By John Dale Dunn MD JD
Junk Science can be a basis for bad policy, let’s consider Obamacare–the fix that has failed. Failed the great American Healthcare System and may auger its demise. Shame on us. I cannot provide you with enough information on this tragedy if you are not already alerted. Too bad, you’re stupid.
What if I told you that the American Healthcare system is one of the glories of the American Success story?
The consensus from the elites, the oligarchs, the Ruling Class (think Angelo Codevilla’s revealing expose on the leftist junk science merchants) was that we in America, with access to the most sophisticated healthcare system in the world, by far, had a “Broken Healthcare System” that required the creation of Obamacare, a revamping of an economic sector that is 17% of the American economy, more than 2 trillion dollars per annum and the home of one of the wonders of modern life–the American Health Care providers and the technological and procedural marvel that is so egalitarian that it provides the best of care to the least of people in the society. A beggar can get care at Houston–consider that?
Here we are committing policy suicide by condemning or criticizing a healthcare system that can claim amazing successes and advances that are too numerous to count.
How is it that the junk scientists of the left could take down such an edifice?
Well consider the influence of the media, the commitment to leftist ideas of the Academy, and the influence of the plaintiff attorneys and the complicity of the political class. Shame on us for allowing such a travesty, a despicable take down of the greatest healthcare system in the history of man.
Your author was the Chief Medical Officer and then the CEO of a Health Maintenance Organization (HMO) in Louisiana in the early 80s, the first generation of “managed care organizations” pushed by government. There had been managed care organization before, formed by companies for their employees, some, like Kaiser in California and then beyond, had become enterprises available to the general public. Other managed care entities were strictly in house, on an employee plan for railroads and public entities. The DOD did the same thing for the uniformed services and their dependents.
In response to an increasing chorus asking for projects to hold down the costs of premium for health insurance, the Nixon administration HMO Act of 1973 created community based, non profit, managed care entities that had closed panel in house contract medical provider and hospital resources that provided healthcare, with a single community premium, guaranteed issue, first dollar coverage with some co pays but no deductible, intended to offer to employee groups and individuals good care with few out of pocket expenses. The HMO act was inaugurated in response to an industry, business, community push for health care that was affordable and comprehensive. Start up grants and then operational loans were intended to push the HMOs to a level of self sustaining membership and income.
The rationale was that there was waste and it could be trimmed with managed care. Sound a little like the sales pitch for Hillarycare/Obamacare?
So managed care projects in the 70s were intended to hold down costs on the theory that they could be reduced by utilization controls, incentives for providers, and a subtle form of rationing based on research that showed differences in cost of care in various parts of the country. The research that showed differences was called small areas research by John Wennberg of Dartmouth.
Again, sound like Hillarycare/Obamacare?
So what was the argument for single payer, government healthcare? Well, like most ambitious utopian projects–good intentions and the assertion there was a crisis or a terrible injustice that must be righted. Also a commitment to the concept that a good centrally controlled plan would fix the problem of the social injustice of a private, partially free market healthcare system. Of course to get to that conclusion the geniuses had to ignore the influence of government in healthcare that had already created many problems and interfered with market principles with mandates and regulations.
Here was the mantra:
1. Healthcare was a right and US premiums were too high. No insurance coverage meant the uninsured were dying or suffering.
2. US Healthcare was unsafe and doctors and nurses and hospitals were greedy and negligent.
3. US Healthcare wasn’t even very good, due to greedy and incompetent, ineffective private sector insurers, providers and suppliers. US infant mortality and other measures of health were poor and our life expectancy was also unacceptable, so US healthcare was less efficacious than many 1st world countries, even less satisfactory than some developing countries.
Answers to the arguments and a review of the junk science that supported these claims are provided.
High Cost without benefit and the crisis of the uninsured (thanks to agit prop from Families USA for 20 years).
There is no question that high tech medicine is what is available for Americans, Cadillac care and plenty of it–more high tech and capable than anywhere in the world. If apples and apples are compared the alleged problems like life expectancy, infant mortality go away as discussed below by Scott Atlas, and John Goodman shows that for sick people America is the place to get good care.
There is no uninsured crisis, the uninsured are either eligible for safety net or charity, or healthy and not in need of healthcare. Hard core uninsureds are not 45 million but a third of that and they all have access to care paid for with the safety net and charity system.
