Wednesday, August 26, 2009

Health Care Notes

Some random thoughts on health care, and the reform there of.

This is an old story but it bears some examination. In October, 2008, then-Senator Obama's grandmother was reported as having broken her hip. She had "hip replacement" surgery. She died about a week later.

On April 14 of this year, President Obama gave an interview about health care reform to the New York Times, in which he said:

"THE PRESIDENT: I don't know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she's my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn't have a hip replacement and she had to lie there in misery in the waning days of her life -- that would be pretty upsetting.

NYT: And it's going to be hard for people who don't have the option of paying for it.

THE PRESIDENT: So that's where I think you just get into some very difficult moral issues. But that's also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

NYT: So how do you -- how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that's part of why you have to have some independent group that can give you guidance. It's not determinative, but I think has to be able to give you some guidance. And that's part of what I suspect you'll see emerging out of the various health care conversations that are taking place on the Hill right now." [The New York Times Magazine, 4/28/09]

There's a lot here that needs to be unpacked. Let's start with the term "hip replacement". First some anatomy. The hip is basically a ball and socket joint. The ball is the end of the femur (the large bone between the hip and knee). The ball is known as the "head of the femur". The head of the femur is joined the the rest of the femur by a column of bone known as "the neck". The socket of the joint is in the pelvis and is known as the "acetabulum". Normally bone gets its blood supply from the tissue surrounding it know as "periosteum". However, because the head of the femur rotates within the acetabulum blood can not get to it from surrounding tissues. So the head gets its blood supply from the periosteum of the neck of the femur. Without blood supply a bone will die.

When most people hear the term "hip replacement" what comes to mind is what is known as a "total hip arthroplasty", or simply "total hip". Total hips are usually done for patients with hip pain from arthritis. In it the head of the femur is replaced, and the a new socket lining is placed in the acetabulum. It is essentially an elective, quality of life surgery.

This is not what was done for the President's grandmother. She broke her hip. What is done for a broken hip depends on the nature on location of the break. If the break is below the neck, then a variety of plates, screws and other hardware can be used to hold the bone in place until it heals naturally. If the break is across the neck and the head has not moved in relation to the neck, then some screws can be placed across the break, and the bone will usually heal naturally. If, however, the head has moved in relation to the neck, then the blood supply through the neck to the head has been disrupted. The head is going to die, so it must be replaced. Until it is, the patient must be kept in traction to reduce the movement of the joint, because every time the joint moves the ends of the broken bone will grind together, which is very painful. Traction reduces, but does not eliminate movement of the joint.

This, then, is the surgery that the President's grandmother received. She did not receive the hip replacement that the nice old man down the block got so that he could continue to play golf. She got the hip replacement that people get to relieve the constant pain from a broken bone. Unless a patient is within hours of death, it is cruel to not perform this procedure. This is the procedure that the President feels that society should consider denying to the terminally ill.

Let's talk about the other issues. The President clearly sees a two-tier system here. HE would pay for the procedure out of pocket, because he loves his grandmother, and he is rich. My grandmother? Sucks to be me.

Now let's talk about the last paragraph. "Not determinative", but "guidance". Congress did not act in a determinative manner when it wanted a 55 mph speed limit. The states were free to choose any speed limit they wanted, but Congress offered "guidance", along with consequences for not following that guidance. Guidance from the body that holds the purse strings is determinative.

Let's also discuss the term "terminally ill". Ted Kennedy was terminally ill for over a year. If he had broken his hip on the same day as the President's grandmother, should he have been denied treatment?

Here's another interesting tidbit. "the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here." Oh, he means sick people. Turns out that sick people use most of the health care resources. Who would have thought that? If we could just keep from spending health care resources on sick people, the health care crisis would be over.

In short, what the President seems to be saying is that there should be some sort of "independent group" that operates outside of the normal political process, that offers guidance. This group would consider whether, in the aggregate, certain treatments are appropriate in certain circumstances. These guidelines will not be "determinative", but they will be guidelines and they will be pushed by those with the purse strings. Part of the goal will be to reduce the cost of sick people to the health care system. But there will be no Death Panels.

