpose of morality is to guide a man's actions toward life-promoting success.

    A pair of recent articles evaluating the current proposals for healthcare reform each looks at one side of that coin.

    The Wall Street Journal editorial, "The Worst Bill Ever" analyzes the impracticality of HR 3962. If implemented, the bill will cause massive increases in both health care spending and national debt, because in spite of significant increases in taxes, all the incentives (political and personal spending) lead to greater consumption of healthcare goods and services, accompanied by political pressure for the government to meet the demands. With or without an immediate "public option," there is still plenty in the bill which will shackle, undercut and eventually destroy private health insurance for all except the very wealthy--giving most of us fewer, more expensive choices.

    An article published on-line at The American Thinker,"Charity and Sacrifice in a Free Society," addresses the other side of the healthcare reform coin: the moral limits of government action. Referencing the works of Ayn Rand, F.A. Hayek and Alexander Hamilton, the authors argue for a government action constitutionally limited by individual rights--rights which "impose no obligation on an individual except to abstain from violating the rights of another individual." Charity is properly the voluntary act of individuals, not an action in which some coerce others in the name of a "public good."

    Economic analysis and arguments can enlighten us on the practical consequences of our actions. The study of ethics and politics are necessary to clarify our moral reasoning. But these are just two different ways of looking at human action. When moral principles are breached, when individual rights are violated, the results will not and cannot be practical.