Government programs distort markets and utilization (the free lunch factor). For example the introduction of Medicare/Medicaid in the late 60s clearly increased healthcare spending and costs and distorted the market. Moreover decades of government regulation with mandates and limiting competition, even suppressing market sensitive insurance programs like Health Savings and Medical Savings Accounts prevented market dynamics from reducing the effect of the free lunch, first dollar coverage, moral hazard problems of 3rd party payer insurance.
Amy Finkelstein demonstrated the effect of government programs in her research for the National Bureau of Economic Research.
Finkelstein A. The effect of Medicare on medical expenditures,mortality and spending risk. National Bureau of Economic Research Report, fall 2005.
If one would argue that managed care fixes the problem the failures of the managed care experiment of the 80s should be a sobering consideration. Now we see a revival of all the managed care myths, this time with a large dose of government control and the proven inefficiencies of the government system. Is no one checking the history of these proposals? Managed care of the 70s and 80s will suddenly become successful if the strategy of the government project?
So is there a crisis for the uninsured?
In a word, no.
In the last 15 years policy makers retooled to impose new managed care mandate, cost containment projects after the rejection of HMOs, but the political crusade kept beating on the Families USA theme of the uninsured.
Multiple studies have shown that uninsured status is not a risk for bad health or death and that the cost of care for the uninsured is a small percentageof the total cost of healthcare in the United States, nothing to justify a complete overhaul of the system.
Junk Science studies were done that claimed lack of insurance was a killer. The studies are exposed below as false confirmation bias exercises and exaggerations.
Cost of care for the uninsured cannot, under any circumstances, justify the catastrophe of revamping into a government controlled system, a sector that is 2 trillion plus. Studies showed that total care for uninsured was less than 100 billion, less than 5 % of the total cost of healthcare at the time–more than 2 trillion.
Herrick D. Crisis of the uninsured: 2007. National Center for Policy Analysis No. 95, Sep 28, 2007. Available at: http://www.heartland.org/policybot/results/23202/Crisis_of_the_Uninsured_2007.html.
Hadley J, Holahan J, Coughlin T, Miller D. Covering the uninsured in 2008:current costs, sources of payment, and incremental costs.
Robert J. Samuelson, Obama’s illusions of cost-control. Washington Post, Mar. 15, 2010
Goodman J, Does lack of insurance cause premature death? National Center for Policy Analysis,
www. healthaffairs.org. Sept. 21,2009.
http://www.ncpa.org/pdfs/2009_harvard_health_study.pdf commenting on
Tate W. 45,000 uninsured deaths? , Oct 23, 2009.
Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor quality health care? NEJM 2006:354:1147-1156.
Levy H, Meltzer D. The impact of health insurance on health. 2008;29(April).
And my essay on the big picture, and myths that drive healthcare system repair projects
Dunn JD ObamaCare Policy Myths: Warnings from a 1980s HMO Executive
However in the world of ambitious mandarins, the false crisis of the uninsured requires an ambitious government fix like Obamacare.
Patient safety issues
In the early 90s as a part of the project to denigrate American Healthcare, patient safety was added to the mix as another reason why government healthcare was the only answer, at the same time costs continued to increase and regulations reduced the impact of free markets, insurance companies were mandated to provide more benefits, people continued to expect little out of pocket expenses but utilized the system heavily.
I analyzed the results of the notorious Harvard study of New York Hospitals publish in the New England Journal of Medicine and found the junk science methodology. In fact almost a decade later Troyen Brennan MD JD, lead researcher in the Harvard group, admitted their methods were unreliable and their judgements as to what was malpractice or negligence or preventable were not necessarily reliable. He said in an essay in the New England Journal of Medicine
Dr. Brennan said:
Troyen Brennan M.D., J.D. — a lead Harvard researcher on the two studies that were the backbone of the IOM report and the source of the negligence death numbers that scared so many — asserted in an essay in NEJM that the research of the Harvard group was weak and was being misused by the IOM. Brennan wrote:
–”I have cautioned against drawing conclusions about the numbers of deaths in these studies.”
–”The ability of identifying errors is methodologically suspect.”