The Left, the CIA, and the DMV

The last few weeks have had several breaking news stories about how the CIA poorly handled the entire process of recruiting and training ‘interrogators’. (Ok, everyone knows that they were really torturers, but that pesky liability law keeps getting in the way). These stories also appeared to magically precede the Obama administration announcement for more oversight on the issue but I’m sure that is a coincidence and good journalism, not collusion. (We all know the national media is simply a detached arbiter and treats the Obama administration with the same professional reserve with which it treated the Bush administration).

The basic premise of these articles was the CIA was unorganized and inept in their attempts to train interrogators (torturers) for Gitmo and other dens of inequity during the misguided attempt to thwart international terrorism. What was found is the CIA had no real training program and very little idea as to what it was doing. The media (I would say leftist media, but is there another kind?) appear to think this is a huge story. But, hey, anyone who has ever been to the DMV would be shocked if it were any other way. All government agencies eventually descend to befuddled incompetence over time.

The real issue is the lefts perception of the CIA. The left has spent years and dedicated millions to portraying the CIA as this huge spy machine, capable of chasing Jason Bourne across the world from a lap-top in New York. Equipment so sophisticate it can hack into and use an image from a surveillance camera three blocks away and, in seconds, come up with 3D images and assign motivations to continue to track its prey. When, in fact, they are just another group of people hamstrung by too much regulation, petty bureaucrats, and budget constraints. Every real world example of the CIA shows a group of people with no more skills or power to read minds then the people at GM, Proctor and Gamble or IBM. These real world examples also show a group that has the additions burdens of Congressional oversight and government red tape that ends up making them look like the Marx Brothers instead of the Tom Clancy warriors they are so often feared to be.

The articles also said a whole lot more then they intended. Between the lines, if the vaulted CIA, terrors of the world and, according to people who also support Nancy Pelosi, the only true and viable threat to world peace are truly befuddled incompetents what does that say about the ability of a government bureaucracy to run anything effectively and efficiently? Ok, I actually believer the CIA are hard working people who make do with what they have, and more importantly the bureaucratic constraints the must operate within.

The real problems within the CIA, the DMV, the IRS, the Post Office, or any other government agency are the very nature of governments. In non-governmental organizations rules are advisable set of conditions that are altered when needed or broken when necessary. Rules within these organizations are more like guidelines. Discretion and performance can lead to a rule breaker being celebrated for a great idea or exceptional service. Within government organizations rules are laws and any rule violation, no matter how necessary or practical, are dealt with harshly (up to and including jail time) and subject to oversight. Once Congress gets involved it is the end of progress.

Why do I discuss this small news event in such detail? One simple question: do we really want the same people applying the same rules to our health care system?

Sunday, August 16, 2009

Un-American or Patriot?

Why was it an act of Patriotism under the Bush administration to protest the Iraq war; yet under the Obama administration it is un-American, according to Nancy Pelosi, to question anything Obama proposes?

This of course pertains to the hotly debated Obamacare Plan.

How much more spending can we as Americans tolerate?!?

Why is Obamacare acceptable for the Plebians; yet, Congress maintains a separate plan?!?

Thursday, August 6, 2009

Some day no one will march there at all.

The last World War I veteran in Britain, and the last man to have fought in the trenches, was laid to rest today. Harry Patch was a private in the Duke of Cornwall's Light Infantry. He arrived in France in June of 1917, and was wounded on September 22 by an artillery shell, which killed three of his comrades. His funeral was in Wells Cathedral in front of a crowd of 14oo, including the Duchess of Cornwall and the Duchess of Gloucester. Thousands more watched on big screens on the cathedral green. His pallbearers were, at his request, privates from the The Rifles, the successor unit to the Duke of Cornwall's Light Infantry. The pallbearers were all about 19 years old, the age Patch was when he was wounded. His coffin was followed by soldiers from the armies of France, Belgium and Germany. A lesson was read by Dr Eckhard Lubkemeier, charge d'affaires at the German Embassy. An extract from Patch's biography, was read by the Belgian charge d'affaires, Marie-France Andre.

As the coffin left the cathedral, it paused and Last Post was played. An old friend of Patch read from the Ode of Remembrance: They shall grow not old, as we that are left grow old: / Age shall not weary them, nor the years condemn. and then read three names "Jack, Jill and Maudy." These were the nicknames of the three comrades killed by the shell that wounded Patch.

Patch selected the music for his funeral. In addition to his favorite hymns, the congregation sang "Where have all the flowers gone."

"Where have all the soldiers gone? Gone to graveyards every one.

Harry Patch Requiescat in Pace