–”In both studies (New York and Utah/Colorado) we agreed among ourselves about whether events should be classified as preventable…these decisions do not necessarily reflect the views of the average physician, and certainly don’t mean that all preventable adverse events were blunders.”
Brennan TA. The Institute of Medicine report on medical errors — could it do harm? NEJM 2000;342:1123-1125.
Here are my two essays on why the methods and finding and scare tactics of the patient safety movement were junk science:
I showed my proof by comparing my data on studies of more than 300,000 hospital admissions analyzed by the Texas Medical Foundation, compared to the 30,000 admissions study in New York.
I concluded that the patient safety crisis was manufactured with unreliable methods and exaggerated claims. The misleading methods include using a small study, big projection game that starts with outcome bias and confirmation bias, then uses the small study numbers to project to a large population, voila big crisis.
This first paper I wrote in response to the panicmongering generated by the Institute of Medicine (Subdivision of the National Academy of Sciences) release of “To Err is Human” that claimed doctors and nurses were killing up to 98,000 people in hospitals in America every year.
Dunn JD. Patient safety in America: comparison and analysis of national and Texas patient safety research. 2000;96:66-74. Available
at: http://www.heartland.org/custom/semod_policybot/pdf/ 23751.pdf.
The second essay was in response to another effort to gin up a safety crisis in the New England Journal of Medicine.
Dunn JD. Patient safety research: creating crisis. Jan 10, 2005. http://www.acsh.org/factsfears/newsID.487/news_detail.asp.
The claim that the US compares badly on quality of healthcare in the world.
The World Health Organization published a report in 2000 that claimed by means of junk science analysis that United States health care was the most expensive in the world, but only ranked 37th in quality and good results.
Scott Atlas MD, Stanford Neuroradiologist analyzed the biases and methodological problems of the socialist tract, and declared it “the worst study ever.” Well that might be hyperbole in our eyes, as regular analysts of junk science.
As demonstrated by Atlas’ essay in Commentary, as the editors assert:
In fact, “World Health Report 2000″ was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all. The report’s true achievement was to rank countries according to their alignment with a specific political and economic ideal—socialized medicine—and then claim it was an objective measure of “quality.”
So again our expensive advanced healthcare system is subjected to a Junk Science analysis and world wide survey conducted by socialista at the UN World Health Organizatio (WHO). The Conclusion by the elite socialist mandarins–we need an ambitious government fix, a socialist utopian healthcare system in Amreica, We need to take down their private free market healthcare, it is repugnant to us socialists.
So the ambitious United States government fix is projected to cost more in the hundreds of billions, destroy the private care system and compromise an already shaky Medicare program, while driving insureds to the government exchanges looking for a way to avoid the increases in premium. The project looks like a calculated way to eliminate private sector health insurance, drive people into a Medicaid on steroids program, and destroy innovative and successful private market based healthcare–in favor of an ambitious government fix.
Now the proponents of government controlled care look at the crash site for Obama care, and say the old system is no good, broken and we can’t go back, Obamacare needs to be refitted/reworked/adjusted/modified because it’s the only solution. No repeal–fix it, modify it, make it work. Agency and political lunkheads say-lets put lipstick on a pig.
Byron York points out that government is always inclined to keep big ambitious central planning, even if it is a catastrophe, because it expands the role of bureaucrats, apparatchiks, the nomenklatura, elites, elected or appointed officials, with the control of bigger purse. York advises in this insightful essay that opponents of Obama care should not fall for the trap of trying to fix the train wreck.
So the politician/central planner delusion survives what would be, in the private sector–a basis for sacking all those responsible.
Now we are expected to let these clowns try to make it palatable when it is inedible, even toxic? Is there ever a time when government elites and geniuses get fired for stupid and incompetent? Answer–did anyone get fired for what happened on 9-11-2001?
American government has been engaged since FDR in an 8 decade effort to make people compliant with ambitious government programs. We shall see if this current problem of the largest government program ever in the ditch is enough to wake the citizenry up. Or do we slide into the mediocrity and tyranny of European socialism?
Is it surprising that an overly ambitious government plan would be poorly conceived and poorly executed? Really? Socialists live in the negative and rarely are focused on solving problems–their goal in life is acquiring power and control while mouthing the words of good intentions.
Think about it, I do.